Chronic pain is becoming increasingly recognized as a common and debilitating health comorbidity among people living with HIV (PLWH). A recent review of the literature indicated that chronic pain may affect over half of all PLWH throughout their lifetimes, with increasing prevalence as these individuals age.35 People living with HIV also endure high-impact chronic pain that interferes with general physical and mental health, as well as HIV-specific clinical outcomes. For example, chronic pain in PLWH is associated with greater odds of functional impairment,29 increased health care service utilization,23 suboptimal retention in HIV care,31 and failure to achieve virologic suppression.27 Despite increasing research efforts focused on the prevalence and consequences of chronic pain in PLWH, still very little is known about the role of psychosocial processes in the development and maintenance of chronic pain in this population.32
One psychosocial factor that may contribute to chronic pain outcomes in PLWH is perception of pain-related injustice, which has been conceptualized as a set of cognitive appraisals reflecting the severity and irreparability of pain-related loss, externalized blame, and unfairness.38,43 Emerging research findings suggest that perceived injustice consequent to chronic pain development might contribute to more severe pain interference beyond what can be attributed to pain severity.44 Pain interference refers to the self-reported consequences of pain on relevant aspects of one's life including engagement in emotional, physical, cognitive, social, and recreational activities.1 A high degree of perceived injustice is also consistently associated with greater pain report,48 depressive and post-traumatic symptoms,39,45 as well as poorer treatment outcomes, such as following multidisciplinary pain rehabilitation.40,45 No study to date has examined perceived injustice among PLWH in relation to pain interference or other pain-relevant clinical outcomes.
When examining the negative impact of perceived injustice on chronic pain outcomes in PLWH, it is likely important to consider resiliency factors that may lessen the deleterious effects of perceived injustice. Social support is a resiliency factor that has been shown to be associated with better adjustment to chronic pain by promoting adaptive coping skills.16,41 Moreover, the stress-buffering hypothesis of social support posits that access to social support can eliminate or weaken the negative effects of a perceived stressor on health and quality of life.6,13 Social support refers to the perception and actuality that one is cared for, has assistance available from other people, and is part of a supportive social network. Five general categories of social support have been conceptualized, including emotional (eg, nurturance), tangible (eg, financial assistance), informational (eg, advice), social network support (eg, sense of belonging), and esteem (eg, validation).8 Taken together, it may be that social support provided by the friends, family, and significant others of PLWH with chronic pain confers benefit by mitigating the negative influence of perceived injustice on pain interference. Alternatively, PLWH with chronic pain who have very little social support may experience a significantly greater impact of their perceived injustice pain interference.
This cross-sectional study sought to examine associations among perceived injustice, social support, and pain interference in a sample of PLWH with chronic pain. Figure 1 displays the putative conceptual model for these associations. Two primary hypotheses were tested. (1) Greater perceived injustice is associated with greater pain interference across the entire study sample. (2) Social support will moderate (ie, buffer) the association between perceived injustice and pain interference, such that greater perceived injustice will be associated with greater pain interference, but only for those with low social support.
2.1. Participants and procedures
The current study is part of a larger completed project that sought to examine risk and resiliency factors related to the experience of chronic pain in PLWH (Comprehensive HIV and Pain Study). Figure 2 presents a flow diagram depicting participant matriculation through the study. A total of 65 PLWH with chronic pain were recruited from a large, urban HIV clinic in the Southeast United States that provides comprehensive medical, behavioral, and social services to approximately 3,500 adults (≥18 years) with HIV. The final sample size was 60 PLWH with chronic pain. Chronic pain status was assessed by asking participants 2 questions: (1) “How long have you had chronic pain?” and (2) “How long has chronic pain been an ongoing problem for you over the past 6 months?” Chronic pain was defined as bodily pain that had persisted for at least 3 consecutive months and that was present on at least half the days in the past 6 months.47 Those interested in study participation completed a telephone screening to determine initial eligibility. Potential participants were excluded if their self-reported health history was positive for other conditions that could potentially confound pain interference or otherwise impede their ability to reliably complete the study measures. These conditions included evidence of uncontrolled hypertension (ie, resting blood pressure >150/95), history of cardiac events/disease, history of stroke or seizure, and history of cancer. Sociodemographic information was collected from all participants and included age, sex (man, women, and transgender), and racial background (non-Hispanic black and non-Hispanic white), as well as poverty status. Annual household income adjusted for number of occupants was used to determine poverty status according to 2017 guidelines put forth by the US Department of Health and Human Services.10 All study procedures were approved by the local Institutional Review Board and performed in accordance with guidelines for the ethical conduct of research.
