Emotional support and gender in people living with HIV: effects on psychological well-being.
ABSTRACT Current research indicates that emotional support is strongly associated with physical and psychological adjustment in persons living with HIV/AIDS. While gender- differences in health and health behaviors of HIV positive patients are well studied, less is known about how men and women living with HIV/AIDS may differentially perceive and integrate support into their lives, and how it subsequently affects their psychological well-being. This cross-sectional study examines how emotional support received from partners and family/friends and gender explains psychological well-being (i.e., stress, depression, anxiety) in a sample of 409 partnered European HIV positive individuals. We hypothesized that gender would modify the associations between support and psychological well-being such that men would benefit more from partner support whereas women would benefit more from family/friend support. Results revealed that regardless of the source of support, men's well-being was more positively influenced by support than was women's well-being. Women's difficulties in receiving emotional support may have deleterious effects on their psychological well-being.
- [Show abstract] [Hide abstract]
ABSTRACT: Psychological distress (e.g., depression and anxiety) has been regarded as the main cause of leaving work for people living with HIV/AIDS (PLWHA) in workplaces. This study aims to explore the associations of functional social support (FSS) and psychological capital (PC) with depressive and anxiety symptoms among PLWHA employed full-time. This cross-sectional study was performed in Liaoning, China, during the period of December 2010--April 2011. The Center for Epidemiologic Studies Depression Scale, the Zung Self-Rating Anxiety Scale, the Duke-UNC Functional Social Support Questionnaire, and the Psychological Capital Questionnaire were completed by PLWHA employed full-time. Structural equation modeling was used to test the proposed relationships between variables. Asymptotic and resampling strategies were performed to explore the mediating roles of PC and its components (self-efficacy, hope, optimism, resilience). Of 320 participants surveyed, 66.3% had depressive symptoms, and 45.6% had anxiety symptoms. Significant negative associations of FSS and PC with depressive and anxiety symptoms were revealed. PC (a*b = -0.209, BCa 95% CI: -0.293, -0.137, p < 0.05), hope (a*b = -0.103, BCa 95% CI: -0.192, -0.034, p < 0.05), and optimism (a*b = -0.047, BCa 95% CI: -0.106, -0.008, p < 0.05) significantly mediated the association between FSS and depressive symptoms. PC (a*b = -0.151, BCa 95% CI: -0.224, -0.095, p < 0.05) and self-efficacy (a*b = -0.080, BCa 95% CI: -0.158, -0.012, p < 0.05) significantly mediated the FSS-anxiety symptoms association. FSS and PC could help reduce depressive and anxiety symptoms among PLWHA employed full-time. PC fully mediates the associations of FSS with depressive and anxiety symptoms. In addition to enhancing FSS, PC development could be included in the prevention and treatment strategies for depressive and anxiety symptoms targeted at PLWHA employed full-time.BMC Psychiatry 12/2013; 13(1):324. · 2.23 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Worldwide, men who have sex with men (MSM) remain one of the most HIV-vulnerable community populations. A global public health priority is developing new methods of reaching MSM, understanding HIV transmission patterns, and intervening to reduce their risk. Increased attention is being given to the role that MSM networks play in HIV epidemiology. This review of MSM network research studies demonstrates that: (1) Members of the same social network often share similar norms, attitudes, and HIV risk behavior levels; (2) Network interventions are feasible and powerful for reducing unprotected sex and potentially for increasing HIV testing uptake; (3) HIV vulnerability among African American MSM increases when an individual enters a high-risk sexual network characterized by high density and racial homogeneity; and (4) Networks are primary sources of social support for MSM, particularly for those living with HIV, with greater support predicting higher care uptake and adherence.Current HIV/AIDS Reports 01/2014;
- [Show abstract] [Hide abstract]
ABSTRACT: The mental health needs of patients who are coinfected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are increasingly addressed in medical settings. This study aimed at examining the prevalence and severity of emotional distress in a sample of HIV/HCV coinfected and HIV mono-infected patients and to examine their sociodemographic, clinical, and psychosocial correlates. The Brief Symptom Inventory and the quality of life instrument WHOQOL-HIV-Bref were administered to a sample of 248 HIV/HCV coinfected patients and 482 HIV mono-infected patients. Thirty-nine (15.9%) HIV/HCV coinfected patients and 55 (11.6%) HIV mono-infected patients reported a T-score ≥ 63 for global severity index (GSI), indicative of a need for further psychological evaluation. Coinfected patients reported significantly higher scores on eight of nine dimensions of psychopathology. The larger differences were found on somatization, hostility, paranoid ideation, anxiety, and the GSI. Among HIV/HCV patients, non-highly active antiretroviral therapy (β = -0.19, p < 0.01) and lower scores for independence (β = -0.24, p < 0.01) and spiritual (β = -0.31, p < 0.001) dimensions were significantly associated with higher emotional distress and accounted for 47.2% of the total variance. Among HIV mono-infected patients, being diagnosed for a longer time (β = 0.12, p < 0.05) and having lower scores on physical (β = -0.23, p < 0.001), social relationships (β = -0.11, p < 0.05), environmental (β = -0.17, p < 0.01), and spiritual (β = -0.21, p < 0.001) dimensions explained 39.4% of the variance of emotional distress. The findings suggest that coinfection with HCV may have an adverse effect on mental health and underscore the interplay of sociodemographic, clinical, and psychosocial variables on emotional distress. Additionally, these data reinforce the need for tailored interventions to improve the overall well-being of both HIV and HIV/HCV patients.AIDS Care 04/2014; · 1.60 Impact Factor
Emotional support and gender in people living with HIV:
effects on psychological well-being
Victoria Gordillo Æ Æ Erin M. Fekete Æ Æ Tom Platteau Æ Æ
Michael H. Antoni Æ Æ Neil Schneiderman Æ Æ
Christiana No ¨stlinger Æ Æ The Eurosupport Study Group
Received: November 4, 2008/Accepted: June 4, 2009/Published online: June 19, 2009
? Springer Science+Business Media, LLC 2009
port is strongly associated with physical and psychological
adjustment in persons living with HIV/AIDS. While gen-
der-differences in health and health behaviors of HIV
positive patients are well studied, less is known about how
men and women living with HIV/AIDS may differentially
perceive and integrate support into their lives, and how it
subsequently affects their psychological well-being. This
cross-sectional study examines how emotional support
received from partners and family/friends and gender
explains psychological well-being (i.e., stress, depression,
anxiety) in a sample of 409 partnered European HIV
positive individuals. We hypothesized that gender would
modify the associations between support and psychological
well-being such that men would benefit more from partner
support whereas women would benefit more from family/
friend support. Results revealed that regardless of the
source of support, men’s well-being was more positively
influenced by support than was women’s well-being.
