Development of a tailored, telehealth intervention to address chronic pain and heavy drinking among people with HIV infection: Integrating perspectives of patients in HIV care

Abstract

Background:
Chronic pain and heavy drinking commonly co-occur and can influence the course of HIV. There have been no interventions designed to address both of these conditions among people living with HIV (PLWH), and none that have used telehealth methods. The purpose of this study was to better understand pain symptoms, patterns of alcohol use, treatment experiences, and technology use among PLWH in order to tailor a telehealth intervention that addresses these conditions.

Subjects:
Ten participants with moderate or greater chronic pain and heavy drinking were recruited from a cohort of patients engaged in HIV-care (Boston Alcohol Research Collaborative on HIV/AIDS Cohort) and from an integrated HIV/primary care clinic at a large urban hospital.

Methods:
One-on-one interviews were conducted with participants to understand experiences and treatment of HIV, chronic pain, and alcohol use. Participants' perceptions of the influence of alcohol on HIV and chronic pain were explored as was motivation to change drinking. Technology use and treatment preferences were examined in the final section of the interview. Interviews were recorded, transcribed and uploaded into NVivo® v12 software for analysis. A codebook was developed based on interviews followed by thematic analysis in which specific meanings were assigned to codes. Interviews were supplemented with Likert-response items to evaluate components of the proposed intervention.

Results:
A number of themes were identified that had implications for intervention tailoring including: resilience in coping with HIV; autonomy in health care decision-making; coping with pain, stress, and emotion; understanding treatment rationale; depression and social withdrawal; motives to drink and refrain from drinking; technology use and capacity; and preference for intervention structure and style. Ratings of intervention components indicated that participants viewed each of the proposed intervention content areas as "helpful" to "very helpful". Videoconferencing was viewed as an acceptable modality for intervention delivery.

Conclusions:
Results helped specify treatment targets and provided information about how to enhance intervention delivery. The interviews supported the view that videoconferencing is an acceptable telehealth method of addressing chronic pain and heavy drinking among PLWH.

Full text

Palfaietal. Addict Sci Clin Pract (2019) 14:35
https://doi.org/10.1186/s13722-019-0165-1
RESEARCH
Development ofatailored, telehealth
intervention toaddress chronic pain andheavy
drinking amongpeople withHIV infection:
integrating perspectives ofpatients inHIV care
Tibor P. Palfai1*, Jessica L. Taylor2, Richard Saitz2,3,4, Maya P. L. Kratzer1, John D. Otis1 and Judith A. Bernstein3
Abstract
Background: Chronic pain and heavy drinking commonly co-occur and can influence the course of HIV. There have
been no interventions designed to address both of these conditions among people living with HIV (PLWH), and none
that have used telehealth methods. The purpose of this study was to better understand pain symptoms, patterns of
alcohol use, treatment experiences, and technology use among PLWH in order to tailor a telehealth intervention that
addresses these conditions.
Subjects: Ten participants with moderate or greater chronic pain and heavy drinking were recruited from a cohort
of patients engaged in HIV-care (Boston Alcohol Research Collaborative on HIV/AIDS Cohort) and from an integrated
HIV/primary care clinic at a large urban hospital.
Methods: One-on-one interviews were conducted with participants to understand experiences and treatment
of HIV, chronic pain, and alcohol use. Participants’ perceptions of the influence of alcohol on HIV and chronic pain
were explored as was motivation to change drinking. Technology use and treatment preferences were examined in
the final section of the interview. Interviews were recorded, transcribed and uploaded into NVivo® v12 software for
analysis. A codebook was developed based on interviews followed by thematic analysis in which specific meanings
were assigned to codes. Interviews were supplemented with Likert-response items to evaluate components of the
proposed intervention.
Results: A number of themes were identified that had implications for intervention tailoring including: resilience
in coping with HIV; autonomy in health care decision-making; coping with pain, stress, and emotion; understanding
treatment rationale; depression and social withdrawal; motives to drink and refrain from drinking; technology use
and capacity; and preference for intervention structure and style. Ratings of intervention components indicated that
participants viewed each of the proposed intervention content areas as “helpful” to “very helpful”. Videoconferencing
was viewed as an acceptable modality for intervention delivery.
Conclusions: Results helped specify treatment targets and provided information about how to enhance intervention
delivery. The interviews supported the view that videoconferencing is an acceptable telehealth method of addressing
chronic pain and heavy drinking among PLWH.
Keywords: HIV, Chronic pain, Alcohol, Heavy drinking, Self-management
© The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Open Access
Addiction Science &
Clinical Practice
*Correspondence: palfai@bu.edu
1 Department of Psychological and Brain Sciences, Boston University, 900
Commonwealth Ave., Boston, MA 02215, USA
Full list of author information is available at the end of the article

