Abstract

A prevalence study was conducted to compare quality of life and food insecurity in men and women living with HIV/AIDS. The sample comprised 481 HIV-infected individuals undergoing antiretroviral therapy at a referral hospital in the State of Paraíba, Brazil. Food insecurity and quality of life were assessed using the Brazilian Household Food Insecurity Scale and WHOQOL-HIV Bref, respectively. The results were presented as absolute and relative frequencies and gender differences were tested using the chi-squared test adopting a significance level of 0.05. The findings showed that 40.1% of the sample were women. A higher percentage of women than men had a low income and low education level (65.8% and 72.5%, respectively). Prevalence of food security was lower in women than in men (29.0% compared to 42.7%), and a higher percentage of women than men reported below average quality of life (54.9% compared to 44.4%). The findings reveal that, besides the usual difficulties faced by HIV-infected patients, this group showed a significant level of gender inequality. The management of HIV patient care should consider these important findings, promoting access to care and support services and gender equality so that women can live fairer and more equal lives.

Key words:
HIV; Gender Identity; Food and Nutritional Security; Quality of Life

Introduction

Before the introduction of antiretroviral therapy (ART) in tem middle of the 1990s, HIV-infected individuals rapidly progressed to AIDS and, consequently, death. Today, adequate treatment permits a near-normal life expectancy¹1 Programa das Nações Unidas no combate à Aids (UNAIDS). Estatísticas globais sobre HIV 2017 [Internet]. 2018 [acessado 2019 mar 20]. Disponível em: https://unaids.org.br/estatisticas/.
https://unaids.org.br/estatisticas... . In 2017, there were 36.9 million [31.1 million - 43.9 million] people living with HIV worldwide. Although the disease is more prevalent among men, every week around 7,000 young women aged between 15 and 24 years are infected. Globally, HIV is the leading cause of death among women aged between 30 and 49 years²2 Programa das Nações Unidas no combate à Aids (UNAIDS). Acelerando o progresso rumo à igualdade de gênero nas Nações Unidas e além [Internet]. 2018 [acessado 2019 mar 20]. Disponível em: https://unaids.org.br/2018/04/acelerando-o-progresso-em-direcao-igualdade-de-genero-nas-nacoes-unidas-e-alem/.
https://unaids.org.br/2018/04/acelerando... . In Brazil, up to June 2018, 926,742 cases of HIV had been reported and, up to 31 December 2017, 327,655 deaths with HIV/AIDS as the underlying cause³3 Brasil. Ministério da Saúde (MS). Boletim epidemiológico HIV/Aids 2018. Brasília: MS; 2018..

People living with HIV/AIDS (PLHA) constitute a specific and vulnerable group⁴4 Jesus GJ, Oliveira LB, Caliari JS, Queiroz AAFL, Gir E, Reis RK. Dificuldades do viver com HIV/Aids: Entraves na qualidade de vida. Acta Paul Enferm 2017; 30(3):301-307. undergoing permanent treatment using complex high-cost therapies. Brazil’s national guidelines for the management of HIV infection in adults highlight the importance of treatment adherence, which includes healthy eating necessary for the proper functioning of the metabolism, preservation of the immune system, and improving tolerance to antiretroviral drugs, by both facilitating their absorption and preventing side effects⁵5 Medeiros ARC, Lima RLFC, Medeiros LB, Trajano FMP, Salerno AAP, Moraes RM, Vianna RPT. Insegurança alimentar moderada e grave em famílias integradas por pessoas vivendo com HIV/Aids: validação da escala e fatores associados. Cien Saude Colet 2017; 22(10):3353-3364.^,66 Grobler L, Siegfried N, Visser ME, Mahlungulu SSN, Volmink J. Nutritional interventions for reducing morbidity and mortality in people with HIV. Cochrane Database Syst Rev 2013; 2:CD004536..

