Factors associated with mental health symptoms in women living with HIV in Southern India: An

Vol. 7(5), pp. 84-93, June, 2015
  DOI: 10.5897/IJPC2015.0310
  Article Number: 561A9A854027                                         International Journal of Psychology and
  ISSN 1996-0816
  Copyright © 2015                                                                                 Counselling
  Author(s) retain the copyright of this article

Full Length Research Paper

    Factors associated with mental health symptoms in
       women living with HIV in Southern India: An
                    exploratory study
         Kendall Sauer1*, Courtney Welton-Mitchell2,3, Sara Anderson1 and N. M. Samuel4
                  Graduate School of Professional Psychology, University of Denver (DU), United States.
                             Josef Korbel School of International Studies, DU, United States.
                          Institute of Behavioral Science, University of Colorado, United States.
                      Concern for AIDS Research and Education Center (C.A.R.E.) Namakkal, India.
                                            Received 8 April, 2015; Accepted 24 June, 2015

    Limited research has focused on the mental health of HIV-infected women in resource poor settings
    such as rural India. This study attempts to fill this gap in the literature, through conducting
    standardized interviews with 20 HIV-infected women in rural, Southern India. Variables of interest
    included trauma exposure, mental health symptoms, shame, guilt, social support, negative social
    reactions, coping, and HIV knowledge. Results indicate most women experienced HIV-related stigma in
    the form of negative social reactions, and limited social support. Many reported a history of
    interpersonal violence, and moderate to severe symptoms of post-traumatic stress and depression.
    Feelings of shame, guilt, and self-blame were significantly correlated with mental health symptoms.
    Seeking comfort in religion, such as engaging in meditation or prayer, was a preferred strategy for
    coping with HIV-infection. Despite the small sample size, this exploratory study provides important
    information about the challenges facing women living with HIV in settings where HIV is highly
    stigmatized. Future research should examine predictors of mental health outcomes in a larger sample,
    and evaluate the efficacy of interventions designed to reduce negative social reactions, shame, and
    self-blame, and increase social support.

    Key words: HIV stigma, social support, mental health, shame, India.


More than two and half million people in India are                   such as a large trucking industry, cultural prohibitions
estimated to be living with HIV and AIDS; of these, 39%              against talking about sexual practices even among
are women (World Bank, 2012). The southern states                    married couples (Pallikadavath et al., 2005), and the
have some of the highest rates of infection, including the           disenfranchised status of women (Claeson and
Indian state of Tamil Nadu (World Bank, 2012). Factors               Alexander, 2008) have been identified as contributing to

*Corresponding author. E-mail: kendall.sauer@state.co.us.

Author agree that this article remain permanently open access under the terms of the Creative Commons
Attribution License 4.0 International License
Sauer et al.       85

