Coping Strategies and Mental Health of the LGBTQ with HIV/AIDS – A Systematic Review

Facing stigma on both HIV and sexuality by the larger society puts significant pressure and stress on the LGBTQ living with HIV to cope with their diagnosis. The promotion of coping strategies as an intervention to increase well-being among PLHIV needs to consider current findings to remain relevant. This systematic review took 17 articles from 2008 to 2018 to provide a comprehensive analysis of issues that influenced coping strategies and investigate the association of the chosen coping strategy with their mental health. The results indicated that the impact of double stigma amplifies the challenge faced by the LGBTQ community to deal with their HIV diagnosis and had a significant impact on their mental health wellbeing. Both positive and negative coping styles were present as coping strategies employed with positive coping being used more as a chosen strategy. Each presenting coping strategy was reviewed, with depression and anxiety becoming the baseline indicator to reflect mental health status. This systematic review also revealed that the positive coping strategy does not necessarily lead to a positive psychological state as it is dependent on the changeability of the stressor faced. The findings emphasized the complexities in untangling the influence of coping on wellbeing among PLHIV. More attention should be paid to the mechanisms of stressor appraisal in selecting a more suitable coping strategy.

It has been reported that PLHIV are more prone to develop mental health issues such as anxiety, poor health-seeking behavior, depression, and poor treatment compliance. They also have a higher tendency to indulge in risky behaviors such as the use of drugs and alcohol and unprotected sex due to their inability to cope well with stimuli and stressors such as diagnosis acceptance, poor social support, and stigma (Flowers et al., 2011;Lowther et al., 2014). Whereas in a situation where sufficient psychosocial support, personal resources, and the ability to cope well are available, a positive healthy functioning and adaptability can be established (Bonanno, 2004(Bonanno, , 2012Flores-Palacios & Torres-Salas, 2017).
Adaptive coping was associated with higher adherence to treatment, increased chance of obtaining undetectable viral load, and better psychological well-being such as having meaning and purpose in life, positive emotions, optimism, and sense of humor (Dale et al., 2014a;Dale et al., 2014b;Park, 2013). Previous reviews had examined the effects of various coping strategies and stigma on mental health (Blashill et al., 2011;Sawyer et al., 2010;Smit et al., 2012). However, these reviews tend to be narrowed towards post-traumatic growth (Sawyer et al., 2010;Sherr et al., 2011), a wider population other than LGBTQ (Blashill et al., 2011;Sawyer et al., 2010;Sherr et al., 2011), focused on treatment effectiveness (Blashill et al., 2011) or categorized with other chronic diseases (Hefferon et al., 2009).
Furthermore, the complexity of the double stigma faced by the LGBTQ people-sexual identity and the HIV/AIDS diagnosis, affecting their choices of the coping mechanism had not been fully explored and represented for this population. The present review tries to expand the understanding of coping strategies used by PLHIV among the LGBTQ community using a broader set of questions. Thus, this systematic review aims to identify coping strategies employed, analyze issues faced that influence the choice of coping strategy, and finally investigate the association of the chosen coping strategy with their mental health.

Method
In this study, the PRISMA framework was used to conduct a systematic review (Moher et al., 2009;Uman, 2011). A SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) framework was used for research questions development to establish a rigorous process of transparency, increasing replication and reliability of search strategy.

Identifying the research questions
The review centered on the exploration of coping strategies employed, issues, and association of the chosen coping strategies onto the state of mental health among PLHIV/AIDS within the LGBTQ community. Therefore, to ensure a substantial range of literature focusing on the said interest areas is captured, the following research questions were established to guide the exploration: 1. What are the coping strategies employed by LGBTQ people with HIV/AIDS? 2. What are the issues related to the choice of coping strategies?
3. What are the associations of the chosen coping strategies with their mental health?

Identifying relevant studies
Key search terms and concepts were used to scour through related published literature on coping strategies used by PLHIV among the LGBTQ community globally. To obtain a wider coverage of available literature, a variety of keywords for search terms was used. The use of Boolean operators to narrow, widen, and combined literature were used as a searching technique. Consultation with the Universiti Malaya's librarian was sought after to help with creating and identifying key search items and databases that would best yield results needed. The descriptive key search items developed are illustrated in Table 1.

