Factors associated with hostility among people living with HIV/AIDS in Northeast China: a cross-sectional study

Acquired immune deficiency syndrome (AIDS) is a spectrum of conditions caused by human immunodeficiency virus (HIV), and is considered one of the most serious health and development issues in the world [1]. According to the World Health Organization (WHO), nearly 36.9 million people were living with HIV/AIDS in 2017, including 1.8 million new cases [2]. Despite substantial efforts in tackling the HIV/AIDS epidemic in China, the total number of people living with HIV/AIDS (PLWHA) is still increasing, which is a fact backed up by evidence: the number of PLWHA nearly doubled between 2012 and 2017, going from 385,817 to 758,610 [3, 4]. This increasing number of HIV cases poses huge challenges to China concerning treatment, care, and support for PLWHA.

The advancements in antiretroviral therapies (ART) have greatly decreased the mortality rates among PLWHA, as well as improved their survival time, which has transformed HIV/AIDS from a terminal illness to a chronic disease [5]. Consequently, PLWHA face more psychological challenges since they need to cope with HIV/AIDS during their extended lifetime [6]. For example, since HIV/AIDS is an incurable disease often accompanied by severe symptoms, PLWHA are faced with high risk of death. Further, PLWHA are easily rejected and stigmatized owing to the misconceptions about HIV transmission and disapproved risk behavior among the infected groups such as men who have unprotected sex with men, sex workers and injection drug users [7]. Additionally, PLWHA are more likely to be exposed to a wide variety of stressful situations, including having somatic symptoms, receiving long-term medical treatments, as well as experiencing medication side effects, marital conflicts, job loss and financial problems [8‐10]. Such factors are associated with an increased risk of developing psychological disorders such as depression, anxiety, guilt and loneliness [11‐13]. Thus, in the absence of support from their social environment or psychological services, PLWHA might turn these internalized negative emotions into hostility towards society [14]. Previous research had corroborated that PLWHA experienced a higher risk of hostility, compared to healthy individuals [15, 16].

Hostility can be conceptualized as a negative attitude towards the outside world [17, 18], and its impact on a person’s life is multifaceted. Previous studies showed that hostility could impact C-reactive protein interleukin, and proinflammatory cytokines to cause inflammation [19‐21], which may worsen the physical health of PLWHA. Further, hostility was associated with engagement in risk behaviors, such as injection drug use, unprotected sex and suicide attempts [22, 23]. In addition, hostility could also lead to dire consequences for society because it had relations with aggressive, vengeful, and antisocial behaviors [24, 25]. In summary, hostility is a potential threat to the health of PLWHA, and to HIV/AIDS control and social safety.

Prior studies showed that hostility can be changed both through external events and internally adjustments related to somatic or psychiatric symptoms [18]. Therefore, exploring potential factors associated with hostility can play a pivotal role in reducing hostility among PLWHA. In this regard, implementing interventions associated with these factors may be important not only for improving the health of PLWHA, but also for controlling the harmful consequences for society. Despite these potential benefits, there is limited research examining the influencing factors of hostility among PLWHA. To our knowledge, only one previous study had explored the association between perceived stigma and hostility among men who have sex with men (MSM) with HIV/AIDS and found that the perceived stigma predicted a higher level of hostility [26]. Thus, more researches are needed on the examination of hostility and its influencing factors among PLWHA.

In this study, we aimed to assess the prevalence of hostility among PLWHA‚ and to explore the multidimensional factors (including sociodemographic characteristics, disease related characteristics, self-reported physical health status, psychological factors, healthcare service factors and social factors) that may influence hostility. Our results could be used as evidence by policymakers and health service providers to improve HIV/AIDS care and intervention programs.

This study contributed to the existing knowledge on hostility among PLWHA and its influencing factors. Results showed that 17.0% of the participants experienced hostility towards society. Further, this rate was higher than that in a previous study conducted in Nigeria, which showed a prevalence rate of hostility was 15.0% among PLWHA [40]. PLWHA who were depressed, had a fear of dying, and had a higher level of perceived HIV stigma were at higher risk for hostility, while those who had a higher level of trust-in-doctor and per capita household income were at lower risk. This finding is important for health professionals in planning targeted intervention strategies to help mitigate hostility among PLWHA.

