Arthritis and HIV: Is There a Connection?

Rheumatic Disease Associated With HIV: Treatment and Prognosis

arthritis patient undergoing physical therapy
What is the connection between HIV and rheumatic diseases?. Credit: John Lund/Drew Kelly / Getty Images

Is there a connection between HIV and arthritis? How common are rheumatic diseases in people with HIV and what special problems might they face with regard to the treatment? When should people with joint, muscle, or arthritis pain be tested for HIV/AIDS?

HIV and Arthritis Symptoms

HIV (human immunodeficiency virus), the virus which causes AIDS (acquired immune deficiency syndrome) can also cause many of the common symptoms of arthritis and rheumatic diseases, and this association was noted only three years after the discovery of the virus.

This virus can cause:

  • Arthritis pain
  • Joint pain
  • Muscle pain
  • Muscle weakness

Yet, in addition to causing joint and muscle pain, HIV/AIDS is associated with several discrete rheumatic conditions.

HIV-Associated Rheumatic Diseases

Rheumatic diseases are very common among people who are infected with HIV, with estimates showing that up to 70 percent of people infected with the virus may develop one of these conditions either before or after their diagnosis. Rheumatic diseases associated with HIV include:

  • Reactive arthritis: Reactive arthritis is a type of arthritis that occurs as a reaction to an infection elsewhere in the body, and may occur with many types of infections including HIV.
  • Psoriatic arthritis: Psoriatic arthritis is one of a group of diseases known as spondyloarthropathies.
  • Rheumatoid arthritis: Rheumatoid arthritis is very common among people with HIV.
  • Painful reticular syndrome: Painful reticular syndrome is a self-limited but extremely painful condition involving asymmetric bone and joint pain in the lower extremities.
  • Osteomyelitis: Osteomyelitis is a bone infection usually caused by bacteria, and often requires lengthy intravenous therapy to clear the infection.
  • Polymyositis: With a confusing constellation of symptoms, polymyositis is a connective tissue disease characterized by inflammation and degeneration of the muscles.
  • Vasculitis: Vasculitis is a condition which involves inflammation of the blood vessels.
  • Infected joints: Joint infections may originate from an infection elsewhere in your body that is carried to the affected joint.
  • Fibromyalgia: Fibromyalgia is a condition characterized by body aches, pain, sleep problems, extreme fatigue, depression, anxiety, tender points. It is sometimes referred to as a "functional" medical condition as there are not clear tests for making the diagnosis.

Diagnosing HIV-Associated Rheumatic Diseases

Rheumatic diseases may occur before or after a diagnosis of HIV.

In someone who has not been diagnosed with HIV, the new onset of a rheumatoid condition may suggest the presence of an infection. In fact, it's thought by some that systematically screening people with rheumatic diseases for HIV may be lifesaving in detecting early HIV infections, even without risk factors for HIV/AIDS. According to the American College of Rheumatology, "HIV-associated rheumatic diseases may precede the diagnosis of HIV." If a person is at high risk for the HIV virus and presents with symptoms of painful joints, painful muscles, or other rheumatic symptoms, testing for the HIV virus could confirm or rule out the diagnosis of HIV.

Likewise, in someone who has been diagnosed with HIV and has joint related symptoms, a work up for rheumatoid conditions should be considered.

HIV-associated rheumatic diseases can affect any age group, race, or gender, but most commonly affects people between 20 and 40 years of age.

Why Are Rheumatic Diseases More Common in People With HIV/AIDS?

While it's clear that rheumatic diseases are more common in people with HIV/AIDS than the general population, the exact reason for this isn't clear. There are several possible theories. One is that the rheumatoid conditions are related to the infection with HIV itself.

Another thought is that rheumatic conditions may be triggered by the changes in the immune system associated with HIV. Yet another idea is that the rheumatic symptoms may be related instead to the opportunistic infections which are common in HIVAIDS. Since the difference between HIV and AIDS, as well as an understanding of opportunistic infections is confusing, let's take a look at these questions before reviewing possible treatment options.

What's the Difference Between HIV and AIDS?

Many people automatically equate HIV with AIDS. However, HIV and AIDS are separate clinical entities. Specifically, a person is initially affected with the HIV virus, but it may take a few years to develop AIDS. Furthermore because the treatments for HIV/AIDS has advanced significantly, many people with HIV who vigilantly take daily antiretroviral treatments have a good chance of never decompensating to a point where they develop AIDS; they may go on to live otherwise healthy lives.

HIV infection attacks CD4 cells (T cells) which help our bodies fight off infection. When CD4 cell counts fall to below 200 cells/cubic millimeter, a person develops AIDS. Alternatively, a person can develop AIDS if they develop an opportunistic infection.

