Introduction

Women demonstrate a biological susceptibility to infectious disease which makes them the fastest growing cross-section of persons living with the Human Immunodeficiency Virus (HIV) and subsequently Acquired Immune Deficiency Syndrome (AIDS) [1]. The lifetime odds for a woman to contract HIV/AIDS depends largely upon ethnic background. Whereas 1 in 32 African-American women and 1 in 106 Hispanic/Latina women will be diagnosed with HIV at some point in their lives, only 1 in every 526 Caucassian or Asian women will forego the same outcome [2]. Highly Active Antiretroviral Therapy (HAART) has helped extended reshaping what was previously considered a terminal diagnosis to a chronic yet manageable disease. Despite these advancements, disparities in disease management exist. AIDS related complications are the leading cause of death in African American women aged 25–34 and the fourth leading cause of death for Hispanic women aged 35–44 [3]. These demographic trends in progression from HIV to AIDS may reflect differences in acculturation, HIV-risk, and socioeconomic status [4]. In light of these findings, a general concern has arisen regarding disparate disease outcomes within ethnic minority communities, and how this may relate to the appraisal of non-disease related environmental stressors. To better quantify these effects, theoreticians have developed psychosocial transactions models amongst stressors, coping methods, and a multitude of psychological and behavioral outcomes [59]. Here, we look to describe the psychological, social, and biological milieu of women living with HIV/AIDS.

A large body of HIV/AIDS research in women has been amassed from the fields of psychology, social epidemiology, and behavioral medicine to help shape our understanding of the many factors related to disease management. The summative power of meta-analysis has provided a useful tool for ascertaining predictors of behavioral and psychological health in persons with HIV. Meta-studies consisting of large male and female cohorts have been useful in identifying outcome moderators. Moscowitz et al. [10] found gender to moderate the effect of higher-order coping mechanisms on specific disease-related outcomes such as self-report ratings of positive and negative affect. These findings suggest maladaptive ways of coping i.e. avoidance have more deleterious effects for women than do men. Longitudinal meta-analyses also provide great resolution into mechanisms of disease progression, and have likewise shown stark gender differences in the magnitude of effect for both environmental and symptom-based stressors [11, 12]. These summative findings suggest that interactions between stress, coping and outcomes must be taken within the context of gender.

Female gender is one of the most significant predictors of distress in HIV-infected persons [1315]. The myriad of psychosocial archetypes observed in women living with HIV/AIDS may pose a seemingly greater challenge for clinical case management [4]. When stressors are encountered they can precipitate a cascade of adrenal and sympathetic nervous system activity known to compromise immune function [14]. These stressors are thought to follow a hierarchy in which chronic strains and major life events pose greater long-term effects on psychopathology than more subtle forms of stress i.e., acute daily hassles [13, 14]. For example, life events such as bereavement can leave a post-traumatic effect which if unimpeded may lead to symptoms of depression and anxiety [1618]. Chronic strains and daily hassles which are commensurate with socioeconomic conditions i.e., financial burden, unemployment, crime/victimization, and access to child/health care, can also compound stress levels and deplete coping resources thus compounding HIV/AIDS prognosis [46, 1922].

Internal physical symptoms are another source of stress for those living with chronic disease. The relationship between the physical burdens of HIV/AIDS and quality of living may be quantified in several ways. Although CD4 count and viral load are frequently compared to measures of disease adjustment, their utility in predicting psychological and behavioral outcomes are debated [2325]. An alternative approach to using biological markers as a predicitive measure is the utilization of self-report inventories [2628]. This form of assessment allows researchers to examine stressors relevant to women of childbearing age (e.g., menstrual abnormalities, cervical dysplacia, increased susceptibility to sexually transmitted infections, amenorrhea, as well as mother–child transmission of the disease) [2932].

Stress appraisals can lead to the mobilization of a coping response. These responses may be considered innate traits or learned behaviors that are recruited to manage the specific external and/or internal demands of an event appraised as taxing or exceeding individual resources [79, 3335]. Furthermore, they may be classified as adaptive or maladaptive depending on the positive/negative valence of short and long-term mental effects [69]. Epochs of psychological adaptation observed in HIV/AIDS are dependent on whether an individual utilizes approach, (e.g., positive reappraisal and seeking social support) or avoidant (e.g., social isolation and denial) coping styles [3645]. Although both strategies may lead to short term relief the consensus across these studies holds that long-term consequences of avoidant coping result in further immune compromise and emotional distress.

