A longitudinal analysis of posttraumatic growth and affective well-being among people living with HIV: The moderating role of received and provided social support

Abstract

Objectives
The aim of this one-year longitudinal study was to examine the temporal relationship between the level of posttraumatic growth (PTG) and affective well-being, measured by the presence of positive and negative affect among people living with the HIV (PLWH). In addition, the moderating effects of received and provided support with respect to the above-mentioned relationship were investigated.

Method
Study participants completed the following psychometric inventories: the Posttraumatic Growth Inventory (PTGI), the Positive and Negative Affect Schedule (PANAS-X), and the Berlin Social Support Scales (BSSS). Three assessments were performed: 129 patients were recruited for the first assessment, 106 patients agreed to participate in the second assessment, and 82 of the initial 129 participants (63.6%) participated in all three assessments.

Results
An indirect association between PTG and positive affect was observed. However, no association was found between PTG and negative affect. Received support, but not provided support, completely moderated the relationship between PTG and positive affect.

Conclusions
This study adds to the literature by examining the temporal relationship between PTG and affective-wellbeing among PLWH. It appears from the results that in this patient group, PTG may enhance the positive affect over time. However, receiving support is vital in this process.

Full text

RESEARCH ARTICLE
A longitudinal analysis of posttraumatic
growth and affective well-being among
people living with HIV: The moderating role of
received and provided social support
Marcin Rzeszutek*
Faculty of Psychology, University of Warsaw, Stawki, Warsaw, Poland
*marcin.rzeszutek@psych.uw.edu.pl
Abstract
Objectives
The aim of this one-year longitudinal study was to examine the temporal relationship bet-
ween the level of posttraumatic growth (PTG) and affective well-being, measured by the
presence of positive and negative affect among people living with the HIV (PLWH). In addi-
tion, the moderating effects of received and provided support with respect to the above-me-
ntioned relationship were investigated.
Method
Study participants completed the following psychometric inventories: the Posttraumatic
Growth Inventory (PTGI), the Positive and Negative Affect Schedule (PANAS-X), and the Ber-
lin Social Support Scales (BSSS). Three assessments were performed: 129 patients were
recruited for the first assessment, 106 patients agreed to participate in the second assess-
ment, and 82 of the initial 129 participants (63.6%) participated in all three assessments.
Results
An indirect association between PTG and positive affect was observed. However, no associ-
ation was found between PTG and negative affect. Received support, but not provided sup-
port, completely moderated the relationship between PTG and positive affect.
Conclusions
This study adds to the literature by examining the temporal relationship between PTG and
affective-wellbeing among PLWH. It appears from the results that in this patient group, PTG
may enhance the positive affect over time. However, receiving support is vital in this process.
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 1 / 17
a1111111111
a1111111111
a1111111111
a1111111111
a1111111111
OPEN ACCESS
Citation: Rzeszutek M (2018) A longitudinal
analysis of posttraumatic growth and affective well-
being among people living with HIV: The
moderating role of received and provided social
support. PLoS ONE 13(8): e0201641. https://doi.
org/10.1371/journal.pone.0201641
Editor: Matthew P. Fox, Boston University, UNITED
STATES
Received: August 22, 2017
Accepted: July 19, 2018
Published: August 6, 2018
Copyright: ©2018 Marcin Rzeszutek. This is an
open access article distributed under the terms of
the Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: This work was supported by the Grant
BST 2018 from the Ministry of Science and Higher
Education in Poland.
Competing interests: The author has declared that
no competing interests exists.

Introduction
Over the past two decades, especially after the advent of positive psychology in the early 2000s,
several studies have been conducted on the positive consequences of traumatic events, referring
to the phenomenon of posttraumatic growth (PTG) [1,2,3,4,5]. According to Tedeschi and
Callhoun [4,5], PTG occurs when an individual experiences highly challenging life events that
manifest as profound transformations in several functional aspects of life such as improved social
relationships, seeking of new life paths, greater appreciation of life, openness to spirituality, and
awareness of personal strength. Several studies have been conducted on PTG, but many aspects
of this positive phenomenon remain unclear [6,7]. One of these is the association between PTG
and psychological well-being (PWB), i.e. whether the above-mentioned positive changes after a
traumatic experience improve the well-being of the trauma survivors over time. Further, if they
do improve the well-being, what is the direction of this improvement [8]. According to Zoellner
and Maercker [9], examining this research question is especially important for clinicians because
if PTG is unrelated to PWB or other aspects of mental health, it remains only an interesting theo-
retical construct without practical clinical utility. The obvious hypothesis in this case would be
that there is a positive association between these two variables. However, studies on this topic are
very inconclusive. While some authors have found a positive link between PTG and PWB [10,11,
12,13], other studies indicate a lack of association [14,15], negative association [16], or even a
curvilinear relationship between PTG and PWB [17,18]. These conflicting findings may be attrib-
uted to the multidimensional nature of PWB and its various operationalisations, in terms of the
general quality of life, life satisfaction, or affective well-being [19,20,1]. Each of these dimensions
may be differently related to PTG, precluding clear conclusions. Other authors noticed that the
majority of studies were cross-sectional studies. Thus, these were unable to provide an under-
standing of whether PTG can accurately predict the improvement in the well-being domains
[21]. Finally, in a meta-analytic review, Park [22] highlighted the role of various moderators (e.g.,
time passed after the trauma, social support received after the traumatic event) that should be
considered for obtaining a detailed representation of the link between PTG and PWB.
The literature on HIV/AIDS is dominated by the negative consequences of HIV infection,
which acts as a traumatic stressor and induces various mental disorders, including depression,
anxiety, and posttraumatic stress disorder (PTSD) [23,24,25,26,27,28,29,30]. In particular,
HIV-related distress, manifested as depressive mood and negative affect may be constantly
present among PLWH several years after HIV diagnosis [31] and is related to worse adherence
to treatment [32] and faster HIV progression [33]. Conversely, research on positive aspects of
living with HIV, including PTG, is relatively scarce [34,35]. In particular, PTG in this patient
group was related to higher viral load [36], less intense perceived HIV-related stigma [37], and
better affective well-being [38]. In addition, the positive affect among PLWH predicted slower
HIV progression [39], better adherence to treatment [40], fewer depressive symptoms [41],
and lower mortality rate [42]. However, according to Sawyer et al. [43] the relationship
between PTG and PWB among PLWH is unclear, and the central question is whether and
how PTG in these patients may be associated with psychological advantages, especially consid-
ering that longitudinal studies on PTG among PLWH are scarce [44,45], establishing only a
few causal relationships.
There is considerable evidence showing a positive influence of received support on well-
being [46,47], especially on affective well-being [48]. On the other hand, some authors have
reported a negative link between receiving support and PWB [49], in accordance with the
equity theory [50]. The equity theory states that receiving support may intensify distress owing
to the rule of reciprocity. Limited research has been conducted on the role of provided social
support in PWB, but some studies [51,52] have indicated that providing support may be more
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 2 / 17

