Pain Management in HIV

HIV is a virus that damages the immune system making people much more vulnerable to infections and diseases. The immune system helps the body fight off infections. Untreated HIV infects and kills CD4 cells, which are a type of immune cell called T cells. Over time, the body is more likely to get various types of infections and cancers as HIV kills more CD4 cells. HIV is found throughout all the tissues of the body. It is transmitted through the body fluids of an infected person which include semen, vaginal and rectal fluids, blood, and breast milk.
The virus does not spread in air or water, or through casual contact. Currently there is no cure for HIV. However, it is possible to manage HIV and live with the virus for many years with treatment called antiretroviral therapy and proper medical care. a person with HIV is likely to develop a serious condition called AIDS without treatment. At this point, the immune system is too weak to fight off other diseases and infections.
Untreated AIDS will have life expectancy of about three years. HIV can be well controlled with antiretroviral therapy and life expectancy can be as long as a person someone who has not contracted HIV. People living with HIV often experience chronic or long term pain. However, the direct causes of this pain vary. Treatment options can be better decided to help manage the pain if the possible cause of HIV-related pain is pin pointed.
Because of the infection or the medications that treat HIV, people living with HIV may experience chronic pain. Some factors that can cause pain include:

• Inflammation and nerve damage caused by the infection.
• Lowered immunity from the effects of HIV infection on the immune system.
• Side effects of HIV medication.

Pain caused by HIV is often treatable. It becomes easier for your healthcare providers to find the direct cause and coordinate a treatment plan for pain that works in conjunction with HIV treatment if you are open about these symptoms.

Finding the right treatments for HIV-related pain:

A team of experts in HIV, pain, pharmacology, psychiatry, palliative care, and addiction medicine, review the patient living with HIV to make a decision for the treatment of denervation pain, neuropathic pain, and musculoskeletal pain.
Patients who screen positive for chronic pain should be evaluated with a physical examination, psychosocial evaluation, and diagnostic testing to determine the underlying cause of the pain. 
As many HIV medications can interfere with pain medications and vice versa, it is important to maintain a balance between relieving pain and preventing complications while treating chronic pain related to HIV. HIV related pain can be more difficult to treat than other types of chronic pain.
The following factors must be considered by your healthcare providers when recommending a treatment for HIV-related pain:

• medications being taken, including over the counter drugs, vitamins, supplements, and herbal products
• history of HIV infection treatment
• history of medical conditions in addition to HIV infection

The first line of treatment is nonpharmacologic management, which includes cognitive behavioral therapy, physical therapy and yoga. If these does not show any improvement in symptoms then medications can be considered.
Some medications may increase pain sensitivity in people with HIV. For this reason in some cases certain medications can be stopped or the dosage can be reduced to see if that helps resolve pain. However, this can be done only in a supervision of a health care provider as, a person with HIV should never stop taking any prescription medication without first consulting their healthcare provider.
If stopping or reducing certain medications doesn't work or isn't possible, the following pain medications may be recommended:

Non-opioid pain relievers:

For treating mild pain, mild pain relievers, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin or ibuprofen, can be used. Overuse of these medications can cause damage to the stomach, liver, or kidneys. Therefore use it only after consulting your health care provider.

Topical anesthetics:

Topical anesthetics, such as patches and creams, can provide some relief in people with mild to moderate pain symptoms. However, topical anesthetics can interact negatively with some medications. So, a healthcare provider should be consulted before using them.

Opioids:

You can get a temporary relief from symptoms of moderate to severe HIV related pain by using Opioids. Opioids should be used for short term to treat acute worsening of pain. These aren't recommended for chronic pain.
oxycodone, methadone, morphine, tramadol and hydrocodone can be used for this purpose.

Treatment with opioids may create complications for some people. Taking these medications as prescribed is critical in order to avoid issues such as opioid misuse and addiction.

HIV neuropathy:

Damage to the peripheral nerves are among the most frequent neurological complications of HIV infection known as HIV neuropathy. It causes a specific type of HIV-related pain. HIV can affect peripheral sensory and motor nerves, thoracic nerves, cranial nerves or autonomic nerves. HIV can affect one nerve at a time called as HIV mononeuropathy or cause an inflammatory neuropathy similar to Guillain-Barre syndrome (GBS).
It can also affect multiple sensory and motor nerves in distal parts of the limbs resulting in HIV polyneuropathy. Sometimes, a group of anti-HIV medications are the cause of this type of neuropathy which is called antiretroviral toxic neuropathy.
Depending on the type of neuropathy the symptoms vary. The patient may experience unusual sensations, numbness and pain in their hands and feet in HIV polyneuropathy. There may be weakness of the muscles in the feet and hands at later stages of the illness.
The symptoms depend on the affected nerve in mononeuropathy. It can affect thoracic nerves and cause numbness and pain in the chest wall. When the cranial nerves gets affected, it can cause sensory or motor deficits in the face. When HIV causes a GBS-like illness, the symptoms are similar to typical GBS. But these are very rare.
Diagnosis of HIV neuropathies include electromyography with nerve conduction studies, skin biopsies to evaluate cutaneous nerve innervation, and nerve and muscle biopsies for histopathological evaluation.
Ddepending on the type of HIV neuropathy, the treatment options will be decided. For example:

• Good control of HIV infection is required for a typical HIV polyneuropathy.
• In antiretroviral toxic neuropathy, the offending drug should be stopped.
• Neuropathic pain due to HIV polyneuropathy can be treated with anti-seizure medications, antidepressants, or analgesics drugs.

Patients may be referred to the Blaustein Chronic Pain Clinic for a multidisciplinary approach to pain management in severe painful conditions. Patients with GBS due to HIV gets the same treatment as other GBS patients.