Chronic pain disorders in HIV primary care: clinical characteristics and association with healthcare utilization

Non-Pharmacological Interventions Addressing Chronic Pain in People Living with HIV

PURPOSE OF REVIEW

Chronic pain affects 25-85% of people living with HIV (PLWH), negatively impacting health behaviors and HIV health outcomes. While opioids are frequently prescribed for pain, there are concerns about side effects and addiction potential, and the current consensus guideline advises against their use as a first-line pain management for this population. Therefore, there is an increasing need for non-pharmacological alternatives and adjunctive interventions. This review aims to examine the characteristics, efficacy, and limitations of existing non-pharmacological approaches to chronic pain management in PLWH to inform clinical practices and future research.

RECENT FINDINGS

A comprehensive literature search identified 13 clinical trials employing cognitive-behavioral techniques, stress management, positive affect enhancement, and complementary medicine approaches (e.g., yoga, acupuncture, hypnosis). These interventions generally showed significant effects with respect to reducing pain intensity and interference in PLWH, with some also addressing and improving depression, substance use, or antiretroviral medication adherence. However, some were pilot trials and others lacked robust methodologies or sufficient follow-up regarding the ability to definitively determine the durability of these benefits. Existing non-pharmacological interventions have potential in addressing pain and related functional impairment in PLWH, such as substance use and emotional well-being. Future research should explore the underlying mechanisms of these interventions and better understand strategies to optimize and establish durability. Incorporating adherence counseling into these interventions could further enhance HIV outcomes by addressing the interconnected challenges of chronic pain and adherence to antiretroviral therapy (ART), thereby supporting both pain management and overall HIV care.

Pain and unhealthy alcohol use among people living with HIV: A prospective cohort study

BACKGROUND

Unhealthy alcohol use is prevalent among people living with HIV/AIDS (PLWH) and contributes to impaired functioning, diminished quality of life, and poorer HIV outcomes. Common cooccurring conditions such as chronic pain may be associated with negative outcomes both directly and through its influence on unhealthy drinking itself. However, there is relatively little known about how pain influences unhealthy drinking among PLWH over time. The current study examined whether pain was associated with indices of unhealthy alcohol use, namely heavy drinking and alcohol use disorder (AUD) assessed 12 months later.

METHODS

The study sample (n = 207) was from the Boston Alcohol Research Collaboration on HIV/AIDS (ARCH) Cohort, a prospective cohort of PLWH with a history of illicit substance or unhealthy alcohol use. We conducted logistic regression analyses to examine the associations between pain and both heavy drinking and AUD status (DSM-5 criteria) (yes/no) over time. In secondary analyses, we examined whether pain was associated with greater AUD severity and whether pain interference was associated with heavy drinking and AUD outcomes.

RESULTS

We found that pain at baseline was associated with greater odds of AUD [aOR = 2.29 (95% CI: 1.13, 4.64), p = 0.02] but not heavy drinking [aOR = 0.91 (95% CI: 0.44, 1.88), p = 0.79] at 12 months. Pain was also associated with more severe AUD. Analyses of pain interference showed similar results.

CONCLUSIONS

Pain is prospectively associated with higher odds of AUD among PLWH with a substance/unhealthy alcohol use history. Providers should routinely address pain among PLWH to improve AUD outcomes.

Efficacy of a Pain Self-Management Intervention Tailored to People With HIV: A Randomized Clinical Trial

Importance

Chronic pain is a common condition for which efficacious interventions tailored to highly affected populations are urgently needed. People with HIV have a high prevalence of chronic pain and share phenotypic similarities with other highly affected populations.

Objective

To evaluate the efficacy of a behavioral pain self-management intervention called Skills to Manage Pain (STOMP) compared to enhanced usual care (EUC).

Design, Setting, and Participants

This randomized clinical trial included adults with HIV who experienced at least moderate chronic pain for 3 months or more. The study was set at the University of Alabama at Birmingham and the University of North Carolina-Chapel Hill large medical centers from August 2019 to September 2022.

Intervention

STOMP combined 1-on-1 skill-building sessions delivered by staff interventionists with group sessions co-led by peer interventionists. The EUC control group received the STOMP manual without any 1-on-1 or group instructional sessions.

Main Outcomes and Measures

The primary outcome was pain severity and the impact of pain on function, measured by the Brief Pain Inventory (BPI) summary score. The primary a priori hypothesis was that STOMP would be associated with a decreased BPI in people with HIV compared to EUC.

Results

Among 407 individuals screened, 278 were randomized to STOMP intervention (n = 139) or EUC control group (n = 139). Among the 278 people with HIV who were randomized, the mean (SD) age was 53.5 (10.0) years; 126 (45.0%) identified as female, 146 (53.0%) identified as male, 6 (2.0%) identified as transgender female. Of the 6 possible 1-on-1 sessions, participants attended a mean (SD) of 2.9 (2.5) sessions. Of the 6 possible group sessions, participants attended a mean (SD) of 2.4 (2.1) sessions. Immediately after the intervention compared to EUC, STOMP was associated with a statistically significant mean difference for the primary outcome, BPI total score: -1.25 points (95% CI, -1.71 to -0.78 points; P < .001). Three months after the intervention, the mean difference in BPI total score remained statistically significant, favoring the STOMP intervention -0.62 points (95% CI, -1.09 to -0.14 points; P = .01).

Conclusion and Relevance

The findings of this randomized clinical trial support the efficaciousness of STOMP as an intervention for chronic pain in people with HIV. Future research will include implementation studies and work to understand the optimal delivery of the intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03692611.

Incarceration history and opioid use among adults living with HIV and chronic pain: a secondary analysis of a prospective cohort study

BACKGROUND

Adults living with HIV have disproportionately high chronic pain, prescription opioid use, history of substance use, and incarceration. While incarceration can have long-lasting health impacts, prior studies have not examined whether distant (>1 year prior) incarceration is associated with opioid use for chronic pain, or with opioid misuse or opioid use disorder among people living with HIV and chronic pain.

METHODS

We conducted a secondary analysis of a prospective cohort study of adults living with HIV and chronic pain. The independent variables were any distant incarceration and drug-related distant incarceration (both dichotomous). Dependent variables were current long-term opioid therapy, current opioid misuse, and current opioid use disorder. A series of multivariate logistic regression models were conducted, adjusting for covariates.

RESULTS

In a cohort of 148 participants, neither distant incarceration nor drug-related incarceration history were associated with current long-term opioid therapy. Distant incarceration was associated with current opioid misuse (AOR 3.28; 95% CI: 1.41-7.61) and current opioid use disorder (AOR 4.40; 95% CI: 1.54-12.56). Drug-related incarceration history was also associated with current opioid misuse (AOR 4.31; 95% CI: 1.53-12.17) and current opioid use disorder (AOR 7.28; 95% CI: 2.06-25.71).

CONCLUSIONS

The positive associations of distant incarceration with current opioid misuse and current opioid use disorder could indicate a persistent relationship between incarceration and substance use in people living with HIV and chronic pain. Additional research on opioid use among formerly incarcerated individuals in chronic pain treatment is needed.

Priorities for HIV and chronic pain research: results from a survey of individuals with lived experience

The Global Task Force on Chronic Pain in HIV published seven research priorities in the field of HIV-associated chronic pain in 2019: (1) causes; (2) management; (3) treatment individualization and integration with addiction treatment; (4) mental and social health factors; (5) prevalence; (6) treatment cost effectiveness; and (7) prevention. The current study used a web-based survey to determine whether the research topics were aligned with the priorities of adults with lived experiences of HIV and chronic pain. We also collected information about respondents' own pain and treatment experiences. We received 311 survey responses from mostly US-based respondents. Most respondents reported longstanding, moderate to severe, multisite pain, commonly accompanied by symptoms of anxiety and/or depression. The median number of pain treatments tried was 10 (IQR = 8, 13), with medications and exercise being the most common modalities, and opioids being viewed as the most helpful. Over 80% of respondents considered all research topics either "extremely important" or "very important". Research topic #2, which focused on optimizing management of pain in people with HIV, was accorded the greatest importance by respondents. These findings suggest good alignment between the priorities of researchers and US-based people with lived experience of HIV-associated chronic pain.

