• New York State Department of Health. Trauma and post-traumatic stress disorder in patients with HIV/AIDS. New York (NY): New York State Department of Health; 2007 Dec. 8 p. [3 references]

This is the current release of the guideline.

This guideline updates a previous version: Trauma and post-traumatic stress disorder in patients with HIV/AIDS (updated online 2004 Sep). In: Mental health care for people with HIV infection: HIV clinical guidelines for the primary care practitioner. New York (NY): New York State Department of Health; 2001 Mar. p. 69-75.

• Human immunodeficiency virus infection/acquired immune deficiency syndrome (HIV/AIDS)
• Acute stress disorder (ASD)
• Post-traumatic stress disorder (PTSD)

Diagnosis
Management
Screening

Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine
Psychiatry
Psychology

Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments

To provide guidelines for the diagnosis and management of post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) in patients with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) in primary care settings

Patients with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS)

1. Screening for post-traumatic stress disorder (PTSD) annually or as clinically indicated
2. Use of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria
3. Screening for other mental disorders
4. Referral to a mental health professional
5. Medications (sertraline, paroxetine)

   Note: Long-term benzodiazepines are not a preferred treatment

6. Psychotherapy including exposure therapy, anxiety management programs, and cognitive therapy

• Prevalence of post-traumatic stress disorder (PTSD) in human immunodeficiency virus (HIV)-infected patients
• Effectiveness of treatment on relieving symptoms of PTSD

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Expert Consensus

AIDS Institute clinical guidelines are developed by distinguished committees of clinicians and others with extensive experience providing care to people with HIV infection. Committees* meet regularly to assess current recommendations and to write and update guidelines in accordance with newly emerging clinical and research developments.

The Committees* rely on evidence to the extent possible in formulating recommendations. When data from randomized clinical trials are not available, Committees rely on developing guidelines based on consensus, balancing the use of new information with sound clinical judgment that results in recommendations that are in the best interest of patients.

*Current committees include:

• Medical Care Criteria Committee
• Committee for the Care of Children and Adolescents with HIV Infection
• Dental Standards of Care Committee
• Mental Health Committee
• Women's Health Committee
• Substance Use Committee
• Physician's Prevention Advisory Committee
• Pharmacy Committee

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review

All guidelines developed by the Committee are externally peer reviewed by at least two experts in that particular area of patient care, which ensures depth and quality of the guidelines.

Key Point

Exposure to traumatic events can lead to increased risk-taking behavior, including substance use, unsafe sexual practices, and difficulty forming therapeutic relationships with medical personnel.

Post-Traumatic Stress Disorder (PTSD)

Key Point

The likelihood of a patient developing PTSD varies according to the vulnerability of the affected person and the severity of the stressor.

Diagnosis

The primary care clinician should screen for PTSD annually or more often as clinically indicated.

Clinicians should use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) for a diagnosis of PTSD in patients with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) (see table below).

Clinicians should screen patients with PTSD or significant trauma histories for clinical depression, anxiety disorders, or alcohol or other substance use disorders.

Key Point

Patients with PTSD may have dissociative symptoms, which may be mistaken for HIV-related dementia or other HIV-related neuropsychiatric disorders.

Management of Survivors of Trauma

Clinicians should refer patients with symptoms of PTSD to a mental health professional as soon as possible for evaluation for psychotherapy or other forms of psychiatric treatment. The goal of treatment should be to reduce symptoms and fully reintegrate a safe sense of self.

If specialized services are unavailable, the primary care clinician should prescribe medications (refer to Appendix XII [see the "Availability of Companion Documents" field]) and monitor the degree of improvement achieved with this strategy alone.

During the acute phase of treatment, clinicians should assess the patient's risk for harm to him/herself or others.

Key Point

Although patients with PTSD may seek help for associated somatic symptoms, they may perceive medical intervention as intrusive and thus re-traumatizing.

Acute Stress Disorder (ASD)

For patients who meet the criteria for ASD, clinicians should follow the same guidelines as those recommended for management of PTSD (see "Management of Survivors of Trauma" section above).

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Appropriate diagnosis and management of post-traumatic stress disorder and acute stress disorder in patients with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) in primary care settings

If benzodiazepines are prescribed, careful monitoring is required due to the potential for abuse and concerns about disinhibition in those with significant dissociative symptoms.

Refer to Appendix XII (see the "Availability of Companion Documents" field) for side effect profile and drug-drug interactions.

Paroxetine should be avoided in patients less than 18 years old because of its possible association with increased suicide risk.

