Immediate reactions of newly-diagnosed HIV-positive persons to the initial news of being HIV-positive: Implications for public health

Background: Ready acceptance of the rst news of HIV-positive diagnosis is a known personal and public health safety-net. Its benecial effects include prompt commencement and sustenance of HIV-positive treatment and care, better management of transmission risk, and disclosure of the HIV-positive status to signicant others. Yet, no known study has explored this topic in Ghana; despite Ghana’s generalised HIV/AIDS infection rate. Existing studies have illuminated the effects of such reactions on affected signicant others; not the infected. Methods: This paper studied qualitatively the initial reactions of 26 persons living with HIV/AIDS upon receiving the initial news of their diagnosis. Sample selection was combined purposive and random, from two hospitals in a district in Ghana heavily affected by HIV/AIDS. The paper applied the theory of hopelessness. Results: As expected, the vast majority of respondents reacted to the initial announcement of their HIV-positive infection with a myriad of negative psychosocial reactions, including thoughts of committing suicide. Yet, few of them received the news with resignation. For the vast majority of respondents, having comorbidities from AIDS prior to the diagnosis primarily shaped their initial reactions to their diagnosis. The respondents’ transitioning to self-acceptance of their HIV-positive status was mostly facilitated by receiving counselling from healthcare workers. Conclusions: Although the rst news of an HIV-positive diagnosis was immobilising to most respondents, the trauma faded, paving the way for benecial public health actions. The results imply the critical need for continuous education on HIV/AIDS by public health advocates, using mass media, particularly, TV. Healthcare workers in VCTs should empathise with persons who are informed of their HIV-positive status for the rst time.

immediate elaborate support structures", extent of level of awareness about HIV/AIDS, level of HIV/AIDS-related stigma, availability of antiretroviral therapy (ART), and support groups to enable them move on with their lives. Feelings of guilt for the infection were explained by whether the individual felt his/her lifestyle exposed him/her to it, and type of sexual involvement they were engaged in. They felt guilty that they would infect a spouse if they were married. If they were in an unstable/non-married relationship, they did not feel guilty, and shared the blame with the casual sexual partner. Sixty-two percent blamed their partners or the environment with the excuse that they stayed loyal to their partners. Fabianova's [23, p. 200] respondents who tested on their own volition did so based on their own or a partner's "failure", poor health or "accidental happening", or work commitments.
The theoretical framework adopted for this paper, the theory of hopelessness, is grounded on depression. Depression is currently one of the ve leading causes of the disease burden internationally, except in sub-Saharan Africa (SSA) [24]. Researchers note that depressive disorders and other common mental health disorders (CMDs-depression, anxiety and somatization) were critically linked to the Millennium Development Goals, particularly gender equity, poverty, HIV/AIDS and maternal and child health [24,25]. Importantly, depression is the most diagnosed psychiatric disorder among PLWHAs. Depression also serves as a risk factor for the progression of HIV/AIDS. In African settings, a growing appreciation of an important link between CMDs and HIV/AIDS has been established [7,23] as well. HIV has unleashed "a signi cant strain" on mental health in Africa [24, p. 61; 26]. The huge burden of HIV/AIDS in SSA accounts for 16% of depression in the sub-region [24]. Alternatively, a neurobiological association exists between HIV and CMDs: "the HIV virus has quite speci c detrimental effects on neuronal function" [24, pp. 61, 65]. Evidence-based reports in African settings and other developing nations (Sao Paulo, Bangkok, Kinshasa, Nairobi, and Ethiopia), found both more symptoms and a higher prevalence of depression among symptomatic PLWHAs than among non-symptomatic or HIV-negative persons [24].
Theoretical framework: the hopelessness theory The hopelessness theory is applied to this paper. It is a diathesis-stress theory which posits that organisms express some form of cognitive and emotional de cits after experiencing a bad event. The theory argues that three depressogenic inferential styles serve as risk factors of depression [27,28]. These are the tendency to attribute a bad event to a global or stable cause; the tendency to perceive bad events as having many disastrous consequences; and the propensity to view oneself as awed or ine cient [28,29]. Making negative inference upsurges the possibility of hopelessness while feeling hopeless makes depression inevitable. With this explanation, the theory assumes hopelessness as a critical underlying factor to depression. Adding to the causal explanation, Seligman [30] stated that the symptoms, cure and prevention of a bad event also model depression. In societies like Ghana, where HIV is associated with nonconformity to societal expectations and/or sexual promiscuity, PLWHAs may be more exposed to adverse emotional and cognitive symptoms after receiving an HIVpositive report.
