AIDS and Behavior

, Volume 22, Issue 10, pp 3130–3140 | Cite as

Avoidant Coping Mediates the Relationship Between Self-Efficacy for HIV Disclosure and Depression Symptoms Among Men Who Have Sex with Men Newly Diagnosed with HIV

  • Emily M. CherenackEmail author
  • Kathleen J. Sikkema
  • Melissa H. Watt
  • Nathan B. Hansen
  • Patrick A. Wilson
Original Paper


HIV diagnosis presents a critical opportunity to reduce secondary transmission, improve engagement in care, and enhance overall well-being. To develop relevant interventions, research is needed on the psychosocial experiences of newly diagnosed individuals. This study examined avoidant coping, self-efficacy for HIV disclosure decisions, and depression among 92 newly diagnosed men who have sex with men who reported recent sexual risk behavior. It was hypothesized that avoidant coping would mediate the relationship between self-efficacy and depression. Cross-sectional surveys were collected from participants 3 months after HIV diagnosis. To test for mediation, multiple linear regressions were conducted while controlling for HIV disclosure to sexual partners. Self-efficacy for HIV disclosure decisions showed a negative linear relationship to depression symptoms, and 99% of this relationship was mediated by avoidant coping. The index of mediation of self-efficacy on depression indicated a small-to-medium effect. Higher self-efficacy was related to less avoidant coping, and less avoidant coping was related to decreased depression symptoms, all else held constant. These findings highlight the role of avoidant coping in explaining the relationship between self-efficacy for HIV disclosure decisions and depression.


HIV Coping Self-efficacy Depression MSM 



This research was funded by the NIH Grant R01-MH078731. We are grateful for our longstanding collaboration with Callen-Lorde Community Health Center and the individuals who offered their participation in the study. We thankfully acknowledge Arlene Kochman, Allyson De Lorenzo, Jessica MacFarlane, Gal Mayer, Anya Drabkin, and William Nazareth for their contributions to this research. In addition, we acknowledge the Duke Center for AIDS Research (NIAID P30-AI064518) for the support in the conduct of this study and preparation of the manuscript.


This research was funded by the NIH Grant R01-MH078731.

Compliance with Ethical Standards

Conflict of interest

Emily M. Cherenack declares that she has no conflict of interest. Kathleen J. Sikkema declares that she has no conflict of interest. Melissa H. Watt declares that she has no conflict of interest. Nathan B. Hansen declares that he has no conflict of interest. Patrick A. Wilson. declares that he has no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all participants included in the study.


