HIV/AIDS remains one of the key challenges for the overall development of Ethiopia, as it has led to a seven-year decrease in life expectancy and a greatly reduced workforce [
Hence it interferes with day-to-day functioning and affects both personal relationships decision making and economic hardships. The importance of finding ways of mitigating these consequences of HIV/AIDS makes quality of life in PLHIV a salient issue for health care [
Government of Ethiopia introduced its free ART program by early 2005, with the goal of reducing HIV-related morbidity and mortality, improving the quality of life of people living with HIV and mitigating some of the impact of the epidemic [
Although there is still no agreed upon definition, there is agreement that quality of life is a multidimensional construct defined in terms of an individual’s subjective experiences and a construct that cannot be generalized across cultures [
The study was conducted in Mekelle town, Tigray Region, from February 15 to April 15 2012. Mekelle town is located 776 Kms north of the capital city Addis Ababa. A facility based comparative cross-sectional study was employed among randomly selected adult PLHIV on HAART who have regular follow-up that were selected from five health institutions found in the town, namely, Mekelle Hospital, Ayder Hospital, Mekelle Health Center, Kasech Health Center, and Semien Health Center. Those in age groups above or equal to 15 years have been on treatment for more than 3 months and with available CD4 count were included in the sample. As the study focused on measuring health related quality of life in female and male groups, differences as little as 3–5 points are considered to be clinically important differences [
Five senior nurses/data clerks one from each study site extract the data on clinical characteristics of PLHIV on HAART according to the selection criteria and five trained peer to peer counselors interviewed the participants on the sociodemographic, psychosocial and quality of life information of study subjects while the investigators and one health officer supervised to assure the quality. The questionnaire was adapted to the study setting context and translated into Tigrigna (local language). The translation of the English version of the questionnaire into Tigrigna (local) language was done using standard methods which consist of three phases: translation, back-translation, and harmonization.
Two independent forward translations into Tigrigna were carried out by native Tigrigna speakers fluent in English. After a critical inspection by the principal investigator and mental health specialist, a first version of the translation was agreed upon. Then it was back-translated into English by three independent bilingual translators of Tigrigna speakers English language professionals. All items which show differences between the original and the back-translated version were thoroughly discussed with the principal investigator and the translators. Finally, it was pretested on 5% of sample size for three days using Tigrigna translated and locally adapted WHO QOL-HIV BREF interview questionnaire in PLHIV on HAART who have follow-up other than the study facilities which have similar characteristics with the study subjects.
Health related quality of life was measured using the interviewer administered World Health Organization’s Quality of Life HIV short form instrument (WHOQOL-HIV BREF) [
The WHOQOL-HIV BREF instrument produces six domain scores and contains 31 items. For each item there is a five-point Likert scale where 1 indicates low or negative perceptions and 5 high or positive perceptions. These items contain six domains: physical health (4 items), psychological well-being (5 items), social relationship (4 items), environmental health (8 items), level of independence (4 items), and spiritual health (4 items). There are two items that examine general quality of life: question 1 asks about an individual’s overall perception of quality of life and question 2 asks about an individual’s overall perception of his or her health. The physical health domain contained information on presence of pain, energy, and sleep. The psychological domain consisted of negative and positive feelings, self-esteem, and thinking. The social domain covered social support, personal relationship, and sexual activity. Mobility, work capacity, and activities were included in the level of independence. Financial issues, home and physical safety and security, and participation in leisure activities were included under the environment domain. The spirituality domain did contain questions about death and dying, forgiveness and blame, and concern about the future. The suggested reference time frame of QOL experienced within two weeks was used in this study [
Information on demographic, behavioral, and psychosocial variables such as perceived stigma was also collected through face to face interview using pretested interviewer administered questionnaires. Perceived stigma was measured using adopted instrument that has been used in local context for the same population (PLHIV on HAART) [
Patients’ self-report adherence was measured by asking about the number of doses missed during the past 7 days and translated quantitatively in to percentage adherence. Optimal adherence means a patient must take more than 95% of their doses (i.e., missing less than 3 doses in a month).
It is support for the PLHIV from family members or friends in terms of psychological, financial, or adherence support.
It is support for the PLHIV outside family members like governmental or nongovernmental organizations, religious based organizations. and community based organizations in terms of psychological, financial, material, or spiritual support.
Data on CD4 count, WHO staging, reported side effects, drug adherence, and functional status of participants were extracted from HIV CARE/ART registries.
Data were analyzed using the SPSS version 16.0 software. First the descriptive statistics were calculated for sociodemographic characteristics, behavioral, psychosocial, and clinical variables in terms of mean, median, standard deviations, and range values for numerical data as opposed to percentage and frequency tables for categorical data.
