AIDS Reviews.

2021;23

Contents available at PubMed

www.aidsreviews.com PERMANYER AIDS Rev. 2021;23:186-195
www.permanyer.com

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Study of quality of life and depression in people
living with HIV/AIDS in India
Deepak Jain1,2, Y.M. Pavan Kumar1*, V.K. Katyal1,2, Promil Jain3, Jay P. Kumar1, and Shreya Singh4
1
Department of Medicine; 2ART Centre; 3Department of Pathology. Pt. B. D. Sharma Institute of Medical Sciences, Rohtak; 4Kasturba Medical
College, Manipal, India

Abstract
The aim of this study was to assess the quality of life (QOL) and the severity of depression in people

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living with HIV/AIDS (PLWHA) and investigate its correlates. This was a cross-sectional study on 700
PLWHA in India. World Health Organization QOL HIV (WHOQOL HIV-BREF) and Patient Health Question-
naire-9 (PHQ-9) were used to assess QOL and depression in PLWHA, respectively. The study population
was divided into five groups on the basis of Cluster of Differentiation 4 (CD4) count as follows: Group
A [< 50 cells/µL], Group B [50-199 cells/µL], Group C [200-349 cells/µL], Group D [350-499 cells/µL],
and Group E [>500 cells/µL]. The lowest mean scores were noted under Group A [< 50 cells/µL] in
physical and psychological domains and the highest mean scores were noted under Group E [> 500
cells/µL] in physical and environment domains. PHQ9 scores negatively correlated with QOL domains
and the correlation was statistically significant (p < 0.001) with the highest negative correlation was
found in relation to the psychological domain (r = −0.739). The PHQ9 score in those who do not have
opportunistic illnesses (7.23 ± 6.14) was lower in comparison to those who had opportunistic illnesses
(9.81 ± 6.40) and the difference was statistically significant (p < 0.001). We observed that there was
almost a chronological increase in the individual QOL domain score and a decrease in the PHQ9 score
with an increase in CD4 count. Our result supports the implementation of routine screening for depres-
sion in antiretroviral therapy centers and multidisciplinary interventions to improve outcomes among
depressed PLWHA.

Key words
HIV/AIDS. Quality of life. Depression. WHOQOL HIV-BREF. Patient Health Questionnaire-9.

Introduction social isolation attached to the disease. The number of

children from HIV households who have to absent
HIV causes progressive deterioration of the immune themselves from school due to their parents’ illness is
status of an individual leading to AIDS. The individuals around 4 times higher as compared to non-HIV house-
and families affected by HIV not only bear the heavy holds1. Feeling stigmatized due to living with HIV has
financial burden but also have to face stigma and been shown to be related to poor quality of life (QOL)

*Correspondence to: Received in original form: 23-10-2020

Y. M. Pavan Kumar Accepted in final form: 27-03-2021
E-mail: [email protected] DOI: 10.24875/AIDSRev.20000114

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 Jain, et al.: QoL of PLWHA in India

in different cultures. Since the beginning of the HIV existing program. Due to lack of studies on this field
epidemic, experiencing the stigma related to HIV has currently in India, there is a need of a larger study to
been shown to be a barrier to treatment and assess various factors, including the biological mark-

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prevention2,3. ers of disease activity affecting the QOL in PLWHA and
QOL is used as an important outcome indicator for regarding the prevalence of depression in these
healthcare decision-making and intervention effects people.
evaluation4. Health-related QOL (HRQOL) in people
living with HIV/AIDS depends on sociodemographic Methods
characteristics such as age, sex, education, occupa-
tion, and income status. In addition, patient CD4 Study setting, sample, design, and
counts, viral load, clinical stage, and patient adher- measures
ence to treatment are significant predictors of different
dimensions of HRQOL5. This was a cross-sectional study carried out at the
Depression is the most commonly observed mental Department of Medicine, PGIMS, Rohtak, India. Patients
health disorder among HIV-infected patients, affecting attending the nodal antiretroviral therapy (ART) center

