Guide to Pain Management in Low-Resource Settings

What is the prognosis of central 
neuropathic pain?
Th
  e natural course of central pain is not known exactly. 
Resolution of pain has been reported in 20% of patients 
with central poststroke pain, occurring over a period of 
years. It is still not known whether treatment of the pain 
has any modifying eff ect on the duration of central neu-
ropathic pain.
Pearls of wisdom
•  Central neuropathic pain may be present from 
the start of the neurological symptoms or may 
appear after a delay of days, months, or even 
years.
• Th
  e most common qualities of central pain are 
burning, pricking, and pressing.
•  Remember that nearly all patients with central 
neuropathic pain have abnormalities of pain and 
temperature sensation.
• Amitriptyline, carbamazepine, and gabapentin 
can be used for symptomatic treatment.
References
[1]  Attal N, Cruccu G, Haanpää M, Hansson P, Jensen TS, Nurmikko 
T, Sampaio C, Sindrup S, Wiff en P. EFNS Task Force. EFNS guide-
lines on pharmacological treatment of neuropathic pain. Eur J Neurol 
2006;13:1153–69. (Current evidence and practical guidelines on phar-
macotherapy of neuropathic pain)
[2]  Moseley GL, Gallace A, Spence C. Is mirror therapy all it is cracked 
up to be? Current evidence and future directions. Pain 2008;138:7–10. 
(Current evidence and practical information of mirror therapy)
[3]  Ofek H, Defrin R. Th
  e characteristics of chronic central pain after trau-
matic brain injury. Pain 2007;131:330–40. (Describes central neuro-
pathic pain after brain injury)

195
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th
  is material may be used for educational 
and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property 
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  e mention of specifi c pharmaceutical products and any 
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Guide to Pain Management in Low-Resource Settings
Chapter 26
Th
  e Management of Pain in Adults and Children                      
Living with HIV/AIDS
Glenda E. Gray, Fatima Laher, and Erica Lazarus
What is the scope of the problem?
In 2007, UNAIDS estimated that 33.2 million people 
were infected with HIV. Most of the HIV-infected men, 
women, and children resided in sub-Saharan Africa. 
Globally, 2 million children under the age of 15 are liv-
ing with HIV. Even though antiretroviral therapy is be-
coming increasingly available in resource-poor settings, 
many HIV-infected people, including children, do not 
know their status and may never have access to treatment 
and care. Although huge strides have been made to make 
HIV/AIDS a chronic manageable condition, little is done 
to address the issues of pain caused by HIV disease, by 
concomitant opportunistic infections, or by HIV-associ-
ated cancers or as a result of side eff ects of antiretroviral 
therapy. Pain in HIV/AIDS is highly prevalent, has var-
ied syndromal presentation, can result from two to three 
sources at a time, is underestimated by doctors, and has 
the potential to be poorly managed. In South Africa, the 
prevalence of neuropathic pain in AIDS patients prior to 
antiretroviral treatment was 62.1%, with men signifi cant-
ly more likely to experience pain than women.
What are the principles for 
successful management of pain?
Five principles are fundamental to the successful man-
agement of pain symptoms:
1)  Taking the symptom seriously.
2)  Conducting an adequate assessment.
3)  Making an appropriate diagnosis.
4) Implementing treatment.
5)  Evaluating pain management.
Th
 e best approach to treating pain in HIV/
AIDS is multimodal: pharmacological, psychotherapeu-
tic, cognitive-behavioral, anesthetic, neurosurgical, and 
rehabilitative. Th
 erapy should begin according to the 
World Health Organization (WHO) ladder, with a non-
opioid such as paracetamol (acetaminophen). Opioids 
should be the fi rst-line therapy for moderate to severe 
pain. Nonsteroidal anti-infl ammatory  drugs  (NSAIDs), 
adjuvants (tricyclic antidepressants and anticonvul-
sants), and nonpharmacological modalities may be im-
portant supplements to eff ective analgesia. NSAIDs use 
in HIV infection could exacerbate bone marrow dis-
ease and worsen gastrointestinal eff ects seen with HIV 
or with antiretrovirals. Continuous use of long-acting 
opioids is the treatment of choice in chronic pain. Th
 e 
WHO analgesic ladder is a stepwise approach to pain 
management that was developed to manage pain (par-
ticularly cancer pain) in a consistent manner and can be 
applied to all cases of pain management.
