integration.samhsa.gov

THE CASE FOR BEHAVIORAL HEALTH 

SCREENING IN HIV CARE SETTINGS

integration.samhsa.gov

SAMHSA-HRSA CENTER for 

INTEGRATED HEALTH SOLUTIONS
The Case for Behavioral Health

Screening in HIV Care Settings

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services
integration.samhsa.gov 3

ACKNOWLEGEMENTS

This report was prepared for the Substance Abuse and Mental Health Services Administration 

(SAMHSA) and Health Resources and Services Administration (HRSA) by the National Council for 

Behavioral Health under contract number HHSS283201200031I, with SAMHSA, U.S. Department of 

Health and Human Services (HHS). Tenly Pau Biggs served as the Government Project Officer.

DISCLAIMER

The views, opinions, and content of this publication are those of the author and do not necessarily 

reflect the views, opinions, or policies of SAMHSA, HRSA or HHS. Any non-Federal resource listed 

in this document does not constitute endorsement by SAMHSA, HRSA or HHS, and resource lists 

are not to be considered all-inclusive. 

PUBLIC DOMAIN NOTICE

All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may 

not be reproduced or distributed for a fee without the specific, written authorization of the Office 

of Communications, SAMHSA, HHS.

ELECTRONIC ACCESS AND PRINTED COPIES

This publication may be downloaded or ordered at http://store.samhsa.gov. Or call SAMHSA at 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

RECOMMENDED CITATION

Substance Abuse and Mental Health Services Administration and Health Resources and 

Services Administration, The Case for Behavioral Health Screening in HIV Care Settings. HHS 

Publication No. SMA-16-4999. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2016.

ORIGINATING OFFICE 

Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 

5600 Fishers Lane, Rockville, MD 20857. HHS Publication No. SMA-16-4999. 2016.
4 SAMHSA-HRSA CENTER for INTEGRATED HEALTH SOLUTIONS

EFFECTIVE MEDICAL AND BEHAVIORAL HEALTH INTERVENTIONS HAVE 

TRANSFORMED HUMAN IMMUNODEFICIENCY VIRUS (HIV) AND ACQUIRED 

IMMUNODEFICIENCY SYNDROME (AIDS) FROM A DEATH SENTENCE INTO A 

CHRONIC AND TREATABLE DISEASE. AS INDIVIDUALS LIVING WITH HIV LEAD 

LONGER LIVES AND ENJOY A GREATER SENSE OF WELL-BEING THAN EVER 

BEFORE, CLINICS THAT PROVIDE HIV TREATMENT SERVICES MUST BE RESPONSIVE 

TO THE VARIETY OF HEALTH NEEDS OF THIS POPULATION. 

SUBSTANCE USE AND HIV/AIDS

The goal of HIV care is to achieve and maintain viral suppression – a very low level of HIV in the 

body. Yet, the health of a person living with HIV cannot be defined solely by their viral load levels. 

Adhering to the antiretroviral treatment (ART) that suppresses HIV and maintaining a healthy lifestyle are critical to controlling the disease and can be complicated by behavioral health conditions 

(mental illness and substance use disorders). People living with HIV have much higher rates of behavioral health disorders than the general population. 

Consider these facts about the connections between HIV/AIDS, mental illness, substance use and trauma.

• People living with HIV have high rates of past or current history of alcohol or substance use 

disorders (SUDs).i,ii,iii 

• 66 percent have used illicit drugs and 16.5 percent have a history of intravenous drug use.ii 

• 24 percent report receiving treatment for SUDs.iii 

MENTAL ILLNESS AND HIV/AIDS 

People living with HIV experience mental illness at significantly higher rates than the general population. A 2008 study stated that the rate of co-occurring mental illnesses in people with HIV was so 

high that “having a single mental health diagnosis was the exception rather than the rule.”iv Specifically, people living with HIV have:

• Two to five times higher rates of depression.v,vi

• Up to four times higher rates of depression among women with HIV than women who do not 

have HIV.vii 

• Higher rates of anxiety.viii,ix,x,xi 

TRAUMA AND HIV/AIDS

People living with HIV are more likely to have a history of trauma. 

