Changes health-related quality of life in HIV-infected patients following initiation of antiretroviral therapy: a longitudinal study

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

Changes

health-related

quality

of

life

in

HIV-infected

patients

following

initiation

of

antiretroviral

therapy:

a

longitudinal

study

Brenda

Soares

Dutra

_,

_Ana

_Paula

_Lédo

_,

_Liliane

_{Lins-Kusterer}

_,

_Estela

_Luz

_,

Indira

Rodriguez

Prieto

_,

_Carlos

_Brites

a_{UniversidadeFederaldaBahia,EscoladeMedicina,Salvador,BA,Brazil}

b_{ComplexoHospitalarUniversitárioProfessorEdgardSantos,LaboratóriodeInvestigac¸ãoemDoenc¸asInfecciosas,Salvador,BA,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received5February2019 Accepted21June2019 Availableonline22July2019

Keywords:

Health-relatedqualityoflife AntiretroviralTherapy HIV

PatientReportedOutcomeMeasures

a

b

s

t

r

a

c

t

Background:SeveraltoolshavebeendevelopedtoevaluateHIVhealth-relatedqualityoflife (HRQoL)duringandafterantiretroviraltherapy(ART).Fewlongitudinalstudiesevaluated theeffectofARTonthequalityoflifeofHIVpatients.

Objective:ToevaluatechangesinHRQoLinHIV-infectedindividualsoneyearafterinitiating ART.

Methods:AprospectivestudywasconductedfromMay2016toJuly2018.Dataonclinical andsociodemographiccharacteristicsof91HIV-infectedpatientswerecollectedpriorto initiationofARTandoneyearthereafter.Demographicandclinicaldatawerecollectedand thequestionnaires36-itemShortFormHealthSurvey(SF-36)andHIV/AIDS-targetedquality oflife(HAT-QoL)wereadministeredinbothperiods.Asymptomaticindividuals,aged≥18 years,wereincludedinthestudy.Patientswhodiscontinuedtreatmentwereexcluded.The associationbetweenpredictorsofphysicalandmentalHRQoLwasanalyzedbymultiple linearregressionanalysis.

Results:Patientswerepredominantlymale(78.0%),meanage35.3±10.7years,withnostable relationship(80.2%),andnocomorbidities(73.6%).MostoftheSF-36domainsimprovedafter oneyear,particularlyPhysicalFunction(p=0.0001),GeneralHealth(p=0.0001),Social Func-tioning(p=0.0001),MentalHealth(p=0.001),andMentalComponentSummary(p=0.004). HAT-QoLdomainsimprovedintheOverallFunction(p=0.0001),LifeSatisfaction(p=0.0001), Provider Trust (p=0.001),and SexualFunction (p=0.0001) domains.Sex (p=0.032),age (p=0.001),income(p=0.007),andstablerelationship(p=0.004)weregoodpredictorsofthe PhysicalComponentSummary.Sex(p=0.002)andstablerelationship(p=0.038)weregood predictorsoftheMentalComponentSummary.SF-36andHAT-QoLscalespresentedstrong correlations,exceptforMedicationConcerns(0.15–0.37),HIVMastery(0.18–0.38),Disclosure Worries(−0.15to0.07),andProviderTrust(−0.07to0.15).

∗ _{Correspondingauthorat:LAPI-ResearchLaboratoryofInfectiousDiseases,EdgardSantosFederalUniversityHospital,Federal}

Uni-versityofBahia.RuaAugustoViana,S/n,Canela,Salvador,BahiaCEP-40110060,Brazil.

E-mailaddresses:brendasdutra@hotmail.com(B.S.Dutra),anapaulaledo3@gmail.com(A.P.Lédo),liliane.lins@ufba.br

(L.Lins-Kusterer),eluz5@yahoo.com.br(E.Luz),indira.rodriguez70@gmail.com(I.R.Prieto),crbrites@gmail.com(C.Brites).

1 _{Theseauthorshaveequallycontributedforthiswork} 2 _{Theseauthorshaveequallycontributedasseniorauthors.}

https://doi.org/10.1016/j.bjid.2019.06.005

1413-8670/©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Conclusions: ARTimprovedHRQoLafteroneyearofuse.TheHAT-QoLandSF-36correlated wellandaregoodtoolstoevaluateHRQoLinHIV-infectedpatientsonART.

