Symptom experience in HIV-infected adults: a function of demographic and clinical characteristics

Physiologically based pharmacokinetic modeling of ritonavir-oxycodone drug interactions and its implication for dosing strategy

The concomitant administration of ritonavir and oxycodone may significantly increase the plasma concentrations of oxycodone. This study was aimed to simulate DDI between ritonavir and oxycodone, a widely used opioid, and to formulate dosing protocols for oxycodone by using physiologically based pharmacokinetic (PBPK) modeling. We developed a ritonavir PBPK model incorporating induction and competitive and time-dependent inhibition of CYP3A4 and competitive inhibition of CYP2D6. The ritonavir model was evaluated with observed clinical pharmacokinetic data and validated for its CYP3A4 inhibition potency. We then used the model to simulate drug interactions between oxycodone and ritonavir under various dosing scenarios. The developed model captured the pharmacokinetic characteristics of ritonavir from clinical studies. The model also accurately predicts exposure changes of midazolam, triazolam, and oxycodone in the presence of ritonavir. According to model simulations, the steady-state maximum, minimum and average concentrations of oxycodone increased by up to 166% after co-administration with ritonavir, and the total exposure increased by approximately 120%. To achieve similar steady-state concentrations, halving the dose with an unchanged dosing interval or doubling the dosing interval with an unaltered single dose should be practical for oxycodone, whether formulated in uncoated or controlled-release tablets during long-term co-medication with ritonavir. The results revealed exposure-related risks of oxycodone-ritonavir interactions that have not been studied clinically and emphasized PBPK as a workable method to direct judicious dosage.

Gender differences in symptom burden among people living with HIV/AIDS receiving antiretroviral therapy in Yunnan, China

ABSTRACTLittle is known about gender differences in the symptom burden of people living with HIV/AIDS (PLWHA) on antiretroviral therapy in China. This study was conducted based on a biopsychosocial-medical model to describe gender differences in symptom burden among 1035 PLWHA in Yunnan Province, China. After propensity score matching, 798 PLWHA were included in this analysis. Feeling stressed, poor sleep, and memory loss were the most burdensome symptoms among men, while feeling stressed, memory loss, and dizziness were the most burdensome symptoms among women. Among men PLWHA, factors associated with symptom burden were being of the ethnic minority, CD4 count ≥ 500 cells/mm3, physical functioning, and social support. Among women PLWHA, factors associated with symptom burden were being an inpatient, physical functioning, psychological functioning, and social support. Our findings suggest that healthcare providers need to take into account gender differences when developing optimal prevention, treatment, and care programs that provide individualized care to reduce patients' symptom burden.

Pathogenic mechanisms of human immunodeficiency virus (HIV)-associated pain

Chronic pain is a prevalent neurological complication among individuals living with human immunodeficiency virus (PLHIV) in the post-combination antiretroviral therapy (cART) era. These individuals experience malfunction in various cellular and molecular pathways involved in pain transmission and modulation, including the neuropathology of the peripheral sensory neurons and neurodegeneration and neuroinflammation in the spinal dorsal horn. However, the underlying etiologies and mechanisms leading to pain pathogenesis are complex and not fully understood. In this review, we aim to summarize recent progress in this field. Specifically, we will begin by examining neuropathology in the pain pathways identified in PLHIV and discussing potential causes, including those directly related to HIV-1 infection and comorbidities, such as antiretroviral drug use. We will also explore findings from animal models that may provide insights into the molecular and cellular processes contributing to neuropathology and chronic pain associated with HIV infection. Emerging evidence suggests that viral proteins and/or antiretroviral drugs trigger a complex pathological cascade involving neurons, glia, and potentially non-neural cells, and that interactions between these cells play a critical role in the pathogenesis of HIV-associated pain.

The relationship between substance use and physical activity among people living with HIV, chronic pain, and symptoms of depression: a cross-sectional analysis

ABSTRACTChronic pain, depression, and substance use are common among people living with HIV (PLWH). Physical activity can improve pain and mental health. Some substances such as cannabis may alleviate pain, which may allow PLWH to participate in more physical activity. However, risks of substance use include poorer mental health and HIV clinical outcomes. This cross-sectional analysis examined the relationships of self-reported substance use (alcohol, cannabis, and nicotine use), gender, and age with self-reports of walking, moderate physical activity, and vigorous physical activity, converted to Metabolic Equivalent of Task Units (METs), among 187 adults living with HIV, chronic pain, and depressive symptoms in the United States. Women reported less walking, vigorous activity, and total physical activity compared to men. Individuals who used cannabis reported more vigorous physical activity relative to those who did not use cannabis. These findings were partially accounted for by substance use*gender interactions: men using cannabis reported more vigorous activity than all other groups, and women with alcohol use reported less walking than men with and without alcohol use. Research is needed to increase physical activity among women who use substances and to evaluate reasons for the relationship between substance use and physical activity among men.

Health-Related Quality of Life, Pain and Sleep in Patients with HIV Depending on the Clinical Situation: A Cross-Sectional Pilot Study

Introduction: Health-related quality of life (HRQL), pain and sleep have been described as relevant traits in patients with human immunodeficiency virus (HIV). The aim of this study is to describe and evaluate HRQL, pain and sleep and their interdependence in HIV-positive patients. Methods: A cross-sectional study on HIV-infected patients was conducted. A set of five different questionnaires was used: two questionnaires addressing HRQL (Short Form 36 [SF-36] Health Survey and Medical Outcomes Study Short Form 30 [MOS-SF 30]), one on pain (McGill Pain Questionnaire) and one on sleep (Pittsburgh Sleep Quality Index [PSQI]). We also collected the sociodemographic and clinical characteristics of patients. Results: The sample included 109 patients (age: 46.08 ± 10.49 years; 68.8% male). The pain experience was independent of HRQL and sleep. Relationships among HRQL, pain and sleep associated to sociodemographic and clinical factors were not detected (p > 0.05). Patients with CDC category A showed moderate to high correlations among HRQL, pain and sleep. In CDC B-type patients, a moderate correlation was observed between pain and mental health. In CDC C patients, moderate correlations were observed between HRQL and sleep and pain and sleep, with no correlations between HRQL and pain. Conclusions: HRQL, pain and sleep are differently correlated in HIV patients depending on their clinical stage. Neither the nadir of CD4-T cells nor the current count of CD4-T cells was found to be related with HRQL, pain or sleep.

Study protocol: an observational study of distress, immune function and persistent pain in HIV

INTRODUCTION

Many people with HIV report both distress and pain. The relationship between distress and pain is bidirectional, but the mechanisms by which distress exacerbates pain are unclear. The inflammatory response to challenge (inflammatory reactivity, IR) may be a partial mediator, given that neuroimmune interactions provide a substrate for IR to also influence neurological reactivity and, thus, pain-related neural signalling. This prospective, observational, case-control study will characterise the relationships between distress, IR, pain-related signalling as captured by induced secondary hyperalgesia (SH), and pain, in people with HIV who report persistent pain (PP) (cases) or no pain (controls).

METHODS AND ANALYSIS

One hundred people with suppressed HIV, reporting either PP or no pain, will be assessed two or four times over 6 months. The primary outcomes are distress (Hopkins 25-item symptom checklist), IR (multiplex assay after LPS challenge), and PP (Brief Pain Inventory), assessed at the baseline timepoint, although each will also be assessed at follow-up time points. Induced SH will be assessed in a subsample of 60 participants (baseline timepoint only). To test the hypothesis that IR partly mediates the relationship between distress and pain, mediation analysis will use the baseline data from the PP group to estimate direct and indirect contributions of distress and IR to pain. To test the hypothesis that IR is positively associated with SH, data from the subsample will be analysed with generalised mixed effects models to estimate the association between IR and group membership, with SH as the dependent variable.

ETHICS AND DISSEMINATION

Information obtained from this study will be published in peer-reviewed journals and presented at scientific meetings. The study has been approved by the Human Research Ethics Committee of the University of Cape Town (approval number: 764/2019) and the City of Cape Town (ref: 24699).

TRIAL REGISTRATION NUMBER

NCT04757987.