• A person who has experienced trauma and has a serious mental illness has an increased likelihood of having an HIV infection.vi 

• The prevalence of traumatic experiences among those with HIV can be as high as 42 percent for 

womenxii and up to 70 percent for all people living with HIV – which means that people with HIV 

are as much as twenty times more likely to have experienced trauma than the general population.xiii,xiv

HOW LIKELY IS IT THAT PEOPLE WITH HIV/AIDS HAVE MULTIPLE CO-OCCURRING MENTAL 

ILLNESSES AND SUBSTANCE USE DISORDERS? 

An estimated 10-28 percent of people with HIV have co-occurring SUDs and mental illnesses.xv 

Many people living with HIV and with depression had several other mental health disorders, including 78 percent with anxiety disorders and 61 percent with SUDs.xvi 
integration.samhsa.gov 5

IMPACT OF BEHAVIORAL HEALTH CONDITIONS 

ON HIV CARE

The prevalence of mental illness among people 

living with HIV poses a threat to the health of the 

individual and has a profound effect on physical 

wellness. For example, people with depression 

and HIV are more likely to have higher viral loads, 

more symptoms of anxiety and are more likely to 

have a substance use problem.xvii People with HIV 

and a co-occurring behavioral health condition 

may increase risky behaviors, such as unprotected 

sex or sharing needles, or diminish self-care, such 

as taking medication as prescribed and getting 

adequate food and rest. Other interrelated social 

determinants of health, including poverty, low 

educational attainment and housing insecurity can 

also complicate HIV treatment and maintenance 

of a healthy lifestyle. Addressing behavioral health 

concerns can play a critical role in the public health 

approach to reducing transmission of HIV. These 

reasons are why it is important for HIV clinics to 

conduct behavioral health screenings.

THE PROBLEM: SCREENING IS 

INCONSISTENT

Despite these compelling data, studies indicate 

there is insufficient screening for substance use in 

HIV care clinics. 

• 35 percent of patients in 10 HIV care centers 

reported talking with their primary care 

provider about their alcohol use.

• 52 percent of those with more serious alcohol and other drug use reported discussing it with 

their primary care provider.xviii 

• Fewer than 50 percent of primary care providers in hospital-based HIV care programs 

conducted recommended screening and brief interventions for reducing alcohol use.xix 

SCREENING FOR BEHAVIORAL HEALTH: CRITICAL BUT UNDERUSED

A truly effective model for supporting individual and population health integrates behavioral 

health services (including screening, assessment and treatment) with primary HIV care. Integrating 

depression screening helps identify those who can benefit from combined psychotherapy and 

pharmacotherapy interventions.xx The Screening, Brief Intervention and Referral to Treatment

(SBIRT) model identifies risky substance use, provides brief interventions for those with lower level 

substance use before it becomes a problem and offers referral for those who need more intensive, 

specialty care. Early detection through screening can result in earlier intervention and substance 

abuse treatment, including medication-assisted treatment, which can make a substantial difference 

in the health of the individual and reduce transmission of HIV by increasing medication compliancexxi 

WHAT SCREENING

FORMS ARE AVAILABLE?

Numerous tools are available for screening 

both general and specific behavioral health 

issues, including: 

• General Wellness — Healthy Living 

Questionnaire or Patient Stress 

Questionnaire

• Trauma — Life Event Checklist

• Depression — PHQ-9 

• Generalized Anxiety Disorder — GAD-7 

• Substance Use Prescreen — National 

Institute on Alcohol Abuse and Alcoholism’s (NIAAA) 3 Question Screen or National Institute on Drug Abuse’s (NIDA) 

quick screen

• Substance Use In-Depth — AUDIT 

or ASSIST 

Visit the Center for Integrated Health Solutions (CIHS) website to learn more about 

these and other screening tools. 