beneficial for PWB than receiving support, which is consistent with the esteem enhancement
hypothesis [53]. With respect to PLWH, while the role of provided support remains largely
unknown, several studies have shown a positive link between receiving support and good
physical as well as mental functioning among PLWH [54,55,56]. By contrast, a relationship
exists between a lack of support and exacerbation of HIV-related mental problems, especially
depression [25,57]. Furthermore, Rzeszutek et al. [45] observed a positive relationship bet-
ween received support and PTG among PLWH, while Cieślak et al. [58] found that received
support was positively associated only with the one PTG dimension, i.e. better relations with
others. However, many studies that investigated the role of social support in PLWH are limited
by several shortcomings, such as the lack of a clear definition and distinction between the dif-
ferent social support dimensions as well as the dominance of cross-sectional studies [59].
Therefore, I used a longitudinal study design and established a clear distinction between rec-
eived and provided support to investigate the moderating effects of these social support dime-
nsions on the link between PTG and affective well-being among PLWH.
Current study
In this study, the link between the level of PTG and affective well-being, measured by the pres-
ence of positive and negative affect (PA/NA) was investigated in a one-year longitudinal study
among PLWH. In addition, the moderating effects of received and provided support were
explored for the above-mentioned relationship. The following hypotheses were formulated in
line with longitudinal study design [60]:
1. There is a positive relationship between the level of PTG in the first assessment and the
intensity of PA in the third assessment, while controlling for the level of PA in the first
assessment.
2. There is a negative relationship between the level of PTG in the first assessment and the
intensity of NA in the third assessment, while controlling for the level of NA in the first
assessment.
3. Received support and provided support in the second assessment moderate the relationships
described by the first and second hypothesis.
A preliminary figure was designed to illustrate data analysis plan (Fig 1).
Method
Procedure
Patients admitted to the Hospital of Infectious Diseases in Warsaw were enrolled as study sub-
jects. The subjects filled out a paper-and-pencil version of the inventories and participated in the
study voluntarily because no remuneration for participation was provided. The study inclusion
criteria encompassed being 18 years old, being medically diagnosed with HIV infection with-
out other infectious co-morbidities (e.g. HCV) and undergoing treatment at aforementioned
hospital. The exclusion criteria included HIV-related cognitive disorders that were identified by
psychiatrists working at this hospital. The experimental design of this study was approved by the
Senate Ethics Committee of the University of Finance and Management in Warsaw.
Measures
To assess the intensity of PTG, a Polish adaptation of the Posttraumatic Growth Inventory
[PTGI; 4] was used [61]. It should be noted that although the original PTGI comprises five
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 3 / 17

specific domains of PTG (‘relating to others’, ‘new possibilities’, ‘personal strength’, ‘spiritual
change’, and ‘appreciation of life’), the Polish adaptation of the PTGI included only four do-
mains of PTG. Exploratory and confirmatory factor analyses revealed a four-factor structure
for the PTG, including changes in self-perception (‘perceiving new possibilities, and ‘feeling of
personal strength’), changes in relationships with others (‘feelings of greater connection with
other people, increase in empathy, altruism’), greater appreciation for life (‘changes in life phi-
losophy and current life goals, greater appreciation for every day’), and spiritual changes (‘bet-
ter understanding of spiritual issues, increase in religiousness’). In the PTGI, participants were
required to rate 21 positive statements that describe the various changes resulting from trau-
matic or highly challenging events that are provided at the beginning of the inventory. Study
subjects were instructed to focus on their diagnosis of HIV infection as an example of a trau-
matic event. Statistical analyses are usually performed only for the global PTG score (sum of all
items), as particular subscales in the Polish version of PTGI are highly intercorrelated [61]. In
particular, Park and Helgeson [8] recommend unifactorial assessment of PTG, which repre-
sents a more valid method of measuring PTG compared to the analysis of the various dimen-
sions of growth that may vary form one study to another. Cronbach’s αin the final sample
population at the third assessment for the whole scale was α= .86, and for the four subscales, it
varied from .81 to .85.
Fig 1. Preliminary hypothesised model. T1 –First Assessment; T2 –Second Assessment; T3 –Third Assessment.
https://doi.org/10.1371/journal.pone.0201641.g001
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 4 / 17

In order to assess affective well-being (the positive and negative affect), a Polish adaptation
[62] of the PANAS-X was used [63]. The PANAS-X comprises 10 adjectives for positive affect
(e.g., proud,excited, etc.) and 10 for negative affect (e.g., frightened,hostile, etc.). The partici-
pants were asked to evaluate their general affective states on a five-point response scale that
ranged from 1 (not at all) to 5 (extremely). The Cronbach’s αcoefficients in the studied final
sample at the third assessment were .81 for the positive affect subscale and .83 for the negative
affect subscale.
Social support was assessed using Schwarzer and Schulz’s [64] Berlin Social Support Scales
(BSSS), adapted in Polish by Łuszczyńska et al. [65]. It evaluates a broad range of support
dimensions. However, in this study, I used two scales: the actually received support and the
provided support. The psychometric properties of the Polish version of the BSSS have been
proven on various groups of patients, including those who had undergone bypass surgery or
had experienced a heart attack as well as patients with chronic, degenerative spinal diseases
[65]. These studies have confirmed the satisfactory reliability and validity of the tool. Cron-
bach’s αreliability coefficients in the final sample at the third assessment were .83 for received
support and .85 for provided support.
The Table 1 clarifies the assessment plan, i.e., it summarizes which variables were assessed
in the three consecutive assessments.
Data analysis
Data analysis was conducted in three stages on the final sample of 82 participants with the use
of IBM SPSS 24 statistical package [66]. Instead of using conventional statistical significance
notation with p values, 95% confidence intervals were presented [67].
First, associations between all analysed interval variables and socio-medical data were
investigated with the use of stepwise regression analysis in order to achieve more precise, unbi-
ased means estimates when testing hypotheses and determining the main results of the study
[67]. The stepwise regression was used only for exploring possible associations between ana-
lysed interval variables and socio-medical data and not for testing hypotheses.
Second, possible differences between three assessments were examined. Socio-medical data
which were found to be related to interval psychological variables were used as covariates.
Therefore, using the repeated measures analysis of covariance (ANCOVA), changes in the
level of analysed variables over time were assessed. The statistical models included all the
socio-medical data that were related to the interval psychological variables. Even if they were
found to be related in only one stage of the study they were included in the model comparing
the three assessments.
Finally, hierarchical regression analysis was performed to determine the main results of the
study [67]. Four models were checked (Fig 1), where each time, the positive or negative affect in
Table 1. Variables assessed in the three consecutive assessments.
T1 T2 T3
Socio-medical Variables x x x
PTG x - -
Actually Received Support x -
Provided Support - x -
Positive Affect x - x
Negative affect x - x
Note: x–The Variable Included In The Consecutive Assessment.
https://doi.org/10.1371/journal.pone.0201641.t001
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 5 / 17

