Quick Reference Guides
Insomnia Screening and Treatment
Mental Health Guidelines Committee, April 2013
Insomnia occurs frequently in HIV-infected patients and during all stages of HIV disease [Reid et al. 2005]. Although insomnia is not unique to the HIV-infected population, insomnia screening should be part of routine HIV care due to the potentially negative effects of insomnia on health, including HIV disease progression.
What is insomnia? Difficulty falling asleep; frequent awakenings during sleep; early morning awakening; or non-restorative sleep despite adequate sleep duration
Possible causes: 1) Major life events, such as the death of a loved one; 2) Changes in sleeping environment (e.g., when in the hospital); 3) Physical and mental health disorders; 4) Prescription or OTC medication use; 5) Use or relapse of use of alcohol or other substances [Feige et al. 2007; Brower 2003; Mahfoud et al. 2009]
Possible consequences of insomnia: Fatigue, irritability, elevated blood pressure, excessive daytime sleepiness; non-adherence to ART [Ammassari et al. 2001]; increase in pain symptoms and worsening of physical health conditions [Ancoli-Israel 2006]; relapse of psychiatric symptoms (e.g., anxiety, depression, mania).
Sleep assessment evaluation checklist for clinicians: Suggest the patient keep a sleep log, which could include the following:
- Events prior to bedtime, including emotional stressors and the consumption of alcohol or caffeine-containing beverages
- Time spent awake in bed before falling asleep
- Number, time, and length of awakenings
- Final time of morning awakening
- Time spent awake in bed before rising
- Frequency and duration of naps during the day
- Patient or bed partner observations of snoring, interrupted breathing, abnormal leg movements
Substance use etiologies: Caffeine, nicotine, alcohol, illicit drug use (particularly stimulants)
- Alcohol may help induce sleep, but its use is associated with sleep disruptions)
Mental health etiologies (the most common contributor to insomnia is the presence of a mental health disorder ):
- Depression and anxiety disorders
- Severe psychiatric disorders, including mania and psychosis
- Side effects of psychotropic medications, including selective seratonin-reuptake inhibitors (SSRIs)
- Respiratory: dyspnea and sleep apnea
- Gastrointestinal: gastroesophageal reflux
- Endocrinologic: hyperthyroidism, menopause
- Neurologic: cognitive impairment, neuropathy, periodic limb movements in sleep or restless limb syndrome
- Cardiopulmonary: lung disease, congestive heart failure
- Nephrologic/urologic: chronic kidney disease, frequent urination and incontinence
- ART medications (e.g., efavirenz, lamivudine)
- Calcium channel blockers
- Immunomodulators (e.g., interferons, interleukin-2)
- Diuretics taken at bedtime
Sleep Hygiene Strategies
Encourage the following “To Do’s”:
- Take warm baths before bed
- Exercise for at least 30 min/day most days of the week
- Maintain a bedtime routine (e.g., going to bed and waking up at a set time)
- Make bedroom cool, dark, and quiet
- Place the clock out of sight
- If unable to fall asleep after 20 minutes, leave bed and do something relaxing (e.g., reading); return to bed later
Discourage the following “Don’ts”:
- Consuming caffeine (coffee, tea, chocolate, soda), alcohol, or nicotine before bedtime
- Eating a large meal just before bedtime
- Napping during the day
- Exercising within 2 hours of bedtime
- Working, eating, reading, or watching television in bed.
Cognitive behavioral strategies: Referral to a sleep specialist to assist patients with cognitive-behavioral techniques may benefit some individuals with insomnia. Techniques include: cognitive therapy, relaxation training, sleep restriction, and phototherapy.
- Assess for patient use of OTC agents for insomnia and offer to prescribe an FDA-approved agent as a better option (e.g., offer ramelteon instead of OTC melatonin)
- Avoid prescribing medications for sleep disturbance that have narrow therapeutic ranges and potential for abuse (e.g., barbiturates, choral hydrate, and meprobamate)
- Limit to 1 week the use of antihistamines for promoting sleep in order to avoid worsening of symptoms due to long-term use
- Advise patients of the potential side effects of melatonin-agonist therapy, including OTC preparations, particularly severe hypersensitivity reactions
- Do not prescribe tricyclic antidepressants to patients with cardiac conduction problems; although some clinicians prescribe these agents for insomnia, most are not FDA-approved for this purpose
Checklist of questions when selecting a pharmacologic agent for insomnia:
- Will this agent improve symptoms that may be contributing to the patient’s insomnia (e.g., depression, anxiety, neuropathic pain, etc.)?
