WHO HIV 2013.51 Eng PDF

WHO/HIV/2013.
51 World Health Organization 2013

1

The Influence of Social Support on the Lives of HIV-Infected Individuals
in Low- and Middle-Income Countries

Kevin Khamarko, MA
Janet J. Myers, PhD, MPH
University of California, San Francisco

WHO/HIV/2013.51 World Health Organization 2013
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Introduction
After thirty years, the HIV/AIDS pandemic remains a significant problem for individuals,
communities and even nations -- especially in regards to low and middle-income countries
(LMIC). As of 2010, over 34 million people were living with HIV across the globe (Joint
United Nations Programme on HIV/AIDS, 2011). Sixty-eight percent of all those infected
with HIV globally reside in LMIC, even though these countries account for just 13% of the
worlds population. Additionally, the HIV epidemic in LMIC has had a major impact on
their social and economic development (Shao & Williamson, 2012).

Advances in the treatment and care of HIV/AIDS have improved the health outlook for
people living with HIV/AIDS (PLWHA; (Joint United Nations Programme on HIV/AIDS,
2011; Volberding, 2003). The success of antiretroviral therapy (ART) has markedly reduced
AIDS-related mortality rates and increased survival for PLWHA (Palella et al., 1998).
HIV/AIDS is now often regarded as a chronic illness because life expectancy estimates are
now similar to those of patients with type-1 diabetes (Lohse et al., 2007). Despite advances
in clinical science, those infected with HIV continue to experience high levels of
discrimination and stigmatization in the communities where they live (Vanable, Carey, Blair,
& Littlewood, 2006), amongst other health-related stressors and challenges (Strine,
Chapman, Balluz, & Mokdad, 2008).

What is Social Support?
Although the construct of social support was first conceptualized by social scientists in the
late 1970s (Berkman & Syme, 1979), the definition of the concept varies widely among
researchers and their study context (William, Barclay, & Schmeid, 2004). Social support is
generally defined as the perception or experience that one is loved and cared for by others,
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esteemed and valued, and part of a social network of mutual assistance and obligations
(Taylor, 2007, pg. 145). Conceptualizations of social support have also focused on the
source of support, which can vary from family, spouse, friend, coworkers, doctor, and
community ties/affiliations. House, Landis, and Umberson (1981) outlined the following
four broad types of social support, which are still extensively used in research conducted
today:

1. Informational Support involves the provision of information, education, or guidance
for use in managing personal and health-related problems.
2. Instrumental Support (also referred to as tangible support) involves the provision of
tangible assistance, in the form of financial aid, material goods, labor, time, or any
direct help. Given the context of LMIC, we included both food insecurity and
microcredit loan programs in this category.
3. Emotional Support involves the provision of empathy, affection, love, trust,
encouragement, listening, and care from members of an individuals social network.
4. Appraisal Support (also referred to as affiliative support and social integration)
involves the number of social relationships an individual has with others that have
mutual interests. This type of support also provides affirmation and feedback.
Social support can be thought of as a meta-construct with multiple dimensions, which makes
measurement of the concept complex (Barrera, 1986). Critiques in the literature on social
support have pointed to the use of heterogeneous methods and metrics as a hindrance in
understanding the true effects of social support on varying outcomes (Decker, 2006; Uchino,
2006). Those that have studies social support have used varying techniques to measure the
concept, often collecting data on one or more of the following dimensions: 1) the nature of
what was provided; 2) the source(s) of support; 3) whether social support was actually
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received (objective) or simply perceived (subjective) to be available; and 4) whether there
was an explicit or implicit expectation of reciprocity of support. Even with these limitations,
we can still draw firm conclusions from this body of literature.

Linking Social Support to Health Outcomes in High-Income Countries
Social relationships, or the relative lack thereof, constitute a major risk factor
for health rivaling the effect of well established health risk factors, such as
cigarette smoking, blood pressure, blood lipids, obesity and physical activity
(House et al., 1988)

The vast majority of research on social support has been conducted in Western Europe and
North America, with a focus on disease management, physical and mental health, and
responses to stress. This research provides evidence that social support is associated with a
decreased risk of mental and physical illness, as well as mortality (Achat et al., 1998; Holt-
Lunstad, Smith, & Bradley Layton, 2010; Lyyra & Heikkinen, 2006; Seeman, 2000), and
suggests that it positively affects cardiovascular, endocrine, and immune functioning
(Seeman, 1996; Uchino, 2006). It can also affect the way people cope with stress (Jackson,
2006), their adherence to medication (DiMatteo, 2004; Honda & Kagawa-Singer, 2006), and
their quality of life (Helgeson, 2003; Keyes, Michalec, Kobau, Zack, & Simoes, 2005). For
example, Strine and colleagues (2008) analyzed data from a state-based surveillance system
that collected data on social support, health-related quality of life, and health behaviors and
discovered that those who reported lower levels of social support had increased obesity,
physical inactivity, alcohol consumption, and a higher prevalence of smoking. Although the
exact means by which social support contributes to health and the factors that influence this
relationship are not yet entirely understood (Vitaliano et al., 2001), these findings indicate
that social support can affect and encourage engagement in positive health behaviors.

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Patient adherence may mediate the relationship between social support and health (Dunbar-
Jacob & Schlenk, 2001). Indeed, support from friends and family can promote patient
adherence, as it buffers the stress associated with the illness, encourages optimism, reduces
depression, and improves healthful behaviors (Shumaker & Hill, 1991; Wallston, Alagna,
DeVellis, & DeVellis, 1983). In a recent meta-analysis, DiMatteo (2004) identified 122
studies published between 1948 and 2001 that correlated social support with patient
medication adherence across multiple medical conditions. The study found that patients were
over two times more likely to adhere if they had greater levels of social support; social
support also had a greater effect on adherence for patients that took more than one
medication. Additionally, this investigation revealed that adherence was strongly and
consistently associated with functional support (i.e., instrumental and emotional support) as
compared to structural support (i.e., living arrangements and relationship status).

However, not all studies on social support demonstrate benefits. Wills and Vaughan (1989)
found that some social relationships might actually encourage partaking in unhealthy
behaviors, such as drinking alcohol, smoking, and drug use among adolescents. Additionally,
findings from Bolger, Zuckerman, and Kessler (2000) suggest the actual receipt of social
support can enhance stress. In this study, couples kept daily diaries that documented
stressors they experienced, the intensity of the stressor, and whether they received or
provided support to their partners. The recipients of support reported poorer adjustment to
stress, suggesting they might feel a sense of obligation following the receipt of supportive
acts. However, stress-protective effects were found when the support provider reported
conducting supportive acts and the recipient did not realize they had received the support.
These findings suggest that the most effective form of support is that which is invisible, in
that the recipients of support are unaware of the assistance theyve received. Interestingly,
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recent studies have also documented the benefits of providing support on health and well-
being (Brown, Nesse, Vinokur, & Smith, 2003; Gruenewald, Karlamangla, Greendale, Singer
& Seeman, 2007; Krause, 2006).