the spread of HIV among women in India."In addition to       woman in India may experience IPA in their lifetime
the physical health challenges HIV-infected women may        (Silverman et al., 2008). IPA appears to be a risk factor
face, HIV status has been associated with poor mental        for contracting HIV among Indian women (Go et al.,
health outcomes, especially in resource poor communities     2003). Intimate partner abuse has also been linked to low
(Das and Leibowitz, 2011; Wu et al., 2007). Various          quality of life among women living with HIV (McDonnell et
factors such as HIV-related stigma, including negative       al., 2005), and has been associated with negative mental
social reactions, lack of social support, risk of            health outcomes, including post-traumatic stress,
interpersonal violence, shame and guilt, may increase the    depressive symptoms (Campbell et al., 2008), and
risk of mental health difficulties, especially for HIV-      substance abuse (McDonnell et al., 2005). Domestic
infected women.                                              violence may also be a barrier to receiving HIV services
   HIV-related stigma and negative social reactions are      (Decker et al., 2009).
common among women living with HIV (Brown et al.,               Considering this, it is perhaps not surprising that
2003; Hollen, 2010; Vlassoff et al., 2012). HIV-related      women living with HIV are at increased risk for poor
stigma is defined as the perception and experience of        mental health outcomes. Depression is one of the most
discrimination from others based on HIV-related attitudes    common psychological disorders experienced by those
and beliefs (Mahajan et al., 2008). HIV-related stigma       living with HIV (Chandra et al., 2005). In one study of
has been associated with mental health symptoms              HIV-infected women in urban Tamil Nadu, India, 40%
(Brown et al., 2003), and diminished quality of life         reported depressive symptoms (Charles et al., 2011).
(Steward et al., 2009; Thomas et al., 2007; Nyamathi et      Much like IPA, depression is considered to be both a risk
al., 2013). Stigma has also been associated with             factor for contracting HIV, and a common outcome of
decreased likelihood of attending medical appointments,      living with a life-threatening illness (Collins et al., 2006;
increased alcohol consumption, high rates of social          Prince et al., 2007). Persons living with HIV are at
isolation (Nyamathi et al., 2013; Moskowitz et al., 2009),   increased risk of - suicide (Cooperman and Simoni,
higher CD4 counts, and a lack of medication adherence        2005), anxiety disorders and post- traumatic stress
(Rintamaki et al., 2006). Specifically for HIV-infected      (PTSD) (Breuer et al., 2011; Jin et al., 2006; Nyamathi et
women of Southern India, stigma and negative self-image      al., 2013). Mental health symptoms can have a direct
have been linked with risk for depression (Charles et al.,   impact on disease state; those with clinical levels of
2011). Such women are also likely to be victims of overt     depression and PTSD are more likely to have a lower
discrimination that may include social banishment (Van       CD4 count and higher viral loads (Boarts et al., 2006;
Hollen, 2010; Vlassoff et al., 2012).                        Breuer et al., 2011). Due to the relationship between
   In addition to stigma, is not uncommon for HIV-infected   mental health symptoms and HIV status, there is a need
persons to report low levels of social support, and          to further understand factors which may be associated
resulting social isolation (Sivaram et al., 2009).           with poor mental health among this population.
Inadequate social support for HIV-infected populations          Given the myriad challenges HIV-infected women may
has been associated with poor mental and physical            face, including the possibility of societal rejection, it may
health outcomes (Moskowitz et al., 2009), and lack of        not be surprising that women living with HIV experience
medication adherence (Gonzalez et al., 2004; Simoni et       feelings of shame and guilt. Shame has been linked to
al., 2006; Weaver et al., 2005; Vyavaharkar et al., 2007).   physiological responses that negatively impact HIV
Adequate social support has been associated with a           disease outcomes (Dickerson et al., 2004). Shame has
reduction in negative affect (Simoni et al., 2006),          also been associated with a decreased likelihood of being
decreased depression (Gonzalez et al., 2004), reductions     tested for HIV (Kalichman and Simbayi, 2003), and an
in stress, enhanced coping (Weaver et al., 2005), and        increase in risky sexual behaviors (Sikkema et al., 2009).
other positive mental health outcomes for persons living     Specifically, in Southern India, shame and guilt were
with HIV and AIDS (Gielen et al., 2001; Serovich et al.,     found to be associated with HIV-infection and subsequent
2001). One study of HIV-infected women in India              reductions in social and familial support (Tarakeshwar et
indicated that women experienced a decline in social         al., 2007).
support after contracting the virus, and experienced            In light of these concerns, it is important to consider
resulting mental health symptoms, including a lack of        coping strategies that may be effective in mitigating
hope for the future (Majumdar, 2004).                        mental health consequences associated with HIV. Some
    Women living with HIV are also at increased risk of      research indicated that HIV-infected women in rural India
interpersonal violence, including intimate partner abuse     may use religion and spirituality as preferred coping
(IPA) (Campbell et al., 2008; Fonk et al., 2005; Gielen et   strategies (Majumdar, 2004; Nyamathi et al., 2013), and
al., 2001). Across various studies, including India, women   may focus an increasing amount of energy on securing
with a history of intimate partner abuse appear to have      the well-being of their children (Majumdar, 2004).
higher rates of HIV (Stockman et al., 2013; UNAIDS,          Although such approaches have typically been considered
2013). Although actual rates are likely influenced by        healthy or adaptive forms of coping, navigating daily life
underreporting, research indicates one-third of married      with HIV and AIDS can also result in harmful or
86        Int. J. Psychol. Couns.

seemingly maladaptive forms of coping. For example,                    construct equivalence between Tamil and English versions.
some HIV-infected individuals may use avoidant strate-                    Data were collected at participants’ residences in order to reduce
                                                                       the burden on participants associated with asking them to travel to
gies such as hiding medications, avoiding healthcare                   the NGO office. The research team traveled to participant homes at
appointments, and not disclosing one’s HIV status                      a pre-arranged day/time. Each interview took approximately one
(Nyamathi et al., 2013). Avoidant coping strategies have               hour. Upon completion participants received a bag of rice or packet
been associated with negative health outcomes, reduced                 of oil as compensation for their time.
quality of life, and psychological distress (Nyamathi et al.,