Pilot RCT comparing low-dose naltrexone, gabapentin and placebo to reduce pain among people with HIV with alcohol problems

BACKGROUND

To estimate the effects on pain of two medications (low-dose naltrexone and gabapentin) compared to placebo among people with HIV (PWH) with heavy alcohol use and chronic pain.

METHODS

We conducted a pilot, randomized, double-blinded, 3-arm study of PWH with chronic pain and past-year heavy alcohol use in 2021. Participants were recruited in St. Petersburg, Russia, and randomized to receive daily low-dose naltrexone (4.5mg), gabapentin (up to 1800mg), or placebo. The two primary outcomes were change in self-reported pain severity and pain interference measured with the Brief Pain Inventory from baseline to 8 weeks.

RESULTS

Participants (N = 45, 15 in each arm) had the following baseline characteristics: 64% male; age 41 years (SD±7); mean 2 (SD±4) heavy drinking days in the past month and mean pain severity and interference were 3.2 (SD±1) and 3.0 (SD±2), respectively. Pain severity decreased for all three arms. Mean differences in change in pain severity for gabapentin vs. placebo, and naltrexone vs. placebo were -0.27 (95% confidence interval [CI] -1.76, 1.23; p = 0.73) and 0.88 (95% CI -0.7, 2.46; p = 0.55), respectively. Pain interference decreased for all three arms. Mean differences in change in pain interference for gabapentin vs. placebo, and naltrexone vs. placebo was 0.16 (95% CI -1.38, 1.71; p = 0.83) and 0.40 (95% CI -1.18, 1.99; p = 0.83), respectively.

CONCLUSION

Neither gabapentin nor low-dose naltrexone appeared to improve pain more than placebo among PWH with chronic pain and past-year heavy alcohol use.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT4052139).

Heavy Alcohol Use and HIV Outcomes: The Moderating Role of Pain

Pain and heavy alcohol consumption are prevalent among people living with HIV/AIDS (PLWH), each contributing to impaired functioning and diminished quality of life. Each of these conditions may have negative effects on the HIV care continuum, but less is known about their combined influences. The current study examined how heavy drinking and pain were associated with HIV viral suppression and CD4 cell count among participants receiving antiretroviral therapy (ART). The study sample consisted of 220 PLWH with past 12-month substance dependence or ever injection drug use enrolled in a large HIV cohort study. Logistic regression analyses showed an interaction between pain level (no/mild pain vs moderate/severe) and heavy drinking on viral suppression such that heavy drinking was a significant predictor of poorer viral suppression only for those who experienced moderate/severe pain. We also examined whether ART adherence differentially mediated the association between heavy drinking and HIV viral suppression by level of pain. Although there was a significant indirect effect of heavy drinking on viral suppression among those with moderate/severe pain, moderated mediational analyses did not indicate that the indirect effect of heavy drinking on viral suppression through ART adherence differed significantly by level of pain. Pain level did not significantly moderate the association between heavy drinking and CD4 cell count. We conclude that heavy drinking may be particularly likely to be associated with poorer HIV viral suppression among PLWH with moderate or severe pain. Providers should routinely address comorbid heavy drinking and pain to improve HIV outcomes.

Prevalence, correlates, and quality-of-life outcomes of major or persistent pain among women living with HIV in Metro Vancouver, Canada

While women living with HIV (WLWH) are twice as likely to report severe or undertreated chronic pain compared to men, little is known about pain among WLWH. Our goal was to characterize the correlates of pain as well as its impact on quality-of-life outcomes among women enrolled in the Sexual Health and HIV/AIDS Women's Longitudinal Needs Assessment (SHAWNA), an open longitudinal study of WLWH accessing care in Metro Vancouver, Canada. We conducted logistic regression analyses to identify associations between self-reported major or persistent pain with sociostructural and psychosocial correlates and with quality-of-life outcomes. Data are presented as adjusted odds ratios (aORs) with 95% confidence intervals. Among 335 participants, 77.3% reported pain at ≥ 1 study visit, with 46.3% experiencing any undiagnosed pain and 53.1% managing pain with criminalized drugs. In multivariable analysis, age (aOR 1.04[1.03-1.06] per year increase), food and housing insecurity (aOR 1.54[1.08-2.19]), depression diagnosis (aOR 1.34[1.03-1.75]), suicidality (aOR 1.71[1.21-2.42]), and non-daily, non-injection opioid use (aOR 1.53[1.07-2.17]) were associated with higher odds of pain. Daily non-injection opioid use (aOR 0.46[0.22-0.96]) and health services access (aOR 0.63[0.44-0.91]) were associated with lower odds of pain. In separate multivariable confounder models, pain was associated with reduced odds of good self-rated health (aOR 0.64[0.48-0.84] and increased odds of health interference with social activities (aOR 2.21[1.63-2.99]) and general function (aOR 3.24[2.54-4.13]). In conclusion, most WLWH in our study reported major or persistent pain. Pain was commonly undiagnosed and associated with lower quality of life. We identified structural and psychosocial factors associated with pain in WLWH, emphasizing the need for low-barrier, trauma-informed, and harm reduction-based interventions.

An Analysis of Biopsychosocial Factors Associated With Chronic Pain Severity Among Hospitalized People Living With HIV in Shenzhen, China: A Cross-Sectional Study

ABSTRACT

Chronic pain is a primary health problem in people living with HIV (PWH). However, there is limited research regarding chronic pain among PWH in Chinese health care settings. To investigate biopsychosocial factors of chronic pain severity, we conducted a cross-sectional study in Shenzhen, China. Chronic pain was defined as pain lasting for more than three months. Pain intensity was measured using the numeric rating scale (NRS). Among 123 hospitalized PWH, 78.86% of participants had mild pain and 21.14% had moderate-severe pain. Multiple logistic regression results indicated that PWH in moderate-severe pain group were more likely to have higher levels of interleukin [IL]-6 (OR = 1.034, 95% CI: 1.003-1.066, p = .029) and anxiety (OR = 1.334, 95% CI: 1.071-1.662, p = .010) than those in the mild chronic pain group. Targeted pain management interventions should be explored in clinical practices and future studies regarding PWH with high levels of IL-6 and anxiety.

Pain catastrophizing levels differentiate between common diseases with pain: HIV, fibromyalgia, complex regional pain syndrome, and breast cancer survivors

OBJECTIVES

Pain catastrophizing is a core psychological factor determining pain experience. We addressed the question of whether patients with different pain syndromes group into different pain catastrophizing phenotypes.

METHODS

A total of 727 patients with chronic pain associated with four primary syndromes: Breast cancer (BC) survivors (n = 400), fibromyalgia (FM, n = 52), complex regional pain syndrome (CRPS, n = 155), and HIV (n = 120) were first studied for differences in levels of pain catastrophizing (Pain Catastrophizing Scale, PCS) and pain intensity by analysis of variance. Subsequently, individual scores of the PCS subscales "rumination", "magnification," and "helplessness" from the pooled cohorts were submitted to multivariate k-means clustering to explore subgroups.

RESULTS

Three clusters defined by the level of catastrophizing were identified. The "low catastrophizing" cluster (n = 377) included most of the BC patients (71.0%) and the "moderate catastrophizing" cluster (n = 256) most of the FM patients (61.5%). HIV (31.9%) and CRPS (44.7%) patients were over-represented in the "high catastrophizing" cluster (n = 94) with the highest catastrophizing tendencies in all dimensions. These patients reported more helplessness than the patients in the two other clusters.

CONCLUSIONS

The primary syndrome causing the pain has an impact on self-reported pain-related catastrophizing. Helplessness is a predominant feature in HIV and CRPS patients and therefore an important target in pain rehabilitation.

The value of herpes zoster prevention in people aging with HIV: A narrative review

OBJECTIVE

Review the evidence on the incidence and impact of herpes zoster among people living with HIV and the potential impact of recombinant zoster vaccine for people aging with HIV.

METHODS

Narrative review.

