Pain 132 (2007) S13S21 www.elsevier.

com/locate/pain

Comprehensive review

Pain in women with HIV/AIDS

Glenda Gray
a

a,*

, Phyllis Berger

Perinatal HIV Research Unit, University of Witwatersrand, Chris Hani Baragwanath Hosoital, Old Potch Road, Soweto, 1864 Johannesburg, Gauteng, South Africa b Pain Management Practice, Block F Rochester Place, 173 Rivonia Road, Morningside, Johannesburg, South Africa Received 21 September 2007; received in revised form 4 October 2007; accepted 4 October 2007

Abstract Poor women and women of color are disproportionately aected by HIV and this is particularly evident in sub-Saharan Africa. Even with increased access to antiretroviral therapy that makes HIV/AIDS a chronic manageable condition, little progress has been made to address the issues of pain caused by HIV disease in women. Women experience pain dierently from men due to biological, psychological, and social factors. Despite a high prevalence of pain associated with HIV disease, pain is usually under-diagnosed and poorly treated. HIV-related pain is usually divided into two categories: nociceptive or neuropathic. Lack of knowledge of health care providers and reluctance to prescribe potent medication or antidepressants concomitantly to relieve pain contribute to the inadequate management of pain. In poor settings, the weak public health infrastructure with its limited human resources and inadequate drug supplies make high-quality palliative and end-of-life care virtually impossible. As the existing hospital infrastructure is unable to manage the large number of AIDS-related deaths, community-based palliative and end-of-life care models are urgently required. Health care providers in the developing world require training on basic pharmacology and eective analgesic care. An improved ability to assess pain and a greater understanding of HIV-specic pain syndromes and their mechanisms will enable health care providers to better alleviate pain in women. Unless the conditions under which women live are addressed, and attempts made to empower them in their daily lives, their limited ability to access treatment, care and pain relief will continue to be unacceptable. 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
Keyword: Developing countries

1. Introduction Throughout the world, women (15 years or older) represent the largest percentage of newly infected HIV individuals [21]. In 2006, UNAIDS estimated that 17.7 million of the 37.2 million adults infected with HIV were women [46]. In sub-Saharan Africa, 59% of people living with HIV are women; for every 10 adult men living with HIV, 14 women are infected. In particular, among the younger generation in sub-Saharan Africa, for every young man three young women are HIV infected [47].

Corresponding author. Tel.: +27 834592680; fax: +27 119899762. E-mail address: gray@pixie.co.za (G. Gray).

In other parts of the world, both in developed and developing countries, the proportion of women infected with HIV is growing. The impact on women is also apparent in South and South-East Asia, where according to UNAIDS almost 2 million women have HIV. In the United States, African American women, who comprise 13% of the female population, accounted for 67% of female AIDS cases in 2004 [19,20], with a case rate of 48.2/100 000 as compared to 2.1/100 000 in white women. Over the past decade, with the availability of highly active antiretroviral therapy (HAART), huge strides have been made to make HIV/AIDS a chronic manageable condition. However, little progress has been made to address the issues of pain caused by HIV disease, by concomitant opportunistic infections and

0304-3959/$32.00 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.pain.2007.10.009