  1. 1.
    Centers for Disease Control and Prevention. HIV in the United States: at a glance [Internet]. 2016. Accessed 25 July 2016.
  2. 2.
    Halkitis PN, Kupprat SA, Hampton MB, Perez-Figueroa R, Kingdon M, Eddy JA, et al. Evidence for a syndemic in aging HIV-positive gay, bisexual, and other MSM: implications for a holistic approach to prevention and health care. Ann Anthropol Pract. 2012;36:365–86.CrossRefGoogle Scholar
  3. 3.
    Mimiaga MJ, O’Cleirigh C, Biello KB, Robertson AM, Safren SA, Coates TJ, et al. The effect of psychosocial syndemic production on 4-year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men. J Acquir Immune Defic Syndr. 2015;68:329–36.CrossRefPubMedCentralGoogle Scholar
  4. 4.
    Mustanski B, Garofalo R, Herrick A, Donenberg G. Psychosocial health problems increase risk for HIV among urban young men who have sex with men: preliminary evidence of a syndemic in need of attention. Ann Behav Med. 2007;34:37.CrossRefPubMedCentralGoogle Scholar
  5. 5.
    Stall R, Mills TC, Williamson J, Hart T, Greenwood G, Paul J, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;93:939–42.CrossRefPubMedCentralGoogle Scholar
  6. 6.
    Ramirez-Avila L, Regan S, Giddy J, Chetty S, Ross D, Katz JN, et al. Depressive symptoms and their impact on health-seeking behaviors in newly-diagnosed HIV-infected patients in Durban, South Africa. AIDS Behav. 2012;16:2226–35.CrossRefPubMedCentralGoogle Scholar
  7. 7.
    Tegger MK, Crane HM, Tapia KA, Uldall KK, Holte SE, Kitahata MM. The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals. AIDS Patient Care STDs. 2008;22:233–43.CrossRefGoogle Scholar
  8. 8.
    Grinsztejn B, Hosseinipour MC, Ribaudo HJ, Swindells S, Eron J, Chen YQ, et al. Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection: results from the phase 3 HPTN 052 randomised controlled trial. Lancet Infect Dis. 2014;14:281–90.CrossRefPubMedCentralGoogle Scholar
  9. 9.
    Safren SA, Reisner SL, Herrick A, Mimiaga MJ, Stall R. Mental health and HIV risk in men who have sex with men. J Acquir Immune Defic Syndr. 2010;55:S74–7.CrossRefPubMedCentralGoogle Scholar
  10. 10.
    Sikkema KJ, Watt MH, Drabkin AS, Meade CS, Hansen NB, Pence BW. Mental health treatment to reduce HIV transmission risk behavior: a positive prevention model. AIDS Behav. 2010;14:252–62.CrossRefPubMedCentralGoogle Scholar
  11. 11.
    Sin NL, DiMatteo MR. Depression treatment enhances adherence to antiretroviral therapy: a meta-analysis. Ann Behav Med. 2014;47:259–69.CrossRefPubMedCentralGoogle Scholar
  12. 12.
    Antoni MH, Carrico AW, Durán RE, Spitzer S, Penedo F, Ironson G, et al. Randomized clinical trial of cognitive behavioral stress management on human immunodeficiency virus viral load in gay men treated with highly active antiretroviral therapy. Psychosom Med. 2006;68:143–51.CrossRefGoogle Scholar
  13. 13.
    Hult JR, Mauer SA, Moskowitz JT. “I’m sorry, you’re positive”: a qualitative study of individual experiences of testing positive for HIV. AIDS Care. 2009;21(185–188):4p.Google Scholar
  14. 14.
    Christopoulos KA, Massey AD, Lopez AM, Hare CB, Johnson MO, Pilcher CD, et al. Patient perspectives on the experience of being newly diagnosed with HIV in the emergency department/urgent care clinic of a public hospital. PLoS ONE. 2013;8:e74199.CrossRefPubMedCentralGoogle Scholar
  15. 15.
    Lawson PJ, Flocke SA. Teachable moments for health behavior change: a concept analysis. Patient Educ Couns. 2009;76:25–30.CrossRefGoogle Scholar
  16. 16.
    Sikkema KJ, Abler L, Hansen NB, Wilson PA, Drabkin AS, Kochman A, et al. Positive Choices: outcomes of a brief risk reduction intervention for newly HIV-diagnosed men who have sex with men. AIDS Behav. 2014;18:1808–19.CrossRefPubMedCentralGoogle Scholar
  17. 17.
    Atkinson JH, Higgins JA, Vigil O, Dubrow R, Remien RH, Steward WT, et al. Psychiatric context of acute/early HIV infection. The NIMH multisite acute HIV infection study: IV. AIDS Behav. 2009;13:1061–7.CrossRefPubMedCentralGoogle Scholar
  18. 18.
    Valente SM. Depression and HIV disease. J Assoc Nurses AIDS Care. 2003;14:41–51.CrossRefGoogle Scholar
  19. 19.
    Ickovics JR, Hamburger ME, Vlahov D, et al. Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV epidemiology research study. JAMA. 2001;285:1466–74.CrossRefGoogle Scholar
  20. 20.
