Abstract

Factors that involve the dynamics in interpersonal relationships and may have consequences in health are still little explored in people living with HIV/AIDS. The aim was to identify the evidences of literature regarding adult attachment style and HIV. It is an Integrative literature review. Seven databases were explored, using the combination of key words and Boolean connectors: "Attachment Style OR Object Attachment AND HIV". A reasonable number of articles addressed attachment among people with HIV as a mediator to post-traumatic stress disorder, depression and stress. The prevalence of insecure attachment in this group was high. Evidence was also found in relation to the attachment as an important factor to adaptation to the diagnosis of HIV, attachment and behavior in interpersonal relationships, and emphasize the possibility of changing the attachment style.

Key words
Attachment style; HIV; Object Attachment

Resumo

Fatores que envolvem a dinâmica nos relacionados interpessoais e podem ter consequências na saúde ainda são pouco explorados em Pessoas vivendo com HIV/AIDS. O objetivo desse estudo é identificar as evidências na literatura relacionando estilo de apego e HIV em adultos. Trata-se de uma revisão integrativa de literatura. Sete bases de dados foram exploradas, usando a combinação das palavras-chave e dos seguintes conectores booleanos em inglês: "Attachment Style OR Object Attachment AND HIV". Um número razoável de artigos abordou o vínculo entre pessoas com HIV como mediador de transtorno de estresse pós-traumático, depressão e estresse. A prevalência de apego inseguro nesse grupo foi alta. Evidências mostram ainda a relação entre apego e a adaptação ao diagnóstico de HIV, apego e estilos de comportamento nos relacionamentos, e destacam ainda a possibilidade de modificação do tipo de apego.

Palavra-chave
Estilo de anexo; HIV; Anexo de objetos

Introduction

Characteristics of one’s personality have influence on individuals behavior towards others. Interpersonal relationships are affected directly by the personality of individuals, and generate dysfunction that can result in conflicts and instability. Adult behavior and the adversities in the relationship dynamics are consequences of the first human relationships, during childhood, period where there is the formation of initial attachments¹1 Bowlby J. Apego : a natureza do vínculo. São Paulo: Martins Fontes; 2002..

Attachment behavior is something different from instinct, but is as vital as food and reproduction. It is a social behavior that is easily observed in children simply a child’s distress when the mother moves away or happiness when the mother returns¹1 Bowlby J. Apego : a natureza do vínculo. São Paulo: Martins Fontes; 2002.. In adults, the theory explains the way people connect themselves emotionally, as they make use of social relationships to mediate their emotional needs and define how to differentiate them according to their type of attachment²2 Vrtička P, Sander D, Vuilleumier P. Influence of adult attachment style on the percep-tion of social and non-social emotional scenes. J Soc Pers Relat 2012; 29(4):530-544..

There are several classifications assigned to attachment styles, with subtle variations in the main types. The four main attachment styles are secure, preoccupied, dismissing and fearful. Preoccupied is the same as Anxious-Ambivalent, Dismissing is similiar to Dismissing Avoidant, and Fearful is also known as Fearful Avoidant. Because there is a wide range of nomenclature, it is important to focus on the key features of each pattern and the formation of its internal working models. Each attachment pattern has a distinction which can be understood as characteristics of an internal working models. These models assess individuals’ level of comfort or anxiety experienced when maintaining intimate relationships including a sense of self-worth and a view of appreciation of the other. It also includes a sense of the partner’s personal worth of trust and love. The feature anxiety relates to self-worth and acceptance/rejection by others, and the feature deprivation refers to the degree to which a person searches or avoids intimacy and interdependence in relationships³3 Collins NL, Feeney BC. A Safe Haven: An Attachment Theory Perspective on Support Seeking and Caregiving in Intimate Relationships. J Pers Soc Psychol 2000; 78(6):1053-1073..

