Introduction: People with HIV are more likely to experience mental health symptoms than those in the general population . Depression, anxiety, post-traumatic stress disorder (PTSD), and cognitive impairment are among the most common disorders. Risk for suicide or violence may be present. Any sudden change in cognitive function, consciousness, or behavior should prompt immediate assessment for delirium caused by an acute medical complication.
The complexity of mental health diagnosis and treatment in the setting of HIV often requires a collaborative approach between primary care and mental health providers. (Mental health providers include psychiatrists, psychologists, clinical social workers, and psychiatric nurse practitioners.)
Screening: For most patients, mental health screening requires approximately 10-20 minutes.
Referral: Refer to a mental health provider when a patient presents with:
- Risk for violence to self or others (see algorithm)
- Psychosis, including delusions, hallucinations, flight of ideas, disordered thinking
- Poor response or relapse of psychiatric symptoms while receiving medication/treatment
- Active substance abuse or relapse to substance use with mental health disorder (Refer to a program for dually diagnosed patients.)
Successful mental health referral involves communication between medical and mental health providers, as well as patient education.
- Bing EG, Burnam MA, Longshore D, et al. Arch Gen Psychiatry 2001;58:721-728.
Depression, Anxiety, and PTSD
Assessment: A brief screening tool, such as the PHQ-2, may be used for routine depression screening. For annual mental health screening, an answer of “yes” to any one of the following questions from the SAMISS questionnaire  should prompt further evaluation by a member of the healthcare team and, if necessary, referral to a mental health provider. For the PHQ-2 and other screening tools, see Mental Health Screening Tools.
Questions to identify depression:
- In the past year, were you ever on medication or antidepressants for depression or nerve problems?
- In the past year, was there ever a time when you felt sad, blue, or depressed for more than 2 weeks in a row?
- In the past year, was there ever a time lasting more than 2 weeks when you lost interest in most things like hobbies, work, or activities that usually give you pleasure?
Questions to identify anxiety:
- In the past year, did you ever have a period lasting more than 1 month when most of the time you felt worried and anxious?
- In the past year, did you have a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy when most people would not be afraid or anxious?
- In the past year, did you ever have a spell or an attack when for no reason your heart suddenly started to race, you felt faint, or you couldn’t catch your breath?
Questions to identify post-traumatic stress disorder (PTSD):
- During your lifetime, as a child, or adult, have you experienced or witnessed traumatic event(s) that involved harm to yourself or to others?
- If “yes”: In the past year, have you been troubled by flashbacks, nightmares, or thoughts of the trauma?
- In the past 3 months, have you experienced any event(s) or received information that was so upsetting it affected how you cope with everyday life?
Question to identify mania:
- In the past year, when not high or intoxicated, did you ever feel extremely energetic or irritable and more talkative than usual?
- Pence BW, et al. Validation of a brief screening instrument for substance abuse and mental illness in HIV-positive patients. J Acquir Immune Defic Syndr 2005;40:434-444.
Questions have been reprinted by permission of Wolters Kluwer Health.
Routine screening: Clinicians should routinely assess kidney function in all HIV-infected patients. A renal assessment should include:
- Glomerular filtration rate estimated from serum creatinine (baseline and at least every 6 months) (AII)
- Blood urea nitrogen (baseline and at least every 6 months) (AIII)
- Urinalysis, total protein, and albumin (baseline and at least annually) (AIII)
- For patients with diabetes and no known proteinuria: calculation of urine albumin-to-creatinine ratio to detect microalbuminuria (baseline and at least annually) (AI)
- For patients receiving a tenofovir-containing regimen, clinicians should estimate glomerular filtration rate at initiation of therapy, 1 month after initiation of therapy, and at least every 4 months thereafter.
Diagnosis and evaluation: All patients with borderline glomerular filtration rate, regardless of age, should undergo the following diagnostic evaluation of kidney function (AII):
- Urinalysis to screen for cells and cellular casts
- Quantification of urinary protein excretion
- Renal sonogram
- Careful physical examination
- Primary care clinicians should refer patients to a nephrologist when (AII):
- The diagnosis is uncertain
- Kidney disease is progressing rapidly
- Stage 4 to 5 chronic kidney disease is present
- Kidney biopsy is being considered
Management: In circumstances when a kidney biopsy is not performed for an HIV-infected patient with kidney dysfunction, because of contraindication, clinician judgment, or patient preference, the following diagnostic criteria for HIV-associated nephropathy are reasonable (BIII): No other explainable cause(s) of kidney disease and proteinuria of >2000 mg and normal to large echogenic kidneys on sonogram and black race
- For patients with empirically diagnosed HIV-associated nephropathy whose kidney disease worsens after initiation of ART, a biopsy should be performed to determine the underlying cause. (AIII)
- Patients with low-grade proteinuria and/or slightly decreased glomerular filtration rate should receive ART if not already receiving it, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and careful monitoring of kidney function.
