Brief suicide preventive intervention in newly dignosed HIV-positive persons Govender RD 1, Schleusch L 2, Esterhuizen T 3 1 Deprtment of Fmily Medicine, University of KwZulu-Ntl, Durn, South Afric 2 Emeritus Professor of Behviourl Medicine, University of KwZulu-Ntl, Durn, South Afric 3 Progrmme of BioReserch Ethics nd Lw, Deprtment of Pulic Helth Medicine, College of Helth Sciences, University of KwZulu-Ntl, Durn, South Afric Astrct South Africn studies hve found tht country wide suicide rtes re high nd tht people dignosed with HIV/AIDS cn hve incresed suicidl idetion nd resultnt suicide risk. In this study, we evluted the effect of rief psychosocil intervention on preventing suicide idetion fter positive HIV test result. Suicidl idetion ws ssessed y oth groups of ptients hving to complete suicide risk screening scle (Annexure 1). The study ws conducted t university-ffilited hospitl in Durn, KwZulu-Ntl, South Afric. Consenting dult ptients (ge 18 yers nd older) recently dignosed s eing HIV-positive following voluntry HIV counselling nd testing were enrolled in the study. Prticipnts (N=126) were ssigned to stndrd post-test counselling (SPTC). Therefter, every lternte ptient (N= 64) ws counselled using rief suicide preventive intervention (BSPI). Ptients were ssessed t seline, 72 hours lter nd 6 weeks fter positive HIV test result. The lnce of 62 prticipnts who received SPTC only were the control group, nd compred with the BSPI group. Although oth groups enefited from post-test counselling, results from the BSPI group demonstrted cliniclly significnt decrese in suicidl idetion over the time period studied. The results provide preliminry evidence on the efficcy of BSPI for recently dignosed vulnerle HIV-positive persons nd the importnce of educting such ptients on suicideprevention strtegies. Keywords: Brief suicide risk screening; HIV Received dte: 2-12-2013 Accepted dte: 30-01-2014 doi: http://dx.doi.org/10.4172/psychitry.1000112 Bckground Worldwide, suicide rtes hve incresed y 60% in the lst few decdes, with projected glol suicide mortlity rte of out 1.5 million people per nnum y 2020. 1 Similrly, suicide hs een recognised s significnt pulic helth concern in South Afric (SA) where the ntionl suicide mortlity rte hs stedily incresed over the pst few decdes from out 1% in the 1980 s to pproximtely 11% or more currently of ll unnturl deths. 2-4 Aside from the numerous complexities ssocited with suicide, the country fces the dded urden of the HIV/AIDS pndemic with one of the lrgest seropositive popultions glolly nd KwZulu-Ntl province (where the present study ws done) ering one of the highest proportions of this lod. 5 Suicidl idetion is defined s hving the intent to commit suicide, wnting to tke one s own life or thinking out committing suicide with or without ctully mking plns to do so. 6 Although there is pucity of suicide nd HIV/AIDS reserch in Afric 7, the studies done, hve shown high suicide risk in this popultion. 6-10 As erly s 1995, AIDS phoi ws cited s trigger in 17% of prsuicide cses mong youth in SA. 11 HIV-positive people re t risk for suicide 2,6 nd when first dignosed with HIV, mny individuls rect with diselief, nxiety nd fer for wht Correspondence Professor L Schleusch, Postnet Suite 208, Privte Bg X10, Musgrve Rod, Durn, 4062, South Afric, Emil: schleuschl@ukzn.c.z lies hed. In previous study, the most commonly endorsed sttement y recently dignosed HIV-positive persons ws, I cn t imgine wht my life would e like in 10 yers. 6 It is known tht in mny cses positive HIV dignosis cn e linked to hopelessness nd depression with the potentil risk for suicidl idetion 6,12-14, nd tht one of the most vulnerle periods for suicide risk is in the immedite post HIV-dignosis period. 