Introduction

In the United States (US), HIV and AIDS are serious health threats to women, particularly young women and minority women. From 1999 to 2003, the annual number of estimated AIDS diagnoses increased 15% among women compared to 1% among men (Center for Disease Control and Prevention, 2004). Women currently account for 32% of cases of HIV infection in the US, and the proportion of women represented among AIDS deaths has increased in recent years, while the proportion for men has declined (CDC, 2003). African-American and Hispanic women are disproportionately affected by AIDS such that together they represent approximately 25% of the all US women, yet account for 83% of AIDS diagnoses reported in 2003. Moreover, the rate of AIDS diagnoses for African American women is 25 times the rate for white women and 4 times the rate for Hispanic women (CDC, 2004).

The mental and physical health consequences for women who are diagnosed with HIV or AIDS is of particular importance because higher levels of psychological distress is associated with lower quality of life and poor treatment outcomes (Catz, Gore-Felton, & McClure, 2002). Additionally, HIV-positive women are more likely than men to receive sub-optimal patterns of care (Shapiro et al., 1999) and have impoverished social status and histories of drug use (Ickovics, Thayaparan, & Eithier, 2000). Women living with HIV tend to be poor and socially disenfranchised (Bozzette et al., 1998; Kamb & Wortley, 2000); and, regardless of HIV status, women from socially and economically marginalized groups report high rates of adverse life events and depression (Moore et al., 1999). In the general population, clinical depression is more common among women than among men (Kessler et al., 1994); and women living with HIV have significantly higher rates of psychological distress and depression (Moore et al., 1999; Rabkin et al., 1997) relative to HIV-positive men (Kennedy, Skurnick, Foley, & Louria, 1995; Perkins et al., 1994; Rabkin et al., 1997; Semple et al., 1996) with prevalence rates for lifetime psychiatric diagnoses reported as high as 88% in women recruited from primary care HIV clinics (Mellins, Ehrhardt, & Grant, 1997).

Depression has significant effects on morbidity and mortality in HIV-positive women. Chronic and intermittent depressive symptoms in HIV-positive women are associated with disease progression, lower CD4 cell count, and higher baseline viral load levels; and, in general, women with chronic depression have mortality rates twice as high as those with little or no depressive symptoms and depressive symptoms were more severe among women in the terminal phase of their illness (Cook et al., 2004; Ickovics et al., 2001). Therefore, it is important to identify and understand the relationship among psychosocial factors that affect depression and health in women living with HIV. By identifying key psychosocial factors that are amenable to change, clinical interventions to promote health can be enhanced.

While there exists a substantial literature describing predictors and correlates of psychological distress among persons living with HIV, most studies are based on samples of HIV-positive men and also pre-date the advent of HAART in 1995–1996. In general, these studies have found that stress, social support, and coping strategies have been linked to mental health (including depression) in HIV-positive persons (Kalichman, Heckman, Kochman, Sikkema, & Bergholte, 2000; McClure, Catz, Prejean, Brantley, & Jones, 1994; Remien, Rabkin Williams, & Katoff, 1992; Wolf et al., 1991). However, these studies have tended to focus on discrete domains of stress, support, or coping and have rarely been placed in a theoretical framework that would explain the relationship among the domains and their impact on the physical and mental health of people living with HIV.

The Cognitive Transactional Theory of Stress (Lazarus & Folkman, 1984; Lazarus & Launier, 1978; McGrath, 1970), a dominant model in the field explaining the relationships among stress, social support, coping, and depression, suggests that an individual experiences stress when stressors and daily hassles exceed his/her resources. Such stress may cause serious emotional distress, including depression (Aneshensel, 1999); however, social support and coping can either buffer or eliminate the effect of stress and, thus, decrease depressive symptomatology. Peterson and colleagues (Peterson, Folkman, & Bakeman, 1996) used the stress and coping framework of Lazarus and Folkman to explain depressed mood in a sample of African-American gay, bisexual, and heterosexual men and found that psychosocial resources moderated the effects of stressors, hassles, and life events on depressive mood. Within this framework, the relationship between stress and depression is moderated by the individual’s coping resources and by the ways in which the individual uses those resources to deal with the internal and external demands of the stressors. Social supports and coping skills provide the means to reduce the negative effects of stress. It is important to know if this model accurately describes the interaction of these variable domains among women living with HIV.

