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Health Psychology Review

ISSN: 1743-7199 (Print) 1743-7202 (Online) Journal homepage: http://www.tandfonline.com/loi/rhpr20

Mindfulness-based stress reduction for people


living with HIV/AIDS: preliminary review of
intervention trial methodologies and findings

Kristen E. Riley & Seth Kalichman

To cite this article: Kristen E. Riley & Seth Kalichman (2015) Mindfulness-based stress reduction
for people living with HIV/AIDS: preliminary review of intervention trial methodologies and findings,
Health Psychology Review, 9:2, 224-243, DOI: 10.1080/17437199.2014.895928

To link to this article: http://dx.doi.org/10.1080/17437199.2014.895928

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Download by: [Canterbury Christ Church University] Date: 30 September 2017, At: 10:26
Health Psychology Review, 2015
Vol. 9, No. 2, 224243, http://dx.doi.org/10.1080/17437199.2014.895928

Mindfulness-based stress reduction for people living with HIV/AIDS:


preliminary review of intervention trial methodologies and findings
Kristen E. Riley* and Seth Kalichman

Department of Psychology, University of Connecticut, 406 Babbidge Road, Unit 1020, Storrs, CT
Downloaded by [Canterbury Christ Church University] at 10:26 30 September 2017

06269, USA
(Received 15 June 2013; accepted 16 February 2014)

In the context of successful antiretroviral therapy (ART) for the management of HIV
infection, the harmful effects of stress remain a significant threat. Stress may increase
viral replication, suppress immune response, and impede adherence to ART. Stressful
living conditions of poverty, facing a chronic life-threatening illness and stigma all
exacerbate chronic stress in HIV-affected populations. Stress-reduction interventions
are urgently needed for the comprehensive care of people living with HIV.
Mindfulness-based stress reduction (MBSR) is one approach that has shown promise
as an intervention for patients facing other medical conditions for reducing disease
progression, psychological distress and maladaptive behaviours. In this systematic
review, we identified 11 studies that have examined MBSR as an intervention for HIV-
positive populations. Of the studies, six were randomised designs, one was a quasi-
experimental design, and the remaining four were pre- and post-test designs. The
preliminary outcomes support MBSR to decrease emotional distress with mixed
evidence for impact on disease progression. Effect sizes were generally small to
moderate in magnitude. The early findings from this emerging literature must be
considered preliminary and support moving forward with more rigorous controlled
trials, evaluated with objective assessments in longer-term follow-ups to determine the
efficacy of MBSR for people living with HIV.
Keywords: HIV/AIDS; mindfulness-based stress reduction; mindfulness; stress;
methodology

Since the beginning of the HIV pandemic, more than 70 million people worldwide have
been infected with the virus and more than 35 million have died of AIDS (WHO, 2011).
Along with the remarkable success of antiretroviral therapy (ART) for the treatment and
management of HIV infection, there is still variability in treatment outcomes (May et al.,
2006). Facing a chronic life-threating condition, poverty, stigma, and the pressure to strictly
adhere to a medication regimen add to the stress of people living with HIV (Howland,
Ausubel, london, & Abbas, 2000). Psychological stress is one known factor that influences
treatment access, medication adherence and HIV disease progression (see Cohen, Janicki-
Deverts, & Miller, 2007 for a review; Vedhara & Irwin, 2005).1 In the context of HIV
infection, stress has been shown to stimulate viral replication (Sheridan et al., 2006),
suppress immune response (Clerici & Shearer, 1994; Nair, Saravolitz, & Schwartz, 2005),