9-10,14 Depression nd nxiety re common in people living with HIV/AIDS. 6,12,13 Not only hve studies shown tht HIV infection is ssocited with greter risk for such disorders, 13 ut untreted depression increses the risk of suicidl ehviour nd or suicidl idetion. 6,13 Suicide prevention is defined s ny self-injury prevention or helth-promotion strtegy tht is generlly or specificlly imed t reducing the incidence nd prevlence of suicidl ehviour. 15 Amongst others, suicide intervention includes: erly recognition nd ssessment of risk; immedite response to suicide risk; resource referrls; nd follow-up mngement nd tretment of t-risk individuls. 16 Although vrious intervention pproches hve een descried to prevent suicidl ehviour, 16 complete nd comprehensive preventive model is the universl/selective/indicted (USI) model, which trgets the generl popultion, vulnerle popultions nd persons t high risk for suicide. Universl preventive interventions re directed t entire popultions; selective interventions re directed t individuls who re t greter risk for suicidl ehviour; nd indicted preventions trget individuls who hve lredy egun to disply self-destructive ehviour. 16 In ddition, systemtic review of suicide-prevention 543
strtegies hs suggested five key res for intervention, viz.:(i) eduction nd wreness; (ii) screening for trisk persons; (iii) tretment of psychitric disorders; (iv) restricting ccess to lethl mens; nd (v) medi reporting of suicide. 17 There is growing evidence tht suicide is incresing in the context of HIV/AIDS with HIV-positive persons hving 3 times higher prevlence thn the generl popultion despite the introduction of Antiretrovirl therpy (ART). 18 Extensive reserch 19 s prt of the World Helth Orgniztion s worldwide inititive for the prevention of suicide cross five continents, found tht rief intervention cn e n importnt component of suicide prevention progrmmes nd confirmed tht indicted suicide prevention strtegies should complement universl nd selective suicide prevention strtegies. Given this, the im of the present study ws to ssess the effect of rief suicide preventive intervention on suicidl idetion in HIV-positive persons immeditely post-test, within 72 hours nd 6 weeks lter. Ptients nd Methods The study ws conducted t university-ffilited hospitl in Durn, South Afric. The study site ws t district level helth fcility in the KwZulu-Ntl province which hs one of the highest locl provincil HIV prevlence rtes.5 Ptients ttending the hospitl clinic for voluntry counselling nd testing (VCT) for the HIV were informed out the study. Those meeting the inclusion criteri (ge 18 yers nd older nd testing seropositive, i.e. HIV Stge 1 nd 2) were pproched for voluntry prticiption (N=126). Prticipnts received stndrd post-test counselling (SPTC) dministered y the resident hospitl VCT nurse counselor nd conducted individully. Therefter, every lternte ptient ws counselled utilizing rief suicide preventive intervention (BSPI) dministered y trined BSPI counsellor. Both the SPTC nd the BSPI were done in ptients preferred lnguge of either English or isizulu (the predominnt lnguges spoken). The counsellor ws certified-trined in HIV pre-post test counselling. Additionlly demogrphic dt ws collected (ge, gender, eductionl sttus, mritl sttus, ethnicity nd religion). The BSPI prticipnts constituted the intervention group (N=64) nd were then compred with the lnce of ptients ( =62) who received SPTC only (the control group). Becuse some ptients were lost on follow-up nd not ll ptients provided relevnt dt, ptient smples vried s depicted in the tles. After counselling, prticipnts in oth groups were sked to complete self-dministered suicide risk screening scle (SRSS) 20 (Annexure 1) t seline, fter 72 hours nd 6 weeks lter. The 14-item SRSS ws developed previously from shortened version of the Beck Hopelessness Scle (BHS) nd the Beck Depression Inventory (BDI). 