Establishing the feasibility, acceptability and preliminary efficacy of a multi-component behavioral intervention to reduce pain and substance use and improve physical performance in older persons living with HIV

Exercise Interventions Conducted Among Individuals with Co-occurring HIV and Unhealthy Substance Use: A Systematic Review

Unhealthy substance use and physical inactivity are prevalent co-occurring risk factors for morbidity and mortality among people with HIV (PWH). Evidence-based exercise interventions targeting both risk factors are limited. We conducted a literature search across seven databases for relevant articles published through 05/07/24. Studies qualified if they involved: (a) PWH ≥ 18 years old who engage in unhealthy substance use; (b) randomized controlled trials (RCTs) or quasi-experimental designs; and (c) an exercise intervention. Two researchers independently completed the Cochrane Data Collection Form and Joanna Briggs Institute Critical Appraisal Tool. PROSPERO registry: CRD42023473582. Out of 6916 potentially qualifying studies, 46 underwent full-text review, and 7 studies qualified (6 pilot RCTs & 1 quasi-experimental). Most (k = 6) were conducted in the US. Sample sizes ranged from 16 to 73 participants and retention rates ranged from 42 to 100%. Interventions met at least 1x/week for 6-24 weeks and consisted of supervised progressive overload aerobic/resistance training (k = 3), home-based training with virtual behavioral counseling (k = 1), yoga (k = 2), and tai-chi with cognitive behavioral therapy (k = 1). Despite inconsistent assessment tools and outcomes measured, exercise interventions were significantly (p < 0.05) and positively associated with outcomes relating to improving HIV, substance use, physical activity, strength/fall risk, quality of life/stress, and pain relief. All studies were high quality with low risk of bias, safe, and feasible. Despite small sample sizes and heterogeneity across studies, evidence from this systematic review supports the use of exercise to improve a variety of health outcomes among PWH with unhealthy substance use.

Management of pain and other palliative needs in older people with HIV

PURPOSE OF REVIEW

Human immunodeficiency virus (HIV) was historically considered a terminal illness. However, medical advancements, including antiretroviral therapy (ART), have extended the lifespan of people with HIV (PWH), emphasizing the importance of maximizing quality of life (QoL) in this aging population. These populations face unique health challenges due to various structural and environmental barriers, and comorbidities. This review aims to consolidate recent data on pain management and other palliative needs in older people with HIV (OPWH ).

RECENT FINDINGS

Recent research developments focus on providing relief by incorporation of geriatric and palliative care (PC) principles, use of long-acting injectable-antiretroviral therapies (LAI-ARTs), cannabinoids, exercise and self-management interventions, and tailored cognitive-behavioral therapy (CBT) for older people with HIV (OPWH; ≥50 years). The potential of these novel interventions can fulfil the needs of this underserved demographic suffering from a niche subset of physical and psychosocial issues. Yet, there remains variability in access to these services, with disparities often linked to healthcare infrastructure and socioeconomic factors.

SUMMARY

Interventions for an aging population of PWH should take a person-centered approach, balancing different priorities and exploring multiple avenues for symptom relief.

Effect of a WeChat-Based Hybrid Intervention on the Adaptation Outcomes of People Living With HIV/AIDS: Pilot Randomized Controlled Trial

BACKGROUND

People living with HIV/AIDS face multiple challenges that collectively impede their adaptation outcomes. These outcomes include quality of life (QoL), acceptance of illness, mental health (including symptoms of anxiety and depression), and antiretroviral therapy (ART) adherence. While existing evidence addresses specific challenges, it often overlooks the interactions among the various problems people living with HIV/AIDS encounter. The comprehensive-task disease management framework and positive self-management framework provide a theoretical basis for understanding the adaptation process. A culturally tailored, theory-based intervention may be necessary and effective in facilitating better adaptation outcomes for people living with HIV/AIDS.

OBJECTIVE

This study aimed to evaluate the effect of a hybrid intervention called AiCare (Adaptation intervention with Comprehensive-task disease management framework to achieve renormal life) on improving QoL, acceptance of illness, mental health (anxiety and depression), and ART adherence among people living with HIV/AIDS in China.