the third assessment was considered as the outcome variable, while the received or provided
support from the second assessment was considered as the moderator of the relation between
PTG in the first assessment and the outcome. Each model consisted of six blocks. In the first
block, socio-demographical variables (sex, age, being in stable relationship, higher education
and being employed) were analysed using the stepwise method. The first block was performed
in order to control appropriate socio-demographical data. The stepwise method ensured the
control of variables that were related to the explained variables, but it was not meant to test
hypotheses. In the second block, clinical variables (CD4 counts, HIV duration, ART duration,
and HIV/AIDS status) were analysed using also the stepwise method. The second block was
performed in order to control for appropriate medical data. In the third block, the positive or
negative affect (depending on which of these two was the outcome variable) in the first assess-
ment was analysed using the entry method. The level of positive or negative affect in the first
assessment was controlled. In the fourth block, the main effects of PTG in the first assessment
as well as the received or provided social support (depending on which of these two was consid-
ered the moderator) in the second assessment were analysed using the entry method. The fifth
and the last block assessed the interaction between PTG in the first assessment and the received
or provided social support was analysed using the entry method. The interactions indicated
moderation all other blocks were conducted in order to control for appropriate variables.
Results
Study sample
The first assessment was conducted between June 2016 and July 2016. Total of 200 patients
with a clinical diagnosis of HIV infection were approached for the study. However, 44 patients
refused to leave their contact details, and 27 patients did not indicate that HIV infection was a
traumatic event for them. Thus, 129 patients met the inclusion criteria, i.e. they not only com-
pleted the questionnaires, but also agreed to provide their contact details (telephone number
and/or e-mail address) to enable the researchers to contact them for the subsequent assess-
ments, and indicated in the PTGI (see Measures) that the diagnosis of the HIV infection was
traumatic for them. The second assessment was conducted between January 2017 and Febru-
ary 2017. Of the initial 129 participants, 106 agreed to participate in the second assessment.
Finally, the last assessment was performed between May 2017 and June 2017, and 82 of the ini-
tial 129 participants (63.6%) participated in all three assessments. There were no missing data
in the final data of the 82 participants. Participants who refused to participate in the follow-up
assessments did not differ from the final sample population in terms of socio-medical variables
and other studied variables. The Table 2 presents the socio-medical characteristics of the final
study sample with 95% confidence intervals and interquartile ranges. The estimation was
based on the National AIDS Centre Report data among officially declared PLWH being on
antiretroviral treatment in Poland in 2017 [68].
Table 3 presents socio-medical data, which were found to be related to psychological vari-
ables. The selection of socio-medical data was performed with the use of stepwise regression
analysis.
In the models concerning PTG at T1 and T2 participants’ gender was entered. In the model
concerning positive affect in T3 stable relationship and CD4 were entered. Negative affect in
T1 was found to be related to CD4 and negative affect in T2 was related to employment. There
were relationships between received support and employment in T1 and between received
support and higher education and stable relationship in T2. Provided support was related to
stable relationship, participants’ gender and higher education in T2.
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 6 / 17

Table 4 presents the estimated marginal means for the analysed variables in three consecu-
tive assessments obtained with the use of ANCOVA in which the socio-medical data men-
tioned in previous analysis were controlled along with the values of skewness and kurtosis. All
the variables followed normal distribution. Repeated measures ANCOVA revealed no changes
across the three assessments with respect to PTG, positive affect, negative affect, received sup-
port, or provided support.
Table 5 presents the results of hierarchical regression analyses wherein PTG in the first
assessment was analysed as a predictor, and positive or negative affect in the third assessment
was analysed as the outcome, while received support in the second assessment was analysed as
the moderator of the relationship between PTG in the first assessment and positive and nega-
tive affect in the third assessment. None of the clinical variables were related to PTG.
Table 2. Socio-medical variables in the studied final sample (N= 82) with Confidence Intervals and interquartile
ranges based on the national AIDS Centre Report data among officially declared PLWH being on antiretroviral
treatment in Poland in 2017.
Variable Final Sample
(N= 82)
Sex
Male 70 (85.4%, 76.4%94.4%)
Female 12 (14.6%, 5.6%23.6%)
Age in Years
Range 21–76
(M±SD) 40.50 ±11.47 (IR = 12.25)
Relationship Status
Stable Relationship 49 (59.8%, 48.8%70.8%)
Lack Of Stable Relationship 33 (40.2%, 29.2%51/2%)
Education
Elementary 5 (6.1%, 015.1%)
Secondary 26 (31.7%, 21.7%41.7)
University degree 51 (62.3%, 51.3%73.3%)
Employment
Full employment 53 (64.6%, 53.6%75.6%)
Unemployment 23 (28.1%, 18.% 38.1%)
Retirement 6 (7.3%, 1.3%13.3%)
HIV/AIDS status
HIV/AIDS status
HIV+ only 66 (80.5%, 71.5%89.5%)
HIV/AIDS 16 (19.5%, 10.5%28.5%)
HIV Infection Duration in Years
Range 1–30
(M±SD) 7.39±5.72 (IR = 7)
Antiretroviral Treatment (ART) Duration in Years
Range 1–21
(M±SD) 5.76±4.88 (IR = 4)
CD4 Count
Range 200–2000
(M±SD) 645.73 ±256.23 (IR = 342.50)
Note:M= Mean; SD = Standard Deviation; IR–interquartile range.
https://doi.org/10.1371/journal.pone.0201641.t002
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 7 / 17

Therefore, these were not included in the model. Regression coefficients of the health parame-
ters in the second block are provided for reference. They were all excluded from the model.
There was an interaction between received support in the second assessment and PTG level
in the first assessment. Except for the control for the positive affect in the first assessment, all
other predictors were not related to the explained variables. The meaning of interactions was
determined using simple effects analyses [67]. Simple effects analyses based on the median
split of received support (median [Me] = 47.00) were performed to find the meaning of the
interaction. Regression analyses performed for the group of participants with received support
below the median showed no relation between PTG in the first assessment and positive affect
in the third assessment, Beta = .02 (-.32.25). The control for positive affect in the first assess-
ment was the only predictor, Beta = .47 (.14.74). Regression analysis performed for the
group of participants with received support above the median showed a relationship between
Table 3. Socio-medical data associated with analysed psychological variables.
Variable T1 T2 T3
PTG Gender, β= .31 (.10.52) Gender, β= .31 (.10.52) -
Positive affect - - Stable Relationship, β= -.22 (-.44-.01)
CD4, β= .21 (.01.41)
Negative affect CD4, β= -.28 (-.42-.01) Employment, β= -.25 (-.47-.04) Gender, β= .27 (.06.49)
Received Support Employment, β= .22 (.01.44) Higher Education, β= .33 (.13.52) -
Stable Relationship, β= -.31 (-.51-.11)
Provided Support - Stable Relationship, β= -.34 (-.54-.13) -
Gender, β= .26 (.06.47)
Higher Education, β= .20 (.01.40)
Note:β–Standardized Regression Coefficients with 95% Confidence Intervals; T1 –First Assessment; T2 –Second Assessment; T3 –Third Assessment.
https://doi.org/10.1371/journal.pone.0201641.t003
Table 4. Estimated marginal means with 95% Confidence Intervals for PTG, positive and negative affect, received support and provided support for three
assessments.
Analysed variable Mean (SE)
(Covariates) T1 T2 T3
PTG 61.25(56.5865.91) 65.40 (60.1670.63) 63.52 (58.6868.34)
(Gender) S= -.29(-.81.23); K= .53
(-1.47.59)
S= -.67(-1.19.15); K= .53
(-1.29.77)
S= -.33(-.85.20); K= .53
(-1.56.50)
Positive Affect 3.40(3.263.56) 3.38(3.223.57) 3.32(3.193.48)
(CD4, Stable relationship) S= -.42(-.94.10); K= .53
(-.931.13)
S= -.11(-.64.41); K= .53
(-1.43.63)
S= .16(-.36.68); K= .53 (-1.75.31)
Negative Affect 2.24(2.052.45) 2.18(1.992.35) 2.22(2.032.43)
(CD4, Employment, Gender) S= .45(-.07.97); K= .53
(-1.930.13)
S= .93(-.041.45); K= .53
(-.271.79)
S= .66(-.141.18); K= .53
(-1.62.44)
Received support 29.47(27.3031.65) 31.58(29.3933.75) 31.84(29.6034.11)
(Employment, Higher education, Stable
relationship)
S= -.67(-1.19.15); K= .53
(-1.420.64)
S= -.74(-1.26.22); K= .53
(-1.140.92)
S= -.68(-1.21.16); K= .53
(-1.220.84)
Provided support 28.78(26.8830.70) 30.37(28.4932.67) 30.76(29.0532.49)
(Gender, Higher education, Stable relationship) S= -.77(-1.09.05); K= .53
(-.091.97)
S= -.56(-1.08.04); K= .53
(-1.310.75)
S= -.61(-1.13.09); K= .53
(-.841.22)
Note.SE–Standard Error; T1 –First Assessment; T2 –Second Assessment; T3 –Third Assessment; S–Skewness with 95% Confidence Intervals; K–Kurtosis with 95%
Confidence Intervals.
https://doi.org/10.1371/journal.pone.0201641.t004
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 8 / 17

