Stress and Coping in Women Living with HIV: A Meta-Analytic
Roger C. McIntosh•Monica Rosselli
? Springer Science+Business Media, LLC 2012
coping mechanisms on behavioral health outcomes a meta-
analysis was conducted using forty empirical articles which
sampled 7,602 adult women living with HIV/AIDS in the
U.S. (M = 36.3 years). Three independent reviewers con-
ducted searches in abstract databases from 1997 to present
day. Articles reporting effect sizes amongst psychosocial
stressors and coping mechanisms with indices of behav-
ioral/mental health were selected. The meta-analyses
revealed that in a time frame characterized by the wide-
spread availability of anti-retroviral medication, poor
mental health outcomes were predicted, in a similar man-
ner, by psychosocial stress and HIV/AIDS symptomology.
Significant effects were also observed with functional
impairment, though to a lesser degree. Coping by avoid-
ance and social isolation predicted more severe mental
health outcomes. Spirituality and positive reappraisal pre-
dicted greater psychological adaptation than did social
support seeking. Despite advancements in anti-retroviral
treatment for women, HIV/AIDS symptoms and acute and/
or chronic psychosocial stress pose the same threat to
behavioral and mental health. In the face of these stressors,
positive reframing appears to promote psychological
To examine effects between stressors and
adaptation in a way which may lead to positive health
outcomes in women living with HIV/AIDS.
Mental health ? Disease adjustment
Stress ? Coping ? Women ? HIV ? AIDS ?
estre ´sylosmecanismosdeadaptacio ´ntienensobreelajustea
laenfermedad;seutilizaroncuarentaartı ´culosempı ´ricosque
incluyeron un total de 7.602 mujeres adultas que sufrı ´an de
VIH/SIDA (Medad = 36,3 an ˜os). Tres revisores hicieron
artı ´culos publicados desde 1997 a la actualidad. Se escogi-
eronartı ´culosquedescribı ´aneltaman ˜odelefectoenelestre ´s
psicosocial,enlosmecanismosdeadaptacion conı ´ndicesde
salud mental o conductual. Tanto el estre ´s psicosocial como
la sintomatologı ´a de HIV/AIDS predijeron una inapropiada
salud mental. En menor grado se observaron alteraciones en
el funcionamiento. El enfrentarse a la enfermedad a trave ´s
del aislamiento social y la evitacio ´n predijeron el desajuste
en la salud mental de HIV/AIDS. La espiritualidad y re-
bu ´squeda de apoyo social. A pesar de los avances en la ter-
apiaHAART,elestre ´spsicosocialagudo ycro ´nico asociado
a los sı ´ntomas de HIV/AIDS, continu ´a contribuyendo a la
psicopatologı ´a y a la presencia de conductas de salud des-
viadas en mujeres con HIV/AIDS. Estas mujeres emplean
una multitud de mecanismos de adaptacio ´n para amortiguar
los efectos del estre ´s.
Enestemeta-ana ´lisisseexamino ´ elefectoqueel
SIDA ? Salud mental ? Ajuste a la enfermedad ? Adaptacio ´n
Estre ´s ? Afrontamiento ? Mujeres ? VIH ?
Portions of this study will be presented at the Annual Meeting for the
International Neuropsychological Society (INS) in Boston
Massachusetts on February 5th 2011.
R. C. McIntosh (&) ? M. Rosselli
Department of Psychology, Charles E. Schmidt College
of Science, Florida Atlantic University, 2912 College Avenue,
Davie, FL 33314, USA
Women demonstrate a biological susceptibility to infectious
persons living with the Human Immunodeficiency Virus
(HIV) and subsequently Acquired Immune Deficiency Syn-
drome (AIDS) . The lifetime odds for a woman to contract
1 in 32 African-American women and 1 in 106 Hispanic/
Latina women will be diagnosed with HIV at some point in
their lives, only 1 in every 526 Caucassian or Asian women
will forego the same outcome . Highly Active Antiretro-
viral Therapy (HAART) has helped extended reshaping what
was previously considered a terminal diagnosis to a chronic
yet manageable disease. Despite these advancements, dis-
parities in disease management exist. AIDS related compli-
cations are the leading cause of death in African American
women aged 25–34 and the fourth leading cause of death for
Hispanic women aged 35–44 . These demographic trends
in progression from HIV to AIDS may reflect differences in
of these findings, a general concern has arisen regarding dis-
environmental stressors. To better quantify these effects,
theoreticians have developed psychosocial transactions
psychological and behavioral outcomes [5–9]. Here, we look
todescribe the psychological, social, and biologicalmilieu of
women living with HIV/AIDS.
