Are religion and spirituality barriers or facilitators to treatment for HIV: a systematic review of the literature

Abstract

Much attention has been given to the relationship between religion/spirituality (R/S) and HIV in recent years, but comparatively little has been explored in regard to R/S and HIV testing, retention in care, and adherence to medication. Religious views concerning HIV risk behavior pose challenges to communication and education about sexual health in religious communities and may serve as barriers to HIV treatment and care. Conversely, religious coping and spiritual well-being, as well as social support could serve as facilitators to HIV treatment and care. This study aims to fill a gap in the literature by addressing the following questions: (1) what dimensions of R/S have been found to be factors associated with HIV outcomes?; (2) which R/S factors function as barriers or facilitators to care among people living with HIV (PLWH)?; and (3) which R/S factors, if any, vary across socio-demographic groups? Thirty-three empirical articles were identified for systematic review. Of the 33 empirical studies included, 24 studies found that at least one measure of R/S was associated with better adherence and clinical health outcomes. Twelve studies found at least one measure of R/S to be associated with poorer adherence and clinical health outcomes. Seven of the studies found at least one R/S measure to have no significant association with outcomes. Though all of the studies included in this review focused on R/S experiences of PLWH, there was very little consistency in regard to measurement of R/S. Studies in this review included a wide range of R/S measures, including beliefs, religious/spiritual practices, R/S coping, organizational religion, and many more. Of the 33 studies reviewed, only 9 focused on unique populations such as women, people with histories of substance abuse, immigrants, etc. Findings from this review highlight opportunities for more studies in various populations using standardized R/S measures.

Introduction

Much attention has been given to the relationship between religion/spirituality (R/S) and health in recent years. Recent research on R/S and health suggests that religiosity is beneficial for both mental and physical health (Bonelli & Koenig, 2013; Brewer, Robinson, Sumra, Tatsi, & Gire, 2014; Doane & Elliott, 2015; Kremer et al., 2014; Jim et al., 2015; Koenig, 2010; Sherman et al., 2015; Shiah, Chang, Chiang, Lin, & Tam, 2015; Zimmer et al., 2016). Some research has found non-significant and negative effects as well (Ironson et al., 2011; Kremer et al., 2014; Lyon et al., 2011; Pargament, Murray-Swank, Magyar, & Ano, 2005; Van Wagoner et al., 2014). Simplistic measures of R/S in population-level studies, such as solely measuring religious service attendance, may mask negative influences of dimensions of R/S that are detrimental to health, or mask effects of R/S in general. Due to the broad range of dimensions of R/S and mechanisms affecting health, an overarching, unifying theory of R/S and health is not quickly identified across studies. Much of the theoretical underpinnings in the literature are meso-level constructs of mechanisms bridging the gap between particular dimensions of R/S and health. A broader exploration of different dimensions of R/S and their impact on health is needed.

Research concerning R/S and health has included significant contributions to the role of R/S in the lives of people living with HIV (PLWH), including understanding the role of religious coping (Dalmida, Koenig, Holstad, & Tami, 2015), religious beliefs and stigma regarding HIV (Harris, 2010; Kang, Delzell, Chin, Behar, & Li, 2013; Szaflarski, 2013; Watt, Maman, Jacobson, Laiser, & John, 2009), congregation-based prevention and intervention programs (Berkley-Patton et al., 2010; Griffith, Pichon, Campbell, & Allen, 2010; Lindley, Coleman, Gaddist, & White, 2010), and more. Comparatively little has been explored in regard to R/S and HIV retention in care, adherence to medication, and clinical outcomes. In the remainder of the introduction, current research is reviewed surrounding R/S and HIV, highlighting potential religious barriers (stigma and negative religious coping) and facilitators (positive religious coping and spiritual well-being, and social support) to HIV screening, care, and medication adherence.

HIV stigma

Religious institutions have long played a significant role in public health efforts in the United States. However, religious beliefs concerning sexuality have led to a fracture in the relationship between religious institutions and public health efforts (Idler, 2014). Views of many religious traditions in the United States discourage behaviors associated with the risk of sexual health issues and HIV/AIDS in particular. These religious views may create and perpetuate HIV stigma, discrimination, and homophobia among religious groups (Dalmida & Thurman, 2014). HIV stigma is negatively associated with HIV and STI testing, perceived risk, participation in prevention efforts, treatment, and quality of care (Darrow, Montanea, & Gladwin, 2009; Mahajan et al., 2008; Sengupta et al., 2010).