The application of the hopelessness thesis to HIV-positive populations in SSA is not new. Govender and Schlebusch's [31] study in Kwa-Zulu Natal, South Africa, applied Beck's Hopelessness Scale and Beck's depression Inventory [32] to their assessment of the correlation between depression, hopelessness, and suicidal thoughts in PLWHAs. Schlebusch and Govender [33] used the same inventories to study PLWHAs in a University-a liated hospital in South Africa. Primarily, they studied the prevalence of risk of suicidal ideation in PLWHAs immediately after their rst diagnosis. Kylmä et al. [34] also studied the full gamut/dynamics of the concept of hope (hope, despair, hopelessness) among PLWHAs. Their study yielded information on how PLWHAs' perceptions of hope could facilitate their clinical care.

Methods
Study setting and cultural context of LMKM The LMKM, the catchment area for the study, is situated in the Eastern Region of Ghana. The region, one of ten at the time of data collection, had 2,633,154 residents by Ghana's last Population and Housing census of 2010, making it the third most-populated region. The Eastern Region is mostly semi-urban [35]. The LMKM, one of 26 administrative municipalities/districts in the Eastern Region by the time of data collection, covers 12.4% of the region, with total land mass of 304.4 km 2 . The 2010 Population and Housing Census recorded 89,246 residents of the Municipality comprising 46.5% males and 53.5% females. Christians form 92.8%; other religious groups include Muslims and traditionalists [36]. The indigenes are ethnic Dangmes and speak Krobo. They are a patrilineal descent group, which means they inherit property through their father's lineage. The primary occupations of the residents are farming and shing. These, and other informal private employment are prevalent in the district, engaging 83.6% of employees. Youth unemployment is particularly entrenched; LMKM has the highest youth unemployment rate in the Eastern Region [20,36,37] with corresponding high poverty rates [38,39]; as informal sector employees in Ghana usually earn below the US$2 national daily minimum wage [40]. Inadequate housing and overcrowding are endemic in Ghana generally [41,42], with four or more persons living in single rooms on average [36,37]. Housing conditions, basic amenities, quality, and overcrowding may, however, be worse in the LMKM [43,44,45]. These poor housing conditions in the LMKM, which include inadequate running water in homes which is only 15%, lightening, and toilets, constitute a huge health challenge to persons with compromised health status, such as PLWHAs [37,45].
Traditional kinship norms in Ghana usually leverage political, social and economic fortunes of persons, particularly women [46,47]. In Ghana, like most parts of Africa, and thus the LMKM, kinship ties comprise both nuclear and extended family, and inform a wide range of behaviours [47, p. 2]. Although on the decline [19,48], the extended family system potentially has immense advantages, including proffering social support, particularly for the vulnerable. It is not without its demerits, though. As Sedziafa et al. [47] point out, kinship and descent norms generally disadvantage women of patrilineal descent, compared to their matrilineal counterparts. Such cultural tenets, then, are expected to play a role in the livelihood of PLWHAs.

Sampling and Data collection
This study used a "descriptive, multiple case study approach" [2, p. 2; 49]. This method generates interviewees' indepth descriptions of their situations, views and realities regarding issues. This provides deep insights of their actions and choices [50]. As Kutnick et al. [2] note, case studies are exceptionally useful in eliciting contextual situations, when they are important to a particular study. Examples are cultural, social and structural impediments (such as stigma, and fear) to post-diagnosis HIV care [49]. This paper analysed data from 26 out of 38 PLWHAs interviewed qualitatively through personal interviews from June to July 2015. The interviews were conducted with the aid of a pretested semi-structured question guide. Table  1 has the key question asked. The initial sample of 38 comprised both males and females who were selected using combined purposive and random sampling [2] as part of a research project which primarily studied the nexus between the health status of PLWHAs in the LMKM and their housing conditions. The project comprised both qualitative and quantitative data collection. First, the study district, LMKM, was purposively selected based on its lead in having persons with HIV/AIDS in Ghana, due to which the government had focused on strengthening healthcare institutions and personnel in the district for the ght against HIV/AIDS. Two out of three health facilities in the study district were also purposively selected-a government and quasi-government hospitals. These had been specially equipped by the Government since 2002, to manage HIV/AIDS cases, thus purposively leaving out the other government hospital [43,45,51,52].