Key search items used to elicit published articles
Search terms "coping strategies" OR "coping mechanism" OR "coping skills" OR "cope" OR "coping" AND "HIV/AIDS" OR "HIV" OR "aids" OR "acquired immunodeficiency syndrome" OR "human immunodeficiency virus" AND "LGBTQ" OR "lesbian" OR "gay" OR "homosexual" OR "bisexual" OR "transgender" OR "transexual" OR "homosexual" OR "queer" OR "sexual minority") To ensure comprehensiveness and feasibility of search on the subject, inclusion and exclusion criteria were created. The review was conducted in 2019 and published literature from the last ten years was used in this review to allow ample coverage of the recent and relevant study on coping strategies with HIV/AIDS. Research before this time may be out-ofdate as the research gap on the issue may have been addressed, redundant, and does not reflect the recency of the research area (Pautasso, 2013). Hence, research done from 2008 to 2018 was deemed appropriate, fitting to the purpose aimed for this review. Due to the South-West University "Neofit Rilski" Psychological Thought 2021, Vol. 14(2), 308-338 https://doi.org/10.37708/psyct.v14i2.583 limitation on cost and time for translation activity, foreign language articles were excluded from this study which may indicate the possibility of missing relevant papers to be considered in this review. Table 2 illustrates the inclusion and exclusion criteria set.

Study selection
PRISMA checklist (Moher et al., 2009) was used to identify the articles. 1109 articles were identified from the key search descriptors determined from the databases and an additional 50 were identified through Google Scholar. Each of the articles' abstracts was reviewed to screen for relevance against the inclusion and exclusion criteria such as peer-review status, period, language, and study focus. 339 duplicated articles that appeared in multiple databases were also removed from the list. The review revealed 779 articles that do not fit into the said criteria, especially related to people living with HIV/AIDS within the LGBTQ community. The process continued with a deeper iteration of the review where a full-text version of the articles was obtained and carefully reviewed and confirmed as relevant guided South-West University "Neofit Rilski" Psychological Thought 2021, Vol. 14(2), 308-338 https://doi.org/10.37708/psyct.v14i2.583 by the inclusion and exclusion criteria by the authors. Each process of the review was done individually by each author and findings from all authors were compared and coordinated to ensure all criteria were consistently fulfilled. The outcome of the process yielded the final 17 articles identified as relevant to the research topic, following the Preferred Reporting of Items for Systematic Review and Meta-Analyses (PRISMA) Statement (Moher et al., 2009) as illustrated in Figure 1 below.

Data charting and collating
Each of the selected articles was summarized by category of author, year, location of study, study design, methods, brief objectives, sample size, and sampling method along with the extraction of findings for each of the research questions. The charting of data stage outcome details is captured and presented in Appendix.

Results summarising, synthesizing, and reporting
Findings from all reviewed articles were summarized and reported based on the research questions. A thematic construction is established by synthesizing the findings to help provide a narrative of the existing literature and determine generalizable findings.

Results
A total of 17 articles were systematically reviewed in this study, retrieved from seven countries. The majority of the articles came from the United States (nine studies), followed by three studies in Canada, and one study each from Mexico, Argentina, Scotland, Netherlands, and Hungary. There was a notable absence of literature from other regions such as Asia, Africa, and the Middle East. This section reports on findings obtained based on the initial research questions set as illustrated in Appendix. The selected articles discussed the types of coping employed, issues revolving around the coping strategy used, and the association it has on the mental health of PLHIV within the LGBTQ population.

