This study evaluated the HRQoL of Zimbabwean PLHIV and associated factors. Overall, our study shows a high HRQoL for PLHIV in Zimbabwe. Anxiety, depression, and poor environmental health were widely reported domains influencing HRQoL. Also, being aware of HIV status for over a year, not experiencing an adverse event, being currently married, having adequate finances and food security and having higher educational status were associated with higher HRQoL. Study participants expressed a higher HRQoL evaluation despite the ongoing socio-economic challenges. These findings are comparable with previous studies conducted in Zimbabwe [22], Zambia and South Africa [23, 24], which yielded these mean EQ-5D VAS utility scores; 0.81±0.30 and 0.88±0.10 and 0.89±0.03, respectively. A high perception of HRQoL could reflect cultural conceptualisation or a manifestation of resilience in PLHIV. Most of the study participants had lived with HIV for over a year and may have developed resilience in living with a chronic condition. Systematic reviews have shown that resilience progressively develops and is associated with improved positive well-being, treatment adherence, and posttraumatic growth in PLHIV [25, 26].
Despite the high HRQoL perception/evaluation, most study participants reported problems in the anxiety/depression dimension and poor environmental health. Systematic reviews and meta-analyses show that depression is two to three times more common in PLHIV than in the general population [27]. Risk factors for poor mental health functioning in PLHIV include challenges coping with a recent HIV diagnosis, adverse external environmental factors (e.g., stigmatisation, poor living conditions), the experience of living with a chronic illness and personal/marital relationships challenges [28–31]. Therefore, it is essential to integrate mental health care into routine HIV care to improve treatment outcomes [32–34]. Routine HRQoL and CMDs assessments using generic and condition-specific outcomes followed by appropriate treatment plans incorporating the multi-disciplinary team approach are paramount [35].
We found individuals in relationships or married to have HRQoL higher than those divorced, widowed, or not in a relationship. Marriage or companionship is an essential source of social support. Social support is an essential buffer to stressful life events; it positively impacts an individual's physical and mental well-being, performance, creativity and competence and brings resilience when confronting stressful situations [36–38]. For example, an Ethiopian systematic review showed that PLHIV with good social support were four times more likely to report higher HRQoL when compared to those without (AOR = 4.01, 95% CI 3.07–5.23) [39]. Our findings further affirm previous evidence on the intertwined relationship between social support, adherence to ART and improvement of the overall HRQoL for PLHIV [40–43].
Consistent with a previous meta-analysis [44], participants who had lived longer with HIV reported a higher HRQoL. Those recently diagnosed may have been in the bereavement process and had not yet accepted their HIV status, leading to poor mental health functioning [45]. More extended periods of awareness and ART intake can facilitate the growth of effective coping approaches, leading to improved mental health and higher HRQoL [44]. In this study, adhering to ART was predictive of improved HRQoL. Increased ART coverage is associated with reduced morbidity, improved immune functioning and psychological well-being, ultimately increasing the overall perceived HRQoL [44]. Also, HIV care centres in Zimbabwe offer infected individuals free counselling and peer support groups [46]. People with more extended treatment periods may have been subjected to formal and informal psychosocial support, which may have led to better acceptance and adherence to care, thus reducing morbidity and improving HRQoL overall [15, 35, 47, 48].
In this study, financial inadequacy and food insecurity, proxy indicators for financial well-being, were predictive of poor HRQoL. For example, participants with adequate finances were four times more likely to have better HRQoL than those with inadequate finances. Our findings follow a previous systemic review showing the link between HRQoL and financial well-being (R2= 0.108, p= 0.04) [11]. The relationship between food security and HIV infection is complex and bidirectional. For instance, food insecurity and HIV infection result in a gradual decline of immunity which may lead to a lower HRQoL [49–51]. Further, most Zimbabwean PLHIV incurs out-of-pocket medical expenses, shrinking their incomes; the financial pressure negatively affects HRQoL. Therefore, providing social and economic incentives for low-income PLHIV should be considered to improve their HRQoL [52].
Further, the experience of adverse events negatively impacted the HRQoL in PLHIV. Commonly reported adverse events included failing a course, bereavement, and loss of income-generation opportunities. Experiencing an adverse event negatively affects mental and physical health as patients may fear reliving past traumatic experiences [25, 26, 44]. Consequently, the burden may lead to troubling memories, poor mental health functioning, and a lower HRQoL [53, 54]. Last, higher education attainment was associated with improved HRQoL; this is consistent with previous systematic reviews [11, 55]. A higher education facilitates stronger awareness of the disease and a better ability to cope with the challenges of a chronic illness [11, 55–58]. Conversely, lower education, a proxy indicator of poor financial well-being [57], is associated with poor health-seeking behaviours; this further reinforces the need for social and financial support for poorer PLHIV and their families.