Pharmacologic and Non-Pharmacologic Treatments for Chronic Pain Used by Patients with Pain, HIV, and Depression

The objective of this study was to understand pain treatment utilization, perceived efficacy, and differences in utilization by gender, clinic site, chronicity of pain, pain severity, and depression severity among people living with HIV (PLWH), chronic pain, and elevated depression symptoms. Participants included 187 PLWH at three HIV clinics in the U.S. Overall, 85% of participants reported taking a pain medication. One quarter (25%) reported non-pharmacological professional treatments for pain (e.g., massage, physical therapy), 60% reported mind-body treatments, including exercise, meditation, and yoga, and 62% reported other non-pharmacological self-administered treatments (e.g., heat/cold). Most pain treatments were considered "slightly helpful" or "moderately helpful." Non-pharmacological self-administered treatments were more commonly used among women than men and among individuals with constant vs. intermittent pain. Further research is needed to evaluate the efficacy of the preferred analgesic modalities of PLWH.

Qualitative interview study exploring the patient experience of living with axial spondyloarthritis and fatigue: difficult, demanding and draining

OBJECTIVE

To explore patients' lived experiences of axial spondyloarthritis (axSpA) and fatigue.

DESIGN

Interpretative phenomenological analysis (lived experience) was used as the study design. Analysis drew together codes with similar meaning to create superordinate and subordinate themes.

SETTING

Rheumatology departments in three National Health Service Foundation Trusts in the north, midlands and south of England.

PARTICIPANTS

A purposive sample of seventeen axSpA patients were recruited. The age range was 22-72 years (median age 46), nine were male and eight, female.

RESULTS

A central concept of achieving balance was identified as the active process of integrating axSpA symptoms and fatigue into daily life, working with and not against their condition to lead a fulfilled life. This was conveyed through three superordinate themes: struggling to find energy, engaging in everyday life and persevering through difficulties. Struggling to find energy was the challenge of retaining enough stamina to do things in daily life. Engaging in everyday life highlighted dedication to being active and organised, learning through experience and acceptance of a changed way of being. Persevering through difficulties identified the physical and emotional effort required to keep moving forward and the importance of feeling supported.

CONCLUSION

Achieving balance through finding energy, engaging and persevering everyday was fundamental to having the best possible life. The experience of energy emerged as a distinct but related component of fatigue. However, while energy could be maintained or replenished, fatigue was more difficult to overcome and required greater effort. Energy may be a useful indicator of an individual's current state and ability to sustain activities that supports their well-being, such as exercise. Awareness of the elements of achieving balance in axSpA may enable patients and clinicians to work together to tailor treatments to individual patient need.

A Critical Review of Symptom Management Nursing Science on HIV-Related Fatigue and Sleep Disturbance

Despite improved antiretroviral treatments, people living with HIV (PLWH) continue to suffer from HIV-related fatigue and sleep disturbances. We first reviewed the definition, etiology, and research breakthroughs of HIV-related fatigue and sleep disturbances, then analyzed nurse-led symptom management studies to describe their efficacy and make recommendations for future symptom research. We searched PubMed, CINAHL, PsycInfo, Psych and Behavioral Sciences Collection, and Scopus to identify nurse-led studies on symptom management for PLWH in the past 20 years. A total of 13 experimental or quasi-experimental studies were identified. The types of interventions included exercise, cognitive behavioral therapy, coaching, and symptom management manualized self-care activities. Currently, we cannot recommend with certainty any of the tested symptom management strategies to reduce fatigue or sleep disturbances. The current findings need to be confirmed and expanded to understand optimal dosing and sustainability.

Effects of a symptom management intervention based on group sessions combined with a mobile health application for persons living with HIV in China: A randomized controlled trial

OBJECTIVE

This study aims to evaluate the effects of a symptom management intervention (SMI) based on symptom management group sessions combined with a mobile health (mHealth) application (app) on the knowledge of symptom management, the certainty of symptom self-management, symptom severity, symptom distress, medication adherence, social support, and quality of life among persons living with HIV (PLWH) in China.

METHODS

A parallel randomized controlled trial with 61 PLWH was conducted in Shanghai, China. The participants in the control group (n = 30) downloaded the Symptom Management (SM) app according to their needs and preferences, and received routine follow-ups. The participants in the intervention group (n = 31) were guided to download and use the SM app, and received four tailored weekly group sessions at routine follow-ups. Each group session lasted for approximately 2 h and targeted one of the major modules of the SM app. All the outcomes were assessed at baseline and post-intervention. The study was registered with the Chinese Clinical Trial Registry (ChiCTR1900024821).

RESULTS

The symptom management knowledge and certainty of symptom self-management were significantly improved after the intervention (all P < 0.01). Compared with the control group, the scores of symptoms reasons knowledge score improved 11.47 points (95% CI: 3.41, 19.53) and scores of symptoms self-management knowledge score improved 12.80 points (95% CI: 4.55, 21.05) in the intervention group after controlling for covariates. However, other outcomes did not show statistically significant differences between the intervention group and the control group (P > 0.05).

CONCLUSION

The SMI could improve PLWH's symptom management knowledge and certainty of symptom self-management. Multi-center studies with larger sample sizes and longer follow-ups are needed to further understand the effects of SM app on ameliorating symptom severity and symptom distress. More innovative strategies are also needed to promote and maintain the sustainability of the SM app.

A Biopsychosocial Approach to HIV Fatigue: A Cross-Sectional and Prospective Analysis to Identify Key Modifiable Factors

This study aimed to identify the prevalence and predictors of current fatigue and fatigue at 1-year follow-up, in people with HIV. Participants were recruited from HIV outpatient clinics in London, England. We explored a range of bio-psychosocial factors associated with current fatigue severity, identifying the most salient factors in a multifactorial model. A prospective study explored the predictive value of specific psychological and behavioral factors in predicting fatigue severity at one year. Sixty-four of 131 (49%) participants met the criteria for clinically significant fatigue at baseline. Psychological and behavioral variables, but not immune-virologic markers or antiretroviral treatment, were associated with current fatigue severity. In the multifactorial model, catastrophizing and distress independently predicted current fatigue severity. Higher levels of fatigue at 1 year was predicted by baseline catastrophizing, symptom focusing, distress and sleep quality, when controlling for baseline fatigue, clinical and demographic variables. These findings suggest psychological and behavioral factors are important in the maintenance of fatigue in people with HIV and identify potential opportunities for treatment. Future interventions for fatigue in HIV should not only address anxiety, depression and distress but could be optimized by targeting psychological processes such as catastrophic thinking styles and symptom focusing.

People living with HIV and the emerging field of chronic pain-what is known about epidemiology, etiology, and management

PURPOSE OF REVIEW

Chronic pain is common in people living with HIV (PLWH). It causes significant disability and poor HIV outcomes. Despite this, little is understood about its etiology and management.

RECENT FINDINGS

Recent studies suggest that chronic pain in PLWH is caused by inflammation that persists despite viral load suppression. This coupled with central sensitization and psychosocial factors leads to chronic pain that is difficult to manage. PLWH with chronic pain often feel that their pain is incompletely treated, and yet there are few evidence-based options for the management of chronic pain in PLWH. Recent studies suggest that an approach pairing pharmacotherapy and nonpharmacologic therapy may address the complex nature of chronic in PLWH. Chronic pain in PLWH is common yet poorly understood. Further research is needed in order to better understand the etiology of chronic pain and its optimal management.

Effect of Baseline Symptom Manifestations on Retention in Care and Treatment among HIV-Infected Patients in Nigeria

BACKGROUND

Symptom management is an important component of HIV care. But symptom patterns and how they affect engagement with HIV care and treatment services have not been adequately explored in the era of increased HIV treatment scale-up. We investigated the relationship between symptom patterns among people living with HIV (PLHIV) and 12 months retention in care, within the context of other clinical and demographic characteristics.

METHODS

Retrospective cohort analysis of 5114 PLHIV receiving care within a large HIV treatment program in Nigeria. We assessed the prevalence and burden of baseline symptoms reported during routine clinic visits from January 2015 to December 2017. Multivariable regression was used to identify relationships between 12-month retention and symptom dimensions (prevalence and burden) while controlling for demographic and other clinical variables.