- Will this agent pose risks to the patient based on comorbid medical conditions?
- Will this agent pose risks based on interactions with other medications, (e.g., zolpidem, zaleplon, and eszopiclone should be used with caution in patients taking protease inhibitors)?
- Is this the optimal agent for a patient with a current or pasthistory of alcohol or sedative abuse/dependence?
- Can the patient afford the prescribed medication?
Agents with an FDA-approved indication for insomnia:
- Antihistamines: Diphenhydramine, doxylamine, hydroxyzine
- Non-benzodiazepine hypnotics: Zolpidem, zolpidem-CR, zaleplon, eszopiclone
- Melatonin agonist: Ramelteon
- Antidepressants: Trazodone, doxepin
- Benzodiazepine hypnotics: Flurazepam, quazepam, estazolam, triazolam, temazepam, lorazepam
Ammassari A, et al. J Acquir Immune Defic Syndr 2001;28:445-449.
Ancoli-Israel S. Am J Manag Care 2006;12(8 Suppl):S221-S229.
Brower KJ. Sleep Med Rev 2003;7:523–539.
Feige B, et al. Alcohol Clin Exp Res 2007;31:19-27.
Mahfoud Y, et al. Psychiatry 2009;6:38-42.
Reid S, et al. Psychosom Med 2005;67:260-269.
HIV Infection in Older Adults
Medical Care Criteria Committee, April 2015
Effective antiretroviral therapy (ART) has prolonged the lifespan of people living with HIV. Non-HIV/AIDS-related conditions now account for most morbidity and mortality among older people with HIV infection. Although ART reduces the effects of HIV disease and chronic inflammation, it does not restore normal immunologic function. The literature describes an aging HIV-infected population (between 50-65 years of age) with high rates of comorbid conditions compared with their non-HIV-infected counterparts. Medical care may be further complicated by neurocognitive decline and high rates of depression, alcohol and substance use, and social isolation. The goals of caring for older people with HIV infection are to minimize illness and frailty, optimize health and well-being, and prolong life.
This reference guide for care of older adults with HIV supplements, but does not replace, standard guidelines for all adults with HIV found on this website.
Initiation of ART in Patients Over 50
To prevent or delay disability, the following assessments are particularly important for older adults with HIV/AIDS:
- Total HIV and non-HIV disease burden and functional status
- Medication adherence, side effects, drug-drug interactions, need for dose adjustments
- Alcohol and substance use, including prescription drugs
- Mental and cognitive status
- Social support
Total Disease Burden and Functional Status
- Disease progression since last visit
- Consultations, specialty care visits, oral health care, ancillary tests, changes in medications
- New symptoms and diagnoses
- Changes in hearing and sight
- Basic and instrumental activities of daily living (ADLs)
- Pain, range of motion, gait
- Need for home care, assisted or congregate living, skilled nursing, or hospice services
- Hygiene: hair, nails, feet
Initiation of ART in Patients Over 50
- Older untreated HIV-infected persons have more rapid disease progression than younger persons [Phillips et al. 2004].
- Immunologic response is less robust in older patients [Gras et al. 2007; COHERE Study Group 2008]; however, patients >50 years of age who initiate therapy with higher CD4 counts are more likely to achieve better immunologic responses [Li et al. 2011].
- Patients who have longstanding HIV infection have increased susceptibility to inflammation-induced diseases and have diminished capacity to fight certain diseases [Fauci 2010].
Polypharmacy significantly increases the chances of serious drug-drug interactions, toxicity, and poor adherence.
- Current medications and adherence
- Potential drug interactions, adverse drug effects, allergies
- Dosing considerations: renal and hepatic function, pharmacokinetic changes with aging
Note: When patients report use of erectile dysfunction medications or products to relieve vaginal dryness, clinicians should use the opportunity to discuss safer-sex practices.
