Human Immunodeficiency Virus (HIV) Infection / AIDS

Human Immunodeficiency Virus (HIV) infection is asymptomatic or mild symptomatic viral infection during the initial phase. Symptoms are like flu and last for several days. Symptoms during initial phase are mild fever, weakness, lethargy, body ache and throat pain like sore throat or pharyngitis. In USA 20% of HIV positive patients are unaware of disease. HIV positive patient may be asymptomatic for several years of latent phase. Latent phase may last 10 years or longer. Few patients may develop generalized lymphadenopathy during latent phase. During latent phase virus spreads through lymph node and bone marrows. Virus stays dormant within white blood cells and lymph nodes. Dormant virus may initiate slow destruction of T lymphocytes.

Human Immunodeficiency Virus (HIV)

HIV is found in all the body fluids including saliva, cerebrospinal fluid, blood, vaginal secretions, tears and breast milk. Only blood, semen, and breast milk have been shown to transmit infection to others.

Pathophysiology of Human Immunodeficiency Virus (HIV) Infection/AIDS

HIV virus is also called Lentivirus and virus is a member of Retrovirus. HIV infection is contagious during initial phase. Symptoms through initial phase are often mild but the number of viruses in the vascular systems is very high. During latent phase of HIV, virus attacks helper T cells in immune system as well macrophages and dendritic cells. Human body immunity supported by T lymphocytes rapidly decreases. HIV infection eventually causes Acquired Immunodeficiency Syndrome (AIDS). Lack of auto immunity results in AIDS and follows with human body susceptible to opportunistic infections and spread of cancer tissue.

Transmission Of Virus And Disease

  • Sexual contact - virus is transmitted during unprotected oral, vaginal, and anal sex.
  • Blood transfusion - several cases of HIV were identified after contaminated blood transfusion were given in life threatening situation.
  • Sharing needles - HIV and AIDS were observed in drug addict and individual taking street drugs. Several HIV patients were found to be sharing needles or injection solutions with HIV infected individual.
  • Pregnancy - HIV can transmit from mother to fetus.

Transmission of HIV is Not Observed with

  • Casual contact
  • Touching or hugging
  • Mosquito bite

Clinical Findings for Human Immunodeficiency Virus (HIV) Infection/AIDS

Human Immunodeficiency Virus (HIV)

In the Early Phase of HIV

Symptoms of Human Immunodeficiency Virus (HIV) Infection

  • Fever
  • Sore throat, pharyngitis (cough and throat pain) and bronchitis (cough and expectorant)
  • Headache - intensity is very severe. Headache is caused by muscle tension (tension headache), stress, sinusitis, migraine, and infection of the nervous system.
  • Night sweats
  • Diarrhea

Signs of Human Immunodeficiency Virus (HIV) Infection

  • Skin rash
  • Muscle soreness
  • Mouth or genital ulcers
  • Swollen lymph glands, mainly on the neck
  • Joint pain

In the Latent Phase of HIV

Symptoms of Human Immunodeficiency Virus (HIV) Infection

  • Asymptomatic
  • Fever
  • Persistent cough and throat pain
  • Fatigue
  • Diarrhea
  • Chest pain from bronchitis

Signs of Human Immunodeficiency Virus (HIV) Infection

  • Weight loss
  • Swollen lymph nodes - often one of the first signs of HIV infection.

Final Phase: AIDS

After latent phase of ten years or longer patient may develop AIDS. Symptoms of AIDS are observed following severe immune deficiency.

Symptoms of AIDS

  • Peripheral neuropathy- severe intractable pain
  • On and often upper respiratory tract infection with continuous and persistent cough
  • Shortness of breath and bronchospasm
  • Profuse sweating is observed in the evening and night
  • Persistent high fever is spotted for months and temperature is higher than 101 F
  • Persistent headache mostly localized over frontal and temporal dermatome
  • Chronic diarrhea
  • Loss of appetite
  • Fatigue, weakness, lethargic and lack of energy observed in advanced stage of AIDS
  • Blurred and distorted vision

Signs of AIDS

  • Weight loss
  • Signs of pneumonia like wheezing and rhonchi are heard on auscultation
  • Skin rashes or bumps
  • Persistent white spots or unusual lesions on your tongue or in your mouth