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
Background
Heavy drinking among people living with HIV/AIDS
(PLWH) has direct effects on HIV-related symptoms and
indirect, deleterious effects on HIV outcomes through
non-adherence to care recommendations [1]. ese con-
siderations have led to recent efforts to integrate alco-
hol interventions into HIV-care. Brief interventions that
emphasize motivational interviewing have been exam-
ined in HIV-care settings [2–4]. Although these interven-
tions have shown some promise, the beneficial effects on
drinking outcomes have been limited and have suggested
that a more intensive approach may be required to moti-
vate and maintain change in alcohol use [2], particularly
among those with significant comorbid conditions [5].
One of the more important of these comorbid conditions
is chronic pain [6, 7]. PLWH report high rates of chronic
pain, which exceed 50% in some HIV-clinic cohorts [6,
7]. e associations between chronic pain, heavy alco-
hol use, and HIV/AIDS have been described as complex
and multidirectional [8], with impacts on medication
adherence [9, 10], immune system efficiency [11], dis-
ease progression [12], depression and anxiety [13], and
sensitivity to pain [14]. Rates of chronic pain are higher
among those who engage in heavy drinking and chronic
pain has a negative impact on alcohol outcomes [15, 16].
Among PLWH, moderate to severe chronic pain has been
linked to increased risky drinking over time [8]. Behav-
ioral interventions have been shown to be effective for
pain management [17] but there have been few efforts to
tailor approaches to the unique needs and characteristics
of HIV-populations (see Merlin etal. [18] for an excep-
tion). Similarly, despite the development of strategies to
address heavy alcohol use among PLWH [2, 3], thus far,
no intervention has been developed to address the highly
comorbid conditions of chronic pain and heavy drinking
together among PLWH.
Even with the development of efficacious behavioral
treatments, attendance to clinic visits represents a sub-
stantial barrier for PLWH who experience pain and alco-
hol/substance use. High rates of drop-out and missed
sessions, common in community-based pain manage-
ment in-person interventions, are a considerable concern
for PLWH [19] who may experience additional burdens
related to HIV symptoms and other co-occurring con-
ditions, financial barriers, and stigma related to alcohol
and substance use [20]. Finding alternative modalities to
deliver integrated, efficacious behavioral treatments that
reduce barriers associated with clinic attendance may
improve outcomes.
e purpose of this study was to learn about the associ-
ations among HIV/AIDS, pain and heavy drinking among
patients in HIV-care in order to tailor a videoconferenc-
ing intervention for chronic pain and heavy drinking. We
chose videoconferencing as our platform because studies
across a number of disorders have shown its advantages
for improving adherence particularly among popula-
tions that face significant barriers to treatment, such as
low-income populations [21–23]. Videoconferencing
has a distinct advantage over many other forms of tel-
ehealth in that it provides the interventionist with real
time information about how patients are able to utilize
skills and provides the capacity to provide synchronous
training and feedback. It also provides a platform to
introduce more extensive technology enhancements (e.g.,
web-based assessments, experience sampling, video-
skills training) for both clinical and research purposes
[21, 24]. A number of studies have shown that video tel-
ehealth interventions are equivalent to in-person sessions
in terms of patient satisfaction with treatment [25, 26].
Based on previous work on cognitive-behavioral treat-
ment for pain [27], self-management approaches for alco-
hol use [28, 29], pain management [18, 30], and alcohol
use [2, 3] an initial integrated intervention addressing the
anticipated treatment needs of the study population was
designed. e first intervention component was designed
to help patients understand the role of various lifestyle
factors in the experience of pain and increase readiness-
to-change alcohol use through motivational interview-
ing strategies. is and subsequent modules included
discussion of how pain and alcohol use were associated
with HIV (e.g., influence of drinking on HIV medication
adherence, HIV-related pain, etc.). Subsequent behavio-
ral components relevant to both pain and heavy drinking
were addressed including behavioral activation, func-
tional analysis, stress and coping, automatic thinking and
cognitive restructuring, and sleep hygiene. Patients also
learned strategies for behavioral pacing related to pain
and alcohol-related harm reduction strategies.
Individual participant interviews were conducted to: (1)
determine the utility and importance of the various con-
tent areas of the proposed intervention and the use of the
telehealth modality (videoconferencing), (2) understand
participant experiences of chronic pain and patterns of
alcohol use, (3) gain insight into health care experiences
that participants found helpful and not helpful related to
HIV, pain and alcohol use, (4) identify potential barriers
and facilitators of intervention adherence, (5) clarify the
use of various technologies and preferences for interven-
tion modalities, and, most importantly (6) learn about
content and process features that may be important to
include in the technology-based intervention.
Methods
Design
In this study, a semi-structured, in-person interview
was administered by a clinical psychologist (White,

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
non-Hispanic, male with 20+ years of clinical experi-
ence) to: (1) elicit participant feedback regarding the
proposed content and structure of the technology-based
intervention, (2) extract themes that could be used to tai-
lor intervention content and structure, and (3) develop a
better understanding of smartphone and internet tech-
nology use in this population to ascertain the acceptabil-
ity of videoconferencing as a modality of delivering the
technology-based intervention.
Participants
Participants were eligible if they were 18 years of age
or older, fluent in English, had documented HIV infec-
tion in the medical record, reported at least 3months of
non-cancer related pain (defined as moderate or greater
pain in the past week) and exceeded US recommended
limits for risky drinking: at least 1 or more heavy drink-
ing episodes in the past month (≥ 4 standard drinks on
one occasion for women and ≥ 5 for men) or exceeded
weekly limits (> 7 for women/> 14 for men). Participants
currently using pharmacological approaches to manage
either pain or alcohol use were permitted if medication
doses were stable (i.e. same prescribed dose for at least
2months). Participants with a history of bipolar disorder,
schizophrenia, or complicated alcohol withdrawal (i.e.
delirium tremens or withdrawal seizure), those in current
psychosocial treatment for pain or alcohol use, and those
with an anticipated surgery in the next 6months were
excluded.
Recruitment
Participants were recruited from the Boston Alcohol
Research Collaborative on HIV/AIDS Cohort (Boston
ARCH Cohort), a component of the Consortia for HIV/
AIDS and Alcohol-Related Research Trials (CHAART)
following study visits. Inclusion criteria for the Boston
ARCH study were documentation of HIV infection in the
medical record, current or past 12-month drug or alco-
hol dependence (based on DSMIV criteria) and/or ever
injection drug use, fluency in English, and age 18years or
older [31]. Participants were also recruited from a hospi-
tal-based HIV/primary care clinic at a large, urban aca-
demic tertiary setting by clinician referral. Participants
were screened for the study in-person or by telephone.
Of the Boston ARCH Cohort, 60 participants were
approached for screening, 50 participants completed
screening, 10 were eligible, and 9 agreed to participate
in the interview study. From the clinic sample, one par-
ticipant was referred, screened, and enrolled in the study.
Enrollment of new participants was terminated when
interviews reached data saturation (the point at which
content was both rich in quality and thick in quantity,
and no new information emerged) [32].
Data collection
A semi-structured interview schedule was developed
using a Delphi process and a panel with expertise in
areas of interest: infectious disease management, pain
management, unhealthy drinking, and techniques for
intervention based on cognitive behavioral therapy. A
one-on-one, 50-min interview was then conducted by a
clinical psychologist to elicit participant experiences of
pain, alcohol use, and treatment within the context of
HIV (see Table1 for key interview probes). Participants
shared their experiences with HIV and HIV care, fol-
lowed by a discussion about pain duration, interference,
triggers and coping strategies. is included medical and
psychological approaches to coping and social supports.
A discussion of alcohol use patterns followed, including
the contexts in which alcohol was most often used, the
role of alcohol in pain management, and effects of alco-
hol on HIV management or medication and treatment
adherence. Perspectives on the need and ability to change
alcohol use were also examined during this section.
In the next section, participants were asked to dis-
cuss their experiences with different types of treatment
for pain, alcohol and substance use and HIV. ey were
prompted to describe barriers to treatment, aspects of
treatment that they liked and disliked, and what they per-
ceived to be helpful and not helpful. is segment ended
with a brief discussion of what the participant saw as
their priorities among health issues and the type of sup-
port that would be most helpful to them in addressing
these needs.
In the final section, participants had an opportunity
to review and comment on proposed intervention mod-
ules and rate them in terms of their perceived usefulness/
helpfulness (1 “not at all”—5 “very”). Participants were
then asked to provide opinions about the structure of
the intervention, including the number and duration of
sessions and the use of videoconferencing. is section
included questions about technology use, including avail-
ability of smartphone and data plan, use and frequency of
text messaging, and use and frequency of internet brows-
ing. e final section was devoted to eliciting ideas about
ways to improve or modify the intervention based on
what would be most helpful to them personally.
Analytic measures
All interviews were recorded, transcribed, and uploaded
into NVivo® v12 software for qualitative analysis. Two
study investigators (TP, JB) and an external consultant
participated in the process, which began with develop-
ing first impression codes independently, comparing
them, and arriving by consensus at a reconciled code-
book. is was followed by thematic analysis of the data

