Pain syndromes in HIV infection

Global Prevalence of Chronic Pain in Women with HIV: A Systematic Review and Meta-analysis

Chronic pain is common among people with human immunodeficiency virus (HIV) and detrimental to quality of life and overall health. It is often underdiagnosed, undertreated, and frankly dismissed in women with HIV, despite growing evidence that it is highly prevalent in this population. Thus, we conducted a systematic review and meta-analysis to estimate the global prevalence of chronic pain in women with HIV. The full protocol can be found on PROSPERO (identifier CRD42022301145). Of the 2984 references identified in our search, 36 were included in the systematic review and 35 in the meta-analysis. The prevalence of chronic pain was 31.2% (95% confidence interval [CI], 24.6%-38.7%; I2 = 98% [95% CI, 97%-99%]; P < .0001). In this global assessment, we found a high prevalence of chronic pain among women with HIV, underscoring the importance of understanding the etiology of chronic pain, identifying effective treatments, and conducting regular assessments in clinical practice.

Prescription of High-Dose Opioids Among People Living with HIV in British Columbia, Canada

People living with HIV (PLHIV) often experience pain for which opioid medications may be prescribed. Thus, these individuals are particularly vulnerable to opioid-related harms, including overdose, misuse, and addiction, particularly when prescribed at high doses. We used a comprehensive linked population-level database of PLHIV in British Columbia (BC) to identify demographic and clinical characteristics associated with being prescribed any high-dose opioid analgesic, defined as > 90 daily morphine milligram equivalents (MME/day). Among PLHIV who were prescribed opioids between 1996 and 2015 (n = 10,780), 28.2% received prescriptions of > 90 MME/day at least once during the study period. Factors positively associated with being prescribed high-dose opioid analgesics included: co-prescription of benzodiazepines (adjusted odds ratio [AOR] = 1.14; 95% confidence interval 1.11-1.17); presence of an AIDS-defining illness (ADI; AOR = 1.78; 95% CI 1.57-2.02); seen by an HIV specialist (AOR = 1.24; 95% CI 1.20-1.29); substance use disorder (AOR = 1.46; 95% CI 1.25-1.71); and more recent calendar year (AOR = 1.05; 95% CI 1.04-1.06). Given the known risks associated with high-dose opioid prescribing, future research efforts should focus on the clinical indication and outcomes associated with these prescribing practices.

Direct effects of HIV-1 Tat on excitability and survival of primary dorsal root ganglion neurons: possible contribution to HIV-1-associated pain

The vast majority of people living with human immunodeficiency virus type 1 (HIV-1) have pain syndrome, which has a significant impact on their quality of life. The underlying causes of HIV-1-associated pain are not likely attributable to direct viral infection of the nervous system due to the lack of evidence of neuronal infection by HIV-1. However, HIV-1 proteins are possibly involved as they have been implicated in neuronal damage and death. The current study assesses the direct effects of HIV-1 Tat, one of potent neurotoxic viral proteins released from HIV-1-infected cells, on the excitability and survival of rat primary dorsal root ganglion (DRG) neurons. We demonstrated that HIV-1 Tat triggered rapid and sustained enhancement of the excitability of small-diameter rat primary DRG neurons, which was accompanied by marked reductions in the rheobase and resting membrane potential (RMP), and an increase in the resistance at threshold (R(Th)). Such Tat-induced DRG hyperexcitability may be a consequence of the inhibition of cyclin-dependent kinase 5 (Cdk5) activity. Tat rapidly inhibited Cdk5 kinase activity and mRNA production, and roscovitine, a well-known Cdk5 inhibitor, induced a very similar pattern of DRG hyperexcitability. Indeed, pre-application of Tat prevented roscovitine from having additional effects on the RMP and action potentials (APs) of DRGs. However, Tat-mediated actions on the rheobase and R(Th) were accelerated by roscovitine. These results suggest that Tat-mediated changes in DRG excitability are partly facilitated by Cdk5 inhibition. In addition, Cdk5 is most abundant in DRG neurons and participates in the regulation of pain signaling. We also demonstrated that HIV-1 Tat markedly induced apoptosis of primary DRG neurons after exposure for longer than 48 h. Together, this work indicates that HIV-1 proteins are capable of producing pain signaling through direct actions on excitability and survival of sensory neurons.

