Causes of HIV Related Pain

It may seem that the blog is being flooded with pain articles at the moment but as anybody with both HIV and neuropathy will know, putting your finger on the cause of your pain (or pains) is anything but straightforward. Today's excellent article from thewellproject.org (see link below) addresses the HIV-patient directly and explains that it's not that simple putting the correct neuropathic, or arthritic, or stomach-related or muscular, or whatever label on your pain. With a bit of luck, after reading this, you will be able to locate the source and reason for your pain before you take it to the doctor and have to explain the whole story again. It's also possible that you have more than one source of pain and it's important to know what causes what. Forewarned is forearmed and if you have a good idea of where the problem is and what's causing it, you'll help your doctor considerably to decide the appropriate tests and treatment. However, having read this, or an article like this, never go ahead and self-medicate! Drugs can very easily negatively interact with each other and it is very important that you talk everything over with your doctor before beginning any form of treatment. This may seem like a lecture but you know it makes sense!

HIV Related Pain
Updated November 2010

Pain is common in people living with HIV (HIV+ people). One study of HIV+ people found that more than 50 percent had pain. Pain can occur at all stages of HIV disease and can affect many parts of the body. Usually pain occurs more often and becomes more severe as HIV disease progresses. But each individual is different. Some people may experience a lot of pain, while others have little or none.

What Causes Pain?
HIV related pain can have many causes:

- A symptom of HIV itself
- A symptom of other illnesses or infections
- A side effect of HIV drugs

Regardless of the reason, pain should be evaluated and treated to help HIV+ people have a good quality of life.

Common Types of Pain
The first step in managing HIV related pain is identifying the type, and if possible, the cause of pain. Some common types of pain include the following:

Peripheral Neuropathy – Pain due to nerve damage, mostly in the feet and hands. It may be described as numbness, tingling, or burning. Nerve damage can be caused by HIV drugs or other medical conditions such as diabetes. The older HIV drugs that caused the most peripheral neuropathy are not commonly used today

Abdominal Pain – There are many possible causes of abdominal pain:
A side effect of some HIV drugs (for example cramps)
Infections caused by bacteria or parasites
Problems of the intestinal tract such as irritable bowels
Inflammation of the pancreas (pancreatitis) caused by some HIV drugs or by drinking alcohol.
Bladder or urinary tract infections (especially in women)
Menstrual cramps or conditions of the uterus, cervix, or ovaries

Headache – Head pain can be mild to severe, and may be described as pressure, throbbing, or a dull ache. The most common causes of mild headaches include muscle tension, flu-like illness, and HIV drug side effects. Moderate or severe headaches can be caused by sinus pressure, tooth infections, brain infections, brain tumors, bleeding in the brain, migraines, or strokes. Sometimes the cause cannot be determined.

Joint, Muscle and Bone Pain – This pain can also be mild to severe. It may be related to conditions such as arthritis, bone disease, injury, or just aging. It can also be a side effect of some HIV drugs and medications for other conditions like hepatitis or high cholesterol.

Herpes Pain – Herpes is a family of viruses common in HIV+ people. Herpes viruses stay in the body for life, going into hiding and flaring up later. The varicella-zoster herpes virus first causes chickenpox and later can cause shingles, a painful rash along nerve pathways. Herpes simplex virus types 1 and 2 cause painful blisters around the mouth (“cold sores”) or genital area. Even after a herpes sore heals, a person may still have persistent pain.

Other Types
- Painful skin rashes due to infections or HIV drug side effects
- Chest pain caused by lung infections such as TB, bacterial pneumonia or PCP pneumonia (Pneumocystis pneumonia)
- Mouth pain caused by ulcers (“canker sores”) or fungal infections like thrush
- Fibromyalgia or related chronic pain conditions
- Pain due to cancer anywhere in the body

Assessing Pain
Once the type of pain is identified, the next step is to evaluate its characteristics. The goals of pain assessment are to:

Define the severity of pain (how much it hurts): Your health care provider may ask you to assign a number to your pain, from one (very mild pain) to ten (the worst possible pain). Pictures can also describe pain. A smiling face represents little or no pain, while a crying face represents severe pain.
Describe details of your pain: Your health care provider may ask you to describe how your pain feels, for example sharp, dull, throbbing, or burning. Is it new (acute) or have you had it for a while (chronic)? Where is it located? Is it constant or does it come and go?

You may be having pain but do not want to complain. Talking about pain to your health care provider is not the same thing as complaining! Telling your health care provider exactly how you feel is the best thing you can do to find out what is wrong and get the right treatment.

