The present descriptive study was conducted at Mysore Medical College and Research Institute, a Government support centre and Ashakirana Hospital, a Non-governmental support centre. The Institutional ethical committee of JSS Dental College and hospital approved the study protocol. The study was conducted between August to October 2012 and the study population consisted of People living with HIV/AIDS (PLWHA) who attended these centers for counseling as well as treatment. During this period a total of 248 people were enrolled in the study and 194 participants gave consent to participate in the study. A written informed consent explaining the nature of the study was obtained from the study participants before administering the questionnaire. Out of 194 PLWHA, 109 were males and 85 were females.

The questionnaire was developed from a similar study conducted by Ojo et al., in Nigeria [11]. The questionnaire was translated to local language, Kannada and was self administered. The process of translation involved two steps: In step one questionnaire was translated from English to Kannada with the help of an expert panel, and pilot testing was carried out on a group of subjects; in second step, re-evaluation was made by back-translation to English. The questionnaire was translated from English to Kannada by three Kannada-speaking professional translators. Two of the three translators were unaware of the concepts used and of the objectives of the study. The validity of the translation was verified by experts in the use of questionnaire in both languages. This was also checked after wording modifications to ensure the conceptual and functional equivalences of the questionnaire.

A pilot study was carried out on 20 participants who were affected with the same disease to validate all questionnaires before using them in the main survey. It served as a preliminary study to identify any organizational and technical problems, to check the feasibility and relevance of study. These 20 subjects were not included in the main study.

The questionnaire was checked for its validity and reliability. It was found to be satisfactory. Question to question reliability was assured by the percentage of agreement (80%) and the internal reliability for the responses to questions was assured using Cronbach’s alpha coefficient (0.86). Spearman’s correlation coefficient was used to ensure criterion and construct validity of the questionnaire (p< 0.001).

The study was performed by a single trained investigator. A structured proforma was used for collecting data. The first part of the proforma recorded variables such as age, gender, patients’ education, occupation and income. Kuppuswamy’s socioeconomic status scale was to measure socioeconomic status [29] (education, occupation and family income). Second part contained information regarding social, psychological and health concerns. A 5 point Likert Scale was used to measure the Social, Psychological and Health responses. The responses varied from ‘Not concerned’, ‘slightly concerned’, ‘concerned’, ‘Highly concerned’ to ‘Extremely concerned’. Trained counselors were available to assist the participants in clarifying any questions that were raised in the questionnaire.

The ratings were assigned weight values of 1,2,3,4 and 5 respectively. The total weight value (TWV) for each item of the questionnaire was obtained through the summation of the product of the number of responses for each rating to a questionnaire item and the respective weight value. Social Concern Index (S̄C̄Ī), Psychological Concern Index (P̄C̄I) and Health Concern Index (H̄C̄Ī) were arrived at by dividing summation of TWV for each variable by the total number of respondents (n=194). The concern index ranged from 1 to 5; the closer the value to 5 the higher the assumed variable concerns among the participants [11].

The mean value of each index (SCI, PCI and HCI) was calculated by the addition of the concern index generated from each questionnaire divided by the number of questionnaire items in each group (i.e. social by 12, psychological and health by 5 each) [11].

The deviation about the mean of each variable, variance and standard deviation (SD) to measure the scatter around the mean was also calculated. The coefficients of variations were calculated to measure the scatter in the data relative to the mean in percentages. A general linear regression model was used for assessing the predictors of the social, psychological and health concerns [30]. The regression model was checked for consistency using standard techniques and found to be within normal limits. The data were entered using SPSS version 17.

The data in [Table/Fig-1] depicts the descriptive characteristics of the study population. Approximately 30% of study subjects had a primary school education level or below. The age range of the study population was 18-78 years (mean age: 37.63±9.83) among them 56.2% were males. Majority of the participants (67%) were married, while 17.5% were either separated and were single because of loss of one of their spouses due to the same condition. Majority of the participants belong to the upper lower class family category (61.3%) according to Kuppuswamy’s scale [29].

The data in [Table/Fig-2] shows, the social concerns expressed by the participants. Six out of twelve questions had SCI higher than the SCI (1.66) which shows these are the areas of higher concern. “Fear of Losing a loved one” had the highest SCI score (2.24), followed by “Feeling very lonely” (2.01) and “Being made fun of” (1.74). The lowest score was for “Might not get married” (1.26), followed by “No close contact with opposite sex” (1.36) and “Attitudes of close relatives” (1.47). Scores greater than the SCI (1.66) indicate a positive deviation about the mean and much concern over these items.

The data in [Table/Fig-3] shows the psychological concerns of the participants. Three of the five items had higher PCI scores and positive deviation about the PCI (2.01). “Too much worry” was the highest psychological concern (2.36), followed by “Lack of interest in things” (2.16) and “Wishing you had never born” (2.04). “Relenting due to discouragement” and “Day dreaming” was below the PCI (2.01).

The data in [Table/Fig-4] depict the most common health concern was “No cure for aids”(2.82) while the remaining four items were having score less than HCI(2.17) which indicates these were of less health concern.