Complications Involved in Human Immunodeficiency Virus (HIV) Infection/AIDS

Peripheral Neuropathic Pain

  • Severe intractable pain is observed in 30% of AIDS patients.
  • Character of pain - burning, lancinating, or electric shock qualities.
  • Onset - pain is observed within 6 to 8 weeks of AIDS symptoms.
  • Associated with tingling and numbness.
  • Moving or touching the limb is often intolerable.
  • Sweating - abnormally increased sweating.
  • Joint are tender, stiff, restricted and painful with movements. Joint mobility is severely restricted secondary to thickening of synovial membrane and joint effusion.
  • Emotional problems are secondary to depression and anxiety.
  • Quality of life is awful because of severe pain and deprived of activities. Chronic severe pain is major hindrance to living a happy productive life.

Opportunistic Infection

  • Pneumonia - caused by pneumocystis bacteria and symptoms are fever, cough, and wheezing.
  • Encephalitis - brain infection often caused by toxoplasmosis. Symptoms are confusion, headache, dizziness and loss of memory.
  • Mycobacterium avium complex infection - infection is widespread in mucosa. Symptoms are fever, weakness, weight loss and lymphadenopathy.
  • Histoplasmosis - a yeast infection of esophagus. Symptoms are mid sternal pain, difficulties in swallowing, fever, cough, weakness, lethargy, loss of weight, and mild fever.

Cancer

  • Lymphoma
  • Kaposi's Sarcoma

Post Herpetic Neuralgia

Shingles rash may erupt during final phase of AIDS. Postherpetic neuralgia is a very common complication of shingles or herpes zoster. Pain continues for a prolonged period after herpes zoster lesions or rash has healed in AIDS patients. Herpes Zoster is a viral infection of the nerves, which results in formation of a rash or lesions on the skin, which can be very painful. Occasionally, the nerves affected by shingles can continue to cause severe pain even after the shingles have cleared. Shingles appear as a patch, a rash or a line of painful blisters which form over the skin along a nerve in the shape of a band. This band forms in the distribution of the nerve where the virus has been residing before its spread to the skin.

Abdominal Pain

  • Side effects of HIV drugs can cause severe abdominal cramps.
  • Bacterial or parasite gastroenteritis secondary to AIDS causes abdominal pain and cramps.
  • Pancreatitisis rare in AIDS but may be seen in few cases causing intense abdominal pain.
  • Bladder or urinary tract infections (especially in women) results in lower abdominal and pelvic pain.
  • Menstrual cramps are frequently inflated in female patients suffering with and pain is refer to the uterus, cervix, or ovaries.

Headache

  • Sinus infection and increased pressure in sinuses.
  • Tooth infections - pain is referred as headache.
  • Brain infections.
  • Brain tumors.
  • Bleeding in the brain.
  • Migraines.
  • Strokes.

Treatment for Human Immunodeficiency Virus (HIV) Infection/AIDS

1. NSAIDs for Human Immunodeficiency Virus (HIV) Infection/AIDS

Anti-inflammatory Action - Pain caused by inflammatory diseases are treated by either steroids ornon-steroidal anti-inflammatory medications. NSAIDS are analgesics mostly prescribed for mild to moderate pain. NSAIDs are less effective as analgesics when treated for pain caused by neuropathic disease. Most common NSAIDs prescribed for mild to moderate pain are aspirin, ibuprofen (motrin, advil), celebrex and naproxen

Side Effects-

  • Minor GI side effects- pain and dyspepsia,
  • Major GI side effects- Gastric ulcer, Gastric perforation, Upper gastrointestinal bleeding and severe blood loss,
  • Erectile Dysfunction

Combination of Aspirin and OX 2 Inhibitor (Celebrex)

Side Effects

  • May block cardio - protective effects of aspirin.
  • NSAIDs with COX2 inhibitor may increase risk of myocardial infarction and stroke.

Tramadol - Also known as Ultram, Ultracet, Ryzolt and Conzip in USA and Ralivia in Canada. Tramadol combined with paracetamol (acetaminophen) provides fast and longer lasting pain relief that is more effective than either drug alone. This combination therapy has demonstrated efficacy, safety and tolerability for up to two years without the development of tolerance in the treatment of chronic pain.

