Beyond HIV shame: the role of self-forgiveness and acceptance in living with HIV

Research is developing regarding the beneficial association of spirituality with numerous health outcomes in people living with HIV (PLWH); however, little attention has been paid to the association of these variables with forgiveness and acceptance of HIV status. This cross-sectional study used a sample of 648 PLWH from the United States aged 18–61 to test the mediating effects of forgiveness and acceptance of HIV status on the relationship of spirituality and life satisfaction. As expected, self-forgiveness and acceptance straightforwardly and serially explained the links between spirituality and life satisfaction, while forgiveness of others was not a significant mediator for this relationship. The data obtained suggest that spirituality and self-forgiveness are two important targets for future experimental research, and therapeutic interventions on these variables may have a synergistic effect of increasing acceptance and improving well-being in PLWH.


Introduction
There are approximately 39 million people living with HIV (PLWH) worldwide (WHO, 2024).With effective antiretroviral therapy, PLWH life expectancy is approaching the average life expectancy for the general population (Marcus et al., 2020).Although it is possible to live with HIV in good health for many years, and the infection is increasingly being compared to a chronic disease, it can still cause extreme stress for PLWH.In UK studies, more than half of people in one study found that being diagnosed with an HIV infection was a traumatic event (Theuninck et al., 2010).In a recent meta-analysis, Tang et al. (2020) estimated the global prevalence of post-traumatic stress disorder (PTSD) among PLWH at 28%.The experience of such intense trauma may have consequences for psychological functioning.The most common effects of the PLWH stress response include increased death anxiety, depressiveness, and lower life satisfaction (Dobrakowski & Skalski, 2019).Previous research also points to the limited acceptance of HIV status and the key role of this variable in shaping well-being (Andrinopoulos et al., 2011;Earnshaw et al., 2013).Skalski et al. (2022) showed that acceptance might be the most significant predictor of life satisfaction in PLWH among all coping strategies proposed by Carver et al. (1989).In a study by Pérez et al. (2009), the association of spiritual striving and depression in PLWH was mediated by acceptance coping.The role of acceptance as a critical coping strategy in reducing the experience of a stress response is also emphasized by numerous stress theories (e.g., Cohen & Williamson, 1991;Lazarus & Folkman, 1984;Selye, 1946).The changing epidemiological picture and the prevalence of negative psychological effects in PLWH require social service providers to develop intervention approaches to increase acceptance of HIV status and improve psychological functioning in the face of crisis.In that regard, recent reports indicate that spirituality and self-forgiveness may be key resources for increasing adaptation (Arefpour et al., 2021;Byra et al., 2020;Hall et al., 2020).
In this intricate web of psychological impacts, the nuanced understanding of "stigma" and "shame" and their effects on PLWH becomes crucial.Stigma, characterized by societal discrimination against PLWH (Andersson et al., 2020), affects their social status and interactions, while shame -a deeply personal sense of guilt or disgrace tied to the HIV diagnosisimpacts self-perception and mental health (Bennett et al., 2016).Unlike stigma, which is fueled by external societal attitudes, shame is an internal reaction to perceived personal failure or societal judgment.This internal struggle highlights the importance of mechanisms like forgiveness and acceptance in combating the detrimental effects of shame and improving life satisfaction among PLWH.Bridging this gap, spirituality emerges as a pivotal element of an individual's functioning, intricately determining their relationship with the broader world and fostering a sense of belonging and hope (Fisher, 2010).