RESULTS

Although antiretroviral therapy has substantially reduced the risk of herpes zoster among people living with HIV, they remain at an increased risk compared with the general population. Among people aging with HIV, aging per se is now the main risk factor for herpes zoster. Beyond pain, herpes zoster is also associated with a risk of sight-threatening complications in case of trigeminal involvement, disseminated diseases and stroke. Post-herpetic neuralgia is also a potential threat to the quality of life of people aging with HIV. The recombinant zoster vaccine has demonstrated high and sustained efficacy in the prevention of herpes zoster, post-herpetic neuralgia, and other herpes zoster complications in the general population. Immunogenicity data among people living with HIV with high CD4+ T-cell count and controlled viral load are comparable to those among the general population. Real-life effectiveness data indicate high vaccine efficacy among immunocompromised patients other than people living with HIV. High vaccine price, vaccine hesitancy, and limited disease and vaccine awareness represent potential hurdles for high vaccine uptake among people aging with HIV in Europe.

CONCLUSIONS

Herpes zoster, and its complications, is a vaccine-preventable disease of aging people. Given its impact on quality of life, herpes zoster prevention using recombinant zoster vaccine is a safe strategy to be considered in every person aging with HIV.

Chronic pain is no more prevalent in people living with HIV than in their uninfected counterparts in South Africa

BACKGROUND

There are few studies on chronic pain prevalence in people living with HIV, and there are no studies comparing chronic pain prevalence in an HIV-infected group (HIV+) to that found in an uninfected group (HIV-) in the same population. This study was undertaken to (1) estimate the chronic pain prevalence in HIV+ individuals and (2) compare chronic pain prevalence between HIV+ and HIV- groups in a population.

METHODS

Individuals ≥15 years old were recruited using multi-stage probability sampling in the 2016 South African Demographic and Health Survey. In an interview, participants were asked whether they currently had pain or discomfort, and if so, whether that pain or discomfort had persisted for at least 3 months (operational definition of chronic pain). Blood samples were taken from a volunteering sub-sample for HIV testing.

RESULTS

A total of 6584 of 12,717 eligible individuals answered the questionnaire and were tested for HIV. Mean age: 39.1 years (95% confidence interval [CI]: 38.3-39.9), per cent female: 55% (95% CI: 52-56) and tested HIV+: 19% (95% CI: 17-20). The prevalence of chronic pain was 19% (95% CI: 16-23) in the HIV+ group, which was similar to that found in the HIV- group (20% [95% CI: 18-22]; odds ratio [adjusted for age, sex, socio-economic status] = 0.93 [95% CI: 0.74-1.17], p-value = 0.549).

CONCLUSION

The prevalence of chronic pain in South Africans living with HIV was approximately 20%, and having HIV was not associated with an increased risk of chronic pain.

SIGNIFICANCE

Using data from a large, national, population-based study in South Africa, I show for the first time that the prevalence of chronic pain in that population did not differ materially between the part of the population that was living with HIV compared with their uninfected counterparts (both approximately 20%). These findings run counter to the dogma that there is a greater risk of having pain in people living with HIV.

Pathogenic mechanisms of human immunodeficiency virus (HIV)-associated pain

Chronic pain is a prevalent neurological complication among individuals living with human immunodeficiency virus (PLHIV) in the post-combination antiretroviral therapy (cART) era. These individuals experience malfunction in various cellular and molecular pathways involved in pain transmission and modulation, including the neuropathology of the peripheral sensory neurons and neurodegeneration and neuroinflammation in the spinal dorsal horn. However, the underlying etiologies and mechanisms leading to pain pathogenesis are complex and not fully understood. In this review, we aim to summarize recent progress in this field. Specifically, we will begin by examining neuropathology in the pain pathways identified in PLHIV and discussing potential causes, including those directly related to HIV-1 infection and comorbidities, such as antiretroviral drug use. We will also explore findings from animal models that may provide insights into the molecular and cellular processes contributing to neuropathology and chronic pain associated with HIV infection. Emerging evidence suggests that viral proteins and/or antiretroviral drugs trigger a complex pathological cascade involving neurons, glia, and potentially non-neural cells, and that interactions between these cells play a critical role in the pathogenesis of HIV-associated pain.

Self-reported musculoskeletal disorders and associated factors among HIV/AIDS patients following ART at University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia, 2021: Aa cross-sectional study design

BACKGROUND

Musculoskeletal disorders is an inflammatory, degenerative diseases and disorders that cause pain and functional impairments. Musculoskeletal disorders are common and the major global health concern among people with human immunodeficiency virus/acquired immunodeficiency syndrome which causes physical disability. Despite, it is a recognized health problem among human immunodeficiency virus-positive patients, there is a lack of data on musculoskeletal disorders among patients following anti-retroviral therapy in sub-Saharan Africa, particularly Ethiopia. Therefore, the main aim of the study was to assess the prevalence and associated factors of musculoskeletal disorders among adult human immunodeficiency virus-positive patients following anti-retroviral therapy.

METHOD

An institutional-based cross-sectional study was conducted from September 1st to October 1st, 2021 at University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia. The data was collected through an interview-administered questionnaire and patient medical record review of 324 participants. Binary logistic regression was used to identify associated risk factors of musculoskeletal disorders. The strength of the association was detected by the adjusted odds ratio and P-value.

RESULT

The annual prevalence of musculoskeletal disorders among participants was 158 (48.5%) with [95% CI: 43%, 54%], opportunistic infection [AOR, 10.43; 95% CI = 2.76-42.25], type of ART medication used, CD4-count [AOR, 0.13; 95% CI 0.03-0.85], and change in anti-retroviral therapy regimen change [AOR, 8.14; 95%CI 2.06-32.09] were significantly associated with musculoskeletal disorders.

CONCLUSION

The prevalence of musculoskeletal disorders was moderate. Recent CD4 count, opportunistic infection, antiretroviral therapy regime at initiation, and anti-retroviral therapy regime change were significantly associated with musculoskeletal disorder. A multidisciplinary approach is required for preventing and treating musculoskeletal disorders among human immunodeficiency virus-positive patients following anti-retroviral therapy.

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.

Pilot study of tolerability and safety of opioid receptor antagonists as novel therapies for chronic pain among persons living with HIV with past year heavy drinking: a randomized controlled trial

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03278886.

Evaluation of the efficacy and mechanisms of a novel intervention for chronic pain tailored to people with HIV: The STOMP protocol

BACKGROUND

Behavioral interventions for chronic pain among people with HIV (PWH) are understudied, with great potential to improve pain and function. Chronic pain is an important comorbidity that affects between 30% and 85% of PWH and is associated with greater odds of functional impairment, increased emergency room utilization, suboptimal retention in HIV care, and failure to achieve virologic suppression. However, to date, there are few effective and scalable interventions for chronic pain in PWH.

OBJECTIVE

This manuscript outlines the protocol for a randomized control trial of a novel theory-based pain self-management intervention, "Skills TO Manage Pain" (STOMP), developed for and tailored to PWH versus enhanced usual care controls. STOMP is a 12-week intervention developed from prior work on pain self-management in PWH and rigorous intervention mapping. The STOMP intervention has three major components: group sessions, one-on-one pain self-management sessions, and peer leaders.

METHODS

STOMP is a 2-arm randomized trial conducted with PWH with chronic pain. The trial compares STOMP, a theory-based intervention tailored to improving chronic pain in PWH, with a comparison group receiving enhanced usual care effectiveness on pain and HIV proximal outcome measures. The proposed sample size is 280 PWH recruited from two high-volume Center for AIDS Research Network of Integrated Clinical Systems clinical sites.

RESULTS

Study procedures are ongoing, and results will be recorded in future manuscripts.

CONCLUSION

The study will generate evidence on the effectiveness of STOMP with the potential to dramatically change chronic pain treatment for PWH.

TRIAL REGISTRATION

clinicialtrials.gov, Clinical Trials Registration # NCT03692611https://clinicaltrials.gov/ct2/show/NCT03692611?term=STOMP&cond=Hiv&draw=2&rank=1.

Adherence to anti-retroviral therapy, decisional conflicts, and health-related quality of life among treatment-naïve individuals living with HIV: a DEARS-J observational study

BACKGROUND

Supporting people living with HIV using anti-retroviral therapy (ART) is important due to the requirement for strict medication adherence. To date, no data from longitudinal studies evaluating adherence by treatment-naïve people living with HIV are currently available. We investigated the adherence of treatment-naïve people living with HIV over time and examined the relationships among decisional conflicts, adherence, and health-related quality of life (HRQL).

