Psychosocial determinants of HIV-related quality of life among HIV-positive military in Nigeria

Abstract

Summary

There is a paucity of research regarding the role played by psychosocial and HIV-related factors on quality of life (QoL) among military in developing countries. On presentation to a military hospital-based HIV clinic, 125 air-force personnel, 56 seropositive (none of whom had AIDS) and 69 seronegative were interviewed. At the interview, participants were assessed using the Medical Outcome QoL and other psychosocial measures. The overall QoL was less among seropositive compared with seronegative air-force personnel. Seropositive personnel also reported a greater number of negative life events and trauma symptoms (post-traumatic stress disorder, PTSD). Seronegative military personnel reported more sexual risk behaviours compared with seropositive personnel. Multivariate analysis showed that trauma symptoms (PTSD) were a significant contributor to QoL and explained of the variance in physical, mental, role and social functioning among HIV-infected air-force personnel. Other variables that predicted QoL, but to a lesser extent, included age, number of negative life events and increased symptomatology. These findings highlight the importance of evaluation of QoL in HIV-infected military personnel.

Keywords

HIV/AIDS quality of life military Nigeria

INTRODUCTION

HIV/AIDS continues to spread in Nigeria as governmental and non-governmental organizations increase efforts to minimize its transmission. Infection with HIV/AIDS is associated with chronicity,¹ however with improvement in treatment options, many persons living with HIV/AIDS (PLWHAs) are expected to live longer. With advances being made in the development of vaccines, prophylaxis as well as treatment of HIV illness has now become possible, albeit with limited effectiveness.²

In Nigeria, as elsewhere, military personnel are among the most susceptible to HIV infection and AIDS.^3–5 The majority of military personnel are young and sexually active, often away from home and family, frequently governed by self-perceptions of invincibility, and usually exposed to opportunities for casual sex.⁶

While studies on the psychological sequelae of HIV/AIDS in both military and civilian populations are replete in developed countries; there has been lack of corresponding data in sub-Saharan Africa.^7–8 Consistently documented psychiatric disorders include major depressive disorder and dysthymic disorder,^7–9 adjustment disorders, alcohol abuse and dependence¹⁰ and post-traumatic stress disorder (PTSD).^11–13

Nonetheless, there have been few studies investigating HIV-related quality of life (QoL), which is a multifactorial construct that refers to both perceptions of emotional and physical wellbeing (e.g. activity level, pain and general health perception.¹⁴ It is a general term applied to the totality of physical psychological, environmental and social functioning.¹⁵ Quality of life is health as perceived by the individual concerned,¹⁵ though difficult to measure,¹⁶ impairment of QoL in HIV/AIDS has been documented in conducted predominantly in Western patients.^14,17–25 With the exception of a study by O'Keefe and Wood,²⁶ no other studies on HIV-related QoL, to our knowledge, have been published in sub-Saharan African.

A prospective psychiatric evaluation of 20 air-force personnel women with HIV found half of the women to have an Axis 1 diagnosis, while 15% exhibited subtle signs of cognitive decline. Sexual functioning was impaired in the majority, with 20% meeting criteria for new onset hypoactive sexual desire disorder.²⁷ Similarly in a follow-up evaluation of a larger sample of women in the air-force with HIV, Brown and Rundel,²⁸ found that high risk sexual behaviour occurred after seroconversion in at least 35% of women.

There is no known study on either psychological distress and/or QoL among HIV seropositive military personnel in Nigeria.

HIV-related QoL assessment is potentially important in that it may serve as a pointer of diverse behavioural and emotional ramifications of the illness, including treatment-seeking behaviour, engagement in unsafe sexual practices and disease progression.^29,30 For example, Cook et al. ²⁹ found that high levels of depressive symptoms and poor mental health QoL significantly reduced utilization of Highly Active Antiretroviral Therapy (HAART) among a cohort of HIV seropositive women in the USA. This study underscores the importance of HIV-related QoL evaluation and its role in determining treatment utilization among infected patients.

The estimated number of PLWHAs in the Nigerian military is 2000–3000, yet other than case reports and anecdotes, little is known about the psychological sequelae of HIV infection in this group. In addition to the potentially stressful military environment, other stressors include poor living conditions, poverty, foreign postings without adequate debriefing, declining social services and a sociocultural context that supports unsafe sexual practices.³¹

In this report, we examine the association of QoL to negative life events, trauma and sexual risk behaviours in HIV-positive patients in the Nigerian air force compared with HIV-negative military air-force personnel.

