Cognition, Coping, and Psychological Distress in HIV

Abstract

Interrelationships among HIV-associated neurocognitive dysfunction, avoidant coping, cognitively-oriented coping, and psychological distress were examined using structural equation modeling in an ethnically diverse sample of 209 adults predominantly in the mid-range of illness. Global neurocognitive deficits, assessed with the HIV-dementia scale, were associated with higher levels of avoidant coping, lower levels of cognitive coping, and a higher avoidant/cognitive coping ratio, which were each in turn associated with higher psychological distress measured by a latent factor comprising symptoms of depression, anxiety, and HIV-related distressing thoughts. There were significant indirect effects through avoidant coping and a higher avoidant/cognitive coping ratio. Results suggest the presence of HIV-associated neurocognitive deficits may interfere with the utilization of cognitive-based coping strategies and increase reliance on more maladaptive strategies, which in turn may translate to elevated reports of psychological distress. Findings may help inform interventions aimed at reducing avoidant coping and psychological distress, two factors associated with accelerated HIV disease progression.

Introduction

Neurocognitive dysfunction is a primary challenge facing people living with Human Immunodeficiency Virus (PLWHIV). Despite the efficacy of contemporary antiretroviral therapies (ART), 25-50% of PLWHIV continue to experience neurocognitive impairments [1, 2]. Current nosology [3] includes three disorders representing increasing degrees of cognitive impairment and functional decline—asymptomatic neurocognitive impairment (ANI), minor neurocognitive disorder (MND), and HIV-associated dementia (HAD)—collectively termed HIV-associated neurocognitive disorder (HAND). In the modern era, widespread availability of ART has drastically reduced the incidence of HAD, whereas ANI and MND are increasingly prevalent [1, 2] and characterized by primary executive functioning and learning deficits [4]. While the negative effects of HAND on everyday functioning are well documented [5], less is known about how they may impact psychological processes.

People living with HIV face perpetual biopsychosocial stressors, and the distress associated with these pressures can manifest in a variety of psychological symptoms including mood disturbances and overwhelming thoughts. This population experiences disproportionately high psychiatric morbidity [6] with rates of depression, anxiety, and posttraumatic stress symptoms ranging from 33-38%, two to three times higher than in the general population [7-9]. Accordingly, researchers have turned to factor analysis to capture shared variance among multiple psychological symptoms (e.g., depression, anxiety, perceived stress, distressing thoughts, etc.) into a latent factor termed psychological distress. This is opposed to examining discrete symptom inventories or clinical diagnoses, which may not capture transdiagnostic or subclinical symptomology. Prior research using this methodology has identified psychological distress as not only an important clinical outcome but also a predictor of accelerated disease progression in HIV [10, 11].

In order to mitigate psychological distress, PLWHIV engage in various coping practices. Coping may be defined as ongoing cognitive and behavioral efforts to manage specific external or internal stressors that are appraised as taxing or exceeding one’s resources [12]. When stressors outweigh one’s coping efforts, affective disturbances, anxiety, and unwanted distressing thoughts may arise [12, 13].

Cognitive coping refers to intrapsychic strategies, such a positive reappraisal and acceptance, for adaptively modifying one’s perception of a stressor and ability to cope with it [14, 15]. Positive reappraisal involves reframing maladaptive cognitions so that individuals may derive positive meaning and purpose from living with HIV [16]. Acceptance involves assimilating stressful stimuli in a way that is syntonic with one’s identity, enabling PLWHIV to adjust to the reality of living with a chronic illness so that stressors can be adequately addressed [13, 14]. For PLWHIV, cognitive coping strategies are considered adaptive as they are associated with reductions in psychological distress and slower disease progression, and are a common focus of cognitive-behavioral interventions [16-18].