HIV stigma often intersects with a number of other stigmatized behaviors and marginalized statuses such as non-monogamous and/or same sex relationships, sex work, and drug use (Sengupta et al., 2010). Religious prohibitions of such behavior may lead to increased stigma and discrimination concerning HIV risk behavior and HIV status among religious communities (Dalmida & Thurman, 2014).

Religious views concerning HIV risk behavior pose challenges to communication and education about sexual health in religious communities. Nunn and colleagues (2012) found HIV stigma and homophobia, as well as discomfort discussing human sexuality in religious contexts, to be barriers to HIV prevention among African-American faith-based institutions. Religious “cultures of silence” concerning sexuality and sexual health may contribute to a lack of knowledge concerning ways to mitigate sexual risk, access to screening and care, as well as discourage disclosure and communication concerning HIV status. Taken together, these potential results of HIV stigma in religious contexts could function as barriers to treatment for HIV.

Negative religious coping

A large majority of HIV-infected patients in the United States affirm the importance of religiousness and spirituality (Lorenz et al., 2005; Szaflarski, 2013). Though beliefs and teaching surrounding sexuality and sexual health in religious contexts may be at odds with the identities of many PLHIV, it has not resulted in a rejection of religion by these individuals at large. However, these beliefs and teaching may cause religious communities to exclude and distance PLHIV and be a cause of pain and struggle (Pargament et al., 2004; Szaflarski, 2013). Religious struggle and negative religious coping, such as belief illness is punishment from God, have been found to negatively affect health outcomes, including among PLWH (Cotton et al., 2006; Lee, Roberts, & Gibbons, 2013; Pargament et al., 2005). Negative religious coping, as well as guilt and shame associated with engaging in activities and behaviors believed to be sinful have been found to be associated with psychological distress and exacerbate physical and mental health problems (Ellison, Boardman, Williams, & Jackson, 2001). Negative religious experiences including religious struggle have been found to be associated with increased depression, anxiety, negative mood, panic disorder, suicide, and poor quality of life (Jawaid, 2014). Negative religious coping, therefore, may serve as a barrier to care for PLWH, and results in poorer outcomes.

Positive religious coping and spiritual well-being

R/S is often an important factor in the lives of PLWH. Many PLWH belong to an organized religion and use their religion to cope with their illness. R/S levels have been found to increase after HIV diagnosis and remain stable over 12–18 months (Cotton et al., 2006). R/S offers foundations for identity development and relationships with family and community, and many PLWH find solace in religious practices and spiritual experiences. A relationship with God or a higher power is often a source of comfort, hope, and meaning, especially during times of crisis or stress, such as being diagnosed with HIV (Seegers, 2007). Increases in R/S have been found to predict slower disease progression, physical and mental health, and quality of life (Ironson, Stuetzle, & Fletcher, 2006; Szaflarski, 2013). Research suggests that stress and psychological distress can exacerbate the symptoms and disease progression of PLWH (Antoni et al., 2015; Grassi, Righi, Sighinolfi, Makoui, & Ghinelli, 2015; Penedo et al., 2001; Vosvick et al., 2002; Weaver et al., 2004; Weaver et al., 2005), but effective coping strategies, including R/S coping, are associated with decreased stress, depression, and slower disease progression (Ano & Vasconcelles, 2005; Ironson et al., 2006; Smith, McCullough, & Poll, 2003; Tuck, Alleyne, & Thinganjana, 2006). Positive religious coping and spiritual well-being can foster beneficial HIV care, as well as improve outcome via reduced stress.

Social support

The relationship between R/S and health is often attributed to social support found in religious communities, or religious participation (Campbell, Yoon, & Johnstone, 2010; Ellison & George, 1994; Koenig, 2001; Krause & Hayward, 2014). Involvement in social networks provides individuals with psychological resources such as sense of purpose, belonging, and connectedness, as well as contexts through which to carry out social roles (Idler, 2014). Additionally, social support provides individuals with emotional and material resources such as caring and supportive others in times of need, people to help with activities such as child and elder care, transportation, etc., and provision of financial resources. Social support is believed to have both a direct effect on health, and an indirect effect via stress reduction (Turner & Turner, 2013). Social support has been found to have a positive effect on physical and mental health, largely due to emotional support and companionship, help with material needs, and influence of shared health lifestyles (Cadge & Ecklund, 2007).

