T. D. is a 32-year-old female who has had human immunodeficiency virus (HIV) for 5 years. Over the past four years, T.D. has been on a variety of antiviral therapies, which included zidovudine (Retrovir®), didanosine (ddI), and indinavir (Crixivan®). She is currently taking emtricitabine (Emtriva®), tenofovir (Viread®), and efavirenz (Sustiva®).

Today T. D. presents to the clinic with recent onset of mouth pain but has no fever or dental problems. When asked about the presence of other symptoms of discomfort, she states she is having only a rare headache, as opposed to last year when she was having them frequently. She denies burning and tingling in her feet, which she had last year when she was taking ddI. She also states that the muscle aches in her legs occur less frequently and are less intense than previously.

Infection with HIV puts an individual at high risk for experiencing a variety of pain syndromes. Knowledge of the common symptoms and patterns of pain related to HIV infection assists providers in identifying the cause, significance, and treatment. Because pain can indicate a life-threatening infection, malignancy, or reaction to a drug, each new pain should be recognized as potentially significant and, if necessary, the client should be referred to an infectious disease specialist with expertise in HIV.

Statistics on the prevalence of pain in clients with HIV infection vary, but it is known that pain can occur at any point throughout the HIV trajectory. A study reported in 1993 found that 53 (28%) of 191 seropositive men with asymptomatic disease had HIV-related pain. According to one study in 1998, 40% to 60% of clients with HIV had pain.

Studies of clients with acquired immunodeficiency syndrome (AIDS) indicate that pain is present in 50% to 80%, and that it is more severe than during earlier stages. Pain related to HIV is often compared to pain related to cancer in terms of its prevalence, intensity, impact on quality of
life, treatment, and undertreatment. Intensity of the pain also increases with progression of HIV, as it does with cancer. The client with HIV commonly has two to three sources of pain at a time, whereas the client with cancer has an average of three. As seen in clients with cancer, pain in clients with HIV also has a negative impact on an individual’s quality of life. It can lead to functional disabilities, social isolation, depression, hopelessness, and suicidal ideation. Comprehensive assessment of the physiological, psychological, sociocultural, developmental, and spiritual dimensions of a client’s life is necessary to adequately address the pain and its impact.

Assessing for the etiology of pain in clients with HIV is particularly challenging because opportunistic diseases, malignancies, and treatments cause pain in so many systems of the body, and the cause of each pain is not always identifiable.

Pain associated with HIV can be related to:

1. An opportunistic infection/condition or malignancy secondary to HIV

2. The virus itself

3. Medication given as treatment of the virus

4. Pathology unrelated to HIV

In terms of duration, HIV-related pain may be acute or chronic. Acute or short-term pain is directly related to tissue injury and resolves with tissue healing. An example of short-term pain related to an opportunistic condition is pain in the oropharynx due to inflammation from candidiasis overgrowth. An example of short-term pain related to treatment for HIV is abdominal pain associated with acute pancreatitis, which is a side effect of certain antiretroviral agents such as didanosine (ddI) and lamivudine (Epivir).

Chronic pain can occur due to HIV pathology (that is, damage to tissue caused by the virus itself), infections, malignancies, or as a side effect of medications such as antiretrovirals. Chronic pain may be persistent or episodic, and it is classified as somatosensory, visceral, or neuropathic. Somatosensory pain arises from bones, muscles, joints, or skin, and is often described as sharp, aching, or throbbing. Visceral pain originates from organ capsules, and varies with the structures involved. It is generally more diffuse in its location. Obstruction of a hollow viscous is
associated with cramping or gnawing pain. Injury to other visceral organs is characterized by aching, stabbing, or throbbing pain. Although it is commonly associated with organs in the abdominal cavity, visceral pain can occur elsewhere, such as in the intrapleural space. Neuropathic pain originates from the central or peripheral nervous system, and is characterized as sharp, burning, shooting, shock-like, tingling, prickling, aching, an uncomfortable numbness, or a combination of the above. It frequently begins in the hands and the feet, but can also involve larger nerves in the chest or other areas of the body. At times, neuropathic pain is difficult for the patient to localize.

Common syndromes of pain related to HIV include headache, arthralgias, myalgias, painful peripheral neuropathy, pharyngeal pain, abdominal pain, painful dermatological conditions, and pain due to extensive Kaposi’s sarcoma (KS).