In this cross-sectional study that evaluated QoL and syndemics among 1530 PLWHA under treatment, the syndemic conditions most frequently observed were binge drinking (56%), IPV (13%), and depression (9%). According to our hypothesis, both individual syndemic conditions and syndemics were associated with worse QoL. Positive screening for depression was associated with worse scores in all domains; polysubstance use, IPV, and binge drinking were associated with worse scores in specific domains. The presence of syndemics led to worse scores in the psychological, social, and environment domains.
When considering the syndemic conditions separately, the environment domain was the most affected, and worse QoL in this domain was reported among individuals experiencing IPV, multiple-drug use, and depression. The environmental domain includes questions about safety, physical environment, financial resources, and opportunities for acquiring new information and skills. In previous studies conducted in Brazil, this domain was also one of the most affected[45–48]. Some authors explain that these low scores (in the environmental domain) are influenced by socioeconomic factors, low income, and less education [45, 46]. A study in Burkina Faso, a country in which 46.5% of people live below the poverty line, found the lowest scores in the environment domain [49], and the same was found in Ethiopia[50, 51]. In addition, another study showed that half of the PLWHA experienced income reduction after an HIV diagnosis, which was associated with lower QoL in this domain [52]. In the present multivariate analysis, not living with a partner was associated with worse QoL in the environment domain, which may be related to lower financial resources and security than when sharing a family income. Conversely, a secondary education or above was associated with better QOL, which may be related with better occupations and employability[53, 54].
Polysubstance use and depression were negatively associated with the score on the social relationship domain, which includes questions about social inclusion, personal relationships, sexual activity, and social support. In the present study, not living with a partner, age 43 or older, and symptomatic disease stage were also associated. This findings may be associated with situations of stigma and discrimination faced by PLWHA[52, 55, 56]. Furthermore, loneliness and lack of support from relatives were associated with a lower global QoL score in the study conducted in Burkina Faso[49]. Older age has also been associated with fewer social interactions and a smaller social network[57]. Feeling alone, social stigma and being discriminated against are associated with depression and substance abuse[52]. Family counseling[52] and the strengthening of the social support network[56] may be important strategies to improve the care of these patients.
The psychological domain covers negative and positive feelings, concentration, self-esteem, and self-image. The presence of depression was the only syndemic condition associated with worse QoL in this domain, being the domain that best negatively correlates with the Beck Depression Inventory[34, 58]. In a study conducted in Sweden, a country with one of the best HIV treatment outcomes, hopelessness, a component associated with depression, negative self-image and social stigma were associated with lower QoL[59]. Although HIV symptoms are decreased by cART, stigma, discrimination and uncertainties remain, affecting PLWHA psychologically[60]. In addition, depression, anxiety, and other psychological factors are associated with adherence to HIV treatment[14], so providing adequate screening and treatment for these patients might improve their QoL.
Level of independence covers questions on activities of daily living, mobility, dependence on medication, and work capacity. Brazilian studies have associated the level of independence with the side effects of treatment and the presence of opportunistic diseases[45, 46, 61]. Our results did not show association of the level of independence with any syndemic condition or syndemics. It is possible that this domain more closely represents problems related to physical comorbidities, since individuals reporting a symptomatic AIDS stage or worse SRH presented lower scores in this domain. It is noteworthy that SRH and the symptomatic stage of AIDS are associated with mortality[36, 62], which may indicate that the level of independence QoL is a sensitive domain to severe disease.
Many studies have found similar associations with demographic characteristics with the ones found in the present analysis. Female sex and advanced age have been widely associated with lower QoL[7–9]. Regarding advanced age, this association may be mediated by multiple comorbidities (and polypharmacy), physiological frailty, and cognitive dysfunction that are common in this population group[63]. In contrast, a secondary education or above was associated with better QoL. In a previous study, this level of schooling reduced syndemic effects on HIV prevalence, making it a resilience factor[64]. It can be inferred, as indicated by other studies, that interventions to improve education could improve the QoL of PLWHA[65].
The limitations of this study include the non-probabilistic nature of the sample, which prevents the generalization of data to other populations of PLWHA. Some participants were excluded because they did not have VL or CD4 information near enough to the date of the interview, and there is a strong possibility that this lack of tests is not random. However, a small proportion of participants were in this situation, mitigating any selection bias. Given the cross-sectional design, it is not possible to infer causality, and it is not possible to discard reverse causality. For example, worse QoL in the environment domain could be the cause of depression and not the reverse. Although we used validated instruments, the data are self-reported, and there may have been measurement and social desirability biases. Lastly, the instruments that evaluate mental health are only screening tools, and a more detailed evaluation would be necessary to diagnose psychiatric disorders. This limitation may have led us to overestimate the prevalence of depression and substance abuse in this sample.
Despite these limitations, there is evidence that a better QoL may influence patient adherence to care and thus viral suppression achievement [66, 67], which are necessary conditions for survival among PLWHA. Our results show that syndemic conditions mostly relate to psychological, social, and environment domains of QoL. This is an important regarding patient -centered outcomes and should be considered when designing health care and public health interventions targeting PLWHA.