With the increased survival rate provided by ART, HIV-infected individuals are concerned not only with the capacity of treatment to increase years of healthy life, but also with maintaining quality of life⁷7 O'Connell KA, Skevington SM. An International Quality of Life Instrument to Assess Wellbeing in Adults Who are HIV-Positive: A Short Form of the WHOQOL-HIV (31 items). AIDS Behav 2012; 16(2):452-460.. Quality of life is an important basic need and also influences morbidity and mortality⁸8 Guimarães MDC, Carneiro M, Abreu DMX, França EB. HIV/AIDS Mortality in Brazil, 2000-2015: Are there reasons for concern? Rev Bras Epidemiol 2017; 20(Supl. 1):182-190.. Studies show a positive correlation between better quality of life and adherence to ART, while the latter directly influences viral load and is associated with the progression of the disease to later stages⁹9 Geocze L, Mucci S, De Marco MA, Nogueira-Martins LA, Citero VA. Quality of life and adherence to HAART in HIV-infected patients. Rev Saude Publica 2010; 44(4):743-749..

Studies also note that food and nutrition insecurity is associated with decreased adherence to ART¹⁰10 Palermo T, Rawat R, Weiser SD, Kadiyala S. Food Access and Diet Quality Are Associated with Quality of Life Outcomes among HIV-Infected Individuals in Uganda. PLoS ONE 2013; 8(4):e62353.. Food and nutrition insecurity is an unequivocal violation of the right to adequate food characterized by irregular access to food of the quality and quantity needed to maintain a healthy life in a socially acceptable manner while also respecting the cultural characteristics of individuals¹¹11 Brasil. Lei nº 1.346, de 15 de setembro de 2016. Cria o Sistema Nacional de Segurança Alimentar e Nutricional - SISAN com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União 2006; 18 set..

The increasing prevalence of HIV-infected women is a reality and it is therefore important to know whether the living conditions of this group are similar to those experienced by men in order to improve the management of the disease.

This study therefore examined differences in prevalence of food insecurity and quality of life scores between men and women living with HIV/AIDS, given that these factors influence adherence to treatment, which in turn is essential to control the virus and prevent progression of the disease to later stages.

Methods

A cross-sectional study was conducted with people living with HIV/AIDS receiving treatment at the Clementino Fraga Infectious Disease Hospital Complex, a referral hospital specializing in the diagnosis and treatment of HIV located in João Pessoa in the State of Paraíba.

All people attending clinical follow-up appointments during the period 2 September to 23 December 2015 were considered eligible to participate in the study.

The following inclusion criteria were adopted: patients diagnosed with HIV at any stage of infection (asymptomatic, symptomatic, and/or AIDS); patients aged over 18 years; and patients who had been undergoing ART for at least six months. With respect to ART, the most commonly used medications are nucleoside reverse transcriptase inhibitors and protease inhibitors. The following individuals were excluded: people whose clinical condition prevented their participation in the study; people in confinement or institutionalized; and pregnant women. All of the 503 PLHAs attending follow-up appointments during the study period were recruited. Twenty-two (4.4%) were excluded because they provided incomplete answers to the data collection instrument, generally because they were called for the appointment and failed to return to the interview, resulting in a final study sample of 481 people.

Previously trained interviewers conducted face-to-face interviews while the patients were waiting for their appointment. The topics and respective items of the data collection instrument presented in Chart 1.

The measure used by this study to assess quality of life was the WHOQOL-HIV-BREF, consisting of 31 items divided into six domains scored on a five-point scale. This widely used instrument demonstrates good psychometric properties and high reliability (27 items obtained Cronbach’s alpha values greater than 0.70 and the remaining items obtained values between 0.32 and 0.65) and excellent internal consistency and validity across items and domains, and is especially recommended for studies with PLHAs¹²12 Whoqol Hiv Group. WHOQOL-HIV for quality of life assessment among people living with HIV and AIDS: results from the field test. AIDS Care 2004; 16(7):882-889.^,1313 Zimpel RR, Fleck MP. Quality of life in HIV-positive Brazilians: application and validation of the WHOQOL-HIV, Brazilian version. AIDS Care 2007; 19(7):923-930.. For the purposes of this study, we only considered the overall score based on the scoring criteria proposed by the WHO¹²12 Whoqol Hiv Group. WHOQOL-HIV for quality of life assessment among people living with HIV and AIDS: results from the field test. AIDS Care 2004; 16(7):882-889..

