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

Evaluation of rapid antiretroviral initiation strategy in a cohort of newly diagnosed people living with HIV in Panama, 2018-2019

Antiretroviral therapy (ART) has been adopted as a form of HIV treatment and prevention. This study assesses rapid ART initiation using clinical outcomes such as viral load (VL) and CD4+ T lymphocytes count. Over the course of one year, the progress of newly diagnosed people living with HIV who started ART early in a hospital in Panama City was followed. The evaluation of early initiation of ART in achieving viral suppression (VL <200 copies/ml) was analyzed using descriptive statistics. Additionally, the cost difference between early (first 7 days) and late initiation of ART was evaluated from the perspective of the service provider. In total, 209 people were followed up during the study; 85% were male, 70% started ART on same day from hospital arrival, 80% had suppressed viral load at 6 months, and the median count of CD4 increased from 285 (IQR: 166-429) to 509 (IQR: 373-696) over 12 months. Starting ART early led to a 42% increase for the provider in terms of staffing costs; however, the clients had the opportunity to decrease absenteeism in daily activities. The results reveal that early initiation of ART generates clinical and economic benefits for the person in treatment.

HIV, multimorbidity, and health-related quality of life in rural KwaZulu-Natal, South Africa: A population-based study

Health-related quality of life (HRQoL) assesses the perceived impact of health status across life domains. Although research has explored the relationship between specific conditions, including HIV, and HRQoL in low-resource settings, less attention has been paid to the association between multimorbidity and HRQoL. In a secondary analysis of cross-sectional data from the Vukuzazi ("Wake up and know ourselves" in isiZulu) study, which identified the prevalence and overlap of non-communicable and infectious diseases in the uMkhanyakunde district of KwaZulu-Natal, we (1) evaluated the impact of multimorbidity on HRQoL; (2) determined the relative associations among infectious diseases, non-communicable diseases (NCDs), and HRQoL; and (3) examined the effects of controlled versus non-controlled disease on HRQoL. HRQoL was measured using the EQ-5D-3L, which assesses overall perceived health, five specific domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), and three levels of problems (no problems, some problems, and extreme problems). Six diseases and disease states were included in this analysis: HIV, diabetes, stroke, heart attack, high blood pressure, and TB. After examining the degree to which number of conditions affects HRQoL, we estimated the effect of joint associations among combinations of diseases, each HRQoL domain, and overall health. Then, in one set of ridge regression models, we assessed the relative impact of HIV, diabetes, stroke, heart attack, high blood pressure, and tuberculosis on the HRQoL domains; in a second set of models, the contribution of treatment (controlled vs. uncontrolled disease) was added. A total of 14,008 individuals were included in this analysis. Having more conditions adversely affected perceived health (r = -0.060, p<0.001, 95% CI: -0.073 to -0.046) and all HRQoL domains. Infectious conditions were related to better perceived health (r = 0.051, p<0.001, 95% CI: 0.037 to 0.064) and better HRQoL, whereas non-communicable diseases (NCDs) were associated with worse perceived health (r = -0.124, p<0.001, -95% CI: 0.137 to -0.110) and lower HRQoL. Particular combinations of NCDs were detrimental to perceived health, whereas HIV, which was characterized by access to care and suppressed viral load in the large majority of those affected, was counterintuitively associated with better perceived health. With respect to disease control, unique combinations of uncontrolled NCDs were significantly related to worse perceived health, and controlled HIV was associated with better perceived health. The presence of controlled and uncontrolled NCDs was associated with poor perceived health and worse HRQoL, whereas the presence of controlled HIV was associated with improved HRQoL. HIV disease control may be critical for HRQoL among people with HIV, and incorporating NCD prevention and attention to multimorbidity into healthcare strategies may improve HRQoL.

Intergenerational spillover effects of antiretroviral therapy in sub-Saharan Africa: a scoping review and future directions for research

BACKGROUND

Antiretroviral therapy (ART) may influence individuals who do not receive the intervention but who are connected in some way to the person who does. Relatively little is known, however, about the size and scope of, what we term, spillover effects of ART. We explored intergenerational spillover effects of ART in sub-Saharan Africa (SSA) and identified several directions for future research.

METHODS

We conducted a scoping review between March and April 2022. We systematically searched PubMed, PsycINFO, EconLit, OTseeker, AIDSInfo, Web of Science, CINHAL, Google Scholar and African Index Medicus. We analysed the distribution of included studies over time and summarised their findings. We examined the intergenerational impact of ART provision to working-age adults living with HIV on children ('downward' spillover effects) and older adults ('upward' spillover effects). We categorised types of intergenerational spillover effects according to broad themes which emerged from our analysis of included studies.

FINDINGS

We identified 26 studies published between 2005 and 2022 with 16 studies assessing spillover effects from adults to children (downward), and 1 study explicitly assessing spillover effects from working-age adults to older adults (upward). The remaining studies did not fully specify the direction of spillover effects. Most spillover effects of ART to household and family members were beneficial and included improvements in wealth, labour market outcomes, health outcomes and health services utilisation, schooling, and household composition. Both children and older adults benefited from ART availability among adults. Detrimental spillover effects were only reported in three studies and included financial and opportunity costs associated with health services utilisation and food insecurity in the first year after ART.

CONCLUSIONS

ART may lead to substantial spillover effects across generations and sectors in SSA. Further research is needed to capitalise on positive spillover effects while mitigating potential negative spillover effects. The returns to investments in large-scale health interventions such as ART may be underestimated without considering these societal benefits.

Association between recent methamphetamine use, antiretroviral therapy and HIV viral load; a mediation analysis from a cohort of HIV positive persons who inject drugs in Hai Phong, Vietnam

BACKGROUND

There has been a significant increase in methamphetamine use among persons who use drugs in Vietnam in the last 5-10 years. We examined the degree to which adherence to antiretroviral therapy (ART) mediates the relationship between recent methamphetamine use and unsuppressed HIV viral load among people who inject drugs (PWID) in Hai Phong, Vietnam.

METHODS

We recruited PWID from October 2016-October 2018 and enrolled HIV positive PWID into a cohort, with up to three years of total follow-up. We assessed relationships among recent methamphetamine use frequency, ART adherence and unsuppressed HIV viral load. Mediation analysis was used to estimate the total and natural direct effects of recent methamphetamine use on unsuppressed HIV viral load and the indirect effect proportion.

RESULTS

We enrolled 792 HIV seropositive PWID into the cohort; approximately 75.9% reported high/perfect ART adherence at baseline and 81.3% were virally suppressed. In mediation analysis, the total effect for the association between methamphetamine use and unsuppressed HIV viral load (1000 copies/mL) was 3.94 (95% CI: 1.95, 7.96); the natural direct effect was 2.14 (95% CI: 1.29, 3.55); the proportion mediated by self-reported ART adherence was 0.444. Similar results were found when examining lower unsuppressed HIV viral load cutpoints of 250 copies/mL and 500 copies/mL.

CONCLUSIONS

Methamphetamine use is associated with unsuppressed HIV viral load among PWID despite high levels of ART adherence. Further research is needed to better understand these relationships, with emphasis on potential biological pathways that may interact with ART.

Pharmacokinetic and pharmacogenetic associations with dolutegravir neuropsychiatric adverse events in an African population

BACKGROUND

Dolutegravir has been associated with neuropsychiatric adverse events (NPAEs), but relationships between dolutegravir concentrations and NPAEs are unclear.

OBJECTIVES

To determine in an African population whether a concentration-response relationship exists between dolutegravir and treatment-emergent NPAEs, and whether selected loss-of-function polymorphisms in genes encoding UDP-glucuronosyltransferase-1A1 (the major metabolizing enzyme for dolutegravir) and organic cation transporter-2 (involved in neurotransmitter transport and inhibited by dolutegravir) are associated with NPAEs.

METHODS

Antiretroviral therapy-naive participants randomized to dolutegravir-based therapy in the ADVANCE study were enrolled into a pharmacokinetic sub-study. Primary outcome was change in mental health screening [modified mini screen (MMS)] and sleep quality from baseline to weeks 4, 12 and 24. Dolutegravir exposure was estimated using a population pharmacokinetic model. Polymorphisms analysed were UGT1A1 rs887829 and SLC22A2 rs316019.

RESULTS

Data from 464 participants were available for pharmacokinetic analyses and 301 for genetic analyses. By multivariable linear regression, higher dolutegravir exposure was associated with worsening sleep quality only at week 12 [coefficient  = -0.854 (95% CI -1.703 to -0.005), P = 0.049], but with improved MMS score at weeks 12 and 24 [coefficient = -1.255 (95% CI -2.250 to -0.261), P = 0.013 and coefficient = -1.199 (95% CI -2.030 to -0.368), P = 0.005, respectively]. The UGT1A1 and SLC22A2 polymorphisms were not associated with change in MMS score or sleep quality.

CONCLUSIONS

Only at week 12 did we find evidence of a relationship between dolutegravir exposure and worsening sleep quality. However, higher dolutegravir exposure was associated with improved MMS scores, suggesting a possible beneficial effect.