METHODS

Subjects

HIV-seropositive, active service, men and women were recruited from the Nigerian Air Force Hospital located at Ikeja – Lagos, Nigeria. The hospital provides specialist and comprehensive care for HIV/AIDS, which includes laboratory testing (CD4, CD8, Viral loading etc), voluntary counselling and testing (VCT) and antiretroviral therapy. HIV-positive patients were in receipt of HAART (lamivudine, stavudine and nevirapine). Participants were considered representative of the Nigerian military as they passed through the same process of recruitment, and training and exposure to military life as their army and navy counterparts. The seronegative group comprised both consecutive blood donors seen at the blood bank of the hospital and VCT seekers, utilizing the VCT facilities of the hospital. All participants were military officers, man or woman, between 18 and 55 years of age, and able to communicate in English. HIV serostatus was determined by enzyme-linked immunoabsorbent assay (ELISA) and confirmed by Western blot analysis. Participants were excluded if they (1) had significant chronic, systemic illness; (2) had a significant neurological disorder, including traumatic brain injury; (3) had a history of schizophrenia or severe psychotic disorder; (4) met DSM-IV criteria for current substance/alcohol abuse or dependence or (5) too ill to follow research protocol.

The study was reviewed and approved by the authorities of Defense Headquarters in Nigeria and the joint UCH/UI institutional review boards of the University of Ibadan, Nigeria. All subjects provided written informed consent and received reimbursement for their time.

Procedures

Each participating air-force man consecutively underwent a thorough outpatient assessment that included a physical examination and pre- and post-testing counselling for blood donors as well as VCT seekers. Thereafter, participants completed a comprehensive set of questionnaires that assessed QoL, negative life events, PTSD and sexual risk behaviour.

MEASURES

Demographic and health characteristics

Demographic information on age, gender, marital status, ethnic grouping and length of military service, years of education, religion and income level was obtained. Clinical information included pulse rate, blood pressure, height, weight, medical/surgical history, previous admissions due to HIV-related conditions and current treatment with antiretroviral (ARV) medications. The HIV staging³² was also determined, with patients' rated as symptomatic or not. Level of symptomatology was assessed using a 12-item checklist. Items included persistent shortness of breath, persistent cough, oral lesions, persistent diarrhoea, recurring fever or excessive and sudden loss of weight. CD4 (helper/inducer) subsets were analysed by staining peripheral blood specimens with flow cytometry ELISA and the Western blot test.

HIV-related QoL

The 30-item Medical Outcomes Study Health Status Questionnaire for HIV (MOS-HIV-30)¹⁴ was utilized as a measure of QoL just as used in a previous study.³³ The MOS-HIV 30 yields a total score, as well as 11 subscale scores. Six subscales were, however, used as outcome measures. The MOS-HIV-30 was used as a brief measure that includes assessment of physical functioning (six items, e.g. ‘For how long (if at all) has your health limited you in vigorous activities you can do, like lifting heavy objects, running or participating in strenuous sports?’), role functioning (two items, e.g. ‘Does your health keep you from working at a job, doing work around the house, social functioning?’ (one item, e.g. ‘How much of the time during the past month has your health limited your social activities, like visiting with friends or close relatives?’), mental functioning (five items, e.g. ‘How much of the time in the past four weeks have you felt downhearted and blue?’), overall health perception (five items, e.g. ‘In general, would you say your health is excellent, very good, good, fair or poor?’), and pain (two items ‘How much bodily pains have you generally had during the past four weeks?’). For the purpose of this study, criterion validity using treatment criterion was established. Pre-test results revealed that HIV patients (20; not same as the present sample) with limited adherence to ARV treatment (measured as reported inconsistent use of drugs since previous appointment) reported higher scores on the six domains compared with a control group = 20). Internal consistency (Cronbach's alpha) was established for the six scales: physical functioning (0.86), role functioning (0.80), social functioning (0.78) mental functioning (0.86) health perception (0.67) and pain (0.56). Scoring was done by reverse scoring certain items and summing the subscale scores. Higher scores indicate better QoL.