Note: These tools are examples and do not 

include all screening forms available. This 

does not constitute particular recommendations or endorsements for use. 
6 SAMHSA-HRSA CENTER for INTEGRATED HEALTH SOLUTIONS

Integrated primary HIV and behavioral health care 

improves physical health outcomes and leads to 

increased savings in health care costs through 

reduced emergency room use, increased efficiency, 

reimbursable use of staff time and other means of 

cost-savings.xxii

Many Federal grant-funded programs require 

routine or universal screening for a range of 

health conditions. The Ryan White HIV/AIDS 

Treatment Extension Act of 2009 requires funded 

organizations to follow the HHS Guidelines for 

the Use of Antiretroviral Agents in HIV-1-Infected 

Adults and Adolescents, which includes screening 

for clinical depression and substance use and, if 

they are identified, developing a follow-up plan to 

address these issues. This emphasis on screening 

for behavioral health conditions helps Ryan 

White-funded organizations ensure that it is a 

routine part of coordinated care.

REPORT FROM THE FIELD

ABOUT THIS REPORT 

The SAMHSA-HRSA Center for Integrated Health 

Solutions (CIHS) conducted interviews with direct 

care HIV provider organizations across the United 

States and an interview with a public health 

program supporting the statewide implementation 

of SBIRT for HIV provider organizations. Several 

of these programs are health centers that include 

primary HIV medical care, although one program 

primarily focuses on behavioral health treatment 

that includes primary care for people living 

with HIV. 

The provider organizations interviewed were at 

varying levels of integration, ranging from partial 

co-location of some behavioral health staff and services to fully integrated. Even the most integrated 

programs referred patients externally for residential 

treatment, some referred for detox and/or medication-assisted treatment for addiction and others 

referred for treatment of serious mental illness. 

WHAT IS SBIRT?

Screening, Brief Intervention 

and Referral to Treatment 

(SBIRT) is an evidence-based practice used to identify, reduce and 

prevent problematic substance 

use, abuse and dependence on 

alcohol and illicit drugs. The 

SBIRT model responds to a recommendation by the Institute of 

Medicine for community-based 

screening of health risk behaviors, 

including substance use.

The Three Steps of SBIRT:

Screening — A health care 

professional assesses a person 

for risky substance use 

behaviors through standardized 

screening tools.

Brief Intervention — A short 

nonjudgmental conversation 

between a health care 

professional and patient 

exhibiting risky substance use 

behaviors, including feedback 

and advice.

Referral to Treatment — 

For patients whose screening 

results indicate the need for 

specialty services, a health care 

professional provides a referral 

for additional treatment.

Learn more about SBIRT at www.integration.samhsa.gov/

clinical-practice/SBIRT and at www.samhsa.gov/SBIRT.

For more information on SBIRT in HIV care settings, see

http://aidsetc.org/sites/default/files/resources_files/sbirt.pdf

1

2

3
integration.samhsa.gov 7

WHO SCREENS, WHEN AND WITH 

WHAT TOOLS?

Almost all of the programs interviewed reported 

screening between 80 to nearly 100 percent of their 

patients with HIV for mental health problems, but 

were less likely to offer universal screening for substance use. 

The most commonly used screening instrument 

was the Patient Health Questionnaire (PHQ-2 and 

PHQ-9), which screens for depression. Programs 

who did regularly screen for substance use (or for 

co-occurring substance use and mental illness) used 

the Substance Abuse and Mental Illness Symptoms 

Screener (SAMISS) or other tools. Typically, 

individuals respond to screening questions and selfreport answers using a pen and paper or a tablet 

computer. Some programs ask patients to fill out a 

written screening from in the waiting room, while 

others have medical assistants/technologists, case 

managers, patient or peer navigators or health 

educators conduct the screening in the exam room. 

Written responses are included in a patient’s medical chart. Screenings administered on tablets or other technologies allow responses to go directly to the electronic health record (EHR).

