Quality of life and related factors among adults exposed to human immunodeficiency virus

Introduction

Background

Human immunodeficiency virus (HIV) exposure, whether through unsafe sexual practices or accidental contact with HIV-infected sources, presents significant health risks that necessitate immediate intervention through post-exposure prophylaxis (PEP). Individuals exposed to HIV often experience significant challenges, including stress, anxiety, and side effects from antiretroviral (ARV) drugs, all of which contribute to a decline in their quality of life (QoL) (1,2). Occupational exposure predominantly affects healthcare workers and public service personnel, while non-occupational exposure typically results from unsafe sexual behaviors or accidental encounters within the community (3-5). The reported lifetime prevalence of needlestick injuries varied widely, ranging between 22% and 95%, while the one-year prevalence was found to range from 39% to 91% (6). Exposure to blood and body fluids continues to be a common issue for healthcare workers (1). In Vietnam, data from the Hospital for Tropical Diseases in Ho Chi Minh City indicates that 26% of HIV exposures occur in occupational settings, while 74% arise from non-occupational contexts (7).

According to national guidelines in Vietnam, individuals exposed to HIV undergo an HIV testing algorithm known as Strategy III, which includes a screening test (HIV Ag/Ab Combo), followed by two different confirmatory tests (HIV Duo and Determine HIV 1/2). If all three tests are positive, the individual is considered HIV-positive. Inconclusive results are re-tested after 14 days, and persistent indeterminate cases are referred for HIV DNA PCR testing. This staged testing process ensures accurate diagnosis and minimizes misclassification while allowing for appropriate psychological support during the post-exposure period. These tests are typically scheduled at baseline and again at day 28, consistent with national PEP protocols.

Rationale and knowledge gap

QoL is a multidimensional measure that reflects an individual’s subjective perception of their well-being in relation to their environment, society, and overall health (8). Modern health assessments now include QoL evaluations as a critical component, especially in cases where individuals undergo treatments such as PEP, which can cause significant side effects, including gastrointestinal disturbances, fatigue, headaches, and dermatological issues (9-11). Despite the known challenges associated with HIV exposure, including the persistent effects of stigma and psychological trauma, research specifically addressing the QoL of individuals following HIV exposure remains limited. Most existing studies focus on the short-term physical impacts, typically within the first few days to one week of treatment, leaving a gap in understanding how these factors influence QoL outcomes and what specific interventions might mitigate these effects (2,3,6). Some studies have also utilized screening tools for mental distress, such as the Self-Reporting Questionnaire (SRQ) (12), but their application to QoL in the context of HIV exposure remains limited (13-15).

Objective

This study is to (I) determine the mean QoL scores of adults exposed to HIV at two time points: immediately after exposure (T1) and after 28 days of prophylactic treatment (T2), (II) evaluate the changes in QoL scores between these two points, and (III) identify the related factors between individual characteristics, social stigma, and psychological trauma on QoL post-exposure. We present this article in accordance with the STROBE reporting checklist (available at https://amj.amegroups.com/article/view/10.21037/amj-24-146/rc).

Methods

Study design and setting

This study employed a prospective cohort descriptive design, chosen for its ability to observe changes in QoL over time among adults exposed to HIV. This design is particularly suited for examining temporal relationships and making causal inferences between HIV exposure and subsequent changes in QoL. By assessing participants at two distinct time points—immediately after exposure and after 28 days of prophylactic treatment—this approach enables the study to capture dynamic changes and identify key factors influencing QoL, providing a comprehensive understanding of the impact of HIV exposure.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Biomedical Research Ethics Committee of the University of Medicine and Pharmacy at Ho Chi Minh City (approval No. 706/HDD-DHYD, dated 24/11/2022). Informed consent was obtained from all participants, to ensure their voluntary participation. All collected data were kept confidential and used solely for research purposes.

Participants and sampling

Participants were selected using purposive convenience sampling, allowing for the targeted recruitment of individuals who met specific criteria relevant to the study. Participants were selected from individuals who presented at the outpatient department of the Hospital for Tropical Diseases in Ho Chi Minh City within 72 hours of confirmed HIV exposure and were eligible for PEP initiation. All participants were screened and received PEP in accordance with the national guidelines for HIV prevention and care issued by the Ministry of Health.