2.2. Medical record review
Medical record review was completed to ascertain the rates of psychiatric diagnoses among participants, as well as to determine whether participants were actively being prescribed medications that could affect their pain, such as analgesics or antidepressants. Medical records were also used to obtain most recent CD4+ T-cell count, a measure of immune status, and most recent viral load value. Those PLWH with ≥200 copies of virus/mL were considered to have a detectable viral load; all others were considered virologically suppressed (ie, without detectable viral loads). Finally, medical record review was used to confirm participants' self-reported health history provided during telephone screening. Those PLWH whose medical records corroborated their self-reported health history, and who met study inclusion criteria, were deemed eligible for ongoing participation. Eligible participants were subsequently scheduled for a single study session at the Biobehavioral Pain Research Laboratory (PI: B.R.G.) to complete the measures listed below. Written informed consent was obtained from each participant at the beginning of the study session, and they were compensated for their involvement.
2.3.1. Pain interference
The Brief Pain Inventory-Short Form (BPI-SF) is a self-administered questionnaire used to measure pain interference and pain severity over the past 24 hours.5,24 The pain interference dimension of the BPI-SF comprises 7 items measuring the degree to which pain interferes with functioning in the following domains: general activity, mood, walking ability, normal work, relations with other persons, sleep, and enjoyment of life. Level of interference is measured using a rating scale from 0 (no interference) to 10 (complete interference), and the mean score denotes the total level of pain interference. The BPI-SF has been widely used and validated as a measure of pain interference in daily functioning.46 In this study, the BPI-SF was used specifically to address pain interference, but not pain severity. This was performed to minimize common-method variance between these 2 dimensions when including both pain interference and pain severity in the same data analytic model. The pain interference dimension of the BPI-SF used in this study demonstrated excellent internal consistency (Cronbach's α = 0.92).
2.3.2. Pain severity
At the beginning of the study, all participants self-reported on the severity of their chronic pain by responding to the following single item, “Please rate the severity of any bodily pain you have experienced during the past week.” Response options included 0 (None), 1 (very mild), 2 (mild), 3 (moderate), 4 (severe), 5 (very severe). Responses to this item were included in data analytic models as an index of chronic pain severity.
2.3.3. Perceived injustice
The Injustice Experience Questionnaire (IEQ) was used to assess perception of pain-related injustice in this sample of PLWH.43 Participants rated the frequency with which they experienced each of 12 thoughts/feelings when reflecting on their chronic pain condition. Items are rated on a scale of 0 (never) to 4 (all of the time). Injustice Experience Questionnaire items broadly reflect the associated factors of “severity/irreparability of loss” and “blame/unfairness.” Representative severity/irreparability items include “Most people don't understand how severe my condition is, and “My life will never be the same.” Blame/unfairness items include “I am suffering because of someone else's negligence, and “It all seems so unfair.” The IEQ has demonstrated strong psychometric properties, including sensitivity to change, among individuals with persistent musculoskeletal pain.43,48 Cronbach's alpha for IEQ in the current study was 0.88, indicating good internal consistency.
2.3.4. Social support
Perceived social support among PLWH was addressed using the Multidimensional Scale of Perceived Social Support (MSPSS).50 This scale consisted of 12 items that measure the extent of social support received from 3 specific sources: friends, family, and significant others. Types of social support assessed by the MSPSS included emotional (eg, “I get the emotional help and support I need from my family”), tangible (eg, “There is a special person who is around when I am in need”), informational (eg, “My family is willing to help me make decisions”), social network support (eg, “I can count on my friends when things go wrong”), and esteem (eg, “I have a special person who is a real source of comfort to me”). Each item was scored on a scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). Summation of the 12 item scores provided a possible total score ranging from 12 to 84 for overall social support, with higher scores corresponding to higher levels of social support. The MSPSS measure used in this study demonstrated excellent internal consistent according to Cronbach's alpha = 0.95.