RESULTS

Increasing symptom burden was associated with higher likelihood of retention at 12 months (adjusted odds ratio [aOR] = 1.19 [95% confidence interval, CI: 1.09-1.29]; P < .001) as was the reporting of skin rashes/itching symptom (aOR = 2.59 [95% CI: 1.65-4.09]; P < .001). Likelihood of retention reduced with increasing World Health Organization (WHO) Clinical staging, with CD4 ≥500 cells/mL and self-reported heterosexual mode of HIV transmission. Conclusions: Symptom dimensions and standardized clinical/immunological measures both predicted retention in care, but effects differed in magnitude and direction. Standardized clinical/immunological measures in HIV care (eg, WHO clinical staging and CD4 count categories) can mask important differences in how PLHIVs experience symptoms and, therefore, their engagement with HIV care and treatment. Symptom management strategies are required alongside antiretroviral treatment to improve outcomes among PLHIV, including retention in care.

Race and satisfaction with pain management among patients with HIV receiving long-term opioid therapy

INTRODUCTION

Management of chronic pain is an essential aspect of HIV primary care. Previous literature in the general population has elucidated racial disparities in the evaluation and treatment of pain. This study examined racial/ethnic differences in patient satisfaction and barriers to pain management among a cohort of PWH receiving LTOT.

MATERIALS AND METHODS

Patient-reported survey and EMR data were compared between non-white (n = 135; 81.3 %) and white (n = 31; 18.7 %) patients in a cohort of 166 PWH receiving LTOT in two clinics in Atlanta and Boston. Quantile and linear regression were used to evaluate the association between race and pain management outcomes: 1) satisfaction with pain management (0-10) and 2) patient-related barriers to pain management, including patient perceptions of pain medications, fatalism, and communication about pain. Models were adjusted for sex, age, clinical site, and baseline general health.

RESULTS

Non-white participants were noted to receive chronic opioids for a shorter mean duration of time than white participants (6.0 versus 11.0 years, p < 0.001) and lower mean morphine equivalent daily dose (MEDD) than white participants (28.1 versus 66.9 mg, p < 0.001). In adjusted analyses, there was no significant difference in satisfaction with pain management among non-white and white participants (p = 0.101). There was no significant difference in barriers to pain management in unadjusted (p = 0.335) nor adjusted models (p = 0.397).

CONCLUSION

While non-white PWH were noted to have received lower doses of chronic opioids and for shorter duration than white PWH, satisfaction with pain management was similar. Patient-related barriers to pain management were similar among non-white and white PWH.

The Development of a Personalized Symptom Management Mobile Health Application for Persons Living with HIV in China

Persons living with HIV (PLWH) continuously experience symptom burdens. Their symptom prevalence and severity are also quite different. Mobile health (mHealth) applications (apps) offer exceptional opportunities for using personalized interventions when and where PLWH are needed. This study aimed to demonstrate the development process of the symptom management (SM) app and the structure and content of it. Our research team systematically searched for evidence-based resources and summarized up-to-date evidence for symptom management and health education. Our multidisciplinary research team that included physicians, nurses, software engineers, and nursing professors, evaluated the structure and content of the drafted app. Both quantitative data and qualitative results were collected at a group discussion meeting. Quantitative data were scores of sufficient evidence, situational suitability, practicability, cost-effectiveness, and understandability (ranged from one to four) for 119 items of the app contents, including the health tracking module, the self-assessment module, coping strategies for 18 symptoms (80 items), medication management, complementary therapy, diet management, exercise, relaxation techniques, and the obtaining support module. The SM app was comprised of eight modules and provided several personalized symptom management functions, including assessing symptoms and receiving different symptom management strategies, tracking health indicators, and communicating with medical staff. The SM app was a promising and flexible tool for HIV symptom management. It provided PLWH with personalized symptom management strategies and facilitated the case management for medical staff. Future studies are needed to further test the app’s usability among PLWH users and its effects on symptom management.

Neuroinflammation in HIV-Related Neuropathic Pain

In the management of human immunodeficiency virus (HIV) infection around the world, chronic complications are becoming a new problem along with the prolonged life expectancy. Chronic pain is widespread in HIV infected patients and even affects those with a low viral load undergoing long-term treatment with antiviral drugs, negatively influencing the adherence to disease management and quality of life. A large proportion of chronic pain is neuropathic pain, which defined as chronic pain caused by nervous system lesions or diseases, presenting a series of nervous system symptoms including both positive and negative signs. Injury caused by HIV protein, central and peripheral sensitization, and side effects of antiretroviral therapy lead to neuroinflammation, which is regarded as a maladaptive mechanism originally serving to promote regeneration and healing, constituting the main mechanism of HIV-related neuropathic pain. Gp120, as HIV envelope protein, has been found to be the major toxin that induces neuropathic pain. Particularly, the microglia, releasing numerous pro-inflammatory substances (such as TNFα, IL-1β, and IL-6), not only sensitize the neurons but also are the center part of the crosstalk bridging the astrocytes and oligodendrocytes together forming the central sensitization during HIV infection, which is not discussed detailly in recent reviews. In the meantime, some NRTIs and PIs exacerbate the neuroinflammation response. In this review, we highlight the importance of clarifying the mechanism of HIV-related neuropathic pain, and discuss about the limitation of the related studies as future research directions.

Adding a Physical Therapist to the Health Care Team in an HIV Clinic Increases Physical Therapy Referrals and Reduces Opioid Prescriptions Provided for Chronic Musculoskeletal Pain in Patients Living With HIV

Background

Musculoskeletal (MSK) pain is common in people living with HIV (PLWH). Health care providers sometimes prescribe opioids to control pain, which may lead to opioid misuse. An interdisciplinary approach that includes physical therapy has been successful in managing MSK pain in various health care settings. Therefore, we sought to find the impact of recruiting a physical therapist (PT) on the number of opioid prescriptions and physical therapy referrals made by physicians in training to manage MSK pain in PLWH.

Methods

We performed a retrospective chart review of patients seen by Internal Medicine physicians in training in an HIV clinic in Detroit before (2017) and after (2018) recruiting a PT to the health care team and collected demographic and clinical data. We also surveyed the trainees to assess how the PT addition influenced their learning. Institutional review board waiver was obtained.

Results

Results showed that of all PLWH seen at the clinic, 28/249 (11%) and 37/178 (21%) had chronic MSK pain in the 2017 and 2018 data sets, respectively. In 2017, all 28 patients with MSK pain were prescribed opioids. This decreased in 2018 after the PT addition (10/37 patients; P < .0001). The number of physical therapy referrals significantly increased after the PT addition (2017: 5/28 patients; 2018: 17/37 patients; P = .03). Trainees felt that the PT helped improve their examination skills and develop a treatment plan for patients.

Conclusions

The addition of a PT encouraged physicians in training to utilize nonopioid management of MSK pain in PLWH and enhanced their learning experience, as perceived by the trainees.

Impact and correlates of sub-optimal social support among patients in HIV care

Social support (SS) predicts health outcomes among patients living with HIV. We administered a brief, validated measure of SS, the Multifactoral Assessment of Perceived Social Support, within a patient-reported outcomes assessment of health domains in HIV care at 4 U.S. clinics in English and Spanish (n = 708). In univariate analysis, low SS was associated with poorer engagement in care, antiretroviral adherence, and health-related quality of life; current methamphetamine/crystal use, depression, anxiety, and HIV stigma (all p < 0.001); any use of either methamphetamines/crystal, illicit opioids, or cocaine/crack (p = 0.001), current marijuana use (p = 0.012), nicotine use (p = 0.005), and concern for sexually transmitted infection exposure (p = 0.001). High SS was associated with undetectable viral load (p = 0.031). Multivariate analyses found low SS independently associated with depression (risk ratio (RR) 3.72, 95% CI 2.93-4.72), lower adherence (RR 0.76, 95% CI 0.64-0.89), poor engagement in care (RR 2.05, 95% CI 1.44-2.96), and having more symptoms (RR 2.29, 95% CI 1.92-2.75). Medium SS was independently associated with depression (RR 2.59, 95% CI 2.00-3.36), poor engagement in care (RR 1.62, 95% CI 1.15-2.29) and having more symptoms (RR 1.75, 95% CI 1.44-2.13). SS assessment may help identify patients at risk for these outcomes.

