Deepika Khakha, Bimla Kapoor. Keywords Coping, People living with HIV/AIDS (PLWHA), quality of life(qol)

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1 Effect of coping strategies intervention on the coping styles adopted by People living with HIV/AIDS at a tertiary care hospital in the national capital Deepika Khakha, Bimla Kapoor Abstract : The study to assess the effectiveness of structured coping strategies intervention on coping of people living with HIV/AIDS (PLWHA) and association between coping and quality of life (QOL) was seen. A pre-experimental one group pre-test post-test time series design was used in the study.the setting was at ART clinic of All India Institute of Medical Sciences, New Delhi. The sample was recruited by convenient sampling comprised of PLWHA,who were sero positive for last six months. A one focus group discussion was conducted and audiotaped with 8 PLWHA.The needs were assessed by conducting focus group discussion and extensive review was done for making structured coping intervention. The content validity was done by 12 experts from Psychiatry, Psychology, Sociology and HIV activists. The tools used to assess the coping and quality of life was BREF COPE and WHOQOL-BREF HIV. The intervention focused on informational support about HIV, adaptive coping strategies, seeking social support,mentalhygiene and living positively with HIV, was administered on one to one basis. The post-test-1 (after one month) and post-test 2(after three months) was taken, and tools for assessing coping and quality of life were administered respectively. Data was analyzed using SPSS. The most commonly used coping styles are acceptance and religion. Results showed that there was statistically significant increase in coping after the administration of coping strategies intervention in various ways of coping.there was positive association seen between coping and quality of life.the structured coping intervention was found effective in improving coping. Keywords Coping, People living with HIV/AIDS (PLWHA), quality of life(qol) Correspondence at Deepika Khakha Lecturer College of Nursing, AIIMS, New Delhi Introduction Human Immunodeficiency Virus (HIV) /Acquired Immune Deficiency Syndrome (AIDS) is a global epidemic, a major challenge as a health care problem of modern times.the reaction to the diagnosis of HIV is an excessively traumatic event in the life of people living with HIV/AIDS (PLWHA). In the first phase of the disease, coping becomes an important parameter, which determines the patient outcome. Nursing and Midwifery Research Journal, Vol-11, No. 2, April

2 There are studies that have examined whether an acceptance' style of coping, as opposed to a mental disengagement' style, selectively influencing the first stages of the processing of neutral, emotional and HIVrelated information. 1,2 Certain psychosocial characteristics (e.g. coping and social support) have been given importance for positive adaptation among youth with behaviourally acquired HIV as revealed by the emerging research. However, there is a dearth of information about the interaction of these traits with cognitive abilities to influence behavioral and 3 emotional adjustment. Coping as theorized by the chronic illness quality of life (CIQOL) model suggests life satisfaction among people living with chronic illness such as HIV/AIDS is a function of illness-related discrimination, barriers to health care,physical well-being, social services, social support. This is in order to understand 4 QOL these areas need to be explored. The people living with HIV is 34 million 5 globally (UNAIDS, 2010). In the history of human existence rarely has society encountered a catastrophe as complex as AIDS. Besides, the devastating physical manifestation of the disease, AIDS is coupled with a number of psychological and social issues. The challenges faced by a PLWHA, be it psychological or internal, varies from individual to individual. Psychological adjustment and coping 6 are central to HIV management. Greater use of maladaptive coping strategies was associated with lower levels of energy and social functioning. As persons with HIV disease live longer as a result of advances in anti- retroviral treatment, there is a need for new research examining HIV-related coping and adaptation. A person who receives a diagnosis of HIV or AIDS often react with coping strategies that may be useful in reducing psychological distress of living with a mixture of emotions including shock, depression, hopelessness, grief, anger and fear. Psychological factors such as coping and social support may affect both disease 7 progression and quality of life (QOL). Objectives - To assess the quality of life of PLWHA and coping strategies adopted by them. - To find out the association between coping strategies adopted by PLWHA and their QOL - To assess the effectiveness of structured intervention administered by the researcher on coping strategies adopted by PLWHA. Methodology The study design was Pre experimental-one group pre-test post-test times series design. The data was collected at baseline and after one month and three months on coping strategies adopted by PLWHA after the administration of the intervention. Study was conducted on HIV positive patients (male and female) of more than six months duration attending ART clinics in a selected hospital.the study sample comprised of PLWHA who consented to be a part of the study. The inclusion criteria was HIV positive patients for more than six months and willing to participate in the study, above 18 years of age, attending A.R.T clinics of All India Institute of Medical Sciences, New Delhi, can speak and understand Hindi/English. Sample was selected by convenient sampling technique. The 180 PLWHA who met the inclusion criteria and consented to Nursing and Midwifery Research Journal, Vol-11, No. 2, April

