Complementary Therapies in Clinical Practice 33 (2018) 12–19
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice
journal homepage: www.elsevier.com/locate/ctcp
Mindfulness-based intervention among People living with HIV/AIDS: A
Systematic Review
Amir Bhochhibhoyaa,∗, Brandon Stoneb, Xiaoming Lic
a
Lander University, School of Nursing, 320 Stanley Ave, Greenwood, SC, 29649, USA
b
The University of Oklahoma, Department of Health and Exercise Science, 1401 Asp Ave, Norman, OK, 73019, USA
c
The University of South Carolina, South Carolina SmartState Center for Healthcare Quality, 915Greene Street, Columbia, SC, 29208, USA
1. Introduction
Unprecedented progress in the areas of public health, pharma-
cology, clinical care, and medical science has gradually shifted HIV
infection from an inevitable fatal condition into a manageable chronic
disease. A recent study reported that people living with HIV/AIDS
(PLWHA) are expected to live in their early 70's (which approaches life
expectancy of the general population). Specifically, those who are
treated before their CD4 counts fall below 350 cells/mm3 [1,2]. Al-
though great advances, such as antiretroviral therapy (ART), have in-
creased live expectancy for PLWHA, a high degree of psychological and
physical distress persists [3–6]. PLWHA accrues additional unique
stressors in conjunction with general stressors associated with chronic
diseases. These unique stressors may include chronic life threating
conditions, loss of perceived control over health, pressure to strictly
adhere to a medication regimen, anticipatory grief, excessive stigma
and changes of major behavioral changes such as sexual behavior [7,8].
These stressors directly (by suppress immune response, stimulating
viral replication, and diminution of the CD4+T cell) and indirectly (by
impeding ART adherence and treatment access) impacts the progression
of HIV/AIDS [9–13]. In addition to disease progression, it also affect the
psychological health and quality of life which often triggers the onset of
additional complications including anxiety, depression, tardiness,
sleeplessness, headaches, despair, and weight gain [14]. This evidence
suggests that PLWHA's wellness (including physical and mental health)
and overall Quality of Life (QoL) is impaired due to chronic stress and
depression [11].
To reduce these aforementioned negative impact of stressors in
PLWHA, various mindfulness-based interventions (MBI) have been in-
vestigated. These include Mindfulness-Based Stress Reduction (MBSR),
Yoga, Qigong, TaiChi, and various meditation and breathing techniques
[15,16]. Mindfulness is commonly defined as the state of being aware of
and attentive to the present surroundings [17]. Thus, MBI attempt to
enhance a state of consciousness to improve overall health and well-
ness. Several studies have studied MBI and its utility in coping with
stress, improving physical and mental health, QoL, and other
∗
Corresponding author.
E-mail addresses: abhochhibhoya@lander.edu (A. Bhochhibhoya), Brandon.l.stone@ou.edu (B. Stone), xiaoming@mailbox.sc.edu (X. Li).
https://doi.org/10.1016/j.ctcp.2018.07.002
Received 5 June 2018; Accepted 10 July 2018
1744-3881/ © 2018 Elsevier Ltd. All rights reserved.
T
physiological parameters [8,18–21].
Irrespective of increasing use of MBI, there is a lack of compre-
hensive understanding of MBI improving stress-related outcomes (an-
xiety, depression, and positive mood, substance use, pain, sleep, and
overall quality of life) among PLWHA. Based on the Cochrane library
database search and literature review, very few systematic reviews have
been identified in this specific area. Also, available reviews were either
limited to one specific MBI (e.g. MBSR or Yoga) [22–24] or did not
specifically focus on PLWHA [22,23,25]. To the best of our knowledge,
there has not been any review that has evaluated the efficacy of MBI in
PLWHA.
The purpose of the present review was to conduct a comprehensive
and up-to-date assessment of the MBI literature with a focus on iden-
tifying key components and their effects on stress-related outcomes
among PLWHA. Specifically, this review aims to answer the following
three research questions.
1. What are the key attributes of the MBI?
2. What is the efficacy (or harms if any) of MBI on stress-related out-
comes?
3. What is the impact of the MBI on HIV/AIDS disease progression
among PLWHA?
2. Methods
2.1. Study search and selection strategy
A literature search was performed utilizing the following databases:
Alt HealthWatch, CINAHL Plus with Full Text, PubMed, PsycINFO, and
Web of Science with full text through October 2017. The keywords used
for the search included: Mindfulness-based, Mindfulness-based Stress
Reduction (MBSR), Mindfulness-based Cognitive Therapy (MBCT), Mind-
body Therapies, Yoga, Qigong, and Meditation in combination with HIV. A
Boolean search strategy was implemented. The review process followed
the Preferred Reporting Items for Systematic Reviews and Meta-analysis
(PRISMA) statement [26].
A. Bhochhibhoya et al.
Table 1
Criteria for inclusion/exclusion of studies in the review.
Inclusion
Population and condition Adult populations (18 years or older) who have been diagnosed
of interest with HIV
Interventions Structured mindfulness-based intervention with a minimum of 4 h
of instructor-guided training. Such as MBSR, MBCT, Qigong,
Yoga, and Meditation)
Comparisons of interest Compare to other control group which could include participants
engaging in other forms of intervention such as exercise, social
support etc.
Outcomes Quantitative response from stress-related scales; Conditions
specific to HIV/AIDS; and other health conditions
Study Design Randomized Controlled Trials and Quasi-experimental studies;
Longitudinal studies
a
