Quality of life and people living with AIDS: relationship with sociodemographic and health aspects1

OBJECTIVE: to analyze the relationship of sociodemographic and health dimensions with the quality of life of people living with the human immunodeficiency virus. METHOD: descriptive and quantitative study. The subjects were 131 seropositive people treated in a specialized center of the Norte-Fluminense municipality, Brazil. A form with sociodemographic and health data was applied, as well as the World Health Organization instrument for the assessment of the quality of life of people with the human immunodeficiency virus. RESULTS: the statistical analysis revealed a significant difference in the assessment of the various dimensions of quality of life by the subjects for gender, education, employment, personal income, medical condition, self-perception of sickness, history of hospitalizations, and bodily alterations due to the antiretroviral drugs. CONCLUSION: professional nursing and health care, as well as public policies in the area, should valorize the quality of life approach, considering the conditions related to its configuration.


Introduction
Quality of life (QoL) constitutes a field of progressive academic interest, given its potential. The development of the concept and its incorporation into the healthcare sector is basically due to: epidemiological studies on happiness and well-being; the search for new social indicators of health; the lack of objective measures of the results of biotechnologies; the positive psychology movement; valorization of the satisfaction of the client; and the need for humanization in health programming and care (1) . The QoL construct has also contributed to the comprehension of the factors involved in the existence of people infected by the Human Immunodeficiency Virus (HIV) and the disease that it causes, Acquired Immunodeficiency Syndrome (AIDS) (2) . This is due to the fact that, despite the increase in lifespan after HIV infection, due to the development of high activity antiretroviral therapy (HAART), many clinical and, in particular, psychosocial issues are still obstacles for the improvement of the QoL (3)(4) . Thus, people living with HIV/AIDS (PLWHA) are still faced with significant difficulties such as: stigma and prejudice (5) ; access to health care (6) ; employment (7) ; relationships with healthcare professionals (8) ; experience of sexuality (9) ; increased social support (9)(10) ; family relationships (4,10) ; and bodily alterations and perception of self-image (4) .
The World Health Organization (WHO), in turn, has invested in the approach to QoL, having constructed the Quality of Life Assessment Group (The WHOQoL Group) for this. This initiative culminated in the creation of a generic QoL assessment instrument called the WHOQoL-100, developed in a multicentric manner, with transcultural potential. Considering the particularities of living with AIDS, the WHOQoL-HIV was created, based on the above mentioned instrument (11) .
Considering the complexity in the conceptualization of QoL, the WHO defines it as "an individual's perception of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, standards and concerns" (11) . It involves a comprehensive assessment of the perception of the subjects regarding a set of domains, in the case of the WHOQoL-HIV these being: physical; psychological; level of independence; social relationships; environment; and spirituality, religion and personal beliefs (SRPB) (11) . Therefore, given that socio-demographic and health characteristics may have an impact on the assessment of QoL (2,5,7,(9)(10) , this work aimed to: analyze the relationship of sociodemographic and health dimensions with the assessment of the QoL of PLWHA. Despite the existence of studies on the assessment of the QoL of PLWHA, there are few studies using the construct with approach facets specific to the WHOQoL-HIV. This is especially the case for medium-sized and small Brazilian municipalities, the spatial delimitation of this study. The analysis of the quality of life is essential for the healthcare policies and services directed toward PLWHA, since this indicator values the perception of people about their own life and health. This therefore serves as a basis for directing the programmatic and professional investments in health (1) .  SRPB (12) . This instrument was translated and validated in Brazil, with acceptable reliability and consistency for the scale and its domains (13) . The questions of the WHOQoL HIV-Bref are structured in a Likert type scale with five grades depending on the nature of the domains and facets. Completion was carried out by the study subjects, unless this was impossible due to reading difficulties (13) .
The sociodemographic and health variables  (14) . For the statistical comparison between the sociodemographic data, health data and the QoL  Table 1 presents the data related to the characterization of the subjects.     The variable covering physical-bodily alterations associated with HAART use presented a statistically significant difference in the physical and psychological domains, with higher scores among PLWHA who did not perceive these alterations. A p value close to 0.05 was also observed in the level of independence domain (Table 3).

Discussion
Considering the comparison with other studies, different results from the present study were observed for the variables: Age group, with the highest scores among the youngest (20 to 39 years) (15)(16) ; time since diagnosis, with higher scores in the SRPB domain between 2 and 5 years (15) ; and CD4+ count, with higher scores in the physical domain (17) and in the level of independence (15) (15) . In other studies, the negative influence of antiretroviral drugs was identified in the physical and social domains among PLWHA in the first year of use, with better assessments in the SRPB and environment domains in the second year (18) . An additional study found the use of HAART to be a predictor of better QoL. This was especially the case when there was permanence of the therapeutic regimen and few adverse reactions (19) .

With regards to the influence of the viral load on
QoL, the findings of this study were similar to others in the literature (15) , in which this variable yielded no statistically significant difference in any of the domains of analysis. However, given that lower CD4 counts and higher viral loads are associated with symptoms of the disease, it is possible that their expressions exist, even indirectly, in other facets of the QoL (15) . In the case of this study, this may occur with the clinical condition variable, with statistically significant differences in five of the six domains.
For the gender variable, the results were similar to other studies (13,(15)(16)(17) , with higher scores in the QoL domains among men. In this sense, although some authors question whether there are indeed differences in the QoL perception between men and women or just a differences in the style of responses, it is known that the socioeconomic and cultural reality in general proves unfavorable for females (13) . economic aspects that generate unequal opportunities in the protection, promotion and maintenance of health (16) .
The results concerning the influence of the education level on QoL presented a similar pattern to other studies (17,20) , with higher scores in the perception of the subjects for the higher strata of education.
This aspect highlights the impact of social factors, such as the educational level, on QoL. Thus, it can be understood that the educational level could influence the self-management skills faced with the disease and its various demands (13) . It is thought that there should be easier access to and comprehension of the information on the issues relevant to the disease.
Regarding the inclusion of PLWHA in the working world, the findings of this study agree with and broaden the perspectives of other studies (16,20) , as statistically significant differences were found in all six QoL domains.

It is comprehended that physical and mental health
can benefit from working activity in an interactive and mutually reinforcing process (7) . This is because work can be a source of suffering and stress, however, also a source of pleasure, self-realization and identity formation (21) . In the case of PLWHA, in addition to access to the material conditions of existence, work allows a deviation from thinking about the often negative issues of the disease, creating feelings of usefulness and productivity. It can also have the potential of broadening social contacts, although commonly some barriers are observed related to the employability of these subjects (21) . The low level of education, which was prevalent among the study participants, may be an additional factor limiting access to work and better positions in this field, indicating the importance of specific policies. Although the design of this study did not allow for a conclusive statement, a possible influence of gender on this dimension could also occur, given the pattern of lower assessments of QoL observed among the women.
Considering personal income, the results are similar to studies carried out in Brazil, with the difference that they found no significant difference in the SRPB domain, while a difference was noted in the social relationships domain (16)(17) . As occurred in the work variable, these findings also highlight the impact of the socioeconomic levels on the QoL of these subjects, included together with education because they are indicators involved in the characterization and implications of the tendency towards a poverty related epidemic in the country (22) .
With regards to the clinical condition of PLWHA, there are reports in the literature of differences in the QoL assessment between asymptomatic and symptomatic people, with higher scores for the first, especially in the physical domain (17) . In the present study, however, as in another study (13) , there was no influence of this  (23) .
Considering the developments regarding the