©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Introduction

HIVinfectionhasevolvedfromadeadlyinfectiontoachronic disease in countries where treatment is widely available.1

Despiteincreaseinlifeexpectancy,health-relatedqualityof life(HRQoL)ofHIVpatientsisinferiorthanthatobservedin generalpopulation.2_{Antiretroviraltreatmentprogramshada}

significantimpactonlifeexpectancyinyoungpopulations, whichresultedinagain ofapproximately 14.4million life-yearsbetween1995and2009.3

HRQoLhasamorerestrictmeaning,incomparisontothe qualityoflifedefinition.Ithasbeendefinedasthewayhealth isestimatedtoaffectindividuals’qualityoflife4_ortheway

apersonperceiveshis/herwell-beinginphysical,mentaland socialdomainsofhealth,5_{aswellasthewayself-perceived}

well-beingarerelatedtooraffectedbythepresenceofdisease ortherapy.6

MeasuringHRQoLinpatientsontreatmentallowsthe eval-uationofmedicationbenefitsandsideeffects.7_{However,there}

isnoagreementinliteratureonthebestapproachforHRQoL measurement.8 _{Normative data for HRQoL generic}

instru-mentsallowscomparisonwithother groups,aswell asthe analysisoftheinfluenceofHIVandassociatedcomorbidities ontheHRQoLinasingleevaluation.9

SeveralspecificinstrumentstoevaluateHIV-HRQoLhave beendeveloped,duetotheassumptionthatspecificHRQoL toolsaresuperiorwhencomparedtogenericinstruments,8_as

theHIV/AIDS-TargetedQualityofLife(HAT-QoL)scale.10_The

useofspecificinstruments11_{ortheuseofboth,specificand}

generic,toevaluateHRQoLinHIV-inefectedpatientshasbeen reported.12,13_{Althoughthe36-ItemShortFormHealthSurvey}

(SF-36)14_{isagenericinstrument,ithasbeenpreferredto}

eval-uateHRQoL,ratherthanspecificinstruments,becauseofits lowerceilingandflooreffect,goodaccuracy,andworldwide use.8,15

Questionnairesthat use patient-reportedoutcomes may render valuable information about patient’s health-related qualityoflife.Evaluatingtheeffectsofantiretroviraltherapy inHRQOLofpatientsbeforeandduringARTisimportantfor anintegralpatientapproach.WeaimedtoevaluatetheHRQoL inHIV-inefectedindividualsatbaselineandafteroneyearof ART.

Material

and

methods

A prospectivecohort study was conductedfrom May 2016 toJuly2018.Dataonclinicalandsociodemographic charac-teristicsofHIV-infectedpatientswerecollectedpriortothe initiationofARTandoneyearthereafter.Patientswho discon-tinuedtreatmentwereexcluded.Thesamplewasconsecutive

and non-probabilistic,and gathered at aReference Outpa-tientClinicofInfectiousDiseases,inSalvador,Bahia,Brazil. Allpatientswhoagreedtoparticipateinthestudysignedthe informedconsentform.Thestudyincludednaïveand asymp-tomaticHIV-infectedpatientsaged≥18years.HIVpregnant women,patientswithactiveopportunisticinfectionsorthose who already on antiretroviral therapy were excluded. The studywasapprovedbytheinstitutionalEthicsandResearch Committee,protocolnumber1,393,890.

To evaluatehealth-related quality oflife, two question-naires were used: the 36-item Short Form Health Survey (SF-36)14,15 _{and the HIV/AIDS Targeted Quality of Life}

(HAT-QoL).15 _{Both questionnaireswereadministered before}

initiationofARTandafteroneyearoftreatment.