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up to 22% of PLWHA6. Depressive symptoms are par- or admitted in wards of PGIMS, Rohtak, were enrolled
ticularly concerning as they can lead to poor treatment in this study after obtaining written informed consent.
adherence, in turn causing low CD4 cell count and The study subjects were recruited between November
increased viral load7. Various studies have shown that 2017 and October 2018. In view of the reported preva-
viral load suppression was associated with satisfactory lence of HIV infection in India by National AIDS Control
QOL. One of the studies from South Carolina had ob- Organization (NACO) as 0.26%, a sample size of 384
served that viral load suppression was significantly was estimated. For this study, we had a total sample
associated with health, psychological health, social size of 700 PLWHA. HIV seropositive subjects con-
relations, and environmental health and negatively as- firmed by enzyme-linked immunosorbent assay or
sociated with spirituality. Among various domains, psy- Western blot technique aged more than 18 years were
chological health was the highest followed by enrolled in the study. All subjects aged less than
environmental health and spiritual domain were low- 18 years and more than 65 years, pregnant and lactat-
est8. Another study was done to evaluate QOL in ing mothers, subjects with an altered sensorium or
PLWHA had shown that QOL for the whole domains of cognitive impairment severely affecting communication
the questionnaire was 12.19 ± 2.44 with domain of were excluded from the study. Patients having estab-
spirituality, religion, and personal beliefs (SRPB) had lished chronic kidney and liver disease before the di-
the highest mean score and level of independence had agnosis of HIV and presence of non-HIV/AIDS-related
the lowest mean score, females had better aspect of malignancy were also not included in this study.
QOL except for SRPB domain. Furthermore, a signifi- After obtaining written informed consent, a detailed
cant association was observed between education and clinical history and biochemical investigation, including
the independence, environment, and spirituality do- CD4 count, was taken. After that, each participant was
mains of QOL9. However, Indian study had shown evaluated with a semi-structured questionnaire, which
equivocal results and only few studies are present was consisted of three parts. The first part consists of
which showed 28.2%-71.25% PLWHA had good QOL. basic sociodemographic details and clinical history of
In terms of domains, one study had the highest score the participant and other factors relating to his disease
in physical and lowest in environmental domains, that may possibly affect the QOL or cause psychologi-
whereas another study had the highest score in envi- cal stress. We also assessed for possible routes of
ronment domain and lowest in social relationship10,11. acquisition of HIV by enquiring about sexual habits,
There is a huge variability of results and also scarcity and intravenous drug abuse history, the clinical status
of data regarding QOL in developing countries like of the patient by CD4 count (measured using flow
India on qualitative identification of QOL determinants, cytometer), adherence to treatment, opportunistic in-
as well as the health and social support needs and fections, and other systemic complications.
constraints of PLWHA in the context of National AIDS The second part of this questionnaire had World
Control Programme (NACP). This deficit hinders a Health Organization (WHOQOL-HIV BREF), a self-ad-
proper understanding of the scope of known quantita- ministered questionnaire specific for HIV/AIDS patients
tive determinants of QOL and responsiveness of the and takes only 8-10 min to complete. Of the several
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QOL measurement tools available, the HIV-specific Group C [200-349 cells/µL], Group D [350-499 cells/
shorter version of WHOQOL-HIV BREF questionnaire µL], and Group E [> 500 cells/µL]. CD4 count was
was selected, which was field-tested in six cross-cul- chosen as the reference standard since it was done in

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turally different centers across the world, including two almost all PLWHA irrespective of patient attributes and
centers in India (Bengaluru and New Delhi)12-14. It has viral load measurement was not routinely available in
six domains, thirty-one items representing the thirty India during our study period. Similarly, the study
facets (including one General facet; containing two group was also subdivided based on the presence or
items asking about an individual’s overall perception absence of opportunistic illness. Finally, all these so-
of the QOL and overall perception of his or her health). ciodemographic factors were correlated with the QOL
Six domains were – (1) Physical domain {pain and and depression in people living with HIV. Since
discomfort, energy and fatigue, sleep and rest, and WHOQOL-HIV BREF and PHQ-9 are widely used and
symptoms of people living With HIV/AIDS (PLWHA)}, validated tools for assessing these variables, no pre-
(2) Psychological domain {positive feelings, thinking, testing was done.
learning, memory, and concentration, self-esteem,
bodily image and appearance, and negative feelings}, Data analysis