                                                                       Participant demographics: Demographics including age, marital
Current study                                                          status, number of children, resources compared to others in the
                                                                       community, education, employment status, and religion were
There is limited research examining various factors                    measured.
associated with mental health outcomes among HIV-
infected women in countries such as India. This study is               HIV-related stigma, negative social reactions: Social reactions
                                                                       were measured using three adapted items based on the Social
designed to explore challenges facing HIV-infected                     Reactions Questionnaire (SRQ; Ullman, 2000). Participants were
women in rural Southern India in hopes of informing                    asked -Did anyone do any of the following when they found out
future research and clinical interventions. Specifically,              about your health situation: indicate you are to blame for the
we investigated - HIV-related stigma in the form of                    situation; stop spending time with you; treat you differently?
negative social reactions and social support; interpersonal            Cronbach’s alpha for these items was 0.97.
violence; mental health symptoms including depression
                                                                       Social Support: Social support was measured using three items
and PTSD; shame, guilt, and HIV knowledge.                             from the Interpersonal Support Evaluation List (Cohen and
                                                                       Hoberman, 1983). Although this scale has not been validated for
                                                                       use with this specific population, it has been administered in various
METHODS                                                                settings including Taiwan (Chen et al., 2000) and Venezuela
                                                                       (Bastardo and Kimberlin, 2000). It has also been administered in
Participants                                                           populations with HIV (Bastardo and Kimberlin, 2000; Yi et al.,
                                                                       2006). The following questions were included with a 4-item
Study participants were selected from HIV-infected women receiving     response scale from definitely true to definitely false - there are
nutrition and health services at a local non-governmental              several people I trust to help solve my problems; when I feel lonely
organization (NGO). Data collection took place over several weeks      there are several people I can talk to; if I were sick I could easily
during the summer of 2013. An institutional review board (IRB) at a    find someone to help me. Because the Cronbach’s alpha was low
university in the U.S. and an IRB-equivalent in New Delhi approved     for the combined items (0.25), items were examined individually.
study procedures prior to data collection.
                                                                       Trauma exposure, including interpersonal violence: Trauma
                                                                       exposure was measured using an adapted 5-item version of the
Procedure                                                              Life Events Checklist (Blake et al., 1995). We did not ask about “life
                                                                       threatening illness,” because HIV-infection is a criterion for receipt
Participant recruitment began with an information session about the    of services at the local NGO where participants were recruited. We
research for all clients receiving services from the local NGO. The    asked about childhood and adulthood exposure to the following
information session allowed potential participants an opportunity to   events: natural disasters, motor vehicle accidents, physical assault
meet the research team and ask questions about the project. After      by a family member (e.g. partner, husband, mother-in-law), physical
the information session, the research team reached out by phone to     assault by someone outside of the family, and sexual assault.
determine interest. Participants were contacted at random. A final
sample of 20 participants was recruited in this manner for this        Depression: The Hopkins Symptom Checklist (HSCL-25) is a self-
exploratory research.                                                  report scale intended to measure symptoms of anxiety and
   Consistent with local consent procedures, the consent form was      depression. The HSCL has been validated for use with a variety of
verbally reviewed with each participant prior to engaging in a         cultural groups (Klein et al., 2001). For this study, the 15-item
structured interview. The voluntary nature of the research was         depression subscale was used, with response options from 1 = not
emphasized in the consent form, and an ‘opt-in’ procedure was          at all to 5 = extremely. One researcher-created somatic symptom
used to determine participation, making it relatively easy for women   item was added to the scale based on suggestions from local NGO
to choose to not participate. Finally, consent was obtained by         staff: Headaches or other pain in my body when thinking about the
signature or thumbprint, as some women were not literate.              problems in my life. An additional item about sexual interest or
   Structured interviews were used to collect information about        pleasure was dropped based on the difficulties local staff had
mental health symptoms, HIV-related stigma in the form of negative     administering the item. Cronbach’s alpha indicated good internal
social reactions, social support, interpersonal violence and           consistency for all items (0.89).
exposure to other adverse events, shame, guilt, coping skills, HIV
transmission knowledge, and demographics (e.g. religion, age,          PTSD: The Harvard Trauma Questionnaire (HTQ) is a self-report
marital status, number of children). The structured interview was      scale developed for research and assessment of trauma symptoms
based on a standardized questionnaire detailed in the following        in Indochinese refugees (Mollica et al., 1992). Various adaptations
section.                                                               of the HTQ have been validated for use with Cambodian, Laotian,
   The questionnaire was translated into Tamil by a local translator   Vietnamese, Arabic, Farsi, Serbo-Croation, and Russian-speaking
and back translated into English by U.S. and Indian researchers.       populations (Klein et al., 2001). The HTQ has been used in Tamil
   Each item was reviewed to ensure clarity and to maintain            Nadu for research and screening of PTSD after the 2004 tsunami
Sauer et al.       87

