Negative test results
The decision on how a negative HIV test result is provided (e.g. in person, by phone, etc.) should be based on clinical judgement. It is essential to check the type of HIV test used and consequently the window period before HIV can be detected (noting a default window period of three months may be used as that is the maximum window period among tests used in Australia).
Post-test discussion following an HIV-negative test result should include reinforcement of education and information messages about safe behaviours, and discussion of any difficulties or issues that the person may have in practising safe behaviours. The relief associated with receiving a negative test result may impede the processing of information and advice at that time. It should be emphasised that a negative test result following a risk event does not indicate that repeated risky behaviour is likely to be safe.
Positive test results
A positive result should always be provided in person except in extenuating circumstances (e.g. the possibility that the patient may not return for the result and/or may engage in risk behaviour based on the incorrect assumption they are HIV negative). It is important to state the HIV test result very clearly to avoid a patient confusing a 'positive result' with a ‘good’ result.
When conveying an HIV-positive result, post-test discussion should include:
- giving the test result in person and in a manner that is sensitive and appropriate to the gender, culture, behaviour and language of the patient
- providing information about and considering support mechanisms, including immediate referral to a support agency
- probable disease progression, discussion of ‘next steps’ including staging and treatment options
- how HIV is transmitted and strategies to prevent onward transmission whether a subsequent consultation is necessary to cover all issues
- legal obligations, including those relating to disclosure which are affected by the state/territory in which diagnosis is made/ where the person is living (see Safe Behaviours and Disclosure)
- contact tracing and partner notification strategies
Patients who do not return for a positive test result may put others at risk if they do not know their HIV status. All efforts should be made to contact these individuals as soon as possible by phone or in writing, asking them to make contact. Public health units can provide contact tracing assistance. Medical practitioners who fail to deliver adverse test results may be held liable (see, for example, the case of Kite v Malycha on the HIV Testing page).
Summary of post-test discussion: giving a positive result
First post-test consultation
- Establish rapport and assess readiness for the result
- Give positive test result
- Avoid information overload
- Listen and respond to needs (the patient may be overwhelmed and hear little after being told the positive result)
- Discuss immediate implications
- Review immediate plans and support
- Reassess support requirements and available services
- Arrange other tests and the next appointment
- Begin contact tracing process and discuss options available to facilitate the process.
- Treatment options, diet and exercise
- Effect of diagnosis on relationships and prevention information
- Issues of disclosure
- Assessment of contact tracing process and difficulties encountered
- Access to life insurance may be affected
- Workplace implications
- Impact of other issues (e.g. drug use, poverty, homelessness) on ability to access health care and treatments
- Referral for ongoing counselling, social worker, medical specialist as appropriate.
From: Talking about testing: pre-test and post-test discussion, in: HIV, viral hepatitis and STIs: a guide for primary care (ASHM 2008)
In the case of PD, doctors were deemed to have failed their duty of care by not checking that the patient had attended post-test counselling either following initial referral or after the clinic notified they had no record of the patient attending. In a number of instances, doctor-patient discussions during pre-test, post-test and subsequent discussions have been key evidence in criminal prosecutions of individuals accused of putting others at risk of HIV infection (see case summary, Duty of Care to Third Parties and Civil Liability). Care in content and consistency of record keeping is important.
Communicating bad news
Before communicating bad news, the environment and length of consultation require additional consideration, as does the patient’s preference for having a person of his or her choice present. In some circumstances, it may be necessary to suggest immediate or early access to additional counselling and support services. A prompt follow-up consultation may be helpful when a condition is diagnosed that is likely to involve hospitalisation, sustained treatment and lifestyle change, or risk of permanent impairment or death. This will give the patient an opportunity to absorb the information, and to think of questions he or she may wish to ask.
From: Communicating with Patients: Advice for Medical Practitioners (Australian Government: National Health and Medical Research Council 2, 2004)
1Australian Government. Department of Health and Ageing: 2011 National HIV Testing Policy. Available at http://testingportal.ashm.org.au/hiv (last accessed November 2012).
2Australian Government: National Health and Medical Research Council (NHMRC) Communicating with Patients: Advice for Medical Practitioners. Australia. Canberra: Commonwealth of Australia; 2004. Available at:http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/e58.pdf (last accessed November 2012).