INTRODUCTION:

Since its emergence in the 1980s, HIV has been an enigma across the medical community and it is considered as one of the most complicated and bewildering social challenges faced by contemporary societies. (Cahill &Valadez, 2013). India has the third largest HIV epidemic in the world.

In 2017, HIV prevalence among adults (aged 15-49) was estimated 0.2% (UNAIDS 2017). Overall this highly heterogenic population is slowing down and concentrated among key affected population. However the vulnerabilities that drive the epidemic vary due to its strong ties with gender inequalities and societal stigmatized behavior. Disclosure of HIV has several important connotations in India, specifically in the context of gender based disparity which adversely affect the psychosocial correlates such as quality of life, well being, ways of coping, mental health, rumination and self-esteem etc. in people living with HIV+(PLWH).

HIV has somatic, behavioral and psychological consequences (Kowal et al., 2013) that differ in males and females due to its strong association with gender based disparity and negative social reactions in the form of socio-cultural stigma and prejudice. Social response towards PLWH is accompanied with denial, stigma and discrimination which is relatively seen more in women (Brown et al., 2003; Hollen, 2010; Vlassoff et al., 2012). This is reflected explicitly in the social disclosure of unfair treatment towards women as a result of pre conceived notion or belief associated with this epidemic. (Mahajan et al., 2008). This affects mental health symptoms (Brown et al., 2003), decreased rate of attending medical appointments (Nyamathi et al., 2013; Moskowitz et al., 2009) and quality of life (Steward et al., 2009; Thomas et al., 2007; Nyamathi et al., 2013). Further it reduces the likelihood of attending medical appointments and a lack of adequate intervention and medical adherence like Anti retroviral therapy (Rintamaki et al., 2006). Earlier researches and studies suggest that HIV increases the risk for depression. In case of women it becomes even more relevant in a country like India where gender plays very significant role in shaping the social construct. Therefore women are facing overt discrimination and social rejection (Van Hollen, 2010; Vlassoff et al., 2012). In addition to stigma, it is seen in PLWH to delineate lack of social support that they face in terms of social isolation or exclusion. (Sivaram et al., 2009). Inadequate fulfillment of need for social affiliation and support results in low level of self esteem, poor mental and physical health outcomes (Moskowitz et al., 2009) such as negative affects (Simoni et al., 2006), stress, emotion focused coping (Weaver et al., 2005). This further reduces the subjective well being and quality of life in persons living with HIV and AIDS (Gielen et al., 2001; Serovich et al., 2001).

Exposure of HIV/AIDS deals with significant physical and psychological consequences which are reflected in terms of psychosocial correlates such poor mental health, depression, rumination, fear, anxiety, shame, alienation, social exclusion and isolation etc. (Logie C, James L, Tharao W, Loutfy M 2013). It drives them to exclude themselves and circumvent the proactive behaviors that might improve their quality of life and well-being (Chaudoir SR, Fisher JD, Simoni, 2011). To counteract this, effective coping mechanisms to deal with the disease, and the stigma associated with it, are essential. Individuals differ in their coping mechanism in dealing with the disease. Ways of coping is defined as a cognitive and behavioral effort an individual makes to alter or manage the stressful situation. It includes active coping like direct confrontation, avoidant coping such as ignoring and denial, and support coping i.e. seeking help from others in addressing the problem. Previous studies suggested that problem-focused active coping was strongly associated with the patients' improved quality of life (QOL) and maladaptive coping mechanism like avoidance and denial reduces the same. Further it adversely affects the compliance to ART and other remedial resources or intervention (Rao D, Desmond M, Andrasik M, et al.,2012). The individuals facing stigmatized attributes and unfair treatment of this epidemic perceive potential social disqualification, through the mechanisms of negative gender stereotypes, devalued cultural images, stigma, discrimination and social rejection.

