Pain and the Use of Outpatient Services Among Persons With HIV

Current perspectives on HIV-related pain and its management: insights from sub-Saharan Africa

SUMMARY Sub-Saharan Africa is the region worst affected by the HIV epidemic and we estimate that at least 10 million HIV-positive individuals in sub-Saharan Africa live with significant pain related to their disease. Until recently there was a lack of studies specifically addressing pain related to HIV infection in sub-Saharan Africa, which limited our understanding of the scope of the problem. Here we describe the current nature of the epidemic of HIV-related pain in sub-Saharan Africa, including the systematic under-recognition and undertreatment of the pain.

The mediating role of pain in substance use and depressive symptoms among Multicenter AIDS Cohort Study (MACS) participants

Pain in human immunodeficiency virus (HIV) frequently co-occurs with substance use and depression. The complex associations among patient characteristics, pain, depression, and drug use in HIV suggests a role for testing models that can account for relationships simultaneously, control for HIV status, and also test for mediation. Using structural equation modeling, the current study examined associations among pain, sociodemographics, illicit drug use, and depressive symptoms in 921 HIV-seropositive and 1019 HIV-seronegative men from the Multicenter AIDS Cohort Study, an ongoing prospective study of the natural history of HIV infection among gay/bisexual men. Longitudinal repeated measures data collected over a 6-year period were analyzed using predictive path models in which sociodemographics, HIV status, and CD4+ cell counts predicted pain, which, in turn, predicted depressive symptoms and illicit drug use. The path models did not differ substantially between HIV-seropositive and -seronegative men. Analyses using the total sample indicated that pain served both as a mediator and as a predictor of more use of cannabis, cocaine, and heroin, as well as more depressive symptoms. HIV-seropositive status predicted more use of inhaled nitrites. In this cohort, having lower CD4+ cell counts (predicted by HIV status), being African American, less educated, and older were all associated with more pain, which, in turn, was associated with more illicit drug use and more depressive symptoms. The results underscore the need for adequate pain management, particularly among vulnerable subgroups of HIV-seropositive and HIV-seronegative men to reduce the risk of drug use and depression.

Escitalopram is associated with reductions in pain severity and pain interference in opioid dependent patients with depressive symptoms

Pain is common among opioid-dependent patients, yet pharmacologic strategies are limited. The aim of this study was to explore whether escitalopram, a selective serotonin reuptake inhibitor, was associated with reductions in pain. The study used longitudinal data from a randomized, controlled trial that evaluated the effects of escitalopram on treatment retention in patients with depressive symptoms who were initiating buprenorphine/naloxone for treatment of opioid dependence. Participants were randomized to receive escitalopram 10 mg or placebo daily. Changes in pain severity, pain interference, and depression were assessed at 1-, 2-, and 3-month visits with the visual analog scale, Brief Pain Inventory, and the Beck Depression Inventory II, respectively. Fixed-effects estimators for panel regression models were used to assess the effects of intervention on changes in outcomes over time. Additional models were estimated to explore whether the intervention effect was mediated by within-person changes in depression. In this sample of 147 adults, we found that participants randomized to escitalopram had significantly larger reductions on both pain severity (b=-14.34, t=-2.66, P<.01) and pain interference (b=-1.20, t=-2.23, P<.05) between baseline and follow-up. After adjusting for within-subject changes in depression, the estimated effects of escitalopram on pain severity and pain interference were virtually identical to the unadjusted effects. This study of opioid-dependent patients with depressive symptoms found that treatment with escitalopram was associated with clinically meaningful reductions in pain severity and pain interference during the first 3 months of therapy.

Chronic pain and hepatitis C virus infection in opioid dependent injection drug users

It is unknown whether infection with hepatitis C is a risk factor for pain among people who have used injection drugs. Multivariate regression was used to determine whether hepatitis C was associated with greater likelihood of reporting significant chronic pain and discomfort intolerance in a cohort of 97 injection drug users dependent on opioids. Study results suggest that participants with hepatitis C may be more likely to experience chronic pain (aOR=1.98; 95% confidence interval=0.76 to 5.12, p=0.16). Furthermore, hepatitis C was found to be associated with a higher discomfort intolerance scale score, reflecting intolerance to physical discomfort (β=2.34; 95% confidence interval=0.06 to 4.62; p=0.04). Hepatitis C may be a cause for chronic pain and discomfort intolerance that is overlooked among injection drug users dependent on opioids.