(Kumar et al., 2007). For this study, 13 HTQ items were selected          and five percent (n=1) did not indicate any religion. All
for use based on recommendations for cultural appropriateness.            participants reported being married, but only 15 percent
Participants were asked about problems people may experience
after a stressful event and how much these problems affected
                                                                          (n=3) indicated that they currently lived with her husband.
[them] in the past week. For all 13 symptom statements, response          Twenty-five percent (n=5) reported being separated from
options ranged from 1 = not at all to 4 = extremely. Cronbach’s           their husbands and 60 percent (n=12) were widows at the
alpha for the 13 items was good (0.83).                                   time of the survey. Ninety-five percent (n=19) reported
                                                                          having children (M =1.90; SD=1.21).             Seventy-five
Shame and Guilt: The 15-item State Shame and Guilt scale                  percent of women (n=15) reported having no more than
(SSGS) was originally developed to capture state shame and guilt
in psychology experiments (Marschall et al., 1994). Although this
                                                                          fifth standard (or approximately 6th grade in the US
measure has not been previously validated in this cultural context, it    school system) education (years of education M= 4.80;
has been used in a variety of naturalistic settings (Gruenewald et        SD=3.72). Seventy-five percent (n=15) were employed in
al., 2004; Tangney and Dearing, 2006). There are five items for           some capacity at the time of the survey, with the majority
each of three subscales. An example of a shame item is I want to          engaged with day labor or other sporadic work. Ninety-
sink into the floor and disappear. An example of a guilt item is I felt   percent (n=18) reported having less than (money, other
bad about something I did. Participants are asked to rate how they
are feeling currently on a 5-point scale from 1 = not feeling this way    resources) or much less than others in the community.
at all, to 5 = feeling this way very strongly. The Cronbach’s alpha for
the shame subscale was 0.64. For the guilt subscale the                   HIV-related Stigma, Negative Social Reactions: The
Cronbach’s alpha was low (0.36); however, we included these scale         majority of respondents reported HIV-related stigma,
items given the exploratory nature of this study.                         indicating others blamed them for their HIV status (74%),
                                                                          and stopped spending time when them due to their status
Coping: The Brief COPE is a 28-item scale that measures utilization
of 14 types of coping derived from both theory and research
(Carver et al., 1989; Carver, 1997). The instrument was piloted in a
racially diverse sample in the USA and has since been translated          Social Support: Perceived social support was low: nearly
into numerous languages (Carver, 1997; Kapsou et al., 2010).              all respondents indicated they did not have many people
Previous studies using the Brief COPE have focused on                     to talk with (95%), or to help them problem-solve (84%).
immigrants, caregivers, students, and refugees (Chase et al., 2013;       More than half (68%) indicated that they don’t have
Sarfo-Mensah, 2009). The dispositional version of the Brief COPE
was administered (Carver, 1997). Participants were asked: In order        anyone to help them when they are sick.
to cope with stressful life events, such as your current health status,
how often do you do the following? Cronbach’s α for the full coping       Trauma exposure, interpersonal violence: Most women
scale was poor (0.59), suggesting the scale did not measure a             reported multiple types of trauma exposure. On average
unified construct, so items were examined individually.                   each participant reported 1.5 events (median= 2;
                                                                          range=0-4). Ten percent reported a history of exposure to
HIV knowledge: An investigator created 11-item inventory was              natural disasters. Fifteen percent reported having been in
used to capture knowledge about HIV transmission: Yes or no, “Is
                                                                          a motor vehicle accident. Thirty-five percent of women
HIV transmitted by…?”- sex with an infected person; contaminated
needles; blood transfusion; God’s will; hugging; shaking hands;           reported physical assault by a stranger. Twenty six-
sharing the same bathroom; insects; donating blood; sharing eating        percent reported a history of an unwanted sexual
utensils. This measure was used based on feedback from local staff        experience. Notably the most frequent form of trauma
and considering what was relevant for the local cultural context.         exposure (65%) was physical assault by a close family
                                                                          member (e.g. partner, husband, mother-in-law). Further-
                                                                          more, 80 percent reported interpersonal abuse by either
RESULTS                                                                   a family member or stranger. Eighty-percent of all
                                                                          reported incidents occurred during adulthood, with 20
All data were analyzed using Statistical Package for the                  percent occurring during childhood. Only fifteen percent
Social Sciences (IBM, SPSS Statistics, 20.0 and 21.0).                    did not endorse at least one form of exposure to adverse
Prior to analysis, variables of interest were examined for                events.
violations of statistical assumptions (e.g., skew, kurtosis,
extreme outliers). No outliers were in need of modification.              Depression: Traditionally, an average score of >1.75
Descriptive statistics were run on variables of interest to               on the HSC is comparable to a diagnosis of clinical
examine prevalence rates (e.g. for exposure to inter-                     depression. When calculating each participant’s average
personal violence, depression symptoms). Pearson-                         score, the denominator was adjusted to reflect excluded
correlations were used to explore associations between                    items. Ninety-four percent of respondents (n=18, 2
mental health symptoms and other variables described                      missing cases) had an average score >1.75 (M=3.32;
previously in the literature review and measures sections.                SD=0.71). However, because the HSC has not been
                                                                          normed or validated for use in this specific population,
Participant demographics: Average age of participants                     diagnostic cut-offs may be misleading.
(N = 20) was 43 years (SD =7.10, range= 28-55 years).                        As a result, we also examined the range of scores in
Eighty-five percent indicated Hinduism was their primary                  this sample (range = 19-54; M = 43; SD = 9.27), and split
religion (n=17), ten percent (n=2) reported Christianity,                 the sample into thirds representing low, medium and high
88      Int. J. Psychol. Couns.

                                  Table 1. Mean scores for depression symptoms (HSC).

                                  Depression symptoms (back translated)             Mean (SD)
                                  1. There is crying/weeping                         3.7 (.56)
                                  2. I feel headache or some pain                    3.6 (.68)
                                  3. I don’t have hope regarding my future           3.5 (.95)
                                  4. I feel very sad                                 3.5 (.83)
                                  5. I don’t put effort in my work                   3.5 (.83)
                                  6. I feel that I have lost something               3.4 (.93)
                                  7. I have extreme sleep                            3.3 (1.2)
                                  8. I feel loneliness                               3.2 (1.1)
                                  9. I don’t feel hungry                             3.2 (1.1)
                                  10.I feel so guilty                                2.6 (1.1)
                                  11.I have many unwanted thoughts about my life     2.5(1.4)
                                  12.I feel I have been caught in a trouble          2.5(1.3)
                                  13.I don’t bother, I don’t show interest           2.5 (1.1)
                                  14.I feel I am not fit for anything                2.3 (1.2)

                  Table 2. Mean scores for PTSD symptoms (HTQ).

                  PTSD symptoms (back translated)                                                Mean (SD)
                  1.   I get angry very easily (I am so angry)                                    3.6 (.61)
                  2.   I am constantly thinking about the event                                   3.5 (1.0)
                  3.   I am very much emotional, I try to behave like in some other way           3.5 (.95)
                  4.   I am thinking I should not repeat this event again                         3.3 (.92)
                  5.   I am afraid/frightened of my future                                        3.3 (1.1)
                  6.   I am being so hyper (anxious) because of this problem                      3.2 (.83)
                  7.   I am feeling that the problem will repeat again                            3.1 (1.1)
                  8.   I cannot sleep                                                             3.0 (1.3)
                  9.   I cannot concentrate                                                       2.8 (.94)
                  10.  I am not interested in my daily activities                                 2.7 (1.0)
                  11.  I cannot control my emotions                                               2.5 (.89)
                  12.  I am trying to withdraw from the thoughts surrounding the experience       2.3 (1.3)
                  13.  Nightmares                                                                 1.9 (.85)

