Health-related quality of life of people with HIV in Zambia and South Africa
Authors: Kirsten A Donald
Journal: The Lancet Global Health (2017)

The face of the HIV epidemic has changed substantially across the globe in the past 10–15 years with a better rollout of effective anti-retroviral treatment (ART) across the world and in particular, in the global south where the greatest proportion of HIV-infected individuals still reside.1UNAIDS 2016On the fast-track to an AIDS-free generation.http://www.unaids.org/sites/default/files/media_asset/GlobalPlan2016_en.pdfGoogle Scholar As more adults and children remain relatively asymptomatic on ART, focus has moved from primarily addressing physical health, to including the promotion of optimal overall health and wellbeing. Therefore, the impact of HIV infection on health-related quality-of-life (HRQoL) would be expected to be better now than in previous years. This expectation is especially true in sub-Saharan Africa, where the cumulative risk of poor general health outcomes may have been higher in HIV-infected populations than in otherwise healthy individuals because of the prevalence of contextual factors, such as nutrition, that affect vulnerable immune-compromised people more severely than otherwise well individuals. Previously reported population studies investigating HRQoL in people with HIV drew from high-income countries or largely preceded the widespread rollout of ART in sub-Saharan Africa. Further, little has been reported globally on the perceived wellbeing of people with HIV in communities rather than in samples drawn from hospitals or clinics or from studies focused on the prevalence of overt mental health issues, such as depression, in people with HIV. In The Lancet Global Health, Ranjeeta Thomas and colleagues2Thomas R Burger R Harper A et al.Differences in health-related quality of life between HIV-positive and HIV-negative people in Zambia and South Africa: a cross-sectional baseline survey of the HPTN 071 (PopART) trial.Lancet Glob Health. 2017; (published online September 27.)http://dx.doi.org/10.1016/S2214-109X(17)30367-4Google Scholar report an important study on HRQoL across a large population sample in Zambia and South Africa, two sub-Saharan countries where the prevalence of HIV infection remains in excess of 20%. Critically, they investigated HRQoL in HIV-positive individuals who were on ART and in those who were HIV-positive but not yet on treatment, as well as in a large group of HIV-negative individuals from the same communities. Additionally, the study design allowed for inclusion of individuals with HIV across the spectrum of diagnosis and care. This ranged from individuals with established HIV diagnosis and who had been on ART for many years, to those who were aware of their infection status but not yet on treatment and, importantly, a unique group of HIV-positive individuals who were not aware of their status at the time of the baseline questionnaire on HRQoL. Because the study sample was adequately powered (>37 000 individuals), the team was also able to adjust adequately for environmental confounders that might have affected HRQoL across HIV-infected and HIV-uninfected groups. Interestingly, both people who had been diagnosed as HIV-positive and had been on ART for more than 5 years and those who were HIV-positive but not aware of their diagnosis showed similar HRQoL scores to those of HIV-negative individuals from the same communities. This finding was true for both South African and Zambian samples. Individuals diagnosed as HIV-positive and who were not yet on treatment and those who had only been on treatment for less than 5 years showed lower HRQoL scores than did HIV-negative community controls. This finding suggests that ART and consequently better physical health and prognosis improves the HRQoL of infected individuals. In the undiagnosed but HIV-positive individuals, the unaffected HRQoL could be an indication of recent infection with little disease progression or, alternatively, a lack of awareness of the chronic disease they will need to manage in their lives ahead. Individuals who had been previously diagnosed and were not receiving treatment and those who had been on treatment for less than 5 years reported more problems in both the physical scales such as mobility and self-care, but also emotional categories such as anxiety and depression, than did the HIV-negative controls. This range of findings across the different groups offers useful insights into how people living with HIV (and not only those who are the sickest or who seek medical help) experience their lives. The effect of HIV infection on HRQoL in this population sample was milder than in previous reports,3Beard J Feeley F Rosen S Economic and quality of life outcomes of antiretroviral therapy for HIV/AIDS in developing countries: a systematic literature review.Aids Care. 2009; 21: 1343-1356Crossref PubMed Scopus (96) Google Scholar, 4Miners A Phillips A Kreif N 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. 2014; 1: e32-e40Summary Full Text Full Text PDF PubMed Scopus (185) Google Scholar, 5O'Keefe EA Wood R The impact of human immunodeficiency virus (HIV) infection on quality of life in a multiracial South African population.Qual Life Res. 1996; 5: 275-280Crossref PubMed Scopus (81) Google Scholar which have described much lower scores across domains in individuals with HIV compared with HIV-negative peers.3Beard J Feeley F Rosen S Economic and quality of life outcomes of antiretroviral therapy for HIV/AIDS in developing countries: a systematic literature review.Aids Care. 2009; 21: 1343-1356Crossref PubMed Scopus (96) Google Scholar, 4Miners A Phillips A Kreif N 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. 2014; 1: e32-e40Summary Full Text Full Text PDF PubMed Scopus (185) Google Scholar, 5O'Keefe EA Wood R The impact of human immunodeficiency virus (HIV) infection on quality of life in a multiracial South African population.Qual Life Res. 1996; 5: 275-280Crossref PubMed Scopus (81) Google Scholar This study addresses an important gap in the literature of HRQoL in HIV infection by contributing robust and nuanced analysis of their data to address questions across the spectrum of HIV diagnosis and management in a region where the HIV infection remains highly prevalent. The authors provide a strong argument for getting individuals diagnosed with HIV onto treatment rapidly, not only in order to preserve and optimise their physical health, but also to give people hope for their future. I declare no competing interests. Differences in health-related quality of life between HIV-positive and HIV-negative people in Zambia and South Africa: a cross-sectional baseline survey of the HPTN 071 (PopART) trialART is successful in helping to reduce inequalities in HRQoL between HIV-positive and HIV-negative individuals in this general population sample. These findings highlight the importance of improving awareness of HIV status and expanding ART to prevent losses in HRQoL that occur with untreated HIV progression. The gains in HRQoL after individuals initiate ART could be substantial when scaled up to the population level. Full-Text PDF Open Access