3 be a part of the study were enrolled as a study subjects.the sample was calculated at power 80 and alpha at 5% after the pilot study. The following tools were used in the study. Brief COPE - For assessing the variable of Coping Brief COPE by C. Carver (Departmernt of Psychology, Miami University, USA.)The Brief COPE scale 8 (Carver, 1997) is a 28-item self-report measure of both adaptive and maladaptive coping skills.the Brief COPE was developed based on concepts of coping from Lazarus 9 and Folkman (1984). The scale was designed to yield fourteen subscales, comprised of two items each. Test Retest Reliability of the following tools was done on 10 subjects by the researcher (0.969). The permission to use the tool was taken by the author. WHOQOL-HIV BREF - For assessing the variable of Quality of Life - WHOQOL-HIV 10 BREF The WHOQOL-HIV BREF produces six domain scores. It has only one item to present each facet. Included in these, there are two items that examine General quality of life. Hence there are 31 items, representing the 30 facets. Five of these facets are specific to HIV/AIDS.The individual items are rated on a 5 point Likert scale where 1 indicates low, negative perceptions and 5 indicates high, positive perceptions. Each domain and facet scores are scaled in a positive direction where higher scores denote higher quality of life. Some facets (Pain and Discomfort, Negative Feelings, Dependence on Medication, Death and Dying) are not scaled in a positive direction, meaning that for these facets higher scores do not denote higher quality of life. These were recoded and high scores reflected better QOL. Items are organized by response scale (capacity, frequency, intensity or satisfaction)domain I: Physical - comprising of pain, discomfort, energy, fatigue, sleep and rest Domain II: Psychological- constitutes positive feelings, thinking, learning, memory, self-esteem, body image, negative feelings and appearance Domain III: Level of independence- includes mobility, activities of daily living, work capacity Domain IV: Social relations- encompasses personal relationship, social support, sexual activity Domain V: Environment -which includes physical safety and security, home environment, financial resources, health and social care, participation in recreation/leisure activities Domain VI: Spiritual- includes forgiveness and blame, concerns about future, death and dying. The tests were administered to 10 PLWHA.It was re administered after a week.the reliability scores were obtained for the tools was The permission was taken from WHO to use the tool. A competency certificate was obtained from an expert for taking the session on structured coping strategies based on the intervention prepared by the researcher. The ethical clearance for collecting data was obtained from the Ethics Committee, AIIMS and informed consent was obtained from the study participants. A focus group discussion was conducted with 8 PLWHA about the challenges and their ways of coping, which was audiotaped. The structured coping strategies intervention was tailored based on the findings of focus group discussion and review of literature.the content validity was done by 12 experts from the field of Psychology, Psychiatric, Sociology and two of them were PLWHA and HIV activists. The intervention was pilot tested on 20 PLWHA at Delhi Positive People network.coping intervention comprised of informational Nursing and Midwifery Research Journal, Vol-11, No. 2, April

4 support, coping with HIV, mental hygiene,seeking family support and network building,know your rights,living positively with HIV,positive thinking and relaxation methods.the structured coping intervention was administered on one to one basis. It was interactive discussion and took one hour per subject in a room in the ART clinic. The main data was collected from July 2012 to March 2013 on 180 PLWHA at Delhi Positive People network at the ART Clinic for the study after taking permission from Hospital Administration. While analysing 20 cases taken for pilot study were also included. Hence data of total 200 subjects was analysed. SPSS 17 was used for data analysis. Descriptive and inferential statistics was used to analyze the data. The baseline variables were assessed using descriptive statistics of mean and frequency percentages. The correlation between the variables of coping and quality of life was done by using Pearson's correlation. Results The demographic profile of the sample was, the mean age of PLWHA was 39.8 ±8.1, ranging from 21 to 61 years. The majority of PLWHA were males (76%). The one third of them (39%) were educated up till class 10.Most of them (75%) were married. The majority (76%) had income between Rs ,000/- INR per month. As evident from Figure 1, the most commonly used coping styles at baseline assessment were acceptance and religion. The moderately used coping strategies include self-distraction, active coping, emotional support instrumental support and positive framing. The least used coping methods are self -blame, venting, humour, denial and substance use, as seen in figure 1.This indicates that mostly adaptive coping strategies were used by PLWHA to face psychosocial and illness related issues of HIV Self distraction Active Coping Denial Substance use Emotional support Instrumental support Behaviourial disengagement Venting Positive Framing Planning Humour Acceptance Religion Coping Strategies Figure1: Bar Graph showing Coping styles of PLWHA at baseline assessment Self Blame Nursing and Midwifery Research Journal, Vol-11, No. 2, April