Assessing the Temporality Between Transitions onto Opioid Agonist Therapy and Engagement with Antiretroviral Therapy in a Cohort of HIV-Positive People Who Use Opioids Daily

A robust evidence-base describes the beneficial association between opioid agonist therapy (OAT) and HIV-related outcomes among people living with HIV and opioid use disorder. While some evidence suggests the stabilizing effect of OAT on antiretroviral therapy (ART) treatment engagement, less is understood about the potential for an inverse relationship. We sought to examine the relationship between transitions in ART engagement and transitions onto OAT. We used data from a prospective cohort of people living with HIV who use drugs in Vancouver, Canada-a setting with no-cost access to ART and low or no-cost access to OAT among low-income residents. Restricting the sample to those who reported daily or greater opioid use, we used generalized linear mixed-effects models to estimate the relationships between our primary outcome of transitions onto OAT (methadone or buprenorphine/naloxone) and transitions (1) onto ART and (2) into ART adherence. Subsequent analyses assessed the temporal sequencing of transitions. Between 2005 and 2017, among 433 participants, 48.3% reported transitioning onto OAT at least once. In concurrent analyses, transitions onto ART were positively and significantly associated with transitions onto OAT. Temporal sequencing revealed that transitions into OAT were also positively and significantly associated with subsequent transitions onto ART. OAT's potential to facilitate the uptake of ART points to the continued need to scale-up low-threshold, client-centered substance use services integrated alongside HIV care.

The Impact of Immediate Initiation of Antiretroviral Therapy on Patients' Healthcare Expenditures: A Stepped-Wedge Randomized Trial in Eswatini

Immediate initiation of antiretroviral therapy (ART) for all people living with HIV has important health benefits but implications for the economic aspects of patients' lives are still largely unknown. This stepped-wedge cluster-randomized controlled trial aimed to determine the causal impact of immediate ART initiation on patients’ healthcare expenditures in Eswatini. Fourteen healthcare facilities were randomly assigned to transition at one of seven time points from the standard of care (ART eligibility below a CD4 count threshold) to the immediate ART for all intervention (EAAA). 2261 patients living with HIV were interviewed over the study period to capture their past-year out-of-pocket healthcare expenditures. In mixed-effects regression models, we found a 49% decrease (RR 0.51, 95% CI 0.36, 0.72, p < 0.001) in past-year total healthcare expenditures in the EAAA group compared to the standard of care, and a 98% (RR 0.02, 95% CI 0.00, 0.02, p < 0.001) decrease in spending on private and traditional healthcare. Despite a higher frequency of HIV care visits for newly initiated ART patients, immediate ART initiation appears to have lowered patients’ healthcare expenditures because they sought less care from alternative healthcare providers. This study adds an important economic argument to the World Health Organization’s recommendation to abolish CD4-count-based eligibility thresholds for ART.

Unified model of short- and long-term HIV viral rebound for clinical trial planning

Antiretroviral therapy (ART) effectively controls HIV infection, suppressing HIV viral loads. Typically suspension of therapy is rapidly followed by rebound of viral loads to high, pre-therapy levels. Indeed, a recent study showed that approximately 90% of treatment interruption study participants show viral rebound within at most a few months of therapy suspension, but the remaining 10%, showed viral rebound some months, or years, after ART suspension. Some may even never rebound. We investigate and compare branching process models aimed at gaining insight into these viral dynamics. Specifically, we provide a theory that explains both short- and long-term viral rebounds, and post-treatment control, via a multitype branching process with time-inhomogeneous rates, validated with data from Li et al. (Li et al. 2016 AIDS30, 343-353. (doi:10.1097/QAD.0000000000000953)). We discuss the associated biological interpretation and implications of our best-fit model. To test the effectiveness of an experimental intervention in delaying or preventing rebound, the standard practice is to suspend therapy and monitor the study participants for rebound. We close with a discussion of an important application of our modelling in the design of such clinical trials.

Predictors of glucose metabolism and blood pressure among Ethiopian individuals with HIV/AIDS after one-year of antiretroviral therapy

OBJECTIVE

Better understanding of glucose metabolism in patients with HIV after initiating antiretroviral therapy (ART) is important to target treatment and follow-up for diabetes risk and other non-communicable diseases in resource-limited settings. The aim of this study was to assess the changes and predictors of glucose metabolism and blood pressure among patients with HIV on ART for 12 months.

METHODS

One-year follow-up of Ethiopian patients with HIV after initiation of ART was done. Outcomes were changes in fasting plasma glucose (FPG), and 30-minute (30mPG) and 2-hour plasma glucose (2hPG) after oral glucose tolerance test, glycated haemoglobin (HbA1c), fasting plasma insulin (p-insulin), homeostatic model assessment index for insulin resistance (HOMA-IR) and blood pressure.   RESULTS: The mean age was 33 years, and the majority were women. During the first 12 months, levels of all plasma glucose parameters decreased, while p-insulin (10^B 3.1; 95% CI2.4, 4.0), HOMA-IR (10^B 3.1; 95% CI2.3, 4.0) and systolic blood pressure (B 4.0; 95% CI2.5, 5.5) increased. Fat-free mass at baseline predicted higher increments in p-insulin, HOMA-IR and blood pressure; whereas, fat mass predicted higher increment in HbA1c.

CONCLUSIONS

Among Ethiopian patients with HIV, blood pressure and insulin increased, and all glucose parameters declined during 12-month of ART. Only longer-term follow-up will tell us whether insulin increase is due to insulin resistance or from recovering β-cells.

Health-related quality of life of patients with HIV/AIDS at a tertiary care teaching hospital in Ethiopia

Background

Patients’ health-related quality of life (HRQoL) and health state utility values are critical inputs in the clinical and economic evaluation of treatments for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). However, information on health state utility values is lacking in the context of Ethiopia. Here, we aimed to assess HRQoL and determine health state utility values and factors that influence the values among HIV/AIDS patients in Ethiopia.

Methods

A cross-sectional study was conducted among 511 HIV/AIDS patients at Tikur Anbessa Specialized Hospital in Ethiopia. Patients aged 18 years or older were eligible for the interview and those who were mentally unstable and with hearing impairment were excluded from the study. We performed face-to-face interviews using EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) in combination with EuroQol-Visual Analog Scales (EQ-VAS). Level-specific disutility coefficients obtained from the general population were used for computing utility values. Patients’ health profiles were described using percentages and different statistical analysis were conducted to determine factors associated with the EQ-5D index and EQ-VAS scores.

Results

A total of 511 patients participated in the study. A higher proportion of patients reported slight or more severe problems on the anxiety/depression (55.2%) and pain/discomfort (51.3%) dimensions. The overall median utility value of HIV/AIDS patients was 0.94 (IQR = 0.87, 1) from the EQ-5D index and 80% (IQR = 70%, 90%) from the EQ-VAS scores. Demographic characteristics including age, occupational status, and household monthly income significantly affected patient’s utility values. Moreover, statistically significant (p < 0.001) differences were seen between the EQ-5D index values of patients with different CD4 count intervals. Furthermore, number of medicines that the patients were taking at the time of the study and comorbidities were significantly associated with the EQ-5D utility index and EQ-VAS score, p < 0.001.

Conclusions

The anxiety/depression and pain/ discomfort dimensions were identified to have critical influence in reducing the HRQoL of adult HIV/AIDS patients in the context of Ethiopia. The study is also the first to use the EQ-5D-5L tool to identify health state utility values for Ethiopian adult HIV/AIDS patients. Future economic evaluations of HIV/AIDS interventions are encouraged to employ the identified utility values.

Assessment of Health-Related Quality of Life and Associated Factors Among HIV/AIDS Patients on Highly Active Antiretroviral Therapy (HAART) at Ambo General Hospital, West Shewa, Ethiopia

Background

Determining the degree of health-related quality of life (HRQoL) and associated factors in human immunodeficiency virus (HIV)-positive people is of great importance.

Objective

The aim of this study was to assess the HRQoL and associated factors among HIV-infected patients who were on highly active antiretroviral therapy (HAART) at Ambo General Hospital.

Methods

A study with a cross-sectional design was conducted on 296 HIV-infected patients who were on HAART at Ambo General Hospital from February 20 to May 20, 2019. Patients were recruited by a random sampling technique and a P-value <0.05 was set as statistically significant. Th main outcome measure was HRQoL.

Results

The majority of study participants were female (56.8%). More than half (53%) of the participants had low overall HRQoL. Those who were married and who earned <1500 ETB were less likely to experience low overall HRQoL than single people (AOR: 4.41, P=0.024) and those who earned more (AOR: 4.27, P=0.000), respectively. Those with current illness and who had no HIV-positive family members were more likely to experience lower overall quality of life than those with no current illness (AOR: 32.29, P=0.000) and with one HIV-positive family member (AOR: 4.03, P=0.003), respectively. Those with recent WHO clinical stage I were less likely to experience a lower overall quality of life than those with stage II (AOR: 0.07, P=0.000).

Conclusion

Current illness, recent WHO stage and having no HIV-positive family members were found to be strongly associated with lower quality of life in HIV-positive patients on antiretroviral therapy.

A stepped-wedge randomised trial on the impact of early ART initiation on HIV-patients' economic outcomes in Eswatini

Background

Since 2015, the World Health Organisation (WHO) recommends immediate initiation of antiretroviral therapy (ART) for all HIV-positive patients. Epidemiological evidence points to important health benefits of immediate ART initiation; however, the policy’s impact on the economic aspects of patients' lives remains unknown.

Methods

We conducted a stepped-wedge cluster-randomised controlled trial in Eswatini to determine the causal impact of immediate ART initiation on patients’ individual- and household-level economic outcomes. Fourteen healthcare facilities were non-randomly matched into pairs and then randomly allocated to transition from the standard of care (ART eligibility at CD4 counts of <350 cells/mm3 until September 2016 and <500 cells/mm3 thereafter) to the ‘Early Initiation of ART for All’ (EAAA) intervention at one of seven timepoints. Patients, healthcare personnel, and outcome assessors remained unblinded. Data were collected via standardised paper-based surveys with HIV-positive adults who were neither pregnant nor breastfeeding. Outcomes were patients’ time use, employment status, household expenditures, and household living standards.