Screening tools: Urine screen; blood panel
Medication list and adherence verification:
- Create/update medication list, including over-the-counter drugs, supplements, and complementary and alternative medications.
- Verify current pharmacy and check prescription pattern and fill dates.
- Ask patients to bring pill bottles to visits, compare with medication list, and perform pill counts.
- Cross-reference information with home health agency or other caregivers.
- Consider use of customized pill cards, pill boxes (for those who can fill them on their own), home delivery, prepackaging of medication, “easy-open” containers.
- Ensure that instructions on medication dosing are appropriately conveyed.
Conditions of aging that may affect adherence:
- Impaired hearing: Perform screening test to determine need for formal testing
- Impaired vision: Perform vision screening every 1-2 years in pts >65; every 1-3 years in pts 55-64; annually for pts with CD4
- Cognitive impairment: Assess cognitive function at baseline and at least annually*
- Polypharmacy (higher pill burden, greater cumulative side effects, medication fatigue): Perform medication review at every visit; discontinue medications that are no longer needed
- Social isolation and lack of support: Assess social support at least annually*
- Depression: Screen for depression at every visit*
- Substance use, including misuse of prescriptions: Screen for substance use at baseline and at least annually
*See next sections for sample screening tools and questions.
Alcohol and Substance Use
Patients >50 years of age are at risk for misuse of prescription drugs. As with all HIV-infected patients, clinicians should screen for alcohol and substance use at baseline and at least annually.
Signs of possible abuse of prescription medications (adapted from the Mayo Clinic):
- Frequent reports of “losing” prescriptions and requests for more to be written
- Seeking prescriptions from more than one doctor
- Taking higher doses than prescribed
- Mood swings
- Change in sleep patterns
- Poor decision-making
Mental Health and Cognitive Status
As with all HIV-infected patients, clinicians should perform a comprehensive mental health screening at baseline and at least annually.
- Depression, anxiety, PTSD
- Psychiatric history
- Cognitive function
- Suicidal/violent ideation
- Sleep habits and appetite
- Psychosocial status
Screening tools for cognitive function and depression are provided.
See Mental Health Screening (Quick Reference Guide) for sample screening tools for all components of the comprehensive mental health screening.
Cognitive Function Screening Tool: International HIV Dementia Scale (IHDS)
Memory-Registration: Give 4 words to recall (dog, hat, bean, red)-1 second to say each. Then ask the patient all 4 words after you have said them. Repeat the words if the patient does not recall them all immediately. Tell the patient you will ask for recall of the words again a bit later.
1. Motor Speed: Have the patient tap the first two fingers of the non-dominant hand as widely and as quickly as possible.
- 4 = 15 in 5 seconds
- 3 = 11-14 in 5 seconds
- 2 = 7-10 in 5 seconds
- 1 = 3-6 in 5 seconds
- 0 = 0-2 in 5 seconds
2. Psychomotor Speed: Have the patient perform the following movements with the non-dominant hand as quickly as possible:
- Clench hand in fist on flat surface.
- Put hand flat on surface with palm down.
- Put perpendicular to flat surface on the side of the 5th digit.
- Demonstrate and have the patient perform twice for practice.
3. Memory Recall: Ask the patient to recall the 4 words. For words not recalled, prompt with a semantic clue as follows: animal (dog); piece of clothing (hat); vegetable (bean); color (red).
Score: Give 1 point for each word spontaneously recalled. Give 0.5 point for each correct answer after prompting. (Maximum: 4 points)
Total Score: This is the sum of the scores on items 1–3. The maximum possible score is 12. Patients with a score of ≤10 should be evaluated further for possible dementia.
Note: Reprinted by permission of Wolters Kluwer Health [Sacktor et al. 2005].
Questions to Identify Depression (PHQ-2)
Over the past 2 weeks, how often have you been bothered by any of the following problems?
- Little interest or pleasure in doing things:
0 = Not at all
1 = Several days
2 = More than half the days
3 = Nearly every day
- Feeling down, depressed, or hopeless:
0 = Not at all
1 = Several days
2 = More than half the days
3 = Nearly every day
Score: A score of 3 or more indicates the need for further evaluation
Note: Reprinted from Kroenke et al. 2003.