The Brazilian Household Food Insecurity Scale (EBIA, acronym in Portuguese) was adapted from the US Household Food Security Survey Module (HFSSM). Validated by Segall-Corrêa et al.¹⁴14 Segall-Corrêa AM, Escamilla RP, Maranha LK, Sampaio MFA. (In) Segurança Alimentar no Brasil: Validação de metodologia para acompanhamento e avaliação. Campinas: UNICAMP; 2003. in 2003, the instrument is widely used in epidemiological studies in Brazil.

The measure consists of 14 items - or only 8 items for households without members under 18 years of age - used to classify food security status based on the sum of affirmative responses to the items as follows: food secure, mild food insecurity, moderate food insecurity, and severe food insecurity, where severe food insecurity indicates that family members experience hunger.

The data was double entered into a worksheet and the data set was analyzed using the statistical software Stata SE 14. The variables were described in frequency tables and the association between categorical variables was tested using Pearson’s chi-squared test adopting a significance level of 0.05.

The study was conducted in accordance with the ethical norms and standards for research involving human subjects set out by National Health Council Resolution 466/2012¹⁵15 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde (CNS). Resolução nº 466, de 12 de dezembro de 2012. Diário Oficial da União 2013; 13 dez. and approved by the Research Ethics Committee of the University of Paraíba’s Health Sciences Center. All participants signed an informed consent form.

Results

The results show that 40.1% of the sample were women. The characteristics of the sample by sex are shown in Table 1.

The age of the sample ranged between 18 and 87 years, with a median age of 44. This age was chosen to categorize the sample into two equal age groups. A higher percentage of men than women had completed at least 8th grade and earned more than half a minimum salary (38.9% versus 27.5% and 54.9% versus 34.2%, respectively). The percentages of men and women who lived with a partner and had an occupation were similar.

A higher percentage of women than men reported below average quality of life (54.9% versus 44.4%) (Table 2).

The overall prevalence of food insecurity was 62.8%, with 18% of respondents experiencing severe food insecurity (Figure 1).

However, the analysis of food security status by sex showed that the situation of women was worse than that of men, with a lower percentage of women than men reporting being food secure and a higher percentage reporting moderate and severe food insecurity (24.9% versus 12.8% and 19.2% versus 16.7%, respectively). It is also important to highlight that there was an association between food insecurity and quality of life in both sexes (Table 3). Among women, the more severe the food insecurity, the higher the prevalence of below average quality of life (28.6% among women who reported being food secure versus 75.7% in those experiencing severe food insecurity). Among the men, the prevalence of below average quality of life was greatest in those who reported moderate food insecurity (78.4%).

Discussion

The findings illustrate, as many other studies reveal, the feminization of HIV/AIDS and, consequently, the changing profile of the population affected by HIV¹1 Programa das Nações Unidas no combate à Aids (UNAIDS). Estatísticas globais sobre HIV 2017 [Internet]. 2018 [acessado 2019 mar 20]. Disponível em: https://unaids.org.br/estatisticas/.
https://unaids.org.br/estatisticas... ^,33 Brasil. Ministério da Saúde (MS). Boletim epidemiológico HIV/Aids 2018. Brasília: MS; 2018.^,1616 Hipolito RL, Oliveira DC, Costa TL, Marques SC, Pereira ER, Gomes AMT. Quality of life of people living with HIV/AIDS: temporal, socio-demographic and perceived health relationship. Rev Lat Am Enferm 2017; 25:e2874.. Almost half of the sample were women, which has direct implications for the management of care for this group, especially considering gender roles in society¹⁷17 Oliveira FBM, Queiroz AAFLN, Sousa ÁFL, Moura MEB, Reis RK. Sexual orientation and quality of life of people living with HIV/Aids. Rev Bras Enferm 2017; 70(5):1004-1010. and that we live in a male chauvinist and patriarchal society where women occupy a markedly disadvantaged position.

