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This is an Accepted Manuscript of an article published in AIDS Care: Psychological and
Socio-medical Aspects of AIDS/HIV, available online:
http://www.tandfonline.com/eprint/p6HS2yGJeIVrw2JKeWsJ/full
Citations details of this paper:
Rzeszutek, M., Oniszczenko, W., Żebrowska, M., Firląg-Burkacka, E. (2015). HIV infection
duration, social support and the level of trauma symptoms in a sample of HIV positives Polish
individuals. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 27 (3), 363-369.
doi: 10.1080/09540121.2014.963018
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RUNNING HEAD: HIV infection duration, social support, trauma symptoms
HIV infection duration, social support, and the level of trauma symptoms in a sample of HIV
positives Polish individuals
Marcin Rzeszutekª*, Włodzimierz Oniszczenkob, Magdalena Żebrowskab, Ewa Firląg-Burkackac
ªFaculty of Management and Finance, University of Finance and Management, Pawia 55, 01-030,
Warsaw, Poland, Tel: +48 22 53 65 430, Fax: +48 22 53 65 496,
e-mail: rzeszutek@vizja.pl
bFaculty of Psychology, University of Warsaw, Stawki 5/7, 00-183, Warsaw, Poland, Tel: +48
22 55 49 805, Fax: +48 22 63 57 991, e-mail: wlodek@psych.uw.edu.pl
bFaculty of Psychology, University of Warsaw, Stawki 5/7, 00-183, Warsaw, Poland, Tel: +48
22 55 49 805, Fax: +48 22 63 57 991, e-mail: sawicka.magdalena@gmail.com
cWarsaw's Hospital for Infectious Diseases, Wolska 37, 01 - 201 Warsaw, Poland, Tel: +48 22 33
55 351, Fax: +48 22 33 55 226, e-mail: burkacka@poczta.onet.pl
*To whom correspondence should be addressed
Faculty of Management and Finance, University of Finance and Management, Pawia 55, 01-030,
Warsaw, Poland, Tel: +48 22 53 65 430, Fax: +48 22 53 65 496,
e-mail: rzeszutek@vizja.pl
Acknowledgments
This work was supported by the Faculty of Psychology, University of Warsaw under Grant BST
1712-10 2014. The authors declare no conflict of interest.
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Abstract
The aim of this study was to investigate the relationship between the average HIV infection
duration and the level of quantitatively rated post-traumatic stress disorder (PTSD) symptoms and
social support dimensions in a sample of 562 Polish HIV positive adults. Possible moderating
effects of social support on the relationship between the average HIV infection duration and the
level of PTSD symptoms were also analysed. The results of the study suggest that the average HIV
infection duration may intensify PTSD symptoms and deteriorate the perceived availability of social
support in HIV+ individuals. However, a positive relationship between HIV infection duration and
the level of trauma symptoms was observed only in the group of HIV+ individuals with low
perceived available social support, but not in the group of HIV infected individuals with high
perceived available social support. This research provided some new insight into the psychological
and social aspects of living with HIV. In particular, our results suggest that although HIV infection
duration may intensify trauma symptoms and deteriorate social support, perceived available social
support may act as a buffer against HIV-related trauma symptoms.
Keywords: HIV infection duration; social support; PTSD symptoms; trauma; HIV/AIDS
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HIV infection duration, social support, and the level of trauma symptoms in a sample of HIV
positives Polish individuals
Introduction
Due to substantial advances in HIV treatment and prevention, HIV-related mortality has
diminished significantly in the last decade (Hughes, 2011; Mavedzenge, Luecke, & Ross, 2014).
