# Situation: A 27-year-old man comes to the social hygiene clinic of a city health office with a painless ulcer on his penis for 1 week and a purulent urethral discharge for 3 days. His rapid plasma reagin (RPR) and treponemal tests are both reactive, and a urethral swab is positive for Neisseria gonorrhoeae. He has one regular female partner and no drug allergies. He asks why the nurse is also offering him a human immunodeficiency virus (HIV) test. Which explanation is accurate?

> source: MyMerci (mymerci.kr)  
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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 27-year-old man comes to the social hygiene clinic of a city health office with a painless ulcer on his penis for 1 week and a purulent urethral discharge for 3 days. His rapid plasma reagin (RPR) and treponemal tests are both reactive, and a urethral swab is positive for Neisseria gonorrhoeae. He has one regular female partner and no drug allergies.

He asks why the nurse is also offering him a human immunodeficiency virus (HIV) test. Which explanation is accurate?

## 보기

1. These infections raise his risk of catching and passing on the virus **✔ 정답**
2. The virus causes the same kind of painless ulcer that syphilis does
3. The test is required by law for everyone treated for these infections
4. The penicillin he received also protects him against the virus

**정답: 1**

## 해설

All sexually transmitted infections increase the risk of acquiring and transmitting HIV, and they share the same routes and risk behaviors. For this reason, anyone with a sexually transmitted infection is offered testing for HIV, syphilis, and hepatitis B. HIV testing remains voluntary under the Philippine HIV and AIDS Policy Act.

## 심화 해설

Clinical context

This client has two confirmed sexually transmitted infections at once: early syphilis, shown by the painless genital ulcer with reactive rapid plasma reagin and treponemal tests, and gonococcal urethritis, shown by the purulent discharge and a urethral swab positive for Neisseria gonorrhoeae. The nurse is not treating these infections in isolation. Because STIs cluster in the same person and signal the same exposure route, HIV testing is offered as part of comprehensive STI care.

Why option 1 is correct

Sexually transmitted infections increase both the likelihood of acquiring HIV and the likelihood of transmitting it to a partner. The reason is both biological and behavioral. On the biological side, genital ulcers from syphilis break the epithelial barrier, creating a portal of entry for HIV. Gonococcal urethritis draws CD4-positive lymphocytes and macrophages to the inflamed mucosa, and these are exactly the cells HIV needs to establish infection. On the behavioral side, the same unprotected sexual exposure that led to syphilis and gonorrhea can also transmit HIV, so the presence of one STI identifies a person whose risk behaviors overlap with HIV exposure [1].

Key point! The offer of an HIV test is not based on symptoms of HIV. It is based on the shared transmission route and the increased biological vulnerability created by the existing STIs.

Why the other options are incorrect

| Option | Why it is wrong |
| --- | --- |
| 2. HIV causes the same painless ulcer as syphilis | HIV does not cause a chancre. The painless genital ulcer is the primary lesion of syphilis. HIV may cause nonspecific symptoms or none at all in early infection. |
| 3. HIV testing is required by law for everyone treated for these infections | HIV testing is voluntary. Under the Philippine HIV and AIDS Policy Act, testing requires informed consent and cannot be forced simply because a person has another STI. |
| 4. Penicillin also protects against HIV | Penicillin treats syphilis and, in some regimens, gonorrhea, but it has no antiviral activity against HIV. Antibiotics do not prevent or treat viral infections. |

Clinical reasoning and nursing implication

The presence of one STI should prompt screening for other STIs, including HIV, syphilis, and hepatitis B, because coinfections are frequent when the transmission route is the same. Coinfections are not merely additive; they can present with more severe or atypical features, lead to more complications, and respond less predictably to treatment [1]. In a cohort of persons in HIV care, incident syphilis, gonorrhea, and chlamydia remained common, reinforcing that STIs and HIV continue to travel together in the same sexual networks . Among HIV-infected women, concomitant STIs are also a recognized concern, and among men who have sex with men, STI-HIV co-infection is associated with identifiable risk factors that overlap with the behaviors that led to the index STI .

For this client, the nurse should explain that the HIV test is being offered because the syphilis and gonorrhea infections show he has been exposed through a route that can also carry HIV, and because the genital inflammation and ulceration make acquisition and transmission of HIV more efficient. The test remains his choice. Watch out! A reactive rapid plasma reagin with a reactive treponemal test confirms syphilis, but it says nothing about HIV status. Only an HIV test can answer that question, and it requires separate consent.References (research sources)

- [1][Sexually transmitted coinfections. HIV coinfections].Research articleMarschalkó M, Pónyai K, Kárpáti S (2015) · DOI: 10.1556/OH.2015.30076

## 임상 시나리오

HIV Testing in STI CareWhy STIs Prompt an HIV Offer
Existing STIs increase both acquisition and transmission risk of HIV. Genital ulcers from syphilis disrupt the epithelial barrier, while gonococcal urethritis recruits CD4 cells that HIV targets.

The same unprotected exposure that caused syphilis and gonorrhea can also transmit HIV, so STI diagnosis identifies overlapping risk behavior.

CautionHIV testing remains voluntary under the Philippine HIV and AIDS Policy Act. Offer testing with consent; do not imply it is legally required.

## 핵심 개념

- **STI-HIV synergy** — STIs increase biological susceptibility to HIV through mucosal inflammation or ulceration and identify shared behavioral risk.
- **RPR** — Rapid plasma reagin, a non-treponemal serologic test used to screen for syphilis.
- **Treponemal test** — Specific serologic test confirming infection with Treponema pallidum, the causative agent of syphilis.
- **Neisseria gonorrhoeae** — Gram-negative diplococcus causing gonococcal urethritis, often presenting with purulent discharge.
- **Voluntary HIV testing** — HIV testing requires informed consent and cannot be mandated solely based on STI diagnosis.

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