Sample size

The sample size was determined using G-Power 3.1 software, assuming an alpha error of 0.05 and a beta error of 0.05, with a chi-square statistical test to measure the relationship between QoL and related factors. The calculated minimum sample size was 134 participants. To account for an estimated 20% dropout rate, the study aimed to recruit at least 160 participants.

Selection criteria

Participants were included if they were aged 18 or older, had been exposed to HIV, tested negative for HIV at the time of screening, and were prescribed PEP. Exclusion criteria included regular exposure to HIV (e.g., having an HIV-positive partner or frequent needle sharing), previous PEP treatment, pregnancy, experiences of sexual abuse, and existing psychosis or depression (as diagnosed by a psychiatrist). Cases were considered missing if participants did not comply with the 28-day treatment, discontinued cooperation, or were lost to follow-up.

Data collection

Data were collected through face-to-face interviews conducted by trained investigators in a private setting at two time points (T1 and T2). Appointments were scheduled based on identifying information, which was not recorded in the interview questionnaires. Instead, each participant was assigned a unique code to maintain confidentiality. Blood samples for HIV testing were analyzed at the Hospital for Tropical Diseases in Ho Chi Minh City, following the standard procedures of the Vietnamese Ministry of Health. Each interview lasted 20–30 minutes. Subsequently, the participants were monitored via telephone following the completion of the initial survey. Specifically, we reconnected with participants by phone at key intervals, such as 14 and 28 days after the initiation of PEP, to gather data on health status, adherence to treatment, and any changes in QoL. This approach was implemented to ensure data continuity, minimize participant attrition, and maintain the confidentiality of their personal information. Data collection spanned from March to June 2023.

Variables

The primary variables assessed in this study were:

• QoL: measured using the MOS-HIV scale, which evaluates the physical, mental, and social aspects of health.
• HIV stigma: assessed using the HIV Stigma Scale (HSS-SF), which measures perceived stigma related to HIV exposure.
• Psychiatric disturbance: assessed using the SRQ-20, a screening tool for psychological distress.
• Demographic variables: sex, age, occupation, and circumstances of HIV exposure.

Measurement tools

Three validated scales were used for data collection:

• HIV Stigma Short Form (HSS-SF): developed by Reinius et al. [2017], this scale measures negative stereotypes associated with HIV (8). It consists of 12 items rated on a 4-point Likert scale, with higher scores indicating greater stigma. The Vietnamese version (HSS-SF/V) has a Cronbach’s alpha of 0.84.
• Self-Reporting Questionnaire (SRQ-20): this WHO tool [1994] assesses psychotic symptoms related to depression and hopelessness (12). It includes 20 items, with scores of 7 or higher indicating psychological trauma. The Vietnamese version (SRQ-20/V) has a Cronbach’s alpha of 0.81.
• Medical Outcomes Study HIV Health Survey (MOS-HIV): developed by Wu et al. [1997], this scale is divided into two subgroups (Physical health and Mental health), measuring various health dimensions of QoL, including general health, pain, physical functioning, role functioning, social functioning, mental health, energy/fatigue, health distress, cognitive function, QoL, and health transition (13). The Vietnamese version (MOS-HIV/V) has a Cronbach’s alpha of 0.91. The content validity index for the Vietnamese versions of these scales ranged from 0.91 to 0.99, as evaluated by a panel of six experts.

Outcomes

• Primary outcome: the primary outcome of this study was QoL, measured at two time points (T1 and T2) using the MOS-HIV scale.
• Secondary outcomes: these included HIV stigma, psychiatric disturbance, and demographic factors such as sex, age, occupation, and the nature of HIV exposure, all of which were evaluated to understand their influence on QoL.

Biases and confounding

To control information bias, interviews were conducted by pre-trained investigators in a private setting. Participant identities were anonymized to minimize self-reporting bias and external influencing factors. Additionally, we employed multivariate regression analysis to adjust for potential confounding variables, thereby clarifying the relationships between the factors under investigation and the QoL of individuals exposed to HIV.

