CASE STUDY:

David

David is a 19-year-old Chinese American. He and his family immigrated to the United States from China when he was 14. Teased in school about his given name, he changed his name to David soon after moving to the United States. He speaks a local Chinese dialect and fluent English with an accent. He lives with his parents, who speak only their local Chinese dialect. Also in the household are his two younger brothers, aged 17 and 15.

David reports having no previous serious illnesses and takes no regular medications. He received all of his immunizations either when he immigrated to the United States or through his doctor while in high school. He was given a skin test for tuberculosis when he was in high school. He doesn't recall whether the result was positive or negative, but he recalls getting an X ray and having to take pills for about 9 months.

About 6 weeks ago, David tested "preliminary HIV positive" at The DL, a community-based organization where free, rapid HIV testing is offered. Following the preliminary positive test result, David returned to The DL clinic where he had blood drawn for a second HIV test, which confirmed that he was infected with HIV.

David was initially upset by the confirmation that he was infected with HIV. He told the counselor that he had convinced himself that the preliminary result was wrong "because Asians don't get HIV." After a couple of weeks, he resigned himself to the diagnosis and reengaged in care to find out what to do next. He met first with the clinic case manager who determined that he was uninsured, but was eligible for the AIDS Drug Assistance Program (ADAP), based on his income. While his application for ADAP is pending, he meets with Dr. Phipps at The DL's HIV primary care clinic.

During the process of documenting his sexual history, David discloses that he uses condoms "about half the time." Dr. Phipps is able to elicit from him that during the previous year he engaged in oral sex and receptive anal intercourse with males. David states that he met "about 20 or 30 men online" during what he calls a "sexual exploration phase" and used drugs with many of these men. However, he claims that he stopped having sex with men several months ago because he is feeling pressure to "get serious" with his Chinese American girlfriend. He says his parents really like her and her family and they are hinting more than usual that it is time he started his own family. He tells Dr. Phipps that they constantly remind him that he is their eldest son and that they would be very proud if he gave them a grandson. David states that he wants to have a son but Dr. Phipps tells him that it would not be a good idea because the risks of his girlfriend and child becoming infected with HIV are too great.

When Dr. Phipps asks whether anyone else knows that he was tested for HIV, he replies, "No, I don't want my situation to be a burden on my family." Moreover, he says that his parents would disown him if they found out how he became infected. He states that they have made homophobic comments in the past such as, "All the perverted homosexuals with AIDS should be killed."

David tells Dr. Phipps that he took the HIV test because he and his girlfriend have had vaginal intercourse without a condom on several occasions. Dr. Phipps asks whether his girlfriend has ever been tested for HIV, and David replies that she has not. When offered a pamphlet on anonymous HIV testing through the health department for his girlfriend, he refuses because he fears that she would immediately suspect that he is HIV infected, as he is the only person she has had sex with. David also tells Dr. Phipps that he is not overly concerned that his girlfriend could be HIV infected because, even though they often did not use condoms, they mostly had anal sex so that she would not become pregnant. Dr. Phipps gives David a flyer on safer sex and other STIs, and tells him to study the information and to try to use condoms every time he has sex.

Following the brief sexual history, Dr. Phipps examines David. A genital examination shows a normal uncircumcised penis, no external lesions suggestive of STIs, and no evidence of hernias or testicular masses. Inspection of the perianal area reveals a couple of raised, verrucous lesions and an old, external hemorrhoid. David reports that he has had those bumps for about a year and that they sometimes get itchy. The remainder of his examination reveals nothing abnormal. David and Dr. Phipps talk about treating the bumps in his anal area and make a plan to do an anal Papanicolaou smear during his next visit. Dr. Phipps recommends a comprehensive panel of blood and urine tests and schedules a follow-up appointment in a couple weeks.

Discussion Questions:

1. What could Dr. Phipps have done to ensure that David has a support system to help him cope with his HIV disease?

• Despite the fact that David believes his family would disown him if they learned that he is infected with HIV, Dr. Phipps should have asked David to think of people in his life who might be supportive if they knew that he was HIV infected. A referral to a mental health professional could help David build a support system so that he can better cope with his disease, take better care of his health, and be more likely to avoid transmitting HIV to others.

2. Given David's situation with his girlfriend, what might have been the best approach for partner notification?

• Dr. Phipps seemed to be in a rush and relied too much on pamphlets from the health department to provide David with options for informing his girlfriend that she may be infected with HIV. A better approach would have been to either coach David so that he could tell his girlfriend alone or offer to meet with David and his girlfriend to deliver the news and offer her HIV testing and support.

3. Were there any signs that David may be misinformed about the risks of HIV transmission via certain sexual activities?

• David's comment that his girlfriend was not at risk because they usually only had unprotected anal sex should have prompted Dr. Phipps to question David more about his sexual activities and his perception of the transmission risks associated with these activities. Again, a pamphlet is no substitute for prevention counseling and it appears that David needs to educated about sexual risk reduction and prevention strategies involving both men and women.

4. How well did Dr. Phipps address David's sexuality?

• David may have stated that his sexual experiences with men were only a phase, but Dr. Phipps should have spent more time with David talking about his sexual identity or made a referral for David to speak to a mental health professional to explore this issue. If David represses parts of his sexuality, it could put him at a higher risk of transmitting HIV to sexual partners of both genders and could put him at greater risk of contracting other STIs.

5. How should Dr. Phipps have answered David's question about parenting?

• Many young adults with HIV want to experience full lives, and for many this includes the joys of parenting. Dr. Phipps should have explained that unprotected vaginal intercourse with his girlfriend would place her at high risk of HIV infection, but that there are technologies available to remove the HIV from his semen and sperm so that she could be artificially inseminated safely. Such a procedure would not only protect her health but also would ensure that their child was born HIV negative.
• If an HIV-infected female patient has the same question, Dr. Phipps should inform her that there are HIV transmission risks associated with carrying a child, but there are extremely effective treatments to prevent a child from becoming infected with a mother's HIV. HIV-infected mothers also should be counseled about healthy feeding choices for their infants, as HIV can be passed through breast milk.