Pain Management
Once the type and characteristics of pain are identified, you and your health care provider will decide how to manage or treat it. The following factors will play a role in selecting the right type of treatment for you:

- Cause, type, and severity of pain
- Whether it is short-term or long-term
- History of substance abuse
- If your pain is being caused by a medication you are taking or another illness, your health care provider will want to take care of that first. If you are still experiencing pain, there are many options for pain relief.

Non-medicinal Therapies
Pain relief without medications such as:

- Massage
- Relaxation techniques
- Physical therapy
- Acupuncture
- Heat and cold therapy
- Hypnosis
- Mental imagery or visualization

While these may be enough to relieve pain, they are often used along with pain medications.

Non-opioid Medications
Pain relief medicines that do not contain narcotics (opiates). They are available over-the-counter or by prescription. These medicines relieve mild to moderate pain related to inflammation or swelling. Some people with a history of drug addiction prefer non-opioid pain medicines such as:

- Tylenol (acetaminophen)
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (for example Advil)
- COX-2 inhibitor, a type of NSAID that is less likely to cause stomach problems, for example Celebrex (celecoxib)
- Steroids, natural or manufactured hormones that reduce inflammation. Examples include prednisone and hydrocortisone

Non-opioid pain medicines can cause side effects including liver damage (Tylenol), easy bleeding (aspirin), stomach pain or damage (aspirin and other NSAIDs), and heart problems (COX-2 inhibitors).

Opioids/Narcotics
Narcotics and related drugs known as opioids are the strongest pain relievers, available only by prescription. They are used to treat moderate to severe pain.

Opioids are classified by how fast and how long they work.

Immediate release opioids – act rapidly but pain relief lasts for a shorter period of time
Sustained-released opioids – take longer to start working but pain relief lasts longer

Opioids are also classified by their strength.

Mild to moderate pain relievers (they are often mixed with non-opioid medicines to improve their action):
- Hydrocodone
- Vicodin (hydrocodone plus acetaminophen)
- Codeine
- Tylenol with codeine (acetaminophen plus codeine)
- Ultram (tramadol)
- Severe pain relievers:
- Morphine
- Fentanyl
-OxyContin (oxycodone)
- Methadone or Buprenorphine (not commonly prescribed in first-line pain reliever treatment)
Opioids can cause side effects including drowsiness, nausea, and constipation. Overdoses can slow down breathing and cause death. Opiates can lead to dependence or addiction and may be a problem for people with a history of substance use.

Topical or Local Therapies
These are medications that are injected or applied to the skin around a painful area. Examples include the local anesthetic Xylocaine (lidocaine) and capsaicin, which comes from chili peppers.

Other Therapies
There are medicines prescribed for other purposes that also have pain-relieving properties.

Anti-depressants – relieve neuropathic pain such as peripheral neuropathy. An example is Cymbalta (dulozetine).
Anti-convulsants – usually used to treat seizures, some of these drugs work for peripheral neuropathy. An example is Neurontin (gabapentin).

Determine if the Pain Treatment Works
Once you start medication or other pain treatment, your health care provider should assess your pain regularly to see if treatment is working. Sometimes pain medications can stop working over time.

What to Do if You Have Pain?
When you experience pain, it is important to know how to get fast, safe relief.

Do not ignore your pain – Pain is the body’s way of telling us something is wrong. Ignoring pain often makes matters worse and can cause more damage in the long run.
Assess your pain – When pain occurs ask yourself the following questions:
- How long have I had the pain?
- Did it happen suddenly or over time?
- Is the pain sharp or dull?
- What makes the pain worse?
- Does anything ease the pain?
- Is the pain limited to one place or does it spread out to other areas?
- Are there other symptoms (for example numbness, cough or fever)?
Notify your health care provider – Report pain to your provider without delay. Describing your pain will help find the cause and how best to treat it.
Take your pain medicine as directed – If you need pain medications, make sure you take them exactly as prescribed. Pain medications work best if they are taken at the first sign of pain. Breaking the cycle of pain means taking medications before your pain is at its worst.
Be responsible – Pain medications are very effective when taken as prescribed. Taking them incorrectly can be dangerous. Opioids are addictive, meaning you can develop physical and emotional dependence on a drug. High doses can cause breathing problems. In the worst cases, incorrect use of opioids can be fatal.
Tell your health care provider if treatment does not work – If your pain medicine is not relieving your pain, talk to your providers. You may be taking a medication that will not work for you, or you may have built a tolerance to the drugs over time. You may need to change doses or switch to a new medication.
Pain is common among HIV+ people. But it can be managed using a variety of methods. Talk to your health care provider if you are having pain. He or she can work with you to find the cause, manage the pain, and improve your quality of life.