Women’s difficulties in receiving emotional support may
have deleterious effects on their psychological well-being.
Current research indicates that emotional sup-
HIV ? Emotional support ? Gender ?
its strong ties with sexual and societal stigmatized behavior,
such as illegal drug use and sexual promiscuity. A diagnosis
of HIV may lead to difficulties with illness-related coping,
reduced self-esteem, social isolation, and poorer psycho-
logical well-being (Vanable et al. 2006; Parker et al. 2002).
members, such as partners, families, or friends may coun-
teract the negative impact of HIV on psychological well-
being. Moreover, it is likely that gender also influences the
extent to which social support is perceived and integrated
into the lives of people living with HIV. The present study
examines how support from partners and support from
a European sample of men and women living with HIV, and
how gender modifies these associations.
Living with HIV poses many challenges, and many
people living with HIV have higher levels of stress and
depression than the general population of healthy individ-
uals (Bing et al. 2001; Cruess et al. 2003). Higher levels of
distress are associated with poorer health behaviors,
including non-adherence to medication, drug use, and un-
safe sex practices (Bing et al. 2001). In addition, elevated
levels of stress and depression are linked with faster dis-
ease progression (Leserman 2008). It is possible that
receiving support from family members, friends, and
partners may help to alleviate or prevent the extent to
which people living with HIV experience psychological
distress (Cohen and Wills 1985).
V. Gordillo (&)
Department of Psychology, University Complutense of Madrid,
28223 Madrid, Spain
E. M. Fekete ? M. H. Antoni ? N. Schneiderman
Department of Psychology, University of Miami,
Miami, FL, USA
T. Platteau ? C. No ¨stlinger
Department of Clinical Sciences, Prince Leopold Institute of
Tropical Medicine, Antwerp, Belgium
J Behav Med (2009) 32:523–531
Current research confirms that receiving social support
from significant social network members can promote po-
sitive psychological adjustment in people living with HIV.
Emotional support provides coping assistance in attempts
to alleviate or prevent distress through actions such as
empathy and understanding (Heller and Rook 1997).
Greater amounts of emotional support are associated with
less negative and more positive affect in people living with
HIV (Deichert et al. 2008; Gonzalez et al. 2004). More-
over, people living with HIV who are satisfied with the
amount of support available to them tend to experience less
psychological distress, a higher quality of life, and more
self-esteem (Safren et al. 2002; Turner-Cobb et al. 2002)
whereas those who perceive low levels of social support
experience increased distress (Catz et al. 2002). Previous
research suggests that sexual orientation influences the
association between social support and psychological well-
being in persons living with HIV (Carels et al. 1998;
McDowell and Serovich 2007), but less is known about
how men and women living with HIV/AIDS may differ-
entially perceive and integrate support into their lives, and
how this support subsequently explains their psychological
Compared to men living with HIV, women living with
HIV often have increased distress, lower health-related
quality of life, and fewer social resources (Cederfja ¨ll et al.
2001; Gaberman and Wolfe 1999). A paucity of research,
however, directly examines if gender differences in social
support processes may help to explain these health dis-
parities in men and women living with HIV. The broader
literature and theory examining gender roles and gender
differences in social support and well-being, however,
suggests that men and women differ in both their social
behaviors and the sources from which they draw support
(e.g., Belle 1989; Eagly et al. 2000). Taken together, these
theories may explain, in part, why gender differences
emerge in the well-being and health of men and women
living with HIV.
According to gender role theory, from the time of
childhood, men and women are socialized to engender
specific attributes and social behaviors (Eagly et al. 2000).
Like other social behaviors, social support interactions can
be viewed as being regulated by social norms; therefore, it
is likely that support processes are influenced by the social
roles that individuals occupy (Eagly and Crowley 1986).
