Trends and predictors of quality of life among HIV-infected adults taking highly active antiretroviral therapy in rural Uganda

No association found between traditional healer use and delayed antiretroviral initiation in rural Uganda

Traditional healer and/or spiritual counselor (TH/SC) use has been associated with delays in HIV testing. We examined HIV-infected individuals in southwestern Uganda to test the hypothesis that TH/SC use was also associated with lower CD4 counts at antiretroviral therapy (ART) initiation. Approximately 450 individuals initiating ART through an HIV/AIDS clinic at the Mbarara University of Science and Technology (MUST) were recruited to participate. Patients were predominantly female, ranged in age from 18 to 75, and had a median CD4 count of 130. TH/SC use was not associated with lower CD4 cell count, but age and quality-of-life physical health summary score were associated with CD4 cell count at initiation while asset index was negatively associated with CD4 count at ART initiation. These findings suggest that TH/SC use does not delay initiation of ART.

Changes in food insecurity, nutritional status, and physical health status after antiretroviral therapy initiation in rural Uganda

OBJECTIVE

To investigate whether time on antiretroviral therapy (ART) is associated with improvements in food security and nutritional status, and the extent to which associations are mediated by improved physical health status.

DESIGN

The Uganda AIDS Rural Treatment Outcomes study, a prospective cohort of HIV-infected adults newly initiating ART in Mbarara, Uganda.

METHODS

Participants initiating ART underwent quarterly structured interview and blood draws. The primary explanatory variable was time on ART, constructed as a set of binary variables for each 3-month period. Outcomes were food insecurity, nutritional status, and PHS. We fit multiple regression models with cluster-correlated robust estimates of variance to account for within-person dependence of observations over time, and analyses were adjusted for clinical and sociodemographic characteristics.

RESULTS

Two hundred twenty-eight ART-naive participants were followed for up to 3 years, and 41% were severely food insecure at baseline. The mean food insecurity score progressively declined (test for linear trend P < 0.0001), beginning with the second quarter (b = -1.6; 95% confidence interval: -2.7 to -0.45) and ending with the final quarter (b = -6.4; 95% confidence interval: -10.3 to -2.5). PHS and nutritional status improved in a linear fashion over study follow-up (P < 0.001). Inclusion of PHS in the regression model attenuated the relationship between ART duration and food security.

CONCLUSIONS

Among HIV-infected individuals in Uganda, food insecurity decreased and nutritional status and PHS improved over time after initiation of ART. Changes in food insecurity were partially explained by improvements in PHS. These data support early initiation of ART in resource-poor settings before decline in functional status to prevent worsening food insecurity and its detrimental effects on HIV treatment outcomes.

Mental disorder and the outcome of HIV/AIDS in low-income and middle-income countries: a systematic review

OBJECTIVES

To conduct a systematic review of the literature to examine the interrelationship between mental health and treatment outcomes in low-income and middle-income settings; to update the work of Collins et al. (2006).

DESIGN

Systematic review of peer-reviewed articles that examined one of the following: the effects of mental disorders (including cognitive impairment) upon engagement with treatment and/or adherence; their influence upon HIV-related clinical outcomes; and the impact of interventions for mental disorder.

METHODS

Articles about mental health and HIV/AIDS were included if they were published after 2005 and addressed one of the areas of interest described above. Systematic methods were used for searching, screening, and data extraction. Studies employing quantitative measures of exposures and outcomes wherein all participants had a diagnosis of HIV/AIDS were included.

RESULTS

This review found ample and moderately consistent evidence that adverse mental health and alcohol consumption are associated with reduced adherence. Variation in measurement and the relative paucity of work meant that interpretation of studies examining engagement with care and other clinical outcomes was difficult. Evidence on the efficacy and effectiveness of mental health interventions in low-income and middle-income settings was very limited.

CONCLUSION

This review suggests that psychosocial factors, namely, depression and alcohol may have adverse effects upon HIV-related outcomes. However, further large, high-quality studies examining outcomes other than adherence are needed. There is also an urgent need for randomized controlled trials of interventions for mental disorder and a need to investigate their impact upon HIV-related outcomes.

Pain among ambulatory HIV/AIDS patients: multicenter study of prevalence, intensity, associated factors, and effect

This study aimed to determine the prevalence, intensity, associated factors, and effect of pain among ambulatory HIV/AIDS patients. Three-hundred two adult ambulatory HIV/AIDS patients were consecutively recruited from HIV/AIDS outpatient clinics at 2 teaching hospitals in Uganda. The presence and intensity of pain were self-reported using the Brief Pain Inventory (BPI); symptom data were collected using the Memorial Symptom Assessment Scale (MSAS-SF); and quality of life (QOL) was assessed using the Medical Outcome Scale-HIV. Forty-seven percent reported pain in the 7 days prior to the survey and pain was a symptom at the time of diagnosis for 68%. On the 0 to 10 numeric scale, 53% reported mild pain (1-4 rating), 20% reported moderate pain (5-6 rating) while 27% reported severe pain (7-10 rating). Gender was not associated with pain intensity, but reduced functional performance, increasing number of symptoms, advanced HIV disease , physical symptom distress (MSAS-SF), and number of health comorbidities were significantly associated with pain intensity (P < .04). Increasing pain intensity was associated with greater functional ability impairment (BPI functional interference index) and poorer QOL. Pain is a common symptom among ambulatory HIV/AIDS patients and has a debilitating effect on QOL. There is a significant unmet need for pain relief in the population.

