This study has shown that being on first-line HAART for at least 12 months leads to a significant improvement in HRQL. High ratings of good HRQL was obtained across all the eight dimensions measured. Nevertheless, respondents’ ratings of good HRQL were highest with physical functioning, role-emotional and social functioning dimensions, in that order. The highest rating of physical functioning indicated that the vast majority of respondents had experienced little or no limitations with performing moderate to vigorous physical activities including lifting or carrying shopping items, climbing stairs, bending/kneeling/stooping, walking moderate distances and caring for one’s self (bathing and dressing).107 This further suggests that majority of the patients had experienced a significant improvement in their health because of HAART and they were particularly more able to perform physical functions that they were hitherto unable to perform.
In Ile-Ife, Nigeria, however, the highest mean scores were obtained with mental health, general health, vitality and physical functioning dimensions, in that order.105 The disparity between this study and the present study may be due to socio-cultural differences. While this study was conducted in South West Nigeria, the present study was conducted in North Central Nigeria.
Nonetheless, findings similar to the present study were obtained in Ilorin, Nigeria58 and other
133 countries,35,57,68 where the highest mean score was observed with physical functioning compared to the other HRQL dimensions measured.
In the present study, the second and third highest reported HRQL were regardingrole-emotional and social functioning dimensions. This indicated that majority of the respondents were able to accomplish their work and other usual/social activities with the same care and within the normal time; and within the normal levels in terms of quantity and quality with which they usually perform them, without experiencing limitations due to emotional problems.107 In contrast, respondents had rated social functioning at the second position;70,74 while role-emotional scores were the fourth highest at baseline, but later increased to attain the third position after 12-months of HAART;68 and this further demonstrates the importance of focusing treatment goals on optimizing HRQL rather than on improving survival only.114
In the present study, majority of the respondents also reported high rates regarding vitality, role-physical, mental health and bodily pain dimensions. This indicated that in most respondents:
energy levels were high; and feelings of peace, happiness and calm were experienced all or most of the time; while there was minimal/no pain.107 In another study, high scores were also obtained on the energy, mental health and pain dimensions.70 In contrast, of the dimensions assessed in another study, HRQL had increased significantly after 12 months of HAART on all the dimensions except for vitality and mental health.In that study, the least scores were obtained on the vitality dimension and after 12 months of HAART, vitality scores appreciated marginally but still remained the least.63 Whereas in another study, role functioning scores were the second highest at baseline, but later dropped to the fourth position at 12-months of HAART. Patients’
134 depressive symptoms at baseline were reported to be significantly predictive of this negative change in role functioning.68
Finally, the least rating in the present study was obtained with general health dimension (93.4%).
This implied that the remaining (6.6%) respondents were expecting that their general health might probably get worse.107 Nonetheless, about three-quarters of respondents had perceived an appreciable improvement with regards to self-evaluated transition (SET) in health and this was believed to be due to the efficacy of HAART.
Determinants of HRQL
Socio-demographic correlates of HRQL
In the present study, younger age (<40 years) and being currently employed were predictors of good role-physical health; while having a care giver and disclosing one’s HIV-positive status were predictors of good vitality. Generally, younger persons are physiologically healthier than older persons and are therefore more able to perform the physical activities considered suitable for their roles by age group. The same situation probably applied to younger persons in the present study. Furthermore, being employed enables one to financially afford better food, be able to access and pay for health care, and thus be able to attain/maintain a state of good physical health. Moreover, when a patient has a caregiver, the caregiver shares his/her responsibilities and accomplishes other tasks the patient might otherwise have to do him/herself. This reduces the stress on the patient and thus conserves his/her vitality. Besides, disclosing one’s HIV-positive status may probably be liberating, reduce emotional burden and lift depression, and as a
135 result, lead to improved vitality. Disclosure may also bring help and support from family members, friends and others; and this may make a patient livelier.