According to the Joint United Nations Programme’s (UNAIDS) global report on the HIV/AIDS
epidemic (2013), the average life expectancy for HIV+ individuals has improved rapidly in the last
ten years. In particular, Samji et al. (2014) has shown that some groups of American HIV+
individuals, particularly those who started antiretroviral therapy before their CD4 level fell below
350 cells/mm3, now have comparable life expectancies to the general U.S. population. Despite this,
HIV+ people at late stages of HIV infection are still at a significant risk for many non-AIDS
diseases, such as cancer (Hasse et al., 2011), cardiovascular disease (Deeks & Phillips, 2009),
various forms of lung and liver disease (Kirk et al., 2013), and HIV-associated brain loss and
dementia (Cohen et al., 2010). Thus, although there are plenty of medical and psycho-social factors
that contribute to higher or lower HIV progression and HIV-related disabilities (e.g. Sankara,
Nevedal, Neufeld, Berry, & Luborsky, 2011), the average HIV infection duration has been
frequently associated as one of them (e.g. High, Brennan, & Clifford, 2012; Lodi et al., 2013).
In general, HIV+ individuals may suffer from many psychological disorders, including
depression (Leserman, 2008), substance disorders (Chawarski, Mazlan, & Schottenfeld, 2006), or
anxiety disorders (Jayarajan & Prabha, 2010), of which PTSD symptoms diagnosed with DSM-IV
(APA, 1994) criteria are increasingly included (Martin & Kagee, 2011; Rzeszutek, Oniszczenko, &
Firląg-Burkacka, 2012; Rzeszutek & Oniszczenko, 2013; Yiaslas et al., 2013). In our study we
concentrated only on PTSD symptoms among HIV+ patients as it is still a relatively new topic in
the studies on psychological aspects of HV/AIDS and also an interesting research gap to fill.
PTSD symptoms among HIV+ individuals mainly result from being diagnosed with a
potentially life-threatening disease (Beckerman & Auerbach, 2010), but they also stem from the
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unpredictability of HIV progression (Safren, Gershuny, & Hendriksen, 2003; Theuninck, Lake, &
Gibson, 2010) and social discrimination, which deteriorates the socio-economic status of HIV+
individuals (Adewuya et al., 2009; Bogart et al., 2011; Emlet, 2006). The presence of mental health
problems and PTSD symptoms in particular may influence the course of HIV infection by lowering
CD4 cell counts and increasing the level of physical HIV symptoms (Pacella et al., 2012). However,
the results of existing studies on the relationship between HIV duration and HIV-related mental
problems are mixed. On the one hand, there are studies which indicate greater levels of
psychological disturbances, such as depression and PTSD symptoms, among older individuals in
the late stages of HIV infection (Heckman, Kochman, & Sikkema, 2002; Machtinger, Wilson,
Haberer, & Weiss, 2012). Conversely, other authors indicate a greater prevalence of anxiety
disorders (see: PTSD symptoms, social phobia, panic disorders) among people recently diagnosed
with HIV (O'Cleirigh, Traeger, Mayer, Magidson, & Safren, 2013).
Several authors have shown a positive association between social support and good physical
and mental functioning among HIV/AIDS patients (Adewuya et al., 2009; Hansen, Vaughan,
Cavanaugh, & Connell, 2009; Shacham et al., 2007). Alternately, a significant relationship was
found to exist between a lack of social support and poorer HIV/AIDS adjustment (especially in the
tendency to discontinue medical treatment) and an exacerbation of HIV-related mental problems,
such as PTSD symptoms, depression, or chronic fatigue (Barroso et al., 2010; MacDonell, Naar-
King, Murphy, Parsons, & Huszti, 2011). Additionally, fear of stigmatization and loss of social
support may be an important argument against the disclosure of HIV+ statuses (Davey, Foster,
Milton, & Duncan, 2009; Emlet, 2006). In particular, Breet, Kagee, and Seedat (2014) proved the
significance of perceived social support in the relationship between HIV-related stigma and PTSD
symptoms. Galvan, Davis, Banks, and Bing (2008) have shown the importance of perceived
available social support for good mental health and reduced perceived HIV stigma among
HIV/AIDS patients. Finally, Ashton et al.(2005) indicated that perceived available social support
may act as predictor of changes in physical health symptoms among the HIV/AIDS population.
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The main goal of the current study was to investigate the relationship between the average
HIV infection duration and the level of quantitatively rated PTSD symptoms and social support
dimensions. We also looked for the possible moderating effects of social support on the relationship
between the average HIV infection duration and the level of quantitatively rated PTSD symptoms.
