The following is this week's problem based learning exercise.
Copyright © 2013 Dr Sallyann Middleton and A/Prof Brian Chapman, Gippsland Medical School, Monash University.



Alan, a 30-year-old gay man, has engaged in occasional high-risk sexual behaviour throughout the 
last ten years. He has usually worn condoms, but has not always been particularly disciplined about 
this. Alan is currently well and, for the past year, has had a stable relationship with his live-in 
partner, Bill. 

 Relationships have not always gone smoothly for Alan; he has been in and out of several 
emotionally-demanding situations before. Things have not been easy with his family either. Alan 
moved to Melbourne from Tasmania five years ago because of the difficulty his family had found in 
coming to terms with his sexuality. 

 Despite being in a stable relationship at present, Alan is increasingly worried about the possibility of 
having contracted HIV infection in the past. He has at last summoned up the courage to go and see 
his GP, Dr Adam Davies, for advice and possible HIV testing. Alan asks Dr Davies, “How common is 
HIV in Australia? And am I at risk of catching it?”

 Dr Davies undertakes a ‘pre-test discussion’ with Alan and confirms that it would be in his best 
interests to be tested for HIV infection. He also gives advice on safe sex, particularly stressing the 
need to use condoms and the increased risk of infection for a person with multiple sexual partners. 
Alan is concerned about the confidentiality of the test result, and what would be done if he is found 
to be HIV positive. Dr Davies informs Alan that, if the test comes back positive, he is required by law 
to notify the Department of Human Services. Alan is dismayed by this and feels that this 
discriminates against gay men. Dr Davies points out that many individuals with HIV infection are not 
gay, that confidentiality will be maintained, and that HIV infection is only one of a long list of 
notifiable diseases, most of which are not sexually-transmitted. 

 Dr Davies performs a rapid HIV test. After an uncomfortable 20-minute wait, Alan returns for the 
test results. He is understandably apprehensive about what he might hear. Dr Davies asks him to sit
down, then commences to explain that the rapid HIV test is positive. 

 Alan turns pale, but retains his composure. "What now, Doctor?", he asks quietly. Dr Davies explains
that the initial rapid test requires further confirmation. He then goes on to say, “HIV infection is
now a very treatable disease. In some ways it is similar to diabetes, because drug therapy can keep 
you pretty healthy for long periods of time, even though the disease is not curable. Current 
expectations are that many patients with HIV who begin treatment now will live for decades, in 
relatively good health and with a good quality of life. Although the drugs do have some side-effects,
and sometimes the virus can mutate to escape the drugs, it is possible that the drugs will stave off 
AIDS indefinitely. So there is hope.” 

 Dr Davies also makes the important point that individuals diagnosed with the disease who have 
better mental and social health seem to have greater quality of life, and survive much longer with a 
slower progression of the disease. On hearing this, Alan realises that there is a lot he can do for 
himself with the support and encouragement of his health carers and social support network. 

 Dr Davies recommends that Alan should have further tests to measure his CD4 lymphocyte count and 
HIV viral load. He also suggests testing for other STIs. These tests are undertaken and show that 
Alan's CD4 count is normal and his HIV viral load is low; there are no other STIs on testing. Alan asks Dr Davies a number of questions, including, “What does the CD4 lymphocyte do? Why is it 
important? How does the HIV virus cause AIDS? What treatments are available and when do they 
start?” 
Dr Davies then asks about Bill, Alan's live-in partner. Alan admits that Bill has not been tested for 
HIV infection, and that they have not been using condoms. Bill is subsequently tested for HIV, and 
his test is also found to be positive. Dr Davies tells Alan that he should ensure that Bill gets his CD4 
and viral load tests done as well. 

 Eight years later, Alan has been coping reasonably well. He has taken advantage of a number of the 
services provided by the Victorian AIDS Council. Bill, on the other hand, was compliant with his 
therapy for a few years, then became less vigilant about his medication. Despite Alan’s best efforts 
to persuade him otherwise, Bill has stopped seeing his doctor for follow-up, is non-compliant with his
medication, and has now developed a cough which will not go away. 
Bill returns to see Dr Davies because of the persistent cough. Dr Davies notices that Bill looks sad 
and worried, and has lost a lot of weight. On examination, Bill is emaciated and has white patches 
inside his mouth and on his oropharynx. Dr Davies orders a CD4 lymphocyte count and a chest X-ray. 

 The blood test result shows that Bill has a CD4 lymphocyte count of 50 per microlitre, while the chest
X-ray shows diffuse opacities. Bill experiences severe side-effects from the medication, and is very 
worried that he is not responding to the treatment. Bill is looking despondent, and Alan is sure that
Bill is suffering from depression. 
H.