Pain, sleep disturbances, and functional limitations in people living with HIV/AIDS-associated distal sensory peripheral neuropathy

Sleep quality and associated factors among adult people living with HIV on follow-up at Dessie Town Governmental Health Facilities Antiretroviral Therapy Clinics, Northeast, Ethiopia, 2020, a multicenter cross-sectional study

BACKGROUND

Poor sleep quality is an important health problem in people living with HIV. The exact cause of sleep disturbance is not well known, but it may relate to HIV itself, antiretroviral drug side effects, and other HIV-related disorders. As a result, the purpose of this study was to assess sleep quality and associated factors among adult HIV patients on follow-up at Dessie Town governmental health facilities' antiretroviral therapy clinics in Northeast Ethiopia in 2020.

METHODS

A multi-center cross-sectional study was conducted among 419 adult people living with HIV/AIDS from February 1/2020 to April 22/2020 in Dessie Town governmental antiretroviral therapy clinics. A systematic random sampling method was used to select the study participants. An interviewer-administered method of data collection with a chart review was used. The Pittsburgh Sleep Quality Index was used to evaluate sleep disruption. A binary logistic regression was conducted to see the relationship between a dependent variable and independent variables. Variables with a p-value of < 0.05 and a 95% confidence interval were used to declare an association between factors and a dependent variable.

RESULTS

A total of 419 study participants were enrolled in this study, with a response rate of 100%. The mean age of the study participants was 36 ± 6.5 SD years and 63.7% of the participants were female. The prevalence of poor sleep quality was found to be 36% (95% CI, 31-41%). Being female (AOR = 3.45, 95% CI: 1.52-7.79), viral loads 1000 copies/ml (AOR = 6.88, 95% CI: 2.79-16.9), CD4 cell count 200 cells/mm3 (AOR = 6.85, 95% CI: 2.42-19.39), WHO stage II and III (AOR = 4.29, 95% CI: 1.05-17.53), having anxiety (AOR = 10, 95% CI: 4.21-23.9.

CONCLUSION

The findings of this study showed that more than one-third of the study participants had poor-quality sleep at the Dessie Town Health Facility ART clinic. Being female, low CD4 cell counts, viral load ≥1000 copies/ml, WHO stage II and III, depression, anxiety, sleeping in a communal bedroom, and living alone were predictors of poor sleep quality.

Self-Reported Disability in Persons With HIV-Related Neuropathy Is Mediated by Pain Interference and Depression

OBJECTIVE

The purpose of this study was to compare disability in people with HIV and peripheral neuropathy with those without neuropathy and explore how neuropathy and other relevant factors are associated with disability.

METHODS

In this cross-sectional study, participants completed the Brief pain inventory, Beck Depression Inventory II, World Health Organization Disability Assessment Schedule (WHODAS 2.0), and a health and demographic questionnaire. Additional data were extracted from the medical record. A raw score of ≥1 on the Subjective Peripheral Neuropathy Screen questions about lower extremity numbness or paresthesia was used to identify peripheral neuropathy. Predictors of disability (as determined by association with World Health Organization Disability Assessment Schedule 2.0 scores) were evaluated bivariately and in a multivariable model. Path modeling was used to identify a parsimonious model to elucidate the mediated effects of peripheral neuropathy on disability.

RESULTS

Participants with peripheral neuropathy had more depression symptoms, more pain (severity and interference), and higher disability scores compared with participants without neuropathy. The relationship between neuropathy and disability was mediated by pain interference and depression (standardized root mean residual = .056).

CONCLUSION

In this sample of people with HIV, those with lower extremity peripheral neuropathy reported more severe disability, worse pain, and more depression symptoms than those without neuropathy. The relationship between peripheral neuropathy and disability may be mediated though pain interference and depression.

IMPACT

Distal sensory polyneuropathy is a common comorbidity experienced by people living with HIV and frequently causes pain. This study can help providers direct care toward lessening disability experienced among people with HIV and peripheral neuropathy by targeting interventions for treatment of pain and depression.

LAY SUMMARY

People living with HIV may experience disabling painful neuropathy. Treatment for pain and depression may help reduce the disability associated with painful neuropathy.