Mechanism of Action

  • Weak mu opioid receptor agonist also acts as a serotonin releasing agent and norepinephrine reuptake inhibitor.
  • Antagonist with receptors such as NMDA, 5-HT, nicotine acetylcholine and muscarinicacetylcholine receptors.
  • Mu receptors agonist-analgesic action is through its effects on mu receptor and modulation of norepinephrine and serotonin uptake.

Metabolites

  • Primary metabolite 0-desmethyltramadol is more potent mu receptor agonist than tramadol.

Potency

  • Tramadol is less potent than hydrocodone but more effective than codeine.

Side Effects

  • Physical dependence and addiction- with long-term use.
  • Withdrawal symptoms similar to opioid observed if abruptly discontinued.
  • Life threatening withdrawal symptoms such as seizures could be life threatening.
  • Naloxone does not reverse analgesic effects of Tramadol.
  • Seizure is an atypical withdrawal symptom caused by lower seizure threshold secondary to 5-Ht blockade.

Symptoms of Discontinuation

Withdrawal symptoms appear in 12 to 24 hours and last several days or weeks because of long ½ life. Symptoms are as follows -

  • Anxiety
  • Depression
  • Paresthesia
  • Sweating
  • Palpitation
  • Restless leg syndrome
  • Insomnia
  • Vivid dream
  • Tremor
  • Headache
  • Mood swing
  • Micropsia (object are seen smaller) or
  • Macropsia (object are seen larger than real size) are rare but can occur in long-term treatment withdrawal

2. Antidepressant Analgesics for Human Immunodeficiency Virus (HIV) Infection/AIDS

Antidepressant leads to improvement in pain and helps with depression, insomnia, and improves quality of life in ailing patients. Medications That increase serotonin and norepinephrine in brain have been proved to treat fibromyalgia in the adult population. These medications are duloxetine and Milnacipran.

a) Tricyclic Antidepressant or Elavil -

  • It is a strong antihistamine and anticholinergic drug.
  • It also restricts sodium and calcium channel in cell membranes.
  • The side effect of this drug like drowsiness is of benefit for fibromyalgia.
  • The drug reduces fatigue, relieves muscle pain and spasms, and facilitates restful sleep in people suffering from fibromyalgia.
  • This drug works by interfering with serotonin in brain. The medication can cause tiredness. Some of the tricyclic antidepressants generally used for fibromyalgia are Elavil as well as Sinequan.

b) Prozac

  • Prozac is an SSRI. It does not restrain or restrict norepinephrine or dopamine reuptake.
  • A low dose of Prozac with Elavil can be given for symptomatic relief.
  • This combination is also beneficial to promote good sleep and improve an overall sense of well-being.
  • Prozac makes a patient more active and alert. it is very useful when used in combination with Elavil.
  • Prozac when used alone is also effective for fibromyalgia.

c) Desyrel

  • It is an anxiolytic.
  • It has very minimal anticholinergic effects like dry mouth, constipation, tachycardia etc., which are quite common with Elavil.
  • This medication can be taken at night for sleep if tricyclic antidepressants are not able to be tolerated.

d) Cymbalta

  • Increases serotonin and norepinephrine in brain by restricting uptake.
  • Therapeutic dosage is useful for treatment of depression and neuropathic pain.
  • Cymbalta also helps with anxiety in people with fibromyalgia and neuropathic pain.

e) Savella

It is also an SSRI.

3. Antiepileptic Analgesics for Human Immunodeficiency Virus (HIV) Infection/AIDS

a) Gabapentin

GABA agonist. Also known as Neurontin, Gabarone, Fanatrex, Gralise and Nupentin. Mechanism action as an analgesic is not known. Several pharmacological actions were observed such as GABA agonist, interaction with voltage gated calcium channel and it halts the formation of new synapses. Gabapentine is very effective in 1/3rd of fibromyalgia and chronic neuropathic pain. Neuropathic pain caused by cancer, HIV, radiation treatment and complex regional pain syndrome is treated with gabapentin.

b) Pregabalin

  • Also known as Lyrica. Calcium channel - Binds to voltage dependent calcium channel and decrease release of neurotransmitter such as glutamate, noradrenaline, substance P, and calcitonin gene related peptide and gamma aminobutyric acid.
  • FDA approved - Lyrica became the first medication approved specifically for treating fibromyalgia.
  • Nerve pain - Lyrica may work by blocking nerve pain in patients with fibromyalgia. Flexible dosage - Lyrica has advantages of flexible dosing that can be adjusted according to persisting symptoms.