Depressive symptoms were assessed using the Center for Epidemiological Studies-Depression Scale (CES-D).36 This 20-item measure assesses the frequency of experiencing depressive symptoms over the past week 0 (never or rarely) to 3 (most of the time/all the time). Symptoms of depression measured by the CES-D include negative mood, guilt/worthlessness, helplessness/hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance. This measure has been shown to be reliable and valid in general populations, including when used in HIV and chronic pain populations.18,34 Responses are summed (range 0–60), with higher scores indicating greater severity of depression. The CES-D measure used in the current study had good internal consistency (Cronbach's α = 0.88).
2.4. Data reduction and analysis
All data were analyzed using SPSS, version 24 (IBM, Chicago, IL). Alpha level for determining significance was set at P < 0.05. All participants provided complete demographic data (eg, sex, age, ethnicity/race, and household income); however, a small portion of missing data existed for the self-report questionnaires (<5% for any one questionnaire). Data were deemed to be missing at random; and therefore, a simple data imputation method was completed using the macro for hot deck imputation.33 This data imputation method is well validated and accepted in the statistical community2 and resulted in complete study data for each of the 60 participants. To test the first hypothesis, Pearson's correlations were used to evaluate the zero-order association between perceived injustice and pain interference, as well as associations among all other continuously measured variables. Group differences across categorical variables (eg, sex and ethnicity/race) were examined using 1-way analysis of variance. To test the second hypothesis, the PROCESS macrocreated and described by Hayes20 was used to examine whether the relationship between perceived injustice and pain interference was significantly moderated by social support. The Johnson-Neyman technique was then applied to probe the interaction between perceived injustice and social support using bootstrapped confidence intervals with 5,000 resamples.20 This technique tests the significance of the conditional association between perceived injustice and pain interference within the observed range of values of the moderator (social support) until the value of the moderator is identified, for which the conditional association is just statistically significant at a set level (α = 0.05). Values of the moderator for which the conditional association is significant constitute the region of significance.
3.1. Participant characteristics
Descriptive characteristics for the 60 study participants are presented in Table 1. The mean age was 47.6 years (SD = 8.6). The sample of PLWH comprised 54% men, 39% women, and 7% transgender women, whereas 92% were non-Hispanic black and the remaining 8% were non-Hispanic white. The mean CD4+ count was 664 (SD = 335), 8% had a detectable viral load (>200 copies/mL), and 98% were prescribed antiretroviral therapy. The most frequently reported location of chronic pain was low back (44%), hips/knees (30%), neck (9%), widespread (3+ sites) (9%), shoulder/arm/hand (4%), and feet (4%). Approximately 3/4 of the sample (73.3%) reported their pain severity over the past week as either severe or very severe. Sixty-one percent of the sample was prescribed analgesic medication for pain, and the most common prescription was nonsteroidal anti-inflammatory drugs (33%). Seventy-five percent of the sample had a psychiatric diagnosis listed in their medical record, with the most common diagnosis being depression (36%). Approximately 46% of PLWH were actively prescribed an antidepressant medication, with the most common prescriptions being selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors (38%).
3.2. Group differences and zero-order correlations
Women reported significantly greater pain interference compared with men (P = 0.046), but not compared with transgender women (P = 0.103). The pain interference reported by non-Hispanic black and white PLWH did not significantly differ (P = 0.426). Pain interference did not significantly differ according to whether participants were actively being prescribed an analgesic (P = 0.968) or antidepressant (P = 0.477). Similarly, the pain interference reported by PLWH with a psychiatric diagnosis listed in their medical chart was not significantly different from those without a psychiatric diagnosis (P = 0.389). Finally, pain interference was comparable between PLWH with a detectable viral load and those who were suppressed (P = 0.998).
