742919

research-article2017
ICM0010.1177/1179916117742919Indian Journal of Clinical MedicineMukherjee et al

Study on Defense Mechanisms to Cope With Stress Due Indian Journal of Clinical Medicine
Volume 8: 1–6

to Stigma Among People Living With HIV/AIDS Reported © The Author(s) 2017
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DOI: 10.1177/1179916117742919
https://doi.org/10.1177/1179916117742919

Ayan Mukherjee1, Sandeep Lahiry1, Anindya Mukherjee2,

Shouvik Choudhury1 and Rajasree Sinha3
1Department of Pharmacology, Institute of Post Graduate Medical Education & Research
(IPGME&R), Kolkata, India. 2Department of Community Medicine, Medical College and Hospital,
Kolkata, India. 3Department of Pediatrics, Medical College and Hospital, Kolkata, India.

ABSTRACT:

Aim: To explore the stigmatizing pattern in people living with HIV/AIDS (PLWHA) and assess coping strategies adopted for quality of life
(QOL) appraisal.

Methods: In the background of a descriptive, cross-sectional research design, PLWHA attending HIV (human immunodeficiency virus)
outpatient clinic at Medical College, Kolkata (n = 120) were enrolled through “snowball sampling.” A brief semistructured interview schedule
was used to elicit data on socio-demographics. Stigma was assessed using a 4-point scale (40-item). Quality of life was assessed using
WHOQOL-BREF (World Health Organization Quality-of-Life) scale (26-item).

Results: About 96.7% reported being stressed. Stigma was mostly confronted in socio-familial context. Fear of being stigmatized was
much higher compared with those who actually faced stigma (69.2% vs 27.5%; P < .01). Quality of life negatively correlated with internalizing
of stigma in the psychological domain (P < .01). Proportion experiencing actual stigma (women vs men: 79% vs 74%) experienced an above
moderate QOL. Multiple defense mechanisms were identified. “Altruism,” “Anticipation,” and “Humor” were the most preferred defense strat-
egies. However, such coping strategies appeared to be self-taught and only modestly helpful in managing perceived stigma.

Conclusions: People living with HIV/AIDS should avoid internalizing stigmatized feeling and engage in social activities to work toward a
better QOL.

Keywords: Defense mechanism, stigma, stress, HIV/AIDS

RECEIVED: August 5, 2017. ACCEPTED: October 22, 2017. Declaration of conflicting interests: The author(s) declared no potential
conflicts of interest with respect to the research, authorship, and/or publication of this
Type: Short Report article.

Funding: The author(s) received no financial support for the research, authorship, and/or CORRESPONDING AUTHOR: Sandeep Lahiry, Institute of Postgraduate Medical
publication of this article. Education & Research (IPGME&R), 244 B, Acharya J.C. Bose Road, Kolkata 700020,
India. Email: sndplry@gmail.com

Introduction
Nearly 36.7 million people worldwide were diagnosed with
HIV/AIDS in 2015, which included 1.8 million (5%) young
children (below 15 years).1,2 The HIV (human immunodefi-
ciency virus) incidence rates have been so alarming that an esti-
mated 2.1 million individuals became newly infected in 2015,3
which included approximately 150 000 children, belonging
mostly to sub-Saharan African areas. Most were infected
through perinatal transmissions or breastfeeding.4
However, apart from such a global crisis which was predicted
way back in the 1980s, a relatively newer menace of “AIDS-
related stigmatization” has been slowly gaining momentum. In
fact, a few years ago, Jonathan Mann, Director of World Health
Organization (WHO) Global Programme on AIDS (1987),
had identified 3 distinct types of epidemic: (1) HIV infection,
(2) AIDS epidemic, and (3) HIV/AIDS stigma.5 The third
entity (stigma) was not given due importance until the 1990s
when AIDS-related stigma and discrimination was actually
identified to be a greater concern for health care providers. The
condition was referred to as prejudice, negative attitudes, abuse
and maltreatment directed at people living with HIV/AIDS
(PLWHA).6 Stigma could be aggravated due to several reasons,
which included being shunned by family and relatives, peers,
and the wider community; poor health care delivery; inadequate
health education; erosion of basic rights; and psychological
damage which would ultimately lead to unsatisfactory patient
compliance and treatment outcomes.7–11
It is very well known today that AIDS and stigma do coexist
worldwide. Although there remain regional and ethnic varia-
tions in prevalence rates, the inherent growing trend remains
comparable worldwide.12–14 They may occur alongside other
forms of discrimination, such as racism, homosexuality or
misogyny, prostitution, and drug abuse, and such associations
complicate situation further because these are considered socially
unacceptable in many parts of the world.15,16 The concern for the
developing world seems even greater. For instance, India has the
third largest HIV population in the world.17 It is considered as a
national epidemic because of very high prevalence rates in the
country (in 2015, HIV prevalence in India was nearly 0.26%).17