The influence of social support on positive health outcomes may also differ by gender and
culture. In the United States, researchers have documented differences between men and
women when receiving support. In a meta-analysis examining gender differences in relation
to coping with stress, women were more likely to seek and use support to handle the stressors
they encounter, as compared to men (Tamres, Janicki & Helgeson, 2002). Furthermore, in an
experimental study that had couples conduct stressful tasks alone and with their partners
found that the presence of the wife buffered mens stress response when completing tasks,
but the presence of the husband increased stress for women when completing tasks (Kiecolt-
Glaser & Newton, 2001). Since gender roles differ across cultures, it is difficult to ascertain
whether these findings would be similar in LMIC.

Taylor (2007) suggests social support may be experienced differently across cultures and is
an area in need of further study. Given that much of the research on social support has been
conducted in Western cultures, which tend to value independence (Markus & Kitayama,
1991) and many other cultures (Asian, Southern European, and Latin) value interdependence,
it is importance to understand how and whether the protective factors associated with social
support differ across cultures. In this review, we will examine and summarize the literature
on social support in low and middle-income countries, with an emphasis on HIV/AIDS.

Methods
Search Strategy and Selection Criteria
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We searched PubMed, the Cochrane Central Register of Controlled Trials, Social Sciences
Citation Index and PsycINFO for manuscripts published in peer-reviewed journals on the
topic of social support for people with HIV, from January 2000 to June 2012. A
comprehensive search strategy, which included a range of terms and keywords relevant to
social support, HIV, and low and middle-income countries, was used. The search was not
restricted by age, gender, or sexual orientation, and no language restrictions were imposed.
After removing duplicates, a total of 542 published papers were found during the electronic
search. Two researchers reviewed the abstracts of the published papers and excluded articles
that did not: 1) focus on a low or middle-income country; 2) have a study sample that
consisted of at least 50% PLWHA; 3) directly measure the construct of social support; and 4)
study the influence of social support on any health-related variables. Full texts of 74 articles
were reviewed and of those, 46 were eligible for inclusion in this narrative review.

Systematic review methods were not utilized for this paper, since measurement of social
support differed greatly across studies and the effectiveness of social support interventions
was not the primary purpose of this review. The purpose of this review is to summarize
research studies on social support among people living with HIV/AIDS in low and middle-
income countries, identify significant findings in this body of literature, and suggest future
research directions needed to expand our understanding of social support among PLWHA in
LMIC.

Results
Almost all of the studies examining the influence of social support on the lives of people with
HIV/AIDS in low- and middle-income countries employed scales that did not distinguish
between the varying types of social support identified by House et al. (1981). A composite
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score of social support was used in most cases, as outlined in Tables 2-5, which includes a
summary of included articles and specifies their measurement of social support. Because of
this, the review is instead organized across four main topics that appeared readily in the
studies on social support among PLWHA in LMIC. The topics included adherence to
medication (serostatus disclosure [4] and access to care [1] were subsumed in this category;
23 articles total), mental (13 articles) and physical health (5 articles), and quality of life (6
articles). Lastly, articles evaluating social support interventions are outlined in Table 1 below
and described in detailed across the four main topical areas.
Table 1. Summary of Articles Evaluating an Intervention in Relation to Social Support (SS) Among
PLWHA in LMIC
Study Country Sample Purpose Intervention
Description
Major Findings Related to SS
Cantrell et
al., 2008
Zambia N=636
PLWHA
(212 male,
414
female)
To evaluate
the effect of
nutritional
support on
ART
adherence
Home-based
adherence support
program that employs
community health
workers to monitor
and encourage patient
adherence to ART, as
well as household
food security.
Patients from 4 clinics
were provided
nutritional support,
while four other
clinics served as the
control arm and only
offered the adherence
support program
without food
supplementation.
Nutritional support was
associated with improvements in
adherence and medication pick-
up. Seventy percent of patients
in intervention arm achieved a
medication possession ratio of
90% or greater, as compared to
only 48% of patients in the
control group (relative risk=1.5;
95% confidence interval: 1.2 to
1.8). However, the provision of
food did not have a significant
effect on weight gain or CD4
cell response.
Chang et
al., 2010
Uganda N=1336
(gender
not
specified)
To examine
the effects of
community-
based peer
health
worker
intervention
on AIDS
care
Fifteen AIDS clinics
were randomized to
receive either the
intervention (N=10)
or control (N=5).
Peer health worker
intervention tasks
were conducted in the
clinics (e.g., providing
ART counseling and
support) and at the
patients' home (e.g.,
counsel and educate
patients on ART
adherence and other
HIV-related health
issues). The analysis
was by intention to
Primary outcomes included
adherence and cumulative risk
of virologic failure; secondary
outcomes were virologic failures
at 24 week intervals. No
significant differences were
found for adherence or
cumulative risk of virologic
failure. However, virologic
failure rates significantly
decreased in intervention arm as
compared to the control.
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treat.
Li et al.,
2011a
**

China N=167 (88
PLWHA,
79 family
members
To examine
the
effectiveness
of a family
intervention
at
decreasing
depressive
symptoms
and
improving
SS
Recruited and
randomized
participants into the
TEA intervention
(N=38) and a control
group (N=41). The
TEA family
intervention consisted
of three main
components: 1) small
group for PLWHA
and family; 2) home-
based family
activities; and 3)
community events
that build social
integration.
Intervention participants
reported significant
improvements in depressive
symptoms, SS, and family
functioning post-intervention, as
compared to the control group.
Muhamadi
et al.,
2011
Uganda N=400
PLWHA
(143 male,
257
female)
To examine
the effects of
a post-test
counseling
intervention
on uptake of
pre-ART
care
400 participants were
recruited and
randomized into the
intervention (N=200)
or the control
condition (N=200).
The intervention
consisted of post-test
counseling by trained
counselors, combined
with monthly, 2-hour
home visits by
community support
agents for continued
counseling.
Participants in control
arm received standard
care, including post-
test counseling by
staff without formal
training in counseling.
Provision of post-test counseling
intervention had a significant
effect on uptake of pre-ART
care, retention in care, and
disclosure of HIV status.
Intervention participants were
80% more likely to accept pre-
ART care as compared to the
control.
Mundell
et al.,
2011
**

