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Received: 29 July 2022
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Revised: 13 January 2023
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Accepted: 21 January 2023
DOI: 10.1002/smi.3231
RESEARCH ARTICLE
Depression during the COVID‐19 pandemic among people
living with HIV: Are low HIV/AIDS stigma and high perceived
emotional support protective resources?
Marcin Rzeszutek
1
|Ewa Gruszczyńska
2
1
Faculty of Psychology, University of Warsaw,
Warsaw, Poland
2
Faculty of Psychology, SWPS University of
Social Sciences and Humanities, Warsaw,
Poland
Correspondence
Marcin Rzeszutek
Email: marcin.rzeszutek@psych.uw.edu.pl
Funding information
Narodowe Centrum Nauki; National Science
Center, Grant/Award Number: 2019/35/B/
HS6/00141
Abstract
This study has two objectives: first, to examine changes in depressive symptoms
among people living with HIV (PLWH) during the COVID‐19 pandemic and, second,
to verify the role of HIV/AIDS stigma and perceived emotional support (PES) in the
heterogeneity of these changes. The participants were 392 people with a medical
diagnosis of HIV who have undergone antiretroviral therapy. Depression was
measured at three time points with 6‐month intervals using the Centre for Epide-
miological Studies Depression Scale (CES‐D). PES was evaluated with the Berlin
Social Support Scales, and HIV/AIDS‐related stigma was assessed with the Berger
HIV Stigma Scale. Latent growth class modelling identified four trajectories of
depression over the study period: three stable (very high, high, and very low) and
one increasing. Both the very high and high stable trajectories had baseline values
above the CES‐D cut‐off point for depression, suggesting that 57.6% of the sample
was likely to be diagnosed with depression. After controlling for sociodemographic
and clinical variables, stigma and PES were found to be significant covariates of the
obtained trajectories; however, they did not protect against an increase in
depression symptoms. There was no overall increase in depression symptoms
among the PLWH participants during the pandemic, but this change in depression
symptoms was heterogeneous. We observed the potential development of
depression in initially well‐functioning individuals despite their personal resources
differing only slightly from those who remained resilient.
KEYWORDS
COVID‐19, depression, HIV/AIDS, HIV/AIDS stigma, social support
1
|
INTRODUCTION
Dozens of studies have shown that depression is one of the most
common neuropsychiatric disorders among people living with HIV
(PLWH) throughout all phases of infection (see reviews and
metanalyses: Ciesla & Roberts, 2001; Gonzales et al., 2011; Nanni
et al., 2015). Several epidemiological analyses have showed that the
prevalence of clinical depression among PLWH is two‐to four‐fold
higher compared to the general population (e.g., Bing et al., 2001;
Nacher et al., 2010). Moreover, long‐term prospective research has
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, pro-
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© 2023 The Authors. Stress and Health published by John Wiley & Sons Ltd.
Stress and Health. 2023;1–10. wileyonlinelibrary.com/journal/smi
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found depression the most important predictor of poor treatment
adherence (Gonzales et al., 2011; Rutakumwa et al., 2021), low
health‐related quality of life (Pérez‐Chaparro et al., 2022; Rzeszu-
tek & Gruszczyńska, 2018), faster HIV infection progression, and
even increasing mortality in this patient group (Ickovicks et al., 2001;
Namagga et al., 2021). However, the aetiology of depression is very
complex, and various biological and psychosocial factors co‐occur as
risk factors in this clinical sample, including potentially terminal
diagnosis (Filiatreau et al., 2022; Leserman, 2003), challenges with
HIV disclosure and related HIV/AIDS stigma (Kiene et al., 2018;
Zotova et al., 2022), and the burden of life‐long treatment adherence
and associated side‐effects (Borran et al., 2021; Fumaz et al., 2005).
