Poor health-related quality of life in people living with HIV co-infected with SARS-CoV-2 in France (the COVIDHIV study)

doi:10.21203/rs.3.rs-3313260/v1

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Poor health-related quality of life in people living with HIV co-infected with SARS-CoV-2 in France (the COVIDHIV study)

https://doi.org/10.21203/rs.3.rs-3313260/v1

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Background: Among people living with HIV/AIDS (PLWHA), comorbid conditions, including COVID-19, could favor impairment of health-related quality of life (HRQL). This study aimed to assess HRQL and its correlates among PLWHA co-infected with SARS-CoV-2 in France.

Methods: This cross-sectional study was conducted using data from PLWHA co-infected with SARS-CoV-2 collected at inclusion in the COVIDHIV cohort study. HRQL was measured using the four dimensions of PROQOL-HIV scale: Physical Health Symptom (PHS), Mental and Cognitive (MC), Social Relationship (SR), Treatment Impact (TI). Factors associated with each dimension were identified using linear regression.

Findings: Of the 371 participants included in this study, 64.7% were male, their mean age (SD) was 52(±12) years. The mean (SD) scores of the HRQL dimensions were 76.7(±21.1) for PHS, 79.2(±23.6) for SR, 67.3(±27.4) for MC and 83.9(±16.5) for TI.

Better PHS score was associated with being professionally active and good self-perceived knowledge about COVID-19. Having acquired HIV by blood transfusion, stage C of CDC HIV-classification, having received discharge instructions in hospital, and number of self-reported symptoms were associated with worse score in PHS dimension.

Living in a couple was associated with better SR score. Having received instructions at hospital discharge, being at stage C of CDC HIV-classification, having acquired HIV by drug injection, number of self-reported symptoms, and self-perceived vulnerable to COVID-19 were associated with worse score in SR dimension.

Better score in the MC dimension was associated with being professionally active, and being born in metropolitan France, while being female, having detectable HIV viral-load, having received instructions at hospital discharge, self-perceived vulnerable to COVID-19, smoking, and number of self-reported symptoms were associated with worse score in MC dimension.

Being born in metropolitan France, having acquired HIV in homosexual or bisexual relationships were associated with better score in TI dimension. Having detectable HIV viral-load, psychiatric disorders, and number of self-reported symptoms were associated with worse score in TI dimension.

Conclusion: Among PLWHIV co-infected with SARS-CoV-2, the scores of HRQL were impaired, particularly in the MC dimension. The knowledge of associated factors can help clinicians for better care of this population.

SARS-CoV-2

COVID-19

PLWHA

Quality of life

France

COVID-19, an infectious disease due to a Severe Acute Respiratory Syndrome coronavirus (SARS-CoV-2) (1) caused several millions of death in the World. Since March 2020, COVID-19 is considered a pandemic (2), and has negatively and dramatically impacted all areas of socioeconomic life. The COVID-19 pandemic affected all regions of the world disproportionately with higher numbers of cases and deaths in developed countries(3). Despite the progressive development of effective prevention strategies and measures, such as masking, physical distancing or vaccination (3), the COVID-19 pandemic significantly impacted certain vulnerable groups, especially people living with comorbidities that maintain a chronic systemic inflammatory state (4)(5). In the general population, cardiovascular diseases (including hypertension and diabetes), chronic kidney diseases, and cancers were the main comorbidities reported to be associated with both COVID-19 severity and a higher risk of death (6). People living with HIV/AIDS (PLWHA), due to their immune status, are the most likely to have serious consequences related to the presence of comorbidities (4)(7). In the early phases of the COVID-19 pandemic, several studies, including systematic reviews on the prevalence have been conducted on clinical and psychosocial issues related to COVID-19 and HIV infection (8)(9)(10). However, the impact of COVID-19 on PLWHA has not been fully evaluated yet (11). In high income countries, even if the good organization of the health care system has made it possible to avoid a total rupture of health care services related to HIV infection (12), studies in PLWHA reported an important psychological impact (13)(14)(15).

Health-related quality of life (HRQL) may be affected in the context of the COVID-19 pandemic, due to a lack of social connection, financial stress, or existing physical or mental health issues (16)(17). In previous studies, findings demonstrated the multidimensional impact of the COVID-19 pandemic on different population groups, with most of the negative impacts being borne by vulnerable people, including PLWHA (18, 19). A recent study, conducted in a low-resource setting, highlighted a reduced quality of life among older PLWHA (19).

Measuring HRQL is needed to evaluate the impact of HIV-SARS-CoV-2 coinfection on general, physical and mental perceived health. HRQL assessment may help caregivers identify modifiable factors and integrate them into care strategies to improve the HRQL of COVID-19 survivors among PLWHA.

In France, to our knowledge, no published studies have assessed the HRQL of PLWHA co-infected with SARS-CoV-2. Thus, this study aimed to document HRQL in PLWHA co-infected with SARS-CoV-2 and to determine the factors associated with its different dimensions.

Design of the COVIDHIV cohort

COVIDHIV is a French, multicenter, observational cohort study aiming at describing the clinical and biological features of the COVID-19 disease in PLWHA. Documenting patient-reported outcomes (including HRQL) among PLWHA with COVID-19 disease was one of the secondary objectives of the cohort study. From March 2020 to June 2022, adult PLWHA with confirmed infection with SARS-CoV-2 since 1st January 2020, with and without criteria of hospitalization, were recruited in 42 hospitals located throughout the national territory, then followed-up for one year. Infection with SARS-CoV-2 was confirmed using Polymerase Chain Reaction (PCR), serology, imaging (CT scan/ radiography), or antigenic. PLWHA known to be co-infected with SARS-CoV-2 since January 2020 were included retrospectively, and those with a positive SARS-CoV-2 diagnostic test were included prospectively within seven days of the positive test.