South
Africa
N=361
pregnant
HIV-
infected
women
To evaluate
a structured
SS group
intervention
Intervention study
with a non-
randomized, quasi-
experimental design.
144 patients
participated in the
intervention, while
217 served in the
control group. The
intervention consisted
of 10 structured
psychosocial support
Intervention arm increased
disclosure, active coping
(t=2.68, p<0.05), self-esteem
(t=2.11, p<0.05), and reduced
avoidant coping (t=-2.02,
p<0.05) as compared to the
control group.
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sessions addressing
issues at the
individual level,
ranging from HIV-
related knowledge to
disclosure, and coping
with stigma.
Munoz et
al., 2011
**

Peru N=60
PLWHA
(gender
not
specified)
To evaluate
the
effectiveness
of a tailored
SS
intervention
on
adherence
Adherence
intervention
consisting of
Community-based
Accompaniment with
Supervised
Antiretroviral (CASA)
support (12 months of
home-based DOT-
HAART delivered by
community health
workers). Other
intervention
components were
tailored to participants
and included the
provision of
emotional and
instrumental support,
microfinancing, and
peer support groups.
Intervention had impact on
adherence (79% of intervention
group was adherent, as
compared to 44% of those in
control), virologic suppression
(66.7% versus 46.7%) and
mortality; participants reported
higher SS (t=3.97, p<0.01) and
lower stigma (t=2.89, p<0.01)
Smith
Fawzi et
al., 2012
Haiti N=178
(168
youth, 130
caregivers)
To examine
the
effectiveness
of a
psychosocial
support
group
intervention
Psychosocial support
group intervention for
HIV-infected youth
and their caregivers
carried out bi-monthly
over the course of 1
year. Consisted of
two phases, phase one
included eight group
sessions for HIV-
positive caregivers
that focused on coping
with the challenges
related to HIV. The
second phase
consisted of six
sessions for
caregivers, seven
sessions for children,
and eight sessions
with both children and
caregivers. Sessions
typically focused on
building support,
lessening distress, and
increasing awareness.
Youth had less psychological
symptoms and improved
psychological functioning and
SS post-intervention. Caregivers
had reduced depressive
symptoms, stigma, and
increased SS post-intervention
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Vu et al.,
2012
**

Vietnam N=228
PLWHA
(155 male,
73 female)
To examine
the
effectiveness
of a peer
support
intervention
on QOL and
internalized
stigma
In the intervention
group, participants
(N=119) received
adherence support
from trained peer
supporters who visited
participants' homes
regularly. The control
(N=109) did not
receive the
intervention.
QOL significantly improved for
intervention participants that
presented at clinical stages 3 and
4 at baseline
**
indicates the use of a validated measures of SS

Adherence and Social Support
Adherence is the second strongest predictor of progression to AIDS and death, after CD4
count (Amberbir, Woldemichael, Getachew, Girma, & Deribe, 2008); high levels of
adherence to ART regimens are necessary to achieve and maintain viral load suppression and
prevent drug resistance (Mills et al., 2006a). Numerous factors may contribute to whether a
patient is adherent to antiretroviral therapy, including whether they have social support. For
instance, Shin and colleagues (2008) conducted a study to identify risk factors for non-
adherence among 43 patients infected with HIV and tuberculosis in Peru; analysis indicated
low social support, substance use, and depression were associated with non-adherence (see
also Amberbir et al., 2008; Peltzer, Friend-du Preez, Ramlagan, & Anderson, 2010).
Additionally, Adewuya et al. (2010) also found a significant relationship between perceived
social support and low adherence; compared to those reporting strong social support, those
reporting fair social support were over three time more likely to report non-adherence and
those reporting poor social support were close to nine times more likely to report low
adherence. Furthermore, a study on the predictors of adherence among PLWHA in Ethiopia
provided evidence that social support was an independent predictor of adherence to ART
(Amberbir et al., 2008).

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Peltzer et al. (2010) assessed the factors contributing to ART adherence among 736 PLWHA
in South Africa; findings revealed that those residing in urban areas were up to three times
more likely to be adherent as compared to those residing in rural areas. The authors suggest
this finding is reflective of the lack of resources available in many rural setting. Poor
environmental factors (e.g., safe and healthy physical environment, having enough money,
ability to access information and health services) and experiences of discrimination were also
associated with lower adherence. Luszczynska, Sarkar, and Knoll (2007) investigated the
relationship between resource variables (social support, self-efficacy, and finding benefits in
disease) and patients physical functioning and adherence to antiretroviral therapy among 104
PLWHA and found that adherence was moderately correlated to receiving social support,
higher self-efficacy, and finding more benefits. Path analysis revealed that both social
support and self-efficacy were related to better physical functioning and finding more
benefits in living with HIV. Although social support was unrelated to adherence directly, the
effects of social support on adherence were mediated by self-efficacy. These findings
suggest that patients that receive more social support are more likely to have stronger self-
efficacy, which in turn can influence both physical functioning and adherence (Luszczynska
et al., 2007).

Support from ones family has also been documented as a source of assistance in accessing
(Posse & Baltussen, 2009) and adhering to ART (Nassali et al., 2012), with some studies
finding that those with family support were twice as likely to adhere to ART than those that
did not have support from family members (Harris et al., 2011; Tiyou, Belachew, Alemseged,
& Biadgilign, 2010). Chamroonsawasdi, Insri, and Pitikultang (2011) confirmed these
findings and produced results that highlighted the significant predictive value of family
support on ART adherence among 230 PLWHA in Thailand. Though, Li et al. (2010) found
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the relationship between social support and adherence to be non-significant, they identified a
predictive relationship between family communication and adherence. Findings from
Muoghalu and Jegedes (2010) study on the role of culture and family among PLWHA in
Nigeria suggest family members feel a sense of cultural obligation to those infected with HIV
and thus care and support them. Likewise, in a study that qualitatively examined the affects
of family support on PLWHA in China (Li et al., 2006), study investigators demonstrated the
myriad ways in which family support (e.g., financial assistance, support in serostatus
disclosure, medical assistance, and psychological support) positively impacted PLWHA.
Although family members experienced high levels of shame and psychological pressure once
their kins HIV status was revealed, this process also brought family members closer and
enhanced support to the PLWHA.