To make matters complicated, depressive symptoms may sometimes
overlap with HIV infection symptoms (Cruess et al., 2003). Also it was
found that depression is highly prevalent among PLWH by repre-
senting racial or sexual minorities (Rendina et al., 2018). Finally,
recent years have brought about additional global stress in the form
of the coronavirus (COVID‐19) pandemic, which particularly
hampered the mental functioning of this vulnerable population (Lee
et al., 2021). Thus, in the present study, our aim was to examine the
trajectories of depressive symptom changes among PLWH during
the critical period of the COVID‐19 pandemic and its covariates in
the form of perceived HIV/AIDS stigma and emotional support.
According to a World Health Organization (2022) report, the
COVID‐19 pandemic was responsible for a significant increase in
mental disorders worldwide, especially depression, anxiety, and sui-
cide. Nevertheless, the report underlined that mental health prob-
lems were disproportionately more prevalent among three key
populations: young people, females, and those with chronic health
conditions. Within this latter group we can include PLWH (May &
Fullilove, 2022). In light of the recent report (WHO, 2022), during the
COVID‐19 pandemic, PLWH have experienced substantial disrup-
tions in their everyday functioning, including barriers to healthcare
due to COVID‐19‐exclusive transformations of hospitals, delays in
HIV testing, problems with HIV treatment, or a lack of anonymity due
to telemedicine services (Lee et al., 2021). In addition, several studies
have found that PLWH as a group suffered particularly strongly from
disruptions in their social life during the pandemic, including isolation
and related depressive and suicidal thoughts (Sun et al., 2020). It was
associated with the epidemic of misinformation surrounding COVID‐
19 in that some linked the COVID‐19 vaccines to the potential for
HIV infection. Such irrational beliefs may have increased the already
high level of societal fear against regarding PLWH, eroding social
support for this patient group and, as a result, increasing perceived
HIV/AIDS stigma among PLWH during this critical period (May &
Fullilove, 2022). Many of the aforementioned medical, social, and
psychological challenges also impacted this group's HIV treatment
adherence, especially during the pandemic (Lee et al., 2021).
However, it should be underlined that some studies conducted in
the general population have revealed differential mental health tra-
jectories over the course of the COVID‐19 pandemic (e.g., Lu
et al., 2022; Tan et al., 2020), including a significant proportion of
individuals who were not emotionally hampered or even experienced
positive psychological changes due to lifestyle adjustments imposed
by the pandemic (Vazquez et al., 2021). In other words, the prediction
that COVID‐19 pandemic would entail a global tsunami of mental
disorders was highly exaggerated (Brülhart et al., 2021). In the
literature, one particular variable has been systematically linked to a
decrease in trajectories of COVID‐19‐related distress: perceived
social support (PES) (Fluharty et al., 2021). In our study we wanted to
examine its role in case of depression and HIV/AIDS stigma among
PLWH.
PLWH are very heterogenous group with respect to adaptation
to HIV infection. More specifically, despite this group's shared
medical diagnosis and experience of HIV‐related distress, there are
significant differences in their emotional functioning over time (e.g.,
Oberje et al., 2015; Rendina et al., 2018). Particularly, PLWH still
experience intense HIV‐related distress and consistently report
lower levels of psychological well‐being in comparison not only to
the general population but also to patients suffering from other
chronic illnesses (Cooper et al., 2017). This latter pessimistic trend
is linked to the present stigmatization of PLWH, which explicit
manifestations of have been altered, but its overall level remains
rather similar to that at the beginning of the HIV/AIDS epidemic
(see meta‐analyses; Rueda et al., 2016; Rzeszutek et al., 2021). In
fact, HIV/AIDS stigma is treated as the main source of emotional
distress and low quality of life for PLWH, as well as the greatest
barrier to effective coping with the HIV epidemic in healthcare
worldwide (Andersson et al., 2020; UNAIDS, 2020). A huge number
of studies have been conducted to understand the complex process
of PLWH's stigmatization, which encompasses both the internal
traumatic character of HIV/AIDS itself, as a potentially life‐
threatening condition, as well as external socio‐cultural issues
that reveal existing inequalities in class, race, gender, and sexuality
(Logie & Gadalla, 2009; Rueda et al., 2016). Regarding this con-
ceptual complexity, psychological research on HIV/AIDS stigma still
lacks a theoretical model that can provide a clear definition of this
term and propose definitive mechanisms via which stigma worsens
the lives of PLWH (Feyissa et al., 2019).
