Psychological adjustment, HIV knowledge, and antiretroviral treatment adherence in newly diagnosed HIV patients: a cross-sectional study from an Albanian infectious diseases clinic

Abstract

Background

The first year after an HIV diagnosis is a period of intense psychological vulnerability, with elevated rates of depression, anxiety, and adjustment problems documented in multiple settings. However, data from Albania and Western Balkan contexts are scarce.

Objective

To assess psychological adjustment, coping responses, HIV knowledge, and antiretroviral treatment (ART) adherence among adults diagnosed with HIV within the previous 12 months in Tirana, Albania.

Methods

A cross-sectional study was conducted with 120 patients registered at the ambulatory HIV/AIDS clinic at the Infectious Diseases Hospital in Tirana. Inclusion criteria: patients diagnosed within the last 12 months. Measures included demographic data, an Albanian version of the Mental Adjustment to HIV Scale (MAHIVS), a researcher-developed, interviewer-administered structured HIV knowledge interview, and a short adherence assessment based on self-report and cross-checking against medical records/clinic records.

Results

The mean age was 34 years (SD = 5); 26.7% were female, and 47 males identified as homosexual. HIV transmission knowledge was high (78% answered correctly), while awareness of biomedical issues (PrEP/PEP, viral load, information regarding fertility) was low. Participants reported high ART adherence, supported by medical records. MAHIVS scores indicated high helplessness (M = 21/36) coexisting with strong adaptive coping: Fighting Spirit/Self-Efficacy (M = 14/24), Personal Control (M = 11/16), and Positive Coping (M = 11/20).

Conclusion

Newly diagnosed Albanian patients show a mixed adjustment profile; notable psychological distress combined with moderate to high adaptive responses. Early psychosocial and educational support focused on reducing helplessness and increasing HIV knowledge within routine HIV care may improve adjustment trajectories during the first-year post-diagnosis.

Introduction

An HIV diagnosis is recognized as a major life stressor and is often accompanied by intense psychological reactions, particularly during the first 12 months after diagnosis [10, 12]. Numerous studies have documented elevated rates of adjustment problems, depression, anxiety [12], and maladaptive coping in people newly diagnosed with HIV [1, 8]. However, individuals may also demonstrate substantial resilience and adaptive coping resources, resulting in heterogeneous adjustment profiles across patients. Dulin et al. [2], Ironson [5].

The psychological impact of HIV diagnosis is mediated by cultural norms, stigma levels, personality differences, and availability of psychosocial and educational support [15]. International reviews have highlighted wide variation in mental health outcomes among people living with HIV across regions and socio-cultural settings, including differences in personality and access to psychological care [18, 4].

Albania is a low-prevalence country within Eastern Europe and Central Asia but has experienced gradual increases in HIV testing, earlier diagnosis, and improved access to antiretroviral therapy (ART) over recent years. National and regional reports describe concentrated epidemics among key populations [16], significant stigma, and persistent gaps in prevention and support services, especially following changes in international funding [19].

Despite epidemiological and service-delivery data, there is a lack of published research on the psychological adjustment of newly diagnosed HIV-positive individuals in Albania. To the best of current knowledge, no prior study has systematically examined adjustment and coping responses, HIV knowledge, and adherence during the first post- diagnosis year in this setting.

This study aimed to address this gap by assessing psychological adjustment using the Mental Adjustment to HIV Scale (MAHIVS), alongside HIV knowledge and ART adherence, in newly diagnosed patients attending the Infectious Diseases Hospital, HIV/AIDS ambulatory clinic of Tirana.

Methods

Study design and setting

A cross-sectional study was conducted in the ambulatory HIV/AIDS clinic of the Infectious Diseases Hospital at the University Hospital Center “Mother Teresa” in Tirana (QSUNT), the main national referral center for HIV care in Albania. The study was conducted over a period of 6 months from February 2025 to July 2025 (Table 1).

Table 1.

