Guide to Pain Management in Low-Resource Settings

What are some possible things that could 
have been done to have prevented this state               
of aff airs?
While it is often traumatic for parents to watch blood 
being drawn from their child, it is more often more 
traumatic for the child to face the procedure alone feel-
ing abandoned by their mother, whom they trust to pro-
tect them from pain. It is therefore advisable to encour-
age parents to remain in the room and speak words of 
comfort to their child during the procedure (they do not 
necessarily need to watch the procedure). Also, parents 
or caregivers should be encouraged to explain why the 
blood has to be taken as far as the child can understand. 
Th
  ey should also be encouraged not to mislead their 
children and promise that no blood will be taken. Par-
ents should be discouraged from “villainizing” the staff  
performing the procedure. It is often the natural instinct 
of mothers in particular to vindicate their child’s pain by 
promising them that they will hit the doctor or, as one 
patient’s mother promised, report them to the police! 
Th
  is behavior serves to increase the child’s fear of the 
staff  and makes the child begin to doubt their mother’s 
word or ability to off er the protection promised.
What can be done in future to alleviate             
the situation?
Th
 e multicomponent approach described in Table 2 
should be introduced. EMLA should be used in an at-
tempt to reduce pain. As soon as the child is old enough 
to make brachial vein blood sampling as easy as exter-
nal jugular vein sampling, this option should be ad-
opted. Th
  e child will be able to remain on her mother’s 
lap with her mother’s loving arms as her unforced re-
straints. Off ering some form of comforting compensa-
tion like a chewy sweet or lollipop will often stop the 
tears or at least attenuate the trauma of the procedure 
with some positive association.
Case report 3 (“pain due to 
opportunistic infection with 
exacerbating psychosocial factors”)
Abigail is a 12-year-old girl who is brought to the clinic 
having just been diagnosed with HIV. Her parents died 
2 years ago from AIDS-related illnesses, and her mater-
nal aunts have been caring for her since then. When they 

200
Glenda E. Gray et al.
saw that she was losing weight rapidly over a period of 
a few months, they decided she needed to be tested for 
HIV as well. At the local clinic Abigail and her aunt had 
pre-test counseling together as it was felt she was mature 
enough to understand the implications of the test and to 
give consent herself. When the results were available they 
were given to Abigail alone without her aunt present. No 
post-test counseling was done, and Abigail was simply 
told that she needed to go to the clinic as she was HIV 
positive and needed treatment.
At the fi rst visit, Abigail, is clearly disturbed by 
the diagnosis. She is a bright child who obviously under-
stands the meaning of the diagnosis and is hence some-
what reserved and noticeably scared—worried about 
her future, scared of rejection, her whole life upturned. 
She has had a chronic cough for more than 4 weeks and 
is wasted, listless, and in respiratory distress, with a 
temperature of 40°C. A chest X-ray reveals a bilateral 
patchy infi ltrate. She clearly requires hospital admis-
sion but is reluctant as she is afraid of leaving the care 
of her aunts and of being abandoned in the hospital. Her 
aunts reassure her of their love, and the doctor assures 
her that it is necessary and in her best interest, and she 
fi nally agrees.
She is admitted with a diagnosis of community-
acquired pneumonia and is started on intravenous an-
tibiotics. Her CD4 count is 4. On admission it is also 
noted that she has severe abdominal pain. Th
  e ward doc-
tors note that the pain is generalized, with some appar-
ent rebound tenderness, and order an abdominal X-ray 
and serum lipase level. Th
  ey start her on tilidine drops 
(an oral opioid analgesic) to be given 6-hourly. Investiga-
tions prove normal, but her tenderness does not seem to 
improve. In the meantime, her condition appears to be 
worsening. She appears weaker and more tired than ever.
Due to her deteriorating condition, Abigail is 
seen by a palliative care specialist. She recommends 
that the tilidine be changed to paracetamol (acetamino-
phen) and codeine (a weak opioid with much less seda-
tive eff ect.) She also arranges for Abigail to be seen by her 
team’s psychologist when she is more lucid. In the mean-
time her temperature and symptoms are still not con-
trolled, despite various diff erent intravenous antibiotics 
including tazobactam, amikacin, and even imipenem. 