What was observed, however, was that adequate social support
may buffer the impact of HIV/AIDS stigma on poor emotional func-
tioning of PLWH, including depression (e.g., Brown et al., 2022;
Campbell et al., 2022; Smith et al., 2008; Qiao et al., 2014). Some
authors provided evidence in line with the classical buffering hy-
pothesis (Cohen & Wills, 1985), according to which perceived social
support is a moderator of association between HIV‐related distress
(including stigma) and its various negative physical and psychological
consequences This buffering effect may be further modified by other
social factors, just like being in an intimate relationship (Rzeszutek &
Gruszczyńska, 2018). Nevertheless, the majority of studies on social
support among PLWH are also limited by various shortcomings, such
as dominance of cross‐sectional assessment and lack of differenti-
ating between social support characteristics (Qiao et al., 2014). Also,
the available research on depression and stigma conducted among
PLWH during the COVID‐19 pandemic provides only cross‐sectional
data (see review: Lee et al., 2021). Thus, to the best of our knowledge,
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our longitudinal study is the first to examine trajectories of change in
depression symptoms among PLWH during universal, socially shared
and chronic stress, which could act as both a trigger and an amplifier
for worsening of emotional functioning (Ross, 2017). This effects may
be observed especially among those who already before the
pandemic suffered from other conditions, including stigmatization,
making them especially vulnerable to an accumulation of external
and internal demands that exceed their resources (Bobo et al., 2022;
Lazarus & Folkman, 1984; Roland et al., 2020).
1.1
|
Current study
Taking the above research gaps into consideration, our study had two
objectives: first, we wanted to examine the heterogeneity of changes
in depressive symptoms among PLWH during the COVID‐19
pandemic and, second, to identify the role of HIV/AIDS stigma and
PES—while controlling for sociodemographic and clinical variables—
as covariates of depression trajectory membership. We expected
that lower HIV/AIDS stigma and higher PES would act as protective
resources against the development of depression symptoms during
the pandemic. In addition to these main effects, we also expected an
interaction between these variables, as, in line with the well‐known
buffering effect of social support (Qiao et al., 2014), the negative
impact of high stigma may be reduced by high PES. Accordingly, we
formulated three study hypotheses:
Hypothesis 1 There is an overall linear increase in depression symptoms
among the participants during the COVID‐19 pandemic; however,
the trajectories of depression symptom changes are heterogeneous
among this group.
Hypothesis 2 HIV/AIDS stigma and PES are covariates of these trajec-
tories and act in different directions, with HIV/AIDS stigma being a
vulnerability factor and PES a protective factor.
Hypothesis 3 The interaction between HIV/AIDS stigma and PES can be
observed in the form of a buffering effect of PSE.
2
|
METHOD
2.1
|
Participants and procedure
The present study was conducted at an infectious disease hospital
specializing in HIV/AIDS diagnosis and treatment. The participants
were recruited during their visits to the outpatient clinic. After
providing written informed consent, the participants were asked to
fill out psychometric questionnaires (see Measures). All patients had
a medically confirmed diagnosis of HIV infection and were on anti-
retroviral therapy (ART). The exclusion criteria encompassed HIV‐
related cognitive disorders and a current diagnosis of substance
use disorder as screened by the medical doctor who cooperated in
our research. Additionally, we also controlled a presence of self‐
reported history of substance use disorder in further analyses as
there is a high lifetime probability of such behaviours among PLWH
(Durvasula & Miller, 2014). The characteristics of the sample are
depicted in Table 1.