Social Support and Daily Care
- Emergency contact information
- Name of case manager, care coordinator, agencies providing services
- Need for interpreter, family conference, advance directives, long-term care, or hospice discussion
- HIPAA consents for communicating with support network
Sample Screening Questions
- Do you do things socially with friends? What do you like to do?
- Is there anyone who could come with you to medical appointments?
- Is there anyone who you would call if you felt really sick?
- Does anyone help you shop, cook, do the laundry, or take care of the house?
Nutrition: How often do you eat? What do you eat for breakfast? Lunch? Dinner?
- What do you do for exercise? How often to do you leave the house?
- Do you ever use a cane, walker, or wheelchair?
- Do you drive? Do you use the subway, buses, or taxis? Can you manage stairs?
- Do you have friends or family members who could help with transportation?
- Have you ever fallen in your home or outside? Do you ever feel that you might?
- Is your telephone always working? Do you have a phone in your bedroom?
- Currently, does anyone hit you, bully you, or yell at you? Do you feel safe in your home and neighborhood?
- Do you manage your own money? Do you think that anyone is stealing from you or taking advantage of you financially?
Communicating with Older Patients
- Use respectful, preferred forms of address
- Engage the patient: maintain eye contact; use frequent, brief, affirmative responses; avoid rushing and interrupting; demonstrate empathy
Compensate for vision and hearing deficits:
- Ensure patients are wearing eyeglasses and/or working hearing aids, if needed
- Speak slowly and clearly; keep hands away from face
- Use large type, visual aids
Create opportunity for discussion of sex:
- Ask whether the patient is sexually active and has any problems to address
- Assess and enhance patient’s knowledge of safer-sex practices
Ensure understanding [NIA 2008]:
- Write down important information
- Avoid jargon, ask if clarification is needed
- Summarize plan and next steps
Discussing long-term care and hospice [Balaban 2000; Casarett et al. 2007]:
- Establish a supportive relationship, acknowledge patient feelings and concerns, and offer reassurance
- Identify and include other decision makers
- Help define expectations based on disease status and prognosis
- Discuss service needs, recommend level of care (home care, assisted living, skilled nursing, hospice), and establish consensus for treatment plan
Balaban RB. A physician’s guide to talking about end-of-life care. J Gen Intern Med 2000;15:195-200.
Casarett DJ, et al. “I’m not ready for hospice”: Strategies for timely and effective hospice discussions. Ann Intern Med 2007;146:443-449.
COHERE Study Group. Response to combination antiretroviral therapy: Variation by age. AIDS2008;22:1463-1473.
Fauci A. NIH statement on National HIV/AIDS and Aging Awareness Day Sept. 18, 2010. 2010 Sep 9. https://www.nih.gov/news-events/news-releases/nih-statement-national-hiv/aids-aging-awareness-day-sept-18-2010 [accessed 2018 Jun 1]
Fried LP, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146-M156.
Gras L, et al. CD4 cell counts of 800 cells/mm3 or greater after 7 years of highly active antiretroviral therapy are feasible in most patients starting with 350 cells/mm3 or greater. J Acquir Immune Defic Syndr 2007;45:183-192.
Justice AC, et al. Predictive accuracy of the Veterans Aging Cohort Study index for mortality with HIV infection: A North American cross cohort analysis. J Acquir Immune Defic Syndr 2013;62:149-163.
Katz S. Assessing self-maintenance: Activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc 1983;31:721-727.
Kroenke K, et al. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care 2003;41:1284-1292.
Lawton MP, et al. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-186.
Li X, et al. CD4+T-cell counts and plasma HIV-1 RNA levels beyond 5 years of highly active antiretroviral therapy. J Acquir Immune Defic Syndr2011;57:421-428.
National Institute on Aging (NIA). A Clinician’s Handbook: Talking With Your Older Patient. 2008. https://order.nia.nih.gov/publication/talking-with-your-older-patient-a-clinicians-handbook [accessed 2018 Jun 6]
Phillips A, et al. Short-term risk of AIDS according to current CD4 cell count and viral load in antiretroviral drug-naïve individuals and those treated in the monotherapy era. AIDS2004;18:51-58.