Studies published in abstract only form (posters, oral presentations) and dissertations.
Inclusion criteria for screening articles were: (i) population:
PLWHA; (ii) intervention: MBI such as MBSR, MBCT, Yoga, Meditation,
and Qigong; (iii) design: randomized control trial and quasi-experi-
mental; (iv) outcome: stress-related physical and mental health, QoL,
and physiological biomarkers; (v) publication: peer-reviewed articles
with full-text availability in English. The comprehensive list of inclu-
sion and exclusion criteria is provided in Table 1.
The initial search identified 423 articles (Alt HealthWatch = 13,
CINAHL Plus with Full Text = 62, PubMed = 227, PsyInfo = 40, Web
of science = 81). After removing duplicate articles and subsequent
screening 43 articles remained. In addition, seminal works referenced
by the authors of the publications that met the original inclusion cri-
teria or relevant systematic review were manually explored and 2 ar-
ticles were identified. The abstracts of the 45 studies were screened by
two independent reviewers to identify articles meeting the inclusion
criteria. This process led to excluding 21 articles. The remaining 24
articles were considered for full-text review. After full-text review, 9
articles were excluded due to not meeting inclusion criteria (not related
with mindfulness-based intervention (n = 3), no control group (n = 2),
participants under 18 years old (n = 2), not RCT or quasi experimental
(n = 1), not related with HIV population (n = 1). Eventually, 15 arti-
cles were included in the review and data synthesis process. This article
selection process is presented in Fig. 1.
2.2. Data extraction
The following data was extracted from the selected articles for the
review: (i) study details and sample population (author, year, location,
participants eligibility criteria, sample characteristics); (ii) intervention
attributes (type, key components, intensity, frequency, program dura-
tion, attrition, and program feasibility); (iii) Outcome Measurements
(measurements, outcomes, and salient outcomes).
3. Results
Table 2 shows the synthesis of the study population based on the
article reviewed. A majority of the studies were conducted in the United
States (US = 8, India = 2, Iran = 2, Spain = 1, Canada = 2). Out of 15
studies, 13 were randomized controlled trial and 2 were quasi-experi-
mental. Frequently stated eligibility criteria for the participants in the
studies included: Participants with a CD4 T-cell count of at least
200 cells/mL (n = 6), no substance use issues (n = 6), and no sig-
nificant mental health issues (n = 10). The sample size in the studies
varied from 22 to 175 [32,35], with most of the studies (n = 12) having
a sample size less than or around 30. The average age range of the
participants in the studies ranged from 34 to 50 years old [20,21]. The
average number of years of HIV diagnoses was reported in seven stu-
dies, ranging from 6.5 to 19.8 years [31,35].
13
Complementary Therapies in Clinical Practice 33 (2018) 12–19
a
Exclusion
People without HIV or not diagnosed with HIV; Children (under 18 years old) as
mindfulness-based intervention administered to children is different in nature
Lacking mindfulness component of the intervention
N/A
Qualitative response on stress-related outcomes or HIV/AIDS-related outcomes
as it might need different set of analysis; Mortality rate from HIV/AIDS after the
intervention is not included as this will require longer follow up period
Nonrandomized designs such as observational studies; articles without original
data (editorials, reviews, and comments); and dissertations
3.1. Intervention key attributes
Table 3 reports the key attributes and feasibility issues of MBI. The
most frequently used MBI were Yoga (n = 5) and MBSR (n = 5). Other
forms included MBCT (n = 2), Tai Chi (n = 2), and Transcendental
meditation (n = 1). Key components specified in the studies included:
bodily movement (n = 12), meditation (n = 10), breathing techniques
(n = 6), group discussion (n = 3), and relaxation techniques (n = 2).
Auxiliary components included a focused gaze, cultivating mindfulness
in daily activities, cognitive exercise, and guided imagery. Instructor
guided in-class training ranged from 10 to 50 h [19,33]. Ten of the
fifteen studies explicitly suggested home-based practice. The number of
hours recommended for home-based practice ranged from 20 to 120 h
[19,20]. Duration of intervention ranged from 4 to 24 weeks, with a
majority at 8 weeks (n = 9) [20,32]. The attrition rate of the studies
ranged from 0% to 48% [20,34]. Positive aspects of MBI as mentioned
in the studies included cost-effective (n = 4), supported/accepted by
the target population (n = 7), and simple to administer (n = 3). Major
challenges raised across studies were small sample size (n = 11) and
the short duration of the program (n = 5). Additional challenges in-
cluded high attrition rate (n = 5) due to time commitment and incon-
venience, the likelihood of HIV disclosure (n = 1), participants com-
pensation (n = 1), and difficult in implementing the intervention in
non-clinical settings (n = 1).
3.2. Stress-related outcomes
Table 4 summarizes the synthesized MBI stress related outcomes.
Frequently measured outcome variables included QoL (n = 10), stress
(n = 8), anxiety and depression (n = 5), and endocrine response to
stress (n = 3). QoL was most often measured utilizing via the MOS-
short form (SF)-36 questionnaire. Stress, anxiety, and depression were
assessed via the Perceived Stress Scale, the Hospital Anxiety and De-
pression Scale and the Beck Depression Inventory, respectively. Ad-
ditionally, saliva, cortisol, and DHEA-S were common measurements of
the endocrine responses to stress. Other variables that were relevant
across studies were loneliness, social support, mindfulness, mental