A large body of HIV/AIDS research in women has been
and behavioral medicine to help shape our understanding of
the many factors related to disease management. The sum-
ascertaining predictors of behavioral and psychological
health in persons with HIV. Meta-studies consisting of large
male and female cohorts have been useful in identifying
outcome moderators. Moscowitz et al.  found gender to
moderate the effect of higher-order coping mechanisms on
specific disease-related outcomes such as self-report ratings
of positive and negative affect. These findings suggest
maladaptive ways of coping i.e. avoidance have more dele-
terious effects for women than do men. Longitudinal meta-
analyses also provide great resolution into mechanisms of
disease progression, and have likewise shown stark gender
and symptom-based stressors [11, 12]. These summative
findings suggest that interactions between stress, coping and
outcomes must be taken within the context of gender.
Female gender is one of the most significant predictors of
distress in HIV-infected persons [13–15]. The myriad of
psychosocial archetypes observed in women living with
HIV/AIDS may pose a seemingly greater challenge for
clinical case management . When stressors are encoun-
tered they can precipitate a cascade of adrenal and sympa-
thetic nervous system activity known to compromise
immune function . These stressors are thought to follow
a hierarchy in which chronic strains and major life events
pose greater long-term effects on psychopathology than
more subtle forms of stress i.e., acute daily hassles [13, 14].
For example, life events such as bereavement can leave a
post-traumatic effect which if unimpeded may lead to
symptoms of depression and anxiety [16–18]. Chronic
strains and daily hassles which are commensurate with
socioeconomic conditions i.e., financial burden, unemploy-
ment, crime/victimization, and access to child/health care,
can also compound stress levels and deplete coping resour-
ces thus compounding HIV/AIDS prognosis [4–6, 19–22].
Internal physical symptoms are another source of stress
for those living with chronic disease. The relationship
between the physical burdens of HIV/AIDS and quality of
living may be quantified in several ways. Although CD4
count and viral load are frequently compared to measures
of disease adjustment, their utility in predicting psycho-
logical and behavioral outcomes are debated [23–25]. An
alternative approach to using biological markers as a
predicitive measure is the utilization of self-report inven-
tories [26–28]. This form of assessment allows researchers
to examine stressors relevant to women of childbearing
age (e.g., menstrual abnormalities, cervical dysplacia,
increased susceptibility to sexually transmitted infections,
amenorrhea, as well as mother–child transmission of the
Stress appraisals can lead to the mobilization of a coping
response. These responses may be considered innate traits
or learned behaviors that are recruited to manage the spe-
cific external and/or internal demands of an event appraised
as taxing or exceeding individual resources [7–9, 33–35].
Furthermore, they may be classified as adaptive or mal-
adaptive depending on the positive/negative valence of
short and long-term mental effects [6–9]. Epochs of psy-
chological adaptation observed in HIV/AIDS are depen-
dent on whether an individual utilizes approach, (e.g.,
positive reappraisal and seeking social support) or avoidant
(e.g., social isolation and denial) coping styles [36–45].
Although both strategies may lead to short term relief the
consensus across these studies holds that long-term con-
sequences of avoidant coping result in further immune
compromise and emotional distress.
Along with the broad categorizations mentioned afore,
hundreds of sub-ordinate coping mechanisms have been
identified in the literature . For example, spiritual
perspective or religious-based practices such as prayer are
shown to provide psychological relief from aversive
experiences in women living with HIV/AIDS [46–51].
Larger effects are noted when this mechanism is reportedly
used by women of African decent [52, 53]. Seeking Social
Support (SSS) is also employed to alleviate physical and
emotional distress associated with adverse environmental
conditions. This construct may be quantified (a) the source
of support (e.g., partner, family, or extended social net-
work) (b) indication of the type of support (e.g., tangible or
informational), and (c) perception of the level or quality of
support received [54, 55].
The HIV/AIDS epidemic impacts the lives of women in a
to face a range of stressors within and outside the biological
context ofthedisease.HAARTregimenshave donemuchto
change the perception of life expectancy , however,
maladaptive coping contaminant with aversive socioeco-
nomic factors and oscillating immune response increasingly
and disparately jeapordize disease adjustment in women
[57–60]. The current meta-analysis examines women being
treated for HIV with the aim of comparing the magnitude of
effect amongst various stressors i.e., psychological, physi-
cal, and functional; ensuing coping mechanisms i.e.,
approach, spirituality, positive reappraisal, seeking social
support, avoidance, denial, and social isolation; and specific
indices of psychological and behavioral adjustment.