METHODS

The survey items included adherence (visual analogue scale [VAS]), decisional conflict (decisional conflict scale [DCS]), and HRQL (Medical Outcomes Study HIV Health Survey [MOS-HIV]). The DCS and MOS-HIV scores and the VAS and MOS scores were collected electronically at the ART initiation time point and at 4-, 24-, and 48-week post-treatment time points.

RESULTS

A total of 215 participants were enrolled. The mean DCS score was 27.3 (SD, 0.9); 23.3% of participants were in the high-score and 36.7% in the low-score groups. The mean adherence rates at 4, 24, and 48 weeks were 99.2% (standard error [SE], 0.2), 98.4% (SE, 0.4), and 96.0% (SE, 1.2), respectively. The least-square means of the MOS-HIV for the DCS (high vs. low scores) were 64.4 vs. 69.2 for general health perceptions and 57.7 vs. 64.0 for HRQL, respectively.

CONCLUSION

Adherence among treatment-naïve people living with HIV was maintained at a higher level, and HRQL tended to improve with ART. People with high levels of decisional conflict tended to have lower HRQL scores. Support for people living with HIV during ART initiation may be related to HRQL.

A Comparison of Self-reported Pain Measures Between Sensory Phenotypes in HIV-associated Sensory Neuropathy

Painful HIV-associated neuropathy (HIV-SN) is a prevalent co-morbidity of HIV infection. Sensory phenotyping, using quantitative sensory testing (QST) could allow for improved stratification to guide personalized treatment. However, previous methods of QST interpretation have demonstrated limited association with self-reported pain measures. This study sought to identify differences in self-reported pain measures between composite QST-derived sensory phenotypes, and to examine any differences in participants reporting multi-site, multi-etiology chronic pain. In this cross-sectional observational study of participants with HIV (n = 133), individuals were allocated to neuropathy and neuropathic pain groups through clinical assessment and nerve conduction testing. They completed symptom-based questionnaires and underwent standardized QST. Participants were assigned, by pre-determined algorithm, to a QST-derived sensory phenotype. Symptoms were compared between sensory phenotypes. Symptom characteristics and Neuropathic Pain Symptom Inventory scores differed between QST-derived sensory phenotypes: 'sensory loss' was associated with more paroxysmal and paraesthetic symptoms compared to 'thermal hyperalgesia' and 'healthy' phenotypes (P = .023-0.001). Those with painful HIV-SN and additional chronic pain diagnoses were more frequently allocated to the 'mechanical hyperalgesia' phenotype compared to those with painful HIV-SN alone (P = .006). This study describes heterogeneous sensory phenotypes in people living with HIV. Differences in self-reported pain outcomes between sensory phenotypes has the potential to guide future stratified trials and eventually more targeted therapy. PERSPECTIVE: This article presents quantitative sensory testing derived phenotypes, thought to reflect differing pathophysiological pain mechanisms and relates them to self-reported pain measures in people with HIV infection. This could help clinicians stratify patients to individualize analgesic interventions more effectively.

Mitochondrial reactivity following acute exposure to experimental pain testing in people with HIV and chronic pain

Background: Physical stressors can cause a physiological response that can contribute to an increase in mitochondrial dysfunction and Mitochondrial DNA damage (mtDNA damage). People living with HIV (PWH) are more likely to suffer from chronic pain and may be more susceptible to mitochondrial dysfunction following exposure to a stressor. We used Quantitative Sensory Testing (QST) as an acute painful stressor in order to investigate whether PWH with/without chronic pain show differential mitochondrial physiological responses. Methods: The current study included PWH with (n = 26), and without (n = 29), chronic pain. Participants completed a single session that lasted approximately 180 min, including QST. Blood was taken prior to and following the QST battery for assays measuring mtDNA damage, mtDNA copy number, and mtDNA damage-associated molecular pattern (DAMP) levels (i.e., ND1 and ND6). Results: We examined differences between those with and without pain on various indicators of mitochondrial reactivity following exposure to QST. However, only ND6 and mtDNA damage were shown to be statistically significant between pain groups. Conclusion: PWH with chronic pain showed greater mitochondrial reactivity to laboratory stressors. Consequently, PWH and chronic pain may be more susceptible to conditions in which mitochondrial damage/dysfunction play a central role, such as cognitive decline.

Pain Is Associated With Depressive Symptoms, Inflammation, and Poorer Physical Function in Older Adults With HIV

OBJECTIVE

People living with HIV (PLWH) frequently experience pain, which often co-occurs with psychological symptoms and may impact functional outcomes. We investigated cross-sectional associations between pain, depressive symptoms, and inflammation, and then explored whether pain was related to poorer physical function among older PLWH.

METHODS

We examined data from PLWH aged 54 to 78 years ( n = 162) recruited from a single outpatient program for a larger study on HIV and aging. Participants reported depressive symptoms (10-item Center for Epidemiological Studies Depression Scale) and then attended a biomedical visit in which they reported past-month pain (Medical Outcomes Study-HIV pain subscale), completed physical function assessments, and provided blood samples (assayed for interleukin 6, interferon-γ, tumor necrosis factor α, and C-reactive protein). Links between pain, depressive symptoms, inflammation, and physical function were tested using linear regression models.

RESULTS

PLWH with greater depressive symptoms experienced more pain than did those with fewer depressive symptoms ( B = 1.31, SE = 0.28, p < .001), adjusting for age, sex, race, body mass index, smoking, disease burden, time since HIV diagnosis, and medication use. Higher composite cytokine levels were associated with worse pain ( B = 5.70, SE = 2.54, p = .027 in adjusted model). Poorer physical function indicators, including slower gait speed, weaker grip strength, recent falls, and prefrail or frail status, were observed among those with worse pain. Exploratory mediation analyses suggested that pain may partially explain links between depressive symptoms and several physical function outcomes.

CONCLUSIONS

Pain is a potential pathway linking depressive symptoms and inflammation to age-related health vulnerabilities among older PLWH; longitudinal investigation of this pattern is warranted. PLWH presenting with pain may benefit from multidisciplinary resources, including behavioral health and geriatric medicine approaches.

Pain management in people with severe mental illness: an agenda for progress

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Geriatric conditions and healthcare utilisation in older adults living with HIV

BACKGROUND

older HIV-positive adults experience a significant burden of geriatric conditions. However, little is known about the association between geriatric conditions and healthcare utilisation in this population.

SETTING

outpatient safety-net HIV clinic in San Francisco.

METHODS

in 2013, HIV-positive adults ≥50 years of age underwent geriatric assessment including functional impairment, fall(s)in past year, cognitive impairment (MOCA <26) and low social support (Lubben social network scale ≤12). We reviewed medical records from 2013 through 2017 to capture healthcare utilisation (emergency room (ER) visits and hospitalisations) and used Poisson models to examine the association between geriatric conditions and utilisation events over 4 years.

RESULTS

among 192 participants, 81% were male, 51% were white, the median age was 56 (range 50-74), and the median CD4 count was 508 (IQR 338-688) cells/mm3. Sixteen percent of participants had ≥1 activities of daily living (ADL) dependency, 58% had ≥1 instrumental activities of daily living IADL dependency, 43% reported ≥1 falls, 31% had cognitive impairment, and 58% had low social support. Over 4 years, 90 participants (46%) had ≥1 ER visit (total of 289 ER visits), 39 (20%) had ≥1 hospitalisation (total of 68 hospitalisations), and 15 (8%) died. In unadjusted and adjusted analyses, IADL dependency and falls were associated with healthcare utilisation (adjusted incidence rate ratios IADL (95%CI): 1.73 (1.33-2.25); falls: 1.51 (1.21-1.87)).

CONCLUSION

IADL dependency and history of falls were associated with healthcare utilisation among older HIV-positive adults. Although our results are limited by sample size, improved understanding of the association between geriatric conditions and healthcare utilisation could build support for geriatric HIV care models.

A collaborative care intervention to improve opioid prescribing among providers caring for persons with HIV: Impact on satisfaction, confidence, and trust

BACKGROUND

HIV clinicians report low confidence and satisfaction prescribing chronic opioid therapy (COT). We hypothesized that the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention [a system-level improvement to increase guideline concordant care for COT] would improve satisfaction, confidence, and trust among PWH and their clinicians.