TIPS FOR IMPLEMENTING SCREENING FOR BEHAVIORAL HEALTH

Based on the key informant interviews, the following recommendations are offered as ways HIV 

clinics can establish consistent behavioral health screening. 

ORGANIZATIONAL CULTURE

EXPECT AND SHARE POSITIVE PATIENT OUTCOMES.

“We’re committed to it. We saw what a difference it made in the lives of our patients.” – Senior Program 

Manager

• Several participants reported that their organizations believed strongly that screening and treatment for SUDs and mental illnesses improves adherence to ART and better health outcomes. 

• Programs ensure that staff are well aware of the link between behavioral health and good 

health outcomes for people living with HIV and use this knowledge as motivation for conducting the screening and referral to treatment.

• Many of the integrated facilities reported that since they began universal screening, viral 

suppression of those with behavioral health disorders was reduced to be the same as those 
8 SAMHSA-HRSA CENTER for INTEGRATED HEALTH SOLUTIONS

without behavioral health disorders. These positive outcomes were 

shared with staff to reinforce the importance of screening and treatment 

for mental illnesses and addictions. 

FOSTER COLLABORATION 

BETWEEN PRIMARY AND 

BEHAVIORAL HEALTH 

PROFESSIONALS.

“I’m there. I’m in their view. It makes it 

more likely that they are going to refer 

to me when they actually see me.” — 

Behavioral Health Clinician 

• Programs that reported high 

rates of screening and referrals to 

treatment provided opportunities for 

primary and behavioral health care 

professionals to communicate and 

collaborate. 

• In programs that were highly 

integrated, multidisciplinary communication takes place during in-person 

case conferences from once a week to 

two times per month. Some programs 

conduct daily morning “huddles.” 

• Several program managers noted that face-to-face contact is critical 

to building effective working relationships that support collaborative 

and coordinated care

• One behavioral health program 

emphasized recruiting for onsite primary care providers who understood

that communication with the behavioral health clinicians was critical to 

the team. 

• Another program affiliated with 

a teaching hospital found annual 

training was necessary to 

reinforce a culture of communication 

to interns and residents. 

TECHNOLOGY-BASED 

SCREENING

Electronic Patient Recorded Outcomes (ePRO) is 

a web-based system that allows patients to complete screenings on a tablet at the beginning of 

their visit. The ePRO system screens for depression, tobacco, intimate partner violence, learning 

needs, drug and alcohol use, anxiety, sexual risk 

behavior, medication adherence, health-related 

quality of life and physical activity and includes a 

symptom index. 

The software can determine which surveys are 

appropriate for each visit based on set criteria 

and determines what issues are most important for each visit based on the results of a brief 

five-minute screening. Screening results flow 

directly into the EHR so that they are immediately available to the team of providers. This 

streamlines documentation workflow, supports 

data-driven evaluation of individual and group 

outcomes and monitors for quality assurance. 

A busy federally qualified health center (FQHC) 

on the east coast uses the ePRO system to 

screen all patients. The clinic has about 40 iPads 

available for use – one per provider. Program 

evaluations indicate the technology is well received by both patients and staff. While the 

technology is intuitive and user-friendly, staff are 

trained to give a brief tutorial on using the iPad 

for patients who need assistance. ePRO has both 

English and Spanish language options; however, 

if a patient speaks another language or cannot 

use the technology, a staff member can conduct 

the screening verbally.

The program received a National Institutes of 

Health grant to study the system’s effectiveness 

and a local health insurance company foundation supported additional iPads. Costs include 

web-hosting services, storage lockers to charge 

the iPad and programming to load information 

directly into the EHR. 
integration.samhsa.gov 9

• Several programs noted that both in-person communication and communication through secure 

EHRs were necessary to distribute critical information to the entire multidisciplinary care team. 

HELP PRIMARY CARE PROVIDERS SEE THE VALUE IN SCREENING.