Assessment and Management of HIV Distal Sensory Peripheral Neuropathy: Understanding the Symptoms

Distal sensory peripheral neuropathy (HIV-DSP) affects upwards of 50% of people living with HIV. Causing often debilitating symptoms of tingling, numbness and burning, HIV-DSP can result in disability, unemployment and low quality of life. Comorbidities further complicate nursing care, heightening risk of polypharmacy and symptom exacerbation. Therefore, a neurological sensory assessment, combined with the patient's self-report of symptoms, can help nurse practitioners visualize, quantify and understand symptoms. Common pharmacological interventions include antiepileptics, antidepressants, analgesics and medical marijuana. The complexity of care for individuals with HIV-DSP merits a comprehensive approach. Implications for practice include interdisciplinary management with neurologists, podiatrists, mental health providers, and nurse-led counseling inclusive of patient safety teaching.

Classification and description of chronic pain among HIV positive patients in Uganda

INTRODUCTION

Chronic pain classification in HIV positive patients is essential for diagnosis and treatment. However, this is rarely done despite association with poor outcomes.

METHODS

A cross-sectional survey of 345 consented patients at a specialized HIV care center in Uganda was conducted. Chronic pain was defined as pain of more than two weeks duration. Data was collected using a socio-demographic questionnaire, the IASP classification of chronic pain; the StEP; Mini Mental Status Examination, Patient Health Questionnaire, Mini International Neuropsychiatric Interview and the World Health Organization quality of life instrument brief version. Chi-square, Fisher's exact, t-test and logistic regression analyses were carried out to determine factors associated with chronic pain.

RESULTS

Description of pain aetiology was difficult. Chronic pain was reported in 21.5% of the participants. Non-neuropathic (92.0%) was more common than neuropathic pain (8.0%). Chronic pain was found to be associated with feeling ill [OR=6.57 (3.48 - 12.39)], and worse scores in the quality of life domain for physical health [OR=0.71 (0.60 - 0.83)].

CONCLUSION

People living with HIV/AIDS commonly have chronic pain that is associated with poor quality of life. More sensitive tools are needed to accurately describe chronic pain in resource limited settings.

Williams AC. Psychosocial factors associated with persistent pain in people with HIV: a systematic review with meta-analysis

Chronic pain remains a prevalent and disabling problem for people living with HIV in the current antiretroviral treatment era. Psychosocial treatments may have promise for managing the impact of this pain. However, research is needed to identify psychosocial processes to target through such treatments. The current systematic review and meta-analysis examined the evidence for psychosocial factors associated with pain, disability, and quality of life in people living with HIV and persistent pain. Observational and experimental studies reporting on the association between one or more psychosocial factors and one or more pain-related variables in an adult sample of people living with HIV and pain were eligible. Two reviewers independently conducted eligibility screening, data extraction, and quality assessment. Forty-six studies were included in the review and 37 of these provided data for meta-analyses (12,493 participants). "Some" or "moderate" evidence supported an association between pain outcomes in people with HIV and the following psychosocial factors: depression, psychological distress, posttraumatic stress, drug abuse, sleep disturbance, reduced antiretroviral adherence, health care use, missed HIV clinic visits, unemployment, and protective psychological factors. Surprisingly, few studies examined protective psychological factors or social processes, such as stigma. There were few high-quality studies. These findings can inform future research and psychosocial treatment development in this area. Greater theoretical and empirical focus is needed to examine the role of protective factors and social processes on pain outcomes in this context. The review protocol was registered with PROSPERO (CRD42016036329).

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.

Comparison of pain burden and psychological factors in Brazilian women living with HIV and chronic neuropathic or nociceptive pain: An exploratory study

Psychological factors including pain catastrophizing and resilience associate with adjustment and quality of life in people living with chronic pain. Nevertheless, their presentation among females living with HIV and chronic pain has been poorly studied. Given that chronic pain in those living with HIV might occur due to different mechanisms (nociceptive or neuropathic), we hypothesize that the associated psychological states could also differ between these groups. We aimed to compare pain frequency and interference, psychological factors and sleep quality between females living with chronic nociceptive or neuropathic pain. Also, we explored correlations between psychological factors, pain severity and interference in females living with HIV and chronic pain. We performed a cross sectional study assessing females living with HIV and chronic pain, and compared it with a female HIV-positive, pain-free control sample in Brazil. To discriminate the most likely underlying mechanism for the chronic pain, we applied the Leeds Assessment for Neuropathic Signs and Symptoms (LANSS). Forty-nine females living with HIV and chronic pain were assessed, and divided in control (n = 12), nociceptive (n = 10) and neuropathic pain (n = 27) groups. Using validated scales, their pain catastrophizing, resilience, depression, anxiety and sleep disorders were assessed between May 2014 and August 2015. Compared to controls, females living with HIV and neuropathic chronic pain had higher pain frequency (p<0.001), interference on activities (p = 0.002), interference with emotions (p<0.001), catastrophizing (p<0.001), depression (p = 0.015), and lower resilience (p = 0.011). Catastrophizing was also significantly correlated to the burden of chronic pain. The type of chronic pain in females living with HIV should raise concerns regarding significant burden in psychological states in this population (particularly neuropathic pain). Using scales such as the LANSS to identify the type of choric pain, could be of use to address relevant issues for the patients, and to propose tailored therapies.