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2 Indian Journal of Clinical Medicine 00(0)
The Government of India (GoI) outlined its National AIDS
Control Programme-IV (NACP-IV), which made elimination
of stigma and discrimination with its major focus alongside ther-
apy success.17 In fact, the GoI had the HIV/AIDS Bill (2006)
passed in 2014, which had one of several clear mandate: provi-
sions for prohibiting discrimination in employment, education,
health care, travel, and insurance among PLWHA.18,19 Moreover,
it recognizes that PLWHA have the right to privacy and confi-
dentiality about disease status.18,19 However, despite such clearly
defined regulations, a major proportion of PLWHA continue to
experience high levels of discrimination in households, commu-
nity, and at workplaces.20 Marfatia et al20 showed that 25% HIV-
infected individuals in India had been refused medical care due
to strong evidence of stigma at workplace, and 74% of PLWHA
did not disclose disease status for fear of discrimination and
community retaliation. Surprisingly, stigma and discrimination
have also been found to be very common in health setups as
pointed by Ekstrand et al.21
Given such a situation, it becomes imperative in many ways,
for PLWHA to adopt defense strategies to cope with an inher-
ent stress associated with stigmatization. Freud in his psycho-
analytical theory defined defense mechanisms as unconscious
psychological strategies brought into play by various entities to cope
with reality and to maintain self-image.22 Structural forms of
defense mechanisms were defined as Id, Ego, and Super Ego23
because it was suggested that defense or coping strategies work
by distorting the Id impulses into acceptable forms or by
unconscious or conscious blockade of these impulses.24 Freud
and Valliant even classified defense mechanism under various
categories for qualitative assessment of such behavior.25
However, it was also suggested that even normal individuals
tend to use different defense mechanisms throughout life.
Rationale
Our study provides insights regarding as to how PLWHA
attending our setup experience stigma. It provides estimates on
proportion being stressed and assesses their coping strategies,
to appraise the quality of life (QOL).
Methods
Ethics
The study was conducted in conformity to Helsinki II
Declaration, and protocol approval was done by the Institutional
Ethics Committee (IEC) at Medical College and Hospital,
Kolkata, India. Oral and written informed consents of study
participation were obtained. Strict confidentiality of subject
data was maintained.
Study design
This study was an observational, descriptive study with a cross-
sectional design. It enrolled subjects from a cohort of PLWHA
attending HIV outpatient clinic at Medical College, Kolkata
by snowballing method. The data were collected over a period of
8 weeks, thrice weekly (September-November, 2016). A brief
semistructured interview schedule was used to elicit data on
socio-demographics.
Stigma was measured using a scale discussed by Berger
et al.26 It is a 40-item 4-point scale which categorizes stigma
into (1) actual stigma (personalized stigma), (2) perceived
stigma (concern with public attitudes about people with HIV),
(3) disclosure concerns, and (4) internalized stigma (negative
self-image). The scores have demonstrated a positive correla-
tion to stigma experience (the higher the score, the higher the
stigma). A translated scale was pilot tested for reliability suited
to our cultural setting. The internal reliability score was 0.95.
Quality of life was assessed using WHOQOL-BREF
(World Health Organization Quality-of-Life) (1998) scale,27
which is a 26-item scale with 4 domain scores. The domains
are studied under physical, psychological, social relationships,
and environmental aspects. The domain scores have a positive
correlation (higher scores denoted higher QOL). It is basically
a brief version of WHOQOL-100 (100-item scale).
Data collection from a respondent was carried in a one-to-
one situation, in the total privacy of a consenting room adjoin-
ing outpatient clinic, and alternate arrangements were made
for the supervision of young children or dependents of the
respondents. On average, each interview required 30 to 40 min-
utes. Outcome assessment included (1) level of stigma-related
stress among HIV-positive persons and (2) defense or coping
strategies adopted to mitigate associated stress.
Statistical analysis
Descriptive data were represented as counts and percentages, if
not stated otherwise. The Pearson correlation coefficient was
calculated to assess associations between stigma and QOL. χ2
analysis was used for categorical data to determine the differ-
ences between the groups. Multivariate analysis was used to
study the influence of some of the socio-demographic variables
on stigma. The analysis was done using SPSS (version 16.0).
Results
In our study, HIV/AIDS was more prevalent in married
women, mostly from urban areas belonging to lower socioeco-
nomic status (Table 1). Most people were diagnosed within
6 months of HIV infection and received antiretroviral therapy.
Disease communicability was rather high between spouse and
near relatives (Table 2).
Most subjects reported that their HIV status was known to
their family members, but relative anonymity was maintained
for neighbors and workplace associates. As a result, stigma
experiencing was mostly from family members and neighbors.
However, the fear of being stigmatized was much higher com-
pared with those who actually faced stigma (69.2% vs 27.5%;
Mukherjee et al 3