Along with the broad categorizations mentioned afore, hundreds of sub-ordinate coping mechanisms have been identified in the literature [33]. For example, spiritual perspective or religious-based practices such as prayer are shown to provide psychological relief from aversive experiences in women living with HIV/AIDS [4651]. Larger effects are noted when this mechanism is reportedly used by women of African decent [52, 53]. Seeking Social Support (SSS) is also employed to alleviate physical and emotional distress associated with adverse environmental conditions. This construct may be quantified (a) the source of support (e.g., partner, family, or extended social network) (b) indication of the type of support (e.g., tangible or informational), and (c) perception of the level or quality of support received [54, 55].

Current Study

The HIV/AIDS epidemic impacts the lives of women in a unique way precipitates the integration of a host of strategies to face a range of stressors within and outside the biological context of the disease. HAART regimens have done much to change the perception of life expectancy [56], however, maladaptive coping contaminant with aversive socioeconomic factors and oscillating immune response increasingly and disparately jeapordize disease adjustment in women [5760]. The current meta-analysis examines women being treated for HIV with the aim of comparing the magnitude of effect amongst various stressors i.e., psychological, physical, and functional; ensuing coping mechanisms i.e., approach, spirituality, positive reappraisal, seeking social support, avoidance, denial, and social isolation; and specific indices of psychological and behavioral adjustment.

Methods

Selection of Studies

A search was conducted of relevant abstract databases i.e., PsycINFO, PubMed, and Science Direct for peer-reviewed articles published from January of 1997–2011. This period was selected to depict seropositive women living in an era with widespread availability of HAART. Only studies published in English within the United States were considered. Independent reviewers searched for articles using the terms: “coping” [and] “stress” [and] “stressors” [and] “mental health” [and] “health behaviors” individually paired with “women with HIV/AIDS”. Published meta-analyses, reviews, and empirical studies were also searched for citations referencing articles from the post-HAART era. Inclusion criteria for this meta-analysis required the study to have: (a) an exclusively female sample, (b) participants recruited within post-HAART era, (c) construct validated stressors and/or coping indices with similarly validated measures as recommended by Cohen [61], (d) appropriate measure of effect size i.e., zero-order bivariate correlation or beta coefficient [62], and (e) published in a peer-review journal. When information was reported incompletely or in an irretrievable format, a written request was forwarded to the corresponding author of the article. Seven authors were contacted for data retrieval with 2 out of 7; 29% being retained for the meta-analysis. A final count of 40 studies met the above criteria (Fig. 1). Methodological quality of each study was determined by two independent reviewers through the use of the STROBE checklist [63]. The percentage of “yes” responses out of the total number of applicable items ranged from 81.7 to 100 with a mean rating of 94.8 on a 100 point scale. The Kappa statistic was used to determine consistency among raters. A near perfect agreement for interrater reliability was found Kappa = .97 (p < 0.001), 95% CI (0.953, 0.981). Attempts were not made to obtain unpublished data.

Fig. 1
figure 1

Flow-chart for selection of studies used in meta-analysis

Coding

Demographic (e.g., ethnicity, age) and methodological (e.g., type of coping) information was coded for each study. To ensure that the same constructs and relationships were interpreted across studies, each article was distributed to and reviewed separately by three researchers. Each reviewer coded the study in a separate database. Before the meta-analysis was conducted, an inter-rater analysis of the descriptive data was examined and reconciled for discrepancies by the first author.

Stressor Classifications

A review of the HIV/AIDS literature suggested physical, functional, and psychological stressors were most commonly reported (see Table 1). The construct of stress differed amongst categories as perceived stress and functional impairment were measured in terms of their psychological impact while HIV symptomology was indexed by frequency of occurrence. Physical symptom-based stressors that contributed to the meta-analysis included: frequency of symptoms [6466] and physical symptom burden [67]. Functional limitation-based stressors included perceived limits of functioning [68], and physical/role functioning [69, 70]. Measures of psychological stress included: chronic burden [71, 72], major/traumatic life events [73, 74], perceived stress [64, 75], and interpersonal conflict [76].