High prevalence of pain among adult HIV-infected patients at University of Gondar Hospital, Northwest Ethiopia

BACKGROUND

HIV/AIDS are pressing global health problems. Pain is a common symptom reported by patients living with HIV/AIDS. The exact cause of pain in HIV patients has not been thoroughly described, but it may, due to a symptom of HIV itself, result from opportunistic infections, as a side effect of antiretroviral drugs, concurrent neoplasia or other causes. In addition, pain perception of HIV-infected patients is highly variable and may vary based on cultural context and patient demographics. In Ethiopia, there is insufficient evidence on the prevalence and factors associated with HIV-related pain.

METHODS

A cross-sectional study was conducted among 422 adult HIV-infected patients at Gondar University Hospital antiretroviral care clinic from March 1 to May 1, 2016. Systematic random sampling was used to select study participants. A pretested interviewer-administered questionnaire and a standardized medical record data abstraction tool were used to collect data. A short form brief pain inventory tool was used to measure the outcome. Bivariate and multivariate logistic regression models were fitted to identify factors associated with pain among adult HIV patients.

RESULTS

The prevalence of pain was found to be 51.2% (95% CI: 46.4%-55.9%). Headache (17.9%), abdominal pain (15.6%), and backache (13.3%) were the most common symptoms of study participants. Being female (adjusted odds ratio [aOR]=1.8, 95% CI: 1.1-2.9); regular alcohol intake (aOR=3.3, 95% CI: 1.5-7.2); baseline World Health Organization clinical disease stage: II (aOR=2.5, 95% CI: 1.2-4.9), III (aOR=2, 95%, CI: 1.1-3.6), and IV (aOR=2.4, 95% CI: 1.1-5.3); and the presence of a chronic comorbid condition (aOR=5.9, 95% CI: 2.1-16.7) were significantly associated with pain.

CONCLUSION

Adult HIV patients in this sample reported a high level of chronic pain. Healthcare providers should better implement a routine pain assessment among HIV-positive patients to alleviate their suffering.

Ambulatory Blood Pressure Monitoring in Individuals with HIV: A Systematic Review and Meta-Analysis

INTRODUCTION

Abnormal diurnal blood pressure (BP) rhythms may contribute to the high cardiovascular disease risk in HIV-positive (HIV+) individuals. To synthesize the current literature on ambulatory BP monitoring (ABPM) in HIV+ individuals, a systematic literature review and meta-analysis were performed.

METHODS

Medical databases were searched through November 11, 2015 for studies that reported ABPM results in HIV+ individuals. Data were extracted by 2 reviewers and pooled differences between HIV+ and HIV-negative (HIV-) individuals in clinic BP and ABPM measures were calculated using random-effects inverse variance weighted models.

RESULTS

Of 597 abstracts reviewed, 8 studies with HIV+ cohorts met the inclusion criteria. The 420 HIV+ and 714 HIV- individuals in 7 studies with HIV- comparison groups were pooled for analyses. The pooled absolute nocturnal systolic and diastolic BP declines were 3.16% (95% confidence interval [CI]: 1.13%, 5.20%) and 2.92% (95% CI: 1.64%, 4.19%) less, respectively, in HIV+ versus HIV- individuals. The pooled odds ratio for non-dipping systolic BP (nocturnal systolic BP decline <10%) in HIV+ versus HIV- individuals was 2.72 (95% CI: 1.92, 3.85). Differences in mean clinic, 24-hour, daytime, or nighttime BP were not statistically significant. I2 and heterogeneity chi-squared statistics indicated the presence of high heterogeneity for all outcomes except percent DBP dipping and non-dipping SBP pattern.