PTG in the first assessment and positive affect in the third assessment, Beta = .31 (.12.70).
The control for positive affect in the first assessment was also a predictor, Beta = .35 (.06.61)
in the first assessment explained 9.2% of the variance in the positive affect in the third assess-
ment. The higher the PTG level in the first assessment, the higher positive affect in the first
assessment. However, this was true only for the group of participants whose level of received
support was above the median (Fig 2).
There was no moderation effect on the received support in the second assessment of the
relation between the PTG level in the first assessment and the negative affect in the third
assessment.
Table 6 shows that there was no moderation effect of the relation between the PTG level in
the first assessment and the positive affect in the third assessment on the provided support in
the second assessment. There was also no moderation effect of the relation between the PTG
Table 5. Results of multiple regression analysis. Received support as moderator of relation between PTG and positive affect and negative affect.
Dependent Block Predictor Assessment β ΔR
2
Positive affect First Stable Relationship Third -.22 (-.44-.01) .05
Second CD4 Third .01 (-.26.21) -
HIV Duration Third -.03 (-.36.55)
ARV Duration Third -.07 (-.54.34)
HIV/AIDS Status Third -.09 (-.36.13)
Third Stable Relationship Third -.21 (-.40-.02) .22
+Positive Affect First .47 (.28.66)
Fourth Stable Relationship Third -.15 (-.35.04) .04
Positive Affect First .42 (.20.61)
+PTG First .15 (-.06.34)
+ Actually Received Support Second .15 (-.07.34)
Fifth Stable Relationship Third -.12 (-.36.03) .04
Positive Affect First .40 (.18.57)
PTG First .17 (-.03.37)
Actually Received Support Second .19 (-.07.33)
+PTG x Actually Received Support First/Second .20 (.01.38)
Negative affect First Gender First .27 (.06.49) .07
Second CD4 Third .09 (-.17.30) -
HIV Duration Third .04 (-.26.64)
ARV Duration Third -.03 (-.54.34)
HIV/AIDS Status Third .07 (-.11.38)
Third Gender First .25 (.04.47) .02
Negative Affect First .14 (-.07.36)
Fourth Gender First .24 (.01.47) .01
Negative Affect First .15 (-.09.36)
PTG First .03 (-.19.27)
Actually Received Support Second .05 (-.29.15)
Fifth Gender First .23 (-.01.48) .01
Negative Affect First .15 (-.09.36)
PTG First .03 (-.19.28)
Actually Received Support Second .04 (-.29.15)
PTG x Actually Received Support First/Second -.07 (-.20.23)
Note:β–Standardized Regression Coefficients with 95% Confidence Intervals; ΔR
2
–Change of the Variance Explained.
https://doi.org/10.1371/journal.pone.0201641.t005
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 9 / 17

level in the first assessment and the negative affect in the third assessment on the provided sup-
port in the second assessment. Participant’s sex was the only predictor. Women had higher lev-
els of negative affect in the third assessment (M= 2.84; SD = .93) than men (M= 2.13; SD = .90).
Discussion
The results of this study were partially consistent with the first hypothesis because only an indi-
rect association between PTG level and positive affect was observed. However, the second
hypothesis was not positively verified because no relationship was found between the PTG
level and negative affect. Thus, this study may provide an answer to important research ques-
tion, i.e. whether the above-mentioned positive changes constituting PTG, which stems from
HIV infection, are related to better well-being in this clinical sample over time. Several authors
have shown that PTG is positively related to the emotional component of well-being (positive
affect) [10,69,70,71]. A previous trial also provides evidence that heightened left frontal brain
activity, a common neurobiological mechanism, links PTG and positive affect [72]. Further-
more, Zoellner & Marcker [9] emphasize the need for a more detailed investigation of the role
of positive emotions in the research on PTG. The need for further research on positive attri-
butes, especially positive affect, has also been highlighted in contemporary HIV/AIDS litera-
ture [35,73]. In particular, this result is in line with the observation of authors who have
reported that PTG may have an indirect positive effect on PWB because this relationship is
moderated by other variables [22,1]. In particular, according to McAdams [74] and Triplet
Fig 2. Scatterplot. Relation between posttraumatic growth in the first assessment and positive affect in the third assessment
depending on the level of actually received support.
https://doi.org/10.1371/journal.pone.0201641.g002
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 10 / 17

et al. [75], the indirect impact of PTG on PWB may be understood by search for a new percep-
tions and direction of life after trauma, resulting in subsequent changes in self-perception and
the attitude towards other people. Nevertheless, the lack of association between PTG level and
negative affect was surprising because several authors reported an association between the
PTG level and a lower negative affect [10,69,76]. However, according to Friedrickson [77],
positive and negative affects should not be treated as two ends of a unitary spectrum, but can
constitute two separate constructs with different physiological backgrounds. This corresponds
with other authors pointing that PTG is only associated with positive affect [78,79].
The results of this study were partially consistent with the third hypothesis because received
support, but not provided support, completely moderated the aforementioned relationship
between PTG and positive affect only. Of the four analysed models, only the one that included
the received support and positive affect, revealed moderation effects. This indicates that the PTG
Table 6. Results of multiple regression analysis. Provided support as moderator of relation between PTG and positive affect and negative affect.
Dependent Block Predictor Assessment β ΔR
2
Positive affect First Stable Relationship Third -.22 (-.44-.01) .05
Second CD4 Third .01 (-.26.21) -
HIV Duration Third -.03 (-.36.55)
ARV Duration Third -.07 (-.54.34)
HIV/AIDS Status Third -.09 (-.36.13)
Third Stable Relationship Third -.21 (-.40-.02) .23
Positive Affect First .47 (.28.67)
Fourth Stable Relationship Third -.16 (-.38.03) .03
Positive Affect First .41 (.22.63)
PTG First .13 (-.06.34)
Provided Support Second .13 (-.17.27)
Fifth Stable Relationship Third -.15 (-.39.03) .01
Positive Affect First .40 (.20.63)
PTG First .13 (-.06.35)
Provided Support Second .14 (-.17.27)
PTG x Provided Support First/Second .05 (-.19.24)
Negative Affect First Gender First .27 (.06.49) .07
Second CD4 Third .09 (-.17.30) -
HIV Duration Third .04 (-.26.64)
ARV Duration Third -.03 (-.5434)
HIV/AIDS Status Third .07 (-.11.38)
Third Gender First .25 (.04.47) .02
Negative Affect First .14 (-.07.36)
Fourth Gender First .25 (.02.49) .01
Negative Affect First .15 (-.08.36)
PTG First .04 (-.19.28)
Provided Support Second -.04 (-.30.16)
Fifth Gender First .26 (.01.48) .01
Negative Affect First .14 (-.08.36)
PTG First .05 (-.18.29)
Provided Support Second -.06 (-.30.16)
PTG x Provided Support First/Second -.07 (-.17.31)
Note:β–Standardized Regression Coefficients with 95% Confidence Intervals; ΔR
2
–Change of the Variance Explained.
https://doi.org/10.1371/journal.pone.0201641.t006
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 11 / 17