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HIV-associated cancers, or as a result of side eects of HAART. According to Breitbart, pain in HIV/AIDS is highly prevalent, has varied syndromal presentation, and can result from two to three dierent sources at the same time. It is also associated with signicant psychological and functional morbidity [10]. Up to 80% of AIDS pain is under-treated [15]. Pain severity appears to correlate with stage of HIV infection, although severe pain has been described at all stages of disease progression [65]. In the developed world, the prevalence of pain in advanced disease is estimated at between 30% and 80%, is usually multifactorial in origin, and is underestimated by doctors and poorly managed, thereby negatively aecting quality of life [40,56]. Studies conducted in Thailand and Morocco have found a high prevalence of pain associated with HIV. The presentation of HIV pain in these resource-limited settings was variable, and the pain was inadequately managed and controlled [23,70]. There is a paucity of research on the impact of gender, race, and socioeconomic conditions on HIV-related pain. Earlier studies reported that non-white patients dying of HIV/AIDS were more likely to have uncontrolled pain and to die in hospital [72]. In the United States, such patients are underrepresented in hospices [29], have fewer discussions on end-of-life care preferences [86], and have higher reported intensity of pain [13]. In contrast, a national survey published in 2004 found that black patients reported less pain than white patients [31]. The same survey found that women, intravenous drug users, and those with less education or who were unemployed reported more pain. A study conducted in Britain found clinically important dierences between men and women and also identied special problems for African women and intravenous drug users. Women were more likely to experience constipation, headache, and musculoskeletal pain. Co-morbid gynecological disease was also a common nding [49]. Women experience pain dierently to men due to biological, psychological, and social factors [50]. Men and women respond dierentially to both pharmacological and nonpharmacological treatments [51]. Women have dierent coping strategies to men and report using more social support networks as well as focusing more on their emotional responses than men [23,84]. Specically, internalizing and catastrophizing coping mechanisms were found to mediate sex dierences in pain in both female adolescents and adults [50]. Community and clinical studies suggest that these dierences may aect treatment outcomes [51]. Women with pain are often under-diagnosed and under-treated; in fact, they are twice as likely to be under-treated as their male counterparts [43]. Many women do not have the information or the education, especially in developing countries, to understand that their painful conditions may be part of their HIV disease

and that they are recognizable as such and treatable. All too often, women accept their pain experience and may not complain of pain or may accept under-treatment as the norm. Culture also inuences the pain experience. In some cultures, women may dismiss pain and other symptoms as being normal, which may lead to the late presentation of serious conditions and the risk of unnecessary suering [44]. 2. HIV disease and pain manifestation in women Given the burden of HIV disease in women, it is apparent that more women with HIV will experience pain. Moreover, in women there are special considerations, not necessarily experienced by all persons with HIV/AIDS. In the developing areas of the world (resource-poor countries in Africa, South America, and Asia), where women bear the brunt of the HIV epidemic, there may be limited access to HAART, poor identication of and management of pain, and no referral to palliative care [68]. It is also probable that some women in the developed world, particularly women of color, may encounter similar barriers to treatment access as those in developing countries. There is a very real concern that women may experience more barriers to accessing treatment programs than men [1]. In the industrialized world, women tend to have lower income, be underinsured for health care, have less access to health care, or have a personal or partner history of intravenous drug use [22,60]. Prejudice and inequality aect the treatment of women and children (especially girls) with reference to HIV/AIDS. Barriers such as poverty, abuse, and violence must be removed to enable eective pain management and restoration of quality of life. A seminal article on the information on the pain and treatment of AIDS for all persons was fully described in Pain: Clinical Updates (2006) [15]; therefore, the present article will address the problems encountered by women in developing countries with pain in HIV/AIDS and possible methods to improve pain management, psychological and palliative care, and education in their unique circumstances. It is essential to address these issues in women with HIV/AIDS, especially as women are known to experience more pain than men, reporting more severe levels of pain, more frequent and widespread pain, and pain of longer duration [43]. Many painful conditions are more prevalent in women [43], and having HIV/AIDS does not exclude them from suering in addition from other conditions such as endometriosis, autoimmune diseases, complex regional pain syndrome, diabetic neuropathies, facial pain, headaches, arthritis, breast cancer, bone fractures due to metastases or osteoporosis, abdominal pain, and bromyalgia. One survey found that women with AIDS were signicantly more