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(3) Level of Independence {mobility, activities of daily
living, dependence on medication or treatments, and Data were recorded and entered carefully in the
work capacity}, (4) Social Relationships {personal rela- master chart prepared using Microsoft Excel 2016. For
tionships, social support, sexual activity, and social all descriptive and statistical analysis, Statistical
inclusion}, (5) Environment {physical safety and secu- Package for the Social Sciences (SPSS) Version 25
rity, home environment, financial resources, health, and was used. The distribution of data was analyzed to
social care: accessibility and quality, opportunities for assess for parametric versus non-parametric analysis.
acquiring new information and skills, participation in The values of all domains were expressed in mean and
and opportunities for recreation/leisure activities, phys- standard deviation for each group separately. All cat-
ical environment (pollution/noise/traffic/climate), and egorical variables were expressed in number out of
transport}, and (6) {SRPB, forgiveness and blame, con- total and their respective percentages. For all tests, a
cerns about the future, death, and dying}. Individual p < 0.05 was considered as statistically significant and
items are rated on a 5-point Likert scale where 1 indi- confidence level was kept at 95%.
cates low, negative perceptions and 5 indicate high,
positive perceptions. Domain and facet scores are Ethical consideration
scaled in a positive direction where a higher score
denotes higher QOL. The mean score of items within The study was approved by the institutional ethics
each domain was used to calculate the domain score. committee and also by the NACO, India. Study partici-
Mean scores are then multiplied by 4 to make domain pation was voluntary and anonymous. Information
scores comparable with the scores used in the about the study and consent was provided in the
WHOQOL-HIV (long form) so that scores range be- questionnaire.
tween 4 and 20.
The third part of the questionnaire consisted of Results
Patient Health Questionnaire-9 (PHQ-9) to screen for
depression and measure its severity. This was also a There were a total of 700 cases included in the study.
self-administered questionnaire and takes only 5 min Table 1 shows the basic sociodemographic character-
to complete15. Severity was calculated by assigning istics of the study population. The mean age of the
scores of 0, 1, 2, and 3 to the response categories of study population was 35.12 ± 10.54 years. Four hun-
“not at all,” “several days,” “more than half the days,” dred eighty-one patients were on 1st line ART and
and “nearly every day,” respectively. PHQ-9 total score Tenofovir-Lamivudine-Efavirenz was the most common
for the nine items ranges from 0 to 27. A score of 0-4 regimen.
indicates none to minimal, 5-9 mild, 10-14 moderate, Table 2 shows the various clinical characteristics of
15-19 moderately severe, 20-27 severe depression. the study population. The mean total domain score of
The study population was divided into five groups on the study population was 85.22 ± 13.56. The overall
the basis of CD4 count for further comparison as fol- mean height (cm) was 164.14 ± 9.99, weight (kg) was
lows: Group A [< 50 cells/µL], Group B [50-199 cells/µL], 54.95 ± 11.07, and body mass index (kg/m2) was 20.37
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Table 1. Basic sociodemographic characteristics of the study Table 1. Basic sociodemographic characteristics of the study
population population (Continued)
Variables Frequencies (percentage) Variables Frequencies (percentage)

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Age in years (Mean ± SD) 35.12 ± 10.54 Income (in rupees/month)
< 2000 131 (18.71%)
Gender 2000‑5000 242 (34.57%)
Male 438 (62.57%) 5001‑20,000 279 (39.86%)
Female 253 (36.14%) > 20,000 48 (6.86%)
Transgender 9 (1.29%)
Marital status
Residence Married 461 (65.85%)
Rural 478 (68.28%) Unmarried 116 (16.57%)
Urban 222 (31.71%) Widow 72 (10.29%)
Widower 23 (3.29%)
Religion Divorces 14 (2%)
Hindu 670 (95.71%) Live in relation 14 (2%)
Muslim 16 (2.29%)
Spouse status

