Our study compared factors influencing HRQoL among stable ART clients accessing care at either HIV clinics or DSD clubs in the Shinyanga region of Tanzania. Majority of participants in our study rate their HRQoL relatively satisfactory. Our results revealed that service access factors contributed considerably to HRQoL among DSD participants. We found that time spent during clinic/club and the settings of service delivery were factors significantly associated with perceived HRQoL.
Understanding HRQoL in African studies is relevant in the current “Treat-all” and DSD era. Previous HRQoL studies mostly compared HIV positive and negative people and/or PLHIV not on and on ART (2)(9). Similar HRQoL among stable clients seen in our study strengthens the case for DSD which may likely impact positively on care delivery to unstable clients concurrently who are more likely to have special needs (39,40). The complex effect of service access factors on overall HRQoL suggest that other non-measured factors are likely also to influence HRQoL.
Time spent during clinic/club was the main service access factor associated with HRQoL in our study followed by reduced frequency of meetings among DSD participants. We found that shorter time spent accessing service and less frequent visits were positively associated with HRQoL. This may reflect the value placed on time saved. Service access factors are more commonly studied in relation to patient satisfaction and retention in care than in HRQoL but both are likely to be related. In Malawi, another DSD model- six-monthly appointments with three monthly refills at the facility, showed reduced time spent in clinic as a favorable outcome predicting retention (41). Similarly, clients reported time saved for other activities as the greatest benefit derived from another DSD intervention in Uganda (42). Relatedly, reduced travel time has been identified as beneficial for DSD participants and enabling its success though it was not independently associated with HRQoL in our study (43,44).
As per HRQoL domains, literature reveals that social and psychological/emotional domains score the lowest in most HRQoL studies among PLHIV (16,21,25,45–49) which is in line with our findings. Reasons adduced for this include stigma and discrimination due to fear and lack of awareness as HIV continues to isolate those infected from meaningful relationships. In our population of stable ART clients, variance explainable to service access factors was notably largest i.e. 53.4% in the EWB domain highlighting the significance of the contribution of DSD among participants who likely face different psychological, emotional and social dilemmas. (16,17,46).
While our finding that being male was associated with a more satisfactory HRQoL aligns with evidence from Tanzania, Burkina Faso, Ghana and Ethiopia (18,50–52), other studies reveal no association or favor women (22,23,53–55). Though these studies did not target stable clients in particular, they illustrate the complexity of associations between gender and HRQoL. These findings also inform implementers on areas to explore when developing interventions.
Similar to findings with gender, age reveals intricacies of associations in literature, showing evidence of declining HRQoL with age (49,50,52,54) among PLHIV, as well as improvement or no association (18,23,53). Our results showed a trend of declining HRQoL with age mainly among clinic participants. Among DSD participants, we found a positive association of age with the EWB domain suggesting a protective effect of DSD on EWB with increasing age. Older adults may enjoy fewer social ties than younger adults and thus reap a larger emotional benefit from DSD. As the PLHIV population on ART ages and comorbidities increase, the emotional support provided by DSD will become increasingly important and could serve as a springboard for additional outreach interventions.
Context such as place of residence has been shown to be associated with HRQoL in LMIC(20,21). Our study showed that urban participants at Ngokolo had higher HRQoL scores across most domains than did their rural counterparts at Bugisi. Better living conditions, greater awareness about HIV, and the anonymity people generally enjoy living in an urban setting likely creates a less-stigmatizing space for PLHIV. Our findings that educational level, employment and income level was not associated with HRQoL however differs from reports in the literature which associates a better HRQoL among PLHIV with a higher level of education (18,20,48–50); with employment (19,54,56) and relatedly to higher income levels (19,57). The prevailing socio-economic circumstances which is similar among participants irrespective of setting may likely be the explanation and can inform the additional interventions to explore for higher impact.
Despite viral suppression, HIV infection ultimately predicts sup-optimal HRQoL (9,25). The assumption of ‘normalcy’ in all areas as PLHIV attain viral suppression may be ambitious especially in the context of stigma, living in socio-economically difficult circumstances or with other chronic illnesses. The need to do more in these areas has been advocated especially for PLHIV in the rural areas, for women and for adolescents and young people living with HIV (AYPLHIV) (18,24,25,56,58).
Strengths and limitations
Our study is among few HRQoL studies conducted recently in SSA in the era of DSD. It provides useful insights into factors influencing HRQoL in an African population. Our participants were drawn from different geographical settings which mimics the reality of our population and generated valuable information about the impact of DSD in these settings. Though observational with known biases, the analytical design of our study allowed for comparisons that produced a rich resource useful for informing implementation and policy nonetheless.
Clinic participants were selected for stability as defined by the Tanzanian guideline at the time of data collection while DSD participants were assumed to be stable. This might have biased our results in favor of clinic participants, however viral load-related variables were similar in both groups and not independently associated with HRQoL in our study.
The project sites were mission clinics which may limit the generalizability of our findings. However, we might expect that larger differences in HRQoL scores would be found when comparing DSD and clinics outside mission hospital setting, as better funding and service which characterize our setting likely obscured the effect of DSD