Social support is one of the backbones of HIV care as it improves clinical outcomes and adherence to antiretroviral treatment.15 Therefore, it is important for health systems to ensure strong social support in HIV care. To inform strengthening of social support to PLWHA in Uganda, we examined the determinants of social support in PLWHA at a large HIV care clinic in Kampala. We found that over 90% had moderate-strong social support. Only disclosure of HIV status was found to be significantly associated with social support in PLWHA. These results suggest that encouraging patients to continuously disclose their status to their acquaintances improves social support and consequently clinical outcomes such as reduction in viral load as it improves support from them. This may further enhance their involvement in HIV programs and decrease the burden of stigma in these patients.
These results are consistent with other literature findings. In a study conducted in Southwestern Uganda, more HIV positive women (73.9%) received support from their partners when they had disclosed their status 22. In fact, this was validated by a multicenter cohort study in central Uganda which revealed that people who had disclosed their HIV status to spouses had a 17% higher chances of being supported 23. Conversely, a systematic review study in Uganda and Kenya showed that 16.7–86% of women could not disclose their status.24 Barriers to disclosure included fear of its various negative outcomes, some of which included divorce, domestic violence, and anticipated withdrawal of financial support.25,26 Efforts to support disclosure of status when deemed safe should be encouraged. Furthermore, different partners should be engaged in the disclosure of HIV status to mitigate the insecurities associated with it. More community-based programs should also be set up to backup this.
Our study was not able to show an association between social support and age, sex, tribe, religion, education level, marital status, alcohol use, smoking, other substance abuse, duration on ART, comorbidities, depression, and stigma score and discrimination. A multicenter study in United Kingdom however indicated that the elderly were less likely to disclose their status leading to poor social support from their partners.27 Our study population was moderately younger, and this could explain why this association was not significant. In a study of PLWHA in Iran, social support was also found to be associated with sex; males were less likely to have strong social support.12 The differences observed could be due to the different social and cultural contexts in which PLWHA live in.
Both stigma and depression were not associated with social support, an unexpected finding. The prevalence of stigma (3.8%) and depression using the PHQ-2 scale (0.85%) in this study were very small. The study could have been under-powered to determine the association with social support. The lack of association between stigma score and social support is inconsistent with other research findings. Studies have showed a negative correlation between stigma score and social support in PLWHA.28,29 Incidentally, the relationship between stigma and depression tends to be bidirectional.28,30 Stigma can lead to depression and depression can lead to stigma. The settings of these two studies is also different. IDI routinely provides its patients with emotional support and community centered groups that address stigma unlike the other rural setting. Notwithstanding these results, health professionals should enhance strategies that decrease stigma most especially in rural areas.
Other research studies have demonstrated a bidirectional relationship between depression and social support.31,32,33 That is, depression could lead to low social support or low social support could lead to depression. Depressed individuals have been identified as self-isolating which consequently leads to people drawing away from them.34 Another study in Canada showed a negative association between social support and depression. Several studies have documented the success of social support on the negative symptoms of depression.35,36 Engagement in social networks has enhanced the physical and mental health of these patients. This could be used as a basis in all HIV treatment programs to improve clinical outcome.
While a study in Brazil showed that there was no association between duration on ART and social support 37, some qualitative studies have showed that more support was obtained after a long duration on ART. For example, a study in Kampala showed that the longer PLWHA had been on ART, the more likely they would get materialistic items, care, and other kinds of support.38 This is because people who had disclosed their status had already established strong and wide social networks. However, duration on ART and social support seem to have a bidirectional relationship.39,40 Social support has also been demonstrated to improve treatment outcomes in PLWHA by encouraging patients to take their medications and hence greater chance of survival.41
From our study, social-economic factors like education, religion, and marital status were not associated with and social support ostensibly due to the different cultural context compared to other studies. This finding is not consistent with the available literature. A study conducted in South Florida showed that participation in religious activities was positively correlated with social support.42 The study further went on to demonstrate that PLWHA with many stressors tend to look up to religion to loosen their burdens. This observation explains the dissimilarity observed in this study. Other studies have shown mixed associations between marital status and social support. A descriptive study in Brazil showed no association while 37 whereas another study also conducted in Brazil showed that marital status was negatively associated with social support.43
There was no association between substance abuse and social support. This is quite different from literature in which social support has been used to enhance the treatment outcomes of ART in substance abusers.44 They could be because in our study only 2.1% were substance abusers in the present study compared to the study in New York. There was also no association between presence of comorbid health conditions and social support in this study. However, it is currently increasingly known that emerging non communicable diseases due to ART need to be addressed.45 It has been documented that presence of one comorbidity increases risk for another.46 This warrants more care and there should be an integral treatment of HIV and these diseases in all HIV centres.
There were few limitations in this study. Firstly, the sample size calculation was not powered to social support which was a secondary objective of the overall study: therefore, the sample size could have been small leading to failure to detect associations between variables. Secondly, this study was carried out in a single modern setting. However, most HIV treatment in Uganda is received from government hospitals and a few aided by non-governmental organizations. These results may therefore not be generalizable to PLWHA receiving care in public health facilities which may have challenges with the quantity and quality of human resources as regards to HIV care. Lastly, our data was from a cross sectional study and thus couldn’t conclude if it’s an association or causation.