Positive coping strategies
There are various positive coping strategies identified. Positive emotional-focused, religious and spiritual-focused, behavioral-focused, and cognitive-focused coping strategies were exercised by PLHIV in the articles reviewed. A total of nine articles discussed the use of emotional-focused coping strategies. Six articles reported peer and social support coping strategies as one of the positive coping mechanisms employed by LGBTQ members. Studied participants were found to seek support groups and self-help networks to obtain emotional support (article 9, 11, and 15,) socialize (article 16), obtain psychoeducational input (article 2), and modeling opportunities (article 2). Self-acceptance of the diagnosis given (article 2, 12, and 15) and using a professional support system such as counselors, psychiatrists, and primary healthcare providers (article 5, 11, and 15) were also observed in three different articles as one of the coping strategies employed. The use of humor (article 15) and being altruistic towards other community members (article 16) were observed as part of emotionalfocused coping strategies adopted by PLHIV in this community.
Religious and spiritual-focused coping strategies were reported in five literature reviewed.
Behavioral-focused coping strategies were observed in eight articles. Planning (article 13 and 15) and being proactive (article 9) were forms of behavioral active coping strategies used to manage the stressor faced by the participants. Three articles discussed the use of self-disclosure of their HIV status to family members, friends, and loved ones (article 1, 2, and 3). Other literature highlighted practicing safe sex with committed or casual sexual partners (article 3), the use of online resources to obtain information about the disease and its management (article 6), and balancing and managing health needs (article 11) as the employed behavioral strategies.
The use of cognitive-focused coping strategies were discussed in four articles. Participants were found to adopt a cognitive-based active coping by adopting a positive attitude (article 11), reappraisal technique, challenging thoughts (article 13 and 15), and resilience (article 9) to overcome their difficulties with challenges faced; both as a sexual minority and HIV/AIDS patients. Other positive coping strategies observed were dependency on legislation and policy set by the authority to protect their interest (article 2).

Negative coping strategies
Behavioral-focused coping strategies were the most used negative coping strategy observed among the studied participants with a total number of eleven articles highlighting the use of it.
Safety behavior was reported in five articles (article 5, 10, 11, 12, and 16) where participants would resort to non-disclosure or selective disclosure (article 11 and 16) of their HIV status to people in their life, social circle, potential partners, and work relations as a general caution to avoid mistreatment, judgment, rejection, and isolation. Four articles (article 1, 4, 8, and 15) reported substance use as the coping strategy used. Substances such as alcohol and drugs were used to help the participants to deal with the stigma faced. Alcohol consumption was also used to enhance sexual performance and positive emotions of the participants in facilitating their sexual experience and encounters (article 8) including as a means to distract the user from engaging in thinking about their issues.
Four articles highlighted dissociation and avoidance behavior (article 5, 11, 15, and 17) as negative coping strategies. Participants reported concealment of behavior including social self-quarantine and behavioral disengagement (article 5 and 15), avoidance of dealing with minor day-to-day stressors (article 11 and 17), and self-distraction (article 15 and 17) resulted from internalized and externalized stigma imposed on them. Meanwhile, practicing South-West University "Neofit Rilski" Psychological Thought 2021, Vol. 14(2), 308-338 https://doi.org/10.37708/psyct.v14i2.583 unsafe sex (article 3 and 10) was reported in two articles of reviewed literature. Unsafe sex such as unprotected anal intercourse (UAI) is one of their ways to secure acceptance and connection that resulted from a lack of self-respect, trust, and intimacy issues faced.
Cognitive escape (article 15 and 17) was the only cognitive-focused strategy found in the literature reviewed. This strategy was exercised through the manifestation of emotionfocused and behavior-focused coping such as self-blame, denial, venting (article 15), and usage of drugs during sex (article 17) as means to cognitively escape from current issues at hand. Religious or spiritual-focused coping strategy was not used as a negative coping in all of the literature reviewed in this study.

