Date Published: February 13, 2019
Author(s): Antonia L. Wadley, Tamar Pincus, Michael Evangeli.
Stigma related to the human immunodeficiency virus (HIV) remains common and has been associated with severity of HIV-related symptoms. Associations between HIV stigma and HIV-related pain, one of the most common symptoms in HIV, have however not been investigated. Data from low back pain populations suggest that stigma is associated with worse pain intensity and so we hypothesised that the same would be the case in HIV.
The goal of this study was to assess the association between HIV stigma and pain intensity in people living with HIV (PLWH) with chronic pain whilst controlling for depression, a well-established correlate of pain.
The study took place at an HIV clinic in Johannesburg, South Africa.
Mediation analysis was used to assess the effect of depression on the relationship between stigma and pain intensity in a cross-sectional cohort of 50 PLWH and chronic pain (pain most days of the week for > 3 months). All participants were assessed using the HIV/AIDS Stigma Instrument – PLWA, an 11-point numerical pain rating scale and the Beck Depression Inventory II.
In all, 88% (44/50) of participants reported experiencing some form of HIV stigma (HIV stigma scale score ≥ 1). Worst pain intensity and depressive symptoms individually correlated with total stigma score (Spearman’s r = 0.33, p = 0.02 for both). The mediation analysis highlighted that mediation of the relationship by depression was equivocal (b = -0.002, bootstrapped confidence interval -0.02 to 0.00).
Whilst these preliminary data are marginal, they do suggest that associations between HIV stigma and HIV-related pain warrant further investigation. Future study should also include potential mechanisms, which may include mediation through depression.
Stigma towards people living with human immunodeficiency virus (HIV) remains prevalent. A survey of over 10 000 HIV-positive individuals in South Africa reported that over one-third perceived themselves as having experienced HIV stigma.1 Stigma against people living with HIV (PLWH) can take different forms including enacted stigma, which refers to acts perceived as stigmatising such as social exclusion or violence, or internalised stigma, whereby prevalent negative attitudes surrounding HIV are internalised and deemed valid by people living with HIV (PLWH).2,3
The cohort of 50 participants is described in Table 2. They were a city-dwelling, middle-aged, predominantly female cohort and had a high level of unemployment. All participants were on stable antiretroviral therapy. Worst pain experienced in the last week was generally severe (7–10 on NRS): the median pain intensity was 8/10, with 62% (31/50) experiencing pain intensity at 8/10 or greater. The majority had more than one pain site, with head and spine being the most frequent sites of pain (both: 40%, 20/50). Forty-eight per cent (24/50) scored > 20 on the BDI-II (moderate or severe depression) and 24% (12/50) scored between 13 and 19 (mild depression).
The hypothesis for the study was that HIV stigma would be associated with pain intensity and that depressive symptoms would mediate the relationship. The results showed that HIV stigma was associated with worst pain intensity, but whether this relationship was mediated by depression is unclear.
In this first assessment of HIV-related pain and stigma, we found an association between perceived HIV stigma and increased pain intensity. The role of depression in mediating this relationship was not clear. Further study is warranted to repeat these findings and determine the mechanisms by which stigma may influence HIV-related pain, including the role of depression. This information is important to inform psychosocial interventions for HIV-related pain. For example, a recent programme piloted in the US for PLWH, pain and depressive symptoms32 may be more effective if perceived stigma is also addressed. Furthermore, behavioural interventions for managing pain in HIV33 may need to take into account that stigma may be a barrier to functional coping with pain.