Pain as a Symptom in Patients Living With HIV/AIDS Seen at the Outpatient Clinic of a Nigerian Tertiary Hospital

Although the negative impact of pain on the quality of life of patients living with HIV has been documented in many Western studies, there is a paucity of data on pain in HIV-infected patients in Nigeria in spite of a large disease burden. We studied the frequency of pain as a symptom and determined the body regions often affected among our cohort of patients attending the antiretroviral (ARV) clinic. An interviewer-administered questionnaire was used to obtain information on presence of pain in the 2 weeks before the interview. Those with pain were further screened with the modified Brief Pain Inventory. There were 79 respondents—40.5% males, mean age 37.1 ± 8.6 years. Pain was present in 22 (27.8%) of the respondents. The major regions affected by pain were lower limbs (40.9%), head and neck (31.8%), and abdomen (31.8%). Only 40% of those with moderate to severe pain intensity reported being on any form of analgesia.

Sex differences in pain and misuse of prescription analgesics among persons with HIV

OBJECTIVE

Women represent the largest percentage of new HIV infections globally. Yet, no large-scale studies have examined the experience of pain and its treatment in women living with HIV.

DESIGN

This study used structural equation modeling to examine sex differences in pain and the use and misuse of prescription analgesics in a representative sample of HIV+ persons in the United Stated within a prospective, longitudinal design.

OUTCOME MEASURES

Bodily pain subscale of the Short-Form 36 and Modified Short Form of the World Health Organization's Composite International Diagnostic Interview (opioid misuse).

RESULTS

Women reported more pain than men over a roughly 6-month period regardless of mode of HIV transmission or prior drug use history. Men acknowledged more misuse of prescription analgesics over an approximate 1-year period compared with women, after taking into account pain, use of analgesics specifically for pain, and drug use history. Weaker associations between pain and use of analgesics specifically for pain that persisted over time were found among women compared with men. For both men and women, pain was stable over time. Problem drug use history exerted significant direct and indirect effects on pain, opioid misuse, and pain-specific analgesic use across sex.

CONCLUSION

The current findings are consistent with prior evidence indicating female pain predominance as well as the undertreatment of pain among women with HIV. Efforts should be made to improve the assessment and long-term management of pain in HIV+ persons.

Risk factors and symptoms associated with pain in HIV-infected adults

Studies suggest that people living with HIV (PLWH) experience many unrelieved symptoms. The purpose of this study was to estimate the occurrence of pain in adult PLWH and to determine whether participants with pain differed from those without pain on selected demographic factors, clinical characteristics, symptoms of fatigue, sleep disturbance, anxiety, or depression. The authors conducted a descriptive, comparative, and correlational study of 317 PLWH seen at academic and community clinics in San Francisco. Participants completed a demographic questionnaire, the Memorial Symptom Assessment Scale, the Fatigue Severity Scale, the General Sleep Disturbance Scale, the Profile of Moods State Tension-Anxiety subscale, and the Center for Epidemiological Studies-Depression Scale. Clinical characteristics (i.e., disease and treatment information) were obtained by self-report. A single item on pain from the Memorial Symptom Assessment Scale was used to classify participants into those with and without pain. Pain was highly prevalent (55%) and was associated with immune status (CD4+ T-cell count), race, and sleep disturbance, but not with age, gender, or symptoms of fatigue, depression, or anxiety.

Pain in persons living with HIV and comorbid psychologic and substance use disorders

OBJECTIVES

There is a dearth of information on the experience of pain in persons living with human immunodeficiency virus (HIV) and cooccurring psychologic and substance use problems. This study examined the prevalence and correlates of pain in 162 HIV-positive persons diagnosed with mood and/or anxiety disorders and substance use disorders.

METHODS

Bodily pain scores in the current sample were compared with pain scores in the United States general population and HIV-positive persons who screened negative for psychologic and substance use problems. Bivariate analyses were used to identify significant correlates of pain scores in the current sample, which were then subjected to multiple regression analysis.