*Corresponding author. Email: Kristen.Riley@uconn.edu


2014 Taylor & Francis
Health Psychology Review 225

impede ART adherence (Antoni, 2010) and interferes with metabolising ART medications
(Leserman, 2008).
Stress, along with negative affective states such as anxiety and depression, can affect
biological processes and behavioural patterns advancing disease and symptoms (Cohen
et al., 2007). Of particular concern for people living with HIV, research has found that
interpersonal stressors, such as bereavement and stigma, impact HIV disease (Goforth,
Lowery, Cutson, Kenedi, & Cohen, 2009; Mahajan et al., 2008). Stress has been shown to
have a direct influence on disease progression, an indirect influence on disease
progression through maladaptive behaviours and adverse effects on quality of life
(QOL; Hays et al., 2000).
Stress has also been shown to directly influence HIV replication via increases in
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autonomic nervous system activity (Cole, Kemeny, Fahey, Zack, & Naliboff, 2003).
Likewise, stress can accelerate declines in immune function as indexed by CD4+ cell
counts in HIV-positive patients (Remor, Penedo, Shen, & Schneiderman, 2007). Stress
also has several indirect mechanisms that can impact HIV disease progression (Antoni,
2010). For example, stress can lead to poor ART adherence, and therefore risk for
developing ART-resistant variants of HIV and more rapid disease progression (Cole,
Kemeny, Fahey, Zack, & Naliboff, 2003). Additionally, stress may hinder ones ability to
access adaptive social support, which in turn can impede effective coping strategies,
responses to stigma and treatment adherence (Antoni, 2010). Stress is also related to
maladaptive coping strategies, including substance use, which have been linked to disease
progression. For example, the use of denial coping at the time of an HIV diagnosis
predicts greater impairments in immune status functioning over time (Antoni, Goldstein,
Laperriere, Fletcher, & Schneiderman, 1995).
As part of a comprehensive approach to HIV disease management, interventions are
needed to decrease stress in HIV-affected populations. There has been considerable
research focused on stress reduction techniques and behavioural interventions for people
living with HIV. Among the most studied stress reduction interventions for people living
with HIV is cognitive-behavioural stress management (CBSM), which has been shown to
be efficacious in reducing stress and the potential to slow HIV disease progression (see
Antoni, 2003; Brown & Vanable, 2008; Scott-Sheldon, Kalichman, Carey, & Fielder,
2008 for a review). CBSM interventions teach relaxation techniques, stress education,
coping strategies, interpersonal skills and problem solving skills to enhance social
support. CBSM reduces psychological distress and depression (Antoni, 2003; Antoni
et al., 2000; Carrico et al., 2006), improves overall QOL, (Lechner et al., 2003) and
enhances immune functioning as indicated by increased numbers of CD4+ T lymphocytes
following HIV diagnosis (Antoni, Ferrari, & Fiaccadori, 1991). Adherence to CBSM
interventions has been associated with less rapid disease progression to AIDS and death
in some studies (Antoni et al., 1991). However, there are mixed findings regarding the
impact of the individual components of the CBSM intervention, such as relaxation
training and social support, on immune system function (Antoni et al., 2005). Other
interventions aimed at stress reduction show the utility of behavioural interventions for
improving physical and mental health functioning (see Bower, Kemeny, & Fawzy, 2002,
for a review).
Along with CBSM, mindfulness-based stress reduction (MBSR) has been shown to
improve health outcomes in a variety of populations, including patients diagnosed with
cancer, chronic pain, low back pain, fibromyalgia, rheumatoid arthritis, cardiovascular
disease, diabetes, irritable bowel syndrome and organ transplant populations (e.g., Campbell,
226 K.E. Riley and S. Kalichman

Labelle, Bacon, Faris, & Carlson, 2012; Carlson, Speca, Faris, & Patel, 2007; see Carlson,
2012 for a review). The positive effects of MBSR include reductions in stress, depression and
fear of symptom recurrence (e.g., Lengacher et al., 2009; Mackenzie, Carlson, Munoz, &
Speca, 2007). For example, MBSR has been shown to improve sleep, mood, stress and
fatigue in cancer patients (Carlson & Garland, 2005). MBSR interventions are typically
standardised and manualised and include mindfulness meditation training programs
developed for treating populations with high levels of stress (Kabat-Zinn, 1982).MBSR
intervention programmes typically consist of eight weekly training sessions on mindfulness
through group discussions and guided mindfulness meditation, as well as homework and a
day-long retreat around week number seven.
Baer (2003) highlighted implementation and theoretical similarities and differences
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between CBSM and MBSR that are worth noting. Both interventions train participants in
self-directed attention that can lead to desensitisation of conditioned responses and
reduction of avoidance behaviours. Cognitive changes result from added attention to
thoughts without further reflections or associated meanings. Meditation is also used in
both CBSM and MBSR to induce relaxation. However, MBSR differs from CBSM in that
MBSR tends to focus on acceptance of current reality whereas CBSM emphasises
systematic attempts to change cognitions and perceptions. There are three additional
major differences between MBSR and CBSM. First, in mindfulness interventions, there is
a focus on observing, rather than evaluating, thoughts, as is emphasised in CBSM.
Second, CBSM tends to emphasise specific goals, whereas MBSR emphasises not
striving for a specific or measurable goal. Finally, MBSR interventionists are encouraged
to engage in their own mindfulness practices, whereas there is no expectation for CBSM
interventionists to utilise the skills they teach (Baer, 2003; Segal, Williams, & Teasdale,
2002). MBSR may offer unique elements that are not incorporated into CBSM programmes.
There are several potential mechanisms that suggest MBSR could benefit people living
with HIV. Mindfulness generally involves focusing ones attention non-judgmentally
on experiences in the present moment while accepting emotional reactions without
getting caught up in them (Kabat-Zinn, 1982). Mindfulness may allow those who are
experiencing chronic disease to slow down and realistically evaluate their prognosis and
identify aspects of the disease that require action and those that should be accepted (see
Brown, Ryan, & Creswell, 2007 and Carlson, 2012 for reviews). Brown and colleagues
(2007) suggest that focusing on somatic states as a result of MBSR may explain the
amelioration of chronic pain (Cioffi, 1991; Leventhal, Brown, Shacham, & Engquist,
1979; Suls & Fletcher, 1985). Emotion regulation is another potential mechanism through
which distress may be decreased (e.g., Carlson, 2012; Feldman, Hayes, Kumar, Greeson,
& Laurenceau, 2007). For example, Holzel et al. (2011) shows that mindfulness-based
interventions such as MBSR and mindfulness meditation are related to emotion regulation
in the form of acceptance, decreased emotional reactivity and positive reappraisal.
Past reviews regarding the efficacy of MBSR for chronic diseases have noted
promising intervention effects, with one broad review across multiple health conditions
noting some initial support for the utility of MBSR for people living with HIV infection
(Carlson, 2012). However, to our knowledge there has not yet been a review of studies
testing MBSR for specific impacts on people living with HIV. As a chronic illness,
HIV infection may be impacted by MBSR in similarly beneficial ways as other chronic
diseases have.
The aim of the current paper is to review the literature on MBSR for people living
with HIV/AIDS. Our review examines the methodological features of MBSR intervention
Health Psychology Review 227