In a qualitative study conducted in South Africa, which consisted of two focus groups (n=12)
with PLWHA and seven in-depth interviews with health care providers, researchers
concluded that family members (excluding spouse/partners) were more likely to be chosen as
treatment supporters and assist with decision-making on care and treatment (Nachega et al.,
2006). Although health care providers emphasized the support needed from clinicians and
adherence counselors, patients identified the financial/material, instrumental, and emotional
support provided by family members as essential to maintenance of high adherence levels.
There is conflicting evidence on whether the support of a spouse/partner may improve or
reduce adherence. Most studies in low- and middle-income countries suggest women face
violence, shame, and stigma from partners once their serostatus is disclosed (Akani &
Erhabor, 2006), while other studies suggest it may be beneficial (Skogmar et al., 2007;
Nassali et al., 2009). Research shows women that disclose their HIV status have increased
social support (Antelman et al., 2001); major reasons for disclosure among both men and
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women included the expectation of economic, spiritual, and emotional support (Akani &
Erhabor, 2006). Indeed, Rotheram-Borus and colleagues (2010) confirmed serostatus
disclosure to be significantly and positively associated with ART adherence in Thailand, in
addition to family functioning and social support.

In resource-limited settings, the impact of poverty on health behaviors and health services
can limit ones ability to access (Posse et al., 2009) and adhere to ART (van Oosterhout,
2005; Brouwer, Lok, Wolffers, & Sebagalls, 2000). Studies have found financial constraints
to be a significant barrier to access and adherence, as patients with middle or high average
family income more likely to adhere as compared to those with low family income (Tiyou et
al., 2010). Patients with high transportation costs (Portelli, Tenni, Kounnavong, &
Chanthivilay, 2012; Posse et al., 2009) and food insecurity (Goudge & Ngoma, 2011),
defined as having limited availability of nutritionally sufficient food (Anderson, 1990), also
faced significant barriers to adherence (Nachega et al., 2006). Additionally, a pilot study
conducted in Zambia found that providing nutritional support to food insecure individuals led
to significantly better adherence to ART and resulted in high medication pick-up as compared
to the control group (Cantrell et al., 2008).

In a study designed to evaluate the effectiveness of a community-based ART adherence
intervention, which included modified directly observed treatment (DOT), daily social
support, and comprehensive support (e.g., financial aid for lab tests and medication,
transportation and nutritional support), forty-eight percent of participants report food
insufficiency at baseline (Franke et al., 2011). Household food insufficiency was associated
with a twofold increase in the odds of having poor adherence to ART. Following the
intervention, participants in the intervention arm reported high levels of adherence; good
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adherence self-efficacy and high social support were significant protective factors against
poor adherence. Munoz and colleagues (2011) implemented a tailored DOT-oriented
intervention in Peru, which also combined components of microfinance assistance and peer
support groups as needed. Patients in the intervention group also received financial
assistance for lab tests and medication, as well as transportation and nutritional support.
Findings show the intervention was successful at increasing adherence and virologic
suppression, as well as reducing mortality within 24 months of implementation. Intervention
participants also reported higher levels of social support and reduced stigma post-
intervention. Though these interventions show promise, the study investigators did not look
at individual components of the interventions, which limits our understanding of what
activities yielded the most benefit.

The majority of research linking adherence to social support has been conducted on adults;
limited information is known about this relationship for children and adolescents. Although
Harris et al. (2011) did not collect data from children; their study revealed that having a child
was not only significantly associated with non-adherence, but also more than doubled the
odds of non-adherence. Findings from this study imply that having one or more children may
cause pressure on the part of the caregiver, which results in less care for oneself. In a study
that examined adherence among caregivers and their children in West Africa, data showed
that children whose caregivers disclosed their serostatus and participated in support groups
were more likely to be adherent. This finding suggests that parents healthy adjustment to
their HIV diagnosis can have benefits to HIV-infected children as well (Polisset, Ametonou,
Arrive, Aho, & Perez, 2009). In a qualitative study that consisted of in-depth interviews with
children and their caregivers (n=36), researchers assessed the barriers and facilitators to
adherence (Fetzer et al., 2011). Study findings indentified lack of food and hunger to be a
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significant barrier to adherence for both children and their caregivers, as taking medicine
without food often made them sick. Children reported the need for assistance from
caregivers in taking their medications and wanted their caregivers to show them love and
support in this process.
Table 2. Summary of Articles on Adherence and Social Support (SS) Among PLWHA in LMIC
Study Country Sample Purpose SS
Measurement
Major Findings
Related to SS
Adewuya et al.,
2010
Nigeria N=182
PLWHA
(86 male,
96 female)
To examine the
relationship
between
psychiatric
comorbidity
and ART
adherence
Single-item
question with a
likert-type scale
(poor, fair, and
good); focused
on support from
spouse/partner
Perceived SS was
significantly
associated with low
adherence; those that
reported poor SS
were 8 times more
likely to report low
adherence
Akani et al., 2006 Nigeria N=187
PLWHA
(105 male,
82 female)
To evaluate the
rate, pattern,
and barriers to
disclosure of
HIV status
SS was
qualitatively
assessed
Participants disclosed
to receive economic,
spiritual, and
emotional SS; fear of
stigma was a barrier
to disclosure.
Amberbir et al.,
2008
Ethiopia N=400
PLWHA
(161 male,
239 female)
To determine
the barriers and
facilitators to
ART adherence
A pre-tested
questionnaire
with 1 or more
questions on SS
was utilized
At baseline,
adherence was
common among
those that perceived
good SS (OR, 1.82).
At follow-up, SS was
found to be an
independent predictor
of adherence
Antelman et al.,
2001
Tanzania N=1087
pregnant
women
with HIV
To examine the
factors
predictive of
women's
disclosure
10-item survey
derived from the
validated Duke-
UNC Functional
SS
Questionnaire
Increases SS
associated with
increased disclosure
rates, as was
attendance at
voluntary self-help
group meetings
Chamroonsawasdi
et al., 2011
**

Thailand N=230
(55.2%
female)
To examine
predictive
factors of ART
adherence
Study
generated,
locally validated
questionnaire
with 15
questions on
family support
Family support
predicted adherence;
family SS also had
the highest in on
ART adherence as
compared to other
study variables
Fetzer et al., 2011 Democratic
Republic of
Congo
N=36 (18
children, 18
caregivers)
To examine the
effects of
child-caregiver
relationships
and
psychosocial
support;
barriers and
facilitators of
adherence were
Qualitatively
assessed
Lack of assistance in
the home was
documented as a
barrier to adherence,
as well as lack
food/hunger.
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also explored
Franke et al.,
2011
**