This was a longitudinal study conducted in Poland in three waves
separated by 6‐month intervals. The first measurement was con-
ducted between July–October 2020 during the so‐called ‘first wave’
of the COVID‐19 pandemic—i.e., soon after the reduction in the most
stringent restrictions of the lockdown in Poland. For the next mea-
surements, participants were approached during their scheduled
controlled visits at the clinic after our establishing of the date via
phone or email based on their preference. The second measurement
took place in January 2021 and the third in July 2021 during the
second and third waves of the pandemic, respectively. Participation
was voluntary. The study protocol was approved by the institutional
ethics committee.
2.2
|
Measures
2.2.1
|
Depressive symptoms
Patients' depressive symptoms were assessed using the Polish
adaptation of the Centre for Epidemiological Studies Depression
Scale (CES‐D) (Ridloff, 1977). The CES‐D is an internationally
recognized questionnaire used to assess depression levels in clinical
trials and epidemiological studies. The cut‐off score for clinical
depression level is equal to or greater than 16 points. In the present
study, the Cronbach's alpha was 0.93, 0.94, and 0.93 for the first,
second, and third measurement points, respectively.
2.2.2
|
Perceived emotional support
We used the Polish adaptation of the Berlin Social Support Scales
(BSSS; Schulz & Schwarzer, 2003), which evaluates a broad range of
support dimensions. However, in the present study, we only used
scale referring to perceived available emotional support. It consists of
four items, evaluated on a 4‐point Likert scale. The Cronbach's alpha
for this scale in our study was 0.82.
2.2.3
|
HIV/AIDS stigma
To assess the level of stigma among the study participants, the Polish
adaptation of the Berger HIV Stigma Scale was used (HSS; Berger
et al., 2001; Wanjala et al., 2021), as it is the most commonly used
and widely validated tool for assessing HIV/AIDS stigma. The HSS
consists of 40 items aimed at evaluating the degree of various as-
pects of HIV/AIDS stigma experienced. In our study, the total HIV/
AIDS score was used. The Cronbach's alpha for the total HIV/AIDS
stigma score was 0.95.
RZESZUTEK AND GRUSZCZYŃSKA
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2.3
|
Data analysis
Latent growth class modelling (LCGM; Nagin, 2005) was used to
analyze the data. The final number of classes was determined based
on the most commonly used indices. These include the Akaike's in-
formation criterion (AIC), Bayesian information criterion (BIC), and
sample size‐adjusted BIC (SABIC). Lower values indicate better
model–data fit. We also used the bootstrap likelihood ratio test
(BLRT), which evaluates the relative adequacy of a (K−1)‐class
model compared to a K‐class model, where significant pvalues sug-
gest the K‐class model fits the data better (Nylund et al., 2007).
Additionally, entropy (i.e., and values closer to 1 indicates better
profile separation; Collins & Lanza, 2013) and sample size (i.e., when
the frequency of the smallest class is no less than 5% of the sample;
Nasserinejad et al., 2017) were applied as supportive indices. The
linear and curvilinear effects of time were examined, with the original
time coding for the consecutive measurement set as 0, 1, and 2.
Once the final model was selected, a bias‐adjusted, three‐step
procedure (Vermunt, 2010) was applied for testing the significant
covariates (auxiliary variables; maximum likelihood method, ML).
Baseline stigma and PES as well as their interaction were thus
included in the model along with sociodemographic and clinical var-
iables to control for their effect. The analyses were performed using
IBM SPSS Statistics version 27 IBM Corp (2021) and Latent Gold
version 5.1.0.16119.