Results

A total sample of 3019 participants were interviewed over the duration of the study. The mean number of participants approached at each facility per time step varied from 4 to 112 participants. Using mixed-effects negative binomial regressions accounting for time trends and clustering at the level of the healthcare facility, we found no significant difference between study arms for any economic outcome. Specifically, the EAAA intervention had no significant effect on non-resting time use (RR = 1.00 [CI: 0.96, 1.05, p=0.93]) or income-generating time use (RR = 0.94, [CI: 0.73,1.20, p=0.61]). Employment and household expenditures decreased slightly but not significantly in the EAAA group, with risk ratios of 0.93 [CI: 0.82, 1.04, p=0.21] and 0.92 [CI: 0.79, 1.06, p=0.26], respectively. We also found no significant treatment effect on households’ asset ownership and living standards (RR = 0.96, [CI 0.92, 1.00, p=0.253]). Lastly, there was no evidence of heterogeneity in effect estimates by patients’ sex, age, education, timing of HIV diagnosis and ART initiation.

Conclusions

Our findings do not provide evidence that should discourage further investments into scaling up immediate ART for all HIV patients.

Funding

Funded by the Dutch Postcode Lottery in the Netherlands, Alexander von Humboldt-Stiftung (Humboldt-Stiftung), the Embassy of the Kingdom of the Netherlands in South Africa/Mozambique, British Columbia Centre of Excellence in Canada, Doctors Without Borders (MSF USA), National Center for Advancing Translational Sciences of the National Institutes of Health and Joachim Herz Foundation.

Clinical trial number

NCT02909218 and NCT03789448.

Health related quality of life of people receiving highly active antiretroviral therapy in Southwest Ethiopia

BACKGROUND

Highly Active Antiretroviral Therapy (HAART) is a standard of HIV management to suppress viral load and delay progression to AIDS. However, questions have been raised about the use of antiretroviral therapy and how it affects quality of life (QoL) of people living with HIV/AIDS (PLWHA). The study hence aimed to assess the QoL of PLWHA who were taking HAART at Mizan-Tepi University Teaching Hospital (MTUTH) and identify factors associated with QoL.

METHODS

A cross sectional study was conducted among PLWHA receiving HAART at MTUTH from March 04-April 1, 2018. Patients were recruited consecutively and interviewed with structured questionnaire. A data abstraction tool was used to extract data from patient medical records. Quality of life was assessed using the World Health Organization Quality of Life HIV- BREF (WHOQOL-HIV-BREF) standard tool. Data was entered to Epi-Info version 3.5.3 and analyzed using SPSS version 22 for windows. A multivariable logistic regression analysis was fitted to identify factors associated with QoL. A statistical significance was established at a p value <0.05.

RESULTS

A total of 240 participants with the mean age of 35.11 (SD = 9.08) years were included in the study. This study found that 57.1% of the patients had high global score of QoL. Patients with normal current health (AOR = 3.38, 95% CI = 1.56-7.31)) and having family support (AOR = 3.12, 95% CI = 1.51-6.46) were positively associated with high global score of QoL, while patients with low HAART adherence (AOR = 0.40, 95%, CI = 0.19-0.86) were negatively associated with high global score of QoL.

CONCLUSION

The study revealed that more than half of the participants had high global score of QoL. Normal current health and family support were associated with better global score of QoL, while low HAART adherence was found to be associated with the lower global score of QoL.

Employment trajectories of PLHIV on ART in Lusaka, Zambia: a short report

The introduction of antiretroviral therapy (ART) has helped mitigate many of the negative consequences of HIV. ART allows people living with HIV (PLHIV) to recover physically and become active members of society. Research thus far is positive about the potential economic impact of ART on household economies. In terms of employment, studies indicate that ART, when initiated early in disease progression, allows PLHIV to maintain their employment and, when initiated late in disease progression, allows PLHIV to return to work once they physically recover. This paper questions the latter by demonstrating that while the employment levels indeed return to normal or baseline levels, the type of employment that PLHIV obtain has undergone a shift. It demonstrates that the type of employment PLHIV are engaged in once they recover is largely less stable and less profitable than what they were doing prior to illness. It additionally demonstrates that PLHIV are engaged in work that is less stable and less profitable than their HIV-negative counterparts. I conclude that a closer inspection of the type of employment that PLHIV are engaged in is needed to provide a more accurate understanding of the impact of ART on the socio-economic status of PLHIV on ART.

Psychological distress in women and men living with HIV in Spain: a cross-sectional telephone survey

BACKGROUND

Psychological distress includes a broader range of experiences, varying from less severe symptoms of depression and anxiety to severe psychiatric disease. Global estimates for depression and anxiety in 2017 were 3.4% and 3.8%, respectively. While for people living with HIV, global estimates were 16% and 33%, respectively.

OBJECTIVE

We aimed to determine the prevalence of psychological distress by gender and associated characteristics in patients living with HIV.

METHODS

A cross-sectional study was conducted within the Spanish HIV Research Network CoRIS. Participants were interviewed by telephone between 2010 and 2014 about their psychological distress, sociodemographics, drug consumption, self-perceived health and combined antiretroviral therapy (cART) adherence. Laboratory tests and medical history details were collected from CoRIS. Logistic regression was used to identify characteristics associated with psychological distress.

FINDINGS

We interviewed 99 women and 464 men, both living with HIV. A greater proportion of women (51, 51.5%) reported psychological distress than men (179, 38.6%; p<0.01). Non-adherence to cART (OR 4.6 and 2.3, 95% CI 1.4‒15.1 and 1.3‒4.2) and non-use of cART (8.4 and 1.8, 2.2‒32.4 and 1.1‒2.8) were related to psychological distress in women and men, respectively. Spending little time in leisure-based physical activity was related to psychological distress in women (3.1, 1.1‒9.0). Living alone (2.0, 1.3‒3.0) and being unemployed (2.3, 1.4‒3.6) were related to psychological distress in men.

CONCLUSIONS AND CLINICAL IMPLICATIONS

As people living with HIV have a high prevalence of psychological distress, their regular screening appointments should include psychological assessment. A gendered approach is needed to detect and manage psychological distress.

Determinants of health-related quality of life among human immunodeficiency virus positive (HIV-positive) patients at Ahmadu Bello University teaching hospital, Zaria, Nigeria- 2015

BACKGROUND

The advent of Highly Active Antiretroviral Therapy (HAART) is associated with improved clinical and laboratory outcomes resulting in prolonged life and well-being of people living with Human Immunodeficiency Virus (PLHIV). However, the needs for life-long therapy, medications' side effects and stigma have raised concerns about their quality of life (QOL). This study assessed the determinants of Health-related quality of life (HRQOL) among HIV-positive patients at Ahmadu Bello University Teaching Hospital (ABUTH) Zaria.

METHODS

We conducted a cross-sectional study of 353 HIV-positive adults on HAART attending the HIV clinic of ABUTH, Zaria. The participants were recruited into the study using a systematic sampling technique. Data on socio-demographics, medical parameters, QOL and family functionality were collected using structured, interviewer-administered questionnaire. The World Health Organization (WHO) Quality of Life HIV short form instrument (WHOQOL-HIV BREF) item and Family APGAR tool were respectively used in assessing the QOL and family functionality of the participants. We performed univariate, bivariate and multivariate analysis.

RESULTS

Mean age was 39.1(±10.9) years, 239 (67.7%) were females, 208 (58.9%) were Hausa-Fulani, 240 (68.2%) married and up to 210 (59.4%) had at least a secondary education. The overall mean scores on the scale of 4-20 for HRQOL were similar in three domains: environment domain 14.5(±2.8); social relationship 14.4(±3.1) and level of independence 14.4(±2.5). Lower scores were recorded in spirituality/religion/personal beliefs 12.3(±4.3). Identified determinants of HRQOL were spousal HIV- positive status (AOR = 3.37; CI; 1.46-7.74) and high family function (AOR = 2.57; CI: 1.51-4.39).

CONCLUSION

Having highly functional family and having HIV-positive partner were the major determinants of HRQOL. Routine family counselling and strengthening the HIV social-support network should be incorporated into the routine patients' care in HIV treatment centers.

Living strategies for disability in men ageing with HIV in Ontario, Canada: a longitudinal qualitative study

OBJECTIVES

To examine the living strategies used by older men living with HIV to deal with the episodic nature of disability and associated uncertainty, over time.

DESIGN

Qualitative longitudinal study in which men living with HIV were interviewed on four occasions over 20 months.

SETTING

Men were recruited from HIV community organisations in Canada.

PARTICIPANTS

14 men with a median age of 57.5 years and median time since diagnosis of 21.5 years.

RESULTS

Five themes depict the living strategies used to deal with the episodic nature of disability and uncertainty over time. Actively engaging in problem-solving by prioritising and modifying activities and avoiding stress, advocating for support, being positive and future oriented, engaging in healthy pursuits and providing social support to others helped men to mitigate their disability. By following participants over time, we were able to gather insights into triggers of episodes of disability, and perceptions of the success of implementing their living strategies and avoiding uncertainty.

CONCLUSIONS

Participants used living strategies to deal with uncertainty and mitigate episodes of disability over time. This study supports the importance of programmes that promote self-management for older men living with HIV through helping them identify triggers of disability, set realistic goals and problem-solve. These may help build self-efficacy, increase sense of control, and decrease feelings of uncertainty and episodes of disability.

Assessment of HIV-related stigma and determinants among people living with HIV/AIDS in Abeokuta, Nigeria: A cross-sectional study

Introduction:

HIV/AIDS-related stigma remains an essential barrier to the formulated care delivery and improved quality of life of people living with HIV/AIDS in sub-Saharan Africa. Only a few studies have evaluated stigma and its determinants as concerns people living with HIV/AIDS in Nigeria.

