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Year 4 I&I 4: HIV & Sexual Health

• Dr Claudia Estcourt
• c.s.estcourt@qmul.ac.uk

Teaching Material for this Module

Introduction

The aims of the HIV and Sexual Health Module are to:

Help students develop a sensitive, non-judgemental attitude to people (patients) regardless of their race, gender and sexual preference and the student’s own personal prejudices.

Equip all graduating doctors to function effectively as a potential Level 1 Provider of sexual health care (National Strategy for Sexual Health and HIV, 2001) as a minimum.

 

Enthuse students to pursue further learning in sexual health, e.g. by additional optional sexual health modules.

 

 

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Index

• General Outcomes for Sexual Health & HIV
• Contraception
• HIV Infection
• Genital Discharge
• Genital Ulcers and Lumps
• Pelvic Pain
• Testicular Pain

• General Outcomes for Sexual Health & HIV
  • Medical knowledge: MICROBIOLOGY and INFECTION (TD 8.9)
    • General Outcomes for HIV and AIDS
      1. Describe factors affecting rates of transmission following exposure to HIV-infected materials
      2. Describe the structure of HIV and name the important constituent structures
    • Sexually Transmitted Infections - General
      1. Understand the pathogenesis, diagnosis and management of Chlamydia trachomatis, Neisseria gonorrhoeae, Candida albicans, Trichomonas Vaginalis, Bacterial Vaginosis and Non-Specific Urethritis
      2. Understand the pathogenesis, diagnosis and management of Herpes Simplex Virus, Syphilis, Lymphogranuloma Venereum,
      3. Understand the pathogenesis, diagnosis and management of Human Papilloma Virus, Molluscum contagiosum and Sarcoptes scabiei
      4. List the major routes of transmission of HIV
    • Sources of Infection and Routes of Transmission
      1. List the major routes of transmission of HIV
  • Medical knowledge: PHARMACOLOGY (TD 8.10)
    • Contraception and HRT
      1. Describe to a patient methods of emergency contraception, indications and guidance for use
      2. Demonstrate basic knowledge of currently available contraceptive methods and be able to communicate to patients the mechanisms of action and failure rate
      3. Manage under supervision or refer as appropriate the contraceptive needs of a patient presenting with a medical condition which may contraindicate the method s/he is currently using
  • Medical knowledge: CLINICAL FEATURES of DISEASE (TD 8 b)
    • HIV Infection
      1. Describe factors affecting rates of transmission following exposure to HIV-infected materials
    • Sexual Assault
      1. Understand the management of male and female victims of sexual assault
      2. To know where to refer patients who have been possible survivors of sexual assault
      3. Identify symptoms and presentations that may indicate that patients have been survivors of sexual assault
      4. Recognise presentations of Domestic Abuse and be able to refer appropriately
      5. Identify and understand Female Genital Mutilation and be able to refer appropriately
      6. Be aware of non-consensual sexual intercourse in male and females and appropriate referral pathways for further management and support
    • General Outcomes for Sexually Transmitted Diseases
      1. Understand the pathogenesis, diagnosis and management of Herpes Simplex Virus, Syphilis, Lymphogranuloma Venereum
      2. Recognise common presentations of patients with psychosexual factors affecting sexual function and / or relationships and know where to refer them.
      3. Understand the pathogenesis, diagnosis and management of Human Papilloma Virus, Molluscum contagiosum and Sarcoptes scabiei
      4. Understand the pathogenesis, diagnosis, management and prevention of the following in the context of HIV: Pneumocystis jiroveci, Cryptococcus neoformans, Candidia albicans, Toxoplasma gondii, Cryptosporidium parvum, Mycobacterium tuberculosis
      5. Understand the pathogenesis, diagnosis and management of Chlamydia trachomatis, Neisseria gonorrhoea, Candida albicans, Trichomonas Vaginalis, Bacterial Vaginosis and Non-Specific Urethritis
      6. Recognise the clinical presentations of primary HIV infection (seroconversion) and describe the management of a suspected case
  • Medical knowledge: PUBLIC HEALTH and GLOBAL HEALTH (TD 11 a-j)
    • HIV/AIDS and Sexually Transmitted Infections
      1. Explain the principles of safe sex and risk reduction, and identify at risk groups
      2. To understand the process when a patient attends a GUM clinic