PERSPECTIVE

This article discusses the characteristics and effect of pain on function and QOL in East African patients. It also contributes information on characteristics of HIV/AIDS adult patients in the East Africa demonstrating the aspects in which pain is similar across different cultures.

Multivitamin supplementation in HIV infected adults initiating antiretroviral therapy in Uganda: the protocol for a randomized double blinded placebo controlled efficacy trial

Background

Use of multivitamin supplements during the pre-HAART era has been found to reduce viral load, enhance immune response, and generally improve clinical outcomes among HIV-infected adults. However, immune reconstitution is incomplete and significant mortality and opportunistic infections occur in spite of HAART. There is insufficient research information on whether multivitamin supplementation may be beneficial as adjunct therapy for HIV-infected individuals taking HAART. We propose to evaluate the efficacy of a single recommended daily allowance (RDA) of micronutrients (including vitamins B-complex, C, and E) in slowing disease progression among HIV-infected adults receiving HAART in Uganda.

Methods/Design

We are using a randomized, double-blind, placebo-controlled trial study design. Eligible patients are HIV-positive adults aged at least 18 years, and are randomized to receive either a placebo; or multivitamins that include a single RDA of the following vitamins: 1.4 mg B1, 1.4 mg B2, 1.9 mg B6, 2.6 mcg B12, 18 mg niacin, 70 mg C, 10 mg E, and 0.4 mg folic acid. Participants are followed for up to 18 months with evaluations at baseline, 6, 12 and 18 months. The study is primarily powered to examine the effects on immune reconstitution, weight gain, and quality of life. In addition, we will examine the effects on other secondary outcomes including the risks of development of new or recurrent disease progression event, including all-cause mortality; ARV regimen change from first- to second-line therapy; and other adverse events as indicated by incident peripheral neuropathy, severe anemia, or diarrhea.

Discussions

The conduct of this trial provides an opportunity to evaluate the potential benefits of this affordable adjunct therapy (multivitamin supplementation) among HIV-infected adults receiving HAART in a developing country setting.

Trial registration

Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01228578

Development of a new instrument for the assessment of psychological predictors of well-being and quality of life in people with HIV or AIDS

This study aims to develop an instrument for the assessment of psychological predictors of well-being and quality of life (QoL) in people living with HIV. A four-step procedure was followed to achieve this objective. A literature review, focus group in different regions of Spain and content analysis generated a preliminary pool of 96 items. Interjudgement ratings over the items and a cognitive debriefing interview were performed to delete or review items (one omitted and 15 reviewed). The psychometric properties of the instrument were assessed in a sample of 84 HIV+. Pilot testing allowed a new wave of depuration process by empirical criteria (30 items omitted). A final pool of 63 items covering 23 facets (α from 0.53 to 0.95) of psychological predictors remained. Exploratory factorial analysis (GLS) assessing the underlying structure of the questionnaire showed a six-factor model explaining 56.5 of variance. Empirical exploratory structure revealed evidence of goodness of fit (χ(2) = 113.110, gl = 130, p > 0.05; RMSEA = 0.017; RMSEA IC90 % 0.000-0.057). This study presents the first instrument able to screen key psychological variables expected to be related to adjustment, well-being and QoL in people with HIV.

Impact of HIV antiretroviral therapy on depression and mental health among clients with HIV in Uganda

OBJECTIVE

With wide-reaching harmful effects of depression, and the absence of psychiatric treatment in most HIV care programs in sub-Saharan Africa, we examined the effects of antiretroviral therapy (ART) on depression and other mental health indicators.

METHODS

602 patients (302 non-ART, 300 ART) were followed for the first 12 months of HIV care in Uganda, with assessments at entry into care and Months 6 and 12. Mental health was assessed with measures of depression, hopelessness, and internalized HIV stigma; physical health functioning was assessed as an explanatory variable.

RESULTS

Thirteen percent had clinical depression, 57% had elevated depressive symptoms, and CD4 cell count was negatively correlated with measures of depression at baseline. Significant reductions in elevated depressive symptoms (time: odds ratio [95% confidence interval] = 0.53 [0.43-0.64]) and hopelessness (time: β = -0.12, p < .001) were observed in both the ART and non-ART groups, but the drop in depression was greater among ART patients in intention-to-treat multivariate analysis (ART × time: p < .001). When added to the regression models, change in physical health functioning predicted positive longitudinal change on measures of depression, hopelessness, and internalized stigma (all p values < .001), yet ART status remained a significant independent predictor of each (ART × time: p values ranged from < .05 to < .001). Most mental health benefits of ART were experienced in the first 6 months of care.