    Kelly JA, Murphy DA, Bahr GR, Koob JJ, Morgan MG, Kalichman SC, et al. Behaviors associated with severity of depression and high-risk sexual behavior among persons diagnosed with human immunodeficiency virus (HIV) infection. Health Psychol. 1993;12:215–9.CrossRefGoogle Scholar
  21. 21.
    Hosek SG, Harper GW, Lemos D, Martinez J. An ecological model of stressors experienced by youth newly diagnosed with HIV. J HIV/AIDS Prev Child Youth. 2008;9:192–218.CrossRefGoogle Scholar
  22. 22.
    Hult JR, Wrubel J, Bränström R, Acree M, Moskowitz JT. Disclosure and nondisclosure among people newly diagnosed with HIV: an analysis from a stress and coping perspective. AIDS Patient Care STDs. 2012;26(181–190):10p.Google Scholar
  23. 23.
    Holt R, Court P, Vedhara K, Nott KH, Holmes J, Snow MH. The role of disclosure in coping with HIV infection. AIDS Care. 1998;10:49–60.CrossRefGoogle Scholar
  24. 24.
    Kamen C, Vorasarun C, Canning T, Kienitz E, Weiss C, Flores S, et al. The impact of stigma and social support on development of post-traumatic growth among persons living with HIV. J Clin Psychol Med Settings. 2015;23:126–34.CrossRefGoogle Scholar
  25. 25.
    Zea MC, Reisen CA, Poppen PJ, Bianchi FT, Echeverry JJ. Disclosure of HIV status and psychological well-being among Latino gay and bisexual men. AIDS Behav. 2005;9:15–26.CrossRefGoogle Scholar
  26. 26.
    Kalichman S, Nachimson D. Self-efficacy and disclosure of HIV-positive serostatus to sex partners. Health Psychol. 1999;18:281–7.CrossRefGoogle Scholar
  27. 27.
    Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer; 1984.Google Scholar
  28. 28.
    Suls J, Fletcher B. The relative efficacy of avoidant and nonavoidant coping strategies: a meta-analysis. Health Psychol. 1985;4:249–88.CrossRefGoogle Scholar
  29. 29.
    Carrico AW, Antoni MH, Durán RE, Ironson G, Penedo F, Fletcher MA, et al. Reductions in depressed mood and denial coping during cognitive behavioral stress management with HIV-positive gay men treated with HAART. Ann Behav Med. 2006;31:155–64.CrossRefGoogle Scholar
  30. 30.
    Gore-Felton C, Koopman C, Spiegel D, Vosvick M, Brondino M, Winningham A. Effects of quality of life and coping on depression among adults living with HIV/AIDS. J. Health Psychol. 2006;11:711–29.CrossRefGoogle Scholar
  31. 31.
    Hansen NB, Harrison B, Fambro S, Bodnar S, Heckman TG, Sikkema KJ. The structure of coping among older adults living with HIV/AIDS and depressive symptoms. J. Health Psychol. 2013;18:198–211.CrossRefGoogle Scholar
  32. 32.
    Moskowitz JT, Hult JR, Bussolari C, Acree M. What works in coping with HIV? A meta-analysis with implications for coping with serious illness. Psychol Bull. 2009;135:121–41.CrossRefGoogle Scholar
  33. 33.
    Penedo FJ, Gonzalez JS, Davis C, Dahn J, Antoni MH, Ironson G, et al. Coping and psychological distress among symptomatic HIV+ men who have sex with men. Ann Behav Med. 2003;25:203–13.CrossRefGoogle Scholar
  34. 34.
    Sanjuán P, Molero F, Fuster MJ, Nouvilas E. Coping with HIV related stigma and well-being. J Happiness Stud. 2013;14:709–22.CrossRefGoogle Scholar
  35. 35.
    Simoni JM, Ng MT. Trauma, coping, and depression among women with HIV/AIDS in New York City. AIDS Care. 2000;12:567–80.CrossRefGoogle Scholar
  36. 36.
    Tarakeshwar N, Hansen N, Kochman A, Sikkema KJ. Gender, ethnicity and spiritual coping among bereaved HIV-positive individuals. Ment. Health Relig. Cult. 2005;8:109–25.CrossRefGoogle Scholar
  37. 37.
    Clement U, Schonnesson LN. Subjective HIV attribution theories, coping and psychological functioning among homosexual men with HIV. AIDS Care. 1998;10:355–63.CrossRefGoogle Scholar
  38. 38.
    Sikkema KJ, Ranby KW, Meade CS, Hansen NB, Wilson PA, Kochman A. Reductions in traumatic stress following a coping intervention were mediated by decreases in avoidant coping for people living with HIV/AIDS and childhood sexual abuse. J Consult Clin Psychol. 2013;81:274–83.CrossRefGoogle Scholar
  39. 39.
    Smith NG, Tarakeshwar N, Hansen NB, Kochman A, Sikkema KJ. Coping mediates outcome following a randomized group intervention for HIV-positive bereaved individuals. J Clin Psychol. 2009;65:319–35.CrossRefPubMedCentralGoogle Scholar
  40. 40.
    Lutgendorf SK, Antoni MH, Ironson G, Klimas N, Fletcher MA, Schneiderman N. Cognitive processing style, mood, and immune function following HIV seropositivity notification. Cogn. Ther. Res. 1997;21:157–84.CrossRefGoogle Scholar
