# Positive relations between sexual quality of life and satisfaction with healthcare in women living with HIV and/or HCV: Results from a multicountry study

Sara Rodriguez, Issifou Yaya, Ben Huntingdon, Ilona Juraskova, Marie Preau, Fatima Etemadi, Svetlane Dimi, Maria Patrizia Carrieri, Pascal Bessonneau, Olivier Chassany, et al.

► To cite this version:

Sara Rodriguez, Issifou Yaya, Ben Huntingdon, Ilona Juraskova, Marie Preau, et al. Positive relations between sexual quality of life and satisfaction with healthcare in women living with HIV and/or HCV: Results from a multicountry study. PLoS ONE, 2023, 18 (1), pp.e0278054. 10.1371/journal.pone.0278054. inserm-04547426

HAL Id: inserm-04547426

https://inserm.hal.science/inserm-04547426

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# Positive relations between sexual quality of life and satisfaction with healthcare in women living with HIV and/or HCV: Results from a multicountry study

Sara Rodriguez, Issifou Yaya, Ben Huntingdon, Ilona Juraskova, Marie Preau, Fatima Etemadi, Svetlane Dimi, Maria Patrizia Carrieri, Pascal Bessonneau, Olivier Chassany, et al.

► To cite this version:

Sara Rodriguez, Issifou Yaya, Ben Huntingdon, Ilona Juraskova, Marie Preau, et al. Positive relations between sexual quality of life and satisfaction with healthcare in women living with HIV and/or HCV: Results from a multicountry study. PLoS ONE, 2023, 18 (1), pp.e0278054. 10.1371/journal.pone.0278054. inserm-04547426

HAL Id: inserm-04547426

https://inserm.hal.science/inserm-04547426v1

Submitted on 15 Apr 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>
RESEARCH ARTICLE

# Positive relations between sexual quality of life and satisfaction with healthcare in women living with HIV and/or HCV: Results from a multicountry study

Sara Rodriguez¹, Issifou Yaya ID ¹,²*, Ben Huntingdon³, Ilona Juraskova³,⁴, Marie Preau ID ⁵, Fatima Etemadi¹, Svetlane Dimi⁶, Maria Patrizia Carrieri⁷, Pascal Bessonneau ID ¹,², Olivier Chassany ID ¹,², Martin Duracinsky¹,²,⁸

<figure><img src="image_1.png" /></figure>

1 Unité de Recherche Clinique en Economie de la Santé (URC-ECO), Hôpital Hôtel-Dieu, AP-HP, Paris, France, 2 Patient-Centered Outcomes Research Unit, UMR 1123, INSERM, Université de Paris, Paris, France, 3 Clinical Psychology Unit, School of Psychology, The University of Sydney, Sydney, New South Wales, Australia, 4 Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia, 5 Groupe de Recherche en Psychologie Sociale (GRePS), Université Lyon 2, Lyon, France, 6 Service de Médecine Interne, Hôpital Foch, Suresnes, France, 7 Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France, 8 Département de Médecine Interne et d'Immunologie Clinique, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France

* drissifouyaya@gmail.com

<figure><img src="image_2.png" /></figure>

OPEN ACCESS

**Citation:** Rodriguez S, Yaya I, Huntingdon B, Juraskova I, Preau M, Etemadi F, et al. (2023) Positive relations between sexual quality of life and satisfaction with healthcare in women living with HIV and/or HCV: Results from a multicountry study. PLoS ONE 18(1): e0278054. https://doi.org/10.1371/journal.pone.0278054

**Editor:** Ngai Sze Wong, Chinese University of Hong Kong, HONG KONG

**Received:** July 1, 2022

**Accepted:** November 8, 2022

**Published:** January 20, 2023

**Copyright:** © 2023 Rodriguez et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

**Data Availability Statement:** All relevant data are within the paper.

**Funding:** This study was funded by the French National agency of research on the Aids and Hepatitis (ANRS). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

**Competing interests:** The authors have declared that no competing interests exist.

## Abstract

## Introduction

The sexual quality of life is a neglected concern in women living with HIV (WHIV) or with HCV (WHCV), which can further be affected by their experience with stigma, social instability, fear of transmission and reduced access to treatment. The objective of this study was to identify sociodemographic, psychosocial, and behavioural factors associated with sexual quality of life (SQoL) in this study group.

## Methods

Between December 2017 and December 2018, PROQoL-Sex Life questionnaire was administered to 404 WHIV and WHCV in five countries. PROQoL-SQoL consists of four dimensions: positive sexual perception (*Psp*), stigma and social distress (*Sti*), soft sexual practices (*Sof*), sexual practices with a partner (*Sp*), all of which were scored from 0 to 100 and considered as main outcomes, lower scores mean better sexual quality of life. Linear mixed effects models were used to evaluate the association with sociodemographic and psychosocial factors.

## Results

Of the participants analyzed, 191 were living with HCV, 180 with HIV and 33 with HIV and HCV, median age was 48. Among WHIV, a higher satisfaction with health care, and talking about sexuality with healthcare workers were associated with lower scores in all the
RESEARCH ARTICLE

# Positive relations between sexual quality of life and satisfaction with healthcare in women living with HIV and/or HCV: Results from a multicountry study

Sara Rodriguez¹, Issifou YayaIFO¹,²*, Ben Huntingdon³, Ilona Juraskova³,⁴, Marie PreauIFO⁵, Fatima Etemadi¹, Svetlane Dimi⁶, Maria Patrizia Carrieri⁷, Pascal BessonneauIFO¹,², Olivier ChassanyIFO¹,², Martin Duracinsky¹,²,⁸

1 Unité de Recherche Clinique en Economie de la Santé (URC-ECO), Hôpital Hôtel-Dieu, AP-HP, Paris, France, 2 Patient-Centered Outcomes Research Unit, UMR 1123, INSERM, Université de Paris, Paris, France, 3 Clinical Psychology Unit, School of Psychology, The University of Sydney, Sydney, New South Wales, Australia, 4 Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia, 5 Groupe de Recherche en Psychologie Sociale (GRePS), Université Lyon 2, Lyon, France, 6 Service de Médecine Interne, Hôpital Foch, Suresnes, France, 7 Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France, 8 Département de Médecine Interne et d'Immunologie Clinique, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France

* drissifouyaya@gmail.com

<figure><img src="image_2.png" /></figure>

<figure><img src="image_3.png" /></figure>

OPEN ACCESS

**Citation:** Rodriguez S, Yaya I, Huntingdon B, Juraskova I, Preau M, Etemadi F, et al. (2023) Positive relations between sexual quality of life and satisfaction with healthcare in women living with HIV and/or HCV: Results from a multicountry study. PLoS ONE 18(1): e0278054. https://doi.org/10.1371/journal.pone.0278054

**Editor:** Ngai Sze Wong, Chinese University of Hong Kong, HONG KONG

**Received:** July 1, 2022

**Accepted:** November 8, 2022

**Published:** January 20, 2023

**Copyright:** © 2023 Rodriguez et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

**Data Availability Statement:** All relevant data are within the paper.

**Funding:** This study was funded by the French National agency of research on the Aids and Hepatitis (ANRS). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

**Competing interests:** The authors have declared that no competing interests exist.

## Abstract

## Introduction

The sexual quality of life is a neglected concern in women living with HIV (WHIV) or with HCV (WHCV), which can further be affected by their experience with stigma, social instability, fear of transmission and reduced access to treatment. The objective of this study was to identify sociodemographic, psychosocial, and behavioural factors associated with sexual quality of life (SQoL) in this study group.

## Methods

Between December 2017 and December 2018, PROQoL-Sex Life questionnaire was administered to 404 WHIV and WHCV in five countries. PROQoL-SQoL consists of four dimensions: positive sexual perception (*Psp*), stigma and social distress (*Sti*), soft sexual practices (*Sof*), sexual practices with a partner (*Sp*), all of which were scored from 0 to 100 and considered as main outcomes, lower scores mean better sexual quality of life. Linear mixed effects models were used to evaluate the association with sociodemographic and psychosocial factors.

## Results

Of the participants analyzed, 191 were living with HCV, 180 with HIV and 33 with HIV and HCV, median age was 48. Among WHIV, a higher satisfaction with health care, and talking about sexuality with healthcare workers were associated with lower scores in all the
dimensions of the SQoL, while psychoactive substance use was associated with lower scores of *Sti* and *Sof*. Moreover, higher satisfaction with health care, talking about sexuality with healthcare workers, and psychoactive substance use (except cocaine use) in WHCV were associated with lower scores in *Psp*, *Sti*, and *Sof*. Besides, cocaine use was associated with higher scores of *Sof*.

## Conclusion

This study highlighted strong relationship between the quality of health care, and psychoactive substance use (except cocaine) and the sexual quality of life in WHIV and WHCV in these five countries. These findings draw attention to the different interventions that can be proposed for improving the sexual quality of life.

## Introduction

HIV and HCV infections are significant public health concerns worldwide [1]. Overall, HIV-related mortality has decreased thanks to broad access to antiretroviral treatments (ART), however it have been higher among women than men [2]. Thus, HIV infection is increasingly considered a chronic pathology, and the assessment of quality of life is becoming essential in the follow-up of people living with HIV (PLWHIV). Moreover, even if advances in HCV infection treatments allow a complete cure. Complications, both hepatic and extrahepatic (including fatigue and depression), can persist with a considerable impact on the quality of life [3–5]. In high-income countries, several studies have shown that the quality of life of PLWHIV or people living with HCV (PLWHCV) remains comparable to that of the general population [6, 7]. However, the SQoL, one of the aspects of people quality of life, is often not explicitly explored in PLWHIV or PLWHCV.

WHO defines sexual health as a state of physical, mental and social well-being in relation to sexuality [8] as it plays an important role in the integral development of a human being. Despite this knowledge, the topic of sexual quality of life has been less in WHIV and WHCV which can be further be affected by their experience with stigma, social instability, substance use and reduce access to treatment [9, 10].

Sexual Quality of Life (SQoL) not only has a relevant impact on people's wellbeing, but it is also associated with adherence to medication, sexual dysfunction such as decreased libido, anorgasmia and dyspareunia, other struggles are related to stigma, difficulties in finding a partner, fear of rejection and other psychological impacts [11, 12].

Several studies found that WHIV experience increasing sexual dysfunction either due to individual reasons including psychological factors and the use of ART [10, 13–15]. Both HIV and HCV infections can be controlled by prevention strategies, effective screening programs and access to treatments [16]. Since there are studies that have investigated sexual dysfunction, physical and physiological issues [9, 17, 18]. It became necessary to develop a quantitative questionnaire that assess SQoL in the context of HIV and HCV infections. Their SQoL could be addressed not only to promote an optimal SQoL but also to improve general quality of life and woman's relationships. Moreover, sexuality is very often taboo and sometimes difficult to talk about it with healthcare professionals (HCP) during follow-up visits to HIV clinics, but this remained more pronounced among WHIV. The relationship between QoL and quality of healthcare was less frequently described in quality of life studies among PLWHIV and people living with HCV [12].
dimensions of the SQoL, while psychoactive substance use was associated with lower scores of *Sti* and *Sof*. Moreover, higher satisfaction with health care, talking about sexuality with healthcare workers, and psychoactive substance use (except cocaine use) in WHCV were associated with lower scores in *Psp*, *Sti*, and *Sof*. Besides, cocaine use was associated with higher scores of *Sof*.

## Conclusion

This study highlighted strong relationship between the quality of health care, and psychoactive substance use (except cocaine) and the sexual quality of life in WHIV and WHCV in these five countries. These findings draw attention to the different interventions that can be proposed for improving the sexual quality of life.

## Introduction

HIV and HCV infections are significant public health concerns worldwide [1]. Overall, HIV-related mortality has decreased thanks to broad access to antiretroviral treatments (ART), however it have been higher among women than men [2]. Thus, HIV infection is increasingly considered a chronic pathology, and the assessment of quality of life is becoming essential in the follow-up of people living with HIV (PLWHIV). Moreover, even if advances in HCV infection treatments allow a complete cure. Complications, both hepatic and extrahepatic (including fatigue and depression), can persist with a considerable impact on the quality of life [3–5]. In high-income countries, several studies have shown that the quality of life of PLWHIV or people living with HCV (PLWHCV) remains comparable to that of the general population [6, 7]. However, the SQoL, one of the aspects of people quality of life, is often not explicitly explored in PLWHIV or PLWHCV.

WHO defines sexual health as a state of physical, mental and social well-being in relation to sexuality [8] as it plays an important role in the integral development of a human being. Despite this knowledge, the topic of sexual quality of life has been less in WHIV and WHCV which can be further be affected by their experience with stigma, social instability, substance use and reduce access to treatment [9, 10].

Sexual Quality of Life (SQoL) not only has a relevant impact on people's wellbeing, but it is also associated with adherence to medication, sexual dysfunction such as decreased libido, anorgasmia and dyspareunia, other struggles are related to stigma, difficulties in finding a partner, fear of rejection and other psychological impacts [11, 12].

Several studies found that WHIV experience increasing sexual dysfunction either due to individual reasons including psychological factors and the use of ART [10, 13–15]. Both HIV and HCV infections can be controlled by prevention strategies, effective screening programs and access to treatments [16]. Since there are studies that have investigated sexual dysfunction, physical and physiological issues [9, 17, 18]. It became necessary to develop a quantitative questionnaire that assess SQoL in the context of HIV and HCV infections. Their SQoL could be addressed not only to promote an optimal SQoL but also to improve general quality of life and woman's relationships. Moreover, sexuality is very often taboo and sometimes difficult to talk about it with healthcare professionals (HCP) during follow-up visits to HIV clinics, but this remained more pronounced among WHIV. The relationship between QoL and quality of healthcare was less frequently described in quality of life studies among PLWHIV and people living with HCV [12].
This study aimed to investigate the relations between individual (sociodemographic, behavioral and physiological) and structural factors associated with the SQoL, among WHIV and WHCV in five different countries.

## Methods

### Study design and participants

The data was obtained from a cross-sectional study validating the PROQoL-Sex Life among WHIV and WHCV treated at treatment centers in Brazil, Canada, Australia, the United States and France. Data were collected during a follow-up visit from December 2017 to December 2018 and the questionnaire was completed online. Inclusion criteria were: 18–75 years of age and living with HIV and/or hepatitis C and followed in one of the treatment centers involved in this study. Exclusion criteria were: Insufficient proficiency in the official language (English, French or Portuguese), presenting significant cognitive impairment or physiological disorder, hospitalization or having an acute infectious disease at the time of the study.

### Variable definitions

The main outcome in this study, the SQoL, was estimated using the validated PROQoL-Sex Life questionnaire [19] consisting of 20 items classified in four dimensions including: positive sexual perception (*Psp*), stigma and social distress (*Sti*), soft sexual practices (*Sof*), and sexual practices with a partner (*Sp*). For answers, a Likert-type scale from 1 (never) to 5 (always) was used, and dimensions were linearly transformed according to a standardized algorithm scored from 0 (best) to 100 (impaired).

The independent variables were: sociodemographic characteristics (gender, profession, level of education, marital status, life-style, origin, and sexual orientation), health status (health problems, treatment, and coinfections), mental health (depression, use of antidepressant treatment, psychiatric disease and feeling sad or anhedonia during the last four weeks), psychoactive substance use, sexual behaviors.

Infections related data were included: i) for HCV infection (viral load, time since HCV infection diagnosis, transmission route, treatment follow up and treatment of HCV infection), and ii) for HIV infection (CDC classification, transmission route, CD4 count, ART duration, and time since HIV infection diagnosis.

Behaviors related data from the SQR-12 questionnaire included prevention issues as knowledge about the risk of transmission and condom use. There were questions that explored satisfaction with health care support, and communication with health professional about sexuality. Sexual dysfunction among was assessed (Vaginal dryness, sexual desire, and pain during penetration).

