AIDS Behav DOI 10.1007/s10461-016-1338-5

ORIGINAL PAPER

Psychosocial Factors Associated with Resilience in a National Community-Based Cohort of Australian Gay Men Living with HIV Anthony Lyons1 • Wendy Heywood1 • Tomas Rozbroj1

Ó Springer Science+Business Media New York 2016

Abstract HIV-positive gay men may experience multiple sources of adversity and stress, related both to their HIV diagnosis and sexual identity. Most of these men, however, do not experience mental health problems. Little is known about factors that help them achieve resilience in the face of life challenges. This study examined psychosocial factors associated with resilience in a national communitybased sample of 357 Australian HIV-positive gay men. Resilience was measured using the Connor–Davidson Resilience Scale. Higher levels of resilience were linked with experiencing low or no internalized HIV-related stigma, having no previous history of mental health problems, and a number of socioeconomic indicators. In addition to providing a more complete picture of the mental health of HIV-positive gay men, findings from this study can be used to inform strength-based approaches to mental health prevention and support. Keywords HIV
Mental health
Positive well-being
Resilience
Gay

Introduction Studies of mental health among HIV-positive gay men tend to focus on vulnerabilities and mental health problems [1, 2]. Yet, not all HIV-positive gay men are experiencing

& Anthony Lyons [email protected] 1

Australian Research Centre in Sex, Health and Society, School of Psychology and Public Health, La Trobe University, 215 Franklin Street, Melbourne, VIC 3000, Australia

poor mental health [3], despite facing the double stigma of being gay and having HIV. Little is known about factors that help them achieve resilience in the face of these and other life challenges. Resilience is defined as the ability to adapt and thrive under adversity [4] or the ability to bounce back quickly from stressful or challenging life events [5]. Although resilience is thought to have a genetic or biological component [6], there is also evidence that it can be increased through psychosocial resources such as the use of specific coping strategies [7, 8] and drawing on social support [9]. Understanding resilience among people living with HIV (PLHIV) is important because measures of higher resilience have previously been linked to lower levels of psychological and emotional distress [10, 11], better health outcomes [10, 12], and reductions in the negative effects of life stress on health-related quality of life among PLHIV [13]. Examples of HIV-positive gay men and other PLHIV displaying resilience while adapting to their HIV diagnosis or in the face of adversities such as discrimination have also been described in a number of qualitative studies [14, 15]. Despite previous research suggesting that resilience is likely to be important to the quality of life of HIV-positive gay men, little is known about factors associated with resilience in this population. Studies in the general population have found resilience is predicted by a wide range of biological, genetic, and environmental factors [16, 17] while a recent study in Australia on lesbians and gay men [8, 18] found higher levels of resilience among those aged 50 years and older, employed full-time, and on higher incomes. Resilience was also associated with seeking social support, particularly from a relationship partner or family member. These associations, however, became nonsignificant when adjusting for other demographic and psychosocial factors.

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HIV-positive gay men face a number of unique challenges and it cannot be assumed that findings on resilience from the broader community reflect these men’s experiences. Stigma is one factor that is specific to living with HIV and may be linked to resilience in PLHIV. Minority Stress Theory suggests that experiences related to sigma have substantial implications for mental health and wellbeing [19]. HIV-related stigma is known to operate through a number of different mechanisms including experiences of discrimination from others as well as internalized stigma, such as feelings of shame and negative beliefs about oneself [20]. According to Minority Stress Theory, both external and internal expressions of stigma are linked to a lowered capacity for maintaining good mental health. There is a particular lack of studies that test associations between a wide range of potential psychosocial factors and standard measures of resilience in HIV-positive gay men. Given the predictions of Minority Stress Theory, studies seeking to identify factors associated with resilience in this population need to examine stigma-related experiences. However, it is also important that studies examine factors known to be associated with resilience in the general population. As mentioned earlier, given the social and health-related challenges of living with a stigmatized chronic illness, it cannot be assumed that findings from the general population would apply to HIV-positive gay men. The role of social support, for example, which has been shown to be a strong predictor of resilience in the general population [9] is one potential factor that ought to be considered when seeking to identify critical factors for resilience in HIV-positive gay men. Having data on factors that are closely associated with resilience can be useful for identifying the most effective strategies to promote and support the quality of life of HIVpositive gay men. There is some evidence to suggest that interventions aimed at building resilience may produce better mental health outcomes and be sustainable over a longer period of time than deficit-based interventions [21]. Some studies also highlight the potential role of resilience in health outcomes among PLHIV. For example, PLHIV recruited from organizations in Connecticut, United States found that a variety of resilience resources (i.e., modifiable factors proposed to increase or promote resilience) buffered the associations between anticipated stigma and HIV symptoms [22]. Indeed, a recent paper has called for a ‘‘resilience agenda’’ as a way of combating social stigma associated with HIV [23]. Having information on factors associated with resilience may therefore help to identify possible ways in which resilience among HIV-positive gay men might be promoted or supported, for example through evidence-based programs. In this study, we aimed to provide a more complete picture of mental health among HIV-positive gay men by

