Ms. G, 44, was a nurse practitioner at an urban, family-practice clinic. One evening, 23-year-old Mr. J came in complaining of a recalcitrant oral ulcer and a history of genital warts. Ms. G referred him to an oral surgeon for the ulcer and ordered a rapid plasma reagin test for syphilis, which was negative.

A month later, Mr. J returned. This time, he complained of wooziness, a sore on his penis, and penile discharge. Ms. G ordered a complete screening for sexually transmitted diseases (STDs), including HIV. When the results came back, Ms. G noted that three tests had been conducted: an enzyme-linked immunosorbent assay (ELISA), a Western blot analysis, and a recombinant DNA (rDNA) test.

The ELISA had been performed twice and was positive for HIV both times. However, the Western blot was indeterminate, and the lab noted a follow-up would be required in six months.

Ms. G was not familiar with rDNA, but she noted those results were negative.

Ms. G then summoned Mr. J to the clinic to break the news that he was HIV-positive. She ordered baseline tests to assess his general health, told him to restrict his sexual activity, and asked him to return for follow-up in three weeks and then quarterly. Her chart notations indicated that Mr. J seemed quiet and calm.

At his next appointment three weeks later, Mr. J’s CD4 count was 955 (normal = 500-1,500 cells/µL). Ms. G noted that she would refer him to an infectious disease specialist if the count dropped below 500 or his physical condition began to deteriorate.

Over the next year, Mr. J returned three times. In each case, his CD4 count was in the 900 range. But about a year after his diagnosis, the count dropped to 344. At that point, Ms. G referred him to Dr. P, an infectious disease specialist who scheduled an appointment within a few weeks.