METHODS

We conducted a two-arm, unblinded cluster randomized controlled trial (RCT) to assess the TEACH intervention. Clinicians were randomized in a 1:1 ratio to receive either the TEACH intervention (an IT-enabled nurse care manager, opioid education, academic detailing, and access to addiction specialists) or usual care. Outcomes were the following: clinician satisfaction (primary); confidence prescribing COT; patient satisfaction with COT; and trust in clinician. Intention-to-treat analyses were conducted using linear and logistic regression models.

RESULTS

Clinicians (n = 41) were randomized and their 114 patients assessed. At 12 months, the adjusted mean difference in satisfaction with COT was 1.11 points for intervention vs control clinicians (Scale 1-10; 95% confidence interval [CI]: -0.04 to 2.26, p = 0.06). The adjusted mean confidence with prescribing COT was 1.01 points higher among intervention clinicians (Scale 1-10; 95% CI: 0.05-1.96, p = 0.04). There were no significant differences in patient satisfaction with COT (adjusted odds ratio (AOR) 1.17, 95% CI: 0.50-2.76, p = 0.72) or trust in provider (AOR 1.63, 95% CI: 0.65-4.09, p = 0.30).

CONCLUSIONS

TEACH did not significantly affect prescriber satisfaction, patient satisfaction with pain management or patient trust; however, it did improve prescriber confidence. TEACH is a promising strategy to improve provider prescribing of COT for PWH without adverse patient satisfaction or trust in provider.

Musculoskeletal Conditions in Persons Living with HIV/AIDS: A Scoping Review

OBJECTIVE

Globally 37.9 million people are living with HIV/AIDS, and with mortality rates declining, there is an increasing focus on comorbidities including musculoskeletal (MSK) disorders. Therefore, the aim of this scoping review was to generate and summarize an overview of the existing scientific literature dealing with MSK complaints in people living with HIV/AIDS (PLWHAs).

METHODS

This scoping review followed the five-stage methodological framework proposed by Arksey and O'Malley. We searched PubMed, EMBASE, CINAHL, and the Cochrane Library from inception to June 1, 2020. Two reviewers independently reviewed the articles for eligibility. A data extraction form was used to chart information such as author, year of publication, data source, sample size, country of origin, ethnicity, age, gender, antiretroviral therapy, MSK condition prevalence, and anatomical location.

RESULTS

The search identified 10 522 articles. Of these, 27 studies were included after full-text screening for data extraction. Studies were conducted in thirteen different countries with diverse data sources such as outpatient clinic files, hospital records, primary care clinic files, and AIDS Service Organization files. PLWHAs have a variety of MSK conditions. Most studies reported spinal pain such as lower back or neck pain, but pain in the extremities and osteoarthritis (OA) were also represented. However, the frequencies of pain at various anatomical sites were highly variable.

CONCLUSION

There is a lack of knowledge regarding MSK conditions in PLWHAs. Future studies designed to specifically study MSK complaints and disabilities are needed to gain a better picture of the impact of these conditions in PLWHAs and to inform prevention and treatment strategies globally in this often-underserved population.

South African men and women living with HIV have similar distributions of pain sites

Background

No studies have investigated sex differences in the location and number of pain sites in people living with human immunodeficiency virus (HIV) (PLWH), despite evidence that women, in general, bear a greater burden of pain than men.

Aim

To determine sex differences in the location and number of pain sites, and whether there were demographic or disease-related differences in the number of pain sites.

Setting

South African tertiary hospital HIV clinics and a community healthcare centre

Methods

We conducted a retrospective analysis of records from South African PLWH who had pain.

Results

Of the 596 participant records, 19% were male (115/596) and the median number of pain sites for both sexes was 2 (interquartile range [IQR]: 1 to 3). Pain was most frequently experienced in the head (men: 12%, women: 38%), feet and ankles (men: 42%, women: 28%), abdomen (men = 19%, women = 28%) and chest (men = 20%, women = 20%). After correcting for multiple comparisons, males were less likely to experience headache than females (Fisher’s exact text, odds ratio [OR] = 0.23, 95% confidence interval [CI]: 0.12 – 0.42, p = 0.000). Pain at other body sites was experienced similarly between the sexes. There was no meaningful variation in the number of pain sites between the sexes (logistic regression, p = 0.157).

Conclusion

A similar location and number of pain sites were experienced by male and female South African PLWH. The locations of pain sites were different from previous reports, however, suggesting that research into pain in PLWH cannot necessarily be generalised across cultures.

Improving the Delivery of Chronic Opioid Therapy Among People Living With Human Immunodeficiency Virus: A Cluster Randomized Clinical Trial

BACKGROUND

Chronic pain is prevalent among people living with human immunodeficiency virus (PLWH); managing pain with chronic opioid therapy (COT) is common. Human immunodeficiency virus (HIV) providers often diverge from prescribing guidelines.

METHODS

This 2-arm, unblinded, cluster-randomized clinical trial assessed whether the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention improves guideline-concordant care compared to usual care for PLWH on COT. The trial was implemented from 2015 to 2018 with 12-month follow-up at safety-net hospital-based HIV clinics in Boston and Atlanta. We enrolled 41 providers and their 187 patients on COT. Prescribers were randomized 1:1 to either a 12-month intervention consisting of a nurse care manager with an interactive electronic registry, opioid education, academic detailing, and access to addiction specialists or a control condition consisting of usual care. Two primary outcomes were assessed through electronic medical records: ≥2 urine drug tests and any early COT refills by 12 months. Other outcomes included possible adverse consequences.

RESULTS

At 12 months, the TEACH intervention arm had higher odds of ≥2 urine drug tests than the usual care arm (71% vs 20%; adjusted odds ratio [AOR], 13.38 [95% confidence interval {CI}, 5.85-30.60]; P < .0001). We did not detect a statistically significant difference in early refills (22% vs 30%; AOR, 0.55 [95% CI, .26-1.15]; P = .11), pain severity (6.30 vs 5.76; adjusted mean difference, 0.10 [95% CI, -1.56 to 1.75]; P = .91), or HIV viral load suppression (86.9% vs 82.1%; AOR, 1.21 [95% CI, .47-3.09]; P = .69).

CONCLUSIONS

TEACH is a promising intervention to improve adherence to COT guidelines without evident adverse consequences.

Chronic Pain in HIV

The evolution of therapeutics for and management of human immunodeficiency virus-1 (HIV-1) infection has shifted it from predominately manifesting as a severe, acute disease with high mortality to a chronic, controlled infection with a near typical life expectancy. However, despite extensive use of highly active antiretroviral therapy, the prevalence of chronic widespread pain in people with HIV remains high even in those with a low viral load and high CD4 count. Chronic widespread pain is a common comorbidity of HIV infection and is associated with decreased quality of life and a high rate of disability. Chronic pain in people with HIV is multifactorial and influenced by HIV-induced peripheral neuropathy, drug-induced peripheral neuropathy, and chronic inflammation. The specific mechanisms underlying these three broad categories that contribute to chronic widespread pain are not well understood, hindering the development and application of pharmacological and nonpharmacological approaches to mitigate chronic widespread pain. The consequent insufficiencies in clinical approaches to alleviation of chronic pain in people with HIV contribute to an overreliance on opioids and alarming rise in active addiction and overdose. This article reviews the current understanding of the pathogenesis of chronic widespread pain in people with HIV and identifies potential biomarkers and therapeutic targets to mitigate it.

Social Contact Frequency and Pain among Older Adults with HIV: An Ecological Momentary Assessment Study

BACKGROUND

Social relationships are important for pain management among individuals with HIV, but the impact of daily social contact on pain responses in real-time, real-world settings has never been specifically examined.

PURPOSE

The purpose of the present study was to examine the relationship between social contact frequency and pain, and the role of negative and positive affect in this relationship among older adults with HIV using ecological momentary assessment (EMA).

METHODS

A total of 66 (Mage = 59.3, SD = 6.3, range: 50-74) older adults with HIV completed EMA surveys that included social contact frequency, pain level, and negative and positive affect four times per day for 2 weeks. Mixed-effects regression models were used to examine concurrent and lagged associations between social contact frequency, pain, and negative and positive affect.