In India, the connotations regarding HIV /AIDS is composed of the notion that the disease afflicts those already marginalized by societies and considered as being “perverted” and “sinful”. Whether perceived or enacted, HIV-related schemas like discrimination, stereotypes and stigma is prevalent in India. Researches in this field signify that such schemas along with depressive symptoms, anxiety, and substance abuse results in to barriers to medication and treatment for people living with HIV/AIDS(PLHA). Poor medical adherence and denial to antiretroviral therapy have contributed to increased morbidity, mortality, and accentuated disease transmission. When public stigmas are internalized, PLHA suffer from depression, anxiety, and poor quality of life (Corrigan PW, Rao D.,2012). It has been observed that ways of coping differ as per the intensity and severity of the disease in people suffering with HIV/AIDS. Coping styles can be adaptive or maladaptive in nature and it differs in males and females. Gender differences in coping strategies are the ways in which men and women differ in managing psychological stress. Available evidences suggest that males often develop stress caused by their occupational and career induced adverse circumstances whereas females often encounters stress because of interpersonal relationships.

HIV/AIDS has gained prominence in India as a growing public health issue. There is a complex but significant interaction between mental health and HIV/AIDS. Mental health is defined as a state of psychological maturity encompasses a relatively persistent and abiding disposition of personality. More than the absence of mental disease symptoms, it is a condition of personal and social functioning with a maximum of effectiveness and satisfaction. Mental health involves positive feelings and attitude toward oneself and others as well. It is described as our social, emotional and psychological states, all wrapped up into one. Having diagnosed and living with a serious illness like HIV is likely to have a big emotional impact on the mental health of people living with this incurable and often fatal disease. In addition to unequal treatment among HIV+ men and women it is not uncommon for HIV-infected women to face the psychosomatic consequences of negative mental health more than their counterpart. One of the study conducted on HIV+ women in India explained that women faced a decline in social support after diagnosed with the virus, and experienced poor mental health symptoms like rumination and a lack of hope for the future (Majumdar, 2004). Women living with HIV are also at increased risk of interpersonal violence, including intimate partner abuse (IPA) as compared to men (Campbell et al., 2008; Fonk et al., 2005; Gielen et al., 2001).

Being a chronic and life-threatening disease, AIDS/HIV is stressful to manage. People suffering from these diseases find themselves incapable to regulate their emotions and face medical, psychological, and socio-economic issues specific to the illness. All these factors may often lead to various psychiatric conditions such as anxiety, depression, rumination etc in people living with this virus. Rumination is the experience of despair or extreme pessimism about the future, and as such, is part of the “cognitive triad” and is dysfunctional and damaging. It has adverse impact on immune system along with a decrease in medications compliance in PLWH and is thought to contribute to self- neglect, apathy, and forgetfulness in patients with HIV. Rumination has been widely studied as a cognitive vulnerability factor to depression, unsupportive social interactions, medication, and HIV- sub-cortical damage. The impact of HIV and AIDS reaches far beyond the health sector with severe economic and social consequences and it has been found that it is much more severe on women than men. Women and girls seem to bear disproportionate brunt of the epidemic psychologically, socially and economically. Although, some researches have been conducted in this fields, but there is a need to study and research further on the gender difference between HIV+ males and females and their psychosocial adjustment, which is limited in India. Therefore, in the present study attempts to assess the gender difference in HIV+ males and females on their mental health, self-esteem and rumination.

The aim of the present study is to assess the gender difference between HIV+ males and females on their ways of coping, mental health and rumination. It was hypothesized that ways of coping, mental health and rumination would differ in HIV+ males and females.

MATERIAL AND METHODS:

Participants: To carry out the research, the purposive sampling was employed on 100 HIV+ patients including 50 males and 50 females.

Instruments:

Ways of coping was measured by the questionnaire prepared by Folkman and Lazarus(1989),which is a four point scale. It measures eight types of coping styles i.e. confrontive coping, distancing, self-controlling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving and positive reappraisal. There were 60 items in the questionnaire. Mental health was measured by mental health inventory (MHI) by Dr. Jagdish and Dr. A.K. Srivastav (1989) which has six dimensions. Operational definition of mental health for the present purpose is defined a person’s ability to make positive self-evaluation, to perceive the reality, to integrate the personality, to have the autonomy and group oriented attitudes and environmental mastery. Rumination was measured by “Rumination: Dealing with emotions” questionnaire developed by Surbhi Purohit and Udai Pareek (2000) in terms of rumination and flow, consisting of seven items.