Regarding the specific types of hostility, the three most alarming types included “desiring to kill the person who infected them”, “blaming the infection on society and others”, and “abandoning themselves to despair”. It is noteworthy that the mean scores for “desiring to kill the person who infected them” and “blaming the infection on society and others”— reflecting how PLWHA hold external and other factors such as the society and other person who infected them responsible for their infection and disease —were nearly 4 (in a maximum of 5). HIV diagnosis could be extremely distressing [41], and that it was common for patients to not accept the fact of their infection, to consider that they are victims, and to further blame other people or society for their situation [42]. Cherilyn and Clement indicated that PLWHA who blamed others for their HIV infection might also have the feeling of inequity or anger (i.e., they believed that they did not deserve to be infected), and if they were unable to redress the situation, they could transfer these feelings directly to the person who infected them, or even to those unrelated with the infection [43, 44]. This might pose a threat to the safety of the society, and warrant greater attention and further investigation.

In this study, depression was the strongest variable associated with hostility. PLWHA with depression were nearly four times more likely to develop hostility, compared to those without depression. Indeed, depression was considered as one of the most common mental health conditions experienced by PLWHA [45, 46], and this study partially corroborated to that notion as data analysis showed that 47.7% of PLWHA suffered from depression. Liu‘s study showed that the prevalence of depression might be even higher (60.6%) among Chinese PLWHA [47]. Depression might be related to hostility for the following reasons. First, depression is commonly accompanied by other symptoms such as anger or irritability [48‐50]; a persistent or frequent feeling of anger might be highly associated with or even be regarded as hostility [51]. Second, it is possible that depressed individuals encounter more barriers in achieving healthy emotion regulation, which could evoke more negative emotions [52]. Third, depression also could serve as a moderating factor for social disorder and hostility [25]. Thus, successful management of depression is a key to mitigating hostility among PLWHA. However, the majority of services provided by China Four Frees and One Care Program focus primarily on physical rather than psychological symptoms; indeed, PLWHA are not adequately screened or treated for psychological problems. Therefore, development of regular psychological healthcare services for PLWHA is urgently needed. This action may have additional benefits that go beyond reducing hostility—it may help patients better adhere to their ART medications and improve treatment retention, which are critical to achieving the WHO’s 90–90-90 global targets.

In this study, as many as 63.3% of the participants reported a high level of perceived stigma, indicating that despite many years of effort and campaign for anti-discrimination, social stigma against PLWHA is still a serious concern in China. PLWHA are highly discriminated against in China, partly because the HIV-related risk behaviors such as homosexuality, commercial sex or drug abuse are not accepted by sociocultural norms [53, 54]. Supporting this assumption, a study conducted in China reported that over 90% of PLWHA perceived HIV-related stigma [55]. Widespread stigmatization and discrimination against PLWHA might in turn trigger PLWHA to be dissatisfied with or resentful against society [26, 56]. In this study, we found that perceived stigma was the second highest contributing factor for hostility. PLWHA with a higher level of perceived stigma were 3.281 times more likely to develop hostility. Currently, advancements in public health programs to address stigma have been comparatively slow and unsystematic in China [57]. Thus, media publicity and educational strategies aimed at converting and mitigating misunderstanding and fear of HIV/AIDS among the public could help reduce social stigma against PLWHA, thereby reducing hostility among PLWHA.

In this study, one-third of PLWHA reported a fear of dying, which was also significantly associated with hostility. PLWHA with a fear of dying were 2.710 times more likely to develop hostility than those without this fear. As there is currently no definite cure for HIV/AIDS, it is not surprising that it evokes the fear of dying. Fear of dying not only revealed psychological stress on PLWHA [58], but also predicted difficulties in coping with stressful events [58, 59]. These facts might explain the association between fear of dying and a higher risk for hostility; however, further analyses are needed to confirm this relationship.

