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. Author manuscript; available in PMC: 2021 Jul 23.
Published in final edited form as: Mindfulness (N Y). 2020 Feb 10;11(5):1159–1169. doi: 10.1007/s12671-020-01315-8

Testing Mindful Awareness as a Moderator in the Association Between HIV-Related Stress and Drug and Alcohol Use Problems Among People Living with HIV

K Marie Sizemore 1, Steven Samrock 1, Shannon Gray 1, David Marcotte 2, H Jonathon Rendina 1,3
PMCID: PMC8300866  NIHMSID: NIHMS1640046  PMID: 34306246

Abstract

Objectives

People living with HIV (PLWH) are disproportionately affected by stressful life events. HIV-related stress adds to general life stressors to increase health risks among this population. Stress has not only been associated with HIV progression but it is also linked to HIV transmission risk behavior (e.g., substance use). Older adults living with HIV (OALWH) experience additional age-related stress and are at increased risk for substance use. Mindfulness buffers against stress for PLWH; however, research has yet to examine mindfulness as a buffer between HIV-related stress and substance use for OALWH.

Methods

Participants were 130 OALWH (Mage = 54.65, SD = 4.20) and 74.6% were Black. The majority were male (69.2%), and nearly half identified as heterosexual (48.5%). A hierarchical linear regression examined the main and interactive effects of mindful awareness and two types of HIV-related stress (e.g., stigma and rumination) on alcohol and drug use problems.

Results

In step one of the model, we examined HIV stigma (β = .231, p = .015) and found no significant interaction with mindful awareness. In step two, HIV rumination (β = .288, p = .001) was added. We found a significant interaction (β = .196, p = .020), indicating those with low mindful awareness and high rumination reported the greatest substance use problems. Exploratory analyses revealed an indirect effect of HIV stigma on substance use through HIV rumination as well as a significant effect for second-stage moderated mediation.

Conclusions

These findings support mindful awareness as a buffer against HIV rumination for OALWH. Further, our results have important implications for the utility of mindfulness-based interventions (MBIs) with OALWH and comorbid substance use disorders.

Keywords: Moderated mediation, Mindfulness, Stigma, HIV, Substance use, Older adults

In the USA, almost half (47%) of all people living with HIV (PLWH) are over the age of 50 (Centers for Disease Control and Prevention 2018a). The Centers for Disease Control and Prevention estimate that the number of older adults living with HIV (OALWH) exceeds 450,000. The OALWH population (aged 50 or older; Millar et al. 2017) is expected to rise as lifelong antiretroviral therapy (ART) treatments help people with HIV to live longer lives (NIH U.S. National Library of Medicine 2019). Given this increase in the aging population of PLWH, comorbidities are becoming an important concern. Comorbid substance use problems are of particular interest as they have been associated with HIV-related mortality (High et al. 2012), issues with medication adherence (Braithwaite and Bryant 2010), and increased risk of HIV transmission (Xu et al. 2014).

Substance use (e.g., alcohol and drug use) is a significant HIV transmission risk behavior (TRB) among both PLWH and OALWH. In addition to the risks of injection drug use, recreational substance use is associated with sexual TRB and increased likelihood for HIV transmission (Xu et al. 2014). Research shows that alcohol abuse (Chander et al. 2008; Galvan et al. 2002) and illicit drug use (Center for Behavioral Health Statistics and Quality, 2018b) are significantly more common in PLWH as compared with HIV-negative populations. Additionally, research has found that older age is associated with increased odds of having an alcohol use diagnosis among PLWH (Gurung et al. 2017). Studies have found that excessive drinking and drug use (e.g., cannabis, tranquilizers, hypnotics, opioids, stimulants, inhalants, or intravenous drugs) increases with age for PLWH, whereas substance use decreases with age for those who are HIV negative (Justice et al. 2004; Skalski et al. 2013). Alcohol and/or drug use diagnoses among PLWH have been associated with lower CD4 counts and increased hospital stays (Gurung et al. 2017). For OALWH specifically, substance use can have a marked effect on psychological and behavioral outcomes such as depression and anxiety, and medication nonadherence (Braithwaite and Bryant 2010; Skalski et al. 2013). Alcohol and drug use are also associated with poorer mental health treatment outcomes for depression (Ramsey et al. 2005), post-traumatic stress disorder (Bedard-Gilligan et al. 2018), and other anxiety disorders (McEvoy and Shand 2008). Sustained alcohol abuse and use of other substances for older adults can also lead to increased risk of HIV-related mortality (Edelman et al. 2014; High et al. 2012).

Minority stress theory is a prominent model for understanding these HIV-related health disparities (Rendina et al. 2016; Turan et al. 2017). PLWH are disproportionately affected by traumatic life events and increased levels of stress (Thompson et al. 1996). Compared with the general population, PLWH face higher rates of discrimination and stigma-related experiences (Porter et al. 2015) as well as higher levels of stress due to chronic illness management (Mugavero et al. 2009). Stress has not only been associated with HIV progression (Evans et al. 1997; Leserman 2003) but it has also been linked to HIV TRB such as decreased condom use, medication nonadherence, and substance use (Thompson et al. 1996). For OALWH, this is in addition to age-related cognitive decline and co-occurring chronic illnesses such as diabetes and heart disease, and other age-related risks such as dementia, bone loss, and cancer (Centers for Disease Control and Prevention 2018b) which likely have a bi-directional association with stress.

Over-and-above general life stressors faced by everyone, PLWH—and particularly OALWH—face HIV-related stressors that can further put them at risk for comorbid health outcomes. For OALWH, these stressors may include HIV rumination (Vance et al. 2010) and social isolation related to HIV stigma (Emlet 2006; Grov et al. 2010; High et al. 2012; Porter et al. 2015). Further, HIV stigma (High et al. 2012; Skalski et al. 2013) and HIV rumination (Vance et al. 2010) may increase the risk for substance use among PLWH and OALWH.

Rumination is described as repetitive thinking about the causes, consequences, and symptoms of one’s negative affect (Nolen-Hoeksema and Morrow 1991). Subsequent research has shown that people with chronic illnesses (Soo et al. 2014), including PLWH (Kidia et al. 2015), may ruminate over the causes, consequences, and symptoms of their illness. Rumination can lead to negative mental health outcomes for PLWH (Bader et al. 2006; Kidia et al. 2015), and is a transdiagnostic factor for depression and anxiety (Mclaughlin and Nolen-Hoeksema 2011). Ruminative thinking is also related to neurological and cognitive changes which occur during the aging process for PLWH. OALWH experience more severe damage to subcortical structures compared with the general population (Vance et al. 2010). As PLWH age, cognitive resources are depleted and mood regulation decreases, which can lead to increased rumination. Further, rumination is associated with substance use (Nolen-Hoeksema and Harrell 2002). Especially in the presence of environmental stressors, people may turn to substances as an attempt to mitigate the negative affect associated with rumination (Nolen-Hoeksema 2006).

