Page 207 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? 2) Conducting an adequate assessment.
3) Making an appropriate diagnosis.
In 2007, UNAIDS estimated that 33.2 million people 4) Implementing treatment.
were infected with HIV. Most of the HIV-infected men, 5) Evaluating pain management.
women, and children resided in sub-Saharan Africa. Th e best approach to treating pain in HIV/
Globally, 2 million children under the age of 15 are liv- AIDS is multimodal: pharmacological, psychotherapeu-
ing with HIV. Even though antiretroviral therapy is be- tic, cognitive-behavioral, anesthetic, neurosurgical, and
coming increasingly available in resource-poor settings, rehabilitative. Th erapy should begin according to the
many HIV-infected people, including children, do not World Health Organization (WHO) ladder, with a non-
know their status and may never have access to treatment opioid such as paracetamol (acetaminophen). Opioids
and care. Although huge strides have been made to make should be the fi rst-line therapy for moderate to severe
HIV/AIDS a chronic manageable condition, little is done pain. Nonsteroidal anti-infl ammatory drugs (NSAIDs),
to address the issues of pain caused by HIV disease, by adjuvants (tricyclic antidepressants and anticonvul-
concomitant opportunistic infections, or by HIV-associ- sants), and nonpharmacological modalities may be im-
ated cancers or as a result of side eff ects of antiretroviral portant supplements to eff ective analgesia. NSAIDs use
therapy. Pain in HIV/AIDS is highly prevalent, has var- in HIV infection could exacerbate bone marrow dis-
ied syndromal presentation, can result from two to three ease and worsen gastrointestinal eff ects seen with HIV
sources at a time, is underestimated by doctors, and has or with antiretrovirals. Continuous use of long-acting
the potential to be poorly managed. In South Africa, the opioids is the treatment of choice in chronic pain. Th e
prevalence of neuropathic pain in AIDS patients prior to WHO analgesic ladder is a stepwise approach to pain
antiretroviral treatment was 62.1%, with men signifi cant- management that was developed to manage pain (par-
ly more likely to experience pain than women. ticularly cancer pain) in a consistent manner and can be
applied to all cases of pain management.
What are the principles for

successful management of pain? Case report 1 (“pain in infants”)

Five principles are fundamental to the successful man- Flavia is a 4-month-old HIV-infected female who is re-
agement of pain symptoms: ferred by the local hospital with a CD4 of 15% (absolute
1) Taking the symptom seriously. value 489) for enrolment into an antiretroviral treatment
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 195
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
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