Respondents had come to HIV/AIDS Voluntary Counseling and Testing (VCT) Centres in the two hospitals--St. Martins de Porres Hospital in Agormanya and Atua Government Hospital in Atua, near Agormanya, for care. Interviewing took place in these VCTs. The VCTs operated only on weekdays. For each day during the weekdays, based on prior reconnaissance survey, 40 respondents were targeted for both qualitative and quantitative interviews from the daily list of attendees in each hospital. One-third of these were selected randomly and interviewed. If there were less than 40 people in a day, half of them were randomly selected for interviews. Respondents were given unique codes to prevent being re-interviewed during the course of the study. Five male and female graduate student interviewers were assigned to each study hospital, including one qualitative interviewer. Qualitative or otherwise, a respondent got randomly selected for an interview when a prior interview had ended, beginning with a random start from the list of assigned codes, till the selected list was exhausted in a day. Similar sampling arrangements were made for each VCT used.
Respondents were males and females, 18 years or older, and con rmed their HIV-positive status to the principal investigators (PIs). The interviewing time for a respondent in the qualitative study ranged between 35 and 50 minutes. To help minimise time spent at the hospital due to the interviews, two retired nurses from the VCTs used who were part of the interviewers collected medications for the respondents. The language used for the interview was left to the respondent's choice between Krobo, the indigenous language in the LMKM, Twi, the indigenous language spoken the most in Ghana, and English, Ghana's o cial language due to its colonial past. With prior permission from the respondents, the interviews were audio recorded. This paper uses the qualitative data from the project. The original sample of 38 for the initial qualitative data was primarily informed by previous literature on the need to reach saturation in qualitative interviews [53,54], which were achieved after interviewing about 10 respondents in each of the two study sites. The sample of 26 for this paper were purposively selected from the 38 because the rest did not respond to the primary question on how they rst reacted to information of their HIV-positive diagnosis [see 2]. Additional data quality approaches taken included a three-day interviewer training and on-site supervision during the data collection by designated supervisors and the PIs. Respondents participated in an informed consent process and provided written consent unless the respondent was not literate; in such cases, verbal consent was provided. They were informed of the study objectives, told they were free to participate voluntarily or otherwise without penalty or immediate tangible gains, and assured of con dentiality. One person declined to be interviewed, citing time constraints. No identi able markers were used for the respondents [see 20,43,51,55].

Data Analysis
The data were transcribed verbatim, and reviewed by the author and team of transcribers to ensure accuracy. The adequacy of translation from the local languages to English was ascertained in several ways. First, the transcriptions were undertaken by the same research assistants (RAs) who did the interviews. Thus they had prior insights to the data and trends of the conversation. Second, these RAs are mostly indigenous Krobos and also speak Twi uently. Hence, they naturally understood the conversations. Third, to enhance the reliability of the data, several meetings were held between the author and the transcribers to interrogate the correct translations forth and back till a mutual agreement was reached on the correct translations. A similar approach was used to verify the coding. The author and RAs speak advanced English as a second language. Occasionally, the respondents used corrupted English for words that do not have direct indigenous language versions of the English language. For instance, AIDS has been commonly adopted by persons in the study locality who speak little or no English, as "AAs". The interviewers always probed what the respondents meant by such colloquial English.
The transcription for this paper was followed with independent coding by two coding experts, using NVivo version 11 professional software [56] to identify sub-themes and themes relevant to the objectives of the study and other relevant information. Thereafter, the coding team, including the lead RA, and the PI for the qualitative study in the Project/author of this paper, engaged in several series of reviews and discussions of the themes and sub-themes till there was mutual agreement in their meaning and context. These repeated processes of reviewing the data enhance intercoder reliability and improve the credibility/validity and reliability of qualitative data [57]. Finally, thematic content analysis which helps to integrate all cases studied for a combined result [2], was used to draft the paper.
Based on previous research [2,11,34] respondents' rst reactions to their HIV-positive diagnosis were adjudged as negative if the respondent either expressed shock, disbelief, worry, fear/panic, felt the HIV infection would kill him/her, or immediately contemplated suicide. Respondents' reactions were classi ed as resigned acceptance if they readily accepted the diagnosis and/or showed some optimism instantly that they could survive the infection. Finally, the reactions were considered resigned neutral when the respondent indicated he/she showed no immediate reaction upon receiving the rst news of his/her HIV-positive status ( Figure 1 & Table 2).