studies, including content-based consistency and measures of clinical outcomes. We also


offer recommendations based on gaps in the literature for moving forward with future
research.

Method
We followed the preferred reporting items for systematic reviews and meta-analyses
(PRISMA) guidelines for conducting systematic reviews (Moher, Liberati, Tetzlaff,
Altman, & The PRISMA Group, 2009). All 27 items of the PRISMA checklist are
included in this report. For this review, the a priori analysis and inclusion criteria were:
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any intervention study that tested MBSR, defined as manualised MBSR programme with
more than one session (i.e., a programme, beyond a general exposure), specifically with
people living with HIV.
We conducted a multi-source literature search utilizing the following databases:
Medline, PsychInfo including Digital Dissertations and PubMed. Databases were
searched for the occurrence of keywords/phrases at any place in the record: mindfulness,
mindfulness-based stress reduction (MBSR), human immunodeficiency virus (HIV),
Acquired Immune Deficiency Syndrome (AIDS). We inspected the reference sections of
retrieved studies, as well as conceptual/theoretical articles on MBSR. Our review
included published and unpublished studies to avoid excluding studies with null findings.

Data collection
Descriptive information and outcomes were extracted from studies meeting the inclusion
criteria. After discussion and consensus among study team members, we created 10 data
extraction categories: first author and year of publication, study design, number of
participants per group, variables of interest, types of variables, including health, emotional
and behavioural variables, time points at which they were sampled, effect sizes and
statistical results and relevant conclusions. Two authors pilot-tested this data extraction
checklist prior to its use in the study, and disagreements in data extraction were resolved
through discussion. For studies that used a randomised design and did not report effect
sizes, we calculated Cohens d (Cohen, 1992) statistic if sufficient data were available (see
Table 3). Cohens d expresses the mean difference between groups in standard deviation
units, where effect sizes of .2 are small, .5 are medium and .8 are large.

Results
Figure 1 provides a flow chart of our search and selection process. Our electronic
database search yielded 1042 abstracts, including 32 additional abstracts from references
sections of these articles. The final number of articles that met the inclusion criteria was
11 and they were all conducted since 2003. The studies vary widely in terms of outcome
variables measured and their methodological approaches.

Populations studied
The 11 studies included a total of 665 participants, with 388 in the treatment groups and
277 in control groups (see Tables 1 and 2). All randomised controlled trials (RCTs; K = 4)
and wait-list control studies (K = 2) described the demographic characteristics of their
intervention group as similar to the control group. Most studies sampled only HIV-positive
228 K.E. Riley and S. Kalichman
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Figure 1. PRISMA ow chart. This chart details the search and selection process.

men, four had a majority of men along with a smaller number of women, and one study did
not specify sample gender (Weston et al., 2012).
Sampling methods also differed across studies. For example, Robinson, Mathews, and
Witek-Janusek (2003) and SeyedAlinaghi et al. (2012) utilized a convenience sample from
local HIV clinics and programmes. Robinson and colleagues (2003) included those who
were interested in an MBSR course in the treatment group, and those who did not want the
intervention served as a non-randomised wait-list control group, creating a confounding
selection bias; the groups were inherently different based on participants interest or lack
Health Psychology Review 229

thereof in MBSR training(Shannahoff-Khalsa, 2003). Other samples were drawn from


larger studies, which also may have impacted participants. For example, Duncan et al.
(2012) sampled participants from a larger trial and did not detail specifically how the
researchers recruited participants.
Nine of 11 studies were conducted in the USA. Jam et al. (2010) and SeyedAlinaghi
et al. (2012) both sampled HIV-positive patients in Tehran, Iran. All of the participants
recruited in Tehran were recently diagnosed with HIV infection and had an average of
250 CD4+ cell counts, indicating compromised immune systems. Rates of participants on
ART varied across studies, with ART use not differing between MBSR and comparison
conditions.
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Methodological consistency
Methodologically, the 11 studies differed in terms of their design, type of control group
and sampling methods. There were seven studies that included control groups; four that
randomised participants to treatment conditions, two that used a wait-list as a control, and
one that used a quasi-experimental design Robinson et al. (2003) allowed participants
choose the MBSR intervention or the control programme. Four studies reported pre- and
post-test designs for an MBSR treatment group (see Table 1).