Zero-order Pearson correlations among continuously measured variables are presented in Table 2. Greater perceived injustice was significantly correlated with more pain interference (P = 0.039) and less perceived social support (P = 0.023). Depressive symptoms were significantly correlated with greater perceived injustice (P < 0.001), less social support (P = 0.009), greater pain severity (P = 0.032), and greater pain interference (P = 0.001). Greater pain severity was also significantly correlated with greater pain interference (P = 0.011). Of note, a partial correlation analysis controlling for pain severity and depressive symptoms revealed that perceived injustice was no longer significantly associated with pain interference (rpartial = 0.087, P = 0.515).
The following covariates were included in the moderation analysis: age, dummy-coded gender, pain severity, and depressive symptoms. The moderation analysis was completed to determine whether the strength of the association between perceived injustice and pain interference differed according to level of social support reported by the participants. The overall moderation model adjusted for covariates (Table 3) accounted for a significant 37% of the variance in pain interference (R2 = 0.371, P = 0.002). There was a significant interaction between perceived injustice and social support in relation to pain interference (R2Δ = 0.063, P = 0.028), suggesting that social support indeed moderated (ie, buffered) the association between perceived injustice and pain interference (P = 0.028). Specifically, as demonstrated in Figure 3, it was found that perceived injustice was significantly associated with greater pain interference among PLWH who reported low levels of social support (P = 0.047), but not those who reported average (P = 0.422) or high levels of social support (P = 0.381). Finally, the results of the Johnson-Neyman technique (Table 4) show that, as the amount of social support increases, the association between perceived injustice and pain interference weakened and became nonsignificant.
In support of our first hypothesis, perception of pain-related injustice was found to be significantly correlated (zero-order) with pain interference across the entire sample of PLWH with chronic pain. However, in the partial correlation controlling for pain severity and depressive symptoms, perception of pain-related injustice was no longer associated with pain interference. This suggests that pain severity and depressive symptoms may be important factors to consider when examining the impact of perceived pain-related injustice on pain interference in future research. Findings further revealed that the amount of social support perceived from friends, family members, and significant others significantly buffered the observed association between perceived injustice and pain interference, which supports our second hypothesis. In particular, perceived injustice was significantly associated with greater pain interference among individuals with low levels of social support, but not those with average or high levels of social support. Our findings remained significant even after statistically controlling for age, sex differences, depressive symptoms, and pain severity. Taken together, these findings lend support to our study hypotheses and suggest that a high-quality social support network may provide an adaptive means of mitigating the negative effects of perceived injustice on chronic pain outcomes. Our interpretation of these findings is consistent with extant literature describing the stress-buffering hypothesis of social support.
4.1. Perceived injustice in people living with HIV with chronic pain
This is the first study of its kind to demonstrate a significant association between perception of pain-related injustice and the extent to which pain interferes with daily functioning in PLWH with chronic pain. In this study, the mean level of perceived injustice reported on the IEQ measure (25.7, SD = 11.9) was higher than what has been reported in previous studies that consisted of non-HIV adult samples with chronic low-back pain (21.9, SD = 13.1),49 whiplash injury (16.2, SD = 8.3),4 fibromyalgia (21.6, SD = 9.7), and rheumatoid arthritis (14.4, SD = 9.8).17 One possible reason for elevated perception of pain-related injustice in our sample may be related to social stigma experienced by PLWH with HIV. The existing literature is replete with studies demonstrating the negative physical and mental health effects of HIV stigma.14,15 However, PLWH are also susceptible to experiencing intersectional stigmas, which can arise at the juncture of multiple stigmatized identities and/or health conditions.9,37 To illustrate, recent research completed by our study team has found that PLWH with chronic pain experience a high degree of stigma related to their chronic pain, as well as their HIV status.19
Although some PLWH with chronic pain have clear pathophysiological causes of pain (eg, avascular necrosis), for many, there is no clear association between pain and identifiable pathology. Medically unexplained pain is often termed “nonspecific” and prone to the stigmatizing reactions of others.12 This is because observers tend to react with uncertainty and confusion to individuals whose pain in not clearly medically understood.12 Previous research has shown that laypersons and providers alike are less inclined to help, feel less sympathy, dislike patients more, suspect deception, and attribute lower pain severity to individuals whose pain does not have an objective basis in tissue pathology.11 Because of these stigmatizing responses from others, PLWH with chronic pain may feel that their pain is being devalued and discredited. As a result, PLWH with chronic pain who experience a high degree of stigma may be particularly susceptible to engaging the cognitive appraisals (ie, severity and irreparability of pain-related loss, externalized blame, and unfairness) that conceptually characterize perception of pain-related injustice. Whether experiences of chronic pain stigma drive perceived injustice in PLWH remains hypothetical and is a question worthy of future research.