Behavioral and Physical Activity Interventions for HAND

Approximately 30-50% of persons living with HIV manifest some degree of neurocognitive impairment. Even mild-to-moderate forms of HIV-associated neurocognitive disorders (HAND) can result in difficulties with everyday functioning, such as suboptimal medication adherence and impaired driving. Despite the pervasive presence and consequences of HAND, there is a significant unmet need to develop effective behavioral strategies to reduce the incidence and consequences of HAND. Although there is an absence of evidence-based behavioral interventions specific to HAND, the literature reviewed in this chapter suggest the following modifiable lifestyle factors as intervention targets: physical activity, diet, sleep, and antiretroviral medication adherence. Adoption and maintenance of these healthy lifestyle factors may reduce inflammation and oxidative stress, which, in turn, may reduce the incidence and/or severity of HAND.

Lifetime Methamphetamine Use Disorder and Reported Sleep Quality in Adults Living with HIV

This study evaluated whether a history of lifetime methamphetamine (MA) use disorder increases risk for poor sleep quality in people with or without HIV infection (HIV+/HIV-). Participants (n = 313) were stratified into four groups based on HIV status and lifetime MA use disorder diagnosis [HIV+/MA+ (n = 84); HIV+/MA- (n = 141); HIV-/MA+ (n = 16); and HIV-/MA- (n = 72)] and compared on global sleep outcomes using the Pittsburgh Sleep Quality Index (PSQI). Significant differences on global sleep were observed between HIV+/MA+ and HIV+/MA- groups, but not between the HIV- groups. Follow-up multiple regression analyses within the HIV+ subgroups examined global sleep scores as a function of MA status and clinical covariates, including those related to HIV disease and demographics. HIV+ individuals with a history of MA use disorder evidenced significantly poorer sleep quality and were more likely to be classified as problematic sleepers than those without a lifetime disorder. This was independent of depressed mood, body mass index, and viral suppression while on treatment. Poorer reported sleep quality among HIV+/MA+ was associated also with multiple adverse functional outcomes, including greater objective cognitive impairment, unemployment, clinical ratings of functional impairment, and self-reported cognitive difficulties, decreased independence in activities of daily living, and poorer overall life quality. Interventions to avoid or curtail MA use in HIV+ individuals may help protect sleep quality and improve functioning.

Sleep disruption and duration are associated with variants in genes involved in energy homeostasis in adults with HIV/AIDS

OBJECTIVE

To determine whether selected genes and plasma markers involved in energy homeostasis are associated with sleep disruption or duration in adults with HIV/AIDS.

METHODS

A sample of 289 adults with HIV/AIDS wore a wrist actigraph for 72 h to estimate total sleep time (TST) and wake after sleep onset (WASO). Twenty-three single nucleotide polymorphisms (SNP) spanning 5 energy homeostasis genes (adiponectin [ADIPOQ], ghrelin [GHRL], leptin [LEP], peroxisome proliferator-activated receptor-alpha [PPARA], and -gamma [PPARG]) were genotyped using a custom array. Plasma markers of energy homeostasis (adiponectin, ghrelin, leptin) were measured by commercial multiplex assay.

RESULTS

After adjusting for demographic and clinical characteristics (race/ethnicity, gender, CD4 cell count, waist circumference, medications), both WASO and TST were associated with SNPs in ADIPOQ (rs182052), LEP (rs10244329, rs3828942), PPARA (rs135551, rs4253655), and PPARG (rs709151). Additional SNPs in ADIPOQ were associated with WASO (rs1501299, rs3821799, rs6773957) and TST (rs2241766). TST was also associated with SNPs in GHRL (rs26802), LEP (rs11760956), PPARA (rs135547, rs8138102, rs4253776), and PPARG (rs12490265, rs796313). Many covariate-adjusted associations involved a significant interaction with markers of HIV (viral load, years since diagnosis). Among plasma markers, higher adiponectin was associated with less WASO, higher ghrelin and glucose levels with shorter TST, and higher leptin with longer TST.

CONCLUSIONS

Replication of SNPs in all five genes and three plasma markers of energy homeostasis were associated with objective sleep measures. HIV disease influenced many of the associations. Findings strengthen evidence for associations between energy homeostasis genetics and poor sleep, and provide direction for pharmacological intervention research.

Dynamics in a simple evolutionary-epidemiological model for the evolution of an initial asymptomatic infection stage

Pathogens exhibit a rich variety of life history strategies, shaped by natural selection. An important pathogen life history characteristic is the propensity to induce an asymptomatic yet productive (transmissive) stage at the beginning of an infection. This characteristic is subject to complex trade-offs, ranging from immunological considerations to population-level social processes. We aim to classify the evolutionary dynamics of such asymptomatic behavior of pathogens (hereafter "latency") in order to unify epidemiology and evolution for this life history strategy. We focus on a simple epidemiological model with two infectious stages, where hosts in the first stage can be partially or fully asymptomatic. Immunologically, there is a trade-off between transmission and progression in this first stage. For arbitrary trade-offs, we derive different conditions that guarantee either at least one evolutionarily stable strategy (ESS) at zero, some, or maximal latency of the first stage or, perhaps surprisingly, at least one unstable evolutionarily singular strategy. In this latter case, there is bistability between zero and nonzero (possibly maximal) latency. We then prove the uniqueness of interior evolutionarily singular strategies for power-law and exponential trade-offs: Thus, bistability is always between zero and maximal latency. Overall, previous multistage infection models can be summarized with a single model that includes evolutionary processes acting on latency. Since small changes in parameter values can lead to abrupt transitions in evolutionary dynamics, appropriate disease control strategies could have a substantial impact on the evolution of first-stage latency.

Metabolomics of sleep disorders in HIV: a narrative review

PURPOSE

Sleep disturbances are prevalent among patients with human immunodeficiency virus (HIV), even those who are being treated on antiretroviral therapy. It is important to understand the metabolomic mechanisms underlying sleep disturbances among people living with HIV (PLWH).

METHODS

A review of recent literature was performed to explore the use of metabolomics in understanding sleep among PLWH.

RESULTS

We found only two studies that used metabolomics to explore sleep health among PLWH.

CONCLUSION

This paper reviews common sleep disorders in HIV, the existing metabolomic studies that may explain the relationship, and implications for future research. The use of metabolomics in exploring sleep disorders among PLWH will help to elucidate mechanistic links to improve patient outcomes.

Physical and mental health in HIV-infected patients with virological success and long-term exposure to antiretroviral therapy

In people living with HIV (PLWH), a decade-long antiretroviral therapy (ART) poses new challenges regarding physical and mental health. The aim of this cross-sectional study is to investigate the health-related quality of life (HRQOL) in adult HIV-infected patients with viral suppression and an ART exposure for at least 5 years in three German HIV centers. Patients were evaluated by the ACTG Augmented Symptoms Distress Module (ASDM) and the SF-12 Health Survey. Among 894 patients, symptom-related distress was highly prevalent. The most common symptoms were fatigue, insomnia, sadness and depression, sexual dysfunction, and changes in body appearance. In the multivariate analysis, ART duration, age and depression were significantly associated with a higher overall symptom summary score. Self-reported mean SF-12 scores were lower for mental health and younger patients compared to the standard random sample of a healthy German population. Depression and occupational status were significantly related to a lower physical component summary score, by contrast older age was associated with higher scores in the mental component summary, implying more favorable mental health status. In this large group of PLWH, the degree of symptom-related distress was high. Mental and physical health should be considered an integral part of ongoing HIV care.

Biomarkers panels can predict fatigue, depression and pain in persons living with HIV: A pilot study

BACKGROUND

Persons living with HIV experience high symptom burden that can negatively impact medication adherence, work productivity, and quality of life. Symptoms are highly subjective, which can lead to under- or improper treatment. The purpose of this exploratory study was to examine relationships between circulating biomarkers representative of inflammatory, coagulation, and vascular function pathways and prevalent HIV symptoms.