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likely to be diagnosed with radiculopathy and headache [59]. Women with HIV disease are at risk of four gynecological disorders that may be more frequent, more severe, and less responsive to treatment as compared to HIV-negative women: cervical human papilloma virus (HPV) infection, cervical intraepithelial neoplasia (CIN), Candida vaginitis, and pelvic inammatory disease. HPV is the most important etiological factor in human cervical cancer, and immune suppression appears to make women particularly susceptible to HPV infection. CIN is more frequent in HIV-infected women as compared to HIV-negative women [73], and in HIV-infected women, advanced CIN appears to be associated with more advanced stages of immunosuppression [58,87]. HIV-infected women may be at higher risk of pelvic inammatory disease and are more likely to have tubo-ovarian abscess formation requiring surgical intervention [45,53,75]. Vaginal candidiasis may be a source of considerable morbidity in immunocompromised HIV-infected women. Pregnancy and childbirth are also compromised by HIV/AIDS. HIV may be associated with adverse pregnancy outcomes such as increased spontaneous abortion, stillbirth, perinatal/infant mortality [17], intra-uterine growth retardation, low birth weight [18,27] and chorioamnionitis [55]. Regarding older women, postmenopausal women had lower CD4 lymphocyte counts 3 years after seroconversion than premenopausal women [85]. In addition, HIV-positive women entering menopause are signicantly more likely to have osteopenia than their HIV-negative counterparts [3]. The pain syndromes seen in HIV-infected patients may be related directly to HIV infection or immunosuppression or to HIV therapies, or they may be unrelated to AIDS or AIDS therapies. Pain may be divided into two categories: nociceptive or neuropathic [34,43]. The most common syndromes reported in HIV-positive patients include painful peripheral neuropathies, pain caused by extensive Kaposis sarcoma, headache, oral and pharyngeal pain, abdominal pain, chest pain, arthralgias and myalgias, and painful dermatological conditions (Table 1) [56].
Table 1 Common sources of pain in HIV/AIDS Cutaneous/Oral Kaposis sarcoma Oral cavity pain Herpes zoster Oral/esophageal candidiasis Visceral Tumors Gastritis Pancreatitis Infection Biliary tract disorders Deep somatic

3. Issues that contribute to pain and suering in women with HIV/AIDS [78] The women who may be predisposed to contracting HIV/AIDS are those whose right to choose is most violated those who live in places where women exchange sex for survival as a way of life. This may not constitute prostitution, but rather a basic social and economic arrangement between the sexes that results on the one hand from poverty aecting men and women, and on the other hand, from male control over womens lives in a context of poverty. Special issues that aect women in African nations and other resource-poor countries include the following powerful factors that hamper changes in government and male attitudes and may increase womens suering: Lack of control over womens sexuality and sexual relationships. Poor reproductive and sexual health, leading to serious morbidity and mortality. The rates of infection in young (15- to 19-year-old) women are between ve and six times higher than in young men (according to recent studies in various African populations). Neglect of health needs, nutrition, and medical care. Womens access to care and support for HIV and AIDS is much delayed (if it arrives at all) and limited because family resources are nearly always devoted to caring for the husband or children. Women, even when infected themselves, are the ones who provide all the care. Clinical management is based on research on men; a module on clinical management of HIV/AIDS and pain in women is required. All forms of coerced sex from violent rape to cultural/economic obligations to have sex when it is not really wanted increase the risk of micro-lesions and therefore of sexually transmitted diseases (STDs) and HIV infection. Harmful cultural practices that include genital mutilation and practices such as dry sex. Stigma and discrimination in relation to AIDS (and all STDs). Discrimination is far stronger against infected women, who risk violence, abandonment,

Neurological/Headache Headaches: HIV-related (encephalitis, meningitis, etc.) Headaches: HIV-unrelated (tension, migraine) Iatrogenic (AZT) Peripheral neuropathy Herpes neuritis Neuropathies associated with ddI, D4T toxicities, alcohol, nutritional deciencies

Rheumatological disease Back pain Myopathies

Modied from Carr DB. Pain in HIV/AIDS A Major Health Problem. IASP/EFIC (press release). Available at www.iasp-pain.org.