level at baseline was positively related to the intensity of positive affect in the third assessment,
but this held true only for the participants who meanwhile received higher level of support. From
the broader perspective, this finding is consistent with the social exchange theory, according to
which received support is associated with improved well-being because individuals seek to maxi-
mize gains (receiving support from other people) and minimize losses (using up resources while
supporting others) [80]. The positive association between received support and PWB has been
reported by several studies [46,47,81]. With respect to PLWH, literature on HIV/AIDS shows
several examples on how receiving social support improves PLWH’s affective well-being [82,83],
promotes health behaviours [84], protects from HIV-related stigma [85] or facilitates more adap-
tive coping strategies [55]. It is possible that for some PLWH, experiencing PTG could be a stim-
ulus for seeking social support, given that this patient group still encounters several challenges in
seeking and receiving support due to the stigma attached to HIV diagnosis [86,87,88,89]. This
is in compliance with the findings of Zeligman et al. [90] who not only observed a positive associ-
ation between social support and PTG, but also found that PLWH who scored high on the PTGI
reported lower levels of HIV-related stigma. A contradictory association between the intensity of
PTG and HIV-related stigma has also been reported by Murphy and Hevey [37]. It is noteworthy
that the current study did not provide evidence for the role of provided support in the link bet-
ween PTG and PWB among PLWH. Although some research projects [51,52] have indicated
that providing support may be more beneficial for PWB than receiving support, other studies
have highlighted the emotional costs of providing social support [91,92], including the cost for
HIV/AIDS care providers [93], which is in line with the aforementioned social exchange theory.
In summary, the role of provided support among PLWH remains unclear. However, this null
finding may be interpreted in the context of the aforementioned challenges that PLWH face dur-
ing the process of seeking, receiving, and perhaps providing support [87].
Strengths and limitations
This longitudinal study is theory-driven wherein three assessments were performed for the
study variables, which are the strengths of this study. Nevertheless, the limitations also need to
be acknowledged. First, the study had a relatively high dropout rate, resulting in a compara-
tively low final sample size at the third assessment. Specifically, low final sample size did not
permit to assess the effect size of the studies associations with high accuracy. This is why the
range of confidence intervals is so vast. In addition, due to organisational reasons, the study
sample was diverse with respect to the duration of HIV infection (although this clinical vari-
able was not a related to the explained variable) and consists of highly functional PLWH, with
a good control of HIV infection (see CD4 count). Future studies should focus on a more
homogenous HIV-infected sample when it comes to HIV infection duration, as well as on a
more heterogeneous sample with respect to viral suppression. Furthermore, some authors crit-
icise the PTGI as a retrospective measurement of growth [6], possibly impeding a detailed
assessment of growth in case of physical illness [94].
Conclusions
This study adds to the literature by examining the temporal relationship between PTG and affec-
tive well-being among PLWH. It appears that in this patient group, PTG may be positively
related to positive affect over time. However, received support is crucial for this process. Research
on HIV/AIDS as well as HIV counselling should concentrate more on the promotion of positive
attributes in this patient group, as emphasized in contemporary literature [35].
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 12 / 17

Supporting information
S1 Dataset.
(SAV)
Author Contributions
Conceptualization: Marcin Rzeszutek.
Data curation: Marcin Rzeszutek.
Formal analysis: Marcin Rzeszutek.
Investigation: Marcin Rzeszutek.
Methodology: Marcin Rzeszutek.
Writing – original draft: Marcin Rzeszutek.
References
1. Helgeson V, Reynolds K, Tomich P. A meta-analytic review of benefit finding and growth. J Couns Clin
Psychol. 2006: 74: 797–816. https://doi.org/10.1037/0022-006X.74.5.797 PMID: 17032085
2. Linley P, Joseph S. Positive change following trauma and adversity: A review. J Traum Stress. 2004;
17: 11–21. https://doi.org/10.1023/B:JOTS.0000014671.27856.7e
3. Prati G, Pietrantoni L. Optimism, social support, and coping strategies as factors contributing to post-
traumatic growth: a meta-analysis. J Loss Trauma. 2009; 14: 364–368. https://doi.org/10.1080/
15325020902724271
4. Tedeschi R, Calhoun L. The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma.
J Traum Stress. 1996; 9; 455–471. https://doi.org/10.1002/jts.2490090305
5. Tedeschi R., & Calhoun L. (2004). Posttraumatic growth: Conceptual foundations and empirical evi-
dence. Psychological Inquiry, 15, 1–18. https://doi.org/10.1207/s15327965pli150101
6. Frazier P, Tennen H, Gavian M, Park C, Tomich P, Tashiro T. Does self-reported posttraumatic growth
reflect genuine positive change? Psychol Sci. 2009; 20: 912–919. https://doi.org/10.1111/j.1467-9280.
2009.02381.x PMID: 19515115
7. Roepke A. Psychosocial interventions and posttraumatic growth: a meta-analysis. J Cons Clin Psychol.
2015; 83; 129–42. https://doi.org/10.1037/a0036872 PMID: 24841865
8. Park C, Helgeson V. Introduction to the special section: growth following highly stressful life events: cur-
rent status and future directions. J Cons Clin Psychol. 2006; 74: 791–796. https://doi.org/10.1037/
0022-006X.74.5.791 PMID: 17032084
9. Zoellner T, Maercker A. Posttraumatic growth in clinical psychology—a critical review and introduction
of a two component model. Clin Psychol Rev. 2016; 26: 626–653. https://doi.org/10.1016/j.cpr.2006.
01.008 PMID: 16515831
10. Abraido-Lanza A, Guier C, Colon R. Psychological thriving among Latinas with chronic illness. J Soc
Iss. 1998; 54: 405–424. https://doi.org/10.1111/j.1540-4560.1998.tb01227.x
11. Mols F, Vingerhoets A, Coebergh J, van de Poll-Franse V. Well-being, posttraumatic growth and bene-
fit-finding in long-term breast cancer survivors. Psychol Health. 2009; 24: 583–595. https://doi.org/10.
1080/08870440701671362 PMID: 20205013
12. Ogińska-Bulik N. Satisfaction with life and posttraumatic growth in persons after myocardial infarction.
Health Psychol Report. 2014; 2: 105–114. https://doi.org/10.5114/hpr.2014.43917
13. Urcuyo K, Boyers A, Carver C, Antoni M. Finding benefit in breast cancer: relations with personality,
coping, and concurrent well-being. Psychol Health. 2005; 20: 175–192. https://doi.org/10.1080/
08870440512331317634
14. Cordova M, Cunningham L, Carlson C, Andrykowski M. (2001). Posttraumatic growth following breast
cancer: A controlled comparison study. Health Psychol 2001; 20: 176–185. doi: 10.33123421
15. Sears S, Stanton L, Danoff-Burg S. The yellow brick road and the emerald city: Benefit finding, positive
reappraisal coping, and posttraumatic growth in women with early-stage breast cancer. Health Psychol.
2003; 22; 487–497. https://doi.org/10.1037/0278-6133.22.5.487 PMID: 14570532
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 13 / 17

