Impact of HIV/AIDS on the Quality Of Life
A Cross Sectional Study among Patients Receiving Antiretroviral Therapy from a Peripheral STD Clinic in Sri Lanka
P.H.M.P Bandara¹, A.A.I.N Jayasekara¹ S.N Jayasuriya², J. Ranatunga² 1. National STD/AIDS Control Programme, Sri Lanka. 2. STD Clinic, Teaching Hospital Colombo North, Sri Lanka
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Introduction 10/27/2014
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Background of the study
• With the miraculous effects of Anti Retroviral Therapy, HIV has become just another chronic disease; having minimal impact on the life expectancy of an affected individual. • On the other hand, increasingly health care planners are recognizing that measures of disease alone are insufficient determinants of health status. • Therefore, Complementary Health Status Measures are required to determine HIV health status 10/27/2014
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Complementary Health Status Measures Health Status Measures
Quality of Life (QOL) measure
Functional Health Status
Objective
Health & Well being
Subjective
These measures are multi-level & multi-dimensional 10/27/2014
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Quality Of Life (QOL) “An individual’s perception of their position in life in the context of the cultural & value systems in which they live and in relation to their goals, expectations, standards & concerns” - World Health Organization 10/27/2014
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Objectives 10/27/2014
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Objectives
1. To assess the quality of life of HIV positive patients who are on ARV for more than six months under four main domains (Physical, Psychological, Social & Environmental) 2. To establish possible associations of each of the above domains with • Socio-demographic characteristics • Selected clinical parameters • Based on literature review & conceptual framework 10/27/2014
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Methodology 10/27/2014
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Details of the study
Study design
Cross Sectional study
Study setting STD Clinic, Ragama • Total Number of adult HIV patients registered – 108 • Number on ART – 59 / Number on ART for >6/12 – 47 • Total number of Children (<12 years)- 04
Study population All HIV positive adult outpatients who are on ART for more than six months
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Inclusion & Exclusion criteria • Inclusion Criteria • All HIV positive patients who are on ART for >6/12
• Exclusion Criteria • HIV positive patients who are still not started on ART • HIV positive patients who are on ART for <6/12 • Children less than 12 years
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Study Methodology • Study Instrument • Interviewer administered pre-tested questionnaire
• Sample Size: • Forty seven (47) patients
• Selection & training of the Interviewer • Interviewer – Trained nursing officer (Not involved in HIV patient management)
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Study Methodology contd…. • Focus on validity of data • Training of the Interviewer • Random supervisions of the Interviewer
• Study Duration • Period of two months
• Data extraction • Clinical data extraction was done by the Investigators using the clinic records
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Questionnaire • Questionnaire - WHOQOL-Bref (Sinhala) instrument • Process of Translation & modification • Pre testing of the questionnaire • Training of the interviewer – by the Principal Investigator • WHOQOL-BREF, an abbreviated version of the WHOQOL-100 (WHOQOL-100 quality of life assessment was developed by the WHOQOL group with 15 international field centres, simultaneously, in an attempt to develop a quality of life assessment that would be applicable cross-culturally)
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Scoring system of the questions
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Summarizing into domains
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Process of calculating the transformed score from the raw score
Transformed score
=
Actual raw domain score- lowest possible raw domain score Possible raw domain score range
x100
Analysis
• Extraction using SPSS v20 • One way Analysis of Variance (ANOVA) • Significant difference between some selected clinical data & the socio-demographic variables on QOL domains
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Results 10/27/2014
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Characteristics of study sample â&#x20AC;˘ The mean age of the study population was 44.23 years (range 27-68 years)(SD 10.4)