Sputum results are delayed due to a backlog at the labo-
ratory, and the cause for abdominal tenderness still has 
not been found. An abdominal ultrasound is ordered, 
which shows splenic microabscesses. She is diagnosed 
with disseminated TB and started on TB treatment. 
Th
  ree days later, her temperature has settled, her consti-
tutional symptoms have improved, her abdominal pain 
is much better, and she is back to her usual self and able 
to be discharged home.
What are some possible contributing factors   
to her pain? 
1)  Intra-abdominal pathology: splenic tuberculosis. 
It is also likely that with splenic involvement, there was 
also further lymphatic involvement. Tuberculosis of 
the mesenteric lymph nodes could cause partial bowel 
obstruction, resulting in the signs of peritonitis found 
on examination.
2)  “Referred” pain. After 4 weeks of coughing and in 
the face of disease-induced malnutrition, the patient’s 
diaphragm and accessory respiratory muscles have been 
sorely overexerted. Her abdomen may be tender due to 
the prolonged muscular strain.
3) 
“Psychological” pain. Children, particularly 
younger children, often present with generalized or 
nonspecifi c abdominal pain without any apparent pa-
thology. Th
  e pain may often simply be a sign of emo-
tional distress (although, of course, physical pathology 
must fi rst be excluded). Caution must be exercised to 
diff erentiate real pain and peritonism from psychologi-
cal pain. Often by distracting the patient with conver-
sation and questions or, for younger children, toys or 
mobiles, you will be able to elicit whether or not the 
pain is real. Real pain will cause a grimace and even an 
interruption in the conversation. Peritonism will result 
in obvious rebound tenderness in spite of the distrac-
tion. Purely psychological pain (or even feigned pain) 
will result in no obvious signs of tenderness during the 
examination while the child is distracted.
What are some possible reasons for the 
deterioration in the patient’s condition?
1)  Incorrect diagnosis with worsening of her oppor-
tunistic infection. Th
  is child had several symptoms that 
should have alerted the clinicians to the strong possibil-
ity of tuberculosis. She had a chronic productive cough, 
an unresponsive fever, and signifi cant weight loss with 
suspicious chest radiograph changes. With a CD4 count 
of 4, the likelihood of TB and especially disseminated 
TB was very strong.
2) New nosocomial (i.e., hospital-acquired) infec-
tion. While this is often the cause of deterioration in 
severely immunocompromised in-hospital patients, it 
was unlikely in view of the lack of positive specimen 

Management of Pain in HIV/AIDS
201
cultures and lack of response to potent intravenous an-
tibiotic therapy.
3) Psychological pain. Loss of the will to continue 
fi ghting and resignation to the possibility of death. Th
 e 
loss of both parents, the tragic way she received her di-
agnosis, and the lateness of her presentation, together 
with her severe ill health and opportunistic infection, 
comprise a daunting load for a young psyche. Th
 e temp-
tation to give up hope must certainly be strong. Th
 e 
need for a strong, loving family support system with ex-
ternal psychosocial intervention is crucial. Fortunately, 
Abigail has very loving aunts who visited her daily and 
caring school friends who sent cards and gifts during 
her hospital stay. Th
  e palliative care psychologist was 
also able to counsel and encourage her and her family 
and provide them with the extra care they needed at 
this diffi
  cult time.
4) Drug side eff ects. Tilidine is a strong opioid. 
Opioid analgesics are known to cause sedation and 
mood changes (euphoria or dysphoria.) Tilidine itself 
can also cause dizziness, drowsiness, and confusion. 
According to the WHO analgesic ladder, strong opi-
oids should be reserved for pain that does not respond 
to less strong analgesia. Th
  ey should not be used as a 
fi rst-line analgesic, except postoperatively or where 
clear pathology requiring strong analgesia is required, 
such as pancreatitis.