### Statistical methods

For data cleaning and statistical analysis, R software was used (R Core Team 2013) along with several additional packages. A descriptive analysis was performed in order to describe the main characteristics of the study participants, some numerical variables such as age and duration of ART were converted into categorical variables, frequency and proportions were reported. In order to manage missing values, a simple imputation was performed using the K-Nearest Neighbor [20] method with the value of five. Then, bootstrap method stepwise linear regression approach was done using the package *caret* [21]. Variable selection for final linear regression model was done by stepwise AIC approach in order to find the subset of variables resulting in the best performing model, in a combination of forward and backward selection. The selected
This study aimed to investigate the relations between individual (sociodemographic, behavioral and physiological) and structural factors associated with the SQoL, among WHIV and WHCV in five different countries.

## Methods

### Study design and participants

The data was obtained from a cross-sectional study validating the PROQoL-Sex Life among WHIV and WHCV treated at treatment centers in Brazil, Canada, Australia, the United States and France. Data were collected during a follow-up visit from December 2017 to December 2018 and the questionnaire was completed online. Inclusion criteria were: 18–75 years of age and living with HIV and/or hepatitis C and followed in one of the treatment centers involved in this study. Exclusion criteria were: Insufficient proficiency in the official language (English, French or Portuguese), presenting significant cognitive impairment or physiological disorder, hospitalization or having an acute infectious disease at the time of the study.

### Variable definitions

The main outcome in this study, the SQoL, was estimated using the validated PROQoL-Sex Life questionnaire [19] consisting of 20 items classified in four dimensions including: positive sexual perception (*Psp*), stigma and social distress (*Sti*), soft sexual practices (*Sof*), and sexual practices with a partner (*Sp*). For answers, a Likert-type scale from 1 (never) to 5 (always) was used, and dimensions were linearly transformed according to a standardized algorithm scored from 0 (best) to 100 (impaired).

The independent variables were: sociodemographic characteristics (gender, profession, level of education, marital status, life-style, origin, and sexual orientation), health status (health problems, treatment, and coinfections), mental health (depression, use of antidepressant treatment, psychiatric disease and feeling sad or anhedonia during the last four weeks), psychoactive substance use, sexual behaviors.

Infections related data were included: i) for HCV infection (viral load, time since HCV infection diagnosis, transmission route, treatment follow up and treatment of HCV infection), and ii) for HIV infection (CDC classification, transmission route, CD4 count, ART duration, and time since HIV infection diagnosis.

Behaviors related data from the SQR-12 questionnaire included prevention issues as knowledge about the risk of transmission and condom use. There were questions that explored satisfaction with health care support, and communication with health professional about sexuality. Sexual dysfunction among was assessed (Vaginal dryness, sexual desire, and pain during penetration).

### Statistical methods

For data cleaning and statistical analysis, R software was used (R Core Team 2013) along with several additional packages. A descriptive analysis was performed in order to describe the main characteristics of the study participants, some numerical variables such as age and duration of ART were converted into categorical variables, frequency and proportions were reported. In order to manage missing values, a simple imputation was performed using the K-Nearest Neighbor [20] method with the value of five. Then, bootstrap method stepwise linear regression approach was done using the package *caret* [21]. Variable selection for final linear regression model was done by stepwise AIC approach in order to find the subset of variables resulting in the best performing model, in a combination of forward and backward selection. The selected
variables were used in a linear mixed effects model analysis, and fitted through the R function lme from the nlme [22] to assess the relationship between each score and variables. Each independent variable was included into the full model as fixed effects and the country was defined as random effect. Variance inflation factors were used to analyze the existence of potential collinearity problems, variance explained by the entire model was calculated using pseudo-R-square (MuMIn) and inter-class correlation (ICC) for checking reliability.

## Ethical consideration

Potential participants were informed orally about the study, voluntariness was underscored, before written consent was obtained. The study is registered on 02 February 2018 with identifier NCT03468673 in ClinicalTrial.gov. The project was approved by ethics committee in each country:

* Chair of the National Data Protection Commission (CNIL) in France (n°1837794v0),

* Human Research Ethics Committee (HREC) of the South Eastern Sydney Local Health District in Australia (n° 15/056—HREC/15/POWH/157),

* Comitê de Ética Pesquisas (CEP) in Brazil (n°015/2014 –Código de Aceitação para Apreciação Ética (CAAE): 35564914.7.0000.5375).

* Canada (Institutional Review Board (IRB): 16152-15:07:3319-05-2017).

## Results

### Characteristics of study's participants

In this study, 404 women were included, among them 180 WHIV, 191 WHCV and 33 women coinfected with HIV and HCV, distributed over five countries Brazil (N = 145), Canada (N = 24), Australia (N = 50), France (N = 123) and USA (N = 62). The Table 1 displays the characteristics of the participants. The median age of 47.8 years. The majority were married (44.4%), caucasian (57.6%), employed (43.5%) and with at least high school level (85.0%). The great majority women were heterosexual (92.8%) and 47.4% lived with a sexual partner with or without children and 38% lived alone or with their children.

Depression and psychiatrics were reported respectively in 27.5% and 19.6% of the participants. Regarding transmission route, 95.1% of WHIV reported have acquired HIV in a heterosexual relation, while 41.6% of WHCV reported injection route. Regarding infection-related characteristics, the antiretroviral most used among WHIV was integrase inhibitors (38.2%). The majority of WHIV (96.4%) had undetectable HIV viral load (<50 copies/mL). Data on HCV treatment were available in three countries (Brazil, France and Canada). Among WHCV, 67.9% reported undetectable HCV viral load (Table 1).

About one third (32.2%) of the participants reported tobacco consumption, while 16.7% and 14.4% of the participants reported alcohol and drug use including cocain respectively. Regarding the satisfaction about the quality of health care support, 57.6% of the participants declared to be satisfied, while 48.2% reported having communication with HCP about sexuality. Consistent condom use during intercourse was reported in 46.1% of the participants (Table 1).

Concerning the sexual dysfunctions, 58.3% of the participants reported vaginal dryness, 54.7% reported pain during penetration, and 70.7% reported sexual desire (Table 1).

Compared to WHCV, WHIV were younger (p = 0.004), reported less married status (p = 0.042), reported more undetectable viral load (p<0.001), reported more consistent condom use (p<0.001) and reported less frequently vaginal dryness (p<0.001) (Table 1).
variables were used in a linear mixed effects model analysis, and fitted through the R function lme from the nlme [22] to assess the relationship between each score and variables. Each independent variable was included into the full model as fixed effects and the country was defined as random effect. Variance inflation factors were used to analyze the existence of potential collinearity problems, variance explained by the entire model was calculated using pseudo-R-square (MuMIn) and inter-class correlation (ICC) for checking reliability.

## Ethical consideration

Potential participants were informed orally about the study, voluntariness was underscored, before written consent was obtained. The study is registered on 02 February 2018 with identifier NCT03468673 in ClinicalTrial.gov. The project was approved by ethics committee in each country:

* Chair of the National Data Protection Commission (CNIL) in France (n°1837794v 0),

* Human Research Ethics Committee (HREC) of the South Eastern Sydney Local Health District in Australia (n° 15/056—HREC/15/POWH/157),

* Comitê de Ética Pesquisas (CEP) in Brazil (n°015/2014 –Código de Aceitação para Apreciação Ética (CAAE): 35564914.7.0000.5375).

* Canada (Institutional Review Board (IRB): 16152-15:07:3319-05-2017).

## Results

### Characteristics of study's participants

In this study, 404 women were included, among them 180 WHIV, 191 WHCV and 33 women coinfected with HIV and HCV, distributed over five countries Brazil (N = 145), Canada (N = 24), Australia (N = 50), France (N = 123) and USA (N = 62). The Table 1 displays the characteristics of the participants. The median age of 47.8 years. The majority were married (44.4%), caucasian (57.6%), employed (43.5%) and with at least high school level (85.0%). The great majority women were heterosexual (92.8%) and 47.4% lived with a sexual partner with or without children and 38% lived alone or with their children.

Depression and psychiatrics were reported respectively in 27.5% and 19.6% of the participants. Regarding transmission route, 95.1% of WHIV reported have acquired HIV in a heterosexual relation, while 41.6% of WHCV reported injection route. Regarding infection-related characteristics, the antiretroviral most used among WHIV was integrase inhibitors (38.2%). The majority of WHIV (96.4%) had undetectable HIV viral load (<50 copies/mL). Data on HCV treatment were available in three countries (Brazil, France and Canada). Among WHCV, 67.9% reported undetectable HCV viral load (Table 1).

About one third (32.2%) of the participants reported tobacco consumption, while 16.7% and 14.4% of the participants reported alcohol and drug use including cocain respectively. Regarding the satisfaction about the quality of health care support, 57.6% of the participants declared to be satisfied, while 48.2% reported having communication with HCP about sexuality. Consistent condom use during intercourse was reported in 46.1% of the participants (Table 1).

Concerning the sexual dysfunctions, 58.3% of the participants reported vaginal dryness, 54.7% reported pain during penetration, and 70.7% reported sexual desire (Table 1).

Compared to WHCV, WHIV were younger (p = 0.004), reported less married status (p = 0.042), reported more undetectable viral load (p<0.001), reported more consistent condom use (p<0.001) and reported less frequently vaginal dryness (p<0.001) (Table 1).
<table><caption>Table 1. Characteristics of the study's participants (N = 404).</caption><thead><tr><th>Participants characteristics</th><th>N = 404</th><th>WHIV (n = 213)</th><th>WHCV (n = 191)</th><th>P-value</th></tr></thead><tbody><tr><td><strong>Sociodemographics</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Age (years)</td><td>N = 404</td><td>n = 213</td><td>n = 191</td><td>0.004<sup>1</sup></td></tr><tr><td>Mean</td><td>47.8</td><td>45.7</td><td>50.2</td><td></td></tr><tr><td>Occupation</td><td>N = 400</td><td>n = 209</td><td>n = 191</td><td>0.002<sup>2</sup></td></tr><tr><td>Employed</td><td>174 (43.5)</td><td>107 (50.2)</td><td>67 (35.1)</td><td></td></tr><tr><td>Student</td><td>8 (2.0)</td><td>8 (3.8)</td><td>0 (0.0)</td><td></td></tr><tr><td>Housewife</td><td>59 (14.8)</td><td>16 (7.5)</td><td>43 (22.5)</td><td></td></tr><tr><td>Retired</td><td>71 (17.8)</td><td>30 (14.1)</td><td>41 (21.5)</td><td></td></tr><tr><td>Unemployed</td><td>74 (18.5)</td><td>38 (17.8)</td><td>36 (18.8)</td><td></td></tr><tr><td>Disable</td><td>14 (3.5)</td><td>10 (4.7)</td><td>4 (2.1)</td><td></td></tr><tr><td>Education</td><td>N = 400</td><td>n = 210</td><td>n = 190</td><td>0.372<sup>2</sup></td></tr><tr><td>Primary</td><td>60 (15.0)</td><td>32 (15.3)</td><td>28 (14.7)</td><td></td></tr><tr><td>High school</td><td>233 (58.3)</td><td>116 (55.2)</td><td>117 (61.6)</td><td></td></tr><tr><td>University</td><td>107 (26.7)</td><td>62 (29.5)</td><td>45 (23.7)</td><td></td></tr><tr><td>Marital status</td><td>N = 401</td><td>n = 210</td><td>n = 191</td><td>0.042<sup>2</sup></td></tr><tr><td>Single</td><td>115 (28.7)</td><td>72 (34.3)</td><td>43 (22.5)</td><td></td></tr><tr><td>Married</td><td>178 (44.4)</td><td>81 (38.6)</td><td>97 (50.8)</td><td></td></tr><tr><td>Divorced</td><td>76 (18.9)</td><td>40 (19.0)</td><td>36 (18.8)</td><td></td></tr><tr><td>Widow</td><td>32 (8.0)</td><td>17 (8.1)</td><td>15 (7.9)</td><td></td></tr><tr><td>Living mode</td><td>N = 392</td><td>n = 206</td><td>n = 186</td><td>0.001<sup>2</sup></td></tr><tr><td>Alone</td><td>100 (25.5)</td><td>67 (32.5)</td><td>33 (17.7)</td><td></td></tr><tr><td>Partner</td><td>115 (29.3)</td><td>52 (25.2)</td><td>63 (33.9)</td><td></td></tr><tr><td>Children</td><td>49 (12.5)</td><td>31 (15.1)</td><td>18 (9.7)</td><td></td></tr><tr><td>Children and partner</td><td>71 (18.1)</td><td>28 (13.6)</td><td>43 (23.1)</td><td></td></tr><tr><td>Other living mode</td><td>57 (14.6)</td><td>28 (13.6)</td><td>29 (15.6)</td><td></td></tr><tr><td>Origin</td><td>N = 403</td><td>n = 212</td><td>n = 191</td><td>&lt;0.001<sup>2</sup></td></tr><tr><td>Caucasian</td><td>232 (57.6)</td><td>110 (51.9)</td><td>122 (63.9)</td><td></td></tr><tr><td>African</td><td>86 (21.3)</td><td>59 (27.8)</td><td>27 (14.1)</td><td></td></tr><tr><td>Hispanic</td><td>45 (11.2)</td><td>17 (8.0)</td><td>28 (14.7)</td><td></td></tr><tr><td>Asian</td><td>33 (8.2)</td><td>19 (9.0)</td><td>14 (7.3)</td><td></td></tr><tr><td>Aboriginal</td><td>7 (1.7)</td><td>7 (3.3)</td><td>0 (0.0)</td><td></td></tr><tr><td>Sexual orientation</td><td>N = 401</td><td>n = 210</td><td>n = 191</td><td>0.108<sup>2</sup></td></tr><tr><td>Heterosexual</td><td>372 (92.8)</td><td>196 (93.3)</td><td>176 (92.1)</td><td></td></tr><tr><td>Homosexual</td><td>11 (2.7)</td><td>8 (3.8)</td><td>3 (1.6)</td><td></td></tr><tr><td>Bisexual</td><td>18 (4.5)</td><td>6 (2.9)</td><td>12 (6.3)</td><td></td></tr><tr><td><strong>Clinical outcomes</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Comorbidity</td><td>N = 400</td><td>n = 209</td><td>n = 191</td><td></td></tr><tr><td>Diabetes, yes</td><td>44 (11)</td><td>19 (9.1)</td><td>25 (13.1)</td><td>0.202<sup>2</sup></td></tr><tr><td>Cardiovascular, yes</td><td>46 (11.5)</td><td>28 (13.4)</td><td>18 (9.4)</td><td>0.213<sup>2</sup></td></tr><tr><td>Psychiatrics, yes</td><td>79 (19.6)</td><td>34 (16.3)</td><td>45 (23.6)</td><td>0.067<sup>2</sup></td></tr><tr><td>Depression, yes</td><td>110 (27.5)</td><td>50 (23.9)</td><td>60 (31.4)</td><td>0.094<sup>2</sup></td></tr><tr><td>Mood</td><td>N = 399</td><td>n = 208</td><td>n = 191</td><td></td></tr><tr><td>Hopeless, yes</td><td>177 (44.4)</td><td>89 (42.8)</td><td>88 (46.1)</td><td>0.482<sup>2</sup></td></tr><tr><td>Anhedonia, yes</td><td>189 (47.4)</td><td>91 (43.8)</td><td>98 (51.3)</td><td>0.120<sup>2</sup></td></tr></tbody></table>