Similar to the present study, younger age was found to be associated with a higher psychological quality of life (QoL) and a higher environmental QoL, while having employment was associated with a higher psychological QoL.67 In other studies, unemployment was significantly associated with poor HRQL74 and unemployed persons were seen to have lower QoL scores than employed persons.64 Regarding the latter, the authors had explained that this might have possibly been as a result of the fact that sicker people are more likely to leave work, rather than joblessness itself affecting wellbeing.64 Contrary to the present study, multivariate analysis elsewherehad shown that age below 47 years and disclosure of HIV sero-positivity in the familial or professional context were associated with an unacceptably low physical HRQL;66 while in a Yoruba population in Ile-Ife, Nigeria, role physical had decreased with older age, although age seemed to have less influence on vitality;105 whereas those with higher life satisfaction scores were seen to have disclosure worries;115 and lower scores in the stigma domain had indicated fear of disclosing one’s HIV-positive status.48 With regards to having a caregiver, divergent findings to the present study had demonstrated that patients with a physical caregiver reported a lower quality of life for all five QoL measures than those who did not have a physical caregiver.64
In the present study, enjoying social support was a predictor of the less likelihood of good role-physical health and good mental health; while being without a spouse/partner was a predictor of the less likelihood of good general health. With regards to the negative association between enjoying social support, and good role-physical and good mental health, it is plausible to suggest
136 that the patients’ state of deteriorated health might have been the trigger that alerted relatives and friends to recognize the need to offer social support to the patient. It is also likely that the form of social support offered was probably not what the patient needed and hence it was not effective.
With particular reference to mental health, a patient recognizing the fact that he/she needed and depended on others for social support might be a depressing situation to be in and this could worsen his/her mental health. These reasons might explain the negative association with good role-physical health and good mental health for patients who enjoyed social support. Contrary to the present study, higher psychological QoL and higher QoL in terms of social relationship were associated with reporting social support from partner and reporting social support from friends, respectively.67 Whereas, baseline family social support was seen to be a significant predictor of 12-month positive change in physical functioning; and it was suggested that enhancing early baseline support from patients’ family members would significantly improve change in physical functioning over time.68
With regards to marital status, another study had demonstrated better QoL among married HIV/AIDS patients than for unmarried women.58 The authors were of the view that the physical and emotional support the married women received from their partners likely led to improved QoL. The present study agrees with this opinion considering that the current state of being without a spouse/partner was associated with the less likelihood of good general health.
Although self-evaluated transition (SET) in health is not part of the SF-36v2 eight dimensions of HRQL,107 it was considered pertinent in the present study to explore determinants of changes in health by comparing present health status to health status one year ago (i.e., one year prior to the
137 study period). The investigator’s opinion was that patients’ subjective assessment of health status could be dynamic, changing over time with experiences at the ARV clinic; and evolving with patients’ changing beliefs, attitudes, emotions, and daily and larger life events; such that patients’
subjective assessment of health status is being continually renegotiated. However, contrary to the investigator’s expectations, of all the explanatory variables examined in the present study, only alcohol consumption was significantly associated with the less likelihood of improved change in health. Alcohol has been documented to cause both social and health (physical and mental) effects. The health effects of alcohol have been observed in nearly every organ of the body, and alcohol consumption has been linked to more than 60 diseases.The effects of alcohol on the brain and body depend on how much and how often one drinks; as well as one’s age, gender, and overall health status. Moreover, heavy alcohol use is reported to increase the risk for many chronic consequences (e.g. diseases such as cirrhosis, cancers, etc) and acute consequences (e.g.
road traffic accidents and injuries).116 This suggests that chronic and heavy alcohol use in patients with chronic illnesses including HIV, will probably cause even less favourable health status outcomes. Furthermore, predictors of poorer HRQL had included alcohol use in another study among HIV/AIDS patients.71 Whereas health transition was reported to be better in women compared to men as median (IQR) scores were 50 (50-75) for men versus 67.1 (50-75) for women.70
Clinical correlates of HRQL
Experiencing an improved change in health was a predictor of good vitality and good mental health; while being satisfied with the general care received at the ARV clinic was a predictor of good general health. The focus of the therapeutic goals of HAART is to optimize patients’
138 HRQLrather than only improving survival114 and this has been evidenced by the positive change in health for respondents in the present study. Furthermore, going by the WHO definition of health as: “.... a state of complete physical, mental and social well-being ....” it is reasonable to suppose that the positive change in health was probably holistic, thus leading to both improved vitality and mental health. Regarding satisfaction with the general care received at the ARV clinic, patient satisfaction is recognized as an important indicator of both quality of care and outcome of care for adults with HIV/AIDS.19 Therefore, the findings of the present study imply that respondents were receiving good quality care that was achieving treatment goals as expressed by good general health.
In the present study, experiencing side effects was a predictor of the less likelihood of good vitality and good general health. Generally, side effects to ARVs are common and are mostly transient, but they can still make a patient feel sicker. However, serious side effects are rare; but when they occur, can be potentially dangerous and even life-threatening.117 In another study, experiencing difficulties as a result of adverse HIV treatment reactions was also shown to be associated with an unacceptably low physical HRQL;66 whereas, physical and mental HRQL were not associated with any ART adverse drug reactions in another study.73