it is well documented that human immunodeficiency virus ( hiv ) enters the central nervous system early after infection and may result in decrements of cognitive , behavioral , and motor performance . neurocognitive impairment occurs in approximately 30 to 50% of asymptomatic individuals receiving highly active antiretroviral therapy ( haart ) . the specific pattern of neuropsychological deficits associated with hiv involves multiple cognitive domains , including processing speed , learning / memory , psychomotor skills , attention / working memory , and executive function . hiv - positive ( hiv+ ) individuals with executive dysfunction often display a flat affect and apathy caused by damage to this region of the brain . it is important to differentiate behavior and affective changes associated with hiv because apathy , but not depression , is associated with cognitive dysfunction . thus , apathy among hiv - infected individuals may reflect hiv - associated neurologic dysfunction , which is not amenable to treatment with antidepressant medications . this may seem a minor problem , since antidepressants are usually not harmful from a medical perspective ; however , from a resource perspective , this can be wasteful , with some hiv+ individuals being prescribed expensive medications without benefit . cognitive impairment and depression often coexist in hiv . depression does not affect neuropsychological function in hiv - infected individuals , but it can impact quality of life and adversely impact medication adherence . previous research has shown that a single question about depressed mood has a sensitivity of 85 to 90% for major depression , and adding a second question about anhedonia increases the sensitivity to 95% . two screening questions from a focused interviewing guide , the mood module of the primary care evaluation of mental disorders , can help to elicit symptoms of depression . this shortened screening instrument , the patient health questionnaire-2 ( phq-2 ) , was designed for use by healthcare workers without formal training in psychiatry , takes only a few minutes ( < 5 minutes ) to administer and score , can be easily interpreted , and has been translated into multiple languages . poor insight is often a component of executive dysfunction , so directly asking patients if they are experiencing cognitive problems may be misleading . it is important to obtain information from family / friends who are familiar with the patient 's behavior . a cross - cultural investigation demonstrated that executive dysfunction is relatively robust to cultural differences . and the willingness of the family members to report such symptoms did not differ between cultures , which suggest that the construct of the dysexecutive syndrome has validity across cultures . a 42-year - old hiv+ man presented for neuropsychological testing because of unusual behavior observed by his family over the past 3 to 4 years , which included decreased social awareness , occasional inappropriate comments , and , these behaviors had gradually worsened , and most recently , he was observed  watering flowers in the rain . the patient himself appeared apathetic and did not understand his family 's concern or why they thought his behavior was strange . he was employed full - time as a church pastor , but had recently been asked to take a medical leave due to concerns about his unusual behavior . consistent with his apathetic demeanor , he had little reaction to this major change in his vocational status . there was no significant medical or psychiatric history prior to the hiv diagnosis . since his diagnosis with hiv 7 years previously , he had been successfully treated with haart , with no history of opportunistic infections . biomarkers were consistently within normal limits , including cd4 cell counts and an undetectable viral load ( < 50 ) . at the time of testing , he was fully oriented and denied cognitive or emotional problems . speech was fluent , and the patient demonstrated an excellent vocabulary consistent with his postgraduate education . affect was noticeably flat , he appeared unconcerned and apathetic , and initiation was poor . based on these changes in affect , he had been diagnosed 3 years previously with depression and prescribed antidepressant medication . there was no improvement in his thinking or affect with the antidepressant medication , so it was discontinued 6 months prior to neuropsychological assessment . testing revealed exceptionally high intelligence quotient ( iq ) scores ( very superior range ) and intact performance on tests of language , attention / working memory , visuospatial perception , and constructional skills . learning and memory scores were in the average range for the patient 's age and education level , which were considered relative impairments in comparison with his high iq scores . he was slow on a measure of sustained attention and executive dysfunction was evident on tests of visual sequencing , verbal and figural fluency , and problem solving / set shifting [ table 1 ] . in addition , a structured behavior rating scale revealed an increase in executive dysfunction since diagnosis with hiv [ table 2 ] . the patient 's flat affect , apathy , and poor initiation were attributed to executive dysfunction rather than depression . since formal neuropsychological testing is often not feasible for individuals infected with hiv in rural settings , this case demonstrates the value of interviewing family members about changes in behavior . thus , family observations may be important in making predictions about performance on executive tasks and by extension , in everyday situations . recent guidelines support the use of standardized mental status examinations , such as the international hiv dementia scale to diagnose hand in regions where neuropsychological testing is not available . although not a replacement for cognitive testing , information from family can provide important supplemental information . it takes only a few minutes to ask family members questions targeted at a range of problems commonly associated with executive dysfunction , such as planning problems , lack of insight , apathy and lack of drive , shallowing of affective responses , motivational changes , and lack of concern . this information , combined with two screening questions about depressed mood and anhedonia , may help to distinguish depression from apathy among individuals with hiv . as a first step to screen for depression , the phq-2 has demonstrated validity [ table 3 ] . in a study that screened for depression in 580 patients in a primary care setting , a cut - off score of > 3 on the phq-2 had a sensitivity of 82.9 and specificity of 90.0 . differentiation of apathy due to executive dysfunction from depression is of great importance , not only clinically , but also to ensure judicious allocation of scarce medical resources . since cognitive and psychiatric symptoms associated with hiv may vary over time , serial monitoring is recommended . the patient health questionnaire-2
individuals infected with human immunodeficiency virus ( hiv ) frequently experience both neurocognitive and psychiatric dysfunction . 
 apathy is a prominent neuropsychiatric symptom associated with hiv and is related to neurologic dysfunction . 
 in contrast , depression is independent of neurocognitive impairment in hiv . 
 this case report illustrates the importance of behavioral observations from family members of hiv - positive ( hiv+ ) individuals as a valuable source of information . 
 these behavioral observations can be particularly important in rural resource - limited settings , where cognitive testing is often limited to standardized mental status examinations .