CONCLUSIONS

An abnormal diurnal BP pattern may be more common among HIV+ versus HIV- individuals. However, results were heterogeneous for most BP measures, suggesting more research in this area is needed.

Mechanisms Influencing Circadian Blood Pressure Patterns Among Individuals with HIV

HIV+ individuals have an increased risk for cardiovascular disease (CVD), but the mechanisms behind this association are poorly understood. While hypertension is a well-established CVD risk factor, clinic-based blood pressure (BP) assessment by itself cannot identify several important BP patterns, including white coat hypertension, masked hypertension, nighttime hypertension, and nighttime BP dipping. These BP patterns can be identified over a 24-h period by ambulatory BP monitoring (ABPM). In this review, we provide an overview of the potential value of conducting ABPM in HIV+ individuals. ABPM phenotypes associated with increased CVD risk include masked hypertension (i.e., elevated out-of-clinic BP despite non-elevated clinic BP), nighttime hypertension, and a non-dipping BP pattern (i.e., a drop in BP of <10 % from daytime to nighttime). These adverse ABPM phenotypes may be highly relevant in the setting of HIV infection, given that increased levels of inflammatory biomarkers, high psychosocial burden, high prevalence of sleep disturbance, and autonomic dysfunction have been commonly reported in HIV+ persons. Additionally, although antiretroviral therapy (ART) is associated with lower AIDS-related morbidity and CVD risk, the mitochondrial toxicity, oxidative stress, lipodystrophy, and insulin resistance associated with long-term ART use potentially lead to adverse ABPM phenotypes. Existing data on ABPM phenotypes in the setting of HIV are limited, but suggest an increased prevalence of a non-dipping BP pattern. In conclusion, identifying ABPM phenotypes may provide crucial information regarding the mechanisms underlying the excess CVD risk in HIV+ individuals.

Management of Sleep Quality and Pain in an Individual Living with HIV and Hepatitis C Coinfection Using an Activity Monitor

STUDY DESIGN

Case report.

BACKGROUND

Twenty-five percent of people living with HIV/AIDS (PLWHA) are also coinfected with hepatitis C virus (HCV). There are limited reports to assist in the symptom management of PLWHA and HCV coinfection.

CASE DESCRIPTION

Our case was a 67-year-old man living with HIV/HCV coinfection and other medical complications. Our intervention consisted of a 6-week progressive conditioning program, while his activity and sleep pattern were monitored using a wrist accelerometer.

OUTCOMES

After completing a conditioning training, there was a 64% decrease in the number of waking episodes per night and 68% decrease in activity at night. Based on Pittsburgh Sleep Quality Index scores, the participant transitioned from being a "poor sleeper" to a "good sleeper." A 40% decrease in pain was reported. Functional outcome measures also showed improvements.

DISCUSSION

There were improvements in the participant's sleep quality and pain. The use of a commercial accelerometer may assist in objectively tracking compliance and activity changes.

Quality of Sleep in an HIV Population on Antiretroviral Therapy at an Urban Tertiary Centre in Lagos, Nigeria

Aim. To determine the prevalence of sleep disturbance and its associated characteristics in HIV-positive outpatients on HAART using the PSQI. Methods. Using a cross-sectional design, 300 patients attending the outpatient HIV/AIDS clinic at the Lagos State University Teaching Hospital were recruited. Baseline data obtained included the participants' demographic data, educational qualification, and marital status. Their treatment history, including duration since HIV diagnosis, the most recent CD4 cell count, and current antiretroviral therapies, was obtained from their case records. Each participant completed the PSQI questionnaire and those with scores ≥5 were diagnosed with poor sleep quality. Results. The participants were made up of 70.7% females and 29.3% males. Their ages ranged between 18 and 74 years with a mean of 38.9 ± 10.3 years. According to the PSQI, 59.3% reported poor sleep quality. The mean score of those with poor quality sleep (9.2 ± 3.3) was comparable to that of those with good quality sleep (1.26 ± 1.4). P < 0.001. Significant differences were observed in all the individual components of the PSQI (P < 0.001). On multivariate analyses, the independent associations with sleep quality were the duration since HIV diagnosis (P = 0.29), efavirenz based regimen (P < 0.001), and lower CD4 cell count (P < 0.001). Conclusions. Sleep disturbances are quite common in the HIV population even in the era of HAART. Early recognition via routine assessment and effective treatments could prevent the resultant complications and improve quality of life.