Methods:

A cross-sectional design study recruited 386 people living with HIV/AIDS attending the government clinic, Federal Medical Centre, Abeokuta, Nigeria, for the assessment of stigma using Berger’s HIV stigma scale and United States Agency International Development-recommended indicators and questions on HIV-related stigma among people living with HIV/AIDS. Data were analyzed using SPSS 21.

Results:

Of the 386 people living with HIV/AIDS, 322 (83.4%) were females and 64 (16.6%) were males, and 96.9% had disclosed their HIV status. Overall, mean perceived stigma score was moderately high at 95.74 (standard deviation = ±16.04). Majority (77.2%) of the participants experienced moderately perceived stigma. Among the subscales, disclosure concerns contributed the most to stigma score at 68.9%. Enacted stigma in the last 12 months was documented in 35.8% (138). There was no association observed between age, gender, marital status and HIV-related stigma. However, low education was associated with higher negative self-image perception (31.83 ± 5.81 vs 29.76 ± 5.74, p < 0.001). Furthermore, higher perceived stigma score was associated with abandonment by spouses (p < 0.001), isolation from household members (p < 0.001) and social exclusion (p < 0.001). We demonstrated a correlation between the domains of enacted stigma and Berger HIV stigma scales except for the loss of resources.

Conclusion:

Perceived HIV-related stigma is moderately high among people living with HIV/AIDS. Low education, disclosure concerns, spousal or household abandonment and social exclusion are the significant contributors. HIV-related stigma preventive interventions at different levels of care are advocated.

Prevalence and factors associated with fertility desires/intentions among individuals in HIV-serodiscordant relationships: a systematic review of empirical studies

INTRODUCTION

Better knowledge about fertility desires/intentions among HIV-serodiscordant partners who face unique challenges when considering childbearing may be helpful in the development of targeted reproductive interventions. The aim of this systematic review was to synthesize the published literature regarding the prevalence of fertility desires/intentions and its associated factors among individuals in HIV-serodiscordant relationships while distinguishing low- and middle-income countries (LMIC) from high-income countries (HIC).

METHODS

A systematic search of all papers published prior to February 2017 was conducted in four electronic databases (PubMed/MEDLINE, PsycINFO, Web of Science and Cochrane Library). Empirical studies published in peer-reviewed journals with individuals in HIV-serodiscordant relationships assessing the prevalence of fertility desires/intentions and/or the associated factors were included in this systematic review. This review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS AND DISCUSSION

After screening 1852 references, 29 studies were included, of which 21 were conducted in LMIC and eight in HIC. A great variability in the prevalence of fertility desires/intentions was observed in LMIC (8% to 84% (one member of the dyad included)). In HIC, the results showed a smaller discrepancy between in the prevalence (32% to 58% (one member of the dyad included)); the prevalence was higher when the couple was the unit of analysis (64% to 73%), which may be related to the fact that all these studies were conducted in the context of assisted reproduction. Few studies examined the factors associated with fertility desires/intentions, and all except one were conducted in LMIC. Individuals (e.g. number of children), couple-level (e.g. belief that the partner wanted children) and structural factors (e.g. discussions with health workers) were found to be associated.

CONCLUSIONS

The results of this systematic review suggest that many individuals in HIV-serodiscordant relationships have fertility desires/intentions, although the prevalence is particularly heterogeneous in LMIC in comparison to HIC. Well-known factors such as younger age and a fewer number of living children were consistently associated with increased fertility desires/intentions. Different couple-level factors emerged, reflecting the importance of considering both the individual and the couple. However, further studies that specifically focus on the dyad as the unit of analysis are warranted.

Early HIV treatment and labour outcomes: A case study of mining workers in South Africa

This study examines whether labour outcomes of HIV-infected workers treated with antiretrovirals are associated with the stage of the disease when commencing therapy. We use data on employment separation and absenteeism from the workplace health programme of South Africa's largest coal mining company over the period of January 2009 to March 2017 in a Cox proportional hazards model. When treatment was initiated at a CD4+ T cell count above 350 cells/μl, the risk of separating from the company was 37% lower and the risk of absence was 20%t lower than initiating at a CD4 count below 200 cells/μl, and these differences persist over time. Also, we find that workers initiating antiretroviral therapy at CD4  ≥  350 have an 8% lower risk of absence prior to treatment. Although many companies and the South African government have adopted universal test-and-treat policies aiming to initiate all HIV-infected people as early as possible, most HIV patients still start treatment late in the disease course when their CD4 counts have fallen to low levels. Our results indicate early HIV detection and treatment could have large productivity gains.

Antiretroviral therapy coverage associated with increased co-residence between older and working-age adults in Africa

OBJECTIVES

To determine whether national antiretroviral therapy (ART) coverage is associated with changes in the living arrangements of older adults.

DESIGN

Retrospective analysis using 103 nationally representative surveys from 28 African countries between 1991 and 2015.

METHODS

The sample consisted of individuals aged at least 60 years. We investigated how three measures of living arrangements of older adults have changed with ART coverage: the number of older individuals living without working-age adults, the number of older individuals living with only dependent children (i.e. 'missing generation' households), and the number of working-age adults per household where an older individual lives.

RESULTS

Our sample consisted of 297 331 older adults. An increase in ART coverage of 1% was associated with a 0.7 percentage point reduction (P < 0.001) in the probability of an older adult living without working-age adult and a 0.2 percentage point reduction (P = 0.005) in the probability of an older adult living in a 'missing generation' household. Increases in ART coverage were also associated with more working-age adults in households with at least one older adult. In our study countries, representing 75% (749 million) of the sub-Saharan population, an additional 103 000-358 000 older adults could be living with working-age adults as a result of increased ART coverage (1%).

CONCLUSION

The scale-up of ART has likely led to substantial increases in co-residence between older and working-age adults in Africa. Returns to investments in HIV treatment will be too low, if the social benefits from these changes in living arrangements of older adults are not taken into account.

Workability of patients with HIV/AIDS in Northern Vietnam: a societal perspective on the impact of treatment program

In Vietnam, the antiretroviral therapy (ART) program has been widely scaled up across the country since 2005, and now covers treatment for about half the HIV population. However, limited data exist about the workability and productivity outcome of ART in Vietnam. We aim to assess the employment status and work productivity among HIV patients taking ART in Northern Vietnam. A cross-sectional study was conducted in Hanoi and Nam Dinh with 1133 participants taking ART at the selected clinics. The Work Productivity and Activity Impairment Questionnaire: General Health (WPAI-GH) was applied. We found that 23% of patients with HIV/AIDS reported overall work productivity loss, and 12% had activity impairment. Among those having a job, their monthly income, however, was significantly lower than national averages 2806 thousand VND vs. 4120 thousand VND). The average education level of participants was low, with only 41.61% having greater than secondary education. Health problems and lower CD4 cell counts decreased workability of the patients while having a more dependent family, being a smoker or having a later HIV stage was associated with being less likely to have a job. The rate of employment among HIV/AIDS patients in this study was high however incomes were substantially lower than average. This could be due to low education levels or social stigma regarding these patients. Vocational education programs and public awareness could empower the patients economically. Similarly, a number of social and behavioral problems were associated with decreasing the working rate and productivity. Addressing these health issues may improve productivity among patients.

Economic costs and health-related quality of life outcomes of hospitalised patients with high HIV prevalence: A prospective hospital cohort study in Malawi

Introduction

Although HIV infection and its associated co-morbidities remain the commonest reason for hospitalisation in Africa, their impact on economic costs and health-related quality of life (HRQoL) are not well understood. This information is essential for decision-makers to make informed choices about how to best scale-up anti-retroviral treatment (ART) programmes. This study aimed to quantify the impact of HIV infection and ART on economic outcomes in a prospective cohort of hospitalised patients with high HIV prevalence.

Methods

Sequential medical admissions to Queen Elizabeth Central Hospital, Malawi, between June-December 2014 were followed until discharge, with standardised classification of medical diagnosis and estimation of healthcare resources used. Primary costing studies estimated total health provider cost by medical diagnosis. Participants were interviewed to establish direct non-medical and indirect costs. Costs were adjusted to 2014 US$ and INT$. HRQoL was measured using the EuroQol EQ-5D. Multivariable analyses estimated predictors of economic outcomes.

Results

Of 892 eligible participants, 80.4% (647/892) were recruited and medical notes found. In total, 447/647 (69.1%) participants were HIV-positive, 339/447 (75.8%) were on ART prior to admission, and 134/647 (20.7%) died in hospital. Mean duration of admission for HIV-positive participants not on ART and HIV-positive participants on ART was 15.0 days (95%CI: 12.0–18.0) and 12.2 days (95%CI: 10.8–13.7) respectively, compared to 10.8 days (95%CI: 8.8–12.8) for HIV-negative participants. Mean total provider cost per hospital admission was US$74.78 (bootstrap 95%CI: US$25.41-US$124.15) higher for HIV-positive than HIV-negative participants. Amongst HIV-positive participants, the mean total provider cost was US$106.87 (bootstrap 95%CI: US$25.09-US$106.87) lower for those on ART than for those not on ART. The mean total direct non-medical and indirect cost per hospital admission was US$87.84. EQ-5D utility scores were lower amongst HIV-positive participants, but not significantly different between those on and not on ART.

Conclusions

HIV-related hospital care poses substantial financial burdens on health systems and patients; however, per-admission costs are substantially lower for those already initiated onto ART prior to admission. These potential cost savings could offset some of the additional resources needed to provide universal access to ART.

