Pain in people with HIV is associated
with an increased risk of missed appointments, investigators from the US report
in the online edition of the Journal of
Acquired Immune Deficiency Syndromes.
The original intention of the study was to
see if the presence of mood disorders and/or substance abuse together with pain
was associated with a number of key indicators of engagement with HIV care,
adherence to therapy, and rates of virologic suppression. After adjustment for
confounding factors, the only significant association was between pain and
missed appointments, and this was only the case for people without
Nevertheless, the authors believe their
findings have implications for HIV care, and suggest that interventions to address
pain could improve outcomes.
Previous research has shown that a large
proportion of people with HIV live with pain, mental health and emotional
difficulties, and substance-abuse issues. However, little is known about the
simultaneous presence of these issues in patients.
It is well known that mood disturbances and
drug and alcohol problems can lead to poorer adherence to HIV therapy. But
there is currently no information concerning the association between
co-occurring pain, mood disorders and substance abuse on outcomes for people.
Investigators in Alabama therefore designed
a study involving 1521 people who received HIV care at a university primary-care clinic between 2008 and 2011.
Participants were asked if they were experiencing
pain when they entered the study. They were also asked if they had mental
health problems such as anxiety and depression, or if they abused drugs and/or
Follow-up lasted for twelve months. The
investigators examined the association between pain, mood disturbances and drug
abuse separately and together and several key indicators of engagement with
care and adherence to HIV therapy. These included not attending routine clinic
appointments; needing emergency care; rates of treatment adherence; and the
odds of achieving an undetectable viral load.
The participants had an average age of 44 years
and 41% were men. Almost two-thirds had a CD4 cell count above 350 cells/mm3
and the majority had an undetectable viral load.
There was a high prevalence of pain, which occurred
in 34% of people. Mood problems were reported by 25% of participants and 10%
stated that they had substance-abuse problems.
Co-occurring pain and mood problems were
present in 16% of participants and 2% of individuals had pain, mood disturbances
and substance-abuse issues.
The investigators’ initial analysis showed
that all three variables were associated with poor clinic attendance. However, after
controlling for potential confounders they found that pain reduced the chances
of clinic attendance by 50%, but only for people who did not have substance-abuse issues.
“By affecting no-show visits, an important
step in the HIV treatment cascade, pain has important implications for
individual and public health outcomes,” write the investigators.
is possible that patients with substance abuse may have more severe and difficult
to control pain, as prior substance abuse may be associated with increased pain
severity,” suggest the authors. “As a result, patients with a history of
substance abuse may be more likely to keep their primary care appointments
because they plan to seek help for their pain from their HIV primary care
Pain was associated with an increased risk
of seeking emergency care (OR = 1.6; 95% CI, 1.2-2.0). However, in the adjusted
model this association weakened and was of borderline significance (OR = 1.3;
95% CI, 1.0-1.7).
Poor mood, substance abuse and
–to a lesser
–pain were all associated with suboptimal adherence to HIV therapy in the
initial analysis. However, these
associations disappeared when the researchers took into account potential
There was no evidence that any of the
variables examined in this study increased the risk of poor virologic outcomes.
“Because pain, mood disorders, and
substance abuse are highly prevalent in HIV-infected patients, our findings
have implications for HIV treatment success,” conclude the investigators. “Our
findings suggest that interventions that incorporate pain management should be
investigated, as they might be important for improving outcomes in patients
living with HIV infection.”