health, positive and negative affect, spirituality and ART side effects
and adherence.
Of the 10 studies that measured QoL, the effectiveness of MBI was
significant (p < 0.05) in 8, while the remaining 2 studies did not reach
significant improvement. Eight studies measured perceived stress and 4
reported MBI as a significant reduction in total perceived stress while 3
studies reported the reduction not statistically significant and 1 study
reported the perceived stress levels elevating post-intervention. Out of
five studies that measured anxiety and depression 3 noted the sig-
nificant effect (p < 0.05) of MBI, while other two studies did not find a
significant effect. Of the 3 studies examining endocrine responses only
A. Bhochhibhoya et al.
Identification
Records identified through
database searching (n =423)
Records for title and
keywords assessment (n
=336)
Screening
Records for abstract review
(43) and manually identified
(2) (n=45)
Eligibility
Full-text articles assessed for
eligibility (n =24)
Included
Studies included in the data
synthesis (n=15)
Fig. 1. Article selection process for systematic review.
1reported a reduction of stress and anxiety.
3.3. HIV/AIDS disease progression
Among the 15 studies, 9 studies reported immune and virological
status (Table 4). Immune and virological status was assessed using one
or combination of following measures: HIV RNA level (n = 3), CD4
count (n = 7), CD8 count (n = 1), and expression of CD38 and HLA-DR
on CD4 and CD8 T cell (n = 1) as an indicator of HIV/AIDS status and
progression. Studies examining RNA levels did not see a significant
change while CD4 counts were increased in 4 studies but were not
significant in their change in 3 studies [19,28,31]. Expression of CD38
and HLA-DR on CD4 and CD8 T cell counts indicated that MBI lowered
the change in HD effectors CD8+ HLA-DR + CD38 + frequency of
CD8+ T cells, indicating the possibility for immune activation stabili-
zation [20].
4. Discussion
The purpose of this systematic review was to conduct a compre-
hensive and up-to-date assessment of MBI, focusing on identifying key
components, effects on stress and HIV related outcomes among PLWHA.
The present review suggests MBI as a mutilifaceted and key components
varied widely in each study. Some studies were based on the standard
guidelines (MBSR, MBCT) and while other lacked specific protocol it
(Yoga, Tai chi). However, both standard and non-standard intervention
mainly included, bodily movement, breathing technique, and medita-
tion [18,27,32]. These components may have been incorporated in the
MBI's due to their complementary nature in stress management. In the
future, systematically manipulating these components may answer
questions about their independent and combined effects as well as
identify standardizing future interventions.
Results of the MBI on stress and stress-related outcomes provided
moderate evidence of improvements on stress, anxiety, depression,
mental health, and QoL [18,31]. MBI were most effective in enhancing
QoL (n = 8) followed by reducing stress (n = 4). The effect size of MBI
in reducing stress corroborates with another review conducted by Goyal
14
Complementary Therapies in Clinical Practice 33 (2018) 12–19
Duplicate articles removed
(n=87)
Articles excluded based on
title and keywords
assessment (n=293)
Irrelevant articles excluded
from abstract review (n=21)
Full-text articles excluded
with reasons (n=9)
et al. [25]. Their meta-analysisreported moderate to low evidence of
meditation program for improving anxiety, depression, perceived
stress, and QoL among diverse adults with chronic health conditions.
Another preliminary review of MBSR interventions among PLWHA
showed small effect sizes on stress-related outcomes [24]. This suggests
that emerging literature offers sufficient support for MBI in producing
small to moderate reductions on multiple negative outcomes of stress.
Finally, the assessment of the impact of MBI on HIV/AIDS disease
progression indicated its effectiveness in diseases related outcomes.
Evidence of MBI impact on immunological and RNA level was not
significant, with all studies reporting indifference as non-significant in
the post intervention. Additionally, 3 out of 7 studies reported no sig-
nificant changes in the CD4 count (immunological status). Thus, the
effects of MBI were mixed. Our findings are similar to the review study
conducted by Riley and Kalichman [24]. This particular review ex-
plored the effect of MBSR on PLWHA, and identified 2 studies (of 4)
that measured CD4 counts as significant pre-to post-intervention.
Considering available evidence for MBI potentially impacting immune
functioning, additional investigations are warranted. The literature
suggests that the increase in CD4 cell counts due to MBI could be direct
(weakening viral replication process, activating immune response
system) or indirect (healthier stress coping method, social support, ART
adherence [9,11,13]. Overall findings from this present review identify
additional evidence on MBI and its effect on immunological and viral
load among PLWHA.
4.1. Knowledge gap
Based on the literature in this systematic review, a few methodo-
logical concerns were identified. First, studies varied widely in terms of
study duration (10–50 h of in class instruction and 20–120 h re-
commended home-based practice), instructor qualifications, and attri-
tion rate (0%–50%). Similarly, the studies included in the review lack
consistency in terms of other key attributes (trainers who met specific
criteria, measurement of primary and secondary outcomes, dose and
duration of the program etc.) making comparisons across studies dif-
ficult to elucidate. With the proliferation of numerous interventions
A. Bhochhibhoya et al. Complementary Therapies in Clinical Practice 33 (2018) 12–19