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gathering data on resilience. We conducted a national community-based survey involving Australian gay men living with HIV and specifically aimed to identify a range of possible demographic and psychosocial factors associated with higher or lower resilience. We included demographic and psychosocial variables known to be associated with resilience in the general population and other samples, such as variables related to social support, as well as stigma-related variables that may be associated with wellbeing according to Minority Stress Theory.

Method Participants A total of 402 men and women who were living with HIV, aged 18 years and older, and resident in Australia completed a national survey on the well-being of PLHIV. The total estimated population of PLHIV in Australia is 27,150 [24]. Of the 402 participants who completed the survey, 357 (89 %) identified as gay men, which reflects the demographic distribution of HIV infection in Australia [24, 25]. Survey Measures Outcome Variable Connor–Davidson Resilience Scale Resilience was measured using the 10-item version of the Connor–Davidson Resilience Scale (CD-RISC-10) [4, 26]. This scale assesses the ability to adapt to change and overcome a range of life challenges and obstacles [26]. It has been tested in a range of samples, including general population samples and specific samples (e.g., groups with medical problems and groups with specific psychiatric problems [27]), and has been shown to have high internal consistency and construct validity as a measure of resilience [4, 26, 28]. Higher scores on the CD-RISC-10 have also been shown to be strongly linked with better health and well-being [27]. Examples of items include ‘‘I am able to adapt when change occurs’’ and ‘‘I can deal with whatever comes my way’’. Participants indicate how much they agree with each item over the last month. Response options range from 0 (not at all) to 4 (true nearly all the time). Item scores are summed with higher scores indicating higher levels of resilience. Internal reliability (Cronbach’s alpha) for the CD-RISC-10 in this study was 0.93. Psychosocial and Demographic Predictor Variables Variables were selected based on potential links to resilience according to Minority Stress Theory [19] as well as

AIDS Behav

factors known to be linked with standard measures of resilience in other populations, such as social support variables [8, 18].

or more of anxiety, depression, bipolar, or post-traumatic stress were coded as currently receiving treatment for a mood or anxiety related disorder.

Stigma and Discrimination Internalized stigma was measured using the Internalized AIDS-related Stigma Scale (IA-RSS) [29]. This scale measures concealment of HIV status and shame using six dichotomous items (agree versus disagree). Examples of items include ‘‘It is difficult to tell people about my HIV infection’’ and ‘‘Being HIV positive makes me feel dirty’’. Item scores are summed with higher scores indicating greater internalized stigma. Internal reliability for the IA-RSS in this study was 0.84. Two questions were used to measure HIV-related discrimination and sexuality-related discrimination. Participants were asked ‘‘When did you last feel like you were treated unfairly as a direct result of your HIV status/sexual orientation?’’ A separate variable was computed for each question to indicate whether participants had experienced each type of discrimination in the past 12 months.