Non-inclusion criteria were as follows: not speaking French, being under 18 years of age, being pregnant or breastfeeding, having a confirmed diagnosis of a pathogen other than SARS-CoV-2, being under guardianship or trusteeship mandate for future protection, participating in another study without the sponsor's consent, not being beneficiary or entitled to a social security scheme or state medical aid.

Data collection

Clinical, biological and therapeutic data were collected from patient records using an electronic case report from (eCRF). Socio-behavioral data and patient-reported outcomes, including HRQL, were collected using self-administered questionnaires (electronic or paper version).

The questionnaires also included a specific module developed to assess knowledge, beliefs, and behaviors in the context of COVID-19. The corresponding items were tested on five patients during a group debriefing prior to implementation.

Study population

In the present study, we analyzed data collected at inclusion for all cohort participants (study population).

Definition of variables

The variable of interest in this study is HRQL, measured using the PROQOL-HIV scale (19) reduced to the following four dimensions (20): Physical Health and Symptoms (PHS: 11 items); Social Relationships (SR: 7 items); Mental and Cognitive (MC: 10 items); Treatment Impact (TI: 10 items). For each dimension, a score ranging from 0 (poorest HRQL) to 100 (best HRQL) was calculated.

On the basis of the scientific literature, we tested potential explanatory variables among sociodemographic, behavioral, clinical, and COVID-19-related characteristics of individuals. Tested sociodemographic characteristics included age, sex, educational level, occupation, country of birth (born in metropolitan France (no/yes)), and living in a couple. Behavioral characteristics focused on the use of psychoactive substances: tobacco or e-cigarette, alcohol (calculated from the AUDIT-C score: greater or equal to 3 for women and greater or equal to 4 for men determined unhealthy alcohol use (21)). HIV-related characteristics included time since diagnosis, transmission mode, CDC clinical stage, CD4 T-cell count (in cells/mm³), plasma viral load detectability (> 50 copies/mL), and the number of self-reported symptoms (experienced during the past two weeks), assessed using the 23-item modified HIV Symptom Index (22)(19). Tested clinical characteristics also included comorbidities, including the presence of overweight or obesity (body mass index (BMI) ≥ 25), psychiatric disorders, respiratory diseases, cardiovascular diseases, hypertension, diabetes, cerebrovascular diseases, as well as hepatitis B virus (HBV) or hepatitis C virus (HCV) co-infection. Tested COVID-19-related characteristics included hospitalization for COVID-19, COVID-19 reinfection, time between confirmed COVID-19 diagnosis and inclusion, receipt of psychological support (“Have you received any psychological support in the last two weeks?”), individuals’ receipt of clear instructions at hospital discharge, as well as their perceptions regarding their level of knowledge about COVID-19 and their vulnerability to this disease. The latter three characteristics were assessed using the following items: “When you were discharged from hospital, did you receive clear instructions about precautions to be taken and further treatment?”, “Do you think you have sufficient knowledge about COVID-19?”, “Do you feel more vulnerable to COVID-19 because of your HIV status?”. For each of these items, individuals had to indicate their level of agreement on a 5-answer Likert scale. We considered the answers “I agree” and “I totally agree” as denoting agreement with the item wording (vs “I do not agree at all”, “I do not agree”, “unconcerned”).

In addition, we adjusted our analyses for the COVID-19 wave period in France (from March 2020 to September 2020 for 1st, from September 2020 to March 2021 for 2nd, from March 2021 to July 2021 for 3rd, from July 2021 to October 2021 4th and from October 2021 to July 2022 for 5th wave).

Statistical analyses

We performed a descriptive analysis of the study population’s characteristics and HRQL scores at inclusion in the COVIDHIV cohort. Continuous variables were expressed as mean (± standard deviation (SD)) and/or median (interquartile range (IQR)), and categorical variables as number (percentage).

Then, univariable analyses were performed using linear regression models to identify factors associated with the four HRQL scores (i.e. PHS, MC, SR, and TI). For each score, variables with a p-value ≤ 0.25 in the univariable analyses were included in the multivariable analysis.

A multivariable linear regression model was built for each HRQL score, in which the crude and adjusted β coefficients and associated 95% confidence intervals (CI) were estimated for all explanatory variables. Backward selection was used to identify potential associated factors, andvariables with a p-value less than or equal to the significance threshold of 5% were retained in the final model for each score. The assumptions of linearity, normality, homogeneity, and independence of the residuals were checked before the synthesis of the results. Finally, to maintain good power in our analyses, missing data were categorized as "not reported" and coefficients were not presented in the table. The R Studio/4.1.3 for software was used for all the analyses (23).

Main characteristics of the study population

Between March 2020 and June 2022, 408 PLWHA were recruited to participate in the COVIDHIV cohort. Among them, 37 were excluded (12 deceased, 24 with negative or unavailable result to the COVID-19 test, and one not speaking French). The study population thus comprises 371 individuals, including 89 (24.1%) prospective cases and 280 (75.9%) retrospective cases of SARS-CoV-2 infection. Most individuals in the study population were male (64.7%), median (IQR) age was 53 (44.0–60.0) years, 62.5% were professionally active, 44.1% were born in metropolitan France, 52.8% were living in couple, 85.1% had secondary education or more. In addition, 35.1% of the participants unhealthy alcohol use, and 17.7% reported smoking tobacco or e-cigarette (Table 1).