      3. To identify opportunities for sexual health promotion including opportunities for early diagnosis of HIV in related and unrelated medical contexts
  • Medical knowledge: PSYCHOLOGY (TD 9 a-g)
    • Bio-Psycho-Social Issues
      1. To appreciate the concerns a patient may have attending a GUM clinic and list three ways you might put patients at ease
      2. Describe the stresses and psychological reactions associated with actual or perceived HIV infection, Hepatitis B and C or STDs, and the buffering effects of adaptive coping skills and social support
  • Clinical skills: HISTORY (TD 13 a-b)
    • General
      1. Be able to obtain an appropriate sexual history, to assess risk for sexually transmitted infections and pregnancy and to communicate this risk to individual patients in a sensitive, non-judgemental manner
      2. List the required competencies in The Fraser Ruling
      3. Understand causes of genital warts and difference between low-risk and high-risk HPV types
      4. Understand some of the difficulties patients might have in discussing issues regarding sex, sexuality and sexual practices and problems
      5. Take a brief alcohol and recreational drug history and understand the relevance to high risk sexual behaviours
      6. To understand how to take a sexual history
      7. To gain an appreciation of some of the different types of sexual practices
      8. Take a sexual history with regard to sexual preference, practice, and problems that is respectful of individual lifestyles and sensitive to social and cultural issues
      9. Be able to obtain an appropriate sexual history, to assess risk for sexually transmitted infections and pregnancy and to communicate this risk to individual patients in a sensitive, non-judgmental manner
  • Clinical skills: PHYSICAL EXAMINATION (TD 13 c)
    • Examining the Patient
      1. To know how to examine female and male genitalia and be able to list 3 abnormal findings for each
  • Clinical skills: PLANNING AND INTERPRETING INVESTIGATIONS (TD 14 c-d)
    • Sexual Health Investigations
      1. Be able to explain candida infection and bacterial vaginosis
      2. Understand treatment options for candida and bacterial vaginosis
      3. Describe the range of microbiological/virological tests that are performed at GUM clincis
  • Clinical skills: MAKING A DIAGNOSIS and CLINICAL JUDGEMENT (TD 14 e-f)
    • General Outcomes for Sexual Health Diagnosis
      1. Understand approach to diagnosing genital sores (history and examination)
      2. Understand the pathogenesis, diagnosis and management of Chlamydia trachomatis, Neisseria gonorrhoeae, Candida albicans, Trichomonas Vaginalis, Bacterial Vaginosis and Non-Specific Urethritis
      3. Understand the pathogenesis, diagnosis and management of Herpes Simplex Virus, Syphilis, Lymphogranuloma Venereum,
      4. Understand the pathogenesis, diagnosis and management of Human Papilloma Virus, Molluscum contagiosum and Sarcoptes scabiei
      5. List the diagnostic tests used for genital sores (Dark ground, PCR)
      6. List a differential diagnosis for a male and female patient presenting with genital ulceration, focussing on Herpes Simplex and Syphilis infection
      7. With reference to HIV, Hepatitis B and C and STDs the student should be able to: a) Identify the skills, roles and responsibilities of the health care team; b) To understand that a patient needs to give consent for an HIV test and that pre-test/post-test counselling are no longer performed routinely in order to reduce the stigma associated with HIV.
      8. Recognise the clinical presentations of non-infective genital ulceration (eg Bechet’s disease)
      9. Be able to explain asymptomatic shedding of HSV
      10. Be able to explain incubation periods and transmission
      11. Understand the pathogenesis, diagnosis and management of HIV infection
      12. Explain other aspects of management – e.g. Patient Information, Partner Notification issues, condom use
      13. To have an introduction to Sexually Transmitted Infection (STI) and their treatments
  • Clinical skills: FORMULATING A TREATMENT PLAN (TD 14 g)
    • Management Sexual Health Disorders (Inc. HIV) - General
      1. Understand the management of psychosexual disorders in male and female patients.
      2. List treatment options for genital warts
      3. List treatments for NGU, Chlamydia, Gonorrohea and LGV