4. Opioids for Human Immunodeficiency Virus (HIV) Infection/AIDS

  • Last resort - "should be considered only after all other medicinal and nonmedicinal therapies have been exhausted."
  • Widely Used - Chronic back ache is treated with opioids when all other non-opioid medications fail.
  • Benefits - Opioids are beneficial in treating chronic intractable pain. Opioids if used with caution help to maintain near normal indoor and outdoor activities. Opioid are prescribed as a short acting or long acting opioids.
  • Tolerance - Continuous opioid treatment for prolonged period of time may result in increased tolerance to dosage. Patient may need increased dosage. Alternatively long acting opioids are prescribed to prevent or overcome tolerance.
  • Resistance - Long-term opioid treatment may result in inducing resistance to therapeutic effects of same dosage of narcotics. Resistance can be overcome by alternating short acting opioids with long acting opioids. Alternatively opioid treatment can be discontinued for short period of time or change over to different opioids.
  • Addiction - Opioids can cause serious problem such as addiction. Addiction in-patient with chronic pain is continuous use of opioids because of craving for opioids in spite life threatening side effects. Addiction is also observed in general population when opioids are taken for pleasure and not for pain.
  • Pseudoaddiction - Pseudoaddiction is not an addiction and seen in chronic pain patients. Patients would take more opioids than prescribed dosage. Reason for higher consumption is inadequate pain relief with inadequate dosage. Pseudoaddiction is treated with adjustment of dosage and addition of long acting pain medications. Pseudoaddiction may be secondary to resistance and tolerance to opioids.

5. Massage for Human Immunodeficiency Virus (HIV) Infection/AIDS

Massage is manual manipulation of superficial and deep layers of muscles as well as connective tissues. It helps improve blood supply to muscles as well as relieves muscle spasms. The tissues include muscles, tendons, ligaments, skin, and joints. It can be done with hands, fingers, elbows, and forearm.

6. Physical Therapy (PT) for Human Immunodeficiency Virus (HIV) Infection/AIDS

Application of heat, ice, ultrasound and electrical stimulation, as well as some muscle-release techniques to the back muscles and soft tissues may help alleviate pain. As the pain subsides the physical therapist may introduce some flexibility and strength exercises for the back and abdominal muscles. Techniques on improving posture may also help. The patient will be encouraged to practice the techniques regularly, even after the pain has gone, to prevent back pain recurrence.

7. Acupuncture for Human Immunodeficiency Virus (HIV) Infection/AIDS

  • Acupressure may or may not help to relieve neuropathic pain caused by AIDS. Acupuncture is executed either by using pressure or needle. Acupuncture treatment was developed and practiced as traditional Chinese Medicine to treat chronic pain.
  • Acupressure points are dermatomal areas under the skin that are especially sensitive to bio-electrical impulses in the body. Stimulating these points with pressure, needles, or heat triggers the release of endorphins that relieves pain. Acupressure inhibits the pain signals that are transmitted to the brain preventing painful sensations from passing through the spinal cord to the brain. As a result, pain is blocked and the flow of blood and oxygen to the affected area is increased. Besides relieving pain, acupuncture helps to re-balance the body by dissolving tensions and stresses. Continuous tension and emotional stress prevents smooth psychological mental function and also inhibits the immune system. Acupressure builds body resistance to various chronic illnesses.

Benefits of Acupressure:

  • Helpful in alleviating pinched nerves that contribute to pain.
  • Eliminates and/or reduces pain.
  • Drug - free substitute to pain management/relief.
  • Great muscle relaxant.
  • Improves blood circulation.
  • Releases endorphins - the body's natural analgesic.
  • Can be used in collaboration with other alternative therapies.
  • Effective in promoting wellness, and boosting the immune system.