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
Table 1 Interview guide andkey probes
Experiences with HIV and HIV care
HIV history To start, would you mind talking with me a little bit about your experience with HIV?
When did you receive your diagnosis? (Probe: When were you told by a health care provider that you
had HIV?)
HIV current status What is your understanding of your HIV status currently? (Probe: How well is your HIV being managed
medically?)
How do you cope with and manage your symptoms?
HIV management for future When you think about the future, how do you imagine you will be managing your HIV?
What do you see as the main challenges for managing your HIV symptoms in the future?
Understanding pain experience and treatment
Description of pain and interference Could you tell me a little bit about the sort of chronic pain you have had? What is it like? When does it
get better? What makes it worse?
How does the pain interfere with your life? How would your life be different if your pain was reduced
or better managed?
Pain treatment and coping What do you do to cope with or manage your pain? (Probe: How do you get through the bad times
with your pain?)
Are you taking any medications for your pain?
Is there anything else that you are currently doing to help deal with your pain? (Probe: How does that
work for you?)
Social support Do other people in your life know about your pain? Have they helped you cope or made it more dif-
ficult? (Probe: In what way?)
Alcohol and substance use
Patterns of use and contexts I would like to get a sense from you about how alcohol fits in with your life. When do you drink? How
many days per week? How much do you typically drink?
What are the main reasons why you drink? (Probe: If you think back over the last week, what things
happened or what were you feeling just before you picked up a drink?)
Drinking and pain How, if it all, is your drinking related to your pain? (Probe: Do you use alcohol to help your pain? How
so?)
Alcohol and medication How is drinking related to your use of medications: HIV meds, pain meds, other medications? (Probe:
Do you tend to drink with medications? What about forgetting to take them?)
Alcohol-related consequences Are there any negative effects of drinking for you? [Probe: Any not so good things, like effects on
either your health in general or HIV?)
Experiences with treatment
Treatment for pain Have you talked to your doctor about your pain? What have they recommended for you?
Have you faced any difficulties getting treatment for your pain? (Probe: If so, what have they been?)
Have you ever had anyone talk to you about ways to manage your pain? (Probe: If so, can you tell me
about it?)
If yes: What did you like and what did you dislike about counseling to help you manage pain?
If no: What do you think about having someone to talk to you about things you could do in addition
to medication to help you or deal with your pain?
Treatment for alcohol use or other substances Have you ever had treatment/counseling for drinking? (Probe: Can you tell me about it?)
What did you like and what did you dislike about this kind of treatment/counseling? (Probe: What did
you get out of your treatment/counseling?)
Have you ever had treatment or any help for drug use?
What about your treatment for alcohol or substances has been most helpful? (Probe: How were you
able to use it to improve your health?)
Technology use and access
Smartphone access Do you have a smartphone: a phone that has access to the internet? What kind of phone is it?
Do you have a data plan that you use? Do you have unlimited data?
For what activities do you usually use your phone?
Internet access Do you have access to the internet?
If yes: How often do you use the internet? Can you use it in a private space? (Probe: Can you be alone
when you use it?)
If no: Where could you get access to the internet if you wanted to? How difficult/easy would it be to
access the internet in this way?
Overview of the program and modalities
Smartphone and videoconferencing What do you think of using the video/phone approach to deliver an intervention?
What do you see as the main advantages and disadvantages of doing an intervention for your pain
and alcohol use by phone or video in this way?

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
in which specific meanings were assigned by the team to
code content retrieved from NVivo. Two coders (TP, JB)
conducted the final data coding. In the last stage, themes
were sorted according to their potential for tailoring spe-
cific intervention components and presented results to
the entire study team. Descriptive analysis of Likert for-
mat questions about preferences for types of content,
formalities, and ease of technology use were performed
using SPSS v. 24.
Results
Sample characteristics
ere were 10 interviews conducted. Descriptive sta-
tistics are provided in Table2. e mean age was 53.3
(SD = 8.8). Seven participants identified as male and
eight identified race as Black/African American, while
two identified as White. Two identified ethnicity as His-
panic. Participants in this sample had been living with
HIV for many years (mean number of years since diag-
nosis = 19.5 (SD = 5.7), range 12.0 to 28.0years). All par-
ticipants had a past history of substance use. Participants
experienced moderate to severe chronic pain (mean pain
severity rating = 7.3 (SD = 2.1), range of 4.0 to 10.0). All
participants were eligible based on heavy episodic drink-
ing with a mean of 8.0 (SD = 7.2) heavy drinking episodes
in the past month.
Intervention themes fromqualitative analysis
Nine categories of themes emerged that helped reinforce
the value of specific intervention components, provided
insight into areas that were of particular importance to
address, or pointed to adaptations that would increase
acceptability of the intervention or enhance its effective-
ness. emes with direct implications for intervention
included: (1) the challenges faced by and the resilience
of participants coping with HIV, (2) a strong need for
autonomy, (3) the importance of providing a clear ration-
ale for treatment approach and components, (4) the prev-
alence of depressed affect and behavioral disengagement,
(5) the central role of stress and emotional triggers for
pain and drinking, (6) factors related to motives to drink
and refrain from drinking, (7) technology use, (8) inter-
est in intervention components, and (9) preferences for
intervention structure and style. Illustrative statements
for each theme are provided below; the set of participant
statements corresponding to themes are presented in
Table3.
Resilience incoping withHIV may serve asafoundation
forself‑ecacy fornew behavioral change
Participants described considerable challenges with dis-
crimination, stigma, and shame related to the diagnosis
and subsequent management of HIV.
“Five or six of those [post-diagnosis] years was a
struggle with doing things I wouldn’t normally do
like drinking, smoking and carrying on…as if nobody
gonna treat me the same anymore.” [Participant 28,
Black male in his 40’s]
Participants expressed pride in their strength and
adaptability. Efforts to manage their lives with HIV was
a marker of resilience and strength and they continued to
face multiple challenges even in the modern era of HIV
treatment.
Table 1 (continued)
Duration What do you see as a reasonable number of sessions for working with a counselor on ways to better
manage your pain and alcohol use?
What do you see as a reasonable amount of time for a session with a counselor to talk about your pain
and alcohol use?
Ways to improve Are there any other ideas that you have about how we could make the intervention better: more
useful to you, more interesting for you, more likely that you would want to use it? (Probe: This could
mean the content, ways of delivering it, other uses of technology [e.g., text messaging, web])
If you were designing a way to help other people living with HIV who had pain and consumed alco-
hol, what sorts of things would you want to do?
Table 2 Sample characteristics
Characteristics n (%)
Age (year), mean (SD) 53.3 (8.83)
Gender
Male 7 (70)
Female 3 (30)
Race
Black or African American 8 (80)
White 2 (20)
Ethnicity
Non-Hispanic or Latino 8 (80)
Hispanic or Latino 2 (20)
Avg. weekly pain (0–10), mean (SD) 7.33 (2.06)
Drinks per week 19.4 (12.6)
Heavy drinking episodes past month, mean (SD) 8.00 (7.17)