The impact of ART initiation on household food security over time

While evidence suggests that adequate nutrition contributes to the efficacy of ART, the potential causal impact of ART initiation on household food security has not been thoroughly examined. In this study, we present some of the first causal evidence of the impact of ART initiation on household food security. We employ a quasi-experimental design, regression discontinuity, over 5540 individuals from an ongoing population cohort study in KwaZulu-Natal, South Africa, by utilizing the CD4 count-based ART eligibility threshold to examine the impact of ART initiation on household food security. We find that ART initiation causes a significant increase in the probability of food insecurity in the first year, which diminishes to zero within three years of initiation. Within the first year, ART initiation was found to significantly increase the probabilities that (1) the surveyed adult had missed any food in the past month by 10.2 percentage points (coefficient = 0.102, 95%CI = [0.039, 0.166]); (2) any adult in the household had missed a meal in the past month by 15.2 percentage points (coefficient = 0.152, 95%CI = [0.073, 0.231]); and (3) any child in the household had missed a meal in the past month by 8.9 percentage points (coefficient = 0.0898, 95%CI = [0.0317, 0.148]). While we cannot definitively isolate the mechanistic pathways from ART to household food security, our results are consistent with ART affecting food security through household resource strain and patient appetite recovery. Several policies could mitigate the negative impact of ART on food security, in particular food parcels or food vouchers for ART patients in the first two years after treatment initiation.

Differences in health-related quality of life between HIV-positive and HIV-negative people in Zambia and South Africa: a cross-sectional baseline survey of the HPTN 071 (PopART) trial

BACKGROUND

The life expectancy of HIV-positive individuals receiving antiretroviral therapy (ART) is approaching that of HIV-negative people. However, little is known about how these populations compare in terms of health-related quality of life (HRQoL). We aimed to compare HRQoL between HIV-positive and HIV-negative people in Zambia and South Africa.

METHODS

As part of the HPTN 071 (PopART) study, data from adults aged 18-44 years were gathered between Nov 28, 2013, and March 31, 2015, in large cross-sectional surveys of random samples of the general population in 21 communities in Zambia and South Africa. HRQoL data were collected with a standardised generic measure of health across five domains. We used β-distributed multivariable models to analyse differences in HRQoL scores between HIV-negative and HIV-positive individuals who were unaware of their status; aware, but not in HIV care; in HIV care, but who had not initiated ART; on ART for less than 5 years; and on ART for 5 years or more. We included controls for sociodemographic variables, herpes simplex virus type-2 status, and recreational drug use.

FINDINGS

We obtained data for 19 750 respondents in Zambia and 18 941 respondents in South Africa. Laboratory-confirmed HIV status was available for 19 330 respondents in Zambia and 18 004 respondents in South Africa; 4128 (21%) of these 19 330 respondents in Zambia and 4012 (22%) of 18 004 respondents in South Africa had laboratory-confirmed HIV. We obtained complete HRQoL information for 19 637 respondents in Zambia and 18 429 respondents in South Africa. HRQoL scores did not differ significantly between individuals who had initiated ART more than 5 years previously and HIV-negative individuals, neither in Zambia (change in mean score -0·002, 95% CI -0·01 to 0·001; p=0·219) nor in South Africa (0·000, -0·002 to 0·003; p=0·939). However, scores did differ between HIV-positive individuals who had initiated ART less than 5 years previously and HIV-negative individuals in Zambia (-0·006, 95% CI -0·008 to -0·003; p<0·0001). A large proportion of people with clinically confirmed HIV were unaware of being HIV-positive (1768 [43%] of 4128 people in Zambia and 2026 [50%] of 4012 people in South Africa) and reported good HRQoL, with no significant differences from that of HIV-negative people (change in mean HRQoL score -0·001, 95% CI -0·003 to 0·001, p=0·216; and 0·001, -0·001 to 0·001, p=0·997, respectively). In South Africa, HRQoL scores were lower in HIV-positive individuals who were aware of their status but not enrolled in HIV care (change in mean HRQoL -0·004, 95% CI -0·01 to -0·001; p=0·010) and those in HIV care but not on ART (-0·008, -0·01 to -0·004; p=0·001) than in HIV-negative people, but the magnitudes of difference were small.

INTERPRETATION

ART is successful in helping to reduce inequalities in HRQoL between HIV-positive and HIV-negative individuals in this general population sample. These findings highlight the importance of improving awareness of HIV status and expanding ART to prevent losses in HRQoL that occur with untreated HIV progression. The gains in HRQoL after individuals initiate ART could be substantial when scaled up to the population level.

FUNDING

National Institute of Allergy and Infectious Diseases, National Institute on Drug Abuse, National Institute of Mental Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, the Bill & Melinda Gates Foundation.

Optimism alongside new challenges: using a rehabilitation framework to explore experiences of a qualitative longitudinal cohort of people living with HIV on antiretroviral treatment in Lusaka, Zambia

Previous research has demonstrated increased comorbidities related to the chronic effects of HIV. Rehabilitation science offers a useful approach for studying chronic illness. This longitudinal qualitative study used a rehabilitation science approach to explore the experiences over time of women and men living with HIV and on antiretroviral therapy (ART) in the high HIV-prevalence setting of Lusaka, Zambia. Thirty-five participants participated in a total of 99 in-depth interviews from 2012 to 2015. The central pattern that emerged across the participants' narratives was the paradoxical experience of profound optimism alongside significant new challenges. Participants' stories of hopefulness in the face of ongoing struggles played out in three interconnected themes: (1) impacts on my body and life; (2) interventions I am grateful to have and new interventions I need; and (3) stigma reduced and created by ART. Results reflected the ups and downs of life with HIV as a chronic illness. Participants, whilst committed to and healthier on ART, typically experienced multiple physical, psychological and sensory impairments that varied in type, severity and trajectory. Participants valued improved relationships enabled by ART, but yearned for support for living long-term with HIV. Frequently participants reflected that their needs were overlooked related to managing side-effects, exercise, family planning and healthy sexuality. ART strengthened acceptance by self and others through improved health and productivity and through becoming a source of support for others. However, being on ART also led to stigma, driven by persistent associations with sickness, death, lack of productivity and uncertainty. This study points to shortcomings in the current focus of HIV care in Zambia and the region, which centres on initiating and adhering to ART. Findings call for evolution of the HIV care continuum to embrace a more holistic and long-term approach to living with HIV as a chronic and episodic condition.

Efficacy of a Social Self-Value Empowerment Intervention to Improve Quality of Life of HIV Infected People Receiving Antiretroviral Treatment in Nepal: A Randomized Controlled Trial

We developed a comprehensive and culturally applicable empowerment intervention social self-value package with an aim to assess its efficacy in order to improve the quality of life (QoL) of HIV infected people receiving antiretroviral treatment. Participants were randomly allocated to receive either six weekly intervention sessions or standard care. Nonlinear mixed-effects models were performed to compare changes in empowerment scores over time. Between September and November 2014, 1447 individuals were screened, of whom 132 were randomly assigned to either the intervention or control group. The mean scores of empowerment, social support and quality of life increased and stigma scores were reduced in the intervention group at 3- and 6-months. An intervention effect on social support, stigma and QoL was significantly increased by time and group with low and high empowerment. No adverse events were reported. The empowerment intervention was efficacious in improving QoL of HIV infected people.

Improved quality of life with immediate versus deferred initiation of antiretroviral therapy in early asymptomatic HIV infection

OBJECTIVE

To determine if immediate compared to deferred initiation of antiretroviral therapy (ART) in healthy persons living with HIV had a more favorable impact on health-related quality of life (QOL), or self-assessed physical, mental, and overall health status.

DESIGN

QOL was measured in the Strategic Timing of Antiretroviral Therapy study, which randomized healthy ART-naive persons living with HIV with CD4 cell counts above 500 cells/μl from 35 countries to immediate versus deferred ART.

METHODS

At baseline, months 4 and 12, then annually, participants completed a visual analog scale (VAS) for 'perceived current health' and the Short-Form 12-Item Health Survey version 2 from which the following were computed: general health perception; physical component summary (PCS); and mental component summary (MCS); the VAS and general health were rated from 0 (lowest) to 100 (highest).

RESULTS

QOL at study entry was high (mean scores: VAS = 80.9, general health = 72.5, PCS = 53.7, MCS = 48.2). Over a mean follow-up of 3 years, changes in all QOL measures favored the immediate group (P < 0.001); estimated differences were as follows: VAS = 1.9, general health = 3.6, PCS = 0.8, MCS = 0.9. When QOL changes were assessed across various demographic and clinical subgroups, treatment differences continued to favor the immediate group. QOL was poorer in those experiencing primary outcomes; however, when excluding those with primary events, results remained favorable for immediate ART recipients.

CONCLUSION

In an international randomized trial in ART-naive participants with above 500 CD4 cells/μl, there were modest but significant improvements in self-assessed QOL among those initiating ART immediately compared to deferring treatment, supporting patient-perceived health benefits of initiating ART as soon as possible after an HIV diagnosis.

Prevalence of Hypertension and Its Associated Risk Factors among 34,111 HAART Naïve HIV-Infected Adults in Dar es Salaam, Tanzania

Background. Elevated blood pressure has been reported among treatment naïve HIV-infected patients. We investigated prevalence of hypertension and its associated risk factors in a HAART naïve HIV-infected population in Dar es Salaam, Tanzania. Methods. A cross-sectional analysis was conducted among HAART naïve HIV-infected patients. Hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg. Overweight and obesity were defined as body mass index (BMI) between 25.0-29.9 kg/m2 and ≥30 kg/m2, respectively. We used relative risks to examine factors associated with hypertension. Results. Prevalence of hypertension was found to be 12.5%. After adjusting for possible confounders, risk of hypertension was 10% more in male than female patients. Patients aged ≥50 years had more than 2-fold increased risk for hypertension compared to 30-39-years-old patients. Overweight and obesity were associated with 51% and 94% increased risk for hypertension compared to normal weight patients. Low CD4+ T-cell count, advanced WHO clinical disease stage, and history of TB were associated with 10%, 42%, and 14% decreased risk for hypertension. Conclusions. Older age, male gender, and overweight/obesity were associated with hypertension. Immune suppression and history of TB were associated with lower risk for hypertension. HIV treatment programs should screen and manage hypertension even in HAART naïve individuals.