Re exivity
Re exively, the author's cultural and theoretical population health orientation admittedly had some in uence on aspects of the research process, although these were minimal. These included the choice of the title. Being fully aware of the extent of stigmatisation culturally associated with HIV/AIDS in Ghana [20,51,55], the PIs of the project from which data for this paper emanates were curious about how respondents would react on the spare of the moment they were diagnosed with the infection. Related contextual in uences on the author include how the PLWHAs would react given the resource-poor setting of the study area and the lower socio-economic status of women in Ghana, arguably more so in patriachical settings such as the LMKM. HIV/AIDS in Africa, Ghana, and the LMKM is mostly feminised [58,59]. Moreover, most of such victims receive very little, if any, social support [20,51,55]. Thus, this study sought to interrogate how newly diagnosed HIV-positive persons would take such diagnosis, and what resources were available to help such persons cope immediately and navigate to adjust to such status thereafter. The author deemed this a critical population/public health challenge of interest, given the background. The aforementioned contexts also informed the choice of the theory of hopelessness.
Nevertheless, given the author's extensive training in the dogma and ethics of scienti c research, particularly regarding the need for value-neutrality and objectivity [57], the author's cultural and theoretical backgrounds did not otherwise in uence the data analysis and interpretation. This was applicable to most of the research process as well.

Results
Socio-demographic characteristics of respondents The respondents' ages ranged from 25 to 68 years old. They were mostly females (80.77%, n =21), primarily indigenous Dangmes (84.62%, n = 22), and generally had low socio-economic status. Also, they were mostly single (separated/widowed after cohabiting/never married/widowed), and they had been o cially diagnosed HIV-positive for a range of six months to 12 years (Table 3).
Thematic ndings Initial reactions Table 2 summarises the reactions of the respondents, upon hearing the news of their HIV seropositive status for the rst time. There were negative and resigned reactions. Verbatim responses are identi ed with respondent numbers.
Negative reactions. The data showed that the vast majority of the respondents seemed to have been very hard hit and traumatised by the news of HIV-positive test result, and expressed very negative sentiments. For these, the reactions ranged from disbelief, to being very disturbed. Few mentioned the thought of killing themselves, incessant crying, and feeling that they would die from HIV. Other reactions included being very frustrated, very surprised, very frightened, deep shock, deep worry, being heartbroken/devastated, self-blame, and avoiding going to hospital till conversion to AIDS ( Table 2): "It was very hard for me when I rst heard it; in fact, I cried and cried." (R4). "In fact I was very frustrated. I even decided to take poison so that I will die before the sickness [HIV] becomes worse." (R5).
"I was very surprised and shocked when I was rst told I had this disease. It was very heart-breaking." (R7).
Resigned reactions. On the contrary, few respondents showed resignation towards the bad news. These comprised three who readily accepted the diagnosis and two who seemed neutral to it. From their responses, respondents who accepted their diagnosis seemed to have readily and consciously accepted/embraced the diagnosis of HIVpositive and encoded it rather smoothly as part of their identity.
"When I was told I was not perturbed because I knew people who were also taking the drug" [ARVs]. (R25).
The very few respondents who seemed to have been neutral to their rst diagnosis of HIV/AIDS seemed to have continued with their lives seamlessly on the spare of the moment they received the news, and did not take a break to react to the news of being HIV-positive.
"I was ill for long time so when I was told about it I only continued to take medications." (R22).
Further analysis indicated that these initial reactions were in uenced by certain background situations. These are discussed in the next section.

Factors in uencing the immediate reactions
For the very few respondents who were neutral in their initial reactions, being ill for a long time before the rst news of HIV-positive diagnosis, and accepting that sickness is inevitable and could happen anytime, were what in uenced their immediate reactions: "…as for sickness, it's sickness; you have less control over sickness, so I didn't really do anything." (R23).
Two of the few respondents who readily accepted their HIV-positive status when diagnosed for the rst time said they experienced persistent comorbidities from the HIV infection. Resultantly, they voluntarily went to the VCTs to test for their HIV status: "I started falling sick and strange rashes kept appearing on my skin, so when I took it to the hospital, I was told it was the virus." (R24).