Conversely, avoidant coping broadly encompasses attempts to escape aversive external stimuli or feelings of distress [13, 15]. These involve refusal to acknowledge the existence of stressors (i.e., denial) and giving up efforts to adaptively confront stressors (i.e., behavioral disengagement). Avoidant strategies can temporarily relieve acute distress and become habitually engrained [19]. However, they are generally conceived as maladaptive in the long-term because they impede implementation of more adaptive coping efforts and fail to alter chronic stressors [13]. For PLWHIV, avoidant coping is associated with worse quality of life [20], increased depressive symptomology [21], poor medication adherence [22], and accelerated disease progression [23].

Cognitive coping strategies are relatively complex and cognitively demanding compared with passive avoidant coping modalities that circumvent elaborated processing of aversive stimuli [19, 24, 25]. For example, positive reappraisal involves overriding initial interpretations of stressful stimuli, coordination within cognitive networks to manage limbic activations, and depletion of cognitive resources [25-27]. Given the different cognitive demands of these coping styles, research examining associations between cognition and coping behaviors is of growing interest. Neuropsychological deficits have been linked with increased avoidant coping and/or decreased cognitively-oriented coping in healthy adults [28], schizophrenia [29-31], Parkinson’s disease [32], multiple sclerosis (MS) [33], and traumatic brain injury (TBI) [34]. There is also evidence that coping style may mediate the effect of cognitive dysfunction on symptoms of psychological distress. In Parkinson’s disease patients [32], global cognitive impairment has been associated with decreased use of cognitively-oriented coping and in turn greater depression and anxiety. In MS patients [33], reduced executive functioning was shown to predicted increased depressive symptoms, and a predominantly avoidant coping style mediated this effect. At present, no studies have examined these links in HIV.

The primary aim of the present study was to examine whether HIV-associated global cognitive dysfunction is linked with two contrasting coping styles, avoidant and cognitive coping, as well as psychological distress in a sample of PLWHIV predominantly in the mid-range of illness during the era of highly effective ART. Within a structural equation model, we hypothesized that poorer global cognition would be 1) directly associated with reduced use of cognitive coping by virtue of diminished ability to exercise these strategies 2) directly associated with greater use of avoidant coping strategies that are presumably more compatible with limited cognitive resources, and 3) indirectly associated with increased psychological distress through each coping style. Additionally, we hypothesized that poorer global cognition would be indirectly associated with elevated psychological distress through a higher proportion of avoidant coping to cognitive coping, measured as a ratio score. Due to its broad manifestations, we measured psychological distress with a latent factor comprising symptoms of depression, anxiety, and HIV-related distressing thoughts. A better understanding of these associations may help to inform psychological interventions and promote psychological well-being for the large proportion of PLWHIV experiencing HAND.

Methods

Participants

The study sample consisted of 209 men and women recruited from physician’s offices, specialty clinics, service organizations, and hospitals in Miami, Florida, between 1997-2002, shortly after introduction of potent antiretroviral medication therapies. Participants were garnered from the recruitment pool of a parent study examining associations between psychosocial factors and markers of HIV disease progression [23]. Therefore, nearly all inclusion/exclusion criteria from the parent study extended to the present study. The parent study’s criteria were designed to capture individuals most vulnerable to the possible impact of psychosocial factors on HIV disease, remove those who were unlikely to have a reasonable chance at immune reconstitution, minimize factors that may confound disease markers, or limit one’s ability to engage with routine follow-up. In the present study, these criteria helped minimize confounding factors that could influence cognitive functioning. People were eligible for inclusion if they were aged 18 years or older, were confirmed HIV-positive, had CD4 cell counts between 150-700 cells/mm³, and completed a measure of global cognitive functioning. People were excluded for 1) history of an AIDS defining (Category C) symptom 2) history of nadir CD4 cell counts below 75 cells/mm³ 3) additional life-threatening illnesses 4) endorsement of psychosis or suicidal ideation in the past six months because not enough study staff were clinically qualified to appropriately manage acute suicidal ideation 5) alcohol or drug dependence (based on DSM-III criteria) in the past six months 6) intravenous drug use in the past six months, or 7) inability to complete paper-pencil tasks due to cognitive, sensory, or motor impediments. Participants were volunteers monetarily compensated with a check for their time and travel.

