Coping Strategies and Symptoms of Mental Health Disorders Among People with HIV Initiating HIV Care in Cameroon

Advances in HIV treatment have increased life expectancy and improved quality of life among people with HIV (PWH) [1‐3]. As a result of increased access to and efficacy of antiretroviral therapy (ART), HIV can now be managed as a chronic disease. Despite significant advances in HIV treatment, PWH continue to experience numerous psychosocial stressors including HIV-related stigma, interpersonal conflict and violence related to HIV disclosure, HIV- and non-HIV-related grief and loss, and HIV- and non-HIV-related material hardship [4‐6]. This is particularly relevant among PWH in sub-Saharan Africa (SSA) where the majority of PWH reside and where the burden of material hardship, interpersonal violence, and HIV-related stigma has been well-documented [7‐9].

PWH are also at increased risk of mental health disorders across global settings [10, 11]. It has been estimated that approximately half of PWH screen positive for one or more mental or substance use disorders. Psychosocial stressors have been associated with increased prevalence of mental and substance use disorders among PWH [7, 12, 13]. Psychosocial stressors and mental and substance use disorders have been consistently associated with poor HIV treatment outcomes, including engagement into HIV care with advanced HIV, delayed ART initiation, poor ART adherence, and virologic failure [14‐17].

The chronic nature of HIV infection and the high prevalence of psychosocial stressors and mental health disorders among PWH call for better understanding of the ways in which PWH cope with stressful situations. Coping has been defined as the cognitive and behavioral strategies used to manage situations that tax or exceed the resources of an individual [18]. A wide range of coping strategies exist and vary across cultures [19, 20]. Coping strategies have been commonly categorized as adaptive or maladaptive [21]. Adaptive coping strategies include those that foster active engagement with psychosocial stressors in ways that may impact positive change and typically include planning, acceptance, positive reframing, and the use of emotional support, among others. Adaptive strategies have been associated with improved mental health and reduced stress [22, 23]. Among PWH, adaptive coping strategies have also been associated with better HIV treatment outcomes, including greater ART adherence and health-related quality of life [24‐26]. Maladaptive coping strategies include those that foster avoidance or disengagement from psychosocial stressors and include strategies such as distraction, disengagement, denial, and substance use, among others. Maladaptive strategies have been associated with increased stress and worse mental health [27, 28]. Among PWH, maladaptive strategies have been associated with suboptimal HIV treatment outcomes, including delayed ART initiation, poor ART adherence, and lower likelihood of viral suppression [29‐31].

Little is known about the coping strategies used among PWH, especially in SSA where PWH are at substantial risk of economic and psychosocial stressors, and the extent to which coping strategies are associated with symptoms of mental health disorders among PWH in SSA. A meta-analysis of coping strategies among PWH found that maladaptive coping strategies of disengagement and substance use were associated with worse mental and physical health while adaptive coping strategies of active coping and positive reframing were associated with better mental and physical health [32]. However, this meta-analysis only included studies from high-income countries. Among studies that have examined coping among PWH in SSA, findings are equivocal. Research with PWH in Botswana and pregnant women with HIV in South Africa found that adaptive coping strategies were negatively associated with depressive symptoms and maladaptive coping strategies were positively associated with depressive symptoms [33, 34]. However, a study among women with HIV in Uganda found that adaptive coping strategies were positively associated with depression and anxiety symptoms [35].

Coping strategies are potentially modifiable mechanisms that may improve the mental health and well-being of PWH. Given the prevalence of mental health disorders among PWH in SSA and the well-established mental health treatment gap in the region, greater understanding of coping among PWH in SSA and the relationship between coping and mental health can inform the development and implementation of coping-related interventions to improve the mental health and quality of life of PWH in SSA [36, 37]. This research sought to: assess the construct validity of the Brief Coping Orientation to Problems Experienced Scale (Brief COPE), describe the prevalence of unique coping strategies, and examine the relationship between coping strategies and symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) in a population of PWH entering HIV care in Cameroon.

Most respondents were female (58.7%), 21–39 years of age (58.5%) and in a romantic relationship (58.5%) (Table 1). The exploratory factor analysis of the original 28-item Brief COPE identified a two-factor structure that accounted for 81% of the total variance. Both items from the active coping, use of emotional support, use of instrumental support, positive reframing, religion, and planning subscales and one item each from the acceptance and humor subscales loaded on Factor 1 which was named ‘adaptive coping strategies.’ Both items from the self-blame, venting, disengagement, and denial subscales loaded on Factor 2 which was named ‘maladaptive coping.’ Both items from the distraction and substance use subscales and one item each from the humor and acceptance subscales did not load onto the two-factor structure. Therefore, the exploratory factor analysis identified 22 items from the original Brief COPE that loaded onto two subscales of adaptive and maladaptive coping.