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Gender Distribution of study population by Gender 29.70% Female
70.20%
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Male
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Marital Status Distribution of the study population by the Marital Status 59.50% Single Married 0 21.20% 6.30%
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8.50%
4.30%
Livingto Seperated Divorced Widowed
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Highest level of Education
Distribution of study population by highest level of Education
57.5% 1-5 6-10
17.00%
GCEOL GCEAL
8.50% 2.10%
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14.90%
DIPdeg NoSchooling
0% 23
Monthly Income Distribution of study population by Monthly Income
53.20% 21.20%
Less than 10000 10000-20000 20000-50000
12.80% 12.80%
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More than 50000
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Current Occupation Distribution of the study population by Current Occupation
44.70%
Unemployed Self Student 2.10%
29.80% 12.70% 6.40%
0% 4.30%
Executive MiddleLevelEmployed Labourer Retired UnableToWork
0%
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Mode of transmission of HIV
Distribution of the mode of Transmission of HIV infection of the study population
23.50%
heterosexual 76.50% homosexual/bisexual
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Stage at Diagnosis of infection Distribution of Stage at Diagnosis of the Infection
WHO clinical stage
4
21.20%
3
27.70%
2
4.30%
1
46.80%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Percentage 10/27/2014
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Reported opportunistic infections Distribution of reported Opportunistic Infections
Opporunistic Infecton
TB
22%
PCP Pneumonia
13%
Other OIs
2%
Oral Candidiasis
7%
Oesophagal candidiasia
6%
No OIs
50%
0%
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10%
20%
30%
Percentage
40%
50%
60%
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Medical co-morbidities Distribution of Medical Co-morbidities
Other
Medical Co-morbidities
Asthma
4.00%
2.00%
None
76%
Hypercholoestreolaemia
2.00%
Hypertension
2.00%
Diabetes
10.00%
CLD
2.00%
CKD
2.00%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
Percentage
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Results Contd……
• The overall QOL mean score on a scale of 0-100 was 74.38
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Comparison of Mean Scores Mean Score four domains of QOL 100 90
86.8 79.41
80
74.17
Mean score
70
57.13
60 50 40 30 20 10 0
Physical
Psychological
Social
Environmental
QOL domain 10/27/2014
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Social domain observation
Three facets of social domain have been assessed Observed: Low satisfaction related to sexual activity Need further analysis 10/27/2014
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Significance of physical health attributes Distribution of p-values for clinical & socio demographic parameters in the Physical health domain
CD4 at present
0.001
Adherence
0.004
Viral load
0.026
Stage at diagnosis
0.079
Variable of interest
Side effects of ARV
0.318
ARV Regimen
0.431
Level of education
0.508
Income
0.512
Marital Status
0.548
CD4 at diagnosis
0.67
Medical Co-morbidities
0.735
Gender
0.829
Occupation
0.851
Age
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0.922
0
0.1
0.2
0.3
0.4
0.5
p-Value
0.6
0.7
0.8
0.9
1
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Significance of Psychological health attributes Variale of interest
Distribution of p-values for clinical & socio demographic parameters in the Psychology domain Adherence
0.001
Income
0.001
Side effects of ARV
0.007
Stage at diagnosis
0.03
Level of education
0.12
Age
0.163
Occupation
0.232
Medical Co-morbidities
0.407
Marital Status
0.426
Mode of transmission
0.492
Recreational drug use
0.494
Alcohol
0.556
Gender
0.793
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
p-Value
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Significance of Social Relationship domain parameters
Distribution of p-values for clinical & socio demographic parameters in the Social Relationship domain
Level of education
0.03
Marital Status
0.15
Variable of interest
Occupation
0.309
Alcohol
0.522
Age
0.548
Mode of transmission
0.814
Income
0.828
Recreational drug use
0.987
Gender
0.995
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
1.1
p-Value
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Significance of Environment domain parameters Distribution of p-values for clinical & socio demographic parameters in the Environment domain Income
0.034
Variable of interest
Occupation
0.345
Level of education
0.079
Marital Status
0.747
Gender
