Mananga Lelo G 1, Mampunza Ma Miezi S 1, Longo-Mbenza B 2, Verbanck P 3 , Nyirenda S 4, Yassa P4
1. Neuropathologic Center, University of Kinshasa, Democratic Republic of Congo.
2. Walter Sisulu University, Faculty of Health Sciences, Mthatha, South Africa.
3. Free University of Brussels, Division of Psychiatry, Belgium.
4. University Teaching Hospital, Lusaka, Zambia.

[emedpub – Psychiatry and Mental Health: Vol 1:2] [Date of Publication: 01.28.2012]
ISSN 2231-6019

January 29, 2012 at 11:16 AM


Objectives: This study examined longitudinally the effects of stressful life events, depression, personality, behavior pattern, religion, social support, coping, and socio-demographic factors on progression of HIV-1 infection to AIDS stages.

Methods: Fifty black Congolese HIV seropositives from various NGOs in Kinshasa were monitored. The longitudinal approach analyzed the onset of an AIDS indicator condition (WHO) using Cox regression model and Kaplan Meier curves.

Results: Type AB behavior pattern, Type D personality, Type A behavior pattern, traditional churches, and higher education attainment were associated with progression to AIDS.

Conclusions: Evidence of association between psychosocial distress, traditional churches and  higher education was shown. The prevention program should focus on promoting social support, active coping, and treatment of psychological distress for HIV-infected patients.


Although the mechanisms linking psycho-social factors to biological changes in HIV/ AIDS infection are not well understood(1-8), studies have at least measured concurrently psychological distress (stress, anxiety, depression, and intrusive thoughts), neuroendocrine (plasma Cortisol levels), and immunological changes (viral load, natural killer lymphocytes, CD4 count reduction) (1,2,5,9-13). However, there are some controversies on the role depression plays in the progression from HIV to AIDS  in sub-Saharan African countries including in the Democratic Republic of the Congo (DRC), a country within the “conflict belt” (14-19)

Compared  to traditional churches (Catholic, Reformed and Kimbanguist), revival churches and imported churches from the United States of America (USA), offer HIV-infected individuals some higher emotional, economic, and social support (17, 20-24). In these new churches, prayers are believed to cure HIV/AIDS infection. With little support from government, Non-Governmental Organizations (NGOs) attempt to offer  efficient social (and medical) support to these HIV/AIDS patients. It was on this background that the study was developed to to examine how chronic psychological distress after positive serostatus notification, religion, and coping, may affect disease progression from HIV to AIDS. The overall goal is to {Write the benefits of this study hoped for in one sentence}

Materials and methods

This was a longitudinal study conducted between January 2008 and December 2010. It included 50 asymptomatic HIV-infected African adults randomly recruited from two Non Government Organizations (NGOs) namely Femmes Plus and AMOCONGO. These organizations are specialized in providing general support to persons living with HIV in  Kinshasa, Democratic Republic of Congo .50 controls were matched with HIV according to the sex, age and modified residence (urban,semi-urban ,and rural areas) of Kinshasa  region (?  ), and randomly selected from each street/setting of HIV participants

Permission to conduct study was sought from ethics committee of Kinshasa University, and during, the study was conducted according to the Helsinki Declaration

Data collection and Procedure

Participants were interviewed by a trained psychiatrist (MLG) at baseline and once every 6 months during 2 years, on socio-demographic and psychosocial features using a structured, standardized, pre-coded questionnaire which was validated in a pilot study involving 20 participants.

Measurements and instruments

The outcome of interest was the advent of the clinical stage of AIDS (WHO). Time for AIDS definition for each participant was measured in years from the date of HIV status notification to the date of the AIDS manifestations onset.

Explanatory (independent) variables included demographic and social-cultural factors. These were gender (men vs.women) and age categories   (≤43 years, 44-51 years, and ≥52 years).Socio-cultural factors  included religion (traditional church vs. revival church), socioeconomic status (low vs. high: low income included crowding, lack of electricity and potable water while  high income included affluent income), education attainment (primary, secondary, tertiary), residential area (urban, semi-urban, rural areas)marital status (married, single, separated/divorce, and widows) and perceived stress. The socioeconomic status (low vs. high) was also defined from local data (25).