4.2. Beneficial effects of social support
Individuals with chronic pain who report high levels of social support experience less distress and less severe pain, with higher levels of support associated with better adjustment.26 People living with HIV with chronic pain may seek social support as one strategy for pain self-management.28 For example, in a recent study of men living with HIV, intensive experience sampling methods were used to understand the relationships between moment-to-moment experiences of social support and pain.7 Findings revealed that perceived social support and feelings of acceptance were associated with less pain within individuals over time.
The buffering hypothesis is one explanation addressing how social support protects (or “buffers”) people from the deleterious effects of stressful life events such as living with chronic pain.6 Specifically, social support promotes adaptive appraisal and coping, which in turn mitigates the impact of stressful life events on health.22 By promoting adaptive appraisals and coping, exposure to high levels of social support may offset the deleterious effects of perceived injustice on pain interference, as observed in the current study of PLWH with chronic pain.
4.3. Clinical implications
These findings have implications for the assessment and management of chronic pain among PLWH. Pain and its interference with the physical and mental functioning of PLWH should be widely assessed by health care providers. Results of this study suggest that it would likely be important for health care providers to prioritize identifying and providing support to those PLWH with chronic pain who report the lowest amounts of social support derived from friends, family, and significant others. By incorporating an empathic and collaborative approach to pain assessment and management, PLWH are likely to feel validated and cared for by their health care provider, which in turn should promote a strong therapeutic alliance between provider and patient.25,42 Health care providers may then provide HIV-related social support, in addition to helping PLWH feel supported when addressing their concerns about chronic pain.21 Feeling supported by their health care provider may serve as an effective substitute for the low levels of social support derived from friends, family, and significant others. As a result of feeling supported by their health care provider, PLWH may be more likely to take an active role in the day-to-day management of their pain.3
Until recently, there existed no evidence-based behavioral pain management interventions for populations affected by HIV. To address this need, a 12-session pain self-management intervention, “Skills TO Manage Pain,” was developed that combines individual coping skills development with group sessions to bolster peer support around the experience of living with chronic pain and HIV (clinicaltrials.gov NCT02824562).30 The feasibility of incorporating Skills TO Manage Pain has been demonstrated,28 and currently a large scale study is underway to test the efficacy and effectiveness of this behavioral pain intervention tailored to PLWH. Our findings highlight the importance of integrating social support into pain management to optimize intervention effects. Specific content addressing how to effectively seek out social support could be integrated into individual- and group-based pain management formats. If feasible, health care providers should consider including a family member, friend, or significant other in sessions to facilitate communication about pain and how to provide appropriate support.
4.4. Study limitations
This study has several limitations that should be considered when interpreting the results, and that future research may expand upon. First, we did not assess the types of social support perceived by PLWH with chronic pain in this study, but future research could determine whether the type of social support (eg, tangible, emotional, informational, and esteem) differentially modifies the effect of perceived injustice on pain-related functional and psychosocial outcomes. Second, the cross-sectional design of this study precludes our ability to form conclusions about whether perception of pain-related injustice indeed predicts the chronification of pain that interferes with daily living. Alternatively, it is possible that PLWH with greater pain interference in this study were more likely to perceive their chronic pain as unjust and unfair. Future longitudinal research could address whether perceived injustice at baseline predicts subsequent pain interference with physical, cognitive, and emotional functioning over time, as well as the ways whereby procurement of social support mitigates the effects of perceived injustice in PLWH with chronic pain. Finally, it is not clear from this study whether the ability of social support to buffer the negative impact of perceived injustice on pain is specific to PLWH or might be found in other non-HIV populations with chronic pain. Future work should test whether our results can be replicated among larger, more diverse chronic pain populations with and without HIV to determine the generalizability of these findings. Despite these limitations, results of this study contribute to a stronger understanding of psychosocial risk (eg, perceived injustice) and resiliency (eg, social support) factors in relation to chronic pain outcomes among PLWH.