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Christian 9 (1.28%)
Not known 284 (40.57%)
Sikh 5 (0.72%)
Positive 263 (37.57%)
Negative 153 (21.86%)
Education
Illiterate 135 (19.28%)
Risk factor
Primary 220 (31.43%)
Heterosexual 567 (81%)
Secondary 247 (35.29%)
Men sex with men 33 (4.71%)
College and above 98 (14%)
Injection drug abuser 13 (1.86%)
Blood transfusion 26 (3.72%)
Occupation
Commercial sex worker 4 (0.57%)
Unemployed 69 (9.86%)
Trucker 46 (6.57%)
Unskilled worker/laborer 140 (20%)
Healthcare worker 11 (1.57%)
Semi‑skilled worker 124 (17.71%)
Skilled worker 76 (10.86%) Treatment status
Agricultural cultivator 84 (12%) No antiretroviral therapy 164 (23.43%)
Housewife 199 (28.43%) 1st line antiretroviral therapy 487 (69.57%)
Govt. employee 8 (1.14%) 2nd line antiretroviral therapy 49 (7%)

(Continues)

± 3.53. The rest of the blood parameters were within found to be statistically significant (p < 0.001) (Fig. 1).
normal limit and the difference was not statistically Table 5 shows the comparison of mean total domain
significant except for mean hemoglobin, which was score and PHQ9 score with opportunistic illnesses. The
less in females (11.20 ± 1.92 g/dL) as compared to total domain score in those who do not have opportu-
males (12.91 ± 2.18 g/dL). On physical domain, most nistic illnesses (86.79 ± 12.65) was higher than those
of the patient had moderate to high amount of physical who had opportunistic illnesses (77.08 ± 15.22) and the
distress. On psychological, social, and environmental difference was statistically significant (p < 0.001).
scale most of the patients fall into dissatisfied or neither Table 6 illustrates the prevalence of opportunistic infec-
satisfied nor dissatisfied category. tion among different depression grades. The PHQ9
Table 3 shows the comparative mean domain values score in those who do not have opportunistic illnesses
of patients with different CD4 groups. As the CD4 (7.23 ± 6.14) was lower than those who had opportu-
count increases, the mean domain score of QOL also nistic illnesses (9.81 ± 6.40) and the difference was
increases and was found to be statistically significant statistically significant (p < 0.001) (Fig. 2).
(p < 0.001). On the other hand, PHQ9 scores decrease
as the CD4 count increases and were also found to be Discussion
statistically significant (p < 0.001).
Table 4 shows the correlation between individual HIV is a chronic debilitating disease with a shift in
QOL domains. Each QOL domain score was positively the natural history of disease from a predominantly
correlated with other QOL domain scores and was mortal endpoint to chronic stable disease stage. The
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Table 2. Clinical characteristics of the study population

p value

< 0.001
Clinical characteristics Mean ± SD

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Height (cm) 164.14 ± 9.99

Questionnaire‑9‡
Weight (kg) 54.95 ± 11.07

Patient Health

15.33 ± 6.41

11.18 ± 5.21

7.15 ± 5.80

6.98 ± 6.18

5.70 ± 5.75
Body mass index (kg/m2) 20.37 ± 3.53

CD4 count (cells/µL) 418.23 ± 252.58

Time since antiretroviral 29.75 ± 36.565

therapy (months)

11.19 ± 2.29

12.53 ± 2.63

14.33 ± 2.41

14.66 ± 2.49

15.48 ± 2.49
SRPB
Total domain score 85.22 ± 13.56

Patient Health Questionnaire‑9 7.65 ± 6.25

score

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Environmental

11.14 ± 2.11

12.80 ± 2.40

14.16 ± 2.13

14.70 ± 2.00

15.58 ± 2.20
Physical domain 14.64 ± 3.05

Psychological domain 14.24 ± 2.78

Level of independence domain 13.86 ± 2.64

Social Relationship
Social relationship domain 13.68 ± 2.40

10.76 ± 2.50

12.48 ± 2.24

13.08 ± 2.21

13.80 ± 1.96

14.85 ± 2.21
Environment domain 14.43 ± 2.46 Quality of life Domains*(Mean ± SD)