TheSF-36has36itemsandevaluateshealth-related qual-ity oflife ineight domains: physicalfunctioning (PF), role limitations due tophysicalproblems (RF), bodilypain (BP), generalhealthperceptions(GH),vitality(VT),social function-ing(SF),rolelimitationsduetoemotionalproblems(RE),and mental health(MH). Theeightscales were aggregated into aphysicalcomponentsummary(PCS)andamental compo-nent summary (MCS)scores. SF-36 scores range from 0to 100, wherehigher scores represent betterHRQoL.14 _Scores

werenormalized,usingtheOptumProCoreprogramversion 1.0.6431.17600. Normalization was based on norms with a meanof50andastandarddeviationof10.14_{Outcomesshould}

beinterpretedasbeloworabovetheUSgeneralpopulationT score.AllthenormalizedSF-36scoreshavethesamevariance andcanbecomparedwitheachother.Thisstudywaslicensed byOptumInsightLifeSciencesInc,numberQM025905.

The(HATQoL)instrumentisa34-itemHIVspecific health-relatedqualityoflifequestionnaire.Theinstrumentassesses nine domains, including overall function, life satisfaction, health worries, financial worries, medication worries, HIV mastery,disclosureworries,providertrust,andsexual func-tion.Theninedomainsaretransformedtoalinear0–100scale where0istheworstpossibleoutcomeand100thebest possi-bleoutcome.10

TheCharlsoncomorbidityindex(CCI)wasusedtoaccess severityofcomorbiddiseasesclassifiedasmild(CCIscoresof 1–2),moderate(CCIscoresof3–4),andsevere(CCIscores≥5).

16

Cronbach’s Alpha coefficient was used to assess inter-nal consistency, considering values under 0.60 to 0.70 as satisfactory17 _{and higherthan 0.70 as ideal.}18 _Pearson

cor-relationcoefficientwasusedtoanalyzelinearrelationships betweentheinstrumentsdomains,consideringresultsfrom 0.50to0.70asmoderatecorrelation,and0.70to0.90ashigh correlation.19

DatawereanalyzedusingtheStatisticalPackageforSocial Sciences (SPSS) version 21. We used descriptive statistics, means and standard deviations for continuous variables,

and percentages for categorical variables. Student’s t-test for paired samples was used to compare the differences betweenthegroupsbeforeandafterARTandchi-squaretest tocompareproportionsbetweendependentandindependent samples. Theassociation between predictive variables and physicaland mentalHRQoL was analyzed by using multi-plelinearregressionanalysis.Variables(age,sex,education, familyincome,maritalstatus,livingwithfamily,Charlson’s comorbidity index, body mass index [BMI], CD4 and CD8 counts,andHIV viralload)were selectedaccordingto uni-variateanalysis.Variableswithp-value≤0.2520_wereincluded

inthemultivariateanalysis.

Results

The sample consisted of 91 HIV-infected patients, mean age 35.3±10.7 years, evaluated at baseline and after one year of ART. Patients did not change therapy during the period of study. In the baseline evaluation, the means of CD4+ and CD8+ count were 407.2±261.4cell/mm3 and 1270.7±727.1cells/mm3_{. Inaddition, all patients presented}

detectableviralload(medianviralload4.60log10copies/ml

IQR:0.05–5.13).Themajorityweremale(78.0%),raciallymixed (60.4%), without stable relationship (80.2%), with equal or morethaneightyearsofschooling(79.1%),livingwithfamily (56.0%),nocomorbidities(73.6%),andwithnormalBMI(62.6%) (Table1).BMIslightlyincreasedafteroneyearofART(from 23.3±4.1kg/m2_{to24.9±4.3kg/m}2_).

Bothhealth-relatedqualityoflifeinstrumentspresented reliability above the desirable Cronbach’s Alpha (≥0.6) for all domains. Table2 showed the descriptionof theHRQoL according to the SF-36 scores. The SF-36 scores were sys-tematicallyhigherafteroneyearofART,exceptfortheRole Physicaldomain(p=0.580).PhysicalFunctioning(p=0.0001), General health (p=0.0001), Social Functioning p=0.0001), MentalHealth(p=0.0001),andMentalComponentSummary (p=0.004)weresignificantlyhigherafteroneyearofART.