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
Table 3 Intervention themes andquotes fromqualitative analyses
Intervention themes Quote
1. Resilience in coping with
HIV may serve as a basis for
self-efficacy for new behav-
ioral change
“Five or six of those [post-diagnosis] years was a struggle with doing things I wouldn’t normally do like drinking, smoking and
carrying on… as if nobody gonna treat me the same anymore.” [Participant 28, Black male in his 40’s]
“So I didn’t let it define me. It was a moment that I needed to make…do you want to get better or do you just want to call it
quits?” [Participant 11, Black Hispanic male in his 40’s]
“I mean to me like, my experience was really heavy, heavy stuff. I don’t know how I was able to get through it, you know? I
mean, I guess my faith in God and prayers from my mom and my family.” [Participant 51, White Hispanic male in his 60’s]
“…So I have to deal with it the best that I can…I don’t let it stop me from doing what I need to do….Just ride the bus until you
can’t anymore and they can’t do anything for you.” [Participant 5, Black female in her 60’s]
2. Importance of autonomy in
health care decision-making “She asked me do you want to go to AA classes or whatever, or be checked in somewhere and I told her no, I can handle
it…I’m trying to get to the point where I could just stop, really. But I want to do it on my own.” [Participant 46, Black female
in her 60’s]
“Bless her heart she tries it because she’s my doctor….What she doesn’t get is these are things that I want to do.” [Participant
32, Black male in his 40’s]
“Everything has to be after 3 pm because I work. And I can’t like take a day off here.” [Participant 44, Black male in his 60’s]
“I’d try it. Like everything, I try. I couldn’t say if I would keep going or not keep going.” [Participant 28, Black male in his 40’s]
“Sometimes people don’t want to leave the house or come for help.” [Participant 11, Black Hispanic male in his 40’s]
3. Importance of clarifying the
rationale for the intervention
approach
“And they started asking about my father. And I got to told them I’m not here for my father, I’m here for myself.” [Participant 5,
Black female in her 60’s]
“I was going and I just stopped. My doctor always say, “We’re going to set you up with physical therapy.” And I go “okay.” I go
for a couple of times and… then that’s it.” [Participant 28, Black male in his 40’s]
“I tried once but I think I didn’t have, maybe it’s the person. I didn’t have a positive- I didn’t receive it positively.” [Participant 42,
Black female in her 40’s]
“I just didn’t get it.”; “ They have ideas to remove (pain), but it’s not working. Like example. She asking me to close my eyes, and
… put all bad memories inside the jar and close it. Go to ocean and throw it. And open your eyes. I opened my eyes. She
said, “How do you feel?” and I told her “terrible.” [Participant 21, White male in his 50’s]
“I’ve never heard of a lot of pain management. I’ve always thought, “What are they talking about?” No idea what they mean
by pain management.” [Participant 13, Black male in his 40’s]
4. Depression and behavioral
withdrawal “It’s okay. You know I’m not doing nothing really. It’s just appointments and I don’t work nowhere. I’m disabled.” [Participant
46, Black female in her 60’s]
“And you just want to crawl in a dark place and no, you don’t want to be bothered.” Participant 11, Black Hispanic male in his
40’s]
“I’m not from here so I don’t know a lot of people here. And all the people here that I did know, either have died or have moved
out of town. So I’m pretty basically in the house.” [Participant 32, Black male in his 40’s]
HIV prevents me from being around certain people or crowds. Because I know what their minds thinking, you know what I
mean….And I wanted to see people treat me the same when after I say that [that I am HIV positive].” [Participant 28, Black
male in his 40’s]
“There are times when I just don’t have the energy to do things…I just don’t want to be a part of society.” [Participant 32, Black
male in his 40’s]
“I don’t have friends. I have acquaintances, I have associates, I don’t have friends.” [Participant 32, Black male in his 40’s]
5. Pain, stress and emotion
coping “So I’m tired about the situation. If I will call my doctor, she will tell me this is age or take ibuprofen or Tylenol. Or do exercise…
When I get more depressed I have more pain.” [Participant 21, White male in his 50’s]
“Sometimes I feel I am responsible about this [family health problems]. …This is why [I have] this pain, pain from deep inside
and pain in my shoulder and in my head… And so sometimes I drink to forget.” [Participant 21, White male in his 50’s]
“If I don’t, sometimes the [pain] will trigger and aggravate me. Then I think about the HIV.” [Participant 46, Black female in her
60’s]
“Because I couldn’t take, I couldn’t face the reality of anything. I was in pain emotionally. I was physically in pain.” [Par ticipant
44, Black male in his 60’s]
“But you know I got off that [Percocets]. But I still didn’t let my drinking go….Well, maybe I do [drink to cope with pain]. I’m not
realizing it.” [Participant 5, Black female in her 60’s]
“With feelings, my anxiety, my depression, if I feel I’m getting very depressed I drink more. And it helps me, a lot if I think about
the HIV, which I try not to think about it.” [Participant 46, Black female in her 60’s]
“Because of pain I just want to be numb. Sometimes I’m so defeated. A whiskey drink can take the pain away…I just drink not
to think.” [Participant 42, Black female in her 40’s]
“Marijuana helps me manage my depression from the pain.” [Participant 28, Black male in his 40’s]
“I smoke marijuana. And it subsides everything. It calms the leg and everything. You know I’m just peachy. I just lay down and
I’m ok.” [Participant 44, Black male in his 60’s]