Method
Participants and procedure
The sample consisted of 562 adults with a clinical diagnosis of HIV infection. Table 1
presents basic demographic characteristics and data on the average HIV infection duration in the
entire sample of HIV+.
[Insert Table 1 about here]
This was an anonymous, cross-sectional study and participation was voluntary.
Participants were asked to complete a paper-pencil version of the measures, where they also had to
assess their average HIV infection duration. However, due to organisational difficulties we did not
ask patients to provide a proof of when they were diagnosed as HIV+. Informed consent was
obtained from all patients before they were included in the study, and participants were not
remunerated. The research project was accepted by the local Ethics Commission at the Faculty of
Psychology, University of Warsaw.
Measures
The quantitative level of PTSD symptoms was assessed using the PTSDF. This factorial
inventory consists of two scales: Intrusion/Arousal (Cronbach’s alpha=0.96) and
Avoidance/Numbing (Cronbach’s alpha=0.92). Scores on each scale were added to calculate the
global trauma symptoms score (Global Scale: Cronbach’s alpha=0.96). The PTSDF has thirty items.
Answers are given by selecting one of four options: 1 means that a symptom is absent and 4 means
that it is always present. The validity of this scale has been proved by correlating it with other
clinical constructs and with the civilian version of the Mississippi PTSD (Strelau, Zawadzki,
Oniszczenko, & Sobolewski, 2002).
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To assess the level of social support, a Polish version of the Berlin Social Support Scales
(BSSS) was used (Łuszczyńska, Kowalska, Mazurkiewicz, & Schwarzer, 2006). It was constructed
specifically to measure social support in situations of post-traumatic stress. The BSSS is a set of six
scales used to measure cognitive and behavioural aspects of social support, especially in cases of
severe somatic disease. It includes the following: Perceived Available Support (the degree to which
help from others is available); Need for Support (the degree to which social support in a stressful
situations is important to the respondent); Support Seeking (the frequency or range of support that
the respondent seeks from others); Actual Support Received (the actual amount of support received
from others); Provided Support (a scale filled out by those who provide support to the respondent);
and Protective-Buffering Support (refers to protecting close family from bad news and is filled out
by both the person receiving and the person providing the support). Taking into consideration that
the two last scales should also be filled out by the support provider, which would be essentially
impossible within the temporal and logistical constraints of this study, we used only the first four
scales. The Polish version of the BSSS has satisfactory psychometric parameters. Cronbach’s alpha
coefficients range from 0.74 to 0.90.
Results
The statistical analysis of the data was conducted using PASW Statistics 18 (SPSS Inc.,
2009). Correlations between HIV infection duration and the level of trauma symptoms and social
support dimensions were calculated using the Pearson product moment correlation procedures. The
results of this analysis are presented in Table 2.
[Insert Table 2 about here]
As we can see in Table 2, the average HIV infection duration correlated weakly and
positively with all trauma symptoms. In addition, HIV infection duration correlated weakly and
negatively with perceived available social support.
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To determine the extent to which the average HIV infection duration can be viewed as a
predictor of global trauma symptoms scored in HIV+ individuals (treated as the explained variable
in the analysis), we conducted a single variable regression analysis.
The results of this analysis are presented in Table 3.
[Insert Table 3 about here]
As we can see in Table 3, the average HIV infection duration accounts for approximately
2% of the global trauma symptoms scored in HIV+ patients.
To determine the extent to which the average HIV infection duration can be viewed as a
predictor of perceived available social support in HIV+ individuals (treated as the explained
variable in the analysis), we conducted a single variable regression analysis. The results of this
analysis are presented in Table 4.
[Insert Table 4 about here]
As we can see in Table 4, the average HIV infection duration accounts for approximately
2% of the level of perceived available social support in HIV+ patients.
Finally, we wanted to investigate whether social support (see: perceived available social
support) can moderate the relationship between the average HIV infection duration and the level of
global trauma symptoms scored among participants. Explanatory variables were centred using
standardization z scores. The results of this analysis can be found in Table 5.