3
|
RESULTS
3.1
|
Descriptive statistics and missing data
Table 1presents the descriptive statistics for the three measurement
points in terms of the participants' depressive symptoms and baseline
values of stigma and PES. As can be seen, in terms of skewness and
kurtosis (see Table 1) a distribution of variables is close to normal
(Hair et al., 2010). For all variables included in the analysis, missing
data can be treated as missing at random (Little's MCAR test:
χ
2
=181.77, df =162, p=0.14). Also, there were no significant
differences between the completers and non‐completers in terms of
most of the sociodemographic and clinical variables—except educa-
tion and CD4 count. Namely, PLWH with no university degree
(χ
2
=14.87, df =1, p<0.001) and a lower CD4 count (t= −2.02,
df =346, p=0.03, Cohen's d=0.27, small effect) dropped out of the
study more often than those who took part in all three measure-
ments. In further analysis, we took into account all available data
(Graham, 2009).
TABLE 1Sociodemographic and
clinical variables in the studied sample
(n=392).
Variable n(%)
Gender
Man 344 (87.8%)
Woman 48 (12.2%)
Age in years (M SD) 39.55 10.54
Stable relationship
Yes 196 (50%)
No 196 (50%)
Education
No university degree 177 (45.2%)
University degree 215 (54.8%)
HIV/AIDS status
HIV +only 330 (84.2%)
HIV/AIDS 60 (15.3%)
Missing data 2 (0.5%)
HIV Infection duration in years (M SD) 10.45 8.48
Antiretroviral treatment (ART) duration in years (M SD) 7.56 6.55
CD4 count 593.47 229.80
History of substance use disorder
Yes 81 (20.7%)
No 311 (79.3%)
Abbreviations: M, mean; SD, standard deviation.
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3.2
|
Hypothesis testing
For Hypothesis 1, we tested general latent growth curve models with
linear and quadratic time effects. For the model of linear growth
(i=19.49, Wald =855.17, p<0.001; s=1.20, Wald =3.04, p=0.08)
as well as that of quadratic growth (i=19.46, Wald =797.11,
p<0.001; s=1.65, Wald =0.41, p=0.52, s
qrt
= −0.24, Wald =0.03,
p=0.90), only the intercept was significant. Thus, the mean change in
the depressive symptoms of the whole sample over 1 year was non‐
significant. The next step was to examine whether there were dif-
ferences among the individual participants in terms of this change.
Models with a quadratic time slope were ultimately not considered,
because, for all of them, this component was not significantly
different from zero nor did it vary significantly across the classes.
Table 2presents the results of the extraction of one to five classes
for testing the heterogeneity of linear growth in the sample.
As can be seen, AIC, BIC, and SABIC have the lowest values for
the four‐class solution. Also, the BLRT indicates that this model
provides a significant fit improvement compared to the three‐class
model, whereas this was not found for the five‐class model when
compared to the four‐class model. A number of the smallest class also
supports the choice of the four‐class model. The entropy values are
low for all the tested solutions, suggesting that the classes are not
clearly differentiated from one another. This may be problematic if a
modal classification (i.e., one based on the most likely class assign-
ment) would be taken for further analysis, but, in a bias‐adjusted,
step‐three procedure, a proportional classification is used. Thus, of
the competing models, the four‐class model was regarded as the best
fitted to the data. Figure 1illustrates the obtained trajectories within
each class for this model.
The most numerous class 1 (n
1
=184, 46.9% of the sample)
consisted of participants who reported no increase in depression
symptoms over the study period (s=0.13, z=0.51, ns.) although their
baseline level was above the cut‐off (i=23.9, z=17.88, p<0.001).
Members of class 2 (n
2
=108, 27.6%) initially reported relatively low
levels of symptoms followed by a significant increase over time
(i=10.3, z=11.09, p<0.001; s=2.3, z=3.72, p<0.001). Class 3
(n
3
=61, 10.7%) was comprised of participants with the lowest
depression values and who did not experience significant change over
the study period (i=3.6, z=5.50, p<0.001; s=1.0, z=1.79, ns.).
