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SSHC Journal Club presentation on AIDS and Behaviour Volume 20 Issue 7
The document compiles various studies on relationship dynamics, mental health, resilience, and disclosure anxiety among HIV-positive men, particularly focusing on gay men. It highlights significant issues such as misperceptions regarding viral suppression among partners, high rates of depression and anxiety, and the impact of relationship quality on disclosure experiences. Additionally, it discusses the implications of internalized stigma and the need for improved mental health screening and support strategies.
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SSHC Journal Club presentation on AIDS and Behaviour Volume 20 Issue 7
- 1. AIDS & Behaviour Preparedby Kristen McCormack March 2017
- 2. Relationship Dynamics andPartner Beliefs about Viral Suppression: A Longitudinal Study of Male Couples Living with HIV/AIDS (The Duo Project) Conroy, Gamarel, Neilands, Dilworth, Darbes, & Johnson • Method – 266 gay males in a relationship (133 couples) completed a survey – HIV-positive participants had blood drawn at 0, 12 and 24 months – Partners’ perceptions of viral load were checked against the actual measured viral load
- 3. Results • ~50% ofmen were virally suppressed, but 74.2% of partners believed there was an undetectable viral load at baseline (89.7% at 24 month visit) • 80.4% of incorrect men assumed their partner was virally suppressed when they were not (93.4% at 24 month visit) • Couple level differences in dyadic adjustment were negatively correlated with accuracy
- 4. • Why? Somepossible explanations: – ~50% of HIV-positive men were virally suppressed at each assessment session, but individuals did change. Perhaps changes were not discussed with partners. – If sexual activity decreases over time, HIV-positive men may find it unnecessary to inform their partner of the change in viral load status. – Men may assume that if their partner is taking ART consistently, then they must have an undetectable viral load.
- 5. HIV and elevatedmental health problems: Diagnostic, treatment, and risk patterns for symptoms of depression, anxiety, and stress in a national community based cohort of gay men living with HIV Heywood & Lyons • 357 HIV-positive Australian gay men completed an online survey on the wellbeing of people living with HIV • Results – Depression scores were higher in this sample than the general male population – 20% met criteria for severe or extremely severe depression (82% diagnosed, 35% receiving treatment). – Depression scores were higher for those who: • Were unemployed • Were born in Australia • had greater internalised HIV-related stigma
- 6. • Results cont. –Anxiety scores were higher in this sample than the general male population – 17% met criteria for severe or extremely severe anxiety (59% diagnosed, 31% receiving treatment) – Anxiety scores were higher for those: • without university education • who were born in Australia • with less emotional and tangible support • with lower CD4 counts.
- 7. • Results cont. –Generalised stress scores were higher in this sample than the general male population – 11% met criteria for severe or extremely severe generalised stress – Stress scores were higher for those: • with greater levels of internalised stigma • with higher levels of HIV-related discrimination • with no university education • with less emotional support • born in Australia.
- 8. • Implications andExplanations: – More consistent screening for mental health problems among HIV-positive men may allow for better detection and opportunities for treatment – “Healthy migrant” effect or cultural/ language related reasons for different responses?