Table 1 Stressor categorization

Coping Classifications

We categorized the coping scales reported in each study using the definitions and strategies provided by Ways of Coping [77] and the COPE scales [78]. Measures developed by authors were assigned to a Ways of Coping or COPE subscale to which it was most closely matched. Coping mechanisms were then placed in hierarchical categories of approach or avoidance (see Table 2). Approach-based coping included positive reappraisal [7781], spirituality [78, 79, 8286], and seeking social support [63, 77, 78, 85, 86]. A measure of general active/approach coping [77, 80, 85] was also included in the meta-analysis. Avoidance measures included denial/distancing [78, 86], social isolation [86], and a general measure of avoidance [63, 85, 87].

Table 2 Coping categorizations

Outcome Classifications

Study outcomes were grouped based upon recommendations by Moskowitz et al. [10] into the categories of positive affect, negative affect, and health behaviors. The five sub-measures of positive affect included: locus of control/perceived control [88, 89], mastery [90, 91], positive affect [92], quality of life [68, 93], self-esteem [92], and stress-related growth [89]. Data was entered so that larger correlations indicated a positive relationship with positive affect and psychological adjustment.

Negative affect included eight sub-categories: anger [88], anxiety [9496], depression [88, 9698], emotional/psychological distress [88, 99], loneliness [100], mood disturbance [88], and suicidal ideation [101]. Data was entered so that higher more positive correlations indicated a stronger effect on psychopathology and negative affect.

Health behaviors included adherence/non-adherence [102, 103] in addition to disclosure distress, substance abuse, and managing illness (see Table 3). Data was entered so that positive correlations indicated a stronger relationship with the maladaptive behavior. In some cases, the scales and diagnostic questionnaires of stress, coping, and disease outcomes were developed by the authors [104127].

Table 3 Stress, coping, and outcome information for studies included in the meta-analysis

Effect-Size Analysis

The most frequently reported measure of effect in this meta-analysis was the correlation coefficient. When two outcomes in a single study were classified as the same outcome type (e.g., anxiety and depression for negative affect), we used the arithmetic mean of the two outcomes with each predictor. Some studies did not report a correlation coefficient, but rather a value for beta (β). Because the relationship between beta (βs) and product moment correlation (rs) is seemingly independent of sample size and number of predictor variables, standardized regression (beta) coefficients within the interval ± .50 were imputed based upon the statistical recommendations of Peterson and Brown [128]. This approach was favored so as to lower the sampling error and produce more accurate estimates of population effect-size. Since the data was collected from a restricted portion of the entire population of studies (women in the post-HAART era), no attempt was made to generalize beyond the studies included [129]. Thus, a fixed-effects model was selected for data input and analysis based upon the assumption that there is one true effect size shared by all studies as it relates to a specific disease outcome. A random effects model was not selected because reported effects are considered highly biased when the number of studies within a meta-analysis are 10 or fewer [130], as was often the case for the current study.

Data was structured in accordance with general linear modeling (GLM). We reported the following results: (a) total heterogeneity (Qt) of the sample tested against the χ2 distribution, (b) resultant p-value, (c) cumulative mean effect size (E) and standard error, (d) 95% confidence intervals surrounding E, and (e) fail-safe number (see Tables 4, 5, 6, 7, 8).

Table 4 Stressors and positive affect
Table 5 Stressors and negative affect
Table 6 Coping and positive affect
Table 7 Coping and negative affect
Table 8 Coping and health behaviors

Cumulative effect size represents the overall magnitude of the effect present within the studies; this value is considered to be significantly different from zero if the associated confidence limits do not bracket zero. Q-total was used to determine whether a set of effect sizes are homogenous, thus total heterogeneity of a sample must be tested against a Chi-square distribution with n − 1 degrees of freedom. The null hypothesis for this test is that all effect sizes are equal. A significant Qt-statistic would indicate that the variance among effect sizes is greater than expected by that of pure sampling error.

Publication bias is a common concern when conducting reviews from amassed literature. Most commonly, we observe the tendency for journals, especially those regarding critical diagnoses such as HIV/AIDS, to published studies with statistically significant results. Publication bias may be caused by the selective process of excluding non-published studies. Fail-safe Ns are the most commonly used method of determining, with publication bias, whether the result of a meta-analysis can be treated as a reliable estimate of the true effect [130]. This calculation reflects the number of studies which must be added to the analysis in order change the results from significance to that of non- significance. Using Rosenthal’s criterion (N < 5 k + 10), when the number is relatively large compared to the observed amount of studies, the data can be treated as a reliable index of effect. Another classic case of publication bias is depicted by the funnel plot. Large studies tend to be included regardless of their treatment effect, whereas small studies are more likely to be included when they show a relatively large treatment effect. Under these circumstances there will be a significant rank order correlation (Kendall’s tau b) between treatment effect and the standard error.