Individuals demonstrating secure style of attachment present low level of anxiety and deprivation, demonstrate comfort with intimacy, want to rely on others and believe they are valued by others. People preoccupied have high level of anxiety and low deprivation, and demonstrate exaggerated interest in maintaining closeness and dependency, while have high fear of being rejected. In dismissing style there is a low level of anxiety and high deprivation, these people do not value the formation of bonds, and appreciate independence and self-confidence. Adults fearful have high anxiety and deprivation, although they wish to engage in relationships and get approval of others, they avoid intimacy because of their fear of rejection³3 Collins NL, Feeney BC. A Safe Haven: An Attachment Theory Perspective on Support Seeking and Caregiving in Intimate Relationships. J Pers Soc Psychol 2000; 78(6):1053-1073..

Attachment style may be associated with increasing in vulnerability. Vulnerability is defined primarily based on social processes, and it is formed by three factors: the first one is the level of exposure to risky situations; the second is the person intrinsic and extrinsic ability to react to these risks; and the last one concerns individual adaptability to cope with the situation, what depends on the extent of the risk and individual resilience⁴4 Schumann LR, Moura LBA. Vulnerability synthetic indices: an integrative literature re-view. Cien Saude Colet 2015; 20(7):2105-2120..

A factor that contributes substantially to the raising of studies about the vulnerability is the spread of Acquired Immune Deficiency Syndrome (AIDS)⁵5 Izumi LY, Bertolozzi MR, Takahashi RF, Fracolli LA. The use of the “vulnerability” concept in the nursing area. Lat Am J Aquat Res 2008; 16(5):923-928.. This infection has been responsible for a persistent pandemic, leading researchers to move efforts for its control. Traits inherent to interpersonal relationships and personality of people with the human immunodeficiency virus (HIV), such as degree of intimacy and forms of attachment, have been pointed as important factors for vulnerability in this population⁶6 Gore-Felton C, Ginzburg K, Chartier M, Gardner W, Agnew-Blais J, McGarvey E, Weiss E, Koopman C. Attachment style and coping in relation to posttraumatic stress disorder Symptoms Among adults living with HIV/AIDS. J Behav Med 2013; 36(1):51-60.. In general, the presence of insecure forms of attachment contributes to a greater difficulty coping with chronic diseases. Among People Living with HIV/AIDS (PLWH) insecure attachment was related to higher prevalence of depressive symptoms, Post-Traumatic Stress Disorders (PTSD), and these symptoms in this population were associated with risk behavior to HIV transmission and acquisition, such as multiple sexual partner and unprotected anal intercourse⁶6 Gore-Felton C, Ginzburg K, Chartier M, Gardner W, Agnew-Blais J, McGarvey E, Weiss E, Koopman C. Attachment style and coping in relation to posttraumatic stress disorder Symptoms Among adults living with HIV/AIDS. J Behav Med 2013; 36(1):51-60..

Understanding factors related to personality and behavior of PLWH is a fundamental tool for the health promotion. It is important to these people to receive a treatment that is holistic, individualized and focused care with the aim to stimulate autonomy and self-care. This research is justified by the lack of scientific publications focusing on research that identifies the relationship between attachment styles as a vulnerability factor in PLWH.

The study hypothesis that insecure attachment styles increase the vulnerability to HIV infection. Therefore, the aim of this study was to identify the scientific publications about attachment style of PLWH, characterize the studies and main attachment of this population, as well as categorize the findings on relationship between attachment and HIV.

Methods

This study is an Integrative review of the literature. Articles included in this research answered the question "What research evidence is available regarding attachment styles in adult people living with HIV (PLWH)?" and addressed attachment within the classifications defined by the attachment system¹1 Bowlby J. Apego : a natureza do vínculo. São Paulo: Martins Fontes; 2002..

The choice of articles was based on a protocol developed by the researcher, in order to make the study more systematic and serve as guide for the data search. It comprised seven items including title, goals, key words, guiding question, databases as well as the inclusion and exclusion criteria. They were included in this study, articles up to December 2015, developed with adults with HIV, regardless of the language of publication. They were excluded studies duplicated.

The databases explored were Scopus, Medical Literature Analysis and Retrieval System Online (Medline)/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Latin American and Caribbean Health Sciences (Lilacs), Scientific Electronic Library Online (Scielo) and PsycINFO/PsycArticles (APA). The search was done in January, 2016, using the combination of key words and Boolean connectors: "Attachment Style OR Object Attachment AND HIV".