(Continued)
<table><caption>Table 1. Characteristics of the study's participants (N = 404).</caption><thead><tr><th>Participants characteristics</th><th>N = 404</th><th>WHIV (n = 213)</th><th>WHCV (n = 191)</th><th>P-value</th></tr></thead><tbody><tr><td><strong>Sociodemographics</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Age (years)</td><td>N = 404</td><td>n = 213</td><td>n = 191</td><td>0.004<sup>1</sup></td></tr><tr><td>Mean</td><td>47.8</td><td>45.7</td><td>50.2</td><td></td></tr><tr><td>Occupation</td><td>N = 400</td><td>n = 209</td><td>n = 191</td><td>0.002<sup>2</sup></td></tr><tr><td>Employed</td><td>174 (43.5)</td><td>107 (50.2)</td><td>67 (35.1)</td><td></td></tr><tr><td>Student</td><td>8 (2.0)</td><td>8 (3.8)</td><td>0 (0.0)</td><td></td></tr><tr><td>Housewife</td><td>59 (14.8)</td><td>16 (7.5)</td><td>43 (22.5)</td><td></td></tr><tr><td>Retired</td><td>71 (17.8)</td><td>30 (14.1)</td><td>41 (21.5)</td><td></td></tr><tr><td>Unemployed</td><td>74 (18.5)</td><td>38 (17.8)</td><td>36 (18.8)</td><td></td></tr><tr><td>Disable</td><td>14 (3.5)</td><td>10 (4.7)</td><td>4 (2.1)</td><td></td></tr><tr><td>Education</td><td>N = 400</td><td>n = 210</td><td>n = 190</td><td>0.372<sup>2</sup></td></tr><tr><td>Primary</td><td>60 (15.0)</td><td>32 (15.3)</td><td>28 (14.7)</td><td></td></tr><tr><td>High school</td><td>233 (58.3)</td><td>116 (55.2)</td><td>117 (61.6)</td><td></td></tr><tr><td>University</td><td>107 (26.7)</td><td>62 (29.5)</td><td>45 (23.7)</td><td></td></tr><tr><td>Marital status</td><td>N = 401</td><td>n = 210</td><td>n = 191</td><td>0.042<sup>2</sup></td></tr><tr><td>Single</td><td>115 (28.7)</td><td>72 (34.3)</td><td>43 (22.5)</td><td></td></tr><tr><td>Married</td><td>178 (44.4)</td><td>81 (38.6)</td><td>97 (50.8)</td><td></td></tr><tr><td>Divorced</td><td>76 (18.9)</td><td>40 (19.0)</td><td>36 (18.8)</td><td></td></tr><tr><td>Widow</td><td>32 (8.0)</td><td>17 (8.1)</td><td>15 (7.9)</td><td></td></tr><tr><td>Living mode</td><td>N = 392</td><td>n = 206</td><td>n = 186</td><td>0.001<sup>2</sup></td></tr><tr><td>Alone</td><td>100 (25.5)</td><td>67 (32.5)</td><td>33 (17.7)</td><td></td></tr><tr><td>Partner</td><td>115 (29.3)</td><td>52 (25.2)</td><td>63 (33.9)</td><td></td></tr><tr><td>Children</td><td>49 (12.5)</td><td>31 (15.1)</td><td>18 (9.7)</td><td></td></tr><tr><td>Children and partner</td><td>71 (18.1)</td><td>28 (13.6)</td><td>43 (23.1)</td><td></td></tr><tr><td>Other living mode</td><td>57 (14.6)</td><td>28 (13.6)</td><td>29 (15.6)</td><td></td></tr><tr><td>Origin</td><td>N = 403</td><td>n = 212</td><td>n = 191</td><td>&lt;0.001<sup>2</sup></td></tr><tr><td>Caucasian</td><td>232 (57.6)</td><td>110 (51.9)</td><td>122 (63.9)</td><td></td></tr><tr><td>African</td><td>86 (21.3)</td><td>59 (27.8)</td><td>27 (14.1)</td><td></td></tr><tr><td>Hispanic</td><td>45 (11.2)</td><td>17 (8.0)</td><td>28 (14.7)</td><td></td></tr><tr><td>Asian</td><td>33 (8.2)</td><td>19 (9.0)</td><td>14 (7.3)</td><td></td></tr><tr><td>Aboriginal</td><td>7 (1.7)</td><td>7 (3.3)</td><td>0 (0.0)</td><td></td></tr><tr><td>Sexual orientation</td><td>N = 401</td><td>n = 210</td><td>n = 191</td><td>0.108<sup>2</sup></td></tr><tr><td>Heterosexual</td><td>372 (92.8)</td><td>196 (93.3)</td><td>176 (92.1)</td><td></td></tr><tr><td>Homosexual</td><td>11 (2.7)</td><td>8 (3.8)</td><td>3 (1.6)</td><td></td></tr><tr><td>Bisexual</td><td>18 (4.5)</td><td>6 (2.9)</td><td>12 (6.3)</td><td></td></tr><tr><td><strong>Clinical outcomes</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Comorbidity</td><td>N = 400</td><td>n = 209</td><td>n = 191</td><td></td></tr><tr><td>Diabetes, yes</td><td>44 (11)</td><td>19 (9.1)</td><td>25 (13.1)</td><td>0.202<sup>2</sup></td></tr><tr><td>Cardiovascular, yes</td><td>46 (11.5)</td><td>28 (13.4)</td><td>18 (9.4)</td><td>0.213<sup>2</sup></td></tr><tr><td>Psychiatrics, yes</td><td>79 (19.6)</td><td>34 (16.3)</td><td>45 (23.6)</td><td>0.067<sup>2</sup></td></tr><tr><td>Depression, yes</td><td>110 (27.5)</td><td>50 (23.9)</td><td>60 (31.4)</td><td>0.094<sup>2</sup></td></tr><tr><td>Mood</td><td>N = 399</td><td>n = 208</td><td>n = 191</td><td></td></tr><tr><td>Hopeless, yes</td><td>177 (44.4)</td><td>89 (42.8)</td><td>88 (46.1)</td><td>0.482<sup>2</sup></td></tr><tr><td>Anhedonia, yes</td><td>189 (47.4)</td><td>91 (43.8)</td><td>98 (51.3)</td><td>0.120<sup>2</sup></td></tr></tbody></table>

(Continued)
<table><caption>**Table 1.** (Continued)</caption><thead><tr><th>Participants characteristics</th><th>N = 404</th><th>WHIV (n = 213)</th><th>WHCV (n = 191)</th><th>P-value</th></tr></thead><tbody><tr><td><strong>Transmission route</strong></td><td><strong>N = 393</strong></td><td><strong>n = 203</strong></td><td><strong>n = 190</strong></td><td><strong>&lt;0.001<sup>2</sup></strong></td></tr><tr><td>Homosexual relation</td><td>7 (1.8)</td><td>2 (1.0)</td><td>5 (2.6)</td><td></td></tr><tr><td>Heterosexual relation</td><td>219 (55.7)</td><td>193 (95.1)</td><td>26 (13.7)</td><td></td></tr><tr><td>Injection</td><td>87 (22.1)</td><td>8 (3.9)</td><td>79 (41.6)</td><td></td></tr><tr><td>Other transmission route</td><td>80 (20.4)</td><td>0 (0.0)</td><td>80 (42.1)</td><td></td></tr><tr><td><strong>Understand risk of HIV transmission<sup>3</sup></strong></td><td><strong>N = 210</strong></td><td><strong>n = 210</strong></td><td>NA</td><td>NA</td></tr><tr><td>Not aware</td><td>17 (8.1)</td><td>17 (8.1)</td><td></td><td></td></tr><tr><td>Neutral</td><td>19 (9.1)</td><td>19 (9.1)</td><td></td><td></td></tr><tr><td>Moderate aware</td><td>75 (35.7)</td><td>75 (35.7)</td><td></td><td></td></tr><tr><td>High aware</td><td>99 (47.1)</td><td>99 (47.1)</td><td></td><td></td></tr><tr><td><strong>HIV treatment<sup>3</sup></strong></td><td><strong>N = 183</strong></td><td><strong>n = 183</strong></td><td>NA</td><td>NA</td></tr><tr><td>Nucleoside reverse transcriptase inhibitors (NRTIs)</td><td>4 (2.2)</td><td>4 (2.2)</td><td></td><td></td></tr><tr><td>Non-nucleoside reverse transcriptase inhibitors (NNRTIs)</td><td>36 (19.7)</td><td>36 (19.7)</td><td></td><td></td></tr><tr><td>Protease inhibitors (PIs)</td><td>68 (37.2)</td><td>68 (37.2)</td><td></td><td></td></tr><tr><td>Integrase inhibitors (INI)</td><td>70 (38.2)</td><td>70 (38.2)</td><td></td><td></td></tr><tr><td>Other</td><td>5 (2.7)</td><td>5 (2.7)</td><td></td><td></td></tr><tr><td><strong>HCV treatment<sup>4</sup></strong></td><td><strong>N = 147</strong></td><td>NA</td><td><strong>n = 147</strong></td><td>NA</td></tr><tr><td>Ribavirine</td><td>101 (68.7)</td><td></td><td>101 (68.7)</td><td></td></tr><tr><td>NS5A inhibitors</td><td>5 (3.4)</td><td></td><td>5 (3.4)</td><td></td></tr><tr><td>Combine</td><td>2 (1.4)</td><td></td><td>2 (1.4)</td><td></td></tr><tr><td>NS5B polymerase inhibitor</td><td>35 (23.8)</td><td></td><td>35 (23.8)</td><td></td></tr><tr><td>NS3 inhibitor</td><td>2 (1.4)</td><td></td><td>2 (1.4)</td><td></td></tr><tr><td>Other</td><td>2 (1.4)</td><td></td><td>2 (1.4)</td><td></td></tr><tr><td><strong>Viral load</strong></td><td><strong>N = 300</strong></td><td><strong>n = 194</strong></td><td><strong>n = 106</strong></td><td><strong>&lt;0.001<sup>2</sup></strong></td></tr><tr><td>Detectable</td><td>41</td><td>7 (3.6)</td><td>34 (32.1)</td><td></td></tr><tr><td>Undetectable</td><td>259</td><td>187 (96.4)</td><td>72 (67.9)</td><td></td></tr><tr><td><strong>Talk to health professional about sexuality</strong></td><td><strong>N = 396</strong></td><td><strong>n = 209</strong></td><td><strong>n = 187</strong></td><td><strong>0.106<sup>2</sup></strong></td></tr><tr><td>No</td><td>205 (51.8)</td><td>98 (46.9)</td><td>107 (57.2)</td><td></td></tr><tr><td>Sometimes</td><td>71 (17.9)</td><td>43 (20.6)</td><td>28 (15.0)</td><td></td></tr><tr><td>Yes</td><td>120 (30.3)</td><td>68 (32.5)</td><td>52 (27.8)</td><td></td></tr><tr><td><strong>Satisfied about healthcare care</strong></td><td><strong>N = 394</strong></td><td><strong>n = 207</strong></td><td><strong>n = 187</strong></td><td><strong>0.056<sup>2</sup></strong></td></tr><tr><td>Not satisfied</td><td>167 (42.4)</td><td>76 (36.7)</td><td>91 (48.7)</td><td></td></tr><tr><td>Satisfied</td><td>141 (35.8)</td><td>82 (39.6)</td><td>59 (31.6)</td><td></td></tr><tr><td>Very satisfied</td><td>86 (21.8)</td><td>49 (23.7)</td><td>37 (19.8)</td><td></td></tr><tr><td><strong>Behavioral</strong></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Substance use</strong></td><td><strong>N = 401</strong></td><td><strong>n = 210</strong></td><td><strong>n = 191</strong></td><td></td></tr><tr><td>Alcohol</td><td>67 (16.7)</td><td>37 (17.6)</td><td>30 (15.7)</td><td>0.608<sup>2</sup></td></tr><tr><td>Smoking</td><td>129 (32.2)</td><td>60 (28.6)</td><td>69 (36.1)</td><td>0.106<sup>2</sup></td></tr><tr><td>Cocaine</td><td>19 (4.7)</td><td>8 (3.8)</td><td>11 (5.8)</td><td>0.359<sup>2</sup></td></tr><tr><td>Cialis/Viagra</td><td>9 (2.2)</td><td>7 (3.3)</td><td>2 (1.0)</td><td>0.123<sup>2</sup></td></tr><tr><td>Other drugs</td><td>39 (9.7)</td><td>17 (8.1)</td><td>22 (11.5)</td><td>0.248<sup>2</sup></td></tr><tr><td>Sex stimulants</td><td>11 (2.7)</td><td>8 (3.8)</td><td>3 (1.6)</td><td>0.170<sup>2</sup></td></tr><tr><td><strong>Condom use</strong></td><td><strong>N = 395</strong></td><td><strong>n = 208</strong></td><td><strong>n = 187</strong></td><td><strong>&lt;0.001<sup>2</sup></strong></td></tr><tr><td>No</td><td>160 (40.5)</td><td>67 (32.2)</td><td>93 (49.7)</td><td></td></tr><tr><td>Sometimes</td><td>53 (13.4)</td><td>27 (13.0)</td><td>26 (13.9)</td><td></td></tr><tr><td>Yes</td><td>182 (46.1)</td><td>114 (54.8)</td><td>68 (36.4)</td><td></td></tr><tr><td><strong>Sexual dysfunctions</strong></td><td></td><td></td><td></td><td></td></tr></tbody></table>