http://www.thewellproject.org/en_US/Living_Well/Health/HIV_Pain_Mgmt.jsp

New Explanation For Diabetes Related Neuropathic Pain

Today's post from Sciencedaily.com (see link below) brings a dilemma with it. A study has shown that changes in 'dendritic spines' in the brain may play an important part in explaining neuropathic pain in diabetes-related cases! Yet nowhere does it say that this is exclusively a diabetes-related occurence. The article states that the reason why diabetes can cause neuropathy is still a mystery, so there is really no reason to assume that these changes in the nerve endings in the brain only occur in diabetes patients. We need the study to include HIV-related neuropathy and many other forms too, If the dendritic spines are not altered in other forms of neuropathy, then they have some important information but at the moment, to a layman like me, it's just not clear.
 Many people with HIV looking for information on neuropathy, may skip over articles about diabetic neuropathy because they think it doesn't apply. This is generally just not true. Most of the information about diabetic neuropathy applies to all neuropathies; it's just that diabetic neuropathy is by far the most common form amongst the general population. If you ask 99 out of a 100 diabetic neuropathy patients what their symptoms are, you'll find that they are exactly the same as your own. What the researchers mean to say is that they don't really understand the processes behind why neuropathy occurs in most of its forms and tying it to one disease depends on who their target readership is. If there are any experts out there who can explain (in relatively simple terms)  the real differences in disease-based neuropathies, please let us know - very many people are interested.

Unexpected Source for Diabetic Neuropathy Pain

ScienceDaily (May 15, 2012)

Normal dendritic spines — microscopic projections on the receiving branches of nerve cells — are shown at top compared to those of diabetic rat. At bottom, spines after receiving treatment. Yale study suggests that neuropathic pain associated with diabetes may be caused by reshaping of these spines in nerve cells, and might be treated by drugs. (Credit: Image courtesy of Yale University)

Nearly half of all diabetics suffer from neuropathic pain, an intractable, agonizing and still mysterious companion of the disease. Now Yale researchers have identified an unexpected source of the pain and a potential target to alleviate it.

A team of researchers from Yale and the West Haven Veterans Affairs Medical Center describes in the May 15 issue of the Journal of Neuroscience how changes in the structure of dendritic spines -- microscopic projections on the receiving branches of nerve cells -- are associated with pain in laboratory rats with diabetes.

"How diabetes leads to neuropathic pain is still a mystery," said Andrew Tan, an associate research scientist in neurology at the Yale School of Medicine and lead author of the study. "An interesting line of study is based on the idea that neuropathic pain is due to faulty 'rewiring' of pain circuitry."
With a growing number of diabetics, the condition represents a huge unmet medical need. Once neuropathic pain is established, it is a lifelong condition.

"Here we reveal that these dendritic spines, first studied in memory circuit processing, also contribute to the sensation of pain in diabetes," Tan said. A single neuron may contain hundreds to thousands of dendritic spines.

The Yale team led by Tan and senior author Dr. Stephen G. Waxman, the Bridget Marie Flaherty Professor of Neurology, professor of neurobiology and pharmacology,found abnormal dendritic spines were associated with the onset and maintenance of pain. They also found that a drug that interferes with formation of these spines reduced pain in lab animals, suggesting that targeting abnormal spines could be a therapeutic strategy.

Tan said that these dendritic spines in nerve cells seem to store memory of pain, just as they are crucial in memory and learning in the human brain.

"We have identified a single, key molecule that controls structural changes in these spines and hopefully we can develop therapeutic approaches that target that molecule and reduce diabetic pain," Waxman said.

Other authors on the paper are Omar A. Samad, Tanya Z. Fischer, Peng Zhao and Anna-Karin Persson,
The research was funded by the Department of Veterans Affairs.

http://www.sciencedaily.com/releases/2012/05/120515203056.htm

What Can I Do About Pain Related Fatigue

Today's post from webmd.com (see link below) may seem like another simplistic self-help post, aimed at  the general public rather than those living with chronic pain but the fact is that many many people living with neuropathy are often desperately tired. Either from the constant pain, or from weakness caused by over-activity that others would see as normal, it doesn't really matter. The point is, what can we do about it, if anything? Some of the tips shown below may well be helpful for you but as long as you're aware of the problem, you're more likely to take steps to help it. One thing is sure; without regular and quality sleep periods, your whole day will be affected by tiredness - don't be ashamed to take naps when necessary and when your body tells you too. Far too many articles stress the need for exercise and activity and they are indeed helpful for neuropathy patients (however you may protest) but rest and recovery are equally important.
 

Why Am I So Tired?
WebMD Feature Reviewed by Jennifer Robinson, MD

Are you always tired? That’s no surprise in these tightly scheduled, overloaded times.