  41. 41.
    Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191–215.CrossRefGoogle Scholar
  42. 42.
    Bandura A. Social cognitive theory and exercise of control over hiv infection. In: DiClemente RJ, Peterson JL, editors. Prev. AIDS [Internet]. Springer US; 1994. p. 25–59. Accessed 28 Mar 2016.CrossRefGoogle Scholar
  43. 43.
    Ehrenberg MF, Cox DN, Koopman RF. The relationship between self-efficacy and depression in adolescents. Adolescence. 1991;26:361–74.PubMedGoogle Scholar
  44. 44.
    Kanfer R, Zeiss AM. Depression, interpersonal standard setting, and judgments of self-efficacy. J Abnorm Psychol. 1983;92:319–29.CrossRefGoogle Scholar
  45. 45.
    Kavanagh DJ, Bower GH. Mood and self-efficacy: impact of joy and sadness of perceived capabilities. Cogn Ther Res. 1985;9:507–25.CrossRefGoogle Scholar
  46. 46.
    Lee Y-H, Salman A. Depression and AIDS preventive self-efficacy among Taiwanese adolescents. Arch Psychiatr Nurs. 2016;30:84–9.CrossRefGoogle Scholar
  47. 47.
    Maciejewski PK, Prigerson HG, Mazure CM. Self-efficacy as a mediator between stressful life events and depressive symptoms. Br J Psychiatry. 2000;176:373–8.CrossRefGoogle Scholar
  48. 48.
    Tucker A, Liht J, de Swardt G, Jobson G, Rebe K, McIntyre J, et al. An exploration into the role of depression and self-efficacy on township men who have sex with men’s ability to engage in safer sexual practices. AIDS Care. 2013;25(1227–1235):9p.Google Scholar
  49. 49.
    Bosmans MWG, Hofland HW, De Jong AE, Van Loey NE. Coping with burns: the role of coping self-efficacy in the recovery from traumatic stress following burn injuries. J Behav Med. 2015;38:642–51.CrossRefPubMedCentralGoogle Scholar
  50. 50.
    Dunkley DM, Ma D, Lee IA, Preacher KJ, Zuroff DC. Advancing complex explanatory conceptualizations of daily negative and positive affect: trigger and maintenance coping action patterns. J Couns Psychol. 2014;61:93–109.CrossRefGoogle Scholar
  51. 51.
    Abler L, Sikkema KJ, Watt MH, Hansen NB, Wilson PA, Kochman A. Depression and HIV serostatus disclosure to sexual partners among newly HIV-diagnosed men who have sex with men. AIDS Patient Care STDs. 2015;29:550–8.CrossRefPubMedCentralGoogle Scholar
  52. 52.
    Lam PK, Naar-King S, Wright K. Social support and disclosure as predictors of mental health in HIV-positive youth. AIDS Patient Care STDs. 2007;21:20–9.CrossRefGoogle Scholar
  53. 53.
    Comer LK, Henker B, Kemeny M, Wyatt G. Illness disclosure and mental health among women with HIV/AIDS. J. Community Appl Soc Psychol. 2000;10:449–64.CrossRefGoogle Scholar
  54. 54.
    Rodkjaer L, Chesney MA, Lomborg K, Ostergaard L, Laursen T, Sodemann M. HIV-infected individuals with high coping self-efficacy are less likely to report depressive symptoms: a cross-sectional study from Denmark. Int J Infect Dis. 2014;22:67–72.CrossRefGoogle Scholar
  55. 55.
    Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.CrossRefGoogle Scholar
  56. 56.
    Comstock GW, Helsing KJ. Symptoms of depression in two communities. Psychol Med. 1977;6:551–63.CrossRefGoogle Scholar
  57. 57.
    Carver CS. You want to measure coping but your protocol’s too long: consider the Brief COPE. Int J Behav Med. 1997;4:92.CrossRefGoogle Scholar
  58. 58.
    Amoyal NR, Mason ST, Gould NF, Corry N, Mahfouz S, Barkey A, et al. Measuring coping behavior in patients with major burn injuries: a psychometric evaluation of the BCOPE. J Burn Care Res. 2011;32:392–8.CrossRefGoogle Scholar
  59. 59.
    Yusoff N, Low WY, Yip CH. Reliability and validity of the Brief COPE Scale (English version) among women with breast cancer undergoing treatment of adjuvant chemotherapy: a Malaysian study. Med J Malays. 2010;65:41–4.Google Scholar
  60. 60.
    Ironson G, Balbin E, Stuetzle R, Fletcher MA, O’Cleirigh C, Laurenceau JP, et al. Dispositional optimism and the mechanisms by which it predicts slower disease progression in HIV: proactive behavior, avoidant coping, and depression. Int J Behav Med. 2005;12:86–97.CrossRefPubMedCentralGoogle Scholar
  61. 61.
    Corp IBM. IBM SPSS statistics. Armonk: IBM Corp; 2014.Google Scholar
  62. 62.
    Baron RM, Kenny DA. The moderator–mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51:1173–82.CrossRefGoogle Scholar
  63. 63.
    Preacher KJ, Kelley K. Effect size measures for mediation models: quantitative strategies for communicating indirect effects. Psychol Methods. 2011;16:93–115.CrossRefGoogle Scholar