Issues related to the choice of coping strategies
Stigma and discrimination, fear, self-concept, knowledge level and protective factor, risktaking behavior, and accessibility were the six issues that influenced the adoption of various coping strategies for LGBTQ people with HIV. Many articles focused on the issue of stigma and discrimination. Twelve articles (article 1-3, 5 ,7-12, 14, and 16) discussed the issue of internalized (article 1, 2, 5, 9, 11, and 12) and externalized (article 2, 8, 9, and 10) stigma because of being HIV-positive. Out of those twelve articles, five articles highlighted participants experienced double stigma (article 3, 7, 9-11, and 14) from their HIV status and sexuality. The felt stigma or internalized stigma accompanied by enacted stigma or externalized stigma in the form of tacit discrimination were highlighted by four articles reviewed (article 2, 8, 9, and 16). The public's perception and schema based on the negative association of HIV being a punishment to the immoral and unacceptable norm of behavior led to enacted stigma (article 1, 2, 9, 10, 11, 14, and 16). The enacted stigma could materialize in the form of subtle rejection and social exclusion (article 9, 10, 11, 14, and 16) or physical behavior such as abuse and violence (article 9 and 10).
The second issue that emerged is fear. Nine articles (article 3, 7, 10-13, and 15-17) identified various types of fears experienced by the participants in dealing with their daily life as HIVpositive people. For example, avoidance behavior (article 7, 11, 15, 16, and 17) in the form of disengagement towards subscribed faith and social circle to minimize conflict, animosity, and stress were reported to be present among the participants. The need to be accepted by family, friends, partners, and society were other fears faced as revealed in article 3, 7, 10, and 16 where the need for social acceptance and support system are important to those who suffer from HIV. Other forms of fears were observed such as a sense of insecurity in a romantic relationship to discuss their HIV status and sexual practices with a partner (article 3) especially when the relationship starts to get more serious (article 16); the potential South-West University "Neofit Rilski" Psychological Thought 2021, Vol. 14(2), 308-338 https://doi.org/10.37708/psyct.v14i2.583 mistreatment from healthcare providers as they cannot hide their HIV status (article 16); and having to adapt and adjust with the diagnosis, changes in lifestyle (article 12) and changes in life goals (article 13).
Self-concept is the third issue observed, being highlighted in six articles (article 1, 3, 7, 10, 11, 13, and 15). Participants reported having negative affect such as feeling guilty, shameful, and hopelessness (article 1, 7, and 11), negative social interaction, and devaluing personal worth due to fear of seclusion (article 10). Competency in meeting basic needs such as worrying about having the personal resources and economics to manage the disease (article The last two issues are risk-taking behavior highlighted in three articles (article 4,8, and 10) and accessibility identified in two articles (article 5 and 6). Risky behavior such as substance abuse (alcohol and drug use) to enhance positive emotion in facilitating sex (article 4 and 8) increases the probability of cross-infection to HIV-negative partners, on top of precipitating and perpetuating more substance-related problems (article 8). The need for acceptance and connection felt by PLHIV induced risky sexual practices such as UAI and high-risk activities.
Accessibility to resources in helping PLHIV to cope better is the final challenge identified.
Access to professional and expert knowledge such as therapist or counselor, primary health care provider and social support group would help in securing emotional and informational support for PLHIV (article 5 and 6). Accessibility issue also refers to the ease of obtaining credible, trustworthy, and latest information to ensure correct and reliable information are properly consumed and practiced (article 6).

Favorable psychological association with their mental health
Emotional-focused coping through family and social support (article 2, 3, 5, and 9) reported having the most favorable association on participants' mental health. Increased level of selfconfidence and autonomy, sense of camaraderie and social identity, development of selfcompetence, optimism and purpose in life, improvement in the quality of life, reduction of stress, better management of loneliness, and finding peace were the outcomes from the chosen coping strategy. The use of online resources and social media (article 6) as a form of instrumental support coping strategy had resulted in higher self-control and personal growth, increased the sense of community, improved competence, avoidance of risky behavior, and better management of loneliness. Self-acceptance coping (article 2 and 12) reported positive associations on mental health such as better self-control and personal growth, problemsolving ability, increased self-confidence and autonomy, and development of selfcompetence, purpose, and optimism. Article 16 reported positive outcomes on developing social identity, a sense of camaraderie, and increased self-worth and value among those who exercised altruistic coping mechanisms.
Two articles (article 7 and 14) reported religious/spiritual-focused coping helped in building higher self-confidence and autonomy, developing a sense of camaraderie and social identity, and increasing self-worth and hope. On the other hand, cognitive-focused coping such as resilience generated positive mental health outcomes in the development of self-competence and usefulness, improvement in problem-solving ability, managing loneliness, and increased in self-worth as reported in two articles reviewed (article 9 and 11).
Whereas behavioral-focused coping such as active coping strategy (article 9, 11, 13, and 15) had shown to assist in managing depression and anxiety symptoms other than improving emotional stability and increasing self-control and personal growth. Similar to social support coping strategy, active coping also helped PLHIV to obtain a higher sense of self-confidence, autonomy, and overall improvements in the quality of life. Finally, self-disclosure coping promotes the improvement of self-confidence and autonomy for PLHIV as reported in article 11.