RESULTS

Greater recent social contact frequency was associated with less severe current pain (unstandardized B = -0.04, 95% CI: -0.08, -0.01, p = .014), while greater current pain was associated with lower subsequent social contact frequency (unstandardized B = -0.07, 95% CI: -0.11, -0.03, p < .001). Further, higher current negative affect was related to greater current pain, and this relationship was dampened by increased recent social contact frequency (unstandardized B = -0.17, 95% CI: -0.26, -0.08, p < .001). Neither negative nor positive affect was significantly associated with the relationship between current pain and subsequent social contact frequency.

CONCLUSIONS

Social contact frequency and pain are bidirectionally and inversely associated among older adults with HIV. Further, recent social contact influences current pain by attenuating negative affect. Together, these results highlight the need to address social engagement in interventions for pain among older adults with HIV.

People living with HIV and the emerging field of chronic pain-what is known about epidemiology, etiology, and management

PURPOSE OF REVIEW

Chronic pain is common in people living with HIV (PLWH). It causes significant disability and poor HIV outcomes. Despite this, little is understood about its etiology and management.

RECENT FINDINGS

Recent studies suggest that chronic pain in PLWH is caused by inflammation that persists despite viral load suppression. This coupled with central sensitization and psychosocial factors leads to chronic pain that is difficult to manage. PLWH with chronic pain often feel that their pain is incompletely treated, and yet there are few evidence-based options for the management of chronic pain in PLWH. Recent studies suggest that an approach pairing pharmacotherapy and nonpharmacologic therapy may address the complex nature of chronic in PLWH. Chronic pain in PLWH is common yet poorly understood. Further research is needed in order to better understand the etiology of chronic pain and its optimal management.

Improving Outpatient Management of Patients On Chronic Opioid Therapy

Managing patients with chronic pain on chronic opioid therapy (COT) can be challenging if done mainly by an individual clinician. A stepwise, systematic approach to managing patients on COT includes centering the discussion around safety for the patient. Treatment agreements and monitoring plans are important to safe prescribing. With a team-based care approach programs can be implemented, which optimize the benefits of opioid therapy and mitigate the risk. In these settings COT can be prescribed adhering to current guidelines in order to help achieve pain management, optimize function, and advance the patients' quality of life goals.

Race and satisfaction with pain management among patients with HIV receiving long-term opioid therapy

INTRODUCTION

Management of chronic pain is an essential aspect of HIV primary care. Previous literature in the general population has elucidated racial disparities in the evaluation and treatment of pain. This study examined racial/ethnic differences in patient satisfaction and barriers to pain management among a cohort of PWH receiving LTOT.

MATERIALS AND METHODS

Patient-reported survey and EMR data were compared between non-white (n = 135; 81.3 %) and white (n = 31; 18.7 %) patients in a cohort of 166 PWH receiving LTOT in two clinics in Atlanta and Boston. Quantile and linear regression were used to evaluate the association between race and pain management outcomes: 1) satisfaction with pain management (0-10) and 2) patient-related barriers to pain management, including patient perceptions of pain medications, fatalism, and communication about pain. Models were adjusted for sex, age, clinical site, and baseline general health.

RESULTS

Non-white participants were noted to receive chronic opioids for a shorter mean duration of time than white participants (6.0 versus 11.0 years, p < 0.001) and lower mean morphine equivalent daily dose (MEDD) than white participants (28.1 versus 66.9 mg, p < 0.001). In adjusted analyses, there was no significant difference in satisfaction with pain management among non-white and white participants (p = 0.101). There was no significant difference in barriers to pain management in unadjusted (p = 0.335) nor adjusted models (p = 0.397).

CONCLUSION

While non-white PWH were noted to have received lower doses of chronic opioids and for shorter duration than white PWH, satisfaction with pain management was similar. Patient-related barriers to pain management were similar among non-white and white PWH.

Neuroinflammation in HIV-Related Neuropathic Pain

In the management of human immunodeficiency virus (HIV) infection around the world, chronic complications are becoming a new problem along with the prolonged life expectancy. Chronic pain is widespread in HIV infected patients and even affects those with a low viral load undergoing long-term treatment with antiviral drugs, negatively influencing the adherence to disease management and quality of life. A large proportion of chronic pain is neuropathic pain, which defined as chronic pain caused by nervous system lesions or diseases, presenting a series of nervous system symptoms including both positive and negative signs. Injury caused by HIV protein, central and peripheral sensitization, and side effects of antiretroviral therapy lead to neuroinflammation, which is regarded as a maladaptive mechanism originally serving to promote regeneration and healing, constituting the main mechanism of HIV-related neuropathic pain. Gp120, as HIV envelope protein, has been found to be the major toxin that induces neuropathic pain. Particularly, the microglia, releasing numerous pro-inflammatory substances (such as TNFα, IL-1β, and IL-6), not only sensitize the neurons but also are the center part of the crosstalk bridging the astrocytes and oligodendrocytes together forming the central sensitization during HIV infection, which is not discussed detailly in recent reviews. In the meantime, some NRTIs and PIs exacerbate the neuroinflammation response. In this review, we highlight the importance of clarifying the mechanism of HIV-related neuropathic pain, and discuss about the limitation of the related studies as future research directions.

Chronic pain and cognitive impairment: a cross-sectional study in people living with HIV

Cognitive impairment and chronic pain are amongst the most prevalent neurological sequelae of HIV infection, yet little is understood about the potential bidirectional relationship between the two conditions. Cognitive dysfunction can occur in chronic pain populations whilst those with cognitive impairment can display modified responses to experimentally induced painful stimuli. To date, this has not been explored in HIV cohorts.This study aimed to identify any contribution of chronic pain to cognitive impairment in HIV and to determine differences in pain characteristics between those with and without cognitive dysfunction.This was an observational cohort study involving people living with HIV (n = 148) in the United Kingdom. Participants underwent validated questionnaire-based measurement of pain severity, interference and symptom quality as well as conditioned pain modulation and quantitative sensory testing. All participants completed a computer-based cognitive function assessment.Fifty-seven participants met the criteria for cognitive impairment and 73 for chronic pain. The cognitive impairment group had a higher prevalence of chronic pain (p = 0.004) and reported more neuropathic symptoms (p = 0.001). Those with chronic pain performed less well in emotional recognition and verbal learning domains. The interaction identified between chronic pain and cognitive dysfunction warrants further exploration to identify causal links or shared pathology.

Health-related quality of life and pain interference in two patient cohorts with neuropathic pain: breast cancer survivors and HIV patients

OBJECTIVES

Persistent pain is common in HIV patients and breast cancer (BC) survivors. The aim of this study was to compare two patient groups with neuropathic pain (NP) regarding several psychological variables and Health-related Quality of Life. Although, treatment of pain is always planned individually, the knowledge of the differences and similarities between the patient groups may help us to understand more precisely the targets of the interventions for pain.

METHODS

Eighty nine BC and 73 HIV patients with symptoms of neuropathic pain (patients with ≥3/7 in the Douleur Neuropathique four interview part (DN4i)) participated in a cross-sectional study. Patients completed questionnaires about mood (HADS), symptoms of insomnia (ISI), pain catastrophizing (PCS), personality (TIPI), Mental and Physical Health-related Quality of Life (M/PHrQoL, RAND/SF-36), and pain intensity and interference (BPI). Analyses were applied by using t-tests and linear regression to assess associations between the studied factors.

RESULTS

HIV patients reported higher anxiety (p<0.001), depressive symptoms (p<0.001), pain catastrophizing (p<0.001) and pain interference (p<0.001), poorer sleep (p<0.001), and lower HrQoL in all dimensions compared with BC survivors. There were significant differences in personality traits extraversion, emotional stability, and agreeableness between the two patient groups. In HIV patients, pain interference (β=-0.344, p<0.001) and mood (β=-0.580, p<0.001) and in the BC group, mood (β=-0.591, p<0.001), extraversion (β=0.229, p=0.005) and sleep (β=-0.154, p=0.042) associated with MHrQoL. Pain interference (HIV β=-0.645, p<0.001, BC β=-0.491, p<0.001) and age (HIV β=-0.016, p=0.042 and BC β=-0.018, p=0.019) associated with PHrQoL in both groups, and catastrophizing in the BC group (β=-0.303, p<0.001).