SRPB domain 14.36 ± 2.76 Level of Independence

success achieved by highly active ART (HAART) has

Table 3. Relationship between the various quality of life domains and CD4 groups

10.05 ± 2.39

12.07 ± 2.37

13.43 ± 2.10

14.27 ± 2.26

15.13 ± 2.37
now transformed the perception about HIV infection
from being a “virtual death sentence” to a “chronic
manageable illness.” QOL has become an important
outcome variable. The present study involving 700 pa-
tients assessed various factors influencing QOL and
depression in PLWHA.
Psychological

12.44 ± 2.56

14.11 ± 2.28

14.68 ± 2.36

15.40 ± 2.55
9.90 ± 2.68

In our study, there were 438 (62.57%) males, 253

*Higher domain scores correspond to better quality of life on a scale of 4‑20.
‡Higher scores correspond to higher levels of depression on a scale of 0‑27.

(36.14%) females, and 9 (1.28%) transgender. Males

were higher in number compared to females probably
because the majority of women remain unaware of their
HIV status, women have limited access to healthcare
12.28 ± 2.98

14.31 ± 2.46

15.25 ± 2.52

16.12 ± 2.44
9.86 ± 2.81

because of various social, cultural, and economic rea-

Physical

sons, rejection by their own families, routine of the

household is likely to be disrupted by women’s absent
at home when both husband and wife are sick, more
importance could be given to see that the man gets
Group C [200‑349]

Group D [350‑499]

well first, in case of a widow, whether staying by herself

Group B [50‑199]

Group E [≥ 500]
Group A [< 50]

or with the in-laws, there may be nobody who is pre-

CD4 Groups

pared to take her to the doctor. Gender inequalities are

[cells/µL]

a key driver of women’s vulnerabilities to HIV16. Majority

of the subjects were in the age group of 20-39 years
(66%).
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Table 4. Correlation between various WHOQOL‑HIV BREF domains

QOL domains Physical Psychological Level of Social Environment SRPB p value

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independence relationships

Physical 1 0.734 0.764 0.534 0.694 0.688 < 0.001

Psychological 0.734 1 0.706 0.548 0.729 0.661

Level of independence 0.764 0.706 1 0.567 0.699 0.647

Social relationships 0.534 0.548 0.567 1 0.614 0.444

Environment 0.694 0.729 0.699 0.614 1 0.645

SRPB 0.688 0.661 0.647 0.444 0.645 1

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Table 5. Mean total domain scores and Patient Health Table 6. Prevalence of opportunistic infections among dif‑
Questionnaire‑9 scores with opportunistic illness ferent depression grades

Opportunistic Mean ± SD p Patient Health Oppotunistic Total

illnesses value Questionnaire‑9 score infections
Absent Present
(n‑587) (n‑113) No Yes

Total domain 86.79 ± 77.08 ± < 0.001 0‑4 (none to minimal) 255 31 286
score 12.65 15.22
5‑9 (mild) 121 20 141
Patient Health 7.23 ± 9.81 ± < 0.001
Questionnaire‑9 6.14 6.40 10‑14 (moderate) 117 32 149
score
15‑19 (moderately 82 22 104
severe)

20‑27 (severe) 12 8 20

Our study found that of the 700 PLWHA, 478 were Total 587 113 700

residing in rural areas, whereas 222 were from urban

localities. This difference might be due to a lack of
awareness about the modes of transmission in people
from rural background. It could also be due to long scores with respect to the route of transmission. This
waiting queues and probable fear of recognition by a means that how a person gets HIV infection has no
neighborhood on ART center visits leading urban peo- bearing on QOL. Similarly, the marital status of an in-
dividual has no effect on QOL domain scores which is
ple toward private clinics.
in contradiction to some of the previous studies show-
The mean total domain score of our study population
ing better QOL in the married group. In a study done
was 85.22 ± 13.56 and the mean PHQ9 score was 7.65
by Arjun et al., married PLWHA showed better QOL
± 6.25. Statistically significant differences were not
domain scores compared to widowers17. The probable
found among gender groups. The social domain was
reason could be that the physical, emotional, and psy-
the worst affected followed by the level of indepen- chological support of a spouse is more effective when
dence domain. compared to the support received from the rest of the
Our study demonstrated that PLWHA who have re- family members. There were no statistically significant
ceived ART for a longer duration had a significant differences in QOL domains when compared with the
difference in physical, psychological, and level of in- type of residence, be it rural or urban. No statistically
dependence domain scores. We found that there were significant difference was observed in the QOL domain
no statistically significant differences in the domain when compared with religious groups, potentiating the
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Figure 1. Matrix scatter plot showing the correlation between various WHOQOL HIV-BREF.