As the findings show, gender inequality, is not just a sociological problem, but also a health and nutritional issue, falling on the whole of society to fight for gender equality, so that women can live fairer and more equal lives¹⁸18 Lima ACO, Lima RSV, Silva JMA. Gênero feminino, contexto histórico e segurança alimentar. DEMETRA Aliment Nutr Saude 2016; 11:789-802..

Another important feature is the growing number of older people affected by HIV. The median age of the patients in the present study was 44 years, confirming what other studies have shown in relation to increased susceptibility to infection across all age groups, with particular concern regarding the rise in the number of cases among older people, representing another change in the profile of the disease¹⁹19 Santos AFM, Assis M. Vulnerability of the elderly to HIV/AIDS: public politics and health professionals in the context of integral care: a literature review. Rev Bras Geriatr Gerontol 2011; 14(1):147-157.^,2020 Torres TS, Cardoso SW, Velasque LS, Marins LMS, Oliveira MS, Veloso VG, Grinsztejn B. Aging with HIV: an overview of an urban cohort in Rio de Janeiro (Brazil) across decades of life. Braz J Infect Dis 2013; 17(3):324-331.. In this regard, a study conducted in 2013 in Montevideo, Uruguay with a sample of 198 individuals reported that the average age of HIV patients admitted to a general hospital was 63 years. It is also interesting to note that the sample was made up of similar percentages of men and women (53% versus 47%)²¹21 Silva AG, Cavalcanti VS, Santos TS, Bragagnollo GR, Santos KS, Santos IMS, Mousinho KC, Fortuna CM. Revisão integrativa da literatura: assistência de enfermagem a pessoa idosa com HIV. Rev Bras Enferm 2018; 71(Supl. 2):884-892..

Our findings show that the proportion of respondents living with a partner was relatively low, corroborating the findings of other studies such as that conducted by Tesfaye et al.²²22 Tesfaye M, Kaestel P, Olsen MF, Girma T, Yilma D, Abdissa A, Ritz C, Prince M, Friis H, Hanlon C. Food insecurity, mental health and quality of life among people living with HIV commencing antiretroviral treatment in Ethiopia: a cross-sectional study. Health Qual Life Outcomes 2016; 14:37. in Ethiopia showing that only 37.3% of HIV-infected individuals were married. Although the present study shows similar percentages of men and women living with a partner, the type of relationship, which may vary between genders, and presence or absence of children in the household living as a family unit, was not investigated. A study that validated the EBIA for use with PLHAs showed differences in family composition between infected men and women, with the presence of children being more common among the latter⁵5 Medeiros ARC, Lima RLFC, Medeiros LB, Trajano FMP, Salerno AAP, Moraes RM, Vianna RPT. Insegurança alimentar moderada e grave em famílias integradas por pessoas vivendo com HIV/Aids: validação da escala e fatores associados. Cien Saude Colet 2017; 22(10):3353-3364.. It might be expected that the presence of children may influence adherence to ART; however, there is a lack of literature on the association between family composition and treatment adherence among PLHAs.

Other gender differences observed in our sample further aggravate the situation of women, such as lower education level and per capita income. These findings are similar to those reported by a study conducted in six Brazilian cities that carried out in-depth interviews with 85 women living with HIV/AIDS aged between 18 and 49 years. The results reveal a picture of social vulnerability characterized by low levels of education, precarious employment, and exposure to violence²³23 Villela WV, Barbosa RM. Trajetórias de mulheres vivendo com HIV/aids no Brasil. Avanços e permanências da resposta à epidemia. Cien Saude Colet 2017; 22(1):87-96..

This situation is not unique to Brazil. For example, a study conducted in 2015 in Cuba with HIV-infected patients noted that the majority of women had completed only primary school, while the majority of men had completed high school²⁴24 Estrada JAF, Hechavarría OB, Pullés Fernández MC, Tabares L, Fong JO. Percepción de riesgo de sida en adultos mayores de un área de salud. MEDISAN 2015; 19(9):1115-1120.. The differences in income observed by the present study, where the percentage of women earning less than half a minimum salary is markedly higher than men, is another important question to be taken into account in the management of care for this group.

