Troy arrived at my office looking fatigued and defeated. Having lived with HIV for nearly 14 years, he was now experiencing a severe downward spiral of depressive symptoms that caused him to sleep many hours each day. He rarely emerged from his apartment, describing his isolation as "far worse than ever before, even when I was diagnosed." Troy is an African-American man in his 50s who had come to Miami from his native Georgia to live openly in a gay community. His family at home knows nothing of his sexual orientation or HIV status, and because of issues of self-worth and avoidance of stigmatizing situations, he never developed a local network of support beyond one or two friends. Even with them, he rarely discusses his HIV status and, as he has aged, he has withdrawn even more, became increasingly distressed at feeling invisible in his own African-American gay community, and totally disconnected from the broader LGBT communities. As his isolation increased, Troy, for the first time, began to use methamphetamine to numb the hopelessness that he was now experiencing most days.
Depression and anxiety are strikingly common among persons living with HIV. This is due to a variety of factors, including stress about one's health and future, trauma, shame, stigma, and the physical effects of the virus itself. Yet, for both HIV and other health issues, evidence exists in the medical literature that provides distinct clues as to why certain individuals seem to thrive with better physical and emotional health while others do not. One of the more significant factors underlying such success is the ability of some individuals to successfully create and sustain social connectedness, defined simply as the quality and quantity of social relationships with others.
Social connectedness comprises several factors, including social integration, the overall level of involvement with informal networks (such as a spouse or close friends) and formal networks (institutions such as the church), which appear to be protective factors for improved health outcomes. In Troy's case, the absence of social integration was a central feature of his isolation. The more web-like and high quality these connections are, the better, because such networks of interrelationships mutually reinforce one another over time.
Studies with people living with HIV have found that direct health benefits derive from specific components of social connection, including individual resilience and a sense of control over one's social interactions, both of which increase the perception of available support and actually help secure social support in stressful times. A sense of social belonging or social capital, a term that describes the quantity and quality of one's network of relationships, is also significantly associated with HIV medication adherence, as well as overall functioning and satisfaction with quality of life.
Related: The Science of Gratitude: How It Improves Your Health
Health risks and disparities, along with self-attitudes and mental health, vary widely among various populations and are impacted by social identity and social connectedness, as well as internalized homophobia and racism. While it is clear that racial, ethnic, and sexual minorities experience additional stressors and barriers that impact health, many minority groups display remarkable resilience. For example, data from the National Survey of American Life found that African Americans who strongly identify with their group and view it very positively have greater self-esteem, greater mastery, and fewer depressive symptoms. However, findings also showed that when beliefs about one's own racial identification were relatively negative, this resulted in lower mastery of self-care skills and higher depressive symptoms.
Other factors such as gender also play a role. Men, for example, tend to mobilize support that is heavily focused on their partners or spouses, whereas women are much more likely to rely on a child, close relative, or a friend as their confidant. Consequently, widowhood is consistently more damaging to the physical and mental health of men than women. Education is important, as well. Educated adults typically have a larger number of close relationships and may experience less overall stress in their interpersonal relationships, leading to the experience of less isolation.
While evidence concerning the overall health benefits of social connection is beyond doubt, specific strategies that promote greater connectivity among people living with HIV have not received as much attention from researchers. Some strategies, however, can improve social connection. Here they are:
- One-to-one support: In the early days of the HIV epidemic, people needed to create supportive communities and networks because no infrastructure was in place for care. One of the better examples of one-to-one support was the buddy system, through which people assisted one another with tasks such as shopping, walking the dog, or simply checking in regularly by telephone. While case management and other services are essential, they cannot replace personal, social support. Create or expand your network friends: Everyone will benefit. If nothing else, where appropriate, try simply giving a hug. While some people are put off by such contact (which must be respected), hugs can be a welcome sign of acceptance and support for someone living with the inherent shame and stigma of HIV.
- Address barriers: There are many reasons why people living with HIV isolate, and not all are related to psychological factors. Transportation, for example, can be a significant barrier for individuals to get to medical appointments. Issues of geographical distance can be aided by technology such as the internet or phone apps, which can provide essential contact for individuals, especially for people living with HIV in rural areas. In some locations, programs help individuals learn how to get the most from technology or to acquire a phone or computer. If formal help is not available, plenty of peers usually have the necessary knowledge to help. Finally, physical challenges may impede many HIV-positive people's ability to connect socially. I personally experience very painful neuropathy, which makes mobility more difficult and can result in less social interaction. Check with your health care provider and support team to be certain you are accessing all possible assistance to overcome barriers that may be contributing to your isolation.
- Volunteer: It is well known that focusing on the needs of others has the powerful benefit of improving our physical and emotional health. Empathy, the ability to identify with the feelings of another person, impacts our social networks in very meaningful ways. In this era of budget cutbacks for HIV services, there is a tremendous need for volunteers to step up and help maintain the fabric of our HIV support communities. Determine what special talents or skills you possess or what might be useful to your social networks. Remember that the benefits of volunteering extend beyond HIV. Countless charities serving mental health, animals, youth, and other populations and causes rely on the generosity of volunteers.
- Enhance your natural, personal network: It is often possible to expand one's social network simply by enhancing contacts that are already in place. For example, an interest group based on a hobby, sport, singing, or advocacy is a natural place to find like-minded people. Getting involved in such a "natural affinity" group will promote both a sense of purpose and health benefits.
- Engage in individual therapy: Sometimes we need professional assistance to help us move us beyond a particular set of challenges. I believe that everyone, especially people living with HIV, can benefit from therapy at certain points in his or her life, including addressing causes and symptoms related to a lack of social connection. A therapist can assist with communication skills and problem solving, developing strategies to elicit more high-quality support, and addressing underlying issues, such as shame or body image, which may be inhibiting social contact.
As medications for HIV improve longevity, other psychosocial factors such as social isolation have greater negative impact on the overall well-being of people living with HIV. The health benefits of improved social connectedness are well documented. Whether you utilize the strategies listed here or get ideas from friends, take the time and care to nurture your social networks. You will be well rewarded.