Resources for Care Providers

Resources for Care Providers

Insomnia Screening and Treatment

Mental Health Guidelines Committee, April 2013

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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).

RECOMMENDATIONS
  • Clinicians should ask patients at routine monitoring visits about sleep quality and difficulty initiating or maintaining sleep.
  • When an HIV-infected patient reports insomnia, primary care clinicians should:
    • Assess the patient’s sleep patterns, as well as perform a differential diagnosis, to clarify the nature of the patient’s insomnia
    • Exclude and manage causes of secondary insomnia
    • When possible, refer the patient at least once for evaluation by a psychiatrist or clinical psychologist
    • Discuss sleep hygiene with the patient and consider nonpharmacologic approaches for treating insomnia before prescribing medications
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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

Differential Diagnosis

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 [7]):

  • Depression and anxiety disorders
  • Severe psychiatric disorders, including mania and psychosis
  • Side effects of psychotropic medications, including selective seratonin-reuptake inhibitors (SSRIs)

Medical conditions:

  • Pain
  • 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

Medications:

  • ART medications (e.g., efavirenz, lamivudine)
  • β-blockers
  • Bronchodilators
  • Calcium channel blockers
  • Corticosteroids
  • Decongestants
  • Immunomodulators (e.g., interferons, interleukin-2)
  • Trimethoprim-sulfa
  • Dapsone
  • Amphotericin
  • Fluconazole
  • Isoniazid
  • 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.

Pharmacologic strategies: 

  • 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
References

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

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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.

RECOMMENDATIONS
Initiation of ART in Patients Over 50
  • All patients, regardless of CD4 count, should be evaluated for ART. Patients >50 years of age are a high-risk group for whom initiation of ART is particularly urgent.
Polypharmacy
  • Perform medication review at every visit
  • Discontinue medications that are no longer needed
  • Encourage patients to use one pharmacy
  • Consider obtaining a dispensing history from the pharmacy
KEY POINTS
  • People with HIV may develop chronic diseases associated with aging earlier in life, resulting in the development of multiple comorbid conditions.
  • Aging can compound the immunological impact of HIV and accelerate HIV disease progression.
  • Older people with HIV are at particular risk for polypharmacy, which increases the risk of drug-drug interactions and adverse events; it also can negatively affect cognitive function and quality of life.

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
RESOURCES

Total Disease Burden and Functional Status

Assess:

  • 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
  • Frailty
  • Need for home care, assisted or congregate living, skilled nursing, or hospice services
  • Hygiene: hair, nails, feet
SCREENING TOOLS
  • Osteoporosis: Bone density, vitamin D
  • Cardiovascular disease risk: Framingham risk score assessment, lipid profile including total cholesterol, HDL, LDL, and triglycerides (at least annually, repeat before initiating ART, and within 4 to 8 months after initiating)
  • Activities of daily living [Katz 1983; Lawton et al. 1969]: Ask patient and/or caregivers whether patient can perform the following activities with or without assistance from others or from assistive devices:
    • Basic ADLs: Feeding, toileting, continence, bathing, grooming, dressing, ambulation, transfers (to or from bed or chair)
    • Instrumental ADLs: Telephone, shopping, food preparation, housekeeping, laundry, transportation, medication management, financial management
  • Pain, range of motion, gait: Note whether patient is impaired by pain, joint stiffness, or abnormal or unsteady gait and is at risk for falls
  • Frailty [See Fried et al. 2001 for full validated assessment]: Using a phenotype assessment, frailty is indicated by the presence of three or more of the following five factors. 
    • Shrinking: unintentional weight loss (>10 lbs in prior year)
    • Weakness: as determined by grip strength
    • Poor endurance and energy: self-report of exhaustion
    • Slowness: more than 6-7 seconds (depending on height) to walk 15 ft
    • Decreasing physical activity
  • HIV disease progression [Justice et al. 2013]: The VACS Index, a prognostic tool based on a calculation of age and eight routine laboratory tests, helps monitor HIV disease progression and response to therapy. An online calculator can be accessed at: http//vacs.med.yale.edu

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

Polypharmacy significantly increases the chances of serious drug-drug interactions, toxicity, and poor adherence.

Assess:

  • 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

See Substance Use Screening (Quick Reference Guide).

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.

Assess:

  • 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.

Score:

  • 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?

  1. Little interest or pleasure in doing things:
    0 = Not at all
    1 = Several days
    2 = More than half the days
    3 = Nearly every day
  2. 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

Update:

  • 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

Social/household support:

  • 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?