Social support is an important protective factor for a number of health outcomes, including HIV (Grodensky et al., 2015; Koenig, 2008; Szaflarski, 2013). R/S often provides such support via social networks, social interaction, and support from a perceived divine being. Frequent religious services for many religious adherents provide these individuals with regular social interaction with like others, as well as a sense of community and mutual support. Especially in adulthood, there are few formal social institutions that provide people with similar access to social resources. Such support, if accessible to PLWH, could have beneficial effects on health outcomes.

Methods

This review has been conducted using systematic review methodology (Johnson, De Li, Larson, & McCullough, 2000), in order to summarize the methodologies and findings from articles published within the specified time frame. Characteristics of the studies, as well as research findings, were collected and summarized.

The key questions of this research were:

• What dimensions of R/S have been found to be factors associated with HIV outcomes?

• Which R/S factors function as barriers or facilitators to care among PLWH?

• Which R/S factors, if any, vary across socio-demographic contexts?

Search strategy and data sources

To answer these research questions, the search strategy for the study includes a number of key works and MESH terms to maximize our ability to find relevant literature. Published studies were identified in the electronic databases of PubMed, Sociological Abstracts & Social Services Abstracts, Social Science Abstracts, PsychINFO, and Web of Science using SCOPUS search engine. Articles in these databases were identified using the search parameter ((HIV OR AIDS OR HIV infection) AND (RELIGI* OR religion OR religiosity OR religious attendance OR spirituality OR SPIRIT* OR church attendance) AND (screening OR testing OR clinic OR care OR retention OR adherence OR clinical outcome) AND (United States)). The publication date and study population were restricted to articles published since 2000 with populations in the United States. The search was also limited to English-language articles published in peer-reviewed academic journals. Our last search was conducted in July of 2015.

For the initial search, abstracts were reviewed to identify full texts for further review. Abstracts were rejected if they did not have (1) measures concerning HIV/AIDS outcomes, (2) a focus on individual R/S (as opposed to institutions such as churches).

The remaining articles were selected for more thorough review to identify those that included exploration of R/S factors’ association with HIV outcomes among PLWH.

Full text review and data extraction

Full texts of identified articles were reviewed to determine eligibility for data extraction. Data from eligible studies were extracted to an electronic spreadsheet.

Data extracted include the following: study characteristics (author(s), publication year, study location, study objectives, and study population), description of the R/S measure, the direction of the effect of the R/S measure on HIV/AIDS outcomes (barrier, facilitator, both, or none), and the description of the HIV/AIDS outcome measure.

Results

Thirty-three studies were selected that explored R/S beliefs and/or experiences among PLWH that had treatment-related outcomes to answer the research questions. Our initial search identified 153 studies. After reviewing the abstracts, only 43 studies were selected for full review. The literature-reviewing process and exclusion criteria are summarized in Figure 1 (Liberati et al., 2009).

Figure 1.

PRISMA flow diagram for the literature-reviewing process.

Study characteristics

Study design and characteristics of the 33 studies are summarized in Table 1. Twenty-two of the 33 studies were cross-sectional in nature, 9 were longitudinal, and 2 were randomized control trials. Most (n = 16) of the studies were conducted in the Southeast; 5 studies were conducted in the Northeast, 4 in the West, and 3 in the Midwest. Five studies included samples drawn from across the United States.

Table 1.

Study characteristics of each article.