How to manage pain in HIV-infected adults
Th
  e pain syndromes seen in HIV-infected adults may be 
directly related to HIV infection, immunosuppression, 
or HIV therapy. Pain can be divided into two categories: 
nociceptive or neuropathic. Th
 e most common syn-
dromes reported in HIV-positive adults include painful 
peripheral neuropathies, as well as pain caused by ex-
tensive Kaposi’s sarcoma, headache, oral and pharyngeal 
pain, abdominal pain, chest pain, arthralgias and myal-
gias, and painful dermatological conditions.
Are the principles of pain management 
diff erent in HIV?
Th
  e principles of pain management in HIV are similar 
to those in other medically ill patients. At each visit, 
both in the outpatient and inpatient facility, it is useful 
to take “pain vital signs” to assess the degree of pain and 
the response to the current analgesic program (also see 
the Brief Pain Inventory).
•  Ask patients if they have experienced pain in the 
last week.
•  Ask them to describe the intensity of pain: mild, 
moderate, or severe.
•  Ask them to tell you what it feels like: burning, 
shooting, dull, or sharp.
•  Find out what makes it better or worse.
•  Ask them to rate the pain (at its worst and at its 
best) on a 0–10 numerical scale.
•  Ask them to rate their quality of life on a 0–10 scale.
•  Ask about sadness, fatigue, and depression.
After obtaining the history, a careful medical 
examination will help elucidate the causative factors. 
Th
  e baseline assessment can be used as an indicator as 
to whether the analgesia is eff ective or not.
Do women with HIV infection have more pain?
Women experience pain diff erently from men due to 
biological, psychological, and social factors. Men and 
women respond diff erently to pharmacological and 
nonpharmacological treatments. Women with pain are 
often underdiagnosed and undertreated. Th
  ey may not 
have the information or education to understand that 
their painful conditions may be part of HIV disease. 
Culture also infl uences pain experience.
Table 3
Common sources of pain in HIV/AIDS
Cutaneous/Oral
Visceral
Deep Somatic
Neurological/Headache
Kaposi’s sarcoma
Oral cavity pain
Herpes zoster
Oral/esophageal 
candidiasis
Tumors
Gastritis
Pancreatitis
Infection
Biliary tract 
disorders
Rheumatological 
disease
Back pain
Myopathies
Headaches: HIV-related (encephalitis, meningitis, etc.)
Headaches: HIV-unrelated (tension, migraine)
Iatrogenic (zidovudine-related)
Peripheral neuropathy
Herpes neuritis
Neuropathies associated with ddI, D4T toxicities, 
alcohol, nutritional defi ciencies.
*Modifi ed from Carr DB. Pain in HIV/AIDS: a major health problem. IASP/EFIC (press release). Available at 
www.iasp-pain-org.

202
Glenda E. Gray et al.
Case report 4 (“postherpetic 
neuralgia”)
A 44-year-old HIV-positive man, compliant and stable 
on antiretroviral therapy for 3 years, complains of sud-
den-onset fatigue and severe pain in his left shoulder. 
He describes the pain as the worst pain he has ever felt, 
with a burning quality, waking him up from his sleep, 
worse with movement of the left shoulder, causing him to 
break out into a sweat and incapacitating him. He has 
no history of trauma. He recalls experiencing a mild fl u-
like illness 1 week ago. His daughter was ill recently with 
chicken pox. On examination of the skin, two vesicles are 
found at the tip of the left shoulder, and the pain extends 
unilaterally in a dermatomal distribution. Oral valacy-
clovir, a combination paracetamol (acetaminophen)-co-
deine tablet, and ibuprofen, were initiated.
What treatments may be used to alleviate the 
pain and itchiness of zoster rash?
Th
  is condition is extremely painful, and analgesic use 
should be liberal. Topical calamine lotion and water 
dressings may help relieve the itchiness. Paracetamol, 
ibuprofen, and dihydrocodeine will be necessary as well. 