Unfavorable psychological association with their mental health
Behavioral-focused coping had the most unfavorable psychological association followed by emotional-focused coping while cognitive and religious/spiritual-focused coping reported not South-West University "Neofit Rilski" Psychological Thought 2021, Vol. 14(2), 308-338 https://doi.org/10.37708/psyct.v14i2.583 to have unfavorable outcomes experienced by the participants. Self-disclosure coping strategy (article 1, 3, and 5) reported the greatest number of unfavorable outcomes for PLHIV. The articles reported participants experiencing a higher level of anxiety, stress, depression, rejection, loss of social support, fear of seroconversion, emotional detachments to love ones, sadness, mental distress, worthlessness, and guilt. Avoidance and safety behavior coping followed second with six reviewed articles (3, 5, 10, 12, 15, 16, and 17) reported similar unfavorable outcomes like self-disclosure with elevated stress, depression, rejection, loss of social support, sadness, mental distress, worthlessness, and guilt. The coping strategy also resulted in a higher tendency of suicide risk and lower mental healthrelated quality of life.
A specific finding was reported on risky sexual behavior as an avoidance strategy where it was found to inhibit intimacy level with their partner and lowered a person's self-respect and self-value as identified in the article (3 and 10). Meanwhile, coping through substance use (article 1, 4, 5, and 8) also shared similar unfavorable outcomes as the first two coping strategies mentioned earlier. Participants reported higher suicide risk, developing depression, anxiety, experiencing rejection, worthlessness, and guilt. Unlike other coping strategies, it was found that coping through substance use resulted in hostility and work problems. Finally, rejection was reported as an unfavorable outcome for online and social media coping in article 6. Self-disclosure, online and social media coping were the only strategies that had both favorable and unfavorable outcomes in this systematic review.

Coping strategies employed by LGBTQ people living with HIV/AIDS
From the reviewed literature, it was concluded that there are two groups of coping strategies employed by PLHIV among the LGBTQ community; positive and negative coping strategies.
The classification of these two groups was based on the associated probability of adopted coping strategy with the desired outcomes where a positive coping strategy would have a higher association towards a positive outcome, and vice versa (Day & Livingstone, 2001;Dempsey, 2002;Heffer & Willoughby, 2017). The articles in this review indicated a higher preference for positive coping strategies as opposed to negative coping strategies. Such Social support, religious/spiritual, and active coping appeared to be the main choice of positive coping strategy; while safety behavior, substance use, and avoidance were the most adopted negative coping strategy. The use of social support, active coping, and religious/spiritual coping enable the user to be empowered to take control of their circumstances in dealing with various stressors such as stigmatization and discrimination towards being HIV-positive and part of the LGBTQ group (Dalmida et al., 2013;Liboro & Walsh, 2016). Having said that, the application of religious/spiritual coping should be taken with caution as it may not represent the whole spectrum of the LGBTQ community since the sample group used for the majority of the articles were mainly gay participants. There is an opportunity to further discover the use of online knowledge and social media as a coping strategy among this population since the internet and online platform have become more accessible in this technological age.
The use of negative coping strategies such as safety behavior, substance use, and avoidance coping were associated with fear, stigma, and discrimination faced by PLHIV for their seropositive status and sexual identity. The overwhelming experience of being diagnosed with HIV, the negative connotation of the disease perceived by the surrounding community, and the uncertainty placed onto those who live with the diagnosis leads to substance usage, avoidance, and safety behavior (Berg et al., 2017;Cramer et al., 2015;Folkman & Lazarus, 1986). Findings from other literature reviews indicated that LGBTQ and HIV-positive people have a higher rate of abusing substances that may lead to various negative implications such as poor mental health well-being and risky behavior (Cramer et al., 2015;Hampton et al., 2010;Skeer et al., 2012) which raise an interesting observation on the role of double discrimination and stigma (Bogart et al., 2010) on this population as compared to the heterosexual group which made them more susceptible towards misusing substances. It is also worth noting that despite the negative connotations of religion towards LGBTQ acceptance, this coping strategy was not adopted as a negative coping option among the community. Further research can be done to understand this phenomenon better to discover the perspective of blaming and locus of control among this sidelined community.

