Relationship between suicidal ideation and stigma, disclosure, and perceived social support in HIV /AIDS patients

【 Abstract 】 Objective : To explore the relationship between suicidal ideation and stigma, disclosure and social support in HIV /AIDS patients. Methods : A total of 1146 HIV-infected /AIDS patients were investigated by a general situation questionnaire, Perceived Social Support Scale (PSSS), Beck Suicidal Ideation Scale (Chinese version) (BSI-CV), disclosure questionnaire and Stigma Scale (SSS-S) on a WeChat platform. Results : 54.01% (619/1146) of the sample reported having suicidal ideation in the past week or at the height of depression; The results of multivariate logistic regression analysis showed that In SS-S, the affective dimension [OR value (95%CI) was 1.63(1.17-2.26)], the cognitive dimension [OR value (95%CI) was 2.06 (1.48-2.87)], the behavioral dimension [OR value (95%CI) was 2.05 (1.53-2.76)], and the family support [OR value (95%CI) was 0.64 (0.47 ~ 0.87)], which were associated with suicidal ideation in HIV /AIDS patients; Social support mediated between AIDS-related stigma and suicidal ideation (19.80% of the total effect). Conclusion : Suicidal ideation in HIV /AIDS patients is strongly associated with stigma, awareness, and perceived social support. So, stigma, awareness, and perceived social support should be incorporated into the suicide intervention system for HIV /AIDS patients.

experience and regulation of negative emotions, Previous studies have also confirmed that negative emotions such as anxiety, depression and despair can affect suicidal ideation [12] [13] , and studies on negative emotions related to suicidal ideation in China are mostly focused on this. Are there any other negative emotions that can affect suicidal ideation? Gao Jun and others [14] suggest that stigma may prompt individuals to exhibit more adaptive behavior or behavioral tendencies, Lester [15] demonstrated that stigma is associated with suicidal behavior but is it a factor in suicidal ideation? The multi-dimensional view of emotional regulation structure [16] holds that adaptive emotional regulation is not control or exclusion, but regulation of emotional experience, including the recognition, understanding, acceptance, control of impulsive behavior and use of regulation strategies. Alexithymia is a mood disorder characterized by difficulty in identifying emotions and experiencing emotions, and difficulty in distinguishing emotional and physical sensations, People with high alexithymia have defects in cognitive processing and regulation of emotions [17] , which can affect the generation and severity of anxiety and depression [18] [19] , does alexithymia also contribute to suicidal ideation? According to social support theory, social support can buffer stress in negative events and is an important protective factor [20] .
Studies have shown that perceived social support can buffer the occurrence of suicidal ideation through the use of social support and increase personal self-esteem [21] , This study hypothesized that perceived social support is a protective factor and explored its impact on suicidal ideation.
Informing the problem, especially PLWHA to their relatives and friends of the fact that they are infected with HIV. Most people in China still see HIV/AIDS as the only consequence of homosexuality, commercial sex, illegal drugs and drug abuse [22][23] [24] . In fact, most of the HIV infections in China occur in rural areas [25] [26] .
This discrimination and stigmatization of the disease itself inevitably create a culture of discrimination.
Because of the untreatability of AIDS and the specific way of infection, PLWHA generally suffers from more severe stress than other disease groups and often suffers from a variety of social discrimination [27] [28] .
Stigmatization of the disease has also led to many PLWHAs since the diagnosis of HIV+, just like people living in cabinets, they hide their HIV infection status, seldom disclose their illness to their relatives and friends, for fear of losing their social reputation and value due to the evaluation of others [29] . Some PLWHA patients are even unwilling to receive HIV-related antiviral treatment, thus becoming an uncontrolled source of infection, which objectively promotes the spread of AIDS [30] [31] . Alexithymia is also known as effective dyslexia or affective dyslexia, It is not a separate mental illness, it can be a personality trait, it can also be some physical or mental illness with more common psychological characteristics [32] . For PLWHA, this concealment of HIV status, the inability to inform and receive social support from family and friends, is also alexithymia. Based on the above considerations, this paper aims to investigate PLWHA's sense of stigma, disclosure, and perceived social support, and to explore their relationship with suicidal ideation.