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neglect (of health and material needs), destitution, and ostracism from their family and community. Furthermore, women are often blamed for the spread of the disease, even though the majority of them have been infected by their only partner/husband. Adolescents: Access to education for prevention (in and out of school and through media campaigns), condoms, and reproductive health services before and after adolescents are sexually active does not often focus on girls. Today, children are being removed from school to care for their AIDS-stricken families, and 70% of these caregivers (according to a study in Zimbabwe) are girls. Once out of school, a young girls vulnerability is compounded. She is removed from the context in which she can gain life-saving information and skills, and does not learn to fend for herself, economically or socially. Promotion and protection of adolescent reproductive rights. There are considerable obstacles for girls in terms of laws and policies, health service provision, cultural attitudes and dierences in expectations of girls and boys sexual behavior, cultural practices, and educational and employment opportunities. Sexual abuse: There is now evidence that sexual abuse is an underestimated mode of transmission of HIV infection in children (even very small children). Adult men now seek ever-younger female partners (younger than 15 years of age) in order to avoid HIV infection, or if they are already infected, in order to be cured (apparently, some men believe that sex with a virgin will cure AIDS). Disclosure of status, partner notication, and condentiality. These issues are all more dicult for women than for men for the reasons discussed above due to the negative consequences and the fact that women have usually been infected by their only partner/husband. Being able to inform others (signicant or not) in this situation is more dicult for a woman, which further decreases access to care and support. It is essential that protection for women is assured when they do disclose their status [78]. Conicts and the attendant violence and poverty exacerbate these human rights abuses as communities disintegrate and basic services are destroyed. Rape is a well-known instrument of war. Women and children are often exposed to sexual violence in crowded, unsafe camps for refugees or the displaced [83].

4. Factors that aect all AIDS patients and may have a stronger impact on women 4.1. Barriers to treatment and care One of the biggest barriers to pain management is lack of knowledge of health care providers. A study con-

ducted in France demonstrated that doctors appear reluctant to prescribe potent medication or to use antidepressants concomitantly to relieve pain. The underestimation and lack of adequate management of pain was attributed to insucient awareness, poor training, and reluctance to use morphine. In a survey of about 500 AIDS care providers, clinicians (primarily physicians and nurses) rated the barriers that they thought interfered with pain management in patients with AIDS [12,14]. The top ve barriers were a lack of knowledge about pain management, a reluctance to prescribe opioids, a lack of access to pain specialists, concern about drug addiction or abuse, and lack of psychological support and drug treatment services. Even considering the current global focus on HIV treatment and the barriers to pain management in developed countries, it must be recognized that the nature of the disease, the weak public health infrastructure, and other factors [26] make high-quality palliative and endof-life care necessary in sub-Saharan Africa. The number of AIDS-related deaths, however, is simply too great for existing hospital infrastructures. Community-based palliative and end-of-life care models are needed [7], as is a renewed focus on the quality of palliative and endof-life care. The fundamental question of whether palliative care is appropriate or possible in developing countries has been discussed elsewhere [74]. The introduction of both home-based and inpatient hospice care in sub-Saharan Africa [5,61,81] has already provided some answers. These approaches have addressed government funding and support, clinical training, and improved pain control through drug policy advocacy. Additionally, given the large number of HIV deaths, program administrators must consider adequate coverage and not simply strive to provide high-quality care to a few patients [33]. The factors that constitute high-quality end-of-life care in non-industrialized countries are worthy of consideration. Total psychosocial care in resource-poor environments includes additional needs such as orphan care, income generation, and food security [9]. Pain intensity appears to be similar or greater in AIDS than in cancer [11]. A comparative study of terminal cancer patients in Kenya and the United Kingdom found that the Africans main concern was for pain control and analgesia, compared to the U.K. patients, whose concerns were for relief of emotional pain [30]. Culturally competent end-of-life care should also incorporate alternative belief and care systems, for example, training traditional healers in care roles [4,54,63]. A survey of end-of-life care programs was conducted in a study of current end-of-life care for terminal HIV/ AIDS in sub-Saharan Africa to investigate models, services, challenges, and priorities [42]. This study addressed the domains of service aims and conguration, barriers to pain control, governmental endorse-