Demographic Variables Participants gave details on a range of sociodemographic items including their age, highest educational attainment, employment status, income, residential location (inner city, suburban, regional/rural), country of birth, and relationship status. Finally, participants indicated the year they first tested positive for HIV, in order to assess whether resilience may have been influenced by the length of time in which they had lived with HIV. We were particularly interested in whether resilience scores might differ between those who were diagnosed before the arrival of highly active antiretroviral therapy (HAART) in 1996 and those who were diagnosed afterward. We wanted to see if those who survived the pre-HAART era had higher resilience scores given that the pre-HAART era was especially challenging for PLHIV. This variable was therefore coded into two categories to indicate whether participants had been diagnosed during either 1980–1995 or 1996–2014.

Social Support Types of social support were measured using the short-form Interpersonal Support Evaluation List (ISEL-SF) [30]. This scale measures three types of social support—appraisal support, sense of belonging, and tangible support—using 12 items rated on a 4-point scale. Appraisal support refers to receiving emotional support. Belonging refers to having companionship or someone to do things with. Tangible support refers to receiving practical help with tasks. Items are summed for each subscale, with higher scores indicating greater perceived social support. Internal reliability for each subscale in this study was 0.80 (appraisal), 0.84 (belonging), and 0.76 (tangible). Sources of social support were assessed by asking participants how much support they had received from a relationship partner, family, friends, and/or support agencies (e.g., HIV organizations, counsellors). Responses for each type of support were coded as ‘‘A lot of support’’, ‘‘Some support’’, ‘‘A little support’’, and ‘‘None’’. Participants also reported how many people in their life they would regard as close friends. Responses were categorized to indicate 0, 1–2, 3–5, and 6 or more close friends.

Procedure The survey was conducted online from August 2014 to December 2014. Recruitment advertisements were distributed via multiple platforms that targeted people living with HIV. These included an email notification sent to a large database of PLHIV who had participated in previous studies conducted by La Trobe University, advertisements on Facebook, Grindr (a popular dating app for gay and bisexual men), and the Facebook page of The Institute of Many (a rapidly growing online community of PLHIV). A range of national and state HIV organizations also promoted the study to their members. Participants were not given any incentives for participating in the study. Before starting the survey, participants were informed that their responses were anonymous and would be kept confidential. The study was approved by the Human Ethics Committee of La Trobe University. Data Analysis

History and Current Treatment of Mood or Anxiety Related Disorders Participants were asked which mental health conditions, if any, they had ever been diagnosed with. Participants who responded yes to one or more of anxiety, depression, bipolar, or post-traumatic stress were coded as ever having been diagnosed with a mood or anxiety related disorder. Those who reported having been diagnosed with a mental health condition were subsequently asked whether they were currently receiving treatment for a mental health problem. Those who reported receiving treatment for one

Separate unadjusted linear regression models were first used to examine bivariate associations between resilience and each demographic and psychosocial predictor variable (e.g., income, social support, and stigma and discrimination). Predictor variables associated with outcomes at p \ 0.25 were then entered into a multiple regression model. This multivariable regression model was used to identify which factors had a significant independent effect on resilience after adjusting for the effect of the other

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variables. All associations were treated as significant at p \ 0.05 and all analyses were conducted using Stata Version 11.2 (StataCorp, College Station, TX).