Samples
The PLWHA population is inaccessible. According to the preliminary investigation, PLWHA in the outpatient department of the Centers for Disease Control and Prevention and the Hospital for Infectious Diseases is usually used for antiviral therapy or seeking medical treatment due to poor health conditions. In this special environment, it is difficult to ensure the confidentiality of the investigation and the privacy of PLWHA, and PLWHA's cooperation degree is quite low, so it is difficult to carry out the study. Considering the development, popularity and reality of the current "we-media" platform, this study took PLWHA users on WeChat ID set up by the center for disease control and prevention in a certain city as the research objects.
As of September 1, 2018, there are 9,987 PLWHA signals in the center for Disease Control and Prevention.
In reference to the world health organization, and recommended by the Chinese center for disease control and prevention sexually transmitted infection of high-risk groups sentinel surveillance standard sample size (usually in 250 ~ 400) [33] based on sample according to the media contact convenience and HIV/AIDS is sensitive to this kind of problem investigation difficulty of objective conditions, the PLWHA minimum sample size for 1500 people. In this study, simple random sampling was used to select samples. First, one infected person was selected from the top 10 fans in the WeChat public account as a random starting point, and then the remaining sample units were selected sequentially, one person was selected every 6 people until 1,500 people were selected. The researchers got in touch with the WeChat ID and conducted a one-to-one questionnaire survey via the WeChat line.

Questionnaires
Self-compiled sociodemographic data questionnaire: including gender, age, nationality, education, marital status, whether a student, residence, occupation, average monthly income, Whether have children, whether have a partner, HIV infection route, whether there are other chronic diseases, etc.
Social Support: PLWHA's Social Support is investigated using the Perceived Social Support Scale (PSSS) [34] . PSSS consists of 12 items. Higher scores in three dimensions of family Support, friend Support and other Support indicate a higher degree of Social Support. This scale has been widely used in China with good reliability and validity [35] [36] .
Information questionnaire: the PLWHA patients inform the problems; including the following 6 items: (1) Do you mind telling others that you are a PLWHA? (2) Have you ever told anyone about your HIV infection?
(3) Who were the first people you told? (4) Who have you told yourself so far? How did they react? (5) Have you ever had a romantic partner, friend or other person tell someone that you are infected with HIV after knowing that you are infected with HIV? (6) Have you ever had a romantic partner, friend or another person who, knowing that you have HIV, threatened you to tell others about your HIV infection? Stigma: Stigma Scale (SSS-S) developed by Winnie [37] was used to investigate the Stigma of PLWHA.
All 9 items of the whole scale are open, including emotion, behavior and cognition. As follows:1. Fear that others will know they are___; 2. As___, you feel helpless; 3. You feel insecure about who you are___; 4. Don't take the initiative to meet friends in case others will know you are___; 5. You will alienate others because you are ___; 6. Avoids contact with others because you are ___; 7.Being gay stigmatizes your life; 8. Being ___ makes your daily life difficult; 9.___ A certain identity is a burden to you. The authors surveyed 175 (51% of women) mental health counselors and 110 immigrant women. The results showed that SSS-S had a very good internal consistency, with Cronbach's for mental health consultants α=0.91 and Cronbach's for immigrant women α=0.84.
Suicidal ideation: The Chinese Version of Beck Scale for Suicide Ideation-Chinese Version (BSI-CV) [38] was used to assess the individual's thoughts about life and death and the severity of suicidal Ideation in the last week or at the peak of depression. There are 19 items in total, each item has 3 options, and the higher the total score is, the higher the degree of suicidal ideation will be. The first 5 items are screening items, and the presence of suicidal ideation is determined according to items 4 and 5 (> 1 is classified as having suicidal ideation); The last 14 items assessed the level of suicidal ideation and suicide risk.

Quality control
All PLWHA samples were investigated by investigators for WeChat one-to-one online interviews and each online survey was conducted in a quiet, undisturbed environment. Every questionnaire must be verified on-site and the items that were not answered in time or clearly by the respondent were questioned and confirmed based on ensuring compliance with ethical principles.