symptom groups. Based on this, 11% of participants have            52), and examined lower and upper thirds, to correspond
mild symptoms, 28% have moderate symptoms, and 61%                 roughly to relatively mild and more severe symptom
have severe depressive symptoms. Symptom items with                scores among this group. Based on this, 11% endorsed
the highest mean severity included: crying, somatic pain,          mild symptoms (13-26), 33% endorsed moderate
lack of hope, and sadness. See Table 1 for individual              symptoms (27-39), and 56% endorsed severe symptoms
HSC item means.                                                    (40-52). The items with the highest mean severity
                                                                   included anger and rumination. See Table 2 for individual
PTSD: Traditionally, an average score of >2.5 on the               HTQ item means.
HTQ indicates a diagnosis of PTSD. When calculating
each participant’s average score, the denominator was              Shame and guilt: The mean shame subscale score was
adjusted to reflect excluded items. Eighty-three percent           14.26 (SD=4.51, range = 9-17, out of a possible 5-25).
had a score of >2.5 (M =2.91; SD= 0.58), indicating an             The guilt subscale score was M=17.11; SD=4.12
unusually high incidence of PTSD symptoms in this                  (range=7-20, out of a possible 5-25). Feeling very small
population (n = 18). However, as with the depression               and as if I am drowning in this problem were frequently
scale, diagnostic cut-offs may be misleading because the           endorsed items.
HTQ has not been normed or validated for use in this
specific population. As with the depression measure, we            Coping: Each item was scored on a scale of 1 to 4,
looked at the range of scores in this sample (range = 13-          where 1= I haven’t been doing this at all and four= I have
Sauer et al.         89

 Table 3. Mean scores for individual coping items.

  Item (back translation, modified Brief COPE, Carver, 1997) 1 = I haven't been doing this at all; 4 = I've
                                                                                                                                  Mean (SD)
  been doing this a lot (N = 20)
  I        will engage prayers or meditation                                                                                     3.9        (.31)
  I would seek religious belief for comfort                                                                                      3.9        (.31)
  I would show more interest or desire in what I’m going to do                                                                   3.8        (.55)
  I would accept the truth of what has happened                                                                                  3.6        (.75)
  I will receiving counseling help/advice from others                                                                            3.6        (.83)
  For comfort, I will seek some other person                                                                                     3.6        (.82)
  I would see what other people do and ask advice from them                                                                      3.6        (.75)
  I will search for others’ help                                                                                                 3.5        (.83)
  I will try some things which could overcome it                                                                                 3.5        (.83)
  I will think about and judge myself again and again*                                                                          3.4        (1.09)
  I will order what I have to do                                                                                                 3.4        (1.0)
  I will try to divert my attention                                                                                              3.3        (.80)
  I would accept and try to live with it                                                                                        3.2        (1.18)
  I will concentrate on some other works                                                                                        3.1        (1.00)
  I will come out from these unwanted thoughts                                                                                  3.1        (1.02)
  I will try to face this in some other angle                                                                                   2.9        (1.18)
  I would feel disturbed; always blame myself                                                                                   2.9        (1.25)
  Instead of thinking about it, I will concentrate on TV, reading books, sleeping or other thoughts                             2.6        (1.31)
  I will see the goodness of what has happened                                                                                  2.3        (1.16)
  I couldn’t/won’t believe that it happened                                                                                     2.1        (1.37)
  I would contradict the thoughts                                                                                               1.95       (1.28)
  I will say this is not true                                                                                                   1.9        (1.04)
  I will compromise                                                                                                             1.9        (1.14)
  I would make a joke of it                                                                                                     1.8        (1.20)
  I would take it as a joke                                                                                                     1.5         (.89)
 *this item significantly associated with symptoms of depression, r (20) = .74; p
90       Int. J. Psychol. Couns.

                             Table 4. HIV knowledge items.

                              Is HIV transmitted by…                  Percentage endorsing “yes”
                              1.    person to person                             100
                              2.    sex with an infected person                   95
                              3.    contaminated needles                          95
                              4.    blood transfusion                             90
                              5.    God (God’s will)                              18
                              6.    insects                                       16
                              7.    sharing eating utensils                       11
                              8.    hugging                                       5
                              9.    donating blood                                5
                              10. shaking hands                                   0
                              11. sharing the same bathroom                       0

                            Table 5. Correlations between interpersonal abuse, shame, guilt, depression
                            and PTSD symptoms.

                            interpersonal abuse (Y/N)        shame    guilt    PTSD      depression
                            -                                 .325    .239      .257        .236
                                                                -     .462      .324        .565
                                                                                    **          **
                                                                        -      .883        .837
                                                                                  -        .908
Sauer et al.          91