Selection of Studies
A search was conducted of relevant abstract databases i.e.,
PsycINFO, PubMed, and Science Direct for peer-reviewed
articles published from January of 1997–2011. This period
was selected to depict seropositive women living in an era
with widespread availability of HAART. Only studies
published in English within the United States were con-
sidered. Independent reviewers searched for articles using
the terms: ‘‘coping’’ [and] ‘‘stress’’ [and] ‘‘stressors’’ [and]
‘‘mental health’’ [and] ‘‘health behaviors’’ individually
paired with ‘‘women with HIV/AIDS’’. Published meta-
analyses, reviews, and empirical studies were also searched
for citations referencing articles from the post-HAART era.
Inclusion criteria for this meta-analysis required the study
to have: (a) an exclusively female sample, (b) participants
recruited within post-HAART era, (c) construct validated
stressors and/or coping indices with similarly validated
measures as recommended by Cohen , (d) appropriate
measure of effect size i.e., zero-order bivariate correlation
or beta coefficient , and (e) published in a peer-review
journal. When information was reported incompletely or in
an irretrievable format, a written request was forwarded to
the corresponding author of the article. Seven authors were
contacted for data retrieval with 2 out of 7; 29% being
retained for the meta-analysis. A final count of 40 studies
met the above criteria (Fig. 1). Methodological quality of
each study was determined by two independent reviewers
through the use of the STROBE checklist . The per-
centage of ‘‘yes’’ responses out of the total number of
applicable items ranged from 81.7 to 100 with a mean
rating of 94.8 on a 100 point scale. The Kappa statistic was
used to determine consistency among raters. A near perfect
agreement for interrater reliability was found Kappa = .97
(p\0.001), 95% CI (0.953, 0.981). Attempts were not
made to obtain unpublished data.
Demographic (e.g., ethnicity, age) and methodological
(e.g., type of coping) information was coded for each
study. To ensure that the same constructs and relationships
were interpreted across studies, each article was distributed
to and reviewed separately by three researchers. Each
reviewer coded the study in a separate database. Before the
meta-analysis was conducted, an inter-rater analysis of the
descriptive data was examined and reconciled for dis-
crepancies by the first author.
A review of the HIV/AIDS literature suggested physical,
functional, and psychological stressors were most com-
monly reported (see Table 1). The construct of stress
Relevant Articles k= 65
Articles contributing to
Articles contributing to
Total articles meeting criteria
• Unpublished dissertations k= 2
• Unpublished thesis k = 7
Retrieved for further
evaluation k= 49
• Qualitative k=11
• Quantitative (w/o effect
size) k= 5
Fig. 1 Flow-chart for selection of studies used in meta-analysis
differed amongst categories as perceived stress and func-
tional impairment were measured in terms of their psycho-
logical impact while HIV symptomology was indexed by
frequency of occurrence. Physical symptom-based stressors
that contributed to the meta-analysis included: frequency of
symptoms [64–66] and physical symptom burden .
Functional limitation-based stressors included perceived
70]. Measures of psychological stress included: chronic
burden [71, 72], major/traumatic life events [73, 74], per-
ceived stress [64, 75], and interpersonal conflict .
We categorized the coping scales reported in each study
using the definitions and strategies provided by Ways of
Coping  and the COPE scales . Measures devel-
oped by authors were assigned to a Ways of Coping or
COPE subscale to which it was most closely matched.
Coping mechanisms were then placed in hierarchical
categories of approach or avoidance (see Table 2).
Approach-based coping included positive reappraisal
[77–81], spirituality [78, 79, 82–86], and seeking social
support [63, 77, 78, 85, 86]. A measure of general active/
approach coping [77, 80, 85] was also included in the meta-
analysis. Avoidance measures included denial/distancing
[78, 86], social isolation , and a general measure of
avoidance [63, 85, 87].
Study outcomes were grouped based upon recommenda-
tions by Moskowitz et al.  into the categories of posi-
tive affect, negative affect, and health behaviors. The five
sub-measures of positive affect included: locus of control/
perceived control [88, 89], mastery [90, 91], positive affect
, quality of life [68, 93], self-esteem , and stress-
related growth . Data was entered so that larger cor-
relations indicated a positive relationship with positive
affect and psychological adjustment.
Negative affect included eight sub-categories: anger
, anxiety [94–96], depression [88, 96–98], emotional/
psychological distress [88, 99], loneliness , mood
disturbance , and suicidal ideation . Data was
entered so that higher more positive correlations indi-
cated a stronger effect on psychopathology and negative
Health behaviors included adherence/non-adherence
andmanaging illness (seeTable 3).Data was enteredsothat
positive correlations indicated a stronger relationship with
the maladaptive behavior. In some cases, the scales and
Table 1 Stressor categorization
StressorType Sample item(s)
PerceivedAppraisalIn the last month, how often have you felt nervous and ‘‘stressed’’?