Statistical Methods
In this study, SPSS21.0 was used for statistical analysis of data. Sociodemographic data of the group with and without suicidal ideation were compared by the Chi-square test, and PLWHA scale scores were compared by Student's t test. to explore the relationship between PLWHA suicidal ideation and stigma, disclosure and appreciate social support, logistic regression analysis was conducted with the presence of suicidal ideation as a binary variable. The results of the χ2 test showed that there was a statistically significant difference in suicidal ideation between whether they were school students, their original household registration, and whether they told their friends the truth that they were infected with HIV+ (Table 1). As shown in Table 2, among the 9 items on the stigma scale, scores of 1146 PLWHA from high to low are: "1. Fear that others will know that you are PLWHA (4.36±0.97)"; "2. Being PLWHA , I feel helpless    Total points 52. 27 14.96 As shown in Table 4, the total score of social support is between 12 and 84.  The total scores of stigma and the cognitive and behavioral dimensions of the group with suicidal ideation were higher than those of the group without suicidal ideation, while the emotional dimension scores were lower than those of the group without suicidal ideation; the total PSSS score and scores of all dimensions of the group without suicidal ideation were higher than the group with suicidal ideation (Table 5).

2.7
The relationship between suicidal ideation and stigma, disclosure, and perceived social support  Table 6 lists the testing process of the mediating role of disclosure and social support between stigma and suicidal ideation. In the first, second, third, and fourth steps, after controlling other variables, stigma can significantly predict suicidal ideation and disclosure and social support; disclosure can also significantly predict social support. After controlling the influence of other variables, social support, and disclosure on suicidal ideation, the predictive effect of stigma on suicidal ideation decreased (regression coefficient was 1.67 before the introduction of the intermediary variable and 1.62 after introduction), but it could still significantly predict suicide ideation. The five-step tests are all significant, and it can be inferred that social support has a mediating effect on stigma and suicidal ideation, which is a partial mediation. It shows that the stigma of PLWHA can directly affect their suicidal ideation, and it can also indirectly affect suicidal ideation through the increase of social support. The ratio of the mediation effect to the total effect is -0.58×(-0.57)/1.67=19.80%.

Discussion
In comparison, the detection rate of suicidal ideation among Chinese college students is 5.5%~ 22.7% [39] , the rate of suicidal ideation among adolescents aged 11~16 years old is 17.4% [40] , and the reported rate of suicidal ideation among mainland medical students is 12.9% [41] .In the past five years, the elderly with suicidal ideation accounted for 4.78% of the national elderly population [42] .In this study, 54.01% (619/1146) of the samples reported that they had suicidal ideation in the past week or the most severe depression, which was much higher than other groups and worthy of attention.
The results of this study showed that PLWHA with suicidal ideation were more likely to experience stigma, less likely to tell friends, relatives or others, and less likely to perceive social support.The interpersonal relationship theory of suicide [10] has three core parts: the trauma of belonging, the sense of burdening and the acquisition of suicidal ability.Individuals with low social support, such as family and friends, have a relatively weak sense of belonging.According to Tangney and Dearing, stigma is a kind of self-conscious emotion related to the sense of incompetence and inferiority. People with stigma often experience feelings of depression, negativity, withdrawal, smallness, worthlessness and powerlessness [43] .In such a state, individuals tend to have a sense of burden.When individuals are in negative emotions but cannot recognize, describe or regulate these emotions, they are prone to psychosomatic diseases, depression and anxiety disorders, etc. [44] .All of these factors may trigger suicidal ideation.According to the results of multivariate logistic regression analysis, PLWHA with high stigma experience of their behavior habits and low perceived family support were more likely to have suicidal ideation：On the one hand, individuals who have high stigma experience are easily sharpened self-criticism and depression [14] , they also are prone to social anxiety [45] , which makes them have smaller opportunities to seek friends, relatives and so on social support, family support for them is very important at this time if they feel the family cannot provide support for them, their negative emotional experience and self-stigma may increase, may be more likely to have suicidal thoughts.On the other hand, families provide little support, and individuals feel alienated in the family, which may enhance their experience of stigma, which further leads to the difficulty for families to have close feelings with them and provide practical and psychological support.The relationship between social support and stigma can be further studied.
Further mediating effect analysis showed that social support played a partial mediating role between stigma and suicidal ideation, that is, higher stigma directly affected PLWHA's suicidal ideation on the one hand, and indirectly affected suicide ideation through increased social support on the other hand.This suggests that reducing suicidal ideation in PLWHA requires, on the one hand, we need to use a variety of measures to reduce stigma.For example, the spread of AIDS-related knowledge and the reduction of social discrimination and exclusion against people living with AIDS; on the other hand, attention should be paid to the level of social support of AIDS patients to reduce PLWHA suicidal ideation by improving the level of social support.Previous studies have shown that providing emotional support, material help and other forms of social support can alleviate individual stress [46] .PLWHA often finds it difficult to get social support directly from relatives and friends.At this time, medical staff provide psychological support and care for AIDS patients playing a very important role.Therefore, the advantage of easy access to patients by health service personnel (especially AIDS prevention and treatment personnel) can be exploited to provide them with adequate and sustainable psychological care and support as much as possible while providing them with medical care to help patients better cope with AIDS-related stress and maintain a good state of the quality of life.
At present, in the worldwide survey on suicidal ideation of AIDS patients, the population with suicidal ideation shows an increasing trend and a younger trend [47] [48] .Perceived family and social support are protective factors for suicidal ideation [49] .In this study, gay people with AIDS were more concerned because they were under more psychological stress than others.Therefore, the elimination of social discrimination, active mobilization of social and family support and establishment of social support models will be very effective ways to help the PLWHA reduce the pressure and psychological burden from all aspects.