Internal consistency of the Albanian translated MAHIVS in the pilot sample (N = 30)

MAHIVS Albanian version: pilot internal consistency analysis	No. of items	Pilot sample (n)	Cronbach’s α
Total scale	24	30	0.79
Helplessness/hopelessness	9	30	0.76
Fighting spirit/self-efficacy	6	30	0.80
Personal control	4	30	0.78
Positive coping	5	30	0.79

Participants

Inclusion criteria were:

• Age ≥ 18 years

• Formal HIV/AIDS diagnosis within the past 12 months

• Currently on ART

• Ability and willingness to complete questionnaires

A total of 120 eligible patients were recruited consecutively during routine outpatient follow-up visits using convenience sampling [3].

Measures

1. Demographics: Participants reported age, sex, sexual orientation, time since HIV/ AIDS diagnosis, education level, employment status and marital status.

2. Mental Adjustment to HIV Scale (MAHIVS): Psychological adjustment was assessed using an Albanian version of the Mental Adjustment to HIV Scale (MAHIVS), originally developed to measure cognitive-emotional responses to HIV infection [6]. The scale is based on earlier work on psychological adjustment to chronic illness and has been widely used to characterize coping patterns among people living with HIV. The Albanian translation of the MAHIVS was developed and pilot tested in a sample of 30 participants.

The final four-factor structure used in this study comprised:

1. Helplessness/Hopelessness (9 items).

2. Fighting Spirit / Self-Efficacy (6 items).

3. Personal Control (4 items).

4. Positive Coping (5 items).

Items are rated on a Likert scale from 1 to 4, with higher scores on Helplessness/Hopelessness indicating poorer adjustment and higher scores on the other three subscales reflecting more adaptive adjustment.

Note: This study combined Factor 4 and 5 (positive coping and minimization) in the MAHIVS totaling to 4 factors.

• 3.A brief researcher-developed HIV knowledge interview schedule was used to assess practical HIV-related knowledge relevant to early post-diagnosis counselling in this clinical setting. The interview included 9 items on core transmission routes (e.g., sexual contact, blood exposure, mother-to-child transmission), viral load, treatment-as-prevention (U = U), reproductive issues, and awareness of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Because no brief locally adapted instrument covering these domains was available for routine use in this setting, the measure was developed for the present study and used as a structured descriptive clinical assessment rather than as a formal psychometric scale. Items were administered in a standardized order, and responses were recorded by the interviewer. Closed-ended responses were coded as correct or incorrect, while open-ended responses were judged against predefined content criteria derived from international HIV counselling guidelines (e.g., WHO, 2021) and local clinical practice at the QSUNT HIV/AIDS Ambulatory Clinic. The item concerning disclosure of HIV status to a sexual partner under Albanian law was treated as a contextual legal knowledge item and interpreted separately from the core biomedical knowledge items.

Sample items

1-What is the difference between HIV and AIDS?

2-What is the concept of viral load in terms of HIV?

3-What is PrEP and PEP?

4-What are the routes of HIV transmission? (Saliva-kissing, physical touch, blood exposure, sexual contact?

5-Should you disclose your HIV status to a potential sexual partner?

• 4.ART Adherence

ART adherence was assessed using patient self-report during the consultation and cross-checked using medical records from the same visit (e.g., missed doses, pharmacy refills, and physician notes). Self-report measures are commonly used in HIV research [14], and have shown acceptable validity when combined with objective indicators such as chart or pharmacy data.

Procedure

Patients attending routine clinical follow-up at the ambulatory clinic were invited to participate. After written informed consent was obtained, questionnaires were administered individually in the psychologist’s office. The HIV knowledge items were administered by the study psychologist in a structured interview format during the same consultation. Questions were asked in a standardized, non-leading manner, and responses were documented immediately at the time of interview. Participation was voluntary and anonymous, and patients could decline without any impact on their clinical care. The study was reviewed and approved according to local institutional procedures by the Psycho-Social Supervisory Sector of the Directorate of QSUNT, with authorization from the Head of the HIV/AIDS Ambulatory Clinic.