CONCLUSIONS

These findings demonstrate the mental health benefits of HIV care and ART. However, in some people, mental health problems persist once physical health is stabilized, in which case mental health treatment may be needed.

Depression in the pathway of HIV antiretroviral effects on sexual risk behavior among patients in Uganda

HIV antiretroviral therapy (ART) can increase safe sex or lead to disinhibition and less condom use. We conducted one of the first controlled studies of ART effects on sexual risk behavior in sub-Saharan Africa, and the potential explanatory roles of physical and mental health. Participants (302 non-ART, 300 ART) were followed for the first 12 months of HIV care in Uganda. Multivariate intention-to-treat regression analysis showed that frequency of sex increased significantly in both groups, but more among ART patients; when added to the model in separate analyses, changes in physical health functioning and depression were both significant predictors, as was time in HIV care, but there was no longer an ART effect. Both ART and non-ART groups had similar dramatic increases in consistent condom use over time; however, change in depression, unlike physical health functioning, was a significant predictor of consistent condom use when added to this model, and there remained a similar level of increased condom use among ART and non-ART patients. HIV care and ART increase sexual activity and condom use, but depression undercuts the prevention benefits of ART, highlighting the need to integrate mental health services into HIV care.

Predictors of linkage to care following community-based HIV counseling and testing in rural Kenya

Despite innovations in HIV counseling and testing (HCT), important gaps remain in understanding linkage to care. We followed a cohort diagnosed with HIV through a community-based HCT campaign that trained persons living with HIV/AIDS (PLHA) as navigators. Individual, interpersonal, and institutional predictors of linkage were assessed using survival analysis of self-reported time to enrollment. Of 483 persons consenting to follow-up, 305 (63.2%) enrolled in HIV care within 3 months. Proportions linking to care were similar across sexes, barring a sub-sample of men aged 18-25 years who were highly unlikely to enroll. Men were more likely to enroll if they had disclosed to their spouse, and women if they had disclosed to family. Women who anticipated violence or relationship breakup were less likely to link to care. Enrollment rates were significantly higher among participants receiving a PLHA visit, suggesting that a navigator approach may improve linkage from community-based HCT campaigns.

Food insecurity is associated with morbidity and patterns of healthcare utilization among HIV-infected individuals in a resource-poor setting

OBJECTIVE

We undertook a longitudinal study in rural Uganda to understand the association of food insecurity with morbidity and patterns of healthcare utilization among HIV-infected individuals enrolled in an antiretroviral therapy program.

DESIGN

Longitudinal cohort study.

METHODS

Participants were enrolled from the Uganda AIDS Rural Treatment Outcomes cohort, and underwent quarterly structured interviews and blood draws. The primary predictor was food insecurity measured by the validated Household Food Insecurity Access Scale. Primary outcomes included health-related quality of life measured by the validated Medical Outcomes Study-HIV Physical Health Summary (PHS), incident self-reported opportunistic infections, number of hospitalizations, and missed clinic visits. To estimate model parameters, we used the method of generalized estimating equations, adjusting for sociodemographic and clinical variables. Explanatory variables were lagged by 3 months to strengthen causal interpretations.

RESULTS

Beginning in May 2007, 458 persons were followed for a median of 2.07 years, and 40% were severely food insecure at baseline. Severe food insecurity was associated with worse PHS, opportunistic infections, and increased hospitalizations (results were similar in concurrent and lagged models). Mild/moderate food insecurity was associated with missed clinic visits in concurrent models, whereas in lagged models, severe food insecurity was associated with reduced odds of missed clinic visits.

CONCLUSION

Based on the negative impact of food insecurity on morbidity and patterns of healthcare utilization among HIV-infected individuals, policies and programs that address food insecurity should be a critical component of HIV treatment programs worldwide.

Measuring quality of life in rural Uganda: reliability and validity of summary scores from the medical outcomes study HIV health survey (MOS-HIV)

PURPOSE

Summary scores derived from the medical outcomes study HIV health survey (MOS-HIV) are used to assess treatment impacts among HIV-infected patients in Western settings, but have yet to be validated in rural, African settings. We examined the reliability, validity and responsiveness of scores among a prospective cohort of 947 HIV-1-infected adults initiating antiretroviral therapy between May 2003 and May 2004 in rural Uganda.

METHODS

Physical (PHS) and mental health (MHS) summary scores were developed from baseline MOS-HIV sub-domains using exploratory factor analysis. Construct and discriminant validity were established by comparing mean summary scores across known groups of sociodemographic, clinical and health status characteristics. Effect sizes were calculated to assess responsiveness to therapy.

RESULTS

Reliability of the PHS and MHS scores was 0.79 and 0.85, respectively. Mean baseline PHS and MHS scores varied significantly by CD4 cell count, HIV viral load, WHO stage of disease and Karnofsky performance status scores. By 12 months on antiretroviral therapy, PHS and MHS scores improved by 14.6 points (P < 0.001) and 13.9 points (P < 0.001), respectively.