Chronic burden Does someone in your household have a problem with drugs/alcohol?
Major eventHas someone close to you died suddenly or unexpected (e.g., murder/suicide)?
InterpersonalI have a hard time keeping pace with my friends.
Functional Appraisal How much does your health limit the kind and amount of activity you can perform?
Physical/roleHave you had difficulty taking care of other people such as family members?
PhysicalSymptom # Frequency of menstrual abnormalities, cervical dysplacia, STI, menopausal issues.
Stage of illnessCD4 count, CD8 count, viral load
Appraisal Physical & sexual functioning, medical interactions
Table 2 Coping categorizations
Coping measures Sample item(s)
Approach Acceptance, confrontive, direct action, fighting spirit, planning, positive reappraisal,
seeking social support, self-blame, self-controlling, spirituality
Avoidance Alcohol/drug disengagement, behavioral disengagement, distancing, escape/avoidance, social isolation
Distancing I went on as if nothing happened
Positive reappraisalI looked for something good in what is happening
Seeking Social Support I talked to someone to find out more about the situation/I talked to someone about how I was feeling
Social IsolationI avoided others
SpiritualityI sought God’s help
Table 3 Stress, coping, and outcome information for studies included in the meta-analysis
Notable inclusion criteria
Stressor instrument (s)
Coping type (s)
Outcome instrument (s)
Prenatal; low SES
Low SES; low Edu
Maternal; low SES
HS(.92); PCQ(.77); SSQ6(.86)
HIV; low SES
Av(.85), PF(.80), SSS(.78)
AIDS; low SES
Ac(.70); PR(.70); SSS(.71)
HAT-R(.86); FPRQ(.76); CBCL(.87)
Low SES; African American
AIDS; low SES
Av(.77), SSS(.82), Sp(.84), PR(.74)
Low SES; PTSD
Av(.79), SSS[.88), Sp(.85)
HIV/AIDS; rural sample
SSS(.67); Is(.69); Sp(.76); Av(.66)
Mothers hetero/bisexual; lesbian
Military; high SES
SC(.81), PF(,73), PR(.89)
RSES(.86); CES-D(.91); ZAS(.84)
Sampled from S.A.
SDA # of stress
Sampled from UK
Ac(.69);SSS(.84); Av(.82); Sp(.74)
Caregivers; low SES
Caregivers; alcohol abuse
van Servellen 
PTS(.95); CES-D(.84); RSES(.86)
HIV/AIDS; low SES
HIV/AIDS; low SES
MS(.62); RSES(.79); CES-D(.84)
HIV/AIDS; single mothers
diagnostic questionnaires of stress, coping, and disease
outcomes were developed by the authors [104–127].
The most frequently reported measure of effect in this meta-
in a single study were classified as the same outcome type
arithmetic mean of the two outcomes with each predictor.
Some studies did not report a correlation coefficient, but
rather a value for beta (b). Because the relationship between
beta (bs) and product moment correlation (rs) is seemingly
independent of sample size and number of predictor vari-
ables, standardized regression (beta) coefficients within the
interval ± .50 were imputed based upon the statistical rec-
ommendations of Peterson and Brown . This approach
was favored so as to lower the sampling error and produce
more accurate estimates of population effect-size. Since the
data was collected from a restricted portion of the entire
population of studies (women in the post-HAART era), no
attempt was made to generalize beyond the studies included
effect size shared by all studies as it relates to a specific
disease outcome. A random effects model was not selected
because reported effects are considered highly biased when
the number of studies within a meta-analysis are 10 or fewer
, as was often the case for the current study.
Data was structured in accordance with general linear
modeling (GLM). We reported the following results: (a) total
heterogeneity (Qt) of the sample tested against the v2 distri-
bution, (b) resultant p-value, (c) cumulative mean effect size
(E) and standard error, (d) 95% confidence intervals sur-
roundingE,and(e) fail-safenumber(seeTables 4,5,6,7,8).