HIV stigma has also shown to contribute to increased alcohol and substance abuse (Rendina et al. 2018; Simbayi et al. 2007). HIV stigma may take form as internalized stigma (applying negative HIV-related feelings and beliefs to the self), enacted stigma (experiencing discrimination, stereotyping, and/or prejudice from others), and anticipated stigma (expecting discrimination, stereotyping, and/or prejudice from others). Each of these domains has been associated with adverse effects on health and wellbeing (Earnshaw et al. 2012; Hernandez et al. 2018; Rendina et al. 2016). HIV stigma, discrimination, and fear of isolation can also be a major source of psychological stress for PLWH (Earnshaw and Chaudoir 2009; Hatzenbuehler et al. 2011; Logie and Gadalla 2009). PLWH may turn to drugs and alcohol to mitigate the pain associated with experiencing high levels of stigma. Research has shown that HIV stigma is correlated with substance use (Centers for Disease Control and Prevention 2018b; Levi-Minzi and Surratt 2014; Rendina et al. 2018) and that substance use impacts both younger and older populations living with HIV (Green et al. 2010).

There is increasing evidence that mindfulness buffers against stress in many populations, including PLWH (Moskowitz et al. 2015; Yang et al. 2015). Among PLWH, mindfulness is associated with decreases in depression and perceived stress (Moskowitz et al. 2015). Mindfulness-based interventions (MBIs) have been shown to significantly increase quality of life and decrease psychological stress in participants aging with HIV (Gonzalez-Garcia et al. 2013). A growing body of evidence suggests that cultivating mindful awareness can also be an effective way for PLWH to cope with and manage HIV-related stress, particularly HIV stigma (Gonzalez et al. 2009). Studies have shown that acting with mindful awareness can buffer against the association between internalized HIV stigma and negative mental health outcomes for PLWH (Gonzalez et al. 2015; Yang and Mak 2017). Although research has yet to examine mindfulness as a buffer against HIV rumination, in clinically depressed populations, mindfulness practice is associated with decreased rumination and symptom alleviation (Deyo et al. 2009; Hawley et al. 2013).

Increases in mindful awareness are associated with improved HIV-related health outcomes and reduced substance use (Price et al. 2013; Yang et al. 2015). Research shows that individuals with substance use disorders report significantly lower levels of mindfulness compared with healthy adults (Shorey et al. 2013). Limited research has examined mindful awareness and substance use among PLWH. One study that found substance using HIV+ individuals had significant improvements in perceived stress after participating in a MBI (Agarwal et al. 2015). However, research has yet to examine mindful awareness as a moderator of the association between HIV-related stress and substance use for PLWH, and more specifically, OALWH.

The current study is a secondary data analysis, which sought to expand upon previous literature by examining the stress-buffering effect of mindful awareness on the association between HIV-related stress and substance use problems among OALWH. We adjusted for standard demographics, as well as variables which have been shown to impact HIV-related stress and substance use outcomes among OALWH specifically, including geriatric depression (Hosaka et al. 2019; Nanni et al. 2014), relationship status (Greene et al. 2017; Hosaka et al. 2019), time living with HIV (Hinkin, Castellon, Atkinson, Goodkin, 2001; Justice 2010), and an undetectable HIV status (Justice 2010). We hypothesized that two types of HIV-related stress, HIV stigma and HIV rumination, would have a positive association with substance use problems. We also expected that mindful awareness would have a negative association with substance use problems. Further, we hypothesized that mindful awareness would moderate the relationship between these two types of HIV-related stress and substance use problems.

Method

Participants

Participants were 130 OALWH (Mage = 54.65, SD = 4.20), recruited from diverse geographic areas of New York City, between November 2011 and March 2013. Eligibility criteria included (a) being at least 50 years of age, (b) being HIV-positive (confirmed with documentation), (c) being currently prescribed an ART medication regimen, (d) being English-speaking, (e) having had a lifetime alcohol/drug dependence in a drug category, which they had used in the past 12 months, and (f) reporting at least three days of HIV medication nonadherence within the last 30 days.

Procedures

The current study is a secondary data analysis, which uses baseline data from a larger randomized control trial of a behavioral intervention, the Wisdom in Spirituality Education (WISE) study. Data were collected between December 2011 and October 2014. Participants were initially screened for eligibility and scheduled for an in-office baseline assessment. All eligibility criteria were confirmed at the first baseline assessment, with substance dependence criteria being confirmed using the Computerized Diagnostic Interview Schedule Version IV (CDIS-IV). Additional eligibility criteria were assessed during this appointment. Participants were excluded from the study during the baseline assessment if they demonstrated evidence of gross cognitive impairment using the Mini-Mental Status Exam (i.e., scored below 24) or unstable, serious psychiatric symptoms, or current suicidal/homicidal ideation using the Structured Clinical Interview, DSM-IV Psychotic Screening Module.

At the baseline assessment, eligible participants completed a two-hour appointment, where they provided consent and completed an online survey administered through audio computer-assisted self-interview (ACASI) software. Also during this appointment, a trained phlebotomist completed a blood draw to gather participant data for viral load and CD4 count. Participant compensation for this assessment was $50. All procedures were approved by the Institutional Review Board at Hunter College of the City University of New York.

Measures

Demographic and Sample Characteristics

Participants reported their age, race, sexual identity, gender, income, and relationship status. Participants reported whether they had ever received medical treatment for drug or alcohol use, and whether they had ever attended a 12-step meeting for drug or alcohol use. Participants also reported, in months, how long they had been living with HIV. For our analyses, participant viral load was transformed into a dichotomous variable indicating whether or not they were undetectable.

Geriatric Depression

Participants completed the Geriatric Depression Scale (GDS; Yesavage et al. 1982). The GDS consists of thirty items and the stem for the scale was “Choose the best answer for how you have felt over the past week.” Sample items from this scale included “Do you feel that your life is empty?” and “Do you feel that your situation is hopeless?” Response options were dichotomous and ranged from 0 (no) to 1 (yes). Scores ranged from 0 to 30, and higher scores indicated greater depressive symptomology. The GDS has been validated to assess depression in OALWH and has been used to screen late-life depression in HIV-positive adults (Heckman et al. 2006). The scale demonstrated very good internal consistency in the current sample (α = .91).