Case report 1 (“pain in infants”)
Flavia is a 4-month-old HIV-infected female who is re-
ferred by the local hospital with a CD4 of 15% (absolute 
value 489) for enrolment into an antiretroviral treatment 

196
Glenda E. Gray et al.
program. She has a history of a single episode of broncho-
pneumonia, for which she was hospitalized and received 
intravenous antibiotics at the age of 2 months. She has no 
known tuberculosis (TB) contacts, and a tuberculin skin 
test done in the ward was nonreactive. Her mother com-
plains that she is “weak,” is not drinking well, and has had 
persistent sores in her mouth for more than 2 months de-
spite treatment with oral Mycostatin drops. On examina-
tion she is 79% of her expected weight for her age, with 
generalized lymphadenopathy, severe oral candidiasis ex-
tending into her pharynx, and a 3-cm hepatomegaly.
Should we be bothered about procedural pain 
in HIV-infected children?
Children infected with HIV experience frequent needle 
pricks for procedures such as venipuncture to obtain 
blood samples, intravenous insertion, injection of medi-
cation, or immunizations. Children who are hospital-
ized may experience nasogastric tube insertion, lumbar 
punctures, and bone marrow aspirates. Painless, but 
anxiety-provoking procedures such as CT scans, X-rays, 
or magnetic resonance imaging can also cause distress. 
A study by Staff ord (1991) found that 22 children with 
HIV experienced a total of 139 painful procedures in 
1 year. Th
  e management of procedural pain should be 
considered by doctors and nurses who look after HIV-
infected children both for outpatient and in-hospital fa-
cilities. Children should be provided with a multicom-
ponent package, based on cognitive-behavioral therapy, 
that teaches eff ective coping skills and could include: 
preparation, rehearsal, breathing exercises for relaxation 
and distraction, positive reinforcement, and pharmaco-
logical approaches.
Should parents be asked to leave the room 
when a HIV-infected child undergoes                   
a procedure?
Th
  ough children tend to display more behavioral dis-
tress when a parent is present, children prefer to have 
their parents present and may experience less subjective 
distress. In addition, parents generally prefer to be to be 
present when their children undergo a medical proce-
dure. Th
  e parent can encourage and coach the child and 
reinforce coping strategies.
How do we assess pain                                               
in HIV-infected children?
It is important to defi ne the characteristics of the 
pain: How intense is it, what is the quality, where is 
it distributed, and what triggers it? It is necessary to 
look at the developmental level of the child, and to en-
courage parent and child communication on pain (see 
the chapter on pain management in children). Th
 e 
history and examination should attempt to delineate 
the area where pain is occurring. Children may com-
plain about having pain “all over” and may not be able 
to tell health care workers the exact location of the 
pain. Training parents and caregivers to observe their 
children may provide helpful insights into the origin, 
severity, and nature of the pain. It is very important 
to treat the underlying cause of the pain in addition to 
prescribing analgesia. If the pain is treatment related, 
the drug causing the pain should be switched (e.g., an-
tivirals ddI or D4T for peripheral neuropathies), and 
an alternate drug used. If the pain is due to an under-
lying infectious disease, part of the pain management 
should be to treat the underlying infection.
What treatment can we prescribe for             
HIV-infected children who are in pain?
