Validation of the MOS-HIV as a measure of health-related quality of life in persons living with HIV and liver disease

Psychosocial risk factors of erectile dysfunction among heterosexual men living with HIV

ABSTRACTThe risk of erectile dysfunction (ED) is significantly higher in men living with HIV (MLWH). Despite the adverse effects of ED on quality of life for MLWH, there is a lack of research on the psychosocial factors that may influence ED, especially among heterosexual MLWH. According to a recent systematic review, findings on the psychosocial risk factors of ED in past studies have been largely conflicting or inconclusive. To bridge this gap, we analyzed psychosocial and other correlates of ED among a sample of 317 primarily Black and Latino heterosexual adult MLWH in New York City. Data collection involved quantitative surveys administered using a combination of computer-assisted personal interview and audio computer-assisted self-interview techniques. After adjusting for age and general health, the relative risk of ED among heterosexual men living with HIV was associated with higher HIV-related stigma, anxiety, depression, and negative HIV-coping; greater social support was associated with a lower risk of ED. In addition, the data were consistent with the potential effects of childhood emotional, physical, and sexual abuse and structural discrimination on the risk of ED. Overall, our research findings help provide a better understanding of the psychosocial factors associated with ED among heterosexual MLWH.

Significant liver fibrosis is a predictor of poor health-related quality of life in people living with HIV

PURPOSE

Liver-related comorbidities can impair the health-related quality of life (HRQL) in people living with human immunodeficiency virus (HIV) (PLWH). However, the role of hepatic steatosis and significant fibrosis in PLWH remains incompletely characterized. Therefore, the aim of this study was to explore the association of hepatic steatosis and significant fibrosis on the HRQL using the medical outcomes study HIV health survey (MOS-HIV) in PLWH.

METHODS

A total of 222 PLWH were included in the final analysis of this cohort study. Metabolic comorbidities, socioeconomic factors, and HIV-related parameters were assessed. Hepatic steatosis and fibrosis were measured using vibration-controlled transient elastography (VCTE). The MOS-HIV survey, containing two summary scores (physical health summary (PHS) and mental health summary (MHS)) and ten domains, was used to assess the HRQL. Clinical predictors were identified using multivariable linear regression models.

RESULTS

The majority of this cohort was male, and the median age was 52 years, with a high prevalence of hepatic steatosis (n = 81, 36.5%). Significant fibrosis was present in 7.7% (n = 17). The mean PHS and MHS scores were 52.7 ± 9.5 and 51.4 ± 10.5, respectively. The lowest scores were in the general health perception (GHP) and energy/fatigue (EF) domains. A high BMI and waist circumference were associated with a poor PHS score. Lower education, unemployment, arterial hypertension, and significant fibrosis remained independent predictors of an impaired HRQL.

CONCLUSION

Metabolic comorbidities, significant fibrosis, and a lower socioeconomic status may negatively affect the HRQL in PLWH. Considering the negative impact of significant fibrosis on the outcome, counseling and preventive measures according to current guidelines are recommended in this subgroup of PLWH.

HIV-Specific Reported Outcome Measures: Systematic Review of Psychometric Properties

BACKGROUND

The management of people living with HIV and AIDS is multidimensional and complex. Using patient-reported outcome measures (PROMs) has been increasingly recognized to be the key factor for providing patient-centered health care to meet the lifelong needs of people living with HIV and AIDS from diagnosis to death. However, there is currently no consensus on a PROM recommended for health care providers and researchers to assess health outcomes in people living with HIV and AIDS.

OBJECTIVE

The purpose of this systematic review was to summarize and categorize the available validated HIV-specific PROMs in adults living with HIV and AIDS and to assess these PROMs using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology.

METHODS

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of 3 recommended databases (PubMed, Embase, and PsychINFO) was conducted on January 15, 2021. Studies were included if they assessed any psychometric property of HIV-specific PROMs in adults living with HIV and AIDS and met the eligibility criteria. The PROMs were assessed for 9 psychometric properties, evaluated in each included study following the COSMIN methodology by assessing the following: the methodological quality assessed using the COSMIN risk of bias checklist; overall rating of results; level of evidence assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluation approach; and level of recommendation.