HIV Stigma

HIV stigma was assessed using the HIV Stigma Scale-Revised (Wright et al. 2007), which was adapted from the original HIV Stigma Scale (Berger et al. 2001). The revised scale has ten items, which captures enacted, anticipated, and internalized forms of HIV stigma. Sample items from this scale included “most people think that a person with HIV is disgusting” and “I feel that I am not as good a person as others because I have HIV.” Response options ranged from 1 (strongly disagree) to 4 (strongly agree). Higher scores indicated greater experience of HIV stigma. The scale demonstrated very good internal consistency in the current sample (α = .82).

HIV Rumination

HIV rumination was measured using two items: “how often do you think about HIV day-to-day?” and “how often do you think about HIV while you’re having sex?” Response options ranged from 0 (never) to 6 (all the time). Higher scores indicated greater experience of HIV rumination. The two items demonstrated limited internal consistency in the current sample (α = .60).

Mindful Awareness

Mindful awareness was measured using the Mindful Attention Awareness Scale (MAAS; Brown and Ryan 2003). The MAAS (Brown and Ryan 2003) consists of fifteen items, which ask participants about their everyday experience with mindful awareness. Sample items from this scale included “I find it difficult to stay focused on what’s happening in the present” and “It seems I am “running on automatic,” without much awareness of what I’m doing.” Response options ranged from 1 (almost always) to 6 (almost never). Higher scores indicated greater mindful awareness. The scale demonstrated very good internal consistency in the current sample (α = .92).

Substance Use Problems

Substance use problems were measured using the Shortened Inventory of Problems – Alcohol and Drugs Scale (SIP-AD; Blanchard et al. 2003). The SIP-AD scale consists of fifteen items, and assesses problems related to drug and alcohol use over the last 3 months. Sample items from this scale were “I have failed to do what was expected of me because of my drinking/drug use” and “I have had money problems because of my drinking/drug use.” Response options ranged from 0 (never) to 3 (daily or almost daily). Higher scores indicated greater substance use problems. The scale demonstrated very good internal consistency in the current sample (α = .95).

Data Analyses

Prior to analyses, missingness and skew of the data were examined. Descriptive statistics (means and standard deviations) and the associations among measures (bivariate correlations) were estimated using SPSS 24. Independent sample t tests were conducted to examine demographic differences in mindful awareness, HIV-related stress, and substance use problems. Specifically, we examined mean differences by race/ethnicity, gender, and sexual identity.

To examine the moderating effect of mindful awareness in the association between HIV-related stress and substance use problems, a two-step hierarchical regression analysis was conducted. All models were adjusted for the following covariates: demographic characteristics (e.g., age, gender, race, sexual orientation, income, and relationship status), geriatric depression, time living with HIV, and whether the participant was undetectable. In step one, mindful awareness, HIV stigma, and their interaction were added to the model. In step two, HIV rumination, and the interaction between mindful awareness and HIV rumination, was entered into the model. Mindful awareness and both HIV-related stress variables were mean-centered before creating the interaction terms.

After examining the data, we conducted exploratory analyses to test a moderated mediation model. This model was tested using the SPSS PROCESS macro developed by Hayes (2017). This macro uses conditional process analysis, which includes probing the significance of the conditional direct and indirect effects at set values of the moderator (± 1 SD). We used the PROCESS Model 14 template to test for second-stage moderated mediation and set bootstrapping at 5000 draws.

Results

Demographics and sample characteristics are presented in Table 1. We note that all participants provided data for the measures used in this study, and data were fairly symmetrical (skewness and standard errors for each measure is presented in Table 2). Bivariate correlations among measures and descriptive statistics (e.g., mean and standard deviation) are also presented in Table 2. We also examined mean differences in mindful awareness, HIV-related stress, and substance use problems by demographic characteristics. Examining race/ethnicity, we found a significant mean difference for substance use problems. Specifically, White participants had significantly less substance use problems (M = 16.71; SD = 10.03) compared with participants of color (M = 22.39; SD = 10.59), t (128) = 2.27, p = .025. Analyses revealed no significant mean differences, based on race, for mindful awareness (t [128] = .51, p = .612), HIV rumination (t [128] = 1.52, p = .131), and HIV stigma (t [128] = .79, p = .433). Examining gender and sexual orientation, we found no evidence of mean differences. Specifically, analyses revealed no significant mean differences, based on gender, for substance use problems (t [128] = .53, p = .594), mindful awareness (t [128] = .56, p = .579), HIV rumination (t [128] = − 1.11, p = .269), and HIV stigma (t [128] = .38, p = .704). Further, analyses revealed no significant mean differences, based on sexual orientation, for substance use problems (t [128] = .18, p = .857), mindful awareness (t [128] = − .77, p = .443), HIV rumination (t [128] = − .28, p = .782), and HIV stigma (t [128] = .30, p = .766).

Table 1.

Sample demographics

N (%) Mean (SD)
Age 54.65 (4.20)
Years HIV+ 17.54 (6.83)
Race/ethnicity
 Black 97 (74.6%)
 Latino/a 11 (8.5%)
 White 12 (9.2%)
 Other 10 (7.7%)
Gender
 Male 90 (69.2%)
 Female 40 (30.8%)
Sexual identity
 Lesbian/gay/queer 48 (36.9%)
 Bisexual 16(12.3%)
 Heterosexual 63 (48.5%)
 Other 3 (2.3%)
In a relationship 63 (48.5%)
Income
 > 50K 2 (1.5%)
 20K–49K 24 (18.5%)
 < 20K 104 (80%)
Ever attended a 12-step meeting for drug or alcohol use 100 (76.9%)
Ever received medical treatment for drug or alcohol use 71 (54.6%)
Current substance dependence (CDIS-IV)
 None 2 (1.5%)
 Alcohol dependence 120 (92.3%)
 Marijuana dependence 8 (6.2%)
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In a relationship is defined as having a primary romantic partner (e.g., boyfriend, girlfriend, spouse)

Table 2.

Bivariate correlations among key measures

1 2 3 4
1. Mindful awareness - − .357*** − .297*** − .388***
2. Drug and alcohol problems - .424*** .352***
3. HIV rumination - .346***
4. HIV stigma -
 Mean (SD) 4.19 (1.03) 21.48 (10.68) 3.18 (1.78) 22.24 (6.67)
 Skewness (SE) − .32 (.21) .21 (.21) .01 (.21) .17 (.21)
 α .92 .95 .60 .82
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*

p < .05;

**

p < .01;

***

p < .001

Next, we conducted a multivariable regression with substance use problems as the outcome variable. Results from these analyses are shown in Table 3. In step one of the multivariable regression model, we added HIV stigma, mindful awareness, and their interaction, which, together with the covariates, accounted for 24.6% of the variance in substance use problems. In this model, mindful awareness (β = − .28, p = .009) and HIV stigma (β = .22, p = .029) were significantly and independently associated with substance use problems. The interaction between mindful awareness and HIV stigma was not significant in the model. In step two, we added HIV rumination and the interaction between HIV rumination and mindful awareness into the model. This accounted for an additional 11.5% of the variance in substance use problems. While adjusting for covariates, and all other variables, mindful awareness (β = − .21, p = .040) and HIV rumination (β = .29, p = .001) were significantly and independently associated with substance use problems. Additionally, the interaction between mindful awareness and HIV rumination was significant (β = .20, p = .016). HIV stigma did not remain significant in the model.