Sacktor NC, Wong M, Nakasujja N, et al. The International HIV Dementia Scale: A new rapid screening test for HIV dementia. AIDS2005;19:1367-1374.
Mental Health Screening
People with HIV are more likely to experience mental health symptoms than those in the general population [Bing et al. 2001]. 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.
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 [Pence et al. 2005] should prompt further evaluation by a member of the healthcare team and, if necessary, referral to a mental health provider.
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?
Note: 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) (A2)
- Blood urea nitrogen (baseline and at least every 6 months) (A3)
- Urinalysis, total protein, and albumin (baseline and at least annually) (A3)
- For patients with diabetes and no known proteinuria: calculation of urine albumin-to-creatinine ratio to detect microalbuminuria (baseline and at least annually) (A1)
- 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 (A2):
- 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 (A2):
- 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 (B3): 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. (A3)
- 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 NYSDOH AI Kidney Disease Guideline > Diagnosis and Evaluation > Table 1: Stages of Chronic Kidney Disease) and require special interventions for hyperparathyroidism, anemia, hemodialysis vascular access, peritoneal dialysis, and/or kidney transplant options. (A2)
- Clinicians should educate patients with HIV-associated nephropathy about the increased urgency of initiating ART. (A2)
- Clinicians should treat hyperglycemia, dyslipidemia, anemia, and hypertension in HIV-infected patients with kidney disease according to standard guidelines for non-HIV-infected patients. (A1)
- 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. (A1)
- Clinicians should refer HIV-infected patients with kidney disease to a nephrologist when:
- Considering management with steroids, immunosuppression, hemodialysis, or transplantation (A3)
- A diagnosis of membranoproliferative glomerulonephritis has been made for HIV/HCV co-infected patients (A3)
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. (A3)
- 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 (B2)
- Adjust tenofovir dosing when glomerular filtration rate approaches 50 mL/min or discontinue tenofovir according to clinical status (A2)
- Withhold tenofovir until all potential causes have been determined in patients who develop acute renal failure (B2)
- 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. (B2)
Sleep and Appetite
Insomnia occurs frequently in HIV-infected patients and during all stages of HIV disease [Reid and Dwyer 2005], and weight loss is a strong predictor of HIV disease progression [Colecraft 2008].
Additional resource: Insomnia Screening and Treatment (Quick Reference Guide)
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 NYSDOH AI: Screening and Ongoing Assessment Guideline.
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.
Acute Suicidal or Violent Ideation or Behavior
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 Pyschosocial 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).
Bing EG, Burnam MA, Longshore D, et al. Arch Gen Psychiatry 2001;58:721-728.
Colecraft E. Proc Nutr Soc 2008;67:109-113.
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.
Reid S, Dwyer J. Psychosom Med 2005;67:260-269.
Online Resources for Education, Information and Services
AIDSinfo: Training for Health Care Providers
AIDS Education Training Center (AETC):
Centers for Disease Control and Prevention (CDC):
E-patients.net: Salzburg Statement on Shared Decision Making
National Center for Transgender Equality: 2015 U.S. Transgender Survey
New York City DOHMH: Making the Sexual History a Routine Part of Primary Care
New York State Department of Health (NYSDOH):
UCSF: HIV InSite
US Occupational Safety and Health Administration:
US Department of Veterans Affairs:
AIDSinfo (DHHS guidelines): https://aidsinfo.nih.gov/
CDC HIV/AIDS Guidelines and Recommendations: http://www.cdc.gov/hiv/guidelines/
IAS-USA Practice Guidelines: https://www.iasusa.org/guidelines
New York City (NYC) Health: Reporting Diseases and Conditions
US Courts: courtsystem.org
National Institutes of Health (NIH): Clinicaltrials.gov
New York City (NYC) Health: STD and HIV Services, including Clinic Locations and Hours
New York eHealth Collaborative: NYEC
New York State (NYS):
UCSF Clinician Consultation Center
Phone consultation: 800-933-3413 (M-F, 9am-8pm EST)
US Occupational Safety and Health Administration:
AIDSinfo: Drug Database
Antiretroviral Pregnancy Registry: For Health Care Providers
HIV Clinical Resource:
University of Liverpool: HIV Drug Interactions
UCSF HIV InSite: Database of Antiretroviral Drug Interactions
HIV Care Provider Definitions
New York State Department of Health AIDS Institute, April 2017
Experienced HIV care provider: Practitioners who have been accorded HIV-Experienced Provider status by the American Academy of HIV Medicine (AAHIVM) or have met the HIV Medicine Association’s (HIVMA) definition of and experienced provider are eligible for designation as an HIV Experienced Provider in New York State.
