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Mental Health in HIV
Simple Questions to Address Mental Health in HIV

Released: October 29, 2024

Expiration: October 28, 2025

Mark Brennan-Ing
Mark Brennan-Ing, PhD
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Key Takeaways
  • Although depression screening tools are effective, simple and easy questions about mental health are all that is needed to start addressing mental health in HIV care.

The healthcare system can often feel like it is more focused on procedure codes than on how well the patient is doing. HIV and infectious disease providers are very focused on viral load suppression and antiretroviral therapy adherence, which is good, but I believe they sometimes miss the bigger picture of what is going on in the patient’s life, especially as it relates to mental health.

A big barrier to achieving viral load suppression is depression, alcohol use, and substance use, as they can interfere with adherence to or lower the efficacy of HIV medications. Assessing mental health is an important service to incorporate when providing HIV care.

Assessing Mental Health
Depression screening does not need to take long during a 15-minute visit, but providers may not be aware of the tools they need to perform this screening. And while there are numerous tools available to screen for depressive symptoms, simply asking, "Have you felt sad or depressed in the past week?" is nearly as effective. This straightforward question paves the way for discussing the patient's emotional health and overall well-being.

Another cause of depressive symptoms is loneliness. For people with HIV, loneliness may in part be due to the stigma of having HIV. People may be rejected by family and friends or withdraw themselves due to the anticipation of stigma and discrimination. A lot of isolation can result from that.

Project RESPECT was a social support intervention, consisting of a weekly check-in over the phone with a care manager, for people with depression. The check-in process would include questions such as: "How are you doing?” "What’s going on in your life?” "Are you facing any problems?” and "Are you experiencing any issues?"

By implementing this simple weekly phone call with people with HIV, depressive symptoms were reduced by half within 6 months. In addition, many participants self-reported either stopping or reducing their use of substances or alcohol. A few of the mental health providers I am connected with adopted this approach into their practice to provide more social support and, in turn, it improved adherence to medications.

Mental and behavioral health has so many implications, not only for HIV treatment but for other comorbidities as well. Incorporating mental health questions during a patient–provider visit can transform the experience from feeling like an interrogation to an open conversation. It can really make a big difference in people's well-being And it only takes a couple of minutes to do.

Face to Face
Healthcare today has transitioned to having electronic systems in the room with the patient, which can become impersonal. I have heard a lot of people with HIV complain that when they are at a healthcare provider visit, they feel the provider is just focused on the computer screen the whole time—they are not having a conversation, they are not making eye contact.

Using claims data, we recently did a study on engagement among people with HIV during the COVID-19 pandemic. We saw a big rise in telehealth during the pandemic. When we looked at postpandemic data, telehealth visits for primary care and specialty care continued, but telehealth visits for behavioral health completely tailed off.

To me, this suggests that people with HIV want face-to-face contact for behavioral health. People benefit from face-to-face behavioral health visits through interactions and the opportunity to have someone listen and care about their emotional health, which cannot be fully captured over a computer screen.

Start the Conversation
Speaking from personal experience, I dealt with mental health issues during COVID-19. As a psychologist, one might expect me to recognize the depressive symptoms, but I didn't. This is an issue that impacts everyone, regardless of occupation, fitness habits, or knowledge.

Luckily, I have a primary care doctor who gives me space to bring up these issues, which I love. At a visit, we go through the vitals and all of that, and then she stops and says, “Okay, Mark, so what is going on?”

She lets me lead the conversation. She lets me bring things up that may not be the reason I made the appointment in the first place.

As a patient advocate, I encourage patients to discuss it with their clinician if they are feeling off, tired all the time, or just not like themselves. The provider does not need to conduct a 25-item depression screening. Some simple questions to ask include: "Have you felt sad or depressed?" "What is going on in your life?" and "Do you feel like anything is different?" 

Your Thoughts?
How often do you integrate mental or behavioral health in your care for patients with HIV? Get involved in the discussion by posting a comment below.