STI- Senarios
Scenario:
You are in the Emergency Department. A patient (male or female, age 25–40) presents worried about possible HIV exposure after recent sexual contact.
Your task:
- Take a relevant sexual history.
- Assess risk of HIV transmission.
- Explain investigations and management, including HIV post-exposure prophylaxis (PEP).
- Address concerns and provide safety-netting.
You are not expected to perform a physical exam.
🔶 1. Introduction and Communication
Approach:
- Introduce yourself, confirm identity.
- Ensure privacy and confidentiality.
- Ask permission to take a sensitive history.
- Use open, non-judgmental language.
“I understand this is a sensitive topic, but I’ll ask a few questions to understand your situation and discuss how best to help you.”
🔶 2. History Taking Framework
A. Presenting Concern
- “Can you tell me what has brought you in today?”
- “What specifically worries you about HIV?”
B. Exposure Details
- Type of sexual contact: vaginal, anal, oral.
- Use of protection (condoms? consistent?).
- Timing of exposure (crucial for PEP window ≤72 h).
- Partner’s status:
- Known HIV-positive?
- Unknown? From high-prevalence area?
- IV drug user / sex worker?
“Was the partner’s HIV status known to you?”
“When did this sexual contact occur?”
“Was a condom used throughout?”
C. Other Risk Factors
- Multiple partners / new partner.
- MSM (men who have sex with men).
- Drug use, especially injection.
- History of STIs, blood transfusions, tattoos, etc.
D. Symptoms
- Current symptoms of acute HIV (usually not relevant for <2 weeks exposure): fever, rash, sore throat, lymphadenopathy.
- Other STI symptoms: discharge, ulcers, dysuria.
E. Past History
- Past STIs, HIV tests, vaccinations (HBV, HPV).
- Medication allergies.
- Relevant medical history.
F. Social History
- Occupation (healthcare worker?).
- Living situation, partner, contraception.
- Emotional state, support, mental health.
🔶 3. Risk Assessment
Summarise back to the patient:
“So, you had unprotected vaginal/anal sex with a partner of unknown status about 36 hours ago — that helps us assess your risk.”
Approximate HIV transmission risks per exposure:
| Exposure Type | Risk (per 10,000 exposures) |
|---|---|
| Receptive anal sex | 138 |
| Insertive anal sex | 11 |
| Receptive vaginal sex | 8 |
| Insertive vaginal sex | 4 |
| Oral sex | <1 |
🔶 4. Management Plan
A. HIV Post-Exposure Prophylaxis (PEP)
- Indication: Within 72 hours of significant exposure to potentially infected source.
- Regimen (UK 2025):
- Tenofovir disoproxil / emtricitabine (Truvada)
- + Dolutegravir (Tivicay)
- Duration: 28 days.
- Baseline tests:
- HIV, Hep B & C, syphilis, pregnancy (if relevant), renal/liver function.
- Follow-up:
- HIV tests at baseline, 4 weeks, 12 weeks, and 24 weeks.
- Sexual health clinic follow-up within 24–48 hours.
“If we start PEP today, it should ideally be taken within 72 hours of exposure and continued for 28 days.”
B. Post-Exposure Vaccination / Prophylaxis
- Hepatitis B: offer vaccine ± immunoglobulin if not immune.
- Other STIs: screen and treat as indicated.
C. Advice & Counselling
- Avoid unprotected sex until follow-up (GUM clinic) confirms negative status.
- Adherence and side effects of PEP.
- Emotional support, referral to GUM Clinic.
- Safe sex practices.
🔶 5. Closing the Station
Summarise:
- Restate plan clearly.
- Check understanding and concerns.
“So, today we’ll do baseline blood tests, and refer you to the sexual health clinic. We’ll support you through the follow-up process. How does that sound?”