Women’s traditional gender roles prescribe that they pro-
vide more social support than they receive. Research
confirms that women tend to offer higher levels of support
and more effective support, including support to spouses,
than do men (Belle 1989; Neff and Karney 2005; Sch-
warzer and Gutie ´rrez-Don ˜a 2005), even when they are ill
(Fekete et al. 2007). For women, the perception of giving
support in one’s intimate relationships may be even more
important for one’s health than the perception of receiving
support (Va ¨a ¨na ¨nen et al. 2005). However, it is possible that
providing more support than one receives may lead women
to experience higher levels of distress than men (Belle
Men and women also differ in the sources from which
they draw support. Compared to men, women tend to have
broader social networks, a greater number of intimate
relationships, and are more likely to report that their closest
social network member is someone other than their spouse
(Antonucci 1994; Belle 1989). Women are also more
capable of mobilizing support networks during times of
stress than are men (Kessler et al. 1985). Especially when
coping with an illness, men tend to rely on their spouses as
primary sources of support, whereas women have a broader
social support network from which they draw support
(Revenson et al. 2005). It is unclear if this pattern of
findings is consistent for individuals living with HIV.
However, research notes that while perceived family sup-
port appears to be important for both men and women
living with HIV, support from a spouse or romantic partner
is also associated with psychological adjustment (Schrim-
shaw 2003; Serovich et al. 2001).
Thus, for people living with HIV who have partners or
significant others, it is plausible that men receive more
support from their partners and also yield more psycho-
logical benefits from their partners’ support than do wo-
men. In contrast, it is likely that women receive more
support from their families and friends and gain more
psychological benefits from these types of relationships
than men. The goal of our study was to examine gender
differences in the extent to which emotional support re-
ceived from partners and family/friends was associated
with psychological well-being (i.e., less stress, depression,
and anxiety) in a sample of European men and women
living with HIV. A better understanding of gender-specific
variables influencing the perception of social support has
important clinical implications for men and women living
with HIV, and is also necessary for developing more
effective psychosocial interventions in a family context.
Our first hypothesis predicted that emotional support
from both partners and family/friends would be associated
with lower levels of stress, depression, and anxiety in both
men and women living with HIV. Our second hypothesis
predicted that gender would modify the associations be-
tween the source of support and psychological well-being.
Specifically, we hypothesized that partner emotional sup-
port and gender would interact such that HIV positive men
would derive stronger psychological benefits from receiv-
ing social support from partners whereas HIV positive
women would obtain stronger psychological benefits from
receiving social support from other family members and
524 J Behav Med (2009) 32:523–531
Participants and procedure
This cross-sectional retrospective study was carried out in the
context of the European Public Health project ‘‘EUROSUP-
treatment and research centers from 13 European countries,
both old and new Member States (for a list of participating
countries see ‘acknowledgements’). Data were collected from
study sites using an anonymous, self-report questionnaire,
which was developed on the basis of a preceding qualitative
elicitation study (No ¨stlinger et al. 2008) with validated scales
integratedwhere appropriate.Ethical approvalwas obtainedat
the coordinating center’s Institutional Review Boards (ITM/
University of Antwerp). The study instrument was piloted at
the coordinating study site for clarity and feasibility, using a
small selected sample of patients.
The current study focuses on a subset of men and wo-
men (n = 409) from these data who reported that they had
been in a committed relationship for at least the past
6 months and were receiving social support from both a
significant others and other family members. Men and
women in the current study (24.9% women) were on
average 39.4 years of age (SD = 8.6, range = 18–68), had
been livingwithHIV for
(SD = 6.3; range = less than 1–24 years), and had a mean
self-rated health score of 7.3 (SD 2.1; range 0–10) on a
scale of 0 (not at all satisfied) to 10 (completely satisfied).
About half of participants in the study identified them-
selves as having a homosexual orientation (51.8%), and the
remaining identified themselves as being heterosexual
(42.3%), or bisexual (5.9%). The majority of participants
contracted HIV through sexual contact (69.7%), and the
remainder contracted it through intravenous (IV) drug use
(11.7%), a combination of sexual contact and IV drug use
(2.9%), blood transfusion (3.2%), mother to child trans-
mission (2.0%), or an unknown route of transmission
(10.5%) and approximately one-third (29.8%) of the par-
ticipants had experienced some sort of discrimination
regarding their HIV-status over the past 3 years. Most
participants described themselves as seropositive without
HIV-related physical complaints (80.0%). Almost half of
the sample (42.3%) reported having a higher secondary
education (±12 years of education), most of the sample
reported that they were employed (72.1%), and over half
had not encountered financial difficulties during the past
Emotional support. The emotional support subscale of the
Social Support Inventory (SSI; Timmerman et al. 2000)
was used to assess participants’ perceptions of the emo-
tional support they received from family/friends and from
partners. Prior research finds the internal consistencies of
the subscales to be satisfactory, with a-values ranging from
0.70 to 0.86 (Timmerman et al. 2000). The subscale con-
sisted of five items (e.g., cheers you up, shows affection for
you, is empathic), and participants indicated whether or not
each item applied to them. Items were summed to create a
continuous measure for each of the subscales with a po-
tential range of 0–5 and participants completed this scale
twice, once in reference to their family members/friends
and once in reference to their partners. The mean amount
of emotional support men and women reported receiving
from partners was 4.42 (SD = 1.4; range = 0–5; a = .78),
and from families/friends was 3.74 (SD = 1.5; range =
0–5; a = .91).