Peru N=134
PLWHA
(55 male,
79 female)
To examine the
relationship
between food
insufficiency
and ART
adherence
Single-item,
likert type
question on
food insecurity.
Duke-UNC
Functional SS
Questionnaire
also collected
Good adherence self-
efficacy and high SS
at baseline were
significantly
protective against
poor adherence; food
insecurity was
predictive of poor
adherence
Goudge et al.,
2011
South Africa N=22
PLWHA (5
male, 17
female)
To examine the
experiences of
PLWHA with
adherences
Qualitatively
assessed
Patients without
stable food sources
faced significant
barriers to ART
adherence
Harris et al., 2011 Dominican
Republic
N=300
PLWHA
To examine
risk factors for
low ART
adherence
Two-items on
family support,
both with a
likert scale
Risk factors for non-
adherent participants
included low SS and
adherence support;
these participants
were twice as likely
to be non-adherent
Li et al., 2006 China N=30
PLWHA
(36.7%
female)
To examine the
influence of
family support
on PLWHA
Qualitatively
assessed
Though family
members felt shame
and distress when
their kin's HIV status
was disclosed to the
community, this also
brought families
closer together.
Support provided by
family had multiple
levels of positive
impact on PLWHA,
Li et al., 2010
**
Thailand N=386
(67.3%
female)
To examine
barriers to
adherence
19-item,
validated
Medical
Outcome Study
SS Survey
Adherence was
significantly
associated with
family
communication.
Family
communication was a
significant predictor
of adherence.
Although SS was
measured, it was not
significant in any
analysis
18

Luszczynska et
al., 2007
**

India N=104
PLWHA
(63.5%
female)
To examine
between
resource
variables and
adherence
Received SS
and SS
satisfaction
subscales of
validated Berlin
Social Support
Scales
SS and self-efficacy
were related to better
physical functioning.
Effects of SS on
adherence were
mediated by self-
efficacy; SS
predicted self-
efficacy
Muoghalu et al.,
2010
Nigeria N=914 (461
male, 453
female)
To examine the
role of culture
and family
among
PLWHA
Analyzed
source of
support and
qualitatively
assessed
Cultural practices and
family play major
roles in care of
PLWHA, as
participants felt a
cultural obligation to
care for the sick
Nachega et al.,
2006
South Africa N=19 (12
PLWHA, 7
health care
providers)
To understand
how patients
select treatment
supporters and
identify the
components of
SS, which
might enhance
adherence
Qualitatively
assessed
Family members
most likely to be
chosen as treatment
support, which
participate in medical
decision-making and
adherence. Barriers
to adherence include
stigma and lack of
financial resources
and food. Disclosure
was identified as a
major factor in
securing effective
adherence support
Nassali et al.,
2009
Uganda N=289
HIV-
infected
mothers
To examine the
factors
associated with
adherence
Qualitatively
assessed
SS from spouse was
key motivator for
mothers to adhere
Peltzer et al. 2010 South Africa N=735
PLWHA
(70.2%
female)
To examine
factors
contributing to
adherence
3-items drawn
from the
validated SS
Questionnaire
on perceived
tangible and
emotional SS
Adherence is 3 times
more likely for urban
residents. Better
adherence associated
with higher SS and
social relationships,
as well as low rates
of depression.
Polisset et al.,
2009
Togo N=148 (74
children
with HIV,
74
caregivers
[42 had
HIV])
To examines
correlates of
pediatric
adherence
Single-item on
caregiver
participant in
support groups
Non-adherence
related to not
participating in
support groups.
Children whose
caregiver disclosed
their HIV status
during interviews
were also more likely
to be adherent
19

Portelli et al.,
2012
Laos N=43
PLWHA
(25 male,
18 female)
To examine the
barriers and
facilitators to
adherence
Qualitatively
assessed
SS and acceptance of
HIV status were
identified as
facilitators of
adherence, while
transportation costs,
stigma and
discrimination were
barriers. Stigma,
discrimination and
fear of disclosure
were linked to a lack
of SS
Posse et al., 2009 Mozambique N=280 (252
PLWHA,
28 health
workers)
To examine the
factors
perceived as
barriers to
accessing ART
Qualitatively
assessed
Patient resource
availability,
community
information, and
family support were
identified as clusters
of categories
associated with
access to ART
Shin et al., 2008 Peru N=43
PLWHA
(31 male,
12 female)
To examine
risk factors for
non-adherence
to ART
Validated Duke-
UNC Functional
SS
Questionnaire
Low SS associated
with non-adherence
Tiyou et al., 2010 Ethiopia N=319
PLWHA
(144 male,
175 female)
To examine the
predictors of
adherence
Study generated
SS questions
measuring
emotional,
financial,
physical care,
and food
provision
Family SS was an
independent predictor
of adherence. Those
with family support
were 2 times more
likely to adhere
**

Health and Social Support
Mental Health
The World Health Organization recommends the psychosocial needs (e.g., prevention and
treatment of mental health disorders, assistance with coping on discrimination and stigma,
and financial forms of assistance) of PLWHA be integrated into HIV care (World Health
Organization, 2005). Indeed, mental health among PLWHA is a pervasive issue, especially
in low- and middle-income countries where studies have shown depression rates reaching up
to 63% for those infected with HIV (Collins, Holma, Freeman, & Patel, 2006). Adewuya and
colleagues (2007) found a similar rate (59%) for participants with psychiatric disorders in
20

Nigeria. Their findings also reveal that having poor social support and the stage of disease
progression were significant factors associated with psychiatric disorders; those reporting
poor levels of social support were 11 times more likely to have a psychiatric disorder as
compared to those with good social support. Additionally, a study examining the
psychosocial and clinical factors associated with depression in Uganda demonstrated that
participants with both current and lifetime depressive disorder were less likely to have social
support, high self-efficacy, and be adherent to ART (Nakimuli-Mpungu, Musisi, Katabira,
Nachega, & Bass, 2011). These studies demonstrate the positive effects of social support on
mental health of those with HIV.

A qualitative study consisting of interviews with 79 PLWHA and an HIV-negative family
member (n=158) in rural China confirmed negative relationships between symptoms of
depression and protective factors, such as social support and family relations (Li, Liang, Ding
& Ji, 2011a). Zhao et al. (2011) utilized data from a longitudinal study of 1299 rural Chinese
children infected with HIV to examine whether functional measures of social support (i.e.,
informational, emotional, instrumental, and appraisal) and structural measures of social
support (i.e., social network, including family, friends, teacher, etc.) predicted psychosocial
outcomes. Study findings indicated informational support to be positively associated with
depression, but tangible support and support from family were negatively associated with
depression. Conversely, findings from Bajunirwe and colleagues (2009) provide conflicting
evidence of a significant, positive relationship between informational and affectionate
support with both mental and physical health, but not tangible support. Patients who received
more overall social support experienced less distress and perceived their health to be better
than those who received less social support. Additionally, they found informational support
and CD4 count to be independently associated with better quality of life for PLWHA and to
21

be protective of having a lower physical health score. These findings suggest social support
is positively correlated with psychological well-being, but the strength of correlations varied
by type and source of support.