16. Tomich P, Helgeson V. Five years later: a cross-sectional comparison of breast cancer survivors with
healthy women. Psycho-Onc. 2002; 11; 154–169. https://doi.org/10.1002/pon.570 PMID: 11921331
17. Lechner S, Carver C, Antoni M, Weaver K, Phillips K. Curvilinear associations between benefit finding
and psychological adjustment to breast cancer. J Cons Clin Psychol. 2006; 74: 828–840. https://doi.
org/10.1037/0022-006X.74.5.828 PMID: 17032087
18. Tomich P, Helgeson V. Posttraumatic Growth Following Cancer: Links to Quality of Life. J of Traum
Stress. 2012; 25: 567–573. https://doi.org/10.1002/jts.21738 PMID: 23073975
19. Bojanowska A, Zalewska A. Lay Understanding of Happiness and the Experience of Well-Being: Are
Some Conceptions of Happiness More Beneficial than Others? J Hap Stud. 2016; 17: 793–815. https://
doi.org/10.1007/s10902-015-9620-1
20. Nolen-Hoeksema S, Davis C. Theoretical and methodological issues in the assessment and interpreta-
tion of posttraumatic growth. Psychol Inq. 2004; 15; 60–65. doi:10.1016666.11.012
21. Calhoun L, Tedeschi R. The foundations of posttraumatic growth: An expanded framework. In Calhoun
L. G. & Tedeschi R. G. (Eds.), Handbook of posttraumatic growth (Chap. 1, pp. 3–23) (2006); NY: Law-
rence Erlbaum Association.
22. Park C. (2004). The notion of growth following stressful life experiences: problems and prospects. Psy-
chol Inq. 2004; 15; 69–76. doi:10.443311.012
23. Barroso J, Hammill B, Leserman J, Salahuddin N, Harmon J, Pence B. Physiological and psychosocial
factors that predict HIV-related fatigue. AIDS Behav. 2010; 14: 1415–1427. https://doi.org/10.1007/
s10461-010-9691-2 PMID: 20352317
24. Beckerman N, Auerbach C. Post-traumatic stress disorder and HIV: A snapshot of occurrence. Soc
Work Health Care. 2010; 49: 687–702. https://doi.org/10.1080/00981389.2010.485089 PMID:
20853209
25. Breet E, Kagee A, Seedat S. HIV-related stigma and symptoms of post-traumatic stress disorder and
depression in HIV-infected individuals: Does social support play a mediating or moderating role? AIDS
Care. 2014; 26: 947–951. https://doi.org/10.1080/09540121.2014.901486 PMID: 24666226
26. Machtinger E, Wilson T, Haberer J, Weiss D. Psychological trauma and PTSD in HIV-positive women:
A meta-analysis. AIDS Behav. 2012; 16: 2091–2100. https://doi.org/10.1007/s10461-011-0127-4
PMID: 22249954
27. Martin L, Kagee A. Lifetime and HIV-related PTSD among persons recently diagnosed with HIV. AIDS
Behav. 2011; 15: 125–131. https://doi.org/10.1007/s10461-008-9498-6 PMID: 19082880
28. Olley B, Zeier M, Seedat S, Stein D. Post-traumatic stress disorder among recently diagnosed patients
with HIV/AIDS in South Africa. AIDS Care. 2005; 17: 550–557. https://doi.org/10.1080/
09540120412331319741 PMID: 16036241
29. Pacella M, Armelie A, Boarts J, Wagner G., Jones T, Feny N, Delahant D. (2012). The impact of pro-
longed exposure on PTSD symptoms and associated psychopathology in people living with HIV: A ran-
domized test of concept. AIDS Behav. 2012; 16: 1327–1340. https://doi.org/10.1007/s10461-011-
0076-y PMID: 22012149
30. Rzeszutek M, Oniszczenko W, Żebrowska M, Firląg-Burkacka E. HIV infection duration, social support
and the level of trauma symptoms in a sample of HIV-positive Polish individuals. AIDS Care. 2015; 27:
363–369. https://doi.org/10.1080/09540121.2014.963018 PMID: 25296635
31. Do A, Rosenberg E, Sullivan P, Beer L, Strine T, Schulden J, Skarbinski J. Excess burden of depression
among HIV-infected persons receiving medical care in the united states: Data from the medical monitor-
ing project and the behavioral risk factor surveillance system. PLoS ONE. 2014; 9: e92842. https://doi.
org/10.1371/journal.pone.0092842 PMID: 24663122
32. Bhatia R, Hartman C, Kallen M, Graham J, Giordano T. Persons newly diagnosed with HIV infection are
at high risk for depression and poor linkage to care: Results from the Steps Study. AIDS Behav. 2010;
15: 1161–1170. https://doi.org/10.1007/s10461-010-9778–9
33. Leserman J. Role of depression, stress, and trauma in HIV disease progression. Psychosom. Med.
2008; 70: 539–545. https://doi.org/10.1097/PSY.0b013e3181777a5f PMID: 18519880
34. Ironson G, Hayward H. Do positive psychosocial factors predict disease progression in HIV-1? A review
of the evidence. Psychosom Med. 2008; 70; 546–54. https://doi.org/10.1097/PSY.0b013e318177216c
PMID: 18541905
35. Moskowitz J, Carrico A, Duncan L, Cohn M, Cheung E, Batchelder A. (2017). Randomized Controlled
Trial of a Positive Affect Intervention for People Newly Diagnosed With HIV. J Cons Clin Psychol. 85;
409–423. https://doi.org/10.1037/ccp0000188 PMID: 28333512
36. Milam J. Posttraumatic growth and HIV disease progression. J Cons Clin Psychol. 2006; 74: 817–827.
https://doi.org/10.1037/0022-006X.74.5.817 PMID: 17032086
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 14 / 17