Table 1

Sociodemographic, clinical, biological and behavioral characteristics of PLWHA co-infected with SARS-CoV-2 followed-up in French hospitals: data at inclusion in the COVIDHIV cohort (n = 371) J’ai surligné en rouge les variables ayant un fort % de valeurs manquantes, qui ne sont pas exploitables en l’état (hormis peut-être la variable réinfection, car elle ne rentre pas dans les multivariées)
Characteristics (% of missing values)	Median (IQR) or n (%)
Sociodemographic characteristics
Age (years) (0)	53 (44.0–60.0)
Sex, female (0)	131 (35.3)
High school level or higher (11.6)	279 (85.1)
Professionally active (2.2)	227 (62.5)
Born in metropolitan France (< 0.1)	163 (44.1)
Living in a couple (2.9)	190 (52.8)
HIV-related characteristics
Heterosexual transmission (2.4)	185 (51.1)
Homosexual or bisexual transmission (2.4)	142 (39.2)
Transfusion transmission (2.4)	5 (1.4)
Drug injection transmission (2.4)	19 (5.2)
CD4 count ≥ 500 cells/mm³ (1.6)	236 (64.7)
Detectable HIV viral load (> 50 copies/mL) (1.9)	30 (8.2)
CDC HIV clinical stage* (1.6) A B C	194 (54.0) 62 (17.3) 103 (28.7)
Time since HIV diagnosis (years) (12.7)	17.0 (8.0–24.0)
Number of self-reported symptoms (14.0)	7.0 (3.0–11.0)
COVID-19-related characteristics
Hospitalization for COVID-19 (4.3)	49 (13.8)
COVID-19 reinfection (41.2)	16 (7.3)
Time between confirmed COVID-19 diagnosis and inclusion (days) (0.5)	35.0 (9.0–77.0)
Receipt of psychological support (15.4)	108 (34.4)
Receipt of clear instructions at hospital discharge (32.3)	184 (73.3)
Perceived knowledge about COVID-19 (14.8)	183 (57.9)
Perceived vulnerability to COVID-19 (15.0)	168 (53.3)
COVID-19 wave** (0) 1st 2nd 3rd 4th 5th	149 (40.2) 107 (28.8) 40 (10.8) 10 (2.7) 65 (17.5)
Comorbidities
HBV coinfection (3.0)	18 (5.0)
HCV coinfection (3.2)	10 (2.8)
Psychiatric disorders (5.4)	53 (15.1)
Respiratory diseases (5.1)	25 (7.1)
Cardiovascular diseases (5.1)	121 (34.4)
Hypertension (67.6)	100 (83.3)
Diabetes (5.1)	43 (12.2)
Overweight or obesity*** (9.4)	190 (56.5)
Unhealthy alcohol use (43.9)	73 (35.1)
Tobacco or e-cigarette smoking (14.6)	56 (17.7)

Concerning HIV-related characteristics, median (IQR) time since HIV diagnosis was 17.0 (8.0–24.0) years, 28.7% of individuals had a CDC clinical stage C, 64.7% had a CD4 count ≥ 500 cells/mm³, and 8.2% a detectable HIV viral load. The median number of self-reported symptoms was 7.0 (3.0–11.0).

Regarding comorbidities, hypertension (83.3%), overweight or obesity (56.5%), cardiovascular diseases (34.4%), psychiatric disorders (15.1%), diabetes (12.2%), respiratory diseases (7.1%), HBV co-infection (5.0%), and HCV co-infection (2.8%) were recorded in the participants.

Regarding COVID-19-related characteristics, 49 participants (13.8%) had been hospitalized. Only 7.3% of the participants were reinfected by the SARS-CoV-2. In addition, 34.4% had received psychological support, 73.3% received clear instructions at hospital discharge (data available for 67.6% of the participants), 53.3% perceived themselves more vulnerable to COVID-19 because of HIV, and 57.9% considered they had sufficient knowledge about COVID-19 (Table 1).

HRQL of participants

The distributions of scores associated with the four PROQOL-HIV dimensions are presented in Table 2. The highest mean and median scores were found in the TI dimension, while the lowest were found in the MC dimension.

Table 2

Health-related quality of life among people living with HIV co-infected with SARS-CoV-2 in France: data at inclusion in the COVIDHIV cohort study (n = 371).
HRQL scores*	N	Median (IQR)	Mean (± SD)
Physical health and symptoms (PHS) Social relationships (SR) Mental and Cognitive (MC) Treatment impact (TI)	312 314 313 309	81.8 (61.4, 95.5) 85.7 (64.3, 100.0) 72.5 (47.5, 90.0) 90.0 (77.5, 95.0)	76.4 (± 21.1) 78.3 (± 23.9) 66.5 (± 26.9) 82.7 (± 17.1)
HRQL: health-related quality of life; IQR: interquartile range; SD: standard deviation
* PROQOL-HIV scale (20)

Factors associated with HRQL scores

Factors associated with each of the four dimensions of the PROQOL-HIV are presented in Table 3.