Finally, the PLWH in class 4 (n
4
=39, 9.9%) had very high and stable
levels of depression (i=43.3, z=26.72, p<0.001; s=0.6, z=0.52,
ns.). In summary, three stable trajectories were identified: two above
the cut‐off point for depression (class 1 and 4, together 57.8% of the
sample) and one below this point (class 3). The only growth trajectory
identified (class 2) started with relatively low baseline values of
TABLE 2Descriptive statistics for
continuous variables in the study. Variable M SD Range Skewness Kurtosis
Depression symptoms
Time 1 19.41 13.68 0–59 0.58 −0.45
Time 2 20.87 13.27 1–49 0.47 −0.80
Time 3 21.79 12.68 1–54 0.68 −0.25
HIV/AIDS stigma 90.32 23.44 40–154 0.25 −0.45
Perceived emotional support 13.32 2.52 4–16 −0.96 0.77
Abbreviations: M, mean; SD, standard deviation.
FIGURE 1 The four trajectories of depression change during the three measurement points for the study sample during the COVID‐19
pandemic.
RZESZUTEK AND GRUSZCZYŃSKA
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depression and did not exceed the cut‐off point—although with the
groups' final values of 15.0 came very close to this point (an increase
of 4.7 points over 12 months).
Finally, for Hypotheses 2and 3, we tested whether HIV/AIDS
stigma and PES and their interaction, respectively, were significant
covariates of class membership—after controlling for sociodemo-
graphic and clinical variables measured in the study (see also Ta-
ble 1). The obtained results are presented in Table 3. In class 4, there
was an overrepresentation of PLWH who were female, single, and
reported a history of substance use disorder. This class also reported
the longest time of being under ART (8.3 years vs. 7.3 for class 2 and
7.5 for both classes 1 and 3) despite the lack of significant differences
between the classes in terms of the time since diagnosis. Also, the
CD4 count was the lowest in class 1 and the highest in class 3 (572.5
vs. 625.4, Wald =6.38, p=0.01).
As seen in Model 2, both stigma and PES turned out to be sig-
nificant covariates of class membership. For stigma, all but one paired
comparison was found to be significant at p<0.01, with the following
order of intensity across the classes, starting from its lowest values:
class 3 (M=69.5), class 2 and 1 (M=85.9 and 92.9, respectively, ns.),
and class 4 (M=117.8). For PES, all six between‐class comparisons
were significant at p<0.05; the increasing order of mean values was
thus as follows: class 4 (M=11.3), class 1 (M=12.7), 2 (M=14.1) and
class 3 (M=15.3). Finally, as seen in Table 4, the interaction between
stigma and PES was revealed to be non‐significant.
4
|
DISCUSSION
The results of our study were in line with our first hypothesis to a
certain degree. Specifically, although we did not observe an overall
increase in depressive symptoms in the whole sample, we identified
four trajectories of changes in these symptoms among the PLWH
during the COVID‐19 pandemic: three with stable (class 1, 3, and 4)
and one with increasing depressive symptoms (class 2) over the
course of the study. The participants with high baseline depressive
symptom intensity (class 1 and 4) did not report a further increase
during the study period. Still, these results indicate that nearly 60%
of the sample can be diagnosed with clinical depression according to
the CES‐D cut‐off score. On the other hand, we identified PLWH with
stable and very low levels of symptoms as accounting for 15% of the
sample (class 3). Thus, our findings suggest that, in general, the
COVID‐19 pandemic as a one‐year period may not have affected
depression trajectories among PLWH. As many as 75% of them re-
ported no change in the overall intensity of their depressive symp-
toms, indicating that the individual baseline level of depression was
crucial for their future level of the symptoms rather than the dy-
namics of the socially shared context of the pandemic. The primary
explanation for this finding may be that, after 3 months of the
pandemic spent mostly in strict lockdown, for most people, individual
differences in terms of psychological adjustment were already
established and relatively resistant to further change over the next
year. This finding could be in line with studies pointing to different
trajectories of mental health during the COVID‐19 pandemic over
TABLE 3Latent class growth curve
analysis for determining the number of
classes (n=392).
