Abstract

Purpose of the Study:

The National Institutes of Health calls for research that explores what it means to age optimally with HIV/AIDS as half of the U.S. people with HIV are aged 50 or older. This study applied the stress process model to examine the association between HIV stigma and psychological well-being and mediating resources (i.e., spirituality and complementary and integrative health [CIH]) approaches) in older adults with HIV.

Design and Methods:

Using data from the Research on Older Adults with HIV (ROAH) study, structural equation modeling was used to estimate these relationships within a latent variable model. Namely, a direct negative association between HIV stigma and psychological well-being was hypothesized that would be mediated by spirituality and/or CIH use.

Results:

The analyses showed that the model fits the data well [χ2 (137, N = 914) = 561.44, p = .000; comparative fit index = .964; root mean square error of approximation = .058, 95% confidence interval = .053 to .063]. All observed variables significantly loaded on their latent factor, and all paths were significant. Results indicated that spirituality and CIH use significantly mediated the negative association between HIV stigma and psychological well-being.

Implications:

Findings highlight the importance of spiritual and CIH interventions for older adults with HIV/AIDS. Practice recommendations are provided at the micro- and mesolevel.

In the past 30 years, HIV/AIDS has rapidly evolved from a “gay plague” to a worldwide pandemic. In its early days, HIV/AIDS decimated a generation of gay men, marking this disease with a pervasive stigma that has not attenuated (amfAR, 2013). During its second decade, the incidence of HIV/AIDS evidenced profound racial and class disparities (amfAR, 2013). Now, effective treatments have transformed HIV into a manageable, chronic, albeit incurable disease (amfAR, 2013). The Centers for Disease Control and Prevention (CDC, 2013) estimates that by 2015 half of those with HIV in the United States will be aged 50 or older. Although there have been great gains in our understanding of what it means to live with HIV, the challenge of the fourth decade is to understand what it means to age with HIV.

The National Institutes of Health (NIH; 2012) outlines several priority areas, including research that elucidates what it means to age optimally with HIV, underscoring positive psychology, resilience, and spirituality. Researchers have called for studies to identify existing coping strategies that improve psychosocial well-being in older adults with HIV (Earnshaw, Lang, Lippitt, Jin, & Chaudoir, 2014). This study tests a stress process model to assess the mediating role of coping resources on the association between HIV stigma and psychological well-being among older adults with HIV. The study aims to move beyond pathogenesis (i.e., factors that cause disease) to salutogenesis (i.e., factors that promote well-being) through the investigation of psychological well-being despite adversity (Antonovsky, 1979). Research in non-HIV samples shows that higher levels of psychological well-being are associated with a healthier immune system as measured by lower cortisol levels, lower proinflammatory cytokines, lower allostatic load (a multisystem concept based on cumulated stress and its effects on biological markers of well-being), and a longer survival time (Ryff, Singer, & Love, 2004). Thus, psychological well-being may contribute to positive aging in people aging with HIV.

Psychological Well-Being

Ryff’s psychological well-being measures are employed in this study (Ryff & Keyes, 1995). Ryff’s measures of psychological well-being were theoretically derived and subsequently developed into scales, which were confirmed using factor analysis; the six identified factors were supported under one conceptual domain. The six dimensions are self-acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth. Self-acceptance represents a positive sense of self and the acceptance of both positive and negative qualities in one’s self and one’s past. Positive relations with others is the development of relationships containing “empathy, affection, and intimacy.” Autonomy is understood as the ability to maintain independent thoughts and actions irrespective of prevailing beliefs. Environmental mastery typifies the capacity to control external factors by embracing opportunities. Purpose in life is finding meaning in the past and the present while constructing goals for the future. Personal growth is the openness to learning and experiencing new things to reach one’s potential (Ryff & Keyes, 1995, p. 727).

The study of negative psychological outcomes is more prevalent in the research literature than the study of positive psychological outcomes, yet absence of one does not infer presence of the other (Ryff et al., 2004, 2006). Researchers have debated whether psychological well-being and distress represent opposite sides of a continuum (Ryff et al., 2006). To investigate this, Ryff and colleagues (2006) conducted research on the relationship between well-being, distress, and different biomarkers. Their findings show that the majority of biomarkers (seven of nine) correlated with different constructs and were associated with either well-being or distress but not with both. These findings support the hypothesis of two correlated, yet independent, constructs highlighting the relevance of research on positive psychological outcomes.