METHODS

We conducted a 2-arm randomized controlled trial, recruiting 92 people living with HIV/AIDS from an HIV clinic in Hunan, China. Participants were randomly assigned in a 1:1 ratio to either the control group (receiving standard care) or the intervention group (receiving AiCare in addition to standard care). All analyses were performed from an intention-to-treat perspective. Sociodemographic and HIV-specific clinical characteristics, along with key adaptation outcomes-including QoL, acceptance of illness, mental health (anxiety and depression), and ART adherence-were assessed at baseline (T0), post intervention (T1), and 3 months post intervention (T2). We used generalized estimating equation models and difference-in-difference analysis to evaluate the interventions' effects.

RESULTS

The difference-in-difference model showed that at T1, the intervention group experienced significant improvements compared to the control group. QoL increased by 6.35 (95% CI 2.62-10.93, P=.001), acceptance of illness improved by 4.49 (95% CI 2.29-6.68, P<.001), and anxiety decreased by 2.15 (95% CI 1.19-3.11; P=.01). At T2, the intervention group's improvement in QoL was not statistically significant (β 3.62, 95% CI -1.53 to 8.77; P=.17). However, acceptance of illness remained significantly improved by 3.65 (95% CI 1.22-6.08; P=.003), and anxiety decreased by 1.58 (95% CI 0.42-2.74; P=.007). No significant changes were observed in depression or ART adherence between the intervention and control groups. Feedback regarding the AiCare program indicated its acceptability and feasibility.

CONCLUSIONS

The AiCare program demonstrated promising effects in improving disease adaptation outcomes among people living with HIV/AIDS, notably in enhancing QoL, fostering acceptance of illness, and mitigating anxiety symptoms. These findings underscore the hybrid program's potential clinical utility to facilitate the adaptation of people living with HIV/AIDS.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2400087255; https://www.chictr.org.cn/showproj.html?proj=220729.

Non-Pharmacological Interventions Addressing Chronic Pain in People Living with HIV

PURPOSE OF REVIEW

Chronic pain affects 25-85% of people living with HIV (PLWH), negatively impacting health behaviors and HIV health outcomes. While opioids are frequently prescribed for pain, there are concerns about side effects and addiction potential, and the current consensus guideline advises against their use as a first-line pain management for this population. Therefore, there is an increasing need for non-pharmacological alternatives and adjunctive interventions. This review aims to examine the characteristics, efficacy, and limitations of existing non-pharmacological approaches to chronic pain management in PLWH to inform clinical practices and future research.

RECENT FINDINGS

A comprehensive literature search identified 13 clinical trials employing cognitive-behavioral techniques, stress management, positive affect enhancement, and complementary medicine approaches (e.g., yoga, acupuncture, hypnosis). These interventions generally showed significant effects with respect to reducing pain intensity and interference in PLWH, with some also addressing and improving depression, substance use, or antiretroviral medication adherence. However, some were pilot trials and others lacked robust methodologies or sufficient follow-up regarding the ability to definitively determine the durability of these benefits. Existing non-pharmacological interventions have potential in addressing pain and related functional impairment in PLWH, such as substance use and emotional well-being. Future research should explore the underlying mechanisms of these interventions and better understand strategies to optimize and establish durability. Incorporating adherence counseling into these interventions could further enhance HIV outcomes by addressing the interconnected challenges of chronic pain and adherence to antiretroviral therapy (ART), thereby supporting both pain management and overall HIV care.

Technology-Based Interventions for Substance Use Treatment Among People Who Identify as African American or Black, Hispanic or Latino, and American Indian or Alaska Native: Scoping Review

BACKGROUND

In the United States, racial and ethnic disparities in substance use treatment outcomes are persistent, especially among underrepresented minority (URM) populations. Technology-based interventions (TBIs) for substance use treatment show promise in reducing barriers to evidence-based treatment, yet no studies have described how TBIs may impact racial or ethnic health equity.

OBJECTIVE

This study explored whether TBIs in substance use treatment research promote health equity among people who identify as African American or Black, Hispanic or Latino, and American Indian or Alaska Native through their inclusion in research. We explored whether research that includes the aforementioned groups consciously considers race and/or ethnicity beyond including these populations as participants.