[Insert Table 5 about here]
The model for the main effects of the explanatory variable (see: average HIV infection duration)
and the moderator (see: perceived available social support) revealed good data fitness,
F=(2,558)=5.871; p<.01. A significant interaction effect was also revealed (semi-partial
correlation=-.090; p<.05). The model with interactive ingredient revealed good data fitness as well,
F(3,557)=5.487; p<.05, and after adding interactive ingredient, approximately 3% of variance of the
explained variable was explained.
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The analysis of the relationship between the average HIV infection duration and the level of
global trauma symptoms scored within groups according to their level of perceived available social
support revealed a positive relationship between these variables in the group with low perceived
available social support (semi-partial correlation=.222; p<.001) but not in the group with high
perceived available social support (semi-partial correlation=-.03; n.s.). In the model, the group with
low perceived social support data fitness was statistically significant, F(1,311)=16.04; p<.001. In
the model dealing with the group with high perceived available social support, statistically
significant data fitness was not achieved: F(1,246)=.35; n.s. Therefore, in the group with low
perceived available social support, average HIV infection duration was a statistically significant
predictor of global trauma symptoms scored and explained approximately 5% of the variance in the
level of global PTSD symptoms. The above mentioned results are presented in Graph 1.
[Insert Graph 1 about here]
Discussion
The results of our study suggest that HIV infection duration may intensify trauma symptoms
and deteriorate perceived available social support in HIV+ individuals. In addition, perceived
available social support moderates the relationship between HIV infection duration and the level of
the general trauma symptoms scored in a studied group.
The awareness of being diagnosed with a life-threatening disease may act as a chronic
stressor and lead to the occurrence of many psychological problems in HIV+ individuals, including
post-traumatic stress disorder symptoms (Rzeszutek, Oniszczenko, & Firląg-Burkacka, 2012).
However, mental health problems in HIV+ populations and PTSD symptoms in particular usually
appear during two stages of HIV infection: in people recently diagnosed with HIV, and after
moving from the clinical latency stage of HIV infection to AIDS. The latter occurs when a person is
particularly susceptible to opportunistic infections (Jayarajan & Prabha, 2010). According to
Leserman (2008), one of the most stressful factors in the course of HIV/AIDS that may cause
depression and/or PTSD symptoms is the unpredictable course of this disease. The state of constant
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unpredictability is rising because HIV infections last longer and because of the awareness that there
is still no effective cure for HIV—these factors may be a substantial source of post-traumatic
symptoms in the HIV+ population (Theuninck et al., 2010). In addition, there is a strong
interrelationship between the physical and mental health of HIV+ individuals (Kesselring et al.,
2011; Rueda et al., 2011). In particular, in the next stages of HIV infection the probability of non-
AIDS diseases grows, which may cause significant emotional distress (Heckman et al., 2002). On
the other hand, Pacella et al. (2012) proved that mental health problems and PTSD symptoms may
influence the course of HIV infection, thereby reducing CD4 levels and increasing the level of
physical HIV symptoms.
Psychiatric disorders, including PTSD symptoms among HIV+ populations, may be
developed by a strong social stigmatization and a lack of adequate social support (Barroso et al.,
2010). In particular, social rejection and discrimination are intensified when there are many
symptoms of HIV infection (Adewuya et al., 2009). In our sample, however, a positive relationship
between HIV infection duration and the level of trauma symptoms was observed only in the group
with low perceived available social support but not in the group with high perceived available social
support. On the one hand, recent studies show that low perceived available social support is an
important risk factor for maintaining PTSD symptoms in various groups of people who are
suffering from traumatic stress (Kaniasty, & Norris, 2008; Robinaugh et al., 2011). On the other
hand, Panagioti, Gooding, Taylor, and Tarrier (2014) proved that perceived available social support
may enhance resilience in the aftermath of traumatic stress.