Procedure:

To carry out the research, purposive sampling was employed on 100HIV+ patients, including 50 males and 50 females. Sample was taken from the registered NGOs and medical setup i.e. Rajasthan state AIDS control society (RSACS) of different cities in Rajasthan as follow: Anti Retro Viral Therapy (ART) Centre, Government Hospital Alwar, Anti Retro Viral Therapy (ART) Centre, Government Hospital Bharatpur, Rajasthan Mahila Kalyan Mandal, Ajmer, ANP+ (Alwar Network For People Living With HIV+) NGO in Alwar, Saksham Mahila Samiti, an NGO in Alwar. The age range of subject was 17 years to 50 years. The mean age of the same was 34 years. The study was approved by the research committee of the university. Statistical Analysis: Mean, S.D. and t-ratio were computed.

RESULTS AND DISCUSSION:

Table 1: Gender difference between HIV+ Male and Female on the dimensions of Ways of coping

Dimensions	Groups (N)	Mean	SD	t-value
Confronting coping	Male (50)	14.54	1.27	2.64*
Confronting coping	Female (50)	13.86	1.31	2.64*
Distance coping	Male (50)	16.04	1.41	7.88**
Distance coping	Female (50)	14.06	1.08	7.88**
Self coping	Male (50)	16.36	1.40	6.33**
Self coping	Female (50)	14.66	1.29	6.33**
Seeking social support	Male (50)	15.70	1.15	5.65**
Seeking social support	Female (50)	14.36	1.22	5.65**
Accepting responsibility	Male (50)	8.88	1.14	1.69
Accepting responsibility	Female (50)	8.50	1.11	1.69
Escape/ avoidance	Male (50)	16.34	1.33	7.35**
Escape/ avoidance	Female (50)	18.68	1.81	7.35**
Planful problem solving	Male (50)	15.32	1.10	5.80**
Planful problem solving	Female (50)	14.06	1.08	5.80**
Positive reappraisal	Male (50)	17.86	1.37	8.07**
Positive reappraisal	Female (50)	15.78	1.20	8.07**

** Significant at p<0.01

* Significant at p<0.05

The aim of the study is to assess the gender difference between HIV+ males and females on their ways of coping, mental health and rumination.

Table 2: Gender difference between HIV+ Male and Female on the dimensions of Mental Health Inventory

Dimensions	Groups (N)	Mean	SD	t-value
Positive Self Evaluation	Male (50)	25.04	1.98	4.96**
Positive Self Evaluation	Female (50)	22.86	2.40	4.96**
Perception of Reality	Male (50)	24.94	1.71	4.69**
Perception of Reality	Female (50)	22.92	2.52	4.69**
Integrated Personality	Male (50)	28.78	1.93	6.73**
Integrated Personality	Female (50)	26.02	2.16	6.73**
Autonomy	Male (50)	24.88	1.97	5.95**
Autonomy	Female (50)	22.42	2.17	5.95**
Group Oriented Attitude	Male (50)	31.44	1.83	7.47**
Group Oriented Attitude	Female (50)	28.12	2.55	7.47**
Environmental Mastery	Male (50)	31.70	1.83	6.30**
Environmental Mastery	Female (50)	28.78	2.72	6.30**
Overall Scores	Male (50)	27.83	1.60	7.62**
Overall Scores	Female (50)	25.16	1.89	7.62**

** Significant at p<0.01

Table 3: Gender difference between HIV+ Male and Female on the dimensions of Rumination

Dimensions	Group (N)	Mean	SD	t- value
Rumination	Male (50)	51.90	1.45	18.55**
Rumination	Female (50)	57.84	1.74	18.55**
Flow	Male (50)	54.58	2.35	3.43**
Flow	Female (50)	52.82	2.76	3.43**

** Significant at p<0.01

Table-1 is showing the gender difference between HIV+ Male and Female on the dimensions of ways of coping. Significant gender difference was found on the dimensions of ways of coping such as confrontive coping (t= 2.64, p.01 level), Distancing coping (t=7.88, p.01 level), self-coping (t=6.33, p.01 level), Seeking social support (t=5.65, p.01 level), Escape/avoidance (t=7.35, p.01 level), Planful problem solving (t=5.80. p.01 level) Positive reappraisal (t=8.07, p.01level). Only one dimension i.e. Accepting responsibility(t=1.69) was found to be used as a common adopted coping styles irrespective of gender. Males tend to have problem focused coping or proactive coping whereas females tend to have emotion focused or combative coping due to differences in behavioral disclosure and reaction towards stressful situation.