SETTING AND SAMPLE

Adults >18 years who were diagnosed with HIV and spoke English for this cross-sectional study were recruited from community clinics and organizations.

METHODS

Symptom burden was measured with the HIV Symptom Index; depression with the Patient Health Questionnaire. Human multiplex kits were used to determine serum concentrations of select biomarkers representing inflammatory, coagulation, and vascular function pathways. The biomarkers were included as features in machine learning models to determine which biomarkers predicted the most prevalent HIV symptoms (fatigue and muscle/joint pain) and the symptom of depression.

RESULTS

Participants (N = 32) were representative of the local population of people with HIV, being mostly Black (54.4%) and male (60.6%). Depression was predicted by age, gender, glucose, hemoglobin A1c, and inflammation. Muscle/joint pain was predicted by adiponectin, C-reactive protein, and serum amyloid A (SAA). Fatigue was predicted by adiponectin, SAA, and soluble interleukin-1 receptor type II (sIL-1RII).

CONCLUSION

Biomarker clusters can be a tool to monitor symptoms. Adding an objective measure to subjective patient experiences could improve management and monitoring of symptoms. Defining a biomarker cluster for the objective assessment of HIV symptoms warrants further investigation; however, the presence of comorbid conditions needs to be controlled.

Prescription of High-Dose Opioids Among People Living with HIV in British Columbia, Canada

People living with HIV (PLHIV) often experience pain for which opioid medications may be prescribed. Thus, these individuals are particularly vulnerable to opioid-related harms, including overdose, misuse, and addiction, particularly when prescribed at high doses. We used a comprehensive linked population-level database of PLHIV in British Columbia (BC) to identify demographic and clinical characteristics associated with being prescribed any high-dose opioid analgesic, defined as > 90 daily morphine milligram equivalents (MME/day). Among PLHIV who were prescribed opioids between 1996 and 2015 (n = 10,780), 28.2% received prescriptions of > 90 MME/day at least once during the study period. Factors positively associated with being prescribed high-dose opioid analgesics included: co-prescription of benzodiazepines (adjusted odds ratio [AOR] = 1.14; 95% confidence interval 1.11-1.17); presence of an AIDS-defining illness (ADI; AOR = 1.78; 95% CI 1.57-2.02); seen by an HIV specialist (AOR = 1.24; 95% CI 1.20-1.29); substance use disorder (AOR = 1.46; 95% CI 1.25-1.71); and more recent calendar year (AOR = 1.05; 95% CI 1.04-1.06). Given the known risks associated with high-dose opioid prescribing, future research efforts should focus on the clinical indication and outcomes associated with these prescribing practices.

In people living with HIV (PLWH), menopause (natural or surgical) contributes to the greater symptom burden in women: results from an online US survey

OBJECTIVE

The majority of people living with HIV in the United States are now over the age of 50, but symptom burden research has seldom included older women or the potential role of menopause. The aim of the study was to examine the influence of menopause as part of sex differences in HIV symptom burden.

METHODS

A cross-sectional study was conducted that included both a sex-based analysis of previously reported HIV symptom characteristics of 1,342 respondents to an online survey (males, n = 957; female, n = 385) and a follow-up online survey of menstrual bleeding patterns (inferred menopause) in eligible females (n = 242) from the respondent pool. Using linear mixed models, we identified predictors of symptom burden scores in female respondents.

RESULTS

For the most troublesome symptoms assessed in the sex-based analysis, depression scores were similar (P > 0.05), but higher (worse) burden scores for fatigue (P = 0.013) and muscle aches/pains (P = 0.004) were exclusively observed in females after adjusting for covariates. Respondents to the female survey (n = 222) were predominantly Black, heterosexual, nonsmokers, and obese, with an HIV diagnosis of approximately 16 years and at least one comorbid condition. Burden scores were higher in women reporting amenorrhea due to natural menopause or hysterectomy (n = 104) versus the menstruating group (n = 118) for muscle aches/pains (P = 0.05), fatigue (P = 0.03), and difficulty falling asleep (P = 0.04), independent of age, HIV duration, and number of HIV-associated non-AIDS conditions.

CONCLUSIONS

Two of the most common symptoms in people living with HIV-fatigue and muscle aches/joint pains-invoke additional burden in women. Independent of aging, symptom burden may be exacerbated after menopause, supporting a shifting paradigm for HIV care management.

Provider opioid prescribing practices and the belief that opioids keep people living with HIV engaged in care: a cross-sectional study

We describe HIV providers' opioid prescribing practices and assess whether belief that chronic opioid therapy (COT) keeps people living with HIV (PLWH) engaged in care is associated with differences in these practices among providers from two HIV clinics. We conducted logistic regression to evaluate the association between the belief that COT keeps PLWH engaged in care and at least one component of guideline-recommended care (i.e., urine drug tests, treatment agreements, and/or prescription monitoring program use). The sample included 41 providers with a median age of 42 years, 63% female, 37% non-white. Routine adherence to guideline-recommended practices was: 34% urine drug tests, 27% treatment agreements, and 17% prescription monitoring program. Over half [54%] agreed that COT keeps PLWH engaged in care. There was no significant association between belief that COT keeps PLWH engaged in care and routinely providing any recommended COT care component (aOR 2.38; 95% CI 0.65-8.73). Most HIV providers do not routinely follow guidelines for opioid prescribing. We observed a positive association between belief that COT keeps PLWH engaged in care and following any guideline-recommended prescribing practices, although the result was not statistically significant. Interventions are needed to improve guideline-concordant care for COT by HIV providers.

The effect of increased physical activity on symptom burden in older persons living with HIV

Advancements in antiretroviral therapy have extended the longevity of people living with HIV (PLWH). However, they often experience symptoms that negatively impact their quality of life, including fatigue, weight change, depression, pain, and memory loss. Although there is a dearth of data on the effect of physical activity (PA) for HIV-associated symptom management, increased PA has generally been associated with improvements in strength and overall quality of life. In this study, we enrolled 40 participants (mean age = 51.5; 40% female; 17.4 mean years living with HIV) and used Omron pedometers to measure daily step counts over 12 weeks. The 20-item HIV Symptom Index was administered at baseline and week 12. Increased PA was not associated with improvement in overall HIV symptom burden. However, bothersome symptoms were reduced, and total symptom burden was highly correlated with PA level at week 12 (r = -.48, p = .01), such that participants with  higher step counts reported lower symptom burden. Significant gender differences in symptom burden were noted: males on average reported lower symptom burden. Further research is needed to examine associations between PA and HIV symptom burden and to further explore gender differences in HIV symptom burden to improve overall quality of life for all older PLWH.

Study protocol for the targeting effective analgesia in clinics for HIV (TEACH) study - a cluster randomized controlled trial and parallel cohort to increase guideline concordant care for long-term opioid therapy among people living with HIV

Background: People living with HIV (PLWH) frequently experience chronic pain and receive long-term opioid therapy (LTOT). Adherence to opioid prescribing guidelines among their providers is suboptimal. Objective: This paper describes the protocol of a cluster randomized trial, targeting effective analgesia in clinics for HIV (TEACH), which tested a collaborative care intervention to increase guideline-concordant care for LTOT among PLWH. Methods: HIV physicians and advanced practice providers (n = 41) were recruited from September 2015 to December 2016 from two HIV clinics in Boston and Atlanta. Patients receiving LTOT from participating providers were enrolled through a waiver of informed consent (n = 187). After baseline assessment, providers were randomized to the control group or the year-long TEACH intervention involving: (1) a nurse care manager and electronic registry to assist with patient management; (2) opioid education and academic detailing; and (3) facilitated access to addiction specialists. Randomization was stratified by site and LTOT patient volume. Primary outcomes (≥2 urine drug tests, early refills, provider satisfaction) were collected at 12 months. In parallel, PLWH receiving LTOT (n = 170) were recruited into a longitudinal cohort at both clinics and underwent baseline and 12-month assessments. Secondary outcomes were obtained through patient self-report among participants enrolled in both the cohort and the RCT (n = 117). Conclusions: TEACH will report the effects of an intervention on opioid prescribing for chronic pain on both provider and patient-level outcomes. The results may inform delivery of care for PLWH on LTOT for chronic pain at a time when opioid practices are being questioned in the US.