Model AIC BIC SABIC
No. of
parameters Entropy
BLRT
Smallest class
(modal
classification)
Value p
% of
nFrequency
1‐Class 5022 5034 5025 3
2‐Class 4826 4854 4832 7 0.64 204.06 <0.001 48.5 190
3‐Class 4776 4820 4785 11 0.64 57.86 <0.001 10.5 41
4‐Class 4745 4806 4758 15 0.62 37.99 <0.001 9.9 39
5‐Class 4746 4820 4760 19 0.56 9.54 ns. 9.4 37
Note: Acronyms explained in the data analysis section.
TABLE 4Results of a bias‐adjusted three‐step procedure for
testing covariates.
Variables Model 1 Model 2 Model 3
Gender 46.58*** 5.96 4.60
Age 1.21 1.63 1.41
Education 4.31 0.37 0.36
Relationship 34.05*** 16.03** 11.65**
Years since diagnosis 7.78 1.19 1.15
Years of antiretroviral therapy 10.88* 1.44 0.76
AIDS 6.02 6.96 7.70
CD4 count 8.23* 8.15 6.47
History of substance abuse 15.57** 6.76 6.35
HIV/AIDS stigma 23.38*** 2.33
Perceived emotional support 50.40*** 7.63
Stigma perceived emotional support 1.00
Note: The categorical variables were dummy coded: gender (0 =woman,
1=man), education (0 =no university degree, 1 =university degree),
relationship (0 =single, 1 =in a stable relationship), AIDS (0 =no,
1=yes), history of substance abuse (0 =no, 1 =yes).
Wald test, ***p<0.001, **p<0.01, *p<0.05.
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time in the general population, including a stable pattern of psy-
chological adjustment to the pandemic (e.g., Lu et al., 2022; Tan
et al., 2020). However, in this study, the participants in class 2
deserve particular attention, as they reported a systematic increase
in depression despite their initial low symptom levels. Nevertheless,
it is difficult to pinpoint what fostered this increase in symptom in-
tensity for this group in terms of sociodemographic and clinical
variables, as they were not distinguished by any particularly char-
acteristic profile. The main difference was only the fact that they
started out as individuals with low depression symptoms, and, as
such, they had the potential to experience deterioration in their
mental health. This may therefore be the group whose resilience
(unlike the resilient people in class 3) under chronic stress is
depleted. In this sense, they could still have been in the process of
adaptation and progressing towards the development of clinical
depression. As a consequence, over time, the differences between
class 3 and class 2 steadily widened.
The most pronounced differences in terms sociodemographic
and clinical characteristics were found in class 4, which had very high
and stable levels of depression. In this group, there was an over-
representation of PLWH who were female, single and with a personal
history of substance use disorder—a finding in line with other studies
on the sociodemographic predictors of depression in this population
(Gonzales et al., 2011). This group also reported an average one‐
year‐earlier implementation of ART; thus, this indicates they were
more concerned about their health or even had observed its faster
deterioration. In contrast, the most resilient participants (class 3)
were mainly men, in a stable relationship, and had the highest CD4
counts.
These two fringe groups, that is, class 3 and 4, also differed
significantly in terms of the expected direction on HIV/AIDS stigma
and PES levels. Thus, it could be said that being a member of a class
with high stable versus low stable depression is associated with
already identified in the literature correlates of depression among
PLWH (Nanni et al., 2015). It was found that low emotional support
and high HIV/AIDS stigma may be a significant predictor of
depression in this clinical sample (see reviews and metaanalyses:
Ciesla & Roberts, 2001; Gonzales et al., 2011). However, again in
case of class 2, the obtained results were not in alignment with
well‐known patterns observed in the literature regarding depres-
sion in this population, as relatively low stigma and high PES did not
protect against an increase in depression symptoms. This finding
may be better understood in light of lack of confirmation of Hy-
pothesis 3, informing that, for the four trajectories obtained in the
study, PES was not found to interact with stigma to buffer its
negative effect. The observed main effects may be a consequence of
the already developed level of depression, and this may be the basic
reason why they are consistent with it. This would also suggest why
there was no buffering effect of PES against HIV/AIDS stigma, as in
such case the perceived support may not reflect the factual con-
dition of the social interactions but be the result of adjustment
between cognitive appraisal and the current emotional state
(Mercan et al., 2021).