"I frequently fell sick…and it was not getting better so I came to the hospital myself…I came (willingly) to them to be tested when I realised I have changed. So they were even happy I walked to them myself to be tested." (R25).
Including two multiple responses, the vast majority who responded negatively to the news of their HIV-positive status, mentioned four main situations that informed their immediate reactions to their HIV-positive diagnosis. Mostly, they suffered comorbidities from their infection.
"For about seven months I was not feeling well. It even got to a point I lost consciousness. All forms of tests were ran on me…but they could not nd exactly what was wrong...My boss advised me…so I went to the hospital for the test and the nurses said I was HIV-positive." (R7).
Next, nearly half of the respondents who reacted negatively said a spouse/partner was HIV-positive and thus knew they had contracted the infection from them, and/or due to that, health personnel tested them also for the infection. Importantly, most of these PLWHAs did not know their partners' HIV status prior to respondent's diagnosis.
"I was staying with my husband by then but he died so it was after he died that the doctors realised that it was this disease he died of…afterwards I was tested and diagnosed with this disease." (R1).
Similar to those who readily embraced their diagnosis, a few of those who reacted negatively were tested voluntarily based on their sexual partner's infection. Likewise, several participants whose reactions were triggered by experiencing comorbidities said they voluntarily went for the testing. Additionally, for a slim minority of the latter, their conviction to go for the VCT was based on mass media (often television) announcements and discussions on the signs and symptoms of HIV/AIDS.
"Already I suspected that my husband had all the symptoms that are discussed on TV and radio about this disease. He fell sick often and also coughed most of the time." (R3).
"Even though I wasn't falling sick, I came to be tested willingly after they announced everybody should get tested…." (R11).
"…I used to fall sick frequently and that was when a lot of noise and adverts were made about this disease on television and radio...I went to the St. Martin's hospital and told the doctors about my situation and he asked me go for an HIV test and that was when I got to know I had this disease." (R2).
Finally, few (including two who gave multiple responses-primarily that a spouse/partner was HIV-positive) mentioned that they got tested when they were pregnant.
"I was about to give birth to my second born…my husband is also HIV-positive." (R4).
"I was diagnosed when I was pregnant when my second born and I visited the hospital… Yes, [my husband is HIVpositive]." (R8).

Factors that facilitated transitioning to accept HIV-positive self
For the few respondents who showed resignation towards the initial news of their HIV-positive diagnosis, there was no need for transitioning to accepting an HIV-positive self. Two of these respondents who readily embraced the diagnosis said they already knew persons who were HIV-positive and were taking antiretroviral medications (ARVs): "I realised I was not the only victim; many people are also victims…" (R26).
Two others said they already had comorbidities from AIDS and started treatment right after diagnosis: "I was ill for a long time so when I was told about it I only continued to take medications." (R22).
Another participant thought sickness is inevitable and thus did not need to worry about such diagnosis.
Nearly one-third of the respondents who initially reacted negatively to an HIV-positive diagnosis gave no response regarding what in uenced their transitioning to accepting their HIV-positive status. They mostly felt uncomfortable/reluctant talking about it. The rest mentioned what facilitated their transitioning more spontaneously and/or more readily after some amount of probing. The vast majority of the rest who reacted negatively said the most important help with their transitioning was counselling from health workers who encouraged them to initiate and continue treatment, with the assurance that if they did so, they would survive the infection.
"…After I came here [VCT] and was advised and encouraged to see something to live for, I have been okay. They [health personnel] have been very friendly and encouraging. In fact, they have helped me a lot." (R9).
"They [health personnel] counsel us and tell us the fact that we have this virus does not mean our world has come to an end." (R11).
"…After being put on medication, going through counselling and tests, and being told what to do, I was hopeful that if you adhered to the medication you could live long." (R19).
For one of these, her mother-in-law was the main person who empathised with her: "I was really worried and disturbed but the encouragement and advice from the nurses and my mother-in-law…has helped me. After I told her [mother-in-law] I had been diagnosed…she brought me here [VCT] to introduce me [to a nurse], so she has been helpful." (R12).
The second main issue that facilitated the transitioning for few of the respondents was their awareness of the current medical advancement in the treatment of HIV infection, due to which "you would live long" (R19) despite the infection: "…because they have drugs to treat it, I was OK. Provided it will not cut short my life span I am happy." (R10).