Nurse practitioners and licensed midwives who provide clinical care to HIV-Infected individuals in collaboration with a physician may be considered HIV Experienced Providers provided that all other practice agreements are met (8 NYCRR 79-5:1; 10 NYCRR 85.36; 8 NYCRR 139-6900)
Physician assistants who provide clinical care to HIV-infected individuals under the supervision of an HIV Specialist physician may also be considered HIV Experienced Providers (10 NYCRR 94.2)
Expert HIV care provider: A provider with extensive experience in the management of complex patients with HIV.
June 2016 Policy Statement: Defining Program Eligibility by HIV Status
State’s AIDS Institute Issues Clinical Guidance Recommending All HIV-Related Care be Initiated Immediately Upon Diagnosis – OTDA Significantly Expanding Eligibility For Emergency Shelter Allowance
Expanding Preventative Care is a Vital Component of Governor Cuomo’s Unprecedented Commitment to End the AIDS Epidemic in New York
Governor Andrew M. Cuomo today announced all HIV-positive individuals in New York City will become eligible to receive housing, transportation and nutritional support. The significant expansion of eligibility for Emergency Shelter Assistance is a result of a policy issued by the State Department of Health’s AIDS Institute that eliminates the technical distinction between those who are considered in need of care and those who are not. It has long been proven that all individuals who are diagnosed with HIV – whether they show symptoms or do not – benefit from receiving care.
“With today’s compassionate and common sense guidance, we are creating a better future for all New Yorkers living with an HIV positive diagnosis,” Governor Cuomo said. “Our commitment to fighting this disease is unrelenting and guided by our remembrance of those we lost. Every individual living with HIV should have access to life-saving care, regardless of whether or not they are symptomatic of the disease at that moment.” Read more
All FDA-Approved HIV Medications
Updated September 13, 2018
Listed below are all FDA-approved HIV medications as of June 4, 2018, with links to the AIDSinfo drug database. For professionals, the links open the FDA label pages, and for consumers, the links open the AIDSinfo patient information pages. The list is organized by drug class, with individual drugs listed in alphabetical order. Combination drugs are also listed in alphabetical order.
Nucleoside Reverse Transcriptase Inhibitors (NRTIs): characteristics
- Abacavir (ABC; Ziagen): FDA label | Patient info
- Emtricitabine (FTC; Emtriva): FDA label | Patient info
- Lamivudine (3TC; Epivir): FDA label | Patient info
- Tenofovir Disoproxil Fumarate (TDF; Viread): FDA label | Patient info
- Zidovudine (AZT, ZDV; Retrovir): FDA label | Patient info
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): characteristics
- Doravirine (DOR; Pifeltro): FDA label | Patient info
- Efavirenz (EFV; Sustiva): FDA label | Patient info
- Etravirine (ETR; Intelence): FDA label | Patient info
- Nevirapine (NVP; Viramune, Viramune XR [extended release]): FDA label | Patient info
- Rilpivirine (RPV; Edurant): FDA label | Patient info
Protease Inhibitors (PIs): characteristics
- Atazanavir (ATV; Reyataz): FDA label | Patient info
- Darunavir (DRV; Prezista): FDA label | Patient info
- Fosamprenavir (FPV; Lexiva): FDA label | Patient info
- Ritonavir (RTV; Norvir): FDA label | Patient info
- Saquinavir (SQV; Invirase): FDA label | Patient info
- Tipranavir (TPV; Aptivus): FDA label | Patient info