Procedure

All participants completed written informed consent, psychosocial self-report questionnaires, a clinical assessment interview, and blood draw for CD4 and viral load assays. Cognitive tests were administered by trained research staff under the supervision of a licensed psychiatrist. Study procedures were approved by the University of Miami institutional review board.

Measures

Global cognitive functioning.

The HIV dementia scale (HDS) [35] is a brief, quantitative instrument used to screen and characterize global HIV-related cognitive impairment. The HDS consists of four subtests: a timed alphabet-writing task (psychomotor speed; 6 points), recall for three words after a short delay (auditory memory; 4 points), a cube-drawing task (visuospatial constructional praxis; 2 points), and an executive saccade inhibition task (4 points). A total of 16 points is possible, with lower total scores indicating more severe cognitive impairment. The HDS is used in clinical and research settings and has adequate sensitivity and specificity for identifying HAND in clinical samples [36].

Coping.

The COPE-brief [37] is a 24-item scale is used to assesses 12 cognitive and behavioral coping strategies rated on a 4-point Likert scale of use frequency ranging from 1 (Not at all) to 4 (A lot). The 12 COPE-brief subscales consist of two items each. Two composite scores were computed based on models of coping theory and prior HIV studies [13, 16, 23]. The avoidant coping composite comprised the summed denial and behavioral disengagement subscale scores; the cognitive coping composite comprised the summed acceptance and positive reappraisal subscale scores. Each subscale has previously demonstrated adequate psychometric properties [37].

Psychological distress.

A latent factor of psychological distress indicated by depression symptoms, anxiety symptoms, and distressing HIV-related thoughts was examined following previous methods [10]. The Beck Depression Inventory (BDI) is a widely used 21-item scale used to assess depressive symptoms over the past two weeks [38]. Each symptom is rated on a scale from 0 to 3 based on severity, and higher total scores reflect more severe depressive symptoms. The scale showed acceptable reliability in our sample (α = .88). The State-Trait Anxiety Inventory [39] was used to assess state anxiety with 20 statements ranging from Almost Never to Almost Always; higher scores indicate higher state anxiety. It has previously demonstrated acceptable internal consistency in a sample of PLWHIV [40]. The Impact of Event Scale (IES) [41] is a 15-item questionnaire that was used to assess distressing thoughts related to living with HIV infection. It consists of seven items measuring intrusive symptoms and eight items measuring avoidant symptoms; higher scores reflect more severe distressing thoughts. The split-half reliability for the total scale indicates acceptable reliability. Continuous metrics were used for each measure in the study analyses.

Disease Markers

CD4 lymphocyte count (CD3+CD4+) was determined by whole-blood 4-color direct immunofluorescence using a coulter XL-MCL flow cytometer. Viral load was determined using the Roche Amplicor RT/PCR assay sensitive to 400 copies of viral plasma RNA.

Covariates

Demographic variables of age, African American race (coded 1 = African American, 0 = other), gender (0 = female, 1 = male) and education (1 = some high school or less, 2 = high school graduate, 3 = some college, 4 = college graduate, 5 = graduate degree) were included as a priori covariates due to their documented relevance to psychological and health outcomes in HIV literature and to maintain consistency with prior studies from our group. For instance, older age, African American race, female gender, and lower socioeconomic status have each been associated with more severe psychiatric symptomology [6, 42]. Education, rather than income or employment, was chosen as a relatively unbiased indicator of socioeconomic status because income and employment are more likely to be influenced by progressing illness. Baseline CD4 lymphocyte counts and viral load were included as markers of disease status. Antiretroviral medication use was coded at three levels (1 = no medication use, 2 = combination therapy without protease inhibitors, 3 = highly active antiretroviral [HAART] medications including protease inhibitors).

Statistical Analyses

Descriptive statistical analyses were performed using Statistical Package for the Social Sciences Version 23.0, and all other analyses were performed using Mplus Version 7. Full information maximum likelihood was used as the estimation method to replace data assumed to be missing at random. All variables of interest were examined visually and statistically for outliers, skewness, and kurtosis.