"In the olden days when there were no drugs you thought you would die…after being told, so you become afraid, but now we know there are drugs available so if you are able to take your drugs you don't have any problem." (R26).
Three respondents alluded to accepting medical diagnoses, facing reality, and living by Biblical principles as facilitating their acceptance of their diagnosis.
"I accepted it because you can't deny what a doctor says" (R10).
"I was disturbed but I thought to myself that it had already happened" (R18).
"I didn't kill myself because I am a Christian and the Bible speaks against that. I forgot about everything and decided to keep coming for the medications and now by the grace of God I have lived for over twelve years." (R5).
There was, however, a lone-voice who said she had still not settled down to the reality of being HIV-positive after having been diagnosed three years prior and seeking treatment for one-year post diagnosis. Thus, she has not been consistent in getting treatment and is already feed up with seeking treatment: "It seemed to be untrue. From time to time I stopped taking the medication…I am fed up with coming to seek treatment. I have been treating the sickness for over a year but the symptoms recur after I see the doctor." (R20).
This lone-voice mentioned having severe comorbidities which were probably due to starting healthcare for HIV two years after diagnosis. She also mentioned experiencing extreme discrimination and ostracisation both at home and in public, which no doubt, are linked to her comorbidities.

Discussion
Fear has been associated with HIV since its discovery in the 1980s. Likewise, this study found that respondents who were already exposed to HIV/AIDS needed no transitioning to selfacceptance of their HIV-positive status. This corroborates previous ndings [60]. Nearly all the respondents settled down later, after their maiden reactions, initiated and continued with their healthcare for HIV/AIDS. This a rms previous assertions that such initial feelings regarding information on a newly-diagnosed HIV-positive status mostly fade away eventually [3,23].
Again, the paper corroborates previous ndings and highlight the buffering role of healthcare providers in moderating the reactions of newly-diagnosed PLWHAs [1,11]: the vast majority of the respondents who adapted to their HIV-positive status attributed it to counselling and support from healthcare personnel. This role of the healthcare workers in aiding respondents' transition to accepting their HIV-positive selves a rms the documented importance of social support in ameliorating the otherwise negative effects of experiencing a health trauma [23,64]. Research has identi ed HIV counsellors' or health providers' choice of words and emotions as crucial in determining peoples' reaction to the initial diagnosis of HIV infection [60,63]. When these emotions were hopeful and assuaging, patients were more likely to be calm and comforted and vice versa [63]. The ndings of this study underscore the fact that newly-diagnosed PLWHAs will need to receive such interventions early [12]. These interventions are needed to give them hope in life to abate extreme psychosocial trauma that can be associated with new diagnosis of an HIV-positive status [11,65]. Per the ndings of this paper, such interventions should include educating newly-diagnosed PLWHAs that new medical advances for HIV-positive infection make it possible for newly-infected PLWHAs to lead normal lives and live long, if they seek early treatment and adhere to prescribed healthcare.
A fair number of the respondents mentioned being infected by their spouses/partners who were alive or deceased [also see 51], implying that they probably were not using condoms and other modes to prevent HIV transmission from their sexual partners. This nding is not unlikely considering that Owusu [55] found that the PLWHAs studied were hardly using any form of protection against HIV with their sexual partners, whether in stable or unstable relationships. Two respondents were exceptions--they used condoms, but inconsistently [51]. Furthermore, Owusu [ 51] found that the unmarried or non-co-habiting PLWHAs had not disclosed their HIV-positive status to their sexual partners, with the exception of one respondent. PLWHAs who fail to disclose their status to their partners may have been living in a state of denial and or may fear/have feared the rami cations of disclosing their status. They may thus refuse to disclose as a way of attenuating the anticipated effect of disclosing, as previous authors have attested to [12,15,23]. The ndings from this paper mostly tally with the theory of hopelessness's core proposition; the respondents overwhelmingly perceived the initial announcement of their HIV-positive status as translating into unwelcome consequences and negative inferences, as did respondents in other SSA settings [12,23]. This plausibly led to depression and feelings of hopelessness among them. Also, this perspective may have underlain the self-blame by a few of them for being HIV-positive [28,29]. Furthermore, this paper con rms the hopelessness theory's propositions that underlying perceived bad situations and experiences which are attributed to internal factors lead to depression. Conversely, those ascribed to presumed external factors/in uences give comfort/are reassuring [4].