Psychological well-being. Psychological well-being was
measured using the 21-item version of the Depression
Anxiety Stress Scale (DASS-21; Antony et al. 1998). The
DASS-21 consists of three subscales of 7 items each
measuring stress, depression, and anxiety on a scale of 0
(‘did not apply to me at all’) to 3 (‘applied to me very
much, or most of the time’) over the past week. Partici-
pants’ mean amount of stress was 6.83 (SD = 4.7,
range = 0–21; a = .87), mean perceived feeling of being
depressed was 5.01 (SD = 4.9; range = 0–21; a = .90),
and meanperceived anxiety
range = 0–21; a = .83). Compared to UK normative data
for this measure, the men and women in our sample had
higher levels of stress, depression, and anxiety than in non-
clinical, broadly representative adult populations (Craw-
ford and Henry 2003).
was 4.00(SD = 4.1;
Hierarchical multiple regressions were used to test our
hypotheses that (1) emotional support from partners and
family/friends would be associated with better psycholog-
ical well-being in people living with HIV and (2) gender
would modify the associations between emotional support
from partners and family/friends and psychological well-
being. Covariates were entered into the first step of the
regression equation, followed by centered predictor vari-
ables (i.e., partner support and family/friend support) in the
second step, and the moderator (i.e., gender) in the third
step. The interaction terms (i.e. partner support 9 gender
and family support 9 gender) were entered into the final
step of the model. Significant interaction terms were further
explored using simple slope procedures set forth by
Holmbeck (2002) for decomposing interactions using a
categorical moderator variable.
Potential covariates in our analyses included socio-
demographic (e.g., age, education, employment, financial
J Behav Med (2009) 32:523–531 525
status, country of origin), social (e.g., partner HIV-status,
children, experience of HIV-discrimination), and health
characteristics (e.g., route of HIV transmission, sexual
orientation, self-rated health, medication status). We used
several methods to select covariates for our analyses. First,
we examined for gender difference in each potential
covariate using chi-square and t-tests. Table 1 presents
sample characteristics by gender for all potential covari-
ates. We next conducted bivariate correlations among each
dependent variable and the potential covariates. Any
additional variables that emerged as significant correlates
of the dependent variables were also retained as covariates
in all analyses. In addition, because sexual orientation has
been linked to the type of support that men and women rely
on (e.g., Kurdek and Schmitt 1987), we covaried sexual
orientation in all analyses. Thus, all models control for
sexual orientation, age, whether or not the participant had
recently experienced financial problems, whether or not the
participant was employed, whether or not the participant
had children, whether or not the participant experienced
HIV-related discrimination, education, country of origin,
route of HIV transmission, years with HIV, HIV status,
intake of antiretroviral medication, and self-rated health.
Table 2 presents means, standard deviations, and t tests by
gender for all key study variables. Compared to men living
with HIV, women living with HIV reported higher levels of
stress t(407) = 4.00, p\.001, depression t(407) = 2.81,
p\.01, and anxiety t(407) = 2.54, p\.01. Women in
our study also reported receiving lower levels of emotional
support from both their families/friends and partners
(t(407) = -2.15, p\.05 for families and t(407) = -2.27,
p\.05 for partners).
Our first hypothesis predicted that emotional support
from family/friends and partners would explain lower
levels of stress, depression, and anxiety in both men and
women living with HIV. After accounting for covariates
(i.e., sexual orientation, age, whether or not the participant
had recently experienced financial problems, whether or
not the participant was employed, whether or not the par-
ticipant had children, education, country of origin, route of
HIV transmission, years with HIV, HIV status, intake of
antiretroviral medication, and self-rated health), emotional
support from family/friends (Table 3) was associated with
lower levels of depression (b = -.11, SE = .05, p\.05)
and anxiety (b = -.11, SE = .05, p\.05) in both men
and women living with HIV but emotional support from
partners was not associated with any indicators of psy-
chological well-being. Together, emotional support from
partners and family/friends accounted for 1.2% of the
variance in stress (p\.10), 2.6% for depression (p\.01),
and 1.2% for anxiety (p\.10).
We next predicted that gender would modify the asso-
ciations between partner support and well-being and be-
accounting for covariates, significant interaction effects
emerged between emotional support from family/friends
and gender in explaining stress (Table 3, b = -.27,
p\.01), depression (Table 3, b = -.21, p\.05), and
anxiety (Table 3, b = -.17, p\.05) in men and women
living with HIV. Decomposition of these interaction effects
revealed that emotional support from family/friends pre-
dicted lower levels of stress (b = -.18, SE = .06,
p\.01), depression (b = -.18, SE = .06, p\.01), and
anxiety (b = -.18, SE = .06, p\.01) in men living with
HIV. For women living with HIV, however, emotional
support from family/friends was marginally associated with
higher stress (b = .16, SE = .09, p = .07) but was not
associated with depression (b = .06, SE = .09, ns) or
anxiety (b = .06, SE = .09, ns). Interactions between
family/friends and partner emotional support and gender
accounted for an additional 2.4% of the variance in stress
(p\.01), 1.2% of the variance for depression (p\.10),
but only 1.1% for anxiety (p\.10).
Consistent with prior research (e.g., Cederfja ¨ll et al. 2001;
Gaberman and Wolfe 1999), women living with HIV in our
study experienced higher rates of stress, depression and
anxiety than their male counterparts, and received less
emotional support from their partners and families. We
expected that emotional support from partners would be
more beneficial for men living with HIV, whereas emo-
tional support from family and friends would be more
beneficial for women living with HIV. However, our
findings suggest that partner support did not explain psy-
chological well-being in men or women living with HIV,
and the effectiveness of family/friend support varied by
gender, such that men living with HIV derived more psy-
chological benefits from family support than did women
living with HIV. In fact, our results suggest that in some
cases social support may have negative implications for the
well-being of women living with HIV.