Table 1.  Baseline characteristics of subjects (n = 120).

Demographic factors Frequency, No. (%) P value

Gender p = 0.698

 Male 56 (46.7)

 Female 64 (53.3)

Residence p = 0.051

 Rural 44 (36.7)

 Urban 76 (63.3)

Literacy p = 0.117

 Primary 63 (52.5)

 Secondary 29 (24.2)

 Tertiary 2 (1.6)

 Illiterate 26 (21.7)

Family member p = 0.791

 <4 63 (52.5)

 >4 57 (47.5)

Marital status p < 0.005*

 Married 73 (60.8)

 Unmarried 16 (13.4)

 Separated 31 (25.8)

Family income (INR per month) p = 0.752

 <500 50 (41.6)

 501-1000 40 (33.3)

 1001-2000 20 (16.6)

 >2000 10 (8.3)

Type of family p = 0.068

 Nuclear 75 (62.5)

 Joint 45 (37.5)

Religion p = 0.078

 Hindu 73 (60.8)

 Muslim 38 (31.6)

 Christian 9 (7.5)

*P < .05; statistically significant.

P < .01). A bivariate analysis revealed that proportion of women
(79%) and men (74%) experiencing actual stigma seemed more
determined to live and experienced an above moderate QOL.
About 96.7% patients reported being stressed due to such rea-
sons (Table 3). Internalizing of stigma showed a negative cor-
relation with QOL in the psychological domain (r = −.265;
P < .01). Proportion experiencing actual stigma seemed more
determined to live and experienced an above moderate QOL
(Table 4). Socio-demographic variables were tested for by mul-
tivariate analysis; however, none of the variables had a signifi-
cant influence on stigma (data not tabulated).
Multiple defense strategies adopted by PLWHA were iden-
tified and classified according to Vaillant’s Categorization of
Defense Mechanism. Altruism (62.9%), Anticipation (94%), and
4 Indian Journal of Clinical Medicine 00(0)
Table 2.  Distribution of study population as per HIV/AIDS-related information (n = 120).
HIV/AIDS-related information
Duration of diagnosis of HIV/AIDS, mo
 <6
 7-12
 13-48
 >48
Antiretroviral therapy taken
 Yes
 No
Duration of drug therapy (n = 69), mo
 <6
 7-12
 >12
Any relative with HIV/AIDS
 Yes
 No
Spouse infected with HIV/AIDS (n = 73)
 Yes
 No
Humor (78.4%) were the most preferred coping strategies
(Level-IV). Coping appeared to be self-taught and only mod-
estly helpful in managing perceived stigma.
Discussion
The study demonstrates that actual stigma experienced
among PLWHA is far less as compared with the fear of being
stigmatized or perceived stigma; however, this leads to
increased stressful situations on part of the affected. As a
result, various defense strategies are embraced, although such
self-taught coping appears to be only modestly helpful in
managing perceived stigma.
The study reported that stigma arises mostly from family
members and neighborhood in directly stigmatized patients;
however, such factors do not alter QOL significantly (Table 4).
However, because impact on psychological domain and QOL is
significantly correlated, a counseling process should go beyond
PLWHA and include near relatives. An encouraging finding is
that those individuals who experienced actual stigma had an
above moderate QOL. This could be due to the fact that being
stigmatized kindles in them a feeling of determination and zeal
to counter the effect of stigma. It indicates that internalizing of
stigmatized feelings accentuates the problem of stigma, as that
study reveals a highly significant negative relationship between
Frequency, No. (%) P value
p = 0.233
52 (43.3)
27 (22.5)
35 (29.2)
6 (5)
p = 0.300
69 (57.5)
51 (42.5)
p = 0.206
39 (56.5)
22 (31.9)
8 (11.6)
p = 0.091
74 (61.7)
46 (38.3)
p = 0.680
40 (54.7)
33 (45.2)
internalized stigma and QOL in the psychological domain.
