In a French cohort of PLWHA in the ANRS-EN12-VESPA Study,66 multivariate analysis showed age <47 years, the absence of a stable relationship, financial difficulties, uncomfortable housing conditions, detectable HIV viral load, experience of AIDS-defining events, difficulties as a result of adverse HIV treatment reactions, experience of rejection by medical staff, disclosure of sero-positivity in the familial or professional context, high hospital anxiety and depression (HAD) scores and the consumption of psychoactive drugs, to be significantly associated with an unacceptably low physical HRQL (p values between <0.0001 and 0.02).
However, among individuals living as couples, women without children were more likely to have an acceptable physical HRQL than were women with children (p = 0.047). Factors found to be negatively associated with an acceptable mental HRQL in the multivariate analysis were financial precariousness, low CD4 cell count, difficulties as a result of adverse treatment reactions, disclosure of sero-positivity in the familial or professional context, experience of discrimination because of HIV infection, high HAD scores and the consumption of psychoactive drugs (p values between <0.0001 and 0.01). Whereas women living with men as couples were more likely to have an acceptable mental HRQL than other individuals (p <0.0001). In this survey however, all participants were included in the analysis regardless of their current HIV treatment status (treatment with HAART 80%; treatment with non-HAART 3%; and not treated 17%). By so doing, authors failed to take into account the HRQL differences that might have existed between these three different groups of patients.
37 In another study conducted at a hospital department specialized in HIV care,67 self-perceived side effects of ARV treatment were found to be associated with all the six measured dimensions of HRQL; while HIV-HCV co-infection was associated with physical, psychological, social relationship and level-of-independence HRQL. AIDS clinical stage was associated with an impaired physical HRQL, a CD4 cell count <200 cells/mm3 and with an impaired social relationship HRQL. A long period since HIV-positive diagnosis was associated with an impaired social relationship HRQL, while taking ARV treatment was associated with both an impaired physical HRQL and level-of-independence HRQL; whereas employment was associated with an improved environmental HRQL and level-of-independence HRQL.However, the authors failed to mention the city and country in which the study had been conducted. Furthermore, only 72 respondents had been recruited. As a result of this small sample size, the spirituality HRQL dimension had yielded a low internal consistency (Cronbach’s α of 0.47) which the authors reported to be unacceptable and chose not to include the dimension in their analysis.
In a study conducted at three infectious disease clinics on HIV-infected men in a southern state in the United States of America (USA),68 results revealed that higher family support and CD4 cell counts at baseline were predictive of improved changes in physical and social functioning over time; while higher depressive symptoms at baseline were predictive of diminished role functioning, emotional well-being and general health perception. These findings were believed to underline the importance of enhancing family social support, identifying and treating depression, and improving immune function in order to optimize HRQL among men with HIV infection.
However, the authors had called it a prospective cohort study but this was a misnomer because
38 there was no comparison (control) group. Furthermore, the authors had failed to specify the city(ies) and southern state in which the study was conducted.
In another multi-site survey among HIV-infected persons in nine state and local health departments in the USA,69 factors found to be associated with lower HRQL scores included older age, female gender, black or Hispanic race/ethnicity, injection drug use, lower education and income, no private health insurance and lower CD4 cell count. In multivariate analysis, lower CD4 cell count was the factor most consistently associated with lower HRQOL. Taking antiretroviral medication was not associated with differences in HRQOL regardless of CD4 cell count. Nevertheless, there was a major flaw in this study which should be considered in the interpretation of the findings. Information was obtained from participants by self-report and as much as 12.5% of the participants could not recall their most recent CD4 cell count. Being that CD4 count cell is a critical indicator of disease progression, the authors should have confirmed patients’ report through clinical testing or from a review of their medical records.
At the AIDS Reference Centre (ARC) of Ghent University Hospital (GUH), Belgium,70 multivariable regression analysis revealed that incapacity to work, depressive symptoms, neurocognitive complaints, dissatisfaction with the patient-physician relationship and non-adherence were negatively associated with HRQL; while clinical parameters such as viral load and CD4 cell count were not independently associated with HRQL. Nonetheless, a major strength of this study was that a representative sample of the HIV population seen at the ARC was obtained because all PLWHA attending the ARC during the one-year period of the study (1
39 January to 31 December 2012) were eligible to participate and there were no constraints concerning age, time since diagnosis, treatment or other variables.