Mobility:

  • 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?

Safety:

  • 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

Establish rapport:

  • 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
References

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

June 2012

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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.)

RECOMMENDATIONS
  • All HIV-infected patients should receive baseline and ongoing assessment of the following:
    • Mental health disorders: depression (every visit); anxiety (at least annually); PTSD (at least annually)
    • Cognitive function (at least annually)
    • Sleep habits and appetite (every visit)
    • Psychosocial status (at least annually)
    • Suicidal/violent ideation (every visit)
    • Alcohol and substance use (at least annually; at-risk drug and alcohol users should be screened more frequently to identify escalation of present levels of use or harmful consequences from use)

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. 

RESOURCES

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.

Cognitive Function

The International HIV Dementia Scale is a validated brief screening instrument that can be administered by non-neurologists and may detect early motor and cognitive slowing.

Cognitive Function Screening Tools: 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.
    1. Score:
      • 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: 1) Clench hand in fist on flat surface. 2) Put hand flat on surface with palm down. 3) Put perpendicular to flat surface on the side of the 5th digit.
    Demonstrate and have the patient perform twice for practice.

    1. Score:
      • 4 = 4 sequences in 10 seconds
      • 3 = 3 sequences in 10 seconds
      • 2 = 2 sequences in 10 seconds
      • 1 = 1 sequence in 10 seconds
      • 0 = unable to perform
  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).
    1. Score:
      • Give 1 point for each word spontaneously recalled
      • Give 0.5 point for each correct answer after prompting
      • Maximum — 4 points

Total International HIV Dementia Scale 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.

Reprinted with permission of Wolters Kluwer Health. Sacktor NC, Wong M, Nakasujja N, et al. The International HIV Dementia Scale: A new rapid screening test for HIV dementia. AIDS 2005;19:1367-1374

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

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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.

Prescribing Considerations

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).

References

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

May 2019

EDUCATION

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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
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): characteristics
Protease Inhibitors (PIs): characteristics
Fusion Inhibitor: characteristics
CCR5 Antagonist: characteristics
Integrase Inhibitors (INSTIs): characteristics
Post-Attachment Inhibitor:
Pharmacokinetic Enhancer:
Combination HIV Medications:

ARV Drug Name Abbreviation Key

Abbreviation Full Drug Name
 
3TC lamivudine
ABC abacavir
APV amprenavir
ATV atazanavir
ATV/c atazanavir/cobicistat
ATV/r atazanavir/ritonavir
AZT zidovudine
BIC bictegravir
COBI or c cobicistat
DCV daclatasvir
ddC zalcitabine
DLV delavirdine 
DRV darunavir
DRV/c   darunavir/cobicistat
DRV/r darunavir/ritonavir 
DTG dolutegravir 
EFV efavirenz
EFV/TDF/FTC efavirenz/tenofovir disoproxil fumarate/emtricitabine
ETR etravirine
EVG/c elvitegravir/cobicistat
EVG/c/TAF/FTC elvitegravir/cobicistat/tenofovir alafenamide/emtricitabine
EVG/c/TDF/FTC elvitegravir/cobicistat/tenofovir disoproxil fumarate/ emtricitabine
EVG/r   elvitegravir/ritonavir
FPV fosamprenavir
FPV/r fosamprenavir/ritonavir
FTC emtricitabine 
IBA ibalizumab
LPV lopinavir
LPV/r lopinavir/ritonavir
MVC maraviroc
NVP nevirapine 
PI/c cobicistat-boosted protease inhibitor
PI/r ritonavir-boosted protease inhibitor 
RAL raltegravir
RPV rilpivirine
RTV ritonavir 
SQV saquinavir
SQV/r saquinavir/ritonavir
T-20 enfuvirtide
TAF tenofovir alafenamide
TDF tenofovir disoproxil fumarate
TPV tipranavir 
TPV/r tipranavir/ritonavir
ZDV zidovudine

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.
Notes
  1. 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].
  2. For other alcohol- and substance use-related screening tools, see NYSDOH AI: Screening and Ongoing Assessment Guideline.
References

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]

GOALS Framework for Sexual History Taking in Primary Care

Download PDF | Download Pocket Guide

Developed by Sarit A. Golub, PhD, MPH, Hunter College and Graduate Center, City University of New York, in collaboration with the NYC Department of Health and Mental Hygiene, Bureau of HIV, July 2019

Background: Sexual history taking can be an onerous and awkward task that does not always provide accurate or useful information for patient care. Standard risk assessment questions (e.g., How many partners have you had sex with in the last 6 months?; How many times did you have receptive anal sex with a man when he did not use a condom?) may be alienating to patients, discourage honest disclosure, and communicate that the number of partners or acts is the only component of sexual risk and health.