Th
 e cause of the pain needs to be established. Th
 e 
health care worker can initiate pain relief with 
paracetamol (acetaminophen) (30 mg/kg every 4–6 
hours). Th
  erapy should be given regularly, not “as neces-
sary.” If this regimen does not relieve the pain, codeine 
phosphate can be added to the paracetamol and given 
every 4–6 hours. Th
  e next step is morphine 0.4 mg/
kg orally or 0.2 mg/kg i.v. every 4 hours, which can be 
increased by 50% or more with each subsequent dose 
until pain is controlled. Once pain control has been 
achieved, the total daily amount of soluble morphine is 
divided into 12-hourly doses and given as long-acting 
morphine sulfate in a controlled-release form. Neither 
addiction nor respiratory depression is a signifi cant 
problem when morphine is used to produce analgesia. 
A side eff ect of morphine is constipation. Drowsiness 
and itching can occur initially on initiation of morphine.
How can painful oral lesions be managed?
Symptomatic relief for stomatitis and other painful oral 
lesions can be achieved by avoiding irritating food like 
orange juice, by using a straw to bypass the oral lesions, 
and by giving cold food, ice cubes, and popsicles. Topi-
cal medications such as lidocaine 2% (20 mg/mL) can 
be used before meals, applied directly to the lesions in 
older children to a maximum of 3 mg/kg/day (not to be 
repeated within 2 hours).

Management of Pain in HIV/AIDS
197
How can we manage procedural pain                  
in HIV-infected children?
Establishing a diagnosis is critical. Th
  e underlying cause 
should be treated in addition to the administration of 
analgesia. For procedural pain a multicomponent inter-
vention is recommended (see Table 2).
Do children experience pain from antiretroviral 
medications?
Many of the antiretrovirals, especially the protease in-
hibitors, cause abdominal discomfort, nausea, and diar-
rhea. Headaches, pancreatitis, and peripheral neuropa-
thies are other common side eff ects of treatment. It is 
Table 2
Multicomponent intervention for procedural pain management
Intervention
Procedure
1) Preparation
Provide detailed information on the events that will follow. Rehearse what is going to happen. Tailor 
the level of information depending on the developmental level of the child.
2) Relaxation and 
distraction
Promote relaxation through the use of breathing exercises. Could use aids like blowing bubbles. 
Children who are taught a specifi c technique such as breathing exercises believe they have more 
control over a painful situation, which improves pain tolerance.
3) Reinforcement
Mostly in the form of verbal praise, stickers, badges, sweets, or small toys that reward and encourage 
children to attempt to comply, e.g., by sitting still. Such reinforcement provides an incentive for 
engaging in coping behaviors.
4) Pharmacological 
approach
Applying EMLA (eutectic mixture of local anesthetics) cream and increasing the role of parents 
during procedures can reduce distress and pain. Apply EMLA 1 hour before the procedure and 
cover with an airtight bandage. Parents play an important role in eff orts to promote children’s coping 
during painful procedures.
*Adapted from Schiff  et al. 2001.
Table 1
Causes of pain in HIV-infected children
Pain in the oral cavity
If the pain is bad, the child may stop eating and drinking. In babies, there may be 
drooling. 
Oropharyngeal candidiasis, dental caries, gingivitis, 
aphthous ulcers, herpetic stomatitis
Pain related to infections in the esophagus
Th
  e cause and diagnosis of pain in the esophagus may be very hard to determine. Im-
munosuppressed children with oral candidiasis may have esophageal candidiasis as 
well. Older children may complain of heartburn or pain during swallowing.
Candida, cytomegalovirus, herpes simplex, and 
mycobacterial esophagitis
Pain in the abdomen
Pain in the abdomen could be constant or intermittent, dull or sharp. Th
  e pain may 
occur after eating or when the stomach is empty. Th
  ere may be associated diarrhea 
and vomiting along with the pain
Infectious gastroenteritis, pancreatitis, hepatitis, or 
infrequently, gastrointestinal lymphoma
Pain in the nerves and/or muscles
HIV can cause muscle pain or joint pain. HIV encephalopathy can be accompanied 
by hypertonicity or spasticity. Certain antiretroviral medications such as D4T can 
cause peripheral neuropathy.