From a community psychological perspective, it is critical to understand the environmental factors that influence individual functioning. Ecological theory presumes that individuals interact with their environments and individual characteristics are the filter for external systems such as family, friends, community, society, and culture (Bronfenbrenner & Morris, 1998), which is consistent with research indicating that the structural and environmental factors moderate the ways in which stress and psychosocial resources influence mood outcomes (Billings & Moos, 1981; Glyshaw, Cohen, & Towbes, 1989; Moos, 1984). Most HIV-positive women in the United States are living in impoverished communities, have lower levels of education than the general population, and often face challenging life circumstances such as unemployment, incarceration, homelessness, and lack of adequate health insurance (Bozzette et al., 1998; Ickovics et al., 2000; Kamb & Wortly, 2000; Moore et al., 1999). Contextual forces involving race, class, and gender intersect in inner cities to shape HIV/AIDS risks and these have also been shown to influence physical and mental health outcomes (Link & Phelan, 1995; Wilson, 1987; Zierler & Krieger, 1997) and should be considered in a comprehensive model of depression in this population. And since AIDS-related physical symptoms are associated with depressed mood (Ferrando et al., 1998; Fleishman & Fogel, 1994; Hays, Turner, & Coates, 1992; Lipsitz et al., 1994), they also need to be included in a depression model for women living with HIV.

Since HAART has decreased HIV morbidity and mortality (Fordyce, Singh, Nash, Gallagher, & Forlenza, 2002), it has been hypothesized that increased survival rates, the hopefulness associated with expanding antiretroviral treatment options, and the direct effects of antiretroviral therapy on the immune system may contribute to decreasing rates of psychiatric symptomatology in HAART era cohorts (Alciati et al., 2001; Rabkin, Ferrando, Lin, Sewell, & McElhiney, 2000 ). Given the limited research on prevalence and severity of depressive symptomatology in HIV-infected women, in the era of HAART, and the absence of models predicting depression in this population, we conducted the current study. We first identified severity of self-reported symptoms of depression and then tested an enhanced stress and coping model in an attempt to understand the interplay of life circumstances, health, social support, and coping resources and their influence on depression among an ethnically diverse sample of HIV-positive women with access to HAART. Findings from this study can guide research and inform theory-driven behavioral interventions to improve the mental health and possibly the physical health in this population.

Method

Procedures

HIV-positive individuals in four U.S. cities (San Francisco, Los Angeles, New York City, and Milwaukee) were screened between July 2000 and January 2002 for recruitment into a randomized, controlled clinical trial of an individually administered cognitive-behavioral intervention. Recruitment and screening of potential intervention study participants were undertaken in medical clinics and community agencies serving HIV-positive clients.

Participants were required to be at least 18 years of age, provide written informed consent and written medical documentation of their HIV-positive serostatus. Potential participants were excluded if they showed severe neuropsychological impairment or psychosis as assessed on a case-by-case basis by senior project personnel in collaboration with the clinical supervisor at the involved institution.

Assessment interviews were conducted in private settings in research offices, community-based organizations, and clinics in the four cities. Procedures involved a combination of Audio Computer Assisted Self-Interviewing (ACASI) and Computer Assisted Personal Interviewing (CAPI) using Questionnaire Development System (QDS) version 2.0 by Nova Research Company. This approach has been proposed as an effective method of decreasing social desirability and thereby enhancing the veracity of self-reports of sensitive behaviors and attitudes (Gribble, Miller, Rogers, & Turner, 1999; Turner et al., 1998). We anticipated a range of literacy among the sample. To accommodate lower literacy respondents, we aimed for low reading levels in assessment selection wherever possible and all items were read aloud, either by the interviewer for CAPI administration or by a recorded voice for ACASI measures. Assessments were conducted in Spanish for participants who expressed a preference for this language. The interview was conducted over a period of two to four hours with regular breaks allowed to minimize respondent fatigue. Participants were compensated $50 for completing the baseline interview and those needing child care were also eligible to receive $10 to defray child care costs. For a complete report of the screening and assessment procedures (see Johnson et al., 2003).