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ment and strategies, funding, monitoring and evaluation, and research. Both closed and qualitative responses were sought. Despite great structural challenges, data from 48 programs in 14 countries with a mean annual funding of US$374,884 demonstrated integrated care delivery across diverse settings. Care was commonly integrated with all advanced disease care (67%) and disease stages (65% oering care from diagnosis). The majority (98%) provided home-based care for a mean of 301 patients. Ninety-four percent of respondents reported challenges in pain control (including availability, lack of trained providers, stigma, and legal restrictions), and 77% addressed the eects of poverty on disease progression and management. Although 85% of programs reported government endorsement, end-of-life and palliative care national strategies were largely absent. The authors of this study concluded that the interdependent tasks of expanding pain control, balancing quality and coverage of care, providing technical assistance in monitoring and evaluation, collaborating between donor agencies and governments, and educating policy makers and program directors of end-of-life care are all necessary if resources are to reach their goals. 5. Suggested management of pain symptoms and palliative care Given that patients with HIV/AIDS live longer with their illness, symptom management has been identied as one of the top priorities for HIV/AIDS nursing research in the 21st century [79]. Newshan and Sherman discussed ve principles that are fundamental to successful symptom management [64]: (1) taking the symptom seriously, (2) assessment, (3) diagnosis, (4) treatment, and (5) ongoing evaluation. Fatigue is a common symptom in HIV/AIDS that aects overall quality of life. It is among the most common and distressing symptoms, aecting 2060% of these patients [2], and is not merely a manifestation of depression [16,36]. Furthermore, circadian rhythms are disrupted in patients with HIV/AIDS, leading to sleep disturbances. One study found that HIV seropositive women with severe fatigue experienced signicantly more diculty falling asleep, more awakenings from nighttime sleep, poorer daytime functioning, and a higher frequency of depressive symptoms [57]. Fatigue is related to sleep quality and perceived stress. Health care practitioners must address psychosocial stressors and sleep quality when developing eective care for HIV-infected patients. Fatigue experienced with HIV may exacerbate pain or impair the ability to respond appropriately to pain. The various treatments being studied for HIV-related fatigue are thyroid replacement therapy, hyperbaric oxy-

gen and dextroamphetamines [6]; supervised aerobic exercise programs and a variety of self-care strategies including vitamins and other nutritional supplements, dietary changes, sleep and rest; adjusting activities, approaches, and thoughts; distraction; and complementary and alternative therapies [28]. A study by nurse researchers was discussed at the 15th Annual Association of Nurses at an AIDS care conference that examined the eects of acupuncture on sleep in patients with HIV disease; the investigators found that sleep activity and sleep quality signicantly improved following 5 weeks of individualized acupuncture. They noted that signicant relationships existed between fatigue and sleep quality, and between fatigue and perceived stress [69]. The relationship between stress and fatigue was also noted by Robinson, working in the eld of psychoneuroimmunology in HIV/AIDS, in a study that investigated the interrelationship among the mind, body, and immune system. The eect of a structured 8-week mindfulness-based (meditation) stress reduction program was evaluated on perceived stress, physiological parameters, and functional health outcomes [71]. By the end of the study, participants noted improvements in perceived stress and fatigue, as well as in depression, tension, anger, and confusion, and had higher natural killer cell counts. Thus, health care practitioners need to address each persons psychosocial stressors and sleep quality as they develop eective care for HIV-infected individuals [48]. Anemia remains a common symptom of patients with HIV disease and aects adolescents, women of reproductive potential, and geriatric patients. Nursing guidelines for HIV-associated anemia recommend nutritional support, micronutrient supplementation, and more frequent screening for mild asymptomatic anemia, the use of erythropoietin therapy as an appropriate treatment for patients with symptomatic mild anemia or moderate anemia, and immediate blood transfusions for patients with severe anemia [41]. The initiation of HAART remains pivotal to the management of HIVrelated anemia. Regimens containing zidovudine may exacerbate existing anemia or may directly cause anemia. 5.1. Pain The best approach to treating pain in HIV/AIDS is multimodal: pharmacological, psychotherapeutic, cognitive-behavioral, anesthetic, neurosurgical, and rehabilitative. Therapy should begin according to the WHO ladder, with a non-opioid such as paracetamol (acetaminophen). Opioids should be the rst-line therapy for moderate to severe pain. Nonsteroidal anti-inammatory drugs (NSAIDs), adjuvants (tricyclic antidepressants and anticonvulsants), and nonpharmacological