Issues related to the choice of coping strategies
Stigma and discrimination became the key issues faced in most of the literature reviewed.
Internalized stigma appeared to be significantly present. However, there is a possibility of enmeshed factors of external perception, the incident of discriminations that fortifies the belief, complex social structure, and lower awareness (Arnold et al., 2014;Haile et al., 2011;Tao et al., 2017) which may intensify negative self-attribute of PLHIV (Henkel et al., 2008;Voisin et al., 2013).
South-West University "Neofit Rilski" Psychological Thought 2021, Vol. 14(2), 308-338 https://doi.org/10.37708/psyct.v14i2.583 For example, in a society where religion is highly dominant that it cannot be separated from the majority of the population (Aminnuddin, 2020), negative coping strategies such as nondisclosure and concealment of behavior would be the preferable choice, being influenced by fear of reprisal and exclusion. The result of this review alluded that stigma plays a crucial element in the choice of coping strategy adopted by the participants. It is seen as the stem of other issues such as fear, poor self-concept knowledge level, protective behavior, and risktaking behavior.
However, further research needs to be done to establish the certainty of the accessibility issue towards the credibility and latest information given the fact that there are more available resources in various channels in recent years compared to before. Small sampling size recruited for the said article (article 6) may also contribute towards biases on arriving at such a conclusion.

