Assessment of pain and associated factors in people living with HIV/AIDS

Objective: to evaluate pain in people living with human immunodeficiency virus/acquired immunodeficiency syndrome and to relate it to sociodemographic and clinical factors, depressive symptoms and health-related quality of life. Method: descriptive, analytical, observational, cross-sectional and quantitative study. Three hundred and two (302) people assisted at a specialized care service participated in the study. Instruments were used to evaluate sociodemographic and clinical data, depressive symptoms, and health-related quality of life. Descriptive, bivariate analysis and multiple logistic regression were used. Results: the incidence of pain of mild intensity was 59.27%, recurrent in the head, with interference in mood, mostly affecting females and individuals with no schooling/low schooling. Women were more likely to have moderate or severe pain. People aged 49 to 59 years had greater pain intensity than people aged 18 to 29 years. The variables depressive symptoms and pain were directly proportional. The higher the health-related quality of life and schooling, the lower was the possibility of presence of pain. Conclusion: presence of pain is of concern and has association with female sex, lack of schooling/low schooling, worse level of health-related quality of life and presence of depressive symptoms.


Introduction
The global epidemic of the Human Immunodeficiency Virus (HIV), which is the cause of the Acquired Immunodeficiency Syndrome (AIDS), began in 1981 in the United States. After thirty years of fight against HIV/AIDS in Brazil, which started in 1985, the analysis is that this country has been exemplary in its role of prevention and treatment of this disease with great advances and few setbacks (1) . However, despite the success of disease prevention and control measures, absence of sleep; muscular pain and pain in the joints and indisposition to work (4)(5) .
An outpatient survey in the UK with 859 PLWHA resulted in a prevalence of pain of 62.8%, with respect to pain felt in the last month, of which 63% reported feeling pain on the day of the interview. Among the interviewees, 20% were taking analgesics daily. The study showed that there are many challenges to control pain related to AIDS, including polypharmacy, increased sensitivity to side effects of the drugs, psychological comorbidity and drug interactions (4) .
A systematic review pointed to several studies reporting the prevalence of pain in PLWHA, and showed that pain is a significant problem but which remains   In this study, it was decided to study only adult individuals because children, adolescents and elderly people are populations that have specific characteristics that deserve to be analyzed in their particularities, which would not be the objective of the present study.
The time of six months under ART was adopted to avoid conflict of interpretation with the variable pain and the beginning of the use of this therapy, because several adverse reactions occur in the first six months of treatment (11) .
The exclusion criteria were: participants who did not understand or were not able answer the questions of the instruments, women who were pregnant and co-infected people (presenting more than one viral infection).
The invitation to participate in the research was made at the place of consultations. Patients were approached and invited while they were in the waiting room on days when they had scheduled appointments.
If the patient accepted, he was given the possibility to choose the most appropriate moment for the interview, that took place in a reserved room to provide the participant with privacy and comfort. The data collection period was from January to July 2017. To characterize the levels of pain intensity, the following scores were used: from 1 to 4, mild pain; from 5 to 7, moderate pain; and from 8 to 10, severe pain (12) .
The Patient Health Questionnaire-9 (PHQ-9) was used to evaluate the Depressive Symptoms. life (four items); health concerns (four items); financial concerns (three items); concerns with medication (five items); acceptance of HIV (two items); concerns with confidentiality (five items); trust in professionals: physicians; nurses; or any other healthcare professionals who provide care for the patient and sexual function (two items). In each domain, zero is the lowest score and 100 the best score possible. The higher the score, the lower is the impact of HIV infection on the individuals' HRQoL.
In turn, the lower the score, the more affected is the function, the greater is the concern and the lower is the life satisfaction (14) .
For data analysis, double typing was used to enter data, which were organized in an Excel spreadsheet and

Results
The results showed that of the 302 PLWHA studied, 179 (59.27%) reported having presented pain in the last 24 hours. In Table 1, the presence of pain was analyzed according to sociodemographic variables, with sex and schooling being the variables with significant values.
In Table 2, the presence of pain was analyzed according to the clinical aspects of the disease, and no   to the conclusion that women are 79% more likely than men to report pain.
In Table 4, another model was adjusted and HRQoL was disregarded, due to its high statistical significance in relation to pain. In this case, the variables sex, schooling and DS remained significant.  It was observed that the OR for sex was 1.89, meaning that women tend to report pain 89% more than men. In turn, the schooling of PLWHA was inversely proportional to pain. The OR was 0.65, that is, people with higher educational level were 35% less likely to report pain. Therefore, PLWHA with higher educational level tended to report less pain than those with less education than complete secondary education.
Regarding DS, when the score was ≥ 9 in the PHQ-9, which means presence of DS, PLWHA had a 2.11-fold greater chance to report pain than PLWHA scoring < 9.
In Table 5, we present the selection of significant variables to classify pain intensity in two large groups. It was possible to observe that as the income increased, there was a decrease in the complaint of moderate/severe pain and that the group of patients with PHQ-9 score ≥ 9 were 2.48-fold more likely to present moderate and severe pain.