Table 3.

Hierarchical regression analyses predicting substance use and alcohol problems

Step 1 Step 2
Step/variable R2 B p R2 B p
Interaction of mindfulness with HIV-related stress .246 .361
1 Age .009 .925 .003 .968
Female − .066 .493 − .127 .162
Heterosexual .037 .719 .051 .602
White −.175 .052 − .140 .096
Income $30K+ − .014 .871 − .060 .465
In a relationship −.168 .083 −.158 .081
Time living with HIV .061 .503 .084 .321
Undetectable .064 .472 .019 .822
Geriatric depression .033 .755 .102 .313
Mindful awareness − .278 .009 − .205 .040
HIV stigma .221 .029 .121 .209
Mindful awareness * HIV stigma − .049 .569 − .102 .217
2 HIV rumination - .299 .001
Mindful awareness * HIV rumination - .203 .016
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The plot of the regression lines demonstrating the significant interaction between mindful awareness and HIV rumination on substance use problems is presented in Fig. 1. This indicated that individuals with low levels of mindful awareness and high rumination exhibited the greatest substance use problems. Further, individuals with high levels of mindful awareness and low levels of rumination reported the least problems with substance use.

Fig. 1.

Fig. 1

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Interaction of mindfulness and HIV rumination in predicting substance use and alcohol problems as measured by the Shortened Inventory of Problems – Alcohol and Drugs Scale (SIP-AD; Blanchard et al. 2003)

After reviewing our findings, we decided to test an exploratory model. Specifically, we wanted to test whether HIV rumination mediated the association between HIV stigma and substance use problems. Further, given our previous findings, we predicted that mindful awareness would moderate the pathway from HIV rumination to substance use problems in this proposed model. As such, we specified a second-stage moderated mediation model. The conceptual model is presented in Fig. 2. These exploratory analyses are presented in Table 4. Findings from the conditional process analyses demonstrated evidence of moderated mediation. Specifically, we examined the conditional indirect effect of HIV stigma (through HIV rumination) at various levels of mindful awareness (± 1 SD). These findings revealed that the conditional indirect effect was significant at moderate (β = .16, CI = .041–.322) and high levels of mindful awareness (β = .27, CI = .092–.480). This effect was not significant at low levels of mindful awareness (β = .07, CI = − .054–.253). Evidence of moderated mediation was further confirmed by the index of moderated mediation and bootstrap confidence intervals (see Table 5).

Fig. 2.

Fig. 2

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Exploratory, second-stage moderated mediation model

Table 4.

Exploratory analyses examining a second-stage moderated mediation model of substance use and alcohol problems

Model 1 Model 2
HIV rumination Substance use problems
R2 β p R2 β p
.164 .361
Age .025 .528 .099 .642
Female .375 .333 − 3.351 .114
Heterosexual .012 .975 .802 .699
White − .360 .442 − 4.410 .083
Income $30K+ .556 .395 − 2.112 .549
In a relationship − .288 .430 − 2.697 .173
Time living with HIV .051 .264 .389 .114
Undetectable .438 .264 .552 .758
Geriatric depression − .019 .188 .248 .148
HIV stigma .093 .001 .192 .223
Mindful awareness - - − 1.687 .0928
HIV rumination - - 1.702 .002
Mindful awareness * HIV rumination - - 1.000 .036
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Table 5.

Conditional process analysis: probing the interaction in a second-stage moderated mediation model predicting substance and alcohol use problems

β BootLLCI BootULCI
Conditional effect of the focal predictor at mindfulness = M±SD
 M − 1 SD (− .9700) .731 − .701 2.163
 M (0) 1.732 .694 2.768
 M + 1 SD (1.2300) 2.932 1.44 4.421
Conditional indirect effect analysis at mindfulness = M±SD
 M − 1 SD (− .9700) .068 − .054 .253
 M (0) .161 .041 .322
 M + 1 SD (1.2300) .272 .092 .480
Index BootLLCI BootULCI
Index of moderated mediation .093 .009 .184
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Unstandardized regression coefficients reported. Bootstrap sample size = 5000. LL, low limit; UL, upper limit; CI, confidence interval

Discussion

HIV-related stress is a public health burden and is known to undermine the health of PLWH (Berger et al. 2001; Earnshaw and Chaudoir 2009; Earnshaw et al. 2013; Levi-Minzi and Surratt 2014). This burden is especially high among OALWH, who may experience multiple intersecting stressors. Further, as a result of HIV-related stress, OALWH are at an increased risk for substance use problems (Justice et al. 2004; Skalski et al. 2013). Research on HIV-associated comorbidities, including substance use problems, is currently a high-priority focus for both NIH’s Institute on Drug Abuse (NIDA) and the Office of Aids Research (OAR). The purpose of this study was to examine the stress-buffering effect of mindful awareness on the association between HIV-related stress and substance use problems among OALWH. Our findings demonstrated that two types of HIV-related stress, HIV stigma and HIV rumination, were both positively associated with substance use problems in this sample of OALWH. We also found that mindful awareness was negatively associated with substance use problems. Our results demonstrated that mindful awareness moderates the association between HIV rumination and substance use problems. Further, our findings also provide some evidence for moderated mediation.

Consistent with our hypotheses, HIV rumination and HIV stigma were both related to greater substance use problems. Although there is limited research examining the association between HIV rumination and substance use problems among OALWH, our findings are consistent with previous work examining rumination and substance use more generally (Nolen-Hoeksema and Harrell 2002; Nolen-Hoeksema 2006). With regard to HIV stigma, our findings are consistent with prior work, which has demonstrated its association with substance use problems more generally (Centers for Disease Control and Prevention 2018b; Levi-Minzi and Surratt 2014), as well as substance use among OALWH (Green et al. 2010).

Our findings demonstrate a significant negative association with substance use problems, as well as HIV-related stress at the bivariate level. These findings are consistent with research on mindfulness and substance use among the general population (Chiesa and Serretti 2013), and are also consistent with the literature on mindfulness and general ruminative thinking (Deyo et al. 2009). However, we note that while these findings were statistically significant, they only reach the recommended minimum effect size for detecting a practically significant effect (Ferguson 2009). Further, we did not find evidence to support our hypothesis that mindful awareness buffered against the association between HIV stigma and substance use problems. We note that our measure included scale items that assessed enacted, anticipated, and internalized HIV stigma. It may be the case that mindful awareness only buffers against one of these forms of HIV stigma (e.g., internalized stigma). As such, future work should further explore this research question.