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modalities may be important supplements to eective analgesia. NSAIDs should be used with caution in HIV, as they may exacerbate bone marrow disease and worsen the gastrointestinal eects seen with HIV infection or with HAART. With chronic pain, continuous administration of long-acting opioids is the treatment of choice. The use of gabapentin, (initially developed as an anticonvulsant) in HIV-associated sensory neuropathies has been associated with pain reduction and improvements in sleep [39]. Patients with HIV/AIDS require both active treatment and palliative care throughout the disease trajectory to relieve the pain. A priority of care for AIDS primary care services is to identify early signs of opportunistic infections and to minimize related symptoms and complications throughout the illness. Meeting this priority requires obtaining a complete health history, a thorough physical examination, and laboratory data, including determinations of immunological and viral status. Although pain medications [10] are needed to alleviate pain, protease inhibitors could interact with some of them. Opioid analgesics are often required for the management of severe pain and can be used in these patients by following appropriate guidelines [82]. It is also important to ensure that there are no drug interactions between HAART and medications used to relieve pain. 5.2. Palliative care In 2006, approximately 2.6 million adults died from AIDS [21]. Approximately 15,000 Americans continue to die from AIDS and/or co-morbid conditions each year [31]. Palliative care is a critical component in the treatment and management of HIV disease. Palliative care can help improve quality of life, enhance adherence to HAART and other therapies, and address the complicated psychosocial issues facing HIV-infected individuals and their families [76]. In addition, end-of-life care is needed by many who will die despite the increasing availability of disease-modifying treatment [1]. A recent review of patient outcomes in HIV palliative care found signicant improvements in the domains of pain and symptom control, anxiety, insight, and spiritual wellbeing [42]. The principles of palliative care should include the following [66]: Respecting patients goals and preferences. Working toward the resolution of conicts among patient, family, and practitioners. Comprehensive caring. Using the strengths of interdisciplinary team members and resources. Acknowledging and addressing caregiver concerns, risks, and the need for support. Building infrastructures supportive of palliative care.

Newshan and Sherman [64] concludes that nurses can provide competent palliative care through ongoing assessments of spiritual well-being and psychosocial issues, assisting with advance care planning, providing advice and assistance with hospice admission, and guiding both patients and family during the dying process, grief, and mourning. 5.3. Providing pain relief for substance abusers Optimal pain relief for patients with HIV with a history of substance abuse is required because pain is common in these patients. Pain management in such patients is a challenging but essential aspect of their medical care because both physicians and HIV-infected patients may have fears of opiate addiction, which might lead to the undermedication of HIV-infected patients who have pain. Optimal pain management involves a multimodal, multidisciplinary approach, using both pharmacological and nonpharmacological interventions. Opioid analgesics may be required for severe pain and can also be used in these patients by following appropriate guidelines. Experience from the cancer literature suggests that it is possible to adequately manage pain in people who misuse drugs and who have a life-threatening illness. Clinicians should err on the side of believing patients when they complain of pain and should use knowledge of specic HIV-related pain syndromes to corroborate the report of a patient perceived as being unreliable [82]. Research on women substance abusers is required that may provide dierent management to that of men, based on studies supporting a sex dierence in opioid-induced analgesia [66]. 6. Factors preventing medically eligible women from access to HAART and care Various factors prevent medically eligible women from initiating highly active antiretroviral therapy (HAART), including women currently using alcohol and illicit drugs, African American women, and women with high levels of depressive symptoms [37]. A study in 2004 [8] on Medically eligible women who do not use HAART: the importance of abuse, drug use and race indicated that a history of sexual abuse, current drug use and non-white race were associated with a lack of HAART use. A history of physical, sexual/childhood abuse is common with HIV infection, with up to twothirds reporting a lifetime experience with abuse. The nding in the 2004 study was that women who had been abused were 1.5 times more likely not to use HAART. Felitti et al. [35] have shown that the association of childhood sexual abuse and other adverse childhood exposures increased risks for alcoholism, drug abuse, depression, and suicide, as does the presence in adult-