AfteroneyearofART,thescoresoftheHAT-QoLdomains Overall Funcion (p=0.0001), Life Satisfaction (p=0.0001), ProviderTrust(p=0.001)andSexualFunction(p=0.0001)were significantlyhigher,andDisclosureWorrieswassignificantly lower(p=0.0001).HealthWorriesandHIVMasterydomains

Table1–Demographicandclinicalcharacteristicsofthe 91HIV-infectedpatients.Salvador,Bahia,Brazil,2018. Demographicandclinicalcharacteristics N(%) Sex Male 71(78.0) Female 20(22.0) Education(Years) <8 19(20.9) ≥8 72(79.1) Race/Ethnicity Caucasian 19(20.9) Raciallymixed 55(60.4) Black 17(18.7)

Familyincome(MinimalWages)a

<1MW 41(45.1) ≥1MW 50(54.9) Maritalstatus Single 18(19.8) Married/stablerelationship 73(80.2) Living Alone 32(35.2) WithFamily 51(56.0) WithFriends 8(8.8) Charlson’scomorbidityindexb

No 67(73.6)

Mild 17(18.7) Moderate 6(6.6) Severe 1(1.1) Bodymassindex(kg/m2₎

Underweight<18,5 7(7.7) Normalweight.=18,5–25 57(62.6) Overweight≥25-<30 21(23.1) Obese≥30 6(6.6)

a _{Familyincome(MinimalWages):284.6USD.}

b _{Charlson’scomorbidityindexscore:No:0;Mild:1-2;Moderate:}

3-5,severe:>5.

were alsoslightly higher,butthe differencesdidnot reach statistical significance. Financial worries showed a slight decrease(p=0.292)afteroneyearoftreatment.(Table3).

The association of predictor variables with the SF-36 physicaland mentalcomponents was exploredusing mul-tivariate linearregression analysis (Table 4).Sex(p=0.028), age (p=0.001), income (p=0.007), and stable relationship (p=0.004)werepredictorsforphysicalcomponentsummary.

Table2–MeansandstandarddeviationsofSF-36Health-RelatedQualityofLifenormalizedscoresin91HIV-infected patientsatbaselineandafteroneyearofART.Salvador,Bahia,Brazil,2018.

SF-36DomainsandComponentSummaries BeforeART Cronbach’sAlpha After1yearofART Cronbach’sAlpha p-valuea

PhysicalFunctioning(PF) 49.3±11.0 0.93 51.4±8.9 0.94 0.0001 RolePhysical(RP) 45.1±12.6 0.95 44.3±13.2 0.98 0.580 BodilyPain(BP) 52.0±12.3 0.76 53.9±10.6 0.82 0.117 GeneralHealth(GH) 47.5±10.6 0.68 51.8±10.2 0.85 0.0001 Vitality(VT) 50.7±11.9 0.77 51.0±12.4 0.85 0.840 SocialFunctioning(SF) 43.6±12.0 0.65 50.0±8.4 0.69 0.0001 RoleEmotional(RE) 40.3±14.3 0.92 41.5±15.1 0.97 0.471 MentalHealth(MH) 43.4±13.4 0.79 47.3±12.1 0.81 0.0001 PhysicalComponentSummary(PCS) 51.4±10.2 52.5±7.9 0.146 MentalComponentSummary(MCS) 42.0±13.0 45.2±11.0 0.004

Table3–MeansandstandarddeviationsofHAT-QoLin91HIVpatients,beforeandafteroneyearofART.Salvador, Bahia,Brazil,2018.

HAT-QoLDomains BeforeART Cronbach’sAlpha After1yearofART Cronbach’sAlpha p-valuea

OverallFunction 58.8±27.2 0.80 71.0±23.2 0.84 0.0001 LifeSatisfaction 53.1±29.2 0.79 68.2±29.0 0.89 0.0001 Healthworries 41.8±31.1 0.82 47.0±29.6 0.90 0.132 FinancialWorries 45.7±39.6 0.91 41.7±37.1 0.95 0.292 MedicationConcerns 65.4±15.1 0.84 HIVMastery 41.2±37.0 0.83 41.5±36.7 0.92 0.941 DisclosureWorries 28.3±26.0 0.70 13.3±21.2 0.72 0.0001 ProviderTrust 78.8±26.0 0.82 82.0±19.7 0.87 0.0001 SexualFunction 59.2±36.9 0.79 79.3±33.3 0.96 0.0001

a _{t-studentforpairedsamples.}

Table4–ResultsofamultiplelinearregressionequationhavingPCSandMCSasthedependentvariablefor91 HIV-patients.Salvador,Bahia,Brazil,2018.