Table 2
Description of study population.
Source Location Types of study Eligibility Criteria Intervention Group Control Group

[18] Florida, USA RCT a

• Crack Cocaine users • NAge==1247.0
(M = 8, F = 4) • NAge==1249.3
(M = 7,F = 5)
• N = 20 ± 8.9 • N = 27 ± 4.1
[27] Quebec, Canada RCT a
• Abstain from alcohol, drug, and smoking prior
to 2 weeks and during the intervention
• •
• Clinically
issues
stable and no major mental health

[19] Washington, USA RCTa • CD4 T-cell count > 200 cells/mL • NAge==2945(M±=622, F = 7) • NAge==2145(M±=1015,F = 6)
• Plasma HIV RNA < 15000 copies/mL • Years HIV positive = 11 ± 5 • Years HIV positive = 11 ± 6
• AtStable
least one CVD risk factors • •
• of cARTand with no plans to change current use
[20] Pennsylvania, USA RCTa • Stable on antiretroviral treatment • NAge==1149.7
(M = 9, F = 2) • NAge==1150(M±=4.4
9, F = 2)
• CD4+ T-Cell count > 300 and plasma viral • Years HIV ± 7.1 • Years HIV positive = 11.2 ± 6.2
load of < 200 copies/ml in the past 6 months • positive = 16.5 ± 6.8 •
• No Hepatitis C, Diabetic and not on steroids
• Mini-mental test score of ≥25
[28] California, USA RCTa • HIV positive for > 6 months • NAge==3340(M±=930, F = 3) • NAge==1542(M±=1113, F = 2)
• CD4 > 200 cells/mm3 • Years HIV positive = 6.5 • Years HIV positive = 5.4
• No substance abuse or psychiatric treatment in
the past 30 days
• •
[29] Indiana, USA RCTa • Taking ART regimen and reporting side effect- • NAge==4047.9
(M = 33, F = 7) • NAge==3648.2
(M = 31, F = 5)
related bother as 8 or above on Symptom
Distress Scale
• ± 6.8 • ± 9.1