Peripheral nerve exposure to HIV viral envelope protein gp120 induces neuropathic pain and spinal gliosis

Painful sensory neuropathy is a common and debilitating consequence of human immunodeficiency virus (HIV). The underlying causes of neuropathic pain are most likely not due to direct infection of the nervous system by active virus. The goal of this study was to determine whether epineural exposure to the HIV-1 envelope protein gp120 could lead to chronic painful peripheral neuropathy. Two doses of gp120 or BSA control were transiently delivered epineurally via oxidized cellulose wrapped around the rat sciatic nerve. Animals were assessed for neuropathic pain behaviors at several intervals from 1-30 days following nerve surgery. Allodynia and hyperalgesia were observed within 1-3 days following gp120 and sustained throughout the testing period. The gp120-exposed sciatic nerve exhibited early but transient pathology, notably axonal swelling and increased tumor necrosis factor alpha (TNF-alpha) within the nerve trunk. In contrast, intense astrocytic and microglial activation was observed in the spinal cord, and this gliosis persisted for at least 30 days following epineural gp120, in parallel with neuropathic pain behaviors. These findings demonstrate that limited peripheral nerve exposure to HIV protein can induce persistent painful sensory neuropathy that may be sustained and magnified by long-term spinal neuropathology.

Classifications of oral lesions in HIV infection

BACKGROUND

Manifestations of immunosuppression may take the form of opportunistic infection, and neoplasia. While this paper has focused on gingival and periodontal manifestations. these tissues cannot be evaluated in isolation. The presence of involvement of other oral tissues such as the cheek or tongue with manifestations associated with HIV such as hairy leukoplakia, Kaposi's sarcoma at these sites, and candidiasis in addition to periodontal manifestations may further increase the clincal suspicion of underlying immunosuppression and/or progression of the immunosuppressive state.

DISCUSSION

The periodontist plays an essential r le in identifying the periodontal status of an individual and has an important r le to play in early recognition of signs and symptoms of HIV disease or progression of the medical condition.

CONCLUSION

Only through such recognition can appropriate definitive diagnostic testing be conducted, and appropriate therapeutic intervention for the oral condition and the systemic condition be considered.

Multidimensional aspects of pain in HIV-infected individuals

To study the prevalence, intensity, and quality of pain in patients with human immunodeficiency virus (HIV) infection and to evaluate factors influencing the different components of pain, a self-administered multidimensional pain questionnaire (Italian Pain Questionnaire [IPQ]) was administered to 153 HIV patients admitted to the Department of Infectious Diseases of a teaching hospital over a 7-month period. Ninety-three (60.8%) patients experienced pain for a total of 131 pain sites. The intensity and the nonsensorial components of pain were greater in ward patients compared to outpatients. In 70% of pain syndromes it was not possible to define the etiology at the time of the visit. Pain was observed more frequently in intravenous drug users (IDUs) (72.9%) compared to patients with other HIV modalities of transmission (50.6%) (p = 0.008). The mean value of sensory class was greater in patients who were not IDUs. Within IDUs group there was a predominance of descriptors of the affective class over the sensory class. The prevalence of pain is high in HIV-infected individuals. The different components of pain are influenced by the modality of transmission and the setting of care. The assessment of scores of different components of pain could help to select and monitor appropriate interventions in pain control.

HIV/AIDS-related Pain as a Chronic Pain Condition: Implications of a Biopsychosocial Model for Comprehensive Assessment and Effective Management

This paper reviews the current literature focusing on pain in HIV/AIDS, including prevalence, pathophysiology, substance abuse, treatment issues, and psychosocial contributions. In light of the high prevalence of pain among individuals with HIV/AIDS, attention is paid to the negative psychosocial impacts of pain in this population and to psychosocial barriers to optimal HIV/AIDS-related pain treatment. The paper conceptualizes HIV/AIDS pain as chronic pain. Subsequently, a biopsychosocial model of chronic pain assessment and treatment is applied. A multidimensional framework is presented for appropriate assessment and treatment of HIV/AIDS patients with pain, and specific recommendations and guidelines are offered for assessment and multimodal treatment of HIV/AIDS-related pain informed by the model.

Pain and symptom control in terminally ill children

The management of pain in terminally ill pediatric patients has incalculable benefits to patients, their families, and physicians and nurses. A therapeutic management plan is dependent on a thorough understanding of the causes of pain in these patients, on pain assessment, and on the myriad drugs and drug strategies that are essential in pain treatment. Aggressive symptom control of treatment-related side effects can ensure successful implementation of such a plan.