RESULTS

Pain scores in the current sample were significantly lower (indicating more pain) than the general population and HIV-positive persons who screened negative for psychologic and substance use problems. Multivariate analysis indicated that the presence of mood disorder, older age, and lower CD4 cell counts (below 200) were associated with increased pain. Presence of mood disorder accounted for the largest amount of unique variance in pain scores.

DISCUSSION

HIV-positive persons with diagnosed mood/anxiety and substance use disorders reported substantially higher levels of pain than the general population and HIV-positive persons without these comorbid conditions. The presence of mood disorder emerged as an important marker for pain in the current sample. Given that individuals living with HIV and comorbid psychologic and substance use disorders are at increased risk for pain, concerted efforts should be directed at identifying and treating pain in this population.

Functional impairment and health care utilization among HIV-infected men who have sex with men: the relationship with depression and post-traumatic stress

This study examined the relationship of post-traumatic and depressive symptom severity with measures of health-related quality of life (HRQOL), and health care utilization in a sample of 503 HIV-infected men who have sex with men (MSM) recruited in their primary HIV care setting. Participants completed computer assisted assessments of mood and anxiety, HRQOL, and HIV treatment. Peripheral blood CD4 (T helper) lymphocyte count, plasma HIV RNA concentration, and number of medical appointments were extracted from an electronic medical record. Controlling for demographics, disease stage, and antiretroviral medication, post-traumatic stress and depression symptoms accounted for significant variation in general health estimates, and in pain, role, and work-related impairment. Additionally, in multivariable models, post-traumatic stress and depression severity accounted for significant variation in health care utilization whereas symptoms and indices of HIV disease progression did not. These results extend the current research by providing evidence of the relationship between post-traumatic stress and depression symptom severity with measures of functional impairment and health care utilization in a relatively healthy, urban cohort of HIV-infected MSM.

Developing a comparative scale of different nociceptive and neuropathic pain through two psychophysical methods

The general aim of this study was to create a comparative scale of different types of pain through different psychophysical methods and different samples. The psychophysical methods used were magnitude estimation and category estimation. The participants were 30 patients from different outpatient clinics, 30 physicians and 30 nurses. The results were: 1) cancer pain, myocardial infarction pain, renal colic, burn-injury pain, and labor pain were considered more intense, regardless of the psychophysical method used or sample studied; 2) The ranking of different pain intensities, comparing the different psychophysical methods used, resulted in significant agreement levels with Kendal values close to 1.00; 3) There were divergences in the perception of the intensities of some types of pain. These divergences were especially observed between professionals and patients.

Influence of coping, social support, and depression on subjective health status among HIV-positive adults with different sexual identities

The authors examined associations between psychosocial variables (coping self-efficacy, social support, and cognitive depression) and subjective health status among a large national sample (N = 3,670) of human immunodeficiency virus (HIV)-positive persons with different sexual identities. After controlling for ethnicity, heterosexual men reported fewer symptoms than did either bisexual or gay men and heterosexual women reported fewer symptoms than did bisexual women. Heterosexual and bisexual women reported greater symptom intrusiveness than did heterosexual or gay men. Coping self-efficacy and cognitive depression independently explained symptom reports and symptom intrusiveness for heterosexual, gay, and bisexual men. Coping self-efficacy and cognitive depression explained symptom intrusiveness among heterosexual women. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women and to symptom intrusiveness for lesbian and bisexual women. Individuals likely experience HIV differently on the basis of sociocultural realities associated with sexual identity. Further, symptom intrusiveness may be a more sensitive measure of subjective health status for these groups.

The role of psychological and behavioral variables in quality of life and the experience of bodily pain among persons living with HIV

With increased life expectancy of individuals living with HIV, quality of life (QOL) has become a focus of treatment. More research is needed to address pain-related QOL and modifiable variables, such as health behaviors, depressive symptoms, and coping styles, which could be included in treatment protocols to improve QOL among individuals with HIV. Objectives of this study were to (1) examine relationships among health behaviors, psychological variables, and QOL, particularly pain-specific QOL, (2) examine the relationships among coping, depressive symptoms, and QOL, and (3) compare QOL scores of individuals with HIV and population-based normative data. HIV positive men and women not currently on highly active antiretroviral therapy were recruited during regular visits to an HIV outpatient clinic. They completed the Medical Outcome Study Health Survey SF-36 scale, which includes a physical components scale, a mental components scale, and a bodily pain subscale. They also completed questionnaires assessing health behaviors, depressive symptoms, and coping styles. Participants (n=97) scored significantly lower on most aspects of QOL than age-matched Canadian and U.S. norms. Hierarchical multiple regressions revealed that physical activity and CD4 cell count were independently related to lower physical components scale scores; smoking and depressive symptoms were independently associated with lower mental components scale scores; and education, physical activity, and depressive symptoms were independently associated with lower pain-related QOL. Depressive symptoms mediated the relationship between coping styles and the mental components scale and pain-related QOL. Results suggest that targeting depressive symptoms, physical activity, and coping strategies as part of comprehensive treatment protocols could help improve pain-specific QOL and overall QOL among individuals with HIV.