In contrast, the GOALS framework is designed to streamline sexual history conversations and elicit information most useful for identifying an appropriate clinical course of action.

The GOALS framework was developed in response to 4 key findings from the sexual health research literature:

  1. Universal HIV/STI screening and biomedical prevention education is more beneficial and cost-effective than risk-based screening [Wimberly, et al. 2006; Hoots, et al. 2016; Owusu-Edusei, et al. 2016; Hull, et al. 2017; Lancki, et al. 2018].
  2. Emphasizing benefits—rather than risks—is more successful in motivating patients toward prevention and care behavior [Weinstein and Klein 1995; Schuz, et al. 2013; Sheeran, et al. 2014].
  3. Positive interactions with healthcare providers promote engagement in prevention and care [Bakken, et al. 2000; Alexander, et al. 2012; Flickinger, et al. 2013].
  4. Patients want their healthcare providers to talk with them about sexual health [Marwick 1999; Ryan, et al. 2018].

Rather than seeing sexual history taking as a means to an end, the GOALS framework considers the sexual history taking process as an intervention that will:

  • Increase rates of routine HIV/STI screening;
  • Increase rates of universal biomedical prevention and contraceptive education;
  • Increase patients’ motivation for and commitment to sexual health behavior; and
  • Enhance the patient-care provider relationship, making it a lever for sexual health specifically and overall health and wellness in general.

The GOALS framework includes 5 steps:

  1. Give a preamble that emphasizes sexual health. The healthcare provider briefly introduces the sexual history in a way that de-emphasizes a focus on risk, normalizes sexuality as part of routine healthcare, and opens the door for the patient’s questions.
  2. Offer opt-out HIV/STI testing and information. The healthcare provider tells the patient that they test everyone for HIV and STIs, normalizing both testing and HIV and STI concerns.
  3. Ask an open-ended question. The healthcare provider starts the sexual history taking with an open-ended question that allows them to identify the aspects of sexual health that are most important to the patient, while allowing them to hear (and then mirror) the language that the patient uses to describe their body, partner(s), and sexual behaviors.
  4. Listen for relevant information and fill in the blanks. The healthcare provider asks more pointed questions to elicit information that might be needed for clinical decision-making (e.g., 3-site versus genital-only testing), but these questions are restricted to specific, necessary information. For instance, if a patient has already disclosed that he is a gay man with more than 1 partner, there is no need to ask about the total number of partners or their HIV status in order to recommend STI/HIV testing and PrEP education.
  5. Suggest a course of action. Consistent with opt-out testing, the healthcare provider offers all patients HIV testing, 3-site STI testing, PrEP education, and contraceptive counseling, unless any of this testing is specifically contraindicated by the sexual history. Rather than focusing on any risk behaviors the patient may be engaging in, this step focuses specifically on the benefits of engaging in prevention behaviors, such as exerting greater control over one’s sex life and sexual health and decreasing anxiety about potential transmission.

Resources for implementation:

  • Script, rationale, and goals: Box 1, below, provides a suggested script for each step in the GOALS framework, along with the specific rationale for that step and the goal it is designed to accomplish.
  • The 5Ps model for sexual history-taking (CDC): Note that the GOALS framework is not designed to completely replace the 5Ps model (partners, practices, protection from STI, past history of STI, prevention of pregnancy); instead, it provides a framework for identifying information related to the 5Ps that improves patient-care provider communication, reduces the likelihood of bias or missed opportunities, and enhances patients’ motivation for prevention and sexual health behavior.
Box 1: GOALS Framework for the Sexual History [download chart PDF]
Component Suggested Script Rationale and Goal Accomplished
Give a preamble that emphasizes sexual health. I’d like to talk with you for a couple of minutes about your sexuality and sexual health. I talk to all of my patients about sexual health, because it’s such an important part of overall health. Some of my patients have questions or concerns about their sexual health, so I want to make sure I understand what your questions or concerns might be and provide whatever information or other help you might need.
  • Focuses on sexual health, not risk.
  • Normalizes sexuality as part of health and healthcare.
  • Opens the door for the patient’s questions.
  • Clearly states a desire to understand and help.
Offer opt-out HIV/STI testing and information. First, I like to test all my patients for HIV and other sexually transmitted infections. Do you have any concerns about that?
  • Doesn’t commit to specific tests, but does normalize testing.
  • Sets up the idea that you will recommend some testing regardless of what the patient tells you.
  • Opens the door for the patient to talk about HIV or STIs as a concern.
Ask an open-ended question.