8. Biofeedback and Relaxation Techniques for Human Immunodeficiency Virus (HIV) Infection/AIDS

  • Biofeedback - is the method of treatment used by physical therapist and psychologist.
  • Goal and Limits - To control certain involuntary bodily process like pulse, blood pressure, and temperature of skin.
  • Aware Process - help individual to learn how to change biological activities in respiratory, cardiovascular and central nervous system.
  • Monitoring - Biological activities monitored for change are brainwaves, heart functions, respiration, muscle activities and skin temperatures. Different equipment's monitor these physiological changes.
  • Feed Back - These information's are 'feed back' to patients.
  • Physiological Changes - in respiration, heart rate, brain monitoring and skin temperature varies with thinking and emotions.
  • Mind to Body Control - Patients are taught to manipulate the reading of these instruments by physiological mind to body control.
  • Physiological Process Controlled - by patients is brainwaves, muscle tone, skin temperature, heart rate and pain perception.
  • Indications - Biofeedback is the treatment used in the past for treatment of headache and migraines.

Monitoring Device-

  • Electroencephalograph (EEG) measures electrical activities of brain.
  • Electromyography (EMG) measures skin electrical activities.
  • Photoplethysmograph - feedback thermometer.
  • Electrocardiograph (ECG), monitors heart rate variability.
  • Pneumograph monitors respiration rate.
  • Rheoencephalograph monitors brain blood flow.
  • Pnemoencephalography monitors oxygenated or deoxygenated blood in brain by using infrared imaging technique. Biofeedback is very effective for a variety of conditions, primarily hypertension, tension headaches, migraines, chronic pains, and urine incontinence.

9. TENS (Transcutaneous Electrical Nerve Stimulation) for Human Immunodeficiency Virus (HIV) Infection/AIDS

TENS machine delivers small electric pulses into the body through electrodes that are placed on the skin. Research indicates TENS encourages the body to produce endorphins, and may possibly block pain signals returning to the brain. Studies on TENS have provided mixed results; some revealed no benefits, while others indicated that it could be helpful for some patients.

10. Alternate Medicine for Human Immunodeficiency Virus (HIV) Infection/AIDS

Alternative medicine is an integrative or complimentary medicine to conventional treatment.

Non-responding disease - to conventional medicine may respond by changing daily habits of eating, relaxation and stress.

Trial of treatment - alternative medicine is practiced by chiropractor, allopathic physician, osteopathic physician and other clinicians and therapist.

Methods: i) Treatment with herbs ii) Spiritual practice iii) Healthy eating iv) Avoid caffeine v) Practice good sleep and vi) Adopt cultural traditions.

Branches: Homeopathy, Ayurveda medicine, aromatherapy, music therapy, prayer therapy, reflexology, massage therapy, biofeedback, myofascial trigger point therapy and magnet therapy.

11. Topical Treatment for Human Immunodeficiency Virus (HIV) Infection/AIDS

  • Lidoderm- This contains lidocaine along with other chemicals. A paste of this mixture is spread over a thin film with adhesive material and covered with a film release liner. Thin layer is removed before the patch is applied over painful area.
  • Flector patch - Flector patch contains 180 mg of diclofenac epolamine in an aqueous base. It is used for external local application at any part of body except eyes and genitals. Diclofeniac is a non steroidal anti-inflammatory drug (NSAIDs). Flector patch may induce allergic reaction such as hives, difficulty breathing, and swelling of your face, lips, tongue, or throat. Gastric ulcer may be seen in few cases after long term use. Patient with history of cardiac disease such as thrombo-embolic disease and myocardial infarction should avoid using patch. History of stroke and stomach bleeding contraindicates use of flector patch.

Prevention of Human Immunodeficiency Virus (HIV) Infection/AIDS

  • Safe sex measures with use of condoms.
  • Avoid illicit drugs or shared needles or syringes.
  • Avoid contact with blood and fluids by wearing protective clothing, masks, and goggles.

Pregnancy: HIV Positive Patient

  • Anti-HIV viral treatment is advised during pregnancy.
  • Avoid breastfeeding.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: July 14, 2015

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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