After implementing SBIRT statewide, the value of screening was demonstrated to primary care 

providers by the number of lower-level substance use issues that were effectively addressed 

through brief interventions by health educators before they reached the level of SUD. Examples 

from similar organizations like, “Using SBIRT, a busy HIV clinic like yours identified 15 percent more 

patients with risky substance use,” can be effective tools to demonstrate the value of screening 

and brief interventions to primary care providers. 

• A state health program that implemented SBIRT in all of its contracted HIV clinics observed that 

some primary care providers incorrectly believe that they already identify individuals with risky 

substance use or mental health problems without screening. 

• A few programs questioned the value of screening, because they believed an effective medical 

provider should be able to identify behavioral health problems based on their clinical judgment 

and knowledge of a particular patient. However, research shows that primary care providers 

recognize depression only 50 to 70 percent of the time.xx 

• A large HIV clinic using electronic screening methods captured reports of mental health or 

substance use problems that were previously missed or undocumented by primary care 

providers for a significant number of patients.xxiii Nurses in that clinic are trained to treat the 

results of screening as “another vital sign,” like blood pressure or heart rate.

INFRASTRUCTURE AND IMPLEMENTATION

SCREEN ALL PATIENTS, NOT JUST THOSE WITH HIV.

Programs reporting high rates of screening conduct behavioral health screening on all of their 

patients, regardless of HIV status. This sets an institutional expectation for screening which helps 

staff become more comfortable with the process and allows screening to become part of workflow 

and quality assurance processes. Universal screening reduces the possibility of biases that might 

influence a decision to skip screening. For example, some programs reported that middle- and upper-income individuals were not always screened. Anything staff can do to “normalize” behavioral 

health screening demonstrates to patients that it is a routine part of health care. 

• In a state that conducts SBIRT throughout its HIV clinics, providers learned to shift their 

thinking from identifying disorders and referring to treatment only those that they perceive 

as “high risk” to identifying risk factors and intervening among all patients. 

• One program reported that patients sometimes leave a number of questions blank at the end 

of the PHQ-9 because of fear of hospitalization if there are too many “yes” responses. In those 

situations, staff recommends a follow-up conversation with the primary care provider or a warm 

hand-off to a behavioral health professional. 
10 SAMHSA-HRSA CENTER for INTEGRATED HEALTH SOLUTIONS

PLAN THE ROLLOUT OF SCREENING CAREFULLY.

Planning for change in a busy primary HIV care program requires an understanding of how the 

change will affect the larger clinic environment. The planning process should include:

• Carefully selecting validated screening tools and a workflow analysis.

• Implementing screening instruments based on clinic workflow and adjusting as necessary. 

• Training all employees in the screening process, including how to conduct screening and 

respond to results. 

• Defining project success to all employees by transparently communicating outcomes. 

A “Plan-Do-Study-Act” cycle of analysis may be effective when implementing change. A program 

that struggled to implement screening said primary care providers were concerned about the time 

it takes. The clinic — which now boasts a 97 percent screening rate — studied the workflow 

process and reduced the time for medical assistants to enter results into the chart to four minutes. 

The program is trying to reduce that time even further.

TRAIN STAFF TO CODE THE SCREENING AND/OR BRIEF INTERVENTIONS FOR BILLING.

The fact that SBIRT was billable under Medicaid was one factor in achieving buy-in for the 

statewide implementation program. Teaching staff to code for screening and brief interventions

ensured the clinic recouped some of the related expenses. Programs should review their states’ 

Medicaid system to determine if brief interventions by paraprofessionals such as health 

educators or peer specialists are reimbursable.
integration.samhsa.gov 11

GET BUY-IN FROM KEY 

STAKEHOLDERS.

 A large urban clinic that uses 

technology-based screening (see box, 

page 8) began its rollout slowly, starting with a “champion” on one floor. 

This early adopter communicated 

success to others, which paved the way 

for implementation to the rest of that 

floor. Program managers studied problems with clinic flow, refined the process and rolled it out on another floor, 

then another. 