Data analysis

Data were analyzed using R software (version 4.3.2, R Foundation for Statistical Computing, Austria). Descriptive statistics, including means and standard deviations (SD) for continuous variables and frequencies and percentages for categorical variables, were calculated. For continuous data normality, tests were administered using the Kolmogorov-Smirnov test. Inferential statistics included Chi-squared tests for categorical variables, t-tests for comparing means, and linear regression analyses for multivariate models.

To examine the associations between QoL and continuous or ordinal variables such as HIV stigma and psychological distress, correlation analyses were conducted. Spearman’s rank correlation coefficient was used for variables that were ordinal or not normally distributed. Pearson correlation coefficients were applied when both variables were continuous, approximately normally distributed, and linearly related. A P value ≤0.05 (bilateral) was considered statistically significant.

Results

Participant characteristics

The flow chart of patient selection was showed in Figure 1. At the initial time point (T1), 190 participants were enrolled in the study. By the second time point (T2), 167 participants remained, reflecting an 87.9% retention rate. The mean age of participants was 31.3±9.5 years. The majority of participants were male (78.4%) and resided in Ho Chi Minh City (83.7%). Educational attainment varied, with 64.7% having a college or university education or higher. Most participants (83.2%) reported community-based HIV exposure, primarily due to unsafe sex (57.4%). Table 1 summarizes the demographic and exposure characteristics of the study participants.

Figure 1 Study flowchart of participant recruitment, eligibility screening, and follow-up assessments. HCMC, Ho Chi Minh City; HIV, human immunodeficiency virus; PEP, post-exposure prophylaxis.

QoL scores

QoL was assessed using the MOS-HIV scale (Figure 2). The mean QoL scores at T1 and T2 were 50.8 and 50.9, respectively, indicating a moderate QoL with no statistically significant difference between the two time points (P=0.38). Similarly, scores for physical health and mental health subdomains did not differ significantly between T1 and T2.

Figure 2 Quality of life scores, assessed by the MOS-HIV scale, immediately post-exposure (T1) and after 28 days of prophylactic treatment (T2). HIV, human immunodeficiency virus; MOS-HIV, Medical Outcomes Study HIV Health Survey.

Factors influencing QoL

Individual characteristics

At T1, significant differences in QoL scores were observed across sex (P=0.05), occupation (P=0.01), circumstances of HIV exposure (P=0.03), and causes of HIV exposure (P=0.04). Females had lower QoL scores than males. Healthcare workers/police had higher QoL scores than other employees/laborers. Those exposed to HIV in the community had lower QoL scores compared to those with occupational exposure. Participants exposed due to unsafe sex had lower QoL scores than those exposed due to sharp object injuries or blood exposure. At T2, only occupation remained a significant factor, with healthcare workers/police maintaining higher QoL scores than employees/laborers (P=0.03). Table 2 details the relationship between individual characteristics and QoL at T1 and T2.

HIV stigma

HIV-related stigma was measured using the HSS-SF scale. A significant negative correlation was observed between HIV stigma and QoL at both T1 and T2. At T1 (immediately post-exposure), Spearman’s correlation coefficient was ρ=−0.23, with a P=0.001. At T2 (after 28 days of PEP treatment), the correlation remained significant with ρ=−0.23, P=0.003. These findings indicate that individuals with higher perceived stigma consistently reported lower QoL, both immediately after exposure and following the completion of PEP. Figure 3 illustrates this inverse relationship.

Figure 3 Correlation between HIV stigma and quality of life, as measured by the MOS-HIV scale, in immediately post-exposure (T1) (A) and after 28 days of prophylactic treatment (T2) (B). HIV, human immunodeficiency virus; MOS-HIV, Medical Outcomes Study HIV Health Survey.

Psychiatric disturbance

Participants with psychiatric disturbances, as identified by the SRQ-20 scale, had significantly lower QoL scores than those without such disturbances at both time points. At T1, the mean QoL score was 48.7 for participants with psychiatric disturbance and 51.5 for those without, with a P=0.003. At T2, the difference was even more pronounced: participants with psychiatric disturbance had a mean QoL score of 44.8, compared to 51.2 in those without, and the difference was statistically significant (P<0.001). These results indicate that the presence of psychological distress consistently and negatively affects perceived QoL, both immediately after HIV exposure and following completion of PEP. Figure 4 details the relationship between psychiatric disturbance and QoL.