Data analysis

Descriptive statistics (means, standard deviations, frequencies, and percentages) were used to characterize the sample, HIV knowledge, adherence, and MAHIVS subscale scores. Pearson product-moment correlations were calculated to examine associations between the MAHIVS subscales. Independent samples t-tests were conducted to explore differences by sex and sexual orientation (homosexual males vs. others). All analyses were performed using SPSS version 28. Significance level was set at p < .05 (two-tailed).

Results

Sample profile

The mean age of participants was 34 years (SD = 5; range 18–55 years). Females represented 26.7% of the sample (n = 32). Among the 88 male participants, 47 identified as homosexual. All participants had been diagnosed with HIV within the previous 12 months and were receiving ART at the time of assessment (Table 2).

Table 2.

Demographics of participants (N = 120 Total)

Characteristic	n	(%)
Education level
Primary school	32	26.7%
Secondary school	60	50.0%
University degree	22	18.3%
Postgraduate degree	6	5.0%
Marital status
Single	39	32.5%
Married/In a relationship	69	57.5%
Divorced / separated	10	8.3%
Widowed	2	1.7%
Employment status
Employed	49	40.8%
Unemployed/With social assistance	58	48.3%
Student/Employed part-time	11	9.2%
Retired	2	1.7%

HIV knowledge

Overall, HIV transmission knowledge was good:

• 78% of participants demonstrated complete knowledge of the established HIV transmission routes assessed in the interview schedule, meaning that they correctly identified the principal biomedical transmission pathways and did not endorse common incorrect routes of transmission

However, awareness and knowledge of biomedical prevention strategies were markedly lower:

• 87% of participants reported being unfamiliar with the concept of viral load and its implications for transmission risks.

• 90% of participants had never heard of PrEP or PEP.

ART adherence

Participants reported high adherence to their ART regimen, which was consistent with information documented in their medical charts for the same period (no missed doses in the previous 3 months recorded). While some over-reporting cannot be excluded, the combined self-report and information retrieved from the medical registers suggested high adherence in this sample (Table 3).

Table 3.

Mean scores on the MAHIVS subscales

Subscale	No. of items	Possible score range	Mean score	SD
1.Helplessness/hopelessness	9	9–36	21	4
2.Fighting spirit/self-efficacy	6	6–24	14	5
3.Personal control	4	4–16	11	3
4.Positive coping	5	5–20	11	4

Higher scores on Helplessness/Hopelessness indicate poorer adjustment. Higher scores on the remaining subscales indicate more adaptive adjustment

Mental adjustment to HIV

Participants thus exhibited

• Marked helplessness/hopelessness, indicating considerable distress and perceived lack of control.

• Moderate to high fighting spirit/self-efficacy, accompanied by moderate personal control and active positive coping.

This pattern reflects a mixed adjustment profile: despite significant emotional burden, many patients reported mobilizing adaptive coping responses early after diagnosis.

Associations between MAHIVS subscales

Pearson correlations showed that Helplessness/Hopelessness was significantly negatively associated with Fighting Spirit/Self-Efficacy (r = − .48, p < .001), Personal Control (r = − .41, p < .001), and Positive Coping (r = − .36, p = .001). The three adaptive subscales were positively inter-correlated (r ranging from 0.29 to 0.51, all p < .01).

Group differences

No statistically significant differences were found between male and female participants on any MAHIVS subscale (all p > .05). Among male participants, those identifying as homosexual reported significantly lower Helplessness/Hopelessness scores than non-homosexual males (t (86) = 2.34, p = .022, Cohen’s d = 0.51). No significant differences emerged on the adaptive subscales by sexual orientation (all p > .05).

Discussion

This study provides, to current knowledge, the first systematic description of psychological adjustment, HIV knowledge, and ART adherence among newly diagnosed HIV/AIDS patients in Albania. The findings point to a complex adjustment pattern characterized by coexisting helplessness and adaptive coping. 90% of participants had never heard of PrEP or PEP, consistent with the limited availability and implementation of these interventions in Eastern and Central Europe, where PrEP access is still limited and implementation barriers are significant ([4]; UNAIDS, [18]).