Perception of pain-related injustice reflects maladaptive beliefs regarding severity of loss consequent to chronic pain development, a sense of unfairness, and irreparability of loss. Findings support the contribution of perceived injustice to pain interference in daily living among PLWH with chronic pain above and beyond depressive symptoms and pain severity. Importantly, a high-quality social support network may provide an adaptive means of mitigating the negative effects of perceived injustice in this population. The current findings support the need for evidence-based behavioral pain management intervention that combines individual coping skills development with group sessions to bolster peer support around the experience of living with chronic pain and HIV.
The authors have no conflict of interest to declare.
This research was supported by the Creative and Novel Ideas in HIV Research Program (B.R.G.) through a supplement to the University of Alabama at Birmingham Center for AIDS Research funding (P30AI027767). This funding was made possible by collaborative efforts of the Office of AIDS Research, the National Institute of Allergy and Infectious Diseases, and the International AIDS Society. This research was also supported by the National Institutes of Health K23MH104073 and R01MH115754 (J.S.M.).
. Amtmann D, Cook KF, Jensen MP, Chen WH, Choi S, Revicki D, Cella D, Rothrock N, Keefe F, Callahan L, Lai JS. Development of a PROMIS item bank to measure pain interference
. PAIN 2010;150:173–82.
. Andridge RR, Little RJ. A review of hot deck imputation for survey non-response. Int Stat Rev 2010;78:40–64.
. Bair MJ, Matthias MS, Nyland KA, Huffman MA, Stubbs DL, Kroenke K, Damush TM. Barriers and facilitators to chronic pain
self-management: a qualitative study of primary care patients with comorbid musculoskeletal pain and depression. Pain Med 2009;10:1280–90.
. Carriere JS, Thibault P, Adams H, Milioto M, Ditto B, Sullivan MJL. Expectancies mediate the relationship between perceived injustice
and return to work following whiplash injury: a 1-year prospective study. Eur J Pain 2017;21:1234–42.
. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994;23:129–38.
. Cohen S, Wills TA. Stress, social support
, and the buffering hypothesis. Psychol Bull 1985;98:310–57.
. Crockett KB, Turan B. Moment-to-moment changes in perceived social support
and pain for men living with HIV
: an experience sampling study. PAIN 2018;159:2503–11.
. Curtona CE, Suhr JA. Controllability of stressful events and satisfaction with spouse support behaviors. Commun Res 1992;19:154–74.
. Darlington CK, Hutson SP. Understanding HIV
-related stigma among women in the Southern United States: a literature review. AIDS Behav 2017;21:12–26.
. Department of Health and Human Services. Annual update of the HHS poverty guidelines, 2017. Available at: https://aspe.hhs.gov/2017-poverty-guidelines
. Accessed June 21, 2018.
. De Ruddere L, Craig KD. Understanding stigma and chronic pain
: a-state-of-the-art review. PAIN 2016;157:1607–10.
. De Ruddere L, Goubert L, Vervoort T, Prkachin KM, Crombez G. We discount the pain of others when pain has no medical explanation. J Pain 2012;13:1198–205.
. Ditzen B, Heinrichs M. Psychobiology of social support
: the social dimension of stress buffering. Restor Neurol Neurosci 2014;32:149–62.
. Earnshaw VA, Lang SM, Lippitt M, Jin H, Chaudoir SR. HIV
stigma and physical health symptoms: do social support
, adaptive coping, and/or identity centrality act as resilience resources? AIDS Behav 2015;19:41–9.
. Earnshaw VA, Smith LR, Chaudoir SR, Amico KR, Copenhaver MM. HIV
stigma mechanisms and well-being among PLWH: a test of the HIV
stigma framework. AIDS Behav 2013;17:1785–95.
. Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The role of psychosocial processes in the development and maintenance of chronic pain
. J Pain 2016;17(9 suppl):T70–92.
. Ferrari R, Russell AS. Perceived injustice
in fibromyalgia and rheumatoid arthritis. Clin Rheumatol 2014;33:1501–7.
. Geisser ME, Roth RS, Robinson ME. Assessing depression among persons with chronic pain
using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis. Clin J Pain 1997;13:163–70.
. Goodin BR, Owens MA, White DM, Strath LJ, Gonzalez C, Rainey RL, Okunbor JI, Heath SL, Turan JM, Merlin JS. Intersectional health-related stigma in persons living with HIV
and chronic pain
: implications for depressive symptoms. AIDS Care 2018;30(suppl 2):66–73.
. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. New York: Guilford Press, 2013.
. Isenberg SR, Maragh-Bass AC, Ridgeway K, Beach MC, Knowlton AR. A qualitative exploration of chronic pain
and opioid treatment among HIV
patients with drug use disorders. J Opioid Manag 2017;13:5–16.
. Jensen MP, Moore MR, Bockow TB, Ehde DM, Engel JM. Psychosocial factors and adjustment to chronic pain
in persons with physical disabilities: a systematic review. Arch Phys Med Rehabil 2011;92:146–60.
. Jiao JM, So E, Jebakumar J, George MC, Simpson DM, Robinson-Papp J. Chronic pain
disorders in HIV
primary care: clinical characteristics and association with healthcare utilization. PAIN 2016;157:931–7.
. Keller S, Bann CM, Dodd SL, Schein J, Mendoza TR, Cleeland CS. Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain. Clin J Pain 2004;20:309–18.
. Lin C, Li L, Wan D, Wu Z, Yan Z. Empathy and avoidance in treating patients living with HIV
/AIDS (PLWHA) among service providers in China. AIDS Care 2012;24:1341–8.
. Lopez-Martinez AE, Esteve-Zarazaga R, Ramirez-Maestre C. Perceived social support
and coping responses are independent variables explaining pain adjustment among chronic pain
patients. J Pain 2008;9:373–9.
. Merlin JS, Long D, Becker WC, Cachay ER, Christopoulos KA, Claborn K, Crane HM, Edelman EJ, Harding R, Kertesz SG, Liebschutz JM, Mathews WC, Mugavero MJ, Napravnik S, C O'Cleirigh C, Saag MS, Starrels JL, Gross R. Brief report: the association of chronic pain
and long-term opioid therapy with HIV
treatment outcomes. J Acquir Immune Defic Syndr 2018;79:77–82.
. Merlin JS, Walcott M, Kerns R, Bair MJ, Burgio KL, Turan JM. Pain self-management in HIV
-infected individuals with chronic pain
: a qualitative study. Pain Med 2015;16:706–14.
. Merlin JS, Westfall AO, Chamot E, Overton ET, Willig JH, Ritchie C, Saag MS, Mugavero MJ. Pain is independently associated with impaired physical function in HIV
-infected patients. Pain Med 2013;14:1985–93.
. Merlin JS, Westfall AO, Long D, Davies S, Saag M, Demonte W, Young S, Kerns RD, Bair MJ, Kertesz S, Turan JM, Kilgore M, Clay OJ, Starrels J, Pekmezi D, Johnson MO. A randomized pilot trial of a novel behavioral intervention for chronic pain
tailored to individuals with HIV
. AIDS Behav 2018;22:2733–42.
. Merlin JS, Westfall AO, Raper JL, Zinski A, Norton WE, Willig JH, Gross R, Ritchie CS, Saag MS, Mugavero MJ. Pain, mood, and substance abuse in HIV
: implications for clinic visit utilization, antiretroviral therapy adherence, and virologic failure. J Acquir Immune Defic Syndr 2012;61:164–70.
. Merlin JS, Zinski A, Norton WE, Ritchie CS, Saag MS, Mugavero MJ, Treisman G, Hooten WM. A conceptual framework for understanding chronic pain
in patients with HIV
. Pain Pract 2014;14:207–16.