Spirituality is recognized as a key aspect of an individual's functioning that determines the relationship with the broader world (Fisher, 2010).According to the literature, spirituality encompasses aspects of religion, anxiety, hope, and a sense of belonging, constituting the purpose and meaning of individuals' lives (Cimete, 2002).Consequently, this means that spirituality is important in securing a person's psycho-physical health and supports healing processes (Coyle, 2002;Koenig, 2008).As per Ahmadi et al. (2015), spirituality may be a stronger predictor of illness acceptance and subjective wellbeing than religiosity.These findings correspond with previous research by Genia (2009) that higher spirituality scores were associated with lower depression severity and higher self-esteem; and findings of Mela et al. (2008) on a sample of Canadian forensic psychiatric patients, according to which spirituality was negatively related to death anxiety and depressive symptoms, yet more strongly positively associated with life satisfaction than religiosity.In studies on PLWH, higher levels of spirituality influenced intermediate variables related to positive adaptation and ultimately resulted in better mental and physical health (Kudel et al., 2011).These findings suggest that spirituality may be a critical determinant of HIV status acceptance and life satisfaction.Interestingly, some reports indicate that forgiveness may strengthen the relationship between these variables (e.g., Currier et al., 2016;Davis et al., 2012;Skalski-Bednarz & Toussaint, 2024).
In considering spirituality, some scholars encourage exploring this construct's complex, relational aspects rather than solely viewing spirituality as a simple and singular phenomenon.For example, Davis et al. (2008) noted that spirituality initiates a relational association with forgiveness.The authors also showed that spiritual appraisals might predict unforgiveness, controlling for hurtfulness and other covariates (Davis et al., 2012).The theoretical foundation for this approach is shaped by the forgiveness and relational spirituality model (Sandage & Williamson, 2010), which provides a comprehensive framework for investigating how seeking forgiveness may act as a mediator between spirituality and health.This model, grounded in the fusion of forgiveness and spirituality within interpersonal relationships, underscores their mutual impact.It suggests that forgiveness is closely linked to an individual's spiritual convictions and relational encounters.In line with this model, spiritual beliefs and practices play a crucial role in facilitating forgiveness by imbuing conflicts with significance, direction, and counsel, thereby nurturing qualities like empathy, compassion, and reconciliation (Tsang et al., 2005).Furthermore, the construct of forgiveness is defined as a psychological-spiritual process in which a person's relationship with God or a spiritual guru plays a vital role (Lin et al., 2012), whether oriented towards oneself or others.According to previous research, individuals with a high tendency to forgive others may exhibit lower levels of depression, death anxiety, and stress and increased well-being than individuals with a lower tendency to forgive others (Kim et al., 2021;Lawler-Row et al., 2011;Long et al., 2020;Skalski-Bednarz & Toussaint, 2024;Webb & Toussaint, 2020;Worthington & Lamb, 2023).Wald and Temoshok (2004) found PLWH who rated themselves as forgiving of others reported fewer depressive symptoms and fewer current life stressors, and the stressors they reported were rated as being of lower severity.Toussaint et al. (2023).demonstrated that both selfforgiveness and forgiveness of others are significant predictors of health and happiness in this vulnerable population, with mediation analysis showing these relationships are fully mediated by perceived stress in PLWH.On the other hand, Tenklova and Slezackova (2016) noted that dispositional self-forgiveness correlates more closely with quality-of-life indicators than interpersonal forgiveness.Similar findings were observed in a recent study by Nkomo and Kufankomwe (2020), which highlighted self-forgiveness as a more resilient indicator of well-being among people living with HIV compared to forgiveness toward others.Self-forgiveness seems important when people perceive that they have done something that violates important personal values or moral norms and when they have done something against themselves (Webb & Toussaint, 2017).Secondly, self-forgiveness becomes important when people feel distressed about their actions (Toussaint et al., 2017).A likely reason for such self-condemnation in the case of PLWH is due to the virus's nature and the transmission routes (most often, people are infected through sexual contact).
Self-forgiveness means acknowledging and taking responsibility for one's actions and seeking to restore oneself to the moral circle by acting to repair harm done (Strelan, 2017).Self-forgiveness is a process.One can only arrive at self-forgiveness by reflecting on one's actions and taking corrective action (Enright, 1996).Toussaint et al. (2017) developed a stress and coping model of self-forgiveness and health, which states that (1) self-condemnation is stressful; (2) selfforgiveness can be used to cope with the stressful effects of self-condemnation; and (3) self-forgiveness is related to health.Numerous empirical studies have supported the assumptions of Toussaint et al. (2017) (see Davis et al., 2015;Lee & Enright, 2019;Webb & Toussaint, 2018).In a study by Jain and Tiwari (2016), PLWH exhibited lower dispositional self-forgiveness rates than the control group (HIV-), and lower dispositional self-forgiveness was also associated with lower life satisfaction.Furthermore, self-forgiveness is the result of reflection, which leads to increased acceptance of the situation experienced (Toussaint et al., 2014).Thus, the relationship between spirituality and life satisfaction in PLWH may be serially mediated by dispositional self-forgiveness and acceptance.