CONCLUSIONS

PHS and MHS scores can be derived from the MOS-HIV and used to assess health status among cohorts of patients taking antiretroviral therapy in rural Uganda.

Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS

Food insecurity, which affects >1 billion people worldwide, is inextricably linked to the HIV epidemic. We present a conceptual framework of the multiple pathways through which food insecurity and HIV/AIDS may be linked at the community, household, and individual levels. Whereas the mechanisms through which HIV/AIDS can cause food insecurity have been fairly well elucidated, the ways in which food insecurity can lead to HIV are less well understood. We argue that there are nutritional, mental health, and behavioral pathways through which food insecurity leads to HIV acquisition and disease progression. Specifically, food insecurity can lead to macronutrient and micronutrient deficiencies, which can affect both vertical and horizontal transmission of HIV, and can also contribute to immunologic decline and increased morbidity and mortality among those already infected. Food insecurity can have mental health consequences, such as depression and increased drug abuse, which, in turn, contribute to HIV transmission risk and incomplete HIV viral load suppression, increased probability of AIDS-defining illness, and AIDS-related mortality among HIV-infected individuals. As a result of the inability to procure food in socially or personally acceptable ways, food insecurity also contributes to risky sexual practices and enhanced HIV transmission, as well as to antiretroviral therapy nonadherence, treatment interruptions, and missed clinic visits, which are strong determinants of worse HIV health outcomes. More research on the relative importance of each of these pathways is warranted because effective interventions to reduce food insecurity and HIV depend on a rigorous understanding of these multifaceted relationships.

Gender and age differences in quality of life and the impact of psychopathological symptoms among HIV-infected patients

The purpose of this study was to determine gender and age differences and interaction effects on the quality of life (QoL) domains in a sample of Portuguese HIV-positive patients, and to examine to what degree psychopathological symptoms are associated with QoL in addition to sociodemographic and clinical variables. The sample consisted of 1191 HIV-positive patients, and measures included the WHOQOL-HIV-Bref and the Brief Symptom Inventory. Controlling for clinical status, there was a significant effect of gender on QoL. Women reported lower scores of Psychological and Spirituality QoL. Younger patients reported higher scores on Physical and Level of Independence domains. Age by gender interactions emerged on all domains of QoL except on the Level of Independence domain. Overall, women over 45 years old showed lower QoL scores. Psychopathological symptoms contributed significantly to the variance of all QoL domains. Gender differences in the association of HIV infection with QoL and psychopathological symptoms seemed to be modulated by age. Understanding gender and age differences (and their interaction) may provide potentially useful information for planning interventions to improve QoL and mental health among people infected with HIV/AIDS, especially among older women.

Sexual behavior and HIV transmission risk of Ugandan adults taking antiretroviral therapy: 3 year follow-up

BACKGROUND

Long-term impact of antiretroviral therapy (ART) on sexual HIV-transmission risk in Africa is unknown. We assessed sexual behavior changes and estimated HIV transmission from HIV-infected adults on ART in Uganda.

METHODS

Between 2003 and 2007, we enrolled and followed ART-naive HIV-infected adults in a home-based AIDS program with annual counseling and testing for cohabitating partners, participant transmission risk-reduction plans, condom distribution and prevention support for cohabitating discordant couples. We assessed participants' HIV plasma viral load and partner-specific sexual behaviors. We defined risky sex as intercourse with inconsistent/no condom use with HIV-negative or unknown serostatus partners in previous 3 months. We compared rates using Poisson regression models, estimated transmission risk using established viral load-specific transmission estimates, and documented sero-conversion rates among HIV-discordant couples.

RESULTS

Of 928 participants, 755 (81%) had 36 months data: 94 (10%) died and 79 (9%) missing data. Sexual activity increased from 28% (baseline) to 41% [36 months (P < 0.001)]. Of sexually active participants, 22% reported risky sex at baseline, 8% at 6 months (P < 0.001), and 14% at 36 months (P = 0.018). Median viral load among those reporting risky sex was 122,500 [interquartile range (IQR) 45 100-353 000] copies/ml pre-ART at baseline and undetectable at follow-up. One sero-conversion occurred among 62 cohabitating sero-discordant partners (0.5 sero-conversions/100 person-years). At 36 months, consistent condom use was 74% with discordant partners, 55% with unknown and 46% with concordant partners. Estimated HIV transmission risk reduced 91%, from 47.3 to 4.2/1000 person-years.

CONCLUSIONS

Despite increased sexual activity among HIV-infected Ugandans over 3 years on ART, risky sex and estimated risk of HIV transmission remained lower than baseline levels. Integrated prevention programs could reduce HIV transmission in Africa.

Quality of life and needs assessment on people living with HIV and AIDS in Malawi

PURPOSE

Malawi is a sub-Saharan African nation with a severe HIV epidemic. The quality of life (QoL) has never been investigated among people living with HIV and AIDS (PLWHA) in Malawi. This study examines the QoL and associated factors including life needs among PLWHA at different stages of their illness in the northern region of Malawi.