CONCLUSIONS

HIV patients and BC survivors with neuropathic pain, measured with DN4i, have significant differences in various health-related variables and Health-related Quality of Life with both patient groups reporting low HrQoL. The differences in low HrQoL may reflect the fundamental differences between these diseases, BC survivors in remission and HIV patients living with a chronic disease that is under control. This study brings information about the diversity of different patient populations with symptoms of neuropathic pain, and how neuropathic pain associates with wide range of health-related factors. Interventions to support better coping with the symptoms of neuropathic pain could be tailored more individually if the background disease is taken into account.

Insomnia severity and depressive symptoms in people living with HIV and chronic pain: associations with opioid use

Chronic pain commonly occurs in people living with HIV (PLWH). Many PLWH in the United States obtain opioids for chronic pain management. Whether insomnia severity and depressive symptoms are exacerbated by chronic pain and opioid use in PLWH remains to be determined. This study examined insomnia severity and depressive symptoms in 85 PLWH with chronic pain and 35 PLWH without chronic pain. Among PLWH with chronic pain, reported opioid use was examined in relation to insomnia severity and depressive symptoms. PLWH with chronic pain reported significantly greater insomnia severity (p = .033) and depressive symptoms (p = .025) than PLWH without chronic pain. Among PLWH with chronic pain who reported opioid use (n = 36), insomnia severity was greater compared to those who denied opioid use (n = 49), even after controlling for pain severity and number of comorbidities (p = .026). Greater pain severity was significantly associated with greater insomnia severity (p < .001) and depressive symptoms (p = .048) among PLWH with chronic pain who reported opioid use. These associations were not significant among those PLWH with chronic pain who denied opioid use. Findings suggest that PLWH with chronic pain are likely to experience poor sleep and depressed mood. Furthermore, poor sleep was associated with opioid use among PLWH with chronic pain.

Prevalence and impact of comorbid chronic pain and cigarette smoking among people living with HIV

Rates of chronic pain and cigarette smoking are each substantially higher among people living with HIV (PLWH) than in the general population. The goal of these analyses was to examine the prevalence and impact of comorbid chronic pain and cigarette smoking among PLWH. Participants included 3289 PLWH (83% male) who were recruited from five HIV clinics. As expected, the prevalence of smoking was higher among PLWH with chronic pain (41.9%), than PLWH without chronic pain (26.6%, p < .0001), and the prevalence of chronic pain was higher among current smokers (32.9%), than among former (23.6%) or never (17%) smokers (ps < .0001). PLWH who endorsed comorbid chronic pain and smoking (vs. nonsmokers without chronic pain) were more likely to report cocaine/crack and cannabis use, be prescribed long-term opioid therapy, and have virologic failure, even after controlling for relevant sociodemographic and substance-related variables (ps < .05). These results contribute to a growing empirical literature indicating that chronic pain and cigarette smoking frequently co-occur, and extend this work to a large sample of PLWH. Indeed, PLWH may benefit from interventions that are tailored to address bidirectional pain-smoking effects in the context of HIV.

Is age and not antiretroviral therapy the strongest risk factor for chronic pain in HIV-infected population?

Background

Chronic pain in HIV-infected patients on effective antiretroviral therapy (ART) limits patients’ normal functioning both somatically and psychologically. The current state of knowledge on the topic is insufficient, with the underlying causes of this pain unexplained. Therefore we analyzed the frequency and factors associated with chronic pain in HIV-infected patients on ART.

Methods

We conducted a prospective, survey study, including consecutive HIV-infected patients under specialist care at the HIV Outpatient Clinic of the Hospital for Infectious Disease in Warsaw between February 2014 and December 2016. During their routine visit all patients who agreed to participate in the study were surveyed using a study questionnaire. For all patients reporting any pain the Brief Pain Inventory (BPI) form and Douleur Neuropathique 4 Questions form (DN4) were completed. Data on history and current ART and laboratory measurements were obtained from electronical database. Chi-squared and Kruskal-Wallis tests were used for group comparison. The potential factors associated with chronic pain were identified via logistic regression models.

Results

In total 196 HIV-infected patients were included in the study, 57 (29,1%) of them reported chronic pain. The reported pain was mostly (75%) limited to a single area of the body. In univariable logistic regression model the odds of chronic pain were significantly higher with increasing age (OR 1.36 [95%CI:1.17–1.58]), time under specialist care (OR 2.25 [95%CI:1.42–35.7]), time on ART (OR2.96 [95%CI:1.60–5.49]), previous ART with zidovudine (OR 2.00[95%CI:1.06–1.55]) and previous treatment with ddI, ddC or d4T (OR4.13 [95%CI:1.92–8.91]). Homosexual route of HIV infection as compared to injecting drug use was decreasing the odds of chronic pain (OR0.33 [95%CI: 014–0.75]). In multivariable analyses, adjusting for all above the only factor associated with chronic pain was age (OR1.28 [95%CI:1.06–1.55]).

Conclusions

The prevalence of chronic pain in the studied population of HIV-infected Polish patients was high. The only risk factor for chronic pain identified was age. With ageing HIV population it is therefore imperative to develop cooperation protocols for specialist HIV treatment clinics, pain treatment clinics, and rehabilitation units.

Emergency Department Utilization Among People Living With HIV on Chronic Opioid Therapy

Chronic pain among people with HIV (PWH) is a driving factor of emergency department (ED) utilization, and it is often treated with chronic opioid therapy (COT). We conducted a cross-sectional analysis of a prospective observational cohort of PWH on COT at 2 hospital-based clinics to determine whether COT-specific factors are associated with ED utilization among PWH. The primary outcome was an ED visit within 12 months after study enrollment. We used stepwise logistic regression including age, gender, opioid duration, hepatitis C, depression, prior ED visits, and Charlson comorbidity index. Of 153 study participants, n = 69 (45%) had an ED visit; 25% of ED visits were pain-related. High dose opioids, benzodiazepine co-prescribing, and lack of opioid treatment agreements were not associated with ED utilization, but prior ED visits (p = 0.002), depression (p = 0.001) and higher Charlson comorbidity score (p = 0.003) were associated with ED utilization. COT-specific factors were not associated with increased ED utilization among PWH.

Internalized HIV Stigma and Pain among Women with HIV in the United States: The Mediating Role of Depressive Symptoms

Pain is common in women with HIV, though little research has focused on psychosocial experiences contributing to pain in this population. In the present study we examined whether internalized HIV stigma predicts pain, and whether depressive symptoms mediate this relationship among women with HIV. Data were drawn from the Women's Interagency HIV Study (WIHS), for 1,364 women with HIV who completed three study visits between 2015 and 2016. We used a sequential longitudinal design to assess the relationship between internalized HIV stigma at time 1 on pain at time 3 through depressive symptoms at time 2. Analyses revealed internalized HIV stigma was prospectively associated with greater pain, B = 5.30, 95% CI [2.84, 7.60]. The indirect effect through depressive symptoms supported mediation, B = 3.68, 95% CI [2.69, 4.79]. Depression is a modifiable risk factor that can be addressed to improve pain prevention and intervention for women with HIV.

The predictors of pain extent in people living with HIV

OBJECTIVE

To investigate the prevalence of widespread pain among people with HIV (PWH) and describe associations with antiretroviral therapy (ART) and markers of HIV disease stage.

DESIGN

Cross-sectional analysis of cohort study in the United Kingdom and Ireland.

METHODS

Pain information was collected during the baseline visit (conducted from 2013 to 2015) through a self-completed manikin identifying pain at 15 sites from five body regions. Pain was classified as widespread if reported at at least four regions and at least seven sites, or regional otherwise. Chi-squared tests, Kruskal-Wallis tests and ordinal logistic regression were used to consider associations between pain extent and sociodemographic and HIV-related factors.

