1. Introduction
Approximately 39 million individuals died due to Human Immunodeficiency Virus (HIV) infection, and >40 million people are currently living with HIV; 14000 new cases are infected by HIV per day (Eilami, Nazari, Dousti, Sayehmiri & Ghasemi, 2019). The number of individuals who live with HIV/Acquired Immunodeficiency Syndrome (AIDS) has increased in recent years. This is because advanced therapies allow patients to live longer (Patton, 2015). Epidemiological studies in Iran revealed that the prevalence of HIV is different in various regions of the country, ranging from 8.1 per 100000 in the west, 5.1 in the north and center, one in the east, to 6.3 in the south. Currently, Iran has reached the HIV epidemic proportion and it is more prevalent among high-risk groups, such as prisoners, substance-dependents, and sex workers (Joulaei, Lankarani, Kazerooni & Marzban, 2017). People Who Live with HIV (PWLH), as a chronic and disabling disease, experience high levels of anxiety (Brandt et al., 2017), depression (Bhatia & Munjal 2014), sleep disorders (Gamaldo et al., 2013), suicidal ideation (Ruffieux et al., 2019), impaired sexual function (Khuat et al., 2018), impairments in daily living activities, and socio-psychological pressures (Russell et al., 2016). There is no definitive cure for HIV; thus, patients accept the feelings of helplessness and inefficiency, instead of managing and controlling the disease. Accordingly, most of the PWLH report low life expectancy (Wandeler, Johnson, & Egger, 2015). Decreased hope for biopsychological health puts individuals at risk (Heidari& Ghodusi, 2015). Hope is a cognitive concept that focuses on the future. Hopeful individuals have a stronger immune system and present higher performance in controlling diseases (Sung et al., 2019).
Psychological wellbeing is another important concept in chronic conditions. The lack of a definitive treatment along with social stigma affects the psychological state of PWLH and make their psychological wellbeing vulnerable (Sun, Wu, Qu, Lu & Wang, 2014). Studies reported that 44%-79% of PWLH suffer from some degree of anxiety and clinical depression (Sun et al., 2014; Betancur, Lins, Oliveira, & Brites, 2017). Psychological flexibility is an ability that helps individuals to modify their thoughts and behaviors in response to various life changes in stressful situations (Asensio-Martínez et al., 2019). Psychological flexibility is more essential in chronic diseases, such as HIV, in which cognitive impairments are among their long-term complications (Alford et al., 2019). Additionally, psychological flexibility plays a protective role in chronic diseases (Rudnik, Piotrowicz, Basińska & Rashedi, 2019); promoting psychological flexibility can increase individuals’ adaptability to chronic diseases (Kuba & Weissflog, 2017).
HIV profoundly affects mental health; thus, psychotherapists have developed various treatment plans to reduce the psychological symptoms of the disease and improve the Quality of Life (QoL) of patients (Sherr, Clucas, Harding, Sibley & Catalan, 2011). This population always experience a sense of shame and guilt, and their self-esteem is at risk (Kalomo, 2018). According to previous evidence, Compassion-focused Therapy (CFT), as an effective psychological intervention for numerous disorders, can improve the secondary symptoms associated with the disease and even help with the biological treatment of the patients (Brion, Leary, & Drabkin, 2014; Montero-Marínet al., 2018). Thus, CFT seems to be an appropriate option for patients with HIV, too (Eller et al., 2014). Neff (2003, 2005) defined self-compassion as a concept with 3 main elements, as follows: kindness against self-judgment, human commonalities against isolation, and the presence of mind in the face of extreme assimilation. Compassion increases psychological flexibility (Asensio-Martínez et al., 2019), hope (Wong, 2018), and psychological wellbeing (Wickland Gastin, 2017). Shahabi, Shahabi, and Foroozandeh (2019) reported that high self-compassion increases the psychological flexibility of couples. Karakasidou and Stalikas (2017) documented that self-compassion increases psychological wellbeing. Tara, Hobbs, Lorraine, and Arthur (2019) also stated that self-compassion presents positive effects on life expectancy. Despite the importance of the psychological consequences of HIV, no study has investigated the efficacy of CFT on increasing the life expectancy, psychological wellbeing, and psychological flexibility of PWLH. Therefore, the current study was conducted in response to this research gap.

2. Methods
This was a quasi-experimental study with a pre-test, post-test, follow-up and a control group design. The study population was all PWLH in Tehran City, Iran, with an active case in the Tehran Blood Transfusion Organization in 2019. Initially, according to the inclusion and exclusion criteria of the study, 60 participants were selected by convenience sampling approach. Then, based on Cohen’s formula (alpha: 0.05 & test power: 84%), 34 participants were invited to participate in this study using a random sampling method. The inclusion criteria of the study were as follows: having an active file as an HIV-infected patient; being aged 18-45 years; not having psychiatric disorders; not taking psychiatric drugs; not having substance-dependence, and not receiving psychological treatment during the past 6 months. The exclusion criteria of the study were absence from >2 intervention sessions and taking any psychiatric medication. The Depression Anxiety Stress Scale (DASS-21) was used to homogenize the research population. In this case, the scores lower than the cut-off point of DASS-21 were used as the criteria of the patients without psychiatric disorders. By random sampling technique, 34 subjects were assigned to the CFT and control groups (n=17/group). The research participants completed a demographic data questionnaire, the Ryff 18-item Wellbeing (PWB) Scale (1995),  Schneider’s Life Expectancy Scale (1999), and Bond Psychological Flexibility Questionnaire (PFQ, 2012) in pre- and post-intervention phases, as well as three months after the intervention (follow-up step). The study was of a double-blind design, as the investigator and participants were blind and only the first author who delivered the intervention was aware of the relevant data. The intervention group received eight 90-minute CFT sessions (based on Gilbert’s protocol); however, the control group received no intervention. During the research process, 2 subjects from the experimental group and 2 control subjects were removed, due to unwillingness to continue the research. Eventually, the data obtained from 30 individuals were analyzed. In addition to descriptive statistical methods (mean, standard deviation, frequency, & percentage),  collected data were analyzed by a blind analyzer, using repeated-measures Analysis of Variance (ANOVA) in SPSS. 

