Integrating Spiritual Practices into HIV Interventions in East African Urban Informal Settlements: A Literature Review

Background

The impact of spirituality and spiritual practices on physical health has historically been dismissed in Western medicine, but as psychology and mental health studies have progressed in recent decades, the conversation of spiritual and medical integration has gained some traction.

Numerous studies have been conducted over the past 10 years on the effects of spirituality and spiritual practices in lowering stress levels and increasing patients’ ability to cope with mental and physical stressors. According to a general review of the literature related to the impacts of spirituality on physical health, there are currently 57 published studies (Ironson, 2006), 44 of which focus on healthy populations and 13 of which focus on chronically or terminally ill populations. As the definition of chronic illness expands to encompass HIV, we find the concept of integrating spiritual practices into long-term medical HIV interventions quite compelling.

Nearly 70% of the 40 million people living with HIV/AIDS in the world live in Sub-Saharan Africa. East and Southern Africa are the regions within Sub-Saharan Africa that are most affected by the HIV/AIDS epidemic, and 50% of new infections in that region in 2016 were clustered in the East African Community (Kenya, Uganda, Rwanda, Tanzania, South Sudan, and Burundi). With such a large and growing infection rate in this region of the world, it is increasingly important to implement innovative and holistic health interventions to curb the mortality rates in the adult HIV+ population in East Africa.

Purpose

In an effort to narrow the scope of study on this topic and propose a basis for further research, the purpose of this qualitative literature review is to zoom in specifically on HIV+ adults and how health outcomes (CD4 count, viral load, mortality rates) may be impacted by spiritual practices such as prayer, contemplation, and meditation when practiced in partnership with medical interventions (ARV or HAART therapy).

Results

Of the 15 articles reviewed, 10 concluded that spiritual practices had a significant, positive effect on health outcomes for adults living with HIV/AIDS, 4 concluded that there was no change in health outcomes, and one concluded that spiritual practices had a negative impact on health outcomes for adults living with HIV/AIDS.

Positive Health Outcomes

The three longitudinal studies each concluded that there was a significant positive correlation between prayer/meditation practices and increased CD4 count over time. Perhaps the most compelling evidence in favor of integrating spiritual practices alongside medical HIV interventions was the study from Ironson et al (2006). This longitudinal study followed 100 HIV+ adults (Americans) over four years and measured their religious journey (increase in faith and spiritual practices, decrease, or neutral), and compared these religious journeys to health data over the four years. The study concluded that patients who experienced an increase in faith (which included an increase in spiritual activities like prayer) preserved their CD4 cells at a significantly higher rate than those patients who experienced a loss of faith post-diagnosis. Those patients who stopped participating in religious and spiritual activities lost CD4 cells 4.5 times faster than those who increased their spiritual activities (Ironson, 2006).

While the study designs in the 15 papers varied, the majority of the results pointed toward the same outcomes—higher levels and frequency of spiritual practices meant lower cortisol levels (Chhatre, 2013), higher CD4 counts, lower viral loads, and lower mortality rates (Dalmida, 2009; Ironson, 2006; Ironson, 2009). One study found that 52% of patients who prayed once a day showed a 90% adherence rate to ARV therapy (ideal adherence rate to maintain low detectable viral load) while only 31% of patients who did not participate in the spiritual practice of prayer or meditation showed 90% ARV adherence (Dalmida, 2009).

 The studies that found a significant positive correlation between spiritual practices and positive health outcomes, including the longitudinal studies referenced above, also spanned various populations. Studies ranged from focusing specifically on African American women (Dalmida, 2009) to people living with HIV/AIDS in Uganda (Kisenyi, 2013). It does appear according to the literature that race, gender, sexual orientation, and even socio-economic are less predictive of health outcomes, and spiritual practice and frequency of spiritual practice is highly predictive of health outcomes.

 One area for improvement in future research is the method by which researchers define and measure spiritual practices. The most common and multi-faceted approach seems to be the Ironson-Woods Spirituality Index, which was used in three of the 15 studies. Other studies used patient interviews, the Behavior Religiosity Scale, and Likert scale questionnaires specific to the purpose of the research to measure spiritual activities and attitudes. In order to validate and streamline the research in this field, there needs to be some work on standardization in measuring spirituality.

 Neutral Health Outcomes

The paper published by Chhatre et al (2013) focused on a Transcendental Meditation intervention with HIV+ American adults and found no significant change in the health (CD4 count and viral load) of those clients in the meditation group compared to the control group. While the methodology of the research was sound, the control group was not a true control. Participants in the study were either placed in a Transcendental Meditation group or a healthy eating education group, both of which had similar lengths and structures (Chhatre, 2013). The confounding factor in this study was the nutrition education provided to the control group—nutrition has a major impact on the effectiveness of ARV therapy, which both groups were taking. The similarity in health outcomes between the two groups could easily be challenged.