Control conditions
There was considerable variation in the type of comparison groups included in the seven
trials that had control conditions. Three studies used wait-list controls. For the four RCTs,
one utilised a one-day stress reduction education seminar (Creswell, Myers, Cole, &
Irwin, 2008), two used an education and support group, focusing on knowledge of HIV
and maintaining positive behavior (SeyedAlinaghi et al., 2012; Weston et al., 2012) and
two utilised treatment as usual (Gayner et al., 2012; Robinson et al., 2003).

Intervention fidelity
Despite the manualised protocol considered standard for MBSR, delivery of the MBSR
interventions differed across trials. Most studies used the manualised MBSR treatment by
Kabat-Zinn (1982) and indicated closely adhering to protocol, two studies did not
implement the standard week seven retreat (Jam et al., 2010; SeyedAlinaghi et al., 2012),
and one trial chose to add cognitive therapy techniques to the MBSR programme as well,
making it more like a mindfulness-based cognitive therapy (MBCT; Segal, Teasdale, &
Williams, 2004; Wood, 2008). MBCT is a theory-based intervention combining Jon
Kabat-Zinns mindfulness training with cognitive therapy (Collard, Anvy, & Boniwell,
2008; Fitzpatrick, Simpson, & Smith, 2010; Segal et al., 2004; Williams et al., 2008;
Wood, 2008). Given the small number of studies and the lack of any components
analyses, it is not possible to know whether divergence from standard approaches to
MBSR account for differences in findings.

Duration of follow-up
The studies that conducted assessments pre- and post-intervention assessments that varied
in length of follow-up. Most studies only measured pre- and immediate post-intervention
outcomes. However, some studies followed participants to assess longer-term impact.
Gayner et al. (2012) measured variables at baseline and again at six months post-
intervention, and Duncan et al. (2012) assessed participants at three and six months
230
Table 1. Articles included in reviewing MBSR for HIV/AIDS populations.
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Emotional and
Peer Variables of Health coping Behaviours
Authors Type of study N reviewed interest outcomes outcomes outcomes Conclusions

Creswell Treatment and wait-list 39 tx, 25 control No CD4+ CD4+ QOL, N/A The MBSR
(2007) control (dissertation) counts counts mindfulness, programme
psychological improved
distress mindfulness,
psychological
symptoms and CD4

K.E. Riley and S. Kalichman


Creswell Small randomized 33 tx, 15 control Yes CD4+ CD4+ N/A N/A Adherence MBSR
et al. (2008) controlled trial (RCT) counts counts programme-mediated
(control = 1 day stress effects of MBSR
seminar) training on buffering
CD4 declines
Duncan Treatment and wait-list 40 tx, 36 control Yes Symptoms Physical QOL, stress, ART MBSR reduced both
et al. (2012) control of ART side positive and adherence the frequency of
effects negative symptoms
of ART affect, attributable to ART
depression
Gayner RCT (control = treatment 78 tx, 39 control Yes Mindfulness N/A Mindfulness, N/A Lower avoidance,
et al. (2012) as usual) avoidance, higher PA, more
positive affect, mindfulness
depression (decrease in avoid,
higher PA, and less
depression 6 months)
Jam Single group (Pilot) 6 tx Yes Psych N/A Psychological N/A Significant increase
et al. (2010) symptoms, distress in CD4 at all time
CD4 symptoms points and on
psychological
symptoms at post-
intervention
Table 1 (Continued)
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Emotional and
Peer Variables of Health coping Behaviours
Authors Type of study N reviewed interest outcomes outcomes outcomes Conclusions

Leaity and Single group (pilot, 7 tx No Depression N/A Positive affect N/A MBSR improves
Hennessey unpublished) and negative affective symptoms
(2006) affect in those with HIV
and depression
Robinson Quasi-experimental 10 tx, 10 control Yes T cell Endocrine Psychological Functional T cell activity and
et al. (2003) activity function distress health number increased in