Table 3

Factors associated with HRQL dimensions (PROQOL-HIV scores) among PLWHA co-infected with SARS-CoV-2 in France (linear regression models, COVIDHIV cohort, n = 371)
Characteristics	Physical Health and Symptom (PHS)		Social Relationships (SR)		Mental and Cognitive (MC)		Treatment Impact (TI)
Characteristics	Univariable Coef [95% CI]	Multivariable^Ψ Coef [95% CI]	Univariable Coef [95% CI]	Multivariable^Ψ Coef [95% CI]	Univariable Coef [95% CI]	Multivariable^Ψ Coef [95% CI]	Univariable Coef [95% CI]	Multivariable^Ψ Coef [95% CI]
Sociodemographic characteristics
Sex,female	-7.92 [-12.78 ; -3.06]		-6.40 [-11.93 ;-0.87]		-17.25 [-23.24 ; -11.26]	-8.04 [-13.48 ; -2.59]	-6.22 [-10.19 ; -2.25]
High school level or higher	8.34 [1.17 ; 15.52]		10.24 [2.22; 18.27]		10.49 [1.44 ; 19.54]		-0.08 [-5.93 ; 5.77]
Professionally active	7.10 [2.29 ; 11.91]	4.77 [0.98 ; 8.55]	8.09 [2.70 ; 13.48]		8.30 [2.15 ; 14.46]	5.81 [0.64 ; 10.97]	2.13 [-1.87 ; 6.12]
Born in metropolitan France	9.48 [4.88 ; 14.08]		6.41 [1.14 ; 11.69]		18.83 [13.20 ; 24.46]	12.10 [6.84 ; 17.35]	6.84 [3.06 ; 10.61]	4.42 [-0.26 ; 8.58]
Living in a couple	2.09 [-2.70 ; 6.87]		6.82 [1.48 ; 12.15]	5.67 [0.90 ; 10.44]	7.05 [1.01 ; 13.08]		0.06 [-3.86 ; 3.97]
Psychoactive substances use
Unhealthy alcohol use	-1.05 [-7.12 ; 5.02]		-0.06 [-6.91 ; 6.79]		2.66 [-4.79 ; 10.11]		2.45 [-2.47 ; 7.37]
Tobacco or e-cigarette smoking	-1.09 [-7.33 ; 5.15]		-5.98 [-13.05 ; 1.08]		-5.23 [-13.10 ; 2.64]	-10.57 [-17.09 ; -4.05]	-3.36 [-8.39 ; 1.67]
HIV-related characteristics
Heterosexual transmission	-4.04 [-8.77 ; 0.69]		-3.36 [-8.70 ; 1.98]		-15.33 [-21.13 ; -9.52]		-6.80 [-10.60 ; -3.00]
Homosexual or bisexual transmission	7.05 [2.28 ; 11.83]		7.61 [2.22 ; 13.00]		17.97 [12.13 ; 23.80]		8.97 [5.16 ; 12.79]	6.70 [2.68 ; 10.71]
Transfusion transmission	-14.77 [-33.48 ; 3.95]	-15.31 [-29.22 ; -1.39]	-11.21 [-32.39 ; 9.98]		-16.71 [-40.59 ; 7.16]		-4.23 [-19.47 ; 11.01]
Drug injection transmission	-10.57 [-20.62 ; -0.52]		-17.67 [-29.25 ; -6.09]	-14.29 [-24.94 ; -3.65]	-5.36 [-18.25 ; 7.53]		-3.98 [-12.18 ; 4.23]
CD4 count ≥ 500 cells/mm³	-0.40 [-5.40 ; 4.61]		3.15 [-2.47 ; 8.77]		4.55 [-1.78 ; 10.87]		3.12 [-0.96 ; 7.20]
Detectable HIV viral load (> 50 cp/mL)	0.64 [-8.21 ; 9.49]		-4.31 [-14.30 ; 5.69]		-12.77 [-23.97 ; -1.57]	-11.50 [-21.16 ; -1.84]	-10.60 [-17.83 ; -3.36]	-11.43 [-18.74 ; -4.11]
CDC HIV clinical stage (ref = A) B C	-6.92 [-13.32 ; -0.53] -9.83 [-15.35 ; -4.30]	-5.98 [-10.94 ; -1.02] -7.48 [-11.78 ; -3.17]	-9.81 [-17.04 ; -2.58] -9.21 [-15.43 ; -2.99]	-5.70 [-12.29; 0.89] -7.13 [-12.78 ; -1.48]	-8.22 [-16.45 ; 0.01] -5.39 [-12.48 ; 1.69]		-3.59 [-8.95 ; 1.77] -1.42 [-5.99 ; 3.15]
Number of self-reported symptoms	-2.69 [-3.05 ; -2.33]	-2.52[-2.88 ; -2.16]	-2.00 [-2.48 ; -1.53]	-1.72 [-2.21 ; -1.24]	-1.93 [-2.48 ; -1.37]	-1.44 [-1.94 ; -0.93]	-0.82 [-1.19 ; -0.45]	-0.83 [-1.20 ; -0.46]
COVID-19-related characteristics
Hospitalization for COVID-19	-4.73 [-12.99 ; 3.52]		-9.62 [-18.75 ; -0.48]		-7.64 [-17.66 ; 2.38]		-5.20 [-11.58 ; 1.17]
New COVID-19 reinfection	6.91 [-5.03 ; 18.85]		-0.07 [-13.58 ; 13.44]		-6.64 [-21.79 ; 8.51]		-8.96 [-18.50 ; 0.57]
Psychological support	-8.22 [-13.12 ; -3.32]		-4.48 [-9.99 ; 1.04]		-9.88 [-16.12 ; -3.64]		-3.42 [-7.46 ; 0.62]
Receipt of clear instructions at hospital discharge	-5.97 [-11.89 ; -0.05]	-5.90 [-10.39 ; -1.41]	-7.34 [-13.94 ; -0.74]	-6.52 [-12.36 ; -0.67]	-7.78 [-15.33 ; -0.23]	-6.60 [-12.67 ; -0.53]	-2.88 [-7.71 ; 1.96]
Perceived knowledge about COVID-19	6.08 [1.33 ; 10.83]	4.18 [0.56 ; 7.81]	-0.39 [-5.80 ; 5.02]		4.40 [-1.68 ; 10.49]		1.30 [-2.61 ; 5.21]
Perceived vulnerability to COVID-19	-11.13 [-15.73 ; -6.54]		-12.06 [-17.24 ; -6.87]	-7.68 [-12.52 ; -2.84]	-23.61 [-29.05 ; -18.17]	-14.97 [-20.21 ; -9.73]	-7.71 [-11.49 ; -3.93]
Comorbidities
Psychiatric disorder	-4.11 [-10.84 ; 2.61]		-14.18 [-21.52 ; -6.84]		-4.31 [-12.80 ; 4.18]		-5.63 [-11.02 ; -0.24]	-6.58 [-11.85 ; -1.32]
Respiratory diseases	-9.43 [-18.59 ; -0.27]		-14.12 [-24.39 ; -3.85]		-2.00 [-13.73 ; 9.73]		-4.27 [-11.75 ; 3.21]
Cardiovascular diseases	-4.39 [-9.45 ; 0.66]		-2.88 [-8.60 ; 2.84]		-1.11 [-7.55 ; 5.33]		-1.52 [-5.65 ; 2.62]
Diabetes	-4.35 [-11.83 ; 3.12]		-2.82 [-11.25 ; 5.61]		0.48 [-8.93 ; 9.89]		1.00 [-5.02 ; 7.02]
Overweight or obesity	-1.18 [-6.13 ; 3.76]		1.23 [-4.34 ; 6.79]		-5.65 [-11.89 ; 0.59]		-2.41 [-6.42 ; 1.61]

Physical Health and Symptoms (PHS)

Participants who were professionally active and those who reported having sufficient knowledge about COVID-19 had better scores in the PHS dimension. In contrast, participants who had acquired HIV by blood transfusion, those who were at CDC stage B or C, those who reported a higher number of symptoms, and those who received clear instructions at discharge had a worse score (Table 3).