HIV Stigma

Stigma is a powerful social process rooted in a cultural and historical context in which one is unable to achieve normative societal expectations (Goffman, 1963). When the HIV/AIDS epidemic was in its early stages, the phrases “gay-related immune deficiency” and “gay cancer” were used as descriptors in media, which initiated the stigmatization of persons with HIV/AIDS (amfAR, 2013). Consequently, HIV-infected persons were and are labeled as being deviant, immoral, contagious, and at fault (Emlet et al., 2013). HIV stigma is a chronic stressor that has a negative impact on psychosocial well-being (Emlet et al., 2013). The evidence is equivocal regarding the relationship between HIV stigma and age. Whereas one study found that older adults with HIV reported higher levels of stigma than their younger counterparts (Rueda, Law & Rourke, 2014), another study found the opposite to be true (Emlet et al., 2013) and a third found no association between HIV stigma and age (Slater et al., 2015). HIV stigma is associated with high rates of social isolation and loneliness, which underlie elevated rates of depression seen in this population (Brennan, Karpiak, Shippy, & Cantor, 2009; Emlet, Furlotte, Brennan, & Pierpaoli, 2014). Although stigma related to sexual minority status is related to depression, HIV stigma was not associated with lower mental health in a sample of sexual minority older adults with HIV (Emlet, Fredriksen-Goldsen, & Kim, 2013; Fredriksen-Goldsen et al., 2013). However, the association between HIV stigma and mental health has not been reported in the research literature for a sample of both heterosexual and sexual minority older adults.

Conceptual Framework

The conceptual framework for this study is based upon the stress process model, a social psychological theory in which stressors resulting from life events, traumas, and chronic life strains alter one’s well-being (Pearlin, Schieman, Fazio, & Meersman, 2005). The theory posits that stress is a normative process of interconnected linkages between social status, cultural context, exposure to stress, and variable coping resources. The combination of stressors within the structural context of social inequality contributes to health inequality (Pearlin et al., 2005). The framework developed for this study adapts the stress process model by conceptualizing HIV stigma as the stressor and psychological well-being as the outcome. The coping resources of spirituality and complementary and integrative health (CIH) use are expected to mediate this association (Figure 1).

Figure 1.

Standardized coefficients for the SEM model (N = 914). Latent constructs are shown in ellipses, and observed variables are shown in rectangles. Significance for all paths p < .05. χ2 (137, N = 914) = 561.44, p = .000, CFI = .964, RMSEA = .058, 95% confidence interval [.053, .063]. Indirect effects: Stigma → Spirituality → Well-being β = −.15, SE = .02, p < .001. Stigma → CIH → Well-being β = −.01, SE =.00, p < .10. CIH = complementary and integrative health; RMSEA = root mean square error of approximation.

Figure 1.

Standardized coefficients for the SEM model (N = 914). Latent constructs are shown in ellipses, and observed variables are shown in rectangles. Significance for all paths p < .05. χ2 (137, N = 914) = 561.44, p = .000, CFI = .964, RMSEA = .058, 95% confidence interval [.053, .063]. Indirect effects: Stigma → Spirituality → Well-being β = −.15, SE = .02, p < .001. Stigma → CIH → Well-being β = −.01, SE =.00, p < .10. CIH = complementary and integrative health; RMSEA = root mean square error of approximation.

Coping resources provide an explanation for how the same experiences may result in different outcomes. Coping resources are described as a set of action-based cognitive and emotional strategies aimed at reducing the negative consequences of stress (Pearlin & Bierman, 2013). Spiritual belief systems, “a major component of successful aging with HIV,” are a coping resource by which some older adults with HIV ascribe meaning to stress (Vance, Brennan, Enah, Smith, & Kaur, 2011, p. 105). Spirituality is structured around the existential pursuit of meaning and is more individualistic compared with religiousness, where persons ascribe to a specific faith and participate formally in measureable activities (Vance et al., 2011). For people challenged by serious illness, spirituality may provide a mechanism for emotionally and cognitively processing life experiences in a positive way that fosters psychological well-being (Brennan, 2004). In a review of 209 studies on people aging with HIV, spirituality was found to be one of the most common forms of emotional coping (Rueda et al., 2014).

The use of CIH approaches among people with chronic health conditions is an active and adaptive coping behavior (Büssing et al., 2006). CIH modalities of treatment include practitioner-provided treatments, such as acupuncture and massage, and self-administered treatments, including herbs and meditation. The evidence base on the effectiveness of CIH as treatment for many age-related health problems is growing, as is its utilization among older adults (Briggs, 2015; Li & Su, 2011). Some findings show that CIH efficacy includes preventative, pain modulating, and immune boosting strategies (Cabýoglu, Ergene, & Tan, 2006). People living with HIV report higher CIH utilization than the general population (Littlewood & Vanable, 2008). Thus, the study of CIH in older adults with HIV is important for understanding its potential as a coping strategy related to psychological well-being.