- 9. Psychosocial Factors Associatedwith Resilience in a National Community-Based Cohort of Australian Gay Men Living with HIV Lyons, Heywood, and Rozbroj • Same sample as previous study • Results – Mean resilience scores were lower than previously reported general population samples – Factors significantly associated with lower resilience were: • Lower income • Higher levels of internalised HIV-related stigma • Having ever been diagnosed with a mood or anxiety disorder • Currently receiving treatment for a mood or anxiety disorder
- 10. • Discussion – FurtherAustralian research is needed – Those with high internalised stigma may have low self-worth, or experience a sense of hopelessness, making it harder to overcome challenges – Should address issues like internalised stigma in resilience training programs
- 11. Taking into Accountthe Quality of the Relationship in HIV Disclosure Smith, Cook, & Rohleder • Method – 95 HIV-positive adults - retrospective self report about HIV status disclosure to an intimate partner • Results – Level of perceived psychological safety, and partner reaction were influenced by: • unequal power relations in the relationship • How tumultuous the relationship was • How emotionally abusive the relationship was
- 12. • Results cont. –Emotional intimacy after disclosure and number of arguments after disclosure were influenced by: • the extent to which the relationship was tumultuous • emotional abuse in the relationship – Those who reported a committed relationship or a trusting relationship took longer on average to tell their partner – Those in tumultuous relationships were more likely to identify disclosure as a factor in a subsequent break up, and those in committed relationships were less likely to
- 13. • Discussion – Theamount of time to disclose may be because the stakes are higher. – Focussing on these variables in disclosure interventions or couples counselling may help set up the relationship for a more positive outcome following potential disclosure.
- 14. HIV Disclosure Anxiety:A Systematic Review and Theoretical Synthesis Evangeli & Wroe • A systematic review of 119 empirical studies that reported on anxiety about HIV disclosure • Demographics of studies: – Location – Study Method – Sample differences: • Size ranged from 4 to 775 • Multiple sub groups • Sex differences • Differences in recipient of disclosure
- 15. Qualitative Findings • Reasonsfor non-disclosure and/or disclosure anxiety: – Fear of discrimination or stigma (58 studies) – Fear of rejection or abandonment (54 studies) – Fear of partner violence (18 studies) – Fear of secondary or indirect disclosure (17 studies) – Fear of causing worry for others (15 studies) – Less common reported reasons included worry about feeling guilty or ashamed, worry about losing job, and fear of being blamed.
- 16. Qualitative Findings cont. •Anxiety about disclosure was: – reported as a barrier to beginning or adhering to ART (14 studies) – reported as a barrier to self care or care for a child (8 studies) – Reported as a barrier to safe sex (3 studies) – Associated with lacking social support (5 studies)
- 17. Quantitative Findings • Positiveassociation between HIV disclosure concerns and general anxiety (2 studies) • Disclosure concerns were associated with higher levels of personally held HIV stigma (2 studies) • Disclosure concerns were associated with negative self-image and low self-esteem (1 study) • Concerns were greater in females than males (1 study)
- 18. Quantitative Findings cont. •Concerns were greater in heterosexual participants (compared with homosexual and/or bisexual participants) (3 studies) • Higher in individuals without an AIDS diagnosis (2 studies) • Higher in those with lower CD4 counts, no partner, and of a younger age (1 study) • Significant relationship between HIV disclosure concerns and depression?
- 19. Strengths • No timeframe on search Limitations • Most studies reviewed were qualitative, and most of the quantitative studies had different variables. • Most studies did not specify who the recipient of the disclosure was, and anxiety levels and causes may differ depending on recipient.
- 20. Model of HIVDisclosure Anxiety
- 21. Evidence for themodel:
- 22. Limitations • Some componentsof the model have no evidence in a HIV-positive sample • Many elements of the model cannot be operationalised currently, so until reliable and valid measures are developed, the relationships can’t be assessed for significance
- 23. Strengths • First modelto incorporate anxiety into HIV disclosure behaviour • Based on existing clinical anxiety models • Model has clinical implications, and may assist in developing or improving counselling techniques or support programs
- 24. Implications • Useful indeveloping interventions or support strategies – The model can be used to help individuals understand what is maintaining their anxiety, which may enable them to manage those factors and keep their anxiety controlled – It will also allow them to assess the likelihood and severity of their threat interpretations
- 25. References (in orderpresented) Conroy, A. A., Gamarel, K. E., Neilands, T. B., Dilworth, S. E., Darbes, L. A., & Johnson, M. O. (2016). Relationship Dynamics and Partner Beliefs about Viral Suppression: A Longitudinal Study of Male Couples Living with HIV/AIDS (The Duo Project). AIDS and Behavior, 20(7), 1572-1583. Heywood, W., & Lyons, A. (2016). HIV and elevated mental health problems: diagnostic, treatment, and risk patterns for symptoms of depression, anxiety, and stress in a national community-based cohort of gay men living with HIV. AIDS and behavior, 20(8), 1632-1645. Lyons, A., Heywood, W., & Rozbroj, T. (2016). Psychosocial factors associated with resilience in a national community-based cohort of Australian gay men living with HIV. AIDS and Behavior, 20(8), 1658-1666. Smith, C., Cook, R., & Rohleder, P. (2017). Taking into Account the Quality of the Relationship in HIV Disclosure. AIDS and Behavior, 21(1), 106-117. Evangeli, M., & Wroe, A. L. (2017). HIV disclosure anxiety: A systematic review and theoretical synthesis. AIDS and Behavior, 21(1), 1-11.