The good news is, it’s simpler than you might think to get your energy back. The trick is to figure out why you’re fatigued. Then you can learn what to do about it. 

5 Common Reasons for Tiredness

1. What you eat. A shot of caffeine and sugar can seem like quick fix when you need an energy boost, but it soon makes things worse. After your blood sugar levels spike, they crash. You end up more fatigued, not less.

A far better solution is a balanced diet full of fruits, vegetables, and lean protein.

“Most people feel like they're less tired if they eat a healthy diet," says J. Fred Ralston Jr., MD. He's a past president of the American College of Physicians. "Eating healthy also means you'll carry less weight, and obesity is a big contributor to fatigue.”

2. How much water you drink. Instead of that caffeine-filled, sugary drink, try a glass of water.

Mild dehydration affects your mood, and it makes you feel more tired, research shows. It can set in when you drink just a little less H20 than you normally do.

The Institute of Medicine recommends that men get about 125 ounces of water a day and women get 91 ounces. Those amounts include water from all foods and beverages.

3. How much you sleep.

Millions of Americans just don’t get the ideal 7 to 9 hours of snooze time. If you’re one of them, avoid caffeine, alcohol, and large meals in the hours just before bedtime. Turn off the TV and unplug the computer before you turn in. Also, go to bed at the same time each night and keep your bedroom quiet and dark.

4. How much you exercise. Studies show that when inactive people start to work out, they feel much less fatigue than those who stay idle. When you move more, you not only use more energy, you also have more on a daily basis.

Ralston recommends you start with 30 minutes of exercise at least 4 days a week. Be sure to finish at least 3 hours before bedtime, so you have time to wind down. After a month, you should notice improvement in your fatigue. Within 3 to 6 months, you should feel much better.

5. What you do to handle stress. Stress is a fact of life. Fatigue sets in when you have more than you can handle. The first step in changing the way you deal with stress is to figure out your body’s stress signals -- aside from feeling fatigued, you might be angry, headachy, tense, or unable to focus.

Once you know how stress affects you, you can teach yourself to control it. Proven ways to limit the toll stress takes on you include:

Short, regular periods of meditation
Talks with friends or family about your challenges
Regular breaks from work
Taking time for yourself
Could It Be Something Else?

If you’ve taken steps to address all five of the most common causes of fatigue and you still feel worn out, visit your doctor.

Chronic tiredness is linked to medical conditions including these:

Anemia, or a lack of iron in the blood, is a common cause of fatigue, and it's easy to check with a simple blood test, says Sandra Fryhofer, MD. She's an associate professor of medicine at Emory University.

"It's particularly a problem for women, especially those who are having heavy menstrual periods,” she says.

An iron-rich diet that's heavy in meats and dark, leafy greens can correct low levels of iron. Ask your doctor if an iron supplement might help, too. Other key nutrients that can hold off fatigue include potassium and vitamins D and B12.

Thyroid problems. Both an over- and an underactive thyroid can cause fatigue. A blood test can help a doctor gauge how well your thyroid's working.

Diabetes. People who have uncontrolled diabetes "just plain don't feel good," Fryhofer says. "If you feel draggy and you're also having blurred vision or lots of urination, you should get that checked with a blood test."

Depression. If your feelings of exhaustion are accompanied by sadness and loss of appetite, and you just can't find any pleasure in things you once enjoyed, you might be depressed. Don't keep it to yourself. Your doctor, or a therapist, can start you on the path back to feeling better.

Sleep problems. Many different sleep issues can keep you from feeling rested and energized. Talk to your doctor about a sleep evaluation, especially if you snore, since that could point to a condition called obstructive sleep apnea, which briefly stops your breathing several times a night. Like other sleep disorders, it’s treatable.

Undiagnosed heart disease. Ongoing tiredness can be a warning sign of heart trouble, Ralston says. “If you have trouble with exercise you used to do easily, or if you start feeling worse when you exercise, this could be a red flag for heart trouble. If you have any doubts, see your doctor.”

http://www.webmd.com/fitness-exercise/features/reasons-tired

Post Herpetic Neuralgia Related To Neuropathic Disorders

Today's short post from painhq.org (see link below) looks at postherpetic neuralgia which is a neurological extension of shingles. It's strange, almost everyone has heard of shingles and rightfully fears it for the pain it can bring but few associate it with neuropathy, yet in fact, it's one of the many forms of nerve damage that can fall under the general term of neuropathy. Shingles is a neuropathy caused by the reawakening of the varicella zoster virus, the same virus that causes chickenpox. In that respect it can be related to other forms of neuropathy brought about by viruses, such as HIV. This article sticks to the point and gives you a decent springboard for further research if you're suffering from either shingles or the misery of postherpetic neuralgia.
 