Sexual risk behaviour

A sexual risk behaviour scale was also administered to participants. This was a 20-item interviewer rating measure adapted from the work of^34,35 and previously used in a study among recently diagnosed HIV/AIDS patients in South Africa.⁸ Adaptation involved replacing the term ‘mentally ill patients’ contained in the original scale^34,35 with the term ‘HIV/AIDS patients’. Participants were asked about their sexual activities in the preceding six months. Questions included: ‘Have you used a condom at last sex?’; ‘Had sex with a partner who used intravenous drugs?’; ‘Had sex after using alcohol heavily or other drugs?’; ‘Had sex with a partner known for less than one day?’ The questions were well understood by the patients and there was no evidence of ambiguity in responses.⁸ Higher scores indicate more sexual risky behaviour. For the purpose of this study internal consistency (Cronbach's alpha, r = 0.94) and the split-half reliability (r = 0.79) were established.

Negative life events

This scale was by Kaminer, Stein, Mbanga and Zungu-Dirwayi³⁶ is an adaptation of Swartz Elk, Teggin and Gills.³⁷ It is a clinician administered checklist that enquires about the number of life events occurring in the preceding 6 months as well as the degree of stress associated with these events. The impact score is 0–2. It has been used in a previous study of newly diagnosed HIV infected individuals in South Africa.^7,38 For the purpose of this study, internal consistency was established through the split-half reliability (r = 0.76) as well as Cronbach's alpha (r = 0.87).

Trauma

The Davidson Trauma Scale (military version) was used to assess the effect of previous trauma. l. Posttraumatic stress symptoms included: repeated disturbing memories, thoughts or images of a stressful military experience; feeling emotionally numb, and trouble falling or staying asleep. Responses were rated using a Likert scale of 1–5. It is a well-validated scale that has been used in the African setting in military personnel.^39,40 For the purpose of the study, internal consistency was established through the split-half reliability (r = 0.76) and Cronbach's alpha (r = 0.87).

Data analyses

Analyses were computed with SPSS software version 10 for Windows. First, several univariate tests of association for categorical variables (χ ²-tests) and continuous variables (student's t-tests) were done to look for associations between demographic, clinical status, psychosocial and QoL variables. To examine for differences in psychosocial factors and QoL scores between HIV-positive and HIV-negative participants, a series of t-tests were done. To examine for correlation of QoL among HIV-positive personnel, a univariate analysis for test of associations was done using the Pearson product moment correlation. Variables identified as statistically significant in univariate analysis were then entered into linear regression models, with the subdomains of QoL on the QoL scale as dependent variables. All statistical tests were two-tailed, using P values of <0.05 to denote significance and 95% confidence intervals.

RESULTS

Characteristics of subjects

Demographic and psychosocial comparisons of the two groups are presented in Tables 1 and 2 respectively. The HIV-positive individuals were significantly older in age, HIV-negative individuals were significantly more likely to have more years of education and earn a higher salary compared with the HIV-positive group. There was a preponderance of women in the HIV-positive group. There were also significant differences in psychosocial status. The HIV positive group endorsed more traumas (PTSD) and poorer QoL in domains of physical, role, mental and social functioning. However, the HIV-negative groups were more likely to engage in risky sexual behaviours. The majority of HIV-positive individuals were asymptomatic with an average CD4 lymphocyte count at 470 (SD = 55.97).

Table 1

Demographic characteristics of 125 military air-force personnel with and without HIV infection

Characteristic	HIV-seropositive (n = 56)		HIV-seronegative (n = 69)
Characteristic	n	(%)	n	(%)	P
Sex
Man	26	(47)	44	(64)	NS
Woman	30	(53)	25	(36)	NS
Marital status
Single	19	(34)	23	(48)	NS
Married	31	(55)	33	(48)	NS
Widowed	6	(11)	3	(4)	NS
Home language
Hausa/Fulani	11	(20)	14	(20)	NS
Yoruba	17	(30)	30	(44)	NS
Igbo	12	(21)	10	(15)	NS
Others	16	(29)	15	(21)	NS
Religion
Christianity	49	(88)	52	(75)	NS
Islam	6	(11)	15	(22)	NS
Others	1	(1)	1	(3)	NS
Family structure
Monogamy	46	(82)	55	(80)	NS
Polygamy	10	(18)	14	(20)	NS
	Mean	(SD)	Mean	(SD)	P
Mean age	36.5	(9.05)	32.9	(8.21)	0.02
Mean years of education	12.07	(5.30)	14.6	(5.15)	0.00
Salary/wages (annual)	36276	(2569.5)	55668	(5355.5)	0.14