Figure 4 Quality of life scores, assessed by the MOS-HIV scale, by presence of psychiatric disturbance immediately post-exposure (T1) (A) and after 28 days of prophylactic treatment (T2) (B). HIV, human immunodeficiency virus; MOS-HIV, Medical Outcomes Study HIV Health Survey.

Multivariate analysis

Multivariable linear regression identified several factors that were significantly associated with QoL at both time points. At T1, being male was significantly associated with higher QoL scores [β=2.030, 95% confidence interval (CI): 0.259 to 3.802, P=0.02], while psychiatric disturbance (β=−2.640, 95% CI: −4.479 to −0.800, P=0.005) and higher HIV stigma scores (β=−0.192, 95% CI: −0.300 to −0.084, P<0.001) were significantly associated with lower QoL.

At T2, the same pattern persisted for psychiatric disturbance (β=−4.955, 95% CI: −7.445 to −2.465, P<0.001) and HIV stigma (β=−0.215, 95% CI: −0.345 to −0.085, P=0.001). Additionally, male remained significantly associated with higher QoL (β=2.139, 95% CI: 0.408 to 3.870, P=0.02). Table 3 presents the regression coefficients for the multivariate analysis.

Discussion

Our study included 190 HIV-exposed adults, of whom 167 completed the follow-up after 28 days of PEP, resulting in a retention rate of 87.9%. The average QoL scores were measured at two points and no statistically significant difference was observed. Furthermore, a significant difference in QoL was noted between sex, with female scoring lower than male.

Characteristics of study participants

This study involved 190 participants at T1 and 167 at T2, with the attrition at T2 due to non-returning participants. Most participants were male, resided in Ho Chi Minh City, and had a relatively high level of education. The majority were exposed to HIV in the community, primarily due to unsafe sex, consistent with findings from Nigeria (3) and reports from the Ho Chi Minh City Hospital of Tropical Diseases (5).

The mean QoL score of adults after HIV exposure

The mean QoL scores at T1 and T2 indicated a moderate QoL that did not significantly change (P=0.38). Scores for physical and mental health subgroups ranged around 50, showing that health was impacted at both T1 and T2. These scores are lower than the average QoL scores for HIV-infected individuals in Korea (mean =53.42) (14). O’Byrne [2019] also found emotional distress related to PEP treatment, aligning with our findings (15).

Factors related to the QoL of adults after HIV exposure

The relationship between individual characteristics and QoL

At T1, QoL showed statistically significant differences by sex, occupation, circumstances, and causes of HIV exposure. Women had lower QoL scores than men, while healthcare workers reported higher QoL than those in other occupations. Community-related exposure was associated with lower QoL compared to occupational exposure. At T2, occupation remained a significant factor, with healthcare and public personnel maintaining better QoL. These findings are consistent with studies from South Korea and Nghe An (14,16).

The observed sex-based disparity in QoL may reflect differences in psychological resilience, health-seeking behaviors, and social expectations. In contexts like Vietnam, women often face heavier caregiving responsibilities, economic dependence, and heightened stigma, which may intensify the psychological burden of HIV exposure. While our study did not directly assess gendered power dynamics, such factors may affect women’s access to support and coping strategies during PEP. Further research, particularly using qualitative methods, is needed to explore these dimensions in depth.

The relationship between HIV stigma and psychiatric disturbance to QoL

HIV stigma scores were high at both T1 and T2, negatively impacting QoL. Pearson correlation results indicated that increased stigma led to decreased QoL scores, similar to findings by Kay [2018] (17). A 2020 study in Kenya also found that social stigma and awareness of post-exposure risk were related to depression and reduced QoL (2). Psychiatric disturbances led to significantly lower QoL scores at both T1 and T2. The percentage of participants experiencing trauma decreased from 19.5% at T1 to 9% at T2, but the average QoL score remained low. These results are consistent with a retrospective study in Boston (11) and a study on ARV drug side effects in healthcare workers (8), highlighting the significant impact of stigma and psychiatric disturbances on QoL, indicating a need for targeted psychological and social support.