Other papers that reported neutral outcomes did so based on the lack of statistical significance in the marginal health improvement measured in study participants. One study showed positive but not significant change in patients’ innate immunity (Pace, 2009), and another study in Tanzania found that the education level of patients affected health outcomes at a higher level than self-reported spiritual practices, but neither indicator showed results statistically significant enough to draw conclusions (Zou, 2009). 

Negative Health Outcomes

One significant factor that was often overlooked in the literature that found positive spiritual practice/health outcomes was the type of spiritual or religious activities and beliefs in patients. This again is a symptom of the lack of standardization in definitions and measurement tools for spirituality and spiritual practices. The one article that appropriately addressed the wide range and various interpretations of spirituality was the study by Ironson, Stuetzle, Balbin, et al. (2011). This study differentiated between the various ideations of God (all within a Judeo-Christian context). The study found that HIV+ adults who view God as benevolent experienced significantly positive health outcomes while those who view God as punishing experienced lower CD4 counts and quicker disease progression over time. Overall the study concluded that, with a positive view of God and with regular prayer/meditation practice, health outcomes were better over time.

Those studies that found either no correlation or negative correlations between health and spirituality were careful to detail the nuanced situations of the study subjects. In the Cobb’s research (2012), many of the negative health outcomes were associated with spiritual grief and anger or the complete separation of spiritual practices and medical interventions. For example, a patient in the study refrained from taking her ARV therapy because she believed that prayer and faith would ultimately heal her disease. In this context, spiritual practices had been used in lieu of medical interventions instead of an integrated spiritual/medical approach. Although this particular case study was with American patients, the outcomes are relevant for the East African client context. The cultural tendency to forego medical treatment in favor of spiritual practices or spiritually based alternative medicine in the East African culture would be an interesting line of research that would certainly provide context for organizations and programs hoping to integrate spirituality into medical interventions. There was some discrepancy in the literature on this point, however, as another study found that meditative prayer correlated with better health outcomes over time for both patients on and off ARV therapy (Creswell, 2009).

Gaps in Current Literature

While there is a decent amount of literature about religiousness and spirituality among American patients with HIV/AIDS, there are shockingly few studies specific to ultra-poor populations in developing nations. While the focus of this literature review is on the effects of spiritual practices on health outcomes for HIV+ adults in East Africa, the lack of specific studies limits the assumptions that can be made about health outcomes and spirituality in the East African urban slum context. The two papers specific to HIV+ adults in East Africa focused only on the impact of religiousness and ARV adherence, which is certainly a start, but by no means a comprehensive review of how spiritual practices enhance medical interventions. Adherence is a necessary step in obtaining positive health outcomes, but the research presented in the papers by Kisenyi et al (2013) and Zou et al (2009) stop short of making the empirical connection between spiritual practice and health measures.

The studies reviewed in this paper that focused on American patients did control for socioeconomic status, gender, education, and other potentially confounding factors, but relative poverty in the United States is a very different experience from extreme poverty in East Africa. Stigma and the associated psychosocial stressors related to HIV/AIDS are also much more extreme in an East African context. There is a need for further study into this specific population in order to better understand the effects of spiritual practices on health outcomes for those living with HIV/AIDS in extreme poverty within an African cultural context.

It is also important to note that, though there is a body of research in this field, many of the studies involve the same small set of researchers. Dr. Gail Ironson, for example, was an author in four of the 15 articles reviewed and Dr. Safiya George Damida was an author in two of the 15 articles. While it is expected to see some overlap in such a narrow field of study, diversity in research methods and personnel would add depth and validity to the body of literature.

Conclusion

Overall, the literature on this particular topic shows a positive effect of spiritual practices on health outcomes. This is a helpful basis upon which to build more research projects, specifically in an East African urban slum context. If further research can draw out similar health outcomes, a huge opportunity exists to enhance care for those regions in Africa most affected by the HIV/AIDS epidemic.

References

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Berger, R. E. (2011). Re: Effect of Compassion Meditation on Neuroendocrine, Innate Immune and Behavioral Responses to Psychosocial Stress. The Journal of Urology,186(4), 1325-1326. doi:10.1016/s0022-5347(11)60439-4

Creswell, J. D., Myers, H. F., Cole, S. W., & Irwin, M. R. (2009). Mindfulness meditation training effects on CD4 T lymphocytes in HIV-1 infected adults: A small randomized controlled trial. Brain, Behavior, and Immunity,23(2), 184-188. doi:10.1016/j.bbi.2008.07.004

Chhatre, S., Metzger, D. S., Frank, I., Boyer, J., Thompson, E., Nidich, S., . . . Jayadevappa, R. (2013). Effects of behavioral stress reduction Transcendental Meditation intervention in persons with HIV. AIDS Care,25(10), 1291-1297. doi:10.1080/09540121.2013.764396

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