We did, however, find evidence to support our hypothesis that mindful awareness buffered against the association between HIV rumination and substance use problems. These findings indicated that participants with low mindful awareness reported higher rates of substance use problems, regardless of their HIV rumination level. Specifically, those with low mindful awareness and high rumination report the greatest problems with substance use. Further, those with high mindful awareness and low rumination reported the least problems with substance use.

Finally, our exploratory analyses revealed evidence of a second-stage moderated mediation model. Specifically, we found that HIV rumination mediated the association between HIV stigma and substance use problems, and that mindful awareness moderated the association between HIV rumination and substance use problems. Future studies should attempt to replicate our findings and further validate this conceptual model.

Limitations and Directions for Future Research

Our study adds to the existing research on substance use among OALWH; however, it also acts to represent the current state of the literature on intersectional stigma. In our review, we found that the research on mindfulness and HIV (Riley and Kalichman 2014), and mindfulness and substance use problems (Chiesa and Serretti 2013) existed as distinctly separate bodies of literature. Despite the fact that many PLWH have comorbid diagnoses, including substance use (Gonzalez et al. 2011), there is limited research examining the utility of mindfulness for HIV-positive substance users. Further, mindfulness research has yet to consider these stressors from an intersectional lens for OALWH. One important limitation of this study was that our conceptual model did not account for intersectional stigma. Intersectional stigma for OALWH with substance use problems may include both HIV stigma and substance use stigma. While less research has focused exclusively on OALWH and these intersecting stigmas, recent research has found an interaction between internalized substance use stigma and HIV stigma in predicting symptoms of depression (Earnshaw et al. 2015) and worse overall health, as well as poorer health care access, including both drug and HIV treatment (Calabrese et al. 2015). While the present study did not include a measure of internalized substance use stigma, recent research has found that these intersecting stigmas are important and unique determinants of health and health care access for HIV-positive substance users (Johannson et al. 2017; Levi-Minzi and Surratt 2014; Stutterheim et al. 2016). As such, future research should consider approaching similar research questions through a theoretical framework that incorporates intersectionality (Earnshaw et al. 2015).

In addition to this, we note that the current study examined only one facet of mindfulness (e.g., mindful awareness). Researchers have identified multiple facets of mindfulness, including acting with awareness, non-judging, non-reacting, describing, and observing (Baer et al. 2006). Future research should also consider using a different measurement tool to explore additional facets of mindfulness, such as the Five Facets of Mindfulness Questionnaire (FFMQ; Baer et al. 2006). This measurement approach may provide important insight into which facets of mindfulness are most useful for OALWH and comorbid substance use. Another limitation is the cross-sectional nature of our study. Given that mindful awareness and HIV-related stress were assessed at the same time as our outcome variable, we cannot confidently assert that these variables predict substance use problems. In the same vein, although our exploratory analyses found evidence for a moderated mediation model, we note that when possible mediation should always be tested using a longitudinal design to infer causality. As such, future researchers should consider using a longitudinal research design to further validate these findings.

Such research has potential to inform the development of MBIs that address and mitigate the downward spiral of combined cognitive decline, decreased mood regulation, and substance abuse in this clinical population (Vance et al. 2010). Research shows that MBIs have demonstrated utility for a variety of chronic health conditions (González-García et al. 2016), including HIV (Scott-Sheldon et al. 2019), as well as substance use (Chiesa and Serretti 2013; Parmar et al. 2018). However, recent research suggests that only a small percentage of OALWH currently engage in mind-body practices (Porter et al. 2015). Continued research is needed in this area to design and develop effective and culturally appropriate MBIs for this population. Future research should also examine the barriers and facilitators to mindfulness-based practice among this population.

Finally, we also note that our assessment of substance use problems for this study was limited. Our measure examined the combined effect of substance use problems, conflating problems of drugs and alcohol use. Future research should examine problems resulting from drugs and alcohol as separate outcomes, which will be important for tailoring and informing future intervention efforts. Secondly, our measure of substance use problems relied on self-report. While the SIP-AD (Blanchard et al. 2003) is a valid and widely used measure of substance use problems, future research should further validate the buffering effect of mindful awareness on substance use problems using clinical assessment, rather than self-report. Finally, it is important to note that the majority of our sample reported alcohol dependence (92.3%). As such, these findings may be more representative of OALWH and comorbid alcohol dependence, as compared with those with other substance use disorders.

Funding Information

Data collection for these secondary analyses was supported by a research grant from the National Institute of Drug Abuse (NIDA; R01-DA029567, PI: Parsons). The content is solely the responsibility of the authors and does not necessarily represent the views of the National Institutes of Health. The researchers have complied with APA ethical standards in the treatment of the sample.

Footnotes

Conflict of Interest The authors declare that they have no conflict of interest.

Ethics Statement All study protocols were approved by the City University of New York (CUNY) Institutional Review Board.

Informed Consent Statement All participants provided their consent to take part in the study.