Measurement model.

Confirmatory factor analysis was used to test a latent factor of psychological distress with three indicators: BDI, STAI-state anxiety, and IES total scores. Indicators were assessed for significant factor loadings (p < .05) of equal to or greater than .40 [43] prior to inclusion of covariates. The BDI total score was set as the reference indicator.

Structural regression path analyses.

We examined a model with direct paths from 1) HDS to psychological distress 2) HDS to avoidant coping 3) avoidant coping to psychological distress 4) HDS to cognitive coping, and 5) cognitive coping to psychological distress, as well as indirect paths from HDS to psychological distress through avoidant and cognitive coping. We also examined a similar model with ratio of avoidant to cognitive coping used as the only coping variable. Significance for parameter estimates was set at p < .05. Indirect paths were examined with bootstrapping analyses (5000 bootstrapped samples).

Model fit.

Model fit was assessed with the following fit indices: a non-significant (p > 0.05) chi-square difference test, a comparative fit index (CFI) value above .95, a root-mean-square error of approximation (RMSEA) value below.06, and a standardized root-mean-square residual (SRMR) value below.08 [44]. In the measurement model of psychological distress we did not examine model fit metrics because the latent variable had three indicators; rather, we evaluated the strength of factor loadings (λ) to determine if the latent variable was viable. If model fit indices were not acceptable, modification indices were used to guide the inclusion of justifiable residual covariances until acceptable fit was achieved.

Results

Demographic and clinical characteristics of the sample are shown in Table 1. On average, participants were middle-aged (M = 37.7, SD = 8.7 years). The majority (71.8%) of the sample identified as male, and approximately equal parts identified as non-Hispanic White (30.6%), non-Hispanic African American (35.4%), and Hispanic (29.7%). The majority of participants reported a high school education or higher; 16.7% were high school graduates without higher education, 38.8% attended some college, and 28.2% were college graduates or higher. Additionally, 20.6% of participants were employed full-time and 43.5% reported receiving disability. On average, participants were in the mid-range of illness (M_CD4 = 323.0 cells/mm³; 86.5% had CD4 cell counts between 150-500 cells/mm³; none with a history of Category C symptom), though 16.7% had CD4 counts below 200 cells/mm³, the current case definition of AIDS. Nearly half of participants reported being on a highly effective ART regimen at baseline, and an additional 31.1% reported being on non-protease inhibitor combination antiretroviral therapy. Descriptive statistics and correlations for variables included in the structural models are shown in Table 2 and Table 3, respectively.

Table 1.

Sample Characteristics

Variable			n	%
Age (M, SD)		37.7 (8.7)	209	100
Gender
	Male		149	71.8
	Female		60	28.2
Race
	Non-Hispanic White		65	30.6
	African American		74	35.4
	Hispanic		62	29.7
	Other		10	4.3
Educational Attainment
	Some high school or less		33	15.8
	High school graduate		35	16.7
	Some college		82	38.8
	College graduate		40	19.1
	Graduate degree		19	9.1
Employment Status
	Full-time		44	20.6
	Unemployed		34	16.3
	Disability		91	43.5
	Other		41	19.6
CD4 cells/mm3 (M, SD)		323.0 (122.8)	209	100
Viral Load copies/mL, median		4171.5	209	100
Antiretroviral Medication Status
	No medication		41	19.6
	Combination therapya		65	31.1
	HAART		104	49.3

Notes. Combination therapy = antiretroviral medications excluding protease inhibitors; HAART = highly active antiretroviral medications including protease inhibitors.

Table 2.

Descriptive Statistics for Key Variables

Variable	Mean	SD
HDS Total	13.61	2.55
Avoidant Coping	5.67	2.32
Cognitive Coping	12.76	2.76
Avoidant to Cognitive Coping Ratio	0.48	0.26
Psychological Distress
Depression (BDI)	11.48	8.93
State Anxiety (STAI)	40.18	12.93
Distressing Thoughts (IES)	22.77	16.47

Note. HDS = HIV-Dementia Scale; BDI = Beck Depression Inventory; IES = Impact of Event Scale; STAI = State-Trait Anxiety Inventory (State Anxiety Subscale).