 The statewide SBIRT program also 

used champions within a primary care provider system to support implementation. 

FACILITATE COMMUNICATION

BETWEEN PRIMARY AND 

BEHAVIORAL HEALTH CARE 

PROVIDERS.

Integrated EHRs allow providers to 

share notes, referrals and medications, 

which enhances their ability to provide 

informed care. A 2011 policy paper by 

the HIV Medicine Association and the 

Ryan White Medical Providers Coalition 

states, “EHRs are a key component of 

effective integrated care and medical 

home models.”xxiv The Institute of Medicine (IOM) notes that both in-person 

and electronic communication facilitates care coordination among providers and are key steps in redesigning 

effective health systems, creating 

patient-centered medical homes and 

ensuring better outcomes.xxv

• A program that allows onsite access to EHRs to only one full-time mental health clinician and 

not to contracted off-site behavioral health clinicians, reported significantly less communication 

between primary care and behavioral health providers. 

PROVIDE SUPPORTS THAT MAKE REFERRAL TO TREATMENT STICK. 

Successful programs with increased referrals and high levels of retention with behavioral health 

interventions are highly integrated, with numerous clinicians who are available to receive a “warm handoff” from either a primary care provider or a non-medical staff member. Support resources may include 

CONNECTING PATIENTS TO 

COMPLEX SYSTEMS OF CARE

A west coast behavioral health program that 

integrated primary care into its services for 

patients who have HIV or AIDS created a 

navigation program to connect patients to 

care, including screenings, assistance navigating the health care system and links to 

behavioral and mental health service. The 

goals are to improve patient experiences by 

delivering care when it is most needed, provide access to additional behavioral health 

supports and improve behavioral health 

follow-up. 

Patient navigators enhance co-located services by completing patient intake procedures, connecting their assigned patients to 

the correct services and “tracking” them using the EHR and other internal management 

information systems. For example, the program uses the PHQ-2 to identify potential 

depression. If patients are flagged for follow-up based on the screening, they receive 

medical care and are then connected to 

the behavioral health specialist on call. The 

patient navigator consults with other service 

providers and provides input on treatment 

for up to three months to ensure the patient 

follows through on referrals. Quality assurance is measured by assessing the number 

of patients assisted by the patient navigator 

and the percentage of patients who follow 

through with service appointments. 
12 SAMHSA-HRSA CENTER for INTEGRATED HEALTH SOLUTIONS

a health educator, case manager or peer/patient navigator focusing on accessing the behavioral health 

program, filling out paperwork and securing other support services, such as transportation.

DEVELOP EFFECTIVE LINKS TO SUBSTANCE USE DISORDER AND 

MENTAL HEALTH TREATMENT PROGRAMS.

Even the most integrated primary HIV care programs do not have the full continuum of behavioral 

health care available onsite such as detox, medication assisted treatment for addiction, intensive 

outpatient treatment for addiction or mental health or residential treatment. Formal partnerships 

that outline in a memorandum of understanding, clear roles, responsibilities and communication 

expectations with shared EHRs and co-location of some services in the primary care site can 

facilitate referrals. 

PEOPLE AND PLACES

CONSIDER USING NON-CLINICAL STAFF FOR SCREENING AND BRIEF INTERVENTIONS.

Most programs use staff without advanced medical training — medical assistants, health educators, 

peer/patient navigators or community health workers — to conduct the brief screening such as the 

PHQ-2 and AUDIT-C and used behavioral health providers for longer assessments like the PHQ-9 

and AUDIT. 

• The state that implemented SBIRT used highly trained health educators to conduct screening 

and brief interventions for substance use to provide effective and nonjudgmental support and 

reduced cost. 

CHOOSE APPROPRIATE BEHAVIORAL HEALTH CLINICIANS FOR WARM 

HAND-OFFS AND REFERRALS.

Behavioral health clinicians in an integrated and/or co-located program must be particularly flexible 

and understand the model for providing services in a primary care setting. This means being 

available for a warm hand-off for immediate assessment and accepting the responsibility 

of providing mostly short-term interventions (four to six visits). Referrals are reserved for longerterm therapy. 