Study Purpose and Hypotheses

This study (a) investigates the association between HIV stigma and psychological well-being and (b) evaluates coping resources (e.g., spirituality and/or CIH) as mediators between the association of HIV stigma and psychological well-being among older adults with HIV. It is hypothesized that those with higher levels of HIV stigma will have lower levels of psychological well-being. It is further hypothesized that coping resources, specifically spirituality and CIH use, will mediate the negative effects of HIV stigma on psychological well-being. That is, those with higher levels of spirituality, as well as CIH users, will report higher levels of psychological well-being despite HIV stigma.

Methods

Data Source and Sample

This study used data from the Research on Older Adults with HIV (ROAH) project, the first large-scale comprehensive survey to provide detailed information on psychosocial issues affecting the HIV/AIDS population aged 50 and older (Brennan et al., 2009). Sampling details of ROAH have been reported elsewhere (Karpiak, Shippy, & Cantor, 2006). The final sample included 914 eligible respondents (e.g., community dwelling, proficient in English, reside in, or a health care recipient of, New York City).

The majority of the sample was identified as male (71%), followed by female (29%), and transgender persons (1%). The sample was racially and ethnically diverse with the majority being non-Hispanic Black (52%), followed by Hispanic/Latino (34%), and non-Hispanic White (13%). The sample identified primarily as heterosexual (67%), followed by gay/lesbian (24%), bisexual (9%), and other (1%). The sample was split with regards to education: 51% had a high school education or less and 49% had at least some college or more. The majority of the study sample suffered from income insecurity; only 8% stated “money was not a problem.” The majority of the sample (53%) was “just managing to get by financially,” 23% “did not have enough to get by,” and 17% had “enough with a little extra.” Mean self-reported physical health (0 = worst to 10 = best) was 6.8 (SD = 1.8). Participants had been living with HIV for an average of 12.6 years (range = 3 months to 26 years). Most (85%) were using HIV medications. Mean CD4 count (range = 5 to 2,000) was 468 (SD = 282), indicating that their HIV disease was being effectively controlled. Half (51%) reported a prior AIDS diagnosis. Sociodemographic and other characteristics of the sample are presented in Tables 1 and 2.

Table 1.

Sociodemographic Characteristics of Participants in ROAH (2009); Age 50+, N = 914

Characteristic n Mean SD 
Sociodemographics     
 Age (50–78 years) 909  55.50 4.87 
 Sex (% male) 904 70.8   
 Sexual orientation 868    
  Heterosexual  67.4   
  Bisexual  8.7   
  Gay/Lesbian  23.9   
 Race/ethnicity 870    
  Non-Hispanic White  12.8   
  Non-Hispanic Black  50.2   
  Non-Hispanic Other  4.0   
  Hispanic  33.0   
 Education 908    
  Less than high school  21.5   
  High school graduate  29.7   
  Some college  27.3   
  College graduate  21.5   
 Income adequacy 864    
  Do not have enough  22.6   
  Just manage to get by  52.9   
  Enough, with a little extra  16.6   
  Money is not a problem  7.5   
Health variables     
 Self-reported health (0–10) 885  6.84 1.78 
 CD4 count (5–2,000) 810  468 282 
 Months since HIV diagnosis 898  151 63 
 AIDS diagnosis (% yes) 903 51.3   
Characteristic n Mean SD 
Sociodemographics     
 Age (50–78 years) 909  55.50 4.87 
 Sex (% male) 904 70.8   
 Sexual orientation 868    
  Heterosexual  67.4   
  Bisexual  8.7   
  Gay/Lesbian  23.9   
 Race/ethnicity 870    
  Non-Hispanic White  12.8   
  Non-Hispanic Black  50.2   
  Non-Hispanic Other  4.0   
  Hispanic  33.0   
 Education 908    
  Less than high school  21.5   
  High school graduate  29.7   
  Some college  27.3   
  College graduate  21.5   
 Income adequacy 864    
  Do not have enough  22.6   
  Just manage to get by  52.9   
  Enough, with a little extra  16.6   
  Money is not a problem  7.5   
Health variables     
 Self-reported health (0–10) 885  6.84 1.78 
 CD4 count (5–2,000) 810  468 282 
 Months since HIV diagnosis 898  151 63 
 AIDS diagnosis (% yes) 903 51.3   

Note: ROAH = Research on Older Adults with HIV.

Table 2.