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hood of heart disease, cancer, lung disease, skeletal fractures, and liver disease, with suboptimal HIV therapy now added to this list. Other factors revealed in this study were that women with a history of abuse characterize their relationships with medical providers as less satisfactory, with a tendency to consider their providers as judgmental, annoyed, and disrespectful. They found it difcult to discuss private and emotional issues in this context. In addition, experiences of abusive relationships may be responsible for damaged self-image resulting in obstacles to ecacious self-care. It is also possible that medical providers may not oer HAART because of concerns regarding emotional instability and adherence to the drug regimen. With the burden of HIV in U.S. women borne by African Americans and Latinas, it is particularly striking to document that race remains predictive of lack of appropriate therapy [25]. Acknowledgment by HIV health providers of these challenges, along with innovative collaborations with experts in mental health, substance abuse, and sexual or physical abuse, provides an opportunity to more eectively treat all women with HIV infection [38]. 7. The emotional experience of HIV

on them as their illness progresses [77]. Women lose their self-esteem if they are unable to take care of others, and single mothers may feel shame or guilt if they are unable to take care of their children as they think they should. These reactions [81] may lead women to accept anger or abuse or to suppress their own anger in order to avoid nding themselves alone; they may continue to use drugs for fear of losing a substance-using partner or may feel guilty about taking time away from responsibilities for others to address their own needs. It may be dicult to self-motivate and establish good self-care when no one will benet except the woman herself. In a study of delays in seeking care among HIV-positive individuals, women were 1.6 times more likely to delay medical care than men [80]. However, motivation to take care of others may encourage some HIV-infected women to undertake changes in their behavior to end substance abuse and make advance plans for their family. Some women with HIV may take on the responsibility of bringing their children or partners into medical care despite signicant barriers, including their own fatigue or ill health, and may demonstrate remarkable resourcefulness in seeking out additional avenues of support [24]. 8. Conclusion

It is important to understand the emotional experience and the potential psychiatric and mental health problems of women who are diagnosed with AIDS and to optimize care. The health care provider can provide signicant comfort during normal adjustment phases and common emotional transitions with skilled emotional support, assessment of coping skills, patient education, and empathy. When normal adjustment issues give way to formal psychiatric or neuropsychiatric disorders, accurate diagnosis and appropriate treatment are required [24]. Women across cultures and around the world have lifetime incidence rates of major depressive disorders twice those of men. A longitudinal cohort study of 93 HIV-positive women and 62 HIV-negative women without current substance abuse found that HIV-positive women were four times more likely (19.4%) to meet clinical criteria for current major depressive disorder than HIV-negative women (4.8%), with signicantly greater anxiety symptoms [35]. The HCSUS study (N = 2864) found that HIV-positive individuals with probable mood disorders had signicantly lower scores on health-related quality of life measures [67]. Women and men dier in their reaction to being HIV-positive [52]. Women frequently dene themselves in the context of their relationships to others, and their fears are more often about separation [62]. They tend to worry more about those who are dependent

In both the developed and developing world, pain attributed to HIV is poorly diagnosed and under-treated. Specically, opioid analgesics are underused, as are adjuvant analgesics such as antidepressants. Health care providers require training on basic pharmacology and eective analgesic care. Improved ability to assess pain and greater understanding of HIVspecic pain syndromes and their mechanisms will enable health care providers to better alleviate pain. Pain assessment should occur at each visit with the use of validated assessment tools that will enable health care providers to manage pain more eectively [32]. In addition, the World Health Organization provides recommendations for treating and management of pain. Only by raising awareness of the prevalence of HIV-related pain in women to their health care professionals, funding organizations, policy makers, and public health organizations will it be possible to improve the assessment and adequate management of pain. Informing the public about these issues is paramount with the hope of achieving a change in attitudes and an increase in the availability of treatment that will improve conditions for women and reduce their suering. It is hoped that negative assumptions about womens roles and discrimination against them will be challenged and that women will become empowered to help themselves.

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