Social Relationships (SR)

Participants living in couple had better scores in the SR dimension. In contrast, participants who perceived themselves vulnerable to COVID-19, those who were at CDC stage C, those who had acquired HIV through drug injection, those who reported a higher number of symptoms, and those who received clear instructions at hospital discharge had a worse score for the SR dimension (Table 3).

Mental and Cognitive (MC)

Participants who were professionally active, those who were born in metropolitan France had better scores in the MC dimension. In contrast, women, participants who had detectable HIV viral load, those who reported a higher number of symptoms, those who received discharge instructions, those who perceived themselves more vulnerable to COVID-19, and those who smoked had a lower scores in the MC dimension (Table 3).

Treatment Impact (TI)

Participants born in metropolitan France, those who had acquired HIV in homosexual or bisexual relationships had better scores in the TI dimension. In contrast, those who had detectable HIV viral load, those who reported a higher number of symptoms, and those with psychiatric disorders had worse scores in the TI dimension (Table 3).

This nationwide multicenter study investigated HRQL in PLWHA co-infected with SARS-CoV-2. This study showed poor scores of all dimensions of HRQL, including PHS, SR, MC and TI scores. In the four dimensions of HRQL, the MC dimension had the lowest mean score and the TI dimension the highest mean score. The score for the TI dimension could be explained by a better adaptation of the structural organization of healthcare that ensures continuity of care for PLHWA, including HIV-related services delivery, quality of healthcare to PLWHA in the context of COVID-19 pandemic (24). However, given the difficulties of supply of HIV treatment and the fear of exposure to COVID-19 for some patients, health care delivery, referral of and the follow-up of the PLWH are also affected (25).

During the COVID-19 pandemic, the strategies and measures implemented to slow down its spread, including social restrictions and lockdown leaded to an increase in stress, anxiety and depression. It also caused considerable daily illnesses, unemployment and economic hardship, which would lead to psychological health problems and barriers to health. In several studies on HRQL conducted in France, prior the COVID-19 pandemic, the mental dimension remained the most altered (26, 27). Studies in many countries have shown the negative impact of the COVID-19 pandemic on mental health among people regardless COVID-19 or HIV status (28)(29)(30). It is important for healthcare providers to take a holistic approach to care, addressing the physical and mental health needs of their patients. This may include providing counseling and support for mental health concerns, as well as ensuring access to HIV prevention and treatment services. In addition, PLWHA with COVID-19 can benefit from peer support groups, which can provide a sense of community and connection during this difficult time. This study showed that the consequences of COVID-19 on the mental health of PLWHA have been considerable while this population faced many situations impacting their mental health, among which stigmatization, discrimination related to HIV status (31)(32).

The COVID-19 pandemic impacted not only the TI and MC dimensions but also the SR dimension, that may due to a fear of exposure to COVID-19, health restrictions etc. The PHS dimension was also affected, as for symptomatic patients, social restrictions may lead to diminution of physical activity.

Even if we observed overall relative low scores for the HRQL dimensions, it is important to mention that this could hide certain heterogeneities related mainly to the characteristics of the participants.

This study highlighted the negative impact of the number of self-reported symptoms on all the dimensions of HRQL. Even though there were not COVID-19 specific symptoms, it is well known that people with chronic inflammatory conditions such as PLWHA (5)(33)(34) are considered at high risk of severe outcomes of COVID-19 or persistent symptoms. Moreover, the number of symptoms would constitute a proxy of comorbidities and by far a severity of COVID-19 in these participants. However, as demonstrated by Lechien J.R et al the COVID-19 related symptoms may vary significantly with age and gender of the patients (35) and exacerbate their impact on the HRQL or well-being. Besides, participants who have a high number of symptoms would certainly be those with comorbidities and would therefore be much more vulnerable to SARS-CoV-2 infection or severe form COVID-19, including because of their HIV status.

In the same line, clinically, it was observed in our study that PLWHA who had detectable HIV viral load or those at CDC stage B or C had worse HRQL. This is consistent with recent studies have shown that PLWHA with CD4 counts above 500 cells/mm3, or those with detectable viremia would have a higher risk of acquiring the SARS-CoV2 than the general population. (36)(37). This double burden of COVID-19 and HIV infection would have a significant impact on their HRQL that may due to the immunological disturbance. Despite considerable progress in the management of HIV infection and the dramatic increase in life expectancy of PLWHA almost comparable to that of a HIV seronegative individual, there remains a vulnerability due to chronic inflammation (33) and poor adherence that could compromise immune balance. This vulnerability may not only be experienced but also self-perceived by some participants.

In our study, because of their sero-status, participants who perceived themselves vulnerable to SARS-CoV-2 infection had worse HRQL, particularly in the MC and SR dimensions. This group may have better knowledge about COVID-19 including its modes of transmission and prevention strategies and might be anxious, depressed and stressed, fearing to be infected by SARS-CoV-2 in absence of effective treatment and vaccines (38). Hence the importance of support in the care of this population, such as awareness campaign, online information accessible to all PLWHA in order to reduce the stress of patients.