Psychological distress and early adjustment

The elevated helplessness/hopelessness scores are consistent with international findings that the first year after HIV diagnosis is associated with high emotional distress, including depression, anxiety, and adjustment difficulties [1, 10, 11].Studies of newly diagnosed individuals have reported high rates of psychological symptoms and stress reactivity during this period, especially in the context of stigma and uncertainty regarding prognosis.

Adaptive coping and resilience

At the same time, participants showed moderate to high Fighting Spirit/Self-Efficacy scores and moderate Personal Control and Positive Coping. This aligns with research suggesting that positive psychosocial factors, such as active coping, self-efficacy, optimism, and a sense of coherence, can buffer psychological distress and are associated with better health-related quality of life and, in some studies, slower disease progression [2, 5, 13].

Knowledge gaps in biomedical prevention

The marked lack of awareness regarding viral load, treatment-as-prevention, PrEP, and PEP is noteworthy. Regional reports indicate that PrEP access in Eastern and Central Europe remains limited, with substantial barriers to implementation, and Albania is not among the countries with established, widely available PrEP programs. In such settings, it is unsurprising that patients (even those engaged in HIV care) may have minimal exposure to biomedical prevention concepts.

Clinical implications

From a clinical perspective, these findings support the integration of early psychosocial support into routine HIV care. International guidelines and policy documents increasingly emphasize that mental health services should be embedded in HIV prevention and treatment programs to improve both psychological and biomedical outcomes [17, 18, 20]. Brief, evidence-informed interventions delivered in ambulatory settings, including psychoeducation, basic emotion regulation skills, problem-solving, and support for adaptive coping, have been shown to improve engagement in care and psychological wellbeing among people living with HIV [7, 9].

In the Albanian context, priority areas may include:

• Directly addressing helplessness/hopelessness (e.g., normalizing emotional reactions, enhancing perceived control, and linking patients to social support).

• Strengthening existing fighting spirit and self-efficacy by validating adaptive efforts and collaboratively setting realistic goals and offering emotional support.

• Providing psychoeducation about viral load, prophylactic measures, and transmission risks, tailored to local service availability, to improve patients’ understanding of biomedical prevention.

Developing simple, scalable psychosocial protocols that can be delivered by medical clinicians or trained counsellors within the ambulatory clinic could be an important first step.

Limitations

Several limitations should be acknowledged. First, the cross-sectional design precludes causal inferences about the temporal relationships between psychological adjustment, knowledge, and adherence. Longitudinal studies are needed to track how adjustment patterns evolve during the first year after diagnosis and beyond.

Second, ART adherence was assessed via self-report supplemented by chart review, approaches that are vulnerable to social desirability and recall biases. Although the convergence of self-report and medical records in this study suggests high adherence, more objective measures (e.g., pharmacy refill data, electronic monitoring, or viral load trajectories) would strengthen conclusions.

Third, the use of convenience sampling from a single tertiary hospital clinic limits generalizability. Patients linked to this center may differ from those not in care, in rural areas, or in more marginalized groups, particularly regarding access to information and psychosocial resources.

Finally, the HIV knowledge interview schedule was researcher-developed for the present study and was not formally psychometrically validated.

Conclusion

Newly diagnosed Albanian HIV/AIDS patients in this sample presented notable psychological distress, reflected in high helplessness/hopelessness, alongside adaptive coping, including moderate fighting spirit, personal control, and positive coping responses. This mixed profile highlights the need for early, integrated psychosocial and educational support within routine HIV care, focused on reducing helplessness while strengthening existing adaptive resources. Enhancing patient education about viral load and biomedical prevention, combined with brief evidence-based psychological interventions, may improve adjustment trajectories and long- term wellbeing during the critical first year following diagnosis.

Author contributions

S.H. is the Sole Author of the study.

Funding

Not applicable.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was reviewed according to local institutional procedures by the Psycho-Social Supervisory Sector of the Directorate of QSUNT, was authorized by the Head of the HIV/AIDS Ambulatory Clinic, Prof. Dr. Arjan Harxhi. No formal IRB reference number was assigned as this was an internal clinical service evaluation conducted under routine care protocols at the University Hospital Center “Mother Teresa”. The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained for every participant.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.