According to theory and research on the impact of
gender roles on social interactions and psychological well-
being, women are usually influenced more than men by the
dynamics of their intimate relationships. As such, the
maintenance of relationships may be more of a central
objective for women than for men (Cross and Madsen
1997). Additionally, during times of stress women are more
likely than men to seek out support and mobilize support
526J Behav Med (2009) 32:523–531
networks (Wethington et al. 1987). However, as the pattern
of results in our study suggests, not only were women with
HIV receiving less emotional support than men with HIV,
but they did not benefit from the emotional support that
they reported receiving.
Considering that emotional support may be defined as
the expression of concern, compassion, sympathy, and es-
teem for an individual (Cohen and Wills 1985), we can
assume that it may be the most successful way to practice,
and also to solicit, aid for women. For instance, women
Table 1 Means and standard
deviations of sample
characteristics by gender
(n = 409)
aBecause there were 13
participating countries, only the
Chi-square value is reported and
not the percentage of men and
women from each country. For a
list of participating countries,
* p\.05; ** p\.01;
Men (n = 307)
Women (n = 102)
Years with HIV8.4 10.02.14*
Men (%)Women (%)
Yes27.5 46.5 12.53***
Country of origina
Sexual orientation 154.3***
Partners’ HIV status 3.05
Did not report10.1 13.7
Experience of HIV discrimination 9.87**
IV drug use7.221.0
Sexual contact and IV drugs1.67.0
Blood transfusion 3.62.0
Occupational risk0.0 0.0
Mother to child transmission 0.76.0
No physical symptoms 80.577.2
On HIV medication 78.583.3
Not on HIV medication 21.516.7
J Behav Med (2009) 32:523–531 527
usually talk more than men about private matters, try to
seek and receive help, and are more engaged in emotional
topics (Dindia and Allen 1992; Wethington et al. 1987).
However, compared to the men in our study, the women in
our study received less emotional support from both part-
ners and family and friends. Women who did receive
emotional support, particularly from their family and
friends, tended to also report higher levels of distress. One
explanation for these results is that there may have been a
mismatch between the amount of support women perceived
that they needed and the amount of support they actually
received. Not receiving adequate support may explain why
women living with HIV in our study did not obtain psy-
chological benefits from receiving emotional support from
It is also possible that women in our study did not want
to relinquish their role of care provider and nurturer as a
result of their illness (Revenson et al. 2005). If family
members provided unsolicited instrumental or emotional
support by offering to help with child care, providing ad-
vice, or even offering financial assistance, women may
have perceived the message that they were not capable of
managing the norms and responsibilities of their social
role. Support that is not asked for can be perceived by
support recipients as controlling or interfering, and is often
met with negative reactions and feelings of incompetence
(Smith and Goodnow 1999). Moreover, even well-inten-
tioned support efforts from others may have negative ef-
fects, especially if support recipients perceive that the
support efforts are insensitive or inconsistent with their
needs (Fekete et al. 2007; Newsom et al. 2005). In contrast,
men whose social roles prescribe that they be recipients of
care rather than providers of care (e.g., Eagly et al. 2000)
may have seen involvement from family as welcome and
helpful, and likely did not feel as if the norms of their
social role were being threatened.
In addition to the influence of gender roles on inter-
personal processes, self-esteem may have played a role in
the extent to which women were able to perceive and re-
ceive support efforts from partners and families. Self-es-
individuals’ feelings of self-worth have a bearing on both
their beliefs and social behaviors (Stinson et al. 2008). Low
self-esteem may damage interpersonal relationships be-
cause it promotes a self-protective interpersonal style
(Stinson et al. 2008). In other words, living with HIV may
cause individuals to feel socially isolated and have negative
perceptions of their social relationships. This process may
be fueled by internalized HIV-related stigma, which has
been described as an emotional reaction to the many dif-
ferent layers of overt HIV-related stigma people living with
HIV have to face (Stewart et al. 2008). At a general level, it
Table 2 Means and standard deviations of study variables by gender (n = 409)
Men (n = 307)
Women (n = 102)
Stress6.30 (4.6) 8.42 (4.7) 4.00***
Depression4.63 (4.9)6.18 (4.8) 2.81**
Anxiety 3.71 (3.9)4.88 (4.4) 2.54**
Family/Friends emotional support 3.84 (1.4) 3.44 (.17)-2.15*
Partner emotional support 4.52 (1.2)4.11 (1.7)-2.27*
* p\.05; ** p\.01; *** p\.001
Table 3 Effects of gender and emotional support from family and partners in the prediction of psychosocial well-being in people living with
HIV (n = 409)
Stress b (SE) Depression b (SE) Anxiety b (SE)
Partner support-.05 (.05)-.09 (.05)-.01 (.05)
Family/Friends support-.08 (.05)-.11 (.05)*-.11 (.05)*
Gender-.16 (.06)**-.12 (.06)*-.09 (.06)
Gender 9 Partner support*-.03 (.08).02 (.08)-.04 (.08)
Gender 9 Family/Friends support*-.27 (.09)**-.21 (.09)*-.17 (.09)*
Note: All models control for sexual orientation, age, whether or not the participant had recently experienced financial problems, whether or not
the participant was employed, whether or not the participant had children, whether or not the participant experienced HIV-related discrimination,
education, country of origin, route of HIV transmission, years with HIV, HIV status, intake of antiretroviral medication, and self-rated health
* p\.05; ** p\.01; *** p\.001
528J Behav Med (2009) 32:523–531
can be posited that a lack of positive social relationships
leads to negative psychological states such as anxiety or
depression, and that only support that is perceived as
adequate would influence the appraisal process and func-
tion as a stress buffer (Cohen and Wills 1985).