RESULTS

A total of 88 PROMs classified into 8 categories, assessing the psychometric properties of PROMs for adults living with HIV and AIDS, were identified in 152 studies including 79,213 people living with HIV and AIDS. The psychometric properties of most included PROMs were rated with insufficient evidence. The PROMs that received class A recommendation were the Poz Quality of Life, HIV Symptom Index or Symptoms Distress Module of the Adult AIDS Clinical Trial Group, and People Living with HIV Resilience Scale. In addition, because of a lack of evidence, recommendations regarding use could not be made for most of the remaining assessed PROMs (received class B recommendation).

CONCLUSIONS

This systematic review recommends 3 PROMs to assess health outcomes in adults living with HIV and AIDS. However, all these PROMs have some shortcomings. In addition, most of the included PROMs do not have sufficient evidence for assessing their psychometric properties and require a more comprehensive validation of the psychometric properties in the future to provide more scientific evidence. Thus, our findings may provide a reference for the selection of high-quality HIV-specific PROMs by health care providers and researchers for clinical practice and research.

Effect of hepatic steatosis and associated metabolic comorbidities on health-related quality of life in people living with HIV

Hepatic steatosis (HS) related to nonalcoholic fatty liver disease (NAFLD) is increasing globally. In people living with human immunodeficiency virus (PLWH) risk factors of HS are increased. The impact of HS on outcomes and in particular health-related quality of life (HRQL) in PLWH remains unknown. The aim of this cross-sectional cohort study (FLASH, Prevalence of Advanced Fibrosis in Patients Living With HIV) was to determine the contribution of HS on HRQL in PLWH and to identify confounders on HRQL. A total of 245 PLWH were prospectively enrolled. HS was assessed using vibration-controlled transient elastography and defined as a controlled attenuation parameter (CAP) of ≥ 275 dB/m. The analysis was performed between CAP < 275 and ≥ 275 dB/m. The generic European Quality-of-Life 5-Dimension 5-Level questionnaire was used to determine differences in the HRQL. Univariable and multivariable linear regression models were applied to identify predictors with impaired HRQL in both groups. In this cohort, 65% (n = 160) presented without and 35% (n = 85) with HS, of whom most had NAFLD (n = 65, 76.5%). The HRQL (UI-value) was significantly lower in PLWH and steatosis (0.86 ± 0.18) in comparison with no steatosis (0.92 ± 0.13). Unemployment (p = 0.025) and waist circumference (p = 0.017) remained independent predictors of a poor HRQL in the steatosis subgroup. In turn, age (p = 0.045), female sex (p = 0.030), body mass index (p = 0.010), and arterial hypertension (p = 0.025) were independent predictors of a low HRQL in the subgroup without steatosis. Conclusion: HS and metabolic comorbidities negatively affect the HRQL. Addressing these factors may improve patient-reported and liver-related outcomes in PLWH.

Study of Treatment and Reproductive Outcomes Among Reproductive-Age Women With HIV Infection in the Southern United States: Protocol for a Longitudinal Cohort Study

BACKGROUND

Nearly a quarter of the 1.1 million individuals with HIV in the United States are women. Racial and ethnic minority women in the Southern United States are disproportionately impacted. Reproductive-age women with HIV are prone to poor HIV outcomes but remain underrepresented in HIV research. We will answer contemporary questions related to the health outcomes in this population by enrolling a prospective cohort of reproductive-age women with and without HIV in the Southern United States.

OBJECTIVE

The Study of Treatment and Reproductive Outcomes (STAR) will enroll and retain 2000 reproductive-age women with and without HIV. The STAR will leverage the infrastructure of the US-based Multicenter AIDS Cohort Study (MACS)/Women's Interagency HIV Study (WIHS) Combined Cohort Study, comprising the WIHS (a cohort of women with and at risk for HIV, which began in 1993), and the MACS (a cohort of gay and bisexual men with and at risk for HIV, which began in 1984). Although the advancing age of the participants enrolled in the MACS/WIHS Combined Cohort Study provides an opportunity to address the questions related to HIV and aging, the research questions pertinent to the reproductive years must also be addressed. The STAR will conduct high-priority scientific research in key areas with the overall aim of addressing the unique needs of reproductive-age women with HIV.

METHODS

The STAR is a prospective, observational cohort study that will be conducted at 6 sites in the United States-Atlanta, Georgia; Birmingham, Alabama; Jackson, Mississippi; Chapel Hill, North Carolina; Miami, Florida; and Washington, District of Columbia. Visits will occur semiannually for 2 years, with additional visits for up to 5 years. At each visit, the participating women will complete a structured interview for collecting key demographic, psychosocial, and clinical variables, and undergo biospecimen collection for laboratory testing and repositing (blood, urine, hair, vaginal, anal, and oral specimens). Pregnant women and infants will undergo additional study assessments. The initial scientific focus of the STAR is to understand the roles of key social determinants of health, depression, reproductive health, and oral health on HIV and pregnancy outcomes across the reproductive life span.