Postherpetic Neuralgia 
Info from Mayo Clinic and Wikipedia: Author unknown: 2014

What is Postherpetic Neuralgia? Postherpetic neuralgia is ​a complication of shingles. A case of shingles will typically only last a few weeks. If pain remains after the blisters and skin irritations subside, postherpetic neuralgia may be diagnosed. Early treatment of shingles can reduce the risk of developing postherpetic neuralgia.

Nerve fibres in the skin can be damaged during an outbreak of shingles, and the virus may remain resident in the nerve cell. When this happens, the nerves in the skin cannot communicate properly with the brain, resulting in postherpetic neuralgia.

What are the symptoms? Symptoms for postherpetic neuralgia present in the distribution of the nerve affected by the shingles. Individuals may experience a burning, sharp pain and a sensitivity to light touch (which may even include the touch of clothing against the skin). Less commonly, patients may experience a numb or itchy feeling in the affected areas, and in some cases, muscle weakness or paralysis.

Is there any treatment? Often a combination of different treatments are used to manage postherpetic neuralgia and any associated pain. Treatments include the use of topical medicines applied to the skin itself, such as lidocaine and capsaicin skin patches; as well as medicines taken by mouth such as anticonvulsants, antidepressants and opioid painkillers.

What treatment have you found most effective for Postherpetic Neuralgia?

Opioids (0)
Physical Therapy and Rehabilitation (0)
Gabapentin (1)
Pregabalin (1)
Topical Lidocaine (1)
Duloxetine (0)

What is the prognosis? Most individuals suffering from postherpetic neuralgia will experience a slow improvement of pain symptoms with treatment.

Related evidence 
Markley HG, Dunteman ED, Sweeney M. Real-World Experience with Once-Daily Gabapentin for the Treatment of Postherpetic Neuralgia (PHN). Clin J Pain. 2014 Jul 28. [Epub ahead of print]

Schlereth T, Heiland A, Breimhorst M, Féchir M, Kern U, Magerl W, Birklein F. Association between pain, central sensitization and anxiety in postherpetic neuralgia. Eur J Pain. 2014 Jul 28. doi: 10.1002/ejp.537. [Epub ahead of print]

References  
Mayo Clinic [Internet]. Postherpetic neuralgia [updated 2014; cited 2014 Aug 5]. Available from: http://www.mayoclinic.org/diseases-conditions/postherpetic-neuralgia/basics/definition/con-20023743

Wikipedia [Internet]. Postherpetic neuralgia [updated 2014 Aug 16; cited 2014 Aug 5]. Available from: http://en.wikipedia.org/wiki/Postherpetic_neuralgia
 
https://www.painhq.org/learning/knowledge-base/category/conditions/peripheral-neuropathic-pain/post-herpetic-neuralgia

Are There Indisputable Predictors For HIV Related Neuropathy

Today's post from catie.ca (see link below) looks at predictors and co-factors associated with neuropathy linked to HIV. Between 30% and 45% of people living with HIV go on to suffer from some degree of neuropathy and the article looks at why this may be and the historical factors involved. However, the truth is, that the rising numbers of neuropathy patients who also have HIV both defy and confuse many of the earlier assumptions about the relationship between the two conditions. As recently as ten years ago, most doctors believed that HIV-related neuropathy was solely the result of the older forms of HIV medication. Then it was assumed that the virus itself was a strong co-factor and then reasons were found in all the areas where people without HIV suffer nerve damage (diabetes, alcohol abuse and many others). The truth may lie somewhere in combinations of all of these indicators but neuropathy amongst HIV positive patients remains a big problem. The fact is that neuropathy tends to defy patterns and profiles and it may turn out that it is an auto-immune disease that affects people both prone to auto-immune diseases and susceptible to them because of outside factors like the HIV virus itself. The article does possibly over-emphasise the role of opioids as a cause of neuropathy - many patients need opioids to suppress the pain - it's not a chicken and egg situation.

Predictors of HIV-related peripheral neuropathy in the modern era
Sean R. Hosein Catie News 31 March 2015
 
HIV infection can cause many problems, including some that affect the nerves. The nervous system that permeates the vast majority of the body outside of the brain is called the peripheral nervous system. As early as 1983, doctors in Manhattan noted the strange appearance of injury to the nerves in the feet and legs of people with HIV. This type of injury is called peripheral neuropathy (PN). Neurologists have found that PN generally first appears in the toes and feet and can result in numbness, intermittent sensations and pain. In one study, doctors have documented the severe nature of the pain associated with PN and found that affected patients used strong words such as the following to describe it: “stabbing,” “burning” and “aching.” 