Not all behavioral health clinicians feel comfortable with this model. Many are used to, or prefer 

the predictable pace of a 50-minute session that provides the opportunity to develop longer-term 

relationships with clients. During the interview process, job previews – like having a prospective 

employee spend time in the clinic shadowing a similar behavioral health clinician or showing videos 

of the clinic experiences – may be helpful in creating realistic expectations. 

HIRE ENOUGH BEHAVIORAL HEALTH PROVIDERS.

Having enough behavioral health staff available increases the probability that further assessment, 

case consultation and warm hand-offs to behavioral health services will take place. One of the 

biggest challenges organizations face is too few internal and external behavioral health providers 

for referrals or case consultation, particularly with psychiatrists or psychiatric nurse practitioners for 

psychopharmacology. 
integration.samhsa.gov 13

• A program that reported having enough behavioral health clinicians to be flexible and easily available 

worried about retaining these positions when the state grant funding that supports their salaries runs 

out. The growing workforce of peer providers is emerging as an important resource for programs.xxvi,xxvii

• Unrealistic workload expectations may affect employee retention and continuity of care. One program reported that its social worker who had a caseload of 190 HIV-positive patients also conducted all the annual assessments, leaving little time for short- or longer-term interventions. The clinic 

reported high turnover among social workers and struggles with fully integrating behavioral health.

TRAIN, TRAIN, TRAIN.

Retraining capabilities should be built into all training programs. 

• One program recognized that the need for increased training to reduce the number of refusals for 

addiction screening, particularly from the transgender population. The number of refusals dropped 

among all populations after they offered additional training to screening staff, primary care providers and others. 

CONSIDER PHYSICAL LOCATION. 

“Space is the final frontier.” – Program Manager who successfully argued for an exam room for 

mental health clinicians

Physical location can influence the outcomes of both screening and subsequent assessment/referral. 

• A program that uses tablets for screening conducted a study on differences in refusal rates. The refusal 

rates were lower when patients were screened in exam rooms compared to screenings in waiting 

rooms. This suggests that willingness to participate in screening depends on perceived privacy.

Physical location also influences post-screening brief interventions or treatment referral. Availability 

of onsite assessment and treatment referral facilitates a warm hand-off from the primary care 

provider to the behavioral health clinician. 

• A program reported a 50 percent rate of follow-through when its behavioral health services 

were 1.5 miles away. Follow-through on referrals increased when services were co-located. 

• Co-location itself does not guarantee a warm hand-off. A clinic with a contracted behavioral 

health clinician was co-located on a floor with primary HIV care; however, the behavioral health 

clinician — who must bill his/her time — is often behind closed doors, making it difficult to 

connect patients to him/her. 

• Three highly integrated programs report that appropriate scheduling allows their behavioral health 

clinicians to be available 50 percent of the time for warm hand-offs, detailed assessments, brief 

interventions, crisis stabilization and other related activities. 

• For many programs, grants and other fundraising enables clinicians to be scheduled for non-billable time.
14 SAMHSA-HRSA CENTER for INTEGRATED HEALTH SOLUTIONS

CONCLUSION

Behavioral health screening is an important step for health care provider organizations to increase 

access to quality behavioral health care. By following the steps and examples outlined, organizations can build effective behavioral health screening that supports a system of integrated care. 

These recommendations and lessons learned, when implemented, can result in a truly effective and 

more comprehensive model to meet the multiple needs of individuals living with HIV. 

STATEWIDE IMPLEMENTATION OF SBIRT

The efficacy of the SBIRT model in identifying risk of SUDs led a western state to implement 

it for all Ryan White programs, including clinics and AIDS service organizations. The state’s 

public health program ensured adoption across all programs by requiring use of SBIRT in its 

contract.