In this study, the immediate reactions to the rst news of being HIV-positive were mostly negative for respondents with internal factors such as having comorbidities and having a spouse/partner with HIV/AIDS.
In consonance with Peterson's and Seligman's [4] hopelessness theory's propositions, respondents of this study said that external factors motivated them to take commendable actions such as going for VCT. These included the in uence of health education through mass media, counselling by healthcare practitioners, and information regarding modern medical advancements which can help PLWHAs live without comorbidities, and possibly survive the infection. Furthermore, these factors facilitated their adaptation to their HIV-positive selves.
Nevertheless, this paper does not substantiate Peterson and Seligman [4] wholly. Contrary to their proposition, in this study, fewer respondents mentioned that a series of external factors such as knowing someone who has This was also true of Assen et al.'s [12] study in Ethiopia.
Hence, this paper corroborates Govender and Schlebusch's [31] synthesis of the hopelessness theory. These authors emphasise that the numerous internal and external challenges that face PLWHAs such as discrimination, stigmatisation, abuse, nancial, marital, and healthcare challenges, among others, may [also combine to] have connotations for the loss of control over one's life, fear of the future, and feeling of helplessness. As well, they may underlie the negative inferences which exacerbate the feeling of hopelessness and increase the likelihood of depressive symptoms by newly-diagnosed PLWHAs.
This paper adds to the knowledge on the personal and public health effects of receiving an HIV-positive diagnosis for the rst time. Particularly, it highlights the commendable public health effects of receiving diagnosis for HIVpositive status and illuminates the role of social support in seeking and continuing healthcare for the diagnosis. Also, it attests to the role of healthcare workers and behaviour change communication, using mass media, in ghting the menace of HIV/AIDS. Furthermore, as articulated above, this paper did not fully support the conclusions of Peterson's and Seligman's [4] hopelessness framework. Rather, the paper contributes additional information to it in the form of an anti-thesis. Additionally, unlike Fabianova's [23] study in Nairobi, this study did not nd that the respondents acted with aggression towards counsellors who rst broke the news of their HIVpositive status to them.
More importantly, this paper has navigated new frontiers in the body of knowledge in its thematic area of study. First, contrary to Fabianova's [23] ndings that some of her respondents attempted suicide, non-of the respondents in this study mentioned having attempted to take their lives, although a few of them revealed they had suicidal ideation. This may be due to the fewer respondents this study engaged as well as its cross-sectional design, compared to Fabianova's [23] respondents, and the longitudinal approach to her study. Second, this study has newly articulated outstanding information on factors which facilitate PLWHAs' transitioning to accepting and settling down to their newly diagnosed HIV-positive status. Third, unlike previous literature, this study has uniquely found that having comorbidities from HIV/AIDS was the primary reason that in uenced the respondents to voluntarily test for their HIV-positive status. The uniqueness of this nding may be linked to the awareness that VCT of HIV/AIDS status is very rare in Ghana [68, 69].

Limitations
The qualitative nature of this study better facilitates unearthing the complexities associated with receiving initial news of an HIV-positive diagnosis and learning about the adaptation process [2]. Also, the repeated data analyses this paper employed strengthens its reliability and validity. However, when interpreting these ndings, some limitations should be considered. First, with HIV-positive status being a very sensitive issue, and highly stigmatised in Ghana [16,70,71], social desirability of responses may have in uenced the ndings [2]. Being a retrospective study, recall bias may also affect the reliability of the responses [2,20]. Furthermore, the study is cross-sectional and does not permit inference of causality [72]. Additionally, being a qualitative study with a mostly purposive and a fairly small sample size, the ndings are not generalisable to non-respondents in the LMKM and also, Ghana as a whole [72]. Lastly, based on the primary focus of the project, this paper did not undertake a diagnostic assessment for depression among the respondents. The paper is thus unable to ascertain if depression contributed to the initial reactions of the respondents upon diagnosis.

Conclusions
Evidence elsewhere suggests that upon receiving the initial news of an HIV-positive diagnosis, most people have strong psychosocial reactions [23,60,73]. Such reactions are also known to have very critical public health implication [1,2,14]. Yet little research has focused on the initial reactions of newly-diagnosed PLWHAs in SSA, particularly Ghana. Neither has the implications of their reactions for personal and public health been extensively studied [2,11]]. This makes this study of the immediate reactions to the rst news of an HIV-positive diagnosis very timely. The personal and public health implications of one's initial reactions to the rst HIV-positive diagnosis is critically important for Ghana, which has a generalised HIV-positive infection.
