Managing pain in HIV/AIDS: a therapeutic relationship is as effective as an exercise and education intervention for rural amaXhosa women in South Africa

Abstract

Background Pain is one of the most prevalent symptoms in people living with HIV/AIDS and is largely undermanaged. Both a peer-led exercise and education Positive Living programme (PL programme) and the PL programme workbook alone were previously found to be effective in reducing pain in urban amaXhosa Women Living With HIV/AIDS (WLWHA). A therapeutic relationship was hypothesised to have contributed to the efficacy of both interventions. The aim of the study was to determine the effectiveness of the PL programme and a therapeutic relationship, compared to a therapeutic relationship alone in managing pain amongst rural amaXhosa WLWHA on pain severity and pain interference, and secondary outcomes, symptoms of depression, health-related quality of life (HRQoL) and self-efficacy. Methods In this two-group, single-blind, pragmatic clinical trial with stratified convenience sampling, the PL programme and therapeutic relationship, was compared to a therapeutic relationship alone in rural amaXhosa WLWHA. The PL programme was a 6-week, peer-led intervention comprising education on living well with HIV, exercise and goal setting. The therapeutic relationship comprised follow-up appointments with a caring research assistant. Outcome measures included pain severity and interference (Brief Pain Inventory), depressive symptoms (Beck Depression Inventory), HRQoL (EuroQol 5-Dimensional outcome questionnaire) and self-efficacy (Self-efficacy for Managing Chronic Disease 6-Item Scale). Follow-up was conducted at 4, 8, 12, 24, and 48 weeks. Mixed model regression was used to test the effects of group, time, and group and time interactions of the interventions on outcome measures. Results Forty-nine rural amaXhosa WLWHA participated in the study: PL group n = 26; TR group n = 23. Both intervention groups were similarly effective in significantly reducing pain severity and interference and depressive symptoms, and increasing self-efficacy and HRQoL over the 48 weeks. A clinically important reduction in pain severity of 3.31 points occurred for the sample over the 48 weeks of the study. All of these clinical improvements were obtained despite low and suboptimal attendance for both interventions. Conclusions Providing a therapeutic relationship alone is sufficient for effective pain management amongst rural amaXhosa WLWHA. These findings support greater emphasis on demonstrating care and developing skills to enhance the therapeutic relationship in healthcare professionals working with rural amaXhosa WLWHA. Trial registration PACTR; PACTR201410000902600, 30th October 2014; https://pactr.samrc.ac.za.

Context counts: Investigating pain management interventions in HIV-positive men living in a rural area

“…Recently, more supportive evidence for the beneficial effect of a TR on pain in rural amaXhosa women LWHA has emerged where similar measures were employed to facilitate a care effect. 10 Facilitating a care effect by utilising measures that include improving communication and empathetic care is consistent with what has been widely described in the literature concerning the therapeutic alliance and physical health. 11 Whether as a result of self-directed engagement with the workbook or in response to a continuous, caring relationship, these improvements in pain across cohorts of PLWHA are encouraging.…”

Study protocol: an observational study of distress, immune function and persistent pain in HIV

“…In PWH, a broad range of distress-related constructs and pathologies (e.g., depression, post-traumatic stress disorder, and psychosocial distress) correlate with pain1 5 18–20; indeed, many PWH explicitly identify that psychosocial factors strongly influence their pain 7 21 22. In South Africa, which is the location of this study, a randomised treatment trial found that just infrequent contact with an empathetic assessor was associated with improved pain outcomes in PWH 23. Empathetic interactions may foster positive emotions and provide a supportive context for adaptive coping that broadens a person’s repertoire of responses to difficult circumstances, increases sense of control, and reduces fear, thus ameliorating distress 24–26.…”

“… 7 21 22 In South Africa, which is the location of this study, a randomised treatment trial found that just infrequent contact with an empathetic assessor was associated with improved pain outcomes in PWH. 23 Empathetic interactions may foster positive emotions and provide a supportive context for adaptive coping that broadens a person’s repertoire of responses to difficult circumstances, increases sense of control, and reduces fear, thus ameliorating distress. 24–26 However, the question remains: through what mechanisms would diminishing distress diminish pain?…”

The effectiveness and sustainability of peer support interventions for persons living with HIV: a realist synthesis

“…Second, measurement tools may not be sensitive to test the intervention effect 14 61 88. Third, small sample sizes may not have enough power to test the intervention effect 59 63 87. We suggest that researchers pay more attention to peer volunteers’ emotional support skill training and encourage more peer-led emotional support for PLHIV.…”

“…We estimate that it may be associated with the following factors. First, most of the clinical trials took emotional support as a secondary intervention component, and the intervention dose may not be enough to show an intervention effect 12 14 59–61 87–89. Second, measurement tools may not be sensitive to test the intervention effect 14 61 88.…”