37. Murphy P, Hevey D. The relationship between internalised HIV-related stigma and posttraumatic
growth. AIDS Behav. 2013: 17; 1809–1818. https://doi.org/10.1007/s10461-013-0482-4 PMID:
23588384
38. Siegel K, Schrimshaw E., Pretter S. Stress-related growth among women living with HIV/AIDS: exami-
nation of an explanatory model. J Behav Med. 2005; 28: 403–414, https://doi.org/10.1007/s10865-005-
9015-6 PMID: 16179979
39. Ironson G, Balbin E, Stuetzle R, Fletcher M, O’Cleirigh C, Laurenceau J, Solomon G. Dispositional opti-
mism and the mechanisms by which it predicts slower disease progression in HIV: Proactive behaviour,
avoidant coping, and depression. Int J Behav Med. 2005; 12: 86–97. https://doi.org/10.1207/
s15327558ijbm1202_6 PMID: 15901217
40. Carrico A, Moskowitz J. Positive affect promotes engagement in care after HIV diagnosis. Health Psy-
chol. 2014; 33: 686–689. https://doi.org/10.1037/hea0000011 PMID: 24245846
41. Li J, Mo P, Wu A, Lau J. Roles of self-stigma, social support, and positive and negative affects as deter-
minants of depressive symptoms among HIV infected men who have sex with men in China. AIDS
Behav. 2016; 21: 261–273.
42. Moskowitz J. Positive affect predicts lower risk of AIDS mortality. Psychosom Med. 2003; 65: 620–626.
https://doi.org/10.1097/01.PSY.0000073873.74829.23 PMID: 12883113
43. Sawyer A, Ayers S, Field A. Posttraumatic growth and adjustment among individuals with cancer and
HIV/AIDS: A meta-analysis. Clin Psychol Rev. 2010; 30: 436–447. https://doi.org/10.1016/j.cpr.2010.
02.004 PMID: 20350775
44. Milam J. Posttraumatic growth among HIV/AIDS patients. J Appl Soc Psychol. 2004; 34: 2353–2376.
https://doi.org/10.1111/j.1559-1816.2004.tb01981
45. Rzeszutek M, Oniszczenko W, Firląg-Burkacka E. Social support, stress coping strategies, resilience
and posttraumatic growth in a Polish sample of HIV+ individuals: results of a one year longitudinal
study. J Behav Med. 2017; Advanced online publication: https://doi.org/10.1007/s10865-017-9861-z
PMID: 28560605
46. Coombs RH. Marital status and personal well-being: A literature review. Fam Relat. 1991; 40–97.
https://doi.org/10.2307/585665
47. Knoll N, Burkert S, Kramer J, Roigas J, Gralla O. Relationship satisfaction and erectile functions in men
receiving laparoscopic radical prostatectomy: Effects of provision and receipt of spousal social support.
J Sex Med. 2009; 6: 1438–1450. https://doi.org/10.1111/j.1743-6109.2009.01244.x PMID: 19473290
48. Kroemeke A, Gruszczynska E. Well-Being and Institutional Care in Older Adults: Cross- Sectional and
Time Effects of Provided and Received Support. PLoS ONE. 2016; 11(8): e0161328. https://doi.org/10.
1371/journal.pone.0161328 PMID: 27548721
49. Knoll N, Schulz U, Schwarzer R, Rosemeier H. Support provider’s appraisal detection bias and the effi-
cacy of received support in medical students preparing for an exam. Br J Soc Psychol. 2006; 45: 599–
615. https://doi.org/10.1348/014466605X59978 PMID: 16984723
50. Pritchard RD. Equity theory:A review and critique. Organ Behav Hum Perform. 1969; 4: 176–211.
https://doi.org/10.1016/0030-5073(69)90005-1
51. Thomas PA. Is it better to give or to receive? Social support and the well-being of older adults. J Geron-
tol. 2010; 65B: 351–357. https://doi.org/10.1093/geronb/gbp113 PMID: 20028952
52. Warner L, Schuz B, Wurm S, Ziegelmann J, Tesch-Romer C. Giving and taking—Differential effects of
providing, receiving and anticipating emotional support on quality of life in adults with multiple illnesses.
J Health Psychol. 2010; 15: 660–670. https://doi.org/10.1177/1359105310368186 PMID: 20603289
53. Batson D, Powell A. Altruism and prosocial behaviour. Handbook of psychology. John Wiley & Sons,
Inc.; 2003
54. Abramowitz S, Koenig L, Chandwani S, Orban L, Stein R, LaGrange R, Barnes W. Characterizing social
support: global and specific social support experiences of HIV-infected youth. AIDS Patient Care
STDS. 2009; 23: 323–330. https://doi.org/10.1089/apc.2008.0194 PMID: 19320599
55. Ashton E, Vosvick M, Chesney M. Social support and maladaptive coping as predictors of the change in
physical health symptoms among persons living with HIV/AIDS. AIDS Patient Care STDS. 2005; 19:
587–598. https://doi.org/10.1089/apc.2005.19.587 PMID: 16164385
56. Hansen N, Vaughan E, Cavanaugh C, Connell C, Sikkema K. Health-related quality of life in bereaved
HIV-positive adults: Relationships between HIV symptoms, grief, social support, and Axis II indication.
Health Psychol. 2009; 28: 249–257. https://doi.org/10.1037/a0013168 PMID: 19290717
57. Brumsey A, Joseph N, Myers H, Ullman J, Wyatt G. Modeling the relationship between trauma and psy-
chological distress among HIV-positive and HIV-negative women. Psych Trauma. 2013; 5: 69–76.
https://doi.org/10.1037/a0022381 PMID: 24587871
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 15 / 17