The Framing and Fashioning of Therapeutic Citizenship Among People Living With HIV Taking Antiretroviral Therapy in Uganda

In this article, we examine how people living with HIV (PLWH) were able to reconceptualize or "reframe" their understanding of HIV and enhance their capacity to self-manage the condition. Two in-depth interviews were held with 38 PLWH (20 women, 18 men) selected from three government and nongovernment antiretroviral therapy (ART) delivery sites in Wakiso District, and the narratives analyzed. ART providers played an important role in shaping participants' HIV self-management processes. Health workers helped PLWH realize that they could control their condition, provided useful concepts and language for emotional coping, and gave advice about practical self-management tasks, although this could not always be put into practice. ART providers in this setting were spaces for the development of a collective identity and a particular form of therapeutic citizenship that encouraged self-management, including adherence to ART. Positive framing institutions are important for many PLWH in resource-limited settings and the success of ART programs.

Women's experience of HIV as a chronic illness in South Africa: hard-earned lives, biographical disruption and moral career

This article presents findings from a longitudinal qualitative study (48 in-depth interviews with 12 women on antiretroviral treatment (ART)) exploring the experience of living with HIV as a chronic illness in South Africa by applying the structural and interactionist perspectives on chronic illness. The structural perspective indicates that the illness experience needs to be contextualised within the wider framework of the women's hard-earned lives: throughout the interviews, the women tended to refuse singularising HIV/AIDS and continuously framed the illness within the context of general hardship and adversity. Employing an interactionist perspective, the repeated interviews demonstrated the partial applicability of the concept of biographical disruption to the illness experience: most women experienced feelings of denial and disbelief upon diagnosis, but the availability of ART clearly mitigated the impact of HIV on their biographies. In addition, our findings demonstrate that the interaction between structural aspects, (stigmatising) social relations, and the illness (and its treatment) determines the never-ending cycle of identity appraisals, revisions and improvements, rendering the moral career of the HIV-positive women on ART a continuous work in progress.

Ability to Work and Employment Rates in Human Immunodeficiency Virus (HIV)-1-Infected Individuals Receiving Combination Antiretroviral Therapy: The Swiss HIV Cohort Study

Background.  Limited data exist on human immunodeficiency virus (HIV)-infected individuals' ability to work after receiving combination antiretroviral therapy (cART). We aimed to investigate predictors of regaining full ability to work at 1 year after starting cART. Methods.  Antiretroviral-naive HIV-infected individuals <60 years who started cART from January 1998 through December 2012 within the framework of the Swiss HIV Cohort Study were analyzed. Inability to work was defined as a medical judgment of the patient's ability to work as 0%. Results.  Of 5800 subjects, 4382 (75.6%) were fully able to work, 471 (8.1%) able to work part time, and 947 (16.3%) were unable to work at baseline. Of the 947 patients unable to work, 439 (46.3%) were able to work either full time or part time at 1 year of treatment. Predictors of recovering full ability to work were non-white ethnicity (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.20-3.54), higher education (OR, 4.03; 95% CI, 2.47-7.48), and achieving HIV-ribonucleic acid <50 copies/mL (OR, 1.83; 95% CI, 1.20-2.80). Older age (OR, 0.55; 95% CI, .42-.72, per 10 years older) and psychiatric disorders (OR, 0.24; 95% CI, .13-.47) were associated with lower odds of ability to work. Recovering full ability to work at 1 year increased from 24.0% in 1998-2001 to 41.2% in 2009-2012, but the employment rates did not increase. Conclusions.  Regaining full ability to work depends primarily on achieving viral suppression, absence of psychiatric comorbidity, and favorable psychosocial factors. The discrepancy between patients' ability to work and employment rates indicates barriers to reintegration of persons infected with HIV.

Finding Meaning: HIV Self-Management and Wellbeing among People Taking Antiretroviral Therapy in Uganda

The health of people living with HIV (PLWH) and the sustained success of antiretroviral therapy (ART) programmes depends on PLWH’s motivation and ability to self-manage the condition over the long term, including adherence to drugs on a daily basis. PLWH’s self-management of HIV and their wellbeing are likely to be interrelated. Successful self-management sustains wellbeing, and wellbeing is likely to motivate continued self-management. Detailed research is lacking on PLWH’s self-management processes on ART in resource-limited settings. This paper presents findings from a study of PLWH’s self-management and wellbeing in Wakiso District, Uganda. Thirty-eight PLWH (20 women, 18 men) were purposefully selected at ART facilities run by the government and by The AIDS Support Organisation in and around Entebbe. Two in-depth interviews were completed with each participant over three or four visits. Many were struggling economically, however the recovery of health and hope on ART had enhanced wellbeing and motivated self-management. The majority were managing their condition well across three broad domains of self-management. First, they had mobilised resources, notably through good relationships with health workers. Advice and counselling had helped them to reconceptualise their condition and situation more positively and see hope for the future, motivating their work to self-manage. Many had also developed a new network of support through contacts they had developed at the ART clinic. Second, they had acquired knowledge and skills to manage their health, a useful framework to manage their condition and to live their life. Third, participants were psychologically adjusting to their condition and their new ‘self’: they saw HIV as a normal disease, were coping with stigma and had regained self-esteem, and were finding meaning in life. Our study demonstrates the centrality of social relationships and other non-medical aspects of wellbeing for self-management which ART programmes might explore further and encourage.

Experiences of work among people with disabilities who are HIV-positive in Zambia

This paper focuses on accounts of how having a disability and being HIV-positive influences experiences of work among 21 people (12 women, 9 men) in Lusaka, Zambia. In-depth semi-structured interviews were conducted in English, Bemba, Nyanja, or Zambian sign language. Descriptive and thematic analyses were conducted. Three major themes were generated. The first, a triple burden, describes the burden of having a disability, being HIV-positive, and being unemployed. The second theme, disability and HIV is not inability, describes participants' desire for work and their resistance to being regarded as objects of charity. Finally, how work influences HIV management, describes the practicalities of working and living with HIV. Together these themes highlight the limited options available to persons with disabilities with HIV in Lusaka, not only secondary to the effects of HIV influencing their physical capacity to work, but also because of the attendant social stigma of being a person with a disability and HIV-positive.

Quality of Life of People Living with HIV/AIDS: A Cross-Sectional Study in Zhejiang Province, China

Health-related quality of life (HRQOL) has become a concept commonly used in the related research. Using the World Health Organization Quality of Life Questionnaire for Brief Version (WHOQOL-BREF), this study evaluated the Quality of Life (QOL) of people living with HIV/AIDS (PLWHA) in Zhejiang province, China, and assessed the influences of demographic, laboratory and disease-related variables on QOL. This cross-sectional study was conducted among PLWHA aged ≥ 18 years in Taizhou municipality, Zhejiang province, China, between August 1 and October 31, 2014. A multiple linear regression model was used to analyze the influential factors. Of 403 subjects, 72.48% were male, 72.46% had received a high- school or above education, 94.79% were of Han ethnicity, and 65.51% were non farmers. The total score of QOL was 15.99±1.99. The scores of QOL in physiological, psychological, social relation, and environmental domains were 14.99 ±2.25, 14.25 ±2.12, 13.22 ±2.37, and 13.31 ±1.99 respectively. Except the total score of QOL and the score of environmental domain (p<0.05), the scores in other domains had no significant difference with the results of the national norm level. The multiple linear regression model identified the physical domain related factors to be age (β = -0.045), CD4 count (β = 0.002), and ART adherence(β = 1.231). And it also showed that psychological domain related factors included CD4 count (β = 0.002) and WHO clinical stage (β = -0.437); social domain related factors included WHO clinical stage (β = -0.704) and ART adherence (β = 1.177); while environmental domain related factors included WHO clinical stage (β = -0.538), educational status(β = 0.549) and ART adherence(β = 1.078).Those who are young, with higher level of education, higher CD4 count and good access and adherence of ART, are likely to have better QOL among PLWHA in Zhejiang province. This suggests that in addition to ART, many other factors should be taken into consideration to improve the QOL of PLWHA. The relatively lower scores the subjects received in social relation and environmental domains also suggest that social relation and environmental interventions need to be strengthened.

The role of depression in work-related outcomes of HIV treatment in Uganda

PURPOSE

The primary goal of this analysis was to examine the influence of depression above and beyond the effects of HIV treatment on work activity and function.

METHODS

We combined data from three longitudinal studies of patients starting antiretroviral therapy (ART) and/or entering HIV care in Uganda. Assessments were conducted at baseline and months 6 and 12. The nine-item Patient Health Questionnaire (PHQ-9) was used to assess depressive symptoms, as well as Major (scores >9) and Minor (scores 5-9) Depression status; work functioning was assessed using a subscale of the Medical Outcomes Study HIV Health Survey (MOS-HIV). Multivariate random-effects logistic regression models for longitudinal data were used to examine the impact of treatment on work status and optimal work functioning, with measures of both baseline and change in physical health functioning, cognitive functioning and depression in the models, controlling for baseline demographics, and CD4 cell count.