fact from previous studies that religion had no net ef- quarrel between the partners and worries about their
fect on overall QOL. However, whether or not spiritual child’s future. Statistically significant differences were
interventions can improve the QOL is still a subject of also observed in income groups with lower scores in
debate. Systemic reviews to date had not advised low-income group (p = 0.011), further supporting the
blanket encouragement or discouragement of religious fact that financial burden badly affects each QOL do-
beliefs18. Healthcare workers should be aware of pa- main and had a negative effect overall QOL in PLWHA.
tients’ spirituality and religious involvement that might We found statistically significant differences in educa-
have a role in shaping the QOL. tion groups with lower scores in lower education groups
We found statistically significant differences in (p = 0.021). This can be explained by the coping
spouse HIV status with lower scores in spouse HIV strategies adopted by literate people and correct
positive group (p = 0.014). The reason could be a knowledge on the disease, mode of transmission, and
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Figure 2. Scatter plot showing the correlation between total quality of life domain scores and Patient Health Questionnaire-9 scores.

good adherence to ART in achieving a healthy life free In our study, we have found that CD4 count had a
from illness. We also found a statistically significant positive linear relationship with individual domain
difference in occupation groups with the lowest scores scores. There was almost a chronological increase
in government employees (p = 0.026), probably due in the mean QOL score with an increase in CD4 cell
to fear of losing government jobs and accompanying count category in all the domains. The lowest mean
financial burden. scores were noted under CD4 Group A [< 50 cells/μL]
Our study found that the physical domain scores are in physical and psychological domains. On the other
positively correlated with psychological, level of inde- hand, the highest mean scores were noted under
pendence, social, environment, and spiritual well-be- CD4 Group E [≥ 500 cells/μL] under the physical and
ing scale (SRPB) domain scores and are statistically environment domains. The QOL score tends to in-
significant. This suggests that physical domain was crease with increases in the CD4 cell count category
influenced by psychological, level of independence, which is consistent with another study in India show-
social, environment, and SRPB factors. Each domain ing a positive correlation between CD4 and QOL20.
was affected by every other domain in our study sub- The differences between consecutive categories are
jects and improving one QOL domain would have a statistically significant (p < 0.001). The improve-
significant positive impact on the rest of the QOL do- ments in clinical variables will translate to improve
mains and a positive feedback circuit was created QOL. Hence, early initiation of ART along with good
automatically. PLWHA had poor social functioning control of opportunistic infections can result in better
which includes a patient’s interaction with other people QOL.
at home, work, and society. The social stigma associ- In a cross-sectional study conducted at Finland by
ated with the disease makes it even harder for patients Nobre et al., on 453 PLWHA, it was found that factors
to socialize in society. Patients are more often isolated; such as male gender, being married or living in a
therefore, they feel lonely, bored, confined, or aban- partnered relationship, being employed, having fewer
doned. Patients are worried, frustrated, and/or disap- financial concerns, and not having depression, and
pointed when it comes to accepting the diagnosis of other medical co-morbidities were positively and con-
HIV; the economic burden of the disease, loss of a job, sistently associated with higher scores in the different
social stigma, and physical appearance is also cause domains of the QOL. HIV-related clinical variables
for psychological problems19. were not associated with QoL, contradicting previous
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 AIDS Reviews. 2021;23

evidence of a significant association between good lower chance of depression compared to those who
clinical parameters and increased QoL. Almost 95% of did not receive ART which is consistent with a previous
participants were receiving combination ART (cART) study showing higher depression among those who did