Factors contributing to attrition behavior in diabetes self-management programs: a mixed method approach

BACKGROUND

Diabetes self-management education is a critical component in diabetes care. Despite worldwide efforts to develop efficacious DSME programs, high attrition rates are often reported in clinical practice. The objective of this study was to examine factors that may contribute to attrition behavior in diabetes self-management programs.

METHODS

We conducted telephone interviews with individuals who had Type 2 diabetes (n = 267) and attended a diabetes education centre. Multivariable logistic regression was performed to identify factors associated with attrition behavior. Forty-four percent of participants (n = 118) withdrew prematurely from the program and were asked an open-ended question regarding their discontinuation of services. We used content analysis to code and generate themes, which were then organized under the Behavioral Model of Health Service Utilization.

RESULTS

Working full and part-time, being over 65 years of age, having a regular primary care physician or fewer diabetes symptoms were contributing factors to attrition behaviour in our multivariable logistic regression. The most common reasons given by participants for attrition from the program were conflict between their work schedules and the centre's hours of operation, patients' confidence in their own knowledge and ability when managing their diabetes, apathy towards diabetes education, distance to the centre, forgetfulness, regular physician consultation, low perceived seriousness of diabetes, and lack of familiarity with the centre and its services. There was considerable overlap between our quantitative and qualitative results.

CONCLUSION

Reducing attrition behaviour requires a range of strategies targeted towards delivering convenient and accessible services, familiarizing individuals with these services, increasing communication between centres and their patients, and creating better partnerships between centres and primary care physicians.

Pain, problem drug use history, and aberrant analgesic use behaviors in persons living with HIV

Little is known about the relationship between pain and aberrant use of prescription analgesics in persons living with HIV. We examined the predictive and concurrent associations among pain, aberrant use of opioids, and problem drug use history in a nationally representative longitudinal sample of 2267 HIV+ persons. Covariance structure analyses tested a conceptual model wherein HIV+ patients with a history of problematic drug use (n=870), compared to those without such history (n=1397), were hypothesized to report more pain and aberrant opioid use, as well as use of opioids specifically for pain at baseline and 6- and 12-month follow-ups, after controlling for key sociodemographic characteristics. In support of the hypothesized model, patients with a history of problematic drug use reported more pain, and were more likely to report aberrant use of prescription analgesics, as well as use of such medications specifically for pain, compared to patients without such history. We also found a trend toward greater stability of aberrant opioid use over time in problem drug users compared with non-problem users suggesting a persistent pattern of inappropriate medication use in the former group. Our findings suggest that even though HIV+ persons with a history of problematic drug use report on-going patterns of using prescription analgesics specifically for pain, these patients continued to experience persistently higher levels of pain, relative to non-problem users. Among non-problem users, pain was not linked to aberrant use of opioids, but was linked to the use of such medications specifically for pain.

Theoretical and methodological issues in conducting research related to health care utilization among individuals with HIV infection

Although empirical information on resource use during HIV infection is vital to improving quality of care, the issues involved in conducting research on resource use have received little attention in the medical literature. The purpose of this paper is to review the theoretical and methodological issues of conducting research on health care utilization patterns among persons with HIV/AIDS. Conceptual definitions of utilization are compared and contrasted. Three theoretical frameworks, the Andersen Behavioral Model, the Health Belief Model, and the Biopsychosocial Model are described to illustrate their applicability in future research studies. Research designs, measurement considerations, sampling approaches, and existing data sources on utilization are reviewed. Recommendations for health care utilization research are summarized and highlight the importance of designing studies and generating data for investigation of the factors facilitating patients' use of an optimal array of services including prevention, long-term, and rehabilitation care.