Our study also showed that another aspect of support might be beneficial for the participants, as those living in couple reported better HRQL, mainly in the SR dimension. According to the study Li X. and al., social support has shown a strong potential to influence quality of life (39). Although our study does not address all of the supports for this population, it does provide information on some of the key support that could affect the well-being of PLWHA. In our study, PLWHA who reported they received clear instructions from hospital staff at discharge reported a poor score on PHS, SR and MC dimensions. The hypothesis would be that discharge instruction might be given to the most vulnerable and those who would have requested it via questioning. In this context, health care providers are recognized as an important source of psychological support (8). This might be crucial for the well-being in PLWHA group (14), who need close attention for early diagnosis of further emotional distress. Apart from the pandemic of COVID-19, PLWHA, may face mental health issues because of the stigmatization and discrimination (31) (40) in spite of the measures taken (32). It is necessary to avoid any chronic worsening of mental health which can have important repercussions on PLWHA (15).

Besides, our study showed that participants who were professionally active had better scores in the PHS and MC dimensions. Being professionally active may offer a great opportunity to be mobile, in particular outside the period of lockdown. Breaking with measures of social, physical distancing, should allow for the improvement of mental and physical well-being, through contact, exchanges with peers, colleagues and community.

Being born in metropolitan France was associated with better scores in the MC and TI dimensions. Even if in the general population, individuals from sub-Saharan Africa reported better mental HRQL (27), in many other context as COVID-19 pandemic, ethnic minorities are recognized as vulnerable to COVID-19 (41)(42), mostly because of their low health literacy and their precarious life conditions (42) (43), including high prevalence of comorbidities (44). Consistent to our study, Drewes and a. underlined that infection, social circumstances, relationships problems, comorbidities (including hypertension), and stigma could have negatively impact the HRQL of PLWHA (45).

This study has two main limitations. First, this is an observational study carried out using self-reported questionnaires; there could thus be a social desirability bias. However, participants were invited to answer with sincerity and they were informed that their responses would be analyzed in a non-judgmental way. Second, this was a multicenter study, but we did not test for a possible center effect, given the very small number of participants in some centers (most of which had only one individual included).

We found in this study that the HRQL in PLWHA co-infected with SARS-CoV-2 in France was impaired, particularly in the Mental and Cognitive dimension. Several factors including clinical features (the number of self-reported symptoms, the clinical stage of HIV infection, HIV viral load), professional activity, living in a couple, perceived vulnerability to COVID-19, being born in France, receiving clear instructions at hospital discharge are associated with the HRQL in this population at the enrolment. Our results offer an opportunity to better inform and educate PLWHA about COVID-19 and caregivers in the context of pandemic, through a combination of stress management and empowerment interventions at the individual, local, national, and international levels.

Ethical Approval

The study was approved by the ethics committee “Comité de Protection des Personnes” (CPP) Ile-de-France 8 (N°200406 of May 28th, 2021) and is registered with the ClinicalTrials.gov identifier (NCT number) NCT04361604. Informed consent was collected from each participant. After data collection, a unique identifier was created for each patient based on the center number to ensure confidentiality for each participant.

Competing interests

There are no conflicts of interest

Authors' contributions

YA conducted formal data analysis, interpreted the data, and drafted the initial manuscript. IY designed the study, supervised data analysis, and contributed to draft the initial manuscript. LY-K, GR and ANO contributed to the analysis of the data and critically reviewed the manuscript. MP, JWG, FM, and OC critically reviewed the manuscript. AC, and MD conceptualized and designed the study, designed the data collection instruments, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted.

Funding

This work was supported by the National Agency for Research on AIDS and Viral Hepatitis (ANRS | Emerging Infectious Diseases) and Fond Métropole Grand Paris. The funders had no role in study design, data collection and analysis, preparation of the manuscript, or decision to submit the manuscript for publication.

Availability of data and materials

Data and materials used in the study for this manuscript are available from Dr Martin DURACINSKY ([email protected]).

Acknowledgments. We are grateful to all the participants, physicians, field investigators, and collaborators for their participation in this project.