Discussion
Regarding the presence of pain, it was possible to observe that 59.27% of the PLWHA had had pain in the last 24 hours. It is understood that the presence of pain in almost 60% of the PLWHA is a matter of concern.
However, it is necessary to know the prevalence of pain in the general population to affirm that this prevalence in PLWHA is really high.
A systematic review was conducted to investigate the prevalence of pain in PLWHA, which resulted in a variation of 54% to 83% in the studies analyzed (6) .
A study carried out in Uganda, with the objective of analyzing the prevalence of pain in PLWHA, resulted in 68% of people reporting pain at the time of interview (7) .
However, in contrast with the present study, other results showed values of prevalence of pain lower than those found here, but still worrying. In Thailand, researchers showed that only 22% of the PLWHA studied reported pain in the last 24 hours (15) . Another study analyzed the presence of pain in the last year in PLWHA in New York and found a prevalence of pain of 40% in this population (16) .
When the pain was correlated with sociodemographic variables, it was possible to observe a predominance of pain in women (70.48%). This correlation was also evidenced in the literature; some studies found strong associations between the female sex and pain (17)(18) .
As for educational level, significant values were observed in its relationship with pain. PLWHA with incomplete high school presented higher prevalence of pain (83.08%), followed by people with no schooling/ low schooling (64.58%). Two other studies (7,10) showed a higher prevalence of pain in PLWHA who only had  (19)(20) .
Regarding pain levels, the present study showed a more frequent report of mild pain (59.88%), followed by moderate pain (36.72%), and severe pain (3.38%).
A study conducted in the state of Rio Grande do Norte, Brazil, resulted in 47.5% of PLWHA showing no pain/ mild pain; 24.1%, moderate pain and 28.4%, severe pain (18) . Pain, in general, is recognized as having a negative impact on the ability to perform daily functions of PLWHA (6) .
On the interference of pain in the daily life of PLWHA, in the present study, it was observed that the activities that suffered the most intense interference were mood, followed by daily activity and, finally, general activity.
The literature shows high interference of pain in daily life, especially in sleep aspects, life enjoyment, and work of PLWHA (15,(21)(22) .
Regarding the areas of the body with greater predominance of pain, the head was the most recurrent area in the present study. Studies have shown similar data, resulting in the identification of the head as one of the most prevalent areas of the body affected by pain (4)(5)(6)(7)11,16) .
As for DS and its relationship with pain, significant values were obtained as a result. In this way, people with pain presented DS in greater proportion. A study found that almost half of PLWHA (42.8%) who had pain also had moderate or severe depression. The direction of the relationship between pain and depression can be reciprocal as it is likely that those who experience pain become depressed and those who are depressed may be more likely to report pain. In addition, changes in the central nervous system of PLWHA associated with depression may influence the evolution of the disease, since they contribute to the increase of biological vulnerability (22)(23)(24)(25) . was not investigated. The domains that did not present statistically significant values (concern with medication and trust in professionals), the level of HRQoL was lower than in other comparative studies where only HRQoL of PLWHA were analyzed (9,26) . Thus, the analysis of the nine domains made clearly visible that pain has a negative impact on the HRQoL of PLWHA.
The multiple logistic regressions performed in the present study indicated that the increase of one point in the HAT-QoL decreased the chance of PLWHA to report pain, i.e. the higher the pain the lower the HRQoL. Two studies reported that moderate to severe pain had a significant impact on functional capacity and HRQoL (4,21) .
Thus, pain has a clear debilitating effect on the HRQoL of PLWHA (7) .
It was also possible to see, in this study, that the highest level of pain was prevalent in women, who had a 79% (OR = 1.05 -3.05) higher chance of reporting pain and 2.07-fold greater chance of reporting moderate or severe pain. When the HRQoL variable was not considered, due to its high statistical significance in relation to pain, women had 89% (OR = 1.12 -3.20) chance of reporting pain in relation to men.
The present study also had as result that higher level of schooling was associated with lower pain. It was found that people with a higher level of education had a 35% lower chance of reporting pain. The relationship of pain with individuals with no schooling/low schooling has already been evidenced in the literature, both with regard to the presence and intensity of pain; lower levels of schooling were associated with more intense pain (15,18) .
It was observed that PLWHA in the age group of 49 to 59 years presented approximately 4-fold greater chance of complaining of pain ranging from moderate to severe than people in the age group of 18 to 29 years.
This result was also present in other studies (7,18,29) . One of these studies carried out with PLWHA in outpatient care showed that patients over 36 years of age presented more pain than these with lower ages, with mild pain as the more common, followed by severe and finally moderate pain. In a logistic regression, it was found that people older than 36 years were 1.02-fold (p < 0.310) more likely to develop moderate pain than mild pain/no pain, and 0.99-fold (p < 0.689) more likely to develop severe pain than mild/no pain (7) .
As for income, as this factor increased, there was a decrease in the claim of moderate and severe pain.
A study listed several risk factors impacting pain, and low income was one of them. Thus, studies show higher pain levels in countries where the population has low and average economic income (15,30) .
As a limitation of the study, the analysis related to the presence of pain was restricted to the last 24 hours because of the instrument used for pain evaluation.
However, this restriction prevents us from knowing the actual presence of pain. This may have eliminated the possibility of identifying a greater number of people with pain, that is, people who did not present pain in the last 24 hours but presented it frequently in the last week or month, so that they did not have their characteristics evaluated.

Conclusion
It is noteworthy that the present study presents data about a poorly investigated variable in the country, Further studies can be developed, for example, with longitudinal monitoring of this sample to understand how these variables behave over time. In addition, studies could also focus on knowing the causes of pain and testing interventions that may minimize it.