3. Results
The current research data concerning the study groups’ demographic characteristics suggested no significant different in terms of age (t=1.3, P=0.19), educational level (x2=0.38, P=0.73), marital status (x2=1.00, P=0.31), and disease duration (F=0.59, P=0.55) (Table 1).

The Kolmogorov-Smirnov results indicated that the data distribution was normal and parametric tests can be used, accordingly (>0.05). There was a significant difference between the post-test scores of the study groups in terms of all research variables (P<0.001); these differences were also significant in the follow-up stage (P<0.001) (Table 2).

Besides, the post-test and follow-up mean values of the intervention groups were significantly higher than those of the control group (Table 3).

Based on the measured Eta-coefficients, the intervention enhanced the psychological wellbeing, life expectancy, and psychological flexibility of the intervention group by 38%, 22%, and 37%, respectively. To compare the pre-test, post-test, and follow-up data, the mean comparison test was used, which its results are presented in Table 4.

There was a significant difference between post-test and follow-up scores in the intervention group; while supporting its effectiveness, its stability was approved in the follow-up stage (Table 5).

4. Discussion
The current study investigated the effectiveness of CFT on increasing psychological wellbeing, life expectancy, and psychological flexibility in PWLH. According to the achieved results, CFT could effectively improve psychological flexibility, psychological wellbeing, and life expectancy in the study participants. In line with the findings of the current study, Asensio-Martínez et al. (2018) concluded that CFT increases mental flexibility. In another study, Wong (2018) reported that compassion increases life expectancy. Besides, Wiklund Gustin (2017) reviewed various studies and concluded that compassion-based interventions improve the dimensions of psychological wellbeing. In justifying this finding, it can be mentioned that a basic principle of CFT is internalizing external thoughts, factors, images, and soothing behaviors; through which, the mind will respond to internal elements, as external components. Therefore, the mind will be relaxed (Gilbert & Irons, 2006). Individuals who are more passionate about themselves are less prone to be confused and depressed. In other words, compassion is an essential supportive factor to cope with anxiety and depression. When individuals feel unable to cope with life challenges, they become emotionally silent and feel scared and shy (Neff, 2003). Self-compassion is a healthy form of self-acceptance that reflects the degree of acceptance of undesirable aspects of life. McLean, Fiorillo, and Follette (2018), in a similar study, concluded that compassion-based exercises increase the flexibility of the mind. Skinta, Lezama, Wells, and Dilley, (2015) also reported similar results. As noted by Gilbert (2009), self-compassion increases emotional flexibility, because individuals can neutralize the threat system (i.e. related to emotions, such as insecurity, defense, & automatic stimulation) and activate the care system. This system is concerned with emotions, such as security, attachment, and the oxytocin addiction system. According to the literature, the higher the self-compassion, the lower the self-criticism, depression, anxiety, rumination, and depression.
Compassion is associated with increased happiness, optimism, personal initiative, and social communications (Neff, 2009); therefore, it may present positive impacts on psychological wellbeing, as an influential factor in HIV-positive patients. These processes enhance life expectancy and promote mental health. Furthermore, those who accept the disease and its living conditions adapt to their new conditions. Subsequently, by increasing self-care behaviors, they feel more hopeful for survival.
The current study had limitations, including the small sample size, i.e. mainly due to difficulties in accessing the information of PWLH and their unwillingness to participate in the research. Another problem was the inability to conduct in-depth clinical interviews to assess patients’ mental health, and only patients’ scores on the stress, depression, and anxiety questionnaires were obtained. Besides, conducting a long-term follow-up was impossible, and patients with a long history of infection refused to participate in this study. 

5. Conclusion 
The present research findings revealed that CFT could improve psychological wellbeing, life expectancy, and psychological flexibility in individuals with HIV. We hope that our results help treatment agencies to design suitable programs addressing the HIV population.

Ethical Considerations
Compliance with ethical guidelines
All ethical principles were considered in this article. The study participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their provided information. Moreover, they could discontinue participation in the study whenever they wished. Eventually, if desired, the results of the research would be available to them. The present study is the result of a doctoral dissertation. The proposal of the study was approved by the Research Committee of the Science and Research Branch of Islamic Azad University, Tehran, Iran. An informed consent form was obtained from all individual participants included in the present study.

Funding
This article was extracted from the PhD. dissertation of the first author at Department of Psychology, Science and Research Branch, Islamic Azad University, Tehran.

Authors' contributions
Methodology: Behrooz Dolatshahi and Farzane Khalaj; Writing the original draft: Behrooz Dolatshahi & Farzane Khalaj; Writing, review, and editing: Fariborz Bagheri; Resources: Behrooz Dolatshahi & Farzane Khalaj; Supervision: Behrooz Dolatshahi & Fariborz Bagheri; Conceptualization, investigation, funding acquisition: All authors.

Conflict of interest
The authors declared no conflicts of interest.


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