Cumulative effect size represents the overall magnitude
of the effect present within the studies; this value is consid-
ered to be significantly different from zero if the associated
confidence limits do not bracket zero. Q-total was used to
total heterogeneity of a sample must be tested against a Chi-
square distribution with n - 1 degrees of freedom. The null
hypothesis for this test is that all effect sizes are equal. A
significant Qt-statistic would indicate that the variance
among effect sizes is greater than expected by that of pure
Publication bias is a common concern when conducting
reviews from amassed literature. Most commonly, we
critical diagnoses such as HIV/AIDS, to published studies
with statistically significant results. Publication bias may be
caused by the selective process of excluding non-published
studies. Fail-safe Ns are the most commonly used method of
Table 3 continued
Notable inclusion criteria
Stressor instrument (s)
Coping type (s)
Outcome instrument (s)
SSS(.67); Av(.66); Is(.69)
PR(.73), De(.76), Sp(.70)
This table does not reflect the complete battery of scales used in each study, but rather the scales which provided effect size data used in the meta-analysis. Coping Scales
Table 4 Stressors and positive affect
Stressor type No. of studies
Q (p) Fail safe (N)
Perceived stress4 580-.26 (.044)
p = .25
p = .41
HIV symptoms3 597-.19 (.041)-.10-.288.0720
Functional imp.2 264-.213 (.062)-.78-.798.690
Table 5 Stressors and negative affect
Stressor TypeNo. of studies
Q (p) Fail safe (N)
Perceived stress13 2897.53 (.019)
p = .68
HIV Symptoms8 2799.49 (.019) .44 .5423.6 10
Functional Iimp.3 508.33 (.045) .25 .41.76 30
Table 6 Coping and positive affect
Coping mechanism No. of studies
Q (p) Fail safe (N)
Positive reappraisal3 575.32 (.04)
p = .14 60
Seek social support3 667.24 (.03) .07-.41 3.16
p = .21 40
Spirituality5 911.32 (.03).22-.412.93
p = .57 160
Table 7 Coping and negative affect
Coping mechanismNo. of studies
Q (p)Fail safe (N)
Approach (active)3 824-.17 (.04)
p = .04720
Positive reappraisal3 317-.17 (.06)-.41.078 1.19
p = .55
p = .13
Seek social support7 1855-.05 (.02)-.11.0143.5110
Spirituality 132300-.12 (.02)-.16 -.0777.46 210
Avoidance4 847.64 (.03) .52.7433.7340
Distancing/denial3 678.30 (.04) .13.473.95 60
Social isolation2 587.56 (.04) .021.08.02
p = .87130
Table 8 Coping and health behaviors
Coping mechanismNo. of studies
Q (p)Fail safe (N)
Positive reappraisal3 670-.18 (.04)
p = .0420
Seek social support2 408-.07 (.05)-.71.56.24
p = .620
Spirituality3 671-.16 (.04)-.33.001 .55
p = .7620
Avoidance2 454.18 (.05)-.42.782.69
p = .10 10
determining, with publication bias, whether the result of a
meta-analysis canbe treated asa reliable estimateof the true
effect . This calculation reflects the number of studies
which must be added to the analysis in order change the
results from significance to that of non- significance. Using
Rosenthal’s criterion (N\5 k ? 10), when the number is
relativelylarge compared tothe observed amount ofstudies,
the data can be treated as a reliable index of effect. Another
Large studies tend to be included regardless of their treat-
ment effect, whereas small studies are more likely to be
included when they show a relatively large treatment effect.
Under these circumstances there will be a significant rank
order correlation (Kendall’s tau b) between treatment effect
and the standard error.
Meta-analyses were conducted using effect size data from 24
and 28ofthe 40 studies which met the criteria for the stressor
and coping analyses respectively (see Fig. 1). Data was pro-
videdfromatotalof7,602adultwomen(Mage = 36.3 years)
sampled between January 1997 and January 2011. The
byHispanic (19%),Caucasian(5%), and other (9%). Clinical
had a near even distribution within the sample (34% asymp-
tomatic-HIV, 29% symptomatic-HIV, and 36% AIDS diag-
nosis) at time of study.
Five categorical meta-analyses were conducted; two
comparing forms of stress with positive and negative affect
and three comparing ways of coping with positive affect,
negative affect and health behaviors. The cumulative effect
and level of significance reflects the average of the raw
correlations reported for each analysis (r). In order to
account for possible publication bias of publishing more
significant effects, it is custom to report the mean effect-
size (R: presented in Tables 4, 5, 6, 7, 8) which accounts
for the sample size from which each raw effect (r) was
reported. Raw effects were converted to z-scores using
Fisher’s Z to r transformation before the data was analyzed.
The meta-analysis of perceived stress (r = -.26) and posi-
tive affect was significant, suggesting that interpersonal
conflict and overall perceived stress from daily hassles and/
or chronic strains predict lower reports of optimism and
quality of life (see Table 4).HIV-symptoms(r = -.19)and
functional impairment (r = -.21) evinced smaller magni-
limitations of the disease were not as great of barrier to
positive psychological adaptation in women living with
HIV/AIDS. Though all measures of effect were significant,
sufficient homogeneity was observed only within the anal-
ysis of HIV/AIDS related symptoms.