Pick one (or use an open-ended question that you prefer):

  • Tell me about your sex life.
  • What would you say are your biggest sexual health questions or concerns?
  • How is your current sex life similar or different from what you think of as your ideal sex life?
  • Puts the focus on the patient.
  • Lets you hear what the patient thinks is most important first.
  • Lets you hear the language the patient uses to talk about their body, partners, and sex.
Listen for relevant information and probe to fill in the blanks.
  • Besides [partner(s) already disclosed], tell me about any other sexual partners.
  • How do you protect yourself against HIV and STIs?
  • How do you prevent pregnancy (unless you are trying to have a child)?
  • What would help you take (even) better care of your sexual health?
  • Makes no assumption about monogamy or about gender of partners.
  • Avoids setting up a script for over-reporting condom use.
  • Can be asked of patients regardless of gender.
  • Increases motivation by asking the patient to identify strategies/ interventions.
Suggest a course of action.
  • So, as I said before, I’d like to test you for [describe tests indicated by sexual history conversation].
  • I’d also like to give you information about PrEP/contraception/other referrals. I think it might be able to help you [focus on benefit].
  • Allows you to tailor STI testing to the patient so they don’t feel targeted.
  • Shows that you keep your word.
  • Allows you to couch education or referral in terms of relevant benefits, tailored to the specific patient.
References

Alexander JA, Hearld LR, Mittler JN, et al. Patient-physician role relationships and patient activation among individuals with chronic illness. Health Serv Res 2012;47(3 Pt 1):1201-1223. [PMID: 22098418]

Bakken S, Holzemer WL, Brown MA, et al. Relationships between perception of engagement with health care provider and demographic characteristics, health status, and adherence to therapeutic regimen in persons with HIV/AIDS. AIDS Patient Care STDS 2000;14(4):189-197. [PMID: 10806637]

Flickinger TE, Saha S, Moore RD, et al. Higher quality communication and relationships are associated with improved patient engagement in HIV care. J Acquir Immune Defic Syndr 2013;63(3):362-366. [PMID: 23591637]

Hoots BE, Finlayson T, Nerlander L, et al. Willingness to take, use of, and indications for pre-exposure prophylaxis among men who have sex with men-20 US cities, 2014. Clin Infect Dis 2016;63(5):672-677. [PMID: 27282710]

Hull S, Kelley S, Clarke JL. Sexually transmitted infections: Compelling case for an improved screening strategy. Popul Health Manag 2017;20(S1):S1-S11. [PMID: 28920768]

Lancki N, Almirol E, Alon L, et al. Preexposure prophylaxis guidelines have low sensitivity for identifying seroconverters in a sample of young Black MSM in Chicago. AIDS 2018;32(3):383-392. [PMID: 29194116]

Marwick C. Survey says patients expect little physician help on sex. JAMA 1999;281(23):2173-2174. [PMID: 10376552]

Owusu-Edusei K, Jr., Hoover KW, Gift TL. Cost-effectiveness of opt-out chlamydia testing for high-risk young women in the U.S. Am J Prev Med 2016;51(2):216-224. [PMID: 26952078]

Ryan KL, Arbuckle-Bernstein V, Smith G, et al. Let’s talk about sex: A survey of patients’ preferences when addressing sexual health concerns in a family medicine residency program office. 2018;2. https://journals.stfm.org/primer/2018/ryan-2018-0004

Schuz N, Schuz B, Eid M. When risk communication backfires: randomized controlled trial on self-affirmation and reactance to personalized risk feedback in high-risk individuals. Health Psychol 2013;32(5):561-570. [PMID: 23646839]

Sheeran P, Harris PR, Epton T. Does heightening risk appraisals change people’s intentions and behavior? A meta-analysis of experimental studies. Psychol Bull 2014;140(2):511-543. [PMID: 23731175]

Weinstein ND, Klein WM. Resistance of personal risk perceptions to debiasing interventions. Health Psychol 1995;14(2):132-140. [PMID: 7789348]

Wimberly YH, Hogben M, Moore-Ruffin J, et al. Sexual history-taking among primary care physicians. J Natl Med Assoc 2006;98(12):1924-1929. [PMID: 17225835]