Pain widespread and rarely relieved in Indian patients with HIV

A substantial proportion of Indian HIV-positive patients experience pain, and few receive adequate pain relief, investigators report in the Indian Journal of Palliative Care. Approximately two-thirds of inpatients reported pain, as did 25% of outpatients.

“There is inadequate assessment of pain, inadequate management and inadequate pain relief for HIV/AIDS patients with pain,” comment the investigators.

Several studies have shown that pain is prevalent in patients with HIV. However, its importance is often underestimated as the emphasis of health care is often the treatment of HIV disease.

Pain in patients with HIV can have multiple sources, including HIV infection and the associated illnesses it leaves patients vulnerable to; the side-effects of antiretroviral treatment and other therapies; and unrelated health conditions and their treatment.

Regardless of the underlying cause of pain, it can affect both functioning and quality of life.

India has the second-highest HIV prevalence in the world, but little is known about the proportion of HIV-positive patients in the country who experience pain, their characteristics, or the consequences of pain.

Investigators therefore performed a cross-sectional pilot study involving 42 inpatients and 98 outpatients at two antiretroviral treatment centres.

Information was gathered for each patient regarding their demographics, stage of HIV disease, CD4 cell count, the presence of pain, and functional status.

The patients were then interviewed about their experiences of pain and asked to rate its severity on a scale of 0 to 10. They were asked to rate their quality of life and to say if pain affected their general activity, mood, sleep, working ability and enjoyment of life.

Data were also gathered on the proportion of patients who received pain relief, the type of medication provided, and the extent to which this alleviated discomfort.

Pain was reported by 67% of inpatients and 25% of outpatients. The majority of patients complaining of pain (79%) had more advanced HIV disease (WHO stages III and IV). Further analysis of the characteristics of patients reporting pain revealed that 90% of inpatients and 40% of outpatients were in the more advanced stages of HIV disease.

Antiretroviral therapy was being taken by 60% of patients reporting pain.

The three most common sites of pain were headache (29%), pain in the feet and legs (25%) and backache (19%). Approximately a quarter of patients reported pain in two or more sites.

Most (70%) of the reported pain was low-grade (0 to 3 on the pain scale), but a quarter reported moderate pain and 4% severe pain. The investigators note the patients often underestimate the severity of pain that they are experiencing.

Only 27% of patients received any form of pain relief, and none received opioids. Of the patients who did receive pain relief, only 21% reported at least a 70% reduction in their pain. The investigators note, “The rest of the patients did not have adequate pain relief.”

Almost three-quarters of patients (73%) reported that pain affected their general activity, two-thirds said that it had an impact on their mood, and 63% indicated that their sleep was affected. Furthermore, the working ability of 73% of patients was reduced by pain.

“Most of the doctors, in the field of HIV/AIDS care, are not familiar with pain management. This is where palliative care training can make a big difference to the quality of life of these patients”, conclude the investigators.