In a cross-sectional multi-site survey conducted at three epicenters of Vietnam including Hanoi, Hai Phong, and Ho Chi Minh City, predictors of poorer HRQL were found to include female gender, lower educational level, unemployment, alcohol and drug use, CD4 count <200 cells/mL and advanced stages of HIV/AIDS.71 However, selection of respondents by the use of a convenience sampling technique would limit generalizability of these study findings to the target population. On the other hand, information had been obtained through interviewer-administered questionnaires and this would have lessened non-response bias. Conversely, another survey conducted at seven hospitals in the same three epicenters of Vietnam had reported better HRQOL in patients who were male, had higher educational attainment and were employed. In reduced regression models, poorer HRQL was found in patients who had advanced HIV infection and had CD4 cell count <200 cells/mL.72 In this study however, authors had reported that patients were randomly selected and invited to participate during their clinic visits. It is unclear what they mean by randomly selected - is it that patients were selected by a random sampling technique or that patients were selected haphazardly?
In Ibadan, Nigeria,asymptomatic patients generally had higher mean quality of life (QOL) scores compared to their symptomatic counterparts on the four dimensions assessed. Furthermore, asymptomatic patients had significantly higher scores in the physical and psychological domains, indicating better QOL compared to their symptomatic counterparts. However, there was no difference in the mean QOL scores of males compared to females in all the domains assessed.59
40 Whereas in Ilorin, Nigeria, being married, fewer pills and longer duration of HAART appeared to predict better HRQL.58 A strength of this latter study is that patients were interviewed at the pharmacy when they came for their drug pick-up; and thus, a more representative sample of the patient population would have been selected.
In a survey at the Nyeri Provincial General Hospital, Nyeri County, Kenya,73 better HRQL was associated with male gender, Christian faith, higher education and paid employment; although the exact mechanism through which they (particularly gender and age) impacted health status might be partially explained by aspects of therapy and current clinical status. Furthermore, the patients’ assessment of their HRQL during treatment was negatively associated with their duration on ART irrespective of socio-demographic, clinical and other therapy-related variables.
It was suggested that HIV care programmes might benefit from strategies that strengthen the patient-provider relationship, with a particular focus on those who have been on treatment for a relatively longer duration. Nevertheless, the study had demonstrated sound methodology by clearly describing the study population, probability sampling technique and sample size estimation.
In another survey at the Felege Hiwot Referral Hospital in Bahir Dar, North West Ethiopia,74 unemployment (AOR = 2.32 [95% CI=1.49, 3.59]), poor adherence to HAART (AOR=3.24, [95% CI=1.02, 10.32]) and being bedridden (AOR=3.19 [95% CI=1.49, 5.04) were independent factors of overall poor HRQL. The fact that less than half (47%) the respondents had low monthly income was thought to probably explain the association between unemployment and poor HRQL. Moreover, being bedridden was thought to lead to inability to engage in one’s daily
41 living activities, which would in turn lead to poor income generation; and this might further explain the associated poor quality of life with unemployment. Furthermore, poor adherence to HAART was thought to lead to lowered immunologic status, which in turn led to poor HRQL. In this study however, age, educational status, marital status and CD4 cell count were not significantly associated with health related quality of life. Nonetheless, this study had demonstrated sound methodology by clearly describing the study population, probability sampling technique, sample size estimation and data analyses.
After one year of treatment in Ouagadougou, Burkina Faso,63 HIV-positive patients who experienced an average of two symptoms during follow-up also presented with significantly lower PHS (63.9) and MHS (43.8) scores compared to patients who had no symptoms, with PHS and MHS of 68.2 (p<0.00001) and 45.3 (p<0.0001), respectively. It was concluded that perceived symptoms experienced during follow-up visits were associated with a significant impairment in HRQL over a 12-month period in this urban African population. Conversely in a study in the Free State province, South Africa,64 males were significantly more likely than females to report problems with mobility and usual activities; unemployed patients were significantly more likely than employed patients to report problems with usual activities and pain/discomfort; and patients with physical caregivers reported a lower quality of life for all 5 dimensions than patients who did not have physical caregivers.