Table 3.

Correlations among all variables

	Variables	1	2	3	4	5	6	7	8	9	10	11	12
1.	HDS Total	--
2.	Avoidant Coping (COPE)	−.24***	--
3.	Cognitive Coping (COPE)	.07	−.09	--
4.	Depressive Symptoms (BDI)	−.15*	.34***	−.25***	--
5.	Distressing Thoughts (IES)	−.14†	.39***	−.02	.42***	--
6.	Anxiety Symptoms (STAI)	−.14*	.21**	−.23**	.58***	.41***	--
7.	Age	−.14*	−.08	.06	−.01	−.01	.04	--
8.	African American Race	−.18**	.11	.04	.12†	.12	.01	−.10	--
9.	Education Attainment	.27***	−.20**	.05	−.15*	−.14	−.07	.27***	−.38***	--
10.	Gendera	−.02	.10	−.10	.01	.06	.01	−.24***	.49***	−.37***	--
11.	CD4 Lymphocyte Count	.10	−.14*	.02	.02	−.01	.06	.01	−.10	.16*	.02	--
12.	HIV Viral Load (log)	−.09	.10	−.08	.06	.06	−.05	−.18*	.18**	−.28***	.18*	−.20**	--
13.	ARV Medication Status	−.02	−.04	.09	.05	.14†	.16*	.12†	−.04	.031	−.03	.01	−.35***

Notes. ARV—Antiretroviral, BDI—Beck Depression Inventory, COPE Coping Inventory, HDS—HIV Dementia Scale, IES—Impact of Event Scale, STAI—State-Trait Anxiety Inventory (State Anxiety Subscale).

^a0= female, 1= male.

^†p<.10

^*p<.05

^**p<.01

^***p<.001

Psychological Distress

All three indicators of psychological distress loaded significantly onto the latent variable (p < .001). Review of standardized factor loadings indicated that depressive symptoms (λ = .78), anxiety symptoms (λ = .71), and HIV-related distressing thoughts (λ = .56) served as strong indicators of psychological distress.

Avoidant and Cognitive Coping

The initially hypothesized model including covariates did not fit the data across all indices (χ²(21) = 37.87, p = .013; CFI = .92; RMSEA = .06, SRMR = .03). After examining modification indices, we revised the model to include correlated residuals for the IES with avoidant and cognitive coping. This modification is justifiable as the IES contains item content specific to coping in relation to traumatic experiences; it is not surprising that residual variance in the IES (i.e., variance not shared with other psychological distress indicators) demonstrated a residual covariance with coping constructs, as other indicators of psychological distress do not contain coping-specific item content.

With these modifications, the hypothesized model demonstrated significant improvement from the baseline model (χ²Δ(2) = 16.04, p < .001) and adequate fit across all indices (χ²(19) = 21.83, p = .293, CFI = .99, RMSEA = .03, SRMR = .03). Results of this model with standardized coefficients are shown in Figure 1. The model revealed that lower HDS scores were significantly associated with greater avoidant coping (β = −.24, b = −0.21, S.E. = 0.06, z = −3.50, p < .001) while the association with lower cognitive coping bordered on statistical significance (β = .13, b = 0.14, S.E. = 0.07, z = 2.00, p = .050). Higher levels of avoidant coping (β = .30, b = 0.88, S.E. = 0.24, z = 3.67, p < .001) and lower levels of cognitive coping (β = −.33, b = −0.82, S.E. = 0.19, z = −2.45, p < .001) were each significantly associated with greater psychological distress. Unique variance of the IES (i.e., variance not shared with other psychological distress indicators) was significantly correlated with both avoidant (r = .23, p = .002) and cognitive coping (r = .21, p = .009). The final model, including covariates, accounted for 27% of the variance in psychological distress, 12% of the variance in avoidant coping, and 6% of the variance in cognitive coping.

Figure 1.