Consistent with the literature, the vast majority of the respondents became extremely traumatised and immobilised when they received the initial announcement of their HIV-positive status. A few, however, more readily resigned to their HIV-positive identity. Regardless of their reactions to the rst news of their HIV-positive diagnosis, having comorbidities prior to diagnosis in uenced their immediate reactions the most. This was followed by having/having had a spouse/partner especially, and/or knowing someone who was HIV-positive, prior to their diagnosis. Next, respondents mentioned being in uenced by health education through mass media, TV particularly, on signs and symptoms of HIV/AIDS. Importantly, health education, counselling, reassurance and empathy from healthcare workers provided hope. Furthermore, these facilitated their transitioning to settling down to selfacceptance of an HIV-positive status and continuing with healthcare. Finally, this paper concludes that to a large extent, the ndings are applicable to the tenets of the hopelessness theory used as a framework for this study.
Consequently, this paper found hopelessness as an important driving force to negative reactions towards one's rst time of hearing about his/her HIV-positive diagnosis.
Conclusions from this paper have several public health signi cance. It highlights the continuous need for and strengthening of behaviour change communication on HIV/AIDS by the Ghana AIDS Commission and Ghana Health Service. This should emphasise its signs and symptoms, the need to seek early treatment, and adherence to prescribed ARVs. Strengthening the use of mass media, small groups, schools, churches/mosques and person-to-person channels in such endeavours is important. HIV/AIDS-related health promotion and education should also continue to emphasise prevention, but importantly, state that once infected, HIV/AIDS can be controlled; the infected person can live without comorbidities and need not succumb to the infection. Stakeholders should work harder towards educating residents in the LMKM, and for that matter, Ghanaians generally, about voluntary testing of HIV status. Most of the respondents in this study mentioned having had comorbidities from HIV/AIDS prior to their initial diagnosis. Onset of comorbidities for HIV/AIDS prior to diagnosis and treatment can make the treatment expensive; it can also diminish the chances of surviving the infection severely [74,75].
Given the high rates of HIV/AIDS in the study district and Region, the health education should also emphasise the need for persons whose sexual partners are HIV-positive-particularly those who show signs and symptoms of the infection, and all who engage in at-risk sex, to practice safer sex. Finally, the paper recommends increased social support and empathy for PLWHAs in LMKM particularly and in Ghana generally, from family, friends, neighbors, community leaders, healthcare professionals, and organised groups such as members of their religious a liation, if any [20,51,55]. This study has unearthed social support as a critical moderating element in the transitioning of PLWHAs to integrating their HIV-positive self-concept, initiating, and adhering to prescribed healthcare. Families, social groups, and healthcare professionals should empathise with PLWHAs.  /14). Permission to conduct the study were also received from 1) the Ghana Health Service's Eastern Regional Directorate, 2) The LMKM Directorate of the Ghana Health Service, and 3) the Administrators of the Atua Government, and St. Martins De Pores hospitals. Each participant gave a written or verbal informed consent to participate before they were interviewed.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during this study are available from the author on reasonable request. The key questions for the study have been provided in the paper, in Table 1.

Competing interests
The author declares that there are no competing interests. Author's contributions AYO contributed to conceptualising the study and served as a co-Principal Investigator (co-PI). AYO mostly focused on the qualitative aspect of the project from which the data for this paper emanates. AYO also developed the indepth interview guide, helped to liaise with technical staff of the Ghana Health Service and Ghana AIDS Commission for explanations to some HIV/AIDS technical and policy-related issues in Ghana. Furthermore, AYO led in the acquisition of ethical clearance from the University of Ghana. Additionally, AYO co-supervised eld staff during the data collection, and handled the quality control, and analysis of the qualitative data. AYO wrote and nalised this paper single-handedly. Since this paper is sole-authored, the nal version of the manuscript does not require the approval of any other person prior to being submitted and published. Table 2: First reactions of PLWHAs after initial news of HIV diagnosis, major themes and subthemes I didn't really do anything, as for sickness, its sickness so I didn't really do anything. I accepted the result. Resigned: Accepted diagnosis 25 When I was told I was not perturbed because I knew people who were also taking the drug.