Table 2

Comparison of HIV-positive and HIV-negative air-force military personnel: psychosocial variables

Variables	HIV-positive (n = 56)		HIV negative (n = 69)
Variables	Mean	SD	Mean	SD	t-value
PTSD	12.58	10.77	4.08	1.72	5.10**
Physical functioning	7.39	2.06	6.31	1.83	3.07*
Role functioning	2.48	1.00	2.08	0.61	2.70**
Mental functioning	11.57	4.03	8.20	5.14	4.00**
Health perception	12.17	4.48	11.08	4.58	1.63
Social functioning	1.75	1.09	1.10	1.61	2.56*
Pain	0.41	0.49	0.44	0.77	−0.32
Risky sexual practices	0.89	0.86	1.37	1.17	−2.56*
Negative life events	2.49	2.29	3.85	1.17	−1.01

*P < 0.05

**P < 0.01

Correlates of QoL: bivariate results

Several significant associations were observed between sociodemographic and clinical factors and QoL domains among HIV-positive air-force personnel. Age (r = −23, P < 0.01); number of negative life events (r = −19, P < 0.05); PTSD (r = −28, P < 0.01) and number of symptomatology (r = –27, P < 0.01) were negatively correlated with physical functioning. Posttraumatic stress disorder symptoms were negatively correlated with role functioning (r = −26, P < 0.01), mental functioning (r = −42, P < 0.01) and social functioning (r = −33, P < 0.01). Years of education (r = −30, P < 0.01) and number of negative life events (r = −36, P < 0.01) also correlated negatively with mental functioning. Risky sexual behaviour (r = −33, P < 0.05) was significantly associated with pain in HIV positive participants.

Predictors of QoL: multivariate results

Table 3 shows the variables that were included in multivariate (linear regression) analyses to identify predictors of the six domains of QoL. Using step-wise regression, associated variables in the bivariate analysis were regressed against each domain of QoL. These variables were ‘stepped in’ if they added at least 1% to the explained variance (r ²). Post-traumatic stress disorder constituted the most effective contributor in the explained variance of physical, mental, role and social functioning respectively. Of the 23% variance on physical functioning, PTSD accounted for 16% with number of negative life events contributing 3%, while age and number of symptomatology contributing 2% respectively. Regarding mental functioning, PTSD contributed 10% of the 16% variance, while number of negative life events accounted for the remaining 4% variance. For role functioning, social functioning and health perception, PTSD was significantly and positively related to these domains accounting for 7%, 14% and 11% respectively. The only variable entering the regression equation for pain was risky sexual practices. Risky sexual practices was positively related to pain, with those engaging in more risky behaviours expressing more pain and contributing 4% to the total variance of pain. Other independent variables either did not enter the regression equations or explained less than 1% of the variance.

Table 3

Regression of independent variables on domains of HIV-related quality of life

Independent variables	B	R² change	Significance
Physical functioning	r ² _Adj 0.23	F = 8.98	<0.000
PTSD	0.30	0.16	<0.00
Number of negative life events	0.18	0.03	<0.03
Age	0.14	0.02	<0.05
Number of symptomatogy	0.10	0.02	<0.05
Mental functioning	r ² _Adj 0.16	F = 4.33	<0.000
PTSD	0.18	0.10	<0.001
Number of negative life events	0.12	0.04	<0.02
Role functioning	r ² _Adj 0.07	F = 2.24	<0.05
PTSD	0.15	0.07	<0.00
Social functioning	r ² _Adj 0.14	F = 3.11	<0.03
PTSD	0.20	0.14	<0.001
Health perception	r ² _Adj 0.11	F = 2.79	<0.04
PTSD	0.19	0.11	<0.01
Pain	r ² _Adj 0.04	F = 2.41	<0.05
Risky sexual practices	0.26	0.04	<0.02

PTSD = post-traumatic stress disorder

DISCUSSION

This study examined HIV-related QoL in air-force military personnel living with HIV/AIDS in Nigeria. We found that, in all domains of QoL, HIV-positive personnel had worse functioning than HIV-negative personnel. This is consistent other with findings that HIV produces debilitating morbidity compared with other chronic conditions.^22,26 Furthermore, compared with HIV-negative personnel, HIV-positive personnel reported more trauma symptoms and exposure to negative life events.

