This study examined associations between spirituality, depressive symptoms, and immune status among predominantly African-American women living with HIV in the Southeastern U.S. On average, the sample was highly spiritual, and spirituality was considered “moderately”, “quite”, or “very” important to a large proportion (86.8%) of the sample. Similarly, Lorenz and colleagues (2005)
reported that 85% of patients with HIV affirm that spirituality is “somewhat” or “very” important in their lives. A great portion of the sample also engaged in spiritual or religious practices such as prayer, meditation, or reading spiritual or religious material, on a daily to weekly basis. These findings reflected, to some extent, the importance of spirituality and spiritual/religious practices among people living in the “bible belt” region of the U.S. It is important to note, however, that only a smaller portion of the sample regularly attended (at least weekly) religious services. This suggested that for some women with HIV private spiritual/religious practices (i.e. prayer, spiritual/religious reading) may be more relevant and, possibly, more accessible than public practices (i.e. church attendance). Hall (1998)
found that due to stigmatization, organized religion served as a barrier to attaining spirituality among men and women with HIV. Tarakeshwar and colleagues (2006)
found that individuals with HIV practiced spirituality in a variety of ways that did not always include organized religion. Similarly, Cotton and colleagues (2006)
found that only 23% of patients with HIV/AIDS participated in organized religion once a week or more. Overall, these findings suggest that organized religion may not be as important as other methods of spirituality for some women with HIV. For some of these women, existential aspects of spirituality, such as meaning and purpose in life, may be more relevant.
The finding of poor psychological well-being is congruent with the literature that women with HIV have an increased prevalence of depression (Hackl, Somlai & Kalichman, 1997
; Moneyham et al., 2005
), and they have significantly higher rates of depression than their counterparts (Evans et al., 2002
; Morrison et al., 2002
; Valverde et al., 2007
; Vyavaharkar et al., 2007
). The demands of living with HIV may predispose HIV-positive persons to the development of depression (Ader, Felten & Cohen, 1991
). This is why the identification of resources that facilitate coping within this population is so essential.
The sample CD4 cell counts and percentages were low, on average (mean = 291 and 16.24, respectively), but this finding is consistent with HIV patients, in general, and the patient population at the infectious disease clinics from where participants were recruited. The clinic generally serves HIV-positive patients with CD4 cell counts less than 200 cells/μl, which is a criterion for a diagnosis of AIDS (CDC, 2004), and it is typical for CD4 cell counts to decline below 500 cells//μl as HIV disease progresses (Cotran et al., 1999
). A CD4 percentage below 14% indicates serious immune deficiency and is a sign of AIDS in people with HIV (Cotran et al., 1999
). This finding suggested that, on average, the sample consists of women with more advanced stages of HIV disease, which also could contribute to more depressive symptoms.
Results indicated that higher SWB and its components (EWB and RWB) were significantly associated with lower depressive symptom scores. This finding suggested the importance of spirituality’s potentially beneficial role in the psychological well-being of women living with HIV in the Southeast. Researchers have studied the relationship between spirituality and various psychological factors, but only few have examined the relationship between spirituality and depressive symptoms among women with HIV/AIDS (Braxton et al., 2007
; Simoni et al., 2002
; Simoni & Ortiz, 2003
). In addition to corroborating previous findings, the findings of this study contributes to the body of literature on this relationship among women living with HIV. Similar to the findings of this study, previous studies have shown significant inverse relationships between spirituality and depression, among mixed groups of persons with HIV (Coleman & Holzemer, 1999
; Nelson et al., 2002
; Yi et al., 2004
) and women with HIV (Braxton et al., 2007
; Simoni et al., 2002
; Simoni & Ortiz, 2003
). Tuck and colleagues (2000)
identified inverse associations between EWB and stress and psychological distress among persons with HIV.
Additional analyses showed that women who had high depressive symptom scores had significantly lower mean SWB, EWB, and RWB scores than women who had low depressive symptom scores. A significant relationship was also observed between spiritual/religious practices, such as prayer or meditation and reading spiritual or religious material, and a woman’s depressive symptom status. More of the women who did not pray or meditate and women who did not read spiritual or religious material had high depressive symptom scores compared to women who did pray or meditate and women who read spiritual or religious material. According to Musgrave and colleagues (2002)
, the “expression of emotion in Black churches offers an outlet for pent-up anguish” (p. 59). Other researchers have reported that specifically among African-Americans, spirituality serves as a strong source of guidance, healing, coping, peace, comfort, and protection during challenging times (Newlin, Knafl & Melkus, 2002
). As the literature suggested, spirituality may have served as a protective psychological resource for this predominantly African-American sample of women living with HIV.
Depression is associated with alterations in immune function, specifically CD4 cell count (Ickovics et al., 2001
) and CD8 T cells among women with HIV (Evans et al., 2002
). However, this study failed to show a significant association between depressive symptoms and immune status. The lack of this finding may be due to methodological issues and measurement errors. Although most of the CD4 cell counts and percentages were measured within eighteen days, on average (a median of 27 days), of the assessment of depressive symptom scores, simultaneous measurement of this variable would have yielded the most valid results, because of the variable nature of CD4 cell counts.
This study was among the first few studies to identify a significant association between spirituality and immune status among women with HIV. In this study, higher EWB was weakly and significantly associated with higher CD4 cell counts and higher SWB, RWB, and EWB were all significantly associated with higher CD4 cell percentages. SWB, RWB, and EWB accounted for significant specific variance in CD4 cell percentages above and beyond that accounted for by demographic variables, HIV medication adherence, and HIV viral load (log). These findings suggested a connection between SWB components and better immune status among women with HIV. These findings add specific information about the positive associations between SWB (and its components) and CD4 cell count and percentages in HIV-positive women to the existing literature on the relationship between spirituality and physical health. A gap currently exists in the literature about the relationship between spirituality and immune status among women with HIV, since many of the studies have been conducted among mixed groups of HIV-positive persons (Bower et al., 1998
; Woods et al., 1999
) or people with cancer. Woods et al. (1999)
found that spiritual or religious behavior, such as prayer and church attendance, was associated with higher CD4+ cell counts and percentages in a population of HIV-positive persons. Other researchers have reported about the positive association between the importance of spiritual expression and CD4+ and CD8 count among women with breast cancer (Sephton et al., 2001
) and the positive association between finding meaning and CD4 cell count among HIV-positive gay men (Bower et al., 1998
). Similar to this study, Ironson et al. (2006)
found a significant association between spirituality/religiousness and better CD4 cell counts. These findings suggested the role of spirituality and EWB in helping to maintain a state that is favorable to CD4 cell function. Alternatively, women with HIV who report higher SWB may also have characteristics or engage in behaviors associated with better immune status.