The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 2: Overview of Clinical IssuesSome of these findings on pain are from the pre-HAART era, and certainly the contribution ofspecific opportunistic infections to pain syndromes and other symptoms in AIDS has diminishedover time as the incidence of such infections declined. However, it should be noted that in someinstances 26 the picas incidence and/or prevalence of pain may have actually increased over time. As isoften the case with AIDS, the irony of decreased mortality rates is that by surviving longer somepatients may thus be vulnerable to new complications and pain, as in the observed increasingprevalence of peripheral neuropathy which occurred with longer survival according to the Multi-Center AIDS Cohort Study. 23 Further, in a recent example of the potential overlap of palliativeand disease-specific therapies in AIDS, analysis of data from an ongoing observational cohortstudy found that the severity of HIV-related neuropathy was associated with plasma viral loadlevels – suggesting that antiretroviral therapy itself might in fact be useful for treating or preventingthis painful syndrome. 24 In addition, while pain due to opportunistic infections may havediminished with the advent of HAART and more effective prophylactic regimens, the medicationsthemselves may cause pain and other symptoms, e.g. the antiretroviral side effects alludedto above, which may compromise effective treatment unless the symptoms are also effectivelypalliated.Despite the high prevalence of pain in AIDS, several studies have also demonstrated that pain inpatients with AIDS is likely to be under-diagnosed and under-treated. 21,25 This failure to diagnoseand treat may reflect both the general under-recognition of pain by most physicians and/orthe additional reluctance to consider seriously any self-report of pain in patients with a historyof substance use problems. Moreover, recent reports have documented that non-white race/ethnicity may be a risk factor for inadequate analgesia in general in medical settings, and thateven the physical availability of narcotic pain medication may be limited in pharmacies serving26, 27poor urban neighborhoods where HIV infection may also be concentrated.Regardless of the possible explanations for under-treatment of pain, the result is that patientswith AIDS are at risk for significant pain and the resulting diminished quality of life—an outcomewhich in most cases could be prevented with adequate pain assessment and management.As described in Chapters 4 (Pain) and 11 (Substance Use Problems), the science of pain managementhas advanced considerably in recent years. It is now fully possible to assess and treatpain effectively in patients with AIDS, including substance users, using standard measurementtechniques, rational decisionmaking, evidence-based practice, and common sense. 28, 29 Thesepain management tools should be as much a part of the pharmaceutical inventory of HIV careproviders as antiretrovirals and prophylactic agents.In addition to pain, patients with AIDS have been found to have a high prevalence of othersymptoms, particularly but not exclusively in the advanced stages of the disease. 30-38 Moreover,one recent study suggested that physicians frequently fail to identify and under-treat commonsymptoms reported by patients with AIDS. 35 Symptoms have included a mixture of physical andpsychological conditions, such as fatigue, anorexia, weight loss, depression, agitation and anxiety,nausea and vomiting, diarrhea, cough, dyspnea, fever, sweats, pruritus, etc. Table 2-1 lists commonsymptoms in AIDS by organ system. Table 2-2 summarizes the findings of several key studiesthat have examined the symptom burden in patients with AIDS in different populations. It isstriking that these studies, conducted in the United Kingdom, Canada, France, and Italy, showeda remarkable consistency of symptoms across populations even with different selection criteria,different time periods, and varying methods for determining the prevalence of symptoms.IIU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 13