• Not enrolled on another behavioral coping or

HIV adherence intervention
• No major mental issues, substance abuse issues
[30] USA RCTa • Age between 20 and 60 • N = 38
• People with advanced HIV/AIDS
• CD4 cell count < 200 in past 12 months
• Not a patients related to central nervous
system and/or pulmonary disease
[36] Toronto, Canada RCTa • No major depression, significant cognitive • NAge==7842.9
(M = 78, F = 0) • NAge==3945.5
(M = 39, F = 0)
deficit and substance abuse issue • Years HIV positive
± 7.1 • Years HIV positive
± 6.7
• = 9.4 ± 6 • N = 20(M = 10,F ==10)10 ± 6.7
[31] Barcelona, Spain RCTa • HIV infection for at least 15 years (pre- • N = 19 (M = 10, F = 9) • Age = 49.7 ± 4.7
HAAART era) and been on cART for at least 5 • Age = 49.2 ± 5.7 • Years HIV positive = 19.8
years • Years HIV positive = 19.8 • N = 30(M = 11,F = 19)
[21] Maharastra, India RCTa • Healthy people living with HIV • NAge(median)
= 31 (M = 11, F = 20) • Age(median) = 30.5
• CD4 > 400 cell//μl • = 34 •
• Not on ART
• No cardiac problems, jaundice, tuberculosis
[32] Manipur, India RCTa • No active infection, severe weakness, and • N•Age= 22= 36.92
(M = 10, F = 12) • NAge==2235.36
(M = 14, F = 8)
under psychiatric medications ± 5.41 • Not provided ± 8.27
[33] Virginia, USA RCT a
• No significant psychiatric illness or cognitive • N = 59 (M = 35, F = 24)
impairment • Age = 42.3 ± 8.3
[34] Illionis, USA Quasi • Self-reported diagnosis of HIV seropositive • NAge==2443.08 (M = 22, F = 2) • NAge==1036.1
(M = 10, F = 0)
experimental • Years HIV ± 6.07 • Years HIV positive
± 8.03
• positive = 8.62 ± 3.46 • = 7.4 ± 4.67

[1] Tehran, Iran Quasi • Not treated for physical and psychological • NAge==24(M = 0, F = 24)
experimental illness • 54.5
[35] Tehran, Iran RCTa • CD4 > 250 cells/mm3 • NAge==8534.7
(M = 55, F = 30) • NAge==8635.6
(M = 63, F = 23)
• No substance addiction • ± 6.1 • Years HIV positive
± 6.1
• No current psychosis or history of Post-
Traumatic Stress Disorder
• Years HIV positive = 6.5 • = 6.5

• No clinically symptomatic sexually

transmitted disease (eg. herpes)

a
Radomized Control Trial.

among PLWHA claiming to be MBI, it is important to operationalize the MBI.

concept of MBI so that it can be used as a guideline to design future
interventions. Second, a majority of the literature utilized self-reporting
4.2. Clinical implications and future directions
instrument for stress, anxiety, depression, quality of life, social support,
etc. Self-reporting measures can be questioned for their accuracy due to
The evidence in the present study suggests that MBI assist in stress
the subjective nature of reporting, limiting the accuracy of results.
reduction and other relevant ailments (quality of life, anxiety, depres-
Future studies may benefit from use of objective measures of stress such
sion, and overall wellbeing). This warrants further research to enhance
as endocrine response to stress as well as identifying the potential
the effectiveness of MBI by addressing conceptual and methodological
mechanism by which MBI affects the different stress-related outcome.
issues identified by this review. Future research can focus on longer-
Furthermore, most of the studies mentioned the issue of small sample
term interventions, which may yield greater outcomes in reducing
size and short-term follow-up. The short-term intervention and under-
stressors and disease progression, as previous evidence suggests that
powered sample sizes prevent from determining significant effects of
MBI require long-term adherence and skill building [25]. Though

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A. Bhochhibhoya et al. Complementary Therapies in Clinical Practice 33 (2018) 12–19