study in which women indicated that turning to religion         Despite the limitations, there are several strengths of
and praying were a helpful means of coping with               this exploratory study. The research highlights challenges
stressors associated with being HIV-infected. Mental          facing women living with HIV in settings such as rural
health interventions should capitalize on this preferred      Southern India where having HIV is highly stigmatized,
coping strategy, ensuring women have adequate access          and can leave one socially ostracized. This study also
to opportunities to practice religious and spiritual          adds to the limited research examining various factors
activities. Social support seeking was also a preferred       potentially associated with mental health outcomes for
coping strategy, despite the seemingly common negative        HIV-infected women in lower-income settings such as
social reactions and a reported lack of available social      rural India. Finally, this study has the potential to inform
support. Given this preference, and the difficulties with     therapeutic interventions for this population, including
access to adequate social support, community-wide anti-       programs targeting – violence prevention, HIV awareness
stigma campaigns should be investigated to determine          and anti-stigma campaigns, and feelings of shame, guilt,
the potential benefits for this population.                   and self-blame. Future research should explore these
   Finally, misconceptions surrounding HIV transmission       potential applications with a larger sample and using a
were reported, despite the fact that all women surveyed       longitudinal design.
are receiving services from a local organization, including
HIV education. Additional HIV trainings with an emphasis
on increasing knowledge about modes of transmission for       ACKNOWLEDGEMENTS
HIV-infected women and community members could be a
focus for future interventions. Community education may       Thanks to the C.A.R.E. Center for making this work
also decrease HIV-related stigma and increase social          possible, including M. Stella, Dr. Buela, and participants
support for HIV-infected women.                               who allowed us to bear witness to their stories. Thanks
   Many of the aforementioned factors were examined for       too for support from the University of Denver, International
potential associations with mental health outcomes. The       Disaster Psychology (IDP) program, including Dr. Judith
small sample size resulted in limited statistical power to    Fox, and former IDP students Megan Hunter, Rachel
detect associations however, and as such, may have            Tepfer, Andrea Varner, Tracy Abbott, Laura Poole, and
resulted in inaccurate null results. For example, there       Alex Weber.
was no significant correlation between a history of inter-
personal violence and PTSD or depression symptoms.
Previous research however, suggests a typically robust        Conflict of Interests
relationship between interpersonal violence and mental
health outcomes (Campbell et al., 2008; Kilpatrick et al.,    The authors have not declared any conflict of interests.
2003; Pico-Alfonso et al., 2006). In addition, somewhat
surprisingly, negative social reactions and social support
were not significantly correlated with mental health          REFERENCES
outcomes. Negative social reactions however, may              Bastardo YM, Kimberlin CL (2000). Relationship between quality of life,
influence feelings of shame, guilt, and self-blame – all        social support and disease-related factors in HIV-infected persons in
factors that were significantly associated with mental          Venezuela. Aids Care 12(5):673-684.
health outcomes in this sample. Future research should        Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD,
                                                                Charney DS, Keane TM (1995). The development of a clinician
examine the potential relationship between negative             administered PTSD scale J. Trauma. Stress 8(1):75-90.
social reactions and shame, guilt, and self-blame to          Boarts JM, Sledjeski EM, Bogart LM, Delahanty DL (2006). The
determine how these constructs may be related.                  differential impact of PTSD and depression on HIV disease markers
   This exploratory study has some limitations. Most            and adherence to HAART in people living with HIV. AIDS Behav.
notably, the sample size is small. In addition, the survey    Breuer E, Myer L, Struthers H, Joska JA (2011). HIV/AIDS and mental
instruments were not specifically normed and validated          health research in sub-Saharan Africa: a systematic review. Afr. J.
for use with this population. Although the research team        AIDS Res. 10(2):101-122.
focused on equivalence of constructs during the               Brown L, Macintyre K, Trujillo L (2003). Interventions to reduce
                                                                HIV/AIDS stigma: what have we learned?. AIDS Educ. Prev. 15(1):
translation process, it is possible that some variables of      49-69.
interest were not fully understood as intended. Finally,      Campbell JC, Baty ML, Ghandour RM, Stockman JK, Francisco L,
participant answers may have been influenced by the             Wagman J (2008). The intersection of intimate partner violence
presence of researchers affiliated with the local service       against women and HIV/AIDS: a review. Int. J. Inj. Contr. Saf.
                                                                Promot. 15(4):221-231.
provider, and in some cases, family or other community        Carver CS, Scheier MF, Weintraub JK (1989). Assessing coping
members were coming in and out of the room during               strategies: A theoretically based approach. J .Pers. Soc. Psychol.
interviews. Attempts were made by the research team to          56:267–283.
address this, but these may have been inadequate,             Carver CS (1997). You want to measure coping but your protocol’s too
                                                                long: Consider the brief cope. Int. J. Behav. Med. 4(1): 92-100.
potentially resulting in under or over-endorsing of some      Chandra PS, Desai G, Ranjan S (2005).                  Indian J. Med.
items.                                                          Res. 121(4):451-467.
92         Int. J. Psychol. Couns.

