NEUROPATHIC PAIN AMONG HIV PATIENTS RECEIVING

ART WITHOUT STAVUDINE IN AN INDONESIAN

REFERRAL HOSPITAL
Fitri Octaviana
Clinical Neurophysiology Division, Department of Neurology
Faculty of Medicine, Universitas Indonesia, Cipto Manungkusumo
Hospital
Background
 Background

• In the pre-Antiretroviral Treatment (ART) era, incidence rates of HIV-

associated sensory neuropathy (HIV-SN) as high as 89%
• HIV-SN in the era of Stavudine:
• Melbourne 42% ( 58% pts used stavudine)
• Kuala Lumpur 19% (47% pts used stavudine)
• Jakarta 34% (100% pts used stavudine)

Affandi JS, et al. AIDS Res and Human Retrovirus. 2008;24:1281-4

Cherry CL, et al. Neurology. 2009;73:31-20
 Introduction

• HIV-SN consequences:
• The pain due to HIV-SN will
influence the quality of live, affect
mood, influence productivity
• Painful HIV-SN correlates with
depression and work impairment,
influence general health and
physical health

Keltner, et al. Psychosomatics. 2012;53:380-6

Mann R, et al. J Intl Assoc Providers AIDS Care. 2016;15:114-25.
Clinical Signs of HIV-SN
• Clinical Signs:
• Neuropathic pain, numbness,
burning sensation
• autonomic neuropathy:
hypotension, urinary
dysfunction
• physical examination:
• Hyperalgesia
• allodynia
• absent physiological reflexes
• sensory loss in the distal limb
Mechanisms implicated in HIV-SN
Binding Gp120 virus
HIV infection
protein + CXCR4

Pro-inflammatory cytokines  Increase CCR5

Stimulate astrocytes release Activation of Chemokine

neurotoxic factors receptor in DRG neurons

CXCR4 and CCR5 expression  Pro-inflammatory mediators

Upregulation CCL5 released by Schwann cells at DRG

Macrophage dysregulation Activate apoptotic

pathway
NERVE &
DRG
NEURON
S INJURY
 Jakarta
HIV- NEUROPATHY
PROJECT

Diagnosis
BPNST

Systemic and local Genotyping

NCS Ahmad Yanuar Safri
inflammation
SSW Jessica Gaff
Fitri Octaviana
response
Kartika Maharani Fitri Octaviana
Jenjira Mountford
Research Methods
Design
• Cross Sectional Study
Inclusion Criteria
• HIV-AIDS patients that had
ART non stavudine> 12
months
• Age > 18 years old
• Willing to be included in this
study
Time and Place
• Recruitment: August
2015-February 2017
Exclusion Criteria
• Diabetes Mellitus, history of
Guillain Barre Syndrome,
Lepra
• Platelet counts < 20.000/dL
HIV-SN Neuropathic Pain

>1 of the lower limb

neuropathic symptoms Shooting, stabbing, sharp or
(pain, aching or burning, burning pain of the lower
pins and needles or limb
numbness)
AND Neuropathic Vs Nociceptive
Ankle reflexes (-) OR Pain
vibration test≤10 s

Assessed by Doloeur
Neuropathique 4-
Assessed by BPNST questionnaire
RESULT
 2596 pts screened

2399 excluded 197 Pts included

684 use stavudin

831 ART < 12 months
119 poor ART adherence Undetectable viral load: 84%
8 DM
3 schizophrenia
22 vasculitis
2 deafness
7 blindness
3 hypothiroid
4 SLE
1 CMV radiculopathy
6 malignancy
701 not consent
 What is the PREVALENCE and
associated factors of
HIV-SN when assessed clinically?
 BPNST (%)

14.2

• Abnormal NCS 6.1%

HIV-SN
• Abnormal SSW 27.4%
HIV-NoSN

85.8

• This prevalence is halved compare to 2006 (34%)1,2

1 Affandi JS, et al. AIDS Res Hum Retroviruses. 2008;24:1281-4

2 Cherry CL, et al. Neurology. 2009:73:315-20
Octaviana F, et al. J Acquir Immune Defic Syndr. 2018;59(4):e108-e110
Last Viral Load was strongly associated with HIV-SN
Logistic Regression, stepwise removal

