Analysis of resilience and sexual behavior in persons with HIV infection

Over the last two decades, researchers have shown greater interest in studying resilience (Carvalho, Morais, Koller, & Piccinini, 2007). This psychological construct has been defined as the patterns of positive adaptation to risk and adversity (Liebenberg & Ungar, 2009; Masten & Cicchetti, 2012; Rutter, 2006), being understood as a process mediated by individual, family, and social factors for overcoming challenging situations (Cameron, Ungar, & Liebenberg, 2007; Masten & Tellegen, 2012) and the capacity to react positively to adverse and traumatic events (Orton, Griffiths, Green, & Waterman, 2012), in such a way that the individual gains additional protection and coping skills (Poletto & Koller, 2006). For building resilience, it is therefore necessary for the person to be exposed to difficult situations that jeopardize his/her physical and/or mental health (De Santis, Florom-Smith, Vermeesch, Barroso, & DeLeon, 2013). Taking resilience to be a process of interaction between the individual and the context in which he/her finds him/herself, two stages can be discerned. In the first stage, considered the acute stage, the problem situation causes the person to perceive a threat and learn to control this situation. Once the person has this new situation under control, the second stage takes place, in which the person must reorganize his/her life by including in it the changes created by the situation. The outcome of this is resilience (Fine, 1991).

In this study, resilience is defined as the individual’s ability to overcome adversity or psychosocial risks (Rutter, 1999). According to this author, resilience is not solely based on positive traits of the individual; a series of psychological determinant factors should be analyzed. Psychology believes that resilience is linked to personal resources, which lead to adaptive behaviors such as self-esteem, self-efficacy, and problem-solving ability, which act as protectors against adversity (Rutter, 1987).

The social and academic relevance of this study is primarily due to the lack of studies on the relationship between resilience and HIV infection (Araújo, Teva, & Bermúdez, 2015) and ways of coping with this disease. Secondly, this study has added ways of detecting levels of resilience and its relationship with psychosocial variables.

The majority of studies on resilience have focused on persons with physical and psychological problems and/or disorders such as stress (Braun-Lewensohn & Sagy, 2013), spouses who died of AIDS (Yu, Chan, Zhang, & Stewart, 2016), transgender women (Perez-Brumer et al., 2017), anxiety (Nabors et al., 2013), coping and resilience (Tippens, 2017), trauma (Pooley, Cohen, O’Connor, & Taylor, 2013), resilience and mastery among HIV-positive older gay and bisexual men (Emlet, Shiu, Kim, & Fredriksen-Goldsen, 2017), quality of life of gay, bisexual men and people/persons living with HIV (PLHIV) (Remor & Ulla, 2002), and disclosure of HIV status and psychological well-being (Zea, Reisen, Poppen, Bianchi, & Echeverry, 2005). A longitudinal study showed that internalized stigma and HIV diagnosis were associated with ways of coping (resilience) among PLHIV (Garrido-Hernansaiz, Murphy, & Alonso-Tapia, 2017). However, not many studies have been carried out on PLHIV.

Living with HIV infection and, prior to that, its diagnosis give rise to circumstances with significant physical and psychological repercussions that the infected person has to cope with (Carvalho et al., 2007). HIV infection, today considered as a chronic disease thanks to the development of and advances in antiretroviral therapies (Deeks, Lewin, & Havlir, 2013), presents a series of characteristics which make it different from other diseases and particularly adverse for the seropositive person. For one thing, most cases of HIV infection are caused by sexual risk behaviors, and for another, even today, seropositive individuals are still the object of stigma, discrimination, and marginalization by society (De Santis et al., 2013). Studies on resilience in the HIV/AIDS context have concluded that the higher the resilience, the higher the perception of quality of life and the lower the mental distress (see for example Faber, Shwartz, Schaper, Moonen, & McDaniel, 2000). Similarly, other studies have shown that resilience is positively associated with better cognitive coping, wellbeing, and acceptance of being HIV-positive (Munro & Edward, 2008; Orton et al., 2012). The study of resilience among these population is, therefore, particularly relevant but, in turn, lacking (De Santis et al., 2013).

As regards the link between resilience and socio-demographic variables, it has been shown that HIV-positive women with low education levels, low income, and no employment had high levels of resilience (Dale et al., 2014). Other studies have concluded that resilience was lower among asymptomatic seropositive males with lower levels of education and limited economic means (Lima, Azevedo, Amorim, & Saldanha, 2014).

Among the sexual behaviors and risk factors for becoming infected with HIV and other sexually transmitted infections (STI) are sexual intercourse without using a condom, starting sexual relations at a young age, and having multiple sexual partners (Teva, Bermúdez, Ramiro, & Ramiro-Sanchez, 2013). Along these lines, some researchers have emphasized the study of resilience as a new direction in which to orient efforts to prevent HIV infection (Yuen et al., 2013) and, similarly, other STI. For their part, Kurtz, Buttram, Surratt, and Stall (2012) concluded that resilience could be a key variable in actions aiming to reduce sexual risk behaviors among men who have sex with other men. So, we can hope that resilience might act as a factor protecting against the propagation of sexual risk behaviors. Bearing in mind that there are no studies which analyze the relationship between resilience and sexual risk behaviors in persons with HIV infection, it would be a valuable study area for contributing information of use for the prevention of STI/HIV: on the one hand, for preventing patients from contracting an STI in the first place and, on the other, to prevent them from passing it on to other people. In addition, analyzing resilience among PLHIV would enable actions to be designed for improving the psychological health and strategies for coping with this disease among these population.