Younger age (χ² = 8.79, p = 0.01), being female (χ² = 6.50, p = 0.04), lower levels of formal education (χ² = 12.12, p = 0.02), not being in a romantic relationship (χ² = 14.39, p < 0.01), and experiencing moderate or severe household hunger (χ² = 11.80, p < 0.01) were associated with greater endorsement of maladaptive coping strategies (Table 1). In contrast, not being in a romantic relationship (χ² = 6.50, p = 0.04) was the only sociodemographic characteristic assessed that was associated with greater endorsement of adaptive coping strategies (Table 1).

Religious coping was the most commonly reported coping strategy: 70.4% of participants reported that they prayed or meditated a medium amount or a lot and 68.8% that they tried to find comfort in their religion or spiritual beliefs a medium amount or a lot (Table 2). The least frequently used coping strategy was substance use with 13.8% reporting that they used alcohol or drugs to feel better a medium amount or a lot and 11.3% reporting that they used alcohol or drugs to get through difficult situations a medium amount or a lot.

Participants reported a variety of concurrent coping mechanisms (Table 3). Overall, 16.4% of participants reported low levels of both adaptive and maladaptive coping and 15.7% reported high levels of adaptive and maladaptive coping. On the contrary, just 5.4% of individuals reported high maladaptive coping and low adaptive coping and 3.3% reported high adaptive coping and low maladaptive coping.

Across all mental health disorders assessed, greater maladaptive coping was associated with higher prevalence of mental health symptoms. The prevalence of moderate to severe depressive symptoms was 2.2%, 18.1%, and 40.9% among those in the lower, middle, and upper tertiles of maladaptive coping, respectively (Table 4). Similarly, the prevalence of moderate to severe anxiety symptoms was 6.0%, 19.5% and 33.1% and the prevalence of probable PTSD symptoms was 2.2%, 12.9%, and 32.1% among those in the lower, middle, and upper tertiles of maladaptive coping, respectively. In contrast, level of adaptive coping was not significantly associated with any of the mental health outcomes assessed.

In multivariable analyses greater maladaptive coping was associated with significantly greater prevalence of all mental health outcomes assessed (Table 5). Individuals in the upper tertile of maladaptive coping had 2.7 (95% CI 1.8, 3.9) times the prevalence of moderate to severe depressive symptoms, 2.2 (95% CI 1.4, 3.3) times the prevalence of moderate to severe anxiety symptoms, and 3.4 (95% CI 2.0, 5.5) times the prevalence of probable PTSD symptoms compared to those in the lower two tertiles of maladaptive coping. Adaptive coping was not associated with symptoms of any of the mental health disorders assessed in bivariate or multivariable models.

In this study, we explored coping strategies and the psychometric properties of the Brief COPE among PWH initiating HIV care in Cameroon. In the exploratory factor analysis, we found 22-items from the Brief Cope clustered around two key domains: ‘adaptive’ and ‘maladaptive’ coping. Greater maladaptive coping was associated with greater prevalence of symptoms of depression, anxiety, and PTSD. In contrast, adaptive coping was not significantly associated with any of the mental health outcomes assessed.

In this revised version of the Brief COPE, two items each related to distraction and substance use were removed, along with one item each related to humor and acceptance. Interestingly, even though distraction was not included in the maladaptive factor, distraction was commonly endorsed as a coping strategy among this group of PWH in Cameroon with 46% reporting that they turned to work or other activities to take one’s mind off things and 65% reporting that they do something to think about stressful situations less. This is somewhat similar to research with PWH in Nigeria which found that 75% of participants reported using distraction to cope and research with pregnant women with HIV in South Africa which found that distraction was the most frequently used maladaptive coping strategy reported [55, 56]. On the contrary, substance use, the other coping strategy removed from our modified version of the Brief COPE, was the least commonly endorsed coping strategy with less than 15% of participants reporting using alcohol or other drugs as a coping strategy. More research is needed to understand the ways in which distraction and substance use function as coping mechanisms among PWH in Cameroon and the relationship among substance use, distraction, and other maladaptive coping strategies.