First author	Publication date	Region	Population	Sample size	Study design
Chang, van Servellen, and Lombardi	(2003)	West	PLWH	182	CS
Cotton et al.	(2006)	Northeast	PLWH	450	CS
Dalmida, Holstad, Diiorio, and Laderman	(2009)	Southeast	PLWH	129	CS
Finocchario-Kessler et al.	(2011)	Midwest	PLWH	204	RCT
Fitzpatrick et al.	(2007)	US	PLWH	901	L
Holstad, Pace, De, and Ura	(2006)	Southeast	PLWH	120	CS
Ironson et al.	(2002)	Southeast	PLWH	279	CS
Ironson et al.	(2006)	Southeast	PLWH	100	L
Ironson and Kremer	(2009)	Southeast	PLWH	147	CS
Ironson et al.	(2011)	Southeast	PLWH	101	L
Konkle-Parker, Erlen, and Dubbert	(2008)	Southeast	PLWH	20	CS
Kremer, Ironson, Schneiderman, and Hautzinger	(2006)	Southeast	PLWH	79	CS
Kremer, Ironson, and Porr	(2009)	Southeast	PLWH	79	CS
Kremer et al.	(2014)	Southeast	PLWH	177	CS
Lorenz et al.	(2005)	US	PLWH receiving care	2266	L
Lyon et al.	(2011)	Northeast	Adolescent PLWH	40	RCT
Maisels, Steinberg, and Tobias	(2001)	Northeast	PLWH who did not receive highly active antiretroviral therapy (HAART)	28	CS
Martinez et al.	(2012)	US	Female PLWH aged 15–24	178	L
Mellins et al.	(2009)	US	Adult PLWH with both a psychiatric and substance abuse disorder	1138	CS
Meredith, Jeffe, Mundy, and Fraser	(2001)	Midwest	PLWH	202	CS
Othieno J	(2007)	Midwest	African-born immigrants and refugees	35	CS
Owen-Smith et al.	(2007)	Southeast	Female PLWH	366	CS
Parsons, Cruise, Davenport, and Jones	(2006)	Southeast	PLWH	306	CS
Pecoraro et al.	(2013)	Northeast	PLWH who dropped out of care	41	CS
Powell-Cope, White, Henkelman, and Turner	(2003)	Southeast	Drug using female PLWH	24	CS
Ramer, Johnson, Chan, & Barrett	(2006)	West	PLWH recruited from clinic	420	CS
Simoni, Frick, and Huang	(2006)	West	PLWH	136	L
Sunil and McGehee	(2007)	US	PLWH from rural counties	2267	L
Trevino et al.	(2010)	Northeast	PLWH	429	L
Van Wagoner et al.	(2014)	Southeast	PLWH presenting to establish initial care	508	CS
Vyas, Limneos, Qin, and Mathews	(2014)	West	PLWH	350	L
Vyavaharkar et al.	(2007)	Southeast	Female PLWH with depression	224	CS
Woodard and Sowell	(2001)	Southeast	Female PLWH	21	CS

Note: CS: Cross-sectional; L: Longitudinal; RCT: random control trial.

All of the included studies were limited to populations of PLWH. Five of the 33 included studies focused on women living with HIV. Two studies limited their study population to populations with current or former substance abuse. Other unique population characteristics include people with depression, immigrants, youth, rural populations, patients presenting to establish initial care, patients dropped from care, and patients who did not receive anti-retroviral therapy (ART).

Description of R/S measures

Conceptualization of religion has not been simple or consistent in the literature. Efforts to conceptualize and measure religiousness/spirituality have proposed a number of dimensions of religious commitment including belief, knowledge, experiences, and many others (Fetzer Institute and National Institute on Aging Working Group, 1999; Stark & Glock, 1968). Few standard measures or conceptualizations of R/S exist for PLWH; however, there have been efforts in the religion and health literature to identify dimensions of R/S that are most pertinent to health. The Brief Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research (BMMRS) has identified and described 12 key dimensions including daily spiritual experiences, meaning, values, beliefs, forgiveness, private religious practices, religious/spiritual coping, religious support, religious/spiritual history, commitment, organizational religiosity, and religious preference (Fetzer Institute and National Institute on Aging Working Group, 1999). Furthermore, Szaflarski and colleagues have utilized the BMMRS in the assessment of PLWH (Szaflarski et al., 2012). To the extent possible, this review has categorized the R/S measures in the included studies based on dimensions identified in the BMMRS. Measures of R/S are displayed in Table 2. None of the studies in this review included measures of forgiveness or commitment as identified in the BMMRS, therefore those dimensions are not included in the table.

Table 2.

Religiousness/spirituality dimensions of each article.