The implications of HIV for the anaesthetist and the intensivist

The acquired immune deficiency syndrome has reached pandemic proportions. Anaesthetists should be aware of the implications of dealing with increasing numbers of both diagnosed and undiagnosed, symptomatic and asymptomatic, human immunodeficiency virus-infected patients in the fields of intensive therapy, operating theatre anaesthesia, obstetrics and pain management. With recent advances, important insights have been gained into the pathogenesis of human immunodeficiency virus. Molecular techniques allow quantification of viral burden, and together with CD4 T-lymphocyte count, prognosis and response to therapy can be evaluated. New drugs and therapeutic regimens have improved prognosis for those who are infected with the virus and vertical transmission of infection from mother to infant can be minimised. Should accidental occupational exposure to the virus occur, a prophylactic regimen of antiretroviral drugs can be administered in an attempt to prevent subsequent human immunodeficiency virus infection.

The impact of HIV infection on primary headache. Unexpected findings from retrospective, cross-sectional, and prospective analyses

Headache is one of the most important factors influencing the quality of life in patients infected with the human immunodeficiency virus type 1 (HIV). However, only symptomatic headache but not changes or primary headache types during HIV infection have been studied to date. Therefore, we aimed to determine the impact of an HIV infection on frequency and semiology of different primary headache types. Patients with confirmed HIV type 1 infection underwent a neurological examination, neuroimaging or EEG, and a standardized interview. Time pattern and symptoms of headaches (cross-sectional analysis), changes of headaches preexisting to their infection (longitudinal retrospective analysis), and changes of primary headaches during a 2-year follow-up (longitudinal prospective analysis) were evaluated as were the correlations between these headache patterns and different markers of HIV infection. One hundred thirty-one consecutive HIV-infected patients without evidence of a cerebral manifestation except mild encephalopathy were enrolled. The point prevalence of migraine was 16.0% (confidence interval (CI) 10.1-25.4%), of headache with a semiology of tension-type headache 45.8% (CI 33.7-62.2%), and of other headache types 6.1% (CI 3.0-12.5%). During the natural course of infection, the migraine frequency significantly decreased in the retrospective and in the prospective analyses, whereas the frequency of the headache with a semiology of tension-type headache significantly increased in all three analyses. In 20% of all patients, the tension-type headache could be considered as symptomatic due to the infection but not due to focal or general cerebral lesions. Changes of primary headache were significantly associated with different stages of the infection and with the presence of mild encephalopathy but not with antiretroviral treatment or CD4 cell count. HIV infection seems to be associated with a progressive decrease in migraine frequency and intensity which probably is related to the immunological state of the patients. Tension-type headache becomes more frequent during HIV infection. However, this can in part be related to secondary headache caused by the HIV in less than 50% of patients with tension-type headache. The progressing immunological deficiency of HIV-infected patients seems to influence pain processing of primary headache types in different ways.

Efficacy of a vibratory stimulus for the relief of HIV-associated neuropathic pain

Pain related to HIV disease is frequently debilitating. Of the many pain syndromes that occur in persons with HIV, distal symmetrical polyneuropathy (DSPN) is particularly devastating. Because DSPN often responds, at best, only partially to available pharmacologic interventions, non-pharmacologic interventions need to be investigated. Vibration has been suggested to be effective for reducing pain in other populations with chronic pain. This randomized, sham-controlled, double-masked study tested the short-term efficacy of a 45-min vibration treatment for DSPN foot pain in persons infected with HIV. Vibration therapy was delivered using a portable platform foot vibrator that provided stimulation at a frequency of 60 Hz. For all patients, the control box for the vibrator emitted an audible hum and part of the control box lit up during treatment, but only patients randomized to active treatment received vibration. Pain intensity (0-10) was measured immediately prior to and after treatment. Subjects were also questioned regarding pain relief (0-100%) immediately after the treatment. The mean percentage pain relief was 61.0+/-33.1% (median 70.0; range 0-100) for all patients, 67.3+/-34.0% (median 80.0; range 0-100) for vibration patients, and 55.0+/-32.0% (median 60.0; range 0-100) for sham patients. No statistically significant differences were found between the vibration and sham groups with respect to percentage pain relief (Mann-Whitney test; P=0.19) or the pre- and post-treatment current-pain difference (Mann-Whitney test; P=0.92). These results underscore the necessity for control groups in studies of non-pharmacologic therapies for pain.