RESULTS

Among the 1207 participants (614 PWH ≥ 50 years, 330 PWH < 50 years, 263 HIV-negative controls ≥50 years), pain was most commonly reported at the upper (left: 28.9%, right: 28.0%) and lower (left: 25.7%; right: 24.5%) leg, upper (18.6%) and lower (29.7%) back and shoulders (left: 16.0%; right: 16.8%). Widespread pain was more commonly reported in PWH than in HIV-negative controls (PWH ≥ 50 years: 18.7%; PWH < 50 years: 12.7%; HIV-negative ≥50 years: 9.5%) with regional pain reported in 47.6, 44.8 and 49.8%, respectively (global P = 0.001). In multivariable analyses, pain extent was greater in those with lower educational attainment, those exposed to more ART drugs, and those with a higher current CD4 cell count but longer exposure to immunosuppression.

CONCLUSION

Widespread pain is commonly reported in PWH and is associated with longer duration of exposure to HIV, immunosuppression and ART. Our findings call for greater awareness, and interventions to support the management, of pain in PWH.

Association of Pain and Pain Medication Use with Multiple Characteristics of Older People Living with HIV

People living with HIV (PLWH) experience chronic pain that may impact function. Gaps in knowledge exist for factors that impact pain and pain medication use in older (age 50+) PLWH. Data for this study were obtained from the Aging with Dignity, Health, Optimism and Community (ADHOC) cohort, an observational study of older PLWH from 10 clinics across the United States. Participants self-reported socioeconomic, psychosocial, and health factors via an online questionnaire. Of 1,051 participants, 66% reported pain. In a multivariable regression model, multimorbidity and tobacco use were associated with a greater likelihood of experiencing pain, whereas being male, black, and having higher cognitive function were associated with a lower likelihood of experiencing pain. Of the 696 participants who reported pain, 46% reported using pain medication. In a multivariable regression model, pain medication use was associated with multimorbidity and with lower income. Recognition of the factors associated with pain and pain medication use in this vulnerable population may lead to strategies that mitigate negative health outcomes.

Association Between Diagnoses of Chronic Noncancer Pain, Substance Use Disorder, and HIV-Related Outcomes in People Living With HIV

BACKGROUND

Chronic pain is common in people living with HIV (PLWH). Few studies have evaluated the association between the diagnoses of chronic pain, substance use disorder (SUD), and HIV-related outcomes in clinical settings over a 10-year period.

METHODS

Using electronic medical records, the study described psychiatric diagnoses, pain medication, and HIV-related variables in PLWH and examined the factors associated with pain diagnosis and HIV-related outcomes.

RESULTS

Among 3528 PLWH, more than one-third exhibited a chronic pain diagnosis and more than one-third a psychiatric disorder. Chronic pain diagnosis has been associated with SUD and mood and anxiety disorders and occurred before SUD or psychiatric disorders about half of the time. Opioids have been commonly prescribed for pain management, more often than nonopioid analgesic, without any change in prescription pattern over the 10-year period. A dual diagnosis of pain and SUD has been associated with more psychiatric disorders and had a negative impact on the pain management by requesting more health care utilization and higher frequency of both opioid and nonopioid medication prescriptions. Chronic pain and SUD had a negative impact on ART adherence. SUD but not chronic pain has been associated with an unsuppressed HIV viral load.

CONCLUSIONS

In the current intertwining opioid prescription and opioid epidemic, opioids are still commonly prescribed in PLWH in HIV care. A diagnosis of chronic pain and/or SUD worsened the HIV-related outcomes, emphasizing the potential risk of the HIV epidemic. These findings called for a better coordinated care program in HIV clinics.

Special Topics in the Care of Older People with HIV

PURPOSE OF REVIEW

Antiretroviral therapy has enabled many people with HIV to live long lives with their infection, but the literature suggests that long term survivors are developing comorbidities and aging-related syndromes at earlier ages than their non-infected counterparts. In addition, there is evidence or sex-based differences in comorbidity risk.

RECENT FINDINGS

How to best care for people aging with HIV is not known, but the tools of comprehensive geriatric assessment can identify people at risk for decline. Newer antiretroviral therapies offer promise of fewer side effects and drug interactions. We will also discuss special needs of women aging with HIV.

SUMMARY

People with HIV and their providers are often unprepared to confront issues of aging, and each clinical program must develop methods to assess older patient and manage age-related complications and syndromes.

Decreasing risk among HIV patients on opioid therapy for chronic pain: Development of the TOWER intervention for HIV care providers

Many people with HIV (PWH) experience chronic pain that limits daily function and quality of life. PWH with chronic pain have commonly been prescribed opioids, sometimes for many years, and it is unclear if and how the management of these legacy patients should change in light of the current US opioid epidemic. Guidelines, such as the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain (CDCG), provide recommendations for the management of such patients but have yet to be translated into easily implementable interventions; there is also a lack of strong evidence that adhering to these recommendations improves patient outcomes such as amount of opioid use and pain levels. Herein we describe the development and preliminary testing of a theory-based intervention, called TOWER (TOWard SafER Opioid Prescribing), designed to support HIV primary care providers in CDCG-adherent opioid prescribing practices with PWH who are already prescribed opioids for chronic pain. TOWER incorporates the content of the CDCG into the theoretical and operational framework of the Information Motivation and Behavioral Skills (IMB) model of health-related behavior. The development process included elicitation research and incorporation of feedback from providers and PWH; testing is being conducted via an adaptive feasibility clinical trial. The results of this process will form the basis of a large, well-powered clinical trial to test the effectiveness of TOWER in promoting CDCG-adherent opioid prescribing practices and improving outcomes for PWH with chronic pain.

Using behavioral psychotherapy techniques to address HIV patients' pain, depression, and well-being

For persons with HIV (PWH), aims of psychotherapy can extend beyond HIV-related topics. Issues such as HIV stigmatization and disclosure and HIV-related self-care including treatment adherence might be ongoing concerns, but patients often need support to develop skills to manage other problems, whether functional or psychiatric. In the context of an ongoing randomized clinical trial, we delivered an individual, behavioral activation-based intervention to PWH with comorbid chronic pain and depression. Our primary treatment target was to reduce pain-related interference in physical and psychosocial functioning. Throughout the course of the 7-session intervention, clinicians used 4 core strategies to help patients improve a variety of domains related to their health and well-being: (a) teaching value-based goal setting, (b) developing skills to be an activated and informed patient, (c) focusing on changing behavior despite discomfort, and, (d) facilitating access to care (e.g., flexible scheduling and primarily phone sessions). The application of these strategies to HIV-related and non-HIV-related problems are presented to illustrate how and when clinicians can utilize these strategies. These practical lessons will inform a flexible approach to helping PWH address a myriad of health and functional issues related to their overall well-being. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Marijuana Use and Its Associations With Pain, Opioid Dose, and HIV Viral Suppression Among Persons Living With HIV on Chronic Opioid Therapy

BACKGROUND

Medical marijuana is legal in 29 US states and the District of Columbia: both HIV and chronic pain are "approved conditions" for receipt. Chronic pain is common among people living with HIV (PLWH). We anticipate PLWH will question their providers about medical marijuana for chronic pain. We examined marijuana use and its associations with pain, opioid dose, and HIV viral suppression among PLWH receiving chronic opioid therapy.

METHODS

PLWH prescribed chronic opioid therapy were recruited into the Targeting Effective Analgesia in Clinics for HIV cohort. The main exposure variable was any past 12-month marijuana use. The primary outcomes were (1) opioid misuse (≥9 on the Current Opioid Misuse Measure) and (2) opioid dose (morphine equivalent daily dose). HIV viral load (VL) suppression (<200 copies/μL) and pain severity and interference using the Brief Pain Inventory were exploratory outcomes.

RESULTS

Participants (n = 166) were men (65%), Black (72%), and had an undetectable VL (89%). We found no significant association between current marijuana use and opioid misuse, opioid dose, or pain. Current marijuana use was associated with 3.03 times the odds of having a detectable VL (95% odds ratio: 1.11-8.31, P = 0.03) while controlling for depressive symptoms and other substance use.

DISCUSSION

We did not detect an association between marijuana use and opioid misuse behaviors, opioid dose, or pain. In an exploratory analysis, current marijuana use was associated with 3× greater odds of having a detectable VL. This study provides insights into potential consequences of marijuana use among PLWH with chronic pain.