Refer to Appendix XII (see the "Availability of Companion Documents" field) for contraindications between human immunodeficiency virus (HIV)-related medications and psychotropic medications.

The AIDS Institute's Office of the Medical Director directly oversees the development, publication, dissemination and implementation of clinical practice guidelines, in collaboration with The Johns Hopkins University, Division of Infectious Diseases. These guidelines address the medical management of adults, adolescents and children with HIV infection; primary and secondary prevention in medical settings; and include informational brochures for care providers and the public.

Guidelines Dissemination

Guidelines are disseminated to clinicians, support service providers and consumers through mass mailings and numerous AIDS Institute-sponsored educational programs. Distribution methods include the HIV Clinical Resource website, the Clinical Education Initiative, the AIDS Educational Training Centers (AETC) and the HIV/AIDS Materials Initiative. Printed copies of clinical guidelines are available for order from the New York State Department of Health (NYSDOH) Distribution Center for providers who lack internet access.

Guidelines Implementation

The HIV Clinical Guidelines Program works with other programs in the AIDS Institute to promote adoption of guidelines. Clinicians, for example, are targeted through the Clinical Education Initiative (CEI) and the AETC. The CEI provides tailored educational programming on site for health care providers on important topics in HIV care, including those addressed by the HIV Clinical Guidelines Program. The AETC provides conferences, grand rounds and other programs that cover topics contained in AIDS Institute guidelines.

Support service providers are targeted through the HIV Education and Training initiative which provides training on important HIV topics to non-physician health and human services providers. Education is carried out across the State as well as through video conferencing and audio conferencing.

The HIV Clinical Guidelines Program also works in a coordinated manner with the HIV Quality of Care Program to promote implementation of HIV guidelines in New York State. By developing quality indicators based on the guidelines, the AIDS Institute has created a mechanism for measurement of performance that allows providers and consumers to know to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical Guidelines Program. These contain practical solutions to common problems related to access, delivery or coordination of care, in an effort to ensure that HIV guidelines are implemented and that patients receive the highest level of HIV care possible.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• New York State Department of Health. Trauma and post-traumatic stress disorder in patients with HIV/AIDS. New York (NY): New York State Department of Health; 2007 Dec. 8 p. [3 references]

Not applicable: The guideline was not adapted from another source.

2004 Sep (revised 2007 Dec)

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Mental Health Committee

Chair: Milton L Wainberg, MD, New York State Psychiatric Institute, New York, New York

Members: Bruce D Agins, MD, MPH, New York State Department of Health AIDS Institute, New York, New York; Kalyana Battu, MD, Albany Medical Center, Albany, New York; Barbara A Conanan, RN, MS, Saint Vincent's Manhattan Department of Community Medicine, New York, New York; Joseph Z Lux, MD, Bellevue Hospital, New York, New York; Peter Meacher, MD, AAHIVS, FAAFP, South Bronx Health Center for Children and Families, Bronx, New York; Yiu Kee Warren Ng, MD, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York; Bella M Schanzer, MD, MPH, Columbia University Medical Center, New York, New York

Liaisons: Francine Cournos, MD, Liaison to the New York/New Jersey AIDS Education and Training Center, Columbia University, New York State Psychiatric Institute, New York, New York; James J Satriano, PhD, Liaison to the New York State Office of Mental Health, Columbia University College of Physicians and Surgeons, New York, New York

AIDS Institute Staff Liaison: L Jeannine Bookhardt-Murray, MD, Harlem United Community AIDS Center, New York, New York

AIDS Institute Representative: Heather A Duell, LMSW, New York State Department of Health AIDS Institute, Bureau of Community and Support Services, Albany, New York

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Trauma and post-traumatic stress disorder in patients with HIV/AIDS (updated online 2004 Sep). In: Mental health care for people with HIV infection: HIV clinical guidelines for the primary care practitioner. New York (NY): New York State Department of Health; 2001 Mar. p. 69-75.

None available

This NGC summary was completed by ECRI on May 5, 2005. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI on October 3, 2005, following the U.S. Food and Drug Administration advisory on Paxil (paroxetine). This summary was updated by ECRI on December 12, 2005, following the U.S. Food and Drug Administration advisory on Paroxetine HCL - Paxil and generic paroxetine. This summary was updated by ECRI on May 31, 2006 following the U.S. Food and Drug Administration advisory on Paxil (paroxetine hydrochloride). This NGC summary was updated by ECRI Institute on June 6, 2008.