Health Psychology Review


and T cell symptoms outcomes MBSR group
activity compared to
comparison group.
No sig changes in
psych, endocrine or
functional health
SeyedAlinaghi RCT (control = edu & 81 tx, 86 control Yes CD4+, CD4+, Psychological N/A Improvements in
et al. (2012) support) psych well- medical well-being CD4+ counts (up to
being, symptoms 9 months),
medical psychological well-
symptoms being (up to 6
months) and medical
symptoms (up to 12
months)
Sibinga Single group (Pilot) 5 tx Yes Psych and Physical Psychological N/A Increase in
et al. (2008) physical well-being well- psychological well-
health, being, QOL being
QOL

231
232
Table 1 (Continued)
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Emotional and
Peer Variables of Health coping Behaviours
Authors Type of study N reviewed interest outcomes outcomes outcomes Conclusions

Weston RCT (control = education 71 tx, 61 control Yes hsCRP and hsCRP Depression, N/A No improvements in
et al. (2012) and support) D-dimer and D- anxiety, hrCRP and D-dimer
dimer distress
Wood (2008) Single group (pilot, 27 tx No Depression- Immune Psychological N/A Decrease in
dissertation) related system symptoms, depression, increase
symptoms function QOL, in mindfulness,

K.E. Riley and S. Kalichman


mindfulness, QOL, physical health
coping skills
Health Psychology Review 233

post-intervention. Jam et al. (2010) followed participants at 3, 6 and 12 months after the
intervention, with outcomes varying by time point. For the eight studies that reported
drop-out rates, participant drop-outs averaged 40.6%, ranging from excellent (13.5%) to
extremely poor (81.5%; see Table 2). Only one study reported session completion rates,
with 27% of participants in the intervention group being excluded from analysis for
missing more than 2 sessions, and 31% of the control group excluded for missing more
than 1 session (SeyedAlinaghi et al., 2012).

Peer review
We included three unpublished studies in our review to avoid publication biases against
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null findings. Specifically, Creswell (2007) and Wood (2008) are unpublished disserta-
tions and Leaity and Hennessey (2006) is an unpublished data-set. It should be noted that
these studies have not been subject to peer review. All three unpublished studies did
report positive outcomes form MBSR. The other eight studies examined were peer
reviewed (see Table 1).

Outcome variables
Table 1 summarises the health, emotional, coping and behavioural outcomes from the
MBSR studies. All 11 studies measured psychological variables, 6 measured physical or
biomedical health outcomes and 2 measured behavioural outcomes. However, the types
of variables within these categories varied. Health outcomes typically included CD4+ cell
counts, side effects of ART, endocrine function, general physical well-being and immune
system function. Psychological variables included QOL, mindfulness, general psycholo-
gical distress, perceived stress, positive and negative affect, coping skills and depression
symptoms. The two behavioural variables measured were functional health outcomes and
adherence to ART.

Effect sizes
Among the three studies that reported effect sizes, Gayner et al. (2012) reported Cohens
d calculations for a number of outcome variables at the eight-week intervention
completion assessment and six-month follow-ups. A medium effect size was only found
for positive affect in a time by group interaction (d = .58); the other effect sizes for
measures were small for both time effect and time by group interaction. The impact of
event scale (IES; Horowitz, Wilner, & Alvarez, 1979) measuring living with a stressful
life event, and its subscales (intrusion subscale and avoidance subscale), negative affect
and measures of depression and anxiety [Hospital Anxiety and Depression Scale
(HADS); Snaith & Zigmond, 1983] all had small or non-significant effects. There were
two small effect sizes that were close to meeting criteria for a medium effect size: the IES
total time by group interaction (0.43) and the IES avoidance subscale time by group
interaction (d = 0.46). SeyedAlinaghi et al. (2012) reported effect sizes for changes
within the MBSR and control conditions, with the MBSR effects on CD4+ cell counts
ranging from .65 at the 3-month follow-up to 0.10 at the 12-month follow-up, compared
to the control condition 0.01 to 0.08 across follow-ups. We calculated Cohens d for
differences between conditions and found medium to large effect sizes across all variables
(CD4+ count, SCL-90R, MSCL) across all time points except for CD4+ count at 12
months and SCL-90R 9 and 12 months, which are small. For example, immediately post-
intervention, CD4+ changes d = 5.41, MSCL changes d = 3.41. Additionally, Creswell
234
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Table 2. Demographic and study information for MBSR studies.