Results Sample Profile A sample profile is displayed in Table 1. Of the 357 HIVpositive gay men who participated in the study, a majority was aged 30 years or older (92 %), born in Australia (79 %), and lived in inner city or suburban areas (79 %). Just over half (53 %) were employed full-time and most (79 %) had some form of tertiary education. Almost three quarters (73 %) first tested HIV-positive after the arrival of HAART in 1996. Resilience Mean CD-RISC-10 scores (mean 27.0, SD = 7.7; median = 28; range 6–40) were lower than previously reported in general population samples (ranging from 29 to 32) but similar to studies of groups living with other chronic illnesses [27], although notably these studies were largely conducted in the United States. Table 2 displays the regression results. In unadjusted analyses, resilience scores were significantly higher among those with a greater income (F [3, 342] = 3.06, p = 0.03), lower internalized HIV-related stigma (F [1, 349] = 33.05, p \ 0.001), greater number of close friends (F [3, 353] = 5.97, p \ 0.001), those who had never been diagnosed with a mood or anxiety related disorder (F [1, 355] = 29.23, p \ 0.001), and were not currently receiving treatment for a mood or anxiety related disorder (F [1, 355] = 27.22, p \ 0.001). Higher levels of resilience were also found among men with greater appraisal support (F [1, 350] = 67.77, p \ 0.001), greater sense of belonging (F [1, 352] = 65.78, p \ 0.001), more tangible support (F [1, 354] = 58.53, p \ 0.001), and greater support from partners (F [3, 353] = 3.19, p = 0.03), friends (F [3, 353] = 15.87, p \ 0.001), and family (F [3, 352] = 8.20, p \ 0.001). We then conducted a multivariable regression model to identify which factors were independently associated with resilience. As mentioned earlier, variables associated with resilience at p \ 0.25 were entered into the regression, which identified significant independent factors by adjusting for the effect of the other variables in the regression. Significant independent factors associated with resilience were income (F [3, 293] = 2.93, p = 0.03), internalized HIV-related stigma (F [1, 293] = 13.20, p \ 0.001), ever being diagnosed with a mood or anxiety related disorder

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(F [1, 293] = 5.84, p = 0.02), and currently receiving treatment for a mood or anxiety related disorder (F [1, 293] = 7.89, p = 0.005). After adjustments, number of close friends, specific types of social support (appraisal, belonging, and tangible), and support from partners and friends were no longer associated with resilience. Overall model fit was adjusted-R2 = 0.29, indicating that almost 30 % of the variance in resilience scores was predicted by factors in the model.

Discussion This national sample of Australian HIV-positive gay men had resilience levels that were lower on average compared to available population norms. It is worth noting, however, that these norms were largely from the United States due to a lack of similar data in Australia. Differences in population levels of resilience between the two countries cannot be ruled out, although the chances of this may be low given that other measures of well-being show similar patterns between the two countries [31]. That said, further studies are needed to fully determine whether resilience is generally lower among HIV-positive gay men compared to the broader population. However, support organizations and health professionals may still wish to consider developing and implementing tailored resilience-training programs for HIV-positive gay men, especially given that resilience has been shown to be a major protective factor for mental health problems [6] and may therefore be one important way of improving quality of life in this population. From the multivariable analysis, we identified several significant independent psychosocial factors linked to greater resilience. The strongest factor was having low or no internalized HIV-related stigma. This factor also appeared to be more central to resilience than a range of other factors, such as several types of social support. Other studies have also found HIV-related stigma to have a negative impact on health and psychological well-being among PLHIV [32, 33]. It would appear that stigma is a major threat to resilience in this population. One possible explanation for the link we found between internalized HIV-related stigma and resilience relates to the likelihood that HIV-related stigma is associated with feelings of shame or low self-worth. Some men with high levels of internalized stigma may therefore experience a sense of hopelessness, which may make it harder to overcome life challenges. However, this is speculative and just one possible explanation. Further research is needed to fully understand the link we found between internalized HIVrelated stigma and resilience. In the meantime, and as others have noted [34], reducing the negative impact of HIV-related stigma needs to be a priority. Unfortunately,

AIDS Behav Table 1 Sample profile (N = 357) No.

%

Age 18–29

30

8.5

30–49

184

52.3

50?

138

39.2

Education Secondary or below

76

21.4

Non-university tertiary

127

35.7

University—undergraduate

77

21.6

University—postgraduate

76

21.4

Full time

188

53.0

Part time or casual

59

16.6

Unemployed

35

9.9

Retired

40

11.3

33

9.3

0–19,999

61

17.6

20,000–49,999

85

24.6

50,000–99,999

133

38.4

100,000?