RESULTS

Enrollment in the STAR commenced in February 2021 and is ongoing.

CONCLUSIONS

Through in-depth, longitudinal data and biospecimen collection, the newly initiated STAR cohort will create a platform to answer scientific questions regarding reproductive-age women with and without HIV. STAR will be uniquely positioned to enable investigators to conduct high-impact research relevant to this population. Building on the legacy of the MACS and WIHS cohorts, the STAR is designed to foster multidisciplinary collaborations to galvanize scientific discoveries to improve the health of reproductive-age women with HIV and ameliorate the effects of the HIV epidemic in this population in the United States.

Health-related quality-of-life in people living with HIV after switching to dual therapy with ritonavir-boosted darunavir + dolutegravir: a DUALIS sub-study

The DUALIS study demonstrated efficacy and safety of switching to dolutegravir plus ritonavir-boosted darunavir (DRV/r) (2DR) as compared to standard-of-care-therapy with two nucleoside reverse transcriptase inhibitors + DRV/r (3DR) in pretreated people living with HIV (PLWH), 48 weeks after switching. This DUALIS sub-study investigates health-related-quality-of-life (HrQoL) in this study-population. The Hospital Anxiety and Depression Scale (HADS) and the Medical Outcome Survey-HIV (MOS-HIV) were used assessing anxiety and depression symptoms, respectively HrQoL. Data were collected at baseline, 4, 24, and 48 weeks after randomization. Outcome scores were dichotomized and used as criteria in longitudinal models identifying differential developments. Odds ratios (ORs) with 95% confidence intervals (CIs) were computed as main measures of effects. ORs<1 indicate better results for HADS, and worse for MOS-HIV scores in the 2DR compared to 3DR group. In total, 263 subjects were randomized and treated (2DR n=131, 3DR n=132; median age 48 years). Significant different progressions could only be found for HADS-Depression scores (OR=.87, 95% CI: .78, .98, p=.02). While HADS-Depression scores decreased in the 2DR group, they increased in 3DR group. This sub-study showed no disadvantages regarding HrQoL in PLWH after switching to DTG+DRV/r. Considering lifelong requirements for antiretroviral medication, close attention to HrQL is required.

The Role of Religiousness and Spirituality in Health-related Quality of Life of Persons Living with HIV: A Latent Class Analysis

PURPOSE

Understanding how religion and spirituality influence health-related quality of life (HRQoL) is important for developing holistic, patient-centered treatment. This study determined distinct latent classes of religiousness/spirituality for adult persons living with HIV (PLWH) and associations between latent class membership and HRQoL.

METHODS

Baseline data was collected from 223 patients in the FAmily CEntered (FACE) Advance Care Planning (ACP) clinical trial for PLWH. Patients completed the Brief Multidimensional Measurement of Religiousness/Spirituality (BMMRS-adapted), Patient Health Questionnaire (PHQ-9), Medical Outcome Study-HIV Survey (MOS-HIV) and the Palliative care Outcome Scale (POS). The optimal number of latent classes was determined by comparing K-Class model with (K-1)-Class model iteratively. The relationship between latent class membership, HRQoL and demographic characteristics was assessed.

RESULTS

Patients were 56.1% male, 86.1% Black/African American, aged 22-77 (Mean=50.83). 75.3% were Christian. LCA identified three classes: traditionally religious (35%), privately religious (47.1%), and spiritual but not religious (17.9%). MOS-HIV mental health (p < 0.001), MOS-HIV quality of life (p = 0.014) and MOS-HIV health transition (p = 0.016) scores were significantly higher among patients who were traditionally religious. These patients were more likely to be 40+ years and Black. Patients in the privately religious group had the lowest levels of mental health and HRQoL.

CONCLUSIONS

Understanding how religiousness and spirituality influence HRQoL can help the medical community develop holistic, patient-centered and culturally-sensitive interventions that could improve outcomes for PLWH and potentially mitigate the impact of health disparities within the Black and LGBTQ communities.