PCS*_(R2_{=37%) MCS**(R}2_=25%)

Variables B SEB p-value* B SEB p-value*

Constant 56.504 5.150 .000 40.800 7.952 .000 Sex(male) 4.002 1.787 .028 9.044 2.759 .002 Age,years −.284 .067 .001 −.169 .104 .107 Familyincome*** .002 .001 .007 .001 .001 .100 BMI**** −.197 .178 .272 −.191 .275 .489 Stablerelationship 5.188 1.767 .004 5.752 2.728 .038 Thenumbersincolumnsareregressioncoefficients(B),standarderrors(SEB)andPvalues.

*PCS-PhysicalComponentSummary;**MentalComponentSummary;***Familyincome(MinimalWages):MW:USD285.00;****BMI-BodyMass Index(kg/m2_).

Table5–PearsoncorrelationamongSF-36andHAT-QoLdomainsin91HIV-infectedpatientsafteroneyearofART. Salvador,Bahia,Brazil,2018.

Domain PF RP BP GH VT SF RE MH PCS MCS Overallfunction 0.77b _0.66b _0.55b _0.71b _0.70b _0.61b _0.62b _0.63b _0.81b _0.72b Lifesatisfaction 0.54b _0.47b _0.41b _0.67b _0.62b _0.57b _0.44b _0.52b _0.59b _0.64b Healthworries 0.37b _0.42b _0.29b _0.45b _0.52b _0.41b _0.41b _0.52b _0.39b _0.58b Financialworries 0.52b _0.63b _0.32b _0.45b _0.45b _0.34b _0.62b _0.46b _0.54b _0.58b MedicationConcerns 0.15 0.29b _{0.18 0.26}a _{0.16 0.30}b _0.33b _0.31b _{0.19 0.37}b HIVmastery 0.27 0.18 0.21a _0.43b _0.35b _0.25a _{0.20 0.42}b _0.26a _0.38b Disclosureworries 0.01 −0.15 0.08 −0.14 0.07 0.04 −0.16 0.07 −0.06 −0.01 ProviderTrust −0.07 0.15 0.02 0.13 −0.03 0.06 0.15 0.03 0.03 0.10 SexualFunction 0.50b _0.35b _0.31b _0.45b _0.52b _0.44b _0.30b _0.54b _0.45b _0.52b

a _{Correlationissignificantatthe0.01level(2-tailed).} b _{Correlationissignificantatthe0.05level(2-tailed).}

Malesex(p=0.002)andstablerelationship(p=0.038)were pre-dictorsofthementalcomponentsummary.

SF-36 and HAT-QoL domains were strongly correlated, exceptforMedicationConcerns(0.15–0.37),HIVMastery(0.18 to0.38),DisclosureWorries(-0.15to0.07)andProviderTrust (-0.07to 0.15)domains. The HATQoLdomain Overall func-tionpresentedthehighestcorrelationwithSF-36domains,all beingabove0.60,exceptforBP(0.55)asshowninTable5.

Discussion

OurprospectivestudyshowedanimprovementintheHRQOL ofHIV-infectedindividualsafteroneyearofART,using SF-36and HAT-QoL.Wedemonstrated thatSF-36and HATQoL

presented good correlations for most domains, except for MedicationConcerns, HIVMastery,Disclosure Worries,and ProviderTrust.ThehighestHAT-QoL correlationwithSF-36 occurredintheOverallFunctiondomain(0.61-0.81).The HAT-QoL scalemeasuresdifferent aspects,which reinforcesthe use of both a specific and a general instruments, to bet-termeasuringHRQOLinindividualslivingwithHIV/AIDS.12

Bothinstrumentspresentedgoodinternalconsistenceinall domains, considering Cronbach’s Alpha coefficient values from 0.60 to0.70,assatisfactory17 _{and higherthan 0.70as}

ideal.18 _{However,thereisno consensusonliteratureabout}

interpretationofthesecorrelations.

