232 AIDS/HIV
treatment options (Low-Beer et al., 2000; Rabkin, Ferrando,
Lin, Sewell, & McElhiney, 2000), HIV disease triggers a host
of powerful stressors. Treatment and support for individuals
experiencing adjustment dif“culties not only can improve
mental health functioning and quality of life, but also may
have direct effects on disease progression. In this section, we
brie”y consider the range of stressors that confront persons
living with HIV disease, the impact these stressors have on
disease progression, and several exemplar studies suggesting
promising intervention approaches to improve coping and
psychological adaptation among persons living with HIV.
HIV-Related Stressors. Persons living with HIV experi-
ence a wide range of stressors throughout the course of their
illness. Although the nature and severity of psychological dis-
tress and coping dif“culties vary from person to person, several
distinct phases of the illness are commonly associated with in-
creased anxiety and depressive symptoms (Kalichman, 1998).
Receipt of a positive test result, even if it was expected, is de-
scribed by many as being among the most challenging and
stressful periods of adaptation faced during the course of the ill-
ness. Individuals often experience a mixture of shock, denial,
guilt and fear, as well as concerns about whether to disclose the
illness to others (Ostrow et al., 1989). During this initial phase,
patients must also consider a bewildering array of options with
regard to the initiation of treatment, including the dif“cult issue
of when to start HAART. Emotional distress is often most in-
tense during the “rst months of HIV infection, but prospective
studies indicate that symptoms of depression and anxiety often
decline in the months following HIV test noti“cation (Rabkin
et al., 1991). Distress during the asymptomatic phase of HIV
disease often results from the multiple uncertainties of future
health decline, impaired occupational functioning, high costs
of medical care, and declining social supports.
The “rst signs and symptoms of HIV disease progression
often lead to a resurgence of more extreme anxiety and de-
pressive symptoms that can often persist inde“nitely as pa-
tients cope with the uncertainties associated with potential
progression to AIDS. Finally, the actual diagnosis of AIDS is
often experienced as being very traumatic, because it can sig-
nify the •beginning of the endŽ for patients facing likely
death. Severe distress associated with an AIDS diagnoses is
often short-lived (Rabkin et al., 1997), suggesting that many
people with AIDS show an extraordinary capacity to adapt to
advancing disease. Regardless of disease stage, other stres-
sors commonly experienced by persons living with HIV in-
clude the challenge of accessing and paying for medical care,
experiences of stigmatization, and bereavement associated
with the loss of other loved ones to AIDS (for a review, see
Kalichman & Catz, 2000).
Although many of the coping challenges experienced by
patients today are similar to those experienced prior to the
advent of combination therapies, a number of new chal-
lenges have emerged following the advent of HAART
(Kelly, Otto-Salaj, Sikkema, Pinkerton, & Bloom, 1998;
Catz & Kelly, 2001). On an individual level, many patients
have experienced a rapid turn-around in health status as a
result of combination therapies. Improvements in health
outlook, described by some as a • second lifeŽ (Rabkin &
Ferrando, 1997), have led to considerable relief for those
experiencing the bene“ts; however, this second life also
gives birth to new stressors. Many who had previously an-
ticipated the prospect of debilitating illness and early death
now must adapt to the uncertain possibility of remaining in
good health for many years to come. Although clearly good
news, anticipation of prolonged periods of good health
forces individuals to confront dif“cult choices concerning
matters such as whether to give up disability bene“ts and re-
turn to work, and the initiation of new relationships. Patients
who succeed with combination therapies must also cope
with the lifelong need to adhere to exceedingly complex
HAART regimens. In stark contrast to individuals who re-
spond well to HAART, those who have not responded well
frequently experience a profound sense of disappointment,
often blaming themselves for •treatment failureŽ (Bogart
et al., 2000). Failure to respond to combination therapies
may result in a sense of injustice that the best available
treatment are not personally effective, as well as fatalism
about the future (Rabkin & Ferrando, 1997). Repeated treat-
ment failure may ultimately precipitate the onset of more
serious major mood disorders requiring psychological or
pharmacological treatment.Coping Interventions and Health. There has been con-
siderable interest in understanding whether psychosocial fac-
tors such as depression, anxiety, and coping style in”uence
HIV disease progression. Studies linking psychosocial vari-
ables longitudinally with disease progression in HIV have
yielded somewhat contradictory results, but nonetheless pro-
vide some evidence to suggest that positive psychological ad-
justment can be associated with improved clinical outcomes.
For example, several studies report a positive association be-
tween HIV disease progression and depressive symptoms
(Burack et al., 1993; Leserman et al., 1999), measures of inter-
personal sensitivity (Cole, Kemeny, & Taylor, 1997), AIDS-
related bereavement (Kemeny et al., 1995), and negative
HIV-speci“c expectancies (Reed, Kemeny, Taylor, &
Visscher, 1999). However, other studies have failed to “nd an
association between stress and HIV disease progression
(Coates, McKusick, Kuno, & Stites, 1989; Rabkin et al., 1991).