Table-2 is showing the gender difference between HIV+ Male and Female on the dimensions of mental health inventory. Significant gender difference was found on the dimensions of mental health such as Positive self-Evaluation (t= 4.96, p.01 level), Perception of Reality (t=4.69, p.01 level), Integration of Personality (t=6.73, p.01 level), Autonomy (t=5.95, p.01 level), Group Oriented Attitudes (t=7.47, p.01 level), Environmental mastery (t=6.30, p.01level). Males tend to have positive mental health whereas females tend to have negative mental health as a consequence of gender inequality and stigmatized social reaction associated with HIV.

Scores depicted in Table 3 show the gender difference between HIV+ Male and Female on the dimensions of Rumination in terms of rumination itself and flow. As regard to rumination (t=18.55, p.01 level), the significant gender difference was found in males and females. Females tend to be inclined more toward rumination as compare to males who scored higher (t=3.43, p.01 level) on flow (a dimension of rumination which is opposite in nature) than females.

DISCUSSION:

Despite the promising developments in medical science in recent years, the global HIV/AIDS epidemic continues to grow. The triumph of Anti-retroviral Therapy (ART) and other initiatives those were taken to fight against this endemic have noticeably lessen the AIDS-related mortality and have increased the life expectancy in the victims. Yet HIV/AIDS pandemic continues to exist as a grave issue for individuals, communities, and even nations, especially in developing countries. This disease is not confined to any one class, community, religion, age, gender, group or profession. At the outset of the epidemic in the 1980s, it was contemplated to consider women scarcely at risk from HIV/AIDS but now this schema has changed globally and witnessed a drastic alteration in the pattern and number of women getting detected HIV+. This “feminization” of the epidemic most apparent in developing countries like India. Considering this, it is perhaps not surprising that women living with HIV are at increased risk for poor mental health outcomes. Therefore in the present study a comparison was made between HIV+ males and females on their ways of coping, mental health and rumination.

The relationship between gender disparity and vulnerability has spread rapidly and is fuelling the prejudice and discrimination towards women with HIV+. It is responsible for the disproportionate impact of this epidemic on women up to a great extent. In India, lower sex ratio is the result of a strong son preference and the widespread sex selective abortion that is prevalent in the country. There is a large gender gap in literacy and employment as well. This social construction of gender disparities affects the perception of the stressful situation in women living with this virus that drives the poor coping mechanism. As an outcome women exhibit different coping behavior which was also found relevant in the present study. Coping strategies the way people deal with stressful situation are intended to moderate or buffer the effect of stress on physical and emotional well being. Coping is a dynamic process not a one-time reaction. It is a series of response involving the reaction of a person and his/her environment. Some coping styles provide temporary relief in the short run, but tend to be maladaptive in long run. Coping strategies are classified as either emotion focused or problem focused. In emotion focused coping people use behavioral and cognitive strategies to manage their emotional reaction to stress. In problem focused coping, people directly deal with stressful situation either by reducing its demand or increasing their capacity to deal with stressors as they believe in their resources and notion that situations never remain alike. Individuals differ in their coping styles especially in a society like India gender plays a significant role in selecting and adopting the coping mechanism and it becomes even more imperative in case of PLWH. It was also seen in the findings of this study. Sample of the present investigation was taken from the various parts in Rajasthan state which has been consistently performing poor as far as gender gap is considered in terms of sex ratio and literacy rate. The notion that gender is a socio-cultural manifestation of sex becomes even more relevant in a state like Rajasthan which was seen in the present investigation. Results depict that men and women differ in their cognitive and behavioral disclosure towards the stressful situation. Men are more inclined toward the proactive approach like anticipating or detecting potential stressor and act in advance, regulating the feelings, seeking social support and acknowledging one’s own role in problem with a concomitant theme of trying to put things right with an analytical and rational approach. Therefore men were found be associated more than women on confronting coping, distancing, self coping, planned problem solving and positive reappraisal. Distancing coping means psychological detachment towards stressful situation which was seen more in males in this study. On the other side women were found to be more associated towards emotion focused coping such as denial, escaping or avoidance due to their vulnerable and submissive tendency. Women are less likely to seek social support due to the social exclusion and family detachment. It minimizes their ability to count their resources and also affect the positive reappraisal of adversity. This was also found true in the present investigation.