What's an HIV/AIDS Opportunistic Infection?

HIV/AIDS is most commonly associated with opportunistic infections. An opportunistic infection is caused by bacteria, viruses, fungi or protozoa which take advantage of the host's weakened immune system. Rheumatic disease isn't an opportunistic infection, however, these infections may lead to the reactive arthritis noted above, and are one of the possible mechanisms behind the association of HIV and rheumatic conditions. Some of the opportunistic infections associated with HIV/AIDS include:

  • Candida
  • Cryptococcus
  • Cytomegalovirus
  • Histoplasmosis
  • MAC
  • PCP
  • Toxoplasmosis
  • Tuberculosis

Diseases Associated with HIV Medications

In addition to the rheumatic conditions described above, side effects of HIV medications can also lead to bone, joint, and soft tissue conditions such as:

  • Gout
  • Tenosynovitis
  • Myopathy (muscle inflammation)
  • Osteonecrosis
  • Osteoporosis

These conditions are, fortunately, less common now with newer HIV/AIDS treatments.

Treating HIV-Associated Rheumatic Diseases

The treatment of rheumatic diseases associated with HIV involves a two-fold approach: Treating the symptoms related to the arthritis, and treating the HIV infection which is associated with these diseases.

That said, the treatment of rheumatic diseases in people with HIV can be very challenging.

Immunosuppressive medications (drugs which suppress the immune response) such as Imuran and methotrexate are commonly used for rheumatic diseases, but these treatments may be contraindicated (should not be used) in people with an HIV infection )as HIV also result in immunosuppression). In theory, there is concern that this combination could compound the effects of immunosuppression, but there is not a lot of information about the safety of this practice.

HAART (Highly Active Anti-Retroviral Therapy), has been effective in treating rheumatic problems associated with HIV. In this approach, treatment of HIV alone may improve the symptoms of a rheumatoid condition.

For people with rheumatoid arthritis, DMARDS (disease modifying anti-rheumatic drugs) are often used, but for those with both HIV/AIDS and rheumatoid arthritis there is currently insufficient evidence to recommend these drugs.

People with HIV-associated rheumatic diseases may also benefit from treatment with pain medications and anti-inflammatory drugs to reduce the symptoms of their rheumatic condition.

Prognosis of HIV Combined With Rheumatoid Diseases

Unfortunately, those who develop a rheumatic condition in addition to HIV/AIDS often have a poorer overall prognosis than people with HIV/AIDS but without a rheumatic condition.

Key Points About HIV and Rheumatic Diseases

There are several key points to note when discussing the association of HIV and rheumatic diseases. These include:

  • Any rheumatic disease can occur without HIV infection.
  • From 30 percent to 70 percent of HIV infected persons may develop an associated rheumatic disease.
  • The presence of an associated rheumatic disease worsens the prognosis of an HIV infection.
  • People who have rheumatic diseases in addition to HIV have a poorer quality of life.

Bottom Line on HIV and Rheumatic Diseases

As noted, the new onset of a rheumatic disease should prompt testing for HIV in people who may be at risk of the infection. Conversely, people with HIV should be observed closely for the presence of rheumatoid conditions. To make this even more confusing, any rheumatic disease may occur without an HIV infection and it may not be known whether the disease would have occurred alone or if it is associated with the infection.

We do know that people with HIV who develop rheumatic diseases have a poorer quality of life and a poorer prognosis. Part of this may be due to the fear of using immunosuppressive drugs for rheumatic diseases in people who are already immunosuppressed due to the virus. The role of these drugs as well as the safety is largely unknown. Fortunately, rheumatic diseases often improve with treatment of HIV alone.

If you have HIV and a rheumatoid condition, it's important to work with infectious disease and rheumatology specialists who are comfortable treating the two conditions together, and who can work together to formulate a plan and monitor your progress.

Sources:

Adizie, T., Moots, R., Hodkinson, B., French, N., and A. Adebajo. Inflammatory Arthritis in HIV Positive Patients: A Practical Guide. BMC Infectious Diseases. 2016. 16:100.

American College of Rheumatology. HIV and Rheumatic Disease. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/HIV-Rheumatic-Diseases

Cunha, B., Mota, L., Pileggi, G., Safe, I., and M. Lacerda. HIV/AIDS and Rheumatoid Arthritis. Autoimmune Reviews. 2015. 14(5):396-400.

Shah, D., Flanigan, T., and E. Lally. Routine Screening for HIV in Rheumatology Practice. Journal of Clinical Rheumatology. 2011. 17(3):154-6.

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