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In the era of highly active antiretroviral therapy, HIV-infected patients live longer and healthier lives, which makes relief of pain associated with the complications of HIV infection an important factor in improving the quality of life. Relief of acute pain is important not only because pain relief affects the quality of life of caregivers as well as the individual suffering pain, but also because unrelieved pain can become chronic pain, which is much more difficult to manage because a vicious cycle that sustains pain develops.1,2

Acute pain may be classified in various ways, but is usually more or less directly related to some pathologic condition, although the intensity of the pain experienced may be out of proportion to the physiologic cause. When unrelieved acute pain has become chronic pain (often called “benign” when it is not associated with malignancy), special management considerations not found in acute pain become important.

A variety of studies have found the prevalence of pain in patients with HIV disease to vary from 40% to 60%, with even higher rates of pain found in inpatient settings and in patients near the end of life.3–5 Although different risk groups (eg, men who have sex with men, intravenous drug users, women) have different degrees of unrelieved pain, in general pain in HIV-infected individuals is underdiagnosed and undertreated. In one survey, only 7.3% of 110 patients with AIDS who reported “severe” pain received a strong opioid according to treatment guidelines, whereas 11.8% received no analgesic and 39.1% received a nonsteroidal anti-inflammatory drug.6

A French study7 found that doctors underestimated pain severity in more than half (52%) of AIDS patients and that only a fifth (21%) received a strong opioid, whereas 57% received no analgesic treatment. This is somewhat higher than a recent estimate based on a meta-analysis of 15 studies that found a median point prevalence of chronic pain of 15% (range 2% to 40%) in adults.8

Many studies show that the intensity of pain in HIV disease is comparable to that experienced by cancer patients. However, a patient with AIDS often experiences several painful syndromes simultaneously. Table 48-1 lists some causes of HIV-related pain.

Table 48-1 Selected Causes of Pain in Persons with HIV Disease

Painful syndromes may be nociceptive, neuropathic, or idiopathic. Nociceptive (somatic or visceral) pain, which is mediated by pain receptors, accounts for the majority of painful syndromes reported by ambulatory AIDS patients. Nociceptive pain is usually effectively relieved by conventional analgesics. Although ...

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