Study	R/S Dimensions
	DSE	M	V	B	PRP	R/SC	RS	R/SH	OR	RP
Chang et al. (2003)						NS
Cotton et al. (2006)		NS		NS	NS	NS			NS
Dalmida et al. (2009)		+		+
Finocchario-Kessler et al. (2011)				−		NS
Fitzpatrick et al. (2007)					+ / NS		+ / NS
Holstad et al. (2006)		+		NS	NS					NS
Ironson et al. (2002)	+	+		+/−	+	+			+
Ironson et al. (2006)								+	+
Ironson and Kremer (2009)								+
Ironson et al. (2011)				+/−					+
Konkle-Parker et al. (2008)				+	+
Kremer et al. (2006)				+ / −
Kremer et al. (2009)				−		+
Kremer et al. (2014)						+ / −
Lorenz et al. (2005)				NS
Lyon et al. (2011)		NS		−					NS
Maisels et al. (2001)				−
Martinez et al. (2012)						+
Mellins et al. (2009)		+
Meredith et al. (2001)					−				NS
Othieno et al. (2007)				−
Owen-Smith et al. (2007)					NS	NS
Parsons et al. (2006)				−					+
Pecoraro et al. (2013)			+	+
Powell-Cope et al. (2003)		+			+		+
Ramer et al. (2006)	NS	NS		NS
Simoni et al. (2006)				+	+	+	+
Sunil and McGehee (2007)				+ / −		+			+
Trevino et al. (2010)				−		+
Van Wagoner et al. (2014)									− / NS
Vyas et al. (2014)	−	+		+ / −	−				−
Vyavaharkar et al. (2007)					+	+
Woodard et al. (2001)	+	+		+	+

Notes: DSE: daily spiritual experience; M: meaning; V: values; B: beliefs; PRP: private religious practices; R/SC: religious/spiritual coping; RS: religious support; R/SH: religious/spiritual history; OR: organizational religion; RP: religious preference; NS: results not significant; +: religion functions as facilitator; −: religion functions as barrier.

Most dimension of R/S were found to function as both facilitators and barriers to care and health outcomes for PLWH, with the exception of meaning, value, religious support, and R/S spiritual history, which were consistently found to function as facilitators. Variations within dimensions such as belief and R/S coping were largely attributed to the fact that survey items used in studies measured negative coping and beliefs that an HIV diagnosis was punishment from God, or other beliefs that have been found to negatively affect health.

Discussion

This review explores which dimensions of R/S are associated with HIV outcomes, and the direction of these associates. In this review, 33 studies were identified that investigated the role of R/S on HIV adherence and clinical outcomes. Table 3 provides a summary of findings from the studies included in this review. Of the 33 empirical studies included, 24 studies found that at least one measure of R/S was associated with better adherence and clinical health outcomes. Twelve studies found at least one measure of R/S to be associated with poorer adherence and clinical health outcomes. Seven of the studies found at least one R/S measure to have no significant association with outcomes.

Table 3.

Summary of article results.