Secondary infection of the blisters may occur and may 
exacerbate pain, and so should be treated with antibiot-
ics and a topical agent such as chloramphenicol, tetra-
cycline, or gentian violet. Th
  ere is some evidence that 
corticosteroid use with acyclovir decreases acute pain, 
but steroids should be used with caution, especially in 
immune-compromised patients.
How can one manage the pain                                
of postherpetic neuralgia?
Amitryptiline and carbamazepine should be considered 
for postherpetic neuralgia. Carbamazepine has drug in-
teractions with antiretrovirals and should be used with 
caution. Consider the use of pregabalin, a new drug in 
the anticonvulsant class, for postherpetic neuralgia pa-
tients who are not responding to tricyclic antidepres-
sants, gabapentin, and other analgesics. Th
 e  initial 
dose of pregabalin is 75 mg b.i.d., but the dose may be 
increased to 150 mg b.i.d. after three days. Pregabalin 
would require dose adjustment if creatinine clearance 
is below 60 mL/min. Dizziness and somnolence has 
been reported frequently with pregabalin, and we sug-
gest care when coadministering the drug with efavi-
renz, which has similar side eff ects in the initial weeks 
of treatment.
What complications of zoster are more 
common in immune-compromised individuals?
Extensive skin involvement, disseminated disease, 
pneumonitis, ocular involvement, meningoencepha-
litis, myelitis, and involvement of cranial nerves have 
been described.
Case report 5 (“cryptococcal 
meningitis”)
An 18-year-old, pregnant, HIV-infected woman with 
baseline CD4 count of 38 × 10
6
/L and viral load 
>500,000 copies/mL has been receiving stavudine/la-
mivudine/nevirapine for 3 weeks. She now presents 
with a 7-day history of headache, described as mild, 
initially, but worsening with time, persistent, stabbing, 
no longer responsive to paracetamol, exacerbated by 
movement and associated with photophobia and vom-
iting. On examination, she is mildly pyrexial, fully 
awake, alert and oriented but restless. Five papular 
skin lesions measuring 2 mm in diameter have been 
noted below the lower right eyelid since prior to antiret-
roviral induction, which were thought to be molluscum 
contagiosum. She displays neither focal neurological 
defi cits nor papilledema. Serum cryptococcal antigen 
is positive, and cerebrospinal fl uid results are as fol-
lows: opening pressure 20 cm H
2
O, slightly turbid fl uid, 
CSF-protein 0.5 g/L, CSF: serum glucose 40%, chloride 
125 mmol/L, acellular, Gram stain negative, CSF-
cryptococcal latex agglutination test positive, India ink 
positive. Skin biopsy results culture Cryptococcus neo-
formans. Intravenous amphotericin B and oral dihy-
drocodeine were given, and the patient reports complete 
pain relief by the third day of treatment.
Which signs will alert the clinician to raised 
intracranial pressure in a patient with 
cryptococcal meningitis?
Focal neurological defi cits. Transient loss in visual acu-
ity, diplopia, hearing loss, confusion, and papilledema.
How should one manage and treat patients with 
raised intracranial pressure >25 cm H
2
O?
To avoid herniation, prior to lumbar puncture, a CT 
or MRI scan of the brain should exclude mass eff ect. 
Drainage of small amounts of cerebrospinal fl uid  daily 
for a maximum of 2 weeks, with monitoring of pres-
sure, usually improves headache and other symptoms 
associated with cryptococcal meningitis. After 2 weeks, 

Management of Pain in HIV/AIDS
203
consider surgical placement of a ventriculoperitoneal or 
lumbar-peritoneal shunt if increased pressure persists.
Which analgesics are contraindicated for use 
with raised intracranial pressure?
Morphine sulfate, pethidine (meperidine).
Case report 6 (“peripheral 
neuropathy”)
A young woman, 23 years old, is referred to the antiret-
roviral (ARV) clinic with a recent positive HIV-ELISA 
test and absolute CD4 of 19 × 10
6
/L. She is ARV-naive. 