Building on the existing literature, we posited that the link between spirituality and life satisfaction among people living with HIV (PLWH) could be elucidated by a series of changes in dispositional self-forgiveness (Mediator 1A) and acceptance of HIV status (Mediator 2).While the preponderance of research underscores the significance of self-forgiveness in promoting health outcomes in PLWH, there are also findings that highlight the (somewhat lesser) impact of forgiving others.Consequently, we incorporated this dimension into our model as an alternate pathway (Mediator 1B).

Participants and procedure
The study included 648 PLWH (252 women and 396 men) aged 18-61 (M = 27.6,SD = 7.3).The project was conducted in the summer of 2023 in the United States.The data were collected on the Google Forms platform.Participation was anonymous and voluntary.The selection of the cohort was intentional (i.e., PLWH).The health condition of infected respondents and treatment did not constitute recruitment criteria.Information about the study was disseminated thanks to announcements at associations for the benefit of PLWH and in social media (e.g., groups for the PLWH on Facebook).Among the participants, 78% had been aware of the HIV infection for over two years, and 96% had been treated with antiretroviral therapy (ARV).A vast majority of the participants (90%) declared undetectable viremia.Moreover, in 87% of the participants, the CD4 cell count was above 350/µl, which may indicate a relatively good health condition (Kamya et al., 2021).The participants were diverse in terms of education (2% elementary 2% middle school 70% high school 3% vocational school 23% higher education), residency (16% small towns, 19% city up to 100,000 inhabitants, 65% larger towns) and marital status (48% single, 43% in relationships, 6% divorced, 3% widowed).Just over half (52%) had a Christian religious affiliation (Catholic, Protestant, etc.), while the rest were agnostics/non-believers.The study procedure included filling in questionnaires on spirituality, forgiveness, HIV status acceptance, and life satisfaction.The average time to participate in the survey was 10 min.

Measures
A short form of the Interfaith Spirituality Scale (IFS) by Kira et al. (2021) was used to measure spirituality as "the feeling of a direct relationship with your creator, and your ability to transcend yourself " (p. 1964).A short form of the IFS consists of four statements arranged into a single factor (in our study α = .81).The participant's task is to respond to each on a 4point Likert scale where 1 = "Definitely not" and 5 = "Definitely yes".
The Forgiveness Scale (FS) by Toussaint et al. (2001) was used to measure forgiveness as a multidimensional disposition.In this study, we used the subscales: forgiveness of others (five items; α = .73)and self-forgiveness (two statements; α = .68).The respondent expresses their attitude towards each of the statements on a 5-point Likert scale where 1 = "I strongly disagree" and 5 = "I strongly agree".
The Acceptance of Illness Scale (AIS) by Felton et al. (1984), validated for HIV, measured HIV status acceptance as the lack of negative responses and emotions associated with the infection.The AIS consists of eight statements arranged into a single factor (α = .89)describing the negative consequences of poor health, limitations imposed by HIV infection, lack of independence, dependence on others, and lowered self-esteem.Each item is scored on a 5-point Likert-type scale, from 1 point = "Completely agree" to 5 points = "Completely disagree".The higher the score, the higher the acceptance of the condition and the lesser the negative emotions associated with the infection.
The Satisfaction with Life Scale (SWLS) by Diener et al. (1985) was used to measure subjective wellbeing.The SWLS consists of five items arranged into a single factor (α = .91).The participant's task is to respond to each statement on a 7-point Likert scale, where 1 = "I strongly disagree" and 7 = "I strongly agree".
In addition, participants completed demographic questionnaires reported medical history, and were asked to identify their religiosity on a 7-point Likert scale, where 1 = "I am not" and 7 = "I am very".