SEM Variable Characteristics of Participants in ROAH (2009); Age 50+, N = 914

Characteristic n Mean SD 
Dependent variables (scale range)     
 Personal growth (11–54) 897  40.59 8.15 
 Self-acceptance (12–54) 890  38.18 8.46 
 Positive relations (16–54) 892  38.91 8.60 
 Purpose in life (17–54) 890  39.19 8.31 
 Environmental mastery (14–54) 892  38.75 8.23 
 Autonomy (21–54) 895  41.10 7.50 
Independent variables (scale range) 
 Berger HIV-Stigma Scales 
  Disclosure (10–40) 910  24.50 6.09 
  Self-image (13–50) 904  26.19 7.99 
  Public attitudes (20–80) 905  45.26 12.08 
  Personalized stigma (18–72) 902  38.35 11.71 
 Spirituality Assessment Scales 
  Purpose in life (4–24) 903  19.78 4.45 
  Inner resources (9–54) 900  45.05 8.98 
  Interconnectedness (9–54) 900  43.01 8.55 
  Transcendence (6–36) 902  27.67 6.07 
  CIH use (% yes) 909 28.8   
 CIH Modalities 
  Medical system 880 12.7   
  Body based 880 14.3   
  Mind-body 880 5.8   
  Biologic 880 12.1   
  Energy 880 2.1   
Characteristic n Mean SD 
Dependent variables (scale range)     
 Personal growth (11–54) 897  40.59 8.15 
 Self-acceptance (12–54) 890  38.18 8.46 
 Positive relations (16–54) 892  38.91 8.60 
 Purpose in life (17–54) 890  39.19 8.31 
 Environmental mastery (14–54) 892  38.75 8.23 
 Autonomy (21–54) 895  41.10 7.50 
Independent variables (scale range) 
 Berger HIV-Stigma Scales 
  Disclosure (10–40) 910  24.50 6.09 
  Self-image (13–50) 904  26.19 7.99 
  Public attitudes (20–80) 905  45.26 12.08 
  Personalized stigma (18–72) 902  38.35 11.71 
 Spirituality Assessment Scales 
  Purpose in life (4–24) 903  19.78 4.45 
  Inner resources (9–54) 900  45.05 8.98 
  Interconnectedness (9–54) 900  43.01 8.55 
  Transcendence (6–36) 902  27.67 6.07 
  CIH use (% yes) 909 28.8   
 CIH Modalities 
  Medical system 880 12.7   
  Body based 880 14.3   
  Mind-body 880 5.8   
  Biologic 880 12.1   
  Energy 880 2.1   

Note: CIH = complementary and integrative health; ROAH = Research on Older Adults with HIV.

Measures

The following were the observed indicators used to estimate the latent variables in the SEM procedure.

Dependent Variables

Psychological well-being was measured using the 9-item scale version of Ryff’s Psychological Well-Being Measure (Ryff & Keyes, 1995). The six subscales described earlier were autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. Each scale used a 6-point response format that ranged from “strongly disagree” to “strongly agree,” with no neutral option. Scores for each scale represented a sum of the items and ranged from 9 to 54; higher scores represented greater well-being. Internal consistency ranged from α = .86 to .93.

Independent Variables

HIV Stigma was measured using the four subscales of the 40-item Berger HIV Stigma Scale (Berger, Ferrans, & Lashley, 2001). The scales assessed disclosure concerns (keeping HIV status secret), negative self-image (shame and guilt), concern with public attitudes toward people with HIV (what most people think about people with HIV), and personalized stigma (fears of rejection due to HIV status). Each scale used a 4-point response format that ranged from “strongly disagree” to “strongly agree” with no neutral option. Scores for each scale represented a sum of the items and ranged from 8 to 160; higher scores represent higher levels of stigma. Internal consistency ranged from α = .83 to .95.

Mediating Coping Resource Variables

Spirituality was measured using the four subscales of the 28-item Spirituality Assessment Scale (Howden, 1992). The scales assessed purpose and meaning in life (sense of worth and reason for living), inner resources (strength in crisis), unifying interconnectedness (harmony with self and others, oneness with the universe), and transcendence (rising above, overcoming). Each scale used a 6-point response format that ranged from “strongly agree” to “strongly disagree,” with no neutral option. Scores represented a sum of the items and ranged from 4 to 54; higher scores represent higher levels of spirituality. Internal consistency ranged from α = .71 to .91.

To quantify CIH use, respondents were asked “Are you currently using alternative, complementary, holistic or New Age treatments such as massage, herbs, etc.?” (yes/no), and “If yes, which types of alternative treatments do you use? (list up to three).” The open-ended responses were recoded based on the five category classification by NIH’s National Center for Complementary and Integrated Health (NCCIH; Wootton, 2005). These five categories were as follows: alternative medical systems (e.g., acupuncture), mind-body interventions (e.g., meditation, yoga), biologically based therapies (e.g., herbs), manipulative and body-based methods (e.g., chiropractic, massage), and energy therapies (e.g., reiki). These categories were not mutually exclusive. Respondents who answered “yes” to CIH use but did not list the types of CIH (n = 34) were classified as nonusers.