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
“So I didn’t let it define me. It was a moment that
I needed to make…do you want to get better or do
you just want to call it quits?” [Participant 11, Black
Hispanic male in his 40’s]
“I mean to me like, my experience was really
heavy, heavy stuff. I don’t know how I was able to
get through it, you know? I mean, I guess my faith
in God and prayers from my mom and my family.”
[Participant 51, White Hispanic male in his 60’s]
Table 3 (continued)
Intervention themes Quote
6. Motives to drink and
motives to refrain from
drinking
“I don’t want to drink during the week. I don’t want to be an alcoholic and stuff like that….so that’s why…only Thursday
Friday Saturday.” [Participant 13, Black male in his 40’s]
“But I take pain meds for it too. But I take them as needed, I try to take them as less as possible.” [Participant 5, Black female in
her 60’s]
“Sometimes the alcohol you use is just to ease your mind…or you get upset and might get frustrated and you take that cold
beer and then you don’t want to hear nothing now.” [Participant 5, Black female in her 60’s]
“I think people are just coping, trying to shut up that inner voice that’s crying for help and they drown themselves…Some-
times I get too bored, nothing to do.” [Participant 11, Black Hispanic male in his 40’s]
“You know I can change the beer drinking but at this point, I’m going to be honest, I don’t want to.” [Par ticipant 5, Black female
in her 60’s]
“Timewise, forgetful you know. Because I’m drinking beer and then I may fall out and I’m like, ‘Oh shoot! The medication.’ So
yeah, it [drinking] has sort of affected it.” [Participant 44, Black male in his 60’s]
“I have my meds on top of the table and view in plain sight. So I’m like, ‘Oh yeah, I need to take my meds.’ So I take them right
away.” [Participant 11, Black Hispanic male in his 40’s]
“Buying alcohol for $20, that’s a lot of money.” [Participant 42, Black female in her 40’s]
“I might drink too much. Too much beer and I can feel like I’m getting lightheaded. Okay, Or I can—it feels funny and I said,
‘my blood pressure has to be up.’” [Participant 5, Black female in her 60’s]
“I’d rather be in my house where I know I can control the things that I do.” [Participant 32, Black male in his 40’s]
“Oh no, I’m drinking the right amount that a person should drink.” [Participant 11, Black Hispanic male in his 40’s]
“I’ve been on top of that from day one. They had the cap box.” [Participant 28, Black male in his 40’s]
“No matter where I am, no matter what I do, I will wake up out of sleep to take my medication.” [Participant 32, Black male in
his 40’s]
“I have two or three friends who come to drink in my apartment. Mostly because I don’t get in trouble with anything after
drinking.” [Participant 13, Black male in his 40’s]
7. Technology use and capac-
ity “I feel like that would be something to reach a lot of other people today. I think a lot of people would be willing to do some-
thing like this. Instead of coming to the office to meet with somebody like ‘can you just FaceTime me?’” [Participant 28, Black
male in his 40’s]
“Sometimes people don’t want to leave the house or come for help. Why not have an app that the app can actually help you
connect with that person. I like that.” [Participant 11, Black Hispanic male in his 40’s]
“I would love that… as long as they give me time to do it so I can be like at home, and to not do it in the streets… I’d have no
problem with that… Schedule it.” [Participant 13, Black male in his 40’s]
“I always use YouTube when I am at home. I watch videos every day.” [Participant 21, White male in his 50’s]
“I like it in a video, yeah, something that you could sort of go back to.” [Participant 13, Black male in his 40’s]
8. Interest and experience with
intervention components “Sayin’ that it’s connected in some kind of way but I’m not looking at it connected in it that kind of way, maybe I can learn, well
maybe it is connected and I never knew this. That would be very helpful to learn.” [Participant 5, Black female in her 60’s]
“I think if I would’ve known, like if there was stuff like that, more particularly like that, I would’ve been able to cope with a lot of
things sooner than later.” [Participant 11, Black Hispanic male in his 40’s]
“Depression could be a problem. Depression is a big; it needs to be kept in tab, you know?” [Participant 13, Black male in his 40’s]
“You know. I- even though I’m dealing with my HIV problem or whatever but I never figured that it would be linked to
something like that, you know. Not my HIV but my pain or whatever, I don’t know. You know it would be interesting to see.”
[Participant 5, Black female in her 60’s]
9. Preference for intervention
structure and style “They (the caseworker, medical team and the interventionist) should be in close communication, not divulging everything,
everything is confidential but keeping an eye on it.” [Participant 11, Black Hispanic male in his 40’s]
“I need motivation. I need someone to either remind me or call me or push me.” [Par ticipant 44, Black male in his 60’s]
“We talk on the level where she understands my every part of the need…because she gives me all the right answers I want to
hear.” [Participant 46, Black female in her 60’s]
“I know that it’s our responsibility, like personal responsibility to get the help that we need but sometimes we need that extra
help.” [Participant 11, Black Hispanic male in his 40’s]
“I’ll say something to the doctor and like I will leave the office and I completely forgot. I would get a phone call from the case-
workers saying…I have the paperwork you needed…..to help is to really make sure that everybody in the person’s team, the
healthcare team, is informed about all of these things.” [Participant 11, Black Hispanic male in his 40’s]
“Well, I mean, having someone to… that you can really feel comfortable with them. Again and I, because I said this earlier,
that I can talk to about any and everything of my personal well-being.” [Participant 44, Black male in his 60’s]
“They make me feel like they know me.” [Participant 28, Black male in his 40’s]
“And we were like family, It was so many years together.” [Participant 51, White Hispanic male in his 60’s]

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
Summary ese comments highlight how HIV has chal-
lenged participants’ identities and their resources.
Importance ofautonomy inhealth care decision‑making
Participants wanted to be afforded control over decisions
about health behavior change and wanted their views
about strategies to be valued.
“She asked me do you want to go to AA classes or
whatever, or be checked in somewhere and I told her
no, I can handle it…I’m trying to get to the point
where I could just stop, really. But I want to do it on
my own.” [Participant 46, Black female in her 60’s]
“Bless her heart she tries it because she’s my doctor…
What she doesn’t get is these are things that I want
to do.” [Participant 32, Black male in his 40’s]
ey wanted control over when and how they engaged
with resources.
“Everything has to be after 3pm because I work. And
I can’t like take a day off here.” [Participant 44, Black
male in his 60’s]
Summary Comments highlighted the importance of
flexibility, and participant participation about decisions
regarding treatment.
Importance ofclarifying therationale fortheintervention
approach
Comments regarding previous experiences with behav-
ioral and medical treatments suggested that participants
often did not perceive the value or rationale for the treat-
ments provided, and thus they were not interested in
adopting or maintaining them.
“I’ve never heard of a lot of pain management. I’ve
always thought, “What are they talking about?” No
idea what they mean by pain management.” [Par-
ticipant 13, Black male in his 40’s]
“I just didn’t get it […] they have ideas to remove
[pain], but it’s not working. Like example. She ask-
ing me to close my eyes, and … put all bad memories
inside the jar and close it. Go to ocean and throw it.
Open your eyes. I opened my eyes. She said, ‘how do
you feel?’ and I told her, ‘terrible.’” [Participant 21,
White male in his 50’s]
Depression andbehavioral withdrawal
Although it was expected that participants would show
elevated levels of depressed affect, the interviews helped
emphasize the salience of low positive affect and behav-
ioral disengagement in participant’s lives. Participants
remarked on the constriction of activities and social con-
tacts that contribute to their sense of isolation.
“It’s okay. You know I’m not doing nothing really. It’s
just appointments and I don’t work nowhere. I’m
disabled.” [Participant 46, Black female in her 60’s]
“And you just want to crawl in a dark place and no,
you don’t want to be bothered.” Participant 11, Black
Hispanic male in his 40’s]
Coping withpain, stress andemotion
Participants recognized a variety of specific triggers for
pain, mentioning rain or cold weather [Participants 5,
28], sitting for a long time [Participant 11], staying home
[Participant 28], and standing all day [Participant 44].
Central among these were stress and emotional triggers
[Participant 44].
“So I’m tired about the situation. If I will call my doc-
tor, she will tell me this is age or take ibuprofen or Tyle-
nol. Or do exercise… When I get more depressed I have
more pain.” [Participant 21, White male in his 50’s]
Some mentioned that they had learned to deal with it,
while others noted that they use alcohol and other sub-
stances for relief from stress, pain and negative emotion.
“Marijuana helps me manage my depression from
the pain.” [Participant 28, Black male in his 40’s]
“Because of pain I just want to be numb. Sometimes
I’m so defeated. A whiskey drink can take the pain
away […] I just drink not to think.” [Participant 42,
Black female in her 40’s]
Motives todrink andmotives torefrain fromdrinking
Beer was thought to be a harmless alternative to use of
opioids for pain management and an acceptable way to
relieve stress, and it was considered safe to drink heavily
as long as it was only a few days per week.
“I don’t want to drink during the week. I don’t want
to be an alcoholic and stuff like that….so that’s
why…only ursday Friday Saturday.” [Participant
13, Black male in his 40’s]
“But I take pain meds for it too. But I take them as
needed, I try to take them as less as possible.” [Par-
ticipant 5, Black female in her 60’s]