Measures

Health status

Based on the AIDS Clinical Trials Group (ACTG) symptom checklist (Justice et al., 2001), respondents were asked whether they had experienced each of a list of 25 possible symptoms in the preceding 30 days. Total HIV-related symptom count had an alpha coefficient of .85. In addition, the Illness Intrusiveness Rating Scale was administered to assess the degree to which illness and/or treatment interferes with 13 life domains (Devins et al., 1983). This self-report measure consists of 13 items with a 7-point Likert response scale ranging from 1(not very much) to 7 (very much). A summary score was created for each respondent, such that higher scores indicate greater intrusiveness. The coefficient alpha in this sample of .80 is consistent with other reports on this measure’s internal consistency (Binik, Chowanec, & Devins, 1990; Devins et al., 1983; Devins, Armstrong, Mandin & Paul, 1990). We collected self-reports of most recent CD4+ count and viral load, and whether or not the participant was currently on HAART.

Marginalization

Prior to analysis, the authors identified five background and demographic characteristics that could reflect or contribute to marginalizing women in their daily lives. These include having less than an eighth grade education, minority racial/ethnic status, being a recent immigrant (within the past 10 years), lack of health insurance, and recent homelessness (within the past year).

Current stress

Perceived stress was assessed with the 10-item form of the Perceived Stress Scale (Cohen, Kamarck, & Mermelsetin, 1983) by summing ratings on a 5-point scale (in this sample, α=.86). The questions in the Perceived Stress Scale ask about the frequency with which participants have experienced stress-related thoughts and feelings during the past month (e.g., “Felt that you were unable to control the important things in your life.”; “Found that you could not cope with all the things that you had to do.”).

Psychosocial resources

The Social Provisions Scale (SPS) (Crutona, 1989; Crutona & Russell, 1990) was used to assess level, type, and perceived satisfaction with social supports from one’s social network. This 24-item scale measures six dimensions of social support using a 4-point Likert scale: guidance, reliable alliance, reassurance of worth, attachment, social integration, and opportunity for nurturance. The SPS is supported by a large number of studies of its reliability and validity (Crutona, 1989), including past mental health intervention research with HIV-positive individuals (Kelly, Murphy, Bahr, & Kalichman, 1993). An overall social support score was created by calculating a mean score across the six dimensions, with a possible range from 4 to 16 (α=.82).

Coping self-efficacy

Coping self-efficacy was assessed with an abbreviated (15-item scale) version of the 26-item scale developed for a coping skills training study in collaboration with Albert Bandura (Chesney, Chambers, Taylor, Johnson & Folkman, 2003). The scale provides a measure of perceived self-efficacy for coping with challenges and threats. Participants rate on a scale from 0 (cannot do at all) to 10 (certain can do) the extent to which they believe they could perform behaviors important to adaptive coping. An overall coping self-efficacy score was created by summing the item ratings (α=0.92).

Beck depression inventory

Depression was assessed with the 21-item Beck Depression Inventory (BDI), (α=.89). This measure assesses the severity of depressive symptomatology during the past week and each of its 21 items is scored from 0 (absent) to 3 (severe). Total scores can range from 0 to 63. While the BDI is a self-report measure and not a clinician’s assessment, it is widely used as a depression rating scale and has been used in studies with HIV-positive patients to evaluate the severity of depressive symptoms (Beck & Steer, 1984).

Statistical methods

Descriptive statistics are provided to orient the reader to proportion of participants and mean values for background characteristics, physical and mental health status, social support, and coping self-efficacy. To examine the predictive value of the theoretical framework described above, we adopted an approach for causal models recommended by Cohen and Cohen (1983) and used earlier by Peterson et al. (1996) in their investigation of stress, coping, and depressive mood among African American men. A hierarchical multiple regression was conducted, and direct and indirect effects and redundancy were examined, to identify possible mediators and spurious effects.

Modeling depressive symptomatology

Modeling of depressive symptoms was guided by the Cognitive Transactional Theory of Stress (Lazarus & Folkman, 1984; Lazarus & Launier, 1978; McGrath, 1970). Use of a hierarchical step-wise procedure allowed us to examine whether and how each set of variables contribute to understanding depressive symptoms: having no effect, directly influencing symptoms, and/or mediating (indirectly affecting) the influence of previously entered constructs. We first block entered variables capturing long-term stress (marginalization), then HIV health-related variables, and then current perceived stress. We next entered variables representing psychosocial resources, that could mitigate the effect of stress on depressive mood, followed by coping self-efficacy, which reflects the individual’s assessment of her ability to cope with challenges and threats.

