Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

350 Abstracts 22428-22432

12th World AIDS Conference

22428 J Pain in HIV disease: A Moroccan survey
Abdelfattah Chakib, S.E. Nejmi, 0. Hliwa, H. Himmich. Service Des Maladies
Infectieuses, Chu Ibnrochd-Casablanca, Morocco
Objectives: To evaluate prevalence and severity of pain, pain syndromes and
pain's impact on quality of life in HIV-infected patients; to measure adequacy of
analgesic management of pain.
Methods: Prospective cross-sectional survey of 60 consecutive HIV-infected
patients admitted to our Infectious Diseases Unit during a 6-month period (December 1996-May 1997). Patients filled out the french language version of the
Brief Pain Inventory (BPI). The BPI asked patients to assess pain intensity and to
rate pain interference with various aspects of daily life. Patients were also asked
to shade the area of human figure to identify the location of the pain(s). We used
the Pain Management Index (PMI), a measure derived from the BPI, to examine
adequacy of analgesic therapy.
Results: Seventy percent of patients with HIV/AIDS reported pain. Nearly
74% of patients with pain reported significant pain (worst pain level >5). The
most common pain syndromes identified included abdominal pain (47.6%) and
headache (42.8%). Seventy six percent of patients stated that pain interfered with
daily life. Using the PMI, 97% of patients were classified as receiving inadequate
analgesic treatement. None of the 18 patients (43%) who reported severe pain
was prescribed a strong opioid, as suggested by published guidelines.
Conclusion: In Morocco, pain among HIV-AIDS patients is highly prevalent,
varied in syndromal presentation, associated with significant impact on quality of
life, and alarming undertreated. These results are similar to those observed in
other countries.
22429 Psychostimulants for fatigue in the HIV positive patient:
Placebo controlled trial of methylphenidate and pemoline
Julie Esch1, B. Breitbart1, B. Rosenfeld', M.C. Kaim1, K.A. Stein2. 1MSKCC Nw
York NY; 2UMDNJ Netwark NJ, USA
Background: Fatigue is a highly prevalent and distressing symptom of HIV
disease that has important consequences for patients with HIV/AIDS. While
anecdotal evidence has suggested that pharmacological interventions are beneficial for fatigue, little empirical research has supported these claims in patients
with HIV/AIDS. This study compares the efficacy of two psychostimulant drugs,
methylphenidate (Ritalin) and pemoline (Cylert), for the treatment of fatigue in
ambulatory patients with HIV/AIDS. Specifically, we assess the impact of these
medications on both subjective and objective measures of fatigue, as well as
psychological distress and quality of life (QOL), while monitoring the frequency
and severity of side effects.
Method: A double-blind, randomized, placebo controlled method, patients
were randomized to one of three treatment arms: methylphenidate, pemoline, or
placebo. All participants completed a battery of objective and self-report measures including: the Piper Fatigue Scale, the Visual Analogue Scale for Fatigue
Severity, Timed Isometric Unilateral Leg Raising, Structured Clinical Interview for
DSM-IV, the Beck Depression Inventory, and the Brief Symptom Inventory. Sociodemographic and medical data were also collected, including CD4 cell count,
viral load, hemoglobin and hematocrit.
Sample Characteristics: As of January, 1998, 106 patients had completed the
study. The demographic characteristics of this sample were: Gender: 44% female,
56% male; Race: 54% African-American, 34% Hispanic, 21% Caucasian, and
3% other; HIV Risk factor: 34% heterosexual contact, 22% homosexual contact,
27% IVDU, 13% multiple risk factors and 4% other.
Results: We anticipate reaching our goal of 120 patients completing the study
by April of 1998. Results will be analyzed using a repeated measures design to
assess the efficacy of these pharmacologic interventions for fatigue as compared
to placebo. Multivariate analyses will also be used to assess the relationship
between improved fatigue on psychological distress and QOL.
Conclusion: We believe this study will help determine whether or not pharmacologic interventions for fatigue are effective. In addition, these efforts will
be interpreted in light of the relative frequency/severity of side effects and the
subsequent impact on QOL. We anticipate that these data will help elucidate the
complex relationship between fatigue and depression.
22430 Survey of care providers and patients about advanced
directives (AD) in a teaching hospital inner city HIV/AIDS
clinic
Nancy Angoff1, B. Belton2, K. Dossantos2, F. Hardy2, T. Hatcher2, P. Marcucio2,
P. Mebane2. 1Nathan Smith Clinic, 15 York St., New Haven; 2 Yale-New Haven
Hospital, New Haven, CT, USA
Issue: HIV/AIDS primary care providers often care for patients in the last stages of
HIV disease. Advanced Directives allow the patients to guide providers in making
difficult end of life decisions; however, many providers are poorly informed about
AD.
Project: In order to develop a program to encourage providers to discuss end