Age Randomly
4 Mean (SD) Gender Stage of HIV and ART status Ethnicity assigned Drop-out rates

Creswell (2007) Not specified 83% male Not specified Not specified Yes Not specified
Creswell 41 (11.0) 91.3% male HIV positive for more than 6 months 50% African- Yes 28.4%

K.E. Riley and S. Kalichman


et al. (2008) + distress + no AIDS + American
Duncan 47.5 (9.0) 84% male HIV positive + ART + reported side 53% European Yes 14% at time 27% at
et al. (2012) effect related bother American time 3
Gayner 44 (6.9) 100% male (men who HIV positive. Mean 11 years Not specified Yes 11.9% at time
et al. (2012) have sex with men) 217.9% at time 3
Jam et al. (2010) 35.7 (7.7) 50% male HIV positive Not specified N/A 40%
Leaity and Not specified 100% male HIV positive Not specified N/A Not specified
Hennessey
(2006)
Robinson 43.08 (6.1) 91.7% male HIV positive + ART 83.3% White No 47.9%
et al. (2003)
SeyedAlinaghi 35.1 (6.5) 69% male HIV positive (CD4+ count > 250) Not specified Yes 13.5%
et al. (2012) + ART
Sibinga 13 to 21 50% male HIV positive Not specified N/A 28%
et al. (2008)
Weston Not specified Not specified ART-untreated HIV+ adults with CD4 Not specified Yes Not specified
et al. (2012) + counts >250 cells/l
Wood (2008) 46.3 (8.7) 92.6% male HIV positive 63% White N/A 81.5%
Health Psychology Review 235

(2007) reported effect size changes for CD4+ between treatment and control group after
the MBSR intervention (d = .44).
We also computed Cohens d for the remaining studies with control conditions and
found predominantly medium to large effect sizes across studies. Namely, Creswell et al.
(2008) found a medium effect size for RNA change and a large effect size for CD4+
within the MBSR intervention and by treatment group. Duncan et al. (2012) provided
enough information to calculate effect sizes for side effects, distress, mindfulness and
adherence variables at three months and six months post-intervention. Side effects
demonstrated medium effect sizes at three months (d = .36) and six months (d = .40)
post-intervention and distress variables such as depression and three months (d = .35) and
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six months (d = .42) post-intervention. Overall, there were several medium to large effect
sizes for measured variables, generally suggesting significant treatment effects above and
beyond controls (see Table 3).

MBSR intervention outcomes


Every study that tested MBSR in this review demonstrated some evidence for efficacy
(see Tables 1 and 3). However, findings varied across health, emotional, coping and
behavioural outcome domains.

Health outcomes
Of the eight studies that included health outcomes, four assessed CD4+ cell counts as an
indicator of disease progression with variable effects; CD4+ cell counts increased as
compared to controls (Creswell, 2007), remained unchanged relative to a decline in the
control (Creswell et al., 2008) and increased compared to controls up to the 9-month
follow-up, then declining back to baseline at 12-month follow-up (SeyedAlinaghi et al.,
2012). In one study without a control group, there was a significant increase in CD4+ cell
counts at all time points (Jam et al., 2010). Robinson et al. (2003) also reported an increase
in natural killer cell counts, another important immune system marker (Shannahoff-
Khalsa, 2003).

Emotional and coping outcomes


Ten of the 11 studies measured emotional and coping outcome variables. The one study that
did not assess emotional or coping outcomes (Creswell et al., 2008) was solely focused on
MBSRs impact on health outcomes. Six studies measured general psychological distress
(Creswell, 2007; Jam et al., 2010; Robinson et al., 2003; SeyedAlinaghi et al., 2012;
Sibinga et al., 2008; Wood, 2008), with five showing significant increases in psychological
well-being, or a decrease in negative psychological symptoms. One study reported non-
significant changes in emotional symptoms (Robinson et al., 2003). All four studies that
measured QOL showed increases as a result of MBSR training (Creswell, 2007; Duncan
et al., 2012; Sibinga et al., 2008; Wood, 2008). The three studies that measured self-
reported mindfulness also showed increases as a result of MBSR (Creswell et al., 2007;
Gayneret al., 2012; Wood, 2008). MBSR also demonstrated increases in positive affect and
decreases in negative affect (Duncan et al., 2012; Gayner et al., 2012; Leaity &
Hennessy, 2008).
236 K.E. Riley and S. Kalichman

Table 3. Effect sizes for the six studies with control groups.

Effect size
Study reported? Effect size (Cohens d)

Creswell (2007) Yes CD4+ change = .77


Creswell et al. (2008) No, but enough CD4+ change = 1.50
information to CD4+ *treatment = 1.63
calculate Viral load change = .45
Duncan et al. (2012) No, but enough Medium to large effect sizes between groups
information to in general. For example,
calculate Side effects post= .36
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Side effects 3 months = .40


Distress 3 months = .35
Gaynor et al. (2012) Yes Positive affect time*group = .58
Intrusions, depression, anxiety = <.2
SeyedAlinaghi et al. (2012) Yes For CD4+, SCL-90R and MSCL, MBSR
time by treatment mean change scores had
medium to large effect sizes; Control group
had small to medium effect sizes, at post,
3 month, 6 month, 9 month, and 12 month
follow-up (see Seyedalinaghi et al., 2012,
Table 3). Computed between group effect
sizes were medium to large (e.g., CD4+
change post treatment by group d = 3.12).
Weston et al. (2012) No, and not enough Cannot calculate
information to
calculate

Behavioural outcomes
Only two behavioural variables were reported in these trials: antiretroviral adherence
and functional health, with no significant changes observed for either outcome (Duncan
et al., 2012).