20 The scle ws tested for vlidity, internl consistency nd receiver operting chrcteristic (ROC) nlysis ws performed for sensitivity nd specificity for suicidl idetion (positive t score of 4). The re under the ROC curve (AUC) ws regrded s the proility of correct prediction. The AUC ws 0.730 (p<0.001; 95% confidence intervl (CI) 0.64-0.81) t seline nd 0.776 (p<0.001; 95% CI 0.68-0.87) 3 weeks therefter. Accordingly, the SRSS score ws considered to e good predictor of suicidl idetion in the popultion studied. 20 Hopelessness ws lso ssessed using pre-determined score of 5 (items V1-V11; Annexure 1) nd direct suicidl risk using score of 1 (itemsv12-v14; Annexure 1). The SRSS ws trnslted into isizulu nd ck-trnslted to ccommodte isizulu speking ptients (one of the lrgest lnguge groups served y the clinic) so s to void possile lnguge is. The trnsltion ws performed y professionl linguist nd hd een through rigorous review y the ethics committee. In the model used for the SPTC group the min principles included: 1. Addressing the impct of disclosure of the HIV test result, llowing the prticipnt to digest this informtion, nd giving the prticipnt time to explore his/her feelings nd fers. 2. Considering tht the prticipnt my e emotionlly shocked, nd giving ressurnce tht he/she would not e ndoned y the tem of helthcre professionls who hve much to provide in terms of different tretment modlities. 3. Explining to ech prticipnt tht coming to terms with the result my tke some time nd tht he/she cn remin helthy y tking cre of him-/herself, which includes following the recommended tretment pln nd n pproprite diet, nd seeing doctor when necessry. 4. Addressing the need to understnd the different modes of HIV trnsmission nd how the virus cn e trnsmitted to others, emphsising sfe-sex prctices nd condom use, nd explining the nturl history of the progression of the disese. 5. Explining the intervention or tretment progrmmes ville nd chnges in lifestyle, nd emphsising tht hospitl socil workers would e prt of the progrmme nd would ssist with socil nd support resources. The BSPI included n extr one-hour individul therpy session tht ddressed dditionl psychosocil issues relted to HIV-positivity t the time of presenttion, nd entiled identifying nd helping to resolve interpersonl difficulties which my cuse or excerte psychologicl distress. To render the BSPI effective nd relevnt to the trget popultion, it ws conducted ccording to protocol tht encompssed: 1. Feedck on reserch-sed epidemiology nd the risk for suicidl ehviour s indictive of psychologicl nd/or socil distress following VCT nd seropositive result. 2. Exploring potentil suicide risk nd protective fctors nd how ptients should del with such risk fctors. 3. Expressing empthy nd discussing the sitution in light of the prticipnt s personl circumstnces, while mintining ojectivity nd eing non-judgementl. 4. Providing simple dvice on how to live positively nd encourging personl responsiility to chnge ehviour, nd encourging self-efficcy nd the prticipnt s elief in his/her ility to mke meningful chnges. 5. Highlighting sociodemogrphic protective fctors. 6. Discourging personlistion of psychosocil fctors such s stigmtistion, fer of disclosure nd discrimintory gender issues. 7. Openly discussing HIV/AIDS, including prevention nd tretment, to help to de-stigmtise the disese, nd discussing lterntive coping mechnisms in cse of suicidl idetion. 544