Mental health is described as adjustment of human being in the world and to each other with maximum effectiveness and happiness. It is the ability to maintain as even temper, an alert intelligence, socially considerate behavior and happy dispositions. Negative mental health is concerned with disorders, symptoms and problems. Mental ill health encompasses a continuum extending from the most severe mental disorders to a range of symptoms of different intensity and duration that result in a variety of consequence. Mental ill health is experienced as part of everyday problems those are correlates of personal distress such as anxiety, depression, alienation, cognitive problems, irritability, and anger etc. Being diagnosed and living with a serious illness like HIV is likely to have a big emotional impact, and people with HIV, as a group, have higher rates of mental health problems than those seen in the general population (Stockman et al., 2013; UNAIDS, 2013).

In the present study mean scores obtained by males were significantly higher than females on different dimensions of mental health namely positive self- evaluation, perception of reality, integrated personality, autonomy, group oriented attitude and environmental mastery which is an indication of positive mental health. This means men were associated with relatively positive mental health whereas woman found to be less associated with the same and more to the poor mental health. Males and females differ in their physical, psychological as well as mental health. Gender is an important biological determinant of vulnerability to psychosocial stress which results in poor mental health. It negatively affects the self-evaluation in women and they feel socially alienated and more vulnerable. It results in low level of autonomy, group orientation and poor environmental appraisal where females scored significantly lower than males as on dimensions of mental health. Earlier researches supported the present findings. Findings suggest that gender based inequality drives the stigmatized social reaction among PLWH which is more common in women as compared to men. A qualitative study conducted in India by Hunter et al., 2015 postulated that once the status of HIV is disclosed women suffering with HIV face rejection by family as well as their broader social networks.

Considerable evidence from various regions of the world indicates HIV/AIDS-related stigma and gender driven discrimination as a barrier in HIV prevention and mitigation (Mahajan, Sayles, Patel, Remien, Sawires, Ortiz et al., 2008). The National AIDS Control Program of India also recognizes AIDS stigma as a significant barrier to HIV prevention efforts. Accordingly, addressing stigma and gender discrimination is a key guiding principle in the current phase of India’s national programmes to prevent and control HIV (NationalAIDS Control Organization-NACO 2016).

Another notable finding of the study was that women scored significantly higher than men on rumination whereas men scored significantly higher on flow. Rumination is the experience of despair or extreme pessimism about the future. In contrast to rumination flow stands for deep involvement in positive activity and thought, the joy one gets in recollection of good and positive experiences, or activates demanding high involvement. Mean scores show that rumination is higher in females than males which means women are relatively more vulnerable towards the exposure to HIV and it is due to personal factors as well as stereotyped social disclosure. On the other hand males scored higher in flow dimension that shows their ability to handle the stressful situation in optimistic manner, whereas females scored lower in flow because of their fear, depressive and helplessness tendency. Men have a tendency to act rather than reflect, but women are likely to ponder their depression, mulling it over and over which magnify rumination. Women are more susceptible to ruminate when they are depressed, whereas men are inclined to distract themselves. This difference in disposition explains the higher rates of depression in women as compared to men.