The data in [Table/Fig-5] reports how age, gender and employment status predicts the social, psychological and health concerns among PLWHA. For every unit increase in age there were fewer social concerns and it was statistically significant. (β coefficient: -0.207 p:0.008, CI:-0.023 and -0.003). Similarly, for every unit increase in age there were fewer psychological concerns and it was also statistically significant. (β coefficient = 0.264 p=0.001, CI:-0.031 and -0.008). But for every unit increase in age there were more health concerns and it was not statistically significant. (β coefficient = 0.81, p=0.313, CI=-0.006 -0.08). Males had more social, psychological and health concerns when compared to females but was not statistically significant. There was no difference in social concerns among employed and unemployed people. Employed people were having fewer psychological concerns than unemployed people. Unemployed people were having fewer health concerns when compared to employed people. Both were statistically not significant.

In spite of the fact that PLWHA were receiving counseling, the findings from the present study revealed that they were still concerned with social, psychological and health issues. This can be due to the fact that health services were not according to their needs. This can also be explained by the fact that self stigmatization decreases the level of perceived support that supposedly reduces PLWHA’s psychological stress [8]. People affected with HIV/AIDS face medical problems as well as social problems associated with this disease. Social stigma is one of the main barrier to reach those people who are at risk or infected with HIV/AIDS [31]. Stigma enhances secrecy and denial, which are also catalysts for HIV transmission [32]. Thus it is necessary to improvise the counseling efforts to meet their specific social, psychological and health concern needs.

In the present study ‘Fear of losing a loved one’ was the highest social concern. Similar result was obtained in a study conducted by Ojo OO et al., at Nigeria [11]. Feeling very lonely, Being made fun of, No one to discuss troubles with, Being left out of things, Being talked about by others need to be given extra emphasis during counseling of the study population. Might not get married was the least social concern. But in the study conducted by Ojo OO et al., attitudes of close relatives were the least social concern [11]. Being criticized by others, not having many friends, not getting well with others, no contact with opposite sex were among the items of less social concern and hence may not need to be the main emphasis during counseling.

Too much worry, lack of interest in things, wishing you had never born were among the items of higher psychological concern and relenting due to discouragement and day dreaming were items of least psychological concern. More efforts need to be focused on reducing psychological concerns.

No cure for aids was the only highest health concern while getting sick often, getting tired easily, gradually getting thinner and no appetite were of least health concerns. A discussion paper prepared for ministerial of council for aids at Canada by Martin Spigelman research associates found that discrimination was the highest health concern [33]. The medical world and scientific community have responded vigorously to HIV/AIDS. People today are living longer and better with HIV/AIDS and AZT, for example, can practically eliminate mother-to-infant transmission. In spite of this progress, “HIV remains a deadly infection for which there is no vaccine, no cure, and for which there is an expanding, but still limited, inventory of available treatments [34].

Increasing age of PLWHA was found to be associated with fewer social and psychological concerns. This finding was expected due to the adaptive coping behaviours of old people as the disease progresses. This may be related to relenting fate, leading to ‘bargaining ways’ as suggested by Bendell [35].

But for increase in age there were more health concerns. This can be due to the increasing symptoms associated with advancing HIV/AIDS infection. Cohort studies have shown that social relationships influence mortality. Having fewer close friends or relatives, less frequent contact with other people, and reduced social participation have all been associated with increased mortality, especially in elderly people and in men [36–39].

Males were having more social, psychological and health concerns when compared to females. This means that males were not coping well with the illness. In general, females are usually more concerned about their interaction with other people, their outward appearance and other social issues. This finding is not in agreement with the report that being a female together with other factors such as level of education, unemployment, high viral loads, the presence of aids symptoms, and low CD4+ counts is significantly associated with anxiety and depression among PLWHA [24,27,40–42].

Employment status was found to influence psychological and health concerns. Employed people were having fewer psychological concerns. This is in contrary to the previous report that unemployed had fewer psychological concerns [43]. The trend of increased health concerns among the employed may be the result of increasing symptoms associated with advancing HIV/AIDS infection. Recurrent symptoms will definitely affect the income and savings of such individuals. The employed individuals relate to the fear of losing their jobs due to ill health and their ability to care for themselves and their loved ones. Also, the employed HIV-infected persons may have functional decline as the disease progresses [43], which may raise their health concerns. In other words, the unemployed have no fear of losing their jobs.

In planning health care for PLWHA, one needs to consider their social, psychological and health concerns. This is because it will definitely effect utilization of health care facilities and compliance to therapy/drugs [7]. Health care workers, including those in public health sector; need to be educated about the importance of these factors that influence the health of the population they are caring for.

1. Comparing the concerns of HIV sero-positives to that of patients with AIDS could further be investigated in the future.

2. Relating social, psychological and health concerns with each stage of HIV/AIDS.

The sample size should have been much larger than it was in the present study to confer a stronger inference for the general population.

The findings from the present study show that older people were having fewer social and psychological concerns. Males were having more social, psychological and health concerns than females and employed people were having more health concerns when compared to unemployed people.

When planning health care services for PLWHA, a careful understanding of their social, psychological and health related concerns is required by all health care workers caring for them. This is because it could have a positive impact on health care facility utilization and adherence to drugs and therapy. Thus it is a crucial time in our global efforts to tackle HIV/AIDS and a time to turn commitments into action.