However, research notes that women may experience
higher levels of HIV-related stigma (Wingwood et al.
2007) and this stigma could prevent women from disclos-
ing that they are HIV-positive (Derlega et al. 2002). Non-
disclosure of a positive HIV status may be a barrier to
women receiving the support they need to cope with their
illness (Serovich et al. 2000). In our study, women with
HIV did tend to report that they experienced more HIV-
discrimination than men, were more likely to be infected
with HIV through IV drug use, and were more likely
to be unemployed and experiencing financial problems.
Although our analyses included route of HIV-transmission,
whether or not participants had experienced financial
problems, and HIV discrimination as covariates, it is still
possible that these factors contributed to the poorer well-
being and lack of support seen in women living with HIV.
Future research should more closely examine the extent to
which gender differences in the support interactions and
psychological well-being of people living with HIV may be
accounted for by perceptions of stigma, HIV-related dis-
crimination, or socioeconomic stress.
There are also other several limitations to our study that
should be noted. Our study is cross-sectional and causal
inferences cannot be made about the direction of associa-
tions, and our heterogeneous sample comprises respon-
dents stemming from 13 European countries. Research
suggests that similarities of behavior are likely due to so-
cial roles rather than traits in traditional cultures (Costa
2001). Even so, we did control for the country from which
the individual originated in all of our analyses. Addition-
ally, our measures of emotional support from partners and
family/friends were reported using dichotomous options.
Even though this measure of support (SSI; Timmerman
et al. 2000), has been validated and used in prior research,
this method of assessing emotional support may have re-
duced the variability in participants’ responses.
Because the current study focuses on comparing support
from partners versus support from family members/friends
on well-being in PLHA, we selected the sample for the
current study from the larger sample based on whether or
not participants were partnered (for at least the past
6 months) and currently receiving support from both
partners and family members/friends. We acknowledge
that this may limit the generalizability of our findings, as
some people may be receiving support from partners and
not family members/friends or vice versa. We also did not
have a measure of length of relationship, and it is possible
that relationship dynamics and interactions change over the
course of a relationship. Moreover, our results may not
generalize to single men and women living with HIV, or
men and women who do not have family involved in their
lives, as it is well-established that strong social ties, such as
marital and family relationships, have benefits for both
physical and psychological well-being (Kawachi and
Finally, more than half of the sample is bisexual or
homosexual, and men were more likely to identify with
these categories of sexual orientation. Although most re-
search on gender role theory has been conducted in het-
erosexual couples, there is some evidence to suggest that
individual power differences within homosexual and
bisexual couples exist, reproducing to some extent the
traditional gender roles expressed in theory and research
(Peplau and Spaulding 2000). While we controlled for
sexual orientation in all analyses, future research should
examine the role that sexual orientation plays in how men
and women are differentially influenced by support pro-
cesses. Our study was also unable to differentiate between
support received from family members and friends. Some
research suggests that friends may be more supportive than
family members because they are ‘chosen’ as part of an
individual’s social network (Kalichman et al. 2003). Thus,
future research should examine how associations between
gender and well-being differ as a function of support from
family versus support from friends.
Despite its limitations, our study provides evidence that
among men and women living with HIV, social support
from families on psychological well-being differs between
genders. These gender differences in support are associated
with differential psychological health outcomes. Our find-
ings illustrate the need to develop more gender-sensitive
psychosocial models for explaining health behavior and
well-being, as well as evidence-based approaches for pro-
fessional support and counseling. Defining HIV as a dyadic
or family disease may also provide a particularly valuable
approach in psychosocial HIV care. While there may be
limits to this approach in most routine HIV care settings, it
would help to strengthen partner and family relations by
enabling the couple or members of the family system to
become involved in the illness management of men and
women living with HIV. Knowledge of how social support
is perceived by HIV positive persons seems to be a nec-
essary requisite for effective psychological treatment;
therefore, a gender specific approach should be applied as
much in clinical practice as in social support research.
contributing to this study. The investigators of the participating
centres were (authors not included): Gloriana Bartoli and Carlo
Giaquinto (University of Padua, Italy), Johannes Bogner (Ludwig
Maximilians University, Germany), Ruth Borms (Sensoa, Belgium),
Robert Colebunders (Institute of Tropical Medicine, Belgium), Peter
The authors are grateful to all participants for
J Behav Med (2009) 32:523–531529
Cse ´pe (Semmelweis University, Hungary), Nikos Dedes (Synthesis,
Greece), Caterina Uberti-Foppa and Giulia Galotta (HSR Ospedale,
Italy), Birgit Mumelter (University of Innsbruck, Austria), Ivo Proc-
hazka (University of Prague, Czech Republic), Gabriele Schmied
(European Centre, Austria), Danica Stanekova (University of Brati-
slava, Slovak Republic), Ed Wilkins and Cinthia Murphy (Pennine
Acute Hospitals NHS Trust, United Kingdom), Anda Vaisla (Latvian
Family Planning Association, Latvia), Michal Pozdal and Zbigniew
Izdebski (University of Zielona Go ´ra, Poland). This study received
funding from the European Commission, SANCO/Public Health,
Grant Agreement nr. 2004314. The Commission is not responsible for
any use that may be made of the information contained herein.