Possible causes of peripheral neuropathy

The causes of PN among HIV-positive people can vary. For instance, in the early 1980s when no effective treatment was available, PN was likely a consequence of untreated HIV disease. In the 1990s, a group of anti-HIV drugs commonly called “d-drugs” was often used:
d4T (stavudine, Zerit)
ddI (didanosine, Videx)
ddC (zalcitabine, Hivid)

Although the use of ddC quickly fell out of favour because of its toxicity and weak antiviral effect, ddI and d4T continued to be used into the early 21st century as part of potent combination anti-HIV therapy (commonly called ART or HAART). These d-drugs could be toxic for nerve cells, and even in the early 1990s doctors found that they could cause PN.

However, today the use of d-drugs is strongly discouraged by treatment guidelines in high-income countries, so their use is unlikely to be the cause of new cases of PN. 

Peripheral neuropathy today

Researchers at major clinical centres in the U.S. have collaborated to study potential causes of PN among HIV-positive people in the modern era. They recruited about 500 people who were free from PN and monitored them for an average of two years, performing extensive assessments. Taking into account many issues, statistical analysis found that there were several factors associated with an increased risk for PN. In this CATIE News bulletin we explore some of those findings and what they mean. 

Study details

Researchers recruited 1,583 HIV-positive people between 2003 and 2010 for a large study about HIV and neurological issues. A subset of this group—493 people—who did not have PN when they entered the study comprised participants for the current analysis.

Doctors and nurses were trained by neurologists to interview, examine and assess participants for any signs and symptoms of PN. Participants were also screened for depressive illness. Blood samples were collected and additional information was obtained from medical records.

The average profile of the 493 participants when they entered the study was as follows:
81% men, 19% women
age – 42 years
68% (335 people) were taking ART, of whom 201 (61%) had an undetectable viral load
Nearly one-third of participants were previously exposed to d4T or ddI
14% of participants were taking d4T or ddI when they entered the study
doctors diagnosed 73% of participants with a "substance use disorder;" commonly used substances were alcohol (55%), cocaine (40%), crystal meth (18%) and opioids (17%) 

Results

After an average of two years of monitoring, 131 participants (27%), all of whom were free from PN at the start of the study, subsequently developed PN. 

Possible risk factors

Taking many factors into account, researchers found statistical links between a number of factors and the subsequent development of PN. Here are some of those factors:
age (50 years or more) – This finding is important because as HIV-positive people age, they may need screening for PN.
detectable HIV viral load – Untreated or poorly managed HIV results in a greater degree of inflammation. HIV-infected cells also produce viral proteins that injure nerve cells. Therefore, it is not surprising that the researchers found that participants with detectable HIV viral load were more likely to develop PN than people whose viral loads were undetectable. 

Treatment and its relationship to PN

Researchers found that “HIV disease and treatment status significantly affected [rates of new cases of PN] in this study.” For instance, they discovered that the “highest rate of PN occurred in a relatively small group of individuals (50 people) who had [previously used ART but discontinued it].” The reasons for discontinuation were not revealed. These participants had very low CD4+ cell counts because they were not on treatment. In part, new cases of PN in this group of people could have been due to untreated HIV infection. Thus the research team issued the following warning:

“Because 30% to 40% of HIV-infected persons on ART in the U.S. do not maintain durable virologic suppression because of transfer of care, poor adherence and other factors, our findings suggest that [PN] will be a persistent or increasing problem.”

Researchers noticed that participants who had never taken ART and who had relatively high CD4+ counts were least likely to develop PN. This is probably because their immune systems had experienced minimal degradation.

The researchers also found that the following factors put participants at a higher risk of developing PN:
substance use – People with a history of opioid use were more likely to subsequently develop PN.
depressive illness – Participants whose depressive illness became more severe over the course of the study were more likely to develop PN.
gender – Women were more likely to develop PN than men. This finding needs to be explored in another analysis but could be related to biological factors—genetics, hormones—or social and psychological factors such as substance use and possibly depression.

Pain and depression

The researchers were struck by the intersection of opioid use, worsening depression and the development of PN. They suspect that the pathways used by brain cells to communicate with each other are affected by addiction and overlap with the pathways that deal with pain. They noted that previous research has found that “regardless of the cause of the underlying pain…pain and depression reinforce each other.” They also pointed out that depression alters the brain, and stimulation that is not normally painful may be experienced as pain by depressed people. It is possible that in people with a history of addiction or substance use, pathways in the brain change and such people become more vulnerable to experiencing pain, particularly when the brain receives and tries to process signals from nerves that are dysfunctional because of PN.