METHODS

Survey analysis of consecutive outpatient participants receiving highly active antiretroviral therapy at the Rainbow Clinic and non-HIV patients receiving care at the affiliated Mzuzu Central Hospital during a one-month period was performed. Laboratory testing and clinical diagnosis were used to determine HIV status, determine CD4 count, and classify WHO clinical stage. A total of 267 HIV-infected patients and 598 non-HIV participants completed a needs assessment and a Short Form-36 (SF-36) questionnaire, which contained a QoL subscale. SF-36 subscales and needs assessment scores were analyzed using t-test, ANOVA test, and Generalized Linear Model-Tukey's test.

RESULTS

HIV-positive patients had significantly lower physical functioning (p=0.0365), mental health (p=0.001), social functioning (p<0.0001), and mental component summary (p=0.0069) scores than HIV-negative patients. Further, WHO Stage III HIV patients had significantly lower vitality (p=0.0439) and mental health (p=0.0022) scores than WHO Stages I and II patients; and WHO Stage IV patients had significantly lower vitality (p=0.0015), mental health (p=0.0006), and physical component summary (p=0.0443) scores than WHO Stages I and II patients. Finally, AIDS patients, as determined by CD4 count, had significantly lower bodily pain (p=0.0423) and physical component summary (p=0.0148) scores than non-AIDS, HIV-positive patients.

CONCLUSION

HIV patients undergoing treatment in Malawi have a significantly lower QoL, both mentally and physically, than their non-HIV counterparts. Further, HIV patients at more advanced stages, both by the WHO definition and by CD4 count, have a significantly lower QoL than HIV patients at earlier stages of the disease.

Economic outcomes of patients receiving antiretroviral therapy for HIV/AIDS in South Africa are sustained through three years on treatment

Background

Although the medical outcomes of antiretroviral therapy (ART) for HIV/AIDS are well described, less is known about how ART affects patients' economic activities and quality of life, especially after the first year on ART. We assessed symptom prevalence, general health, ability to perform normal activities, and employment status among adult antiretroviral therapy patients in South Africa over three full years following ART initiation.

Methodology/Principal Findings

A cohort of 855 adult pre-ART patients and patients on ART for <6 months was enrolled and interviewed an average of 4.4 times each during routine clinic visits for up to three years after treatment initiation using an instrument designed for the study. The probability of pain in the previous week fell from 74% before ART initiation to 32% after three years on ART, fatigue from 66% to 12%, nausea from 28% to 4%, and skin problems from 55% to 10%. The probability of not feeling well physically yesterday fell from 46% to 23%. Before starting ART, 39% of subjects reported not being able to perform their normal activities sometime during the previous week; after three years, this proportion fell to 10%. Employment rose from 27% to 42% of the cohort. Improvement in all outcomes was sustained over 3 years and for some outcomes increased in the second and third year.

Conclusions/Significance

Improvements in adult ART patients' symptom prevalence, general health, ability to perform normal activities, and employment status were large and were sustained through the first three years on treatment. These results suggest that some of the positive economic and social externalities anticipated as a result of large-scale treatment provision, such as increases in workforce participation and productivity and the ability of patients to carry on normal lives, may indeed be accruing.

Healthcare infrastructure and emotional support are predictors of CD4 cell counts and quality of life indices of patients on antiretroviral treatment in Free State Province, South Africa

While many AIDS patients in sub-Saharan Africa are receiving antiretroviral treatment (ART) via public clinics, improvements in health status also depend on socioeconomic and psychological factors and quality of healthcare services. Inter-dependence between patients' clinical markers and quality of life indicators should be analyzed using comprehensive models. This longitudinal study compiled socioeconomic and clinical variables at six monthly intervals on patients receiving ART in South Africa; patients' ratings of quality of services and staff in "Assessment" and "Treatment" sites were assessed. Dynamic random effects models were estimated by maximum likelihood for CD4 cell counts and for quality of life indices (EQ-5D and Visual Analogue Scale), incorporating the inter-dependence between plasma HIV RNA levels and CD4 cell counts. The results showed that emotional support received by patients was a significant predictor (P<0.05) of CD4 cell counts and quality of life indices. Ratings of services and staff in Assessment and Treatment sites were significantly associated with CD4 cell counts and quality of life indices; CD4 cell count was a significant predictor of quality of life indices. The results indicated that it is important to compile socioeconomic and psychological variables for AIDS patients and monitor healthcare services for improving their health status and quality of life.