References

  1. Agarwal RP, Kumar A, & Lewis JE (2015). A pilot feasibility and acceptability study of yoga/meditation on the quality of life and markers of stress in persons living with HIV who also use crack cocaine. The Journal of Alternative and Complementary Medicine, 21, 152–158. 10.1089/acm.2014.0112. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bader A, Kremer H, Erlich-Trungenberger I, Rojas R, Lohmann M, Deobald O, … & Brockmeyer N (2006). An adherence typology: coping, quality of life, and physical symptoms of people living with HIV/AIDS and their adherence to antiretroviral treatment. Medical Science Monitor, 12, CR493–CR500. [PubMed] [Google Scholar]
  3. Baer RA, Smith GT, Hopkins J, Kriete-meyer J, & Toney L (2006). Using self-reportassessment methods to explore facets of mindfulness. Assessment, 13, 27–45. 10.1177/1073191105283504. [DOI] [PubMed] [Google Scholar]
  4. Bedard-Gilligan M, Garcia N, Zoellner LA, & Feeny NC (2018). Alcohol, cannabis, and other drug use: engagement and outcome in PTSD treatment. Psychology of Addictive Behaviors, 32, 277–288. 10.1037/adb0000355. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Berger BE, Ferrans CE, & Lashley FR (2001). Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale. Research in Nursing & Health, 24, 518–529. 10.1002/nur.10011. [DOI] [PubMed] [Google Scholar]
  6. Blanchard KA, Morgenstern J, Morgan TJ, Lobouvie EW, & Bux DA (2003). Assessing consequences of substance use: psychometric properties of the inventory of drug use consequences. Psychology of Addictive Behaviors, 17, 328–331. 10.1037/0893-164x.17.4.328. [DOI] [PubMed] [Google Scholar]
  7. Braithwaite RS, & Bryant KJ (2010). Influence of alcohol consumption on adherence to and toxicity of antiretroviral therapy and survival. Alcohol Research & Health, 33, 280–287 Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860503/pdf/arh-33-3-280.pdf. Accessed June 2019. [PMC free article] [PubMed] [Google Scholar]
  8. Brown KW, & Ryan RM (2003). The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822–848. 10.1037/0022-3514.84.4.822. [DOI] [PubMed] [Google Scholar]
  9. Calabrese SK, Burke SE, Dovidio JF, Levina OS, Uusküla A, Niccolai LM, & Heimer R (2015). Internalized HIV and drug stigmas: interacting forces threatening health status and health service utilization among people with HIV who inject drugs in St. Petersburg, Russia. AIDS and Behavior, 20, 85–97. 10.1007/s10461-015-1100-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Centers for Disease Control and Prevention. (2018a). HIVamong people aged 50 and older. Retrieved from https://www.cdc.gov/hiv/group/age/olderamericans/index.html. Accessed June 2019
  11. Centers for Disease Control and Prevention. (2018b). HIVand substance use in the United States. Retrieved from https://www.cdc.gov/hiv/risk/substanceuse.html. Accessed June 2019
  12. Chander G, Josephs J, Fleishman J, Korthuis P, Gaist P, Hellinger J, & Gebo K (2008). Alcohol use among HIV-infected persons in care: results of a multi-site survey. HIV Medicine, 9, 196–202. 10.1111/j.1468-1293.2008.00545.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Chiesa A, & Serretti A (2013). Are mindfulness-based interventions effective for substance use disorders? A systematic review of the evidence. Substance Use & Misuse, 49, 492–512. 10.3109/10826084.2013.770027. [DOI] [PubMed] [Google Scholar]
  14. Deyo M, Wilson KA, Ong J, & Koopman C (2009). Mindfulness and rumination: does mindfulness training lead to reductions in the ruminative thinking associated with depression? Explore, 5, 265–271. 10.1016/j.explore.2009.06.005. [DOI] [PubMed] [Google Scholar]
  15. Earnshaw VA, & Chaudoir SR (2009). From conceptualizing to measuring HIV stigma: a review of HIV stigma mechanism measures. AIDS and Behavior, 13, 1160–1177. 10.1007/s10461-009-9593-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Earnshaw VA, Quinn DM, Kalichman SC, & Park CL (2012). Development and psychometric evaluation of the Chronic Illness Anticipated Stigma Scale. Journal of Behavioral Medicine, 36, 270–282. 10.1007/s10865-012-9422-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Earnshaw VA, Smith LR, Cunningham CO, & Copenhaver MM (2013). Intersectionality of internalized HIV stigma and internalized substance use stigma: Implications for depressive symptoms. Journal of Health Psychology, 20, 1083–1089. 10.1177/1359105313507964. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Edelman EJ, Tetrault JM, & Fiellin DA (2014). Substance use in older HIV-infected patients. Current Opinion in HIV and AIDS, 9, 317–324. 10.1097/COH.0000000000000069. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Earnshaw VA, Smith LR, Cunningham CO, & Copenhaver MM (2015). Intersectionality of internalized HIV stigma and internalized substance use stigma: Implications for depressive symptoms. Journal of Health Psychology, 20, 1083–1089. 10.1177/1359105313507964. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Emlet CA (2006). “You’re awfully old to have this disease”: experiences of stigma and ageism in adults 50 years and older living with HIV/AIDS. The Gerontologist, 46, 781–790. 10.1093/geront/46.6.781. [DOI] [PubMed] [Google Scholar]
  21. Evans DL, Leserman J, Perkins DO, Stern RA, Murphy C, Zheng B, et al. (1997). Severe life stress as a predictor of early disease progression in HIV infection. American Journal of Psychiatry, 154, 630–634. 10.1176/ajp.154.5.630. [DOI] [PubMed] [Google Scholar]
  22. Ferguson CJ (2009). An effect size primer: a guide for clinicians and researchers. Professional Psychology: Research and Practice, 40, 532–538. 10.1037/a0015808. [DOI] [Google Scholar]
  23. Galvan FH, Bing EG, Fleishman JA, London AS, Caetano R, Burnam MA, et al. (2002). The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV cost and services utilization study. Journal of Studies on Alcohol, 63, 179–186. 10.15288/jsa.2002.63.179. [DOI] [PubMed] [Google Scholar]
  24. Gonzalez A, Solomon SE, Zvolensky MJ, & Miller CT (2009). The interaction of mindful-based attention and awareness and disengagement coping with HIV/AIDS-related stigma in regard to concurrent anxiety and depressive symptoms among adults with HIV/AIDS. Journal of Health Psychology, 14, 403–413. 10.1177/1359105309102193. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Gonzalez A, Barinas J, & O’Cleirigh C (2011). Substance use: impact on adherence and HIV medical treatment. Current HIV/AIDS Reports, 8, 223–234. 10.1007/s11904-011-0093-5. [DOI] [PubMed] [Google Scholar]
  26. Gonzalez A, Locicero B, Mahaffey B, Fleming C, Harris J, & Vujanovic A (2015). Internalized HIV stigma and mindfulness. Behavior Modification, 40, 144–163. 10.1177/0145445515615354. [DOI] [PubMed] [Google Scholar]
  27. Gonzalez-Garcia M, Ferrer MJ, Borras X, Muñoz-Moreno JA, Miranda C, Puig J, et al. (2013). Effectiveness of mindfulness-based cognitive therapy on the quality of life, emotional status, and CD4 cell count of patients aging with HIV infection. AIDS and Behavior, 18, 676–685. 10.1007/s10461-013-0612-z. [DOI] [PubMed] [Google Scholar]
