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.

The advent of highly active antiretroviral therapy (HAART) has been associated with improved clinical and laboratory outcomes, which in turn has translated to fewer opportunistic infections and overall reductions in morbidity and mortality [4][5][6]. However, the need for life-long medication therapy, medication side effects, and the constant stigma, discrimination and prejudice experienced by PLWHA have raised concern about other domains of health such as overall physical and mental health functioning and socioeconomic and spiritual wellbeing [7]. These domains of health which serve as indicators of quality of life (QOL) have emerged as important factors in HIV/AIDS management [7].
Quality of life is a multidimensional and subjective concept and currently there is no consensus definition of QOL [4][5][6]. The World Health Organization Quality of Life (WHOQOL) group defines quality of life as individuals' perceptions of their position in life in the context of culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns [8,9].
The term health-related quality of life (HRQOL) is often used to indicate QOL as it relates to diseases or treatments [10].
The measure of QOL is of both public health and clinical research significance since it showcases the definition of health according to World Health Organization (WHO) as a "complete state of physical, mental and social wellbeing -not merely the absence of disease or infirmity" [8,9]. Studies on QOL provides an estimation of the impact of treatment in chronic diseases for which improvement in functional status and wellbeing can be regarded as an essential outcome [10,11]. An improved QOL and resultant ability of the patient to resume normal life, including supporting the families and working productively will encourage long-term sustenance of treatment [7]. However, if QOL is poor, it impacts negatively on lifelong adherence to medication [7]. Quality of life also serves as an indicator of prognosis among patients with HIV as those from lower quartiles of physical and mental scores have a higher incidence of The methodologies for assessing QOL and socioeconomic wellbeing vary greatly in published literature since different HRQOL instruments with established validity and reliability were employed [4][5][6][12][13][14][15][16][17][18][19][20][21][22][23][24]. Studies have shown that the HRQOL in PLWHA is lower than those without HIV/AIDS and HRQOL improves with HAART [4][5][6][12][13][14][15][16]. While some studies only assessed the HRQOL in PLWHA, other studies further assessed the clinical predictors of QOL [4][5][6][12][13][14][15][16][17][18][19][20][21][22][23][24]. Since HRQOL has to do with individuals' perceptions of their position in life in the context of culture and value systems in which they live, the clinical predictors of HRQOL vary in different studies and this makes it difficult extrapolating the findings in one centre or country to the other.
Most of the publications on QOL in sub-Saharan Africa had come from South Africa, Zimbabwe, and Uganda [15][16][17][19][20][21][22]. There is a dearth of literature or publications on HRQOL in PLWHA from Nigeria despite the fact that Nigeria has the second highest number of PLWHA in the world [20][21][22]. Also, only few published studies from Nigeria [21]. have used the World Health Organization Quality of Life Brief Version (WHOQOL-BREF) instrument which is diseasespecific and has a proven cross-cultural validity [8,9]. In addition, the numbers of participants involved in these published studies were rather small [20][21][22] The instrument used was the WHOQOL-HIV BREF [8,9]. which is a multidimensional, conceptualized, generic, 31-item QOL instrument [8,9]. The questions in this instrument cover the respondent's perception of the overall quality of life within the following 6 broad domains (facets) of the quality of life that summarize that particular domain: [8,9]. indicates high, positive perception. Some items such as pain and discomfort, dependence on medication, death and dying, and negative feelings (Q3, Q4, Q5, Q8, Q9, Q10, and Q31) were not scaled in a positive direction, meaning that for these facets higher scores do not denote higher quality of life. To transform these scores in a positive direction, the formula: 6 -x (where x was the facet score) was used. The mean score of items within each domain was used to calculate the domain score.
Patients who were literate were given the questionnaire to complete themselves after going through the questionnaire with them. In the case of patients who were not literate or who were not comfortable with English Language, a "Yoruba" version of the instrument was administered face-to-face by a trained Treatment Support Specialist or a Specialist Nurse in a private room. The Yoruba version of the instrument was produced using two translators/linguists who were fluent in both languages. The first translator translated the English version of the questionnaire to "Yoruba" language. The translated "Yoruba" version was then given to the second linguist to backtranslate to English. Translators were encouraged to report contentious areas and difficulties that were encountered.
Thereafter, the two translators reconciled any difficult section. The authors then compared the "forward-translated" and the "backtranslated versions" to ensure that there were no contentious and/or ambiguous section of the questionnaire.
The weight (kilogram) of each participant was taken in light clothing with the shoes off and the height (meters) was done using a stadiometer. Body mass index (BMI) was calculated from the formula: weight (kg) / (height)2 (m)2. Overweight and obesity were defined as BMI of 25-29.9 kg/m2 and ≥30 kg/m2 respectively [26].
Patients' WHO stage, CD4 count, previous body weights before commencement of study, height, packed cell volume and serum creatinine were obtained from the case notes.
Ethical approval for the study was obtained from the Research Ethics Committee of our institution (LTH) Osogbo, Nigeria.

Statistical Analysis
The

Results
The socio-demographic and clinical characteristics of the study population are presented in  Deribew et al. [24]. However, there is no significant differences in the mean scores in the social relationship, environment and spirituality domains unlike the report by Deribew et al. [24]. It is believed that the occurrence of two stigmatizing diseases can impact negatively on the QOL of the patients [24]. Unlike the study by Deribew et al., [24]. we found a significant association between Published reports have shown that participants on HAART reported significant improvements in physical health, emotional well-being and mental health, reduced absenteeism from work, improved work productivity and performance when compared with those not yet on treatment [7,15,16,19]. In our cohort, participants who were on HAART had better QOL in the physical, psychological, level of independence and spirituality domains when compared with those who were not on HAART, consistent with published studies [15,16,19]. Although some workers have raised the possibility that the side effects from HAART may impact negatively on QOL, many studies in the post-HAART era have shown improvement in selfreported QOL in PLWHA [15,16]. When compared with those who had been on HAART for 18 months or less, participants who had been on HAART for more than 18 months had higher, albeit nonsignificant mean scores in all the domains except the social domain. The strength of our study is that the study population is larger than most published studies from Nigeria [20][21][22]. and we used the WHOQOL-BREF instrument which is disease-specific and has been shown to have cross-cultural validity [8,9].
Our study has some limitations.

Conclusion
The QOL of our patients in the social and environment domains were not as good as other domains. This underscores the need to improve social support and personal relationships of our patients and to provide a supportive environment without discrimination, stigmatization and marginalization which in turn will allow our patients to thrive socially, physically and financially. Although we were not able to show significant gender difference in all the QOL domains, the brunt of HIV/AIDS is still being borne by females as shown by the preponderance of females in our study population.
Marital relationship, the absence of tuberculosis, the absence of wasting, CD4 count ≥ 350 cells /mm3 and use of HAART positively impacted QOL of our patients.

Competing interests
The authors declare no competing interests.     Key: HIV -Human immunodeficiency virus, SD -standard deviation, HAART -highly active antiretroviral therapy, BMI -body mass index, Cr -creatinine, eGFR -estimated glomerular filtration rate, PCV -packed cell volume.
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