Stigmatization, or the experience of discrimination to the extent that normal social life is
disrupted, can have a profound impact on the lives of PLWHA, as the experience can affect
their mental health (Wang et al., 2012), whether they disclose their serostatus (Akani et al.,
2006), and what level of social support they have available to them (Li, Lee, Thammawijaya,
Jiraphongsa & Rotheram-Borus, 2009). Adewuya et al. (2009) suggests the intense
stigmatization associated with having HIV can be traumatic for those in sub-Saharan Africa.
Their study examined the probability of developing posttraumatic stress disorder (PTSD)
after experiencing intense stigma; over 27% of participants reported experiences of HIV-
stigma related PTSD. Poor levels of social support was found to be an independent predictor
of this type of PTSD, as those with low social support were three times more likely to have
experienced HIV-stigma related PTSD. Similarly, Li et al. (2009) found that higher levels of
stigma were significantly associated with lower levels of social support, with low social
support significantly associated with higher levels of depression. Study findings also
revealed that both internalized shame and social support were significant predictors of
depression, after controlling for age, gender, education, and income level. In a study
investigating the relationship between varying risk and protective factors for depression,
involving 755 AIDS orphans and 466 children of HIV-infected parents in rural China, study
investigators documented that trusting relationships, future orientation and perceived social
support mediated the effects of traumatic events and HIV-related stigma on depression
(Wang et al., 2012). However, trusting relationships was the most influential protective
factor for depression.
22

Food insecurity may also be a risk factor for poor mental health, even though it can be altered
to improve health outcomes. Research conducted in developing countries has suggested an
association between food insecurity and poor mental health (Cole & Tembo, 2011; Gupta et
al., 2010; Maes, Hadley, Tesfaye, & Shifferaw, 2010). A cross-sectional study investigating
the prevalence and risk factors for depression in Uganda found food insecurity to be
significantly associated with depression, after controlling for age and gender. However, this
study also specified that social support was neither significantly associated with depression,
nor did it moderate the effects of stress, negative life events, or depression (Kinyanda,
Hoskins, Nakku, Nawaz & Patel, 2011). Conversely, Tsai and colleagues (2012) found
social support to buffer the effects of food insecurity on depression among women. Study
investigators went further to explore the type of social support that was most significant at
buffering this relationship and it was discovered that instrumental support was the most
influential variable. This longitudinal study, which collected data from 456 PLWHA in rural
Uganda, also found significant gender differences as increased severity of depression among
women was associated with increased food insecurity and decreased social support; these
findings were non-significant among men in the study sample.

Three studies highlighting findings from intervention programs, which contained a social
support component, aimed at improving participant mental health were obtained for this
review. The first study evaluated the effectiveness of a psychosocial support group
intervention for HIV infected youth (n=168) and their caregivers (n=130) in Haiti (Smith-
Fawzi et al., 2012). One year post assessments showed program participants had decreased
psychological symptoms, improved psychosocial functioning, and social support. Caregivers
(95% were HIV-infected) had significantly reduced depressive symptoms and HIV-related
23

stigma, as well as improved social support post-intervention. Qualitative findings were
convergent with quantitative, as decreased psychological distress and social isolation, as well
as greater hope for the future were emergent themes in analysis. The second intervention was
grounded in qualitative data collected from 317 women with two pilots conducted to refine
the intervention. The intervention consisted of 10 structured psychosocial support sessions
for newly HIV-infected, pregnant women in South Africa (Mundell et al., 2011). A total of
15 support groups were held for 144 women, while 217 women chose not to participate and
subsequently served as the control. The first follow-up assessment (2 months post-
intervention) indicated the intervention group had higher levels of active coping, lower levels
of avoidant coping, and those who attended at least half of the intervention support sessions
reported improvements in self-esteem. The second follow-up assessment (8 months post-
intervention) indicated the intervention groups rate of serostatus disclosure was significantly
higher than that of comparison group. The third intervention aimed at reducing depressive
symptoms and increasing social support for PLWHA and their family members in rural China
(Li et al., 2011b). The intervention had three main components: 1) small group sessions for
PLWHA and their family member; 2) home-based family activities; and 3) community events
intended to build social integration. A total of 79 families (n=167) were recruited with 38
families assigned to the intervention and 41 families in the control group. All PLWHA were
parents and more than half of family members were PLWHAs spouse. Intervention
participants reported significant improvements in depressive symptoms, social support, and
family functioning following the intervention. Gender emerged as significantly associated
with social support and family functioning, as men were more likely to perceive better social
support and family functioning as compared to women.
Table 3. Summary of Articles on Mental Health and Social Support (SS) Among PLWHA in LMIC
Study Country Sample Purpose SS Measurement Major Findings Related
to SS
24

Adewuya
et al., 2007
Nigeria N=175 (88
PLWHA, 87
non-HIV
infected)
To estimate the
prevalence of
psychiatric
disorders among
PLWHA, as
compared to the
control group
Single-item question
with a likert-type
scale (poor, fair, and
good)
Poor levels of SS were
significantly associate
with psychiatric
disorders; those with
poor SS were up to 11
times more likely to
have a disorder
Adewuya
et al., 2009
Nigeria N=182
PLWHA (86
male, 96
female)
To investigate
the correlates of
PTSD after
experiencing
intense forms of
stigma
Single-item question
with a likert-type
scale (poor, fair, and
good); focused on
support from
spouse/partner
Participants with low
SS were more likely to
have experienced HIV-
stigma related PTSD.
Bajunirwe
et al.,
2009
**

Uganda N=329
PLWHA
(107 male,
222 female
To examine the
factors associated
with QOL among
PLWHA on ART
Utilized Sarason's
validated SS scale,
which measures
tangible, affectionate,
and informational SS
Patients perceiving
more SS experienced
less health distress and
perceived themselves to
have better health as
compared to those with
low SS. CD4 count and
informational SS were
independently
associated with having
better QOL.
Kinyanda
et al., 2011
Uganda N=618 (169
male, 449
female)
To examine the
prevalence and
risk factors of
depression
Adapted the
European Parasuicide
Interview Schedule
SS not associated with
depression, but food
insecurity was
Li et al.,
2009
**

Thailand N=408
PLWHA
(72.5%
female)
To examine the
relationships
between SS,
depression, and
HIV-related
stigma
Composite score of
two subscales of
Medical Outcomes
Study SS Scale
Emotional SS
negatively associated
with depression;
internalized shame and
emotional SS
significant predictors of
depression.
Li et al.,
2011b
**

China N=158 (79
families [79
PLWHA, 70
family
members])
To examine the
predictive value
of SS and family
relationships on
depression
19-item, validated
Medical Outcome
Study SS Survey
Negative associations
between depressive
symptoms and both SS
and family relations
were observed; finding
true for both groups of
participants
Nakimuli-
Mpungu et
al., 2011
**