  64. 64.
    MacKinnon DP, Lockwood CM, Hoffman JM, West SG, Sheets V. A comparison of methods to test mediation and other intervening variable effects. Psychol Methods. 2002;7:83–104.CrossRefPubMedCentralGoogle Scholar
  65. 65.
    Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. 1st ed. New York: Guilford Press; 2013.Google Scholar
  66. 66.
    Atkinson JH, Grant I, Kennedy CJ, Richman DD, Spector SA, McCutchan JA. Prevalence of psychiatric disorders among men infected with human immunodeficiency virus: a controlled study. Arch Gen Psychiatry. 1988;45:859–64.CrossRefGoogle Scholar
  67. 67.
    Lima VD, Geller J, Bangsberg DR, Patterson TL, Daniel M, Kerr T, et al. The effect of adherence on the association between depressive symptoms and mortality among HIV-infected individuals first initiating HAART. AIDS. 2007;21:1175–83.CrossRefGoogle Scholar
  68. 68.
    Abramowitz JS, Tolin DF, Street GP. Paradoxical effects of thought suppression: a meta-analysis of controlled studies. Clin Psychol Rev. 2001;21:683–703.CrossRefGoogle Scholar
  69. 69.
    Marcks BA, Woods DW. A comparison of thought suppression to an acceptance-based technique in the management of personal intrusive thoughts: a controlled evaluation. Behav Res Ther. 2005;43:433–45.CrossRefGoogle Scholar
  70. 70.
    Doron J, Trouillet R, Maneveau A, Neveu D, Ninot G. Coping profiles, perceived stress and health-related behaviors: a cluster analysis approach. Health Promot Int. 2015;30:88–100.CrossRefGoogle Scholar
  71. 71.
    Trew JL. Exploring the roles of approach and avoidance in depression: an integrative model. Clin Psychol Rev. 2011;31:1156–68.CrossRefGoogle Scholar
  72. 72.
    Carrico AW. Substance use and HIV disease progression in the HAART era: implications for the primary prevention of HIV. Life Sci. 2011;88:940–7.CrossRefGoogle Scholar
  73. 73.
    Chesney MA, Chambers DB, Taylor JM, Johnson LM, Folkman S. Coping effectiveness training for men living with HIV: results from a randomized clinical trial testing a group-based intervention. Psychosom Med. 2003;65:1038–46.CrossRefGoogle Scholar
  74. 74.
    Fisher JD, Fisher WA, Williams SS, Malloy TE. Empirical tests of an information-motivation-behavioral skills model of AIDS-preventive behavior with gay men and heterosexual university students. Health Psychol. 1994;13:238–50.CrossRefGoogle Scholar
  75. 75.
    Hosek SG, Lemos D, Harper GW, Telander K. Evaluating the acceptability and feasibility of Project ACCEPT: an intervention for youth newly diagnosed with HIV. AIDS Educ Prev. 2011;23:128–44.CrossRefPubMedCentralGoogle Scholar
  76. 76.
    Johnson MO, Charlebois E, Morin SF, Remien RH, Chesney MA, National Institute of Mental Health Healthy Living Project Team. Effects of a behavioral intervention on antiretroviral medication adherence among people living with HIV: the healthy living project randomized controlled study. J Acquir Immune Defic Syndr. 1999;2007(46):574–80.Google Scholar
  77. 77.
    Kalichman SC, Rompa D, Cage M, DiFonzo K, Simpson D, Austin J, et al. Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. Am J Prev Med. 2001;21:84–92.CrossRefGoogle Scholar
  78. 78.
    Rollnick S, Miller WR. What is Motivational Interviewing? Behav Cogn Psychother. 1995;23:325–34.CrossRefGoogle Scholar
  79. 79.
    Hayes SC. Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behav Ther. 2004;35:639–65.CrossRefGoogle Scholar
  80. 80.
    Cherenack EM, Wilson PA, Kreuzman AM, Price GN, The Adolescent Medicine Trials Network for HIV/AIDS Interventions. The feasibility and acceptability of using technology-based daily diaries with HIV-infected young men who have sex with men: a comparison of internet and voice modalities. AIDS Behav. 2016;20:1744–53.CrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Emily M. Cherenack
    • 1
    Email author
  • Kathleen J. Sikkema
    • 1
    • 2
  • Melissa H. Watt
    • 2
  • Nathan B. Hansen
    • 3
  • Patrick A. Wilson
    • 4
  1. 1.Department of Psychology and NeuroscienceDuke UniversityDurhamUSA
  2. 2.Duke Global Health InstituteDuke UniversityDurhamUSA
  3. 3.Department of Health Promotion and BehaviorUniversity of GeorgiaAthensUSA
  4. 4.Department of Sociomedical Sciences, Mailman School of Public HealthColumbia UniversityNew YorkUSA

Personalised recommendations