Table 3
Description of Intervention in chronological order.
Source Intervention/Control Key Components Program Program Features

Class (hrs) Home (hrs) Duration Attrition Strength Challenges

(weeks)

[18] Yoga/NSc • Bodily Movement 16 NS 8 17% • Widely supported • Inadequate sample

• Breathing • High attendance rate • Short term follow up
Techniques • Accepted by the target
• Meditation population
• Relaxation
Techniques
[27] Art of Living (Yoga)/ • Bodily Movement 15 day Y-NS 12 33% • Positive and profound • High attrition
SoCd • Breathing residence experience reported • Inadequate sample
Technique • Useful skill sets learned
• Group
Discussion
for everyday live

• Meditation
[19] Yoga/SoCd • Bodily Movement 50 20 20 15% • Cost effective • Increase in perceived
• Breathing • Simple to administer pain among
Technique • Popular among participants
• Focused Gaze participants
[20] Transcendental NSc
25 120 24 0% • Feasible and acceptable • Inadequate sample
Meditation/ intervention • Short term follow up
Education • Group Support
[28] MBSRa/Education • Bodily Movement 40 28 8 25% • Cost effective • Inadequate sample
Seminar • Group Discussion • Group Support • High attrition
• Meditation • Short term follow up
[29] MBSRa/NSc • Bodily Movement 30 48 8 14% • Assessment of side effects • Adherence to classes
• Meditation • Simple to administer • No effects of secondary
measures
[30] Tai chi/SoCd • Bodily Movement 16 NS 8 25% • Cost effective • Time commitment
• Group Discussion • Group support • Transportation problems
• Meditation • Physical problems
• Inadequate sample
[36] MBSRa/SoCd • Cultivating 32 48 8 40% • Highly accepted by the • High attrition
Mindfulness in
Daily Activities
gay HIV community • Inadequate sample
• Meditation
[31] b
MBCT /NS c
• Bodily Movement 20 36 8 5% • Low attrition • Inadequate sample
• Cognitive Exercises • Short term follow up
• Meditation
[21] Yoga/SoCd • Breathing 24 Y-NS 12 17% • Practiced in daily life • Inadequate Sample
Technique • Simple to administer • Likelihood of HIV status
• Meditation • Cost effective disclosure
• Non-invasive • Short term follow up
[32] Yoga/NSc • Bodily Movement 24 NS 4 NS • Use of specified validated • Inadequate sample
• Breathing
Techniques
yoga protocol and
assessments tool
• Lack of objective
assessment such as bio-
• Meditation markers
• Relaxation
Techniques
[33] Tai chi/Wait list • Bodily Movement 10 NS 10 Not Available • Preferred by participants • Inadequate sample
control group • Breathing
Technique
• Guided Imagery
[34] MBSRa/Education • Bodily Movement 30 42 8 48% • More acceptable to • Inadequate sample
and Support • Meditation motivated and
committed subgroup
• High attrition
[1] MBCTb/NSc • Bodily Movement 16 NS 8 0 • Suitable and proper • Difficult to implement
• Cognitive Exercises method to reduce intervention in non-
• Meditation loneliness and increase
quality of life
clinical setting

[35] MBSRa/Education • Bodily movement 40 28 8 30% • Group based intervention • Need to compensate
and Support • General Discussion • High attrition
• Meditation
a
MBSR = Mindfulness-based Stress Reduction.
b
MBCT = Mindfulness-based Cognitive Technique.
c
NS = Not specified.
d
SoC = Standard of Care.

potential barriers of this are the various challenges present with this addition, to long term interventions, future interventions may benefit
population [27] suggest that benefits of the MBI are not sustainable if from including a larger sample size. This may address under powered
the interventions are not continued. Thus, future studies can improve data analyses that prevent MBI impact. Other areas to address include
outcomes by addressing both the barriers and benefits of MBI [24]. In four aspects (key components, trainer qualification, the intensity of the

