Patients with pain have poorer engagement with HIV care

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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 substance-abuse problems.

Nevertheless, the authors believe their findings have implications for HIV care, and suggest that interventions to address pain could improve outcomes.



A feeling of unease, such as worry or fear, which can be mild or severe. Anxiety disorders are conditions in which anxiety dominates a person’s life or is experienced in particular situations.


A mental health problem causing long-lasting low mood that interferes with everyday life.


Confounding exists if the true association between one factor (Factor A) and an outcome is obscured because there is a second factor (Factor B) which is associated with both Factor A and the outcome. Confounding is often a problem in observational studies when the characteristics of people in one group differ from the characteristics of people in another group. When confounding factors are known they can be measured and controlled for (see ‘multivariable analysis’), but some confounding factors are likely to be unknown or unmeasured. This can lead to biased results. Confounding is not usually a problem in randomised controlled trials. 

treatment cascade

A model that outlines the steps of medical care that people living with HIV go through from initial diagnosis to achieving viral suppression, and shows the proportion of individuals living with HIV who are engaged at each stage. 

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 alcohol.

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.

 “It 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 provider.”

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 extent –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 confounders.

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.”


Merlin JS et al. Pain, mood, and substance abuse in HIV: implications for clinic utilization, ART adherence, and virologic failure. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0b013e3182662215, 2012.