Topical capsaicin in the management of HIV-associated peripheral neuropathy

Distal symmetrical peripheral neuropathy (DSPN) is a particularly distressing pain syndrome associated with human immunodeficiency virus (HIV) disease. Capsaicin has been found to be effective in relieving pain associated with other neuropathic pain syndromes, and is mentioned as a possible topical adjuvant analgesic for the relief of DSPN. This multicenter, controlled, randomized, double-masked clinical trial studied patients with HIV-associated DSPN and compared measures of pain intensity, pain relief, sensory perception, quality of life, mood, and function for patients who received topical capsaicin to the corresponding measures for patients who received the vehicle only. Twenty-six subjects were enrolled in the study. At the end of 1 week, subjects receiving capsaicin tended to report higher current pain scores than did subjects receiving the vehicle (Mann-Whitney test; P = 0.042). The dropout rate was higher for the capsaicin group (67%) than for the vehicle group (18%) (chi 2 test of association; P = 0.014). There were no other statistically significant differences between the capsaicin and vehicle groups with respect to current pain, worst pain, pain relief, sensory perception, quality of life, mood, or function at study entry or at any time during the 4-week trial. These results suggest capsaicin is ineffective in relieving pain associated with HIV-associated DSPN.

The experience of pain in persons with HIV/AIDS

A phenomenological design was used to elicit data about the experience of pain caused by HIV from 21 men and 1 women who attended ambulatory clinics. Data were generated through open-ended interviews. The phenomenon of pain appeared to be interpreted by the participants in a broad manner. The four themes that emerged from the data were physical pain, painful losses, the pain of not knowing, and social pain. In addition, coping strategies used to deal with pain are identified in this study. This study offers nurses a view into the phenomenon of pain in people with HIV that goes well beyond physical pain and associated-pain syndromes.

[Anesthesia in the HIV positive or AIDS patient]

OBJECTIVE

To analyze the current anaesthetic management of HIV/AIDS patients.

DATA SOURCES

References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service, personal files.

STUDY SELECTION

Original articles, reviews, cases reports, letters to the editor in French and English were analyzed and selected.

DATA EXTRACTION

Current data on HIV infection, perioperative clinical and biological symptoms, arguments for choice of the type of anaesthesia, risks of transmitting HIV to health care workers and protective measures were extracted.

DATA SYNTHESIS

Twenty per cent of HIV-positive patients require surgery during their illness. Anaesthesia and surgery decrease cell mediated immunity and modify the activity of immune mediators. These changes are more pronounced under general anaesthesia compared to regional anaesthesia. They are transient and not clinically significant. Poor information is available concerning the perioperative management of HIV-positive patients and the effects of anesthesia on their immune status. Preoperative evaluation focuses on the following three important data: patient's status, surgery, and anaesthesia. In patients in good clinical conditions who comply with treatment, the anesthetist assesses the effects of the antiretroviral treatment and the risk of interactions between anaesthetic and antiretroviral agents. Etomidate, atracurium, cisatracurium, remifentanil and desflurane are not dependent on hepatic metabolism by the cytochrome P450 system. In patients in bad clinical conditions or in patients who do not comply with treatment, attention focuses on cardiovascular, pulmonary, neurologic and nutritional status. The specific antiretroviral treatment is not discontinued in the perioperative period, as far as compatible with the type of surgery and associated dysfunction of the digestive tract. Regional anaesthesia offers the benefits of not interfering with the immune system and antiretroviral agents. However, the viral infection can be enhanced by regional anaesthesia due to the cofactors' effect of local anaesthetic agents in cerebrospinal fluid. Homologous blood transfusion is not recommended as it increases postoperative infection and viral activation. Erythropoietin can be of benefit in selected cases. In the future, supportive immunotherapy will probably be the main tool for perioperative management of HIV and AIDS patients.

Symptom-specific use of upper gastrointestinal endoscopy in human immunodeficiency virus-infected patients yields high dividends

The yield of upper gastrointestinal endoscopy (esophago-gastroduodenoscopy; EGD) in human immunodeficiency virus (HIV)-infected patients based on presenting symptoms has not been well studied. We studied consecutive patients with documented HIV infection undergoing EGD at a large innercity hospital between August 1, 1990 and December 31, 1993; all had presenting symptoms and indications for EGD prospectively recorded at the time of EGD. All endoscopic abnormalities were routinely subjected to biopsy, and extensive histopathological evaluation was performed. EGD was considered helpful when the findings stimulated specific therapeutic intervention other than antifungal or antacid medications. The specific indications for EGD in 156 patients were as follows: esophageal symptoms, 102 patients (65%); abdominal pain, 18 (12%); upper gastrointestinal bleeding, 25 (16%); refractory nausea and vomiting, 11 (7%). Overall, pathologic findings were identified in 116 patients (74%): in refractory esophageal symptoms, 82%; upper gastrointestinal bleeding, 92%; abdominal pain, 39%; nausea and vomiting, 27%. EGD with biopsy identified a specifically treatable opportunistic disorder other than Candida in 80 patients (51%), including idiopathic esophageal ulcer (22%) or viral esophagitis and/or duodenitis (29%). EGD was not helpful in 22.3% of cases, those involving Candida (12.3%) and peptic ulcer disease (PUD)-related causes (10%). The mean CD4 count of patients with opportunistic pathologic findings (24/mm3, n = 79) was significantly lower than that of patients with PUD/gastroesophageal reflux disease (GERD) (167/mm3, n = 9) or negative EGDs (165/mm3, n = 35). Overall, the results of EGD influenced patient management in 78% of cases. We conclude that selective symptom-specific use of EGD, particularly in patients with esophageal symptoms refractory to antifungal therapy or gastrointestinal bleeding, usually identifies specifically treatable abnormalities, whereas EGD is less useful for the evaluation of abdominal pain or nausea and vomiting.