Religion was the most frequently used coping strategy among this group of PWH in Cameroon with 70% reporting using religion to cope. This is consistent with previous research that has found religion to be among the most commonly used strategies to deal with stress or mental health concerns among PWH in SSA. Research with women with HIV in South Africa and PWH in Ethiopia and Zimbabwe found that religion was among the most frequently reported coping strategies [34, 57, 58]. Similarly, research with women (with and without HIV) in Ethiopia found that 75% reported using religion to cope with depression [59]. Interestingly, prior research with this same group of PWH in Cameroon found that religious leaders were the most commonly reported source of mental health support with 40% of participants with symptoms of a mental health or substance use disorder reporting seeking mental health-related support from religious leaders [60]. In recognition of the important role of religious leaders and faith healers across global settings, the 2013–2030 World Health Organization Mental Health Action Plan recommended greater collaboration with religious leaders and faith healers as mental health treatment resources [61]. Religious leaders can play an important role in reducing mental health- and HIV-related stigma, promoting adaptive coping strategies, providing culturally appropriate, safe, and effective mental health treatment, and reducing the mental health treatment gap [62]. Greater collaboration between religious leaders and the medical community has the potential to increase access to mental health care, destigmatize mental health disorders and treatment, and enhance the cultural relevance of mental health treatment [62]. Research to advance understanding of acceptable and sustainable methods of collaboration between religious leaders and the medical community is needed, particularly in SSA.

In multivariable analyses, endorsing a high level of maladaptive coping was associated with significantly greater prevalence of depression, anxiety, and PTSD symptoms. However, endorsing a high level of adaptive coping strategies was not associated with the prevalence of symptoms of depression, anxiety, or PTSD. Similar to current study findings, previous research has found maladaptive coping strategies to be positively associated with mental health symptoms. For example, studies with PWH in Botswana and pregnant women with HIV in South Africa found that maladaptive coping strategies were positively associated with depressive symptoms [33, 34]. A study with PWH in Vietnam found that maladaptive adaptive coping strategies were associated with depression [63]. Contrary to current findings, prior research has found adaptive coping strategies to be associated with lower prevalence of mental health symptoms [22, 23]. Further research is needed to better understand the relationship between adaptive coping and mental health in this context.

Coping is a multidimensional process. Participants concurrently endorsed a variety of coping mechanisms, both adaptive and maladaptive. A US-based study of men who have sex with men (MSM) living with HIV similarly found that the concurrent use of adaptive and maladaptive coping strategies was commonly reported. Importantly, this US-based study also found that greater use of maladaptive coping strategies was associated with higher prevalence of depressive symptoms, regardless of use of adaptive coping strategies [64]. Our research aligns with these findings and suggests that in the presence of high maladaptive coping, concurrent adaptive coping may be insufficient to improve mental health.

Interventions that seek to reduce maladaptive coping strategies have the potential to improve the mental health of PWH in Cameroon and may be more effective than interventions focused exclusively on enhancing adaptive coping. However, few coping-focused interventions have been developed and implemented with PWH in SSA. A coping-focused intervention with women in South Africa with HIV and sexual abuse histories was associated with reduced PTSD symptoms and increased social or spiritual coping [65]. A coping-focused intervention for bereaved PWH in the U.S. was associated with decreased depression. Further, this relationship was mediated through avoidant coping [66]. That is, the intervention was associated with decreased avoidant coping which, in turn, was associated with decreased depression [66]. A coping intervention with PWH in the U.S. who experienced childhood sexual abuse was associated with reduced PTSD symptoms and alcohol use [67, 68]. Given the well-documented global mental health treatment gap and the modifiable nature of coping strategies, coping-focused interventions, particularly ones that can be task-shifted and delivered by non-specialized providers, present a promising and feasible strategy to improve the mental health of PWH in SSA and other resource-limited settings.

This study has limitations worth noting. Data were collected from three urban HIV treatment facilities in Cameroon and may not be fully representative of other areas of Cameroon or SSA. In addition, all participants were initiating HIV care at the time of study enrollment, and time of first HIV-positive diagnosis was unavailable for study participants. Coping strategies may differ based on time since diagnosis and time in HIV care. Finally, all data are cross-sectional. As such, the causal relationship between coping mechanisms and symptoms of mental health disorders cannot be assessed.

Our study found that PWH endorsed a range of concurrent adaptive and maladaptive coping strategies. Greater maladaptive coping was associated with worse mental health across all outcomes assessed. Future efforts should explore the extent to which coping strategies change throughout the HIV care continuum. Interventions to reduce maladaptive coping have the potential to improve the mental health of PWH in Cameroon.