She complains of a burning sensation on the soles of both 
feet. Positive fi ndings on examination include marked 
muscle wasting, malnourishment, a weight of 50 kg, pal-
lor, a right-sided 5-cm supraclavicular lymphadenopa-
thy, and a grade 1 sensorimotor peripheral neuropa-
thy. Of note in the blood results is HIV-1 viral load by 
branched DNA, 238,810 copies/mL, and normocytic 
normochromic anemia. Chest X-ray reveals hilar ad-
enopathy. A fi ne needle aspirate is undertaken of the 
lymph node and is consistent with TB. She is commenced 
on cotrimoxazole prophylaxis, TB treatment, pyridoxine 
25 mg daily, and vitamin B complex.
Ten days after starting TB treatment, she calls 
the doctor at 3 am to complain of worsening foot pain, 
and is advised to present herself to the clinic at 8 am 
that day. She does so, in a wheelchair and wearing slip-
pers, and complains that she cannot bear to walk on her 
own because of the pain in her feet, so she sleeps all day. 
At the consultation, the causes and course of her periph-
eral neuropathy, now grade 2 sensory and grade 3 mo-
tor, are explained to her. Amitryptiline 25 mg at night, 
ibuprofen and paracetamol, are started, and pyridoxine 
dosage is increased to 50 mg daily. Vitamin B
12
 and fo-
late levels are normal, and iron studies suggest anemia 
of chronic disorders.
Th
 ree days later she calls the doctor at 1 am 
and complains of the nonresolution of her foot pain. She 
is asked once more to come in, and is assessed again as 
having grade 2 peripheral neuropathy. Pyridoxine is in-
creased to 75 mg daily, amitryptiline to 50 mg at night, 
and a highly active antiretroviral therapy (HAART) regi-
men of nucleoside analog reverse transcriptase inhibitors 
(NRTIs) and non-nucleoside reverse transcriptase inhibi-
tors (NNRTIs) is started. After 3 months, the neuropathy 
regresses to grade 1, and after 6 months the neuropathy 
has resolved completely.
Name all the contributory factors of the 
peripheral neuropathy!
HIV itself, possible vitamin B defi ciencies, and isoniazid 
prophylaxis or treatment.
Which NRTI agents should be avoided,               
if possible, in such a case?
Stavudine and didanosine, as both can cause peripher-
al neuropathy with long-term use owing to mitochon-
drial toxicity.
Which nutritional defi ciencies can cause 
peripheral neuropathy?
Vitamin B
1
 (Th
  iamine), vitamin B
3
, vitamin B
6
, vitamin B
12
.
Why did the neuropathy progress to grade 2?
Th
  e initial presenting neuropathy was most likely sec-
ondary to HIV. Th
  e pain was exacerbated by the addi-
tion of isoniazid, a component of TB treatment and a 
cause of peripheral neuropathy via vitamin B
6
 (pyridox-
ine) depletion. Peripheral neuropathy has also been re-
ported as a side eff ect of cotrimoxazole (used in higher 
doses for treatment and lower doses in prophylaxis of 
Pneumocystis jirovecii pneumonia treatment).
What drug used to treat peripheral neuropathy 
may be unsuitable for this patient?
Carbamazepine may be unsuitable because it induces 
the metabolism of efavirenz and nevirapine via the cyto-
chrome P450 3A4 system.
Remember the WHO analgesic 
ladder for pain management
Step 1: MILD PAIN 
Paracetamol (acetaminophen), nonsteroidal anti-in-
fl ammatory drugs) (NSAIDS) (and adjuvants if needed) 
Adjuvants include (if there is neuropathic pain): tri-
cyclic antidepressants (TCAs), anticonvulsants, steroids
Step 2: MILD TO MODERATE PAIN 
Mild-acting opioids + step 1 nonopioids (and adju-
vants if needed) 
Mild-acting opioids: codeine, dihydrocodeine, dex-
tropropoxyphene 
Step 3: MODERATE TO SEVERE PAIN 
Stronger opioids + Step 1 nonopioids (and adjuvants 
if needed) 
Stronger opioids: morphine, diamorphine, fentanyl, 
hydromorphone

204
Glenda E. Gray et al.
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