8. To prevent prticipnts from plying pssive role, the counsellor focussed on re-enforcing positive prticipnt mindset, discussing referrl options where more intensive psychologicl/psychitric tretment ws required, encourging the possiility of fmily therpy if the ptient ws greele incresing the ptient s sense of personl vlue, dvising the ptient to seek help when difficulties rise, encourging openness to exploring potentil suicide risk fctors, grnering support from socil networking nd relevnt people, nd developing renewed sense of purpose in life. Ethics considertions The reserch protocol ws pproved y the University of KwZulu-Ntl Biomedicl Reserch Ethics Committee. All enrolled ptients provided written informed consent for prticiption. All ptients considered to e t high risk for suicidl idetion were referred for pproprite psychitric/ psychologicl tretment. Sttisticl nlyses Strt softwre (version 12) ws used for sttisticl nlysis. Generlised liner modelling ws used to ctegorise prticipnts with suicidl idetion. Person s chi-squre test ws used to determine the sttisticl significnce of differences etween the control nd intervention groups. McNemr s chi-squre test ws used for pired inry proportions. Results Tle 1 depicts the ssessment of suicidl idetion mong prticipnts following SPTC nd BSPI t the 3 time-points (seline, 72 hours nd 6 weeks fter positive HIV test result). Although Person s chi-squre tests showed no sttisticlly significnt outcome etween the SPTC nd BSPI t ll 3 timepoints, the trend nlysis for suicidl idetion from seline, to 6 weeks (Tle 2) showed suicidl idetion incidence of 019.79/1000 person dys (95% CI 14.31-25.28) in the SPTC group nd 015.87/1 000 person dys (95% CI 11.07-20.67) in the BSPI group. In comprison with the control group, the crude incidence rte rtio for suicidl idetion mong the intervention group ws 0.80 (95% CI 0.52-1.23). Therefore, lthough oth groups enefitted from post-test counselling, the BSPI proved more protective ginst the possiility of suicidl idetion in the ptients studied. In ddition, there ws significnt chnge from positive (suicidl idetion) to negtive (no suicidl idetion) from seline to 72 hours nd from seline to 6 weeks. The chnge from 72 hours to 6 weeks ws not sttisticlly significnt. This suggests Tle 1: Suicidl idetion following SPTC nd BSPI t 3 timepoints fter positive HIV test result Time-point Outcome (suicidl idetion 4) Negtive n (%) Positive n (%) p-vlue Bseline 0.275 Control 25 (40.3) 37 (59.7) BSPI 32 (50.0) 32 (50.0) 72 hours 0.610 Control 44 (71.0) 18 (29.0) BSPI 48 (75.0) 16 (25.0) 6 weeks 0.189 Control 42 (67.7) 20 (32.3) BSPI 50 (78.1) 14 (21.9) Person s chi-squre test. Tle 2: Crude incidence rte rtio for suicidl idetion following BSPI tht the mximum chnge from positive to negtive took plce in the first 72 hours fter the BSPI. Tle 3 depicts the corresponding sttisticl significnce (using McNemr s chi-squre test) of the effectiveness of the BSPI, from hving suicidl idetion (positive) t seline to hving no thoughts of suicide (negtive) 6 weeks lter. The first 11 items of the SRSS (Annexure I) mesures fetures of hopelessness. Consistent with previous findings,6 descriptive sttistics for ech of the SRSS sttements reveled tht the sttement, I cn t imgine wht my life would e like in ten yers (Annexure 1) hd the highest ffirmtive score in oth the control nd intervention groups t ll 3 time-points, lthough in the BSPI group there ws significnt norml reduction in this view over the time period studied (Tle 4). Discussion BSPI Control Totl Cses (n) 42 50 92 Ptient time 2 646 2 526 5 172 Incident rte 0.015873 0.0197941 0.0177881 Point estimte Incident rte difference -0.0039211 95% CI -0.0112113-0.0033691 Incident rte rtio (exct) 0.8019048 0.5191035-1.233345 Previous frction explined (exct) 0.1980952 Previous frction for popultion 0.1013457 (midp) Pr(k<=42) = 0.1466 (exct) (midp) 2*Pr(k<=42) = 0.2932 (exct) Tle 3: Chi-squre tests Group Numer of vlid cses (n) -0.2333446-0.4808965 Exct Sig. (2-sided) Control 62 0.000 BSPI 64 0.000 Totl 126 0.000 McNemr s chi-squre test; Binomil distriution used. HIV/AIDS hs een shown to e ssocited with higher risk for suicide in certin ptients. 