When looking for potential mechanisms through which social support exerts its influence
on either the development or maintenance of PTSD symptoms, some theorists have posited that
greater social support may impact PTSD by impeding the development and persistence of negative
post-trauma cognitions (Vogt, King, & King, 2007). Negative post-trauma cognitions about the self
(i.e., a sense of the self as incompetent, or self-blame regarding the traumatic event) and the world
(i.e., belief that the world is entirely dangerous) are thought to contribute to the intensity of PTSD
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by producing an ongoing sense of threat (Ehlers, & Clark, 2000). It is still unclear, however, if
social support helps regain health after trauma, or if the negative consequences of trauma lead to a
decrease in the availability and level of perceived social support (Kaniasty, & Norris, 2008).
Our study is not free of limitations. First, we did not investigate the other social support
dimensions (see, e.g. provided social support) that may be related to trauma symptoms associated
with HIV infection duration. Second, the correlational and cross-sectional design of the study may
diminish the reliability of our analyses. It is not well documented as to whether social support
characteristics are modified during the course of HIV infection. Third, we did not control for any
possible traumas that could have preceded HIV infection in our sample. Finally, due to
organisational difficulties we did not ask patients to provide a proof of when they were diagnosed as
HIV+. Despite these limitations, we believe that our research provided some new insight into the
psychological and social aspects of living with HIV. Our results especially suggest that although
HIV infection duration may intensify trauma symptoms and deteriorate social support, perceived
available social support may act as a buffer against HIV-related trauma symptoms. Further research
with HIV-infected individuals on above the mentioned topic is necessary.
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Tables
Table 1.
Demographic characteristics and data on the average HIV infection duration in the sample of HIV+
(N = 562).
Variables
N = 562
Sex
Male
Female
379
183
Age
Range
M
SD
19-74
37.83
9.47
Education
Primary
Secondary
Tertiary
99
229
234
HIV infection duration (years)
Range
M
SD
1-33
7.40
6.52
19
Table 2.
Correlation Coefficients (Pearson’s r) Between the PTSDF Scales, BSSS Scales, and the Average HIV
Infection Duration Among Participants (N=562).
Intrusion
/Arousal
Avoidance
/Numbing
Global
trauma
score
Perceived
support
Need for
support
Support
seeking
Actual
support
received
Average HIV
infection
duration
.121**
.127**
.129**
-.125**
.018
-.042
-.076
Note: **p<.01.
Table 3.
Regression Analysis of the Average HIV Infection Duration as a Predictor of the Level of Global
Trauma Symptoms Scored in HIV+ Individuals (N=562).
Model
F
F Δ
R
R²
Predictor
Semipartial
correlation
Average HIV
infection
duration
9.402a **
-
.129
.017
Average HIV
infection
duration
.129**
Note: (a) df = 559; **p<.01.
20
Table 4.
Regression Analysis of the Average HIV Infection Duration as a Predictor of the Level of Perceived
Social Support in HIV+ Individuals (N=562).
Model
F
F Δ
R
R²
Predictor
Semipartial
correlation
Average HIV
infection
duration
8.876a **
-
.125
.016
Average HIV
infection
duration
-.125**
Note: (a) df = 559; **p<.01.
21
Table 5.
Hierarchical Regression Analysis of Perceived Social Support as Moderating the Link Between the
Average HIV Infection Duration and the Level of Global Trauma Symptoms Scored Among HIV+ (N = 562).
Model
F
F Δ
R
R²
Predictor
Semipartial
correlation
+ Perceived
social support
Average HIV
infection
duration
5.871(a)**
-
.144
.021
Perceived
social support
Average HIV
infection
duration
-.064
.120**
+ Perceived
social support
x
Average HIV
infection
duration
5.487(b)*
4.64*
.169
.029
Perceived
social support
Average HIV
infection
duration
Perceived
social support
x
Average HIV
infection
duration
-.056
.115**
-.090*
Note.: (a) df = 2/558; (b) df = 3/557; * p <.05; **p<.01.
22
Figure caption
Graph 1. Scatterplot:
Global Trauma Symptoms Score as a Function of Average HIV Infection Duration in the Group
with Low Perceived Available Support and in the Group with High Perceived Available Support