Introduction
The global Human Immunodeficiency Virus (HIV) epidemic remains a significant public health challenge, with sub-Saharan Africa bearing the greatest burden [1]. In Nigeria, home to the world's second-largest HIV-positive population, the epidemic is characterised by a mix of biomedical challenges and profound psychosocial complexities [2]. While the scale-up of antiretroviral therapy (ART) has transformed HIV into a manageable chronic condition, optimal clinical outcomes are contingent upon sustained treatment adherence and effective long-term self-management [3].
Beyond virological suppression, the holistic well-being of individuals living with HIV; measured through health-related quality of life (HRQoL), is a crucial treatment goal [4]. HRQoL is a multidimensional construct encompassing physical, psychological, social, and environmental domains of functioning. Research consistently demonstrates that HRQoL is not merely a secondary outcome but is intrinsically linked to clinical endpoints; poorer HRQoL predicts higher morbidity, mortality, and sub-optimal ART adherence [5].
The determinants of HRQoL and clinical outcomes in HIV are multifactorial, involving biomedical, socio-economic, and psychological factors [6]. Among these, psychological processes have garnered increasing attention. The Psychological Flexibility model, derived from Acceptance and Commitment Therapy (ACT), posits that the ability to consciously contact the present moment and persist or change behaviour in accordance with valued goals is fundamental to mental health and adaptive functioning [7]. In chronic illness, psychological flexibility allows individuals to accept difficult thoughts and feelings related to their condition without being dominated by them, thereby facilitating adherence to demanding treatment regimens and engagement in meaningful life activities [8]. Conversely, catastrophising; a cognitive pattern characterised by the tendency to magnify the threat value of a stimulus and perceive oneself as unable to cope with it; is a potent maladaptive response [9]. In chronic pain and illness literature, catastrophising is a robust predictor of heightened distress, disability, and poorer health outcomes [10].
Despite the established relevance of these constructs in Western contexts, there is a paucity of research exploring their role in HIV care within sub-Saharan Africa, particularly Nigeria. The unique socio-cultural milieu, stigma dynamics, and healthcare delivery models in this region necessitate context-specific investigation [11]. This study, therefore, aimed to examine the associations of psychological flexibility and catastrophising with HRQoL and key clinical management outcomes (treatment adherence and virological suppression) among patients with HIV attending a major tertiary hospital in Northwest Nigeria. We hypothesised that higher psychological flexibility would be associated with better HRQoL and more favourable clinical outcomes, whereas greater catastrophising would be associated with poorer HRQoL and less favourable clinical outcomes.
Materials and Methods
Study Design and Setting
A hospital-based, analytical cross-sectional study was conducted between March and August 2025 at the Adult Antiretroviral Therapy Clinic of Ahmadu Bello University Teaching Hospital (ABUTH), Shika-Zaria, in Northwest Nigeria. ABUTH is a major referral centre serving a large population.
Study Participants
The study participants were adults, diagnosed of HIV and attending the Adult Antiretroviral Therapy Clinic of Ahmadu Bello University Teaching Hospital (ABUTH), Shika-Zaria, in Northwest Nigeria.
Inclusion Criteria
The inclusion criteria were: (1) confirmed HIV diagnosis, (2) age ≥18 years, (3) on ART for at least six months, and (4) provided informed consent.
Exclusion Criteria
The exclusion criteria were: (1) severe cognitive impairment or active psychosis precluding questionnaire completion, (2) critical illness requiring immediate hospitalisation, and (3) deafness or inability to communicate in English or Hausa.
Sample Size Determination
The sample size was calculated using the formula for estimating a single proportion [N = (Z² * P(1-P)) / d²], with a conservative prevalence (P) of 50% for good HRQoL (to yield maximum sample size), a 95% confidence level (Z=1.96), and a margin of error (d) of 0.05. This yielded 384. Accounting for a 10% non-response rate, a minimum of 423 participants was required. A final sample of 500 was recruited to enhance analytical power.
Sampling Method
Systematic random sampling was employed. The average daily clinic attendance was 80; every 4th patient meeting the criteria was invited until the daily quota was met.
Study Instruments and Measures
Sociodemographic and Clinical Proforma: Captured age, sex, education, employment, marital status, duration of HIV diagnosis, and ART regimen.
Acceptance and Action Questionnaire-II (AAQ-II) [12]: Used to measure psychological flexibility. This 7-item instrument (e.g., “I am afraid of my feelings”) uses a 7-point Likert scale (1=never true to 7=always true). Higher total scores indicate greater psychological inflexibility. For clarity, we reverse-scored it so higher scores denoted greater flexibility. The AAQ-II has demonstrated good reliability and validity in Nigerian samples with chronic health conditions [13]. In this study, Cronbach’s alpha was 0.87.