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
“So I had to dumb it down a little bit and go to my
beers and leave the hard alcohol alone […] I don’t
think my body could take that anymore.” [Partici-
pant 28, Black male in his 40’s]
Consistent with the above, participants reported a
number of emotion triggers for drinking such as depres-
sion and boredom.
“Sometimes the alcohol you use is just to ease your
mind…or you get upset and might get frustrated and
you take that cold beer and then you don’t want to
hear nothing now.” [Participant 5, Black female in
her 60’s]
“I think people are just coping, trying to shut up
that inner voice that’s crying for help and they
drown themselves… Sometimes I get too bored,
nothing to do.” [Participant 11, Black Hispanic
male in his 40’s]
Generally speaking, participants described low moti-
vation to change their alcohol use patterns.
“You know I can change the beer drinking but at
this point, I’m going to be honest, I don’t want to.”
[Participant 5, Black female in her 60’s]
ere was a general lack of knowledge or concern
about the effect of heavy alcohol use on HIV progres-
sion but some did recognize its potential effect on med-
ication adherence.
“Timewise, forgetful you know. Because I’m drink-
ing beer and then I may fall out and I’m like, ‘Oh
shoot! e medication.’ So yeah, it [drinking] has
sort of affected it.” [Participant 44, Black male in
his 60’s]
However, participants placed high priority on getting
and staying healthy and taking medications.
“I have my meds on top of the table and view in
plain sight. So I’m like, ‘Oh yeah, I need to take my
meds.’ So I take them right away.” [Participant 11,
Black Hispanic male in his 40’s]
Participants identified specific negative consequences
of drinking that might be considered in the context of
goals and values that are incongruent with heavy drink-
ing. ese included themes related to work, money,
family and health (including HIV).
“Buying alcohol for $20, that’s a lot of money.”
[Participant 42, Black female in her 40’s]
“I might drink too much. Too much beer and I can
feel like I’m getting lightheaded. Okay, Or I can—it
feels funny and I said, ‘my blood pressure has to be
up.’” [Participant 5, Black female in her 60’s]
Participants identified strategies that they were cur-
rently using to prevent alcohol-related harm, primarily
through reducing exposure to risk environments.
“I’d rather be in my house where I know I can con-
trol the things that I do.” [Participant 32, Black
male in his 40’s]
Summary ere were a number of comments in the
interviews that provided insight into the goals and values
that participants identified as incongruent with alcohol
use. Participants identified medication adherence, HIV
progression, and health more generally as factors that
may contribute to readiness to change drinking.
Technology use andcapacity
e interviewer asked participants about how they used
smartphones and computers and elicited their opinions
about the perceived value of videoconferencing as a way
of interacting with a provider. For many participants, the
use of videoconferencing was familiar as they used phone
video capacities (e.g., FaceTime) to connect to friends and
relatives. Unlimited data plans were common, and there
was consistent use of texting but less web or computer
use. Participants were enthusiastic about the potential
to have sessions through videoconferencing. e notion
of using video segments to supplement sessions was also
well received as participants reported frequent use of the
smartphone to watch videos.
“I feel like that would be something to reach a lot of
other people today. I think a lot of people would be
willing to do something like this. Instead of coming
to the office to meet with somebody like ‘can you just
FaceTime me?’” [Participant 28, Black male in his
40’s]
“Sometimes people don’t want to leave the house or
come for help… Why not have an app that the app
can actually help you connect with that person.”
[Participant 11, Black Hispanic male in his 40’s]
“I like it in a video, yeah, Something that you could
sort of go back to.” [Participant 13, Black male in his
40’s]
Summary Videoconferencing appears to be a feasible and
well-received modality that could be supplemented with
additional media such as video segments to reinforce
learning. is is a modality that is familiar to participants
and readily accessible.

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Interest andexperience withintervention components
In the structured component of the interview, partici-
pants provided feedback about experiences and interest
in different aspects of the intervention including insight
into what information might be most helpful. Partici-
pants were asked to rate the usefulness of the various
content modules (e.g., behavioral activation, activity pac-
ing) that were proposed for the intervention.
Comments ranged from: “It’s a good idea”; “I would
be interested because I need to find ways to improve
myself”; “I think it would be awesome”; I would give
it a try, why not”; “Nice to open your mind to other
things”; to “Depends on how useful it is.”
Regarding psychoeducation about pain, alcohol,
HIV associations: “Sayin’ that it’s connected in some
kind of way but I’m not looking at it connected in it
that kind of way, maybe I can learn, well maybe it is
connected and I never knew this. at would be very
helpful to learn.” [Participant 5, Black female in her
60’s]
Regarding the use of adjunct video materials: “I
think if I would’ve known, like if there was stuff like
that, more particularly like that, I would’ve been
able to cope with a lot of things sooner than later.”
[Participant 11, Black Hispanic male in his 40’s]
Regarding intervention features to keep in mind:
“Depression could be a problem. Depression is a big;
it needs to be kept in tab, you know?” [Participant
13, Black male in his 40’s]
Summary e comments suggested that the participants
were receptive to the content and modalities proposed
including adjuncts to the intervention such as video
clips to help them learn skills. Comments suggested par-
ticular interest in learning more about the association
between alcohol, pain, and HIV and a recognition of the
importance of addressing depressed mood as part of the
intervention.
Preference forintervention structure andstyle
Participants made a number of comments about the
characteristics of interventions that have been helpful
for them in the past, including the importance of trust,
empathy and efforts by the care team to seek out the
participant to maintain engagement. Participants sup-
ported the idea of communication between the inter-
ventionist and the health care team, as long as they
could be sure of protection of confidentiality within the
health care team.
“ey (the caseworker, medical team and the inter-
ventionist) should be in close communication, not
divulging everything, everything is confidential but
keeping an eye on it.” [Participant 11, Black Hispanic
male in his 40’s]
“I need motivation. I need someone to either remind
me or call me or push me.” [Participant 44, Black
male in his 60’s]
Participants valued respect and empathy from their
support team above concerns about structure and style,
but mentioned a preference for sessions once a week, less
than an hour, and scheduled around other obligations
such as work.
“We talk on the level where she understands my
every part of the need…because she gives me all the
right answers I want to hear.” [Participant 46, Black
female in her 60’s]
Summary Participants were very responsive to health
care workers who exhibited high empathy and concern,
including following up on missed appointments.
Intervention component ratings
At the end of the interview, participants were asked
to rate the perceived usefulness of the various content
areas proposed for the intervention based on a brief
description of each. Each content area was rated from
1 (“not at all” useful/helpful) to 5 (“very” useful/help-
ful) using Likert-type items. ese Likert-response rat-
ings of the content areas showed a generally positive
response to intervention components. Mean ratings for
the different content modules were as follows: learn-
ing about personal triggers and breathing exercises 4.22
(SD = 0.83); learning ways to manage negative thoughts
4.29 (SD = 1.25); psychoeducation about pain, alcohol
and HIV 4.63 (SD = 0.74); behavioral activation [pleasant
activities] 4.75 (SD = 0.46); addressing sleep and becom-
ing more active 4.86 (SD = 0.38); managing stress, anxiety
and other pain triggers 4.86 (SD = 0.38); learning pac-
ing and alcohol-related harm reduction strategies 4.89
(SD = 0.33); learning ways to continue self-management
after treatment was completed 5.0 (SD = 0.0). Partici-
pants were also asked whether they would like an adjunct
to treatment in the form of a website with information
and tips about alcohol and pain management and rated
this as 4.29 (SD = 0.76) on a scale from 1 “(dislike very
much”) to 5 (“like very much). us, ratings of each of
the intervention sessions suggested that participants
viewed the content developed for the intervention as
useful or helpful to them. ese ratings were consistent
with participant comments in the interviews regarding