Association of chosen coping strategies on their mental health
The choice of coping strategy made by participants does not necessarily lead to the desired psychological outcome. Although it can be concluded from the review that a negative coping strategy would have a higher likelihood of an unfavorable psychological outcome, the same conclusion cannot be made for a positive coping strategy as it may lead to either favorable or unfavorable psychological outcomes depending on how an individual chooses their coping strategy to respond with the type of stressor. If a positive coping strategy is used on an unchangeable stressor, a negative psychological effect may take place hence, making it maladaptive. This is consistent with previous studies that suggested the "goodness of fit" of coping strategy against the type of stressor that will influence the psychological outcomes (Allen & Leary, 2010;Folkman & Moskowitz, 2004;Sikkema et al., 2008).
The result from the systematic review indicated online and social media support and selfdisclosure coping strategies can either yield desirable or undesirable outcomes on their mental health. Online platforms provide PLHIV with faster access to information and reach to the community versus conventional ways. This expedites their ability to procure information and knowledge to equip themselves in better care of their health, sharing with peers and providing support to each other virtually (Mo & Coulson, 2010a;Perazzo et al., 2017).
The virtual environment can act as a protective factor for those who are slowly trying to gain trust and acceptance with others compared to physical socialization which can be overwhelming for those who are still adjusting to their current diagnosis. Thus, helping PLHIV to obtain higher self-control and personal growth, increase the sense of community, improving competence, and avoidance of risky behavior (Courtenay-Quirk et al., 2010;Mo & South-West University "Neofit Rilski" Psychological Thought 2021, Vol. 14(2), 308-338 https://doi.org/10.37708/psyct.v14i2.583 Coulson, 2008Coulson, , 2010bPerazzo et al., 2017). However, the discreetness and slower pace of adjustment available through social media and online resources also serves as a doubleedged sword as the sense of anonymity could also empower people to behave negatively and inconsiderable towards others or engage in risky and compulsive sexual behavior (Rhodes et al., 2007) and rejection from the potential partner (Courtenay-Quirk et al., 2010).
Similarly, self-disclosure coping strategy appears to be a double-edged sword as there are multiple factors in play that may lead to both favorable and unfavorable outcomes. Double stigma and discrimination play an important success factor in self-disclosure and its impact on the well-being of an individual (Cramer et al., 2015;Dalmida et al., 2013;Lowther et al., 2014;Vreeman et al., 2013). The pre-conceived notion that HIV is a punishment towards sexual orientation and moral values subscribed by the society becomes a barrier towards acceptance and embracement of PLHIV and the LGBTQ community (Bird & Voisin, 2013;Land & Linsk, 2013;Liboro & Walsh, 2016). Such findings suggest the coping strategy chosen should be carefully thought and addressing the right stressor instead of inferring all positive coping strategies will help to resolve issues faced and improve the psychological well-being of an individual.
The presence of social support provides PLHIV a sense of belonging, worthiness, and purpose in life, which enables them to be productive members of their community and function effectively in their daily life. This resulted in positive outcomes on their mental health where they can obtain better self-confidence, autonomy, self-competence, optimism, lower level of stress and loneliness, development of social identity, and ultimately better quality of life (Berg et al., 2017;Slater et al., 2013).
This review discovered that only active coping strategy reported having a positive outcome on depression and anxiety symptoms. This could be very well related to the mechanics behind the coping strategy that utilizes cognitive skills in managing stress factors. A person's ability to cognitively evaluate and appraise their stressors would result in better management of emotional and behavioral outcomes (Fumaz et al., 2015;Li et al., 2017). Avoidance and safety behavior coping strategy often create a temporary comfort towards the stressors faced but does not resolve the stressors in the longer run.
The act of avoidance and safety behavior only serves as an escape form to the issue and reintroduction to the same stressor repeatedly will eventually amplify and put a strain on the person's mental health. The result of reviewed studies has shown that the misuse of substances is associated with various physiological and mental health issues. The majority of the literature concluded that substance usage has a significant impairment on a person's South-West University "Neofit Rilski" Psychological Thought 2021, Vol. 14(2), 308-338 https://doi.org/10.37708/psyct.v14i2.583 cognitive and emotional ability which resulted in various behavioral and physical complications including increased risk of seroconversion (Devlin et al., 2011;Fumaz et al., 2015).

Limitations and future research suggestions
The study presented with some limitations where the scope of the study selection was delimited to the LGBTQ population without considering men who have sex with men who might not identify themselves as part of the LGBTQ community. Next is the exclusion of studies that were published in other languages due to the language capability barrier in translation resources. Another limitation in this study is the age group. The research was focused on people within the age of 20 to 39 years old that represent the largest age group of people infected with HIV/AIDS. Consideration to include men who have sex with men, studies that were published in other languages, and expansion of the age group would help to generate wider understanding and strength on the subject for future research. Future research should consider expansion of geographical representation for replication would be beneficial to extend the current body of knowledge into other regions such as Asia, Middle-east, and Africa. Expanding the sample size for both qualitative and quantitative studies would also help to bring better representation for each sub-group of the LGBTQ population. It was observed that online coping through the use of social media and the internet was not widely explored, suggesting an opportunity for further research to be done on the role of online coping strategy given the advancement of technology and accessibility to such platforms in recent years.

Conclusion
The findings illustrated an intricate relationship between the coping strategies used and issues that enable the choice of coping strategies adopted which will influence the mental health state of the individual. It is becoming evident that stigma plays an important role in determining the choice of coping strategy. The impact of double stigma amplifies the challenge faced by the community to deal with their HIV diagnosis and this had a significant influence on their mental health and wellbeing. Both positive and negative coping was present as a mode of coping strategies employed with positive coping being used more as a chosen strategy among participants in the reviewed articles.