Analytic Strategy

This study used a correlational design within a SEM framework to test the hypothesized relationships. SEM is a latent-variable modeling approach that allowed for multiple observed indicators of the same construct and account for measurement error, while minimizing issues of multicollinearity among covariates (Kline, 2005). Stata, Version 13, software was employed to estimate the SEM models (StataCorp, 2013).

Data were screened for violations of SEM model assumptions. The spirituality assessment scales showed a slight departure from normality; this was not a concern as maximum likelihood estimation was used to account for non-normal data. Correlations were computed, and multicollinearity was checked for variables with correlations (r > .85; Kline, 2005). This was the case for Berger’s HIV stigma personal stigma and public stigma subscales (r = .94) and the Spirituality Assessment Scale’s inner resources and purpose in life subscales (r = .87). Strong correlations were expected among subscales because they were measures of the same latent variable.

Missing data were assessed; the highest missing frequency on any variable was 2.6% (Ryff’s self-acceptance and purpose in life). Full Information Maximum Likelihood (FIML) estimation was used to account for missing data and maximize sample size (Enders & Bandalos, 2001). Descriptive statistics (means and standard deviations) for all variables are reported in Tables 1 and 2. Table 3 provides bivariate correlations among the observed indicators.

Table 3.

Pairwise Correlation Matrix in ROAH (2009; Age 50+, N = 914)

           10  11  12  13  14  15  16  17  18  19 
Autonomy                                     
Mastery .52 ***                                   
Personal growth .61 *** .50 ***                                 
Positive relations .47 *** .64 *** .55 ***                               
Purpose in life .45 *** .61 *** .64 *** .60 ***                             
Self-acceptance .47 *** .71 *** .44 *** .62 *** .54 ***                           
Disclosure −.25 *** −.27 *** −.26 *** −.36 *** −.25 *** −.28 ***                         
Self-image −.44 *** −.44 *** −.47 *** −.53 *** −.46 *** −.44 *** .75 ***                       
Public attitudes −.28 *** −.37 *** −.33 *** −.47 *** −.36 *** −.34 *** .78 *** .84 ***                     
10 Personalized stigma −.29 *** −.37 *** −.35 *** −.49 *** −.37 *** −.34 *** .67 *** .81 *** .94 ***                   
11 Transcendence .33 *** .42 *** .27 *** .30 *** .32 *** .46 *** −.04  −.16 *** −.04  −.05                  
12 Interconnectedness .38 *** .47 *** .37 *** .43 *** .37 *** .50 *** −.07 −.24 *** −.12 *** −.14 *** .80 ***               
13 Inner resources .44 *** .55 *** .39 *** .42 *** .44 *** .56 *** −.07 −.25 *** −.11 *** −.14 *** .81 *** .80 ***             
14 Purpose/meaning .39 *** .56 *** .38 *** .46 *** .51 *** .61 *** −.09 ** −.28 *** −.16 *** −.19 *** .73 *** .75 *** .87 ***           
15 Medical CIH .06  .09 ** .14 *** .14 *** .13 *** .09 ** −.03  −.06  .00  −.02  .10 ** .11 ** .10 ** .08         
16 Body CIH .09 .10 ** .15 *** .13 *** .10 ** .06  −.04  −.06  .00  −.03  .12 *** .11 ** .08 .06  .45 ***       
17 Mind-body CIH .10 ** .06  .11 ** .08 .07 .04  −.04  −.08 −.01  −.01  .10 ** .09 ** .10 ** .08 .23 *** .30 ***     
18 Biological CIH .06  .00  .10 ** .03  .09 ** .03  −.03  −.02  .03  .05  .05  .03  .02  .00  .25 *** .25 *** .22 ***   
19 Energy CIH .06  .01  .07 .08 .04  .01  −.02  −.01  .01  .00  .07 .06  .03  .03  .23 *** .22 *** .07 .05  
           10  11  12  13  14  15  16  17  18  19 
Autonomy                                     
Mastery .52 ***                                   
Personal growth .61 *** .50 ***                                 
Positive relations .47 *** .64 *** .55 ***                               
Purpose in life .45 *** .61 *** .64 *** .60 ***                             
Self-acceptance .47 *** .71 *** .44 *** .62 *** .54 ***                           
Disclosure −.25 *** −.27 *** −.26 *** −.36 *** −.25 *** −.28 ***                         
Self-image −.44 *** −.44 *** −.47 *** −.53 *** −.46 *** −.44 *** .75 ***                       
Public attitudes −.28 *** −.37 *** −.33 *** −.47 *** −.36 *** −.34 *** .78 *** .84 ***                     
10 Personalized stigma −.29 *** −.37 *** −.35 *** −.49 *** −.37 *** −.34 *** .67 *** .81 *** .94 ***                   
11 Transcendence .33 *** .42 *** .27 *** .30 *** .32 *** .46 *** −.04  −.16 *** −.04  −.05                  
12 Interconnectedness .38 *** .47 *** .37 *** .43 *** .37 *** .50 *** −.07 −.24 *** −.12 *** −.14 *** .80 ***               
13 Inner resources .44 *** .55 *** .39 *** .42 *** .44 *** .56 *** −.07 −.25 *** −.11 *** −.14 *** .81 *** .80 ***             
14 Purpose/meaning .39 *** .56 *** .38 *** .46 *** .51 *** .61 *** −.09 ** −.28 *** −.16 *** −.19 *** .73 *** .75 *** .87 ***           
15 Medical CIH .06  .09 ** .14 *** .14 *** .13 *** .09 ** −.03  −.06  .00  −.02  .10 ** .11 ** .10 ** .08         
16 Body CIH .09 .10 ** .15 *** .13 *** .10 ** .06  −.04  −.06  .00  −.03  .12 *** .11 ** .08 .06  .45 ***       
17 Mind-body CIH .10 ** .06  .11 ** .08 .07 .04  −.04  −.08 −.01  −.01  .10 ** .09 ** .10 ** .08 .23 *** .30 ***     
18 Biological CIH .06  .00  .10 ** .03  .09 ** .03  −.03  −.02  .03  .05  .05  .03  .02  .00  .25 *** .25 *** .22 ***   
19 Energy CIH .06  .01  .07 .08 .04  .01  −.02  −.01  .01  .00  .07 .06  .03  .03  .23 *** .22 *** .07 .05  