Results

Sample characteristics

Of the 3819 individuals who underwent baseline assessment, 26% (978) were women. The median age of women participants was 41 years; and they were predominantly ethnic minority: 61% Black or African-American, 20% Latina, 14% White, and 5% mixed/other. Fifteen percent of women had immigrated to the US within the prior 10 years. Women reported high levels of unemployment (77%). Most of the sample was publicly insured (69%), principally by Medicaid; and 15% reported either that they were uninsured, obtained health care at free clinics, or paid for care out-of-pocket. Forty-three percent had not completed high school or a GED; nine percent were homeless in the preceding year; and 7% reported IDU in the same time period. Slightly less than half (48%) of women had at some time been convicted of a crime. Ninety-five percent of the women reported at least one of the five background and demographic characteristics that could reflect or contribute to marginalizing women in their daily lives and 58% of the sample reported two or more of these characteristics.

Health status

Almost three-fourths of women participants were on HAART (72%), and 53% of all women reported that their most recent viral load was undetectable. The mean CD4 count among women in the sample was 485 and the mean number of years since learning of a seropositive status was eight. CD4+ count is a measure of current immune functioning, with a lower value indicating poorer immune status. In uninfected adults, the typical range is between 500 and 1,500 cells per cubic millimeter of blood (American Association for Clinical Chemistry, 2005). A CD4+ count below 200 is one of several criteria to diagnose AIDS. In the treatment of HIV infection, current guidelines are tied closely to CD4 counts, in conjunction with other variables such as viral load and replication, and current and past HIV-related opportunistic infections. While other factors are also considered, antiretroviral treatment is generally recommended when CD4+ counts are below 350 (National Institute Health, 2004). Treatment typically results in an increase of CD4 counts and decrease in viral load. Note that neither detectable viral load, CD4 count nor being on HAART were related to BDI score (r=.042, p=.206; r=−.024, p=.470; and r=−.027, p=.400, respectively). Women reported an average of 12.5 (of a possible 25) AIDS-related symptoms, with a mean Illness Intrusiveness rating of 3.5 on a seven-point scale.

Stress, resources and coping

The mean Perceived Stress score among women was 19.19 (s.d.=7.34) of a possible 50. Social Provisions scores were relatively high, with a mean 11.10 (s.d.=2.20) of a possible 16. Coping Self-efficacy scores also tended to be high, with a mean self-efficacy score of 100.00 (s.d.=27.87) out of a possible 150.

Depression

The mean BDI score of 13.08 (s.d.=9.16) is within the range of mild symptomatic distress, although 21% of women (209 of 975 participants) scored in the moderate to severe range (BDI score of 14–20); and 20% (N=194) scored in the severe range (BDI ≥ 21). Those who reported current use of antidepressant medication (N=316; 32% of women) had higher mean BDI scores than women not on antidepressants (16.20 v 11.60; t=−7.55, df =1,973, p=.000).

Modeling depressive symptomatology (See Fig. 1). Because of its univariate association with the BDI, we controlled for possible effects of psychiatric medication in modeling depressive symptoms. Although we present the controlled model, the magnitude and direction of findings was essentially unchanged whether controlling for medication or not.

Fig. 1
figure 1

A schematic representation* of a model of stress and coping for HIV+Women

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As shown in Table 1, use of antidepressant medication was positively associated with depressive symptoms, accounting for 6.3% of explained variance. After controlling for medication, marginalization accounted for a significant though small amount of the variance in depressive symptoms (3.0%). Controlling for previous variables, the health variables accounted for an additional 26.7% of the variance. Taking medication, marginalization and health into account, current stress accounted for an additional 10.8% of variance; when psychosocial resources were added to the model, 2.0% more variance was explained. In the final step, coping uniquely added an additional 3.9% of explained variance beyond that accounted for by the other factors. At each step, the increase in explained variance was significant beyond p < .001. The final model accounted for 52.6% of variance in depressive symptomatology (51.7% when adjusted for number of variables and degrees of freedom).