The modern era

The findings from the current era are important and underscore PN-related risk factors that are different from previous eras. For instance, in the past, height and the presence of type 2 diabetes among HIV-positive people were co-factors in the development of PN. However, in the present study, no link was found with these factors. Part of the reason for this is that only a small proportion of participants had type 2 diabetes (8%).

Also, in previous eras the use of d-drugs was a major factor in the development of PN. However, today d-drugs are seldom used, and even in the cases where they were taken by participants in the present study, their use was not linked to the development of PN.

In general, alcohol addiction is a major co-factor for the development of PN. This occurs in part because alcohol can be toxic to nerves and also because it depletes the body of nutrients (such as B-complex vitamins) that are needed by nerve cells. However, researchers did not find alcohol use linked to PN in the present study. 

Future research

PN can cause distress, disability and a reduction in quality of life. The researchers stated that “neuropathic pain can wax and wane in severity”; also, sometimes PN can resolve or go into remission “either spontaneously or as a result of treatment and might even recur at a later time.” This underscores the importance of studying PN.

The researchers suggest that future studies are needed to address strategies to help prevent PN, particularly among people at high risk for this complication, such as people who use opioids or who have depression.

Resources

Nerve pain and numbness – Practical Guide to HIV Drug Side Effects

Ask the Experts: Peripheral Neuropathy – The Positive Side

REFERENCES:
Snider WD, Simpson DM, Nielsen S, et al. Neurological complications of acquired immune deficiency syndrome: analysis of 50 patients. Annals of Neurology. 1983 Oct;14(4):403-18.
Malvar J, Vaida F, Sanders CF, et al. Predictors of new-onset distal neuropathic pain in HIV-infected individuals in the era of combination antiretroviral therapy. Pain. 2015 Apr;156(4):731-9.
Keltner JR, Fennema-Notestine C, Vaida F, et al. HIV-associated distal neuropathic pain is associated with smaller total cerebral cortical gray matter. Journal of Neurovirology. 2014 Jun;20(3):209-18.
Keltner JR, Vaida F, Ellis RJ, et al. Health-related quality of life “well-being” in HIV distal neuropathic pain is more strongly associated with depression severity than with pain intensity. Psychosomatics. 2012 Jul-Aug;53(4):380-6.
Ellis RJ, Rosario D, Clifford DB, et al. Continued high prevalence and adverse clinical impact of human immunodeficiency virus-associated sensory neuropathy in the era of combination antiretroviral therapy: the CHARTER Study. Archives of Neurology. 2010 May;67(5):552-8.
Kallianpur AR, Jia P, Ellis RJ, et al. Genetic variation in iron metabolism is associated with neuropathic pain and pain severity in HIV-infected patients on antiretroviral therapy. PLoS One. 2014 Aug 21;9(8):e103123.
Badiee J, Moore DJ, Atkinson JH, et al. Lifetime suicidal ideation and attempt are common among HIV-positive individuals. Journal of Affective Disorders. 2012 Feb;136(3):993-9.

http://www.catie.ca/en/catienews/2015-03-31/predictors-hiv-related-peripheral-neuropathy-modern-era

Nerve Related Erectile Disfunction

As an HIV patient you may already suffer, or have suffered from erectile disfunction. As an older man, you may also be finding that it's an unwelcome problem irrespective of health concerns but if you've been lucky enough to avoid it as a result of age, or HIV, or the meds and then it turns up as a symptom of neuropathy you couldn't be blamed for feeling frustrated and annoyed. There are of course, several well-known solutions that work for many people but not many people are aware of the reasons behind ED, related to their neuropathy and also how it works (or in this case, doesn't)! This article comes from a rather unusual source; Streetdirectory.com (see link below)but is nevertheless informative and worth a read, whether you're affected by the problem or not.

Nerve Related Erectile Disfunction

Nerves play an essential role in the penile erection process. This is how an erection works. When you are sexually stimulated the nerves in the penis’ cavernous area become active and those same nerves then release what are known as neurotransmitters. Neurotransmitters are chemical substances that carry messages from one nerve cell to another and back and forth from the brain. In the case of sexual arousal the nerves tell the brain that stimulation has occurred and the brain then sends signal to the penile area that the following events should occur (the neurotransmitters are in charge of delivering these messages):

Penile arteries should become relaxed enough to allow more blood to enter the penile chamber.
The blood that enters the penis should become temporarily trapped in order for the penis to become and remain rigid during sexual activity. This is accomplished by expanding the sinusoids (the space located within the smooth muscles of the penis). The sinusoids will return to their normal state after sexual stimulation stops so the blood can leave and the penis can return to its flaccid state.
Blood pressure needs to increase until the penis is completely rigid and the penis needs to stretch to its maximum capacity. The outflow of blood through the veins is also reduced to a minimum.
All of these events will only occur if the nerves do their job and send the orders back and forth from the penis to the brain.