METHODS

We conducted a scoping review of 5 electronic databases to identify TBIs in substance use treatment studies published in English between January 2000 and March 2021. Studies were included if ≥50% of participants identified as African American or Black, Hispanic or Latino, or American Indian or Alaska Native when combined. Included studies were evaluated for conscious consideration of race and ethnicity in at least one manuscript section. Finally, we conducted a critical appraisal of each study's potential to facilitate insights into the impact of a TBI for members of specific URM groups.

RESULTS

Of 6897 titles and abstracts screened and 1158 full-text articles assessed for eligibility, nearly half (532/1158, 45.9%) of the full-text articles were excluded due to the absence of data on race, ethnicity, or not meeting the aforementioned demographic eligibility criteria. Overall, 110 studies met the inclusion criteria. Study designs included 39.1% (43/110) randomized trials, and 35.5% (39/110) feasibility studies. In total, 47.3% (52/110) of studies used computer-based interventions, including electronic screening, brief interventions, and referrals to treatment, whereas 33.6% (37/110) used interactive voice response, ecological momentary assessment or interventions, or SMS text messaging via mobile phones. Studies focused on the following substances: alcohol or drugs (45/110, 40.9%), alcohol alone (26/110, 23.6%), opioids (8/110, 7.3%), cannabis (6/110, 5.5%), cocaine (4/110, 3.6%), and methamphetamines (3/110, 2.7%). Of the studies that consciously considered race or ethnicity (29/110, 26.4%), 6.4% (7/110) explicitly considered race or ethnicity in all manuscript sections. Overall, 28.2% (31/110) of the studies were critically appraised as having a high confidence in the interpretability of the findings for specific URM groups.

CONCLUSIONS

While the prevalence of TBIs in substance use treatment has increased recently, studies that include and consciously consider URM groups are rare, especially for American Indian or Alaska Native and Hispanic or Latino groups. This review highlights the limited research on TBIs in substance use treatment that promotes racial and ethnic health equity and provides context, insights, and direction for researchers working to develop and evaluate digital technology substance use interventions while promoting health equity.

Outcomes of Psychotherapy for Co-Morbid Pain and Substance Use Disorders: A Review of the Literature

Chronic pain is often treated with opioids, placing patients at risk for misuse. An estimated 11.5% of these patients engage in opioid misuse behaviors such as self-medication. Non-pharmacological interventions have efficacy in managing chronic pain and substance use disorders separately; comorbid management may benefit from psychotherapy. This review provides perspective on novel and existing therapies and their efficacy. The literature search was conducted using PubMed. Boolean search terms were selected from DSM and ICD diagnoses. Studies were included if patients had comorbid substance use disorder and chronic pain diagnoses, participants were age 18 or older, and psychotherapeutic interventions were implemented. The PubMed search yielded 1937 references; 25 references were obtained through other means. 30 sources met inclusion criteria. Reported trials included: Acceptance and Commitment Therapy (ACT, 2 trials); Cognitive Behavioral Therapy (CBT, 11 trials); Mindfulness-Oriented Recovery Enhancement (MORE, 5 trials); and novel psychotherapies (12 trials). Unique features included primary care (4 trials), technology such as phone or Internet (6 trials), and group settings (9 trials). Several psychotherapies effectively treat co-occurring substance use disorders and chronic pain; novel treatments continue to be developed. Further investigation may lead to a wider variety of treatments for clinical use.

A Descriptive Review and Meta-Regression Study of Demographic and Study Context Factors in US Clinical Trials of Cognitive Behavioral Interventions for Alcohol or Other Drug Use

Objectives. Cognitive-Behaviorally Based Interventions (CBIs) are evidence-based treatments for alcohol and other drug (AOD) use with potential variable effectiveness by population sub-groups. This study used evidence synthesis to examine treatment effect by demographic and study context factors in clinical trials of CBI for AOD. Methods. Studies were systematically identified, and their characteristics and outcome data were extracted and summarized. Standardized mean differences were calculated for within- and between-condition effects on substance use outcomes. Demographic and study context moderators were identified during data acquisition and several sensitivity analyses were conducted. Results. The sample included K = 29 trials and a total of 15 study-level moderators were examined. Information on participants' age, biological sex, and race were reported in at least 26 trials, but information on gender identity, sexual orientation, and ethnicity were reported infrequently or in non-inclusive ways. The mean between-condition effect size was small and moderately heterogenous (d = 0.158, 95% CI = 0.079, 0.238, I2 = 46%) and the mean within-condition effect size was large and showed high heterogeneity (dz = 1.147, 95% CI = 0.811, 1.482, - I2 = 96%). The specific drug targeted in the study and whether biological assay-based outcomes were used moderated between-condition CBI efficacy and the inclusion of co-occurring mental health conditions and study publication date moderated within-condition CBI effects. Conclusions. Results provide preliminary data on study context factors associated with effect estimates in United States based clinical trials of CBI for AOD.