Author	Outcome measure	Results	Direction
Chang et al. (2003)	CD4 and VL	The use of religion was not associated with any symptoms, behaviors to control symptoms, or health-related outcomes	NS
Cotton et al. (2006)	CD4, VL, ART	Spirituality was not generally associated with clinical variables (CD4 count and viral load)	NS +
Dalmida et al. (2009)	CD4	Higher emotional well-being (EWB) was weakly and significantly associated with higher CD4 cell counts and higher spiritual well-being, religious well-being, and EWB were all significantly associated with higher CD4 cell percentages	+
Finocchario-Kessler et al. (2011)	ART medication adherence	Those more likely to have perceived God as the locus of control over their health were 42% less likely to have 90% or greater adherence compared to those less likely to perceive God as in control. No evidence found of association between religious coping and adherence	NS −
Fitzpatrick et al. (2007)	Risk of death	The relationship between spiritual activity and risk of death moderated by use of HAART; those not using HAART participating in spiritual activities had reduced risk of death; this relationship was strongest for spiritual activities of prayer and affirmations	NS +
Holstad et al. (2006)	Adherence	A weak correlation was found between EWB and adherence; persons who loved life, found meaning in their activities, viewed life as positive, felt some hope in the future, were satisfied with life and themselves, enjoyed life, and felt a definite purpose in living (all components of the EWB scale, without “religiosity”) were more adherent	NS +
Ironson et al. (2002)	Treatment adherence, physical symptoms, and psychological well-being, CD4-counts and viral load and survival three to five years later.	The presence of spiritual transition (ST) was significantly associated with better treatment success (undetectable viral loads, higher CD4 counts), better medication adherence, fewer symptom, more spiritual practices, and increased spirituality; Survival up to five years was more likely among participants with ST	NS +
Ironson et al. (2006)	Long-term survival	Long survivors were significantly higher than the HIV-positive comparison group on religious behavior	+ −
Ironson and Kremer (2009)	Disease progression (CD4, LV) adherence, survival	The increase in religiousness/spirituality (INCRS) from before to after finding out that one was HIV-positive was significantly related to change in CD4 over four years (t = 3.03) and to change in VL(log) over four years	+
Ironson et al. (2011)	CD4, VL	Positive and negative views of God were significant predictors of CD4 cell slope and VL log slope even after adjusting for church attendance, health behaviors, mood, and coping	+ −
Konkle-Parker et al. (2008)	Adherence	Prayer and spirituality were considered an important support. Prayer was described as the ability to trust God to help them through difficulties and was described as a foundational support in managing medicines	+
Kremer et al. (2006)	CD4, VL, adherence	Spiritual coping predicted sustained undetectable VL and CD4 cell preservation over four years, independent of covariates; even when controlling for the effect of VL suppression, CD4 cell decline was 2.25 times faster among those engaged in negative versus positive spiritual coping	+ −
Kremer et al. (2009)	ART decision-making	The belief in a God = Higher Power controlling health was associated with not taking anti-retroviral, and the belief in the individual’s mind controlling health was associated with not starting antiretroviral. The only spiritual belief that was identified as a motivator to adherence was the perception that spirituality helped coping with treatment side effects	+ −
Kremer et al. (2014)	ART decision-making	When asked about the criteria for their decision about ART, 65% spontaneously mentioned a belief in mind–body connection, whereas 35% did not; 58% of the participants considered spirituality/worldview in their decision about ART, whereas 42% participants did not	+ −
Lorenz et al. (2005)	Clinical stage	Clinical stage was not associated with religiousness or spirituality	NS
Lyon et al. (2011)	Adherence	Youth living with HIV/AIDS who persisted in beliefs that HIV was a punishment from God had lower spirituality scores (p = .05) and poorer HAART adherence (p = .04) than those who did not have this belief	NS −
Maisels et al. (2001)	Refusing ART	Religious beliefs reported as reason to decline HAART for 3 out of 28 people	−
Martinez et al. (2012)	Adherence	Spiritual coping identified as moderator of stigma’s effect on medication adherence	+
Mellins et al. (2009)	Adherence	Increased spirituality correlated to better adherence	+
Meredith et al. (2001)	On ART	Those selecting prayer as most important were less likely to report using anti-retroviral medications; a religious leader was rated very important by only 19.3% of the respondents	NS −
Othieno (2007)	Seeking/remaining in care	Certain cultural and religious beliefs and practices (including discussion of sex, marriage, and breastfeeding) are very germane to the African community, and the risk of compromising them leads to distrust of the system and informs decisions by African PLWH concerning whether to enter or remain in care	−
Owen-Smith et al. (2007)	Adherence	There was no significant association between religious/psychic healing or bodywork and HAART non-adherence	NS
Parsons et al. (2006)	Adherence; being in care; keeping an appointment in the last three months and the gap between diagnosis and the start of medical care for HIV	Being in medical care associated with a stronger belief that HIV is not a sin in the eyes of God; a longer gap was explained, in part, by a stronger belief that HIV is a punishment from God; a longer lag since the last appointment kept was related to less frequent church attendance; being in medical care related to a weaker belief that HIV is a sin; a shorter gap in medical care for women was related to a greater frequency of church attendance; and fewer missed appointments were related to a greater frequency of church attendance; Men in medical care currently were more satisfied with their medical care and were less inclined to believe that HIV is a sin. Keeping an appointment in the past 3 months was related to a higher frequency of church attendance and a weaker belief that HIV is a sin than their counterparts who were not in medical care. There were no statistically significant associations between gaps from diagnosis to the start of medical care, missed appointments, and missed medications	+ −
Pecoraro et al. (2013)	Returning to treatment	spirituality frequently played a role in substance abuse recovery; some participants mentioned making positive changes due to reflection, conscience, and faith	+
Powell-Cope et al. (2003)	Adherence	Many believed religion, God, spirituality helped take medications	+
Ramer et al. (2006)	Viral load, US Center for Disease Control and Prevention (CDC) category, CD4 level, ART therapy, protease inhibitor therapy, disease comorbidity, VL, or opportunistic infections	Subjects with higher energy levels reported significantly (p < .01) higher self-transcendence scores. No significant associations were found between self-transcendence and the other clinical factors of CDC category, CD4 level, HAART therapy, protease inhibitor therapy, depression, pain, disease comorbidity, viral RNA counts, or opportunistic infections	NS
Simoni et al. (2006)	Self-efficacy to adhere, adherence, VL	The final model indicated that negative affect, spirituality, and self-efficacy to adhere mediated the relationship between social support and adherence	+
Sunil and McGehee (2007)	Adherence	Adherent patients more likely to be less religious; For African Americans, “religious attendance” and “seek comfort through religion” positively influenced treatment adherence; For Hispanics, only “seek comfort through religion” was found to increase the likelihood of treatment adherence, but the variable had a strong effect; Whites benefited from being religious, though not from attending religious services or finding comfort in religion strong effect	+ −
Trevino et al. (2010)	CD4, VL, HIV symptoms,	Spiritual struggle was associated with having a detectable viral load, poorer quality of life, more bothersome HIV and depressive symptoms, lower levels of spirituality, less social support, and poorer self-esteem; spiritual struggle was a significant predictor of log CD4 at Time 2 after controlling for baseline log CD4, positive religious coping, and demographic variables	+ −
Van Wagoner et al. (2014)	CD4 count <200 at time of entry in care	HIV-infected MSM who reported current church attendance were more likely to present with advanced disease and less likely to report a history of previous HIV screening than non-church-attending MSM. Church-attending WSM were no more or less likely to present with advanced disease but were more likely to report previous HIV screening; In MSW, there was no association with church attendance and self-reported prior HIV testing	NS −
Vyas et al. (2014)	Adherence	Participants who said their beliefs gave meaning to their lives, made them feel they had a connection with a higher being, were influential during their recovery, and helped them feel connected to humanity were more likely to be ≥90% adherent (p < .015). Conversely, participants who believed God created all things in the universe; that God will not turn his back on them; and those who regularly attended religious services, participated in religious rituals, and prayed and meditated to get in touch with God were less likely to be ≥90% adherent (p ≤ .025).	+ −
Vyavaharkar et al. (2007)	Adherence	Coping by spiritual activates negatively correlated w/ reasons missed; Coping by spiritual activities and focusing on the present mediated the effect of social support on medication adherence.	+
Woodard and Sowell (2001)	Care	Women use spirituality to enhance care prescribed by providers	+