The Medical Outcome Study-HIV Health Survey: A systematic review and reliability generalization meta-analysis

The Medical Outcome Study-HIV Health Survey (MOS-HIV) is one of the most used questionnaires for the evaluation of the health-related quality of life (HRQoL) in people living with HIV (PLWHIV) in both medical settings and research studies. This study aimed to estimate the average reliability of the MOS-HIV scores and to evaluate the characteristics of the studies that could explain the variability between reliability estimates. Furthermore, the study aimed to estimate the induction rate of the reliability of the MOS-HIV. A systematic review of the previous literature, including studies that reported α and/or test-retest coefficients with the data at hand for the total score of the MOS-HIV and the subscales, was conducted. Fifty studies (52 samples; N = 14,132) were included in the reliability generalization meta-analysis. The average α coefficient for the total score of MOS-HIV was .91 and above .80 for all of the subscales, except for role functioning, which had an average coefficient of .76. Different study dimensions were related to the heterogeneity of reliability between studies. Reliability induction was found to be 76.1%. The results obtained in the present study indicate that the MOS-HIV is a reliable instrument for HRQoL evaluation in PLWHIV, for clinical and research purposes. In the clinical practice of health services, nurses could employ this gold standard for reliable evaluations of HRQoL in PLWHIV.

Understanding Symptom Burden in Patients With Advanced Cancer Living in Rural Areas

OBJECTIVES

To evaluate the feasibility of using a biobehavioral approach to examine symptom burden in rural residents with advanced cancer.

SAMPLE & SETTING

21 patients with advanced lung, colorectal, or pancreatic cancer were enrolled at the University of Iowa in Iowa City.

METHODS & VARIABLES

Using Cleeland's cytokine-immunologic model of symptom expression, symptom burden (i.e., severity, count, and interference) and inflammatory cytokines were measured for 24 weeks. Potential predictors included demographics, clinical characteristics, optimism, social support, and cancer-related stress. Descriptive statistics, Wilcoxon rank-sum, and Fisher's exact test were used for analysis.

RESULTS

Recruitment and retention rates were similar for rural and nonrural patients. Demographics, optimism, and social support were no different between groups. The cancer-related stress total score for rural patients was nearly half of the score of nonrural patients, with rural patients reporting significantly less avoidance. Symptom severity for the five worst symptoms remained moderate during the 24 weeks, whereas nonrural residents reported steady declines in severity of their five worst symptoms. Significant differences in inflammatory cytokines between groups were only found at one time point.

IMPLICATIONS FOR NURSING

Rural residents who seek care at a cancer center may be clinically and demographically more similar to their nonrural counterparts than to rural residents seeking local care.

Neurocognitive SuperAging in Older Adults Living With HIV: Demographic, Neuromedical and Everyday Functioning Correlates

OBJECTIVES

Studies of neurocognitively elite older adults, termed SuperAgers, have identified clinical predictors and neurobiological indicators of resilience against age-related neurocognitive decline. Despite rising rates of older persons living with HIV (PLWH), SuperAging (SA) in PLWH remains undefined. We aimed to establish neuropsychological criteria for SA in PLWH and examined clinically relevant correlates of SA.

METHODS

734 PLWH and 123 HIV-uninfected participants between 50 and 64 years of age underwent neuropsychological and neuromedical evaluations. SA was defined as demographically corrected (i.e., sex, race/ethnicity, education) global neurocognitive performance within normal range for 25-year-olds. Remaining participants were labeled cognitively normal (CN) or impaired (CI) based on actual age. Chi-square and analysis of variance tests examined HIV group differences on neurocognitive status and demographics. Within PLWH, neurocognitive status differences were tested on HIV disease characteristics, medical comorbidities, and everyday functioning. Multinomial logistic regression explored independent predictors of neurocognitive status.

RESULTS

Neurocognitive status rates and demographic characteristics differed between PLWH (SA=17%; CN=38%; CI=45%) and HIV-uninfected participants (SA=35%; CN=55%; CI=11%). In PLWH, neurocognitive groups were comparable on demographic and HIV disease characteristics. Younger age, higher verbal IQ, absence of diabetes, fewer depressive symptoms, and lifetime cannabis use disorder increased likelihood of SA. SA reported increased independence in everyday functioning, employment, and health-related quality of life than non-SA.