5 Table 1 depicts baseline Quality of Life of PLWHA assessed as per WHOQOL-HIV BREF. As shown in table 1,the lowest level of QOL is seen in social relations (domains 4), followed by independence spiritual domain of QOL.This reflects the social implication of the disease. QOL in independence domain refers to PLWHA work capacity, their mobility and functioning in context of activities of daily living. Their concern about future aspects pertaining to death and dying, blame and forgiveness are pertinent to the spiritual domain (domain 6). This suggests that PLWHA experience discomfort in their daily living and have concerns about their future. Table 1 : QOL of PLWHA assessed as per WHOQOL-HIV BREF N=200 Domains of QOL Mean ±SD Range Mean Percent DOMAIN 1 ( Physical ) 53.4± DOMAIN ( Psychological ) 58.7± DOMAIN3 (Independence) 56.8± DOMAIN 4 (Social relation) 53.2± DOMAIN5 ( Environment) 114.6± DOMAIN 6 (Spiritual/ Religious/ Believes) 56.9± Table 2 shows the association between baseline assessment of different domains of QOL and coping strategies adopted by PLWHA as per Pearson's correlation of coefficient (r). The association between the self -distraction and physical, psychological, independent, social relations, and environment domain of QOL was statistically significant (p< 0.001). This indicates as there is increase in use of self-distraction, the QOL in physical, psychological, independence, social relations and environmental increases. The association between the active coping and physical, independent, social relations and spirituality domains of QOL was significant. This means that, as active coping increases there was increase in independence, social relations, environment, and spirituality domain. Active coping is an adaptive coping style which improves the QOL of PLWHA. The significant negative association between substance use and environment was observed (p = 0.02).This implies that as substance use increases there is decrease in domain 5 i.e., environment of PLWHA. This indicates that if PLWHA indulges in substance use the quality of environment around them deteriorates. The environment domain implies physical safety and security, home environment, financial resources and all these are negatively affected due to substance use. Nursing and Midwifery Research Journal, Vol-11, No. 2, April

6 The positive association between emotional support and the QOL in the domains of physical, independence, social relations, environment and spirituality was significant.this implies the importance of emotional support and its pertinent role in QOL of PLWHA.The association between instrumental support and physical, independence, social relations and environment domains of QOL was significant (p <0.001).This means that as PLWHA is able to get help and advice from others this improves their QOL.The positive association was found between social relations and behavioural disengagement (p< 0.01). This means as the PLWHA give up attempting to cope with the situation there is a significant change in the social relations domain of QOL. The positive association between venting as a way of coping with social relations and environment domains of QOL was observed. This suggests as PLWHA express their feelings there is increase in the social relations and environment of PLWHA. The association between positive reframing and physical, independence, social relations and environment of QOL was statistically significant. This implies as PLWHA views things in a positive perspective physical, independence, social relations and environment domains of QOL improves.the association between planning as a way of coping and physical, psychological, social relations and environment domains of QOL was statistically significant. This indicates as planning (strategy planned by PLWHA as to how to encounter the situation) increases; the physical, psychological, social relations and environment domains of QOL of PLWHA increases.there was no association seen between humour and QOL. There was positive association between acceptance and independence, social relations, environment, spirituality domains of QOL. This indicates that the PLWHA who had come in terms with reality of the fact that they are infected with HIV and learning to live with it had increased QOL. The association between religion as a way of coping and physical, psychological, independence, social relation and environment was significant indicating that, as religion (finding comfort in religion and praying for themselves) increases there was increase in physical psychological, independence, social relations and environment domain of QOL.So finding comfort with God has a positive impact on the QOL of PLWHA. The significant negative association between self-blame and physical, independence, social relations, environment and spiritual domains of QOL indicates that as self-blame increases the physical, independence,social relations,and environment and spiritual domains of QOL decreases. This reflects as PLWHA keep blaming themselves for the situation and criticize themselves it has a negative impact on the physical, independence, social relations and spiritual domains of QOL. As shown in Table 3, in self-distraction the reduction from baseline to the third month is statistically significant. This indicates that there is decrease in the use of self-distraction as a way of coping by the PLWHA. Use of active coping was statistically significant increased at one month and three months, there is a drop in the scores indicating that regular reinforcement of coping is required by the PLWHA to encounter daily stresses faced by them in relation to the disease. The intervention empowered them to improve their situation and become proactive. There Nursing and Midwifery Research Journal, Vol-11, No. 2, April