      4. With reference to HIV, Hepatitis B and C and STDs the student should be able to: a) Identify the skills, roles and responsibilities of the health care team; b) To understand that a patient needs to give consent for an HIV test and that pre-test/post-test counselling are no longer performed routinely in order to reduce the stigma associated with HIV.
      5. Offer STI & HIV testing as part of genital wart management
      6. Offer STI & HIV testing as part of management
      7. To understand the efficacy, side effects, drug interactions and contraindications of drugs used in the management of STIs
      8. Explain other aspects of management – eg Patient Information, Partner Notification issues, condom use
      9. List treatments for HSV and Syphilis
      10. Offer STI & HIV testing as part of genital sores management
      11. Understand the pathogenesis, diagnosis and management of HIV infection
      12. Explain other aspects of management – eg Patient Information, Partner Notification issues, condom use
      13. To have an introduction to Sexually Transmitted Infection (STI) and their treatments
      14. To appreciate the importance of contact tracing and partner notification
    • Management of general O&G problems
      1. Understand the range of psychological responses to the actual or perceived physical illness and the disease process in relation to the health care experience
  • Clinical skills: SUPPORTING PATIENTS and IDENTIFYING ABUSE and NEGLECT (TD 14 h-i)
    • General Outcomes for Integrated Health
      1. Explain other aspects of management – eg Patient Information, Partner Notification issues, condom use
  • Clinical skills: INTERACTION WITH PATIENTS (TD 15 a-b)
    • Interacting with Patients - General
      1. Be able to obtain an appropriate sexual history, to assess risk for sexually transmitted infections and pregnancy and to communicate this risk to individual patients in a sensitive, non-judgmental manner
  • Clinical skills: PRESCRIBING DRUGS SAFELY AND EFFECTIVELY (TD 17 a-h)
    • Pharmacological Therapy - Sexual Health (General)
      1. To understand the efficacy, side effects, drug interactions and contraindications of drugs used in the management of STIs
      2. Understand the indications for PEPSE
  • Professional issues: WORKING IN TEAMS (TD 22 a-c)
    • Multi-disciplinary Team Work (MDT)
      1. Understand the need for a multi-disciplinary approach to HIV and other infectious diseases encountered in the Immunology and GUM clinics
      2. To understand the multidisciplinary team working in a GUM clinic
  • Professional issues: ETHICS and LAW (TD 20 a-g)
    • Legal, Moral, Ethical Responsibilities of Patient Care
      1. Be aware of Child Protection issues
  • Professional issues: RISK MANAGEMENT and PATIENT SAFETY (TD 23 d)
    • Human Factors
      1. Explain the principles of safe sex and risk reduction, and identify at risk groups
    • Principles of Risk Management
      1. Be able to obtain an appropriate sexual history, to assess risk for sexually transmitted infections and pregnancy and to communicate this risk to individual patients in a sensitive, non-judgmental manner
• Contraception
  • General Outcomes for Contraception
    1. List the reasons for high teenage pregnancy rates or rises in STI prevalence
    2. Be able to obtain a contraceptive and reproductive health history to assess contraceptive need and to discuss contraceptive choices to enable patients to make informed decisions on those choices
    3. Understand and be able to explain the principles of Fraser Competency for under 16s and vulnerable young people and adults
    4. Demonstrate correct condom technique
• HIV Infection
  • General Outcomes for HIV Infection
    1. Describe the spectrum of clinical problems associated with HIV infection: primary HIV infection, asymptomatic HIV infection, persistent generalised lymphadenopathy, symptomatic HIV infection and Acquired Immunodeficiency Syndrome
    2. To understand the basic epidemiology of STIs and HIV and public health issues for control of spread of infection locally and globally
    3. Engage in relevant HIV pre-test discussions to assess relative risk of infection and enable patients to make an informed decision on testing (both in GU setting and outside of GU)
    4. Recognise the significance and list possible causes for the following symptoms in an HIV infected person: Generalised seizures; Loss of consciousness; Focal neurological deficit; Change in affect; Shortness of breath; Rash; Fever
    5. Recognise the major clinical presentations of neurological complications of HIV
    6. Recognise the clinical presentations of primary HIV infection (seroconversion)\and describe the management of a suspected case