Table 5 reports effect-sizes found between various
forms of stress and measures of negative affect. Small to
moderate effect sizes for degree of functional impairment
(r = .33), HIV-related symptoms (r = .49), and perceived
psychological stress (r = .53) were observed. The findings
suggest women with HIV/AIDS report comparable levels
of anxiety, depression, and psychological distress from
physical symptoms associated with HIV/AIDS, as do they
from the burden of major life events, chronic strains, and
acute daily hassles. Sufficient homogeneity was observed
within each analysis with the exception of functional
impairment (p[.05), suggesting inconsistency of report.
Table 6 reports cumulative effects from a small to mod-
erate range between the use of various coping mechanisms
and indices of positive affect. Comparable effect sizes were
observed amongst positive reappraisal (r = .32), seeking
social support (r = .24), and spirituality based coping
(r = .32), all of which significantly predicted positive
psychological adaptation. This suggests women who
practice the cognitive and spiritual reframing of stress
report greater levels of perceived control and stress-related
growth than those who turn to outside sources for support
relief. Tests for homogeneity of report were null across all
three coping measures, suggesting consistency between
Table 7 reports significant effect sizes amongst a host of
coping mechanisms and negative mental health outcomes.
Most effect sizes were in the small to medium range with
social isolation (r = .56) and avoidance coping mecha-
nisms (r = .64) demonstrating the largest positive associ-
ations. Large effects of this nature suggest poorer mental
health outcomes in women living with HIV/AIDS i.e.,
depression and anxiety are mainly attributed to the practice
of maladaptive coping styles. Despite the robust effect
sizes sufficient homogeneity was not observed (p\.001).
Smaller effect-sizes within the range of r = -.17 to r =
-.25 were reported for positive reappraisal, spirituality,
approach, and problem-focused coping, suggesting these
strategies have a significant buffering effect on the devel-
opment of psychopathology.
To determine whether any publication bias exists, fail-
safe Ns were calculated for each meta-analysis (see
Tables 4, 5, 6, 7, 8). Overall, Rosenthal’s criterion
(N\5 k ? 10) was met for 10 out of 20; 50% of the
studies. Based upon this criterion, associations with suffi-
cient heterogeneity (Q-total) that may also be considered
for publication bias included that of HIV-symptoms, psy-
chological stress, approach coping, and seeking social
support with negative affect. In contrast, the association
observed with negative affect between spirituality and
avoidance evinced sufficient heterogeneity free of publi-
cation bias. The Begg and Mazumdar Rank Correlation
Test for funnel plot asymmetry suggested marginal sig-
nificance for publication bias for the analysis of spirituality
and negative affect (p = .04) but not avoidance (p = .15),
perceived stress (p = .41), HIV-symptoms (p = .35),
seeking social support (p = .15), and approach coping
(p = .15). The test also was not significant for the analysis
of positive reappraisal and negative health behaviors
(p = .50). It should be noted that non-significant correla-
tion may be the result of low statistical power, and cannot
be taken as evidence that bias is absent, whereas significant
correlations suggests that bias exists but not the implica-
An unexpected findings from these meta-analyses was that
acute and chronic forms of psychosocial stress had a
comparable magnitude of effect on the development of
psychopathology as did the physical burden of disease
management. Previous studies have suggested that internal
physical symptoms contribute only partially to the psy-
chological stability in women living with HIV/AIDS [10,
131–135]. It is very likely that disparities in income, access
to education, and accessibility of health-related services
interact to alter the intensity and frequency of life stress
compounding the negative impact on disease outcomes
[16–18]. One likely barrier directly related to socioeco-
nomic status is dependency within the household envi-
ronment i.e., the burden of being a caregiver living with
chronic illness may tax tangible and intangible resources in
a way which might compound the level of difficulty for
disease adjustment [136–138].
Despite treatment advancements in HAART physical
stress resulting from HIV-related symptomology is still a
significant predictor of adverse psychological consequence
in women. Studies predating the U.S. era of HAART avail-
ability suggested that seropositive women attributed greater
distress to disease symptomology and often expressed
stronger negative views of self-health than do their male
counterparts [13–15]. Intuitively, modern expectations of
HAART effectiveness may lead to more negative appraisals
of oscillating immune status and treatment-related side
effects currently observed in response to anti-reteroviral
treatement [26–29, 56].
Functional impairment was also found to significantly
predict negative affect, suggesting one’s incapacity to meet
daily occupational demands may have a considerable
impact on overall mood. Daily hassles and other acute
stressors derived from functional disease-related limita-
tions are known to impact setting and accomplishment of
daily goals resulting in marked changes in motivation and
affect . Research has also found that cognitive dys-
function, in the memory and motor domains can predict the
severity of functional limitation in ADLs as well as the
probability of returning to work for HIV? persons .
