Case 1: HIV Testing as the Gateway to Care: A 28-Year-Old HIV-Seronegative Man at Risk of HIV Exposure
Case 1: HIV Testing as the Gateway to Care: A 28-Year-Old HIV-Seronegative Man at Risk of HIV Exposure
A 28-year-old black man presents to the New York City Department of Health STI clinic in the Bronx. The patient does not have a consistent connection to medical care nor insurance, so he visits city STI clinics to receive sexual health–related services. He almost never visits the doctor unless something is wrong and does not feel comfortable having his family doctor address his main health concerns: HIV infection and other STIs. He has never discussed his sex life with a practitioner outside of his visits to STI clinics. During triage, he notes that he wishes to be tested for HIV infection and other STIs. He denies having any STI symptoms, including dysuria, skin rashes, genital lesions, sore throat, or any rectal STI complaints. While speaking to the triage nurse, he reveals that he engaged in condomless, receptive anal sex 22 hours ago with a man he met online using a smartphone app. He states that they did not discuss their HIV serostatus and that this partner did not report his HIV serostatus nor his “prevention” status (PrEP/treatment as prevention) on the app. Records reviewed at the clinic reveal that this is the patient’s second visit in the last 6 months that is related to an episode of condomless anal sex.
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What is the next appropriate step in managing this patient’s exposure to HIV, given his report of condomless anal sex with men?
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Question 2 of 3
2. Question
The patient starts PEP with dolutegravir plus tenofovir/emtricitabine provided through the STI clinic. A rapid fourth-generation HIV test is conducted and the results are negative. Additionally, a sample of the patient’s blood is sent for pooled HIV NAAT to detect acute HIV infection. Full STI testing is also conducted, including 3-site NAAT for gonorrhea, rectal and urine testing for gonorrhea and chlamydia, testing for syphilis, and testing for hepatitis B and C viruses. Because he is uninsured, the patient decides to complete his full 28 days of PEP and have his follow-up visits at the New York City STI clinic’s nPEP program. Using EtE resources, the clinic provides him access to a complete course of nPEP and conducts the entire battery of initial and follow-up testing necessary to support the use of this regimen.
During this first visit, the patient and his practitioner discuss the possibility of starting PrEP in the future. The patient is hesitant but states that he will consider it. He is provided information about PEP and PrEP from New York City and New York State. The patient is also introduced to social workers and patient navigators in the STI clinic who review his options for insurance with him, and an intake assessment evaluating any social factors in his life that might increase his chance of HIV exposure and infection is completed. He is assigned a patient navigator committed to helping him complete the visits needed for PEP-related care at the STI clinic. Telephone follow-up occurs 7 days after provision of nPEP, and a follow-up visit is scheduled for 2 weeks after initiation of treatment.
Three days after starting nPEP, the clinic receives laboratory test results that indicate the patient has been newly infected with Treponema pallidum (rapid plasma reagin [RPR] score, 1:32; positive for T pallidum protein agglutination), and rectal NAAT results are positive for gonorrhea. The navigator and the clinic physician reach out to the patient to bring him back to the clinic more urgently for further management. The patient was tested for syphilis during his last visit 6 months ago and his RPR test result was nonreactive. The patient returns to the clinic the next day. Evaluation reveals no signs, symptoms, or physical findings of T pallidum infection, including any visual or other neurologic symptoms. His HIV NAAT results are negative for evidence of viremia associated with acute HIV infection.
Clinical Decision Point B
Which is the best antibiotic regimen to treat this patient’s rectal gonorrhea and syphilis?
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Question 3 of 3
3. Question
After the patient is treated for syphilis and gonorrhea, the practitioner at the STI clinic brings up PrEP again. The practitioner and patient discuss the epidemiologic implications of syphilis and rectal gonorrhea for subsequent HIV acquisition.
Clinical Decision Point C
The practitioner wants to give the patient an estimate of his annual risk for HIV infection as a man who has sex with men, given his history of condomless sex with other men and his recent diagnosis of syphilis and rectal gonorrhea. What is the correct estimate of this patient’s annual HIV risk?