Stigma deprives an individual of social support, which in turn
could negatively affect the QOL. The finding, where in conjunc-
tion with previous studies, reported that internalized stigma is
likely to make an individual more sensitive to both actual and
anticipated rejection and stigmatization by others which nega-
tively affect disclosure.28 Stigmatized individuals are also vulner-
able to feelings of self-hatred, which can result when they
internalize society’s negative views of them.29–32 Discrimination
was also found to be prevalent among medical professionals.33
Stigma can affect disclosure34–36; hence, hiding one’s status may
not only preclude HIV-related social support. In 2003, a study
from South India showed similar findings.37
The findings of this study encourage PLWHA, therefore, to
rise above stigma and live a QOL. Understanding and address-
ing moderating variables can inform health care provision,
stigma reduction interventions, and public health policy. The
findings also support the need for psychosocial counseling for
the infected as well as the caregivers to cope with the illness
positively. Increment in cultural and media exposure of people
living with AIDS is the need of the hour. Fear-inculcating
information about HIV/AIDS that emphasize the fatality of
the condition or try to portray HIV as a result of moral decay
and social deterioration does little to motivate people to change
Mukherjee et al 5

Table 3.  Distribution of study population according to stigma-related factors (n = 120).

Stigma-related factors Frequency, No. (%) P value

Disease known to family members <.01*

 Yes 97 (80.8)

 No 23 (19.2)

Disease known to neighbors .043*

 Yes 36 (30)

 No 84 (70)

Disease known in workplace <.01*

 Yes 19 (15.8)

 No 101 (84.2)

Stigma faced .632

 Yes 33 (27.5)

 No 4 (3.3)

 Feared of being stigmatized 83 (69.2)

Stigmatized by/at (n = 33) .873

 Spouse/partner 5 (15.1)

 Family 10 (30.3)

 Neighbors 10 (30.3)

 Workplace 1 (3.1)

 Composite 7 (21.2)

Whether stressed? <.01*

 Yes 116 (96.7)

 No 4 (3.3)

*P < .05; statistically significant.

Table 4.  Correlation coefficient (r) between stigma and quality of life.

Stigma Physical domain Psychological domain Sociological domain

Actual −.116 −.182 −.063

Perceived −.105 −.002 −.003

Disclosure .045 .065 .012

Internal −.123 −.265* −.086

*P < .05; statistically significant.

their behavior but cast infected individuals as immoral and
deserving of discrimination.
Limitation(s)
(1) The generalizability of study findings may not be appro-
priate because it was a single center experience, (2) the
cross-sectional design may have lent itself to retrospective
bias, (3) limited study time frame to assess the defense mech-
anism for a long period was not an ideal approach, (4) assess-
ment of defense mechanism was based on only Vaillant’s
categorization, and (5) assessment was subjectively based on
patient’s mood during interviewing, which could be affected
in the wake of recent events.
6 Indian Journal of Clinical Medicine 00(0)
Author Contributions
AnM conceived and designed the experiments, made critical
revisions, and approved final version. SL analyzed the data.
AM wrote the first draft of the manuscript. SC contributed to
the writing of the manuscript. RS agree with manuscript results
and conclusions. AM and SL jointly developed the structure
and arguments for the paper. All authors reviewed and approved
the final manuscript.
2 0. Marfatia YS, Sharma A, Modi M. Overview of HIV/AIDS in India. Ind J Sex
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