Though coping responses are typically characterized as
buffers or moderators in the stress response, this study
examined the direct effects of a host of coping mechanisms
on mental and behavioral health outcomes. Spirituality and
allied religious activities were the most frequently reported
coping mechanism across affect and behavioral outcome
categories. Despite small effect sizes across these domains,
the construct of spiritual-based coping is considered by
some to be an integral component of psychological well-
being in ethnic minority women coping with chronic ill-
nesses [141–146]. It is likely that the positive reframing
associated with spiritual/religious activities (e.g. search for
meaning and prayer) plays a substantial role in reshaping
the appraisal of HIV-related life stressors . It is pos-
sible that larger effect sizes were not observed because
effectiveness of spirituality/religious-based interventions
are thought to be attributed to: (1) whether or not the
construct was in place before onset of the major life event,
and (2) the availability of religious resources to the indi-
vidual pursuant to the event [44, 148].
Positive reframing, outside the context of spirituality and
religion, may also predict enhanced psychological health.
Unlike response-focused coping mechanisms (e.g. avoid-
ance) which allow for the resurfacing of negative events,
in a way which may buffer the impact of subsequent expo-
sures to the same stimuli [149, 150]. Reappraisal has been
implicated in cognitive behavioral therapy (CBT) and
treatment regimens, and other facetsof disease management
In the context of social support seeking women are clas-
sically depicted as more likely to tend to and befriend others
as a primary coping mechanism compared to their male
counterparts . Despite this stereotype, our meta-anal-
mental health advantage compared to other adaptive coping
option for persons living with HIV/AIDS. To this day, HIV/
AIDS is associated with levels of stigma unparalleled by
other common infectious or non-communicable diseases.
This factor is shown to be a significant predictor in the delay
of HIV-disclosure andsubsequent management of
healthcare options . Cultural factors too i.e., language
as major limitations in the access of essential health and
social support services [155–157].
Coping mechanisms such as avoidance, denial, and
social isolation were found especially maladaptive from a
psychological and behavioral standpoint. It is quite evident
that when these mechanisms are put in place, patterns of
chronic stress develop . HIV-positive women who
report greater use of avoidant coping mechanisms are less
inclined to seek assistance from health and social service
providers and are more likely to delay initiation of anti-
retroviral drug regimen [20, 79]. Our meta-analysis also
revealed that avoidance coping predicts substance abuse
and non-adherence to HAART. More adaptive devices,
namely coping skills training and group processing of
personal issues, result in added gains for disease adjust-
One possible shortcoming of our study occurred in the pre-
liminary dataretrievalstages. Thephrase‘‘women with HIV/
AIDS’’ in combination with other key terms was used as the
initial search strategy. The use of phrases compared to single
studies from abstract databases. To test this limitation we
performed a posthoc analysis comparing the number of
studies extracted from PsycINFO, PubMed, and Science
Direct using the term ‘‘stress’’ and the phrase ‘‘women with
HIV/AIDS’’ to the number of studies which show using the
terms ‘‘women’’, ‘‘HIV/AIDS’’ and ‘‘stress’’ separately; the
analysis revealed identical search results within the three lit-
erature databases ruling out the omission of relevant articles
using the afore mentioned strategy. Another possible short-
coming was the homogeneity of inclusion criteria across the
various articles. A diverse array of criteria was observed
across studies with participants screened on the basis of CDC
classification, sexual orientation, ethnicity, and maternal sta-
tus, in conjunction with random sampling methods. Also, the
manner in which the stress/coping-outcome associations are
mediated by disease progression could not be determined, as
instances provided immune markers i.e. viral load and CD4
count to describe the sample (see Table 9). This review may
include unpublished data. Non-significant findings are less
likely to appear in published vs. unpublished literature .
Some tests for publication were confirmatory suggesting
readers should be cautious when interpreting findings on
spirituality and negative affect. There are also several con-
textual variables not accounted for in the design of the meta-
analysis. For instance, Moskowitz and colleagues  tested
disease outcome. This is of great relevance to psychosocial
plus strategy selection are likely to change as the patient
progresses from the initial diagnosis .
When scales purporting to measure a construct (e.g.
coping) contain items that measure another construct (e.g.,
distress), statistical tests of their association will be biased
[4, 160]. This is an inherent flaw of all meta-analyses
comparing antecedents, intervening variables, and disease
outcomes. For example, scales reporting fatigue, a com-
monly reported symptom in HIV/AIDS, may be rather
ambiguous considering the antecedents of such symptoms
are shown to stem comorbidly from natural prognosis, pre-
existing mood disorder, as well as HIV-associated cogni-
tive dementia [161–163].