RESULTS

The sample of 1,731 participants consisted of 1,204 starting ART and 527 not yet eligible for ART. At baseline, 35 % were not working, and 37 % had sub-optimal work functioning. Intention-to-treat analyses revealed that those on ART experienced greater improvement in both work outcomes over 12 months relative to non-ART patients, and that baseline and change in physical health functioning, continuous and categorical depression were all independently associated with improvement in both work outcomes, even after accounting for the direct effect of ART.

CONCLUSIONS

Improvement in physical and mental health plays a key role in the positive impact of HIV treatment on work activity and function, suggesting potential economic benefits of integrating depression treatment into HIV care.

Linkage to care following a home-based HIV counselling and testing intervention in rural South Africa

Introduction

Efforts to increase awareness of HIV status have led to growing interest in community-based models of HIV testing. Maximizing the benefits of such programmes requires timely linkage to care and treatment. Thus, an understanding of linkage and its potential barriers is imperative for scale-up.

Methods

This study was conducted in rural South Africa. HIV-positive clients (n=492) identified through home-based HIV counselling and testing (HBHCT) were followed up to assess linkage to care, defined as obtaining a CD4 count. Among 359 eligible clients, we calculated the proportion that linked to care within three months. For 226 clients with available data, we calculated the median CD4. To determine factors associated with the rate of linkage, Cox regression was performed on a subsample of 196 clients with additional data on socio-demographic factors and personal characteristics.

Results

We found that 62.1% (95% CI: 55.7 to 68.5%) of clients from the primary sample (n=359) linked to care within three months of HBHCT. Among those who linked, the median CD4 count was 341 cells/mm³ (interquartile range [IQR] 224 to 542 cells/mm³). In the subsample of 196 clients, factors predictive of increased linkage included the following: believing that drugs/supplies were available at the health facility (adjusted hazard ratio [aHR] 1.78; 95% CI: 1.07 to 2.96); experiencing three or more depression symptoms (aHR 2.09; 95% CI: 1.24 to 3.53); being a caregiver for four or more people (aHR 1.93; 95% CI: 1.07 to 3.47); and knowing someone who died of HIV/AIDS (aHR 1.68; 95% CI: 1.13 to 2.49). Factors predictive of decreased linkage included the following: younger age – 15 to 24 years (aHR 0.50; 95% CI: 0.28 to 0.91); living with two or more adults (aHR 0.52; 95% CI: 0.35 to 0.77); not believing or being unsure about the test results (aHR 0.48; 95% CI: 0.30 to 0.77); difficulty finding time to seek health care (aHR 0.40; 95% CI: 0.24 to 0.67); believing that antiretroviral treatment can make you sick (aHR 0.56; 95% CI: 0.35 to 0.89); and drinking alcohol (aHR 0.52; 95% CI: 0.34 to 0.80).

Conclusions

The findings highlight barriers to linkage following an increasingly popular model of HIV testing. Further, they draw attention to ways in which practical interventions and health education strategies could be used to improve linkage to care.

Qualitative study of the influence of antidepressants on the psychological health of patients on antiretroviral therapy in Uganda

The study set out to explore how HIV-positive individuals conceptualise and describe depression and its manifestation in their lives, and how this may change over time in the context of antiretroviral therapy (ART) and antidepressant treatment. We conducted in-depth interviews using a semi-structured interview guide with 26 adult HIV-positive clients receiving ART in Uganda. We asked the participants to describe their depression and its impact on their general health, physical functioning and psychological wellbeing, as well as the influences of receiving ART or antidepressant treatment. Although depressive experience among the patients was largely described in terms of criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), some of the symptoms used to describe depression, such as 'thinking too much' or worrisome thoughts, did not fit into the DSM-IV criteria. The participants attributed their depression to news of the HIV diagnosis, a fear of dying, the potential socioeconomic consequences of their HIV infection on their family, ART side-effects and continued bad health. Their subjective reports indicated that the treatment of depression with antidepressants had made a positive impact on their general and psychological health. These findings highlight the need for models of HIV care that integrate mental health services and promote the diagnosis and treatment of depression in culturally sensitive ways so as to improve the quality of life and health outcomes for clients. However, keeping the particular study design in mind, these findings should be interpreted as preliminary.

Benefits of task-shifting HIV care to nurses in terms of health-related quality of life in patients initiating antiretroviral therapy in rural district hospitals in Cameroon [Stratall Agence Nationale de Recherche sur le SIDA (ANRS) 12110/Ensemble pour une Solidarité Thérapeutique Hospitalière en Réseau (ESTHER) substudy]

OBJECTIVES

The World Health Organization (WHO) recommends task-shifting HIV care to nurses in low-resource settings with limited numbers of physicians. However, the effect of such task-shifting on the health-related quality of life (HRQL) of people living with HIV (PLHIV) has seldom been evaluated. We aimed to investigate the effect of task-shifting HIV care to nurses on HRQL outcomes in PLHIV initiating antiretroviral therapy (ART) in rural district hospitals in Cameroon.

METHODS

Outcomes in PLHIV were longitudinally collected in the 2006-2010 Stratall trial. PLHIV were followed up for 24 months by nurses and/or physicians. Six HRQL dimensions were assessed during face-to-face interviews using the WHO Quality of Life (WHOQOL)-HIV BREF scale: physical health; psychological health; independence level; social relationships; environment; and spirituality/religion/personal beliefs. The degree of task-shifting was estimated using a consultant ratio (i.e. the ratio of nurse-led to physician-led visits). The effect of task-shifting and other potential correlates on HRQL dimensions was explored using a Heckman two-stage approach based on linear mixed models to adjust for the potential bias caused by missing data in the outcomes.

RESULTS

Of 1424 visits in 440 PLHIV (70.5% female; median age 36 years; median CD4 count 188 cells/μL at enrolment), 423 (29.7%) were task-shifted to nurses. After multiple adjustment, task-shifting was associated with higher HRQL level for four dimensions: physical health [coefficient 0.7; 95% confidence interval (CI) 0.1-1.2; P = 0.01], psychological health (coefficient 0.5; 95% CI 0.0-1.0; P = 0.05), independence level (coefficient 0.6; 95% CI 0.1-1.1; P = 0.01) and environment (coefficient 0.6; 95% CI 0.1-1.0; P = 0.02).

CONCLUSIONS

Task-shifting HIV care to nurses benefits the HRQL of PLHIV. Together with the previously demonstrated comparable clinical effectiveness of physician-based and nurse-based models of HIV care, our results support the WHO recommendation for task-shifting.

Mediation analysis of health-related quality of life among people living with HIV infection in China

The effects of stigma, social support, and depressive symptoms on health-related quality of life are well documented in the literature, but how these psychological factors interact with each other, and the combined effects when taken together on the health-related quality of life for people living with HIV, remain unclear. This cross-sectional study investigated 114 people living with HIV who were taking antiretroviral medication using the HIV/AIDS-related Stigma Scale (Chinese version), the Social Support Rating Scale, the Center for Epidemiological Studies Depression Scale, and the Medical Outcomes Study-HIV health survey. Multiple linear regression analyses were used to examine the mediation effect of the psychosocial factors on health-related quality of life. Results showed that stigma and social support did not have direct effects, but indirect effects on health-related quality of life through a full mediation effect of depressive symptoms. The results indicate that interventions targeting depression might be the most effective approach to improving health-related quality of life among people living with HIV who are taking antiretroviral medication in China.

Linkage to HIV care, postpartum depression, and HIV-related stigma in newly diagnosed pregnant women living with HIV in Kenya: a longitudinal observational study

Background

While studies have suggested that depression and HIV-related stigma may impede access to care, a growing body of literature also suggests that access to HIV care itself may help to decrease internalized HIV-related stigma and symptoms of depression in the general population of persons living with HIV. However, this has not been investigated in postpartum women living with HIV. Furthermore, linkage to care itself may have additional impacts on postpartum depression beyond the effects of antiretroviral therapy. We examined associations between linkage to HIV care, postpartum depression, and internalized stigma in a population with a high risk of depression: newly diagnosed HIV-positive pregnant women.

Methods

In this prospective observational study, data were obtained from 135 HIV-positive women from eight antenatal clinics in the rural Nyanza Province of Kenya at their first antenatal visit (prior to testing HIV-positive for the first time) and subsequently at 6 weeks after giving birth.

Results

At 6 weeks postpartum, women who had not linked to HIV care after testing positive at their first antenatal visit had higher levels of depression and internalized stigma, compared to women who had linked to care. Internalized stigma mediated the effect of linkage to care on depression. Furthermore, participants who had both linked to HIV care and initiated antiretroviral therapy reported the lowest levels of depressive symptoms.

Conclusions

These results provide further support for current efforts to ensure that women who are newly diagnosed with HIV during pregnancy become linked to HIV care as early as possible, with important benefits for both physical and mental health.

A comparison of quality of life between HIV positive and negative diamond miners in South Africa

Objective

To analyse the health-related quality of life (HR-QOL) in two groups of diamond miners (HIV negative and positive) in South Africa using three instruments. Two hypotheses were to be tested. One, was that the HR-QOL of HIV positive miners would be lower than that of HIV negative miners; and two, the selected instruments would behave consistently and thus all would confirm hypothesis one.

Methods

In our study, workers were recruited during a voluntary counselling and testing programme for HIV. HR-QOL were estimated using the Assessment of Quality of Life (AQOL) Mark 2, EQ-5D (EuroQOL), and Health Utilities Index 3 (HUI3) instruments. The data were analysed for utility values and for correlations between variables of interest (in particular HIV status). Goodness of fit, Pearson's r coefficient and t-tests were the statistical tests applied to the data.