Findings of earlier studies also supported the results. The psychosocial factors associated with gender difference influence the emotional expressions in an individual regarding the exposure to this disease. (Dickson and Ciesla., 2009). Researchers have confirmed the greater likelihood of rumination in women if they are already facing the depression. Eduardo et al., (2007) reported that HIV-infected women who also suffer from depression experience more complications and have lower survival rates than other HIV- infected women. In a study it was observed that depression and rumination are common outcome of living with a life-threatening illness (Collins et al., 2006; Prince et al., 2007).

From the discussion it is concluded that hypothesis is accepted. Findings of the study reveal that HIV+ males and females differ on psychosocial variables such as ways of coping, mental health and rumination. The present study reiterates the general perception that women are discriminately affected by HIV and AIDS. It is clear from the study that besides the medical enigma there is strong gender bias in HIV and AIDS related stigmatization, discrimination and denial in our socio-cultural set-up that results in relatively emotion focused coping, poor mental health and rumination in women as compared to men.

Historically and even in contemporary times gender inequality and discrimination cuts among all sections, strata and spheres of society, it is indispensable to see that women who are disproportionately affected by HIV/AIDS get equal opportunity to access medical adherence and social acceptance in combating with this deadly epidemic similar to their counterpart. As rightly emphasized by the NACO and UNAIDS Inter-Agency Task Team on Gender and HIV and AIDS, equality and nondiscrimination should not only be the cardinal principles of human rights law, but are also imperative for HIV and AIDS prevention and for securing equitable access to care, treatment and support for those affected by the infection. It is very important that quality of life and well being of PLWH be improved.

Thus the findings of the present study provide useful insight that gender plays a very significant role in psychological factors among HIV+ subjects. The present research has given a baseline towards the gender difference associated with ways of coping, mental health, and rumination among PLWH. Hence, it will help in understanding the gender specific implementation of psychological intervention. This will facilitate the desired and effective outcomes of such intervention or counselling among HIV+ patients.

REFERENCES:

1. Aldao, A. N.-H. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30 (2), 217–237.

2. Angelino, A. F. (2002). Depression and adjustment disorder in patients with HIV disease. Top HIV Med, 10(5):31–35.

3. B, M. (2004). An exploration of socioeconomic, spiritual, and family support among HIV-positive women in India. J. Assoc. Nurses AIDS Care, 15 (3):37-46.

4. Baker, R. H. (2004). Emotional processing and panic. Behaviour Research and Therapy, 42 (11), 1271–1287.

5. Berking, M. O. (2008). Prospective effects of emotion regulation on emotional adjustment. Journal of Counseling Psychology, 55 (4), 485–494.

6. Brown L, M. K. (2003). Interventions to reduce HIV/AIDS stigma: what have we learned? AIDS Educ. Prev., 15(1): 49-69.

7. C, V. H. (2010). HIV/AIDS and the Gendering of Stigma in South India. Cult. Med. Psychiatr, 34, 633-657.

8. Cahill, S. V. (2013). Growing older with HIV/AIDS New public health challenges. American Journal of Public Health, dol:10.2105/AJPH:2012.301161.

9. Campbell JC, B. M. (2008). The intersection of intimate partner violence against women and HIV/AIDS: a review. Int. J. Inj. Contr. Saf. Promot., 15(4):221-231.

10. Charles B, J. L. (2011). Association between stigma, depression and quality of life of people living with HIV/AIDS (PLHA) in South India-A community based cross sectional study. Health Qual. Life Outco.

11. Chaudoir SR, F. J. (2011). Understanding HIV disclosure: A review and application of the Disclosure Processes Model. Soc Sci Med [PubMed], 72, 1618–1629.

12. Collins PY, H. A. (2006). What is the relevance of mental health to HIV/AIDS care and treatment programs in developing countries? A systematic review. AIDS, 20(12):1571-1582.

13. Cooperman NM, S. J. (2005). Suicidal ideation and attempted suicide among women living with HIV/AIDS. J. Behav. Med., 28(2):149-156.

14. Corrigan PW, R. D. (2012). On the self-stigma of mental illness: Stages, disclosure, and strategies for change. Can J Psychiatry [PubMed], 57, 464–469.

15. Das S, L. G. (2011). Mental health needs of people living with HIV/AIDS in India: A literature review. AIDS Care., 23(4):417-425.