67

19.4

Employment

Other Income (Australian dollars)

Residential location Inner city

209

58.7

Suburban

71

19.9

Regional/rural

76

21.4

Australia

282

79.0

Overseas

75

21.0

168

47.1

189

52.9

1980–1995

96

27.0

1996–2014

260

73.0

Mean

SD

27.0

7.7

Country of birth

Regular relationship Yes No Year first tested positive

Resilience (CD-RISC-10)

eliminating the stereotypes and attitudes that underpin stigma can take time [35–37], so it may also be important that any resilience-building programs also address ways of tackling internalized stigma. Not having a history of mood or anxiety related disorders was another factor associated with resilience. Links between lower resilience and psychological distress have been reported in previous studies of HIV-positive gay men and other PLHIV [10, 11]. It perhaps suggests that having a history of mental health problems is indicative of lower overall resilience. We know from previous research that there are high relapse rates for depression and anxiety

disorders [38–40]. It may therefore be important to target support programs and resilience-training to those with a history of mental health problems to help prevent future mental health problems. It is also not surprising that those who were currently receiving treatment for a mental health problem also reported significantly lower resilience given the strong link between resilience and mental health outcomes. One further independent factor for resilience was income. A number of studies have previously linked resilience and socioeconomic indicators among gay men [8, 41] and HIV-positive women [42]. Other studies also show a link between having a higher income and having better mental health outcomes among gay men [43]. It is currently not known, however, the degree to which greater access to financial resources helps buffer detrimental experiences or the degree to which having greater resilience helps these men to maintain high-income employment. Previous research suggests that poverty is a determinant of poorer mental health outcomes [44, 45], but a longitudinal study may be needed in future to examine changes in resilience over time and to test possible directions of causality among HIV-positive gay men. Measures of social support (including types and sources of support) were associated with resilience in the bivariate analyses, however these relationships became non-significant after adjusting for other psychosocial factors in the multivariable analysis. This is in contrast with studies of the general population that show a strong link between social support and resilience [9]. This may be due to the use of different measures to assess social support. However, given that the ISEL-SF is known to have very good validity as a measure of social support, the fact that the ISEL-SF subscales were no longer significantly associated with resilience in the multivariable regression again highlights just how central other factors are to resilience in this population, such as internalized HIV-related stigma. Interestingly, whether men were diagnosed with HIV either before or after the arrival of HAART was not associated with resilience in this sample. Although large numbers of men who were diagnosed pre-HAART did not survive, we included this variable in the analysis because those who did survive faced the most difficult challenges coping with HIV during that period in the HIV epidemic, including living during the worst years of HIV-related stigma. Given our findings, it is possible that while a preHAART diagnosis may have been initially more challenging and may have had implications on well-being and resilience, these men have also had longer to adapt to HIVrelated challenges. It is also possible that, because the preHAART era ended almost 20 years ago, being diagnosed pre-HAART may simply no longer be a factor in how men cope with their life today. In any case, further research may

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AIDS Behav Table 2 Regression results for factors associated with The Connor–Davidson Resilience Scale (10-items) (N = 357) Adjustedb

Unadjusted Mean

B

(SE B)

b

18–29

26.4

-0.66

(1.54)

-0.02

30–49a 50?

27.0 27.1

– 0.11

– (0.88)

– 0.01

B

Age

(SE B)

b

p = 0.89

Education

p = 0.11

Secondary or below

a

p = 0.27

25.6

–

–

–

–

–

–

Non-university tertiary

26.6

0.94

(1.12)

0.06

0.39

(1.04)

0.02

University—undergraduate

28.4

2.79

(1.25)

0.15*

2.14

(1.18)

0.11

University—postgraduate

27.7

2.04

(1.25)

0.11

0.71

(1.19)

0.04

–

–

–

Employment

p = 0.09

p = 0.92

Full timea

27.6

–

Part time or casual

27.3

-0.35

(1.15)

-0.02

0.13

(1.25)

0.01

Unemployed

24.4

-3.19

(1.42)

-0.12*

-0.63

(1.77)

-0.02

Retired

27.8

0.22

(1.34)

0.01

0.34

(1.57)

0.01

Other

24.9

-2.76

(1.46)

-0.10

-1.06

(1.66)

-0.04

–

–

Income (Australian dollars)

p = 0.03

p = 0.04

0–19,999

25.3

-1.83

(1.19)

-0.09

-0.05

(1.50)

-0.002

20,000–49,999 50,000–99,999a

26.8 27.1

-0.29 –

(1.07) –

-0.02 –

-0.04 –

(1.24) –

-0.002 –

100,000?