We used selected scales from the Cope’ Carver (26) to assess coping) Participants were asked to indicate on  a 4 point scale (where 1= not at all and 4 =  very much ) how  they globally cope with or handle positive reinterpretation and personal growth/ denial. Participant’s level of satisfaction with the support received from the family, friends, government, and religious institutions was assessed using the Brief Social Support questionnaire where social support is rated from very dissatisfied (score=1) to very satisfied (score=6). (27). Participants also completed the Bradford Somatic Inventory (BSI) Usually used in cardiovascular diseases (28) at entry  which evaluated  the association of somatic symptoms with  anxiety and depression. A self  reported count of symptoms was reported as present on more 15 days during previous month according to 46 items for  men and 44 for women .The symptom score on  Bradford Somatic Inventory indicated this scale: 0 =  lack of symptom,; 1 =  presence of symptom on less 15 days during the previous month ≥,and 2  =   presence of symptom on more than 15 days during previous month. The sum of score ≥ 44 and ≥ 46 were the cut-off points for altered functional somatic symptoms in women and men , respectively .Type A behavior  pattern, derived from an action-emotion complex observed in any participant who was aggressively involved in a chronic, incessant struggle to achieve more in less time, and if required to do so, against the opposing efforts of other things or other persons (29).To achieve this, the instrument used was the self-reported questionnaire evaluation of Bortner (30) which includes 14 items scored from 1 to 5. A sum of scores defined Type B4 (scores 11 to 14), type A2 (scores 15 to 19), and type A (scores 20 to 24). Type A behaviour pattern (heterogeneous hodgepodge of behaviour symptoms) is the opposite of type B (B3 b4) and type D personality (homogeneous subgroup).

Type D personality has been associated with a variety of emotional and social difficulties, including depressive symptoms, chronic tension, anger, pessimism, lack of perceived social support, and a low level of subjective well-being (31)

The  Bradford Somatic Inventory ,type A behavior pattern and type D personality in this study because of their ease to use and their  associated to stress ,anxiety, depression  and  bad quality of  life which are frequent   in HIV/AIDS (28, 32). These scales are also easy to use in a poor, illiterate and religious population as in India where the Bradford Somatic Inventory has been used (28) and by non-psychiatric health professional who treat most HIV population.

Stressful life events perception

Stressful life events and difficulties were assessed using a Perceived stress scale (34). Norms for each stressful event were based on the degree of stress that most people would experience given the particular circumstances such as HIV status notification, financial impact, life threat, and personal involvement. Each stressor was rated from 1 (no threat) to 5 (threat). All ratings were summed with values between 14 and 70. A higher Perceived stress score was ≥ 42 versus lower Perceived stress score < 42.

Statistical analysis

For descriptive purposes categorical variables were expressed as proportions (%) while continuous variables were described as median, means ± standard deviation (SD)., Kaplan-Meier estimates and Wilcoxon tests were computed to plot the survival probability for variables and  were grouped in different categories. Survival analysis with Cox regression models was used to calculate the risk of AIDS onset. Log rank tests

A p-value of <0.05 was considered as statistically significant. All analyses were performed using  a statistical software package SPSS for Windows version 18.0 (SPSS Inc, Chicago, Il, USA).


The study included 50 HIV participants (14 men, 36 women, 47 ±3 years). The baseline psychological patterns between HIV-positive and HIV negative participants were comparable except for Type D personality which was exclusively among HIV-positive participants (Table 1 ). The Values of Bradford symptoms inventory, and perceived stress score tended to be high in both groups without significant difference in HIV sample. However type D personality was exclusively among HIV sample and type B behavior pattern in both groups.

Table 1. Baseline Psychological patterns comparison between 50 HIV-positive and 50 HIV-negative participants.

Psychological pattern

Participants HIV


Positive Negative
[Means ±SD or n(%)] [Means ±SD or n(%)]
Anxiety score  (BSI) 30 ± 2.1 16.2 ± 1.1 0.063
Perceived Stress score 35.5 ± 5.7 37.1 ± 6.2 0.89
Type D personality 5 (10) 0 (0) 0.022
Type A behaviour pattern 3 (6) 6 (12) 0.295
Type AB behaviour pattern 20 (40) 29 (58) 0.072
Type B behaviour pattern 22 (40) 15 (30) 0.147
B3 17 15
B4 5 0

Among the  50 HIV-positive  participants, 8 women died after a median period of 2 months from time of enrollment. Of these, 5 were type D personality and 3 were Type A behavior pattern. As regards their maritial status 30 (71.4%) were widowed, 7 (16.7%) were married, 4(9.5) were single and 1(7.4%) was divorced.

The first forward stepwise Cox regression model indicated Det som for bare var noe du kunne gjore om du reiste til et casino online lokale, er na tilgjengelig fra din egen sofa hjemme, sa lenge du har tilgang til internett sa klart. that Type AB behaviour pattern had a higher risk of AIDS onset (Risk ratio = 11.3 CI 95% 1.3 to 102.8; p=0.03, B=2.427, ES=1.125, Wald=4.651) in comparison with Type B behaviour pattern after  adjusting  for age, sex, religion, marital status, education attainment, socio-economic status, Bradford Symptoms Inventory and Perceived Stress Score.

Table 2.  Interaction of Type AB Behaviour pattern and traditional religion in predicting onset of AIDS.