Statistical analyses
The analyses were performed using the IBM SPSS Statistics 28 software and the PROCESS 4.2 plug-in for mediation effects analysis.Normality was assessed using the Kolmogorov-Smirnov test, whereas homoscedasticity of variance was assessed using Levene's test.The data allowed for applying parametric tests.The links between variables were evaluated using Pearson's r correlation analysis.The mediation effect was analyzed using the bootstrap method.The Bootstrap analysis sample size was 5000, and the mediation effect test was obtained as significant when it did not contain zero within the 95% confidence interval.The effect size was assessed based on adjusted R 2 .The significance level was determined at p ≤ .05.

Discussion
In light of previous research, spirituality has been recognized as a multidimensional phenomenon that improves quality of life and psychophysical health in PLWH, which directly or through mediating factors (e.g., healthy behaviors, optimism, social support) provides resources for coping with stressors, especially stigma and discrimination (Kudel et al., 2011;Szaflarski, 2013).The present study aimed to extend these findings by assessing the potential mediating effect of self-forgiveness, forgiveness of others, and acceptance of HIV status on the relationship between spirituality and quality of life.As expected, these three mediators straightforwardly and serially mediated the relationship between the independent and dependent variable.The data obtained shows that self-transcendent PLWH who feel connection to a supreme being are more likely to free themselves from unacceptance and unforgiveness of self and others and replace these emotions with self-beneficial beliefs, feelings and behaviors that facilitate to adaptation to the situation and a reduction in psychological discomfort, which consequently promotes perceptions of well-being.The obtained effects indirectly correspond with the results of previous studies, according to which self-forgiveness and acceptance were critical resources in adaptation to HIV (Andrinopoulos et al., 2011;Jain & Tiwari, 2016;Skalski et al., 2022;Toussaint et al., 2023).
Given the cross-sectional nature of our analysis, it is important to note that the associations observed do not imply causation.While our findings suggest that spirituality, self-forgiveness, and acceptance play significant roles in enhancing life satisfaction among PLWH, we cannot conclusively determine the directionality of these relationships.This acknowledgment brings to the forefront the importance of considering bidirectionality in our findings, as the relationships among spirituality, self-forgiveness, acceptance, and life satisfaction could potentially influence each other in multiple directions.Future research should delve into these bidirectional influences to provide a more nuanced understanding of the dynamics at play.In the tested serial mediation model, the inclusion of the mediators improved the predictive validity of spirituality relative to quality of life in PLWH, indicating a classical suppression effect.At the statistical level, this means that the mediators controlled (suppressed) the variance of spirituality (i.e., the variance they shared with the independent variable) causing the regression coefficient of spirituality on life satisfaction to be larger than when the suppressor variables were not in the model.On a theoretical level, therefore, it seems likely that freedom from the shame and guilt associated with HIV infection is, to some extent, necessary for PLWH to make sense of their continued existence and to "connect" with the Creator, as well as to derive satisfaction from doing so.Since the simple mediation-by-acceptance model yielded a positive statistic in the Bootstrap analysis, it seems that the suppression effect is primarily about self-forgiveness.These findings align with the concept of relational spirituality (Sandage & Williamson, 2010), which posits that spirituality nurtures forgiveness through meaningful, purposeful interactions that enhance empathy and reconciliation.Conversely, recent developments in this theoretical area, such as those by Skalski-Bednarz and Toussaint (2024), propose that the act of forgiveness may further deepen spiritual connections by encouraging qualities like humility, grace, and unconditional love, suggesting multiple pathways through which spirituality and forgiveness may interact to enhance well-being.
Forgiveness of others was not a significant mediator in the tested model, and correlated less strongly with life satisfaction compared to self-forgiveness.These observations correspond with the results of a previous study (Nkomo & Kufankomwe, 2020), according to which self-forgiveness may be a stronger predictor of PLWH's well-being than interpersonal forgiveness, as it is more likely to enable positive reevaluation and acceptance of the patient's social role (e.g., undergoing ARV treatment).Already earlier, Hua (2012) indicated that shame, which is strongly associated with self-stigma and unforgiveness, prevents seeking and accessing medical care by PLWH.On the other hand, a recent study by Toussaint et al. (2023) on a sample of French PLWH provided different results relative to the general consensus.The authors explained that France being a very secular country where forgiveness is not taught or preached universally may be a place where people who forgive others feel more satisfaction in doing so than people in other countries.Thus, the conclusions of Toussaint et al (2023).emphasize the potential moderating effect of culture on the benefits of forgiveness and the possible local validity of the effects of forgiveness research.