58. Cieslak R, Benight B, Schmidt N, Łuszczyńska A, Curtin E, Clark A. Predicting posttraumatic growth
among Hurricane Katrina survivors living with HIV: The role of self-efficacy, social support, and PTSD
symptoms. Anxiety Stress Coping. 2009; 22: 449–463. https://doi.org/10.1080/10615800802403815
PMID: 19296264
59. Qiao S, Li X, Stanton B. Social support and HIV-related risk behaviors: a systematic review of the global
literature. AIDS Behav. 2014; 18: 419–441. https://doi.org/10.1007/s10461-013-0561-6 PMID:
23921582
60. Fitzmaurice G, Laird N, Ware J. Applied Longitudinal Analysis, 2nd Edition. Harvard: Wiley; 2011.
61. Ogińska-Bulik N. Juczyński Z. Rozwo
´j potraumatyczny—charakterystyka i pomiar [Posttraumatic
growth: characteristics and measurement]. Psychiatria. 2010; 7; 129–142.
62. Brzozowski P. Skala UczućPozytywnych i Negatywnych. Podręcznik (Positive and Negative Emotions
Scale: Manual). Warszawa: Pracownia Testo
´w Psychologicznych Polskiego Towarzystwa Psycholo-
gicznego; 2010.
63. Watson D, Clark L, Tellegen A. (1988). Development and validation of brief measures of positive and
negative affect. The PANAS Scales. J Pers Soc Psychol. 1988; 54: 1063–1070. doi: 022-35l4/88/00.75
PMID: 3397865
64. Schulz U, Schwarzer R. Soziale Unterstu¨tzung bei der Krankheitsbewa¨ltigung. Die Berliner Social Sup-
port Skalen (BSSS). Diagnostica. 2003; 49: 73–82. https://doi.org/10.1026//0012-1924.49.2.73
65. Łuszczyńska A, Kowalska M, Mazurkiewicz M, Schwarzer R. Berlińskie Skale Wsparcia Społecznego
(BSSS). Wyniki wstępnych badan nad rzetelnościąi trafnością. [Berlin Social Support Scales (BSSS).
Preliminary results on the reliability and validity]. Studia Psychologiczne. 2006; 44; 17–27.
66. Corp IBM. Released. IBM SPSS Statistics for Windows.Version 24. Armonk, NY: IBM Corp. 2016.
67. Uusipaikka E. (2008). Confidence Intervals in Generalized Regression Models (Statistics:A Series of
Textbooks and Monographs). University of Copenhagen. 2008.
68. Krajowe Centrum ds. AIDS. Raport z 31.07.2017 r. [National AIDS Centre. Report from 02.10.2017].
69. Boyraz G, Efstathiou N. Self-focused attention, meaning, and posttraumatic growth: the mediating role
of positive and negative affect for bereaved women. J Loss Trauma. 2011; 16: 13–32. https://doi.org/
10.1080/15325024.2010.507658
70. Evers A, Kraaimaat F, van Lankveld W, Jongen P, Jacobs J, Bijlsma J. Beyond unfavorable thinking:
The illness cognitions questionnaire for chronic diseases. J Cons Clin Psychol. 2001; 69: 1026–1036.
https://doi.org/10.1037/0022-006X.69.6.1026
71. Park C, Cohen L, Murch R. Assessment and prediction of stress-related growth. J Person. 1996; 64; 1–
35. https://doi.org/10.1111/j.1467-6494.1996.tb00815.x
72. Rabe S, Zo
¨llner T, Maercker A, Karl A. Neural correlates of posttraumatic growth after severe motor
vehicle accidents. J Cons Clin Psychol. 74: 880–886. https://doi.org/10.1037/0022-006X.74.5.880
PMID: 17032092
73. Wilson T, Weedon J, Cohen M, Golub E, Milam J, Young M, Fredrickson B. Positive affect and its asso-
ciation with viral control among women with HIV infection. Health Psychol. 2016; 36: 91–100. https://
doi.org/10.1037/hea0000382 PMID: 27685456
74. McAdams D. (2006). The redemptive self-stories Americans live by. New York: Oxford University
Press.
75. Triplett K, Tedeschi R, Cann R, Calhoun L, Reeve C. Posttraumatic growth, meaning in life, and life sat-
isfaction in response to trauma. Psychol Trauma. 2012; 4: 400–410. https://doi.org/10.1037/a0024204
76. Parry C, Chesler M. Thematic evidence of psychosocial thriving in childhood cancer survivors. Qual
Health Res. 2005; 15: 1055–1073. https://doi.org/10.1177/1049732305277860 PMID: 16221879
77. Fredrickson B. The role of positive emotions in positive psychology. The broaden-and-build theory of
positive emotions. Am Psychol. 2001; 56: 218–226. https://doi.org/10.1037/0003-066X.56.3.218
PMID: 11315248
78. Yu Y, Peng L, Tang T, Chen L, Li M, Wang T. Effects of emotion regulation and general self-efficacy on
posttraumatic growth in Chinese cancer survivors: assessing the mediating effect of positive affect. Psy-
cho-Onc. 2014; 23: 473–478. https://doi.org/10.1002/pon.3434 PMID: 24243737
79. Schroevers M, Helgeson V, Sanderman R, Ranchor A. Type of social support matters for prediction of
posttraumatic growth among cancer survivors. Psycho-Onc. 2010; 19: 46–53. https://doi.org/10.1002/
pon.1501 PMID: 19253269
80. Cropanzano R, Mitchell M. Social exchange theory: An interdisciplinary review. J Manag. 2005; 31:
874–900. https://doi.org/10.1177/0149206305279602
81. Schwarzer R, Knoll N. Functional roles of social support within the stress and coping process: A theoretical
and empirical overview. Int J Psychol. 2007; 42; 243–252. https://doi.org/10.1080/00207590701396641
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 16 / 17

82. Lee S, Detels R, Rotheram-Borus J, Duan N, Lord L. Depression and social support among HIV-
affected adolescents. AIDS Patient Care STDs. 2007; 21: 409–417. https://doi.org/10.1089/apc.2006.
0066 PMID: 17594250
83. Li L, Wu S, Wu Z, Sun S, Cui H, Jia M. Understanding family support for people living with HIV/AIDS in
Yunnan, China. AIDS Behav. 2006; 10: 509–517. https://doi.org/10.1007/s10461-006-9071-0 PMID:
16741672
84. Gielen A, McDonnell K, Wu A, O’Campo P, Faden R. Quality of life among women living with HIV: The
importance of violence, social support, and self care behaviours. Soc Sci Med. 2001; 52: 315–322. 10.
1016/S0277-9536(00)00135-0 PMID: 11144787
85. Adewuya A, Afolabi M, Ola B, Ogundele O, Ajibare A, Oladipo B, Fakande I. Post-traumatic stress dis-
order (PTSD) after stigma related events in HIV infected individuals in Nigeria. Soc Psychiat Psychiat
Epidem. 2009; 44: 761–766. https://doi.org/10.1007/s00127-009-0493-7 PMID: 19225704
86. Luszczynska A, Sarkar Y, Knoll N. Received social support, self-efficacy, and finding benefits in disease
as predictors of physical functioning and adherence to antiretroviral therapy. Pat Edu Couns. 2007; 66:
37–42. https://doi.org/10.1016/j.pec.2006.10.002 PMID: 17097259
87. Emlet C. A comparison of HIV stigma and disclosure patterns between older and younger adults living
with HIV/AIDS. AIDS Patient Care STDS. 2006; 20: 350–358. https://doi.org/10.1089/apc.2006.20.350
PMID: 16706709
88. Peterson J. The challenges of seeking and receiving support for women living with HIV. Health Comm.
2010; 25; 470–479. https://doi.org/10.1080/10410236.2010.484878 PMID: 20677050
89. Serovich J, Greene K, Parrott R. Boundaries and AIDS testing: Privacy and the family system. Fam
Relat. 1992; 41; 104–109. PMID: 11659486
90. Zeligman M, Barden S, Hagedorn W. Posttraumatic Growth and HIV: A Study on Associations of
Stigma and Social Support. J Counsel Develop. 2016; 94: 141–149. https://doi.org/10.1002/jcad.12071
91. Schulz R, Beach S. Caregiving as a risk factor for mortality: The caregiver health effects study. JAMA.
1999; 282; 2215–2219. https://doi.org/10.1001/jama.282.23.2215 PMID: 10605972
92. Taylor S. Social support: A review. In Friedman H.S. (Ed.), The Oxford handbook of health psychology
(pp. 189–214). Oxford: Oxford University Press; 2011.
93. Bennett L, Ross M, Sunderland R. The relationship between recognition, rewards and burnout in AIDS
caring. AIDS Care. 1996; 8: 145–154. https://doi.org/10.1080/09540129650125830 PMID: 8861414
94. Casellas-Grau A, Ochoa C, Ruini C. Psychological and clinical correlates of posttraumatic growth in
cancer: A systematic and critical review. Psycho-Onc. 2017. Advanced online publication: https://doi.
org/10.1002/pon.4426 PMID: 28317221
Posttraumatic growth & HIV/AIDS
PLOS ONE | https://doi.org/10.1371/journal.pone.0201641 August 6, 2018 17 / 17