Quality of life, socioeconomic profile, knowledge and attitude toward sexuality from the perspectives of individuals living with Human Immunodeficiency Virus1

Objectives: to analyze the quality of life of "patients" with Human Immunodeficiency Virus and relate it to their socioeconomic profile, knowledge and attitudes toward sexuality. Method: crosssectional and analytical study with 201 individuals who are 50 years old or older. The Targeted Quality of Life and Aging Sexual Knowledge and Attitudes Scales were applied during interviews. Multiple Linear Regression was used in data analysis. Results: dimensions of quality of life more strongly compromised were disclosure worries (39.0), sexual function (45.9), and financial worries (55.6). Scores concerning knowledge and attitudes toward sexuality were 31.7 and 14.8, respectively. There was significant correlation between attitudes and the domains of overall function, health worries, medication worries, and HIV mastery. Conclusion: guidance concerning how the disease is transmitted, treated and how it progresses, in addition to providing social and psychological support, could minimize the negative effects of the disease on the quality of life of patients living with the Human Immunodeficiency Virus.


Introduction
The Joint United Nations Programme on HIV/AIDS (UNAIDS) reports that more than 34 million people live with HIV worldwide: 30.7 million are adults and 3.4 million are younger than 15 years old, while 16.7 million are women. A total of 1.4 million are in Latin America, 350,000 of which live in Brazil, while estimates show that 250,000 Brazilians are infected but do not know that they are (1) .
In 2010, in Brazil, the incidence of the disease was higher among individuals aged between 40 and 49 years old, representing 24.8% of the cases, though an increase has been observed among individuals aged from five to 12 years old and those 50 years old or older (2) .
The growing number of 50 years old or older individuals living with HIV may be related to the fact they acquire the virus at an older age; they do not realize they may acquire the virus, probably because, as the disease came to notoriety, it was more associated with young individuals, intravenous drug users and homosexuals; and to the fact that medications improve sexual performance and favor the establishment of new and multiple sexual partnerships (3) . Additionally, some of the young population who became infected is now aging. Due to the efficacy of the antiretroviral therapy, there has been an increase in the number of individuals 50 years old or older with the disease (3) .
Even though sexuality is a basic need and an aspect of humankind that cannot be separated from other aspects of life, regardless of age, the aging process leads to some physical changes that sometimes affect one's ability to practice sex and have such pleasure with another person (4) . The knowledge of the patients addressed in this study concerning sexuality was associated with myths and changes in the sexual functioning of individuals as they age.
Sexuality, as an important aspect of life, can lead to changes in the quality of life over time (5) . Arguably, information concerning sexuality contributes to a healthy and safe sexual life in old age (6) .
One's attitude toward sex is a result of social and sexual experiences (6) . Choosing a sexual partner, the frequency with which one practices sex, good sexual life, and interest in sex are positively associated with the health of adults and elderly individuals and may be reflected in a positive attitude toward sexuality and the prevention of diseases (7) .
A positive attitude among elderly individuals toward sexuality may favor an understanding that sexual activity is a natural process and that the sexual function remains throughout life (8) . The individuals interviewed in this study were assessed as to whether they had a positive attitude toward sex in old age or not; in Brazil, elderly individuals are those 60 years old or older (9) .
The presence of HIV/AIDS, as well as symptoms and complications associated with the disease, negatively affect the quality of life (QoL) of those living with the virus.
Additionally, several sociodemographic, clinical, and psychosocial factors have been reported in the literature as variables that can impact the QoL of these individuals (10)(11) . In general, QoL dimensions include physical, psychological, social, interpersonal, environmental, and spiritual aspects that enable complementing morbidity and mortality models traditionally used to assess the impact of a given disease. In this context, assessing factors that interfere in the QoL of people living with HIV/AIDS is an important marker of disease and also important to implementing therapeutic interventions among this population (12) .
Identifying potentially modifiable factors of QoL is essential to making medical decisions, implementing health care measures and optimizing the use of resources in healthcare services to improve the well being of people living with HIV/AIDS (10) .
Since variables that affect the QoL of patients with   represents an economic class (from A to E), is the sum of points concerning level of education and amount of consumer goods the individual has at home (13) .
The Targeted Quality of Life Instrument (HAT-QoL) (14) was used. It is composed of 34 items addressing nine dimensions: overall function, life satisfaction, health worries, financial worries, medication worries, HIV mastery, disclosure worries, provider trust, and sexual function. The individual is instructed to consider his/her QoL in the last four weeks and answers are presented on a five-point Likert scale: "all the time", "most of the time", "some of the time", "a little of the time" and "never". The scores range from zero (worst situation) to 100 (best possible situation).

The Aging Sexual Knowledge and Attitudes
Scale (ASKAS) (15) was also used. It is composed of 20 questions addressing the construct "knowledge", ranging from 20 to 60, and eight questions addressing "attitudes," which range from 8 to 40. The options for answers to the knowledge questions include: true (one point); false (two points); and do not know (three points); the lower the score, the higher one's knowledge regarding sexuality in old age. The options for answering the questions addressing attitudes include: strongly disagree (one point), partially disagree (two points), do not agree or disagree (three points), partially agree (four points), and strongly agree (five points). The lower the score, the more favorable is one's attitude toward sexuality in old age.
The patients were invited to participate in the study when they visited the clinic for routine exams or medical appointments. If they consented, they were individually interviewed in a private outpatient clinic. The researcher read the instruments' items only once and the interviews lasted 40 minutes, on average.