Variables OR 95%CI p Overall Model

>500 copies 5.5 1.5-17.2 0.02 p=0.001
HIV RNA pseudo R2= 0.06
Age (years) 1.1 0.9-1.1 0.06

• When stavudine is no longer use, risk factor for HIV-SN is almost identical to the
era before ART such as high plasma viral load 1
• HIV-SN can occur before ART and confirmed by several studies.2,3
• Increasing age and height weren’t independent risk factors anymore since
stavudine is not used.
1 Childs EA, et al. Neurology. 1999;52:607-13
2 Dubey TN, et al. Neurol India. 2013;61:478-80
3 Centner CM, et al. Muscle Nerve. 2018;57:371-9
What is the PREVALENCE
and associated factor of
neuropathic pain?
 Neuropathic Pain (%)

6.6

93.4

Neuropathic Pain No pain

• India: Neuropathic pain 32% of all pain in HIV patients (25% on ART) 1; Africa:
Neuropathic pain 3.2% of all pain in HIV/AIDS patients 2. Both studies included
patients on stavudine
1 Nair SN, et al. Indian J Palliat Care. 2009;15:67-70
2 Azagew AE, et al. J Pain Res. 2017;2461-9
 **

ART duration in 1st group is significantly shorter (1.7 (1.4-2.7) years) than 2nd (5.1
(1-6.4) years and 3rd group (6 (1.2-10.9) years.
Horizontal line showed median and interquartile range. *p<0,05; **p>0,05
 Positive Symptom Negative Symptom
?? • Numbness
• Burning sensation
• Allodynia • Loss in vibration, thermal
stimuli
• Reduced Tendon Reflex

Axonal Numbness
degeneration
Neuropathic Pain Vibration 
Failure of re-
innervation Reflex 

1. Impairment of Endoneurial circulation and following it

ischaemia
2. Impairment of Axon-glia relationship
3. Axonal injury and following it Wallerian degeneration

Dobretsov M, et al. World J Gastroenterol.2007;13:175-91

HOW IS THE PATTERN OF EPIDERMAL NERVE IN
HIV-SN, HIV-NoSN, HEALTHY CONTROL?
 Skin biopsy
Site:
Leg, 10cm proximally laterally of
ankle

Anesthetize Biopsy the Excise the

using Lidocain skin biopsy
1% Using a sterile
3mm skin punch
Performed by Fitri Octaviana
 Protocol IHC staining
3 days procedure of staining

Blocked in 200µL of 300µL primary 200µL secondary

Melanin bleaching antibody mix
Image-iT FX Signal antibody mix
(5% oxalic acid)
Enhancer (30 mins) (overnight at 4oC) (overnight at 4oC)

Performed by Jenjira Mountford

Visualization

• 3 lasers: 405nm (blue), 561nm (red) and 640nm (yellow) were

used to view nuclei, nerve fibres and CD14 macrophages
respectively.
• 20x dry objectives (NA 0.75) provided optimal visualization of
nerves
 6 raters (manually
and blinded)

3 slides/rater

Number of counted
nerves of each
subjects were
averaged

Lauria G, et al. Peripheral neuropathy. 2005

Van Acker N, et al. BMC Res Notes. 2016
 Subjects Characteristics
n Male Age Height ART Current
duration CD4 count
SN 5 3 34 (33-47) 167 (158-175) 6.8 (3.5- 406 (284-
7.5) 729)
No-SN 9 6 36 (25-44) 165 (170-179) 2.2 (1-12) 448 (84-
693)
HC 3 1 33 (28-37) 160 (151-169) NA NA
p=1 p=0.84 p=0.5 p=0.14 p=1

DAPI (nuclei;405nm) PGP 9.5 (nerves; 561nm) Alexa Fluor (CD14; 640nm)
Courtesy of Jenjira Mountford)
 Healthy Control HIV-No SN
(Male, 33 yo, 12 years on ART, anti TBC +)