Hypertonicity/spasticity, peripheral neuropathies, 
headache, myelopathy, myopathy, herpes zoster, 
and postherpetic neuralgia
Pain due to procedures
Much of the pain from procedures can be minimized.
Venipuncture, tuberculin skin testing, lumbar 
puncture, bone marrow aspirates, intravenous infu-
sions, nasogastric tube insertions, immunizations
Pain due to side eff ects of treatment
Peripheral neuropathies, pancreatitis, renal stones, 
myopathy, headache
*Adapted from Children’s Hope Foundation. Pain assessment and management of pediatric HIV infection. Pediatric HIV/AIDS Training 
Module; 1997.

198
Glenda E. Gray et al.
be an NSAID, for example diclofenac suppositories, but 
children who are in this amount of pain will most likely 
need admission for intravenous (i.v.) fl uids and parenter-
al analgesia in addition to i.v. fl uconazole.
One week later, the mother reports that that her 
child shows weakness, but the oral sores have resolved 
and there are no new complaints. Th
 e child’s baseline 
blood work reveals no contraindications to antiretroviral 
therapy, so she is started on stavudine, lamivudine, and 
lopinavir/ritonavir.
Case report 1 (cont.)
Four weeks after initiating HAART, the mother com-
plains that her baby has developed a lump under her 
right arm but is otherwise well. Examination reveals a 
4-cm mobile mass in her right axilla. Th
  e baby is clearly 
miserable and cries on examination of the lesion. A new 
workup to exclude TB is started, but a working diagno-
sis of BCG-related immune reconstitution infl ammatory 
syndrome (IRIS) is made.
Th
  e TB workup proves negative, so a decision is 
made to await the results of specimen culture before con-
sidering TB treatment. Th
 e node continues to enlarge, 
causing further discomfort to the baby, and eventually it 
becomes red, hot, and fl uctuant.  Th
  e child is referred to 
the pediatric surgery department for incision and drain-
age of the node, and a course of oral prednisone is started. 
Th
 e surgeons then duly perform an incision and drain-
age (I&D) in the outpatient department. Th
  e baby is se-
dated with valerian syrup and is also given a dose of 
paracetamol (acetaminophen) prior to the procedure. Six-
hourly paracetamol is prescribed for analgesia at home.
Th
 e node improves, somewhat, following I&D 
and prednisone, but two new areas of fl uctuation develop 
later on. Th
  e lesions are aspirated in the consulting rooms 
under the same sedation and analgesia as before. Th
 e re-
sults of the sputum test and fi ne needle aspiration (FNA) 
fi nally show that the sputum is negative for TB, and the 
FNA reveals Mycobacterium bovis as the causative agent. 
No TB treatment is started, HAART is continued, and 
the baby receives a total of 6 weeks of prednisone. No 
further procedures are required, and the node improves 
slowly over time, with resolution after 1 year of HAART. 
What other options were available for       
manag the initial axillary abscess?
1) Conservative.  Th
 is is not an advisable option 
as the pus will need to be drained, and if a controlled 
important to look at the package inserts of the antiret-
roviral drugs that are being prescribed to assess side ef-
fects and drug interactions.
What is the most likely cause of swallowing 
disorder, and how can you manage it?
Esophageal candidiasis is the most likely diagnosis and 
should be suspected on the basis of a history of diffi
  cul-
ty in feeding and the presence of extensive thrush into 
the oropharynx.
While mild oral candidiasis may respond well to 
topical therapy, the effi
  cacy of Mycostatin drops is large-
ly dependent on the length of time that the medication 
remains in contact with the lesions. It is important to 
explain to mothers that they need to try and remove 
the thick plaques that form and then apply the drops di-
rectly to the lesions (giving the drops as one would give 
a syrup). Allowing the baby to swallow it quickly will 
prove ineff ective. Th
  is procedure should be repeated at 
least 4 times per day. Alternatively, one could prescribe 
a gel formulation like Daktarin oral gel, which will ad-
here to the aff ected areas.