Acceptability and Feasibility of a Tai Chi/Qigong Intervention for Older People Living With HIV

Tai chi/qigong (TCQ) is a low impact, meditative movement with breathwork that may benefit people with HIV (PWH) over 50 years old. This study is a feasibility clinical trial of a remote TCQ intervention for older PWH. Participants (n = 48) were recruited via clinic sites and social media and randomized to a TCQ, sham qigong, or wait-list control group. The 12-week intervention included fourteen 45-60-minute sessions. Acceptability (satisfaction, attitudes, practice, attendance) and feasibility (retention rate, adverse events, remote delivery) data were surveyed. Overall retention rate was 72.9%, but 81.2% for the TCQ group. Most TCQ participants attended at least 10 sessions (62.5%) and were practicing TCQ after 2 weeks (72.7%). Over 92% of TCQ participants reported satisfaction and positive attitudes and preferred remote versus in person delivery (63.6%). Two mild intervention related adverse events occurred. Findings suggest that a remote TCQ intervention is acceptable, feasible, and safe among older PWH.

Brief transdiagnostic group intervention for people living with HIV and emotional disorders: feasibility and clinical utility

Emotional regulation-based transdiagnostic interventions provide positive but limited evidence regarding efficacy with people living with human immunodeficiency virus (HIV). In the present study, 10 participants living with HIV with emotional disorders completed a five-session transdiagnostic group intervention to improve their emotional regulation skills (Unified Protocol). Changes at pre-treatment, post-treatment and three-month follow-up were explored at the population (mean-rank) and the individual level (reliable change index). Compared to pre-treatment, participants improved significantly in anxiety, depression, negative affect and quality of life. Changes were maintained at the three-month follow-up. Emotion regulation, particularly the confusion factor, improved when comparing pre-treatment with the three-month follow-up. At the three-month follow-up, the percentage of normalized scores was the largest in maladjustment (70%), followed by depression, negative affect, and lack of control (50%). All participants indicated high treatment satisfaction and perceived benefits. These promising results suggest that brief emotion regulation interventions might be feasible and effective in the public health settings for people living with HIV suffering emotional disorders.

Pain Is Associated With Depressive Symptoms, Inflammation, and Poorer Physical Function in Older Adults With HIV

OBJECTIVE

People living with HIV (PLWH) frequently experience pain, which often co-occurs with psychological symptoms and may impact functional outcomes. We investigated cross-sectional associations between pain, depressive symptoms, and inflammation, and then explored whether pain was related to poorer physical function among older PLWH.

METHODS

We examined data from PLWH aged 54 to 78 years ( n = 162) recruited from a single outpatient program for a larger study on HIV and aging. Participants reported depressive symptoms (10-item Center for Epidemiological Studies Depression Scale) and then attended a biomedical visit in which they reported past-month pain (Medical Outcomes Study-HIV pain subscale), completed physical function assessments, and provided blood samples (assayed for interleukin 6, interferon-γ, tumor necrosis factor α, and C-reactive protein). Links between pain, depressive symptoms, inflammation, and physical function were tested using linear regression models.

RESULTS

PLWH with greater depressive symptoms experienced more pain than did those with fewer depressive symptoms ( B = 1.31, SE = 0.28, p < .001), adjusting for age, sex, race, body mass index, smoking, disease burden, time since HIV diagnosis, and medication use. Higher composite cytokine levels were associated with worse pain ( B = 5.70, SE = 2.54, p = .027 in adjusted model). Poorer physical function indicators, including slower gait speed, weaker grip strength, recent falls, and prefrail or frail status, were observed among those with worse pain. Exploratory mediation analyses suggested that pain may partially explain links between depressive symptoms and several physical function outcomes.

