Quality of life of men with AIDS and the model of social determinants of health1

OBJECTIVE: to analyze the quality of life (QoL) of men with AIDS from the perspective of the model of social determinants of health (MSDH). METHOD: cross-sectional study conducted in an outpatient infectious diseases clinic from a Brazilian university hospital over the course of one year with a sample of 138 patients. A form based on the MSDH was used to collect sociodemographic data addressing individual, proximal, intermediate determinants and the influence of social networks together with an instrument used to assess the QoL of people with HIV/AIDS. The project was approved by the Institutional Review Board (Protocol No. 040.06.12). RESULTS: according to MSDH, most men with AIDS were between 30 and 49 years old (68.1%), mixed race (59.4%), heterosexual (46.4%), single (64.5%), Catholic (68.8%), had a bachelor's degree (39.2%), had no children (61.6%), and had a formal job (71.0%). The perception of QoL in the physical, level of independence, environment, and spirituality domains was intermediate, while QoL was perceived to be superior in the domains of psychological and social relationship. A perception of lower QoL was presented by homosexual (p=0.037) and married men (p=0.077), and those with income below one times the minimum wage (p=0.042). A perception of greater QoL was presented by those without a religion (p=0.005), living with a partner (p=0.049), and those who had a formal job (p=0.045). CONCLUSION: social determinants influence the QoL of men with AIDS.


Introduction
The Human Immunodeficiency Virus (HIV) infection is currently a health problem due to its pandemic nature and severity. A total of 686,478 cases of AIDS were reported to the Notifiable Diseases Information System (SINAN) from 1980 to December 2013; 445,197 of which refer to men and 241,223 to women (1) . The epidemic is currently stable in Brazil and concentrated in vulnerable population groups, but male adults are still the most frequently affected (1)(2) .
The availability of antiretroviral treatment (ART) in Brazil since 1996 has enabled a reduction in both morbidity and mortality caused by HIV. Brazil was the first developing country to adopt a public policy for patients to have access to ART and is recognized worldwide for providing a program that has achieved good response against the HIV/AIDS epidemic (3) .
Even though there is a national program and very well-organized to combat sexually transmitted diseases (STD) and AIDS, one should consider that economic and political aspects have an essential meaning to each population in which AIDS has been disseminated. Most cases of AIDS are located in poor countries, suggesting the need to analyze the social determinants of health in these populations (4) .
Because ART has enabled increased survival rates of people with HIV/AIDS, characterizing it as a chronic disease, the health care provided to these individuals gains greater importance for these individuals who require unique care procedures to maintain their quality of life (QoL) The World Health Organization (WHO) developed, within a multi-center collaborative study, an instrument to assess QoL from an international and cross-cultural perspective. This instrument is called the World Health Organization Quality of Life (WHOQOL-100), which originated a specific instrument for people living with HIV/AIDS, WHOQOL-HIV (5) that has been already validated in Brazil (6) . QoL is a perception of individuals in regard to their position in life in the context of the culture and value system in which they live and in relation to their objectives, expectations, standards and concerns (7) . Studies show that the QoL of people with HIV/AIDS is compromised due to discrimination and the unfavorable socioeconomic conditions in which they live, which may determine increased rates of mortality (8)(9)(10) .
Given the previous discussion and with the intent to contribute to the quality of healthcare provided to people living with HIV/AIDS, considering that most individuals affected by HIV infection are male and that social determinants impacting this process, we proposed this study to analyze the QoL of men with AIDS using the WHOQOL-HIV bref, with the Model of Social Determinants of Health (MSDH) as theoretical framework.

Theoretical framework
The social determinants of health are the social conditions in which people live and that affect people's health. There are different models of social determinants of health but the National Commission on the Social Determinants of Health chose Dahlgren and Whitehead's model to be used in Brazil due to its simplicity and clear graphic representation of social determinants (11) .
In this model (12)

Method
This cross-sectional study with quantitative approach was conducted in an infectious disease outpatient clinic in a Brazilian university hospital that provides care to adults with HIV/AIDS. This hospital has an outpatient service, inpatient wards and an intensive care unit and also provides laboratorial and radiological exams, ART and condoms.
Data were collected over the course of one year.
In order to meet the study's objectives, the sample size was determined to estimate the mean of the scores obtained in the domains assessing the QoL of people living with HIV/AIDS, the WHOQOL-HIV bref (6) , with a 95% confidence level that the estimation error would not surpass 3%, considering that the mean of these scores, according to prior studies (13)(14) , is about 13.7, with a standard error of 3. 8 A form was developed in accordance with MSDH (12) to address the sociodemographic characterization of people with HIV/AIDS and was arranged into four layers Scores range from 4 to 20 points, which reflect worst and best QoL, respectively (6) .