Summary of results
Taken as a whole, the studies reviewed offer preliminary support for positive effects of
MBSR on the health, emotional well-being and coping of people living with HIV
infection. Considering the pervasive effects of HIV infection on well-being, and because
there was evidence for MBSR potentially impacting immune functioning, additional
study of the health benefits of MBSR interventions in HIV-positive patients is warranted.
The relatively small number of studies conducted suggests that some health improve-
ments, particularly CD4+ cell counts, may be more durable than positive psychological
outcomes. One important question for future research is whether psychological changes
mediate the effects of MBSR on health improvements. Another potential mediator that
has been linked separately to both MBSR and HIV disease progression is coping styles
(e.g.,Witek-Janusek et al., 2008). Improved adaptive coping may alleviate maladaptive
coping, such as substance use, that itself has adverse effects on the immune system and
impedes medication adherence. Other potential explanatory variables should be included
Health Psychology Review 237

in future MBSR intervention trials, such as access to services, social support and stage of
HIV disease.
The studies also suggested benefits of MBSR for general psychological well-being
and QOL. Future research will be more informative if general distress is decomposed into
more specific components, such as depressive or anxiety symptoms. Similarly, the
general well-being variable measured in these studies would also be more informative if
operationalised with greater specificity. Research regarding MBSRs impact on specific
psychological disorders such as clinical depression and anxiety disorders among people
living with HIV is also needed.
Results of this review indicate that the studies conducted to date are limited in their
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assessment of functional or behavioural outcomes. Only two studies measured these


important outcomes, one of which was a quasi-experimental study (Robinson et al.,
2003). It is therefore not possible to draw reliable conclusions about the effects of MBSR
on behavioural outcomes. It is critical that future MBSR trials include state of the science
measures of ART adherence, medical appointment adherence and health behaviours such
as substance use, sleep and nutrition.
In comparing outcomes of studies that were among the more methodologically sound
(i.e., the four RCTs) to the less methodologically sound studies, the more rigorous trials
provided stronger and more consistent results in support of MBSR, including impact on
CD4+ cells and psychological well-being. These findings are encouraging and suggest
moving forward with more rigorous tests of MBSR for people living with HIV.

Recommendations for future research


The lack of methodological rigour in a number of the reviewed studies limits our ability
to draw conclusions. However, the relative strengths and weakness of the studies offer
directions for future trials testing the efficacy of MBSR. Specific recommendations for
improved future research are discussed below.

Control conditions
Trials testing MBSR for people living with HIV will benefit from inclusion of treatment as
usual, as well as alternative interventions for people living with HIV. Trials with three
conditions, MBSR and two comparisons, are warranted at this stage of research given the
positive effects from two-condition RCTs. Future trials can therefore remove confounding
effects of participants assigned to an MBSR condition receiving other mental health
interventions. For example, in one study we reviewed, 56% of participants receiving MBSR
were already enrolled in psychotherapy (Gayner et al., 2012). Controlling exposure to
multiple interventions will inform whether MBSR adds to treatment as usual. Including
alternative interventions, such as CBSM or Dialectical Behavior Therapy, within the same
study design can allow for comparisons of differential effectiveness relative to standard of
care. These more complex designs may answer critical questions about any unique
contributions of MBSR to improving outcomes for people living with HIV.

Alternative interventions
This review of MBSR for persons living with HIV should be considered in the context of
other interventions for improving health, emotional and coping and behavioural outcomes.
Other mindfulness-based interventions may have similarly promising effects. MBSR seeks
to increase mindfulness, so other interventions beyond the manualised MBSR interventions
238 K.E. Riley and S. Kalichman

reviewed here, that also impact mindfulness may be useful for people living with HIV. Baer
(2003) reviews differential outcomes for MBSR, MBCT, as well as other interventions that
incorporate aspects of mindfulness such as dialectical behavioural therapy, acceptance and
commitment therapy and relapse prevention. Mindfulness meditation should also be
considered in this family of interventions (Davidson et al., 2003). Comparisons of
MBSR with yoga and meditation may also shed light on the parameters of mindfulness
interventions (Shelov, Suchday, & Friedberg, 2009). Yoga and meditation are both
components of the MBSR interventions, and are now independent interventions for
populations with chronic health conditions (see Ross & Thomas, 2010, for a review).
Research is needed to extend these approaches to people living with HIV.
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As noted earlier, some versions of CBSM interventions have mindfulness components


