Our study underscores the importance of expanding services for PLH beyond their physical and medical needs. In addition to the medical challenges associated with living with HIV, PLH in Thailand face multiple mental, social, and behavioral challenges. In addition to negative factors such as depression that impact PLH’s quality of life, there are protective factors associated with improving PLH’s quality of life. For instance, as we identified the negative effects of PLH’s level of depression and perceived internalized shame on their perceived general health and mental health, we also observed that family functioning was positively associated with their perceived general health. These negative and positive factors are interconnected and call for integrated interventions to address the complexity of these challenges and improve PLH’s ability to cope with the illness.
Our study has provided evidence that PLH’s quality of life can be improved by a behavioral intervention. Compared to the standard care condition over 12 months, we found the intervention significantly improved the quality of life for PLH, both in their perceived general health and mental health. PLH in the intervention condition reported a significant increase in their general health and mental status over 12 months.
Physical health and mental health were central issues addressed in the intervention. With two out of four modules on health and mental health, we addressed challenges that PLH and their families face in Thailand. Our study further suggests that programs must be culturally adapted to ensure long-term effectiveness. For instance, to target mental health in the intervention, we learned that feelings of “guilt,” associated with the notion of “self-acceptance” and “karma,” are dominant themes in coping with HIV status in Thailand. This concept is highly relevant and identifiable in Thai Buddhist philosophy35
and was fully integrated into the intervention. Our findings again demonstrated the importance of adaptations to local culture as a better choice than “one size fits all” packaged interventions.36
Furthermore, by incorporating the intervention sessions in the routine healthcare system of district hospitals, we were able to involve service providers at the local level and implement the intervention activities at the routine care setting to maximize the possibility of sustainability. Thus, the mental health of PLH and other vulnerable populations can be achieved without the need for substantial additional resources.
Of the three quality of life outcomes examined, we found no significant intervention effect on PLH’s physical health. This finding was anticipated, as all PLH who participated in our trial were recruited from the district hospitals where they had continuous access to care, including access to ART. What was supplemented from our intervention session focused more on addressing the mental health and family relationship challenges that PLH face while coping with HIV. Therefore, while the improvement in their perceived mental health and general health may eventually translate to better perceived physical health, we may not have been able to observe this relationship within the confines of the 12 month follow-up period.
This study found significant relationships between family functioning and PLH’s perceived general and mental health for this population. Thailand is a strongly family-oriented society and families in Thailand are tightly knit, where good family functioning becomes an even more critical factor in an individual member’s well-being. Families living with HIV face many challenges that can compromise family functioning, such as health-seeking demands, treatment adherence, stress, financial difficulties, and stigma, both within and outside the family. During difficult times, it becomes particularly important for families to stay close and to help and support each other. If the family as a unit is able to successfully overcome these challenges, the quality of life for PLH and family members can be maintained. To examine the impact of the intervention on the family members of PLH, we are in the process of finalizing the data on the intervention provided to family members who were aware of the PLH’s serostatus.
In this study, we continued to see significant impacts of depressive symptoms and internalized shame on PLH quality of life, including the measure of physical health. Previous studies have demonstrated that mental health issues are closely associated with the experience of living with HIV/AIDS and with the course and management of the disease. For instance, depressive symptoms were associated with disease progression, and were a significant barrier to adherence to ART.37–40
Although we could not show intervention efficacy on physical health in this study, the relationships between mental health and general and physical health are evident. Our results imply that providing mental health intervention could lead to improved medical and treatment outcomes for PLH.
As with all studies, some inherent limitations should be noted. Although the randomization resulted in a balanced group, our study found that at baseline, PLH in the standard care condition reported slightly higher levels of perceived general health, compared to those in the intervention condition. One of the plausible explanations could be that our randomization was based on geographic location (pre-determined sub-districts) to avoid potential contaminations; this could have led to sample unbalance due to chance alone. We adjusted for this baseline difference in our repeated measure analysis, and we found that the level of perceived general health increased significantly over 12 months in the intervention condition, compared to a decline in general health in the standard care condition, after adjusting for the baseline differences. Our scales, although validated in pilot studies prior to this main trial, are prone to potential biases associated with self-report data. Another limitation pertains to how we measured depression. When we examined the intervention effect on depressive symptomatology over 12 months, we found that depressive symptoms reported by the PLH in the intervention group declined more than those in the control group. However, this difference over 12 months was not statistically significant. This could be due to the fact that we assessed depressive symptomatology rather than clinical diagnosis. Therefore, our study findings may not be generalizable to PLH with clinical depression.
Despite these limitations, the results of this study have important implications for future intervention and treatment programs for PLH. This study underscores the importance of applying the participatory approach to the development and implementation of intervention programs. This process can be applied to future interventions to address specific stressors by tailoring the intervention to a particular target group. Given the need to expand mental health interventions within HIV efforts,41
it is encouraging to see that PLH quality of life can be improved by a behavioral intervention. Program developers, clinicians, policymakers should pay close attention to PLH’s mental health challenges, coping skills, and family and social support, while simultaneously being aware of HIV-related stigma and discrimination in their community. Both social and psychological components should be integrated and incorporated into the programs. Advances in the understanding of family functioning and PLH quality of life suggest that program developers and researchers should address the connection between individual and family well-being. An intervention that helps PLH can strengthen the family as a unit, and strengthening family resiliency can also have positive impact on PLH.