Domain scores in the WHOQOL-HIV were scaled in positive direction with higher score denoting good quality of life. Negative questions like pain and discomfort were recorded so that higher scores reflected better QOL. Mean scores of the items within each domain were used to calculate the domain score. Mean scores were then multiplied by 4 in order to make domain score comparable with the scores used in WHOQOL-100. Independent sample
To assess predictors of QOL (poor versus good), first univariate analysis was employed and then variables that show statistically significant association with each of the six WHOQOL domains QOL in the univariate analysis (
Ethical clearance was obtained from the health research and postgraduate coordinating office of College of Public Health and Medical Sciences of Jimma University. Permission letter was obtained from study facilities and all information was confidentially used only for research purpose.
A total of 250 females and 244 males responded to the questionnaires making a response rate of 97.6%. Most of the respondents, 332 (67.2%), were attending their follow-up services at Mekelle Hospital followed by 56 (11.3%) at Mekelle Health Center. Their mean age was 35.46 (SD ± 8.03) years for females and 39.75 (SD ± 7.85) years for males. One hundred sixty-nine (67.6%) females and 214 (87.7%) males were literate. One hundred seventy-eight (71.2%) females and 232 (95.1%) males reported to have some form of employment. Two hundred thirty-four (93.6%) females and 231 (94.7%) males were Orthodox Christians (Table
Sociodemographic characteristics, psychosocial variables, and clinical parameters of people living with HIV, in public health institutions, Mekelle town, 2012.
Sociodemographics | Gender | |
---|---|---|
Female number (%) | Male number (%) | |
mean (±SD) age | 35.46 (±8.03) | 39.75 (±7.85) |
Marital status | ||
Single | 13 (5.2) | 30 (12.3) |
Divorced/separated | 86 (34.4) | 48 (19.7) |
Married | 80 (32.0) | 144 (59.0) |
Widowed | 71 (28.4 ) | 22 (9.0) |
Employment status | ||
Employed | 178 (71.2) | 232 (95.1) |
Unemployed | 72 (28.8) | 12 (4.9) |
Monthly income✦ | ||
Below average (<83.75$) | 236 (94.4) | 207 (84.8) |
Average and above (≥83.75$) | 14 (5.6) | 37 (15.2) |
Religion | ||
Orthodox | 234 (93.6) | 231 (94.7) |
Muslim, Protestant | 16 (6.4) | 13 (5.3) |
Educational status | ||
Illiterate | 81 (32.4) | 30 (12.3) |
Literate | 169 (67.6) | 214 (87.7) |
Psychosocial variables | ||
Psychosocial support from family members | ||
Yes | 79 (31.6) | 88 (36.1) |
No | 171 (68.4) | 156 (63.9) |
Psychosocial support outside family | ||
Yes | 179 (71.6) | 164 (67.2) |
No | 71 (28.4) | 80 (32.8) |
Perceived stigma | ||
Low | 118 (47.2) | 140 (57.4) |
High | 132 (52.8) | 104 (42.6) |
Clinical parameters [extracted from client records] | ||
CD4 count at start of ART | ||
Median (IQR)† | 163 (95–240) | 137 (66–215.5) |
CD4 count at start of ART | ||
<200 | 151 (63.2) | 164 (70.4) |
≥200 | 88 (36.8) | 69 (29.6) |
Most recent CD4 count | ||
Median (IQR)† | 366 (250–523) | 296 (205–441) |
<200 | 37 (15.2) | 56 (24.2) |
≥200 | 206 (84.8) | 175 (75.8) |
Months on ART | ||
Mean (±SD) | 43.57 ± 24.08 | 45.90 ± 24.16 |
Adherence to doses of ARV | ||
≥95% adherent | 231 (92.4) | 219 (89.8) |
<95% adherent | 19 (7.6) | 25 (10.2) |
Recent WHO clinical stage | ||
Stage I | 52 (20.8) | 31 (12.7) |
Stage II | 46 (18.4) | 33 (13.5) |
Stage III | 35 (14.0) | 51 (20.9) |
Stage IV | 117 (46.8) | 129 (52.9) |
†Median and IQR are reported due to nonnormal distribution, 1 USD = 17 ETB, and ✦the cutoff point is based on World Bank 2010 report.