Editor's Notes
- #3 266 gay males (aged 18+) in a relationship (i.e. 133 couples) completed surveys (separately) about their relationship dynamics and their perception of their partners viral load. The relationship had to be for more than 3 months with someone “you feel committed to above anyone else and with whom you have had a sexual relationship”, with at least one person in the couple being HIV-positive and on an acknowledged ART regimen Viral load tests were conducted using COBAS_ AmpliPrep/COBAS_ TaqMan_ HIV test kit (Roche Molecular Systems, Inc.), which has a threshold of < 48 copies/ml, and viral load was rated as detectable or undetectable using this cut off value. Viral load was assessed against partners’ perceptions of viral load. Congruent responses were coded as 1, incorrect responses were coded as 0, meaning it didn’t matter whether the partner incorrectly assumed an undetectable load or a detectable one, it was incorrect. Assessments were completed 5 times, 6 months apart, and each HIV-positive participant had blood drawn at 12 and 24 months, and Partners’ perceptions of viral load were checked against the actual measured viral load Cohabitation status, relationship length, and couple HIV status were controlled for
- #4 ~50% of men were virally suppressed (unchanged over 5 sessions), but 74.2% of partners believed there was an undetectable viral load at baseline. Accuracy gradually declined, with 89.7% of partner’s thinking there was an undetectable viral load at 24 month visit Among men who were incorrect about their partners viral load, 80.4% assumed their partner was virally suppressed when they were not (93.4% at 24 month visit) Couple level differences in dyadic adjustment were negatively correlated with accuracy (i.e. a bigger difference in ratings of dyadic adjustment was associated with lower accuracy), and this was the only remaining significant relationship once other factors were controlled for. No significant difference in suppression beliefs between men in sero-discordant relationships compared to men in HIV-positive sero-concordant relationships, however those in sero-discordant relationships were more likely to be virally suppressed at baseline than (but not at the 24 month visit)
- #5 Men discuss viral load status early in the relationship, but don’t revisit the discussion once the relationship is settled. Approximately 50% of HIV-positive men were virally suppressed at each assessment session, but individuals did change, with 119 of 407 men having a change in their viral suppression status from baseline to 12 months, and a further 43 changing between 12 and 24 months. Perhaps changes were not discussed with partners. If sexual activity (or, more specifically, CAI) decreases over time, HIV-positive men may find it unnecessary to inform their partner of the change in viral load status. Men may have overly optimistic beliefs about the effectiveness of ART, and assume that if their partner is taking it consistently, then they must have an undetectable viral load.