Based on what we have set out above, we propose this study. Its aims are as follows: (1) to assess resilience and its relationship with socio-demographic variables and (2) to study whether resilience is a predictor of sexual risk behaviors among PLHIV.

Looking at the first objective of this study, almost half of the participants (49.05%) showed medium resilience and 27.68% showed high resilience. Corroborating this study, a previous study demonstrated that the participants had low level of resilience (Wilson et al., 2016). Some studies show that persons with HIV infection have a high capacity to adapt and recover (resilience) in spite of the adversities they face (De Santis et al., 2013; Kurtz et al., 2012; Munro & Edward, 2008). As regards sex, age group, education level, income, and current employment situation, no significant differences were found among patients. However, a recent study revealed that HIV-positive women with a low education level, low income, and no employment had high levels of resilience (Dale et al., 2014). Another previous study on asymptomatic seropositive men with low income and low education level showed that they had low levels of resilience (Lima et al., 2014). The differences revealed between these studies may be due to cultural differences and/or sample sizes.

As regards sexual orientation, heterosexual patients scored more highly in spirituality compared with homosexual patients. In recent studies, it can be observed that spirituality has helped PLHIV to cope with HIV (Ironson, Kremer, & Lucette, 2016; Pecoraro et al., 2016). Other studies have indeed shown that spirituality is a resource used to overcome the challenges presented by HIV (Hussen et al., 2014; Szaflarski, 2013). Spirituality in overcoming adverse events could therefore play an important role among persons with HIV infection/AIDS, particularly among heterosexuals.

In addition, patients who were diagnosed between 1985 and 1990 scored more highly for spirituality than patients diagnosed more recently. The group of persons whose HIV diagnosis dates from further back have lived through a period during which antiretroviral therapies had not been developed which, in tandem with their being older, might explain their greater reliance on spirituality as a means of support and coping. A recent systematic review showed that the diagnosis of HIV caused people to increase their spirituality as a way of coping with this disease (Araújo et al., 2015, Mishra, Togneri, Tripathi, & Trikamji, 2017). A relevant future research would be to investigate the association between spirituality and psychosocial variables.

Patients who had disclosed their seropositive status to more than 30 persons showed greater personal competence, higher standards, and greater tenacity than patients who had revealed their seropositive status to fewer persons (1–5 persons). The first group probably has a larger social support network, which would provide greater psychological protection and coping resources for the adversities of HIV. This group might also have better assimilated their seropositive status and feel less stigmatized and discriminated against, leading them to tell a larger number of people about their condition, thus facilitating their receiving more social support. Thus, it can be demonstrated that social support mediated the relationship between the disclosure of serological status and self-esteem and depression (Zea et al., 2005). In line with this idea, it has been concluded that social support contributes to higher resilience among persons with HIV (Carvalho et al., 2007). Moreover, lack of social support has been identified as a factor in the progression of HIV/AIDS (Schuster, Bornovalova, & Hunt, 2012).

Moving on to the second objective of this study, it was not found that resilience acts as a predictor of sexual behaviors among persons with HIV infection. This lack of significant association might be explained by the reduced number of patients who answered the questions on sexual behaviors. Another plausible explanation could be that patients did not perceive their sexual risk behaviors as adverse situations for infection and/or reinfection by STI/HIV. It is important to underline that for resilience to come about, persons must be exposed to difficult situations that threaten their physical and/or psychological health (De Santis et al., 2013), so it may be that this sample did not feel that sexual risk behaviors were a threat to their health and, therefore, there is no link between resilience and these behaviors. Finally, in a recent systematic review, we found studies that showed that resilience was a protective variable of mental health, satisfaction with PLHIV’s life (Lyons & Heywood, 2016), and risky sexual behavior for HIV (Araújo et al., 2015).

This study has significant implications. It contributes results on resilience among HIV-positive young people and adults, where a large proportion of articles published focus on resilience among healthy children (Araújo et al., 2015; De Santis et al., 2013). It does, however, suffer from some limitations, given that as patient recruitment was incidental, the results cannot be generalized to the population as a whole. Ultimately, it would be appropriate to undertake studies which look more closely at resilience from a mixed-methods perspective (qualitative and quantitative) as suggested by Ungar (2009), with the aim of understanding what such studies can contribute in subjective and objective terms to how persons with HIV infection build up resilience.

In conclusion, this study increases our understanding of the association between resilience, socio-demographic variables, and sexual behavior of PLHIV. This study contributed to fill the gap of studies on resilience and HIV infection. Secondly, it was not possible to verify this construct as a predictor for risky sexual behaviors of PLHIV. Finally, it was found in this sample that living with HIV does not represent an adversity for these people.

However, this study has some limitations. Because it was a cross-sectional study, it is not possible to make causal inferences. In addition, given that as participant recruitment was incidental, the results cannot be generalized to the population as a whole. Thus, it would be interesting to carry out future studies with a larger, more representative sample of the HIV-positive Spanish population, as well as compare the different socio-cultural contexts.

It is also suggested that future studies may consider other variables (not contemplated in this study), such as health status, perceived health or perceived illness, and quality of life (Remor & Ulla, 2002) of PLHIV. Furthermore, it would be important to develop a specific tool to assess the resilience of PLHIV in order to measure levels of this construct within the context of HIV infection. The data from this study may support future psychosocial interventions to help PLHIV to cope with adversity, as well as prevent future risky sexual behaviors for HIV.