7 Table 2 : Association of QOL with the Coping measured by WHOQOL-HIV BREF and BREF COPE of People Living with HIV/AIDS N= 200 QOL Dom 1 Dom 2 Dom 3 Dom 4 Dom 5 Dom 6 Physical Psychol- Indepen- Social Environ- Religon Coping ogical dence ment Self -distraction r p 0.001** 0.001** 0.001** 0.001** 0.001** Active coping r p 0.001** ** 0.001** 0.001** 0.04* Denial r p ** 0.001** ** Substanceuse r p * 0.69 Emotional support r p 0.001** ** 0.001** 0.001** 0.001** Instrumental r support p 0.001** ** 0.001** 0.001** 0.35 Behavioral r disengagement p * Venting r p ** 0.04* 0.71 Positive framing r p 0.002* ** 0.001** 0.001** 0.11 Planning r p 0.03* 0.004* ** 0.001** 0.38 Humor r p Acceptance r p *.001*.001*.006* Religion r p 0.01* 0.006** 0.001** 0.01* 0.001** 0.60 Self-blame r p 0.005** * 0.02* 0.002**.003** #Pearson'scorrelation p 0.05* p 0.01** Nursing and Midwifery Research Journal, Vol-11, No. 2, April

8 Table 3 : Comparison of different domains of coping styles adopted by PLWHA at Baseline, first month and third month of intervention as assessed by BREF COPE N= 200 Domains Baseline Mean ± SD First Month Mean ± SD Third Month Mean ± SD Self distraction 2.6 ± ± ± 0.8 Diff (95% CI) (-0.14, 0.11) (-0.29, -0.03) p value * Active coping 2.7 ± ± ± 0.6 Diff (95% CI) 0.82 (0.68, 0.95) (-0.28, -0.01) p value 0.001** 0.03* Denial 1.8 ± ± ± 0.9 Diff (95% CI) (-0.18, 0.11) 1.09 (0.94, 1.2) p value ** Substance use 1.2 ± ± ± 0.7 Diff (95% CI) (-0.12, 0.08) 0.36 (0.25, 0.46) p value ** Emotional support 2.5 ± ± ± 0.6 Diff (95% CI) 1.1 (0.96, 1.2) 0.31(0.16, 0.46) p value 0.001** 0.001** Instrumental support 2.4 ± ± ± 0.7 Diff (95% CI) 1.02 (0.87, 1.1) 0.33 (0.18, 0.48) p value 0.001** 0.001** Behavioral disengagement 1.7 ± ± ± 0.7 Diff (95% CI) (-0.16, 0.08) 0.36 (0.23, 0.48) p value ** Venting 2.0 ± ± ± 0.6 Diff (95% CI) (-0.14, 0.07) (-0.52, -0.30) p value ** Positive framing 2.9 ± ± ± 0.9 Diff (95% CI) (-0.18, 0.10) (-0.19, 0.09) p value Planning 2.5 ± ± ± 0.7 Diff (95% CI) (-0.17, 0.21) (-0.21, 0.08) p value Humor 1.1 ± ± ± 0.3 Diff (95%CI) (-0.14, 0.12) (-0.17, 0.14) p value Acceptance 3.1 ± ± ± 0.7 Diff (95% CI) 0.30 (0.17, 0.42) 0.10 (-0.02, 0.22) p value 0.001** 0.10 Religion 3.0 ± ± ± 0.8 Diff (95% CI) 0.55 (.40, 0.70) 0.05 (-0.09, 0.19) p value 0.001** 0.50 Self- blame 2.0 ± ± ± 0.8 Diff (95% CI) (-0.18, 0.11) (10.17, 0.12) p value p.01**; p.05* Nursing and Midwifery Research Journal, Vol-11, No. 2, April