Zhu N, Zhang D, Wang W, Li X, Yang B, Song J et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med [Internet]. 20 févr 2020 [cité 6 mars 2023];382(8):727–33. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7092803/.
Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta Bio-Medica Atenei Parm 19 mars. 2020;91(1):157–60.
Ochani RK, Asad A, Yasmin F, Shaikh S, Khalid H, Batra S et al. COVID-19 pandemic: from origins to outcomes. A comprehensive review of viral pathogenesis, clinical manifestations, diagnostic evaluation, and management.
Nomah DK, Reyes-Urueña J, Llibre JM, Ambrosioni J, Ganem FS, Miró JM et al. HIV and SARS-CoV-2 Co-infection: Epidemiological, Clinical Features, and Future Implications for Clinical Care and Public Health for People Living with HIV (PLWH) and HIV Most-at-Risk Groups. Curr HIV/AIDS Rep [Internet]. 2021 [cité 6 mars 2023];18(6):518–26. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8661831/.
Appay V, Sauce D. Immune activation and inflammation in HIV-1 infection: causes and consequences. J Pathol [Internet]. 2008;214(2):231–41. Disponible sur:. https://onlinelibrary.wiley.com/doi/abs/10.1002/path.2276.
Cruz JC, Martins CK, Katchborian Neto A, de Araújo CM, Dellalibera-Joviliano R, Barbosa F. Age, gender, and 11 comorbidities as risk factors associated with COVID-19 mortality: A retrospective cohort including 1.8 million individuals. J Toxicol Environ Health A 15 juin 2023;1–10.
Lee KW, Yap SF, Ngeow YF, Lye MS. COVID-19 in People Living with HIV: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health [Internet] 30 mars 2021 [cité 7 mars 2023];18(7):3554. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8037457/.
Winwood JJ, Fitzgerald L, Gardiner B, Hannan K, Howard C, Mutch A. Exploring the Social Impacts of the COVID-19 Pandemic on People Living with HIV (PLHIV): A Scoping Review. AIDS Behav [Internet]. 2021 [cité 7 mars 2023];25(12):4125–40. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137806/.
Heidary M, Asadi A, Noorbakhsh N, Dashtbin S, Asadollahi P, Dranbandi A et al. COVID-19 in HIV‐positive patients: A systematic review of case reports and case series. J Clin Lab Anal [Internet]. 20 févr 2022 [cité 7 mars 2023];36(4):e24308. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8993621/.
Huang D, Zunong J, Li M, Li D, Gong J, Vermund SH et al. COVID-19 Clinical Presentation Among HIV-Infected Persons in China: A Systematic Review. Curr HIV/AIDS Rep [Internet]. 2022 [cité 7 mars 2023];19(3):167–76. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8990500/.
Kalichman SC, El-Krab R. Social and Behavioral Impacts of COVID-19 on People Living with HIV: Review of the First Year of Research. Curr HIV/AIDS Rep [Internet]. 2022 [cité 7 mars 2023];19(1):54–75. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8617547/.
Nosyk B, Armstrong WS, del Rio C. Contact Tracing for COVID-19: An Opportunity to Reduce Health Disparities and End the Human Immunodeficiency Virus/AIDS Epidemic in the United States. Clin Infect Dis Off Publ Infect Dis Soc Am [Internet]. 27 avr 2020 [cité 13 mars 2023];71(16):2259–61. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197593/.
Jones DL, Morgan KE, Martinez PC, Rodriguez VJ, Vazquez A, Raccamarich PD et al. COVID-19 Burden and Risk Among People With HIV. J Acquir Immune Defic Syndr 1999 [Internet]. 1 juin 2021 [cité 7 mars 2023];87(2):869–74. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136457/.
Berman M, Eaton LA, Watson RJ, Andrepont JL, Kalichman S. Social Distancing to Mitigate COVID-19 Risks Is Associated With COVID-19 Discriminatory Attitudes Among People Living with HIV. Ann Behav Med Publ Soc Behav Med [Internet]. 17 sept 2020 [cité 7 mars 2023];54(10):728–37. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7516104/.
Pan KY, Kok AAL, Eikelenboom M, Horsfall M, Jörg F, Luteijn RA et al. The mental health impact of the COVID-19 pandemic on people with and without depressive, anxiety, or obsessive-compulsive disorders: a longitudinal study of three Dutch case-control cohorts. Lancet Psychiatry [Internet]. févr 2021 [cité 7 mars 2023];8(2):121–9. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831806/.
Shek DTL. COVID-19 and Quality of Life: Twelve Reflections. Appl Res Qual Life [Internet]. 2021 [cité 31 mars 2023];16(1):1. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786317/.
Ferreira LN, Pereira LN, da Fé Brás M, Ilchuk K. Quality of life under the COVID-19 quarantine. Qual Life Res [Internet]. 2021 [cité 31 mars 2023];30(5):1389–405. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7778495/.
Gogoi M, Chaloner J, Qureshi I, Wobi F, Al-Oraibi A, Wilson H, et al. One virus, many lives: a qualitative study of lived experiences and quality of life of adults from diverse backgrounds living in the UK during the COVID-19 pandemic. BMJ Open 1 mars. 2023;13(3):e067569.
Olivieri-Mui B, Hoeppner SS, Tong Y, Kohrt E, Quach LT, Saylor D et al. Associations of the COVID-19 pandemic with quality of life: A cross-sectional study of older-age people with and without HIV in rural Uganda. J Glob Health 13:06003.
Duracinsky M, Herrmann S, Berzins B, Armstrong AR, Kohli R, Le Coeur S et al. The development of PROQOL-HIV: an international instrument to assess the health-related quality of life of persons living with HIV/AIDS. J Acquir Immune Defic Syndr 1999. 15 avr 2012;59(5):498–505.
Lalanne C, Duracinsky M, Marcellin F, Lert F, Chassany O, Carrieri PM, et al. Confirmation of the Factor Structure of the Proqol-HIV Questionnaire to Assess Health-Related Quality of Life in PLWHA. Value Health J Int Soc Pharmacoeconomics Outcomes Res nov. 2014;17(7):A681–682.
Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. sept 1998;14(16):1789–95.
Justice AC, Holmes W, Gifford AL, Rabeneck L, Zackin R, Sinclair G, et al. Development and validation of a self-completed HIV symptom index. J Clin Epidemiol déc. 2001;54(Suppl 1):77–90.
Posit [Internet]. Posit. [cité 27 avr 2023]. Disponible sur: https://www.posit.co/.
Duffy S, Lee TH. In-Person Health Care as Option B. N Engl J Med [Internet]. 11 janv 2018 [cité 21 avr 2023];378(2):104–6. Disponible sur: https://www.nejm.org/doi/10.1056/NEJMp1710735.
Qiao S, Li Z, Weissman S, Li X, Olatosi B, Davis C et al. Disparity in HIV Service Interruption in the Outbreak of COVID-19 in South Carolina. AIDS Behav [Internet]. 2021 [cité 9 mars 2023];25(1):49–57. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453068/.