After the first search with the key terms it was found six articles through LILACS, six in Cochrane, 54 in Scopus, 54 in MEDLINE/PubMed, 100 in PsycINFO/PsycARTICLES, 163 in CINAHL and no article was found in the SCIELO database. The first search included a total of 383 articles, in Portuguese, English and Spanish, which were initially read by title and abstract. From the total, 40 initially met the interests of the study. Of these, 18 were duplicated, resulting in an initial sample of 22 articles, fully read. Subsequently, 12 articles were excluded, eight because explored attachment in the general sense unrelated to the attachment system and four because the sample did not consist of people with HIV (Table 1). Finally, ten studies were included in the final sample.

Studies were classified in four main thematic categories: attachment and adaptation to HIV; attachment and relationship behavior; attachment, quality of life and adherence; and Attachment as a changeable trait.

Ethical aspects were respected, and no modifications were made to the original content of the analyzed studies. In addition, copyright of mentioned research were respected.

Results

Table 2 describes articles by country, author and year, field of the authors, journal, field of the journal and study design. Three studies were found on Cochrane database and seven on Scopus, all published in English, although research included studies up to 2015, all articles found were published between the years of 2000 and 2013. They were carried out in different countries, eight held in the United States, one in Netherlands and one in Italy. The main areas of authors were psychology, medicine and social work.

Different areas were included, such as interdisciplinary, HIV/AIDS field, sexual science, behavioral sciences, psychology and social work. About study design, nine were cross-sectional quantitative studies and one was a case report. Studies were also described in relation to the objective, sample characteristics, results and conclusions (Table 3).

Studies presented a great variability approaching the relationship between attachment and HIV. For discussion purposes, the studies were divided into four groups. Most studies investigated the use of the attachment as a mediator for HIV adaptation, relating the types of attachment with coping, view of social support, stress and depression. Other studies analyzed the relationship of bonding and sexual habits and behavior in relationships; related attachment to the quality of life and adherence to antiretroviral therapy; and explored the possibility of changing attachment to the development of security (Table 4).

Discussion

All articles were published between 2000 and 2013. Half of the studies were published after 2010. Given that the research did not determined time as an exclusion criterion and the final sample included only ten articles, it can be inferred that research linking attachment style and HIV are recent, and still insufficiently explored.

Despite the high prevalence of insecure patterns in all studies, attention needs to be given to the presence of a large number of individuals with Fearful attachment in three articles that explored this classification⁷7 Ciesla J, Robert JE, Hewitt RG. Adult Attachment and High-Risk Sexual Behavior Among HIV-Positive Patients. J Appl Soc Psychol 2004; 34(1):108-124.

8 Riggs SA, Vosvick M, Stallings S. Attachment style, stigma and psychological distress Among HIV plus adults. J Health Psychol 2007; 12(6):922-936.^-99 Hinnen C, Schreuder I, Jong E, van Duijn M, Dahmen R, van Gorp EC. The contribution of adult attachment and social perceived support to depressive Symptoms in Patients with HIV. AIDS Care 2012; 24(12):1535-1542., compound 27%, 58% and 20% of the sample, respectively. This prevalence was also found in a study of adolescents with obsessive-compulsive personalities. According to the author, this kind of attachment is the most problematic, the most insecure, marked by high fear of commitment. People with this pattern present high anxiety and deprivation, as well as distrust, which deprive them of developing close and stable relationships¹⁶16 Wiltgen A, Adler H, Smith R , Rufino K, Frazier C, Shepard C, Booker K, Simmons D, Richardson G, Allen UG, Fowler JC. Attachment insecurity and obsessive-compulsive per-sonality disorder among inpatients with serious mental illness. J Affect Disord 2015; 174:411-415..

Evidence suggests that the diagnosis of a disease that threatens life, such as AIDS, can produce enough trauma to influence the formation of attachment. Around 90% of PLWH have insecure attachment of some sort, though it was unclear whether the type of attachment was present after the diagnosis or it was a vulnerability factor for contagious⁸8 Riggs SA, Vosvick M, Stallings S. Attachment style, stigma and psychological distress Among HIV plus adults. J Health Psychol 2007; 12(6):922-936..