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and 63% had a CD4+ T-cell count > 500 cells/mm3. not receive ART23.
They concluded that in a stable patient population We have found that CD4 count had a negative linear
treated with modern cART, the significance of these relationship with PHQ9 scores. On face value, there
HIV-related clinical variables may disappear21. was almost a chronological decrease in the PHQ9
In a study of QOL among PLWHA conducted by P S score with an increase in CD4 cell count category. The
Chandra on 82 patients, it was observed that signifi- highest PHQ mean scores were noted under CD4
cant associations were seen between low CD4 counts Group A [< 50 cells/μL]. On the other hand, the lowest
and the psychological and social relationships domain. PHQ9 mean scores were noted under CD4 Group E
However, there were no significant differences be- [≥ 500 cells/μL]. The PHQ9 score tends to increase with
tween the CD4 subgroups for the domains related to increases in the CD4 cell count category. The differ-
physical health, level of independence, environment, ences between consecutive categories were statisti-
and spirituality domains. In addition, as part of the in- cally significant (p < 0.001), implicating that depression

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clusion criteria, they excluded subjects with harmful associated with HIV was also likely to improve when the
alcohol use and clinical depression. These might have clinical parameters got better. This was supported by
independent influences on immunological and QOL a study conducted by Taniguchi et al. in which they
parameters and would have acted as confounding found that the decline of CD4 cell count was indepen-
factors22. dently associated with an increase in depression24,25.
In our study, the most common opportunistic illness PHQ9 scores negatively correlated with WHOQOL
was pulmonary tuberculosis (TB) which was detected HIV-BREF domains and the correlation was statistically
using Cartridge-based Nucleic Acid Amplification Test significant (p < 0.001), with the highest negative cor-
in 76 patients followed by candidiasis in 30 patients. Ten relation, was found in relation to the psychological
patients had extrapulmonary TB, 4 had Cytomegalovirus domain (r = −0.739), and lowest negative correlation
retinitis, 3 had cryptococcal meningitis, 2 had was found in relation to social relationships domain.
Mycobacterium avium complex infection, and 1 patient This finding is supported by a study done in Thailand
had cerebral toxoplasmosis. We found that the total showing a negative correlation between PHQ9 and
domain score in those who do not have opportunistic QOL26. Hence, depression also affects QOL domains
illnesses was higher than those who had opportunistic very significantly.
illnesses and the difference was statistically significant A study conducted in Uganda by Mwesiga et al. on
(p < 0.001). About 16.1% of the participants had op- 345 HIV-positive patients found that patients of depres-
portunistic infections, with lower QOL scores in all the sion with pain co-morbidity (DPC) had a poorer QOL in
domains compared to participants with the absence of all domains compared to the total population. They con-
opportunistic infection. This was comparable to a study cluded by stating that screening as well as early and
conducted by Arjun et al., where PLWHA with opportu- appropriate management of DPC in PLWHA may help
nistic illnesses had lower domain scores compared to to improve the QOL. Simple and self-rated instruments
those who did not have opportunistic illnesses17. such as PHQ9 and Mini International Neuropsychiatric
The total mean PHQ9 score of the study population Interview used in this study could easily be implemented
was 7.65 ± 6.25. There were no statistically significant into routine clinical practice to get patients with DPC into
differences between gender groups (p = 0.618). care that is appropriate for their situation27.
Twenty (2.85%) PLWHA were having severe depres- The PHQ9 score in those who do not have opportunistic
sion at the time of study as screened by the PHQ9 illnesses (7.23 ± 6.14) was lower in comparison to those
questionnaire. Two hundred and eighty-six (40.85%) who had opportunistic illnesses (9.81 ± 6.40) and the dif-
PLWHA belonged to “No-Minimal depression” catego- ference was statistically significant (p < 0.001). It means
ry. The mean PHQ9 scores who were “NOT ON ART” those who had opportunistic illnesses tend to have higher
were higher (10.73 ± 5.42) than those who were “ON categories of depression and had suicidal tendencies
ART” (1st line-6.67 ± 6.13 and 2nd line-7.10 ± 6.74) and compared to those who do not have opportunistic ill-
were statistically significant (p < 0.001). PHQ9 scores nesses which is consistent with previous study23,25.
negatively correlated with ART receival status with Some limitations must be considered in interpreting
p < 0.001, meaning those who were on ART had a the results of our study. The cross-sectional nature of
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 Jain, et al.: QoL of PLWHA in India

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