16
A. Bhochhibhoya et al. Complementary Therapies in Clinical Practice 33 (2018) 12–19

Table 4
Description of outcome measurements.
Source Instrument Variable measured Outcome

f
[18] MOS -Short Form (SF)-36 Quality of life SF-36 score did not changed significantly
PSSi Stress Perceived stress score lowered significantly compare to baseline [F(1.9,17.1) = 3.6; p = 0.05]
IESe Distress IESe score did not changed significantly
Saliva cortisol and DHEA-Sb Endocrine response to stress Cortisol, DHEA-S2, and cortisol-to-DHEA-S2 ratio did not changed significantly
[27] Mental Health Index Mental health MHI score lowered significantly compare to control group (p = .03)
MOSf-HIV Health Survey Quality of life MOSf-HIV Health survey score increased significantly compare to control group for its 3
subscales (General Health (p = .02), Social Function (p = .001), and Cognitive Function
(p = .02)
Daily Stress Inventory Stress DSI scores changed significantly for IES5 (p = .01) and ratio of events to impact (p = .04)
[19] MOSf-Short Form (SF)-36 Quality of life SF-36 score did not changed significantly
CD4 T cell count and HIV RNA level Immune and virological CD4 T cell count and HIV RNA level were unchanged
status
[20] Serum norepinephrine and cortisol Endocrine response to stress Lowered Cortisol (0.14 ± 1.17) and Norepinephrine (0.13 ± .64) slightly compare to baseline
levels
Expression of CD38 and HLA-DR on Immune and virological Lowered change in HD Effectors CD8+ HLA-DR + CD38 + frequency of CD8+ T cells compare
CD4 and CD8 T cell status to control group (p = 0.0633)
PSSi Stress Lowered perceived stress score by 1.27 ± 4.3 compare to baseline
MOSf-Short Form (SF)-36 and FAHId Quality of life Significantly improvement only in SF-36 domain in vitality (p = 0.013) and FAHId domains in
physical wellbeing (p = 0.039) compare to control group
Center for Epidemiological Studies Depression Lowered CESD score by 4.8 ± 10.8 compare to baseline
Depression (CESD) scale
Quality of Well-being (QWB-SA) Quality of well being QWB improved compare to control group
survey
[28] CD4 Lymphocyte levels Concentrations Immune and virological Intervention group reported increase of 20 CD4+T lymphocytes whereas control participants
of HIV-1 RNA status reported decrease of 185 CD4+ T lymphocytes from baseline to post intervention. HIV RNA
level were inchanged
[29] CD4 cell count Immune and virological No statistically significant among groups at baseline. Not measured post intervention
status
AIDS Clinical Trails Group Symptom ART medication side effect A decreasing number of overall symptoms and bother reported over time (F (2, 132) = 21.89,
checklist checklist P < 0.0001)
AIDS Clinical Trails Group Self-report ART adherence No statistically significant effects reported for adherence
Adherence measure
BDIa Depression The difference between groups on depression were not significant
PSSi Stress The difference between groups on stress were not significant
PANASg Positive and negative affect The difference between groups on Positive and negative affect were not significant
Five factor Mindfulness Questionnaire Mindfulness The difference between groups on mindfulness were not significant
[30] Physical Performance Test Quality of life Physical performance was improved among control (aerobic exercise) group
MOSf-HIV Survey Quality of life Significant group difference on the MOS6-HIV subscale, overall health (p = .04) only
POMSh Psychologic state Significant time effect observed for subscale confusion-bewilderment (p = 0.00) and tension-
anxiety (p = 0.05)
SWBSj Spirituality Overall greater well-being reported
IES5 HIV-Specific distress Reduction on IESe avoidance subscale (F = 16.3, p < 0.00; (f = 2.2, n.s.) compared with
controls group
Toronto Mindfulness Scale Mindfulness Statistically significant for TMS total score compare to control group
PANASg Positive and negative affect Improved positive affect (PANAS7) (F = 1.7, p = n.s.; f = 3.5, P < 0.05) compared with
controls group
HADSc Anxiety and depression No group difference reported for HADS3 score
[31] CD4 cell count HIV-RNA viral load Immune and virological Observed a statistically significant difference in CD4 cell count between the intervention and
status the control group at week 20 (Coef. 135.8; p < 0.001)
Nottingham Health Profile Quality of life QoL improved significantly after the program (NHP Total: Coef. −25.8; p < 0.001) compare
to control group
PSSi Stress PSSi lowered significantly compare to baseline (Coef. −10.1; p < 0.001)
BDIa-II and Beck Anxiety Inventory Anxiety and depression Depressive symptom (Coef. −13.6; p < 0.001) and anxiety symptoms (Coef. −10.4;
(BAI) p < 0.001) improved significantly compared to control group
[21] WHOQOLk-HIVBREF Quality of life Overall QoL score increased but were significant only for physical domain by 12.5%
(p = 0.004) and level of independence by 3% (p = 0.02) compare to baseline
CD4 cell count Immune and virological No significant changes reported for CD4 count
status
c
[32] HADS Anxiety and depression Significant reduction in depression scores (F [1,21] = 5.65, P = 0.02) compared to control
group
CD4 cell count Immune and virological Significant improvement in CD4 counts (F [1,21] = 5.35, P = 0.04) compared to control group
status
[33] Dealing with Illness scale Stress and coping patterns More frequent use of appraisal focused coping (p ≤ .05) compare to pre-intervention but no
significant changes reported for problem focused and emotional focused coping
Revised social provisions scale Social support No significant changes reported for social support
IESe Distress lower HIV-related psychological distress (p ≤ .05) compare to baseline
FAHId Quality of life Higher overall quality of life compare to baseline (p ≤ .001), mainly accounted for higher
emotional (p ≤ .001) and social (p ≤ .05) well-being
SWBSj Spirituality No significant changes reported for spirituality well-being
(continued on next page)