Improvements in physical wellbeing over the first two years on antiretroviral therapy in western Kenya

Improvements in physical wellbeing during the first six months on antiretroviral therapy (ART) are well known, but little is known regarding long-term follow-up. We conducted a prospective cohort study among 222 HIV-positive adult tea plantation workers in western Kenya to assess wellbeing over their first two years on ART. Study subjects completed a standardized questionnaire during repeat ART clinic visits. A 30-day recall period was used to elicit the number of days when subjects experienced poor health and the number of days that pain made it difficult to complete usual activities at home and work. A seven-day recall period was used to assess the severity of bodily pain, nausea, fatigue, and rash. Prevalence of most symptoms declined over time. A median of seven days poor health during the first month on ART declined to three days in the 24th month (p=0.043). For pain making usual activities difficult, a median of seven days during the first month on ART fell to zero by 12 months (p< or =0.0001) but increased to three days by two years. Any bodily pain (range 59-83%) and fatigue (range 51-84%) over the past seven days were common through two years. However, pain and fatigue often over the past seven days declined over two years (from 24-10% (p=0.067) and 41-15% (p=0.002)). Skin rash was rare at all times, though higher at two years (8.6%) than any other time. Initial improvements in physical wellbeing were sustained over two years, however, increased pain and skin rash at year two may indicate problems as treatment programs mature. These improvements in physical wellbeing will be important in sustaining the long-term success of HIV treatment programs.

Economic and quality of life outcomes of antiretroviral therapy for HIV/AIDS in developing countries: a systematic literature review

The impacts of antiretroviral therapy (ART) on quality of life, mental health, labor productivity, and economic wellbeing for people living with HIV/AIDS in developing countries are only beginning to be measured. We conducted a systematic literature review to analyze the effect of ART on these economic and quality of life indicators in developing countries and assess the state of research on these topics. We searched Ovid/Medline, PubMed, Psych Info, Web of Science, Google Scholar, and the abstract database of the International AIDS Society Conference and the Conference on Retroviruses and Opportunistic Infections. Both qualitative and quantitative studies were included, as were peer-reviewed articles, gray literature, and conference abstracts and presentations. Findings are reported from 21 publications, including 14 full-length articles, six abstracts, and one presentation (representing 16 studies). Compared to HIV-positive patients not yet on treatment, patients on ART reported significant improvements in physical, emotional and mental health, and daily function. Work performance improved and absenteeism decreased, with the most dramatic changes occurring in the first three months of treatment and then leveling off. Little research has been done on the impact of ART on household wellbeing, with modest changes in child and family wellbeing within households where adults are receiving ART reportrd so far. Most studies from developing countries have not yet assessed economic and quality of life outcomes of therapy beyond the first year; therefore, longitudinal outcomes are still unknown. Findings were limited geographically, with an emphasis on sub-Saharan Africa and adult treatment. As ART roll out extends throughout high HIV prevalence, low-resource countries and is sustained over years and decades, research on pediatric and differential gender economic and quality of life outcomes will become increasingly urgent, as will systematic evaluation of ART programs.

Higher risk of unsafe sex and impaired quality of life among patients not receiving antiretroviral therapy in Cameroon: results from the EVAL survey (ANRS 12-116)

OBJECTIVE

Cameroon has initiated a national programme of HIV care decentralization providing access to antiretroviral therapy (ART) for patients with CD4 cell counts less than 200 cells/microl or AIDS stage. Current clinical research suggests these criteria may be too stringent. This study aimed at evaluating the effect of not receiving ART on patients' psychosocial outcomes.

DESIGN

The national cross-sectional survey EVAL (ANRS 12-116) collected psychosocial and clinical data for 3151 patients attending HIV services (September 2006 to March 2007).

METHODS

Propensity score matching was used to control for demographic/clinical-immunological differences between patients receiving ART and those who did not. Generalized linear models were used to assess the impact, for different CD4 cell levels, of "not receiving" ART on health-related quality of life (HRQoL) inconsistent condom use with a sexual partner either serodiscordant or of unknown HIV status, self-reported symptoms and disclosure of HIV status to relatives or friends.

RESULTS

Seventy-eight per cent of patients included in the survey were receiving ART. Non-treated patient breakdown was as follows: 8% (CD4<200 or AIDS stage), 5% (200<or=CD4<or=350) and 8% (CD4>350). In the multivariate matched-pairs analysis, impaired physical HRQoL, more frequent inconsistent condom use, more self-reported symptoms and less frequent disclosure of HIV status were all significantly associated (P < 0.0001) with not receiving ART, irrespective of the CD4 cell level.

CONCLUSION

In addition to increasing clinical effectiveness, earlier initiation of ART at less severe immune-depression levels than previously recommended by World Health Organization guidelines for low-resource settings may be justified for improving subjective health and positive prevention among people living with HIV.

Quality of life, psychosocial health, and antiretroviral therapy among HIV-positive women in Zimbabwe