Neuropathy
People with diabetes, kidney failure, cancer, HIV, people suffering from poor nutrition, and people taking certain kinds of drugs or medications or undergoing certain medical treatments such as chemotherapy, may develop what is known as neuropathy. Neuropathy is a condition or disease which damages the nerves or nervous system. It may cause a loss of feeling in the extremities. It may also cause muscle weakness, numbness, tingling sensations, swelling, and even pain. On top of that, neuropathy can damage the nerves within the penis.

Damaged penile nerves can diminish or stop the erection process. Since the brain uses nerves and neurotransmitters to tell the penis when and when not to become rigid, damaged penile nerves can cause erectile dysfunction by not sending the proper signals to and from the brain.

Neuropathy, E.D. and Diabetes
The National Institute of Diabetes & Digestive & Kidney Diseases estimates that approximately one-half of people with diabetes suffer from some form of neuropathy. They also claim that around 21 million people suffer from diabetes in the US alone. That’s 7 percent of the population. These figures indicate that 3.5 percent of the population currently suffers from neuropathy. That means that 3.5 percent of all diabetic men will likely also suffer from E.D. Huge figures! Especially considering this is only accounting for diabetic men and that many other conditions such as high cholesterol, high blood pressure, etc, also cause E.D.

Treating E.D. in Patients with Neuropathy
Fortunately, there are currently many effective treatments for erectile dysfunction, whether it be for nerve related E.D. or not. Ask your doctor about drug treatments such as Viagra, Cialis, or Levitra. Also ask about possible lifestyle changes you may be able to make to help restore your nerve conditions. Also ask about the possibilities of other nerve related treatments which may be able to indirectly help regain your sexual functioning by re-establishing nerve workings. Combating E.D. requires active participation on the part of patients. E.D. issues can almost always be resolved with the help of your doctor.

About The Author,
Albert Brown is a writer for Nerve Related Erectile Dysfunction. Read more details on the subject of this article here www.blog.manofpeople.com/archives/11

http://www.streetdirectory.com/travel_guide/25120/medical_conditions/nerve_related_erectile_dysfunction.html

HIV Related Neuropathy Vid

Today's video comes from painclinician.com(see link below) and talks specifically about neuropathy brought about as a result of HIV infection, or the treatment thereof. Well worth a view because of the clear and concise way the subject is presented. People living with HIV and neuropathy (between 33% and 50%) may learn quite a lot of new information.

HIV-Related Neuropathy  

Catherine L. Cherry, MBBS, PhD

Infectious Diseases Unit
The Alfred Hospital
Burnet Institute
Department of Medicine
Monash University
Melbourne, Australia

HIV patients are at increased risk for a range of nervous system pathologies, and in particular peripheral sensory neuropathies. HIV is associated with a typical small-fiber neuropathy, characterized predominantly by sensory loss and/or neuropathic pain in the lower limbs. Clinically, patients present with reduced sensation and diminished ankle-jerk reflexes, but without associated muscle wasting or weakness. HIV does not appear to infect neurons, but HIV-produced proteins, such as Gp-120, are clearly neurotoxic. Moreover, several antiretroviral drugs have been identified as independent risk factors for neuropathy. HIV-induced and treatment-induced neuropathies are difficult to distinguish aside from the temporal onset of the latter relative to the initiation of pharmacotherapy, and it is possible that the two may, in fact, both contribute to the disease. Recent research has indicated that increased height and age are almost universally associated with greater risk of neuropathy in HIV. Here, Dr. Cherry give an overview of HIV-associated neuropathies discusses her research into neuropathy risk factors, such as age and height, as markers to prescreen HIV patients and help shape therapy.

References

1. Cherry CL, Affandi JS, Imran D, et al. Age and height predict neuropathy risk in patients with HIV prescribed stavudine. Neurology. 2009;73:315-320.
2. Pettersen J, Jones G, Worthington C, et al. Sensory neuropathy in human immunodeficiency virus/acquired immunodeficiency syndrome patients: protease inhibitor mediated neurotoxicity. Ann Neurol. 2006;59:816-824.
3. Cheng YJ, Gregg EW, Kahn HS, et al. Peripheral insensate neuropathy: a tall problem for US adults? Am J Epidemiol. 2006;164:873-880.
4. Morgello S, Estanislao L, Simpson D, et al. HIV associated distal sensory polyneuropathy in the era of highly active antiretroviral therapy: The Manhattan HIV Brain Bank. Arch Neurol. 2004;61:546-551.

http://painclinician.com/video/hiv_related_neuropathy/