While some SBIRT programs pose one or two questions about substance use, this state asks 

four key questions. Two questions focus on alcohol — the number of drinks per week and 

the last time four to five drinks were consumed in one day — one asked about the use of an 

illegal drug or a prescription drug for nonmedical reasons in the past year and one focused 

on tobacco use. If the results indicate a possible substance use problem, health educators 

use additional screens or longer assessment instruments to explore the scope of the issue. 

Staff at many primary care programs were skeptical about the effectiveness of screening 

and worried about its effect on various clinic flow issues. Questions arose about the time it 

would require, who would perform the screening and brief intervention, where would it take 

place and finding appropriate places for referral. As training rolled out across the state and 

similar clinics reported success, primary care providers started to embrace SBIRT. Approximately 85 percent of patients at publicly funded clinics who are HIV-positive are screened 

with SBIRT at least once a year and 50 to 60 percent are screened annually for mental health 

concerns. 

Focus groups revealed that patients appreciated the opportunity to talk with medical providers about substance use when asked in a respectful way and providers felt it gave them a 

more complete picture of patients’ health. The SBIRT program helped normalize discussions 

about substance use in medical settings by demonstrating to primary care providers that 

those who screen positive for some risky behaviors are not necessarily addicted to alcohol 

or other drugs, but are part of a wider continuum of people who may need intervention. 

Lessons learned about supporting SBIRT implementation included the importance of finding 

champions within each program and using them to develop staff support, define clear protocols that match clinic flow and improve referral systems to ensure that those who need more 

than a brief intervention receive additional treatment.
integration.samhsa.gov 15

REFERENCES

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Bing, E. G., Burnam, M. A., Longshore, D., Fleishman, J. A., Sherbourne, C. D., London, A. S. & Shapiro, M. (2001). Psychiatric disorders and drug use among human immunodeficiency virus–infected adults in the United States. Archives of General Psychiatry, 58(8), 

721-728. 

iiNational Survey on Drug Use and Health (2010). HIV/AIDS and Substance Use. Substance Use and Mental Health Services Administration. http://www.samhsa.gov/sites/default/files/hiv-aids-and-substance-use.pdf

iiiDurvasula, R., & Miller, T. R. (2014). Substance Abuse Treatment in Persons with HIV/AIDS: Challenges in Managing Triple Diagnosis. 

Behavioral Medicine, 40(2), 43-52.

ivGaynes, B. N., Pence, B. W., Eron Jr, J. J., & Miller, W. C. (2008). Prevalence and comorbidity of psychiatric diagnoses based on reference standard in an HIV+ patient population. Psychosomatic medicine, 70(4), 505

v

Do, A. N., Rosenberg, E. S., Sullivan, P. S., Beer, L., Strine, T. W., Schulden, J. D., ... & Skarbinski, J. (2014). Excess burden of depression 

among HIV-infected persons receiving medical care in the United States: data from the medical monitoring project and the behavioral 

risk factor surveillance system. PLoS One.

viCiesla, J. A., & Roberts, J. E. (2001). Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Meta, 

158(5).

viiMorrison, M. F., Petitto, J. M., Have, T. T., Gettes, D. R., Chiappini, M. S., Weber, A. L., ... & Evans, D. L. (2002). Depressive and anxiety disorders in women with HIV infection. American Journal of Psychiatry, 159(5), 789-796.

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SPECIAL THANKS

SAMHSA and HRSA would like to thank the following people for their assistance in the preparation 

of this document: 

• Advocates for Human Potential, Inc., Fran Basche

• AIDS Arms, Inc., Dallas, TX

• Baystate Health, Brightwood Health Center, Springfield, MA

• Fenway Health, Boston, MA

• Health Care Center for the Homeless, Orlando, FL

• Integrated STI/HIV/Viral Hepatitis Care and Prevention Program, Colorado Department of 

Public Health and Environment, Denver, CO

• Montefiore Medical Group, Bronx, NY

• Tarzana Treatment Centers, Inc. Los Angeles, CA
HHS Publication No. SMA 16-4999