    7. Recognise the clinical presentations of primary HIV infection (seroconversion)\and describe the management of a suspected case
    8. Understand the pathogenesis, diagnosis and management of HIV infection
    9. Understand the pathogenesis, diagnosis, management and prevention of the following in the context of HIV: Pneumocystis jiroveci, Cryptococcus neoformans, Candidia albicans, Toxoplasma gondii, Cryptosporidium parvum, Mycobacterium tuberculosis, atypical My
    10. To describe principles of partner notification for STIs and HIV
    11. Understand the concept of opt-out testing and the settings in which opt-out testing are conducted.
    12. Understand the changing significance neurological complications of HIV, in particular, HIV-associated neurocognitive disease
    13. Assess risk of HIV transmission in individual presenting after occupational and non-occupational potential exposure to HIV
    14. Demonstrate knowledge of the CDC classification system for HIV infection
    15. Explain the functions of the various parts of the HIV virus particle
    16. Identify barriers to testing (from patients and healthcare professionals)
    17. Identify neurological clinical presentations that may indicate undiagnosed HIV infection
    18. Correlate the degree of immunosuppression of an individual patient with the likely clinical problems
    19. Describe the genome of HIV with reference to the regulatory proteins produced and their functions.
    20. Describe the tests used in the diagnosis and monitoring of HIV infection including: tests for antibodies to HIV-1 and HIV-2; Tests for the virus itself (viral antigen, viral DNA and RNA, viral subtypes and genetic analysis for resistance mutations); Tests of the immune system (lymphocyte subsets)
    21. Describe available PEP regimens and how best to access these regimen
    22. Understand a range of testing methods
    23. Formulate a plan for the treatment and prevention of neurological disease in HIV
    24. Critically evaluate the utility of individual tests in specific clinical situations including: Diagnosis in chronically infected individual; HIV seroconversion; pregnancy; neonates and children less than 2 years old; patients on antiretroviral therapy
    25. Understand the circumstances in which HIV testing can be performed with out the patient’s consent
    26. Demonstrate the events that occur at a cellular level during acute HIV infection
    27. Describe the management of a person who has sustained a needlestick injury from a known HIV positive source
    28. Be able to explain the events within the immune system which result from HIV infection
    29. Describe the specific immune responses to HIV
    30. Correlate the changes in the immune system at a cellular level with the clinical consequences for the patient with HIV infection
    31. Explain the factors that may confer resistance to HIV
    32. Define the term long-term non progressor
    33. Describe the potential uses of vaccination and immunotherapy in HIV
  • Infections and Disorders Associated with HIV
    1. List the fungi and protozoa that commonly cause clinical disease in the context of HIV infection
    2. Describe the epidemiology and natural history of Hepatitis A, B, C and D
    3. Describe the spectrum of clinical problems associated with HIV infection: primary HIV infection, asymptomatic HIV infection, persistent generalised lymphadenopathy, symptomatic HIV infection and Acquired Immunodeficiency Syndrome
    4. List the bacteria and viruses that commonly cause clinical disease in the context of HIV infection
    5. Understand the effect of co-infection with HIV and Hepatitis B and C on the natural history of HIV and Hepatitis B and C
    6. Recognise the major clinical presentations of: Pneumocystis jiroveci; Cryptococcus; Candidiasis; Toxoplasmosis; Cryptosporidium; Herpes viruses (Herpes Simplex, Herpes Zoster, Cytomegalovirus); Human papilloma virus; Papovavirus; Salmonella; Mycobacteria; Haemophilus; Pneumococcus
    7. Describe the methods of diagnosis and monitoring of Hepatitis B and C infection
    8. Describe the investigation of abnormal liver function tests / hepatomegaly in an HIV-infected individual
    9. Describe the treatment of Hepatitis B and C and how this differs in the context of HIV co-infection
    10. Describe prevention strategies, including vaccination, for Hepatitis A, B and C
    11. Describe the spectrum of renal disease in HIV
    12. Describe the investigation and management of abnormal renal function in an HIV-infected individual
  • Treatment of HIV Infection