Chronic Pain Mitigation and Opioid Weaning at a Multidisciplinary AIDS Clinic: A Case Report

Background and Purpose

Chronic pain has emerged as a treatment priority among people living with HIV (PLHIV). Recent studies indicate the use of physical therapy (PT) for chronic pain mitigation among PLHIV, however there is a paucity of literature regarding PT as part of multidisciplinary collaboration to address the intersection of HIV, chronic pain and opioid use.

Case Description

This case report examined the effect of a 24-session PT intervention aimed at decreasing chronic pain and opioid weaning for a 64 year-old patient at a multidisciplinary AIDS clinic in Atlanta, Georgia. The PT intervention focused on pain mitigation, utilizing using pain-relief techniques such as a home TENS unit, home stretching regimen, diaphragmatic breathing techniques. In addition, the physical therapist communicated regularly with the patient's primary HIV provider regarding patient progress.

Outcomes

After the intervention, outcomes included: decreased pain from 10/10 to 0/10, independent pain management, and increased independence in functional activities. In addition, the patient decreased opioid usage from 15 to 2.5 mg Hydrocodone, an 83.3% decrease.

Discussion

In a complex chronic pain case with a patient on chronic opioid therapy, multidisciplinary communication is key in successful management. To truly address opiate weaning in the context of pain management, physical therapists' expertise in pain management should ideally be complemented by close communication with the patient's primary medical provider. This allows for open dialogue, and acknowledges the importance of various specialty areas committed to a joint effort of not simply opioid weaning, but of patient-centered, multidisciplinary chronic pain control.

Effects of Sleep Health on Cognitive Function in HIV+ and HIV- Adults

OBJECTIVES

People living with HIV (PLWH) are more likely to report sleep difficulties and cognitive deficits. While cognitive impairment associated with sleep problems have been found in healthy and medical populations, less is known about the effects of poor sleep health (SH) on cognition among PLWH. This study examined differences in cognitive performance among participants classified based upon their HIV status and reported SH.

METHODS

One hundred sixteen (N=116) adults recruited from the Greater Los Angeles community were administered a comprehensive cognitive test battery and completed a questionnaire about SH. Participants were classified into the following HIV/SH groups: [HIV+/good sleep health (SH+; n=34); HIV-/SH+ (n=32); HIV-/poor sleep health (SH-; n=18) and HIV+/SH- (n=32)].

RESULTS

For both HIV+ and HIV- individuals, poor SH was associated with lower cognitive performance, with the domains of learning and memory driving the overall relationship. The HIV+/SH- group had poorer scores in domains of learning and memory compared to the SH+ groups. Additionally, the HIV-/SH- group demonstrated poorer learning compared to the HIV-/SH+ group.

CONCLUSIONS

Our findings suggest that sleep problems within medical populations are relevant to cognitive functioning, highlighting the clinical and scientific importance of monitoring sleep health and cognition to help identify individuals at greatest risk of poor health outcomes. Longitudinal investigations using both objective and subjective measures of sleep are needed to determine the robustness of the current findings and the enduring effects of poor SH in the context of chronic disease. (JINS, 2018, 24, 1038-1046).

Differential relationships between cannabis consumption and sleep health as a function of HIV status

BACKGROUND

There is evidence that regular cannabis use has negative effects on sleep health. Relative to HIV- populations, HIV + individuals consistently report greater sleep impairments. The number of HIV + individuals reporting frequent cannabis use, often to treat sleep issues, has significantly increased recently. It is unknown, however, if HIV status moderates the association between cannabis use and sleep health. The current study, therefore, examines these associations in a sample of HIV + and HIV- adults.

METHODS

HIV + and HIV- (N = 107) individuals completed one laboratory visit. Participants completed a 30-day drug use history questionnaire quantifying consumption of cannabis, cigarettes, and alcohol, and a sleep health questionnaire. To verify substance use and HIV status, participants completed a urine toxicology screening and serology testing.

RESULTS

HIV + individuals demonstrated lower sleep health than HIV- individuals. Linear regressions indicated that HIV status moderated the association between total 30-day cannabis consumption and sleep health; cannabis consumption was negatively associated with sleep health in HIV-, but not HIV + individuals. This interactive effect was significant after examining cigarette/alcohol use, depression symptoms, and demographic variables as covariates.

CONCLUSIONS

These results corroborate studies demonstrating an inverse relationship between sleep health and cannabis consumption. This study also suggests that factors other than cannabis may be associated with lower sleep health in HIV + individuals. Emerging studies suggest that inflammation may mediate effects of cannabis on HIV infection. Future studies examining this mechanism are warranted to understand cannabis further and sleep in HIV + individuals.

Effects of Discrimination on HIV-Related Symptoms in Heterosexual Men of Color

HIV-related symptoms have a deleterious effect on quality of life. One determinant of HIV symptom burden among individuals of color may be discrimination. The aim of this study was to explore whether multiple lifetime discrimination events are associated with a greater number of HIV-related symptoms among heterosexual HIV-positive men of color and to examine the influence of anxiety and social support on this relationship. Data for this study were drawn from a cross-sectional survey of 307 heterosexual HIV-positive men recruited from health and social service agencies in New York City (NYC). This study indicated that the number of discrimination events experienced in one’s lifetime was positively associated with the number of HIV-related symptoms experienced in the past month. Moreover, the direct effect of discrimination on HIV symptoms remained significant after anxiety was included as a mediator in the model, and there was a significant indirect effect of discrimination on HIV symptoms through anxiety. Evidence supported a potential moderated mediation effect involving social support: As social support increased, the indirect effect of discrimination on HIV symptoms through anxiety decreased. The results of this study suggest an association between discrimination and HIV-related symptom burden. Furthermore, the relationship between number of major discrimination experiences and HIV symptom burden was partially mediated by anxiety. Future research should consider how lifetime discrimination might be associated with negative health outcomes among HIV-positive individuals of color.

2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With HIV

Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Racial and socioeconomic disparities in the symptom reporting of persons living with HIV

Persons living with HIV (PLWH) today can survive decades with the disease, making the symptom experience much more relevant to their lifestyle and health outcomes. The goal of the research reported here was to assess the symptom reporting of PLWH in the Unites States (US) in the combined antiretroviral therapy (cART) age of the epidemic. We conducted an anonymous online survey of symptomatic PLWH in the US and asked participants to report the frequency and intensity of 28 frequently occurring symptoms in the past 30 days. The relationship between symptom reporting and demographic factors was investigated using the adaptive least absolute shrinkage and selection operator (LASSO) method. Fatigue was the most frequently reported symptom in our study population. Those with the lowest income were more likely to report more burdensome symptoms. In comparison to other racial and ethnic groups, Black non-Hispanic participants were significantly more likely to report a lower symptom burden score for fatigue, depression, muscle aches, anxiety, difficulties with memory and concentration. There were no racial/ ethnic differences in the burden of the symptoms related to sleep or neuropathy. Findings from this study present new evidence on the symptom reporting of PLWH in the US. Neuropathy continues to be a pervasive neurological symptom with no difference noted between racial/ ethnic groups.

Using Patient Perspectives to Inform the Development of a Behavioral Intervention for Chronic Pain in Patients with HIV: A Qualitative Study

Background

Chronic pain is a common and disabling comorbidity in individuals living with HIV. Behavioral interventions are among the most effective and safe nonpharmacologic treatments for chronic pain. However, the success of a behavioral intervention is influenced by how well it is tailored to the target population's biological, psychological, and social context. Given well-documented psychosocial vulnerabilities among persons with HIV, it is critical to develop a behavioral intervention for chronic pain tailored to this population.

Objective

To use qualitative methods to investigate patient preferences for the structure and delivery of a behavioral intervention for chronic pain in individuals with HIV.

Methods

Interviews and focus groups were used to elicit participant preferences. A thematic analysis approach, with an initial round of open coding, was used to develop the codebook and analyze the data.