Given that PLHAs are a biologically vulnerable group, the percentage of respondents who reported experiencing food insecurity (62.8%) is alarming, considering that it is double that of the general Brazilian population²⁵25 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicilios - Segurança Alimentar 2013. Ministério do Planejamento Orçamento e Gestão. Rio de Janeiro: IBGE; 2013.. The reality in more developed countries is no different. Studies published in 2005, 2011, and 2013 using a cohort of HIV-infected individuals on highly active ART (HAART) in British Columbia, Canada reported the following results: the occurrence of food insecurity was nearly five times higher than in the general Canadian population; a high (71%) prevalence of food insecurity among HIV-infected individuals receiving HAART; food insecurity status is associated with a compendium of behavioral and environmental factors; and highly vulnerable groups such as HIV-positive injection drug users (IDUs) reporting food insecurity were almost twice as likely to die, compared to food secure IDUs²⁶26 Normén L, Chan K, Braitstein P, Anema A, Bondy G, Montaner JSG, Hogg RS. Food insecurity and hunger are prevalent among HIV-positive individuals in British Columbia, Canada. J Nutr 2005; 135(4):820-825.

27 Anema A, Weiser SD, Fernandes KA, Ding E, Brandson EK, Palmer A, Montaner JSG, Hogg RS. High prevalence of food insecurity among HIV-infected individuals receiving HAART in a resource-rich setting. AIDS Care 2011; 23(2):221-230.^-2828 Anema A, Chan K, Chen Y, Weiser S, Montaner JSG, Hogg RS. Relationship between Food Insecurity and Mortality among HIV-Positive Injection Drug Users Receiving Antiretroviral Therapy in British Columbia, Canada. PLoS ONE 2013; 8(5):e61277..

Our findings reveal that food security status is worse among women. Both the prevalence of moderate food insecurity (where people are forced to reduce the quantity of food they consume) and severe food insecurity (where household members experience hunger) is higher among women. Given that in Brazilian culture it is women who are mostly responsible for managing the household budget and preparing meals, this finding reveals that these people and their families face a grave situation in their everyday lives.

Studies conducted in Uganda in 2013 and 2014 with 902 PLHAs undergoing ART showed that those experiencing food insecurity were more likely to show poor clinical outcomes, contributing to a higher mortality rate. Access to food and diet quality are associated with quality of life and should be addressed by interventions designed to mitigate the psychosocial impact of HIV¹⁰10 Palermo T, Rawat R, Weiser SD, Kadiyala S. Food Access and Diet Quality Are Associated with Quality of Life Outcomes among HIV-Infected Individuals in Uganda. PLoS ONE 2013; 8(4):e62353.^,2929 Rawat R, Faust E, Maluccio JA, Kadiyala S. The Impact of a Food Assistance Program on Nutritional Status, Disease Progression, and Food Security Among People Living With HIV in Uganda: JAIDS J Acquir Immune Defic Syndr 2014; 66(1):e15-e22.. Our findings show an association between quality of life and food insecurity in both sexes. The results are particularly worrying for women, given that quality of life is worse among this group than in men.

People with inadequate access to food can feel shame or embarrassment, which may be worse in PLHAs due to discrimination and other treatment needs³⁰30 Programa das Nações Unidas no combate à Aids (UNAIDS). UNAIDS Policy Brief: HIV, Food Security and Nutrition [Internet]. 2008 [acessado 2015 fev 10]. Disponível em: http://www.tandfonline.com/doi/abs/10.2989/AJAR.2009.8.4.4.
http://www.tandfonline.com/doi/abs/10.29... . Achieving and maintaining optimal nutrition is an important part of the clinical care of HIV-infected patients, since it can improve an individual’s immune function, limit disease-specific complications, and improve quality of life and survival⁶6 Grobler L, Siegfried N, Visser ME, Mahlungulu SSN, Volmink J. Nutritional interventions for reducing morbidity and mortality in people with HIV. Cochrane Database Syst Rev 2013; 2:CD004536..