(Continued)
<table><caption>**Table 1.** (Continued)</caption><thead><tr><th>Participants characteristics</th><th>N = 404</th><th>WHIV (n = 213)</th><th>WHCV (n = 191)</th><th>P-value</th></tr></thead><tbody><tr><td><strong>Transmission route</strong></td><td><strong>N = 393</strong></td><td><strong>n = 203</strong></td><td><strong>n = 190</strong></td><td><strong>&lt;0.001<sup>2</sup></strong></td></tr><tr><td>Homosexual relation</td><td>7 (1.8)</td><td>2 (1.0)</td><td>5 (2.6)</td><td></td></tr><tr><td>Heterosexual relation</td><td>219 (55.7)</td><td>193 (95.1)</td><td>26 (13.7)</td><td></td></tr><tr><td>Injection</td><td>87 (22.1)</td><td>8 (3.9)</td><td>79 (41.6)</td><td></td></tr><tr><td>Other transmission route</td><td>80 (20.4)</td><td>0 (0.0)</td><td>80 (42.1)</td><td></td></tr><tr><td><strong>Understand risk of HIV transmission<sup>3</sup></strong></td><td><strong>N = 210</strong></td><td><strong>n = 210</strong></td><td>NA</td><td>NA</td></tr><tr><td>Not aware</td><td>17 (8.1)</td><td>17 (8.1)</td><td></td><td></td></tr><tr><td>Neutral</td><td>19 (9.1)</td><td>19 (9.1)</td><td></td><td></td></tr><tr><td>Moderate aware</td><td>75 (35.7)</td><td>75 (35.7)</td><td></td><td></td></tr><tr><td>High aware</td><td>99 (47.1)</td><td>99 (47.1)</td><td></td><td></td></tr><tr><td><strong>HIV treatment<sup>3</sup></strong></td><td><strong>N = 183</strong></td><td><strong>n = 183</strong></td><td>NA</td><td>NA</td></tr><tr><td>Nucleoside reverse transcriptase inhibitors (NRTIs)</td><td>4 (2.2)</td><td>4 (2.2)</td><td></td><td></td></tr><tr><td>Non-nucleoside reverse transcriptase inhibitors (NNRTIs)</td><td>36 (19.7)</td><td>36 (19.7)</td><td></td><td></td></tr><tr><td>Protease inhibitors (PIs)</td><td>68 (37.2)</td><td>68 (37.2)</td><td></td><td></td></tr><tr><td>Integrase inhibitors (INI)</td><td>70 (38.2)</td><td>70 (38.2)</td><td></td><td></td></tr><tr><td>Other</td><td>5 (2.7)</td><td>5 (2.7)</td><td></td><td></td></tr><tr><td><strong>HCV treatment<sup>4</sup></strong></td><td><strong>N = 147</strong></td><td>NA</td><td><strong>n = 147</strong></td><td>NA</td></tr><tr><td>Ribavirine</td><td>101 (68.7)</td><td></td><td>101 (68.7)</td><td></td></tr><tr><td>NS5A inhibitors</td><td>5 (3.4)</td><td></td><td>5 (3.4)</td><td></td></tr><tr><td>Combine</td><td>2 (1.4)</td><td></td><td>2 (1.4)</td><td></td></tr><tr><td>NS5B polymerase inhibitor</td><td>35 (23.8)</td><td></td><td>35 (23.8)</td><td></td></tr><tr><td>NS3 inhibitor</td><td>2 (1.4)</td><td></td><td>2 (1.4)</td><td></td></tr><tr><td>Other</td><td>2 (1.4)</td><td></td><td>2 (1.4)</td><td></td></tr><tr><td><strong>Viral load</strong></td><td><strong>N = 300</strong></td><td><strong>n = 194</strong></td><td><strong>n = 106</strong></td><td><strong>&lt;0.001<sup>2</sup></strong></td></tr><tr><td>Detectable</td><td>41</td><td>7 (3.6)</td><td>34 (32.1)</td><td></td></tr><tr><td>Undetectable</td><td>259</td><td>187 (96.4)</td><td>72 (67.9)</td><td></td></tr><tr><td><strong>Talk to health professional about sexuality</strong></td><td><strong>N = 396</strong></td><td><strong>n = 209</strong></td><td><strong>n = 187</strong></td><td>0.106<sup>2</sup></td></tr><tr><td>No</td><td>205 (51.8)</td><td>98 (46.9)</td><td>107 (57.2)</td><td></td></tr><tr><td>Sometimes</td><td>71 (17.9)</td><td>43 (20.6)</td><td>28 (15.0)</td><td></td></tr><tr><td>Yes</td><td>120 (30.3)</td><td>68 (32.5)</td><td>52 (27.8)</td><td></td></tr><tr><td><strong>Satisfied about healthcare care</strong></td><td><strong>N = 394</strong></td><td><strong>n = 207</strong></td><td><strong>n = 187</strong></td><td>0.056<sup>2</sup></td></tr><tr><td>Not satisfied</td><td>167 (42.4)</td><td>76 (36.7)</td><td>91 (48.7)</td><td></td></tr><tr><td>Satisfied</td><td>141 (35.8)</td><td>82 (39.6)</td><td>59 (31.6)</td><td></td></tr><tr><td>Very satisfied</td><td>86 (21.8)</td><td>49 (23.7)</td><td>37 (19.8)</td><td></td></tr><tr><td><strong>Behavioral</strong></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Substance use</strong></td><td><strong>N = 401</strong></td><td><strong>n = 210</strong></td><td><strong>n = 191</strong></td><td></td></tr><tr><td>Alcohol</td><td>67 (16.7)</td><td>37 (17.6)</td><td>30 (15.7)</td><td>0.608<sup>2</sup></td></tr><tr><td>Smoking</td><td>129 (32.2)</td><td>60 (28.6)</td><td>69 (36.1)</td><td>0.106<sup>2</sup></td></tr><tr><td>Cocaine</td><td>19 (4.7)</td><td>8 (3.8)</td><td>11 (5.8)</td><td>0.359<sup>2</sup></td></tr><tr><td>Cialis/Viagra</td><td>9 (2.2)</td><td>7 (3.3)</td><td>2 (1.0)</td><td>0.123<sup>2</sup></td></tr><tr><td>Other drugs</td><td>39 (9.7)</td><td>17 (8.1)</td><td>22 (11.5)</td><td>0.248<sup>2</sup></td></tr><tr><td>Sex stimulants</td><td>11 (2.7)</td><td>8 (3.8)</td><td>3 (1.6)</td><td>0.170<sup>2</sup></td></tr><tr><td><strong>Condom use</strong></td><td><strong>N = 395</strong></td><td><strong>n = 208</strong></td><td><strong>n = 187</strong></td><td><strong>&lt;0.001<sup>2</sup></strong></td></tr><tr><td>No</td><td>160 (40.5)</td><td>67 (32.2)</td><td>93 (49.7)</td><td></td></tr><tr><td>Sometimes</td><td>53 (13.4)</td><td>27 (13.0)</td><td>26 (13.9)</td><td></td></tr><tr><td>Yes</td><td>182 (46.1)</td><td>114 (54.8)</td><td>68 (36.4)</td><td></td></tr><tr><td><strong>Sexual dysfunctions</strong></td><td></td><td></td><td></td><td></td></tr></tbody></table>

(Continued)
<table><caption>**Table 1.** (Continued)</caption><thead><tr><th>Participants characteristics</th><th>N = 404</th><th>WHIV (n = 213)</th><th>WHCV (n = 191)</th><th>P-value</th></tr></thead><tbody><tr><td><strong>Vaginal dryness</strong></td><td><strong>N = 389</strong></td><td><strong>n = 206</strong></td><td><strong>n = 183</strong></td><td><strong>&lt;0.001<sup>2</sup></strong></td></tr><tr><td>Frequently</td><td>137 (35.2)</td><td>44 (21.4)</td><td>93 (50.8)</td><td></td></tr><tr><td>Sometimes</td><td>90 (23.1)</td><td>45 (21.8)</td><td>45 (24.6)</td><td></td></tr><tr><td>Not frequently</td><td>162 (41.6)</td><td>117 (56.8)</td><td>45 (24.6)</td><td></td></tr><tr><td><strong>Pain at penetration</strong></td><td><strong>N = 397</strong></td><td><strong>n = 210</strong></td><td><strong>n = 187</strong></td><td><strong>0.868<sup>2</sup></strong></td></tr><tr><td>Frequently</td><td>158 (39.8)</td><td>82 (39.1)</td><td>76 (40.6)</td><td></td></tr><tr><td>Sometimes</td><td>59 (14.9)</td><td>33 (15.7)</td><td>26 (13.9)</td><td></td></tr><tr><td>No frequently</td><td>180 (45.3)</td><td>95 (45.2)</td><td>85 (45.5)</td><td></td></tr><tr><td><strong>Sexual desire</strong></td><td><strong>N = 397</strong></td><td><strong>n = 209</strong></td><td><strong>n = 188</strong></td><td><strong>0.361<sup>2</sup></strong></td></tr><tr><td>Frequently</td><td>128 (32.2)</td><td>66 (31.6)</td><td>62 (33.0)</td><td></td></tr><tr><td>Sometimes</td><td>153 (38.5)</td><td>87 (41.6)</td><td>66 (35.1)</td><td></td></tr><tr><td>Not frequently</td><td>116 (29.2)</td><td>56 (26.8)</td><td>60 (31.9)</td><td></td></tr><tr><td><strong>Worried during sex<sup>3</sup></strong></td><td><strong>N = 207</strong></td><td><strong>n = 207</strong></td><td></td><td>NA</td></tr><tr><td>No worried</td><td>96 (47.3)</td><td>96 (47.29)</td><td></td><td></td></tr><tr><td>Neutral</td><td>33 (16.3)</td><td>33 (16.26)</td><td></td><td></td></tr><tr><td>Worried</td><td>52 (25.6)</td><td>52 (25.62)</td><td></td><td></td></tr><tr><td>Very worried</td><td>22 (10.8)</td><td>22 (10.84)</td><td></td><td></td></tr></tbody></table>

https://doi.org/10.1371/journal.pone.0278054.t001

## PROQoL-Sex Life

The PROQoL Sexlife's dimensions and their mean scores are shown in Table 2. The mean score of the PROQoL Sexlife's dimensions varied from 26.2 in the *Sp* dimension to 69.8 in the *Sof* dimension among WHIV. While, it varied from 23.1 in the *Sp* dimension to 67.3 in the *Sof* dimension among WHCV (Table 2).

## Factors associated with PROQoL-Sex Life dimensions

Multivariable mixed linear regression results are shown in Table 3 for WHIV and in Table 4 for WHCV.

Among WHIV (Table 3), final models showed that being Hispanic, being very satisfied with health care, tobacco use and talking about sex with HCP were associated with lower

<table><caption>**Table 2.** PROQOL-Sex life dimensions.</caption><thead><tr><th>PROQOL-Sex life dimensions*</th><th>WHIV, Mean</th><th>WHCV, Mean</th></tr></thead><tbody><tr><td>Positive sexual perception (Psp)</td><td>49.5</td><td>45.1</td></tr><tr><td>Stigma and social distress (Sti)</td><td>41.6</td><td>37.4</td></tr><tr><td>Soft sexual practices (Sof)</td><td>69.8</td><td>67.3</td></tr><tr><td>Sexual practice with partner (Sp)</td><td>26.2</td><td>23.1</td></tr></tbody></table>

https://doi.org/10.1371/journal.pone.0278054.t002

<footnote n="1">¹ = t-test;</footnote>

<footnote n="2">² = chi square test;</footnote>

<footnote n="3">³ = Only for WHIV;</footnote>

<footnote n="4">⁴ = Only for WHCV;</footnote>

<footnote>NA = non applicable</footnote>

<footnote>* the lower the score is, the better the SQoL is.</footnote>
<table><caption>**Table 1.** (Continued)</caption><thead><tr><th>Participants characteristics</th><th>N = 404</th><th>WHIV (n = 213)</th><th>WHCV (n = 191)</th><th>P-value</th></tr></thead><tbody><tr><td><strong>Vaginal dryness</strong></td><td><strong>N = 389</strong></td><td><strong>n = 206</strong></td><td><strong>n = 183</strong></td><td><strong>&lt;0.001<sup>2</sup></strong></td></tr><tr><td>Frequently</td><td>137 (35.2)</td><td>44 (21.4)</td><td>93 (50.8)</td><td></td></tr><tr><td>Sometimes</td><td>90 (23.1)</td><td>45 (21.8)</td><td>45 (24.6)</td><td></td></tr><tr><td>Not frequently</td><td>162 (41.6)</td><td>117 (56.8)</td><td>45 (24.6)</td><td></td></tr><tr><td><strong>Pain at penetration</strong></td><td><strong>N = 397</strong></td><td><strong>n = 210</strong></td><td><strong>n = 187</strong></td><td><strong>0.868<sup>2</sup></strong></td></tr><tr><td>Frequently</td><td>158 (39.8)</td><td>82 (39.1)</td><td>76 (40.6)</td><td></td></tr><tr><td>Sometimes</td><td>59 (14.9)</td><td>33 (15.7)</td><td>26 (13.9)</td><td></td></tr><tr><td>No frequently</td><td>180 (45.3)</td><td>95 (45.2)</td><td>85 (45.5)</td><td></td></tr><tr><td><strong>Sexual desire</strong></td><td><strong>N = 397</strong></td><td><strong>n = 209</strong></td><td><strong>n = 188</strong></td><td><strong>0.361<sup>2</sup></strong></td></tr><tr><td>Frequently</td><td>128 (32.2)</td><td>66 (31.6)</td><td>62 (33.0)</td><td></td></tr><tr><td>Sometimes</td><td>153 (38.5)</td><td>87 (41.6)</td><td>66 (35.1)</td><td></td></tr><tr><td>Not frequently</td><td>116 (29.2)</td><td>56 (26.8)</td><td>60 (31.9)</td><td></td></tr><tr><td><strong>Worried during sex<sup>3</sup></strong></td><td><strong>N = 207</strong></td><td><strong>n = 207</strong></td><td></td><td>NA</td></tr><tr><td>No worried</td><td>96 (47.3)</td><td>96 (47.29)</td><td></td><td></td></tr><tr><td>Neutral</td><td>33 (16.3)</td><td>33 (16.26)</td><td></td><td></td></tr><tr><td>Worried</td><td>52 (25.6)</td><td>52 (25.62)</td><td></td><td></td></tr><tr><td>Very worried</td><td>22 (10.8)</td><td>22 (10.84)</td><td></td><td></td></tr></tbody></table>

https://doi.org/10.1371/journal.pone.0278054.t001

## PROQoL-Sex Life

The PROQoL Sexlife's dimensions and their mean scores are shown in Table 2. The mean score of the PROQoL Sexlife's dimensions varied from 26.2 in the *Sp* dimension to 69.8 in the *Sof* dimension among WHIV. While, it varied from 23.1 in the *Sp* dimension to 67.3 in the *Sof* dimension among WHCV (Table 2).

## Factors associated with PROQoL-Sex Life dimensions

Multivariable mixed linear regression results are shown in Table 3 for WHIV and in Table 4 for WHCV.

Among WHIV (Table 3), final models showed that being Hispanic, being very satisfied with health care, tobacco use and talking about sex with HCP were associated with lower

<table><caption>**Table 2.** PROQOL-Sex life dimensions.</caption><thead><tr><th>PROQOL-Sex life dimensions*</th><th>WHIV, Mean</th><th>WHCV, Mean</th></tr></thead><tbody><tr><td>Positive sexual perception (Psp)</td><td>49.5</td><td>45.1</td></tr><tr><td>Stigma and social distress (Sti)</td><td>41.6</td><td>37.4</td></tr><tr><td>Soft sexual practices (Sof)</td><td>69.8</td><td>67.3</td></tr><tr><td>Sexual practice with partner (Sp)</td><td>26.2</td><td>23.1</td></tr></tbody></table>

https://doi.org/10.1371/journal.pone.0278054.t002

<footnote n="1">¹ = t-test;</footnote>

<footnote n="2">² = chi square test;</footnote>

<footnote n="3">³ = Only for WHIV;</footnote>

<footnote n="4">⁴ = Only for WHCV;</footnote>

<footnote>NA = non applicable</footnote>

<footnote>* the lower the score is, the better the SQoL is.</footnote>
<table><caption>Table 3. Factors associated with PROQOL-Sex Life dimensions among WHIV (multivariable linear mixed effects regression).</caption><thead><tr><th rowspan="2">SQOL dimensions (outcomes)*</th><th colspan="4">Fixed effects</th><th rowspan="2">Random effect</th></tr><tr><th>Participants' characteristics</th><th>β</th><th>SE</th><th>p-value</th></tr></thead><tbody><tr><td rowspan="5">Positive Sexual Perception (Psp)</td><td>Hispanic origin</td><td>-18.50</td><td>6.61</td><td>0.006</td><td rowspan="5">SD = 5.7<br>ICC = 0.04<br>R<sup>2</sup> = 0.34</td></tr><tr><td>Very satisfied about health care</td><td>-14.13</td><td>5.22</td><td>0.007</td></tr><tr><td>Cigarret use</td><td>-8.68</td><td>4.02</td><td>0.032</td></tr><tr><td>Talk about sex with health professional</td><td>-9.89</td><td>4.72</td><td>0.038</td></tr><tr><td>Worried during sex: neutral</td><td>15.60</td><td>5.29</td><td>0.004</td></tr><tr><td rowspan="8">Stigma and social distress (Sti)</td><td>Very worried during sex</td><td>18.41</td><td>6.47</td><td>0.005</td><td rowspan="8">SD = 3.03<br>ICC = 0.01<br>R<sup>2</sup> = 0.43</td></tr><tr><td>Marital status: widow</td><td>-15.57</td><td>5.67</td><td>0.007</td></tr><tr><td>Other drugs use</td><td>-13.15</td><td>5.93</td><td>0.028</td></tr><tr><td>Hispanic origin</td><td>-12.47</td><td>5.48</td><td>0.024</td></tr><tr><td>Very satisfied about health care</td><td>-9.01</td><td>3.92</td><td>0.023</td></tr><tr><td>Cigarret use</td><td>6.82</td><td>3.38</td><td>0.046</td></tr><tr><td>Anhedonia mood</td><td>8.81</td><td>4.33</td><td>0.044</td></tr><tr><td>Worried during sex</td><td>11.05</td><td>4.07</td><td>0.007</td></tr><tr><td rowspan="7">Soft sexual practices (Sof)</td><td>CV disease:</td><td>14.26</td><td>4.43</td><td>0.002</td><td rowspan="7">SD = 4.4<br>ICC = 0.18<br>R<sup>2</sup> = 0.51</td></tr><tr><td>Worried during sex: neutral</td><td>15.56</td><td>4.23</td><td>0.000</td></tr><tr><td>Very worried during sex</td><td>20.31</td><td>5.19</td><td>0.000</td></tr><tr><td>Marital status: divorced</td><td>-24.17</td><td>5.54</td><td>0.000</td></tr><tr><td>Understand about risk of HIV transmission: neutral</td><td>-24.05</td><td>9.82</td><td>0.016</td></tr><tr><td>Homosexual</td><td>-21.45</td><td>7.94</td><td>0.008</td></tr><tr><td>Sexual stimulants use</td><td>-19.26</td><td>8.28</td><td>0.022</td></tr><tr><td rowspan="8">Sexual practices with partner (Sp)</td><td>Education level: university</td><td>-16.32</td><td>6.66</td><td>0.016</td><td rowspan="8">SD = 0.009<br>ICC = 0.04<br>R<sup>2</sup> = 0.56</td></tr><tr><td>Employ: housewife</td><td>-16.01</td><td>5.86</td><td>0.008</td></tr><tr><td>Talk about sex with health professional</td><td>-13.68</td><td>4.02</td><td>0.001</td></tr><tr><td>Hopeless mood</td><td>9.91</td><td>4.04</td><td>0.016</td></tr><tr><td>African origin</td><td>13.48</td><td>4.20</td><td>0.002</td></tr><tr><td>Hispanic origin</td><td>15.84</td><td>5.24</td><td>0.003</td></tr><tr><td>Living with children</td><td>22.32</td><td>6.34</td><td>0.001</td></tr><tr><td>High awareness about risk of HIV transmission:</td><td>-44.62</td><td>19.33</td><td>0.028</td></tr><tr><td>Very Satisfied about health care</td><td>-23.21</td><td>10.01</td><td>0.027</td></tr><tr><td>HIV treatment: non-nucleoside transcriptase inhibitor</td><td>-18.96</td><td>8.23</td><td>0.028</td></tr><tr><td>Age group: 46.7-70.1</td><td>38.53</td><td>16.94</td><td>0.030</td></tr></tbody></table>

https://doi.org/10.1371/journal.pone.0278054.t003

scores in *Psp*. While being worried or neutral during sex was associated with impairment in *Psp* dimension.