Four additional major findings emerge from this study. Perhaps most important, but unexpected, was the practice of safer sex among HIV-positive compared with HIV-negative personnel. While an individual's most recent sexual encounter may not be truly reflective of the actual average behaviour, it is been indicated⁴¹ that counselling tends not to alter risky sexual behaviour among participants who test negative. This may be difficult to explain, since it has been noted that the content of most counselling sessions are brief and may not contain motivational components for real behavioural change.⁴¹ Similarly denial as a coping style, re-enforced by misperceptions about the existence of HIV may also partly explain the more risky sexual behaviours in this group. Furthermore, the effect of regular counselling and the assumption of the sick role may explain the reduction in sexual risk behaviours. Furthermore, it might be that infected air-force men may have come to accept their serostatus and resolve to play safe or might be too sick to engage in sexual relationships as reflected in their level of functioning.

Our results, however, are inconsistent with earlier studies where HIV-positive individuals continue to report unprotected sex despite exposure to education and counselling.¹³ Nevertheless, more rigorous educational interventions relating to safe sexual practices are still needed in the military.

We found that PTSD consistently predicted less functioning on all measured domains. There are some data in HIV-infected men and women that suggests that PTSD is commonly associated with HIV and might be predictive of disability and diminished role functioning.^11,12,38 Post-traumatic stress disorder may be particularly relevant to HIV/AIDS because of the traumatic impact of being infected, which can be compounded by additional professional responsibilities. Many air-force personnel in Nigeria have witnessed combat in recent times as part of United Nations foreign assignments. The extent of debriefing upon discharge from such military services may be inadequate to impact on combat trauma, which often is experienced and compounded by the knowledge of an HIV/AIDS diagnosis.

Some other variables, which were associated and predictive of QoL in this study include: increased symptomatology, age, number of negative life events and risky sexual practices. The finding of a negative relationship between clinical symptoms and health related QoL among patients supports other studies^18,22 and emphasizes the importance of the conceptual link between clinical measures and health related QoL.²² We found an inverse relationship between age and physical functioning, just as previously reported.^18,22 The finding of the association between risky sexual practices and pain in this sample of HIV patients is incidental, but expected in view of the increase activity level often accompanied such behaviours. This explanation seems plausible especially as these individuals are more likely to be HIV negative with reported more increased level of functioning. However unprotected sex among HIV patients has been shown to be associated with psychopathology, including major depression.^8,22

We did not confirm previous finding of a positive relationship between CD4, HIV staging, annual income and HIV-related QoL.^17,22,26

Similarly, no association between older age and lower income and worse health-related QoL among 205 HIV-patients in Los Angeles were reported.²¹ Methodological differences with respect to sample size and subject selection may account for these variable results.

Limitations of this study include the small sample and the fact that the patients were receiving treatment and as such constitute a selective group. In addition, the cross-sectional nature of the data makes it difficult to draw any conclusions about causality. Caution should be exercised in interpreting these findings as the sample may not be representative of the military personnel with HIV/AIDS in Nigeria but could be a pointer to the evaluation of QoL among air-force personnel in Nigeria. Trauma was measured as a retrospective recount of combat experiences rather than those related to HIV-status. These experiences may overlap and may have a confounding effect on QoL. Future studies should consider delineating the relative impact of trauma as a result of HIV/AIDS and its association with QoL.

In summary, these data underscore the need for periodic assessment of the course of a chronic medical condition as HIV and AIDS. Continuous evaluation of QoL may assist in determining treatment utilization and potentially help to curtail the faster progression to AIDS among HIV/AIDS patients in the military.

Footnotes

ACKNOWLEDGMENTS

This work was supported by the Air Force Military Hospital Base Lagos as part of intervention for HIV and AIDS program for Military Personnel.

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