Articles that explored Attachment and adaptation to HIV diagnosis assessed variables as stigma, stress, positive state of mind, depression and social support. Researches have emphasized that attachment style, as well as internal working models of self and others, are responsible for people adjust to major events in life and also for chronic diseases in adulthood¹⁷17 Maunder RG, Hunter JJ. Assessing patterns of adult attachment in medical patients. Gen Hosp Psychiatry 2009; 31(2):123-128..

Living with HIV/AIDS involves facing individual challenges, difficulties to maintain interpersonal relationships and deal with society prejudices. Afflictions arise regarding live with a chronic condition, perception of social judgments, which can be psychologically damaging. An example of this is that there are a reasonable number of PLWH who have symptoms of Post-traumatic stress disorder⁶6 Gore-Felton C, Ginzburg K, Chartier M, Gardner W, Agnew-Blais J, McGarvey E, Weiss E, Koopman C. Attachment style and coping in relation to posttraumatic stress disorder Symptoms Among adults living with HIV/AIDS. J Behav Med 2013; 36(1):51-60.. Then, thinking of the psychological factors of adaptation to HIV, the formation of a secure attachment has shown high relevance.

Attachment style may determine the view that PLWH have about social support, and the demand for this in times of need¹⁸18 Mikulincer M, Shaver PR. An attachment and behavioral systems perspective on social support. J Soc Pers Relatsh 2009; 26(1):7-19.. Perceived social support was identified as positive factor in the formation of attachment security. Otherwise, if an individual believes that he is less socially supported, the chances of engaging in risky behavior are higher, as long-term chances of survival are lower⁹9 Hinnen C, Schreuder I, Jong E, van Duijn M, Dahmen R, van Gorp EC. The contribution of adult attachment and social perceived support to depressive Symptoms in Patients with HIV. AIDS Care 2012; 24(12):1535-1542..

Difficulties related to the development of coping strategies and insecure attachment patterns contribute to the perceived stress in PLWH. Subjects with anxious and less secure attachments were highly vigilant in relationships, which predisposes interpretation bias about behavior of others, what was seen as sign of rejection or criticism, intensifying the stress. However, it is possible that the stress levels seen in people with HIV already exist since childhood. Thus, health actions aimed at reducing stress among PLWH may find success through patient awareness to the inherent characteristics of their attachment styles. An example of a way to reduce stress would be changing interpretation of the social distance, looking at this less negatively and finding it as opportunities to rely more on personal value rather than understand it as rejection signal¹⁰10 Koopman C, Gore-Felton C, Marouf F, Butler DL, Field N, Gill M, Chen XH, Israelski D, Spiegel D. Relationships of perceived stress to coping, social support attachment and Among HIV-positive persons. AIDS Care 2000; 12(5):663-672..

Dealing with afflictions and adaptation to stressors are crucial factors to adjustment to HIV. It was used the measure of positive state of mind to assess adjust to HIV and it was found that this adaptation is linked to secure attachment, social support related to HIV and engaged behavior. Authors believe that psychological interventions to improve quality of life of PLWH can be effective if it includes interpersonal functioning of individuals with regard to attachment, coping and social support¹¹11 Turner-Cobb JM, Gore-Felton C, Marouf F, Koopman C, Kim P, Israelski D, Spiegel D. Coping, Social Support, and Attachment Style the Psychosocial Correlates of Adjustment in Men and Women with HIV/AIDS. J Behav Med 2002; 25(4):337-353..