Regarding the *Sti* dimension, widowed, Hispanic or WHIV satisfied with health care and those who reported drug use were less likely to experience stigma and social distress. While factors as cardiovascular disease, tobacco consumption, anhedonia and being worried or neutral during sex were associated with more stigma and social distress.

Being a housewife, university level education, divorced, homosexual orientation, use of sexual stimulants, talking about sex with HCP and being aware about HIV transmission were associated with lower score of *Sof*. While depression, African origin, Hispanic origin and living with children were associated with impaired *Sof* dimension.

WHIV who reported a higher satisfaction with health care, those who were aware of the risk of HIV transmission, and those who reported non-nucleoside transcriptase inhibitor

<footnote>* the lower the score is, the better the SQoL is.</footnote>
<table><caption>Table 3. Factors associated with PROQOL-Sex Life dimensions among WHIV (multivariable linear mixed effects regression).</caption><thead><tr><th rowspan="2">SQOL dimensions (outcomes)*</th><th colspan="4">Fixed effects</th><th rowspan="2">Random effect</th></tr><tr><th>Participants' characteristics</th><th>β</th><th>SE</th><th>p-value</th></tr></thead><tbody><tr><td rowspan="5">Positive Sexual Perception (Psp)</td><td>Hispanic origin</td><td>-18.50</td><td>6.61</td><td>0.006</td><td rowspan="5">SD = 5.7<br>ICC = 0.04<br>R<sup>2</sup> = 0.34</td></tr><tr><td>Very satisfied about health care</td><td>-14.13</td><td>5.22</td><td>0.007</td></tr><tr><td>Cigarret use</td><td>-8.68</td><td>4.02</td><td>0.032</td></tr><tr><td>Talk about sex with health professional</td><td>-9.89</td><td>4.72</td><td>0.038</td></tr><tr><td>Worried during sex: neutral</td><td>15.60</td><td>5.29</td><td>0.004</td></tr><tr><td rowspan="9">Stigma and social distress (Sti)</td><td>Very worried during sex</td><td>18.41</td><td>6.47</td><td>0.005</td><td rowspan="9">SD = 3.03<br>ICC = 0.01<br>R<sup>2</sup> = 0.43</td></tr><tr><td>Marital status: widow</td><td>-15.57</td><td>5.67</td><td>0.007</td></tr><tr><td>Other drugs use</td><td>-13.15</td><td>5.93</td><td>0.028</td></tr><tr><td>Hispanic origin</td><td>-12.47</td><td>5.48</td><td>0.024</td></tr><tr><td>Very satisfied about health care</td><td>-9.01</td><td>3.92</td><td>0.023</td></tr><tr><td>Cigarret use</td><td>6.82</td><td>3.38</td><td>0.046</td></tr><tr><td>Anhedonia mood</td><td>8.81</td><td>4.33</td><td>0.044</td></tr><tr><td>Worried during sex</td><td>11.05</td><td>4.07</td><td>0.007</td></tr><tr><td>CV disease:</td><td>14.26</td><td>4.43</td><td>0.002</td></tr><tr><td rowspan="5">Soft sexual practices (Sof)</td><td>Worried during sex: neutral</td><td>15.56</td><td>4.23</td><td>0.000</td><td rowspan="5">SD = 4.4<br>ICC = 0.18<br>R<sup>2</sup> = 0.51</td></tr><tr><td>Very worried during sex</td><td>20.31</td><td>5.19</td><td>0.000</td></tr><tr><td>Marital status: divorced</td><td>-24.17</td><td>5.54</td><td>0.000</td></tr><tr><td>Understand about risk of HIV transmission: neutral</td><td>-24.05</td><td>9.82</td><td>0.016</td></tr><tr><td>Homosexual</td><td>-21.45</td><td>7.94</td><td>0.008</td></tr><tr><td rowspan="10">Sexual practices with partner (Sp)</td><td>Sexual stimulants use</td><td>-19.26</td><td>8.28</td><td>0.022</td><td rowspan="10">SD = 0.009<br>ICC = 0.04<br>R<sup>2</sup> = 0.56</td></tr><tr><td>Education level: university</td><td>-16.32</td><td>6.66</td><td>0.016</td></tr><tr><td>Employ: housewife</td><td>-16.01</td><td>5.86</td><td>0.008</td></tr><tr><td>Talk about sex with health professional</td><td>-13.68</td><td>4.02</td><td>0.001</td></tr><tr><td>Hopeless mood</td><td>9.91</td><td>4.04</td><td>0.016</td></tr><tr><td>African origin</td><td>13.48</td><td>4.20</td><td>0.002</td></tr><tr><td>Hispanic origin</td><td>15.84</td><td>5.24</td><td>0.003</td></tr><tr><td>Living with children</td><td>22.32</td><td>6.34</td><td>0.001</td></tr><tr><td>High awareness about risk of HIV transmission:</td><td>-44.62</td><td>19.33</td><td>0.028</td></tr><tr><td>Very Satisfied about health care</td><td>-23.21</td><td>10.01</td><td>0.027</td></tr><tr><td>HIV treatment: non-nucleoside transcriptase inhibitor</td><td>-18.96</td><td>8.23</td><td>0.028</td></tr><tr><td>Age group: 46.7-70.1</td><td>38.53</td><td>16.94</td><td>0.030</td></tr></tbody></table>

scores in *Psp*. While being worried or neutral during sex was associated with impairment in *Psp* dimension.

Regarding the *Sti* dimension, widowed, Hispanic or WHIV satisfied with health care and those who reported drug use were less likely to experience stigma and social distress. While factors as cardiovascular disease, tobacco consumption, anhedonia and being worried or neutral during sex were associated with more stigma and social distress.

Being a housewife, university level education, divorced, homosexual orientation, use of sexual stimulants, talking about sex with HCP and being aware about HIV transmission were associated with lower score of *Sof*. While depression, African origin, Hispanic origin and living with children were associated with impaired *Sof* dimension.

WHIV who reported a higher satisfaction with health care, those who were aware of the risk of HIV transmission, and those who reported non-nucleoside transcriptase inhibitor

<footnote>* the lower the score is, the better the SQoL is.</footnote>
<table><caption>Table 4. Factors associated with PROQOL-Sex Life dimensions among WHCV (multivariable linear mixed effects regression).</caption><thead><tr><th rowspan="2">SQOL dimensions (outcomes)*</th><th colspan="4">Fixed effects</th><th rowspan="2">Random effect</th></tr><tr><th>Participants' characteristics</th><th>β</th><th>SE</th><th>p-value</th></tr></thead><tbody><tr><td rowspan="10">Positive Sexual Perception (Psp)</td><td>Heterosexual transmission route (HCV)</td><td>-29.20</td><td>12.21</td><td>0.018</td><td rowspan="10">SD = 5.05<br>ICC = 0.041<br>R<sup>2</sup> = 0.34</td></tr><tr><td>Other HCV transmission route:</td><td>-25.71</td><td>12.31</td><td>0.038</td></tr><tr><td>Living with partner</td><td>-24.39</td><td>4.89</td><td>0.000</td></tr><tr><td>Injection transmission route (HCV)</td><td>-23.50</td><td>11.80</td><td>0.048</td></tr><tr><td>Living with children and partner</td><td>-21.90</td><td>5.48</td><td>0.000</td></tr><tr><td>Other drugs use</td><td>-17.00</td><td>5.93</td><td>0.005</td></tr><tr><td>Very satisfied about health care</td><td>-11.07</td><td>4.51</td><td>0.015</td></tr><tr><td>Condom use</td><td>-7.28</td><td>3.64</td><td>0.047</td></tr><tr><td>Depression</td><td>11.48</td><td>3.44</td><td>0.001</td></tr><tr><td>Age group: 40-61</td><td>14.06</td><td>4.16</td><td>0.001</td></tr><tr><td rowspan="10">Stigma and social distress (Sti)</td><td>Injection transmission route (HCV)</td><td>-30.19</td><td>9.78</td><td>0.002</td><td rowspan="10">SD = 3.02<br>ICC = 0.17<br>R<sup>2</sup> = 0.38</td></tr><tr><td>Heterosexual transmission route (HCV)</td><td>-25.64</td><td>10.34</td><td>0.014</td></tr><tr><td>Very satisfied about health care</td><td>-14.10</td><td>3.72</td><td>0.000</td></tr><tr><td>Asian origin</td><td>-11.48</td><td>5.47</td><td>0.038</td></tr><tr><td>Other drugs use</td><td>-10.64</td><td>5.04</td><td>0.036</td></tr><tr><td>Satisfied about health care</td><td>-7.69</td><td>3.34</td><td>0.023</td></tr><tr><td>Depression</td><td>10.03</td><td>3.18</td><td>0.002</td></tr><tr><td>Condom use</td><td>15.09</td><td>3.11</td><td>0.000</td></tr><tr><td>Take anticholesterol</td><td>15.36</td><td>7.33</td><td>0.038</td></tr><tr><td>Bactrim use as prevention treatment</td><td>23.64</td><td>11.10</td><td>0.035</td></tr><tr><td rowspan="10">Soft sexual practices (Sof)</td><td>Other living mode</td><td>-22.63</td><td>6.60</td><td>0.001</td><td rowspan="10">SD = 0.02<br>ICC = 0.18<br>R<sup>2</sup> = 0.36</td></tr><tr><td>Asian origin</td><td>-22.16</td><td>6.34</td><td>0.001</td></tr><tr><td>Education level: university</td><td>-14.61</td><td>6.69</td><td>0.032</td></tr><tr><td>Education level: high school</td><td>-12.44</td><td>5.95</td><td>0.039</td></tr><tr><td>Alcohol consumption</td><td>-9.30</td><td>4.42</td><td>0.038</td></tr><tr><td>Satisfied about health care</td><td>-8.42</td><td>4.32</td><td>0.054</td></tr><tr><td>Age group: 40-61</td><td>10.60</td><td>4.01</td><td>0.010</td></tr><tr><td>Cocaine consumption</td><td>14.42</td><td>6.86</td><td>0.039</td></tr><tr><td>Other HCV transmission route</td><td>22.19</td><td>10.96</td><td>0.046</td></tr><tr><td rowspan="4">Sexual practices with partner (Sp)</td><td>Hispanic origin</td><td>-21.90</td><td>9.45</td><td>0.029</td><td rowspan="4">SD = 0.05<br>ICC = 0.07<br>R<sup>2</sup> = 0.40</td></tr><tr><td>Depression</td><td>20.21</td><td>9.48</td><td>0.043</td></tr><tr><td>Unemployed</td><td>22.94</td><td>10.67</td><td>0.041</td></tr><tr><td>Living with children</td><td>38.94</td><td>13.90</td><td>0.010</td></tr></tbody></table>

treatment reported also lower score of *Sp*. Being older than 46 years was associated with a impaired *Sp*.

Adding country as random effect, Brazil in *Psp* dimension (-7), in *Sti* dimension (-2) and in *Sof* dimension (-5), while Australia (-7) in *Sp* dimension had a better outcome comparing with others countries. The Fig 1 showed how participants from five countries interact in PROQoL--Sex Life among WHIV.

Among WHCV (Table 4), being older than 40 years, and depression were associated with impaired *Psp* dimension. While living with a partner, drug use, heterosexual and injection HCV transmission route, higher satisfaction about health care, and condom use were associated with lower score of *Psp* dimension.

<footnote>* the lower the score is, the better the SQoL is.</footnote>
<table><caption>Table 4. Factors associated with PROQOL-Sex Life dimensions among WHCV (multivariable linear mixed effects regression).</caption><thead><tr><th rowspan="2">SQOL dimensions (outcomes)*</th><th colspan="4">Fixed effects</th><th rowspan="2">Random effect</th></tr><tr><th>Participants' characteristics</th><th>β</th><th>SE</th><th>p-value</th></tr></thead><tbody><tr><td rowspan="10">Positive Sexual Perception (Psp)</td><td>Heterosexual transmission route (HCV)</td><td>-29.20</td><td>12.21</td><td>0.018</td><td rowspan="10">SD = 5.05<br>ICC = 0.041<br>R<sup>2</sup> = 0.34</td></tr><tr><td>Other HCV transmission route:</td><td>-25.71</td><td>12.31</td><td>0.038</td></tr><tr><td>Living with partner</td><td>-24.39</td><td>4.89</td><td>0.000</td></tr><tr><td>Injection transmission route (HCV)</td><td>-23.50</td><td>11.80</td><td>0.048</td></tr><tr><td>Living with children and partner</td><td>-21.90</td><td>5.48</td><td>0.000</td></tr><tr><td>Other drugs use</td><td>-17.00</td><td>5.93</td><td>0.005</td></tr><tr><td>Very satisfied about health care</td><td>-11.07</td><td>4.51</td><td>0.015</td></tr><tr><td>Condom use</td><td>-7.28</td><td>3.64</td><td>0.047</td></tr><tr><td>Depression</td><td>11.48</td><td>3.44</td><td>0.001</td></tr><tr><td>Age group: 40-61</td><td>14.06</td><td>4.16</td><td>0.001</td></tr><tr><td rowspan="10">Stigma and social distress (Sti)</td><td>Injection transmission route (HCV)</td><td>-30.19</td><td>9.78</td><td>0.002</td><td rowspan="10">SD = 3.02<br>ICC = 0.17<br>R<sup>2</sup> = 0.38</td></tr><tr><td>Heterosexual transmission route (HCV)</td><td>-25.64</td><td>10.34</td><td>0.014</td></tr><tr><td>Very satisfied about health care</td><td>-14.10</td><td>3.72</td><td>0.000</td></tr><tr><td>Asian origin</td><td>-11.48</td><td>5.47</td><td>0.038</td></tr><tr><td>Other drugs use</td><td>-10.64</td><td>5.04</td><td>0.036</td></tr><tr><td>Satisfied about health care</td><td>-7.69</td><td>3.34</td><td>0.023</td></tr><tr><td>Depression</td><td>10.03</td><td>3.18</td><td>0.002</td></tr><tr><td>Condom use</td><td>15.09</td><td>3.11</td><td>0.000</td></tr><tr><td>Take anticholesterol</td><td>15.36</td><td>7.33</td><td>0.038</td></tr><tr><td>Bactrim use as prevention treatment</td><td>23.64</td><td>11.10</td><td>0.035</td></tr><tr><td rowspan="10">Soft sexual practices (Sof)</td><td>Other living mode</td><td>-22.63</td><td>6.60</td><td>0.001</td><td rowspan="10">SD = 0.02<br>ICC = 0.18<br>R<sup>2</sup> = 0.36</td></tr><tr><td>Asian origin</td><td>-22.16</td><td>6.34</td><td>0.001</td></tr><tr><td>Education level: university</td><td>-14.61</td><td>6.69</td><td>0.032</td></tr><tr><td>Education level: high school</td><td>-12.44</td><td>5.95</td><td>0.039</td></tr><tr><td>Alcohol consumption</td><td>-9.30</td><td>4.42</td><td>0.038</td></tr><tr><td>Satisfied about health care</td><td>-8.42</td><td>4.32</td><td>0.054</td></tr><tr><td>Age group: 40-61</td><td>10.60</td><td>4.01</td><td>0.010</td></tr><tr><td>Cocaine consumption</td><td>14.42</td><td>6.86</td><td>0.039</td></tr><tr><td>Other HCV transmission route</td><td>22.19</td><td>10.96</td><td>0.046</td></tr><tr><td rowspan="4">Sexual practices with partner (Sp)</td><td>Hispanic origin</td><td>-21.90</td><td>9.45</td><td>0.029</td><td rowspan="4">SD = 0.05<br>ICC = 0.07<br>R<sup>2</sup> = 0.40</td></tr><tr><td>Depression</td><td>20.21</td><td>9.48</td><td>0.043</td></tr><tr><td>Unemployed</td><td>22.94</td><td>10.67</td><td>0.041</td></tr><tr><td>Living with children</td><td>38.94</td><td>13.90</td><td>0.010</td></tr></tbody></table>

treatment reported also lower score of *Sp*. Being older than 46 years was associated with a impaired *Sp*.

