Year 4 I&I 4: HIV & Sexual Health

Intro to Sexual Health and HIV

Lecture: Epidemiology STI's & HIV

1. To understand the basic epidemiology of STIs and HIV and public health issues for control of spread of infection locally and globally
2. To describe principles of partner notification for STIs and HIV

Lecture: Sexual History

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. 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. Take a brief alcohol and recreational drug history and understand the relevance to high risk sexual behaviours

Lecture: HIV Natural History & Diagnosis

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. Demonstrate knowledge of the CDC classification system for HIV infection
3. Correlate the degree of immunosuppression of an individual patient with the likely clinical problems
4. 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)
5. 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

Lecture: Opportunistic Infections and Malignancies in HIV

1. List the fungi and protozoa that commonly cause clinical disease in the context of HIV infection
2. List the bacteria and viruses that commonly cause clinical disease in the context of HIV infection
3. 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
4. Describe the principles of diagnosis, management and prevention of opportunistic fungi and protozoa
5. Describe the principles underpinning the diagnosis, management and prevention of opportunistic bacterial and viral infection in HIV infected patients
6. Formulate a plan for the treatment and prevention of opportunistic bacterial and viral pathogens
7. Explain why HIV infection predisposes to certain malignancies
8. Understand the relationship between HHV8, EBV and HPV in the etiology of malignancy
9. List the presenting clinical features of Kaposi’s sarcoma, non-Hodgkin’s B cell lymphoma and squamous cell carcinoma in HIV infection
10. Consider appropriate differential diagnoses for each condition
11. Discuss potential management strategies for each type of malignancy

Lecture: Genital 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)
3. Understand causes of genital warts and difference between low-risk and high-risk HPV types
4. List treatment options for genital warts
5. Offer STI & HIV testing as part of genital wart management
6. Be able to explain incubation periods and transmission
7. Explain other aspects of management – e.g. Patient Information, Partner Notification issues, condom use

Lecture: Genital Sores

1. Understand approach to diagnosing genital sores (history and examination)
2. List the diagnostic tests used for genital sores (Dark ground, PCR)
3. List a differential diagnosis for a male and female patient presenting with genital ulceration, focussing on Herpes Simplex and Syphilis infection
4. Recognise the clinical presentations of non-infective genital ulceration (eg Bechet’s disease)
5. Be able to explain asymptomatic shedding of HSV
6. List treatments for HSV and Syphilis
7. Offer STI & HIV testing as part of genital sores management
8. Explain other aspects of management – eg Patient Information, Partner Notification issues, condom use

Lecture: Vaginal Discharge

1. Understand approach to diagnosing vaginal discharge (history and examination)
2. List diagnostic tests used (eg microscopy, culture, NAATs)
3. List a differential diagnosis for a female patient presenting with vaginal and/or rectal discharge
4. Be able to explain candida infection and bacterial vaginosis
5. Understand treatment options for candida and bacterial vaginosis
6. Offer STI and HIV testing if appropriate

Lecture: Psychological aspect of HIV

1. Understand the need for a multi-disciplinary approach to HIV and other infectious diseases encountered in the Immunology and GUM clinics
2. Understand the range of psychological responses to the actual or perceived physical illness and the disease process in relation to the health care experience
3. Understand some of the difficulties patients might have in discussing issues regarding sex, sexuality and sexual practices and problems
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. 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
6. 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

Lecture: Unprotected Sexual Intercourse

1. List the required competencies in The Fraser Ruling
2. Be aware of Child Protection issues
3. Describe to a patient methods of emergency contraception, indications and guidance for use
4. Demonstrate basic knowledge of currently available contraceptive methods and be able to communicate to patients the mechanisms of action and failure rate
5. 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
6. Be aware of non-consensual sexual intercourse in male and females and appropriate referral pathways for further management and support

Lecture: Rape and 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

Lecture: Sexual Dysfunction

1. Understand the management of psychosexual disorders in male and female patients.
2. Recognise common presentations of patients with psychosexual factors affecting sexual function and / or relationships and know where to refer them.
3. List a differential diagnosis for a patient presenting with acute or chronic testicular pain
4. Understand the pathogenesis, diagnosis and management of epididymitis
5. Describe the presenting features and referral pathway for testicular torsion
6. Offer STI and HIV testing as part of management for male pelvic pain
7. Explain other aspects of management – eg Patient Information, Partner Notification issues, condom use

Workshop: Male Dysuria & Discharge

1. Understand approach to diagnosing dysuria & discharge (history and examination)
2. List the diagnostic tests used (microscopy, culture, urinalysis)
3. List a differential diagnosis patient presenting with urethral or rectal discharge and/or dysuria (including NGU and LGV)
4. List treatments for NGU, Chlamydia, Gonorrohea and LGV
5. Offer STI & HIV testing as part of management
6. Explain other aspects of management – eg Patient Information, Partner Notification issues, condom use

Lecture: Antiretroviral Therapy

1. To describe the basic principles of anti-HIV therapy, including major side-effects and interactions of therapy
2. Describe the different groups of antiretroviral drugs and their mode of action
3. Describe examples of the most commonly prescribed antiretroviral drugs including major side-effects and interactions of therapy
4. Describe why adherence to ARVs is important
5. Review the specific details of development of ARV resistance
6. Consider specific difficulties associated with ARVs that have an impact on adherence and resistance including: bioavailability; side-effects (short and long-term); confidentiality; interactions
7. 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