Results

Meta-analyses were conducted using effect size data from 24 and 28 of the 40 studies which met the criteria for the stressor and coping analyses respectively (see Fig. 1). Data was provided from a total of 7,602 adult women (Mage = 36.3 years) sampled between January 1997 and January 2011. The majority of the sample (67%) was African-American followed by Hispanic (19%), Caucasian (5%), and other (9%). Clinical status was identified in 54% of the reported sample; serostatus had a near even distribution within the sample (34% asymptomatic-HIV, 29% symptomatic-HIV, and 36% AIDS diagnosis) at time of study.

Five categorical meta-analyses were conducted; two comparing forms of stress with positive and negative affect and three comparing ways of coping with positive affect, negative affect and health behaviors. The cumulative effect and level of significance reflects the average of the raw correlations reported for each analysis (r). In order to account for possible publication bias of publishing more significant effects, it is custom to report the mean effect-size (R: presented in Tables 4, 5, 6, 7, 8) which accounts for the sample size from which each raw effect (r) was reported. Raw effects were converted to z-scores using Fisher’s Z to r transformation before the data was analyzed.

Stressors

The meta-analysis of perceived stress (r = −.26) and positive affect was significant, suggesting that interpersonal conflict and overall perceived stress from daily hassles and/or chronic strains predict lower reports of optimism and quality of life (see Table 4). HIV-symptoms (r = −.19) and functional impairment (r = −.21) evinced smaller magnitudes of effect, suggesting the stress appraised from physical limitations of the disease were not as great of barrier to positive psychological adaptation in women living with HIV/AIDS. Though all measures of effect were significant, sufficient homogeneity was observed only within the analysis of HIV/AIDS related symptoms.

Table 5 reports effect-sizes found between various forms of stress and measures of negative affect. Small to moderate effect sizes for degree of functional impairment (r = .33), HIV-related symptoms (r = .49), and perceived psychological stress (r = .53) were observed. The findings suggest women with HIV/AIDS report comparable levels of anxiety, depression, and psychological distress from physical symptoms associated with HIV/AIDS, as do they from the burden of major life events, chronic strains, and acute daily hassles. Sufficient homogeneity was observed within each analysis with the exception of functional impairment (p > .05), suggesting inconsistency of report.

Coping

Table 6 reports cumulative effects from a small to moderate range between the use of various coping mechanisms and indices of positive affect. Comparable effect sizes were observed amongst positive reappraisal (r = .32), seeking social support (r = .24), and spirituality based coping (r = .32), all of which significantly predicted positive psychological adaptation. This suggests women who practice the cognitive and spiritual reframing of stress report greater levels of perceived control and stress-related growth than those who turn to outside sources for support relief. Tests for homogeneity of report were null across all three coping measures, suggesting consistency between studies.

Table 7 reports significant effect sizes amongst a host of coping mechanisms and negative mental health outcomes. Most effect sizes were in the small to medium range with social isolation (r = .56) and avoidance coping mechanisms (r = .64) demonstrating the largest positive associations. Large effects of this nature suggest poorer mental health outcomes in women living with HIV/AIDS i.e., depression and anxiety are mainly attributed to the practice of maladaptive coping styles. Despite the robust effect sizes sufficient homogeneity was not observed (p < .001). Smaller effect-sizes within the range of r = −.17 to r = −.25 were reported for positive reappraisal, spirituality, approach, and problem-focused coping, suggesting these strategies have a significant buffering effect on the development of psychopathology.

To determine whether any publication bias exists, fail-safe Ns were calculated for each meta-analysis (see Tables 4, 5, 6, 7, 8). Overall, Rosenthal’s criterion (N < 5 k + 10) was met for 10 out of 20; 50% of the studies. Based upon this criterion, associations with sufficient heterogeneity (Q-total) that may also be considered for publication bias included that of HIV-symptoms, psychological stress, approach coping, and seeking social support with negative affect. In contrast, the association observed with negative affect between spirituality and avoidance evinced sufficient heterogeneity free of publication bias. The Begg and Mazumdar Rank Correlation Test for funnel plot asymmetry suggested marginal significance for publication bias for the analysis of spirituality and negative affect (p = .04) but not avoidance (p = .15), perceived stress (p = .41), HIV-symptoms (p = .35), seeking social support (p = .15), and approach coping (p = .15). The test also was not significant for the analysis of positive reappraisal and negative health behaviors (p = .50). It should be noted that non-significant correlation may be the result of low statistical power, and cannot be taken as evidence that bias is absent, whereas significant correlations suggests that bias exists but not the implications thereof.