Adding country as random effect, Brazil in *Psp* dimension (-7), in *Sti* dimension (-2) and in *Sof* dimension (-5), while Australia (-7) in *Sp* dimension had a better outcome comparing with others countries. The Fig 1 showed how participants from five countries interact in PROQoL--Sex Life among WHIV.

Among WHCV (Table 4), being older than 40 years, and depression were associated with impaired *Psp* dimension. While living with a partner, drug use, heterosexual and injection HCV transmission route, higher satisfaction about health care, and condom use were associated with lower score of *Psp* dimension.

<footnote>* the lower the score is, the better the SQoL is.</footnote>
<figure><img src="image_3.png" /><figcaption>Fig 1. Variation of scores due to random effect among WHIV.</figcaption></figure>

https://doi.org/10.1371/journal.pone.0278054.g001

Regarding the second dimension *Sti*, Asian origin and drug use were associated with lower score of *Sti* dimension, in addition WHCV with a higher satisfaction about health care, and who reported injection route of HCV transmission were less likely to experience stigma. In contrast, depression, taking Bactrim as prevention treatment that reflects a lower CD4 count and consistent condom use were associated with impaired *Sti* dimension.

For soft sexual practices dimension, satisfaction about health care, asian origin, higher level of education, alcohol consumption, and living with other family members were associated with lower score of *Sof* dimension. Being older than 40 years was associated with impaired *Sof* dimension as well as cocaine consumption.

Factors associated with lower score of sexual practices with a partner was Hispanic origin, while depression, unemployment and living with children were associated with worse *Sp* dimension.

Adding Country as random effect, Brazil in *Psp* Dimension (-6), USA in *Sti* dimension (-0.93), in *Sof* dimension (-1) and Brazil in *Sp* dimension (-2.1); had a better outcome comparing with other others countries; the ICC was not bigger than 0.20, which means that variation explained by Country was not wide (Fig 2).

Discussion

This multicountry study is one of the first studies that explore the SQoL among WHIV and WHCV. It showed a great variability through individual characteristics (sociodemographic and physiological) and structural factors (satisfaction with health system, including patient-
<figure><img src="image_4.png" /><figcaption>Fig 1. Variation of scores due to random effect among WHIV.</figcaption></figure>

https://doi.org/10.1371/journal.pone.0278054.g001

Regarding the second dimension *Sti*, Asian origin and drug use were associated with lower score of *Sti* dimension, in addition WHCV with a higher satisfaction about health care, and who reported injection route of HCV transmission were less likely to experience stigma. In contrast, depression, taking Bactrim as prevention treatment that reflects a lower CD4 count and consistent condom use were associated with impaired *Sti* dimension.

For soft sexual practices dimension, satisfaction about health care, asian origin, higher level of education, alcohol consumption, and living with other family members were associated with lower score of *Sof* dimension. Being older than 40 years was associated with impaired *Sof* dimension as well as cocaine consumption.

Factors associated with lower score of sexual practices with a partner was Hispanic origin, while depression, unemployment and living with children were associated with worse *Sp* dimension.

Adding Country as random effect, Brazil in *Psp* Dimension (-6), USA in *Sti* dimension (-0.93), in *Sof* dimension (-1) and Brazil in *Sp* dimension (-2.1); had a better outcome comparing with other others countries; the ICC was not bigger than 0.20, which means that variation explained by Country was not wide (Fig 2).

Discussion

This multicountry study is one of the first studies that explore the SQoL among WHIV and WHCV. It showed a great variability through individual characteristics (sociodemographic and physiological) and structural factors (satisfaction with health system, including patient-
<figure><img src="image_4.png" /><figcaption>Fig 2. Variation of scores due to random effect among WHCV.</figcaption></figure>

https://doi.org/10.1371/journal.pone.0278054.g002

HCP relationship and quality of health care). However, no significant variability between countries was observed.

Our analysis revealed globally higher scores of the SQoL, meaning a high sexual problems among WHIV and WHCV for most PROQoL-Sex Life's dimensions. But, it was lesser for Sexual practices with partner dimension. In fact, the participants had commonly a better score for the dimension "Sexual practices with partner", which included preliminary and vaginal sexual relation aspects of sexual life. About four participants out of ten reported being married or living with a partner, with or without children, that may provide sexual satisfaction but also indirectly support in order to face stigmatization and other social rejection [23]. As highlighted in previous studies, sexual dissatisfaction was more reported in PLWHIV who did not have a regular sexual partner or were not living in couple [24, 25]. Studies either in WHIV or WHCV found that female sexual dysfunctions including desire, arousal, pain, orgasm, lubrication and satisfaction, were frequently reported [3, 10, 15, 26-28]. Many factors may affect female sexual function, including psychological and couple relationship factors [27]. Furthermore medical staff and social support, as mentioned in many other studies could be therefore needed to improve their global QoL, including the sexual dimensions [29-31]. For example, social support contributes to better global HRQOL by promoting healthy behaviors, avoiding stress and enhancing adherence to antiretroviral treatments [32-34].

We observed that, for WHIV the scores for all SQoL dimensions were slightly higher than those in WHCV. Even if this difference remains unclear, it should be noted that the characteristics of WHIV and WHCV included in this study were statistically different, in particular age, marital status, geographical origin but also consumption and sexual behavior. Besides, the
<figure><img src="image_5.png" /><figcaption>Fig 2. Variation of scores due to random effect among WHCV.</figcaption></figure>

https://doi.org/10.1371/journal.pone.0278054.g002

HCP relationship and quality of health care). However, no significant variability between countries was observed.

Our analysis revealed globally higher scores of the SQoL, meaning a high sexual problems among WHIV and WHCV for most PROQoL-Sex Life's dimensions. But, it was lesser for Sexual practices with partner dimension. In fact, the participants had commonly a better score for the dimension "Sexual practices with partner", which included preliminary and vaginal sexual relation aspects of sexual life. About four participants out of ten reported being married or living with a partner, with or without children, that may provide sexual satisfaction but also indirectly support in order to face stigmatization and other social rejection [23]. As highlighted in previous studies, sexual dissatisfaction was more reported in PLWHIV who did not have a regular sexual partner or were not living in couple [24, 25]. Studies either in WHIV or WHCV found that female sexual dysfunctions including desire, arousal, pain, orgasm, lubrication and satisfaction, were frequently reported [3, 10, 15, 26-28]. Many factors may affect female sexual function, including psychological and couple relationship factors [27]. Furthermore medical staff and social support, as mentioned in many other studies could be therefore needed to improve their global QoL, including the sexual dimensions [29-31]. For example, social support contributes to better global HRQOL by promoting healthy behaviors, avoiding stress and enhancing adherence to antiretroviral treatments [32-34].

We observed that, for WHIV the scores for all SQoL dimensions were slightly higher than those in WHCV. Even if this difference remains unclear, it should be noted that the characteristics of WHIV and WHCV included in this study were statistically different, in particular age, marital status, geographical origin but also consumption and sexual behavior. Besides, the
duration of the HIV infection course and especially the exposure to antiretroviral may contrib-
ute to the impairment of some SQoL dimensions.

In addition, this study highlighted that interactions between patients and HCP could be
beneficial to improve the SQoL in its global dimensions, both in WHIV and WHCV. Indeed,
those who were satisfied with health care or those who talk about sex with HCP reported better
SQoL scores. Although, there is few studies focused on the effect of interactions between
WHIV or WHCV and HCW on the SQoL, perceived discrimination in healthcare settings has
been found to be negatively associated with health-seeking behaviours, access HIV or HCV
treatment, adherence and other clinical outcomes including viral load suppression, both in
WHIV and WHCV [35-39]. Stigma against WHIV or WHCV in the healthcare settings is
widespread in some countries and could be shown as for example HCP sitting far away from
patients and or not touching them [35, 40, 41]. Besides, the role of HCP in the quality of global
health care provided to WHIV or WHCV remains essential. This takes place through good
communication allowing the establishment of an environment of mutual confidence, the good
respect of the therapeutic indications and the instructions to the adherence ART. HCP may
also take to ask their female HIV-positive patients, some essential questions related to sexual
health, which could remove the stigma around discussing sex and normalize these discussions.
In this environment, WHIV or WHCV may receive objective information about medical risks,
preventive interventions for other diseases, psychological support and about safe sex practices.

Similar to previous studies in both PLWHIV and PLWHCV, psychoactive substance use, including alcohol, were associated with better score in the positive sexual perception, stigma and social distress and soft sexual practices dimensions [42–44]. This could be explained by the fact that the women who reported substance use usually are involved in high risk sexual behavior, which produces a strong sense of euphoria, physical agility and other feelings of mood elevation [45]. This positive association must be interpreted with great caution, especially since the substance use more often leads to an alteration of consciousness, and that this relative good perception may not really reflect participants experience. Besides, unsurprisingly in WHCV, those who reported cocain use had lower score of soft sexual practices.

This study also highlighted the influence of geographical origin on scores of several dimen-
sions of SQoL. Hispanic participants reported lower scores of *Psp*, *Sti* and *Sp*, lower score of
*Sof* were reported in Asian WHCV while higher score of *Sof* were reported in African and His-
panic WHIV. This could be mediated by cultural beliefs which could greatly vary across coun-
tries and regions. In addition, findings of this study have also shown that the differences
between the five counties are not wide. It highlighted the importance of a support network
among WHIV and WHCV, focused in all social determinants for each woman, as well the
high importance that the quality of sexual activity plays as a determinant to wellbeing. Even
though, sexual health is an essential element of overall health and well-being, the sexuality of
women, including WHIV, is obscured by that of men in current patriarchal societies [46]. For
example, in African society there exists several taboos about WHIV and they have no control
about sexual practices [47]. More effort are needed in African communities to liberalize the
voice of WHIV, including the expression and respect of their sexual right.

Non-nucleoside reverse transcriptase (NNRTI) was associated with lower scores in sexual
practices with partner among WHIV. That could favor better adherence to ART overall well-
being [48]. It is important to mention that this association remained unclear, and yet a previ-
ous study found a positive relation between NNRTI and a sexual satisfaction WHIV [49]. Also
investigators suggest that this could be explained because NNRTI have a lower side effect bur-
den than protease inhibitors.

This study had some limitations related to data collection, since the questionnaire was dis-
tributed in five countries; in three different languages there were variables that were not
duration of the HIV infection course and especially the exposure to antiretroviral may contrib-
ute to the impairment of some SQoL dimensions.

In addition, this study highlighted that interactions between patients and HCP could be
beneficial to improve the SQoL in its global dimensions, both in WHIV and WHCV. Indeed,
those who were satisfied with health care or those who talk about sex with HCP reported better
SQoL scores. Although, there is few studies focused on the effect of interactions between
WHIV or WHCV and HCW on the SQoL, perceived discrimination in healthcare settings has
been found to be negatively associated with health-seeking behaviours, access HIV or HCV
treatment, adherence and other clinical outcomes including viral load suppression, both in
WHIV and WHCV [35-39]. Stigma against WHIV or WHCV in the healthcare settings is
widespread in some countries and could be shown as for example HCP sitting far away from
patients and or not touching them [35, 40, 41]. Besides, the role of HCP in the quality of global
health care provided to WHIV or WHCV remains essential. This takes place through good
communication allowing the establishment of an environment of mutual confidence, the good
respect of the therapeutic indications and the instructions to the adherence ART. HCP may
also take to ask their female HIV-positive patients, some essential questions related to sexual
health, which could remove the stigma around discussing sex and normalize these discussions.
In this environment, WHIV or WHCV may receive objective information about medical risks,
preventive interventions for other diseases, psychological support and about safe sex practices.

Similar to previous studies in both PLWHIV and PLWHCV, psychoactive substance use, including alcohol, were associated with better score in the positive sexual perception, stigma and social distress and soft sexual practices dimensions [42–44]. This could be explained by the fact that the women who reported substance use usually are involved in high risk sexual behavior, which produces a strong sense of euphoria, physical agility and other feelings of mood elevation [45]. This positive association must be interpreted with great caution, especially since the substance use more often leads to an alteration of consciousness, and that this relative good perception may not really reflect participants experience. Besides, unsurprisingly in WHCV, those who reported cocain use had lower score of soft sexual practices.

This study also highlighted the influence of geographical origin on scores of several dimen-
sions of SQoL. Hispanic participants reported lower scores of *Psp*, *Sti* and *Sp*, lower score of
*Sof* were reported in Asian WHCV while higher score of *Sof* were reported in African and His-
panic WHIV. This could be mediated by cultural beliefs which could greatly vary across coun-
tries and regions. In addition, findings of this study have also shown that the differences
between the five counties are not wide. It highlighted the importance of a support network
among WHIV and WHCV, focused in all social determinants for each woman, as well the
high importance that the quality of sexual activity plays as a determinant to wellbeing. Even
though, sexual health is an essential element of overall health and well-being, the sexuality of
women, including WHIV, is obscured by that of men in current patriarchal societies [46]. For
example, in African society there exists several taboos about WHIV and they have no control
about sexual practices [47]. More effort are needed in African communities to liberalize the
voice of WHIV, including the expression and respect of their sexual right.

Non-nucleoside reverse transcriptase (NNRTI) was associated with lower scores in sexual practices with partner among WHIV. That could favor better adherence to ART overall well-being [48]. It is important to mention that this association remained unclear, and yet a previous study found a positive relation between NNRTI and a sexual satisfaction WHIV [49]. Also investigators suggest that this could be explained because NNRTI have a lower side effect burden than protease inhibitors.