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
the importance of addressing domains such as stress,
reduced activity, and behavioral withdrawal.
Discussion
Although chronic pain is common among PLWH, there
are few behavioral intervention approaches designed
for this population [30, 33] and no intervention, to our
knowledge, has been developed to address both chronic
pain and heavy drinking for PLWH. is study sought
to gain insight from semi-structured interviews with
patients in HIV care about how best to develop and
deliver an intervention to improve chronic pain manage-
ment and reduce heavy drinking. Moreover, the goal of
these interviews was to improve understanding of how
patients used and experienced technologies to inform
the delivery of interventions that reduce barriers to care.
rough qualitative analyses of these interviews, we were
able to develop a patient-informed perspective on how to
modify, integrate, and deliver an intervention to reduce
heavy drinking and help patients better manage chronic
pain. Results provided insight into the importance of dif-
ferent content areas, the potential value of intervention
strategies, and the type of therapeutic climate that would
maximize patient engagement and behavior change.
We initially constructed a working draft of an interven-
tion tailored to patients in HIV-care based on evidence
indicating high rates of functional impairment from pain,
high rates of depressive symptoms, stigma and discrimi-
nation associated with HIV status [30], and elevated rates
of current and prior heavy drinking and substance use
[4, 5]. In addition, as these participants were not spe-
cifically seeking specialty treatment for alcohol use, we
anticipated that enhancing motivation to change alcohol
use would be an important intervention target consistent
with populations who undergo screening and brief inter-
vention in outpatient medical settings [2–4].
e depressive symptoms and social withdrawal
observed in this study was consistent with previous qual-
itative research on PLWH with chronic pain [18]. Many
participants experienced significant social isolation,
engaged in few activities, and spent little time outside of
the home. e factors that contribute todepressed affect
are manifold but clearly the fear of rejection and beliefs
about others’ reactions to their HIV status contributed
to concerns. Stigma was highly salient to participants
in the interviews and exacerbated by other stigmatizing
conditions such as chronic pain and alcohol or substance
use [18]. Comments from the interviews clarified the
importance of directly addressing depressive symptoms
such as self-blame, low self-efficacy, withdrawal, and low
positive affect in the initial phases of the intervention.
Results from the interviews also highlighted the need to
find ways to increase pleasant activities among patients,
particularly strategies to help patients establish and re-
engage with social networks. Behavioral activation is a
particularly valuable strategy for addressing depressive
symptoms among those experiencing chronic pain [27]
and has been utilized with PLWH specifically [30]. is
treatment component also provides a way of developing
non-alcohol/substance related alternatives for promot-
ing positive affect. A number of studies have shown the
value of developing non-substance related alternative
reinforcers in patients’ lives for reducing problem drink-
ing [34–36]. As such, the behavioral activation module
serves an important dual purpose for addressing negative
emotional components of pain and providing alternative
sources of positive reinforcement to alcohol use.
e role of emotional stress triggers on chronic pain
was also readily identified among participants in this
sample consistent with previous work [37]. Participants
often identified negative emotions and stress as triggers
for chronic pain. Alcohol also served as a way of manag-
ing negative emotions for some [6], helping highlight the
potential value of a treatment component to help patients
address both heavy drinking and chronic pain with more
effective affect management strategies. By providing the
patient with more effective ways to cope with stress and
emotion triggers, one may decrease drinking even among
those who do not have an explicit goal of reducing their
alcohol use.
Participant comments related to alcohol use provided
insight into potential ways to address heavy drinking in
this population. Generally, participants did not identify
their alcohol use as a point of concern and some stated
explicitly that they intended to maintain current use
patterns. However, participants identified a number of
important goals, values, and concerns (e.g., health, fam-
ily) that were viewed as inconsistent with heavy drink-
ing. ese, particularly health concerns, might be useful
to highlight and discuss in efforts to enhance motiva-
tion to change [35, 38]. Information about the impact of
alcohol on medication adherence and HIV progression
for instance, aligns with the priority that participants
placed on HIV managementand may thus contribute to
increased readiness to change.
ere were additional comments in the interviews that
may be used to inform the alcohol specific component
of the intervention. Participants were generally unaware
how heavy drinking, chronic pain and HIV symptoms
may be related and did not know what levels of alcohol
use constitute risk. Psychoeducation to correct miscon-
ceptions about standard drinks and provide information
about potential risks of drinking to health outcomes may
encourage patients to think more about their current
alcohol use given the expressed interest in health. Many
participants did report the use of strategies to minimize