Discussion

An unexpected findings from these meta-analyses was that acute and chronic forms of psychosocial stress had a comparable magnitude of effect on the development of psychopathology as did the physical burden of disease management. Previous studies have suggested that internal physical symptoms contribute only partially to the psychological stability in women living with HIV/AIDS [10, 131135]. It is very likely that disparities in income, access to education, and accessibility of health-related services interact to alter the intensity and frequency of life stress compounding the negative impact on disease outcomes [1618]. One likely barrier directly related to socioeconomic status is dependency within the household environment i.e., the burden of being a caregiver living with chronic illness may tax tangible and intangible resources in a way which might compound the level of difficulty for disease adjustment [136138].

Despite treatment advancements in HAART physical stress resulting from HIV-related symptomology is still a significant predictor of adverse psychological consequence in women. Studies predating the U.S. era of HAART availability suggested that seropositive women attributed greater distress to disease symptomology and often expressed stronger negative views of self-health than do their male counterparts [1315]. Intuitively, modern expectations of HAART effectiveness may lead to more negative appraisals of oscillating immune status and treatment-related side effects currently observed in response to anti-reteroviral treatement [2629, 56].

Functional impairment was also found to significantly predict negative affect, suggesting one’s incapacity to meet daily occupational demands may have a considerable impact on overall mood. Daily hassles and other acute stressors derived from functional disease-related limitations are known to impact setting and accomplishment of daily goals resulting in marked changes in motivation and affect [139]. Research has also found that cognitive dysfunction, in the memory and motor domains can predict the severity of functional limitation in ADLs as well as the probability of returning to work for HIV+ persons [140].

Though coping responses are typically characterized as buffers or moderators in the stress response, this study examined the direct effects of a host of coping mechanisms on mental and behavioral health outcomes. Spirituality and allied religious activities were the most frequently reported coping mechanism across affect and behavioral outcome categories. Despite small effect sizes across these domains, the construct of spiritual-based coping is considered by some to be an integral component of psychological well-being in ethnic minority women coping with chronic illnesses [141146]. It is likely that the positive reframing associated with spiritual/religious activities (e.g. search for meaning and prayer) plays a substantial role in reshaping the appraisal of HIV-related life stressors [147]. It is possible that larger effect sizes were not observed because effectiveness of spirituality/religious-based interventions are thought to be attributed to: (1) whether or not the construct was in place before onset of the major life event, and (2) the availability of religious resources to the individual pursuant to the event [44, 148].

Positive reframing, outside the context of spirituality and religion, may also predict enhanced psychological health. Unlike response-focused coping mechanisms (e.g. avoidance) which allow for the resurfacing of negative events, positive reappraisal facilitates reinterpretation of the stressor in a way which may buffer the impact of subsequent exposures to the same stimuli [149, 150]. Reappraisal has been implicated in cognitive behavioral therapy (CBT) and mindfulness training (MT) for HIV-positive persons with the goal of modifying views and behaviors related to drugs, diet, treatment regimens, and other facets of disease management [151153].

In the context of social support seeking women are classically depicted as more likely to tend to and befriend others as a primary coping mechanism compared to their male counterparts [154]. Despite this stereotype, our meta-analysis found higher reports of support seeking did not predict a mental health advantage compared to other adaptive coping mechanisms. One possibility is lack of attractiveness for this option for persons living with HIV/AIDS. To this day, HIV/AIDS is associated with levels of stigma unparalleled by other common infectious or non-communicable diseases. This factor is shown to be a significant predictor in the delay of HIV-disclosure and subsequent management of healthcare options [136]. Cultural factors too i.e., language barrier and level of acculturation have been reported by some as major limitations in the access of essential health and social support services [155157].

Coping mechanisms such as avoidance, denial, and social isolation were found especially maladaptive from a psychological and behavioral standpoint. It is quite evident that when these mechanisms are put in place, patterns of chronic stress develop [55]. HIV-positive women who report greater use of avoidant coping mechanisms are less inclined to seek assistance from health and social service providers and are more likely to delay initiation of antiretroviral drug regimen [20, 79]. Our meta-analysis also revealed that avoidance coping predicts substance abuse and non-adherence to HAART. More adaptive devices, namely coping skills training and group processing of personal issues, result in added gains for disease adjustment [158].