This study had some limitations related to data collection, since the questionnaire was dis-
tributed in five countries; in three different languages there were variables that were not
identical. Some countries had lower number of patients and especially variables as homosexual relationship status or taking drugs and Viagra, which was a limit for the study. In addition, clinical data was self-reported by the participants, and a recall bias may have affected the data, as well it was difficult to establish temporal relationships between variables. There are behavioral variables that could not be modified by interventions, such as the care or advice of health-care workers. Our data are from a cross-sectional study and they cannot claim the determination of causality, so they are limited to describing the associations.

## Conclusion

This study revealed fairly higher scores in SQoL dimensions among WHIV and WHCV in these five countries. In addition the quality of health care, and psychoactive substance use (except cocaine) were associated with the quality of sexual life in WHIV and WHCV. This give us a wide vision about the necessity to assess WHIV and WHCV patients not only clinical analysis but also all determinants, in order to improve their quality of sexual life.

## Acknowledgments

We acknowledge people living with HIV and people living with HCV who have contributed to this study.

## Author Contributions

**Conceptualization:** Sara Rodriguez, Martin Duracinsky.

**Data curation:** Sara Rodriguez, Pascal Bessonneau.

**Formal analysis:** Sara Rodriguez, Issifou Yaya, Fatima Etemadi, Pascal Bessonneau.

**Funding acquisition:** Olivier Chassany, Martin Duracinsky.

**Investigation:** Olivier Chassany, Martin Duracinsky.

**Methodology:** Olivier Chassany, Martin Duracinsky.

**Project administration:** Olivier Chassany, Martin Duracinsky.

**Software:** Sara Rodriguez.

**Supervision:** Martin Duracinsky.

**Validation:** Issifou Yaya, Martin Duracinsky.

**Writing – original draft:** Sara Rodriguez, Issifou Yaya.

**Writing – review & editing:** Ben Huntingdon, Ilona Juraskova, Marie Preau, Fatima Etemadi, Svetlane Dimi, Maria Patrizia Carrieri, Pascal Bessonneau, Olivier Chassany, Martin Duracinsky.

## References

1. UNAIDS. Fact sheet—Latest global and regional statistics on the status of the AIDS epidemic. [Internet]. 2021 [cité 7 oct 2021]. Disponible sur: https://www.unaids.org/en/resources/documents/2021/UNAIDS_FactSheet

2. UNAIDS. Global HIV & AIDS statistics—Fact sheet [Internet]. 2021 [cité 7 oct 2021]. Disponible sur: https://www.unaids.org/en/resources/fact-sheet

3. Elshimi E, Morad W, Mohamad NE, Shebl N, Waked I. Female sexual dysfunction among Egyptian patients with chronic hepatitis C. J Sex Med. mars 2014; 11(3):768-75. https://doi.org/10.1111/jsm.12412 PMID: 24283464
identical. Some countries had lower number of patients and especially variables as homosexual relationship status or taking drugs and Viagra, which was a limit for the study. In addition, clinical data was self-reported by the participants, and a recall bias may have affected the data, as well it was difficult to establish temporal relationships between variables. There are behavioral variables that could not be modified by interventions, such as the care or advice of health-care workers. Our data are from a cross-sectional study and they cannot claim the determination of causality, so they are limited to describing the associations.

## Conclusion

This study revealed fairly higher scores in SQoL dimensions among WHIV and WHCV in these five countries. In addition the quality of health care, and psychoactive substance use (except cocaine) were associated with the quality of sexual life in WHIV and WHCV. This gives us a wide vision about the necessity to assess WHIV and WHCV patients not only clinical analysis but also all determinants, in order to improve their quality of sexual life.

## Acknowledgments

We acknowledge people living with HIV and people living with HCV who have contributed to this study.

## Author Contributions

**Conceptualization:** Sara Rodriguez, Martin Duracinsky.

**Data curation:** Sara Rodriguez, Pascal Bessonneau.

**Formal analysis:** Sara Rodriguez, Issifou Yaya, Fatima Etemadi, Pascal Bessonneau.

**Funding acquisition:** Olivier Chassany, Martin Duracinsky.

**Investigation:** Olivier Chassany, Martin Duracinsky.

**Methodology:** Olivier Chassany, Martin Duracinsky.

**Project administration:** Olivier Chassany, Martin Duracinsky.

**Software:** Sara Rodriguez.

**Supervision:** Martin Duracinsky.

**Validation:** Issifou Yaya, Martin Duracinsky.

**Writing – original draft:** Sara Rodriguez, Issifou Yaya.

**Writing – review & editing:** Ben Huntingdon, Ilona Juraskova, Marie Preau, Fatima Etemadi, Svetlane Dimi, Maria Patrizia Carrieri, Pascal Bessonneau, Olivier Chassany, Martin Duracinsky.

## References

1. UNAIDS. Fact sheet—Latest global and regional statistics on the status of the AIDS epidemic. [Internet]. 2021 [cité 7 oct 2021]. Disponible sur: https://www.unaids.org/en/resources/documents/2021/UNAIDS_FactSheet

2. UNAIDS. Global HIV & AIDS statistics—Fact sheet [Internet]. 2021 [cité 7 oct 2021]. Disponible sur: https://www.unaids.org/en/resources/fact-sheet

3. Elshimi E, Morad W, Mohamad NE, Shebl N, Waked I. Female sexual dysfunction among Egyptian patients with chronic hepatitis C. J Sex Med. mars 2014; 11(3):768-75. https://doi.org/10.1111/jsm.12412 PMID: 24283464
4. Jacobson IM, Cacoub P, Dal Maso L, Harrison SA, Younossi ZM. Manifestations of chronic hepatitis C virus infection beyond the liver. Clin Gastroenterol Hepatol. déc 2010; 8(12):1017-29. https://doi.org/10.1016/j.cgh.2010.08.026 PMID: 20870037

5. Fletcher NF, McKeating JA. Hepatitis C virus and the brain. J Viral Hepat. mai 2012; 19(5):301-6. https://doi.org/10.1111/j.1365-2893.2012.01591.x PMID: 22497808

6. Miners A, Phillips A, Kreif N, Rodger A, Speakman A, Fisher M, et al. Health-related quality-of-life of people with HIV in the era of combination antiretroviral treatment: a cross-sectional comparison with the general population. Lancet HIV. oct 2014; 1(1):e32-40. https://doi.org/10.1016/S2352-3018(14)70018-9 PMID: 26423814

7. Popping S, Kall M, Nichols BE, Stempher E, Versteegh L, van de Vijver DAMC, et al. Quality of life among people living with HIV in England and the Netherlands: a population-based study. Lancet Reg Health Eur. sept 2021; 8:100177. https://doi.org/10.1016/j.lanepe.2021.100177 PMID: 34557859

8. World Health Organization (WHO), United Nations Population Fund (UNFPA). Sexual and reproductive health of women living with HIV/AIDS: guidelines on care, treatment and support for women living with HIV/AIDS and their children in resource-constrained settings [Internet]. Geneva: WHO; 2006 [cité 13 oct 2021] p. 83. Disponible sur: https://www.who.int/hiv/pub/guidelines/sexualreproductivehealth.pdf

9. Soykan A, Boztaş H, Idilman R, Ozel ET, Tüzün AE, Ozden A, et al. Sexual dysfunctions in HCV patients and its correlations with psychological and biological variables. Int J Impot Res. avr 2005; 17 (2):175-9. https://doi.org/10.1038/sj.ijir.3901267 PMID: 15510190

10. Toorabally N, Mercer CH, Mitchell KR, Blell M, Burns F, Gilson R, et al. Association of HIV status with sexual function in women aged 45-60 in England: results from two national surveys. AIDS Care. mars 2020; 32(3):286-95. https://doi.org/10.1080/09540121.2019.1653436 PMID: 31411046

11. Fane ME, Bensghir R, Sbai S, Chakib A, Kadiri N, Ayouch A, et al. Quality of sexual life for people living with HIV (PLWHA). Sexologies. 2011; 3(20):158-62.

12. Huntingdon B, Muscat DM, de Wit J, Duracinsky M, Juraskova I. Factors Associated with General Sexual Functioning and Sexual Satisfaction among People Living with HIV: A Systematic Review. J Sex Res. sept 2020; 57(7):824-35. https://doi.org/10.1080/00224499.2019.1689379 PMID: 31755793

13. Florence E, Schrooten W, Dreezen C, Gordillo V, Nilsson Schönnesson L, Asboe D, et al. Prevalence and factors associated with sexual dysfunction among HIV-positive women in Europe. AIDS Care. juill 2004; 16(5):550-7. https://doi.org/10.1080/09540120410001716333 PMID: 15223523

14. Bell C, Richardson D, Wall M, Goldmeier D. HIV-associated female sexual dysfunction—clinical experience and literature review. Int J STD AIDS. oct 2006; 17(10):706-9. https://doi.org/10.1258/095646206780071063 PMID: 17059642

15. Wilson TE, Jean-Louis G, Schwartz R, Golub ET, Cohen MH, Maki P, et al. HIV infection and women's sexual functioning. J Acquir Immune Defic Syndr. août 2010; 54(4):360-7. https://doi.org/10.1097/QAI. 0b013e3181d01b14 PMID: 20179602

16. Westbrook RH, Dusheiko G. Natural history of hepatitis C. J Hepatol. nov 2014; 61(1 Suppl):S58-68. https://doi.org/10.1016/j.jhep.2014.07.012 PMID: 25443346

17. Baker BD, Lea EJ, Lavakumar M. The impact of HIV on sexual functioning: Considerations for clinicians. Psychotherapy (Chic). mars 2020; 57(1):75-82. https://doi.org/10.1037/pst0000268 PMID: 31855043

18. El Kassas M, Salah E, Gad A, Hosny A. Improvement of sexual dysfunction in patients after treatment of hepatitis C virus using directly acting antivirals. Curr Med Res Opin. juin 2021; 37(6):967-72. https:// doi.org/10.1080/03007995.2021.1901677 PMID: 33688780

19. Duracinsky M, Fofana D, Juraskova I, Hungting B, Préau M, Da Silva M, et al. PIN161 Validation of a Sexual Quality of Life Questionnaire in HIV and Hepatitis C (PROQOL-SEXLIFE). Value in Health. 1 déc 2020; 23:S570-1.

20. Kowarik A, Templ M. Imputation with the R package VIM. J Stat Softw. 2016.

21. Kuhn M. Caret Package. J Stat Softw. 2008.

22. Bates D. Fitting linear mixed models in R. R News. 2005.

23. Carlsson-Lalloo E, Rusner M, Mellgren Å, Berg M. Sexuality and Reproduction in HIV-Positive Women: A Meta-Synthesis. AIDS Patient Care STDS. févr 2016; 30(2):56-69. https://doi.org/10.1089/apc.2015. 0260 PMID: 26741804

24. Lazăr F, Verdeş L, Henry E, Fugon L, Bernier A, Otis J, et al. Satisfaction with sexual life in people living with HIV in Romania, together with associated individual and social factors. AIDS Care. 2014; 26 Suppl 1:S65-69. https://doi.org/10.1080/09540121.2014.906550 PMID: 24735229

25. Rojas Castro D, Le Gall JM, Andreo C, Spire B. Stigma, discrimination, and sexual (dis)satisfaction among people living with HIV: results from the « AIDES et toi » survey. AIDS Care. août 2010; 22 (8):961-9. https://doi.org/10.1080/09540121003758614 PMID: 20552468
4. Jacobson IM, Cacoub P, Dal Maso L, Harrison SA, Younossi ZM. Manifestations of chronic hepatitis C virus infection beyond the liver. Clin Gastroenterol Hepatol. déc 2010; 8(12):1017-29. https://doi.org/10.1016/j.cgh.2010.08.026 PMID: 20870037

5. Fletcher NF, McKeating JA. Hepatitis C virus and the brain. J Viral Hepat. mai 2012; 19(5):301-6. https://doi.org/10.1111/j.1365-2893.2012.01591.x PMID: 22497808

6. Miners A, Phillips A, Kreif N, Rodger A, Speakman A, Fisher M, et al. Health-related quality-of-life of people with HIV in the era of combination antiretroviral treatment: a cross-sectional comparison with the general population. Lancet HIV. oct 2014; 1(1):e32-40. https://doi.org/10.1016/S2352-3018(14)70018-9 PMID: 26423814

7. Popping S, Kall M, Nichols BE, Stempher E, Versteegh L, van de Vijver DAMC, et al. Quality of life among people living with HIV in England and the Netherlands: a population-based study. Lancet Reg Health Eur. sept 2021; 8:100177. https://doi.org/10.1016/j.lanepe.2021.100177 PMID: 34557859

8. World Health Organization (WHO), United Nations Population Fund (UNFPA). Sexual and reproductive health of women living with HIV/AIDS: guidelines on care, treatment and support for women living with HIV/AIDS and their children in resource-constrained settings [Internet]. Geneva: WHO; 2006 [cité 13 oct 2021] p. 83. Disponible sur: https://www.who.int/hiv/pub/guidelines/sexualreproductivehealth.pdf

9. Soykan A, Boztaş H, Idilman R, Ozel ET, Tüzün AE, Ozden A, et al. Sexual dysfunctions in HCV patients and its correlations with psychological and biological variables. Int J Impot Res. avr 2005; 17 (2):175-9. https://doi.org/10.1038/sj.ijir.3901267 PMID: 15510190

10. Toorabally N, Mercer CH, Mitchell KR, Blell M, Burns F, Gilson R, et al. Association of HIV status with sexual function in women aged 45-60 in England: results from two national surveys. AIDS Care. mars 2020; 32(3):286-95. https://doi.org/10.1080/09540121.2019.1653436 PMID: 31411046

11. Fane ME, Bensghir R, Sbai S, Chakib A, Kadiri N, Ayouch A, et al. Quality of sexual life for people living with HIV (PLWHA). Sexologies. 2011; 3(20):158-62.

12. Huntingdon B, Muscat DM, de Wit J, Duracinsky M, Juraskova I. Factors Associated with General Sexual Functioning and Sexual Satisfaction among People Living with HIV: A Systematic Review. J Sex Res. sept 2020; 57(7):824-35. https://doi.org/10.1080/00224499.2019.1689379 PMID: 31755793

13. Florence E, Schrooten W, Dreezen C, Gordillo V, Nilsson Schönnesson L, Asboe D, et al. Prevalence and factors associated with sexual dysfunction among HIV-positive women in Europe. AIDS Care. juill 2004; 16(5):550-7. https://doi.org/10.1080/09540120410001716333 PMID: 15223523

14. Bell C, Richardson D, Wall M, Goldmeier D. HIV-associated female sexual dysfunction—clinical experience and literature review. Int J STD AIDS. oct 2006; 17(10):706-9. https://doi.org/10.1258/095646206780071063 PMID: 17059642

15. Wilson TE, Jean-Louis G, Schwartz R, Golub ET, Cohen MH, Maki P, et al. HIV infection and women's sexual functioning. J Acquir Immune Defic Syndr. août 2010; 54(4):360-7. https://doi.org/10.1097/QAI. 0b013e3181d01b14 PMID: 20179602

16. Westbrook RH, Dusheiko G. Natural history of hepatitis C. J Hepatol. nov 2014; 61(1 Suppl):S58-68. https://doi.org/10.1016/j.jhep.2014.07.012 PMID: 25443346

17. Baker BD, Lea EJ, Lavakumar M. The impact of HIV on sexual functioning: Considerations for clinicians. Psychotherapy (Chic). mars 2020; 57(1):75-82. https://doi.org/10.1037/pst0000268 PMID: 31855043

18. El Kassas M, Salah E, Gad A, Hosny A. Improvement of sexual dysfunction in patients after treatment of hepatitis C virus using directly acting antivirals. Curr Med Res Opin. juin 2021; 37(6):967-72. https:// doi.org/10.1080/03007995.2021.1901677 PMID: 33688780

19. Duracinsky M, Fofana D, Juraskova I, Hungting B, Préau M, Da Silva M, et al. PIN161 Validation of a Sexual Quality of Life Questionnaire in HIV and Hepatitis C (PROQOL-SEXLIFE). Value in Health. 1 déc 2020; 23:S570-1.