One hundred seventy-one (68,4%) females and 156 (63.9%) males reported they did not receive any psychosocial support from family members/friends; in contrast 179 (71.6%) females and 164 (67.2%) males reported they get psychosocial support outside of their family. members or friends such as governmental and nongovernmental, and religious organizations. Median CD4 count at start of ART was 163 (IQR = 95–240) for females and 137 (IQR = 66–215.5) for males, respectively. And most recent CD4 cell counts were 366 (IQR = 250–523) for females and 296 (IQR = 205–441) cells/mm3 for males (Table
The internal consistency (Cronbach’s
The interdomain correlation showed that there was statistically significant association between domains. Weak correlation was observed between spiritual and environmental domains (
The overall mean ± SD quality of life perception was 3.96 ± 0.91 and 4.11 ± 0.85 for females and males, respectively. Similarly the mean ± SD score for general health perception score was 4.08 ± 3.52 and 4.27 ± 0.79 for females and males, respectively. Perceived health related quality of life was highest in the domain spiritual/PB with mean ± SD = (17.0 ± 2.74 males, 16.41 ± 3.09 females) and the lowest social relationships domain with mean ± SD score (13.50 ± 2.71 males and 13.14 ± 2.93 females). The average scores for the females for all the six domains and two general questions were between 0.15 and 0.59 points lower than the men’s score on the 4–20 scales. The difference was statistically significant for all domains and two general Questions except the social relationship domain are shown in Table
Gender difference in mean score of health related QOL domains of PLHIV on HAART in public health institutions, Mekelle town, Ethiopia, 2012.
Domains |
|
|||
---|---|---|---|---|
Mean ± SD |
Mean ± SD |
|
| |
Physical | 15.90 ± 2.95 | 16.44 ± 2.76 | −2.08 | 0.037∗∗ |
Psychological | 15.54 ± 2.44 | 16.06 ± 2.47 | −2.35 | 0.01∗ |
Level of independence | 14.01 ± 2.86 | 14.60 ± 2.69 | −2.37 | 0.01∗ |
Social relationships | 13.14 ± 2.93 | 13.50 ± 2.71 | −1.43 | 0.15 |
Environment | 14.08 ± 2.43 | 14.51 ± 2.41 | −1.98 | 0.04∗ |
Spiritual/personal belief | 16.41 ± 3.09 | 17.03 ± 2.74 | −2.37 | 0.018∗∗ |
Overall HRQOL | 3.96 ± 0.91 | 4.11 ± 0.85 | −1.94 | 0.05∗ |
General health perception | 4.08 ± 3.52 | 4.27 ± 0.79 | −2.53 | 0.01∗ |
Factors strongly associated with poor HRQOL domains in men and women living with HIV on HAART in the current study were psychosocial support, perceived stigma, educational status, WHO staging, and monthly income. In female respondents those who have no psychosocial support outside family members were 2.6 times more likely to have poor physical health in relation to individuals who had psychosocial support [AOR = 2.6 (1.4,4.9)]. Similarly those illiterates were 1.8 and 3.2 times more likely to have poor physical health as compared to literates in female and male respondents, respectively. Among female respondents, those who had high perceived stigma were 2.89 times more likely to have poor psychological health as compared to those who had low perceived stigma [AOR = 2.89 (1.69, 4.96)]. Perceived stigma was also associated with poor psychological quality of domain among male PLHIV [AOR = 2.5 (1.4, 4.4)]. Educational status and family income were also significantly associated with poor social quality of life in both female and male respondents. WHO stage was significantly associated with physical and psychological domains and level of independence and environmental quality of life domains in males and with environmental domain social quality of life domain in female counterparts, respectively (
Months on ART was significantly associated with physical, level of independence and social quality of life domains among female PLHIV (