People with HIV and who are also insecure, when exposed to stressors often demonstrate difficulties to adapt behaviors, low resilience and vulnerability to emotional problems⁸8 Riggs SA, Vosvick M, Stallings S. Attachment style, stigma and psychological distress Among HIV plus adults. J Health Psychol 2007; 12(6):922-936.. Moreover, persons exhibiting secure attachment presented less stress and depression than the three Insecure groups. People securely attached have fewer anxieties about their illness, less perceive stigma and less negative self-image. The study also talks about the benefits of therapies focused on attachment, as couple therapy, in order to improve the well-being and reduce the progression of HIV. Likewise, high anxiety and insecure attachments are related to symptoms of post-traumatic stress disorders, indicating a relationship between attachment style and mental health in adulthood⁶6 Gore-Felton C, Ginzburg K, Chartier M, Gardner W, Agnew-Blais J, McGarvey E, Weiss E, Koopman C. Attachment style and coping in relation to posttraumatic stress disorder Symptoms Among adults living with HIV/AIDS. J Behav Med 2013; 36(1):51-60.. Social support appears as a mediator to increase attachment security⁹9 Hinnen C, Schreuder I, Jong E, van Duijn M, Dahmen R, van Gorp EC. The contribution of adult attachment and social perceived support to depressive Symptoms in Patients with HIV. AIDS Care 2012; 24(12):1535-1542.^,1111 Turner-Cobb JM, Gore-Felton C, Marouf F, Koopman C, Kim P, Israelski D, Spiegel D. Coping, Social Support, and Attachment Style the Psychosocial Correlates of Adjustment in Men and Women with HIV/AIDS. J Behav Med 2002; 25(4):337-353..

The exposure of individuals to traumatic experiences is related to the great chances of behaviors that increase the likelihood of HIV transmission⁶6 Gore-Felton C, Ginzburg K, Chartier M, Gardner W, Agnew-Blais J, McGarvey E, Weiss E, Koopman C. Attachment style and coping in relation to posttraumatic stress disorder Symptoms Among adults living with HIV/AIDS. J Behav Med 2013; 36(1):51-60.. People living with HIV/AIDS insecurely attached has greater perceived stress rates, and this stress is compounded of difficulties adjusting to the disease, resulting in increased vulnerability, identified by more depressive symptoms, stress and general behavior problems. Forms of insecure attachment in PLWH is a vulnerability factor also for development of depressive traits, which should justify special attention towards them. This author has found that attachment style accounts for 20% of the variation in distress in PLWH. On the other hand, positive state of mind has strong relation with secure attachment style, reducing stress, depression and perceived stigma⁹9 Hinnen C, Schreuder I, Jong E, van Duijn M, Dahmen R, van Gorp EC. The contribution of adult attachment and social perceived support to depressive Symptoms in Patients with HIV. AIDS Care 2012; 24(12):1535-1542..

Thus, there are several therapeutic benefits of an HIV treatment also focused on attachment style. The advantages include since reducing stress improvement in prognosis to improvement in overall quality of life⁶6 Gore-Felton C, Ginzburg K, Chartier M, Gardner W, Agnew-Blais J, McGarvey E, Weiss E, Koopman C. Attachment style and coping in relation to posttraumatic stress disorder Symptoms Among adults living with HIV/AIDS. J Behav Med 2013; 36(1):51-60.^,88 Riggs SA, Vosvick M, Stallings S. Attachment style, stigma and psychological distress Among HIV plus adults. J Health Psychol 2007; 12(6):922-936.^,1010 Koopman C, Gore-Felton C, Marouf F, Butler DL, Field N, Gill M, Chen XH, Israelski D, Spiegel D. Relationships of perceived stress to coping, social support attachment and Among HIV-positive persons. AIDS Care 2000; 12(5):663-672.^,1111 Turner-Cobb JM, Gore-Felton C, Marouf F, Koopman C, Kim P, Israelski D, Spiegel D. Coping, Social Support, and Attachment Style the Psychosocial Correlates of Adjustment in Men and Women with HIV/AIDS. J Behav Med 2002; 25(4):337-353..