In addition to classic demographic variables, we controlled for religious affiliation and religiosity as covariates in the analyses.In addition, nearly half of our respondents were agnostics or non-believers.Although spirituality and religiosity are constructs strongly associated with religion (Lin et al., 2012), they can also be used by non-believers.According to Walach (2017), spirituality can help people discover meaning and significance in the world around them without any assumptions about the existence of supernatural factors, while the results of a meta-analysis by Lundahl et al. (2008) suggest similar effects of forgiveness in believers and non-believers.In the margin, a strong obtained association between religiosity and spirituality warrants further exploration.The correlation between these phenomena is typically robust, with studies frequently indicating a range of .50-.80 (Jeserich et al., 2023), even in clinical samples (Rippentrop et al., 2006).This strong relationship signifies considerable overlap in the ways individuals engage with and understand the sacred, encompassing both personal beliefs and practices related to spirituality, and the more organized, formal aspects of religiosity.Despite this overlap, it's essential to acknowledge that spirituality and religiosity are distinct: spirituality embodies a broader, more personal connection to the sacred, which can exist both within and beyond traditional religious frameworks, whereas religiosity is closely tied to formal religious institutions and practices (Hill, 2013).This distinction underscores the varied ways individuals find meaning and connection to the transcendent.
Despite its strengths, this study has some limitations.First, it was cross-sectional, which prevents passing clear judgment on the causes and effects, a cautionary point already emphasized at the beginning of the discussion.Longitudinal studies and randomized controlled trials are recommended to understand causal assertions.Nevertheless, there is still much to be learned from studies examining mediation in crosssectional data.Secondly, the sample's self-selection through a Google Forms survey, its anonymity, and the reliance on self-reported HIV status introduce potential biases that could affect the representativeness and accuracy of our data.Thirdly, the sample was highly homogeneous in terms of treatment and health outcomes, making it impossible to include these variables as covariates.Finally, in the study, we did not control for sexual orientation, which may have influenced the severity of the phenomena.Due to the effect of dual stigma (route of infection and sexual orientation), homosexuals may present greater difficulties in self-forgiveness, but there is no reason to believe this would affect the direction or magnitude of the demonstrated relationships.
The findings of our study indicate that offering spiritual care as an option within health services for PLWH could be beneficial.In addition to identifying spiritual needs, social service providers might consider introducing teach their patients repetition techniques concerning a holy word/mantra, mindfulness meditation or centering prayer to improve their mental state (Szaflarski, 2013).Future interventions could include options for self-forgiveness education (e.g., Restore: The Journey Toward Self-Forgiveness), which encourages self-acceptance, self-improvement and commitment through prayer/meditation.In such programs, the participant learns the definition of unforgiveness of self and learns to redirect negative thoughts or feelings about yourself and restore a positive, productive selfimage.As per Toussaint et al. (2014), even a 90-minute Restore intervention can be sufficient for real changes in self-forgiveness and health benefits.
In summary, this study examines the interplay between spirituality, depicted as a profound connection with the creator and the ability to surpass oneself, and various psychological factors such as self-forgiveness, forgiveness of others, acceptance of HIV status, and life satisfaction in PLWH, suggesting that spirituality and self-forgiveness may contribute to increased life satisfaction through the mechanism of acceptance.However, the study design is correlational in nature, and we caution against overinterpreting the directions of the relationships explored.Therefore, while the study points to potentially significant connections between spirituality, self-forgiveness, acceptance, and well-being in PLWH, it also highlights the complex nature of these relationships and the need for further research.This future research should aim to elucidate these potential pathways more clearly and inform the development of targeted interventions.