(Antoni et al., 2000). How different these interventions are depends on implementation
protocols, adaptation and fidelity. Better operationalisation of specific interventions, as well
as further study about the differential impacts (if any) on outcomes, is an important avenue
for future research. An important question going forward is whether MBSR is as beneficial
as CBSM for people living with HIV infection. There are substantially more rigorous trials
testing the effects of CBSM for people living with HIV (see Antoni, 2003; Brown
&Vanable, 2008; Scott-Sheldon, Kalichman, Carey, & Fielder, 2008 for a review). It is also
possible that MBSR may be particularly helpful for certain sub-populations. For example,
MBSR may be more appealing to individuals that are more exposed to meditative practice
and less exposed to cognitive therapy work. MBSR may be more attractive to those from
eastern cultures, and using MBSR may increase intervention adherence in that population.
The intervention that an individual may respond best to may also be a function of gender,
socio-economic status and other person variables. For example, more women than men
practice and prefer yoga, a type of mindfulness intervention (Birdee et al., 2008). Should
future trials continue to demonstrate positive outcomes from MBSR, there will be a
pressing need for larger comparative effectiveness trials that compare MBSR to CBSM.

Components analyses
MBSR is a multi-component intervention that will benefit from therapy deconstruction
study designs. Of particular importance will be studies that experimentally manipulate the
inclusion and exclusion of the day-long retreat that is considered a standard element of
MBSR and has been omitted from some trials. In addition, some approaches to CBSM
have included mindfulness activities that have not yet been tested independent of the
CBSM elements. It is possible that the day-long retreat does not add to the effects of
MBSR and that mindfulness activities add significantly to the effects of CBSM. In both
cases, systematically manipulating these intervention elements will answer questions
about their independent and added effects. Factorial designs, where individuals assigned
to conditions do and do not receive specific components offer parsimonious approaches
to answering these critical questions.

Intervention fidelity
Interventionists for MBSR should be trained in the manualised approach, and a
description of the type of intervention, as well as the training, should be described.
Interventionist supervision should be sustained over the entire trial to maintain fidelity.
Quality assurance checks, session monitoring and mechanisms for correcting drift away
from protocol are all essential for future MBSR intervention trials.
Health Psychology Review 239

Outcome variables
Outcome variables with greater specificity will yield clearer trial outcomes. With respect
to physical health, studies should continue to include CD4+ cell counts as well as other
markers of immune functioning, such as natural killer cells and HIV RNA viral load.
HIV-related symptoms, medication side effects and co-occurring opportunistic infections
are important aspects of HIV-related health. In terms of mental health, beyond global
distress, measures of negative affect, mood, depressive symptoms, anxiety symptoms,
QOL and reactions to stressful events will provide evidence for relative impacts of MBSR
on emotional well-being. In addition, depression and anxiety should be assessed with
instruments designed from medical populations or using forms of standard scales that do
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not include somatic symptoms that often overlap with symptoms of advancing HIV
disease (Kalichman, Rompa, & Cage, 2000). Importantly, studies should assess
behavioural outcomes including state of the science measures of ART adherence, such
as home-based pill counts (Bangsberg, Hecht, Charlebois, Chesney, & Moss, 2001;
Kalichman et al. 2007) and pharmacy refills (Grossberg & Gross, 2007) as well as
measures of medical appointment adherence and adaptive coping responses. Finally,
studies should include measures to assess potential mechanisms of MBSR intervention
effects. For example, measures of mindfulness, as well as other proposed mechanisms of
change as a result of MBSR, such as types of emotion regulation, acceptance, decreased
emotional reactivity and positive reappraisal should be studied.

Intervention settings
Attending to the target population is important in designing the intervention. As discussed
previously, psychological stress is prevalent among individuals with HIV, many of whom
face poverty, discrimination, homophobia and stigma (Howland et al., 2000). These
aspects of living with HIV can direct optimal implementation of MBSR. For example,
holding the MBSR sessions in accessible community health centres or social services as
well as providing transportation to sessions, will help reach those in the most need.
Empirical research has emphasised the importance of considering utility when
implementing health interventions (Head & Noar, 2014; Wallace, Brown, & Hilton,
2014). Intervention trials are therefore needed in community service as well as clinical
settings.

Conclusion
With all of the above caveats regarding the limited number of studies, sample sizes and
methodologies, we conclude that the current literature on MBSR used for improving the
mental and physical health of people living with HIV warrants further study. We
recommend that researchers conduct trials that include control groups focused on
examining efficacy, mechanisms of change and mediators of positive outcomes. In
addition, the field should move towards conducting comparative trials that include
established efficacious interventions such as CBSM. Additionally, as more trials are
concluded, there may be need for translational research to determine optimal implementa-
tion strategies for MBSR in healthcare as well as alternative community-based settings. As
people living with HIV live longer and healthier lives, interventions are needed to bolster
treatment effects and improve QOL. We believe the emerging literature on MBSR offers
sufficient support to encourage more research in this area.
240 K.E. Riley and S. Kalichman

Note
1. In this article, the term stress will be used to indicate psychological stress.

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