Discussion
The social determinants of health are important because they predict the proportion of variation in one's health condition, sanitary inequity, and healthrelated behaviors. The social determination of health is rooted in an ethical foundation that is equity, defined as the absence of unfair differences among population groups so that inequities in health are socially-produced differences (11) .
According to MSDH's layer 1, which depicts individual determinants, the age of most individuals was between 30 and 49 years old, revealing national dynamics in which most men infected with AIDS between 2000 and 2011 were in this age range (1) . In regard to race, the results were similar to those found by a study conducted in Maranhão, Brazil in which mixed race was prevalent (15) . Note that individual determinants are, in general, considered to be non-modifiable determinants (11) .
The analysis of layer 2 showed that the category of exposure heterosexual was predominant, which also represents the national context (1) . This finding involves the issue of vulnerability in regard to HIV/AIDS, which is linked to a set of individual and behavioral aspects that facilitate one becoming infected, in addition to sociopolitical aspects, which are represented by the commitment displayed by authorities, inter-sector actions and funding (16) .
Most men with AIDS were single and Catholic, which also was observed in another study (4) . In regard to education, most had a bachelor's degree and per capita income greater than two times the minimum wage, differing from the findings of other studies, where most men with AIDS had low educational levels and income, and performed occasional jobs without formal contracts (4,14,17) . Most men had no children, which may be explained by the considerable number of homosexual (39.9%) and bisexual (13.7%) individuals.
The average scores obtained for the WHOQOL-HIV bref domains were similar to those found in other studies addressing people living with AIDS, highlighting an intermediate perception of QoL (13)(14) . Note that the lowest scores are for domain III, which represents level of independence. Hence, the individuals face changes in their mobility, activities of daily living, depend on medication and treatment, in addition to experiencing interference in their capacity to work. These results are related to changes in lifestyle after the diagnosis of HIV infection, starting ART, and also as a consequence of stigmatization (2)(3)9,(13)(14) .
In the context of MSDH, homosexual men obtained low average scores in regard to spirituality (p=0.037), the domain that refers to forgiveness and blame, concerns over the future, death and dying. This finding reflects the early days of HIV/AIDS, during which the infection was attributed to risk groups, especially homosexual individuals, in addition to the fact that infection meant death, a situation which was later changed due to the advent of ART, which led to increased survival rates for people with AIDS (8)(9)(10)(11) .
Married men scored lower than single men, on average, in regard to domain V (p=0.077), which refers to physical safety, housing, finance, access to health and social care, the ability to acquire information and learn new skills, leisure, environment and transport. This result may be explained by the fact that married men have to provide for their families, which decreases the per capita income of those living in the same household (4) .
Those who did not profess a religion scored higher than Catholics in domains I (p=0.005), II (p=0.017) and III (p=0.038). This finding contrasts with related literature, which shows positive correlation between health and spirituality as having a religion supports and strengthens the individual in the face of the adversities imposed by pathological conditions. Additionally, AIDS represents, in the social sphere, a series of disparaging metaphors such as associations with punishment, which would amount to being convicted for socially disapproved behaviors (18)(19) .
Living with a partner also increased the perception of QoL in regard to domain V (p=0.049). This aspect may be related to social support, which indicates the influence of social interactions with the well-being and health of people. Due to stigma, however, a seropositive status for HIV may hinder social support specifically related to the disease (20) .  (21) .
As for layer 5, we have the distal or macrodeterminants, represented by society's economic, cultural, and environmental conditions (12) . This layer was not included in the data collection, which may be seen as a limitation of this study. This coping policy gained momentum by reaching various social groups, when civil society mobilized and ensured its priority, political pressure to accomplish it and funding for it. Currently, Brazil has one of the most progressive policies to cope with HIV/AIDS and is a point of reference for the world (22) .
The current policy concerning the prevention, Hence, these approaches were inefficient and did not favor coping with the epidemic, for they did not consider social, cultural and contextual determinants (23) . The epidemic in Brazil is currently stable and the concept of vulnerability began to be considered in the context of HIV/AIDS, since the epidemic is centered in vulnerable population subgroups (3,18) . This means that, in addition to groups initially affected by HIV/AIDS, such as homosexuals, sex workers, intravenous drug users and hemophiliacs, people in stable relationships with a risk behavior and who do not use condoms, adolescents, elderly individuals, those with a low level of education, low income, and living in the interior of the country are also taken into account (3,18,(22)(23) .

Conclusion
The We stress the importance of this study for understanding the context of those living with AIDS, since it can contribute to the delivery of care. Note that further studies are needed to contribute to the QoL of these individuals and reduce morbidity and mortality.
Hence, even through there is no cure, HIV infection and AIDS can effectively be considered chronic conditions.