Little is known about the psychosocial impact of antiretroviral therapy (ART) among women in sub-Saharan Africa. Therefore, we conducted a cross-sectional study in Zimbabwe to assess the impact of ART on HIV-positive women's health-related quality of life, using the Medical Outcomes Study-HIV Quality of Life (QOL) questionnaire. Additionally, we assessed socio-demographics, reproductive and sexual health, HIV-related history, disclosure, social stigma, self-esteem, and depression. Structured interviews were conducted with 200 HIV-positive women and categorized into three groups by treatment: (1) Group 1 (n=31) did not meet clinical or laboratory criteria to begin treatment; (2) Group 2 (n=73) was eligible to begin treatment but awaiting initiation of treatment; and (3) Group 3 (n=96) was on ART for a median of 13 months. The women had similar socio-demographic characteristics but varied significantly in clinical characteristics. Women on ART reported fewer AIDS-related symptoms in the last week and year and had higher current and lower baseline CD4 counts compared to women not on ART. On most QOL domains women on ART reported higher mean scores as compared to women not on ART (p<0.01). Additionally, women on ART reported less depression compared to women not on ART (p<0.001). Between the two groups of women not on ART, unexpectedly, there were no significant differences in their scores for QOL or depression. Thus, Zimbabwean women living with HIV experience better overall QOL and lower depression on ART. Altogether, our findings suggest that ART delivery in resource-poor communities can enhance overall QOL as well as psychosocial functioning, which has wide-ranging public health implications.

Routes to government TB treatment: private providers, family support, and the process of TB treatment seeking among Ugandan women

Tuberculosis (TB) remains a major source of morbidity and mortality in Uganda. This cross-sectional study explores Ugandan women's TB treatment-seeking processes to determine the routes to effective government TB treatment among a sample of urban, semirural, and rural women. This research focuses on women in particular as Ugandan women with tuberculosis must negotiate their treatment paths in a context where women tend to be politically and economically marginalized, with limited control of household resources and senior family members' health care decisions. The results examine the structural, social, and economic forces similarly guiding treatment seeking across the three research sites and then the specific differences among the settings. The findings suggest that the modest number of nongovernmental health care providers' diagnoses and referrals, particularly for urban and semirural participants, represents a critical barrier to biomedical TB treatment. Private providers' diagnosis delays also carry financial and physical costs, which undermine the resources available for subsequent TB treatment and participants' social and economic well-being. This study indicates that conceptualizations of the political economy of treatment seeking need to more fully acknowledge the dynamic nature of the microlevel political economic context of treatment seeking, including the domino social, economic, and health effects of structurally problematic health care systems.

Quality of life and social support among patients receiving antiretroviral therapy in Western Uganda

Quality of life (QOL) among patients with HIV/AIDS has been shown to improve once treatment with antiretroviral therapy (ART) has been initiated. We conducted a cross-sectional study in Western Uganda to examine the factors associated with QOL among patients who had received ART for the duration of at least six months. We interviewed 330 patients attending the HIV/AIDS clinic at two government-supported hospitals in Western Uganda. We measured QOL using a culturally adapted version of the Medical Outcomes Study (MOS-HIV) tool and calculated the physical health summary (PHS) and mental health summary (MHS) scores. In addition, data were collected on sociodemographic factors, three-day self-reported adherence, social support, sexual behavior, CD4 count and viral load. Informational social support was significantly positively correlated with PHS (p=0.001) and MHS (p=0.002). Affectionate support was also significantly positively correlated to PHS (p=0.05) and MHS (p=0.03) but tangible support was not (PHS p value=0.85 and MHS p value=0.31). In the univariate analysis, older age, rural dwelling, alcohol use, CD4 count less than 200, and ART duration of less than one year were significantly associated with lower PHS scores. Lower PHS scores were also associated with sexual inactivity. In multivariate analysis, higher scores on informational social support and CD4> or =200 were associated with higher PHS score and past or recent alcohol consumption was associated with lower scores on MHS. Optimizing ART to restore CD4 count and provision of informational and affectionate social support but not tangible support, to HIV/AIDS patients may improve their QOL.

Factors related to quality of life in treatment-adherent, successfully treated HIV patients in France

The objectives of this study were to document the psychosocial characteristics of treatment-adherent, successfully treated HIV patients and to examine the relationships between psychosocial variables. The sample was composed of 133 persons living with HIV, with optimal adherence to antiretroviral therapy and with no detectable viral load. The psychosocial profile of the cohort showed that participants had moderate levels of stress, used a wide range of strategies to adjust to their situation and perceived their social support to be good. As well, they evaluated their quality of life (Medical Outcome Study-HIV) as moderate. Quality of life in psychological domain is largely explained by perceived stress (53%). Quality of life in physical domain is largely dependent on discomfort reported arising from HIV-associated symptoms and treatment (39%). Findings suggest that treatment-adherent, successfully treated patients with HIV are still a fragile population, and that it is essential to provide interventions that reinforce their ways of coping.

Quality of life and the impact of drug toxicities in a South African community-based antiretroviral programme

BACKGROUND

The impact of highly active antiretroviral therapy (HAART) on health-related quality of life has been widely researched in the developed world, but there are few data from sub-Saharan Africa, where the vast majority of HIV-infected individuals live. This study examined health-related quality of life among HIV-positive individuals initiating HAART in Cape Town, South Africa, and explored the impact of HAART-related drug toxicities on quality of life.

METHODS

Health-related quality of life was assessed using a standardised questionnaire, the Medical Outcomes Survey Short Form 36. Physical health summary scores and mental health summary scores were compared pre-HAART and at regular intervals during the first 48 weeks of HAART. The relationships between socio-demographic, baseline and on-treatment variables and decline in health-related quality of life, as well as the impact of drug toxicities on quality of life, were assessed in unadjusted bivariate and adjusted multivariate analyses.