It is notable that self-perceived quality of life is lower among women than in men. A study conducted in Ethiopia in 2016 with 1,180 people living with HIV/AIDS undergoing ART also reported gender differences for self-reported quality of life and the social, economic, and psychological impact of the disease. Multivariate analysis showed that psychological distress, low CD4+ count, unemployment, and food insecurity were associated with lower quality of life scores in both sexes. However, the effects of food insecurity on quality of life were greater among women, explained by the fact that women play a larger role in domestic responsibilities in the region³¹31 Vo QT, Hoffman S, Nash D, El-Sadr WM, Tymejczyk OA, Gadisa T, Melaku Z, Kulkarni SG, Remien RH, Elul B. Gender Differences and Psychosocial Factors Associated with Qualityof Life Among ART Initiators in Oromia, Ethiopia. AIDS Behav 2016; 20(8):1682-1691..

Gender equality and non-discrimination are basic human rights and components of a healthy, peaceful and prosperous world. Despite gender equality having been on the global health agenda for decades, gender inequality persists worldwide. Gender equality and discrimination jeopardize progress in the AIDS response and deprive women and girls of their basic rights and their ability to prevent HIV and access treatment³²32 Programa das Nações Unidas no combate à Aids (UNAIDS). Agir para mudar leis discriminatórias [Internet]. 2019 [acessado 2019 mar 10]. Disponível em: https://unaids.org.br/wp-content/uploads/2019/02/ZeroDiscrimina%C3%A7%C3%A3o2019_Brochura.pdf.
https://unaids.org.br/wp-content/uploads... ^,3333 Programa das Nações Unidas no combate à Aids (UNAIDS). UNAIDS Gender Action Plan 2018-2023 - A framework for accountability [Internet]. 2018 [acessado 2019 mar 10]. Disponível em: https://www.unaids.org/sites/default/files/media_asset/jc2925_unaids-gender-action-plan-2018-2023_en.pdf.
https://www.unaids.org/sites/default/fil... . Gender equality and women’s empowerment are key for ending the AIDS epidemic by 2030²2 Programa das Nações Unidas no combate à Aids (UNAIDS). Acelerando o progresso rumo à igualdade de gênero nas Nações Unidas e além [Internet]. 2018 [acessado 2019 mar 20]. Disponível em: https://unaids.org.br/2018/04/acelerando-o-progresso-em-direcao-igualdade-de-genero-nas-nacoes-unidas-e-alem/.
https://unaids.org.br/2018/04/acelerando... .

The findings paint a negative picture of the situation of HIV-infected women, in which a complex and interrelated set of factors accentuate the negative effects of each individual factor. Factors such as restricted income, low levels of education, food insecurity, low quality of life - and in the case of women gender inequalities - work together to make this group even more vulnerable.

Conclusion

Despite advances in increasing survival in recent years, care management and quality of life remain a challenge for people living with HIV/AIDS.

This study shows that, besides being more vulnerable biologically, PLHAs undergoing clinical follow-up at a referral hospital in the State of Paraíba were socially vulnerable due to low levels of education and per capita income, unemployment, and not having a complete family unit.

This study provides important new information, revealing that the situation of female HIV-infected patients was worse than that of men, with women showing lower income and education levels, lower quality of life, and a higher prevalence of food insecurity, particularly moderate and severe insecurity.

It is known that throughout history women have faced inequality. This study shows that this trait of society is reflected in the situation of PLHAs in the State of Paraíba, emphasizing that gender inequality is not just a sociological problem, but also a health, quality of life, and nutritional issue.

It is important that healthcare services directed at PHVAs consider these factors in developing positive actions to tackle HIV/AIDS that go beyond the biological dimension, promoting access to care and support services and gender equality, so that women can live fairer and more equal lives.

References

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