Results

Just over 1100 respondents were included in the analysis. HIV positive workers scored significantly lower on quality of life on the HUI3 as compared to HIV negative workers but this relationship did not (surprisingly) hold for the AQOL or EQ-5D. There was a significant positive correlation between all three instruments.

Conclusion

There was inconsistency among the instruments in measuring quality of life differences according to HIV status. The HUI3 confirmed the a priori expectation that the HR-QOL of HIV positive miners would be lower than HIV negative miners. There was no statistical difference for the AQOL and a confounding result was found for the EQ5D.

Cognitive impairment and psychiatric morbidity in HIV+ Zambians with new-onset seizure

A prospective cohort study of new-onset seizure in people with human immunodeficiency virus (HIV) in Zambia is ongoing to determine the incidence of subsequent epilepsy and risk factors for epileptogenesis in this population. At enrollment, we evaluated this cohort for cognitive impairment and psychiatric morbidity. Over 50% of participants had cognitive impairment and significant psychiatric morbidity. Most participants had advanced HIV disease based on CD4+ T-cell count and World Health Organization stage, but we found no association between cognitive impairment or psychiatric morbidity and HIV disease staging.

Higher quality of life and lower depression for people on ART in Uganda as compared to a community control group

Provision of antiretroviral treatment (ART) to people living with HIV (PLWH) has increased globally. Research measuring whether ART restores subjective well-being to "normal" levels is lacking, particularly in resource limited settings. The study objectives are to compare quality of life and depression symptoms for PLWH on ART to a general community population and to explore factors to explain these differences, including socio-economic status and the impact of urban or rural residence. PLWH on ART (n = 263) were recruited from ART delivery sites and participants not on ART (n = 160) were recruited from communities in Wakiso District, Uganda. Participants were interviewed using the translated World Health Organisation Quality of Life brief measure, the Hopkins Symptom Checklist depression section, and questions about socio-economic status, residence as urban or rural and, for PLWH on ART, self-reported adherence and use of HIV counselling. Compared to the community sample and controlling for location of residence, PLWH on ART had significantly higher quality of life (QOL) for physical, psychological and environment domains, but not the social domain. These differences were not due to socio-economic status alone. Depression scores were significantly lower for PLWH on ART. Both comparisons controlled for the effect of location of residence. People on ART self-reported high adherence and the majority had used HIV counselling services. Our findings show better QOL amongst PLWH on ART compared to a general community sample, which cannot be explained solely by differences in socio-economic status nor location of residence. The general community sample results point towards the challenges of life in this setting. Access to health services may underpin this difference and further research should explore this finding, in addition to identification of psychological mechanisms that relate to better QOL. ART provision infrastructure has clear benefits. Further work should consider sustainability and replication for other health conditions.

Progression of pain in ambulatory HIV-positive South Africans

Cross-sectional studies report that pain in ambulatory HIV-infected individuals is frequent and often undermanaged. Expanding access to HIV treatment in developing countries means that infected individuals are living longer, but there is a dearth of pain-directed studies from developing countries that describe the progression of pain and its treatment over any period of time. The aim of this study was to characterize the progression of pain and its treatment over a 6-month period in 92 ambulatory HIV-positive patients attending an outpatient clinic in Johannesburg, South Africa. We used the Wisconsin Brief Pain Questionnaire to assess changes in pain intensity, pain sites, pain interference, and pain treatment. At visit 1, pain was present in 78 of 92 patients (85%). Of the 78 patients with pain, 67 had moderate or severe pain (86%) and pain affected two or more body sites simultaneously in 57 of these patients (73%). After 6 months, pain prevalence still was high, but had fallen to 50 patients (54%). Of the patients with pain at visit 2, the proportion with moderate or severe pain (82%), or two or more pain sites (62%) had decreased. Analgesic use was low at both time points (5% and 25% analgesic use at visit 1 and 2, respectively). Despite the high pain burden, pain interference in daily activities was very low across the period assessed. The burden of pain in this cohort of ambulatory HIV-positive patients was high, but there were significant reductions in pain burden over time.

Quality of life of Nigerians living with human immunodeficiency virus

Introduction

Few reports from Nigeria have examined the quality of life (QOL) of people living with HIV/AIDS (PLWHA) despite the fact that Nigeria has the second largest number of PLWHA in the world. This study evaluated the QOL of Nigerians living with HIV/AIDS using the World Health Organization Quality of Life Questionnaire for HIV-Brief Version (WHOQOL-BREF) instrument and assessed the impact of demographic, laboratory and disease-related variables on QOL.

Methods

This cross-sectional study involved 491 consecutive PLWHA aged ≥ 18 years attending the dedicated clinic to PLWHA in South-west Nigeria.

Results

The lowest mean QOL scores were recorded in the environment and social domains. Participants aged ≥ 40 years had better QOL in the environment (p = 0.039) and spirituality (p = 0.033) domains and those in relationships had better QOL in the social relationship domain (p = 0.002). Subjects with no or primary education and those who rated their health status as good gave significantly higher ratings in all QOL domains. Participants with AIDS had significant lower QOL in the level of independence domain (p = 0.018) and those with CD4 count ≥ 350 cells /mm3 had better QOL scores in the physical, psychological and level of independence domains. Subjects without tuberculosis co-infection and those on antiretroviral therapy (ART) reported significantly better QOL in the physical, psychological, level of independence and spirituality domains.

Conclusion

Marital relationship, absence of tuberculosis, CD4 count ≥ 350 cells /mm3 and use of ART positively impacted QOL of our patients.

CD4+ cell count at antiretroviral therapy initiation and economic restoration in rural Uganda

OBJECTIVE

To determine whether earlier initiation of antiretroviral therapy (ART) is associated with better economic outcomes.

DESIGN

Prospective cohort study of HIV-positive patients on ART in rural Uganda.

METHODS

Patients initiating ART at a regional referral clinic in Uganda were enrolled in the Uganda AIDS Rural Treatment Outcomes study starting in 2005. Data on labor force participation and asset ownership were collected on a yearly basis, and CD4 cell counts were collected at pre-ART baseline. We fitted multivariable regression models to assess whether economic outcomes at baseline and in the 6 years following ART initiation varied by baseline CD4 cell count.

RESULTS

Five hundred and five individuals, followed up to 6 years, formed the estimation sample. Participants initiating ART at CD4 cell count at least 200 cells/μl were 13 percentage points more likely to be working at baseline (P < 0.01, 95% confidence interval 0.06-0.21) than those initiating below this threshold. Those in the latter group achieved similar labor force participation rates within 1 year of initiating ART (P < 0.01 on the time indicators). Both groups had similar asset scores at baseline and demonstrated similar increases in asset scores over the 6 years of follow-up.

CONCLUSION

ART helps participants initiating therapy at CD4 cell count below 200 cells/μl rejoin the labor force, though the findings for participants initiating with higher CD4 cell counts suggests that pretreatment declines in labor supply may be prevented altogether with earlier therapy. Baseline similarities in asset scores for those with early and advanced disease suggest that mechanisms other than morbidity may help drive the relationship between HIV infection and economic outcomes.

Does duration on antiretroviral therapy determine health-related quality of life in people living with HIV? A cross-sectional study in a regional referral hospital in Kenya

Objective

To measure the extent to which health-related quality of life (HRQoL) in people living with HIV is associated with duration of antiretroviral therapy (ART) after controlling for sociodemographic, clinical, and other therapy-related factors.

Design

Cross-sectional analysis.

Methods

A gender-stratified random sample of 421 participants aged 18–64 years was selected from the patients on ART at a health facility in Kenya. Three hundred and ninety two patients participated in the study, representing a 93% response rate. Data on general physical and mental health functioning status were collected using the SF-36 health survey questionnaire. Hierarchical logistic regression analysis was used to predict the SF-36 summary scores.

Results

In regression analyses, the duration of ART was negatively associated with HRQoL (odds ratio (OR): 0.6, 95% confidence interval (CI): 0.45–0.92) after controlling for sociodemographic, clinical, and other therapy-related factors. Patients with chronic diseases or clinical symptoms of acute illness had significantly worse HRQoL (OR: 0.5, 95% CI: 0.30–0.79 and OR: 0.3, 95% CI: 0.16–0.59, respectively). Therapy interruptions, adverse drug reactions, and World Health Organization stage at initiation of therapy were not associated with HRQoL.

Conclusion

Patients on ART for a relatively longer duration reported poorer HRQoL at the study facility independent of the effect of other therapy-related, clinical, and sociodemographic factors. Program managers and clinicians in the Kenyan health system may need to refocus attention on this subgroup to avert ‘loss to treatment’ that may have negative repercussions on the substantial gains made against the HIV scourge.

Nanoparticle-based drug delivery to improve the efficacy of antiretroviral therapy in the central nervous system

Antiretroviral drug therapy plays a cornerstone role in the treatment of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome patients. Despite obvious advances over the past 3 decades, new approaches toward improved management of infected individuals are still required. Drug distribution to the central nervous system (CNS) is required in order to limit and control viral infection, but the presence of natural barrier structures, in particular the blood-brain barrier, strongly limits the perfusion of anti-HIV compounds into this anatomical site. Nanotechnology-based approaches may help providing solutions for antiretroviral drug delivery to the CNS by potentially prolonging systemic drug circulation, increasing the crossing and reducing the efflux of active compounds at the blood-brain barrier, and providing cell/tissue-targeting and intracellular drug delivery. After an initial overview on the basic features of HIV infection of the CNS and barriers to active compound delivery to this anatomical site, this review focuses on recent strategies based on antiretroviral drug-loaded solid nanoparticles and drug nanosuspensions for the potential management of HIV infection of the CNS.