Spirituality in Suicide Prevention among People Living with HIV/AIDS-A Review

Introduction: Suicide is a significant public health concern. Suicidal behavior remains highly prevalent among people living with HIV (PLHIV). In addition to the risk factors for committing suicide, it is important to know the factors contributing to preventing suicide. Although previous studies claim that spirituality is considered a protective factor against suicide, it is still understudied in HIV-positive patients. Objective: The present study aimed to provide a critical literature review on the association between spirituality and suicidality among PLHIV. Methods: We reviewed clinical studies evaluating the potential effect of spirituality in suicide prevention among PLHIV in Pubmed and Embase. Discussion: In the present review, spirituality was considered a protective factor for suicidal behavior in PLHIV. Although there are few studies among HIV-positive patients, spirituality remains a powerful resource for coping with HIV infection. Enhanced spiritual well-being has been positively associated with lower levels of depression and suicide risk, increased resilience, active coping strategies, finding meaning and purpose in life, better social support, and quality of life among PLHIV. Conclusion: In the present review, spirituality may be considered a protective factor for suicide among PLHIV. Therefore, implementing spirituality as a key part of the suicide prevention strategy could help decrease suicide rates among PLHIV.

that the expression of suicide risk results from complex interactions of risk factors and limited access to protective factors [6,7]. The risk and protective factors are summarized in (Table  1).
Regarding protective factors, recently published data had examined the relationship between spirituality and suicidal behavior [6,7]. Spirituality can be defined as "the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred" [8].
The route to attain enhanced spiritual well-being (SWB) is unique to each individual since spirituality can assume different meanings according to each person's background, life experiences, and beliefs. Finally, spirituality should provide the individual his/her source of value, meaning, purpose, and a sense of inner and outward connection, contributing to individual health outcomes. [6,8,9].
In this sense, previous studies have shown that SBW is positively associated with lower depressive symptoms [10], more effective coping, more significant social support, and better quality of life in HIV-positive individuals [11]. However, it is still an open question whether SWB would have a protective effect against suicidal behavior among PLHIV. Thus, the present study aimed to provide a critical review of the extant literature on the association between spirituality and suicidality among adults living with HIV/AIDS [12][13][14].

Review of Literature
We reviewed clinical studies evaluating the potential effect of spirituality in suicide prevention among PLHIV in Pubmed and Embase. The following terms were searched: 'spirituality" OR 'spiritual' AND 'HIV"AND "suicide" OR "suicidal".
Multiple studies had demonstrated that psychological well-being is a predictor of overall health status [15][16][17].
Therefore, it has been suggested that personal perceptions, mental status, feelings, and family or friends' support would be more significant predictors of quality of life [15]. Thus, there is a growing interest in researching the association between SWB and better health outcomes among PLHIV. It is also possible that spirituality may be associated with reduced depressive symptoms and suicide rates by increasing coping strategies, better social support, enhanced personal control, and understanding the disease experience [15][16][17][18][19][20].
Given that social support and coping skills are potentially protective in suicide risk in HIV-positive patients, Peterson, et al. [9] highlighted the strong connection between social support and spirituality. This research evaluated spirituality as a lifeline among 46 women living with HIV and its role in their support system. They found that social acceptance and assisted coping can regulate behavior, give a meaningful sense to life, and provide the courage to deal and fight problems positively and constructively. Finally, women who participated in the study described spirituality as a source of support or emotional control and enable them to develop new meanings and perspectives on HIV.
Pérez, et al. [12] prospectively examined the effects of spiritual striving, social support, and acceptance coping on depressive symptoms among adults living with HIV/AIDS. This study was conducted using longitudinal data from a randomized controlled trial through a model that measured spiritual striving, social support, coping styles, and depressive symptoms at baseline, three-month follow-up, and six-month follow-up. Spiritual striving resulted in less negative experiences related to HIV infection and predicted lower levels of depressive symptoms. However, contrary to a similar study [9], social support did not predict depressive symptoms changes. The argument was that the relationship between SBW and depressive symptoms is mediated by acceptance coping, but not by social support.
In addition, as spiritual beliefs may be useful in suicide prevention, Zarei & Joulaei [13] investigated the correlation

Conclusion
In the present review, spirituality may be considered a protective factor for suicide in adults living with HIV/AIDS. Our findings support that SBW serves as a buffer to stress associated with HIV/AIDS, providing comfort, better understanding and acceptance of the disease, and the confidence to cope with HIV infection. Therefore, implementing spirituality as a part of the suicide prevention strategy could decrease suicide rates among PLHIV.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of Conflicting Interest
The authors declare that there is no conflict of interest.
between the perceived stigma, quality of life, and spiritual beliefs with suicidal ideation in 351 adult HIV-positive patients. Spiritual beliefs and reduced internal stigma were the most significant factors of less suicidal ideation. In particular, they showed that having religious beliefs had a significant negative correlation with suicidal ideation. Therefore, this study stated the need to implement counseling services and harm reduction programs to reduce internal HIV-stigma and increase spiritual beliefs.

Discussion
The present review sheds light on the possible association between spirituality and suicidality among people living with HIV/AIDS. Although there are few studies, we found that spirituality may be considered a protective factor for suicidal behavior among HIV-positive patients.
Spirituality remains a powerful resource for coping with HIV infection. Enhanced spiritual well-being has been positively associated with lower levels of depression and suicide risk, increased resilience, active coping strategies, finding meaning and purpose in life, better social support, and better quality of life among PLHIV.
This review's findings can have significant clinical implications for healthcare professionals who work with HIV-positive patients. In depressed patients, assessing individual spiritual beliefs and supporting spiritual striving may be a useful complement to standard therapy for depression [12]. Consequently, it could also impact the suicidal behavior prevention of adults living with HIV/AIDS [12]. Of note, a recent study showed a significant negative correlation between spiritual beliefs and suicidal ideation among PLWH [13].
As spirituality is considered a protective factor for suicide behavior, spiritual interventions could be implications in suicide prevention in PLWH. In this regard, few publications have described interventions involving spirituality to improve HIV-related outcomes [21,22]. For example, Brown, et al. [21] found that a group-based self-management intervention can increase optimism and spiritual well-being at the end of the ten-week intervention in PLWH. Another study demonstrated that high levels of positive religious coping and low spiritual struggle levels were associated with significant depression improvement [22]. However, further studies are needed to demonstrate the role of spiritual intervention in reducing the suicide risk among HIV-positive patients.
This review should be interpreted in light of its limitations. First, we not included religiosity in our research. As religiosity is a well-known protective factor for suicide risk in the general population, it is also possible to positively influence PLHIV. Second, we did not research whether spiritual practices could have a protective effect on suicidal behavior in PLHIV.
Finally, we found that higher SBW would be considered a strategy to cope with HIV infection, providing meaning and hope. Besides, spirituality can also positively influence social support and perceived stigma [9,12,13,15,19]. Moreover, potential mechanisms through which spirituality would impact