Results
The patients' ages ranged from 50 to 74 years old;    There were significant associations between the ASKAS' attitudes domain and the HAT-QoL's overall   function, health worries, medication worries, and HIV mastery. The ASKAS' knowledge domain, however, was not significantly associated with any HAT-QoL domains, as shown in Table 5.  (16) .
The scores of the HAT-QoL's domains were as follows: disclosure worries (39.03); sexual function (45.96); and financial worries (55.64). These scores were also similar to those found in studies conducted in Porto Alegre and a city in the interior of São Paulo, showing that regardless of the place of residence, the aspects of QoL most compromised are common among patients (11,16) .
Disclosure worries, the domain with the lowest score, Many participants of another study reported that HIV affected their sexual function (18) .

Lower QoL portrayed in the financial worries domain
is probably related to the low income of individuals with the disease, which makes survival more difficult. QoL is closely linked to socioeconomic matters and social inclusion (10) .  (19) .
The favorable attitudes toward sexuality in old age found among these individuals suggest they are sexually active; however, better knowledge of sexuality does not mean less risk of infection and educational practices are required to prevent the spread of the disease (7) .  Okuno MFP, Gosuen GC, Campanharo CRV, Fram DS, Batista REA, Belasco AGS.
immunological factors, increasing the production of natural antibodies, which in turn, can delay the progression of HIV/AIDS (20) .
Life satisfaction and health worries were domains with higher average scores that were associated with a longer period since HIV was diagnosed. One study conducted with seropositive individuals aged 50 years old and older reports that most react negatively when they received the diagnosis, though aging with HIV implied self-acceptance, wisdom, and a positive attitude toward life, essential aspects to maintaining life satisfaction and QoL (18) .
Patients belonging to economic classes A and B and food (17) . A low level of education also influences one's occupational options. Low income and poor socioeconomic condition influence the access of people living with HIV/AIDS to preventive measures and integral healthcare (11) .
The HIV mastery domain presented significantly higher scores among those with higher levels of education. Another study reports that lower education levels among infected people 50 years old or older hinders access to essential AIDS-related information, such as knowledge regarding antiretroviral medications that can control the disease. This information indicates that a low level of education may interfere in adherence to antiretroviral medication, as it influences one's understanding of the importance of using medications and accessing the treatment (21) .
Even though the average score obtained in the disclosure worries domain was low, it was better among unemployed individuals and those younger than 60 years old. Working individuals obtained the worst scores, possibly due to fear of discrimination and the possibility of losing their jobs. Many employers do not hire seropositive individuals due to prejudice, to the side effects caused by antiretroviral medications that may interfere in their productivity and to patients' needs to miss work days for consultations and exams (17) .
Social moral overload that patients experience seems to worsen with age. Another study conducted with elderly individuals with HIV/AIDS identified that the diagnosis impacted the individuals' affection-bonds, family ties and friendships. Fear of rejection was a major factor influencing the decision whether or not to disclose the diagnosis to the individuals' social circles (4) .
Being aware of the forms of transmission and a higher level of education were associated with higher scores on the HAT-QoL's provider trust domain. Higher levels of education may favor understanding about the disease and medication therapy, which is relevant for treatment adherence. Another study reports that individuals who do not adhere to the use of antiretroviral medication had lower levels of education than those who adhere to the treatment (19) . The lower scores found regarding the provider trust domain, may be explained, in part, by the fear some patients hold of being judged by healthcare providers and associated with homosexuality, drug users, and sex workers (22) . The sexual function domain showed that being a Caucasian man belonging to economic classes A or B was associated with higher scores. The maintenance of affective-sexual relationships is essential in the lives of individuals with HIV/AIDS as a contribution to better QoL (11) . Higher levels of education may be associated with the maintenance of sexual desire in the later stages of adult life (23) .
The study showed that some sociodemographic and hours of work and those of the health services are not always reconcilable for working individuals (25) .
The interviewees who presented a better attitude toward sexuality were those with higher levels of education and who were younger than 60 years old.
Another study reports that individuals with higher educational levels assigned greater importance to sex in their relationships with their spouses, showing that education seems to play an important role in people's attitudes toward sexuality (23) .
Sexuality in old age is a subject neglected by society, healthcare providers, and elderly individuals themselves as if love and even sex are no longer within the array of interests of those of advanced age (5) . It may be one of the reasons patients older than 60 years of age presented a less favorable attitude toward sexuality in old age.
More favorable attitudes toward sexuality were associated with the domains of overall function, health worries, medication worries, HIV mastery and addressed in the HAT-QoL in the multiple linear regression analysis.
No studies related the HAT-QoL and the ASKAS, which hindered the comparison of results.

Conclusion
The variables of physical exercise, long period since diagnosis, better economic conditions, higher level of education, being unemployed, being younger than 60 years old, being aware how transmission occurred, being a man, and being Caucasian were associated with one or more of the HAT-QoL's domains and increased its scores. Women and unemployed individuals had greater knowledge concerning the sexuality of elderly individuals, while patients with higher education levels and who were younger than 60 years of age showed more favorable attitudes toward sexuality in old age.