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IM6.1-22 | HIV — Assignment

CLINICAL SCENARIO

This assignment asks you to construct a structured clinical case report for a patient presenting with HIV/AIDS at an ART centre or general medicine ward in an Indian teaching hospital. You will take a complete HIV-focused history, apply CDC and WHO staging, select and interpret the diagnostic workup, construct a prioritised differential diagnosis, and build a comprehensive management plan that integrates NACO ART guidelines, OI prophylaxis, counselling, and the ethical-legal framework of the HIV and AIDS (Prevention and Control) Act 2017. You may base your case on a real patient encountered during clinical postings (with patient details anonymised) or construct a realistic fictional case that reflects an authentic Indian clinical scenario.

Instructions

Write your structured clinical case report in the six sections provided. Use professional clinical language. Anonymise all patient-identifying information. Base your management plan on NACO and WHO 2023-24 guidelines. Do not reproduce SDL text verbatim — integrate the material through your own clinical reasoning. Word limit: 1,400–1,800 words.

Length: 1,400–1,800 words across all sections

What to Submit

Section 1: Clinical Presentation and HIV-Focused History

Guidance: Present your patient (anonymised demographics, presenting complaint). Conduct a structured HIV-focused history: (a) presenting complaint using OLDCARTS; (b) HIV-specific history — date and mode of diagnosis, risk factor history (sexual contacts, IV drug use, transfusion, occupational exposure), STI co-infection history; (c) ART history — current regimen, duration, adherence self-report, side effects; (d) OI history — prior OIs, hospitalisations; (e) nutritional status — weight loss percentage, appetite, dietary intake; (f) social history — disclosure status, support system, employment, stigma. Directed physical examination findings covering at minimum: lymphadenopathy, oral cavity, skin, fundoscopy, neurological screen, and respiratory examination. Apply and state the WHO Clinical Stage and CDC Category with supporting evidence from your history and examination. Approximately 350 words.

Section 2: Investigation Selection and Differential Diagnosis

Guidance: List the investigations you would order, organised as: (a) HIV-specific tests (fourth-generation Ag/Ab assay if newly diagnosing, or confirmatory test results, CD4 count, HIV viral load); (b) OI screening investigations appropriate to the CD4 count (e.g., CrAg if CD4 <100, AFB screen, CMV PCR if CD4 <50); (c) general investigations (FBC, LFTs, RFTs, blood glucose, chest X-ray, urinalysis). For each key result, state what value was found and what it means clinically. Construct a prioritised differential diagnosis (at least 3 diagnoses) for the presenting symptoms, explicitly linking each diagnosis to the CD4 count context. Approximately 300 words.

Section 3: ART and OI Management Plan

Guidance: Present your comprehensive management plan: (a) ART — apply NACO Treat All; specify the first-line regimen (TLD: Tenofovir Disoproxil Fumarate 300 mg + Lamivudine 300 mg + Dolutegravir 50 mg, once daily); address any OI co-treatment sequencing requirements (TB co-infection: start within 2 weeks if CD4 <50, within 8 weeks otherwise; cryptococcal meningitis: defer ART 4-6 weeks); (b) OI treatment — specific drug, dose, and duration for any active OI; (c) OI prophylaxis — co-trimoxazole (dose, indication), CrAg screening if CD4 <100, MAC prophylaxis if CD4 <50; (d) IRIS — acknowledge the risk, state monitoring plan and management approach (continue ART, corticosteroids for severe IRIS); (e) monitoring — viral load and CD4 schedule, toxicity monitoring. Approximately 300 words.

Section 4: Counselling and Communication Plan

Guidance: Describe your structured counselling approach across three areas: (a) Diagnosis disclosure — if newly diagnosed, outline the steps you would take to communicate the result (structured breaking-bad-news approach, using the patient's level of understanding, allowing time for response, avoiding jargon); (b) Adherence counselling — identify the barriers specific to your patient (side effects, forgetfulness, stigma, cost, travel), describe the motivational interviewing technique you would use (open questions, reflective listening, eliciting the patient's own reasons to adhere — not fear-based messaging); and explain the 95% adherence requirement and its link to viral suppression; (c) Prevention counselling — offer partner HIV testing, discuss PrEP for a seronegative partner, address safe sex practices, and use the U=U (Undetectable = Untransmittable) message for a virally suppressed patient. State the follow-up schedule and care cascade plan. Approximately 300 words.

