Infection with the human immunodeficiency virus (HIV) is associated with a range of social, emotional, and neuropsychiatric complications. While HIV/AIDS has become a potentially manageable chronic disease, living with HIV/AIDS continues to be a practical and psychospiritual challenge. Persons at highest risk for HIV/AIDS (we use the term HIV/acquired immunodeficiency syndrome [AIDS] to designate the entire spectrum of clinical manifestations of HIV disease, from asymptomatic infection through advanced AIDS) are disproportionately likely to suffer behavioral and mood disorders and to be socially disenfranchised and economically disadvantaged. Once infected, they must contend with a stigmatized, contagious, and if untreated, a relentlessly progressive medical condition. In addition, many people with HIV have other significant comorbid conditions, such as chronic hepatitis, psychiatric problems, and/or substance use that may make adhering to HIV treatment more difficult. Although undiagnosed and untreated patients with HIV/AIDS can present with life-threatening neuropsychiatric sequalae of HIV (central nervous system [CNS], opportunistic infections, HIV dementia), most patients' behavioral concerns will be focused on maintaining medication adherence, maximizing quality of life, and managing lifestyle issues.
Human immunodeficiency virus is primarily transmitted through sexual exposure or shared injection drug paraphernalia (sharing needles). Initially, an epidemic concentrated among gay men in cities, new cases of HIV infection now are disproportionately seen in socioeconomically disadvantaged populations, especially women and men of color. Some patients do not fit "classic" risk factor profiles. For example, a monogamous woman may be infected through her husband who is bisexually active. Although past HIV prevention programs successfully reduced rates of new HIV infections in gay men, incidence of new HIV infection in multiple patient populations is significant. These patient groups include men who have sex with men but who do not self-identify as "gay," speed users who share straws for intranasal use, teenagers, elders, and women. In the United States, almost one-third of the approximately 1 million HIV-positive persons have never been tested and are not being treated. In spite of the great advances in prognosis with antiviral therapy, HIV/AIDS remains underdiagnosed and undertreated in the United States and worldwide.
In 2006, the Centers for Disease Control (CDC) formally modified its HIV screening recommendations from that of focused testing in high-risk groups and in high prevalence settings to universal testing. In this paradigm, all patients are encouraged to be tested as part of routine preventative care, and detailed consent procedures modified to opting in or out of HIV testing as part of routine care. Newer rapid testing procedures allow for patients to receive their results at the time of testing, improving the number of patients who receive their results and facilitating triage for medical follow-up. Importantly, these simplified tests—involving oral swabs or finger sticks—are as sensitive as the enzyme-linked immunosorbent assay (ELISA)/Western blot tests, which require phlebotomy and more time to be processed.
Integrating HIV screening and HIV prevention counseling into routine health care maintenance activities can facilitate this discussion in primary care settings. For example, following ...