Structural model of HIV-dementia scale (HDS) total scores, coping, and psychological distress controlling for covariates (not shown). Standardized path coefficients are displayed. p≤.05;**p<.01;***p<.001

We tested our hypothesis that HIV-associated neurocognitive dysfunction would be linked with increased psychological distress through coping styles in several steps. First, we examined the path from HDS to psychological distress with and without coping variables excluded in order to examine changes in the regression path from the “unmediated” to the “mediated” model. The path was significant excluding the coping variables (β = −.19, b = −0.49, S.E. = 0.20, z = −2.45, p = .014), whereas it dropped to non-significant with inclusion of the coping variables. Comparison of the models suggested that inclusion of coping variables accounted for 42% of the association between HDS and psychological distress. Next we examined indirect effects through each coping style, which revealed a significant indirect association between lower HDS scores and greater psychological distress through avoidant coping (β = −.07, b = −0.19, S.E. = 0.07, z = −2.71, p = .010) and a marginal association through cognitive (β = −.05, b = −0.12, S.E. = 0.07, z = −1.71, p = .075).

Avoidant to Cognitive Coping Ratio

In a subsequent structural model examining HDS scores, ratio of avoidant to cognitive coping, and psychological distress, the theoretical model fit the data well without modifications (χ²(19) = 18.29, p = .437, CFI = .99, RMSEA = .01, SRMR = .04). Lower HDS scores were associated with higher levels of avoidant coping relative to cognitive coping (β = −.25, b = −0.03, S.E. = 0.01, z = −3.00, p = .003), which in turn was associated with greater psychological distress (β = .42, b = 11.59, S.E. = 2.76, z = 4.20, p = .003). Again, the direct path from HDS to psychological distress was not significant (β = −.08, b = −0.21, S.E. = 0.20, z = −1.05, p = .289), while the indirect path through the avoidant to cognitive coping ratio was significant (β = −.11, b = −0.29, S.E. = 0.11, z = −2.64, p = .012).

Discussion

Despite the growing prevalence of HAND in the era of highly effective ART and disproportionately high rates of psychological distress among PLWHIV, there are few studies seeking to understand how these conditions may be related. Our structural equation model showed that global HIV-associated neurocognitive dysfunction was not only associated with heightened psychological distress but also increased use of avoidant coping, diminished use of cognitive coping, and a higher proportion of avoidant to cognitive coping. These findings were independent of sociodemographic factors and markers of disease severity. Moreover, global cognitive dysfunction was indirectly associated with elevated psychological distress through higher levels of avoidant coping, measured both in isolation and relative to cognitive coping.

The present study corroborates prior reports linking HIV-associated cognitive impairment with elevated depressive symptoms [45-48], and extends this finding to the broader construct of psychological distress measured with a latent factor comprising symptoms of depression, anxiety, and HIV-related distressing thoughts. Given evidence that clinical depression has a negligible effect on cognition in PLWHIV with the exception of severe or chronic cases [49, 50], our findings align with the notion that for many PLWHIV, impaired cognitive abilities may contribute to exacerbations in psychological distress.

Our findings linking poorer global cognition with increased avoidant coping and decreased cognitive coping, though novel within the HIV literature, are in agreement with reports from non-HIV clinical populations. In schizophrenia patients, for example, executive functioning and memory deficits have been associated with greater use of avoidance and decreased use of cognitively oriented coping strategies [29-31]. Similarly, executive functioning has been linked with these coping behaviors in TBI patients [34]. Collectively, this body of work suggests that cognitive impairments, across multiple disease models of frontal-subcortical dysfunction, may be an important determinant of coping behavior. Unsurprisingly, our data showed that both avoidant and cognitive coping were in turn robustly linked with elevated psychological distress, confirming previous findings in PLWHIV [16, 17, 21, 51].