Notes: CD4: number of T cells expressing CD4; VL: viral load; ART: anti-retroviral therapy; NS: Results not significant; +: R/S functions as facilitator; −: R/S functions as barrier.

The studies identified were conducted across the country, but the largest proportion of the studies was focused in the Southeast. Studies from other regions of the country are limited, especially studies of various populations of PLWH such was women, adolescents, or men who have sex with men (MSM). Studies in the Southeast concerning R/S and HIV provide useful knowledge concerning the role of R/S dimensions on clinical outcomes (Dalmida et al., 2009; Holstad et al., 2006; Ironson & Kremer, 2009; Ironson et al., 2002, 2011, 2006; Konkle-Parker et al., 2008; Kremer et al., 2014; Kremer et al., 2009; Kremer et al. 2006; Owen-Smith, Diclemente, & Wingood, 2007; Parsons et al., 2006; Powell-Cope et al., 2003; Van Wagoner et al., 2014; Vyavaharkar et al., 2007; Woodard & Sowell, 2001), but they do not provide a representative sample of the country. Religious norms may vary by region, and could function differently or be of less importance outside of the Southeast. Large, nationally representative samples are needed to explore the relationships between R/S factors and clinical outcomes for PLWH, especially in the case of intersecting identities. Additional regional studies of various populations would also be beneficial to help understand the roles of R/S factors among people of different racial ethnic backgrounds, sexes, sexualities, religions, and ages.