The aforementioned findings may be another sign that PLWH are
a very heterogenous group with respect to their adaptation to HIV
infection, and, despite the same medical diagnosis, there are signifi-
cant differences in their emotional functioning over time (Oberje
et al., 2015), which was visibly seen during the COVID‐19 pandemic.
More specifically, PLWH are likely to suffer from emotional dysre-
gulation, defined as experienced difficulty in the self‐regulation of
one's affective states and emotion‐driven behaviours (Brandt
et al., 2017; Rendina et al., 2018). Emotion dysregulation is mostly
observed in recently diagnosed PLWH (Bhatia et al., 2011), but is also
associated with enduring high levels of negative affect many years
post‐diagnosis (Do et al., 2014), which can transform into chronic
depression co‐occurring with life with an HIV infection (Gonzalez
et al., 2011; Nanni et al., 2015). However, even if, in our study, we
managed to catch the process of potential development of depres-
sion during the pandemic in initially well‐functioning individuals, their
resources differ only slightly from the resources of those who remain
resilient. The question then remains whether this small difference,
when confronted with extraordinary external demands in the form of
a pandemic, is great enough to trigger the process of emotional
deterioration to the clinical level. This requires more thorough ex-
amination, ideally in the form of future studies linking a prospective
longitudinal framework with observations of daily life of PLWH
during the pandemic.
4.1
|
Strengths and limitations
This study has several strengths, including its longitudinal design with
a large clinical sample, three measurement points, and observations
conducted during the critical moment of the COVID‐19 pandemic.
However, a few limitations should also be highlighted. First, the
participants' pre‐pandemic depression levels were unknown; there-
fore, the stability of the trajectories above the clinical cut‐off point
may represent a ceiling effect, especially in the group with the
highest scores. Second, we did not control sufficiently for other
sources of stress, including potential critical life events experienced
during the pandemic, as well as possibility of stigma accumulation
among PLWH representing sexual, gender or ethnic minorities. Third,
we only used self‐descriptive data collected via the CES‐D ques-
tionnaire and thus were missing information regarding possible cur-
rent or historical psychiatric diagnoses of depression and related
treatment. Finally, our sample was comprised of relatively highly
functioning PLWH with good control and treatment of HIV.
5
|
CONCLUSION
The COVID‐19 case showed that pandemics do not occur within a
social vacuum but instead reveal preexisting inequalities and dis-
parities in terms of access to socioeconomic resources (Cabin, 2021).
During our study period, the majority of participants reported some
degree of depression. However, our results indicate that they were
RZESZUTEK AND GRUSZCZYŃSKA
-
7
also a heterogeneous group, where differences in personal resources
may play a role in affective responses to an external context, while
their role in protecting against depression development requires
further studies.
ACKNOWLEDGEMENTS
This study was financed by the National Science Center in Poland
(research project no. 2019/35/B/HS6/00141).
CONFLICT OF INTEREST STATEMENT
The authors report no conflicts of interest.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ETHICS STATEMENT
The study protocol was accepted by the institutional ethics com-
mittee. Written informed consent was obtained from all participants
before participation in the study.
RESEARCH INVOLVING HUMAN PARTICIPANTS
The study protocol was accepted by the institutional ethics com-
mittee. Written informed consent was obtained from all participants
before participation in the study.
ORCID
Marcin Rzeszutek
https://orcid.org/0000-0002-4230-3806
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