9 was significant increase in the coping style of acceptance (learning to live with reality of the disease) after one month from the baseline and after three months there was a drop in score. This indicates that regular psycho education support is required for PLWHA. The retention of the intervention effect does not last long. The use of denial significantly showed reduction at the third month. This indicates that use of denial reduced significantly at the third month, which is a positive indicator that PLWHA reduced the use of maladaptive way of coping with HIV. The way of coping with substance use, there was significant increase in the use of substance at third month (p value 0.001). The emotional support as a way of coping increased at first and third month. This implies after the intervention PLWHA were able to get emotional support and understanding from others. The effect lasted till the third month. The instrumental style of coping, increased significantly at the first and third month. The intervention enabled the PLWHA to seek help from others thus, enabling PLWHA to seek help from others. These results suggest that developing interventions that improve mastery and reduce maladaptive coping may minimize the negative impact of life stressors on the mental health of people with HIV. The coping style of venting, there is significantly decrease in the use of venting from baseline to three months. This indicates that there was reduction in expressing of negative feelings by the PLWHA over period of three months. Discussion The emerging research suggests the importance of psychosocial domains (e.g., coping and social support) are vital for positive adaptation and outcome among PLWHA. However, little is known about how these traits interact with cognitive abilities to impact emotional and behavioural adjustment related to HIV. The demographic profile of the sample of the present study in relation to age,sex, education, marital status and is in accordance with the study of Tsevat et.al 11 (2009). In the present study the most commonly used coping styles by PLWHA were acceptance and religion congruent with 12 the study of Trevino et.al (2010). Positive religious coping was associated with positive outcomes. The results facilitated assessing religious coping and enabled designing interventions targeting spiritual struggle in patients with HIV/AIDS. The association between the active coping and QOL domains of physical, independent, social relations and spirituality was positively statistically significant. This is 13 concordant with study of SteglitzJ (2012) conducted in Iringa, Tanzania on 135 rural, low-income HIV-positive adults. The relationships between spirituality, religiosity, social support, coping responsesand psychological distress were examined using structural equation modelling. Spirituality was positively related to social support and active coping. Results suggested that coping strategies and social support mediated the relationship between religiosity and spirituality. The association between denial and QOL domains of independence, social relations and spirituality was significantly increased. This finding is congruent with the 14 study Kamen C et al.(2012). Study shows Nursing and Midwifery Research Journal, Vol-11, No. 2, April

10 that there was significant negative association between substance use and environment. This implies as the substance use increases there in deterioration in the quality of environment of PLWHA. This is in agreement with the study by Leiberich P 15 (2005) in a longitudinal study over 3 years on 56 patients, with three measurements each 18 months, they examined these patients for the influence of distress and coping (assessed by interviews) on physical, cognitive-emotional and social QOL. The patients reported significantly worse physical and cognitive-emotional QOL than healthy subjects. HIV-positive persons with great distress showed significantly lower QOL scores. HIV-positive patients with ARC or AIDS reported more physical complaints and lower physical QOL than asymptomatic persons. The patients reported significantly worse physical and cognitive-emotional QOL than healthy subjects. So, as use of religion as a way of coping increases, there was increase in physical psychological, independence, social relations and environment domain of QOL. This is in congruence with the study of Douaihy 16 (2001) There was negative association between self-blame and physical, independence, social relations, environment and spiritual domains of QOL with significant p value. This indicates as self-blame increases the physical, independence, social relations, environment and spiritual domains of QOL decreases. This was congruent with 7 the study of Vosvick M, (2003) in their study examined factors associated with four dimensions of functional quality of life (physical functioning, energy/fatigue, social functioning, and role functioning) in 142 men and women living with HIV/AIDS. Participants completed the Brief COPE inventory and the Medical Outcomes Study Health Survey, with HIV-relevant items added. Greater use of maladaptive coping strategies was associated with lower levels of energy and social functioning. There was increase in use of active coping strategies after one month and three month of intervention. The instrumental style of coping increased significantly at the first and third month. This was congruent with 16 Heckman (2006) where pilot research tested whether a 12-session, coping improvement group intervention delivered to life quality in 90 middle-aged and older adults living with HIV/AIDS through selfadministered surveys. The participants reported fewer psychological symptoms, lower levels of life-stressor burden, increased coping self-efficacy and less frequent use of avoidance coping. However, the intervention demonstrated little ability to reduce depressive symptoms in this sample of HIV-infected older adults diagnosed with depression. The most commonly used coping styles were acceptance and religion. The coping strategies intervention was found effective in improving significantly active coping, instrumental support, emotional support at post-test 1(after one month of intervention ) and post-test 2(after three months of intervention). Nurses working with PLWHA need to be prepared to manage the psychosocial implications of the disease as they play a key role in empowering PLWHA. Community health nursing is an essential area to health Care delivery system. They need to organize holistic health services for PLWHA in the community. The nurse administrators can Nursing and Midwifery Research Journal, Vol-11, No. 2, April