HIV- SN
(Male, 47 yo, 2.5 years on ART, anti TBC +)

DAPI nuclei (Blue), Dylight nerves (Red), Alexa Fluor CD14+ (Yellow).
 HIV-No SN HIV-SN

Basal membran
Basal membran

(Male, 33 yo, 12 years on ART, anti TBC +) (Male, 47 yo, 2.5 years on ART, anti TBC +)

DAPI nuclei (Blue), Dylight nerves (Red), Alexa Fluor CD14+ (Yellow).
Nerve fibers were turned into white color on the software to simplify nerve count.

Courtesy of Jenjira Mountford, with Permission

Nerve Counts

p= 0,14

n IENFD p= 0,47
20
HIV-SN 5 3 (0.8-9.7) p= 0,16

HIV-NoSN 9 5.8 (1.3-14) 15

IENFD /mm3
HC 3 11.2 (5.8-15.2) 10

/C

N
oS

-S
H

IV
-N

H
IV
H
Kruskal-Wallis test, p=0.17)
HOW IS THE PATTERN OF EPIDERMAL NERVE IN
HIV-SN, HIV-NoSN, HEALTHY CONTROL?

• IENFD on both HIV-SN and HIV-NoSN was reduced

compare to Healthy Control
• IENFD in HIV-SN was lower than HIV-NoSN
 Scattered Plots IENFD vs nadir CD4+ in HIV-SN and HIV-No SN

4/5 HIV-SN vs 1/9 HIV-No SN had

low IENFD and low nadir CD4+
counts.
p = 0.02 (Fisher’s Exact test)

IENFD is reduced in HIV patients neurotoxic ART; correlate with low CD4+.
(Polydefkis M, et al. Neurology. 2002;58:115-9

HIV-SN and reduced IENFD were associated with severity of HIV

This study also showed that HIV-SN associated with detectable plasma HIV-
RNA viral load.
HIV-SN might be already happened before ART initiation → longitudinal study
is necessary to confirm
 Can CD14 macrophages be
identified around the nerves in
skin biopsy of HIV-SN?
Healthy Control HIV-NoSN HIV-SN
Nerve CD14+ cells Nerve CD14+ cells Nerve CD14+ cells

Macrophage CD14 can be identified in HIV-NoSN and HIV-SN patients in skin

biopsy.

Courtesy of Jenjira Mountford, with

Permission
 Treatment of Neuropathic Pain
NICE CPS NeuPSIG
First-Line Amytriptiline Gabapentin Gabapentin
Therapy Duloxetine Pregabalin Pregabalin
Gabapentin Duloxetin Duloxetin
Pregabalin TCA TCA
Capsaicin
cream

Cruccu G, et al. Pain Ther. 2017;6 (Suppl 1):S35-S42

PLoS ONE.2010
 ACKNOWLEDGEMENT
JAKCCANDO TEAM:
Dr. Henny S, S.Si, M.Biomed
Ibnu Ariyanto, S.Si, M.Biomed
UPT-HIV RSCM:
Prof. Dr. dr. Sjamsuridjal D,
Sp.PD(KAI)
dr. Teguh H Karyadi, Sp.PD-KAI
Dr.dr.Evy Yunihastuti, Sp.PD-KAI
dr. Darma Imran, Sp.S(K)
Nurses and Councelor
Laboratory technician
Administrator
MONASH UNIVERSITY:
Catherine L Cherry, MD,
PhD
CURTIN UNIVERSITY TEAM
Prof. Patricia Price, PhD
Sylvia Lee
Jenjira Mountford
Jessica Gaff
IHVCB FMUI TEAM:
All staffs and
administrator
NEUROLOGY TEAM:
Prof. Dr. Teguh A.S
Ranakusuma, Sp.S(K)
dr. Manfaluthy Hakim, Sp.S(K)
dr. Ahmad Yanuar, Sp.S(K)
dr. Kartika Maharani, Sp.S
dr. Denise Dewanto
POKDISUS HIV-AIDS