Charles B, Jeyaseelan L, Pandian AK, Sam AE, Thenmozhi M,                   Kumar MS, Murhekar MV, Hutin Y, Subramanian T, Ramachandran V,
   Jayaseelan V (2011). Association between stigma, depression and             Gupte MD (2007). Prevalence of Posttraumatic Stress Disorder in a
   quality of life of people living with HIV/AIDS (PLHA) in South India-A      Coastal Fishing Village in Tamil Nadu, India, After the December
   community based cross sectional study. Health Qual. Life Outcomes.          2004 Tsunami. Am. J. Public Health. 97(1).
   9(84).                                                                   Leserman J (2008). Role of depression, stress and trauma in HIV
Chase LE, Welton-Mitchell C, Bhattarai S (2013). “Solving tension”:            disease progression. Psychosom. Med. 70(5):539-545.
   coping among Bhutanese refugees in Nepal. Int. J. Mig, Health Soc.       Mahajan AP, Sayles JN, Patel VA, Remien RH, Ortiz D, Szekeres G,
   Care. 9(2):71-83.                                                           Coates TJ (2008). Stigma in the HIV/AIDS epidemic: a review of the
Chen CH, Tseng YF, Chou FH, Wang SY (2000). Effects of support                 literature and recommendations for the way forward. AIDS 22(2):S67.
   group intervention in postnatally distressed women: a controlled         Majumdar B (2004). An exploration of socioeconomic, spiritual, and
   study in Taiwan. J. Psychosom. Res. 49(6):395-399.                          family support among HIV-positive women in India. J. Assoc. Nurses
Claeson M, Alexander A (2008). Tackling HIV in India: Evidence-based           AIDS Care 15 (3):37-46.
   priority setting and programming. Health Aff. 27(4): 1091-1102.          Marschall D, Sanftner J, Tangney JP (1994). The state shame and guilt
Cohen S, Hoberman HM (1983). Positive events and social supports as            scale. Fairfax, VA: George Mason University.
   buffers of life change stress. J. Appl. Soc. Psychol. 13(2):99-125.      McDonnell KA, Gielen AC, O’Campo P, Burke JG (2005). Abuse, HIV
Collins PY, Holman AR, Freeman MC, Patel V (2006). What is the                 status and health-related quality of life among a sample of HIV
   relevance of mental health to HIV/AIDS care and treatment programs          positive and HIV negative low income women. Qual. Life Res.
   in developing countries? A systematic review. AIDS 20(12):1571-             14(4):945-957.
   1582.                                                                    Mollica RF, Caspi Y, Bollin P, Truong T, Tor S, LaVelle J (1992). The
Cooperman NM, Simoni JM (2005). Suicidal ideation and attempted                Harvard trauma questionaire: validating a cross-cultural instrument
   suicide among women living with HIV/AIDS. J. Behav. Med.                    for measuring torture, trauma, and posttraumatic stress disorder in
   28(2):149-156.                                                              Indochinese refugees. J. Nerv. Ment. Dis. 180(2):111-116.
Das S, Leibowitz GS (2011). Mental health needs of people living with       Moskowitz JT, Hult, JR, Bussolari C, Acree M (2009). What works in
   HIV/AIDS in India: A literature review. AIDS Care. 23(4):417-425.           coping with HIV? A meta-analysis with implications for coping with
Decker MR, Seage GR, Hemenway D,Raj A, Saggurti N, Balajah,                    serious illness. Psychol. Bull. 135(1):121.
   Silverman JG (2009). Intimate partner violence functions as both a       NACO (2014). Annual Report 2013-2014. Department of AIDS Control.
   risk marker and risk factor for women’s HIV infection: Findings from        Ministry of Health and Family Welfare Government of India.
   Indian husband-wifes dyads. J. Acquir. Immune Defic. Syndr.              Nyamathi A, Heravian A, Salem B, Suresh P, Sinha, S, Ganguly K, Liu
   51(5):593-600.                                                              Y (2013). Physical and mental health of rural southern Indian women
Dickerson SS, Gruenewald TL, Kemeny ME (2004). When the social                 living with AIDS. J. Int. Assoc. Provid. AIDS Care. 12(6):391-396.
   self is threatened: Shame, physiology, and health. J. Pers.              Pallikadavath S, Garda L, Apte H, Freedman J, & Stone WR (2005).
   7(26):1191-1216.                                                            HIV/AIDS in rural India: context and health care needs. J. Biosoc.
Fonk K, Els L, Kidula N, Ndinya-Achola J, Temmerman M (2005).                  Sci. 37(05):641-655.
   Increased risk of HIV in women experiencing physical partner             Pico-Alfonso MA, Garcia-Linares M, Celda-Navarro N, Blasco-Ros C,
   violence in Nairobi, Kenya. AIDS Behav. 9(3):335-340.                       Echeburúa E, Martinez M (2006). The impact of physical,
Gielen AC, McDonnell KA, Wu AW, O’Campo P, Faden R (2001).                     psychological, and sexual intimate male partner violence on women's
   Quality of life among women living with HIV: the importance violence,       mental health: depressive symptoms, posttraumatic stress disorder,
   social support, and self care behaviors. Soc. Sci. Med. 52(2):315-          state anxiety, and suicide. J. Womens Health 15(5):599-611.
   322.                                                                     Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, & Rahman
Go VF, Sethulaskshmi CJ, Bentley ME, Sivaram S, Srikrishnan, AK,               A (2007).No health without mental health. Lancet. 370(9590):859-
   Solomon S, Celentano DD (2003). The HIV-prevention messages                 877.
   and gender norms clash: The impact of domestic violence on               Rintamaki LS, Davis TC, Skripkauskas S, Bennett C, Wolf MS (2006).
   women’s HIV risk in slums of Chennai, India. AIDS Behav. 7(3):263-          Social stigma concerns and HIV medication adherence. AIDS Patient
   273.                                                                        CARE and STDs, 20(5):359-369.
Gonzalez JS, Schneiderman N, Penedo FJ, Antoni MH, Duran RE,                Sarfo-Mensah AG (2009). Coping methods and meaning making of
   McPherson-Baker S, Fletcher MA (2004). Social support, positive             Liberian refugees in the Buduburam refugee camp of Ghana.
   states of mind, and HIV treatment adherence in men and women                University of Connecticut.
   living with HIV/AIDs. Health Psychol. 23(4):413 - 418.                   Serovich JM, Kimberly JA, Mosack KE, Lewis TL (2001). The role of
Gruenewald TL, Kemeny ME, Aziz N, Fahey JL (2004). Acute threat to             family and friend social support in reducing emotional distress among
   the social self: Shame, social self-esteem, and cortisol activity.          HIV-positive women. AIDS Care. 13(3): 335-341.
   Psychosom. Med. 66(6):915- 924.                                          Sikkema KJ, Hansen NB, Meade CS, Kochman A, Fox AM (2009).
Hunter M, Gray R, Welton-Mitchell C & Samuel NM (2015). “They will             Psychosocial predictors of sexual HIV transmission risk behavior
   not even give me a cup of water”: Stress and coping among women             among HIV-positive adults with a sexual abuse history in child- hood.
   living with HIV in Southern India. Int. J. Psychol. Couns. 7(2):40-46.      Arch. Sex. Behav. 38: 121–34.
Jin H, Hampton, Atkinson J, Yu X, Heaton RK, Shi C, Marcotte TP,            Silverman JG, Decker MR, Saggurti N, Balajah D, Raj A (2008).
   Grant I (2006). Depression and suicidality in HIV/AIDS in China. J.         Intimate partner violence and HIV infection among married women.
   Affect. Disorders 94(1):269-275.                                            JAMA, 300(6):703-710.
Kalichman SC, Simbayi LC (2003). HIV testing attitudes, AIDS stigma,        Simoni JM, Frick PA, & Huang B (2006). A longitudinal evaluation of a
   and voluntary HIV counselling and testing in a black township in            social support model of medication adherence among HIV-positive
   Cape Town, South Africa. Sex. Transm. Infect. 79(6):442-447.                men and women on antiretroviral therapy. Health Psychol. 25(1):74.
Kapsou M, Panayiotou G, Kokkins CM, Demetriou AG (2010).                    Sivaram S, Zelaya C, Srikrishnan AK, Latkin C, Go VF, Solomon S,
   Dimensionality of coping an empirical contribution to the construct         Celentano D (2009). Associations between social capital and HIV
   validation of the brief-cope with a Greek-speaking sample. J. Health        stigma in Chennai, India: considerations for prevention intervention
   Psychol. 15(2):215-229.                                                     design. AIDS Educ. Prev. 21(3):233-250.
Kilpatrick DG, Ruggiero KJ, Acierno R, Saunders BE, Resnick HS, Best        Steward WT, Herek GM, Ramkrishna J, Bharat S, Chandy S, Wrubel J,
   CL (2003). Violence and risk of PTSD, major depression, substance           Ekstrand M (2009). HIV related stigma: Adapting a theoretical
   abuse/dependence, and comorbidity: results from the National                framework for use in India. Soc. Sci. Med. 67(8):1225-1235.
   Survey of Adolescents. J. Consult. Clin. Psychol. 71(4):692.             Stockman JK, Lucea MB, Campbell JC(2013). Forced sexual initiation,
Klein WC, Hovens JE, Rodenburg JJ (2001). Posttraumatic stress                 sexual intimate partner violence and HIV risk in women: A global
   symptoms in refugees: assessments with the Harvard Trauma                   review of literature. AIDS Behav. 17(3):832-847.
   Questionnaire and the Hopkins symptom Checklist-25 in different          Tarakeshwar N, Srikrishnan AK, Johnson S, Vasu C, Solomon S,
   languages. Psychol. Rep. 88(2):527-532.                                     Merson M, Sikkema K (2007). A social cognitive model of health for
Sauer et al.         93