Limitations

One possible shortcoming of our study occurred in the preliminary data retrieval stages. The phrase “women with HIV/AIDS” in combination with other key terms was used as the initial search strategy. The use of phrases compared to single terms could have possibly resulted in the omission of relevant studies from abstract databases. To test this limitation we performed a posthoc analysis comparing the number of studies extracted from PsycINFO, PubMed, and Science Direct using the term “stress” and the phrase “women with HIV/AIDS” to the number of studies which show using the terms “women”, “HIV/AIDS” and “stress” separately; the analysis revealed identical search results within the three literature databases ruling out the omission of relevant articles using the afore mentioned strategy. Another possible shortcoming was the homogeneity of inclusion criteria across the various articles. A diverse array of criteria was observed across studies with participants screened on the basis of CDC classification, sexual orientation, ethnicity, and maternal status, in conjunction with random sampling methods. Also, the manner in which the stress/coping-outcome associations are mediated by disease progression could not be determined, as nearly half of the studies failed to report serostatus and in some instances provided immune markers i.e. viral load and CD4 count to describe the sample (see Table 9). This review may also suffer from publication bias since no efforts were made to include unpublished data. Non-significant findings are less likely to appear in published vs. unpublished literature [159]. Some tests for publication were confirmatory suggesting readers should be cautious when interpreting findings on spirituality and negative affect. There are also several contextual variables not accounted for in the design of the meta-analysis. For instance, Moskowitz and colleagues [10] tested for time since diagnoses as a moderator for ways of coping and disease outcome. This is of great relevance to psychosocial processes in women as the frequency and intensity of stressors plus strategy selection are likely to change as the patient progresses from the initial diagnosis [53].

Table 9 Demographics of studies included in the meta-analysis

When scales purporting to measure a construct (e.g. coping) contain items that measure another construct (e.g., distress), statistical tests of their association will be biased [4, 160]. This is an inherent flaw of all meta-analyses comparing antecedents, intervening variables, and disease outcomes. For example, scales reporting fatigue, a commonly reported symptom in HIV/AIDS, may be rather ambiguous considering the antecedents of such symptoms are shown to stem comorbidly from natural prognosis, pre-existing mood disorder, as well as HIV-associated cognitive dementia [161163].

Finally, variables inherent to personal background such as substance abuse and mental health history introduce a great deal of unaccounted variance in measured effects. For some women, drug abuse history renders them more vulnerable to stress, while for others the recovery process can promote mastery and help to inoculate them from exposure to future stressors [42]. One common finding related to chemical dependency and coping is that persons at greatest risk for substance abuse adapt escape-avoidant strategies as a way to manage their anxiety/distress, thus creating an added barrier against psychological adjustment disease management [148]. Many women seeking treatment for HIV/AIDS also suffer from psychopathology. The adverse effects of pre-existing mental health conditions such as anxiety and depression are an additional concern as they may contribute to immune compromise [151]. Immune suppression stemming from opportunistic infection and neoplasias often leads to repeated outbreaks in persons chronically living with HIV/AIDS. Psychosocial variables are known to contribute to some of the variability in immune parameters such as CD4+ count, viral load, and preservation of natural killer (NK) cells. Specifically, maladaptive responses to stress or one’s efficacy in coping with that stress are associated with more rapid progression from HIV to AIDS in both men and women [153].

Conclusion

This meta-analytic review brings to light the contextual factors associated with stress, coping, and disease adjustment for women living with HIV/AIDS in the HAART era. It is quite evident that women, particularly those of ethnic minority background, face unique challenges related to the disease in the 21st century. There remains a tremendous amount of work to be done in order to elucidate the interaction of certain cross-sections such as mothers/care-givers, intravenous drug-users, women of color and those of varying sexual orientation. Some culturally-sensitive scales have already been developed to address poverty, acculturation, racism, access to care, maternal stress, relationship conflict and other agents relevant to disease management [164, 165].

These psychosocial variables can now be directly implicated in CD4 count and viral load slope within longitudinal female cohorts [166]. Clinicians and social/healthcare providers should be aware of these disparities and encourage the use of adaptive stress-resistant resources so as to keep pace with treatment regimens focused on decelerating disease progression and increasing quality of life for women living with HIV/AIDS in the twenty-first century.