2,6-10 Brief interventions hve consistently een found to e effective in different ptient popultions. 19-21 In this study, the implementtion of rief suicide preventive intervention long with the stndrd post-test counselling decresed suicidl idetion in seropositive ptients prticulrly within the first 72 hours. We cn consider these first 72 hours s the golden hours of suicide prevention in HIV-positive persons. The dded dvntge is tht during this erly period those ptients tht re lost to follow up over longer time frme would still hve the enefit of suicide intervention tretment. Within the South Africn context, this is n solute dvntge, given tht so mny HIV-positive persons re lost to follow up. More importntly, in South Afric, suicide risk ssessment nd interventions re limited y the shortges of dequtely trined helth cre professionls, suicide risk screening nd suicide preventive intervention guidelines. HIV counsellors 545
Tle 4: Descriptive results for the SRSS SRSS item Bseline 72 hours 6 weeks Control (%) BSPI (%) Control (%) BSPI (%) Control (%) BSPI (%) V1 51.6 43.8 43.5 42.2 38.3 39.7 V2 83.9 78.1 62.9 56.3 63.3 55.6 V3 32.3 25.0 17.7 18.8 21.7 17.5 V4 35.5 32.8 21.3 20.3 13.3 11.1 V5 47.5 42.2 24.2 23.4 21.7 20.6 V6 50.0 40.6 19.4 14.1 18.3 19.0 V7 50.8 45.3 17.7 15.6 31.7 22.2 V8 36.1 31.3 17.7 12.5 18.3 14.3 V9 50.0 40.6 23.0 20.3 23.3 14.3 V10 38.7 37.5 16.1 14.1 23.3 12.7 V11 37.1 31.3 6.5 3.1 15.0 4.8 V12 3.3 3.1 4.8 3.1 5.0 1.6 V13 0.0 0.0 0.0 0.0 0.0 0.0 V14 11.5 10.9 1.6 1.6 0.0 0.0 Refer to Annexure 1. nd primry cre physicins who re responsile for prend post-test HIV counselling nd psychosocil eduction cn esily e tsk-shifted to screen nd provide suicide interventions resulting in effective reduction of suicidl idetion t resonle cost nd miniml trining. Although the BSPI ws intended s n intervention to reduce suicidl idetion in recently dignosed seropositive ptients, its vlue to potentilly prevent eventul suicidl ehviour t lter stge cnnot e underestimted ecuse of the vrious suicide risk phses HIV/AIDS ptients my go through. 2,6 Importntly, multi-site reserch study using stndrdised methodology 22 hs shown tht suicidl idetion cn e construed s sign of distress nd tht there is strong culturl underpinning underlying suicidl ehviour. 22 Our findings suggest tht witin this context the BSPI ssisted in decresing hopelessness nd psychosocil stress, therey helping the ptients to cope etter nd ttenute suicidl idetion. This is supported y other studies, 23-26 which showed tht people living with HIV/AIDS cn develop enhnced coping skills if they hve ccess to medicl tretment nd strong nd supportive socil network. Resilience in individuls fcing dversity is considered to e ttriuted to comintion of personl nd contextul resources tht enle effective djustment to chllenges nd life situtions. 23 This implies tht with pproprite help, HIV-seropositive individuls cn overcome the perception of dversity rought on y the infection, nd in some ptients it my e this resilience tht serves s protective fctor or coping mechnism 27 which cn lso e postulted to e one of the effects of the BSPI. Furthermore, studies hve shown tht the durtion of psychosocil intervention cn e relevnt to its effectiveness. 