. Myers TA. Goodbye, listwise deletion: presenting hot deck imputation as an easy and effective tool for handling missing data. Commun Methods Meas 2011;5:297–310.
. Natamba BK, Achan J, Arbach A, Oyok TO, Ghosh S, Mehta S, Stoltzfus RJ, Griffiths JK, Young SL. Reliability and validity of the center for epidemiologic studies-depression scale in screening for depression among HIV
-infected and -uninfected pregnant women attending antenatal services in northern Uganda: a cross-sectional study. BMC Psychiatry 2014;14:303.
. Parker R, Stein DJ, Jelsma J. Pain in people living with HIV
/AIDS: a systematic review. J Int AIDS Soc 2014;17:18719.
. Radloff LS. A self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401.
. Rice WS, Logie CH, Napoles TM, Walcott M, Batchelder AW, Kempf MC, Wingood GM, Konkle-Parker DJ, Turan B, Wilson TE, Johnson MO, Weiser SD, Turan JM. Perceptions of intersectional stigma among diverse women living with HIV
in the United States. Soc Sci Med 2018;208:9–17.
. Rodero B, Luciano JV, Montero-Marin J, Casanueva B, Palacin JC, Gili M, Lopez del Hoyo Y, Serrano-Blanco A, Garcia-Campayo J. Perceived injustice
in fibromyalgia: psychometric characteristics of the Injustice Experience Questionnaire and relationship with pain catastrophising and pain acceptance. J Psychosom Res 2012;73:86–91.
. Scott W, Sullivan M. Perceived injustice
moderates the relationship between pain and depressive symptoms among individuals with persistent musculoskeletal pain. Pain Res Manag 2012;17:335–40.
. Scott W, Trost Z, Milioto M, Sullivan MJ. Barriers to change in depressive symptoms after multidisciplinary rehabilitation for whiplash: the role of perceived injustice
. Clin J Pain 2015;31:145–51.
. Sturgeon JA, Zautra AJ. Social pain and physical pain: shared paths to resilience. Pain Manag 2016;6:63–74.
. Stutterheim SE, Sicking L, Brands R, Baas I, Roberts H, van Brakel WH, Lechner L, Kok G, Bos AE. Patient and provider perspectives on HIV
-related stigma in Dutch health care settings. AIDS Patient Care STDS 2014;28:652–65.
. Sullivan MJ, Adams H, Horan S, Maher D, Boland D, Gross R. The role of perceived injustice
in the experience of chronic pain
and disability: scale development and validation. J Occup Rehabil 2008;18:249–61.
. Sullivan MJ, Scott W, Trost Z. Perceived injustice
: a risk factor for problematic pain outcomes. Clin J Pain 2012;28:484–8.
. Sullivan MJ, Thibault P, Simmonds MJ, Milioto M, Cantin AP, Velly AM. Pain, perceived injustice
and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries. PAIN 2009;145:325–31.
. Tan G, Jensen MP, Thornby JI, Shanti BF. Validation of the Brief Pain Inventory for chronic nonmalignant pain. J Pain 2004;5:133–7.
. Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA, Kaasa S, Kosek E, Lavand'homme P, Nicholas M, Perrot S, Scholz J, Schug S, Smith BH, Svensson P, Vlaeyen JW, Wang SJ. A classification of chronic pain
for ICD-11. PAIN 2015;156:1003–7.
. Trost Z, Agtarap S, Scott W, Driver S, Guck A, Roden-Foreman K, Reynolds M, Foreman ML, Warren AM. Perceived injustice
after traumatic injury: associations with pain, psychological distress, and quality of life outcomes 12 months after injury. Rehabil Psychol 2015;60:213–21.
. Trost Z, Van Ryckeghem D, Scott W, Guck A, Vervoort T. The effect of perceived injustice
on appraisals of physical activity: an examination of the mediating role of attention bias to pain in a chronic low back pain sample. J Pain 2016;17:1207–16.
. Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff KA. Psychometric characteristics of the multidimensional scale of perceived social support
. J Pers Assess 1990;55:610–17.