B ES Wald Hazard Ratio

(CI, 95%)

Step 1
Type AB Behaviour 2.457 1.119 4.819 11.7

(1.3 to 105)

Step 2
Type AB Behaviour 4.006 1.476 7.368 54.9

(3.1 to 991)

Traditional religion 3.061 1.250 6 21.4

(1.8 to 247)


After regrouping religions, type AB behavior pattern (versus Type B behavior pattern) and traditional churches (versus revival churches) were the most  independent predictors of AIDS onset, adjusting for age, sex, marital status, education attainment, socio-economic status, Bradford symptoms inventory and perceived stress score (p=value).(Table 3)

Table 3.  Predictors of AIDS onset in HIV status sample.

B ES Wald Ratio risk (CI 95%) P
Independent variables
  • Type AB behaviour
2.397 1.045 7.582 11

(1.4 to 85.2)

  • Traditional churches
1.457 0.641 5.164 4.2

(1.2 to 15.1)


Figure 1. Progression of HIV-positive participants to AIDS among different religious groups.

Only Type AB behaviour pattern (versus Type B behaviour patterns) and traditional churches (versus revival churches) predicted significantly the onset of AIDS (p-value) after excluding sex, marital status, socioeconomic status, education attainment, and adjusting for age, Bradford symptoms inventory, and Perceived stress score. The introduction of religion increased the Type AB behavior-related risk for AIDS and that related to religion by 5 times, respectively (Table 2).

Figure 2. Progression of HIV-positive participants to AIDS among three different behavior patterns.

After plotting survival probabilities based on Kaplan-Meier curves, higher rates   of progression among HIV positive participants to AIDS in traditional churches compared to new religious groups(Figure 2), Type AB behavior pattern compared to B3 and B4 behavior pattern (Figure 3)and  University school levels compared to (Figure 3), respectively. Figure 4 shown the mean period of living HIV- positive status by regrouped churches and Type behaviors patterns

Figure 3.  Progression of HIV-positive participants to AIDS between  different education levels.

Figure 4. Mean period of living with HIV status by regrouped churches and Types Behaviour patterns.


This study assessed the progression to AIDS of African HIV-positive patients not on HAART and how the chronic psychological distress, religion, socio-demographic variables, coping, and social support may affect this disease progression. There were more females among HIV-positives as reported elsewhere (35-6). The mean age of (47± 3 years) among the participants   suggests that HIV disease is becoming a chronic disease with long survival not on HAART.

The similar higher  levels of Bradford Somatic Inventory, Perceived Stress Score in both   groups of participants may be explained by  the stressful life in Kinshasa, DRC,  a post conflict country  ( 14) . However, the highest rate Type D personality among HIV sample strongly suggests the place of depressive symptoms among subjects with HIV/AIDS (37).

Both Type D personality and Type A behaviour pattern (anxiety), which  induce more depressive symptoms online casino in HIV-infected patients (23), were associated with faster progression to AIDS and mortality (1-3, 38).

Contrary to the studies which did not report a significant association between behavior patterns, strategies for coping with stress of adult life, anxiety, and AIDS progression/mortality (39), the present study demonstrated the interactions of religion with Type AB behavior pattern in AIDS onset.  Considering only age, gender, socio-economic status, and education attainment, the study identified higher education levels as risk factor of AIDS as reported in the United States of America (40).

Since type A behavior pattern and Type D personality were inexistent among these long time survivors, and religion was not considered, Type AB pattern was defined as the only fastest progressing behavior pattern to AIDS among the assessed psychological distress patterns and non psychological factors. Thus , older age and low social class (41) were not risk factors of AIDS in these HIV-infected Africans. Type AB behavior pattern was considered as a short term survivor among the long time survivors (Type AB, Type B3, Type B4 behavior pattern) (40). This behavior pattern includes both a part of Type A and another of Type B (The opposite to Type A behavior pattern considered as the short time survivor). Type A behavior may play a role of a magnifying prism after an HIV-positive status notification. Its opposite Types B (B3 B4) behavior, long time survivor, may act as a filter after the notification of an HIV-positive status. The longest survivors were Type B4 behavior pattern, while Type B3 behavior was a low progressors. The Type B is a epidemiological dangerous subject because he can play the role of virus reservoir in HIV infection.

It is thus possible that that type B behavior patterns may play the role of virus reservoirs in HIV infection. The presence of Type AB behaviour pattern has also increased the risk of AIDS induced by traditional religion. Thus, the relationship between religion and behavior pattern depends on two indirect effects: association with religion and psychological distress by avoidant coping, and association between religion and psychological distress through both social support and avoidant coping (17).

The University school level was identified with higher probability of progress towards AIDS in comparison with the lower levels of education (primary and secondary school). In our previous study (22), depression was commoner among Congolese at the University level. However, in Uganda, depression is more prevalent among the lowest levels of education in comparison the highest education ones (37).


These data provide evidence that Type AB behavior pattern, traditional churches, Type A behavior pattern, Type D personality, Higher education levels  may accelerate the HIV-1 progression to AIDS.


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