Section 5: Ethical and Legal Dimension

Guidance: Identify one specific ethical or legal challenge that arises in your case — for example: a patient refusing to disclose to their partner; a family member demanding to know the diagnosis without consent; a patient from a marginalised group who has experienced discrimination at a health facility; a healthcare worker needlestick scenario; or a patient wishing to conceive. Apply the relevant provision of the HIV and AIDS (Prevention and Control) Act 2017 to the scenario. State what the law requires, explain how you would approach the scenario while upholding both confidentiality and duty of care, and demonstrate a non-judgmental stance. Approximately 200 words.

Section 6: Reflection

Guidance: Reflect on the complexity of managing HIV beyond prescribing ARTs. What specific aspect of the social, ethical, or structural challenge of HIV care in India has this case brought to your attention that you could not have understood from textbook reading alone? Approximately 150 words.

Grading Rubric — HIV Clinical Case Report and Management Plan Rubric

Criterion	Points	Full-marks descriptor
HIV-Focused History and Clinical Assessment (Section 1): Elicits and presents a complete, structured HIV history including risk factor assessment, transmission route, STI co-infection risks, nutritional status, ART history, and CDC/WHO staging data; examination findings are relevant and systematically recorded.	20 pts	Full HIV history structure present (risk factors, mode of exposure, STI screen, nutritional status, OI history, ART history); CDC and WHO staging applied correctly with supporting data; examination includes all HIV-relevant systems (lymph nodes, oral cavity, skin, fundoscopy, neurology); staging classification is accurate.
Investigation Interpretation and Differential Diagnosis (Section 2): Selects and correctly interprets the diagnostic workup including HIV-specific tests, CD4 count, viral load, OI investigations, and imaging; constructs a prioritised differential diagnosis driven by CD4 count and clinical presentation.	20 pts	Investigation selection justified by clinical need and CD4 threshold; results interpreted accurately (HIV Ag/Ab, CD4, VL, OI-specific investigations); differential diagnosis is CD4-stratified with at least 3 diagnoses prioritised by probability, with supporting clinical reasoning for each.
ART and OI Management Plan (Section 3): Correctly applies NACO Treat All policy; specifies first-line TLD regimen with dose; addresses OI-specific treatment and sequencing (if applicable); includes OI prophylaxis with correct drugs, doses, and CD4 thresholds; documents IRIS risk and management.	25 pts	NACO Treat All correctly applied; first-line regimen stated as TLD with full dose; any OI co-treatment is correctly sequenced (with specific ART timing rules for TB, cryptococcus); OI prophylaxis prescribed with correct drugs (co-trimoxazole, CrAg screen) and CD4 thresholds; IRIS recognised as a risk and management outlined (continue ART, corticosteroids for severe).
Counselling Framework and Communication Plan (Section 4): Documents a structured counselling approach covering diagnosis disclosure, adherence counselling technique, prevention of transmission (PEP/PrEP for partner, safe sex, U=U), partner testing, follow-up plan; demonstrates non-judgmental, rights-based communication aligned with the HIV Act 2017.	20 pts	Disclosure communication structured (SPIKES or equivalent approach); adherence counselling uses motivational interviewing and barrier exploration, not fear-based messaging; prevention counselling includes partner testing offer, PrEP discussion for seronegative partner, safe sex, U=U; HIV Act 2017 confidentiality referenced; follow-up plan specified.
Ethical and Legal Dimensions (Section 5): Applies HIV Act 2017 principles (confidentiality, non-discrimination, consent for testing and disclosure) to a specific ethical scenario arising from the case; demonstrates non-judgmental attitude toward the patient's lifestyle or circumstances.	10 pts	Specific HIV Act 2017 provision cited and correctly applied to the case scenario; ethical analysis is nuanced (balancing patient autonomy and partner protection); non-judgmental stance explicitly demonstrated; correct response to the ethical challenge identified.
Clinical Reflection (Section 6): Reflects on the complexity of HIV care beyond pharmacology — including the social, ethical, and structural factors that influence outcomes in the Indian context.	5 pts	Reflection is specific and credible; identifies at least one concrete insight about the social determinants, stigma, health system barrier, or ethical complexity of HIV care that is not available from textbook reading alone.

PEER REVIEW

Review your peer's HIV case report using the rubric provided. For each section, assign a score and write one specific comment. For Section 1, verify that the CDC category and WHO stage are correctly applied with supporting clinical evidence. For Section 3, check: (a) is the ART regimen stated as TLD with specific doses? (b) Is OI prophylaxis prescribed with the correct drug (co-trimoxazole DS) and CD4 threshold? (c) Is IRIS risk acknowledged? For Section 4, check whether adherence counselling uses motivational interviewing rather than fear-based messaging. For Section 5, confirm the HIV Act 2017 is cited and the specific legal provision is correctly applied. Complete your review within 72 hours and give constructive, actionable feedback for each criterion.