Table 1 Explaining BDI scores: Hierarchic regression statistics
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A variable can be said to mediate the effects of another when it is on the causal pathway; and there is a 20% or greater reduction in the effect estimate for the previously entered variables (Baron & Kenny, 1986; MacKinnon & Dwyer, 1993). An examination of the partial coefficients in Table 1 indicates that stress mediates the effect of health status on depressive symptomatology, as the addition of stress variables attenuate the effects of symptoms (from .362 to .263) and Illness Intrusion (from .256 to .151). This suggests that stress — or its absence — can exacerbate or ameliorate the effects of health status on depression. The addition of psychosocial resources does not mediate the effects of either health status or stress on depressive symptomatology; although there is a significant main effect for Social Provisions. Coping Self-efficacy mediates the effect of resources on depressive mood, indicated by the attenuated effect of Social Provisions in step 5 (from .150 to .090), and suggests that perceived coping ability affects the extent to which resources come to bear in influencing depressive symptomatology.

In Table 2, zero-order correlations are partitioned into total and redundant (or spurious) effects. The total effect represents the partial regression coefficients when the variable is first entered. Direct effects are reflected in the partial coefficient from the final model. Redundancy (r- total effect) indicates the extent to which the zero-order relationship between the variable and BDI scores are spurious, (i.e., due to common causes). The high redundancy of Social Provisions indicates that approximately 62.7% of the zero-order relationship (redundancy/r) was due to common causes (shared variance among predictors). This also was true of Coping Self-efficacy, where about half (53.1%) of the zero-order association was due to common causes. The five variables with the strongest effects on depressed symptomatology are Coping Self-efficacy, number of symptoms, Illness Intrusiveness, Perceived Stress, and Social Provisions. The effects of coping are direct, while symptoms, Illness Intrusiveness, Perceived Stress and Social Provisions have both direct and indirect (mediated) effects on depressive symptomatology.

Table 2 Explaining BDI scores: Partition into direct and indirect effectsa
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Discussion

This study identified significant levels of depressive symptomatology among an ethnically diverse, predominantly poor group of HIV-positive women living in four cities in the US during the period following widespread access to and utility of HAART. Forty-one percent of women reported moderate to severe levels of depression. This is substantive and noteworthy, since it had been hypothesized that medical treatment advances and renewed optimism could lead to a reduction in the prevalence and severity of distress among people living with HIV (Alciati et al., 2001; Rabkin et al., 2000). The findings from this study suggest that women living with HIV, especially those who are socially and economically marginalized, continue to experience significant distress, even when they receive ongoing medical care and have access to HAART. While there was no relationship between depression and HAART utilization or standard clinical markers of disease status (i.e., CD4+ count or detectable/undetectable viral load), depressive symptomatology was related to the experience of physical symptoms of disease and the degree of perceived intrusiveness of those symptoms. This suggests that the women in this study were more distressed by the experience of feeling sick than by the biological markers of disease progression that clinicians deem to be most relevant. Increased viral load and decreased CD4+ count are not necessarily accompanied by feelings of illness. The overall high levels of depressive symptoms in this sample suggest that clinicians working with HIV-positive women should consistently inquire about physical symptoms of illness, their level of “bother” and associated feelings of distress, in the course of routine evaluation, regardless of health status as measured by routine laboratory markers.

Although our data were cross-sectional, we employed an analytic approach that allowed us to test an enhanced stress and coping model predicting self-reported depressive symptoms in this cohort of HIV-positive women. All domains in the model were predictive of depression, supporting prior research in other populations that has shown that stress, coping, social support, health status, and environmental conditions are all associated with depressive symptomatology. This study advances our understanding of the inter-relationships among these domains to help explain depressive symptomatology among women living with HIV, placing these results within a specific theoretical framework. As a result, these findings provide implications for specific ways in which community service and health care providers can intervene to improve the mental health and well being of women living with HIV.

Our finding that stress mediates the effects of symptoms and illness intrusiveness, and that coping mediates the effects of social provisions on depression, strongly suggests that interventions that enhance coping skills are important to help women better utilize their social resources and manage stress, and thereby, reduce the negative impact of poor physical health on mental health. Thus, although health status (i.e., physical symptoms) and stress can lead to depressive symptoms, it should not be accepted as a given that depression is an inevitable outcome of poor health in the context of HIV illness or that a greater frequency of HIV-related physical symptoms should necessarily lead to the experience of depressed symptomatology for women living with HIV. This is concordant with reports among cohorts of gay men early in the epidemic, prior to the availability of HAART (Rabkin, Remien, Katoff, & Williams, 1993; Rabkin, Williams, Neugebauer, Remien, & Goetz, 1990), in which serious illness and impending mortality were not always associated with depression and despair.