Only four articles⁶6 Gore-Felton C, Ginzburg K, Chartier M, Gardner W, Agnew-Blais J, McGarvey E, Weiss E, Koopman C. Attachment style and coping in relation to posttraumatic stress disorder Symptoms Among adults living with HIV/AIDS. J Behav Med 2013; 36(1):51-60.^,77 Ciesla J, Robert JE, Hewitt RG. Adult Attachment and High-Risk Sexual Behavior Among HIV-Positive Patients. J Appl Soc Psychol 2004; 34(1):108-124.^,1010 Koopman C, Gore-Felton C, Marouf F, Butler DL, Field N, Gill M, Chen XH, Israelski D, Spiegel D. Relationships of perceived stress to coping, social support attachment and Among HIV-positive persons. AIDS Care 2000; 12(5):663-672.^,1111 Turner-Cobb JM, Gore-Felton C, Marouf F, Koopman C, Kim P, Israelski D, Spiegel D. Coping, Social Support, and Attachment Style the Psychosocial Correlates of Adjustment in Men and Women with HIV/AIDS. J Behav Med 2002; 25(4):337-353. differentiated patients only infected from those with AIDS. No difference was found in perceived stress among people who have developed AIDS. However, the presence of AIDS was related to the reduction in the number of support figures or change in the profile of these contacts¹⁰10 Koopman C, Gore-Felton C, Marouf F, Butler DL, Field N, Gill M, Chen XH, Israelski D, Spiegel D. Relationships of perceived stress to coping, social support attachment and Among HIV-positive persons. AIDS Care 2000; 12(5):663-672.^,1111 Turner-Cobb JM, Gore-Felton C, Marouf F, Koopman C, Kim P, Israelski D, Spiegel D. Coping, Social Support, and Attachment Style the Psychosocial Correlates of Adjustment in Men and Women with HIV/AIDS. J Behav Med 2002; 25(4):337-353..

The majority of PLWH still engage in risky sexual behavior. It has been noticed that people with positive internal working models of self has fewer casual sex partners and fewer partners without HIV therefore at risk of contamination. But those with Fearful attachment type showed a significant number of sexual partners. Anxiety was a strong predictor in order to have partners at risk for contamination. Therefore, attachment pattern is a relevant factor for the study of interpersonal risk behavior in PLWH, especially in the investigation of those who continue to engage in sexual risk activity after disclose of diagnosis. Understanding the reasons why individuals are exposed to risky sexual practices is essential to fight HIV, helping to increase the effectiveness of interventions in this population⁷7 Ciesla J, Robert JE, Hewitt RG. Adult Attachment and High-Risk Sexual Behavior Among HIV-Positive Patients. J Appl Soc Psychol 2004; 34(1):108-124..

Unprotected anal sex practices were related to the seriousness of interpersonal connections¹⁵15 Starks TJ, Parsons JT. Adult attachment among partnered gay men: patterns and associ-ations with sexual relationship quality. Arch Sex Behav 2014; 43(1):107-117.. The attachment style is related to the quality of relationships, as well as some aspects of sexual activity, such as sex frequency. The author mentions that the challenges faced by homosexual couples in maintaining their relationships can contribute to the development of problems in the security of their attachment styles. The study found that anxious and ambivalent men, as well as those with anxious partners had significantly lower scores in sexual communication. Having anxious or ambivalent partner was related to less sex frequency in relationships.

Compared to those secure attached, anxious and avoidant had significantly more casual partners for unprotected anal intercourse, with avoidant overcoming anxious. This relationship was similar regarding partners attachment. People with avoidant attachment style had 31.5 times more casual sex partners for unprotected anal sex compared with those securely attached. It was identified a relationship between insecure attachment of Preoccupied and Fearful types and infidelity in relationships. It is observed that attachment security is crucial to quality of relationships and to reduce vulnerability to HIV¹⁹19 Fish JN, Pavkov TW, Wetchler JL, Bercik J. Characteristics of those who participate in infidelity: the role of adult attachment and differentiation in extradyadic experiences. Am J Fam There 2012; 40(3):214-216..

Attachment was related to psychological and behavioral consequences among PLWH⁶6 Gore-Felton C, Ginzburg K, Chartier M, Gardner W, Agnew-Blais J, McGarvey E, Weiss E, Koopman C. Attachment style and coping in relation to posttraumatic stress disorder Symptoms Among adults living with HIV/AIDS. J Behav Med 2013; 36(1):51-60.. Differences were found between attachment of homosexuals and heterosexuals persons. Heterosexuals were more likely to be Secure or Fearful and less likely to be Dismissing or Preoccupied, while homosexuals were more likely to be Preoccupied and less likely to be Secure⁸8 Riggs SA, Vosvick M, Stallings S. Attachment style, stigma and psychological distress Among HIV plus adults. J Health Psychol 2007; 12(6):922-936.. Bisexuals were more likely to be Dismissing and less likely to be Secure or Fearful. Many behavioral disorders attributed to people with insecure attachment develop as consequence of the assumption that the other is not worthy of care or that other will not be available in times of need⁹9 Hinnen C, Schreuder I, Jong E, van Duijn M, Dahmen R, van Gorp EC. The contribution of adult attachment and social perceived support to depressive Symptoms in Patients with HIV. AIDS Care 2012; 24(12):1535-1542..