16. Decker MR, S. G. (2009). Intimate partner violence functions as both a risk marker and risk factor for women’s HIV infection: Findings from Indian husband-wife. . J. Acquir. Immune Defic. Syndr., 51(5).

17. Dickerson SS, G. T. (2004). When the social self is threatened: Shame, physiology, and health. J. Pers., 7(26):1191-1216.

18. Dickson, K., Ciesla, J. A., and Reilly, L. C. (2011). Rumination, worry, cognitive avoidance, and behavioural avoidance: Examination of temporal effects. Behavior Therapy, 937–959.

19. Druley, J. A. (1998). arthritis, Self-esteem as a mediator between spousal support and depressive symptoms: A comparison of health individuals and individuals coping with. Health Psychology, 17, 255-261.

20. Fonk K, E. L.-A. (2005). Increased risk of HIV in women experiencing physical partner violence in Nairobi, Kenya. AIDS Behav., 9(3):335-340. .

21. Gielen AC, M. K. (2001). Quality of life among women living with HIV: the importance violence, social support, and self care behaviors. Soc. Sci. Med, 52(2):315-322.

22. Gonzalez JS, S. N.-B. (2004). Social support, positive states of mind, and HIV treatment adherence in men and women living with HIV/AIDs.. Health Psychology, 23(4):413 - 418.

23. Halli SS, K. C. (2017). Family and community level stigma and discrimination among women living with HIV/AIDS in a high HIV prevalence district of India. J HIV AIDS Soc Serv, 16:4-19.

24. Halli SS, K. C. (2017). Family and community level stigma and discrimination among women living with HIV/AIDS in a high HIV prevalence district of India. J HIV AIDS Soc Serv, 16:4-19. .

25. Hunter M, G. R.-M. (2015). They will not even give me a cup of water”: Stress and coping among women living with HIV in Southern India. Int. J. Psychol. Couns., 7(2):40-46.

26. Kalichman SC, S. L. (2003). HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa. Sex. Transm. Infect. 79(6):442-447.

27. Komiti, A.,. (2003). Depression in people living with HIV/AIDS attending primary care and outpatient clinics. Aust N Z J Psychiatry, 37:70–77.

28. Kowal, J. O. (2008, Sep.). The Role of Psychological and Behavioral Variables in Quality of Life and the Experience of Bodily Pain among Persons Living with HIV. Journal of Pain and Symptom Management, 36, 247-258.

29. Kumar S, M. R. (2015). Positive coping strategies and HIV-related stigma in South India. AIDS Patient Care STDS, 29, 157-63.

30. Logie C, G. T. (2009). Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care, 21, 742-53.

31. Mahajan AP, S. J. (2008). Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS, 22(2):S67.

32. Nyamathi A, E. M.-G. (2013). Correlates of stigma among rural Indian women living with HIV/AIDS. AIDS Behav, 17, 329–339.

33. Pedersen, C. W. (2011). The impact of rumination on aggressivethoughts, feelings, arousal, and behaviour. British Journal of SocialPsychology, 50 (2), 281–301.

34. Rao D, D. M. (2012). Feasibility, acceptability, and preliminary efficacy of the ‘Unity Workshop’: An internalized stigma reduction intervention for African-American women lving with HIV. AIDS Patient Care STDs [Pub Med], 26, 614-620.

35. Rintamaki LS, D. T. (2006). Social stigma concerns and HIV medication adherence. AIDS Patient CARE and STDs, 20(5), 359-369.

36. Vlassoff C, W. M. (2012). HIV-related Stigma in Rural and Tribal Communities of Maharashtra, India. J. Health. Popul. Nutr., 30 (4), 394.

37. Weaver KE, L. M. (2005). A stress and coping model of medication adherence and viral load in HIV-positive men and women on highly active antiretroviral therapy (HAART). Health Psychol, 24(4), 38.

Received on 10.02.2019 Modified on 05.03.2019

Res. J. Humanities and Social Sciences. 2019; 10(2):609-615.

DOI: 10.5958/2321-5828.2019.00099.8