1. Treatment in HIV/AIDS
Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions.

2. Objectives Discuss common sources of pain for patients with HIV/AIDS
Review the clinical presentation, causes, and treatment for specific HIV/AIDS-related pain

3. Pain in HIV/AIDS
Pain in HIV is common, has various presentations, and can result from multiple sources at the same time
Pain may be related to HIV infection, immunosuppression, or HIV therapy
Many people with HIV/AIDS also have cancer
Beating Pain, 2nd Ed. APCA (2012)

4. Common sources of pain in HIV/AIDS
Cutaneous/Oral
Visceral
Somatic
Neurological/Headache
Kaposi’s sarcoma
Oral cavity pain
Herpes zoster
Oral/oesophageal candidiasis
Tumours
Gastritis
Pancreatitis
Infection
Biliary tract disorders
Rheumatological disease
Back pain
Myopathies
HIV-related headaches: encephalitis, meningitis, etc.
HIV-unrelated headaches: tension, migraine, etc.
Iatrogenic (AZT)
Peripheral neuropathy
Herpes neuritis
Neuropathies associated with DDI, D4T toxicities
Alcohol, nutritional deficiencies
Beating Pain, 2nd Ed. APCA (2012), adapted from Carr DB

5. Treatment of pain in HIV/AIDS
Follow the World Health Organization (WHO) analgesic ladder
Use NSAIDs with caution in those with low platelets or those with a history of gastrointestinal disease such as peptic ulcer disease
Adjuvants (co-analgesia) can be very useful
Some antiretroviral medications interact with analgesics, so check interactions or consult with an expert
Main interactions involve adjuvants: phenytoin, carbamazepine, dexamethasone, and amitriptyline
Beating Pain, 2nd Ed. APCA (2012)

6. Peripheral neuropathy
Clinical presentation
Causes
Treatment
Burning pain: hands and feet
Pins and needles
Allodynia (the experience of pain from a stimulus that would not usually cause pain in a normal individual)
Pain relieved by local pressure
HIV itself (distal sensory neuropathy)
Post-herpetic neuralgia
ARVs, especially D4T and Efavirenz
Other treatments: chemotherapy, Isoniazid, Metronidazole
Remove offending agents if possible: change from D4T to Abacavir or from Efavirenz to Ritonavir/Lopinavir
Treat herpes zoster early with Acyclovir to limit post-herpetic neuralgia
Use WHO analgesic ladder –NSAIDs and opioids
Gabapentin in resistant cases
Try topical analgesics
For localized neuropathies-nerve block
Beating Pain, 2nd Ed. APCA (2012)

7. Abdominal pain Clinical presentation Causes Treatment
Presents as acute or chronic pain
TB abdomen
MAC (mycobacterium avium complex)
Pancreatitis
Peptic ulcer disease
Gastro-oesophageal reflux disease
Gall bladder and biliary tract disease
Malabsorption syndromes
Drug side effects
Neuropathic abdominal pain (diagnosis of exclusion)
Diagnose and treat underlying cause if possible
Start ARVs if indicated
Treat pain according to WHO analgesic ladder
Beware of ileus/constipation caused by opioids: can make pain worse
Remember morphine causes contraction of sphincter of Oddi, so pethidine is a better choice in pancreatitis
For MAC immune reconstitution inflammatory syndrome (IRIS), try low dose steroids
Beware of NSAIDs and gastritis
Beating Pain, 2nd Ed. APCA (2012)

8. Muscle spasm Clinical presentation Causes Treatment Muscle spasm
Caused by HIV itself in the form of HIV encephalopathy with increased tone
Secondary to cerebral insults from bacterial or tuberculosis meningitis
ARVs
Levodopa (extrapyramidal dysfunction)
Analgesics (Step 2: non-opioid + weak opioid)
NSAIDs may help for musculoskeletal pain
Baclofen (for muscle spasm, can cause seizures)
Adjuvants, especially Rivotril
Beating Pain, 2nd Ed. APCA (2012)

9. Raised intracranial pressure
Clinical presentation
Causes
Treatment
Headache
Focal neurological deficits
Cryptococcal meningitis
Toxoplasmosis
Treat pain according to WHO analgesic ladder
Morphine and pethidine are contraindicated for raised intracranial pressure
Beating Pain, 2nd Ed. APCA (2012)

10. Take home message
ARVs may not relieve all causes of pain for people people with HIV/AIDS and patients may need additional pain treatment
Cancer is common in people living HIV/AIDS

11. References
African Palliative Care Association. Beating Pain: a pocketguide for pain management in Africa, 2nd Ed. [Internet] Available from:
African Palliative Care Association. Using opioids to manage pain: a pocket guide for health professionals in Africa [Internet] Available from:
Amery J, editor. Children’s Palliative Care in Africa [Internet] Available from: Africa-Full-Text.pdf
Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet] Available from: pain.org/files/Content/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_ Management_in_Low-Resource_Settings.pdf
The Palliative Care Association of Uganda and the Uganda Ministry of Health. Introductory Palliative Care Course for Healthcare Professionals