0.538
Age
0.253
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
p-Value
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Analysis & Results • Significantly better QOL scores in the Physical Health domain (p=0.01) with respect to • CD4 count • > 95% adherence
• Significantly better QOL scores in the Psychology domain (p=0.01) with respect to • >95% adherence • Income • ARV 10/27/2014
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Results Cont. No associations were observed with; • Socio demographic parameters • • • •
Age Gender Marital status Occupation
• Clinical parameters • Duration of ARV medications • Current ARV regimen • Alcohol and recreational drugs 10/27/2014
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Inter-domain correlation
Domain Parameter Physical health Pearson Correlation domain Transformed p-value (2-tailed) score N Psychological Pearson Correlation domain Transformed p-value (2-tailed) score N Social domain Transformed score
Psychology
Social
Environmental
.567**
.178
.713**
.000
.231
.000
47
47
47
.567**
.158
.671**
.000
.290
.000
47
47
47
Pearson Correlation
.178
.158
.297*
p-value (2-tailed)
.231
.290
.042
47
47
47
.713**
.671**
.297*
.000
.000
.042
47
47
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N Environment Domain Transformed score
Physical health
Pearson Correlation p-value (2-tailed) N
Inter Domain Correlation â&#x20AC;˘ Environmental domain attributes are positively correlated with Physical and Psychological domain attributes at 1% significance â&#x20AC;˘ Psychological domain attributes are positively correlated with Physical domain attributes at 1% significance Detailed study on Inter-attribute correlation across the above domain pairs will provide specific clues in improving QOL 10/27/2014
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Conclusion Testing at 1% Significance level,
QOL of HIV patients is associated with; • • • •
Income Current CD4 count Drug adherence Side effects of ARV
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Recommendations 1. National cohort analysis of patients on ART should be done annually to assess the ART outcome 2. QOL assessment should be integrated into the HIV management protocols
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Future Scope
• Detailed analysis of each domain • To find relative contribution of each component • To address the facets with low contribution
• Comparison of QOL of different cohorts in different ART centers in Sri Lanka • To assess the significance in order to take necessary actions to improve QOL
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Limitations
• Small sample size
• Relatively low sample size of females ( 70% vs 30%) • Quality of life of children could not be assessed • Need a separate tool for that
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Acknowledgement
• Staff at the STD Clinic Ragama • Co-researchers • Dr Jayadarie Ranatunga • Dr Niroshan Jayasekara • Dr Subashini Jayasuriya
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References
1. Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med. 1998;28:551–8. 2. Clayson DJ, Wild DJ, Quarterman P, Duprat-Lomon I, Kubin M, Coons SJ. A comparative review of health related quality of life measures for use in HIV/AIDS clinical trials. Pharmacoeconomics. 2006;24:751–65. 3. Fauci AS. The AIDS Epidemic: Considerations for the 21st Century. N Engl J Med. 1999;341:1046–50. 4. Walker N, Grassly NC, Garnett GP, Stanecki KA, Ghys PD. Estimating the global burden of HIV/AIDS: What do we really know about the HIV pandemic? Lancet. 2004;363:2180–5. 5. Beck EJ, Miners AH, Tolley K. The cost of HIV treatment and care: A global review. Pharmacoeconomics. 2001;19:13–39. 6. Halloran J. Increasing survival with HIV: Impact on nursing care. AACN Clin Issues. 2006;17:8–17. 7. Kassutto S, Maghsoudi K, Johnston MN, Robbins GK, Burgett NC, Sax PE, et al. Longitudinal analysis of clinical markers following antiretroviral therapy initiated during acute or early HIV Type I infection. Clin Infect Dis. 2006;42:1024–31. 8. Aranda-Naranjo B. Quality of life in HIV-positive patient. J Assoc Nurses AIDS Care. 2004;15:20–7. 9. Hays RD, Cunningham WE, Sherbourne CD, Wilson IB, Wu AW, Cleary PD, et al. Health-related quality of life in patients with human immunodeficiency virus infection in the United States: Results from the HIV Cost and Services Utilization Study. Am J Med. 2000;108:714–22. 10. Mannheimer SB, Matts J, Telzak E, Chesney M, Child C, Wu AW, et al. Quality of life in HIV-infected individuals receiving antiretroviral therapy is related to adherence. AIDS Care. 2005;17:10–22. 10/27/2014
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Thank You
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