   HIV-positive adults receiving care in India. AIDS Behav. 11(3):491-       The World Bank (2012). HIV/AIDS in India. Wu DY, Munoz M, Espiritu
   504.                                                                         B, Zeladita J, Sanchez E, Callacna M, Shin S (2007). Burden of
Thomas BE, Rehman F, Suryanarayanan D, Josephine K, Dilip M,                    depression among impoverished HIV-positive women in Peru. J.
   Dorairaj VS, Swaminathan S (2005). How stigmatizing is stigma in             Acquir. Immune Defic. Syndr. 48(4): 500-504.
   the life of people living with HIV: a study on HIV positive individuals   Wu E, El-Bassel N, Witte SS, Gilbert L, Chang M (2003). Intimate
   from Chennai, South India. AIDS Care 17(7):795-801.                          partner violence and HIV risk among urban minority women in
Ullman SE (2000). Psychometric characteristics of the Social Reactions          primary health care settings. AIDS Behav. 7(3):291-301.
   Questionnaire: A measure of reactions to sexual assault victims.          Yi MS, Mrus JM, Wade TJ, Ho ML, Hornung RW, Cotton S, Tsevat J
   Psychol. Women Quart. 24:169–183.                                            (2006). Religion, spirituality, and depressive symptoms in patients
UNAIDS (2013). HIV in Asia and the Pacific. UNAIDS Reports. Geneva.             with HIV/AIDS. J. Gen. Int. Med. 21(S5):S21-S27.
Van Hollen C (2010). HIV/AIDS and the Gendering of Stigma in South
   India. Cult. Med. Psychiatr. 34:633-657.
Vlassoff C, Weiss MG, Rao S, Ali F, Prentice T (2012). HIV-related
   Stigma in Rural and Tribal Communities of Maharashtra,
   India. J. Health. Popul. Nutr. 30(4):394.
Vyavaharkar M, Moneyham L, Tavakoli A, Phillips KD, Murdaugh C,
   Jackson K, Meding G (2007). Social support, coping, and medication
   adherence among HIV-positive women with depression living in rural
   areas of the southeastern United States. AIDS Patient Care
   STDS. 21(9):667-680.
Weaver KE, Llabre MM, Durán RE, Antoni MH, Ironson G, Penedo FJ,
   Schneiderman N (2005). A stress and coping model of medication
   adherence and viral load in HIV-positive men and women on highly
   active antiretroviral therapy (HAART). Health Psychol 24(4):385.
You can also read
NEXT SLIDES ... Cancel