CONCLUSIONS

Despite combined neurological risk of aging and HIV, youthful neurocognitive performance is possible for older PLWH. SA relates to improved real-world functioning and may be better explained by cognitive reserve and maintenance of cardiometabolic and mental health than HIV disease severity. Future research investigating biomarker and lifestyle (e.g., physical activity) correlates of SA may help identify modifiable neuroprotective factors against HIV-related neurobiological aging. (JINS, 2019, 25, 507-519).

Quality of life of persons living with HIV and congruence with surrogate decision-makers

PURPOSE

Physicians and caregivers rate patient quality of life (QOL) lower than patients rate their own QOL. This study investigated discrepancies between self-assessments of patient QOL by adults with HIV and their surrogate decision-makers.

METHODS

We collected baseline data from 223 adult dyads in the FAmily-CEntered (FACE) Advance Care Planning (ACP) clinical trial, consisting of HIV positive patients and their chosen surrogates. Participants independently completed the Medical Outcome Study-HIV Survey (MOS-HIV) and the Palliative care Outcome Scale (POS). We used Wilcoxon Signed-Rank Test to assess differences in overall patient-surrogate means. We used Prevalence Adjusted Bias Adjusted Kappa (PABAK) statistics to assess dyadic agreement, with surrogate HIV status and cohabitation status as grouping variables.

RESULTS

Patients were 56.1% male, 86.1% Black/African-American, aged 22-77 (mean = 50.83, SD = ± 12.33). Surrogates were 43.8% male, 84.1% Black/African-American, aged 18-82 (mean = 49.73, SD = ± 14.22). 46.2% of surrogates lived with the patient. 64.6% of surrogates reported negative HIV status. Surrogates were more likely to state patients were ill, p = 0.032. Among patient-surrogate dyads, most QOL assessments showed poor (0.00-0.39) or fair (0.40-0.59) agreement and agreement tended to be even poorer among patient-surrogate dyads where the surrogate had a shared HIV diagnosis.

CONCLUSIONS

QOL discrepancies are said to arise from healthy surrogates overestimating the effects of chronic illness. In this novel assessment, many surrogates had a shared HIV diagnosis, without increased agreement. These findings highlight the challenge of accurately assessing patient QOL by surrogates, even when there is a shared HIV diagnosis. Improved communication is needed between patients and surrogates about the patients' representation of illness. National Clinical Trial Number: NCT01775436.

Reliability and validity of the Chinese version of the Medical Outcomes Study HIV Health Survey (MOS-HIV) in people living with HIV/AIDS (PLWHA) in China

OBJECTIVE

The aim of the study was to assess the psychometric properties of the Medical Outcomes Study HIV Health Survey (MOS-HIV) in people living with HIV/AIDS (PLWHA) in mainland China.

METHODS

A cross-sectional survey was conducted in 646 PLWHA between May 2015 and March 2016 in Dalian, Ningbo, and Zhengzhou City, China. The MOS-HIV includes 35 items and measures 10 scales. These ten scales can be effectively calculated under two summary scale scores, the physical health score (PHS) and the mental health score (MHS), with the physical functioning, pain and role functioning scales contributing to the PHS, the mental health, health distress, quality of life and cognitive function scales contributing to the MHS, and the energy/fatigue, general health and social functioning contributing to both factors. Reliability was measured in terms of internal consistency and test-retest reliability. The internal consistency of the questionnaire was analyzed using Cronbach's α coefficient, and test-retest reliability was assessed using Pearson's correlation coefficient. Validity was analyzed via construct validity, convergent and discriminant validity, and known group validity. Confirmatory factor analyses (CFA) were used to test construct validity. A multiple-group CFA analysis was conducted to investigate whether the MOS-HIV measured the same constructs across gender groups.

RESULTS

The MOS-HIV questionnaire was reliable and valid. Reliability of the PHS and MHS scales was 0.87 and 0.89, respectively. While the Cronbach's α coefficients for each of the dimensions were > 0.70. According to the results of the confirmatory factor analysis (CFA), the hypothesized model was acceptable. The instrument showed factorial invariance across gender groups. All correlation coefficients were greater than 0.40, with a range of 0.60-0.94. The correlation coefficients observed between items and other dimensions were lower than the coefficients for the correlations between items and hypothesized dimensions for all scales, suggesting good convergent and discriminant validity. Patients with CD4 counts >500 cells/mm3 demonstrated better QOL than those with lower CD4 counts on six scales and the PHS (p<0.05) and symptomatic respondents had significantly lower scores than asymptomatic respondents on all the scales except health transition scales (p<0.05) suggesting good known group validity.

