[Table, General Medical Status, History, and Physical Examination]. - Comprehensive Primary Care for Adults With HIV

Table 2: Psychosocial, Behavioral Health, Sexual Health, and Well-Being Assessment of Adults With HIV *Frequency Key: I = initial (baseline) visit; A = annual visit; N = as needed
Assessment	To Include	Frequency*
I	A	N
Gender and Sexual Identity
Gender identity	Current gender identity and sex assigned at birth Pronouns	I	A	N
Current sexual identity	History of sexual identity	I	A	N
Gender transition	Gender transition goals; successes and challenges History of, planned, or desired gender-affirming surgery Current, past, or planned use of gender-affirming hormones Source of gender-affirming hormones Adverse effects of gender-affirming treatments	I
Inventory of sexual organs	Presence or absence of penis, testes, prostate, breasts, vagina, cervix, uterus, and ovaries; determination of patient’s preferred terms for body parts	I	A	N
Current Psychosocial Status and History
Housing	Housing stability or connection to resources if housing is unstable Relocation plans Monitor for signs of housing instability.	I	A	N
Family and other significant relationships and responsibilities	Immediate and extended family members as defined by the patient Significant relationships HIV disclosure status Financial and care-giving dependents, including children, spouse or life partner, aging parents, and extended or chosen family members Community support, including functional needs and agency or family assistance Transportation Pets in home Monitor for signs of instability.	I	A
Interpersonal and social support network	Members of the patient’s primary interpersonal and social support network People to whom the patient has disclosed their HIV status Discussion of experienced and perceived stigma Monitor for signs of instability.	I	A	N
Employment	Current employment status or employment goals Access to financial support if unemployed or under-employed Employment-associated risks to health or well-being, including stigma and discrimination	I	A
Medical insurance	Access to private medical insurance, Medicaid, ADAP, or Medicare Prescription coverage Hospitalization coverage Access to resources for coverage if uninsured (see NYSDOH Uninsured Care Programs)	I	A	N
Incarceration	History of incarceration Probation, parole, and other legal status	I
End-of-life planning	Documented healthcare proxy Documented preferences for end-of-life care and living will Long-term care plans	I	A
Current Mental Health Status and History
Mental illness	History of mental illness and treatment Adverse reactions to medications History of psychiatric hospitalization Suicide risk assessment and past history of suicide attempts Family history See USPSTF: Screening for Depression in Adults (2016); assess mental health using standardized tools, such as the PHQ-2, PHQ-9, and C-SSRS.	I	A
Trauma	History of trauma, including domestic violence; physical, verbal, sexual, or emotional abuse; or witnessed trauma History or current experience of elder abuse Any effects on current function and coping strategies	I	A	N
Stress	Current major stressors Stress management and coping skills Current experience or history of HIV-associated or other stigmas	I	A	N
Current Substance Use and History
Alcohol	History of use, including use disorder diagnosis and treatment Adverse reactions to medications Screening for current use, and if indicated, risk assessment using standardized tools If indicated, implementation of a harm reduction treatment plan	I	A	N
Tobacco use and vaping	Current level of tobacco use and type; smoking prevalence is high in people with HIV [Pacek and Cioe 2015] History of use and prior treatment Adverse reactions to medications	I	A	N
Use of nonprescription drugs and misuse of prescribed drugs	All types of drug use, including misused prescription medications History of use, including use disorder diagnosis and treatment Route of use History of overdose Screening for current use, and if indicated, risk assessment using standardized tools If indicated, implementation of a harm reduction treatment plan	I	A	N
Sexual and Reproductive Health and History
Sex partner(s) and activity	Current sex partner(s) HIV, ART, and viral load status of partner(s), if known; PrEP and other measures to prevent STIs used by partner(s) Frequency of and preferred sexual activities; challenges History of sexual dysfunction History of or current engagement in transactional sex NYSDOH AI resources: GOALS Framework for Sexual History Taking in Primary Care, U=U Guidance for Implementation in Clinical Settings	I	A	N
Sexually transmitted infections	History of and treatment for syphilis, gonorrhea, chlamydia, human papillomavirus, and other STIs Source of prior treatment for any STI Assessment of ongoing risk factors, and if indicated, implementation of harm or risk reduction plan; use of condoms or other barrier protection Screening of all potentially exposed sites (see CDC Sexually Transmitted Infections Treatment Guidelines, 2021 > Screening Recommendations for evidence-based recommendations)	I	A	N
Reproductive history	Offspring Previous failed attempts at reproduction Previous treatment for reproductive issues and source Adverse effects Contraceptive history Previous abortion(s)	I
Reproductive goals	Family planning goals Contraception use and options Possible drug-drug interactions for individuals taking ART	I		N

Table 2: Psychosocial, Behavioral Health, Sexual Health, and Well-Being Assessment of Adults With HIV *Frequency Key: I = initial (baseline) visit; A = annual visit; N = as needed

Assessment

To Include

Frequency*

Gender and Sexual Identity

Gender identity

Current gender identity and sex assigned at birth
Pronouns

Current sexual identity

History of sexual identity

Gender transition

Gender transition goals; successes and challenges
History of, planned, or desired gender-affirming surgery
Current, past, or planned use of gender-affirming hormones
Source of gender-affirming hormones
Adverse effects of gender-affirming treatments

Inventory of sexual organs

Presence or absence of penis, testes, prostate, breasts, vagina, cervix, uterus, and ovaries; determination of patient’s preferred terms for body parts

Current Psychosocial Status and History

Housing

Housing stability or connection to resources if housing is unstable
Relocation plans
Monitor for signs of housing instability.