Results

Qualitative data from 12 interviews and 3 focus groups with patients living with HIV and chronic pain (total N = 24) were analyzed. Emergent themes fell into four major categories: perceived value of group sessions, incorporating peer leadership, and two key elements of how the intervention should be delivered: the HIV status of group participants and views on phone-delivered intervention content.

Discussion

This study provides a framework for the structure and delivery of a behavioral intervention for chronic pain in individuals with HIV based on patient preferences. We will use these results to design our intervention, and hope that our approach informs the work of investigators in other disciplines who seek to incorporate patient preferences during intervention development.

Physical therapy as non-pharmacological chronic pain management of adults living with HIV: self-reported pain scores and analgesic use

BACKGROUND

HIV-related chronic pain has emerged as a major symptom burden among people living with HIV (PLHIV). Physical therapy (PT) has been shown to be effective as a non-pharmacological method of chronic pain management in the general population; however, there is a gap in research examining the role of PT for chronic pain among PLHIV.

MATERIALS AND METHODS

This study examined the effect of PT on self-reported pain scores and pain medication usage in PLHIV enrolled in a multidisciplinary HIV clinic. Data were collected via reviews of patient medical records within a certain timeframe. Data were gathered from patient charts for two points: initial PT encounter (Time 1) and PT discharge or visit ≤4 months after initial visit (Time 2).

RESULTS

Subjects who received PT during this timeframe reported decreased pain (65.2%), elimination of pain (28.3%), no change in pain (15.2%), and increased pain (6.5%). Three-quarters of the subjects reported a minimal clinically important difference (MCID) in pain score, and more than half reported a decrease in pain score over the MCID. Subjects showed a trend of decreasing pain medication prescription and usage during the study period.

CONCLUSION

Results of the current study indicate that in this sample, PT intervention appears to be an effective, cost-effective, non-pharmacological method to decrease chronic pain in PLHIV.

Pain and Risk Behaviors Among HIV-Infected Persons in St. Petersburg, Russia

We analyzed baseline data from an observational cohort of HIV-infected ART-naïve patients in St. Petersburg, Russia to explore whether pain was associated with HIV risk behaviors. The primary outcomes were (1) unprotected vaginal or anal sex in the past 90 days and (2) sharing of needles or equipment in the past month. Secondary outcomes included: use of alcohol prior to sex, current injection drug use, number of unprotected sex and sharing episodes, and days injected in the past month. The main independent variable was any past week pain. Multivariable regression models were fit for outcomes. After adjustment, the association with unprotected sex was of borderline significance (AOR = 2.06; 95 % CI 0.98-4.36, p = 0.058); there was no significant association between any past week pain and sharing of needles/equipment (AOR = 1.52; 95 % CI 0.65-3.59, p = 0.33). Participants with pain had higher odds of reporting alcohol use prior to sex (AOR = 2.42; 95 % CI 1.10-5.28, p = 0.03).

Common and Distinct Characteristics Associated With Trajectories of Morning and Evening Energy in Oncology Patients Receiving Chemotherapy

CONTEXT

Although energy conservation strategies are recommended in clinical practice guidelines, little is known about changes in energy levels in oncology patients undergoing cancer treatment.

OBJECTIVES

The objective of this study was to identify variations in the trajectories of morning and evening energy levels and determine which characteristics predicted initial levels and the trajectories of morning and evening energy.

METHODS

Outpatients receiving chemotherapy (CTX) completed demographic and symptom questionnaires six times over two CTX cycles. Energy was assessed using the Lee Fatigue Scale. Hierarchical linear modeling was used to analyze the data.

RESULTS

A large amount of interindividual variability was found in the morning and evening energy trajectories. Patients who lived alone, had childcare responsibilities, had a lower functional status, did not exercise on a regular basis, had lower hemoglobin levels, had lower attentional function, higher trait anxiety, and higher sleep disturbance reported lower morning energy levels at enrollment. Variations in the trajectories of morning energy were associated with a higher body mass index and higher levels of morning energy and higher sleep disturbance scores. For evening energy, patients who were female, white, had lower functional status, and had lower attentional function and higher sleep disturbance reported lower evening energy levels at enrollment. Evening energy levels at enrollment were associated with changes in evening energy over time.

CONCLUSION

Patients undergoing CTX experience decrements in both morning and evening energy. The modifiable characteristics associated with these decrements can be used to design intervention studies to increase energy levels in these patients.

Faces of Frailty in Aging with HIV Infection

PURPOSE OF THE REVIEW

The number of adults who are aging successfully and have HIV infection is increasing. More effective antiretroviral therapy (ART) regimens are preventing individuals infected with HIV from reaching end stages of the HIV infection and developing AIDS (acquired immunodeficiency syndrome). However, even at lower viral loads, chronic HIV infection appears to have consequences on aging processes, including the development of frailty.

RECENT FINDINGS

Frailty is a term used to describe vulnerability in aging. Frailty indices such as the Fried Frailty Index (FFI), the Veterans Aging Cohort Study (VACS) Index, and the Center for Epidemiologic Studies Depression scale (CES-D), an index of emotional frailty, associate with or predict clinical outcomes and death. However, even among existing frailty definitions, components require rigorous and consistent standardization. In the Women's Interagency HIV Study (WIHS), we have shown that frailty does not exist in isolation, even in midlife, and we use frailty to predict death. Frailty indices should be systematically used by health professionals to evaluate health and future risks for adverse events. Frailty prevention efforts, especially among those with HIV infection, appear to be essential for "successful aging" or aging without disability or loss of independence and may prevent HIV transmission. Taking care of elderly people is one of the major challenges of this century, and we must expect and be prepared for an increase in the number of aging adults, some of whom are patients with many co-morbidities and HIV infection.

Cytokine polymorphisms are associated with daytime napping in adults living with HIV

OBJECTIVE/BACKGROUND

Daytime napping longer than one hour has been associated with an increased risk for all-cause mortality. Associations between cytokine polymorphisms and daytime napping in chronic illnesses such as HIV, however, have not been well described. The purpose of this study was to examine cytokine polymorphisms associated with long daytime napping in adults living with HIV.

METHODS

A cross-sectional analysis was conducted using a convenience sample of 257 adults living with HIV. Daytime napping was assessed with wrist actigraphy data collected over three days. Participants categorized as long nappers (≥60 min) were compared to short nappers and non-nappers (<60 min). Single nucleotide polymorphisms (SNPs) for 15 candidate genes involved in cytokine signaling were analyzed. Genes included: interferon-gamma (IFNG), IFNG receptor 1 (IFNGR1), interleukins (IL1B, IL1R, IL1R2, IL2, IL4, IL6, IL8, IL10, IL13, IL17A), nuclear factors of kappa light polypeptide gene enhancer in B cells (NFKB1 and NFKB2), and tumor necrosis factor alpha (TNFA).

RESULTS

After adjusting for relevant demographic and clinical characteristics, long daytime napping was associated with 12 SNPs from seven genes: 1) IFNG rs2069728; 2) IL1B rs1143642, rs1143627, and rs16944; 3) IL2 rs2069763; 4) IL6 rs4719714, rs1554606, and rs2069845; 5) IL17A rs3819024 and rs8193036; 6) NFKB1 rs4648110; and 7) NFKB2 rs1056890.

CONCLUSIONS

Cytokine genetic variations may have a role in physiological regulation of daytime napping as well as nocturnal sleep. Cytokine polymorphisms associated with long daytime napping could help identify adults with HIV who may benefit from targeted therapeutic interventions.

A Mixed-Methods Pilot Study of Mindfulness-Based Stress Reduction for HIV-Associated Chronic Pain

Treatment guidelines for chronic pain recommend nonpharmacologic modalities as part of a comprehensive management plan. Chronic pain is common among people living with HIV/AIDS, but there is little data to guide the choice of nonpharmacologic therapies in this complex population. We performed a mixed-methods feasibility study of Mindfulness-Based Stress Reduction (MBSR) versus health education control with 32 inner city, HIV-infected participants. Outcome measures included: the Brief Pain Inventory, Perceived Stress Scale, HIV Symptoms Index, autonomic function testing, and audiotaped focus groups. Post-intervention, participants reported modest improvements in pain measures and perceived stress, but no effect of group assignment was observed. At 3-month follow-up, 79% of MBSR participants were still practicing, and pain intensity was improved, whereas in the control group pain intensity had worsened. Qualitative analysis revealed a strong sense of community in both groups, but only MBSR was perceived as useful for relaxation and pain relief.