Deficiencies of this study and future research directions
This study also has certain limitations; (1) we only investigated the PLWHA of a certain CDC WeChat account. Among the 1146 valid samples, men who had sex with men accounted for 86.6% (992/1146). We believe this is related to the higher education level of men who have sex with men [50] and the daily interaction of friends who rely more on Blued, WeChat, Weibo and other new media. The situation of men who have sex with men is also unique. Our results cannot be generalized to the entire PLWHA group because of sample bias. In the future, we can sample the PLWHA population nationwide. (2)Due to the difficulty of the actual survey in the PLWHA special population, for the 220 (14.67%) survey subjects who did not cooperate with the investigation, we did not record their basic information such as age, gender and infection route.
Therefore, we cannot give a specific explanation as to whether there is a difference between the situation of the persons who do not cooperate with the investigation and the persons who cooperate, and whether it will affect the results of this research.(3) In addition, we investigated the WeChat connection. There are still some differences between WeChat's connection and a face-to-face survey. For example, during the WeChat online survey, it was difficult for us to comprehend the environment of the survey; other details such as the participants' body language were also difficult to observe. (4)Finally, this survey is only a cross-sectional survey; the respondents' recall bias or reporting bias on some issues is still out of control. For example, some PLWHA cannot recall the previous situation well. In the case of sensitive problems, some respondents may be unwilling to give correct answers and cause reporting bias. Research can only provide clues for the generation of suicidal ideation as a purpose for the current situation investigation, but cannot form causal inference. (5) Suicidal ideation and suicide are different concepts. The research on suicidal ideation cannot completely guide the work of suicide crisis intervention.In future studies, case-control studies and psychoanatomical methods can be used to further explore the relationship between suicide and stigma, disclosure, and social support in PLWHA patients with suicidal behaviors and suicidal deaths.

Declarations Ethics approval and consent to participate
The study protocol was approved by the Guangxi Normal University Board of Ethics (0108-2018), Ethics Committee of Shizhong District CDC of Jinan(2018-007),Guangxi Nanxishan Hospital' Ethics Committee (2019079). Administrative clearance was obtained from the District Health Officer of Shandong CDC.
Verbal informed consent was obtained in this study using a standardized form, which included counseling on the risks, benefits and anonymities. Informed consent was obtained from all the samples. Consent was documented on a standardized form that was included in samples' paper study record. Obtaining verbal informed consent was approved by the institutional review boards and ethics committees that reviewed this study.

Consent to publish
Not applicable.

Availability of date and materials
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.