Our model further indicated that the link between HIV-associated cognitive dysfunction and elevated psychological distress may be partially explained by maladaptive coping patterns. Specifically, we identified a significant indirect pathway from global cognitive dysfunction to psychological distress through higher levels of avoidant coping, and trend through cognitive coping. We also found a significant indirect effect through increased utilization of avoidant coping relative to cognitive coping, suggesting that higher levels of impairment are associated with a more avoidant coping style that is particularly vulnerable to psychological distress. Interestingly, we did not find a significant correlation between coping styles in our data, suggesting avoidant and cognitive coping are distinct psychological processes, and that the former is not merely the absence of the latter.

These findings compliment prior research including studies in Parkinson’s disease [32] and MS [33]. Notably, Rabinowitz & Arnett found that an avoidant coping style mediated the effect of executive functioning deficits on progression of depressive symptoms in MS patients [33]. In HIV, subjective cognitive complaints have been linked with greater depressive symptoms through avoidant coping (i.e., denial and behavioral disengagement) [51]. We advance this finding by including an objective measure of global cognitive functioning and broader characterization of emotional symptomology for the first time. As observed in other neurodegenerative conditions [32, 33], HIV-associated cognitive impairments may too impact coping behavior and have downstream consequences for successfully mitigating psychological distress.

Overall, HIV-associated cognitive deficits may shape coping behavior in a manner that increases psychological distress by 1) disrupting the ability to successfully deploy more cognitively demanding coping strategies that promote wellbeing and 2) increasing reliance on passive avoidant strategies that conserve limited cognitive resources but exacerbate distress in the long-term. The predominant executive functioning deficits [4, 52] and compromised cognitive neural networks [53, 54] associated with HIV-infection can undermine cognitive coping processes. For example, PLWHIV exhibit decreased electrocortical activity during cognitive reappraisal of distressing stimuli compared with controls [55]. Given the relative complexity and cognitive demands of these strategies, PLWHIV may default to less taxing, avoidant strategies. Indeed, emotion regulation research indicates that individuals tend to favor less cognitively demanding strategies when faced with stressors of high emotional intensity in order to minimize cognitive expenditure [56]. From this perspective, cognitive functioning may be conceptualized as a coping resource for PLWHIV, that when attenuated, disrupts successful enactment of cognitively coping strategies and shifts one’s coping style towards more avoidant modalities.

There are several limitations of the present study to be considered. The cross-sectional design precludes drawing definitive conclusions regarding causality or directionality. Similarly, while these results suggest a potential mediational process is occurring, such conclusions cannot be drawn with cross-sectional data, and other directional processes may be at play. For example, it is possible that psychological symptoms may impact coping behaviors or cognitive functioning. Alternatively, there may be shared vulnerability to cognitive impairment and propensity for using avoidant coping strategies. While our findings offer an important first step, future longitudinal studies are needed to establish the temporal ordering necessary for addressing issues of causality. Additionally, our findings may not generalize to PLWHIV outside of the mid-range of illness or with substance abuse histories. This study used the HDS, a brief cognitive screening measure that lacks sensitivity to more mild cognitive impairments [57], and therefore our findings may not generalize to more subtle cognitive disturbances. Also, we were unable to conduct a fine-tuned analysis of specific cognitive domains most closely associated with coping and psychological distress that may be afforded by comprehensive neuropsychological assessment. However, the HDS offers significant advantages in circumstances where time and resources are limited and comprehensive neuropsychological evaluation is not feasible. We were unable to examine reliability indices for some of the psychological measures without access to their item level data from the parent study. Finally, coping and psychological stress were assessed by self-report and thus subject to the inherent limitations of this methodology.

Conclusion and Clinical Implications

Our findings highlight reduced global cognitive functioning as a key correlate of increased maladaptive coping and psychological distress for PLWHIV predominantly in the mid-range of their illness. Importantly, these factors are associated with worse quality of life [20], poor medication adherence [22], and accelerated disease progression [10, 11, 23, 58]. Among patients with cognitive impairment, it may therefore be beneficial for clinicians to carefully assess coping behaviors and emotional functioning, and more aggressively prescribe interventions (e.g., cognitive-behavioral stress management) shown to improve coping skills and reduce symptoms of psychological distress [16-18].