Family and other significant relationships and responsibilities

Immediate and extended family members as defined by the patient
Significant relationships
HIV disclosure status
Financial and care-giving dependents, including children, spouse or life partner, aging parents, and extended or chosen family members
Community support, including functional needs and agency or family assistance
Transportation
Pets in home
Monitor for signs of instability.

Interpersonal and social support network

Members of the patient’s primary interpersonal and social support network
People to whom the patient has disclosed their HIV status
Discussion of experienced and perceived stigma
Monitor for signs of instability.

Employment

Current employment status or employment goals
Access to financial support if unemployed or under-employed
Employment-associated risks to health or well-being, including stigma and discrimination

Medical insurance

Access to private medical insurance, Medicaid, ADAP, or Medicare
Prescription coverage
Hospitalization coverage
Access to resources for coverage if uninsured (see NYSDOH Uninsured Care Programs)

Incarceration

History of incarceration
Probation, parole, and other legal status

End-of-life planning

Documented healthcare proxy
Documented preferences for end-of-life care and living will
Long-term care plans

Current Mental Health Status and History

Mental illness

History of mental illness and treatment
Adverse reactions to medications
History of psychiatric hospitalization
Suicide risk assessment and past history of suicide attempts
Family history
See USPSTF: Screening for Depression in Adults (2016); assess mental health using standardized tools, such as the PHQ-2, PHQ-9, and C-SSRS.

Trauma

History of trauma, including domestic violence; physical, verbal, sexual, or emotional abuse; or witnessed trauma
History or current experience of elder abuse
Any effects on current function and coping strategies

Stress

Current major stressors
Stress management and coping skills
Current experience or history of HIV-associated or other stigmas

Current Substance Use and History

Alcohol

History of use, including use disorder diagnosis and treatment
Adverse reactions to medications
Screening for current use, and if indicated, risk assessment using standardized tools
If indicated, implementation of a harm reduction treatment plan

Tobacco use and vaping

Current level of tobacco use and type; smoking prevalence is high in people with HIV [Pacek and Cioe 2015]
History of use and prior treatment
Adverse reactions to medications

Use of nonprescription drugs and misuse of prescribed drugs

All types of drug use, including misused prescription medications
History of use, including use disorder diagnosis and treatment
Route of use
History of overdose
Screening for current use, and if indicated, risk assessment using standardized tools
If indicated, implementation of a harm reduction treatment plan

Sexual and Reproductive Health and History

Sex partner(s) and activity

Current sex partner(s)
HIV, ART, and viral load status of partner(s), if known; PrEP and other measures to prevent STIs used by partner(s)
Frequency of and preferred sexual activities; challenges
History of sexual dysfunction
History of or current engagement in transactional sex
NYSDOH AI resources: GOALS Framework for Sexual History Taking in Primary Care, U=U Guidance for Implementation in Clinical Settings

Sexually transmitted infections

History of and treatment for syphilis, gonorrhea, chlamydia, human papillomavirus, and other STIs
Source of prior treatment for any STI
Assessment of ongoing risk factors, and if indicated, implementation of harm or risk reduction plan; use of condoms or other barrier protection
Screening of all potentially exposed sites (see CDC Sexually Transmitted Infections Treatment Guidelines, 2021 > Screening Recommendations for evidence-based recommendations)

Reproductive history

Offspring
Previous failed attempts at reproduction
Previous treatment for reproductive issues and source
Adverse effects
Contraceptive history
Previous abortion(s)

Reproductive goals

Family planning goals
Contraception use and options
Possible drug-drug interactions for individuals taking ART

From: Comprehensive Primary Care for Adults With HIV

Cover of Comprehensive Primary Care for Adults With HIV

Comprehensive Primary Care for Adults With HIV [Internet].

Dyer M, Kerr C, Fine SM, et al.

Baltimore (MD): Johns Hopkins University; 2022 Dec.

Copyright © Johns Hopkins University Clinical Guidelines Program 2000-2024. The Clinical Guidelines Program, a collaborative effort of the NYSDOH AI and the Johns Hopkins University School of Medicine, Division of Infectious Diseases, encourages the use, reproduction, and distribution of original documents and related graphics from this program website accompanied by a full citation of source that includes: Author(s). Committee. Title. Date of publication. Full URL. Date accessed. Links to pages on this Clinical Guidelines Program website are also encouraged and may be created without seeking permission. Requests to adapt material, i.e., to change or alter in any way material from this website for inclusion in another publication, should be sent to aiguidelines@jhmi.edu. Please include detailed information about the intended use and desired adaptations.

This book is licensed under the terms of the Attribution-NonCommercial-NoDerivs 3.0 Unported (CC BY-NC-ND 3.0).

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.