- #6 357 HIV-positive Australian gay men Australians completed an online survey on the wellbeing of people living with HIV Mental health variables were measured using the short-form Depression Anxiety Stress Scales Results Depression scores were higher in this sample than the general male population (m = 11.2 vs m = 6.6), with 45% of men reporting some level of depression, and 20% meeting criteria for severe or extremely severe depression (equivalent to top 5% of general population norms). Of those who met criteria for severe or extremely severe depression, 82% had been diagnosed, and 35% were receiving treatment. Depression scores were significantly higher for those who were unemployed, or had “other” as their employment category (e.g. student or self-employed), those who were born in Australia, and those with greater internalised stigma surrounding HIV
- #7 Anxiety scores were higher in this sample than the general male population (m = 7.15 vs m = 4.6), with 36% of men reporting some level of anxiety, and 17% meeting criteria for severe or extremely severe anxiety. Of those who met criteria for severe or extremely severe anxiety, 59% had been diagnosed, and 31% were receiving treatment Anxiety scores were significantly higher for those without university education, who were born in Australia, with less emotional and tangible support, and with lower CD4 counts.
- #8 Generalised stress scores were higher in this sample than the general male population (m = 12.25 vs m = 9.93), with 33% of men reporting some level of stress, and 11% meeting criteria for severe or extremely severe generalised stress. After adjusting for other factors, stress scores were significantly higher for those who reported greater levels of internalised stigma, higher levels of HIV-related discrimination, those without university education, with less emotional support, and who were born in Australia.
- #9 Depression and anxiety may be under-diagnosed and under-treated among men with HIV in Australia – more consistent screening for mental health problems among HIV-positive men may allow for better detection and opportunities for treatment Lower levels of mental health problems in overseas born participants may be due to the “healthy migrant effect” (i.e. successful migrants are more resilient than the general population), or because overseas participants had cultural or language related reasons for different responses.
- #10 Mean resilience scores were lower than previously reported general population samples (data from USA – no existing Australian data) (27 vs 29-32), although they were similar to other (mostly American) studies of groups living with chronic illnesses After adjusting for other factors, the ones significantly associated with resilience were income, internalised HIV-related stigma, having ever been diagnosed with a mood or anxiety disorder, and currently receiving treatment for a mood or anxiety disorder
- #11 Further research is needed to ascertain whether resilience is significantly lower in HIV-positive gay men compared to the general population in Australia. Having low or no internalised stigma regarding HIV was the strongest factor associated with higher resilience - those with high internalised stigma may also have low self-worth or feelings of shame, and therefore may experience a sense of hopelessness, making it harder to overcome life challenges. May be beneficial to develop and implement tailored resilience training programs for HIV positive gay men, which include addressing issues such as internalised stigma, as resilience has been shown to be a protective factor against mental health problems.
- #12 Collected retrospective self report accounts from 95 HIV-positive individuals (age of 18+, all UK residents) who had disclosed their HIV status to an intimate partner at some point in time. Results Level of perceived psychological safety directly after disclosing was influenced by unequal power relations in the relationship, the extent to which the relationship was tumultuous, and the extent to which emotional abuse was an issue in the relationship. These three factors were also associated with whether or not the partner reacted positively to the disclosure.
- #13 Results cont. the extent to which emotional intimacy increased following disclosure, and the extent to which disclosure was associated with an increase in arguments were influenced by both the extent to which the relationship was tumultuous, and the extent to which emotional abuse was an issue in the relationship. Those who reported a committed relationship took longer on average to tell their partner (months or years, compared with days or weeks). Similar patterns were found with whether or not participants reported a trusting relationship, with those reporting trust in the relationship taking longer to tell their partner. Perhaps this is because there is more at stake in a committed and trusting relationship. Those in tumultuous relationships were more likely to identify their HIV status disclosure as a factor in a subsequent break up. The level of emotional abuse was a significant predictor of the extent to which arguments increased following disclosure.
- #14 While higher levels of commitment were related to taking longer to disclose, those who reported higher levels of commitment were less likely to cite their HIV disclosure as a factor in a subsequent break up. In line with previous research, the authors suggest that the amount of time to disclose may be because the stakes are higher (i.e. there’s more to lose in a more committed relationship). Focussing on these variables associated with disclosure outcomes (especially trust, as it’s the easiest to work on developing) in disclosure interventions or counselling with couples may lead to disclosure and set up the relationship for a more positive outcome following disclosure.