Uganda N=500
PLWHA
(151 male,
349 female)
To examine the
factors associated
with having
depression
12-item
Multidimensional SS
Scale, which was
validated in Uganda
PLWHA with
depressive disorder
were less likely to be
adherent, have SS, and
have self-efficacy
Tsai et al.,
2012
Uganda N=456
PLWHA
(132 male,
324 female)
To examine the
relationship
between food
insecurity and
depressive
symptoms, as
well as the
buffering effects
of SS
9-item Household
Food Insecurity
Access Scale and 10-
item modified Duke-
UNC Functional SS
Questionnaire
Food insecurity was
associated with
depressive symptoms
among women; SS
buffered the impact of
food insecurity on
depression
25

Wang et
al., 2012
**

China N=1221 (755
AIDS
orphans, 466
children of
HIV-infected
parents
To examine the
relationship
between
protective factors
for depressive
symptoms
16-item validated
scale for HIV-
infected children in
rural China
SS, trusting
relationships, and future
orientation mediated the
effects of stigma and
traumatic events on
depression. HIV-
related stigma was
negatively related to
perceived SS
Zhao et al.,
2011
China N=1299
HIV-infected
children (648
male, 651
female)
To examine the
predictive value
of functional
measures of SS
and structural
measures of SS
to psychosocial
outcomes
Study generated, 25-
item survey modeled
after the Medical
Outcome Study SS
Survey
SS linked to
psychological well-
being.
**

Physical Health
There was limited research linking social support to the physical health of PLWHA in low-
and middle-income countries. However, of the research that has been published, we are able
to ascertain that social support does play a significant role. For instance, in a cross-sectional
study conducted in South Africa, McInerny et al. (2008) provides evidence of a significant,
positive relationship between physical functioning and social support among 149 PLWHA.
In addition, a study exploring the impact of depressive symptoms and social support on CD4
cell progression and weight change among 1814 PLWHA in Ethiopia showed that strong
levels of social support had a positive effect on both weight gain and CD4 cell progression;
one unit increase in social support was associated with an average of 10kg increase in weight
(Alemu, Haile Mariam, Tsui, Ahmed & Shewamare, 2012). In a randomized control trial
assessing the effectiveness of a community-based peer health worker intervention on HIV
care in Uganda, 10 AIDS clinics participated in the intervention arm and five served as the
control (Chang et al., 2010). Peer health workers provided services with PLWHA both at the
clinics and in the patients home. These tasks included providing ART counseling and
support in group and individually while at the clinic and home visits consisted of health-
26

related discussions, reviews of symptoms, discussions on adherence, and pill counts. The
intervention was associated with decreased virologic failure rates occurring 96 weeks and
longer into ART, but did not affect cumulative risk of virologic failure, adherence measures,
or short-term virologic outcomes. A similar intervention paired post-test counseling by
trained staff with monthly home visits by community support agents focused on uptake of
pre-ART care for recently diagnosed program participants in Uganda (Muhamadi et al.,
2011). Following implementation of the intervention, program participants were 80% more
likely to accept pre-ART care, 67.5% more likely to return for care, and the majority
disclosed their serostatus to family as compared to the control group.
Table 4. Summary of Articles on Physical Health and Social Support (SS) Among PLWHA in LMIC
Study Country Sample Purpose SS Measurement Major Findings Related
to SS
Alemu et
al., 2012
Ethiopia N=1815
PLWHA
(667 male,
1056
female)
To explore the
effects of
depressive
symptoms and
perceived SS on
weight gain and
CD4 cell
progression
6 questions (5-point
rating scale) from
the Norbeck SS
Questionnaire were
used, that measured
emotional and
tangible support
SS had positive effect on
weight and CD4 cell
progression
McInerney
et al.,
2008
**

South
Africa
N=149
PLWHA
(95.6%
female)
To examine the
effects of various
psychosocial and
health-related
variables on
PLWHA
19-item, validated
Medical Outcome
Study SS Survey
Significant relationships
found between physical
functioning and SS
Rotheram-
Borus et al.,
2010
**

Thailand N=409
PLWHA
(72.6%
female)
To examine the
influence of
family, social
relationships and
disclosure on the
health of PLWHA
19-item, validated
Medical Outcome
Study SS Survey
Disclosure significantly
and positively associated
with SS and family
functioning. SS
significantly associated
with health and mental
health perceptions, as
well as better QOL and
fewer depressive
symptoms
**

Quality of Life and Social Support
Social support has been linked to improved quality of life (QOL) among PLWHA in a variety
of settings (Khumsaen, Aoup-Por & Thammachak, 2012; Skevington, Norweg & Standage,
27

2010). Indeed, in a study assessing the relationship between satisfaction with social support,
hope and QOL among PLWHA in Nepal, participants overall satisfaction with their social
support and hope was significantly and positively correlated with all domains of QOL
measured (i.e., physical functioning, psychological functioning, social relationships,
environmental functioning, and global functioning). Satisfaction from informational and
tangible support was a better predictor of quality of life as compared to satisfaction with
emotional support (Yadav et al. 2010). Khumsaen et al (2012) confirmed social support was
a statistically significant predictor of QOL. When examining the relationship between
personal characteristics, coping style, and social support on QOL among Thai PLWHA, they
also found QOL to be related to social support, living with family members, spiritual well-
being, monthly income and coping style. Additionally, Rotheram-Borus et al. (2010) found
social support to be significantly associated with both better QOL and fewer depressive
symptoms. This study of 409 PLWHA in Thailand also documented the significant
relationship between social support and PLWHAs self-perceptions of their physical and
mental health.

The concept of health-related quality of life (HRQOL), which encompasses more physical
health domains, is important to PLWHA as the disease impacts every part of their daily lives.
Social support has been significantly associated with the domains of HRQOL, but Bastardo
and Kimberlin (2000) found it to be correlated higher among mental and psychosocial scales
than those measuring physical health (e.g., physical functioning and bodily pain).
Interestingly, Tangkawanich, Yunibhand, Thanaslip and Magilvy (2008) found an indirect
effect between social support and HRQOL via self-care strategies (e.g., taking vitamins,
eating healthy foods, exercise, etc.). In addition, a negative direct effect between social
support and symptom experience was revealed. In an intervention providing adherence
28

support through peer supporters that conducted weekly home-visits in Vietnam, after 12
months, quality of life significantly improved among intervention participants that presented
at clinical stages three and four at baseline (Vu et al., 2012).
Table 5. Summary of Articles on Quality of Life (QOL) and Social Support (SS) Among PLWHA in
LMIC
Study Country Sample Purpose SS Measurement Major Findings
Related to SS
Bastardo et al.,
2000
**