Regarding the healthcare service related factors, a higher level of trust-in-doctor stood out as an important protective factor for hostility. PLWHA with higher trust in their doctors were less likely to experience hostility, compared to those with lower trust. Due to discrimination and stigma, it could be particularly difficult for PLWHA to disclose their infection to friends, family, and sex partners [60, 61]. Additionally, it had been reported that non-disclosure was associated with lower levels of social support [62]. In this context, PLWHA usually regard their doctors whom they can discuss their situation with as a crucial part of their social support networks [63]. Therefore, a trust-worthy relationship with doctors might be an important supportive factor for PLWHA’s psychological health and clinical treatment. Nevertheless, this study found that 45.3% of the participants did not have a high level of trust-in-doctor. This might be partly associated with deteriorative patient-doctor relationships in China. Moreover, discriminatory attitudes and lack of willingness to interact with AIDS patients displayed by Chinese health professionals might also deteriorate patients’ trust [64]. Nowadays, the majority of providers of HIV-related services in China are clinicians who have not been trained in the provision of psychological interventions [65], which may directly interfere with their ability to meet the multidimensional needs of PLWHA. Based on these facts, there is an urgent need to establish comprehensive treatment and care services including clinical treatment, psychological care and social support for PLWHA in China. This could be potentially valuable for reducing hostility among PLWHA.

Further into the protective factors for hostility, among the sociodemographic characteristics, higher per capita household income was a significant protective factor. Household income plays an important part in the economic and social stability of PLWHA [66]. However, HIV infection could lead to a decrease in household income, since patients cannot work as much as before, and some might have to quit or change their jobs [67, 68]. A previous study showed that household income reduced on average by 16% after a member of the household was infected with HIV [69]. In our study, more than half the participants had a lower household income (less than 2000 CNY per capita monthly) and more than half of the participants were at the age stage of earning the main salary in their family (30–49 years). However, the possibility of failing to provide for their family due to their reduced work ability may place great psychological burden on PLWHA, which may, in turn, increase their risk of hostility towards society. Policies aimed at maintaining the household income of PLWHA (e.g., by providing appropriate re-employment chances) should also be a priority in China.

Our study has several limitations. First, the data were collected through a self-reported questionnaire; therefore, recall bias and social desirability bias may exist. Second, as it was a cross-sectional study, we could not establish causal relationships based on the results. Third, our sample included only people who agreed to participate in this study, thus, findings in this sample might differ from those in PLWHA who refused. Fourth, the generalizability of the findings was limited because after the data cleaning process, we did not include non-Han and non-illiteracy PLWHA who failed to complete the questionnaire and this study was only conducted in one HIV-designated hospital in Heilongjiang. Further studies with a larger and more diverse sample and those that thoroughly analyze the mechanisms of various factors influencing hostility among PLWHA, are needed.

The prevalence of hostility among PLWHA in the present study was 17.0%. Further, depression, perceived stigma, fear of dying, trust-in-doctor, and per capita household income were associated with hostility. Our findings highlighted the prominent influence of psychological, healthcare, and social factors on hostility among PLWHA, which are important for developing more targeted intervention strategies for reducing hostility among PLWHA. First, the psychological component of PLWHA should be incorporated into HIV/AIDS management guidelines, aiming at providing screening and appropriate care for psychological disorders, and consequently reducing PLWHA’s negative beliefs about the disease and society. Second, to enhance PLWHA’s trust-in-doctor, in addition to provide better communication and more humanistic care, healthcare professionals also should be provided with specific educational programs to help improve their attitudes, knowledge and practices regarding HIV/AIDS. Third, there is an urgent need to establish comprehensive services including clinical treatment, psychological care and social support for PLWHA in China. Fourth, social interventions should focus on changing the social stigma against PLWHA by raising disease awareness, as well as providing more financial and medical assistance to PLWHA with financial problems.