Illness burden mediates the relationship between pain and illicit drug use in persons living with HIV

We investigated predictive and concurrent relationships among reported pain, HIV/AIDS illness burden, and substance use history in 2,267 participants in the longitudinal HIV Cost and Services Utilization Study (HCSUS). Substance use history was classified as screening positive for current illicit drug use (N=253), past drug use (N=617), and non-user (N=1,397) at baseline. To control for demographic correlates, age, sex and socioeconomic status (SES) were included as predictors. Covariance structure models indicated greater pain at baseline among participants acknowledging current substance use. Pain at baseline was also directly predicted by greater HIV/AIDS illness burden, lower SES, and older age. At 6 months, pain was directly predicted by prior pain, worse concurrent HIV/AIDS illness burden and female sex. At 12 months, pain was predicted by older age, prior pain, and concurrent HIV/AIDS illness. It was also modestly but significantly predicted by current substance use at baseline. In addition to the direct effects on pain, there were significant indirect effects of demographic and drug use variables on pain mediated through HIV/AIDS illness burden and prior pain. There were significant and positive indirect effects of current and past drug use, greater age, and lower SES on pain at all three time periods. Pain at 6 months and pain at 12 months were also indirectly impacted by previous illness burden. Our results indicate that HIV+persons who screened positive for current use of a range of illicit substances experienced greater HIV/AIDS illness burden which in turn predicted increased pain.

Pain and use of complementary and alternative medicine in a national sample of persons living with HIV

The current study investigated the relationship of pain to use of complementary and alternative medicine (CAM) in a U.S. nationally representative sample of 2466 persons with human immunodeficiency virus (HIV), using data from the HIV Cost and Services Utilization Study. Pain was conceptualized as a need characteristic within the context of predisposing, enabling, and need (PEN) characteristics following Andersen's Behavioral Model of Health Services Use. Multivariate analyses were used to examine the association of baseline PEN characteristics with CAM use by follow-up (approximately 6 months later), including use of five specific CAM domains. Change in pain from baseline to follow-up was also examined in relation to CAM use. Baseline pain was a strong predictor of CAM use, and increased pain over time was associated with use of unlicensed or underground drugs with potential for harm. These results highlight the importance of medical efforts to control pain in persons living with HIV.

Review: use of health care services among persons living with HIV infection: state of the science and future directions

Health care services for persons living with HIV have broadened from short-term, crisis-oriented, and palliative care to include preventive, acute, and long-term services because of advances in HIV treatment and earlier detection. This integrated literature review on utilization of HIV-related health care services provides information on barriers to access, disparities in treatments, and factors contributing to wasteful use of services. Early research focused on describing and quantifying use of in-hospital care. As HIV transformed into a chronic disease, research on utilization expanded into outpatient settings. Predisposing factors such as race, gender, and injection drug use, and enabling factors (i.e., insurance, social support systems, housing) were strong predictors of utilization patterns. Clinical factors, such as immune status, symptoms, and depression, as well as contextual factors (i.e., characteristics of clinicians, urban/rural residence) determined the amounts of services obtained. Additional research is recommended on the utilization of nursing and preventive services and care in rehabilitation settings, home health, and nursing homes. Understanding the patterns and predictors of resource use can facilitate health professionals' efforts in improving the health care delivery system for individuals with HIV infection.

Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders

Insomnia is a pervasive problem for many patients suffering from medical and psychiatric conditions. Even when the comorbid disorders are successfully treated, insomnia often fails to remit. In addition to compromising quality of life, untreated insomnia may also aggravate and complicate recovery from the comorbid disease. Cognitive behavior therapy for insomnia (CBT-I) has an established efficacy for primary insomnia, but less is known about its efficacy for insomnia occurring in the context of medical and psychiatric conditions. The purpose of this article is to present a rationale for using CBT-I in medical and psychiatric disorders, review the extant outcome literature, highlight considerations for adapting CBT-I procedures in specific populations, and suggest directions for future research. Outcome studies were identified for CBT-I in mixed medical and psychiatric conditions, cancer, chronic pain, HIV, depression, posttraumatic stress disorder, and alcoholism. Other disorders discussed include: bipolar disorder, eating disorders, generalized anxiety, and obsessive compulsive disorder. The available data demonstrate moderate to large treatment effects (Cohen's d, range=0.35-2.2) and indicate that CBT-I is a promising treatment for individuals with medical and psychiatric comorbidity. Although the literature reviewed here is limited by a paucity of randomized, controlled studies, the available data suggest that by improving sleep, CBT-I might also indirectly improve medical and psychological endpoints. This review underscores the need for future research to test the efficacy of adaptations of CBT-I to disease specific conditions and symptoms.