Pain Catastrophising Scale (PCS) [9]: The modified version was used to measure catastrophising. The 13-item scale was adapted by replacing the word "pain" with "my HIV condition" (e.g., "I keep thinking about how much my HIV condition hurts"). It comprises rumination, magnification, and helplessness subscales, rated on a 5-point scale (0=not at all to 4=all the time). This adaptation has been used previously in African chronic illness studies [14]. In this study, Cronbach's alpha was 0.89.
WHOQOL-HIV BREF [15]: Measures health-related quality of life. This 31-item instrument assesses six domains: Physical, Psychological, Independence, Social, Environmental, and Spiritual/Personal Beliefs, plus two general items. Items are rated on a 5-point Likert scale, with domain scores transformed linearly to a 0-100 scale; higher scores denote better HRQoL. It is extensively validated for use in Nigeria [15]. In this study, Cronbach's alpha for the overall scale was 0.91.
Clinical Outcomes
Treatment Adherence: Assessed via a validated self-report tool used in the Nigerian AIDS Indicator and Impact Survey (NAIIS) [16], categorising adherence over the past month as "optimal" (≥95% of doses taken) or "sub-optimal" (<95%).
Virological Suppression: Defined as a viral load measurement of <1000 copies/mL (per national guidelines at the time) [17].
Immunological Status: Most recent CD4 count (cells/μL).
Study Procedure
Ethical approval was obtained from the ABUTH Health Research Ethics Committee (Ref: ABUTHZ/HREC/C28/2025). Eligible participants were approached in the waiting area, and the study was explained. Written informed consent was obtained. Participants completed the questionnaire battery in a private room with a trained research assistant available to clarify items. Clinical data (most recent viral load, CD4 count, and duration on ART) were extracted from patient records after questionnaire completion.
Ethical Consideration
The study procedures were reviewed and approved by the Health Research Ethic Committee of Ahmadu Bello University Teaching Hospital, Shika-Zaria (Ref: ABUTHZ/HREC/C28/2025). Informed consent was obtained from all participants prior to their inclusion in the study. Confidentiality and anonymity of participants was maintained throughout the research process.
Statistical Analysis
Data were analysed using IBM SPSS Statistics version 29. Descriptive statistics (frequencies, percentages, means, standard deviations) characterised the sample. Pearson’s correlation examined bivariate relationships. Multiple linear regression models (enter method) determined independent predictors of total HRQoL score, controlling for covariates (age, sex, education, CD4 count). Multivariate analysis of covariance (MANCOVA) compared HRQoL domain scores across adherence and viral load categories, with psychological flexibility and catastrophising as covariates. Binary logistic regression examined associations between psychological constructs and dichotomised clinical outcomes (adherence, viral load). Significance was set at p<0.05.
Results
A total of 500 participants with a confirmed HIV diagnosis completed the study. The mean age of the sample was 42.3 years with a standard deviation of 9.1 years. The majority of participants were female (n=345, 69.0%) and married (n=287, 57.4%). Most participants (n=368, 73.6%) had an educational attainment of secondary level or below. Clinically, the mean duration since HIV diagnosis was 7.2 years (SD=4.5). The mean CD4 count was 512 cells/μL (SD=211). Based on self-report, 382 participants (76.4%) were classified as having optimal antiretroviral therapy (ART) adherence (≥95% of doses taken). Review of medical records indicated that 358 participants (71.6%) had achieved virological suppression, defined as a viral load of less than 1000 copies/mL (Table 1).
As presented in Table 2, bivariate correlation analysis revealed a strong, statistically significant positive correlation between psychological flexibility and overall health-related quality of life (HRQoL) score (r=0.52, p<0.001). In contrast, catastrophising showed a strong, statistically significant negative correlation with overall HRQoL score (r=-0.48, p<0.001). Psychological flexibility was positively correlated with CD4 count (r=0.21, p<0.001) and with optimal adherence (r=0.38, p<0.001). Catastrophising was negatively correlated with CD4 count (r=-0.18, p<0.001) and with optimal adherence (r=-0.31, p<0.001). A strong negative correlation was observed between psychological flexibility and catastrophising (r=-0.54, p<0.001).
Multiple linear regression was conducted to identify independent predictors of total HRQoL score, controlling for age, sex, education, and CD4 count (Table 3). The model was statistically significant (Adjusted R² = 0.38, F(6, 493) = 52.67, p < 0.001). Psychological flexibility (β=0.41, p<0.001) and catastrophising (β=-0.33, p<0.001) emerged as the strongest predictors, with higher flexibility and lower catastrophising associated with a higher HRQoL score. CD4 count was also a significant, though weaker, predictor (β=0.18, p<0.001).