    1. Recognise the clinical presentations of primary HIV infection (seroconversion)\and describe the management of a suspected case
    2. Recognise the clinical presentations of primary HIV infection (seroconversion)\and describe the management of a suspected case
    3. To describe the basic principles of anti-HIV therapy, including major side-effects and interactions of therapy
    4. Understand the pathogenesis, diagnosis and management of HIV infection
    5. Describe the management of a person who has sustained a needlestick injury from a known HIV positive source
    6. Describe the different groups of antiretroviral drugs and their mode of action
    7. Explain the rationale for risk assessment and the use of antiretroviral agents for prophylaxis following sexual intercourse with a known or suspected HIV positive person
    8. Describe examples of the most commonly prescribed antiretroviral drugs including major side-effects and interactions of therapy
    9. Demonstrate the life cycle of HIV, with particular reference to the areas that have implications for therapeutic interventions
    10. Describe the principles of diagnosis, management and prevention of opportunistic fungi and protozoa
    11. Describe why adherence to ARVs is important
    12. Describe the principles underpinning the diagnosis, management and prevention of opportunistic bacterial and viral infection in HIV infected patients
    13. Review the specific details of development of ARV resistance
    14. Consider specific difficulties associated with ARVs that have an impact on adherence and resistance including: bioavailability; side-effects (short and long-term); confidentiality; interactions
    15. Formulate a plan for the treatment and prevention of opportunistic bacterial and viral pathogens
    16. Describe how antiretroviral therapy may be used to prevent HIV transmission including: Mother to child transmission; Post-exposure prophylaxis (PEP / PEPSE); Pre-exposure prophylaxis (PrEP); Treatment as Prevention (TAsP) strategies including “test and treat” initiatives in high prevalence settings
    17. Describe the potential uses of vaccination and immunotherapy in HIV
  • Malignancies Associated with HIV Infection
    1. Explain why HIV infection predisposes to certain malignancies
    2. Understand the relationship between HHV8, EBV and HPV in the etiology of malignancy
    3. List the presenting clinical features of Kaposi’s sarcoma, non-Hodgkin’s B cell lymphoma and squamous cell carcinoma in HIV infection
    4. Consider appropriate differential diagnoses for each condition
    5. Discuss potential management strategies for each type of malignancy
• Genital Discharge
  • General Outcomes for Genital Discharge
    1. Understand approach to diagnosing dysuria & discharge (history and examination)
    2. Understand approach to diagnosing vaginal discharge (history and examination)
    3. List the diagnostic tests used (microscopy, culture, urinalysis)
    4. List diagnostic tests used (eg microscopy, culture, NAATs)
    5. List a differential diagnosis patient presenting with urethral or rectal discharge and/or dysuria (including NGU and LGV)
    6. List a differential diagnosis for a female patient presenting with vaginal and/or rectal discharge
    7. Offer STI and HIV testing if appropriate
• Genital Ulcers and Lumps
  • General Outcomes for Genital Ulcers and Lumps
    1. Understand approach to diagnosis of genital lumps (history and examination)
    2. List a differential diagnosis for a male and female patient presenting with genital lumps (including normal anatomical variance)
• Pelvic Pain
  • General Outcomes for Pelvic Pain
    1. Understand approach to diagnosing female pelvic pain (history, examination, pregnancy test)
    2. List the diagnostic tests used (microscopy, culture, urinalysis, pregnancy test)
    3. List differential diagnoses (eg ectopic pregnancy, PID, UTI)
    4. Understand referral pathway for urgent management of ectopic pregnancy
    5. Offer STI & HIV testing as part of management
    6. Explain other aspects of management – eg Patient Information, Partner Notification issues, condom use
• Testicular Pain
  • General Outcomes for Testicular Pain
    1. List a differential diagnosis for a patient presenting with acute or chronic testicular pain
  • Epididymitis
    1. Understand the pathogenesis, diagnosis and management of epididymitis
  • Testicular Torsion
    1. Describe the presenting features and referral pathway for testicular torsion

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