  28. González-García M, Borràs X, López JG, & McNeil KG (2016). Mindfulness-based cognitive therapy application for people living with chronic disease: the case of HIV. In Eisendrath SJ (Ed.), Mindfulness-based cognitive therapy (pp. 83–103). Switzerland: Springer International Publishing. [Google Scholar]
  29. Green TC, Kershaw T, Lin H, Heimer R, Goulet JL, Kraemer KL, et al. (2010). Patterns of drug use and abuse among aging adults with and without HIV: a latent class analysis of a US veteran cohort. Drug and Alcohol Dependence, 110, 208–220. 10.1016/j.drugalcdep.2010.02.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Greene M, Hessol NA, Perissinotto C, Zepf R, Parrott AH, Foreman C, …, John M. (2017). Loneliness in older adults living with HIV. AIDS and Behavior, 22, 1475–1484. 10.1007/s10461-017-1985-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Grov C, Golub SA, Parsons JT, Brennan M, & Karpiak SE (2010). Loneliness and HIV-related stigma explain depression among older HIV-positive adults. AIDS Care, 22, 630–639. 10.1080/09540120903280901. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Gurung S, Ventuneac A, Cain D, Mirzayi C, Ferraris C, Rendina HJ, et al. (2017). Alcohol and substance use diagnoses among HIV-positive patients receiving care in NYC clinic settings. Drug and Alcohol Dependence, 180, 62–67. 10.1016/j.drugalcdep.2017.07.034. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Hatzenbuehler ML, O’Cleirigh C, Mayer KH, Mimiaga MJ, & Safren SA (2011). Prospective associations between HIV-related stigma, transmission risk behaviors, and adverse mental health outcomes in men who have sex with men. Annals of Behavioral Medicine, 42, 227–234. 10.1007/s12160-011-9275-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Hawley LL, Schwartz D, Bieling PJ, Irving J, Corcoran K, Farb NA, … Segal ZV (2013). Mindfulness practice, rumination and clinical outcome in mindfulness-based treatment. Cognitive Therapy and Research, 38, 1–9. 10.1007/s10608-013-9586-4. [DOI] [Google Scholar]
  35. Hayes AF (2017). Introduction to mediation, moderation, and conditional process analysis a regression-based approach. New York: The Guilford Press. [Google Scholar]
  36. Heckman TG, Barcikowski R, Ogles B, Suhr J, Carlson B, Holroyd K, & Garske J (2006). A telephone-delivered coping improvement group intervention for middle-aged and older adults living with HIV/AIDS. Annals of Behavioral Medicine, 32, 27–38. 10.1207/s15324796abm3201_4. [DOI] [PubMed] [Google Scholar]
  37. Hernandez D, Kalichman SC, Katner HP, Burnham K, Kalichman MO, & Hill M (2018). Psychosocial complications of HIV/AIDS-metabolic disorder comorbidities among patients in a rural area of southeastern United States. Journal of Behavioral Medicine, 41, 441–449. 10.1007/s10865-018-9912-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. High KP, Brennan-Ing M, Clifford DB, Cohen MH, Currier J, Deeks SG, …, OAR Working Group on HIVand Aging (2012). HIVand aging: state of knowledge and areas of critical need for research. Journal of Acquired Immune Deficiency Syndromes, 60, 1–33. 10.1097/QAI.0b013e31825a3668. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Hinkin CH, Castellon SA, Atkinson JH, & Goodkin K (2001). Neuropsychiatric aspects of HIV infection among older adults. Journal of Clinical Epidemiology, 54, S44–S52. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Hosaka KR, Greene M, Premeaux TA, Javandel S, Allen IE, Ndhlovu LC, & Valcour V (2019). Geriatric syndromes in older adults living with HIV and cognitive impairment. Journal of the American Geriatrics Society, 67, 1913–1916. 10.1111/jgs.16034. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Johannson A, Vorobjov S, Heimer R, Dovidio JF, & Uusküla A (2017). The role of internalized stigma in the disclosure of injecting drug use among people who inject drugs and self-report as HIV-positive in Kohtla-Järve, Estonia. AIDS and Behavior, 21, 1034–1043. 10.1007/s10461-016-1647-8. [DOI] [PubMed] [Google Scholar]
  42. Justice AC (2010). HIV and aging: Time for a new paradigm. Current HIV/AIDS Reports, 7, 69–76. 10.1007/s11904-010-0041-9. [DOI] [PubMed] [Google Scholar]
  43. Justice AC, Mcginnis KA, Atkinson JH, Heaton RK, Young C, Sadek J, … Simberkoff M (2004). Psychiatric and neurocognitive disorders among HIV-positive and negative veterans in care. AIDS, 18, 49–59. doi: 10.1097/00002030-200418001-00008. [DOI] [PubMed] [Google Scholar]
  44. Kidia K, Machando D, Bere T, Macpherson K, Nyamayaro P, Potter L, … Abas M (2015). ‘I was thinking too much’: experiences of HIV-positive adults with common mental disorders and poor adherence to antiretroviral therapy in Zimbabwe. Tropical Medicine & International Health, 20, 903–913. 10.1111/tmi.12502. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Leserman J (2003). HIV disease progression: depression, stress, and possible mechanisms. Biological Psychiatry, 54, 295–306. 10.1016/s0006-3223(03)00323-8. [DOI] [PubMed] [Google Scholar]
  46. Levi-Minzi MA, & Surratt HL (2014). HIV stigma among substance abusing people living with HIV/AIDS: implications for HIV treatment. AIDS Patient Care and STDs, 28, 442–451. 10.1089/apc.2014.0076. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Logie C, & Gadalla T (2009). Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care, 21, 742–753. 10.1080/09540120802511877. [DOI] [PubMed] [Google Scholar]
  48. McEvoy PM, & Shand F (2008). The effect of comorbid substance use disorders on treatment outcome for anxiety disorders. Journal of Anxiety Disorders, 22, 1087–1098. 10.1016/j.janxdis.2007.11.007. [DOI] [PubMed] [Google Scholar]
  49. Mclaughlin KA, & Nolen-Hoeksema S (2011). Rumination as a transdiagnostic factor in depression and anxiety. Behaviour Research and Therapy, 49, 186–193. 10.1016/j.brat.2010.12.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Millar BM, Starks TJ, Gurung S, & Parsons JT (2017). The impact of comorbidities, depression, and substance use problems on quality of life among older adults living with HIV. AIDS and Behavior, 21, 1684–1690. 10.1007/s10461-016-1613-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Moskowitz JT, Duncan LG, Moran PJ, Acree M, Epel ES, Kemeny ME, … Folkman S (2015). Dispositional mindfulness in people with HIV: associations with psychological and physical health. Personality and Individual Differences, 86, 88–93. 10.1016/j.paid.2015.05.039. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Mugavero MJ, Raper JL, Reif S, Whetten K, Leserman J, Thielman NM, & Pence BW (2009). Overload: Impact of incident stressful events on antiretroviral medication adherence and virologic failure in a longitudinal, multisite human immunodeficiency virus cohort study. Psychosomatic Medicine, 71, 920–926. 10.1097/psy.0b013e3181bfe8d2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Nanni MG, Caruso R, Mitchell AJ, Meggiolaro E, & Grassi L (2014). Depression in HIV infected patients: a review. Current Psychiatry Reports, 17, 530–541. 10.1007/s11920-014-0530-4. [DOI] [PubMed] [Google Scholar]