- Clinicians should consult with a nephrologist when managing patients who are approaching end-stage renal disease due to stage 4 to 5 chronic kidney disease (see the table stages of chronic kidney disease) and require special interventions for hyperparathyroidism, anemia, hemodialysis vascular access, peritoneal dialysis, and/or kidney transplant options. (AII)
- Clinicians should educate patients with HIV-associated nephropathy about the increased urgency of initiating ART. (AII)
- Clinicians should treat hyperglycemia, dyslipidemia, anemia, and hypertension in HIV-infected patients with kidney disease according to standard guidelines for non-HIV-infected patients. (AI)
- HIV-infected normotensive patients with kidney disease should receive angiotensin-converting enzyme inhibitors or angiotensin receptor blockers according to standard guidelines for non-HIV-infected patients. (AI)
- Clinicians should refer HIV-infected patients with kidney disease to a nephrologist when:
- Considering management with steroids, immunosuppression, hemodialysis, or transplantation (AIII)
- A diagnosis of membranoproliferative glomerulonephritis has been made for HIV/HCV co-infected patients (AIII)
Medication adjustments: Clinicians should determine whether dose adjustments are required for certain antiretroviral agents or whether patients should avoid use of certain agents when glomerular filtration rate reaches ≤50 mL/min; see the DHHS guideline, Antiretroviral Dosing Recommendations in Patients with Renal or Hepatic Insufficiency for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, Appendix B. (AIII)
- For patients receiving tenofovir-containing regimens, clinicians should:
- Estimate glomerular filtration rate at initiation of therapy, 1 month after initiation of therapy, and at least every 4 months thereafter (BII)
- Adjust tenofovir dosing when glomerular filtration rate approaches 50 mL/min or discontinue tenofovir according to clinical status (AII)
- Withhold tenofovir until all potential causes have been determined in patients who develop acute renal failure (BII)
- Clinicians should assess for use of nonsteroidal anti-inflammatory drugs in HIV-infected patients with declining renal function. Decisions about the use of such agents for these patients should be individualized and patients should be educated about the importance of using these drugs with caution. (BII)
Sleep and Appetite
Insomnia occurs frequently in HIV-infected patients and during all stages of HIV disease , and weight loss is a strong predictor of HIV disease progression .
- Reid S, Dwyer J. Psychosom Med 2005;67:260-269.
- Colecraft E. Proc Nutr Soc 2008;67:109-113.
Substance Use Screening
A positive screen with any one of the following tools indicates the need for additional evaluation. Many more tools are available. For additional information, see Screening and Ongoing Assessment.
Single Alcohol Screening Question
“How many times in the past year have you had x or more drinks in 1 day?”
Where x = 4 for women and x = 5 for men, and one or more heavy drinking days in the past year is considered a positive screen.
Reprinted from the National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide, 2005.
The Two-Item Conjoint Screen (TICS)
In the last year, have you ever drunk or used drugs more than you meant to?
Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
Where ≥1 positive may be suggestive of a problem.
Reproduced by permission of the American Board of Family Medicine. Brown RL, Leonard T, Saunders LA, et al. A two-item conjoint screen for alcohol and other drug problems. J Am Board Fam Pract 2001;14:95-106. Copyright © 2001, JABFM Online by American Board of Family Medicine.
CAGE-AID (CAGE-Adapted to Include Drugs)
Have you ever felt the need to cut down on your use of alcohol or drugs?
Has anyone annoyed you by criticizing your use of alcohol or drugs?
Have you ever felt guilty because of something you’ve done while drinking or using drugs?
Have you ever taken a drink or used drugs to steady your nerves or get over a hangover (eye-opener)?
Where a total of ≥2 may be suggestive of a problem.
Reproduced by permission of the Wisconsin Medical Society; cited from Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: Criterion validity in primary care practice. Wisconsin Medical Journal 1995;94:135-140.
HIV-Related Triggers of Mental Distress
Clinicians should be aware of triggers that can cause mental distress, such as:
- Learning of HIV status and disclosure to sex partners, family, and friends
- Physical illness, diagnosis of an STI, introduction of ART medications, AIDS diagnosis
- Hospitalization (particularly first hospitalization)
- Life changes (death of a significant other, end of relationship, job loss)
- Necessity of making end-of-life permanency-planning decisions
Elements of Psychosocial Assessment
The following assessment may help determine the need for additional support:
- Stability of housing,* employment, government assistance, and level of education
- Support network and safety:
- Does the patient have contact with family and friends? …Are they aware of the patient’s HIV status?
- Does the patient have a partner?…Is the patient afraid of his/her partner or someone else close?
- Legal issues, including end-of-life arrangements
*Contact information, housing, and support network should be closely monitored for patients with unstable living situations.
Use of full prescribing information, knowledge of drug-drug interactions, and patient education are important components of effective psychopharmacologic treatment. Consultation with a psychiatrist experienced in HIV treatment may be warranted. Consultation for providers in New York State can be obtained at Columbia University HIV Mental Health Training Project: HIV Mental Health Warmline (1-212-543-5413).