Perceived stigma was also significantly associated with physical and psychological quality of life and level of independence quality of life in male PLHIV (Tables
Independent predictors of poor HRQOL domains among female PLHIV on HAART in public health institutions, Mekelle, Ethiopia, 2012 [
Variables | PH |
Psy |
Ind |
Soc |
Env |
Spir | |
---|---|---|---|---|---|---|---|
Psychosocial support outside family | Yes | 1 | 1 | ||||
No | 2.6 (1.4, 4.9)∗ | 2.8 (1.3, 6.2)∗ | |||||
|
|||||||
Recent WHO stage | Stage I | 0.69 (0.32, 1.48) | 2.2 (1.1, 4.4)∗ | ||||
Stage II | 0.56 (0.26, 1.2) | 3.2 (1.6, 6.7)∗ | |||||
Stage III | 2.0 (0.85, 4.98) | 2.4 (1.1, 5.4)∗ | |||||
Stage IV | 1 | 1 | |||||
|
|||||||
Educational status | Illiterate | 1.86 (1.03, 3.35)∗ | 2.4 (1.2, 4.9)∗ | ||||
literate | 1 | 1 | |||||
|
|||||||
Monthly income✦ | Below average (<83.75$) | 1 | 1 | 1 | |||
Average and above (≥83.75$) | 0.27 (0.07, 0.99)∗ | 0.15 (0.03, 0.65)∗ | 0.15 (0.03, 0.70)∗ | ||||
|
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Residence | Urban | 1 | 1 | 1 | |||
Rural | 6.5 (1.37, 30.66)∗ | 4.1 (1.0, 15.8)∗ | 4.1 (1.15, 14.9)∗ | ||||
|
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Psychosocial support from family/friends | Yes | 1 | 1 | ||||
No | 2.05 (1.15, 3.66)∗ | 2.1 (1.07, 4.38)∗ | |||||
|
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Perceived stigma | Low | 1 | |||||
High | 2.89 (1.69, 4.96)∗ | ||||||
|
|||||||
Months on ART | <36 months | 0.48 (0.26, 0.88)∗ | 0.52 (0.29, 0.8) | 0.48 (0.2, 0.92)∗ | |||
≥36 months | 1 | 1 | 1 | ||||
|
|||||||
Age category | 15–24 | 4.7 (1.1, 20.3)∗ | |||||
25–34 | 2.7 (1.3, 5.2)∗ | ||||||
35–44 | 1 | ||||||
≥45 | 0.48 (0.1, 1.1) | ||||||
|
|||||||
Time since diagnosis | <36 months | 0.35 (0.19, 0.61)∗ | |||||
≥36 months | 1 | ||||||
|
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Family size | ≤2 | 2.1 (1.16, 3.72)∗ | |||||
≥3 | 1 | ||||||
|
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Recent side effect | Yes | 2.5 (1.01, 6.25)∗ | |||||
|
|||||||
No | 1 |
AOR = adjusted odds ratio, CI = confidence interval,
The Hosmer-Lemeshow goodness-of-fit test statistic is greater than 0.05 for all the models.
Independent predictors of Poor HRQOL domains among male PLHIV on HAART in public health institutions, Mekelle, Ethiopia, 2012 [
Variables | PH |
Psy |
Ind |
Soc |
Env |
Spir | |
---|---|---|---|---|---|---|---|
Psychosocial support outside family | Yes | 1 | |||||
No | 2.4 (1.29, 4.46)∗ | ||||||
|
|||||||
WHO stage recent | Stage I | 0.15 (0.05, 0.44)∗ | 0.24 (0.09, 0.63)∗ | 0.12 (0.04, 0.34)∗∗ | 0.31 (0.13, 0.76)∗ | ||
Stage II | 0. 50 (0.21, 1.18) | 0.14 (0.04, 0.4)∗ | 0.20 (0.08, 0.51)∗∗ | 0.16 (0.06, 0.46)∗∗ | |||
Stage III | 1.18 (0.6, 2.3) | 1.1 (0.55, 2.2) | 0.42 (0.21, 0.85)∗∗ | 0.86 (0.44, 1.69) | |||
Stage IV | 1 | 1 | 1 | 1 | |||
|
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Educational status | Illiterate | 3.26 (1.35, 7.85)∗ | 3.1 (1.2, 7.9)∗ | ||||
literate | 1 | 1 | |||||
|
|||||||
Monthly income✦ | Below average (<83.75$) | 1 | 1 | ||||
Average and above (≥83.75$) | 0.32 (0.14, 0.77)∗∗ | 0.20 (0.08, 0.46)∗∗ | |||||
|
|||||||
Perceived stigma | Low | 1 | 1 | 1 | 1 | ||
High | 1.88 (1.06, 3.25)∗ | 2.5 (1.44, 4.44)∗ | 2.90 (1.6, 5.41)∗∗ | 3.58 (2.03, 6.32)∗∗ | |||
|
|||||||
Marital status | Married | 1 | |||||
Single/widowed/ |
1.8 (1.04, 3.19)∗ | ||||||
|
|||||||
Time since diagnosis | <36 months | 0.54 (0.30, 0.98)∗ | |||||
≥36 months | 1 | ||||||
|
|||||||
Family size | ≤2 | 1.9 (1.03, 3.69)∗ | |||||
≥3 | 1 | ||||||
|
|||||||
Adherence status | Yes | 1 | 1 | ||||
No | 2.5 (1.01, 6.26)∗ | 2.62 (1.16, 6.25)∗ |
AOR = adjusted odds ratio, CI = confidence interval,
The Hosmer-Lemeshow goodness-of-fit test statistic is greater than 0.05 for all the models.