The partial redundancy of social provisions and coping self-efficacy indicates that the variance accounted for by each overlaps with variance explained by other variables in the equation, a pattern of findings which Cohen and Cohen describe as “the most common pattern of relationship in nonexperimental research in the behavioral sciences” and “the plague of our efforts to understand the causal structure that underlies observations” (Cohen & Cohen, 1983, p. 94). This overlap makes sense, to the extent that one would expect social provisions, for example, to be related to homelessness and relationship status, with each in turn being expected to influence depressive symptoms. Similarly, coping self-efficacy is associated with perceived stress and social provisions, with all three variables expected to affect depressive mood. Nonetheless, social provisions demonstrated a significant direct impact on depressive symptoms, and coping self-efficacy both directly influenced depressive mood and mediated the effects of resources on mood. Thus, it is important to both increase functional social support as well as improve coping responses for women living with HIV.

It should be noted that inferences about causal direction are not conclusive since this was a cross-sectional study. It is possible that depression itself may influence perceptions of stress as well as experience of symptom impact, support, and subjective self-efficacy. It is also possible that, for some participants, there is a bi-directional effect. Participants with ongoing depression may perceive more stress and cope less efficaciously, thereby compounding their depressed mood associated with more reported symptoms. A more definitive test of the stress and coping model for understanding depressive symptomatology in HIV-positive women awaits longitudinal evaluation.

Our results also underscore the importance of understanding factors associated with better coping and ways to enhance self-efficacy for coping among HIV-positive women. It seems that the level of confidence in one’s ability to effectively handle stress influences the extent to which supportive resources are utilized, and, can directly influence depression. A recent study demonstrated that a group intervention aimed at improved coping among HIV-positive gay men was effective in reducing psychological distress and improving psychological states (Chesney et al., 2003).

From its outset, the HIV epidemic has disproportionately struck the poorest and most marginalized women (Kamb & Wortley, 2000). To understand why this may be the case we can use an environmental framework that asserts neighborhood demographic indictors such as poverty affect behavior associated with HIV transmission through lower social cohesion and control resulting in higher rates of substance use, crime, lower education attainment (Duncan, Duncan, Okut, Strycker, & Hix-Small, 2003), all of which have been associated with higher HIV/AIDS rates. The finding that marginalization, as operationalized in this study, accounted for a relatively small amount of the variance in our model, could be mostly due to the fact that there was little variability in that the sample as a whole was disenfranchised in one or several ways. Economic and social marginalization may operate on an individual level to increase depressive symptomatology. This underscores the intersection of race, class, and gender for HIV positive women residing in impoverished inner cities and points to the possible need for gender-based support concerning women’s needs such as employment initiatives, child care support, assistance in transferring from welfare to work, and access to health care. While it was beyond the scope of this study to examine social and political factors associated with psychological functioning, future research needs to examine structural and policy-level initiatives that address economic and social disparities and the need to develop models that consider the interactive affect of environmental and individual characteristics on health-related behavior as well as psychological functioning (Farmer, 1996; Parker, Easton, & Klein, 2000).

Results from this study show the extent of depressive symptomatology among women living with HIV and the importance of attending to stress and coping, as well as a woman’s confidence in her ability to cope. This study highlights the need for the routine integration of mental health services into HIV primary care settings. While many hospital and community based HIV and general health clinics provide mental health services, physicians don’t always make the appropriate referrals. It is important to sensitize primary care providers to the widespread need for psychological support and ongoing mental health services for women living with HIV. Providers can play a specific role in instilling confidence in their patients’ ability to cope and handle stress in their lives. And when these formal mental health services are unavailable onsite a referral should be made to one of the numerous locations for such services available in most states in the US. Listings of said services are widely available through State and City Departments of Mental Health. In addition to current standard mental health interventions, peer support (either one-on-one or in group) and counselor and volunteer led HIV support groups, common in many community based organizations across the country, can be more formally linked to standard medical treatment and referral practices.

Future research needs to address coping among HIV-positive women in greater detail, explicating the range of strategies that are most effective in helping to ameliorate psychological distress in general and depression in particular. Findings from our study suggest that developing and tailoring coping interventions for HIV-positive women can lead to decreased distress, improve mental health outcomes, and perhaps also serve to contribute to improved physical health. Furthermore, there is a need to develop community-level interventions that incorporate environmental and individual constructs in an effort to prevent new HIV infections and well as increase overall functioning for those already living with the disease.