Antonucci, T. C. (1994). A life-span view of women’s social
relations. In B. F. Turner & L. E. Troll (Eds.), Women growing
older (pp. 239–269). Thousand Oaks, CA: Sage Publications.
Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R.
P. (1998). Psychometric properties of the 42-item and 21-item
versions of the depression anxiety stress scales (DASS) in
clinical groups and a community sample. Psychological Assess-
ment, 10, 176–181.
Belle, D. (1989). Gender differences in children’s social networks and
supports. In D. Belle (Ed.), Children’s social networks and
social supports (pp. 173–188). New York: Wiley.
Bing, E. G., Burnam, M. A., Longshore, D., Fleishman, J. A.,
Sherbourne, C. D., London, A. S., et al. (2001). Psychiatric
disorders and drug use among human immunodeficiency virus-
infected adults in the United States. Archives of General
Psychiatry, 58, 721–728.
Carels, R. A., Baucom, D. H., Leone, P., & Rigney, A. (1998).
Psychosocial factors and psychological symptoms: HIV in a
public health setting. Journal of Community Psychology, 26,
Catz, S. L., Gore-Felton, C., & McClure, J. B. (2002). Psychological
distress among minority and low-income women living with
HIV. Behavioral Medicine, 28, 53–60.
Cederfja ¨ll, C., Langius-Eklo ¨f, A., Lidman, K., & Wredling, R. (2001).
Gender differences in perceived health-related quality of life
among patients with HIV infection. AIDS Patient Care and
STDs, 15, 31–39.
Cohen, S., & Wills, T. A. (1985). Stress, social support, and the
buffering hypothesis. Psychological Bulletin, 98, 310–357.
Costa, P. T. (2001). Gender differences in personality traits across
cultures: Robust and surprising findings. Journal of Personality
and Social Psychology, 81, 322–331.
(DASS): Normative data and latent structure in a large non-clinical
sample. British Journal of Clinical Psychology, 42, 111–131.
Cross, S. E., & Madsen, L. (1997). Models of the self: Self-construals
and gender. Psychological Bulletin, 122, 5–37.
Cruess, D. G., Petitto, J. M., Leserman, J., Douglas, S. D., Gettes, D.
R., Ten Have, T. R., et al. (2003). Depression and HIV infection:
Impact on immune function and disease progression. CNS
Spectrums, 8, 52–58.
Deichert, N. T., Fekete, E. M., Boarts, J. M., Druley, J. A., &
Delahanty, D. L. (2008). Emotional support and affect: Asso-
ciations with health behaviors and active coping efforts in men
living with HIV. AIDS and Behavior, 12, 139–145.
Derlega, V. J., Winstead, B. A., Greene, K., Serovich, J., & Elwood,
W. N. (2002). Perceived HIV-related stigma and HIV disclosure
to relationship partners after finding out about the seropositive
diagnosis. Journal of Health Psychology, 7, 415–432.
Dindia, K., & Allen, M. (1992). Sex differences in self-disclosure: A
meta-analysis. Psychological Bulletin, 112, 106–124.
Eagly, A. H., & Crowley, M. (1986). Gender and helping behavior: A
Meta-analytic review of the social psychological literature.
Psychological Bulletin, 100, 283–308.
Eagly, A. H., Wood, W., & Deikman, A. B. (2000). Social role theory
of sex differences and similarities: A current appraisal. In T.
Eckes & H. M. Trautner (Eds.), The developmental social
psychology of gender (pp. 123–174). Mahwah, NJ: Lawrence
Fekete, E. M., Stephens, M. A. P., Mickelson, K. D., & Druley, J. A.
(2007). Couples’ support provision during illness: The role of
perceived emotional responsiveness. Families, Systems, and
Health, 25, 204–217.
Gaberman, B., & Wolfe, L. R. (1999). AIDS: The women’s epidemic.
New York: The National Council for Research on Women.
Gonzalez, J. S., Penedo, F. J., Antoni, M. H., Duran, R. E.,
Fernandez, M. I., McPherson-Baker, S., et al. (2004). Social
support, positive states of mind, and HIV treatment adherence
in men and women living with HIV/AIDS. Health Psychology,
Heller, K., & Rook, K. S. (1997). Distinguishing the theoretical
functions of social ties: Implications for support interventions. In
S. Duck (Ed.), Handbook of personal relationships: Theory
research and interventions (2nd ed., pp. 649–670). Chichester,
Holmbeck, G. N. (2002). Post-hoc probing of moderational and
meditational effects in studies of pediatric populations. Journal
of Pediatric Psychology, 2, 87–96.
Kalichman, S. C., DiMarco, M., Austin, J., Luke, W., & DiFonzo, K.
(2003). Stress, social support, and HIV-status disclosure to
family and friends among HIV-positive men and women.
Journal of Behavioral Medicine, 26, 315–332.
Kawachi, I., & Berkman, L. F. (2001). Social ties and mental health.
Journal of Urban Health: Bulletin of the New York Academy of
Medicine, 78, 458–467.
Kessler, R. C., McLeod, J. D., & Wethington, E. (1985). The costs of
caring: A perspective on the relationship between sex and
psychological distress. In I. G. Sarason & B. R. Sarason (Eds.),
Social support: Theory research and applications (pp. 491–506).
The Hague: Martinus Nijhoff.