About attachment, quality of life and medical adherence, people who adhere to antiretroviral therapy (ART) exhibit less concerns with relationships, yet when made multiple comparisons by gender, this feature was only related to women¹²12 Ubbiali A, Donati D, Chiorri C, Bregani V, Cattaneo E, Maffei C, Visintini R. Prediction of adherence to antiretroviral therapy: Patients can ‘gender play some role? An Italian pilot study. AIDS Care 2008; 20(5):571-575.. Non-adherent women demonstrated greater concern about negative feedback and rejection. In addition, fear of being left or neglected and the constant need for approval may reduce the attention paid to therapy. Thus, strategies to increase adherence to ART in women can benefit from the research of the dynamics of interpersonal relationships.

Quality of life was investigated based on physical functioning, pain and forgiveness¹³13 Martin LA, Vosvick M, Riggs SA. Attachment, forgiveness, and physical health quality of life in HIV adults. AIDS Care 2012; 24(11):1333-1340.. Physical functioning had 21% of the variation explained by the anxiety of attachment. Anxiety was inversely related to physical functioning and pain, this feature was also negatively related to the ability to forgive. Forgiveness of others in anxious individuals was related to greater pain and forgiveness of self-increased the perception of health.

Last category was attachment as a changeable trait. Attachment style may change with time, although it is relatively stable. Interventions to develop adaptive coping skills and focus on the causes of attachment formation can be particularly effective in reducing symptoms related to trauma in PLWH⁶6 Gore-Felton C, Ginzburg K, Chartier M, Gardner W, Agnew-Blais J, McGarvey E, Weiss E, Koopman C. Attachment style and coping in relation to posttraumatic stress disorder Symptoms Among adults living with HIV/AIDS. J Behav Med 2013; 36(1):51-60.. Similarly, it is unclear whether adult attachment style changes in response to HIV diagnosis or insecurity already existed before the infection and characterize a group of individuals who are more likely to be infected⁸8 Riggs SA, Vosvick M, Stallings S. Attachment style, stigma and psychological distress Among HIV plus adults. J Health Psychol 2007; 12(6):922-936..

It was evident that the group under domestic violence, has high risk of having problems in attachment security. Psychotherapy focusing on the development of security in adults proved to be fundamental in changing lives and maintaining emotional stability of these people¹⁴14 Davis KB. Understanding and addressing stigma and attachment insecurity in HIV-positive women who experience intimate partner violence: a model of medical and psycho-social care. Soc Work Health Care2012; 51(3):213-231..

Conclusions

The literature relating to attachment patterns in PLWH although still insufficient and recent presents several aspects regarding these two variables. It was possible to categorize the studies found, describing the main variables involved in this issue. The prevalence of insecure attachment in PLWH may be higher than in the general population. Evidence was also found in relation to the attachment as an important factor to adaptation to the diagnosis of HIV, behavior in interpersonal relationships and the possibility of development of attachment security. However, more careful studies are needed to confirm the findings.

The articles found confirm the hypothesis that insecure attachment is a vulnerability factor for PLWH, especially in face of negative internal working models of self and others. Changing insecure attachment styles for Secure can result in better adaptation to life with a stigmatizing chronic disease such HIV, reduction in risky behavior and improving quality of life of this population.

Monitoring PLWH should take into account their attachment styles, especially as refers to awareness of these individuals to understand their own attachment type, and later self-analysis of their actions, as well as through offering greater support social, which contribute to security of attachment. Therefore, the importance of evaluating the attachment style in the first PLWH follow-up consultation, as a way of expanding care.

Key Considerations

The reduced number of publications as well as the type of design were some of the limiting factors of this study. It was not possible to proceed a meta analysis study since the majority of research found were no experimental, cross-sectional surveys. It is suggested the development of experimental studies in this subject and research which also address the reality of developing countries.

References

Publication Dates

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