The relationship between personal characteristics, stigma, psychological trauma, and QoL

Linear regression analysis at T1 and T2 revealed statistically significant inverse correlations between QoL and factors such as sex, stigma, and trauma. The strongest contributing factors to decreased QoL were psychological trauma, stigma, and sex. This suggests that interventions to improve QoL should prioritize addressing psychological trauma and reducing stigma, particularly for women who may be more adversely affected. These findings are consistent with previous research, which has shown that HIV-related stigma significantly undermines mental health and QoL by exacerbating feelings of isolation and anxiety (18). Additionally, women are disproportionately impacted by psychological trauma and stigma, as highlighted by Machtinger et al. (19), who found that women living with HIV are more likely to experience post-traumatic stress disorder, leading to a more pronounced decline in their QoL. Our findings emphasize the importance of comprehensive care approaches that include mental health support and stigma reduction to enhance QoL for HIV-exposed individuals.

Strengths and limitations

This study has several strengths, including its prospective cohort design, which allowed for the observation of changes in QoL over time and the identification of factors affecting QoL after HIV exposure. The use of validated tools for measuring QoL and psychological variables ensured the reliability and validity of the findings. However, there are limitations. The sample size, although adequate for initial analysis, may not be representative of all adults exposed to HIV. The short follow-up period limits the ability to capture long-term changes in QoL. Additionally, the study was conducted in an urban setting (Ho Chi Minh City), which may not reflect the experiences of individuals in rural areas. Future research should consider longer follow-up periods and include a more diverse sample to validate and expand upon these findings.

Practical implications and context in Vietnam

In Vietnam, a developing country facing barriers in healthcare access and persistent HIV-related stigma, the findings of this study highlight the need for integrated interventions. Mental health support and anti-stigma efforts should be included in PEP services to improve the QoL of exposed individuals. Tailored counseling, especially for women, and education programs promoting safe behaviors are also essential.

Although the study was conducted at a single institution, the Hospital for Tropical Diseases is a national referral center for HIV care. The participant characteristics—particularly non-occupational exposure and urban residence—reflect common patterns among PEP users in Vietnam, supporting the relevance of these findings to similar settings.

In addition, previous studies have suggested specific interventions that may benefit individuals receiving PEP. Tosini et al. emphasized the need for early psychological counseling and structured follow-up to address side effects and reduce treatment discontinuation (20). Osei-Yeboah et al. highlighted the importance of strengthening mental health support to reduce anxiety and stigma during PEP (21). Based on these findings, integrated PEP programs should include routine screening for psychological distress, stigma-reduction counseling, and access to peer support systems to enhance adherence and overall well-being.

Conclusions

The average QoL scores of adults after HIV exposure showed no significant change after 28 days of PEP. Factors such as psychological distress, HIV-related stigma, and sex significantly influenced QoL outcomes. Based on these findings, we recommend implementing targeted interventions to support individuals undergoing PEP. These may include routine mental health screening, structured psychological counseling during and after treatment, stigma-reduction programs integrated into HIV services, and tailored communication strategies to address the needs of vulnerable groups—especially women. Such efforts can help reduce emotional burden and improve overall QoL for people exposed to HIV.

Acknowledgments

We gratefully acknowledge the University Medical Center Ho Chi Minh City for funding the article processing charge (APC) for this publication. We also sincerely thank the University of Medicine and Pharmacy at Ho Chi Minh City for supporting this research under Contract No. 09/2021/HD-DHYD.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://amj.amegroups.com/article/view/10.21037/amj-24-146/rc

Data Sharing Statement: Available at https://amj.amegroups.com/article/view/10.21037/amj-24-146/dss

Peer Review File: Available at https://amj.amegroups.com/article/view/10.21037/amj-24-146/prf

Funding: This work was supported by University of Medicine and Pharmacy at Ho Chi Minh City (Contract number: 09/2021/HD-DHYD).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://amj.amegroups.com/article/view/10.21037/amj-24-146/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Biomedical Research Ethics Committee of the University of Medicine and Pharmacy at Ho Chi Minh City (approval No. 706/HDD-DHYD, dated 24/11/2022). Informed consent was obtained from all participants, to ensure their voluntary participation. All collected data were kept confidential and used solely for research purposes.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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