11 plan interventions by taking help of experts to improve mastery and reduce maladaptive coping which may minimize the negative impact of life stressors on the mental health of people living with HIV. Nurses can create awareness regarding the issues faced by PLWHA to the public. Nurses can sensitize the public regarding the vulnerabilities of PLWHA. A similar study could be conducted with a true experimental design like pre-test posttest control group design. A Cognitive Behavior Therapy intervention for longer duration can be administered to PLWHA and follow up study can be done to study its effect on other variables. The long term effect of the coping strategies intervention can be evaluated.other outcomes like level of disease burden, anxiety, depression, subjective wellness, stress related to disease condition can be assessed.the coping strategies to deal with the disease should be available to PLWHA as regular reinforcement and support is needed. References 1. Makoae L, Greeff M, Phetlhu RD, Uys LR, Naidoo JR, Kohi TW, et al. Coping with HIV related stigma in five African countries. J Assoc Nurses AIDS Care Mar Apr;19(2): doi: /j.jana Novara C, Casari S, Compostella S, Dorz S, Sanavio E, Sica C. Coping and cognitive processing style in HIV-positive subjects.psychotherpsychosom Nov- Dec;69(6): Salama C, Morris M, Armistead L,KoenigLJ,DemasP,Ferdon C, et al.depressive and conduct disorder symptoms in youth living with HIV: the independent and interactive roles of coping and neuropsychological functioning.aids Care. 2013;25(2): Heckman TG.The chronic illness QOL (CIQOL) model: explaining life satisfaction in people living with HIV disease. Health Psychol Mar;22(2): UNAIDS report on the global AIDS epidemic 2010http:// al_report.htm 6. Brown JL, Vanable PA. Cognitive-behavioral stress management interventions for persons living with HIV: a review and critique of the literature. Ann Behav Med Feb;35(1): Epub 2008 Feb Vosvick M, Koopman C, Gore-Felton C, Thoresen C, Krumboltz J, Spiegel D.Relationship of functional quality oflife to strategies for coping with the stress of living with HIV/AIDS.Psychosomatics Jan- Feb;44(1): Carver, C. S. (1997). You want to measure coping but your protocol's too long: Consider the Brief COPE.International Journal of Behavioral Medicine, 4, available atwww.psy.miami.edu/faculty/ccarver/sclbrco PE.html 9. Stress, Appraisal, and Coping. Richard S. Lazarus PhD, Susan Folkman PhD. Springer Publishing Company, Mar 15, 1984 available at WHO.Department of Mental Health and Substance dependence,geneva,2002available at /whoqol_hiv_bref.pdf 11. Tsevat J, Leonard AC, Szaflarski M, Sherman SN, Cotton S, Mrus JM, et al. Change in quality oflife after being diagnosed with HIV: a multicenter longitudinal study. AIDS Patient Care STDS Nov;23(11): doi: /apc Trevino KM, Pargament KI, Cotton S, Leonard AC, Hahn J, Caprini-Faigin CA, et al. Religious coping and physiological, psychological, social, and spiritual outcomes in patients with HIV/AIDS: cross-sectional and longitudinal Nursing and Midwifery Research Journal, Vol-11, No. 2, April

12 findings. AIDS Behav.2010 Apr;14(2): Epub 2007 Dec Steglitz J, Ng R, Mosha JS, Kershaw T. Divinity and distress: the impact of religion and spirituality on the mental health of HIV-positive adults in Tanzania. AIDS Behav.2012 Nov;16(8): doi: /s Kamen C, Taniguchi S, Student A, Kienitz E, Giles K, Khan C, et al. The impact of denial on health-related QOL in patients with HIV.Qual Life Res Oct;21(8): doi: /s y. Epub 2011 Oct. 15. Leiberich P, Brieger M, Schumacher K, Joraschky P, Olbrich E, Loew H, et al. Effects of distress and coping on QOL in HIV-positive patients: results of a longitudinal study.dernervenarzt Sep;76(9):1117-9, , Douaihy A, Singh N. Factors affecting QOL in patients with HIV infection.aids Read Sep;11(9):450-4, 460-1, Heckman TG, Barcikowski R, Ogles B, Suhr J, Carlson B, Holroyd K, et al. A telephonedelivered coping improvement group intervention for middle-aged and older adults living with HIV/AIDS.AnnBehav Med Aug;32(1): Nursing and Midwifery Research Journal, Vol-11, No. 2, April