Profiles of subjective well-being among people living with HIV during the COVID-19 pandemic

Despite nearly four decades of intensive empirical research on the tripartite model of subjective well-being (SWB; Diener [1]), there is still no agreement on the internal structure of this model nor on the mutual relationships between its cognitive (life satisfaction) and affective components (positive affect [PA]; negative affect [NA]; see these reviews and meta-analyses: [2‐4]). Several studies found that those SWB elements are associated but also constitute independent constructs, especially with respect to their time stability or underlying predictors (e.g., [5, 6]). More specifically, in a meta-analytic review, Busseri [2] observed small to medium associations between SWB indicators and argued for more research on heterogeneous profiles of SWB, which could not be reduced to only high versus low SWB. Relatively recently, Shmotkin [7] created the dynamic and modular model of SWB, which postulates that all the components of SWB can be structured within various individuals in congruous and incongruous ways, and as such, one should explore them simultaneously. However, until now, the dominant methodological attitude to the study of SWB has been a variable‐centered approach, which focuses on the analysis of mean levels of satisfaction with life, PA and NA, and disregards the problem of the heterogeneity of SWB indicators across particular individuals [8, 9]. The latter can be obtained with the aid of the person-centered approach, which has still been rarely used in SWB research (e.g., [10, 11]). In addition, there is a scarcity of studies on the structure of SWB other than in the general population (i.e., a paucity of studies including clinical samples) [2]. In our study, we searched for SWB profiles and their sociodemographic and clinical correlates among people living with HIV (PLWH).

June 2021 marked the 40th anniversary of the first cases of human immunodeficiency virus (HIV) infection detected by the Centers for Disease Control [12], which resulted in a previously unknown illness, acquired immunodeficiency syndrome (AIDS). Since that time, substantial advancement in HIV treatment has transformed HIV from progressing to a terminal condition (AIDS) to now being reclassified as a chronic medical illness [13]. As such, nowadays, the average life expectancy of PLWH does not greatly differ from the life expectancy of healthy individuals in the general population [14]. Nevertheless, PLWH still experience HIV-related distress and consistently declare worse psychological well-being not only compared to the general population but also to patients suffering from other chronic illnesses [15]. Many studies have found that this latter tendency is a derivative of still existing, strong stigmatization of PLWH (see these meta-analyses: [16, 17]). At the same time, several authors have observed that PLWH are also a heterogeneous patient group with respect to coping and adapting to their illness [18‐20]. Specifically, although they share the same medical diagnosis (i.e., HIV infection), PLWH display different trajectories in their psychological functioning over time (e.g., [21, 22]). Consequently, applying the person-centered approach to investigating well-being outcomes among PLWH is increasingly recommended [18, 19].

Exploring distinct profiles of SWB of PLWH may be particularly justified during the COVID-19 pandemic as, during this critical period, individual differences in SWB structure may be more pronounced (see the review by [23]. According to a World Health Organization report [24], PLWH were at a 78–95% higher risk of death from COVID-19 in comparison to the general population and also had about a 20% higher risk of hospitalization due to coronavirus infection. In many European countries, access to regular medical care was limited during this period, which translated to a deterioration in adherence to antiretroviral treatment and a significant decline in HIV testing. Additionally, PLWH were under-prioritized for COVID-19 vaccination in approximately 60% of European countries, further exacerbated by misinformation associating COVID-19 vaccines with a risk of HIV infection [25]. All these factors contributed to elevated emotional distress and social isolation within this patient group [23]. On the other hand, studies conducted in the general population showed that the COVID-19 pandemic did not necessarily affect people in a negative way only, that is, some people were either not hampered by the circumstances or even experienced positive changes in their lives (e.g., [26, 27]). The question is whether this heterogeneity of SWB during this pandemic could be observed among PLWH.

The results of our study are in accordance with our first research hypothesis, as we observed heterogeneity of the SWB profiles among PWLH. However, the pattern of the profiles obtained was intriguing. Namely, the largest and second-largest groups of participants belonged to, respectively, the average negative profile (profile 1), with SWB values close to the sample average, and the average positive profile (profile 2), with slightly larger deviations from the average and generally higher SWB. The next two profiles more strongly reflected the patterns already observed in the average profiles. Specifically, profile 3 comprised flourishing participants with PA and SWL above one standard deviation from the mean, and profile 4 comprised languishing participants, with high NA and very low PA and SWL. On the one hand, the profiles obtained provide support for those SWB theories that highlight the bidirectional association between cognitive and affective aspects of well-being such that life satisfaction enhances positive affect or vice versa, but they are both oppositely linked to NA [4]. On the other hand, however, the most highly contrasting profiles comprise less than 25% of the sample, revealing that the typical profiles for PLWH in our study are rather flat, i.e., average negative and average positive, with small differences making them better or worse in terms of SWB. Flourishing and, more importantly, languishing can therefore be considered as less frequent characteristics than simply slightly better or slightly worse SWB. This is a significant finding in the context of this study.