RESULTS

Two hundred and ninety-five patients were enrolled into the study. There was a significant increase in health-related quality of life during the first 48 weeks on HAART. The median physical health summary score increased from 45 to 53 units (p < 0.001) and median mental health summary score increased from 45 to 50 units (p < 0.001).The bulk of this increase occurred during the first 16 weeks. Overall, 23% of participants experienced a decline in their physical health summary score, while 34% showed a decline in the mental health summary score. Average drops in median physical and mental health summary scores were 8.4 units (SD 9.31) and 9.9 (SD 11.4) units respectively. Participants with drug toxicity had lower physical health summary scores than participants without drug toxicity at all time points. However, only three participants with toxicity (27%) reported an actual decline in health-related quality of life by week 48. Drug toxicities had little impact on mental health summary scores.

CONCLUSION

These results confirm the health-related quality of life benefits of HAART. While the majority of patients experienced a significant improvement in health-related quality of life on HAART, up to a third of patients reported declines in this quality of life. This was largely related to better baseline clinical state. HAART-related drug toxicities did not have a significant impact on health-related quality of life during the first year of HAART, which supports the ongoing use of the current national first-line regimen.

Patients with advanced HIV type 1 infection initiating antiretroviral therapy in Botswana: treatment response and mortality

The response to highly active antiretroviral treatment (HAART) and predictors of mortality among patients with advanced HIV infection (CD4(+) cell count <50 cells/mm(3)) in Botswana are described. Clinical and laboratory data for 349 patients with CD4 <50 cells/mm(3) initiating HAART from January 23 to November 18, 2002 at Princess Marina Hospital in Gaborone, Botswana were extracted from clinical charts and electronic patient management systems. The Kaplan-Meier method was used to estimate survival and log-rank tests used for group comparisons. Cox regression was used to identify independent predictors of survival. A total of 349 adults initiated HAART. In all, 78.2% (95% CI: 73.7%, 82.9%) of patients survived 1 year. Among survivors, the mean CD4(+) cell count increase was 239.8 cells/mm(3) (95% CI: 217.0, 262.8) at 12 months; 92.1% (95% CI: 87.8%, 94.9%) of patients (as treated) had plasma HIV-1 RNA < or =400 copies/ml at 9 months declining to 59.9% (95% CI: 54.7%, 64.9%) (ITT). There was a 2-fold higher mortality rate among patients with CD4(+) < or =10 cells/mm(3) compared to 11-49 cells/mm(3), hazard ratio (HR) = 1.91 (95% CI:1.16, 3.14). A 10 cell/mm(3) higher CD4(+) cell count corresponded to a 22% decrease in hazard of death (HR = 0.78; 95% CI: 0.64, 0.94). Lower baseline CD4(+) cell count (p < 0.001) and WHO clinical stage 4 HR = 2.41 (95% CI:1.32, 4.38) were independent predictors of poorer survival. HAART confers significant benefit even among persons with advanced immunosuppression. Adults with CD4(+) cell counts < or =10 cells/mm(3) and/or WHO clinical stage 4 disease at the time of HAART initiation have a higher risk of death.

Differences in normal activities, job performance and symptom prevalence between patients not yet on antiretroviral therapy and patients initiating therapy in South Africa

OBJECTIVES

Little is known about how antiretroviral therapy (ART) affects patients' economic activities in resource-constrained settings. This study examined the association of ART with functional impairment, symptom prevalence, and employment during the first 6 months on therapy.

METHODS

Interviews were conducted with 453 patients receiving pre-ART care and 427 patients on ART for 1-6 months in South Africa.

RESULTS

Pre-ART subjects were almost twice as likely to report being functionally impaired (unable to perform primary normal activity) in the previous 5-day work week [adjusted odds ratio (OR) 1.97; 95% confidence interval (CI) 1.46-2.66], with a mean of 1.61 impaired days for pre-ART subjects versus 0.87 days for ART subjects (P < 0.0001). Pre-ART subjects were more likely to report fatigue (OR 2.84; 95% CI 2.10-3.84), pain (OR 2.06; 95% CI 1.53-2.76), and nausea (OR 1.61; 95% CI 1.13-2.28) in the previous week and feeling unwell physically (OR 1.71; 95% CI 1.27-2.32), feeling depressed (OR 1.42; 95% CI 1.04-1.95) or resting (OR 1.52; 95% CI 1.12-2.07) on the previous day. The prevalence of pain, fatigue, skin problems, and resting exceeded 40% in both groups. Employed subjects on ART for 3-6 months reported 3 days less health-related absenteeism per month than those on ART less than 3 months (P = 0.0353).

CONCLUSION

Patients who have initiated ART reported significantly less functional impairment, fewer symptoms, and better work performance than those who had not yet started treatment. The prevalence of some impairment, symptoms, and absenteeism remained high, however.