Notes: N = 914; pairwise. CIH = complementary and integrative health; ROAH = Research on Older Adults with HIV.

*p < .05. **p < .01. ***p < .001.

The SEM analytic model is presented in Figure 1. Each multiple indicator latent variable had the factor loading of one observed variable set to 1 to provide a metric for latent-variable estimation. The error variances of observed variables were assumed to be uncorrelated. The measurement model was evaluated for significant factor loadings, using t tests, and for reliability, using squared multiple correlations.

Effect sizes were reported as standardized regression coefficients, and explained variance was based on the squared multiple correlations. Interpretation of the SEM coefficient effect size was based upon Kline (2005): small effect size was < .10, a typical or medium effect size was around .3, and a large effect size was ≥ .5. The mediation hypothesis was tested during the SEM procedure with the two latent coping resource variables: spirituality and CIH use.

Following recommended practice, model goodness-of-fit was assessed using three measures (Kenny, 2014; Kline, 2005). The root mean square error of approximation (RMSEA) estimated how well the model would fit the covariance matrix with regard to unexplained variance (< .05 = good fit, < .08 = reasonable fit). The comparative fit index (CFI) compared the model covariance matrix with a null model assuming zero covariance among the observed variables (> .9 = good fit, although .95 is more widely used). Although limited, researchers recommend reporting the model chi-square, which measures the variance between the observed covariance matrix and the estimated model (p ≥ .05 = good fit). For samples more than 400, as in the current analyses, the chi-square is typically statistically significant, making it less useful as a measure of model fit (Kenny, 2014).

Results

Tables 1 and 2 provide the sociodemographic and other characteristics of the participants with HIV aged 50 and older (N = 914). Please refer to the Data Source and Sample section and Tables 1 and 2 for a detailed description of the sample.

The SEM structural model was tested for model fit. Modification indices suggested that fit could be improved by correlating error terms on several observed indicators of the same latent construct. It was plausible that there would be correlated error variance due to survey item phrasing, response categories, and subject from the parent scale. Thus, those error terms were allowed to be correlated, which resulted in improved model fit. This involved the error variance between (a) HIV stigma subscales: disclosure with self-image and personalized stigma, and public attitudes and personalized stigma; (b) spirituality assessment subscales: inner resources and transcendence, and interconnectedness with purpose in life and transcendence; and (c) psychological well-being subscales: personal growth with positive relations, purpose in life and autonomy, and self-acceptance and environmental mastery.

The model showed a good fit [χ2 (137, N = 914) = 561.44, p = .000; CFI = .964; RMSEA = .058, 95% CI = .053 to .063]. All of the indicators for each latent variable significantly loaded on their latent factor (p < .001). All paths were statistically significant in the hypothesized directions. The R-squared value for the overall model was .98, thus there was very little (e.g., 2%) unexplained (residual) variance in the model. Psychological well-being had a high R2 = .621. The R-squared values for the spirituality and CIH latent variables clarify only how much variance in those two domains are explained by the HIV stigma latent variable. Thus, these values were expected to be low given the small size of the correlations between the observed stigma, spirituality, and CIH variables (Table 3); spirituality R2 = .022 and CIH R2 = .001.