of life objectives with patients, a survey was conducted about provider and patient
understanding and use of AD. Anonymous questionnaires were distrubuted to
patients and providers in an inner city HIV/AIDS clinic affiliated with a teaching
hospital.
Results: Questionnaires were given to all providers and all patients at the
clinic during a representative month. 86% of health care providers said they understood AD well enough to explain them to patients; 64% said they understood

the concepts of "health care agent" and "durable power of attorney". 71% felt
comfortable discussing these concepts. Some providers estimated that from 5%
to 40% of their patients had AD, but most did not know how many patients had
AD. Only 27% of patients said they had AD and 37% said their providers had
discussed AD with them. 43% of patients whose providers had not discussed AD
said that they would like them to. There was no association between CD4 count
and whether a patient had AD. The major barrier to discussion of AD was felt to
be time, and many providers felt that it would be helpful to have the clinic social
worker and nurses help explain AD to patients.
Lessons Learned: Although providers claim to understand and feel comfortable discussing AD, in actual practice this does not occur. Potential interventions
to increase the discussion of AD are computer generated reminders, an office
visit specifically to discuss AD and nurses and social workers trained as catalysts
in starting these discussions.
22431 Changing needs of "palliative care" for patients with
AIDS/HIV
Brenda L. Done, M.F. Defend. 1448 Oxford Street East, St Joseph's Health
Centre, London, ON, Canada
The development and use of protease inhibitors in multi-drug cocktails have
resulted in a significant decrease in HIV/AIDS morbidity in a number of individuals. Many people who were severely ill due to HIV infection are experiencing
stabilization of immune function and a decrease in HIV related symptoms. We are
faced with the challenge of helping people with HIV/AIDS who are experiencing
improved immune and functional status decide how to plan for a longevity many
did not expect to have.
Project: The John Gordon Home originally opened as a traditional hospice,
providing palliative care for those with end stage HIV/AIDS illness. The John
Gordon Home offered compassionate care in a homelike environment. A decision
was made to change the Home's mandate, since the need for end of life care
decreased, and many of our residents were thriving under the Home's nurturing
supports. The John Gordon Home now is a supportive living environment for
people living with HIV throughout the entire continuum of their illness.
Results: In eight one bedroom units, residents live independently, with the
ability to access support they require from on site staff, and in collaboration with
existing community resources. Through case presentations, it will be demonstrated how this unique model of care has improved residents' physical and
psychological health. We will show enhanced length and quality of life through a
variety of mechanisms including improved nutrition, increased socialization, and
better adherence to complex medication schedules.
Conclusion: The need for traditional hospice care is decreasing in light of new
treatment modalities. Supportive housing must address the changing physical
and psychological needs of those with HIV illness, as it increasingly becomes a
more chronic manageable illness.
122432 | Pain in children with HIV/AIDS
Lynn Czarniecki1, J. Oleske2, M. Passannante2, J. Barros1, N. Colabelli1,
M. Boland1. 'FXB Center ADMC 4 30 Bergen Street Newark NJ 07107; 2NJ
Medical School UMDNJ Newark NJ, USA
Over 50% of children with HIV/AIDS have pain as a major feature of their disease.
Adults with HIV report various types of pain but there is less information on pain
in children with HIV/AIDS. An exploratory study was conducted in 1996, which
aimed to describe and quantify the pain experienced by children with HIV/AIDS.
Objectives: To describe and quantify the pain experienced by children with
HIV/AIDS.
Design: Prospective, descriptive.
Method: Verbal patients 4 years and older with HIV/AIDS and their caregivers
were interviewed regarding their pain experiences since their last monthly clinic
visit and on the day of the interview using a questionnaire developed by the
researchers. The Wong/Baker Faces Pain Rating Scale was used to rate the
severity of any identified pain. Caregivers of children whose developmental level
was below 4 or who were non-verbal were interviewed to determine whether
they believed their child had pain. Each subject's medical record was reviewed to
collect pertinent demographic and medical data. Both the Internal Review Boards
of the New Jersey Medical School and United Hospital Medical Center gave
approval for this study.
Results: 40 children were interviewed. 21 (52%) reported having had pain
since the last clinic visit. 60 caregivers were interviewed. 32 (53%) reported that
their child experienced pain. There was no significant difference in pain by age
although there was a slight trend towards more pain in older children. Patients
in all three clinical classifications (A, B, C) experienced pain with a slight trend
towards more pain in class B and C. There was good, but not excellent agreement between the reports of pain by patients and caregivers with no significant
difference found. The types of pain reported included headache (9), leg pain (8),
stomach pain (3) and back pain (2).
Conclusions: The results of this study demonstrate that children with HIV/AIDS

frequently experience pain. Pain occurs across the continuum of the disease rather
than, as is frequently believed, only in the end stages. Caregivers' assessments
of their child's pain can be taken seriously and when a patient is unable to report
pain, caregivers should be utilized for the assessment.