28,29 In the present study the mximum chnge in reducing suicidl idetion occurred within the first 72 hours following positive HIV dignosis, which confirms the vlue of erly intervention to prevent suicidlity in these ptients. Study limittions Although the results of the present study provide vlule informtion on how to reduce suicidl idetion in newly dignosed HIV-positive individuls, importnt limittions should e considered when interpreting the reserch findings. Firstly, the study's overll generlisility needs to e considered. The smple sizes were not lrge nd the study ws confined to the post-hiv-test period, with the iggest prt of the study popultion eing urn-sed. Thus, the results should e interpreted with cution. Secondly, the prticipnts should e followed up for longer period thn 6 weeks to determine the prolonged effectiveness of the intervention. This together with the reltively smll smple size might hve contriuted to lower sttisticl significnce in this study, s suggested in met-nlysis of studies on psychosocil interventions. 28 Further reserch is required to gin greter clrity regrding the presence of suicidl idetion t the different stges of HIV infection nd the effectiveness of suicide preventive intervention t these different stges within the context exposure to ntiretrovirl tretment. Conclusion In the present study, suicidl idetion ws reduced in oth the SPTC nd BSPI groups, ut to greter degree in the ltter, suggesting tht lthough generl counselling cn hve positive psychologicl outcome, the BSPI ws more effective in reducing suicidl idetion. We showed decrese in the levels of suicidl idetion in newly dignosed HIV-positive persons following pproprite counselling nd BSPI. Thus the findings of our study support the vlue of such n pproch in recently dignosed HIVpositive persons in the primry cre setting nd especilly for those presenting with either overt or covert signs of hopelessness, depression nd suicidl idetion. All helth cre workers t HIV/AIDS clinics, ut especilly in poorly resourced countries, should e trined to increse their knowledge regrding suicide prevention nd reduce suicidl idetion in vulnerle HIV-positive ptients. Declrtion The uthors declre tht this is originl work nd hs not previously een pulished. Conflict of Interest None. 546
Acknowledgements The uthors wish to thnk the fieldworkers for their excellent work ethic nd the collection of dt for this reserch. We express sincere grtitude to Ms P Pilly for reserch ssistnce. Finncil cknowledgements: RDG ws supported y Doctorl Reserch Grnt Awrd (2010) funded y the University of KwZulu-Ntl. References 1. Bertolote JM, Fleischmnn A. A glol perspective on the mgnitude of suicide mortlity. In: D. Wssermn, & C. Wssermn, eds, Oxford Textook of Suicidology nd Suicide Prevention. A Glol Perspective. Oxford: Oxford University Press, 2009; 91-98. 2. Schleusch L. Suicidl ehviour in South Afric. Pietermritzurg: University of KwZulu-Ntl Press, 2005. 3. Flisher AJ, Prry CDH. Suicide in South Afric. Act Psychit Scnd 1994; 90: 348-353. 4. Schleusch L. Suicide prevention: proposed ntionl strtegy for South Afric. Afr J Psych 2012;15: 436-440. 5. Acturil Society of South Afric (ASSA). ASSA 2008 AIDS nd Demogrphic Model (lite version 110207). Pretori: ASSA, 2011. http://ids.cturilsociety.org.z/ ASSA2008-Model-3480.htm (ccessed 16 July 2013). 6. Govender RD, Schleusch L. Hopelessness, depression nd suicidl idetion in HIV-positive persons. S Afr J Pysch 2012; 18:16-21. 7. Kinynd E, Hoskins S, Nkku J, Nwz S, Ptel V. The prevlence nd chrcteristics of suicidlity in HIV/ AIDS s seen in n Africn popultion in Entee district, Ugnd. BMC Psychit 2012; 12: 63. 