29.3

2.22

(1.15)

0.11

3.16

(1.08)

0.16**

Residential location a

p = 0.12

Inner city

26.9

–

Suburban

25.8

-1.08

(1.06)

-0.06

Regional/rural

28.4

1.54

(1.03)

0.08

–

–

Country of birth

p = 0.06 –

–

–

-0.07

(0.99)

-0.004

2.27

(0.99)

0.12*

p = 0.24

p = 0.28

Australiaa

26.8

–

–

–

–

–

–

Overseas

27.9

1.17

(1.01)

0.06

1.04

(0.95)

0.05

Yes

27.3

0.62

(0.82)

0.04

Noa

26.7

–

–

–

1980–1995

26.9

-0.13

1996–2014a

27.0

–

25.8

-1.68

0.59

(0.94)

0.03

27.5

–

–

–

–

-0.73

(0.20)

-0.20**

–

–

–

Regular relationship

p = 0.45

Year first tested positive

Treated unfairly because of HIV status past 12 m Yes Noa

p = 0.89 (0.93) –

-0.01 – p = 0.08

(0.94) –

-0.09 –

Treated unfairly because of sexual orientation past 12 m

p = 0.53

p = 0.44

Yes

26.4

-0.83

Noa

27.2

–

Internalized AIDS-related Stigma Scale

-1.06

(1.07) – (0.18)

-0.04 – -0.29**

p \ 0.001 p \ 0.001

Number of close friends

p = 0.50

0a

26.8

–

1–2

23.7

-3.13

(1.38)

-0.14*

-1.29

(1.33)

-0.06

3–5

27.0

0.19

(1.12)

0.01

-1.62

(1.11)

-0.10

6?

29.1

2.30

(1.19)

0.13

-0.79

(1.20)

-0.05

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–

–

p \ 0.001

AIDS Behav Table 2 continued Adjustedb

Unadjusted Mean

B

(SE B)

b

B

(SE B)

b

Social support—appraisal

1.01

(0.12)

0.40**

p \ 0.001

0.24

(0.21)

0.10

p = 0.26

Social support—belonging

0.93

(0.11)

0.40**

p \ 0.001

0.30

(0.19)

0.13

p = 0.11

Social support—tangible

0.97

(0.13)

0.38**

p \ 0.001

0.19

(0.22)

0.07

Support from partner/spouse

p = 0.02

A lota

28.4

–

Some

26.7

-1.68

(1.44)

A little

22.6

-5.81

(2.24)

None

26.4

-1.99

(0.89)

–

–

–

–

–

-0.07

0.48

(1.35)

0.02

-0.14*

-0.68

(2.15)

-0.02

-0.13*

1.01

(0.90)

0.07

–

–

–

p \ 0.001

Support from friends

p = 0.48

A lota

29.8

–

Some

26.9

-2.93

(0.90)

-0.18**

-1.17

(0.97)

-0.07

A little

23.5

-6.25

(1.05)

-0.33**

0.002

(1.36)

0.0001

None

20.9

-8.93

(1.99)

-0.23**

-1.72

(2.46)

-0.04

–

–

p \ 0.001

Support from family

p = 0.11

A lota Some

30.4 26.5

– -3.90

– (1.07)

– -0.23**

– -2.16

– (1.06)

– -0.13*

A little

25.1

-5.22

(1.13)

-0.29**

-2.41

(1.20)

-0.14*

None

26.2

-4.13

(1.20)

-0.21**

-0.85

(1.28)

-0.04

Support from agencies

p = 0.30

A lota

29.1

–

Some

27.1

-2.05

(1.48)

-0.11

A little

26.6

-2.50

(1.46)

-0.14

None

26.6

-2.47

(1.35)

-0.16

–

–

p \ 0.001

Ever diagnosed with a mood or anxiety related disorder Yes Noa Currently receiving treatment for a mood or anxiety related disorder

p = 0.40 p = 0.63

25.3

-4.39

29.7

–

(0.81) –

-0.28** –

p = 0.02 -2.15

(0.89)