CONCLUSIONS

Pain is a potential pathway linking depressive symptoms and inflammation to age-related health vulnerabilities among older PLWH; longitudinal investigation of this pattern is warranted. PLWH presenting with pain may benefit from multidisciplinary resources, including behavioral health and geriatric medicine approaches.

Frailty and HIV: Moving from Characterization to Intervention

PURPOSE OF REVIEW

While the characteristics associated with frailty in people with HIV (PWH) have been well described, little is known regarding interventions to slow or reverse frailty. Here we review interventions to prevent or treat frailty in the general population and in people with HIV (PWH).

RECENT FINDINGS

Frailty interventions have primarily relied on nonpharmacologic interventions (e.g., exercise and nutrition). Although few have addressed frailty, many of these therapies have shown benefit on components of frailty including gait speed, strength, and low activity among PWH. When nonpharmacologic interventions are insufficient, pharmacologic interventions may be necessary. Many interventions have been tested in preclinical models, but few have been tested or shown benefit among older adults with or without HIV. Ultimately, pharmacologic and nonpharmacologic interventions have the potential to improve vulnerability that underlies frailty in PWH, though clinical data is currently sparse.

A Comprehensive Review of Alternative Therapies for the Management of Chronic Pain Patients: Acupuncture, Tai Chi, Osteopathic Manipulative Medicine, and Chiropractic Care

INTRODUCTION

Non-pharmacologic alternative therapies for pain have been around for a long time, some for hundreds of years. They have been used throughout history to treat many issues.

RECENT FINDINGS

Currently, alternative medicine is most frequently used to treat musculoskeletal pain, and between 59 and 90% of patients utilizing alternative therapies for chronic pain claimed they were helpful and can serve as an effective adjunctive for the treatment of chronic pain. Some examples of alternative therapies that will be discussed in this review include acupuncture, tai chi, osteopathic manipulation, and chiropractic care. Acupuncture, traditionally a Chinese practice, is becoming more popular across the world to attempt to relieve pain. It involves the placement of thin needles at various points in the body. The efficacy of acupuncture for pain is heavily debated. More research and discussion are necessary to determine the exact role it plays in the treatment of chronic pain. Tai chi is also a traditional Chinese practice that is often used as a form of meditation and for potential health benefits. Tai chi involves a series of complex movements such as squatting combined with deep breathing to achieve relaxation and pain reduction. Osteopathic manipulative treatment (OMT) is a technique used by both osteopathic physicians (DO) as well as other health professionals to manage a wide range of conditions in any given patient. The technique involves utilization and manipulation of the musculoskeletal system to achieve potential health benefits. OMT has been used as therapy for many issues but is commonly used for pain conditions. Alternative therapies may serve as an effective adjunctive treatment modality for the management of chronic pain conditions. There has been a tremendous amount of research dictating the effectiveness of alternative therapies for chronic pain management. The purpose of this review is to provide a comprehensive evidence-based update of alternative therapy used for the management of chronic pain conditions.

Daily factors driving daily substance use and chronic pain among older adults with HIV: An exploratory study using ecological momentary assessment

BACKGROUND

Adults 50 and older make up approximately 50% of persons living with HIV. Multiple co-morbidities are common among this group, including chronic pain and substance abuse, yet little is known about the daily factors that either enhance or inhibit these experiences or behaviors. This study explored daily drivers of substance use, pain, and relief from pain among older adults living with HIV utilizing ecological momentary assessment (EMA).

METHOD

Participants (N = 55), ages 49-71, completed seven consecutive days of daily EMA online surveys prior to treatment initiation within a randomized controlled trial. Multilevel modeling tested predictors of pain, substance use, and relief from pain by examining within- and between-person relationships.

RESULTS

Results revealed an associational, reciprocal relationship between daily worst pain and daily drinking, where greater worst pain ratings predicted heavier drinking and heavier drinking predicted greater daily and overall pain. Greater happiness and poorer quality of sleep predicted greater daily worst pain. Exercising and overall confidence to cope with pain without medication were associated with lower levels of daily worst pain. Finally, spending less time with a loved one over time and reporting any coping behavior were associated with relief from pain.

CONCLUSION

Investigation of daily factors that drive pain and substance use behaviors among this unique population help inform which daily factors are most risky to their health and well-being. Alcohol use emerged as the only substance associated with both driving pain and responding to pain. Findings suggest key points for prevention and intervention.