We examined the relative contribution that social support, coping self-efficacy, and cognitive depression made on illness symptom reports among a US national sample of HIV-positive persons. In a much smaller sample, other researchers found that depression was more comprehensively related to HIV-related quality of life than either coping or social support was.44
However, this is the first time these relationships have been examined for their association with subjective health status using a large, diverse national sample. We conducted the analyses across different sexual identity groups, controlling for the effects of ethnicity, age, and CD4 counts on subjective health status.
Our analyses indicated that heterosexual and bisexual women, in particular, experience more symptom intrusiveness than either heterosexual men or gay men do. This gender difference is consistent with research that has found that HIV-positive women have lower health-related quality of life, particularly with regard to pain and physical functioning.45
Cultural factors may be related to the perception of pain or discomfort as well.42
Further, socioeconomic status, life stressors associated with poverty, racial discrimination, and single parenthood likely affect certain groups more than others, particularly HIV-positive ethnic minority women.46-47
Future research needs to be conducted to better understand the interaction between illness experiences and related cultural norms or life stressors for women in particular.
Cognitive depression was evident in a quarter of the sample, and there were no significant differences between groups on depressive symptoms. Depression independently explained symptom reports and intrusiveness for nearly all groups (although it did not explain symptom reports for lesbians). Further, cognitive depression independently accounted for the largest percentage of the variance for the number of symptoms reported and symptom intrusiveness in all groups. Consistent with other research,48-51
our results demonstrate the presence of a relationship between psychological symptoms and physiological disease. When taken together, the results suggest that the most salient point of intervention with regard to illness adjustment or health-related quality of life is the alleviation of cognitive depression, regardless of sexual identity status. Therefore, identifying and treating psychological distress is likely to decrease physiological morbidity among a substantial proportion of HIV-positive persons. This has important implications for structural change with regard to standard-of-care medical practice in the treatment of HIV disease such that HIV-positive patients may experience significant improvement in overall health outcomes if infectious disease practitioners regularly assess depression and provide appropriate referrals to mental health services.
Lower coping self-efficacy also independently predicted more symptom reports and greater symptom intrusiveness for all 3 groups of men. These results suggest that a strength-based approach may assist HIV-positive men, in particular, to achieve a sense of competence in adjusting to their illness. Cognitive–behavioral interventions can promote the identification of personal strengths and facilitate the development of skills to cope with particularly difficult or stressful life events. Individuals can then learn how to reframe life stressors as manageable challenges and develop strategies to effectively deal with them, which reduces psychological stress by improving not only their overall mental health, but also their symptom experiences.
Last, although statistically significant differences were found among the groups on a measure of social support, the degree of difference may not be clinically significant. Furthermore, social support did not independently explain symptom reports or intrusiveness as cognitive depression or coping self-efficacy did. Although social support likely plays an important role in disease management and quality of life, subjective health status may be better reflected in measures of cognitive depression and coping self-efficacy.
A paucity of quantitative research exists related to the experience of HIV-positive sexual minority women. Although we were able to recruit a small sample of lesbian (n = 61) and bisexual (n = 91) women for our study, the small sample sizes limited statistical power. For example, we failed to find differences with regard to psychosocial variables for lesbian and bisexual women, although our data suggest that lesbians may actually experience more social support and less cognitive depression than the other groups. The hierarchical regression results indicate that cognitive depression accounts for a significant amount of the variance in symptom intrusiveness for this group. Yet, limited power may have resulted in nonsignificant relationships between the psychosocial variables and symptoms reports. For example, the standardized beta indicating the relationship between cognitive depression and symptom reports was identical to that for heterosexual men (.27), although these results were not significant in the former sample. Researchers must use targeted sampling plans to further quantitative research agendas related to the experience of living with HIV among lesbians in particular. We know little about the psychosocial stressors that may influence physical symptoms in this population, and such nescience likely results in inadequate approaches to addressing sexual minority women's specific illness adjustment needs.
We used 2 measures of subjective health status for this study. The results indicate that measures of symptom intrusiveness, particularly questions about how much the symptoms bother people, may be a better indicator of subjective health status than the total number of symptoms experienced. The symptom intrusiveness model accounted for a larger portion of the variance for each subsample, and the individual predictors appear to be more strongly associated with symptom intrusiveness than the number of symptoms experienced. For these reasons, symptom intrusiveness may be a more salient measure of subjective health status, a contradiction of others' findings.30
The results also suggest that it may be beneficial for health care providers to evaluate the degree to which particular symptoms influence an individual's quality of life or daily functioning. Moreover, self-report symptom checklists should be used to facilitate a discussion about symptom intrusiveness and not as the sole indicator of functional status.
There are 2 significant limitations to this study. First, this is a cross-sectional analysis. Therefore, we cannot determine causality. In this article, we chose to examine the influence of psychosocial factors on symptom reporting to test the hypothesis that poorer psychosocial functioning manifests in relation to greater experience of negative symptoms. This perspective is consistent with results from longitudinal studies that have demonstrated the influence of psychosocial factors on salient health outcomes.11,12,52
For example, depression and coping style could influence not only the perception of symptoms, but also important physiological processes, such as immunological functioning.11,49,50,53
However, illness experiences, such as a greater number of or more intrusive symptoms, could lead to clinical depression,54,55
although this relationship has received less research attention. Ultimately, we are able to examine 1 piece of the puzzle with these data; longitudinal studies, ideally with more frequent assessments, are needed to provide a thorough analysis of the nature of the association between psychological and physiological symptoms and their recursive influence.
The second limitation of this study is related to the demographics and health status of the samples. There were substantial differences among the groups in terms of key demographic variables. On the basis of these differences and those that appear to be most salient in the literature in terms of illness experiences, we controlled for ethnicity, CD4 counts, and age in the hierarchical regression analyses. Beyond variability among the groups, the mean age was approximately early 40s in each group, and 80% of the participants learned of their HIV status prior to 1995. Therefore, this sample is overrepresented by those who are somewhat older and have been living with HIV for many years. In addition, more than one-fifth of the sample had an AIDS diagnosis at the time of the interview, and nearly the entire sample had taken antiretroviral therapies. Thus, these results may be more generalizable to those who have lived with HIV for a number of years compared with those who have been recently diagnosed or those who are significantly younger. Although this study contributes to a better understanding of the mental and physical health correlates of long-term survivors in the contemporary HAART era, understanding the needs of younger and newly diagnosed individuals is also necessary to address mental health, HIV-related risk behavior, and treatment adherence factors that may have serious and long-term effects on illness adjustment and disease progression.