-0.14*

–

–

–

p \ 0.001

Yes

23.5

-4.75

Noa

28.2

–

(0.91) –

-0.27** –

p = 0.005 -2.79

(0.99)

-0.16**

–

–

–

B unstandardized beta coefficient, SE standard error, b standardized beta coefficient * p \ 0.05; ** p \ 0.01 R2 = 0.36, adjusted R2 = 0.29, F(32, 293) = 5.11, p \ 0.001 a

Reference category

b

Adjusted for education, employment, income, residential location, country of birth, treated unfairly because of HIV status past 12m, internalized AIDS-related stigma, number of close friends, appraisal support, belonging support, tangible support, support from partner/spouse, support from friends, support from family, ever diagnosed with a mood or anxiety related disorder, and currently receiving treatment for a mood or anxiety related disorder

be warranted, particularly research that examines other aspects of well-being between the pre- and post-HAART cohorts. For now, the lack of difference in resilience suggests that targeted resilience training may be beneficial to both those who are newly diagnosed as well as those who have been living with HIV for a longer period of time.

Having knowledge of demographic and psychosocial factors associated with resilience among HIV-positive gay men is important. Research suggests that resilience can be built using a range of psychosocial techniques [6]. Resilience-training programs are currently available for the general population, including self-help and group-based

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programs [8]. Such programs, however, may need to be adjusted to take into account the specific needs of HIVpositive gay men, including issues identified in our study such as managing HIV-related stigma and accessing appropriate forms of support. We are unaware of any empirically tested resilience-training programs specifically designed for HIV-positive gay men, so this is an area that deserves further attention. This study had a number of strengths and limitations. Surveying a large community-based sample of HIV-positive gay men from across Australia was a major strength of the study. However, the sample was not population-based, so we cannot claim that it is fully representative of the entire population of Australian HIV-positive gay men. It is worth noting though that the sample was diverse, including men from a range of socioeconomic backgrounds as well as urban and rural areas. The demographic profile was also similar to other studies of Australian HIV-positive gay men. For example, in our sample, 43.0 % reported having a university education, 69.6 % were in paid employment, and 8.5 % were aged younger than 30 years. A national study involving offline data collection methods reported 41.5 % with a university education, 69.5 % in paid employment, and 7.7 % aged younger than 30 years [46]. It is also worth noting that our sample was cross-sectional. Thus, directions of causality between some predictor variables and resilience are therefore unknown. Longitudinal research is needed to gather detailed information on the directions of these relationships. The sample was further limited to gay men. Excluding other subpopulations of PLHIV, such as heterosexual men or women, was necessary due to small response rates and previously reported differences in experiences of resilience across different genders and sexual identifies [41]. It is therefore unknown whether our findings are generalizable to other PLHIV subpopulations and this needs to be examined in future research that targets specific subpopulations or gathers a larger sample.

Conclusions This was among the first studies to specifically examine resilience among HIV-positive gay men in a national community-based sample. Of a range of demographic and psychosocial factors, we found internalized HIV-related stigma was the strongest factor associated with lower resilience. There are well-established and strong links between resilience and health outcomes, thus making resilience an important issue to address for preventing mental health problems and increasing health and wellbeing. This study suggests that stigma may be an important topic to address in any efforts to support resilience among

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HIV-positive gay men and therefore to improve health outcomes. Tackling stigmatizing attitudes and beliefs among the general population is clearly essential to this. However, according to the findings of this study, it may also be necessary to directly address internalized HIV-related stigma at an individual level, especially given that it may still take considerable time to eliminate stigmatizing attitudes in the broader population. Anyone devising resilience-training programs for HIV-positive gay men may therefore wish to consider ways of preventing internalized stigma. A focus on other factors in addition to internalized stigma, such as having a history of mental health problems, as identified in this study may also be helpful for tailoring programs aimed at building resilience. Acknowledgments This study was funded by the Australian Government Department of Health.

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