Severe oral candidiasis and esophageal candi-
diasis will not respond to topical therapy. Th
  is is often a 
severely painful condition, and it is often present in in-
fants and toddlers, causing loss of appetite or diffi
  culty 
in feeding. Systemic therapy is required, and the fi rst-
line drug of choice is fl uconazole.  Th
  e decision needs 
to be made whether the child will need to receive fl uco 
needs to nazole intravenously, thus requiring hospital 
admission and possible separation from her mother, or 
whether the child can tolerate it orally. A child who is 
still taking in some oral feeds will often be able to tol-
erate treatment orally. Of course, esophageal candidiasis 
is a CDC (Centers for Disease Control and Prevention) 
category C (“severely symptomatic”) diagnosis, and 
highly active antiretroviral therapy (HAART) is also an 
important part of the treatment.
As mentioned above, this condition can be ex-
tremely painful, and analgesia should also be prescribed 
for this patient. According to the WHO analgesic ladder, 
one could begin with oral paracetamol (acetaminophen) 
syrup if the patient is able to take oral medication or else 
paracetamol suppositories. Th
  is drug can be safely and 
easily administered 6-hourly in children. It is often useful 
to advise the mothers to try to give the dose 30 minutes 
before a scheduled feed so that the maximum effi
  cacy is 
reached at the feed time, reducing pain on swallowing. 
If this therapy proves inadequate, the next step would 

Management of Pain in HIV/AIDS
199
drainage procedure is not undertaken, a poorly healing 
sinus or fi stula may develop. Also not addressed, is that 
the abscesses are extremely painful, particularly in an 
area such as the axilla, which will be manipulated during 
dressing, transportation, and so on. Relief of the pressure 
is in itself an eff ective pain management procedure.
2) Aspiration. Small abscesses can be aspirated with 
ease with minimal pain to the child. Th
  is process allows 
the pus to be drained to the surface and prevents sinus 
formation as well as relieving the pain of the abscess it-
self. Unfortunately, inadequately aspirated abscesses of-
ten recur with resultant recurrence of pain. It is diffi
  cult 
to adequately aspirate large abscesses, particularly those 
which have been present long enough to begin develop 
into separate locations.
3) Incision and drainage (I&D) under general an-
esthesia. In some cases this method is preferable to the 
outpatient procedures for children as the pain of the 
procedure is completely dealt with by the anesthetic. It 
allows the abscess to be completely drained and to en-
sure that all septae are broken for good drainage. On the 
other hand, general anesthesia requires that the child be 
separated from her mother, admitted to hospital, and 
exposed to an unfamiliar and scary operating room. 
And, of course, the postoperative pain still has to be 
managed, just as for the outpatient procedure.
Case report 2 (“psychological pain 
due to recurrent procedures”)
Edith is a 2½-year-old girl who has been attending the 
antiretroviral  clinic since she was 6 weeks of age. She 
was started on HAART at 12 weeks of age and was seen 
monthly for the fi rst year of her life. Blood samples were 
taken every 3 months. Since she was 6 months old, the 
necessary blood samples have been taken from her exter-
nal jugular vein, which involved her being held supine on 
an examination bed with her neck slightly extended over 
the edge of the bed while her hands were held by a nurse to 
prevent her from trying to pull the needle out. Her mother 
has a fear of needles and couldn’t bear the sight of the doc-
tors inserting a needle into her baby’s neck, so she would al-
ways place the baby on the examination bed in the care of 
the nurse ready for the blood drawing and then leave the 
room until the procedure was complete, when she would be 
called back in. Two years later, it now takes two nurses to 
hold her down fi rmly enough to make phlebotomy safe for 
her, with the doctor performing the procedure. As soon as 
she is supine, she begins to gag until she induces vomiting 
and brings up her breakfast all over the clinic fl oor, making 
the procedure exceedingly challenging for the staff .