Fusion Inhibitor: characteristics
CCR5 Antagonist: characteristics
Integrase Inhibitors (INSTIs): characteristics
- Dolutegravir (DTG; Tivicay): FDA label | Patient info
- Raltegravir (RAL; Isentress, Isentress HD): FDA label | Patient info
- Abacavir/Lamivudine (ABC/3TC; Epzicom): FDA label | Patient info
- Abacavir/Dolutegravir/Lamivudine (ABC/DTG/3TC; Triumeq): FDA label | Patient info
- Abacavir/Lamivudine/Zidovudine (ABC/3TC/ZDV; Trizivir): FDA label | Patient info
- Atazanavir/Cobicistat (ATV/COBI; Evotaz): FDA label | Patient info
- Bictegravir/Emtricitabine/Tenofovir Alafenamide Fumarate (BIC/FTC/TAF; Biktarvy): FDA label | Patient info
- Darunavir/Cobicistat (DRV/COBI; Prezcobix): FDA label | Patient info
- Darunavir/Cobicistat/Emtricitabine/Tenofovir Alefenamide (DRV/COBI/FTC/TAF; Symtuza): FDA label | Patient info
- Dolutegravir/Rilpivirine (DTG/RPV; Juluca): FDA label | Patient info
- Doravirine/Lamivudine/Tenofovir Disoproxil Fumarate (DOR/3TC/TDF; Delstrigo): FDA label | Patient info
- Efavirenz/Emtricitabine/Tenofovir Disoproxil Fumarate (EFV/FTC/TDF; Atripla): FDA label | Patient info
- Efavirenz/Lamivudine/Tenofovir Disoproxil Fumarate (EFV/3TC/TDF; Symfi, Symfi Lo): FDA label | Patient info
- Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Alafenamide Fumarate (EVG/COBI/FTC/TAF; Genvoya): FDA label | Patient info
- Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Disoproxil Fumarate (EVG/COBI/FTC/TDF; Stribild): FDA label | Patient info
- Emtricitabine/Rilpivirine/Tenofovir Alafenamide Fumarate (FTC/RPV/TAF; Odefsy): FDA label | Patient info
- Emtricitabine/Rilpivirine/Tenofovir Disoproxil Fumarate (FTC/RPV/TDF; Complera): FDA label | Patient info
- Emtricitabine/Tenofovir Alafenamide Fumarate (FTC/TAF; Descovy): FDA label | Patient info
- Emtricitabine/Tenofovir Disoproxil Fumarate (FTC/TDF; Truvada): FDA label | Patient info
- Lamivudine/Tenofovir Disoproxil Fumarate (3TC/TDF; Cimduo): FDA label | Patient info
- Lamivudine/Zidovudine (3TC/ZDV; Combivir): FDA label | Patient info
- Lopinavir/Ritonavir (LPV/r; Kaletra): FDA label | Patient info
ARV Drug Name Abbreviation Key
|Abbreviation||Full Drug Name|
|COBI or c||cobicistat|
|EFV/TDF/FTC||efavirenz/tenofovir disoproxil fumarate/emtricitabine|
|EVG/c/TDF/FTC||elvitegravir/cobicistat/tenofovir disoproxil fumarate/ emtricitabine|
|PI/c||cobicistat-boosted protease inhibitor|
|PI/r||ritonavir-boosted protease inhibitor|
|TDF||tenofovir disoproxil fumarate|
Mental Health Screening Tools
Updated June 2018
BAI (Beck Anxiety Inventory): Patient-administered; 21 items; 5-10 minutes
BDI-II (Beck Depression Inventory-II) [a]: Patient-administered; 21 items; 5 minutes
- The most widely accepted measure of depressive distress.
- Originally developed for use as a measure of symptom severity in psychiatric patients, it has also been used in numerous studies of depression in medically ill patients [Levenson 2005].
BSI 18 (Brief Symptom Inventory 18): Patient-administered; 18 items; 4 minutes
- Screens for depression, anxiety, somatization.
- For patients >18 years old.
CDQ (Client Diagnostic Questionnaire): Trained assistant-administered; 15-20 minutes
- Screens for: depression, anxiety, PTSD, psychosis, alcohol and substance use, general health worries.
CESD-R (Center for Epidemiologic Studies Depression Scale Revised) [a]: Patient-administered; 20 items
- Originally designed for use in non-psychiatric community samples. It may be the most widely used screening instrument in North America.