In line with the bivariate correlational analysis, HIV stigma exhibited a significant negative association with psychological well-being, as hypothesized (β = −.42, p < .001), and spirituality (β = −.25, p < .001). Findings concerning the relation of stigma to CIH use were mixed. In the correlational analysis, the only significant relationship between CIH use and stigma variables was between mind-body CIH and negative self-image stigma. However, all CIH use variables were retained in the SEM model due to their conceptual importance. In the context of the other latent variables in the SEM model, HIV stigma was significantly related to lower CIH use (β = −.10, p < .05; Table 3, Figure 1). Spirituality, and CIH use to a lesser degree, exhibited a significant positive association with psychological well-being (β = .59, p < .001 and β = .09, p < .01, respectively).

With respect to spirituality, the direct effect of HIV stigma accounted for a significant amount of variance in psychological well-being, with significant indirect effects via spirituality, indicating a partial mediation as hypothesized (Figure 1). Although a small effect size, HIV stigma also accounted for significant indirect effects of HIV stigma via CIH use on psychological well-being, which also supported a partial mediation. These results suggested that HIV stigma has a direct negative effect on psychological well-being, with coping resources of spirituality and CIH use as partial mediators of that relationship.

Discussion

Finding ways to diminish HIV stigma is a national priority, according to both NIH (2012) and the White House Office of National AIDS Policy (2010). HIV stigma is stubbornly pervasive and continues to undermine the health of people living with HIV. We hypothesized that (a) HIV stigma would be negatively associated with psychological well-being and (b) that coping resources, spirituality and CIH use, would mediate the negative effects of HIV stigma on psychological well-being. Our findings support both these hypotheses such that the negative relationship between HIV stigma and psychological well-being was lower for persons who used these coping strategies.

HIV stigma was negatively associated with psychological well-being with a medium effect size. Thus, the first hypothesis was confirmed. The application of stress process theory to the study of psychological well-being in people aging with HIV has highlighted an important mediating role for spirituality and CIH use. The positive association of spirituality to psychological well-being revealed a large effect size. Quantitative results from this study were consistent with qualitative research that indicated spirituality as an important aspect of resilience in older adults with HIV (Emlet et al., 2014; Slomka, Lim, Gripshover, & Daly, 2013). Although some quantitative research has evaluated HIV stigma within a stress process model, methodological differences make comparisons problematic. For instance, HIV stigma was the outcome variable in Emlet and colleagues (2013), whereas HIV symptoms were the outcome in Earnshaw, Bogart, Dovidio, & Williams (2014).

With regard to mediation, we hypothesized that coping resources would mediate the association of HIV stigma and psychological well-being. This hypothesis was supported as our findings demonstrated a partial mediation of HIV stigma from spirituality and CIH use on psychological well-being. Thus, spirituality is affirmed as an element of positive aging with HIV (Vance et al., 2011). The ability to maintain a sense of worth in spite of (i.e., purpose and meaning in life), and rise above (i.e., transcendence) in response to, the experience of stigma is the cognitive and emotional reframing process (Brennan, 2004) through which spirituality mediates.

These findings are consistent with those of Noh and colleagues (2012), who investigated the association between HIV stigma and a psychological outcome (depression) that was mediated by coping resources. The most comparable study of older adults with HIV (N = 349) investigated the mediating role of coping resources, including spiritual coping, on the relationship between life stress and quality of life (which included emotional well-being; Fang et al., 2015). The present study’s findings corroborated those of Fang and colleagues, showing that coping resources partially mediated the relationship between stress and well-being.

CIH use can be viewed as a form of problem-focused coping (i.e., behavioral strategy) in response to HIV which has been shown to be more beneficial than either emotion-focused (i.e., balance emotions) or avoidant coping (i.e., denial; Pakenham & Rinaldis, 2001; Swindells, Mohr, Justic, & Berman, 1999). The majority of participants were not using CIH, which may explain the less robust effect size of the association. Studies of CIH use as a coping resource in older adults with HIV are nascent, thus these findings could not be compared with other research.

Study Limitations and Contributions

A cross-sectional, correlational survey design was employed, therefore causal statements cannot be made. In addition, it was not possible to examine change in psychological well-being over time. Reciprocal causation was possible between key variables in the models (i.e., psychological well-being may predict variability in perceived HIV stigma). Also, those who had higher rates of psychological well-being may have been more apt to utilize resources such as spirituality and CIH. A survivorship bias could not be discounted as those who have survived HIV/AIDS into older age may be more resilient than persons who died before the survey was taken.

Self-selection bias and response bias may have been created via the purposive, nonprobability sampling and self-report measurements. The sensitive nature of the questions increased the risk for social desirability bias; however, this was balanced by the self-administered paper and pen format of the survey. In addition, psychological well-being was not a clinical measure; however, the measures used in this study have shown strong reliability and validity in a number of other studies. The effects of demographic and other potential covariates are not assessed in the SEM analysis due to model complexity. Given that ROAH data were collected in 2005–2006, the influence of changing demographics and other social forces, which may include variations in HIV stigma, on psychological well-being cannot be predicted. Finally, the participants were all HIV-service-users in New York City, which made them unique and the data were based on a nonprobability sample; thus, these results may not be generalizable to any known population.