Though all of the studies included in this review focused on R/S experiences of PLWH, there was very little consistency in regard to measurement of R/S. Studies in this review included a wide range of R/S measures, and actual measurement of each dimension varied significantly between studies. This finding is unsurprising, as there is not a consistently agreed upon measure for R/S in the literature. However, research in the field of religion and health could benefit from use of a standard set of measures, such as those identified by the Fetzer Institute for use in the study of religion and health (Fetzer Institute and National Institute on Aging Working Group, 1999), or measures validated for use with populations living with HIV (Ironson et al., 2002; Szaflarski et al., 2012). More consistent use of validated measures can allow for comparison of findings and opportunities to advance the body of research in this field.

The majority of the studies in this review found R/S factors to be beneficial for adherence and clinical outcomes of PLWH, particularly the dimensions of meaning, values, religious support, and R/S history (Dalmida et al., 2009; Fitzpatrick et al., 2007; Holstad et al., 2006; Ironson & Kremer, 2009; Ironson et al., 2002, 2006; Mellins et al., 2009; Pecoraro et al., 2013; Powell-Cope et al., 2003; Simoni et al., 2006; Vyas et al., 2014; Vyavaharkar et al., 2007; Woodard & Sowell, 2001). However, 12 studies found at least one R/S measure to have a negative effect on these outcomes. Most of these factors which found to have a harmful effect were measures related to negative religious coping or spiritual struggle, when a person is trying to preserve spirituality or religiosity that has to be threatened by their illness experience (Pargament et al., 2005). Such factors may be associated with experiences of stress and psychological distress and therefore would be expected to have a deleterious effect on health (Woods, Antoni, Ironson, & Kling, 1999). One notable finding of R/S functioning as a barrier to care is that of Van Wagoner and colleagues (2014). Findings from this study suggest that religious attendance is a barrier to seeking treatment among MSM, but not among women who have sex with men (WSM) or men who have sex with women (MSW). This and other findings suggest R/S may function differently for populations due to additional or exacerbated stigmas in religious contexts resulting from beliefs concerning sexuality and drug use. Additional studies are needed to examine variation in the role of R/S across diverse populations.

Conclusion

Much research has explored the role of R/S and health outcomes among PLHIV, finding that R/S is largely protective for HIV outcomes such as viral load, CD4 count, disease progression, and survival. However, negative and non-significant effects, and extreme inconsistency in the measures of R/S used indicate areas that are yet to be explored. Understanding of which dimensions of R/S are most important for health in general, and particularly HIV/AIDS outcomes, is still needed. The literature has also not yet provided a clear understanding of how R/S affects health for various socio-demographic groups, including variation by gender, sexual orientation, race/ethnicity, religious affiliation, etc. Different dimensions of R/S may be of greater importance to different people based on gender, racial/ethnic, religious affiliation, etc. Furthermore, it is not entirely clear how R/S gets under the skin to impact physiological outcomes. Mediating mechanisms joining R/S dimensions to biomarkers should be included in studies to better understand the pathways through which R/S influences HIV outcomes.

Expanding the current research about R/S factors’ association with HIV treatment and clinical outcomes is an important next step in advancing the field. Of the 33 studies reviewed, only 9 focused on unique populations such as women, people with histories of substance abuse, immigrants, etc. Few studies include nationally representative samples, or populations recruited from multiple sites across the country. Findings from this review highlight opportunities for more studies in various populations using standardized R/S measures. A specific examination of the role of R/S among populations such as MSM, racial/ethnic minorities, and people with a history of substance abuse is needed to understand the impact of intersecting identities and stigmas. A fuller understanding of the part these factors play could guide development and improvement of interventions at religious institutions, as well as public health programs that incorporate R/S aspects. Furthermore, when clinicians understand the nuances of the role of R/S in the lives of PLWH, they are better equipped to provide appropriate care. Ultimately, continued research concerning the role of R/S among PLWH will likely improve treatment and medication adherence, as well as health outcomes, for this population.