CONCLUSIONS

The results of this study provide evidence that the MOS-HIV may be an acceptable, valid and reliable instrument for evaluating QOL of PLWHA in mainland China.

A Systematic Review of Palliative Care Intervention Outcomes and Outcome Measures in Low-Resource Countries

CONTEXT

To meet the growing need for palliative care in low-resource countries, palliative care programs should be evidence based and contextually appropriate. This study was conducted to synthesize the current evidence to guide future programmatic and research efforts.

OBJECTIVES

This systematic review evaluated palliative care outcome measures, outcomes, and interventions in low-resource countries.

METHODS

After title searches, abstracts and full-text articles were screened for inclusion. Data were extracted to report on intervention models, outcome measures used, and intervention outcomes.

RESULTS

Eighteen papers were reviewed, reporting on interventions conducted across nine low-resource countries. These interventions evaluated home-based palliative care models; a community-managed model; palliative care integrated with hospitals, hospices, or HIV clinics; and models focused on patients' self-management. Three studies were randomized controlled trials. Other studies used nonrandomized trials, cohort studies, mixed methods, pre-post test evaluation, cost-accounting evaluation, and cross-sectional surveys. Thirteen studies measured physical outcomes, 10 using multidimensional instruments. Nine studies measured psychological outcomes, eight using multidimensional instruments. Nine studies measured social outcomes, seven using multidimensional instruments. Nine studies measured outcomes across multiple domains. Across outcomes evaluated, results were reported in the direction of benefit associated with palliative care interventions.

CONCLUSION

Many palliative care intervention models exist to serve patients in low-resource countries. Yet, limited high-quality evidence from low-resource countries is available to document intervention outcomes. Rigorous experimental studies and greater measurement of multidimensional aspects of palliative care are needed to advance the science of palliative care in low-resource settings.

Health-related quality of life assessment after antiretroviral therapy: a review of the literature

Antiretroviral (ARV) treatment for HIV infection has resulted in significant improvement in immunologic and virologic parameters, as well as a reduction in AIDS-defining illnesses and death. Over 25 medications are approved for use, usually in combination regimens of three or four ARVs. Several ARVs are now available as combinatorial products, which have been associated with better adherence. However, while ARV therapy has prolonged life, ARVs also pose a challenge for quality of life as they can cause significant side effects in addition to the potential for drug toxicity and interaction. Given the many complications, side effects and symptoms of HIV/AIDS in addition to associated medical and psychiatric co-morbidities, the need to understand and assess how these interactions may affect health-related quality of life (HRQOL) has grown. Numerous instruments (some validated, others not) are available and have been applied to understanding how ARV treatment affects HRQOL in those with HIV infection, both in clinical trials and clinical practice. In general, ARV treatment improves HRQOL, but this is dependent on the population being studied, the HRQOL instrument being used and the timeframe during which HRQOL has been studied. This article provides a review of the literature on quality of-life assessment as it relates to ARV treatment in developed countries and briefly reviews the HRQOL instruments used, how they have been applied to ARV utilization, and where future research should be applied in HRQOL assessment and HIV infection.

Symptom Status Predicts Patient Outcomes in Persons with HIV and Comorbid Liver Disease

Persons living with human immunodeficiency virus (HIV) are living longer; therefore, they are more likely to suffer significant morbidity due to potentially treatable liver diseases. Clinical evidence suggests that the growing number of individuals living with HIV and liver disease may have a poorer health-related quality of life (HRQOL) than persons living with HIV who do not have comorbid liver disease. Thus, this study examined the multiple components of HRQOL by testing Wilson and Cleary's model in a sample of 532 individuals (305 persons with HIV and 227 persons living with HIV and liver disease) using structural equation modeling. The model components include biological/physiological factors (HIV viral load, CD4 counts), symptom status (Beck Depression Inventory II and the Medical Outcomes Study HIV Health Survey (MOS-HIV) mental function), functional status (missed appointments and MOS-HIV physical function), general health perceptions (perceived burden visual analogue scale and MOS-HIV health transition), and overall quality of life (QOL) (Satisfaction with Life Scale and MOS-HIV overall QOL). The Wilson and Cleary model was found to be useful in linking clinical indicators to patient-related outcomes. The findings provide the foundation for development and future testing of targeted biobehavioral nursing interventions to improve HRQOL in persons living with HIV and liver disease.