HIV-associated Pain
Principles of managing HIV-related pain Pain is a common symptom in people infected with HIV, with the prevalence ranging from approximately 30% in the early stages of infection, to 80% in those with acquired immunodeficiency syndrome (AIDS). Pain relating to HIV/AIDS may be due to the following: The effects of HIV on the peripheral or CNS (neuropathic pain). Opportunistic infections or ne
Principles of managing HIV-related pain
Pain is a common symptom in people infected with HIV, with the prevalence ranging from approximately 30% in the early stages of infection, to 80% in those with acquired immunodeficiency syndrome (AIDS).
Pain relating to HIV/AIDS may be due to the following:
- The effects of HIV on the peripheral or CNS (neuropathic pain).
- Opportunistic infections or neoplasms as a result of immunosuppression.
- Antiretroviral drugs (ARVs) that may be neurotoxic. However, the prolonged use of highly active antiretroviral therapy (HAART) decreases the prevalence and severity of neuropathic pain.
As for any patient presenting with pain, anatomical, physiological, pharmacological, grading (distribution, type, duration, etc.) and psycho-social factors should be assessed to guide appropriate management. Nociceptive pain is treated with ‘typical’ analgesics, while neuropathic pain is treated with ‘atypical analgesics’.
Pain in HIV patients is frequently undertreated. Clinician-, patient- and system-related factors account for this, including underestimation of pain by the clinician, fear of analgesic adverse effects by the clinician and patient, and drug interactions between analgesics and ARVs.
Principles of managing HIV-related pain
Management of the pain must be individualised and directed, depending on the type of pain; whether nociceptive or neuropathic (Table IV). Acute nociceptive pain is managed according to the guidelines discussed under acute nociceptive pain, but may fail to relieve ANP. ANP is managed according to the guidelines discussed above.
Since the use of HAART decreases the occurrence of opportunistic infections, including that of the CNS, peripheral sensory polyneuropathy has become the most important HIV-related neurological complication. The most common forms of sensory neuropathy are infection-related distal sensory polyneuropathy (direct nerve injury by the virus, and effects of viral protein coat on chemokines and cytokines) and antiretroviral-induced mitochondrial dysfunction causing a toxic neuropathy.
Amitriptyline is not effective in the management of HIV-related neuropathic pain. Gabapentin improves pain and sleep disturbances, but pregabalin is ineffective. Lamotrigine of approximately 4mg/kg/day relieves pain in HIV-related neuropathic pain. The lidocaine 5% patch and high-dose capsaicin cream are effective.
Table IV: Recommended approach to pain in HIV/AIDS
| Pain | Aetiology | Treatment |
| HIV-related neuropathic pain | HIV, HAART (stavudine, didanosine), isoniazid, neoplasms, oncotherapy, herpes zoster | Gabapentin or lamotrigine, topical lignocaine and capsaicin |
| Abdominal pain, headache | Infections, neoplasms | As for nociceptive and neuropathic pain |
| Oral, pharyngeal pain | Aphthous ulcers, herpes simplex virus, cytomegalovirus ulcers, necrotising gingivitis | Antibiotics for gingivitis, oral or IV acyclovir, or oral valacyclovir, are used for HSV Mouthwash containing benzydamine and topical corticosteroids |
| Genital ulceration | Herpes simplex | Acyclovir or valacyclovir, plus standard analgesia |
| Stroke | Spasticity, muscle spasms | Oral baclofen as the first choice, and diazepam and dantrolene alternatively |
| Central neuropathic pain | Following a stroke or intracranial neoplasms | Gabapentin, SSNRIs, IV morphine |
| Oesophageal pain and odynophagia | Candida, cytomegalovirus, aphthous ulcers, herpes simplex | Upper endoscopy ulcer appearance, biopsy and viral cultures help to make a definitive diagnosis Oral fluconazole 200–400mg/day for 14–21 days, or IV if patient cannot swallow Treat HSV with acyclovir 15mg/kg/day IVI or 200mg 5 times/day p.o. for 14–21 days For CMV, ganciclovir IVI (but has many adverse effects) |
| Kaposi sarcoma | Malignancy | Analgesics, radiotherapy |
| Herpes neuropathy | Herpes zoster | Early treatment of PHN with antiviral agent and TCA |
South African Society of Anaesthesiologists (SASA) Guidelines for the Management of Acute Pain in Specific Scenarios 2022