20. Kowarik A, Templ M. Imputation with the R package VIM. J Stat Softw. 2016.

21. Kuhn M. Caret Package. J Stat Softw. 2008.

22. Bates D. Fitting linear mixed models in R. R News. 2005.

23. Carlsson-Lalloo E, Rusner M, Mellgren Å, Berg M. Sexuality and Reproduction in HIV-Positive Women: A Meta-Synthesis. AIDS Patient Care STDS. févr 2016; 30(2):56-69. https://doi.org/10.1089/apc.2015. 0260 PMID: 26741804

24. Lazăr F, Verdeş L, Henry E, Fugon L, Bernier A, Otis J, et al. Satisfaction with sexual life in people living with HIV in Romania, together with associated individual and social factors. AIDS Care. 2014; 26 Suppl 1:S65-69. https://doi.org/10.1080/09540121.2014.906550 PMID: 24735229

25. Rojas Castro D, Le Gall JM, Andreo C, Spire B. Stigma, discrimination, and sexual (dis)satisfaction among people living with HIV: results from the « AIDES et toi » survey. AIDS Care. août 2010; 22 (8):961-9. https://doi.org/10.1080/09540121003758614 PMID: 20552468
26. Bouhnik A-D, Préau M, Schiltz M-A, Obadia Y, Spire B, VESPA study group. Sexual difficulties in people living with HIV in France—results from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA). AIDS Behav. juill 2008; 12(4):670-6. https://doi.org/10.1007/s10461-007-9355-z PMID: 18188689

27. Agaba PA, Meloni ST, Sule HM, Agaba EI, Idoko JA, Kanki PJ. Sexual dysfunction and its determinants among women infected with HIV. Int J Gynaecol Obstet. juin 2017; 137(3):301-8. https://doi.org/10.1002/ijgo.12140 PMID: 28273350

28. Elshimi E, Sakr N, Morad W, Mohamad NE, Waked I. Direct-acting antiviral drugs improve the female sexual burden associated with chronic HCV infection. Expert Rev Anti Infect Ther. nov 2019; 17 (11):919-26. https://doi.org/10.1080/14787210.2019.1682551 PMID: 31625425

29. George S, Bergin C, Clarke S, Courtney G, Codd MB. Health-related quality of life and associated factors in people with HIV: an Irish cohort study. Health Qual Life Outcomes. 5 août 2016; 14(1):115. https://doi.org/10.1186/s12955-016-0517-4 PMID: 27495166

30. Abebe Weldsilase Y, Likka MH, Wakayo T, Gerbaba M. Health-Related Quality of Life and Associated Factors among Women on Antiretroviral Therapy in Health Facilities of Jimma Town, Southwest Ethiopia. Advances in Public Health. 16 sept 2018; 2018:e5965343.

31. Anuradha S, Makkar AM, Nandi PK, Rajeshwari K. Quality of life and its determinants among people living with HIV attending an antiretroviral treatment center in Delhi, India. Indian J Public Health. juin 2020; 64(2):148-53. PMID: 32584297

32. Vyavaharkar M, Moneyham L, Tavakoli A, Phillips KD, Murdaugh C, Jackson K, et al. Social support, coping, and medication adherence among HIV-positive women with depression living in rural areas of the southeastern United States. AIDS Patient Care STDS. sept 2007; 21(9):667-80. https://doi.org/10.1089/apc.2006.0131 PMID: 17919094

33. Rueda S, Raboud J, Mustard C, Bayoumi A, Lavis JN, Rourke SB. Employment status is associated with both physical and mental health quality of life in people living with HIV. AIDS Care. avr 2011; 23 (4):435-43. https://doi.org/10.1080/09540121.2010.507952 PMID: 21271396

34. Bekele T, Rourke SB, Tucker R, Greene S, Sobota M, Koornstra J, et al. Direct and indirect effects of perceived social support on health-related quality of life in persons living with HIV/AIDS. AIDS Care. 2013; 25(3):337-46. https://doi.org/10.1080/09540121.2012.701716 PMID: 22774876

35. Brener L, Horwitz R, von Hippel C, Bryant J, Treloar C. Discrimination by health care workers versus discrimination by others: countervailing forces on HCV treatment intentions. Psychol Health Med. 2015; 20(2):148-53. https://doi.org/10.1080/13548506.2014.923103 PMID: 24889417

36. Sweeney SM, Vanable PA. The Association of HIV-Related Stigma to HIV Medication Adherence: A Systematic Review and Synthesis of the Literature. AIDS Behav. janv 2016; 20(1):29-50. https://doi.org/10.1007/s10461-015-1164-1 PMID: 26303196

37. Turan B, Rogers AJ, Rice WS, Atkins GC, Cohen MH, Wilson TE, et al. Association between Perceived Discrimination in Healthcare Settings and HIV Medication Adherence: Mediating Psychosocial Mechanisms. AIDS Behav. déc 2017; 21(12):3431-9. https://doi.org/10.1007/s10461-017-1957-5 PMID: 29081045

38. Kemp CG, Lipira L, Huh D, Nevin PE, Turan JM, Simoni JM, et al. HIV stigma and viral load among African-American women receiving treatment for HIV. AIDS. 15 juill 2019; 33(9):1511-9. https://doi.org/10.1097/QAD.0000000000002212 PMID: 31259767

39. Armoon B, Higgs P, Fleury M-J, Bayat A-H, Moghaddam LF, Bayani A, et al. Socio-demographic, clinical and service use determinants associated with HIV related stigma among people living with HIV/AIDS: a systematic review and meta-analysis. BMC Health Serv Res. 22 sept 2021; 21(1):1004. https://doi.org/10.1186/s12913-021-06980-6 PMID: 34551772

40. Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend. 11 mai 2007; 88(2-3):188-96. https://doi.org/10.1016/j.drugalcdep.2006.10.014 PMID: 17118578

41. Nyamathi A, Ekstrand M, Zolt-Gilburne J, Ganguly K, Sinha S, Ramakrishnan P, et al. Correlates of stigma among rural Indian women living with HIV/AIDS. AIDS Behav. janv 2013; 17(1):329-39. https://doi.org/10.1007/s10461-011-0041-9 PMID: 21915715

42. Yeung MW, Young J, Moodie E, Rollet-Kurhajec KC, Schwartzman K, Greenaway C, et al. Changes in quality of life, healthcare use, and substance use in HIV/hepatitis C coinfected patients after hepatitis C therapy: a prospective cohort study. HIV Clin Trials. juin 2015; 16(3):100-10. https://doi.org/10.1179/5011000000024 PMID: 25972048

43. Walter KN, Petry NM. Lifetime suicide attempt history, quality of life, and objective functioning among HIV/AIDS patients with alcohol and illicit substance use disorders. Int J STD AIDS. mai 2016; 27 (6):476-85. https://doi.org/10.1177/0956462415585668 PMID: 25953963
26. Bouhnik A-D, Préau M, Schiltz M-A, Obadia Y, Spire B, VESPA study group. Sexual difficulties in people living with HIV in France—results from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA). AIDS Behav. juill 2008; 12(4):670-6. https://doi.org/10.1007/s10461-007-9355-z PMID: 18188689

27. Agaba PA, Meloni ST, Sule HM, Agaba EI, Idoko JA, Kanki PJ. Sexual dysfunction and its determinants among women infected with HIV. Int J Gynaecol Obstet. juin 2017; 137(3):301-8. https://doi.org/10.1002/ijgo.12140 PMID: 28273350

28. Elshimi E, Sakr N, Morad W, Mohamad NE, Waked I. Direct-acting antiviral drugs improve the female sexual burden associated with chronic HCV infection. Expert Rev Anti Infect Ther. nov 2019; 17 (11):919-26. https://doi.org/10.1080/14787210.2019.1682551 PMID: 31625425

29. George S, Bergin C, Clarke S, Courtney G, Codd MB. Health-related quality of life and associated factors in people with HIV: an Irish cohort study. Health Qual Life Outcomes. 5 août 2016; 14(1):115. https://doi.org/10.1186/s12955-016-0517-4 PMID: 27495166

30. Abebe Weldsilase Y, Likka MH, Wakayo T, Gerbaba M. Health-Related Quality of Life and Associated Factors among Women on Antiretroviral Therapy in Health Facilities of Jimma Town, Southwest Ethiopia. Advances in Public Health. 16 sept 2018; 2018:e5965343.

31. Anuradha S, Makkar AM, Nandi PK, Rajeshwari K. Quality of life and its determinants among people living with HIV attending an antiretroviral treatment center in Delhi, India. Indian J Public Health. juin 2020; 64(2):148-53. PMID: 32584297

32. Vyavaharkar M, Moneyham L, Tavakoli A, Phillips KD, Murdaugh C, Jackson K, et al. Social support, coping, and medication adherence among HIV-positive women with depression living in rural areas of the southeastern United States. AIDS Patient Care STDS. sept 2007; 21(9):667-80. https://doi.org/10.1089/apc.2006.0131 PMID: 17919094

33. Rueda S, Raboud J, Mustard C, Bayoumi A, Lavis JN, Rourke SB. Employment status is associated with both physical and mental health quality of life in people living with HIV. AIDS Care. avr 2011; 23 (4):435-43. https://doi.org/10.1080/09540121.2010.507952 PMID: 21271396

34. Bekele T, Rourke SB, Tucker R, Greene S, Sobota M, Koornstra J, et al. Direct and indirect effects of perceived social support on health-related quality of life in persons living with HIV/AIDS. AIDS Care. 2013; 25(3):337-46. https://doi.org/10.1080/09540121.2012.701716 PMID: 22774876

35. Brener L, Horwitz R, von Hippel C, Bryant J, Treloar C. Discrimination by health care workers versus discrimination by others: countervailing forces on HCV treatment intentions. Psychol Health Med. 2015; 20(2):148-53. https://doi.org/10.1080/13548506.2014.923103 PMID: 24889417

36. Sweeney SM, Vanable PA. The Association of HIV-Related Stigma to HIV Medication Adherence: A Systematic Review and Synthesis of the Literature. AIDS Behav. janv 2016; 20(1):29-50. https://doi.org/10.1007/s10461-015-1164-1 PMID: 26303196

37. Turan B, Rogers AJ, Rice WS, Atkins GC, Cohen MH, Wilson TE, et al. Association between Perceived Discrimination in Healthcare Settings and HIV Medication Adherence: Mediating Psychosocial Mechanisms. AIDS Behav. déc 2017; 21(12):3431-9. https://doi.org/10.1007/s10461-017-1957-5 PMID: 29081045

38. Kemp CG, Lipira L, Huh D, Nevin PE, Turan JM, Simoni JM, et al. HIV stigma and viral load among African-American women receiving treatment for HIV. AIDS. 15 juill 2019; 33(9):1511-9. https://doi.org/10.1097/QAD.0000000000002212 PMID: 31259767

39. Armoon B, Higgs P, Fleury M-J, Bayat A-H, Moghaddam LF, Bayani A, et al. Socio-demographic, clinical and service use determinants associated with HIV related stigma among people living with HIV/AIDS: a systematic review and meta-analysis. BMC Health Serv Res. 22 sept 2021; 21(1):1004. https://doi.org/10.1186/s12913-021-06980-6 PMID: 34551772

40. Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend. 11 mai 2007; 88(2-3):188-96. https://doi.org/10.1016/j.drugalcdep.2006.10.014 PMID: 17118578

41. Nyamathi A, Ekstrand M, Zolt-Gilburne J, Ganguly K, Sinha S, Ramakrishnan P, et al. Correlates of stigma among rural Indian women living with HIV/AIDS. AIDS Behav. janv 2013; 17(1):329-39. https://doi.org/10.1007/s10461-011-0041-9 PMID: 21915715

42. Yeung MW, Young J, Moodie E, Rollet-Kurhajec KC, Schwartzman K, Greenaway C, et al. Changes in quality of life, healthcare use, and substance use in HIV/hepatitis C coinfected patients after hepatitis C therapy: a prospective cohort study. HIV Clin Trials. juin 2015; 16(3):100-10. https://doi.org/10.1179/5011000000024 PMID: 25972048

43. Walter KN, Petry NM. Lifetime suicide attempt history, quality of life, and objective functioning among HIV/AIDS patients with alcohol and illicit substance use disorders. Int J STD AIDS. mai 2016; 27 (6):476-85. https://doi.org/10.1177/0956462415585668 PMID: 25953963
44. Pokhrel KN, Sharma VD, Shibanuma A, Pokhrel KG, Mlunde LB, Jimba M. Predicting health-related quality of life in people living with HIV in Nepal: mental health disorders and substance use determinants. AIDS Care. sept 2017; 29(9):1137-43. https://doi.org/10.1080/09540121.2017.1332331 PMID: 28547996

45. Harzke AJ, Williams ML, Bowen AM. Binge use of crack cocaine and sexual risk behaviors among African-American, HIV-positive users. AIDS Behav. déc 2009; 13(6):1106-18. https://doi.org/10.1007/s10461-008-9450-9 PMID: 18758935

46. Norwald K, Holmström C, Plantin L. HIV and Sexuality: Perceptions and Experiences of Sexuality among Women Who Live with HIV in Sweden. ACRS. 27 déc 2017; 4(2):1-4.

47. Burgoyne AD, Drummond PD. Knowledge of HIV and AIDS in women in sub-Saharan Africa. Afr J Reprod Health. août 2008; 12(2):14-31. PMID: 20695040

48. Liping M, Peng X, Haijiang L, Lahong J, Fan L. Quality of Life of People Living with HIV/AIDS: A Cross-Sectional Study in Zhejiang Province, China. PLoS One. 2015; 10(8):e0135705. https://doi.org/10.1371/journal.pone.0135705 PMID: 26308088

49. Murri R, Fantoni M, Del Borgo C, Longo B, Deiana G, Visonà R, et al. Nonnucleoside reverse transcriptase inhibitor-containing regimens are associated with increased satisfaction with sexual life. J Acquir Immune Defic Syndr. 15 déc 2003; 34(5):532-4. https://doi.org/10.1097/00126334-200312150-00014 PMID: 14657766
44. Pokhrel KN, Sharma VD, Shibanuma A, Pokhrel KG, Mlunde LB, Jimba M. Predicting health-related quality of life in people living with HIV in Nepal: mental health disorders and substance use determinants. AIDS Care. sept 2017; 29(9):1137-43. https://doi.org/10.1080/09540121.2017.1332331 PMID: 28547996

45. Harzke AJ, Williams ML, Bowen AM. Binge use of crack cocaine and sexual risk behaviors among African-American, HIV-positive users. AIDS Behav. déc 2009; 13(6):1106-18. https://doi.org/10.1007/s10461-008-9450-9 PMID: 18758935

46. Norwald K, Holmström C, Plantin L. HIV and Sexuality: Perceptions and Experiences of Sexuality among Women Who Live with HIV in Sweden. ACRS. 27 déc 2017; 4(2):1-4.

47. Burgoyne AD, Drummond PD. Knowledge of HIV and AIDS in women in sub-Saharan Africa. Afr J Reprod Health. août 2008; 12(2):14-31. PMID: 20695040

48. Liping M, Peng X, Haijiang L, Lahong J, Fan L. Quality of Life of People Living with HIV/AIDS: A Cross-Sectional Study in Zhejiang Province, China. PLoS One. 2015; 10(8):e0135705. https://doi.org/10.1371/journal.pone.0135705 PMID: 26308088

49. Murri R, Fantoni M, Del Borgo C, Longo B, Deiana G, Visonà R, et al. Nonnucleoside reverse transcriptase inhibitor-containing regimens are associated with increased satisfaction with sexual life. J Acquir Immune Defic Syndr. 15 déc 2003; 34(5):532-4. https://doi.org/10.1097/00126334-200312150-00014 PMID: 14657766