How Focusing on the Positive Could Impact Care of Women With HIV

More than 30 years ago, the arrival of anti-retroviral therapy (ART) brought the promise that HIV might no longer be a death sentence and instead could be managed as a chronic illness. Guidelines recommend starting ART as soon as someone is diagnosed, both to maintain health and reduce the likelihood of transmission.

Of course, adhering to a medication regimen can be easier said than done. Thus, identifying the psychological factors that can limit patients’ ability to manage HIV is essential—along with finding those factors that could boost medication adherence.

A new study of Black women with HIV approached the challenge a different way. Instead of identifying the negative factors that make adherence difficult, the researchers wanted to understand what positive attributes were linked with good ART adherence and better outcomes. Future interventions might then seek to boost these positive psychological factors.

The authors state that women with HIV in the United States “are predominantly Black, live below the poverty line, and have high levels of physical and sexual childhood abuse. They have also experienced many life stressors linked to structural marginalization of disenfranchised communities, including racial and gender discrimination, homelessness, incarceration, IV drug use, and transactional sex.”

These women are already under great stress, and coping with an HIV diagnosis and a new ART regimen just adds to their mental strain, they wrote. Previously, they found that 25% to 30% of those in the Women’s Interagency HIV Study (WIHS) struggled with adherence, and depression was a common culprit.

So, why focus on the positive things in their lives? “Less attention has been paid to positive psychological factors (such as gratitude or optimism) that [women living with HIV] use that may enhance positive emotions, well-being, and adaptive interpersonal relationships,” they wrote.

Positive emotions have been linked with slower disease progression, better medication adherence, and improved chances of achieving HIV suppressed viral load. Patients with positive emotions may be more likely to seek HIV care and have higher CD4+ cell counts, with lower risk of mortality, studies show.

For this study, investigators selected 98 women with HIV who were current participants in the longitudinal cohort of the WIHS, which calls for period check-ins with the study team

The 98 women took part in a process in which they shared 3 important autobiographical narratives from their lives with investigators, and the themes raised in these narratives were examined alongside participants’ depressive symptoms, ART adherence (at least 95% of time), and undetectable viral load (< 80 copies/mL).

Across the entire longitudinal cohort, women had average age of 45.32 years and 90.8% were Black, with 4.1% identifying as Hispanic. More than two-thirds (68.3%) earned less than $12,000 per year; 80% were unmarried and 44.9% did not finish high school. The majority (89%) identified as heterosexual, while 7% were bisexual, and 4% were lesbian. The vast majority (86.7%) reported a lifetime history of sexual or physical abuse at one or more study visits. Those taking part in the narrative sharing process had an average age of 45.3 years; 91% were Black.

Investigators coded each participant’s narratives for 10 positive psychological factors: gratitude, insight, compassion, meaning-making, acceptance, mindfulness, generativity, optimism, self-reliance, and benevolent God beliefs) and 3 positive life themes (health improvements, positive relationships, and accomplishments). Higher accomplishments, overall positive factors, insight, mindfulness, self-reliance, optimism, meaning-making, and acceptance were related to symptoms recorded on the Center for Epidemiologic Studies Depression Scale.

“Overall, women who more frequently used positive factors, especially mindfulness, meaning-making, acceptance, insight, and self-reliance had significantly lower depressive symptoms, including lower negative affect, somatic symptoms, or interpersonal problems,” the authors wrote. “Women who had higher levels of compassion had better ART adherence.”

Accomplishments such as gaining a job or completing an educational program was linked with lower depressive symptoms and undetectable viral load, independent of ART adherence, they wrote.

The authors wrote that compassion stood out as an important factor; 62 of 98 women expressed it, and the significant relationship between compassion and adherence, “highlight the powerful role compassion may play in these women’s lives.”

“Compassion for others may minimize the self-focus that accompanies depression and facilitate mutual and supportive relationships, which have been found to be health-promoting” in women with HIV.

The investigators concluded that positive emotions and accomplishments may contribute to lower levels of depression, especially negative affect, somatic symptoms, and interpersonal problems. They called for randomized controlled trials that included the teaching the skills of gratitude, kindness, positive re-appraisals, and mindfulness.

“Along with other trauma treatment components (e.g., emotion regulation skills, self-compassion practices, and strategies to ensure safety), the inclusion of these positive factors can potentially contribute to the development of a trauma-informed positive psychology intervention for Black women living with HIV,” the investigators concluded.


Brody LR, Firpo-Perretti Y, Bruck-Segal D, et al. Positive psychological factors and life themes in relation to health outcomes in women living with HIV. Intl J Behav Med. Published October 28, 2021. doi: 0.1007/s12529-021-10032-y

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