Préau M, Mora M, Puppo C, Laguette V, Sagaon-Teyssier L, Boufassa F et al. Does Quality of Life and Sexual Quality of Life in HIV Patients Differ Between Non-treated HIV Controllers and Treated Patients in the French ANRS VESPA 2 National Survey? AIDS Behav. janv 2019;23(1):132–9.
Douab T, Marcellin F, Vilotitch A, Protopopescu C, Préau M, Suzan-Monti M, et al. Health-related quality of life of people living with HIV followed up in hospitals in France: comparing trends and correlates between 2003 and 2011 (ANRS-VESPA and VESPA2 national surveys). AIDS Care. 2014;26(Suppl 1):29–40.
Pierce M, Hope H, Ford T, Hatch S, Hotopf M, John A et al. Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. Lancet Psychiatry [Internet]. oct 2020 [cité 7 mars 2023];7(10):883–92. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7373389/.
Penninx BWJH, Benros ME, Klein RS, Vinkers CH, How. COVID-19 shaped mental health: from infection to pandemic effects. Nat Med [Internet]. oct 2022 [cité 20 avr 2023];28(10):2027–37. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9711928/.
Global prevalence and burden of depressive and anxiety disorders. in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet Lond Engl [Internet]. 6 nov 2021 [cité 20 avr 2023];398(10312):1700–12. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8500697/.
Adewuya AO, Afolabi MO, Ola BA, Ogundele OA, Ajibare AO, Oladipo BF et al. Post-traumatic stress disorder (PTSD) after stigma related events in HIV infected individuals in Nigeria. Soc Psychiatry Psychiatr Epidemiol [Internet]. 1 sept 2009 [cité 14 mars 2023];44(9):761–6. Disponible sur: https://doi.org/10.1007/s00127-009-0493-7.
Andersson GZ, Reinius M, Eriksson LE, Svedhem V, Esfahani FM, Deuba K et al. Stigma Reduction Interventions in People Living with HIV to Improve Health-Related Quality of Life. Lancet HIV [Internet]. févr 2020 [cité 14 mars 2023];7(2):e129–40. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7343253/.
Hunt PW. HIV and Inflammation: Mechanisms and Consequences. Curr HIV/AIDS Rep [Internet]. 1 juin 2012 [cité 20 avr 2023];9(2):139–47. Disponible sur: https://doi.org/10.1007/s11904-012-0118-8.
Deeks SG, Tracy R, Douek DC. Systemic Effects of Inflammation on Health during Chronic HIV Infection. Immunity [Internet]. 17 oct 2013 [cité 20 avr 2023];39(4):633–45. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012895/.
Lechien JR, Chiesa-Estomba CM, Place S, Van Laethem Y, Cabaraux P, Mat Q et al. Clinical and epidemiological characteristics of 1420 European patients with mild‐to‐moderate coronavirus disease 2019. J Intern Med [Internet]. sept 2020 [cité 13 mars 2023];288(3):335–44. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267446/.
Sun S, Hou J, Chen Y, Lu Y, Brown L, Operario D. Challenges to HIV Care and Psychological Health During the COVID-19 Pandemic Among People Living with HIV in China. AIDS Behav [Internet]. 2020 [cité 7 mars 2023];24(10):2764–5. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7203543/.
Dandachi D, Geiger G, Montgomery MW, Karmen-Tuohy S, Golzy M, Antar AAR et al. Characteristics, Comorbidities, and Outcomes in a Multicenter Registry of Patients with HIV and Coronavirus Disease-19. Clin Infect Dis Off Publ Infect Dis Soc Am [Internet] 9 sept 2020 [cité 7 mars 2023];ciaa1339. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7499544/.
Herrman H, Patel V, Kieling C, Berk M, Buchweitz C, Cuijpers P et al. Time for united action on depression: a Lancet–World Psychiatric Association Commission. The Lancet [Internet]. 5 mars 2022 [cité 20 avr 2023];399(10328):957–1022. Disponible sur: https://www.sciencedirect.com/science/article/pii/S0140673621021413.
Li X, Lin C, Gao Z, Stanton B, Fang X, Yin Q et al. HIV/AIDS knowledge and the implications for health promotion programs among Chinese college students: geographic, gender and age differences. Health Promot Int [Internet]. 1 sept 2004 [cité 13 mars 2023];19(3):345–56. Disponible sur: https://doi.org/10.1093/heapro/dah308.
Fauk NK, Ward PR, Hawke K, Mwanri L. HIV Stigma and Discrimination: Perspectives and Personal Experiences of Healthcare Providers in Yogyakarta and Belu, Indonesia. Front Med [Internet]. 2021 [cité 21 avr 2023];8. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8149745/.
Families and households [Internet]. 2019 [cité 21 avr 2023]. Disponible sur: https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/demographics/families-and-households/latest.
Niedzwiedz CL, O’Donnell CA, Jani BD, Demou E, Ho FK, Celis-Morales C et al. Ethnic and socioeconomic differences in SARS-CoV-2 infection: prospective cohort study using UK Biobank. BMC Med [Internet] 29 mai 2020 [cité 21 avr 2023];18:160. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7255908/.
Webb Hooper M, Nápoles AM, Pérez-Stable EJ. COVID-19 and Racial/Ethnic Disparities. JAMA [Internet]. 23 juin 2020 [cité 21 avr 2023];323(24):2466–7. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9310097/.
Weiser JK, Tie Y, Beer L, Neblett Fanfair R, Shouse RL. Racial/Ethnic and Income Disparities in the Prevalence of Comorbidities that Are Associated With Risk for Severe COVID-19 Among Adults Receiving HIV Care, United States, 2014–2019. J Acquir Immune Defic Syndr 1999. 1 mars 2021;86(3):297–304.
Drewes J, Gusy B, von Rüden U. More than 20 years of research into the quality of life of people with HIV and AIDS–a descriptive review of study characteristics and methodological approaches of published empirical studies. J Int Assoc Provid AIDS Care. 2013;12(1):18–22.

No competing interests reported.

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Poor health-related quality of life in people living with HIV co-infected with SARS-CoV-2 in France (the COVIDHIV study)

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Abstract

Introduction

Methods

Design of the COVIDHIV cohort

Data collection

Study population

Definition of variables

Statistical analyses

Results

Main characteristics of the study population

HRQL of participants

Factors associated with HRQL scores

Physical Health and Symptoms (PHS)

Social Relationships (SR)

Mental and Cognitive (MC)

Treatment Impact (TI)

Discussion

Conclusion

Declarations

References

Additional Declarations

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