How trauma, recent stressful events, and PTSD affect functional health status and health utilization in HIV-infected patients in the south

OBJECTIVE

In addition to biological markers of human immunodeficiency virus (HIV) disease progression, physical functioning, and utilization of health care may also be important indicators of health status in HIV-infected patients. There is insufficient understanding of the psychosocial predictors of health-related physical functioning and use of health services among those with this chronic disease. Therefore, the current study examines how trauma, severe stressful events, posttraumatic stress disorder (PTSD), and depressive symptoms are related to physical functioning and health utilization in HIV-infected men and women living in rural areas of the South.

METHODS

We consecutively sampled patients from 8 rural HIV clinics in 5 southern states, obtaining 611 completed interviews.

RESULTS

We found that patients with more lifetime trauma, stressful events, and PTSD symptoms reported more bodily pain, and poorer physical, role, and cognitive functioning. Trauma, recent stressful events, and PTSD explained from 12% to 27% of the variance in health-related functioning, over and above that explained by demographic variables. In addition, patients with more trauma, including sexual and physical abuse, and PTSD symptoms were at greater risk for having bed disability, an overnight hospitalization, an emergency room visit, and four or more HIV outpatient clinic visits in the previous 9 months. Patients with a history of abuse had about twice the risk of spending 5 or more days in bed, having an overnight hospital stay, and visiting the emergency room, compared with those without abuse. The effects of trauma and stress were not explained by CD4 lymphocyte count or HIV viral load; however, these effects appear to be largely accounted for by increases in current PTSD symptoms.

CONCLUSION

These findings highlight the importance of addressing past trauma, stress, and current PTSD within clinical HIV care.

Clinical Sequelae Affecting Quality of Life in the HIV-Infected Patient

Physical and mental changes resulting from HIV infection and its treatment can affect a patient's quality of life (QOL). Some of the most commonly reported symptoms affecting QOL in HIV-infected patients are fatigue, pain, anxiety/depression, and sleep disturbances. Fatigue often has a multifactorial etiology, including advanced HIV disease, opportunistic infections, poor nutrition, hormonal insufficiency, and anemia. Pain is one of the most overlooked factors by clinicians. Anxiety/depression and sleep disturbances are experienced by many HIV-infected individuals and are highly correlated with the perception and progression of disease. Although these common clinical symptoms impact QOL in HIV-positive patients, there are no established guidelines for treating them. As pain, anxiety/depression, and sleep disturbances can influence fatigue, as well as each other, the HIV care provider should monitor them closely because their severity reflects the clinical course of HIV as well as the overall well-being of the patient.

Panic disorder and pain in a national sample of persons living with HIV

Research to date has focused on depression and co-existing pain in HIV with relatively little attention devoted to the study of anxiety disorders and concurrent pain. We therefore examined the relationships among panic disorder, posttraumatic stress disorder (PTSD), major depression and pain in a US national sample of persons with HIV, controlling for key sociodemographic and clinical variables, including HIV disease status. The study sample comprised 1489 HIV+ individuals (representing 219 667 persons). In multivariate analyses, panic disorder showed a strong association with pain ( beta= -15.70; 99% confidence interval [CI]=-21.33 to -10.08; P<0.001, which was significantly greater than PTSD (P=0.002) but only marginally greater than major depression (P=0.002). Longitudinal analyses of the three psychological disorders revealed that increasing pain from baseline to follow-up (an approximately 6-month period) was associated with panic disorder only (relative risk ratio=2.18, 99% CI=1.02-4.69; P<0.01), after controlling for baseline pain scores, baseline HIV disease status and change in disease stage across time. We discuss specific mechanisms by which clinical anxiety and chronic pain may be mutually maintained in HIV+ individuals. Our findings suggest that panic disorder, as well as PTSD and major depression are associated with greater pain in HIV patients.