Kurdek, L. A., & Schmitt, J. P. (1987). Perceived emotional support
from family and friends in members of homosexual, married,
and heterosexual cohabitating couples. Journal of Homosexual-
ity, 14, 57–68.
Leserman, J. (2008). Role of depression, stress, and trauma in HIV
disease progression. Psychosomatic Medicine, 70, 539–545.
McDowell, T. L., & Serovich, J. M. (2007). The effect of perceived
and actual social support on the mental health of HIV-positive
persons. AIDS Care, 19, 1223–1229.
Neff, L. A., & Karney, B. R. (2005). Gender differences in social
support: A question of skill or responsiveness? Journal of
Personality and Social Psychology, 88, 79–90.
Newsom, J. T., Rook, K. S., Nishishiba, M., Sorkin, D., & Mahan, T.
L. (2005). Understanding the relative importance of positive and
negative social exchanges: Examining specific domains and
appraisals. Journals of Gerontology: Psychological Sciences,
No ¨stlinger, C., Gordillo, V., Borms, R., Murphy, C., Bogner, J. R.,
Csepe, P., et al. (2008). Differences in perceptions on sexual and
reproductive health between service providers and people living
with HIV: A Qualitative elicitation study. Psychology, Health
and Medicine, 13, 516–528.
Parker, P., Aggleton P., Attawel K, Pulerwitz, J., and Brown, L.
(2002). HIV/AIDS related stigma and discrimination: a concep-
tual framework and an agenda for action. Horizons Program. The
530 J Behav Med (2009) 32:523–531
Population Council. Accessed at: http://www.popcouncil.org/
Peplau, L. A., & Spaulding, L. R. (2000). The close relationships of
lesbians, gay men, and bisexuals. In C. Hendrick & S. S.
Hendrick (Eds.), Close relationships: A sourcebook (pp. 111–
124). Thousand Oaks, CA: Sage.
Revenson, T. A., Abraı ´do-Lanza, A. F., Majerovitz, S. D., & Jordan,
C. (2005). Couples coping with chronic illness: What’s gender
got to do with it? In T. A. Revenson, K. Kayser, & G.
Bodenmann (Eds.), Couples coping with stress: Emerging
perspectives on dyadic coping (pp. 137–156). Washington,
DC: American Psychological Association.
Safren, S. A., Radomsky, A. S., Otto, M. W., & Salomon, E. (2002).
Predictors of psychological well-being in a diverse sample of
HIV-positive patients receiving highly active antiretroviral
therapy. Psychosomatics, 43, 478–485.
Schrimshaw, E. W. (2003). Relationship-specific unsupportive social
interactions and depressive symptoms among women living with
HIV/AIDS: Direct and moderating effects. Journal of Behavioral
Medicine, 26, 297–313.
Schwarzer, R., & Gutie ´rrez-Don ˜a, B. (2005). More spousal support
for men than women: A comparison of sources and types of
support. Sex Roles, 52, 523–532.
Serovich, J. M., Brucker, P. S., & Kimberly, J. A. (2000). Barriers to
social support for persons living with HIV/AIDS. AIDS Care, 12,
Serovich, J. M., Kimberly, J. A., Mosack, K. E., & Lewis, T. L.
(2001). The role of family and friend social support in reducing
emotional distress among HIV-positive women. AIDS Care, 13,
Smith, J., & Goodnow, J. J. (1999). Unasked-for support and
unsolicited advice: Age and the quality of social experience.
Psychology and Aging, 14, 108–121.
Stewart, W. T., Herek, G. M., Ramakrishna, J., Chandy, S., Wrubel,
J., & Elstrand, M. L. (2008). HIV-related stigma: adapting a
theoretical framework for the use in India. Social Science and
Medicine, 67, 1225–1235.
Stinson, D. A., Logel, C., Zanna, M., Holmes, J., Cameron, J., Wood,
J., et al. (2008). The cost of lower self-esteem: Testing a self-
and social-bonds model of health. Journal of Personality and
Social Psychology, 94, 412–428.
Timmerman, I. G. H., Emanuels-Zuurveen, E. S., & Emmelkamp, P.
M. G. (2000). The social support inventory (SSI): A brief scale
to assess perceived adequacy of social support. Clinical
Psychology and Psychotherapy, 7, 401–410.
Turner-Cobb, J. M., Gore-Felton, C., Marouf, F., Koopman, C., Kim,
P., Israelski, D., et al. (2002). Coping, social support, and
attachment style as psychosocial correlates of adjustment in men
and women with HIV/AIDS. Journal of Behavioral Medicine,
Va ¨a ¨na ¨nen, A., Buunk, B. P., Kivima ¨ki, M., Pentti, J., & Vahtera, J.
(2005). When it is better to give than to receive: Long-term
health effects of perceived reciprocity in support exchange.
Journal of Personality and Social Psychology, 89, 176–193.
Vanable, P. A., Blair, D. C., & Littelwood, R. A. (2006). Impact of
HIV-related stigma on health behaviors and psychological
adjustment among HIV-positive men and women. AIDS and
Behavior, 10, 473–482.
of life events for explaining sex differences in psychological
and stress (pp. 144–156). New York: Free Press.
Wingwood, G. M., Hardin, J. W., DiClemente, R. J., Peterson,
S. H., Mikhail, I., Hook, E. W., et al. (2007). HIV discrimination
and the health of women living with HIV. Women & Health, 4,
J Behav Med (2009) 32:523–531 531