Despitethelowfrequencyofpatientswithcomorbidities, theinstrumentswereabletoidentifyimprovementsintheir

health-relatedqualityoflife,consideringphysicalandmental aspects.AfteroneyearofARTsignificantimprovementswere observedinPhysicalFunctioning,GeneralHealth,Social Func-tioning,MentalHealth,andMentalComponentSummary.The useofnormalizedSF-36scoresshowedthatallpatientswere stableandhadscoresofHRQoLinstrumentatbaselineclose totheexpectedvalue(50±10).AllSF-36domainswerehigher afteroneyearofART,exceptforthe RolePhysicaldomain, whichpresentedanon-significantslightdecrease (p=0.58). However,theresultwasnotbelowtheexpectedvalue.

Therecentdiagnosisatstudy entrymayhaveinduced a worstperceptionofpatientsabouttheirHRQoL,21whichmay justifytheimprovementofSF-36domains.Incontrast,HIV infectionitselfmayhaveanegativeimpactonpatients’ phys-icaland mental HRQOL,22 _{even afterthe initiation ofART,}

comparedtothegeneralpopulation.2_{Inaddition,HIV}

infec-tionisachronicdiseasethatmaydecreasepatients’physical health,23,24_{includingthementalaspectsofhealth.}

The impact of antiretroviral therapy in HIV-infected patients,isstillcontroversial.Theworseningofmotor func-tion and health-relatedquality oflifeinHIV-patients have been reported,25 _{whilephysicalfunctioning}26 _{and HRQoL}27

ofasymptomaticinfectedindividualshavebeenreportedto besimilartothatofthegeneralpopulationornon-infected healthyindividuals.

Althoughourresultsshow anincreaseof6.5%inmean BMIafteroneyearofART,thisindexwasnotapredictorof HRQoLinthelinearmultivariateregressionanalysis. Never-theless,metabolicandbodyfatchangesduringARTshould bemonitored28_{withcaution,astheseeffectsmaynegatively}

impacttheHRQoLofthesepatients.

Beingmale, young, withwith astablerelationship, and withhigherincomeweregoodpredictorsoftheSF-36 Physi-calComponentSummarybylinearmultivariateanalysis.The associationofhigherPCSwithmalesexhasbeenpreviously reported.29,30_{BeingfemalewaspredictiveoflowerMCS,while}

havingastablerelationshipwasapredictor ofhigherMCS andPCS.Thesefindingsareinlinewithpreviousstudies,that associatedlowermentalhealthscorestoyoungerage,female sex,livingalone,andfeweryearsofschooling,22_and

physi-calimpairment.30,31,32_{However,aChinesecohortshowedno}

differencesin theHRQoL scoresbysexduringthe first six monthsafterstartingART.33 _{Thesame study alsorevealed}

higher HRQoL scores associatedwith stable relationship,33

whileanotherstudyassociatedthevariablewithlower Physi-calfunctioning.29

SignificantimprovementinMCSafteroneyearofARTis consistentwithpreviousstudies.DespitethelikelihoodofART adverseeffectsonphysicalwell-being,earlyintroductionof ARTsignificantlyincreasespsychologicalwell-beingoverthe years,anddecreasesmorbidity.21_{Patients’understandingof}

HIV-infection,aswellasthebenefitsofcontrollinginfections withART,leadstolessanxietyinHIV-infectedpatients.21,34

Depressionisthemostfrequentpsychiatricdisorderin HIV-infectedpatientsandisrelatedwithseverityofsymptoms35 andpatients’negativeself-image.36_{InterruptionofARTand}

lowsocialsupportalsocontributedfordecreasingofMCSin infectedpatients.37

The absence of normalized data may difficult HAT-QoL interpretation in cross-sectional studies. However, using

HAT-QoL together withanormalized instrument orin lon-gitudinal studies allow for comparisons at different times andmayaddspecificpatientoutcomethatisnotmeasured withaHRQoLgeneralinstrument.Inourstudy,theHAT-QoL questionnaire was also capable ofdetecting differences in asymptomaticpatientsbeforeandafteroneyearoftreatment. ThemeanofHAT-QoLscorespresentedlargestandard devia-tionassociatedwithwidedistributionofscores.Oursample presentedsignificantimprovementinOverallFunction,Life Satisfaction, Provider Trust and Sexual Function HAT-QoL domains.Suchresultsmaybeexplainedbythepositiveimpact ofART,improvingpatients’generalhealth,satisfactionwith lifeandperspectivesforlife.38

