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 .

Keywords: Education; Exercise; HIV/AIDS; Pain; Therapeutic relationship.

Fig. 1

Screening, recruitment and allocation procedure

Fig. 2

Attendance at PL programme and data collection points

Fig. 3

Change in Pain Severity Scores and Pain Interference Scores for both intervention groups over time Panel A: Pain Severity Scores: Change in Pain Severity Scores for PL and TR intervention groups over 48 weeks, (N = 49, PL intervention group (n = 26) and TR intervention group (n = 23)); Panel B: Pain Interference Scores: Change in Pain Interference Scores for PL and TR intervention groups over 48 weeks, *data missing for 1 participant for PIS scores, (N = 48, PL intervention group (n = 26) and TR intervention group (n = 23))

Fig. 4

Change over time in scores on the Beck Depression Inventory, self-efficacy and EQ-5D VAS scores. Each dot represents an individual participant’s score; Panel A: Beck Depression Inventory: Changes in scores on the Beck Depression Inventory over time (N = 49); Panel B: Self-efficacy scores: Change in self-efficacy scores over time (N = 49); Panel C: EQ-5D VAS scores: Change in EQ-5D VAS scores over time (N = 49)