Binary logistic regression analyses were performed to examine associations with dichotomous clinical outcomes (Table 4). After adjusting for age, sex, education, and CD4 count, a one-unit increase in psychological flexibility score was associated with 2.45 times greater odds of optimal ART adherence (Adjusted Odds Ratio, aOR=2.45; 95% CI: 1.72-3.49) and 1.89 times greater odds of virological suppression (aOR=1.89; 95% CI: 1.31-2.72). Conversely, a one-unit increase in catastrophising score was associated with reduced odds of optimal adherence (aOR=0.42; 95% CI: 0.29-0.61) and virological suppression (aOR=0.53; 95% CI: 0.37-0.76).
| Characteristic | Category | Frequency (n) | Percentage (%) |
| Age (years) | 18–30 | 68 | 13.6 |
| 31–45 | 272 | 54.4 | |
| 46–60 | 142 | 28.4 | |
| >60 | 18 | 3.6 | |
| Sex | Male | 155 | 31.0 |
| Female | 345 | 69.0 | |
| Education | None/Primary | 145 | 29.0 |
| Secondary | 223 | 44.6 | |
| Tertiary | 132 | 26.4 | |
| Employment Status | Employed | 301 | 60.2 |
| Unemployed | 199 | 39.8 | |
| ART Adherence (Self-reported) | Optimal (≥95%) | 382 | 76.4 |
| Sub-optimal (<95%) | 118 | 23.6 | |
| Viral Load | Undetectable (<1000 copies/mL) | 358 | 71.6 |
| Detectable (≥1000 copies/mL) | 142 | 28.4 | |
| Mean CD4 Count (cells/µL ± SD) | — | 512 ± 211 | — |
| Variable | 1. PF | 2. CAT | 3. HRQoL | 4. CD4 | 5. Adherence* |
| 1. Psychological Flexibility (PF) | 1.00 | -0.54*** | 0.52*** | 0.21*** | 0.38*** |
| 2. Catastrophising (CAT) | -0.54*** | 1.00 | -0.48*** | -0.18*** | -0.31*** |
| 3. Total HRQoL Score | 0.52*** | -0.48*** | 1.00 | 0.32*** | 0.45*** |
| 4. CD4 Count (cells/µL) | 0.21*** | -0.18*** | 0.32*** | 1.00 | 0.26*** |
| 5. Adherence (Optimal = 1) | 0.38*** | -0.31*** | 0.45*** | 0.26*** | 1.00 |
* Point-biserial correlation used for dichotomous adherence variable; *** p < 0.001
| Predictor Variable | B (Unstandardised) | SE B | β (Standardised) | t-value | p-value |
| Constant | 42.15 | 3.21 | — | 13.14 | <0.001 |
| Age | 0.08 | 0.05 | 0.06 | 1.60 | 0.110 |
| Sex (Female) | 1.23 | 0.89 | 0.05 | 1.38 | 0.168 |
| Education (Tertiary) | 2.11 | 0.94 | 0.08 | 2.24 | 0.025 |
| CD4 Count | 0.02 | 0.00 | 0.18 | 4.89 | <0.001 |
| Psychological Flexibility | 0.68 | 0.07 | 0.41 | 9.71 | <0.001 |
| Catastrophising | -0.61 | 0.08 | -0.33 | -7.63 | <0.001 |
Model statistics: Adjusted R² = 0.38; F(6, 493) = 52.67; p < 0.001
Outcome: Optimal ART Adherence (≥95%)
| Predictor | Adjusted Odds Ratio (aOR) | 95% Confidence Interval | p-value |
| Psychological Flexibility | 2.45 | 1.72 – 3.49 | <0.001 |
| Catastrophising | 0.42 | 0.29 – 0.61 | <0.001 |
| Age | 1.01 | 0.98 – 1.04 | 0.541 |
| CD4 Count (per 50 cells/µL increase) | 1.12 | 1.05 – 1.19 | 0.001 |
Outcome: Virological Suppression (<1000 copies/mL)
| Predictor | Adjusted Odds Ratio (aOR) | 95% Confidence Interval | p-value |
| Psychological Flexibility | 1.89 | 1.31 – 2.72 | 0.001 |
| Catastrophising | 0.53 | 0.37 – 0.76 | 0.001 |
| Age | 1.02 | 0.99 – 1.05 | 0.182 |
| CD4 Count (per 50 cells/µL increase) | 1.18 | 1.10 – 1.26 | <0.001 |
All models controlled for age, sex, education, and CD4 count.
Discussion
This study provides compelling evidence from a large Nigerian sample that psychological flexibility and catastrophising are significantly associated with HRQoL and clinical management outcomes in HIV care. Our findings confirm the hypotheses, demonstrating that adaptive psychological processes are linked to better health outcomes, while maladaptive cognitive patterns are linked to poorer ones.