Workshop: 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

Lecture: HIV Testing

1. 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)
2. Understand the concept of opt-out testing and the settings in which opt-out testing are conducted.
3. Identify barriers to testing (from patients and healthcare professionals)
4. Understand a range of testing methods
5. Understand the circumstances in which HIV testing can be performed with out the patient’s consent
6. Describe the management of a person who has sustained a needlestick injury from a known HIV positive source

Lecture: Neurological Complications of HIV

1. Recognise the major clinical presentations of neurological complications of HIV
2. Understand the changing significance neurological complications of HIV, in particular, HIV-associated neurocognitive disease
3. Identify neurological clinical presentations that may indicate undiagnosed HIV infection
4. Formulate a plan for the treatment and prevention of neurological disease in HIV

Workshop : What Happens when a patient attends a GUM clinic & investigations

1. To appreciate the concerns a patient may have attending a GUM clinic and list three ways you might put patients at ease
2. To understand the process when a patient attends a GUM clinic
3. To understand the multidisciplinary team working in a GUM clinic
4. To understand how to take a sexual history
5. To gain an appreciation of some of the different types of sexual practices
6. To know how to examine female and male genitalia and be able to list 3 abnormal findings for each
7. Describe the range of microbiological/virological tests that are performed at GUM clincis
8. To have an introduction to Sexually Transmitted Infection (STI) and their treatments
9. To appreciate the importance of contact tracing and partner notification
10. To identify opportunities for sexual health promotion including opportunities for early diagnosis of HIV in related and unrelated medical contexts
11. 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

Lecture: HIV Emergencies

1. 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
2. Describe the management of a person who has sustained a needlestick injury from a known HIV positive source
3. 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

Lecture: Hepatitis Co-infections & Renal Complications of HIV

1. Describe the epidemiology and natural history of Hepatitis A, B, C and D
2. Understand the effect of co-infection with HIV and Hepatitis B and C on the natural history of HIV and Hepatitis B and C
3. Describe the methods of diagnosis and monitoring of Hepatitis B and C infection
4. Describe the investigation of abnormal liver function tests / hepatomegaly in an HIV-infected individual
5. Describe the treatment of Hepatitis B and C and how this differs in the context of HIV co-infection
6. Describe prevention strategies, including vaccination, for Hepatitis A, B and C
7. Describe the spectrum of renal disease in HIV
8. Describe the investigation and management of abnormal renal function in an HIV-infected individual

Lecture: Post Exposure Prophylaxis in HIV

1. Describe factors affecting rates of transmission following exposure to HIV-infected materials
2. Assess risk of HIV transmission in individual presenting after occupational and non-occupational potential exposure to HIV
3. Understand the indications for PEPSE
4. Describe available PEP regimens and how best to access these regimen

Lecture: Patient Perspective

Formative Assessment : Sexual Health & HIV Course Assesment

Lecture: HIV Basic Science and Immunology

1. Describe the structure of HIV and name the important constituent structures
2. Explain the functions of the various parts of the HIV virus particle
3. Describe the genome of HIV with reference to the regulatory proteins produced and their functions.
4. Demonstrate the life cycle of HIV, with particular reference to the areas that have implications for therapeutic interventions
5. List the major routes of transmission of HIV
6. Demonstrate the events that occur at a cellular level during acute HIV infection
7. Be able to explain the events within the immune system which result from HIV infection
8. Describe the specific immune responses to HIV
9. Correlate the changes in the immune system at a cellular level with the clinical consequences for the patient with HIV infection
10. Explain the factors that may confer resistance to HIV
11. Define the term long-term non progressor
12. Describe the potential uses of vaccination and immunotherapy in HIV

Workshop: Role-play - Explaining Results, PN & Treatments

1. Understand the pathogenesis, diagnosis and management of Herpes Simplex Virus, Syphilis, Lymphogranuloma Venereum,
2. Understand the pathogenesis, diagnosis and management of Human Papilloma Virus, Molluscum contagiosum and Sarcoptes scabiei
3. 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
4. Understand the pathogenesis, diagnosis and management of Chlamydia trachomatis, Neisseria gonorrhoeae, Candida albicans, Trichomonas Vaginalis, Bacterial Vaginosis and Non-Specific Urethritis
5. To understand the efficacy, side effects, drug interactions and contraindications of drugs used in the management of STIs
6. Recognise the clinical presentations of primary HIV infection (seroconversion)\and describe the management of a suspected case
7. Understand the pathogenesis, diagnosis and management of HIV infection
8. Recognise the clinical presentations of primary HIV infection (seroconversion)\and describe the management of a suspected case

Lecture: Partner Notification, Results & Treatment

1. Understand the pathogenesis, diagnosis and management of Herpes Simplex Virus, Syphilis, Lymphogranuloma Venereum
2. Understand the pathogenesis, diagnosis and management of Human Papilloma Virus, Molluscum contagiosum and Sarcoptes scabiei
3. 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
4. Understand the pathogenesis, diagnosis and management of Chlamydia trachomatis, Neisseria gonorrhoea, Candida albicans, Trichomonas Vaginalis, Bacterial Vaginosis and Non-Specific Urethritis
5. To understand the efficacy, side effects, drug interactions and contraindications of drugs used in the management of STIs
6. Recognise the clinical presentations of primary HIV infection (seroconversion) and describe the management of a suspected case
7. Understand the pathogenesis, diagnosis and management of HIV infection