- #15 Studies from peer-reviewed journals were retrieved from Pubmed/Medline and Psychinfo with no date restriction. Articles considered relevant (screened by first author and independently rated by undergrad psych student, which Cohen’s Kappa of 0.78, p<0.01, so good inter-rater reliability) were retrieved and then assessed for eligibility by both reviewers. 159 articles were screened as potentially eligible, and 119 made the final cut. Most of the studies rejected were because they did not report on anxiety about HIV disclosure Demographics of studies: Location: 51 African, 39 North American, 15 Asian, 8 European, 4 South American, and 2 Australasian. Study Method: 64 qualitative interviews, 43 surveys, 18 focus groups, 8 self-report questionnaires, and 3 participant observations. 15 studies used more than one method. Sample differences: Ranged from n=4 to n=775 (median = 52) 23 were based on parent samples, 8 on ethnic minority groups, 6 on people taking ART, 5 on adolescents, 3 on MSM, and 59 studies had participants who did not belong to a specific subgroup of HIV-positive individuals. The remaining 15 sampled various diverse populations (e.g. sex workers, prisoners) 32 female only studies, 10 male only studies, 77 mixed sex. 24 were about disclosing to a partner, 9 to the participants children, 5 to family and friends, 3 to work colleagues, 1 to dentists, and 77 did not specify recipient of disclosure.
- #19 1 study found a significant relationship between HIV disclosure concerns and depression but another study failed to find the same significant relationship.
- #20 Strengths No time frame on search - covered all relevant articles. Limitations Most studies reviewed were qualitative, and most of the quantitative studies had different variables. This made it hard to quantify the extent of anxiety regarding different variables, and to compare findings between studies. It also meant the authors were unable to assess the causes and consequences of anxiety. Most studies did not specify who the recipient of the disclosure was, and it would be logical to assume that anxiety levels and causes may differ depending on recipient.
- #21 Most models of HIV disclosure behaviour do not include anxiety, but this review suggests that perhaps anxiety may be relevant in some peoples choice to disclose. HIV core beliefs and stigma (pretty self explanatory) Conditional assumptions (e.g. HIV is shameful, so I should hide my HIV-positive status) context (essentially demographic factors) trigger event (what triggers the anxiety about disclosing) threat interpretation (taken from a cognitive-behavioural model of health anxiety, in which threat interpretation was described as the probability of a negative outcome, multiplied by the awfulness of the outcome, dividing by coping plus rescue factors) behavioural maintaining factors (avoidance behaviours, safety seeking behaviour) Cognitive maintaining factors (e.g. preoccupation and rumination, focus on negative talk about people with HIV) affective and psychological maintaining factors (HIV disclosure concerns associated with general anxiety) There is no evidence in terms of HIV disclosure for the conditional assumptions, threat interpretation, or for the cognitive maintaining factors, but further research could attempt to determine the truth behind these assumptions. Many of the components cannot be operationalised, so the relationships are currently unable to be tested for significance.
- #23 Some components of the model have no evidence in a HIV-positive sample Many elements of the model cannot be operationalised currently, so until reliable and valid measures are developed, the relationships can’t be assessed for significance
- #24 Model has clear clinical implications, and may assist in developing or improving counselling techniques or support programs First model to incorporate anxiety into HIV disclosure behaviour Based on clinical anxiety models, and adapted to fit HIV disclosure
- #25 Useful in developing interventions or support strategies (particularly if further research is done to confirm elements of the model and assess the impact on interventions) Authors suggest maintenance components of the model should be focused on in interventions where individuals are most affected by HIV disclosure anxiety and are motivated to consider sharing their status The model can be used to help individuals understand what is maintaining their anxiety, which may enable them to manage those factors and keep their anxiety controlled It will also allow them to make considered and logical decisions about the likelihood and severity of their threat interpretations