The pharmacologic management of pain and discomfort in persons with AIDS near the end of life: use of opioid analgesia in the hospice setting

To determine the prevalence and management of pain and discomfort during the last 2 weeks of life in persons with acquired immunodeficiency syndrome (AIDS) being cared for in hospice settings, and to find the extent to which opioids are used for relief of pain and discomfort during this period, we conducted a retrospective cohort study of patients treated by AIDS hospice agencies in Seattle, Washington (1987-1992). The medical records for the last 2 weeks of life were reviewed for 185 consecutive adults with AIDS who were receiving hospice care. Most [93% (172/185)] experienced at least one 48-hr period of pain and discomfort during the last 2 weeks of life, with prevalence increasing from over one-half of the cohort early in the 2-week course to two-thirds of the cohort late in the course; 88% (162/185) received some form of opioid analgesia (0-100 mg/hr morphine equivalent), with the majority [62% (100/162)] experiencing some relief thereafter. Ten of the 172 with pain and discomfort did not receive an opioid drug; 4 had relief anyway. Among the 7% (13/185) who did not report pain and discomfort during the last 2 weeks of life, 4% (8) received opioid analgesia. Pain and discomfort in persons with AIDS approaching the end of life is a common experience. Opioids are frequently given in widely varying dosages (and dosing strategies), with variable results. Some patients require high doses yet continue in pain; others are comfortable on no medication. The majority of patients receive opioid medications and experience relief from pain and discomfort.

Opioid use in HIV patients with neurological changes

The neurological changes that are common in the HIV population may complicate the use of analgesics, particularly opioids. These changes, in combination with care providers' fear of opioids, often lead to the inappropriate use of antagonists, such as naloxone. Used injudiciously, naloxone can lead to withdrawal syndrome, return of severe pain, and other adverse effects. The authors describe the many disease and treatment-related causes for pain in patients with HIV disease, as well as common neurologic conditions that alter cognition and complicate the use of opioids. A case study is included to illustrate the dangers of inappropriate naloxone use.

[AIDS and pain management-a survey of German AIDS and pain management units.]

The number of AIDS patients is steadily increasing. According to the literature these patients are often in severe pain.

METHODS

We evaluated pain diagnoses and treatments with two almost identical questionnaires for AIDS treatment units (ATU) and pain management units (PMU). Questions dealt with unit type and size, number of patients treated per year and the proportion of intravenous drug users. The units were also asked to give an estimate of pain aetiologies, pain types and localizations and treatment modalities offered.

RESULTS

Completed questionnaires were returned by 38 of 235 ATU and 85 of 127 PMU. In the ATU, 16% of the patients (estimated at 580 patients per year) had pain requiring treatment. In 26 of the PMU approximately 120 AIDS patients per year were treated, while 59 PMU had not yet seen any AIDS patients. Pain was caused mainly by opportunistic infections and by neurological syndromes connected with AIDS. Pain aetiologies could not be differentiated in the ATU in 22% of patients (PMU 9%), and pain types in 33% (PMU 9%). Neuropathic pain (ATU 38%, PMU 89%) was more frequent than nociceptive pain (ATU 29%, PMU 36%). The treatment modalities were systemic pharmacotherapy in 76% of ATU and 73% of PMU and nerve blocks in 37% of ATU and 42% of PMU. In 82% of ATU the staff thought their analgesic therapy was adequate, and in 92% staff were interested in closer cooperation with PMU such as was currently practised in only 6 of the 38 units (16%) that responded.

CONCLUSIONS

The high incidence of complicated neuropathic pain syndromes in AIDS patients requires a sophisticated therapeutic approach. Closer cooperation between AIDS specialists and pain specialists, comparable to that already existing for other patient groups, is therefore desirable.