- It has also been used extensively in medically ill samples, with evidence of good psychometric properties.
- Studies support the value of CES in the medically ill, although the positive predictive value has been relatively low in some studies, and a lack of consensus remains about the optimal cutoff score [Levenson 2005].
DRS-2 (Dementia Rating Scale-2): Patient-administered; 14 items; 15-30 minutes
- Screens for depression, anxiety.
- Specifically designed for use in the medically ill.
- A lack of consensus exists about the utility of the HADS and about the optimal cutoff scores to screen for major and minor depression [Levenson 2005].
HAM-D/HDI (Hamilton Depression Rating Scale): Clinician-administered; 21 items; 15-20 minutes
- Screens for: depression, anxiety, suicidal ideation, insomnia, diminished appetite, weight loss, obsessive compulsive behavior.
- Widely used in psychiatric research.
- High reliability and validity for diagnosing and monitoring clinical depression.
HANDS (Harvard Dept. of Psychiatry, NDSD Scale): Patient or clinician-administered; 10 items
- Screens for depression.
- Other tools available.
IHDS (International HIV Dementia Scale): Clinician-administered; 3 areas (12 points)
- Can be administered by non-neurologists.
- May detect early motor and cognitive slowing [Bing et al. 2001].
Mental Alternation Test: Clinician-administered
- Screens for HIV-associated dementia.
- Patients with early dementia usually will show impairments in timed trials, such as this test [Levenson 2005].
MHDS (Modified HIV Dementia Scale): Clinician-administered; 4 areas (12 points); 5-7 minutes
- Memory-registration, psychomotor speed, memory-recall, constructional.
MMSE (Mini-Mental State Exam): Interviewer-administered; 11 items
- Screens for cognitive status/ability.
- This is the most widely used and tested brief battery for cortical impairment, but has lower sensitivity with signs of subcortical impairment, such as slowing and motor abnormalities.
PHQ-2 (Patient Health Questionnaire-2): Patient- or assistant-administered; 2 items
- Screens for depression
- A PHQ-2 score of 3 or greater was found to have a sensitivity of 83% and specificity of 92% for major depression in a sample of primary care and OB-GYN clinic patients [Levenson 2005].
PHQ-9 (Patient Health Questionnaire-9) [a]: Patient- or assistant-administered; 9 items
- Screens for depression.
- Specifically designed for the primary care setting, it has been studied in thousands of primary care and medical specialty outpatients.
- Spanish version has also been validated [Levenson 2005].
PHQ-15 (Patient Health Questionnaire-15): Patient- or assistant-administered; 15 items
- Somatic symptom severity scale.
- Details symptoms that account for 90% of somatic symptoms encountered in the primary care setting [Levenson 2005].
PRIME-MD (Primary Care Evaluation of Mental Disorders): Patient- or assistant-administered; 3 pages; 5 minutes
- Screens for depression, anxiety, alcohol, eating disorders.
SAMISS (Substance Abuse and Mental Illness Symptoms Screener) [b]: Administered by trained assistant; 13 items
- Designed to detect symptoms of co-occurring substance use and mental health disorders [Whetten et al. 2005].
ZUNG (Zung Self-Rating Depression Scale): Patient-administered; 20 items
- Screens for depression, insomnia, diminished appetite, weight loss, diminished self-esteem, suicidal ideation, anhedonia.
- Any of these instruments (CESD-R, HADS, PHQ-9, BDI-II) may be acceptable to screen for depression in the medically ill, although the evidence for the utility of the HADS is less strong than for the CES and BDI-II. The PHQ has better sensitivity and specificity than the HADS. The cutoff score used on any of these instruments should depend on the purpose of screening and resources for follow up [Levenson 2005].
- For other alcohol- and substance use-related screening tools, see NYSDOH AI: Screening and Ongoing Assessment Guideline.
Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry 2001;58:721-728. [PubMed]
Levenson JL, ed. Textbook of Psychosomatic Medicine. American Psychiatric Publishing Inc; 2005.
Whetten K, Reif S, Swartz M, et al. A brief mental health and substance abuse screener for persons with HIV. AIDS Patient Care STDS 2005;19:89-99. [PubMed]