Finally, variables inherent to personal background such
as substance abuse and mental health history introduce a
great deal of unaccounted variance in measured effects. For
some women, drug abuse history renders them more vul-
nerable to stress, while for others the recovery process can
promote mastery and help to inoculate them from exposure
to future stressors . One common finding related to
chemical dependency and coping is that persons at greatest
risk for substance abuse adapt escape-avoidant strategies as
a way to manage their anxiety/distress, thus creating an
added barrier against psychological adjustment disease
management . Many women seeking treatment for
HIV/AIDS also suffer from psychopathology. The adverse
effects of pre-existing mental health conditions such as
anxiety and depression are an additional concern as they
may contribute to immune compromise . Immune
suppression stemming from opportunistic infection and
neoplasias often leads to repeated outbreaks in persons
chronically living with HIV/AIDS. Psychosocial variables
are known to contribute to some of the variability in
immune parameters such as CD4? count, viral load, and
preservation of natural killer (NK) cells. Specifically,
maladaptive responses to stress or one’s efficacy in coping
with that stress are associated with more rapid progression
from HIV to AIDS in both men and women .
This meta-analytic review brings to light the contextual
factors associated with stress, coping, and disease adjust-
ment for women living with HIV/AIDS in the HAART era.
It is quite evident that women, particularly those of ethnic
minority background, face unique challenges related to the
disease in the 21st century. There remains a tremendous
amount of work to be done in order to elucidate the
interaction of certain cross-sections such as mothers/care-
givers, intravenous drug-users, women of color and those
of varying sexual orientation. Some culturally-sensitive
scales have already been developed to address poverty,
acculturation, racism, access to care, maternal stress,
relationship conflict and other agents relevant to disease
management [164, 165].
These psychosocial variables can now be directly
implicated in CD4 count and viral load slope within lon-
gitudinal female cohorts . Clinicians and social/
healthcare providers should be aware of these disparities
and encourage the use of adaptive stress-resistant resources
so as to keep pace with treatment regimens focused on
decelerating disease progression and increasing quality of
Table 9 Demographics of
studies included in the meta-
Largest % ethnicity Mean age % symptomatic or AIDS
Blaney  200430771% Black28.6NR
Braxton 2007 308 100% Black35.1NR
Burns  2008265 100% Black35.4 NR
Catz  2002100 84% Black3123%
Cooperman  2005207 44% Black39.5 55%
Dalmida  2009 12991% Black42 NR
Gray  200280 50% White. 35.8NR
Gurung 2004 22139% Black30.81 NR
Hayayneh  200916262% Black35 NR
Hough 2002147 86% Black36.1 42%
Jones  200372100% Black31.8 NR
Jones2003 17454% Black 37NR
Lathman 2001 275 81% Black31.239%
Martinez 200247 51% Black41.8 NR
Moneyham 1998 184 85% Black 3468%
Moneyham  2005 280 84% Black39.8NR
Morse 2000 104100% Black 30.3 NR
Mosack 2009 96061% Black40.8NR
Nannis 1997 5857% White 30.8 NR
Neff 2003 32100% Latina 32.75NR
Olley 2006 105 100% Black28.650%
Onwumere 2002 56100% Black 35NR
Prado  2004 252100% Black 35.3 NR
Remeien 2006 97861% Black41 NR
Rose 2006 40 100% Black40.9 NR
Sanchez 2010216100% Latina39.2NR
Scarinci 200983 63% Black43.3NR
van Servellen 1998 4452% Black 34.6 100%
Siegel  200513838% Black37 86%
Simoni 2003 142100% Latina 42.858%
Simoni 2000230 47% Latina39.5 57%
2002 23047% Latina 39.560%
Simoni  2000143 74% Black38.664%
Sowell 2000 184 75% Black3468%
Sublette 200880 100% Black 33.21NR
Underlaff 2002 18948% Black 37 NR
Townsend 2007 33 100% Black 44100%
Vyavaharkar 200722482% Black39.8 NR
Weaver 2004 90 85% Black37 100%
Woods 1999 33 100% Black31.7 100%
life for women living with HIV/AIDS in the twenty-first
Tamara Hochman, and Julieth Hoyos for their diligence in the prep-
aration of this manuscript. The authors would also thank the Sheryl
Catz, Benjamin Olley, Monica Sanchez, Jane Simoni, and Richard
Sowell whom provided supplemental information for the meta-
The authors are grateful to Kristen Eddinger,
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