Burden and risk factors for gastrointestinal symptom distress in HIV patients in the modern antiretroviral era

In the modern antiretroviral (ARV) era, there is limited knowledge about the prevalence and risk factors for HIV patient-reported gastrointestinal (GI) symptoms (diarrhoea/soft stool, nausea/vomiting, bloating/painful abdomen, loss of appetite, and weight loss/wasting) and distress. We prospectively analysed data (2007-2014) on distressing GI symptoms from the Ontario HIV Treatment Network Cohort Study, which follows people attending HIV clinics. Using generalized estimating equations with a logit link, we estimated the associations of psychosocial, demographic, behavioural, and clinical factors with each GI symptoms compared to asymptomatic and non-bothersome symptoms. Among 1532 included participants, 80.4% were male, mean age was 45 years, and 64.6% reported being men who have sex with men. Most were Caucasian (56.3%), a median time since HIV diagnosis of 9.8 years (interquartile range (IQR): 4.1-16.9), and 83.1% were on ARV. More than two-thirds (68.7% (95% confidence intervals (CI): 63.1% to 69.2%)) reported one or more symptoms with a median of 1.2 (IQR: 0-1.7). The proportion remained stable over time since HIV diagnosis and ARV initiation. Risk factors varied for multivariable models. A strong association with Centre for Epidemiologic Studies Depression scale scores of ≥23 was found for all symptoms. Adjusted odds ratios (95% CI) were 1.72 (1.39-2.12), 2.95 (2.33-3.72), 2.20 (1.81-2.68), 4.97 (3.99-6.19), and 2.98 (2.52-3.82) for diarrhoea, nausea/vomiting, bloating, loss of appetite, and weight loss, respectively. With the exception of bloating, odds were significantly lower for those on ARV containing integrase inhibitors and greater for patients reporting current cannabis use. GI symptoms in the modern ARV era are highly prevalent and may arise as a common pathway of distress in response to psychosocial vulnerabilities, regardless of the stage of diagnosis. These findings support the need for integrated approaches to address psychological and physical distress in HIV disease.

Better Antiretroviral Central Nervous System Penetration is Not Associated with Reduced Chronic Pain in People Living with Human Immunodeficiency Virus

OBJECTIVE

To determine if better antiretroviral (ARV) central nervous system (CNS) penetration is associated with reduced rates of chronic pain in people living with HIV (PLWH).

BACKGROUND

Chronic pain remains prevalent in PLWH despite widespread ARV use. Mechanisms underlying this prevalence remain unknown, though neuroinflammation from persistent CNS HIV infection and maladaptive plastic changes in the CNS have been implicated. Here we hypothesize that better CNS ARV penetration, measured using the CNS Penetration-Effectiveness (CPE) score, would decrease rates of chronic pain.

METHODS

We interviewed 254 consecutive adults from an HIV clinic in Chiang Mai, Thailand. We collected data on demographics, HIV history, ARV use, and pain characteristics. Patients were evaluated for depression using a Thai two question Patient Health Questionnaire (PHQ-2). Modified CPE score was calculated using established methods and grouped a priori into "low CPE" (≤7, poor penetration) and "high CPE" (≥8, good penetration). CPE score was compared with chronic pain scores in SPSS using appropriate statistical tests. A relationship between CPE score and a positive depression screen was tested further using multivariable binary logistic models.

RESULTS

245 of 254 subjects were on ARVs. Complete ARV data was available for 235 patients. 137 of these 235 patients (58.3%) had a CPE score ≤7, and 98 (41.7%) had a score ≥8. 49 patients had chronic pain, and 9 had neuropathic pain. Low CPE score was not associated with chronic pain (p=0.64), neuropathic pain (p=0.56), or frequent pain (p=0.80), nor was it associated with the severity of reported "worst pain" or "average pain" in the last 24 hours (p=0.18 and 0.48, respectively). Post-hoc analysis revealed that higher CPE score was a significant independent risk factor for depression measured by a positive PHQ-2 screen [OR (95% CI) = 1.29 (1.04-1.61), p=0.02]. This relationship was mediated primarily by exposure to zidovudine.

CONCLUSIONS

CPE score is not associated with chronic pain in PLWH. Post-hoc analysis demonstrated that CPE score, and zidovudine exposure in particular, predicts a positive depression screen. Given the substantial morbidity associated with chronic pain and mood disorders in PLWH, additional studies to determine preventable and treatable factors are imperative.

Correlates of Antiretroviral Therapy Adherence among HIV-Infected Older Adults

BACKGROUND

Despite the success of antiretroviral therapy (ART), HIV-infected older African Americans experience higher mortality rates compared to their white counterparts. This disparity may be partly attributable to the differences in ART adherence by different racial and gender groups. The purpose of this study was to describe demographic, psychosocial, and HIV disease-related factors that influence ART adherence and to determine whether race and gender impact ART adherence among HIV-infected adults aged 50 years and older.

METHODS

This descriptive study involved a secondary analysis of baseline data from 426 participants in "PRIME," a telephone-based ART adherence and quality-of-life intervention trial. Logistic regression was used to examine the association between independent variables and ART adherence.

RESULTS

Higher annual income and increased self-efficacy were associated with being ≥95% ART adherent. Race and gender were not associated with ART adherence.

CONCLUSION

These findings indicated that improvements in self-efficacy for taking ART may be an effective strategy to improve adherence regardless of race or gender.

Pain and Mortality Risk in a Cohort of HIV-Infected Persons with Alcohol Use Disorders

Pain has been associated with increased risk for mortality in some studies. We analyzed data from a cohort study [HIV-longitudinal interrelationships of viruses and ethanol (HIV-LIVE)] of HIV-infected persons with alcohol use disorders enrolled 2001-2003 to explore whether reporting moderate or greater pain interference was associated with mortality. The main independent variable was pain that at least moderately interfered with work based on a single question from the SF-12. Primary analyses dichotomized at "moderately" or above. Cox proportional hazards models assessed the association between pain interference and death adjusting for demographics, substance use, CD4 count, HIV viral load and co-morbidities. Although significant in unadjusted models (HR = 1.58 (95 % CI 1.03-2.41; p value = 0.04)), after adjusting for confounders, ≥moderate pain interference was not associated with an increased risk of death [aHR = 1.30 (95 % CI 0.81-2.11, p value = 0.28)]. Among HIV-infected persons with alcohol use disorders, we did not detect a statistically significant independent association between pain interference and risk of death after adjustment for potential confounders.

Medication adherence among transgender women living with HIV

Medication adherence is linked to health outcomes among adults with HIV infection. Transgender women living with HIV (TWLWH) in the US report suboptimal adherence to medications and are found to have difficulty integrating HIV medication into their daily routine, but few studies explore the factors associated with medication adherence among transgender women. Thus, the purpose of this paper is to examine demographic and clinical factors related to self-reported medication adherence among transgender women. This secondary analysis is based on data collected from the Symptom and Genetic Study that included a convenience sample of 22 self-identified transgender women, 201 non-transgender men, and 72 non-transgender women recruited in northern California. Self-reported medication adherence was assessed using the AIDS Clinical Trials Group Adherence Questionnaire. Gender differences in demographic and clinical variables were assessed, as were differences between transgender women reporting high and low adherence. Transgender women had lower adherence to medications compared to non-transgender males and non-transgender females (p = .028) and were less likely to achieve viral suppression (p = .039). Within the transgender group, Black/African-Americans reported better adherence than participants who were Whites/Caucasian or other races (p = .009). Adherence among transgender women was unrelated to medication count and estrogen therapy, but consistent with other reports on the HIV population as a whole; transgender women with high adherence were more likely to achieve viral suppression compared to the transgender women with low adherence. Despite the high incidence of HIV infection in the transgender population, few studies focus on TWLWH, either in regard to their adherence to antiretroviral therapies or to their healthcare in general. To address ongoing health disparities, more studies are needed focusing on the transgender population's continuum of care in HIV therapies.