Venezuela N=118
PLWHA
(generated
not
specified)
To examined
the relationship
between health-
related QOL,
SS, and
measures of
physical heath
Translated the
validated
Interpersonal
Support Evaluation
List into Spanish;
40 true-false
questions on
tangible, appraisal
and emotional SS
SS significantly
associated with all
domains of health-
related quality of life,
except physical
functioning and bodily
pain. Of all
independent variables,
SS explained the
largest amount of
variance.
Khumsaen et
al., 2012
**

Thailand N=120
PLWHA
(46 male,
74 female)
To examine the
relationship
between
psychosocial
factors and
QOL
Thai version of the
validated Personal
Resource
Questionnaire,
which has 25 items
Higher levels of SS
and living with family
members had a
significant positive
relationship with
QOL; SS was also a
statistically significant
predictor of QOL
Tangkawanich
et al., 2008
**

Thailand N=422
PLWHA
(188 male,
234 female)
To examine the
relationship
between SS,
self-care
strategies and
health-related
QOL
Thai version of the
validated Personal
Resource
Questionnaire,
which has 25 items
SS and self-care
strategies had a
positive direct effect
on health-related
QOL. SS had a
negative effect on
symptom experience
Yadav et al.,
2010
**

Nepal N=160
PLWHA
(110 male,
50 female)
To examine the
relationship
between
satisfaction with
SS and QOL
Nepali version of
the 14-item
modified Sarason's
SS Questionnaire
Satisfaction with SS
correlated with all
domains of QOL.
Tangible an emotional
SS were strong
predictors of physical
functioning,
psychological
functioning, and
environmental
functioning
**

Discussion
Key findings from research on social support effects among PLWHA in LMIC
29

The aim of this review was to identify and synthesize findings from studies that examined the
influence of social support on health-related outcomes among PLWHA in LMIC. We
reviewed a total of 46 studies and found that social support was examined relative to the
following four categories: adherence to ART medication, mental health, physical health, and
quality of life. Based on these studied, we are able to infer that social support is associated
with improvement in access and adherence to ART, medication uptake, retention in care,
physical functioning, CD4 cell progression, virologic suppression, body weight of PLWHA,
and mortality. The concept of social support has also been associated with the following
improvements in psychosocial functioning: stronger self-esteem, rates of serostatus
disclosure, self-efficacy, family functioning, active coping, and health outlook. Lastly,
research suggests social support may lead to reductions in HIV-related stigmatization,
psychiatric disorders, depression, psychological distress, and avoidant coping (See Tables 1-
5).

The key limitation of the literature on social support and HIV is that measurement of social
support differs across studies, with most utilizing a composite score of several distinct
components of social support in analysis. The several studies defining and exploring specific
types of support did yield results that help illustrate how components of support influence the
health domains we identified (See Tables 1-5 for the measures used across studies). The
concept of family support was positively associated with increased access and adherence to
ART, as well as reductions in depressive symptoms. Though instrumental support was an
independent predictor of quality of life, there was conflicting evidence on whether it lessened
or improved depression; whereas emotional support was consistently linked to reductions in
depression. Informational support appeared to be the most influential of the differing types
of support, as it was associated with increased mental and physical health, as well as quality
30

of life. As Taylor (2007) explains, informational support provides individuals with relevant
information, which can thus empower them in decision-making and taking ownership of their
health.

Of the 49 articles reviewed, only eight evaluated interventions that contained a distinct
component of social support. Five of these interventions focused on adherence support for
PLWHA, while three addressed mental health concerns. Although the majority of the
interventions studied contained multiple levels (e.g., support groups combined with
microfinance and home-based adherence support), none explored the specific components to
provide detailed information on which aspects were most beneficial. However, based on
these interventions, we can infer that interventions providing social support in the form of
nutritional support, adherence support, directly observed treatment, structured peer support
groups, microfinancing, and coverage of diagnostic exams and transportation, yield positive
outcomes for those with HIV.

The relationship between social support and improved ART adherence is particularly
significant. Although they can lengthen life and reduce the changes of onward transmission
(Anglemyer, Rutherford, Baggaley, Egger & Siegfried, 2011); ART medications require a
strict level of adherence to be effective and minimize drug resistance (Mills et al., 2006b).
Patients that develop drug resistance must turn to a second-line ART regimen, but in LMIC
these are often far more expensive than first-line regimens (World Health Organization,
2010).

Directions for future research and intervention on social support
31

The majority of social support literature from LMIC is focused on adherence, and rates of
adherence are generally high (Tiyou et al., 2010). A recent meta-analysis (Mills et al.,
2006b) shows that adherence rates are higher in resource-limited countries as compared to
developed countries. Future studies should thus be directed toward less well understood
relationships such as the association between income-generating activities, stigmatization and
disclosure on health outcomes. These studies have the potential to guide future intervention
efforts with significant potential.

Strengthening social support among PLWHA in LMIC cannot occur without also addressing
the pervasive stigmatization and discrimination often associated with HIV in these contexts,
as well as fear of disclosure of ones HIV status. In general, research shows a cyclical pattern
in which people choose not to disclose their status out of fear of stigma and violence, but that
those that do disclose their status are often able to develop strong social support networks and
surround themselves with people that are experiencing similar issues in regards to HIV and
coping. Findings from this review suggest that those that disclose their HIV status are more
likely to adhere to medication, due to increased social support. Anti-stigma campaigns are a
potential solution, as more will disclose their HIV status, which may lead to increased social
support and all the benefits associated with strong social support.

Multifaceted interventions aimed at increasing social support need to be developed; these
interventions would benefit from financial assistance and nutritional support components.
The benefits of the varying components need to be analyzed in relation to health outcomes.
Indeed, effective strategies to strengthen positive social support need to ascertain what level
of social support yields positive health outcomes (i.e., what is an adequate level of social
32

support?). The varying influence of social support on men, women, and children also needs
to be examined further.

In general, the measurement of social support should be improved. Of the 46 studies we
included, only 19 used validated measures (developed in high-income countries), and only 3
of the studies validated the instrument in their local settings. Furthermore, the majority of
studies were cross-sectional and future study should focus on intervention effects and on
trends in social support levels, to understand the dynamic nature of it.

In addition to measurement inconsistency and lack of specificity, there are key areas in need
of further study. Limited research has been conducted in LMIC on social support provided
by care providers. Research in the US has demonstrated the important role of care provider
support on adherence and should be replicated in LMIC. Community-level studies of social
support interventions are also lacking.

Despite the limitations in the research directed at social support in LMIC, it is clear that
social support plays an important role relative to health outcomes among people with HIV.
Researchers should leverage what we know in the development of interventions to improve it
among all people living with HIV/AIDS.

33

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