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
alcohol-related harm even if they did not identify them
as such. To maximize engagement and utilization, it may
be useful to anchor the discussion of alcohol harm reduc-
tion strategies in the context of current strategies that
patients use to help keep themselves safe.
By beginning our interview with a discussion of HIV
experiences, we were able to appreciate the broader
impact of living with HIV on current stressors and cop-
ing strategies, motives to use and limit alcohol use,
and resilience. It was important to understand partici-
pant perspectives on the points of intersection between
HIV, alcohol use, and pain and how these conditions
had shaped their identities and behavioral choices over
time. Participant remarks suggest that the intervention-
ist may foster collaboration by appreciating the ways that
HIV has challenged patients’ identity and resources and
affirming patients’ resilience where possible. e inter-
ventionist may enhance patient engagement and self-effi-
cacy for current intervention objectives by recognizing
and drawing upon the patients’ capacity for HIV-related
coping and behavior change. It should be noted that par-
ticipants in this sample were older and had been in sta-
ble HIV care for a long time. Specific symptoms of pain,
drinking patterns, and concerns about HIV were likely
different than patients with new diagnoses of HIV.
e results of the interviews also provided valuable
insights into how to structure and modify the proposed
modules of the intervention and address key interven-
tion objectives. First, it will be critical to provide clear
and explicit rationales for the approach and content areas
that comprise this treatment. Participants had varied and
unsuccessful experiences with general psychotherapy
approaches to pain which led to some skepticism about
the value of treatment. Similarly, descriptions of past
unsuccessful and brief experiences with physical therapy
from participants highlighted the importance of setting
realistic expectations about how this approach to pain
management might be helpful. It is critical to set expec-
tations for the course of treatment, the expected roles of
patient and interventionist, and what outcomes might be
expected over what timeframe. As patients may not have
experience with behavioral approaches to change, it will
be important to explain that the intervention requires
practice and sustained involvement to gradually reduce
pain interference and control of pain intensity rather
than an immediate and significant impact on pain sever-
ity. is emphasis on rationale and expectations should
be considered throughout the duration of the interven-
tion and provided for each of the content domains with
reminders and encouragement.
Second, the importance of patient autonomy and flex-
ibility in the treatment process were clear from partici-
pant comments. Participants expressed a strong desire to
have choice in the intervention process, including selec-
tion of times and circumstances in which they receive
information. ere may be benefit to offering patients a
menu of resource options to permit them some flexibility
to modify the intervention approach to fit their lives and
current concerns. A related consideration is the critical
role of empathy, acceptance, and intervention efforts that
demonstrate care and concern. Although the provider-
patient relationship is critical to any intervention, they
may be particularly important to patients who have faced
many years of discrimination and stigma related to HIV.
Participants were very responsive to health care workers
who exhibited high empathy and concern. is included
expressed statements of caring as well as efforts to ensure
that the participant stayed engaged in treatment includ-
ing following up on missed appointments. is interven-
tion must involve particular attention to establishing a
collaborative relationship and would likely benefit from
a more active strategy to address missed appointments
(e.g., more frequent reminders, reaching out to patient to
reschedule) than is typical in behavioral practice.
Finally, the interviews provided significant information
about technology use and interest in this cohort. Unex-
pectedly, all participants had their own smartphones,
many with unlimited data plans. In contrast, few had
ready, private access to a computer. is made it clear
that any videoconferencing approach would need to take
place over personal smartphones. e videoconferenc-
ing approach was very well received by participants who
liked the convenience and flexibility of this approach.
Participants had sufficient experience through the regu-
lar use of video technology to be able to understand and
feel confident about using the videoconferencing proce-
dures described.
e interview supported the acceptability of using vid-
eoconferencing to reach patients and suggested the pos-
sibility of other technologies that might be considered to
support the intervention and intervention delivery. e
use of videos and other learning materials (e.g., example
of homework exercises) may supplement video-confer-
encing intervention content and be delivered through
smartphones. A variety of administrative supports could
also be provided through the use of smartphone technol-
ogy including reminders for appointments and home-
work scheduling. e ready use of text messaging and use
of apps makes it feasible to incorporate these elements
to foster engagement. e technology components pro-
posed in the current study provides the potential to auto-
mate a number of features of the intervention to ensure
that provider time can be used to maximal benefit (e.g.,
as opposed to reminding patients to do specific tasks),
avoid redundancy in service delivery, and promote acces-
sibility and optimal flexibility for patients who wish to use

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Palfaietal. Addict Sci Clin Pract (2019) 14:35
the intervention. e next step will be to pilot test these
intervention components among patients recruited from
HIV-care to discern acceptability, preferences for tech-
nology features, and feasibility prior to an efficacy trial.
Although not part of the current intervention, delivery
of the intervention through a health technology platform
opens the possibility for a range of additional adjunct
components delivered through social media. Given the
frequent experience with social withdrawal among HIV
patients and stated preferences for group interactions
identified in previous work [18], investigators may con-
sider the use of social media and online platforms as
additional ways to extend the impact of the intervention
by incorporating peer support [39] and other peer-led
components [40]. Development of these and other tech-
nology-based components will require that investigators
are mindful of digital literacy and utilization of specific
HIV-populations as they seek to craft mobile health solu-
tions for chronic health conditions [41–43].
Conclusion
In sum, this study shows how formative qualitative
research that identifies themes specific to our target
population can have implications for tailoring a novel
mobile health intervention to address the confluence of
HIV/AIDS, chronic pain and unhealthy alcohol use and
testing its efficacy in a randomized controlled trial. ese
points might have been missed without the inclusion of
interviews with patients as the first step in this research
agenda. Attention to the identified themes has the poten-
tial to increase both patient engagement and motivation
to change by addressing specific priorities, matching
intervention modalities with patient preferences, and
building on lessons from participants’ past experiences
with illness and health care delivery.
Abbreviations
PLWH: people living with HIV/AIDS; Boston ARCH Cohort: Boston Alcohol
Research Collaborative on HIV/AIDS Cohort; CHAART : Consortia for HIV/AIDS
and Alcohol-Related Research Trials.
Acknowledgements
The authors wish to thank Christine Gebel, MPH for consultation on qualitative
analyses and the CARE unit research associates at the Boston Medical Center,
Jasmin Choi, Alexandra Chretien, and Susie Kim for their efforts in study
implementation.
Authors’ contributions
All authors contributed to the manuscript; TP study development, interview
development, study implementation, data analysis, manuscript writing,
JT study development, interview development, manuscript writing, RS
study development, interview development, manuscript writing, MK study
implementation, data analysis, manuscript writing, JO study development,
interview development, and JB study development, interview development,
study implementation, data analysis, manuscript writing. All authors read and
approved the final manuscript.
Funding
This research was supported in part by a Grant from the National Institute on
Alcohol Abuse and Alcoholism, UH2 AA026192. The NIAAA played no role in
the design of the study and collection, analysis, and interpretation of data and
in writing the manuscript.
Availability of data and materials
Data supporting the analyses are provided in the table in transcribed form.
Ethics approval and consent to participate
This study was approved by the Boston University Institutional Review Board.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1 Department of Psychological and Brain Sciences, Boston University, 900
Commonwealth Ave., Boston, MA 02215, USA. 2 Clinical Addiction Research
and Education (CARE) Unit, Section of General Internal Medicine, Department
of Medicine, Boston Medical Center and Boston University School of Medicine,
801 Massachusetts Ave, Boston, MA, USA. 3 Department of Community Health
Sciences, Boston University School of Public Health, 801 Massachusetts Ave,
Boston, MA, USA. 4 Grayken Center for Addiction, Boston Medical Center,
Boston, MA, USA.
Received: 13 May 2019 Accepted: 23 August 2019
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