8. Skinner D, Mfecne S. Stigm, discrimintion nd the implictions for people living with HIV/AIDS in SA. J Soc Aspects of HIV/AIDS 2004; 1: 157-164. 9. Govender RD, Schleusch L. Suicidl idetion in seropositive ptients seen t South Africn HIV voluntry counselling nd testing clinic. Afr J Psychit 2012; 15:94-98. 10. Schleusch L, Govender RD. Age, gender nd suicidl idetion following voluntry HIV counselling nd testing. Int J Environ Res Pulic Helth 2012; 9: 521-530. 11. Mhlongo T, Peltzer K. Prsuicide mong youth in generl hospitl in South Afric. Curtionis 1999; 22: 72-6. 12. Ciesl GR, Roerts JE. Met-nlysis of the reltionship etween HIV infection nd risk for depressive disorders. Am J Psychit 2001; 158: 725-730. 13. Olley BO, Seedt S, Nei DG, Stein DJ. Predictors of mjor depression in recently dignosed ptients with HIV/AIDS in South Afric. AIDS Ptient Cre STDs 2004; 18: 481-487. 14. Thom R. Common mentl disorders in people living with HIV/AIDS. S Afr J HIV Med 2009; 10: 8-13. 15. Silvermn MM, Felner RD. The plce of suicide prevention in the spectrum of intervention: Definitions of criticl terms nd constructs. Suicide Life Thret Behv 1995; 25: 70-81. 16. Nordentoft M. Crucil elements in suicide prevention strtegies. Prog Neuropsychophrmcol Biol Psychit 2011; 35: 848-853. 17. Mnn JJ, Apter A, Bertolote J, Beutris A, Currier D, et l. Suicide prevention strtegies: A systemtic review. JAMA 2005; 294: 2064-2074. 18. Crrico AW. Elevted suicide rte mong HIV positive persons despite enefits of ntiretrovirl therpy: Implictions for stress nd coping model of suicide. Am J Psychitry 2010; 167: 117-119. [http://dx.doi.org/10.1176/ ppi.jp.2009.09111565] 19. Fleischmnn A, Bertolote JM, Wssermn D, De Leo D, Bolhri J, et l. Effectiveness of rief intervention nd contct for suicide ttempters: rndomized controlled tril in five countries. Bull World Helth Orgn 2008; 86: 703-709. 20. Bertolote JM, Govender RD, Schleusch L. A suicide risk screening scle for HIV-infected persons in the immedite post-dignosis period. S Afr J HIV Med 2013; 14: 58-63. 21. Bien TH, Miller WR, Tonign JS. Brief interventions for lcohol prolems: A review. Addiction 1993; 88:315-36. PMID:8461850 doi:10.1111/j.1360-0443.1993.t00820 22. Fleischmnn A, de Leo D, Wssermn D. Suicidl thoughts, suicide plns nd ttempts in the generl popultion on different continents. In: D. Wssermn, C. Wssermn, eds, Oxford Textook of Suicidology nd Suicide Prevention. A Glol Perspective. Oxford: Oxford University Press, 2009; 99-104. 23. Crvlho FT, Moris NA, Koller SH, Piccinini CA. Protective fctors nd resilience in people living with HIV/AIDS. Cd Sude Pulic 2007; 23: 2023-33. 24. Zhng Y, Zhng X, Aleong TH, et l. Impct of HIV/AIDS on Socil Reltionships in Rurl Chin. The Open AIDS Journl 2011; 5: 67-73. 25. Ncm BP, McInerney PA, Bhengu BR, Corless IB, Wntlnd DJ, Nichols PK, et l. Socil support nd mediction dherence in HIV disese in KwZulu-Ntl, South Afric. Int J Nurs Stud 2008; 45(12):1757-1563. 26. Wddell EN, Messeri PA. Socil support, disclosure, nd use of ntiretrovirl therpy. AIDS Behv 2006; 10: 263-272. 27. Seery MD, Leo RJ, Lupien SP, Kondrk CL, Almonte JL. An Upside to dversity? Moderte cumultive lifetime dversity is ssocited with resilient responses in the fce of controlled stressors. Psychologicl Science. 2013. 28. Crwford MJ, Thoms O, Khn N. Psychosocil interventions following self-hrm. Systemtic review of their efficcy in preventing suicide. Br J Psych 2007; 190: 11-17. 29. Rehse B, Pukrop R. Effects of psychosocil interventions on qulity of life in dult cncer ptients: met nlysis of 37 pulished controlled outcome studies. Ptient Eduction nd Counseling 50: 2003; 179-186. 547