This study provided several contributions to the research literature on psychological well-being among older adults with HIV. First, the partial mediation of spirituality and CIH is important as this study uniquely contributed to the literature by investigating mediating coping resources understudied (i.e., spirituality) or unstudied (i.e., CIH use) within a stress process theoretical framework. Second, levels of spirituality and CIH use are modifiable. Consequently, these particular sources of coping can be incorporated or enhanced as interventions. Third, this study used the spirituality assessment scale, which does not confound spirituality and religiousness as have many other measures of spirituality (Howden, 1992). Interventions that help to strengthen spiritual resources may be vital for a population that may be reluctant to access religious congregations due to stigma (Brennan, Strauss, & Karpiak, 2010).

Practice Implications

Findings highlight the salience of developing and examining spiritual interventions for people aging with HIV. One successful model, the SystemCHANGE HIV intervention, was found by Brown, Hanson, Schmotzer, and Webel (2013) to significantly increase one’s spiritual well-being. This group-based intervention included spiritual practices in the context of meditation, 12-step groups, and volunteerism. These practices overlap well with the spirituality assessment scale dimensions of spirituality. Meditation creates a sense of inner peace (inner resources), connection to the universe (interconnectedness), and deeper awareness (transcendence) and is an accessible intervention that can be self-taught (Shonin, Van Gordon, & Griffiths, 2014). Volunteerism is an act of service to others (interconnectedness), which extends one beyond the self (transcendence); opportunities are available in every community (Rueda et al., 2014). Participants in 12-step groups speak of a sense of serenity (inner resources), the ability to find meaning through crisis (purpose in life), kinship with others (interconnectedness), and self-healing (transcendence); these groups are available at no charge throughout the United States (Sandoz, 2014).

In clinical settings, retirement communities, assisted living facilities, and nursing homes, patients are typically asked about religious group affiliation, in part, as a proxy for religious and spiritual practices (Vance et al., 2011). Expanding the question(s) to ask about spirituality will better represent people engaging in a spiritual practice without a religious affiliation (DePalo & Brennan, 2004). Facilities that provide regular religious services could additionally offer nondenominational spiritual activities such as workshops in meditation. AIDS Service Organizations (ASOs) are recommended to provide spirituality workshops and CIH services to mitigate the HIV stigma clients perceive when outside the safety provided by ASO environments.

These findings provide evidence that CIH use is positively associated with psychological well-being. Many ASOs offer CIH modalities; participation in these treatments is recommended for people aging with HIV. Body-based and medical-system based modalities showed the highest factor loadings, which included acupuncture, massage, and chiropractic, thus, these modalities are particularly recommended. CIH providers have an opportunity to extend their outreach to people aging with HIV by proving visually welcoming messages to counteract HIV stigma such as including “HIV” in the list of conditions treated on promotional materials.

Future Research

Future research in non-HIV populations may explore the mediating role of spirituality and CIH in psychological well-being. In addition, these mediating effects can be investigated in younger people with HIV to assess potential benefits. Longitudinal research with probability samples is needed to investigate causal pathways. Coping with stressors such as stigma may be a skill developed over time (Emlet et al., 2013); therefore, research to consider differences between long-term survivors and those more recently diagnosed is recommended. Research evaluating between group differences by time of diagnosis (pre-antiretroviral treatment vs post-treatment) is recommended as recent studies suggest cohort differences (de Vries, 2013; Emlet et al., 2014).

Conclusion

This study expanded upon the current knowledge base by offering a new way in which the negative association of HIV stigma on psychological well-being could be attenuated via spirituality and CIH use as coping resources. This study intended to fill a gap in the literature by providing research that “emphasizes positive psychology, mindfulness, hardiness, and resilience and to translate those findings to help those not successfully aging with HIV” (Emlet et al., 2014, p. 147). Elucidating ways in which people can age positively with HIV is an important step in the further development of interventions. The results from this study can inform medical and long-term care providers, researchers, policy makers, religious and spiritual leaders, CIH providers, and HIV service systems. Although HIV has become a chronic condition for many in the United States, there is still no cure making this a historic time to study the biopsychosocialspiritual aspects of aging with HIV.

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Author notes

*Address correspondence to Kristen E. Porter, ACRIA, Center on HIV and Aging, 575 8th Ave 502, New York, NY 10018. E-mail: kristen.e.porter@hotmail.com
Decision Editor: Rachel Pruchno, PhD