In the current study, there was statistically significant gender difference in perceived stigma among PLHIV on highly active antiretroviral treatment. This finding is similar to a study done in Thailand [
Among male PLHIV variables that predict poor physical health quality of life were illiterate, WHO clinical stage I, and those who have no psychosocial support outside family members and high perceived stigma. Male respondents in WHO clinical stage I were 85% less likely to have poor physical quality of life domain as compared to WHO clinical stage IV. A study in Brazil also reported that as the disease progresses, scores related to physical and level of independence decrease, as the clinical aggravation of the infection has an impact on the body and self-management capability [
The common statistically significant predictors of poor physical health quality of life domain in both genders were being illiterate and no psychosocial support outside family members (Tables
Regarding psychological HRQOL domain in females, rural dwelling, having no psychosocial support from family members or friends, and high perceived stigma were the predictors. Similarly predictors of poor psychological health in the male counterparts were WHO stage and perceived stigma. Perceived stigma was common predictor of poor psychological health for both genders. This is comparable with research in Ethiopia [
Level of independence domain assesses persons mobility, activities of daily living, dependence on medication or treatments, and work capacity. In this study women scored lower than males in this domain are shown in Table
The factors found to have significant influence on level of independence quality of life domain in multiple logistic regressions among PLHIV on HAART were residence, duration of ART, and recent side effect compliant for female PLHIV and perceived stigma, clinical staging, and monthly income for their male counterparts, respectively (Tables
Reports from Thailand [
Factors associated with poor social health quality of life domain among male respondents were being single/widowed/divorced/separated, those who were on ART for >36 months, illiterate, and those who have a monthly income of average and above (
Environment plays a major role in determining health status. In the current finding environmental domain score was the second lowest score among all six domains.
The current study found that males had higher quality of life than their female counterparts (Table
Studies in USA [
Spiritual/religious/personal belief quality of life had the highest score of all domains with mean ± SD = (17.0 ± 2.74 males, 16.41 ± 3.09 females) (Table
The independent predictors of spiritual/religious/personal belief domain were family size abd WHO staging for females and adherence for ART and perceived stigma for male counterparts (Table
Use of culturally adapted and validated quality of life questionnaire and permitting equal opportunity for selecting clients from all ART sites in Mekelle town were strengths of this study. The present study had some limitations that should be acknowledged. The instrument used for assessing HRQOL for this study and the study used for calculating the current sample size are not similar. Hence, information bias could have been introduced.
The respondents were ones who were actively seeking routine medical care. There are also people who do not come to the institution from the communities; therefore, generalizability is only for those who are on follow-up. Another limitation is that there could have occurred interviewer and respondent biases even if the instrument was preuse-tested. Use of self-reported measurements in adherence may cause overestimation. One more concern is that social desirability bias may have occurred. Lastly, though variables such as alcohol use, smoking, and chewing khat have been assessed, they were not controlled due to small frequencies observed.
This study revealed that there is a statistically significant gender difference (
Thus, to achieve global commitments including universal access to HIV/AIDS prevention, care, and treatment and Millennium Development Goals 3 and 6, there is need to measure and monitor clinical care of people living with HIV on HAART through the QOL assessment tools. Hence, National AIDS program and policy makers at different levels should realize the importance of measuring quality of life as part of the services to be provided to PLHIV. As women are most economically, culturally, and socially disadvantaged and lack equal treatment acceptance and empowerment, gender sensitive approaches should be enhanced in treatment, care, and support in dealing with PLHIV.
Different stakeholders including the PLHIV associations, religion based organizations, and other stakeholders that work in the ARV scale-up program should focus on care strategies in the area of psychological health and spiritual and environmental health directed towards PLHIV on HAART, especially women to improve their quality of life. Continued efforts are needed to reduce the stigmatizing attitudes and behavior toward PLHIV in the general population and improve support networks for PLHIV, particularly for females as they perceived stigma highly which might be barrier to seeking necessary health care and support. Health care providers should focus on counseling and providing continued education to families, friends, and relatives, to augment quality of life of PLHIV besides giving psychological support to play major role for PLHIV on HAART especially women to alleviate the burdens of HIV/AIDS related physical limitation. A large scale HRQOL research (preferably cohort) might be necessary in order to examine gender difference and address the problems of PLHIV on HAART as well as to identify changes in domain scores over time in response to treatment regarding alcohol use, smoking, and khat chewing as they were not controlled due to small frequency.
The authors declare that they have no competing interests.
The authors would like to thank Jimma University for financial assistance. They extend their deepest gratitude to Tigray Regional Health Bureau and all staffs working on ART services, of study sites, supervisors, and the data collectors, for facilitating the process and cooperation and for their full commitment and technical support to carry out the study. Last but not least The authors thank the study participants who shared their priceless time.