The HAT-QoL domain Disclosure Worries significantly decreased whileProviderTrust significantlyincreasedafter oneyearofART,evidencingthatdespiteofgood physician-patient relationship,HIV-infectedpatients needspecialized psychologicalcaretoimprovehealth-relatedquality oflife. Thefearofstigmaanddiscriminationbyinfectedpatientsis relatedtoagreaterconcernwithsecrecy,decreasingpatients’ HRQoL.31

The improvement in HAT-QoL Sexual Function domain afteroneyearofARTcorroboratedtheimprovementof Phys-ical Functioning, General Health, Social Functioning, and Mental Health measuredby SF-36.The correlationof HAT-QoL Sexual Functiondomain withSF-36 was good inboth mentalandphysicaldomains.Theaffective-sexual relation-shiprepresentsanimportantaspectforHRQoLinHIV-infected patients. The partner is important for emotional support, whichisdirectlyassociatedwithbetterHRQoL.39_Ourresults

underscorethatstablerelationshipwasgoodpredictorofboth mental(MCS)andphysical(PCS)SF-36summaries.

The simultaneoususe ofinstruments with specific and generic dimensions,brought benefitstothisstudy, sinceit expanded the dimensionof the specificinformation about theHRQoLofindividuals.WhileHAT-QoLisconsidereda spe-cificinstrumentfortheseropositivepopulation,theSF-36has satisfactoryinternalconsistenceandnormativedata, allow-ing clinicalinterpretation ofHRQoLevenincross-sectional studies withgood precision.Arecent studyalsoevidenced the benefitsofusingmultipleinstruments when accessing HIVoutcomes.Authorsinvestigatedphysicaland psycholog-ical themes associatedto HIV by using different validated instruments.Socialsupport,self-esteem,andsexual difficul-tieswereassociatedwithgeneralhealth.40

Ourstudyhassomelimitationssuchastheimpossibilityof randomallocationofparticipants.Inaddition,differentART regimensandhealthcareproviderscouldbeimportantfactors indeterminingchangesinHRQoLforHIVpatients.However, theinitialARTregimenisstandardizedinBrazil,whichmeans allpatientsreceivethesameregimen.Inaddition,theAIDS clinicareattendedbythesamehealthprofessionals,and ini-tialcasesareusuallydiscussedwiththeClinicCoordinator, whichguaranteesasimilarstandardofcareforallpatients. WeconductedourstudyatasingleStatereferencecenterfor HIV,whichcouldintroducesomebias.However,itisthe sec-ondlargestHIVreferralcenterinthestate,anditspopulation reflectstheoverallcharacteristicsofHIV-infectedpatientsin Bahia.Longitudinalstudiesallowformorepreciseevaluation, establishingcause and effect.Measuresofpatient-reported

outcomesofqualityoflifearenecessarilysubjective,andthis canmakethestudyvulnerabletorecallbias.Toreducethis effect,theresearchersusedtwoqualityoflifeinstruments, bothwithgoodreliability.

In conclusion, ART improved HRQoL of HIV-infected patientsafteroneyearoftreatment.TheSF-36andHATQoL showedgoodcorrelations,mainlyinOverallFunctionDomain andpresentedgoodinternalconsistenceinalldomains.We recommendtheuseofbothspecificandgeneralinstruments formeasuringHRQoLinHIV-infectedpatients.Havinga sta-blerelationshipwasagoodpredictorofbettermental(PCS) andphysical(MCS)health.Malesex,beingyoung,and hav-inghigherincomeweregoodpredictorsofthephysicalhealth component,whilebeingfemalewaspredictoroflowermental health(MCS).

Conflict

of

interest

Theauthorsdeclarenoconflictofinterest.

Funding

Thisresearchdidnotreceiveanyspecificgrantfromfunding agenciesinthepublic,commercial,ornot-for-profitsectors.

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