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A. Bhochhibhoya et al. Complementary Therapies in Clinical Practice 33 (2018) 12–19

Table 4 (continued)

Source Instrument Variable measured Outcome

[34] NK activity and NK cell number, level Immune and virological Significantly increases for NK cell activity (t = −2.64, df = 23, p = 0.015) and NK cell number
of chemokines RANTES status (t = −3.98, df = 20, p = 0.001) and RANTES (t = 2.66, df = 21, p = 0.015) compare to
baseline
PSSi Stress Perceived stress was reported as elevated
POMSh Psychologic State No significant changes were found for psychological variables
Saliva cortisol and DHEA-Sb Endocrine response to stress No significant changes were found for endocrine variables
FAHId Quality of life The quality of life scores in the test team increased from pre to post tests in all dimensions
(physical, mental health, social and environmental).
[1] UCLA Loneliness Scale of Russell Loneliness Reduced loneliness compared to baseline (43.58 ± 6.78, 55.17 ± 8.16)
WHOQOLk-HIVBREF Quality of life Improved overall quality of life compare to baseline (41.51 ± 1.75, 50.25 ± 1.78)
[35] CD4 T Lymphocytes Counts Immune and virological Significant difference compare to control group [F(1169.05) = 10.35, P = .002)] and baseline
status [F(5169.02) = 7.58, p < .001] for CD4 count
Symptoms Checklist 90 Revised Mental health Significant different compare to baseline for SCL-90R score [F(5168.17) = 40.31, p < .001]
Medical Symptoms Checklist Physical symptomatology Significant difference compare to control group [F(1169.69) = 7.30, p = .008)] and baseline
[F(5169.82) = 24.19, p < .001] for MSCL score

a
BDI = Beck Depression Inventory.
b
DHEA-S = dehydroepiandrosterone.
c
HADS = The Hospital Anxiety and Depression Scale.
d
FAHI = Functional Assessment HIV Infection.
e
IES = Impacts of Events Scale.
f
MOS = Medical outcome study.
g
PANAS = The Positive and Negative Affect Schedule.
h
POMS = Profile of Mood States.
i
PSS = Perceived Stress Scale.
j
SWBS = Spirituality Well-Being Scale.
k
WHOQOL = World Health Organization Quality of Life.

practice, and skills acquired by the participants) in designing and im-
plementing MBI. Future investigations should examine the extent to
which each of these factors plays a role in influencing the effectiveness
of MBI in reducing stress and curbing HIV/AIDS progression.
5. Conclusions
The present review points to the complexity of mindfulness and
operationalizing MBI. The present review expanded to include up to
date studies that utilized MBI. Acquiring and synthesizing information
from these studies can help to inform future MBI for PLWHA. Overall,
the present study concludes MBI as a cost-effective, non-pharmacolo-
gical, non-invasive and simple-to-administer intervention in the re-
duction of stress among PLWHA [19–21]. MBI have the potential of
slowing HIV/AIDS progression, bolster the treatment effects of ART and
improving QoL [20,28–30]. However, additional translational research
is necessary for determining optimal implementation strategies for
mindfulness-based intervention among PLWHA in clinical as well as
community settings.
Compliance with ethical standards
Funding
N/A.
Conflict of interest
The authors declare that they have no conflict of interest.
Appendix A. Supplementary data
Supplementary data related to this article can be found at https://
doi.org/10.1016/j.ctcp.2018.07.002.
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