The first interesting result is that many people (45%) reported an increase in religiousness/spirituality after the diagnosis of HIV. This was corroborated as a significant increase by the “religiousness/spirituality at various times in one’s life” measure. Being diagnosed with a devastating illness may be a time when people re-examine their relation to the sacred. This increase in spirituality is consistent with and may contribute to the observation that many patients (49%) feel that life with HIV is better than it was before getting diagnosed.19
Spirituality/religiousness may contribute to this through their role in coping and meaning making.20
The process by which HIV transforms the lives of people with HIV and the impact of spirituality and coping is quite moving and is further described qualitatively elsewhere.21
For many people, getting HIV becomes a catalyst for positive change, and spirituality is often involved in that change.21
Could this increase in spirituality be related to the maintenance of health? In another study of people with HIV in this issue,20
50% of people with HIV believed that their religiousness/spirituality helped them live longer.22
While we did not examine prediction of mortality, our results showed that those who reported an increase in spirituality had significantly better maintenance of CD4 cells, and significantly better control of the HIV virus. The effect is both statistically and clinically significant as people who showed a decrease in spirituality lost CD4 cells 4.5 times faster than people who showed increased spirituality/religiousness. The effect sizes also highlight the importance of INCRS in comparison with other, more well-established psychosocial predictors of disease progression such as depression and avoidant coping.4,5
Additionally important is our finding that the INCRS-disease progression relationship is independent of other variables known to predict disease progression in HIV, such as depression. As such, it adds a new variable for clinicians seeing patients with HIV to be aware of—one that could have linkages to health in addition to quality of life (other articles in this issue).
While the substudy results corroborated findings in the literature for depression and avoidant coping4,5
even above the effects of INCRS, adherence failed to predict to CD4 or VL changes. We believe this is an issue of sampling as the larger parent study did find adherence significantly predicted better control of VL in 177 people.5
Note that the results for psychosocial predictors in this substudy might also differ from the parent as this substudy controlled for INCRS.
What could possibly account for the relationship between the increase in spirituality and slower disease progression? Behavioral medicine theorizes that the relationship between psychosocial variables and disease course may occur through 3 major pathways: psychological, behavioral, and biological.23
Higher spirituality has been related to a number of these pathways including lower cortisol, less depression, hopelessness, safer sex, and less smoking.8
In the present study, although increase in spirituality was significantly correlated with more optimism and less hopelessness, neither these nor any of the other pathways tested (health behaviors, negative affect or optimistic outlook, coping, or social support) provided the answer. Biological pathways were not tested in this study. Some candidates for psychoendocrine or psychoneuroimmune pathways include cortisol, norepinephrine, or natural killer cells as these have been related to spirituality (cortisol),8
and HIV disease processes.4,25,26
Having ruled out many potential mediators, it is not clear at this point just what is responsible for this relationship and that remains for future study. Our data do not address the possibility of divine intervention, although it should be noted that the beliefs of many of the people in our sample include this as a possible pathway.
The effect of INCRS was present even after accounting for church attendance, which has been the major variable studied in predicting mortality to date.1,2
In fact, our data indicate that both INCRS and church attendance contribute uniquely and significantly to the prediction of slower loss of CD4 cells, and are virtually independent. Church attendance is a commonly used, albeit limited, proxy for religiousness. The distinction between religiousness and spirituality is presently one of intense interest and discussion.27,28
They are both multifaceted and may involve differences in beliefs and contextual differences in lifestyle, nutritional practices, and social support.
The first limitation of the study is that the establishment of a relationship between an increase in spirituality and a change in CD4/VL over time does not infer causality. Both directions are feasible: that spirituality increases (decreases) are a result of continued good (poor) health or that spirituality increases result in better health. INCRS was measured retrospectively, introducing a possible bias. Longitudinal designs could be strengthened by repeatedly measuring changes in spirituality and health in order to disentangle this chicken and egg question.
A second limitation of the study is that the INCRS measure was a single item with 5 options. While it adds a different construct beyond a single item measure of church attendance that has been used for years in studies of mortality,1
one cannot possibly measure the richness of the concept of increase in spirituality with a single item. Changes in spirituality often involve changes in views of self, view of others, view of the world, view of God, and values and priorities.21
People often re-examine who they are and the meaning of life, and often make concomitant changes in their behavior such as getting off drugs.21
Positive and negative methods of religious coping29
are also relevant. In fact, Pargament and colleagues30
found that religious struggle predicted mortality among medically ill elderly patients followed for 2 years.
The correlation between INCRS and the measure “religiousness/spirituality at various times in one’s life” difference in religion/spirituality pre- to post-HIV diagnosis was, while significant, lower than expected. Part of this may be accounted for by the 3-year difference in question administration. The difference in the way the questions were asked may also account for some of the discrepancy. Finally, some validity to measurement may be given by the remarkable consistency in percent of people with HIV showing an increase in spirituality between our study (45%) and the Cotton et al.22
study (41%) in this issue.
The generalizability of the findings may be limited by the sample being in the midrange of illness. Participants were chosen for the parent study this way as we hypothesized that relationships between psychosocial variables and health would be the strongest in that range. Another limitation is that this study did not address the relationship between increase in spirituality and quality of life. Significant correlations were found between INCRS, optimism, and hopelessness, suggesting that this might be a fruitful area for future research. Several of the other papers in this issue address the spirituality-quality of life relationship.
In conclusion, the relationship between an increase in spirituality/religiousness and slower disease progression is present and physicians should be aware of it. Given the potential health impact of change in spirituality/religiousness surrounding the diagnosis of HIV, both physicians, psychologists, social workers, and clergy ought to consider addressing religious/spiritual coping in their practice. In fact, some studies have suggested that many patients are comfortable with physicians discussing spirituality with them.31
How does one go about addressing this potentially sensitive issue? One way would be to ask a patient how they are coping with the diagnosis and HIV. A follow-up question may be whether the patient has religious or spiritual beliefs that are helping them to cope. A recent report by Kristeller et al.31
outlines a way in which physicians can bring this up that appears to be well accepted by patients. Readers may find additional material for assessing and managing religious and spiritual issues with patients in the March 2006 special issue of Psychiatric Annals
which is devoted entirely to this topic. In conclusion, these findings suggest a way that coping by turning to spirituality or religiousness may have health benefits.