The strong positive association between psychological flexibility and overall HRQoL (β=0.41) aligns with the core tenets of the ACT model [7], which frames flexibility as central to valued living despite health challenges. This finding resonates with global studies. A study among Nigerian PLWHA found psychological flexibility significantly predicted better social relationships and lower cognitive symptoms, supporting its role in enhancing quality of life [13]. Similarly, research from South Africa linked acceptance (a core flexibility process) to better psychosocial adjustment in HIV [8]. Our study extends this evidence to Northwest Nigeria, suggesting that the benefits of psychological flexibility transcend cultural contexts, potentially serving as a universal buffer against the distress of chronic illness.
Conversely, the robust negative association between catastrophising and HRQoL (β=-0.33) underscores the detrimental impact of this cognitive distortion. This finding is consistent with chronic illness literature globally [9,10], including studies on HIV. Our study confirms this pattern in an African setting, highlighting catastrophising as a critical intervention target.
Crucially, this study moves beyond subjective well-being to demonstrate links with objective clinical endpoints. The finding that psychological flexibility nearly doubled the odds of optimal adherence (aOR=2.45) and virological suppression (aOR=1.89) is highly significant. This supports the proposition that flexibility aids in persisting with challenging, long-term behaviours (like daily pill-taking) in line with the value of health [7]. A pilot study from Colombia demonstrated that an ACT-based intervention improved ART adherence and reduced viral load in PLWHA, providing direct evidence for this link [18]. Previous Nigerian research has identified factors like stigma and medication side-effects as barriers to adherence [19], but less attention has been paid to modifiable intrapersonal processes like flexibility. Our work suggests that interventions targeting these processes could directly improve ART adherence rates, a perennial challenge in HIV programmes.
The inverse relationships for catastrophising with adherence (aOR=0.42) and viral suppression (aOR=0.53) are equally telling. Catastrophising likely fuels anxiety and helplessness, eroding the self-efficacy necessary for consistent self-management [10]. This aligns with a Ghanaian study that found negative illness perceptions predicted poorer adherence [20]. Our study adds specificity by pinpointing catastrophising as a key maladaptive cognitive component within these broader perceptions.
When situated within the Nigerian and West African context, these findings are particularly salient. The region contends with high HIV stigma, economic hardship, and healthcare system constraints [2,11]. In such an environment, cultivating psychological flexibility; accepting stigma-related distress without avoidance, committing to care despite logistical hurdles, may be especially protective. Conversely, the tendency to catastrophise may be exacerbated by systemic uncertainties, creating a vicious cycle that undermines care. Culturally adapted psychological interventions, such as ACT-based group therapy, could be integrated into existing clinic structures to address these needs. For instance, a study in Southwestern Nigeria successfully used mobile phone-delivered ACT to improve psychological flexibility in HIV-positive pregnant women [14], and similar work is emerging in Uganda [19].
Limitations
This study is not without some limitations. This study is limited by its cross-sectional design, which precludes causal inferences. Self-reported adherence is subject to social desirability bias, though we used a nationally validated tool. The use of a modified PCS, while rational, requires full validation in HIV populations in Africa. Strengths include the large sample size, use of validated instruments, inclusion of both subjective (HRQoL) and objective (viral load) outcomes, and the novelty of investigating these psychological constructs in a Nigerian HIV cohort.
Conclusion
In this large sample of Nigerian patients with HIV, psychological flexibility was independently associated with superior health-related quality of life, optimal treatment adherence, and virological suppression. Catastrophising was associated with significantly poorer outcomes across these domains. These findings highlight the critical role of modifiable psychological factors in the holistic management of HIV. We recommend that HIV care programmes in Nigeria and similar settings consider incorporating routine screening for maladaptive cognitive patterns and implementing evidence-based psychological interventions, such as Acceptance and Commitment Therapy, to foster psychological flexibility and mitigate catastrophising, thereby improving both the quality of life and clinical outcomes for people living with HIV.
Declarations
Authors’ Contributions
AAY, SMB, AMA, AIA, and BAY conceptualised and designed the study. AAY, SMB, AMA, AIA, and BAY were involved in data collection and analysis. AAY, SMB, AMA, AIA, and BAY drafted and revised the manuscript. All authors critically reviewed for intellectual content, approved the final version, and agreed to be accountable for all aspects of the work.
Availability of Research Data
Data are available upon reasonable request from the corresponding author.
Funding
No funding was received for this research.
Conflict of Interest
The authors declare no conflict of interest.
Acknowledgement
We thank the study participants, research assistants, the staff and leadership of the Adult Antiretroviral Clinic of Ahmadu Bello University Teaching Hospital (ABUTH), Shika-Zaria, For their cooperation throughout the study.