Trying to interpret aforementioned result it should be stated that satisfaction with life concerns the global evaluation of life and, thus, is more driven by external events, whereas affective well-being is grounded more on the evaluation of recent activities and, therefore, can be much more transient and dynamic over time. For example, Luhmann et al. [6], in a meta-analytic review, found that various critical life events (e.g., divorce, job loss, retirement) may leave their footprint much more indelibly on cognitive components of SWB than on affective ones. In contrast, affective components of SWB are much more fluid and originate mostly in personality traits [46]. The COVID-19 pandemic constituted for PLWH a critical life event, resulting in the previously mentioned substantial disruption in their medical care and social life [23]. However, the event, by virtue of its scale and duration, also initiated a socially shared chronic stress. It was therefore interesting that within the same clinical sample in the similar context of uncontrollable external circumstances, we observed two such contrasting profiles, i.e., flourishing versus languishing [47], which is another argument for PLWH being a heterogeneous patient group with regard to adaptation not only to HIV infection but also in terms of general functioning [19, 20].

Our study also provided some support for our third research hypothesis but yielded a null result with regard to the second hypothesis. Specifically, as expected, intimate relationship status, education level, and current employment status were significant correlates of the probability of membership of SWB profiles, which supports the third hypothesis. Additionally, COVID-19-related distress was positively related to membership in the less-favorable profiles of SWB. To some extent, these findings can be drawn intuitively and are in line with previous studies on PLWH, as well as with studies on psychological functioning during the COVID-19 pandemic (e.g., [23]. However, in contrast to our second hypothesis, there was no effect of gender and age not only in terms of profile membership but also in terms of the SWB components in these profiles. These results may contribute valuable insights to the existing literature on the psychological well-being of PLWH [15]. It is noteworthy that the majority of well-being studies in this population have predominantly employed a variable-focused approach, neglecting to consider the potential influence of various sociodemographic factors, which often extend beyond individuals' personal control, on the heterogeneity of SWB profiles among PLWH [48]. This oversight bears significant implications, both in theoretical and practical terms, for the development of effective interventions targeting individuals and specific groups [49], particularly given the growing disparity observed between advancements in disease management and the mental health status of PLWH [50].

Interestingly, in line with the above, it is worth noticing that clinical variables describing the duration of the disease and its current state (i.e., years since diagnosis, years of ART, AIDS diagnosis and CD4 count) in our study had no effect on profile membership. This finding might be specific to our sample (which we will discuss in more detail in the limitations section). However, it highlights the importance of acknowledging resources beyond those directly linked to the disease, particularly in the context of coping with a chronic somatic condition. These resources are often overlooked in medically oriented interviews but may play a crucial role in functioning, especially when somatic symptoms can be well managed through good compliance but remain incurable, resulting in ongoing psychological and social implications [51]. In this sense, the findings support the basic premise of the conservation of resources theory [52], which, although not an SWB theory, highlights the role of broadly understood resources in human functioning, especially in the face of stress, with a social perspective that goes beyond exclusively individualized coping behaviors [53]. For instance, as Das et al. [9] showed in a systematic review, not only socioeconomic status (i.e., income, education, employment, family structure, and immigration status) but also religion, culture, and geographical location may be relevant for individual SWB. Similar ideas have been discussed in light of the effect of cross-country differences on SWB-related indexes [54, 55]. Consequently, this gap neglecting the systematic inclusion of more structural and basic factors together with a variable-oriented approach contributes to contradictory results and an incomplete picture of SWB determinants and correlates in the literature [9, 19, 56, 57]. The novelty of our study is, thus, our analysis of the heterogeneity of PLWH with regard to their sociodemographic and clinical characteristics and associations with SWB profiles, particularly in the critical time of the pandemic.

Finally, we obtained results in line with the growing body of research that applies a person-centered approach to SWB [10, 11, 58]). These findings showed that mixed SWB profiles (i.e., those with incongruent values for each component) can differently impact various areas of psychological functioning. Accordingly, disregarding the mutual interplay between well-being indicators and solely adhering to unidimensional relationships, as advocated by the variable-centered approach, hinders a comprehensive understanding of well-being structure and dynamics. It appears that SWB operates through various modules, engaging in a transactional process influenced by both internal and external factors [7]. Moreover, the SWB components demonstrate varying stability levels over the life course. This observation aligns with our own research findings, which suggest that profiles likely strive for internal consistency. Hence, alongside the height of the profiles, this internal consistency (or lack thereof) emerges as another crucial characteristic. To these characteristics should also be added a susceptibility to change and the persistence of these changes, which is also subject to marked individual differences [59].

Consequently, to ensure further progress in this research area, SWB should be described in a way that takes into account all these parameters and extends beyond testing the intensity of isolated components. This broader conceptualization of SWB may be particularly useful in the case of clinical samples similar to PLWH, whose well-being has constantly been challenged due to chronic HIV-related stress and still-existing strong social stigmatization [15‐17], which was further strengthened during the COVID-19 pandemic [23].

This study contributed to the literature on SWB among PLWH by applying a person-centered approach that provides data beyond and complementary to what can be gleaned by a variable-centered approach only. More specifically, it seems that SWB is not the sum of the tripartite components of Diener’s model [1, 3] but rather a complex and dynamic system. In addition, the components of SWB develop congruent profiles, also in the context of chronic illness and socially shared stressful circumstances. Additionally, their extreme intensity, in both directions (flourishing versus languishing), is observed in less than 25% of the sample. PLWH with fewer personal and socially valid resources belonged to the worst SWB profile, which was independent of their clinical characteristics. This picture of SWB is particularly informative given the chronic nature of medical and social stressors among PLWH [15‐17] and the unique context of this study.