  54. NIH U.S. National Library of Medicine. (2019). HIV and older adults. Retrieved June 6, 2019, from https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/25/80/hiv-and-older-adults# Accessed June 2019.
  55. Nolen-Hoeksema S (2006). Eating, drinking, overthinking: the toxic triangle of food, alcohol, and depression and how women can break free. New York: Holt, Henry & Company. [Google Scholar]
  56. Nolen-Hoeksema S, & Harrell ZA (2002). Rumination, depression, and alcohol use: tests of gender differences. Journal of Cognitive Psychotherapy, 16, 391–403. 10.1891/jcop.16.4.391.52526. [DOI] [Google Scholar]
  57. Nolen-Hoeksema S, & Morrow J (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: the 1989 Loma Prieta earthquake. Journal of Personality and Social Psychology, 61, 115–121. 10.1037/0022-3514.61.1.115. [DOI] [PubMed] [Google Scholar]
  58. Parmar A, Kuppili P, Gupta A, & Balhara YS (2018). Role of yoga in management of substance-use disorders: a narrative review. Journal of Neurosciences in Rural Practice, 9, 117–122. 10.4103/jnrp.jnrp_243_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Porter KE, Brennan-Ing M, Burr JA, Dugan E, & Karpiak SE (2015). Stigma and psychological well-being among older adults with HIV: the impact of spirituality and integrative health approaches. The Gerontologist, 57, 219–228. 10.1093/geront/gnv128. [DOI] [PubMed] [Google Scholar]
  60. Price CJ, Diana TM, Smith-Dijulio KL, & Joachim VG (2013). Developing compassionate self-care skills in persons living with HIV: a pilot study to examine mindful awareness in body-oriented therapy feasibility and acceptability. International Journal of Therapeutic Massage & Bodywork: Research, Education, & Practice, 6, 9–19. 10.3822/ijtmb.v6i2.197. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Ramsey SE, Engler PA, & Stein MD (2005). Alcohol use among depressed patients: the need for assessment and intervention. Professional Psychology: Research and Practice, 36, 203–207. 10.1037/0735-7028.36.2.203. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Rendina HJ, Gamarel KE, Pachankis JE, Ventuneac A, Grov C, & Parsons JT (2016). Extending the minority stress model to incorporate HIV-positive gay and bisexual men’s experiences: a longitudinal examination of mental health and sexual risk behavior. Annals of Behavioral Medicine, 51, 147–158. 10.1007/s12160-016-9822-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Rendina HJ, Millar BM, & Parsons JT (2018). Situational HIV stigma and stimulant use: a day-level autoregressive cross-lagged path model among HIV-positive gay and bisexual men. Addictive Behaviors, 83, 109–115. 10.1016/j.addbeh.2018.01.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Riley KE, & Kalichman S (2014). Mindfulness-based stress reduction for people living with HIV/AIDS: Preliminary review of intervention trial methodologies and findings. Health Psychology Review, 9, 224–243. 10.1080/17437199.2014.895928. [DOI] [PubMed] [Google Scholar]
  65. Scott-Sheldon LA, Balletto BL, Donahue ML, Feulner MM, Cruess DG, Salmoirago-Blotcher E, & Carey MP (2019). Mindfulness-based interventions for adults living with HIV/AIDS: a systematic review and meta-analysis. AIDS and Behavior, 23, 60–75. 10.1007/s10461-018-2236-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Shorey RC, Brasfield H, Anderson S, & Stuart GL (2013). Mindfulness deficits in a sample of substance abuse treatment seeking adults: a descriptive investigation. Journal of Substance Use, 19, 194–198. 10.3109/14659891.2013.770570. [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, & Mqeketo A (2007). Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Social Science & Medicine, 64, 1823–1831. 10.1016/j.socscimed.2007.01.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Skalski LM, Sikkema KJ, Heckman TG, & Meade CS (2013). Coping styles and illicit drug use in older adults with HIV/AIDS. Psychology of Addictive Behaviors, 27, 1050–1058. 10.1037/a0031044. [DOI] [PMC free article] [PubMed] [Google Scholar]
  69. Soo H, Sherman KA, & Kangas M (2014). Assessing rumination in response to illness: the development and validation of the Multidimensional Rumination in Illness Scale (MRIS). Journal of Behavioral Medicine, 37, 793–805. 10.1007/s10865-013-9531-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Stutterheim SE, Baas I, Roberts H, Brands R, Schmidt J, Lechner L, … Bos AE (2016). Stigma experiences among substance users with HIV. Stigma and Health, 1, 123–145. doi: 10.1037/sah0000015. [DOI] [Google Scholar]
  71. Thompson SC, Nanni C, & Levine A (1996). The stressors and stress of being HIV-positive. AIDS Care, 8, 5–14. 10.1080/09540129650125957. [DOI] [PubMed] [Google Scholar]
  72. Turan B, Hatcher AM, Weiser SD, Johnson MO, Rice WS, & Turan JM (2017). Framing mechanisms linking HIV-related stigma, adherence to treatment, and health outcomes. American Journal of Public Health, 107, 863–869. 10.2105/AJPH.2017.303744. [DOI] [PMC free article] [PubMed] [Google Scholar]
  73. Vance DE, Ross JA, Moneyham L, Farr KF, & Fordham P (2010). A model of cognitive decline and suicidal ideation in adults aging with HIV. Journal of Neuroscience Nursing, 42, 150–156. 10.1097/jnn.0b013e3181d4a35a. [DOI] [PubMed] [Google Scholar]
  74. Wright K, Naar-King S, Lam P, Templin T, & Frey M (2007). Stigma scale revised: reliability and validity of a brief measure of stigma for HIV+ youth. Journal of Adolescent Health, 40, 96–98. 10.1016/j.jadohealth.2006.08.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  75. Xu JJ, Zhang C, Hu QH, Chu ZX, Zhang J, Li YZ, et al. (2014). Recreational drug use and risks of HIV and sexually transmitted infections among Chinese men who have sex with men: mediation through multiple sexual partnerships. BMC Infectious Diseases, 14, 642–648. 10.1186/s12879-014-0642-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  76. Yang X, & Mak WW (2017). The differential moderating roles of self-compassion and mindfulness in self-stigma and well-being among people living with mental illness or HIV. Mindfulness, 8, 595–602. 10.1007/s12671-016-0635-4. [DOI] [Google Scholar]
  77. Yang Y, Liu Y, Zhang H, & Liu J (2015). Effectiveness of mindfulness-based stress reduction and mindfulness-based cognitive therapies on people living with HIV: a systematic review and meta-analysis. International Journal of Nursing Sciences, 2, 283–294. 10.1016/j.ijnss.2015.07.003. [DOI] [Google Scholar]
  78. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, & Leirer VO (1982). Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research, 17, 37–49. 10.1016/0022-3956(82)90033-4. [DOI] [PubMed] [Google Scholar]

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