AIDS and Behavior

A Spanish study on psychosocial predictors of quality of life in people with HIV.

--Manuscript Draft-Manuscript Number:
Full Title:

A Spanish study on psychosocial predictors of quality of life in people with HIV.

Article Type:

Original Research

Keywords:

HIV; Quality of life; predictors; physical health; psychological health

Corresponding Author:

Rafael Ballester-Arnal, Ph.D.

Facultad de Ciencias de la Salud. Universitat Jaume I de Castell
Castelln, SPAIN

Corresponding Author Secondary

Information:
Corresponding Author's Institution:

Facultad de Ciencias de la Salud. Universitat Jaume I de Castell

Corresponding Author's Secondary

Institution:
First Author:

Rafael Ballester-Arnal, Ph.D.

First Author Secondary Information:

Order of Authors:

Rafael Ballester-Arnal, Ph.D.

Sandra Gmez-Martnez, Ph.D.
Carmina R. Fumaz, Ph.D.
Marian Gonzlez-Garca, Ph.D.
Eduardo Remor, Ph.D.
M Jos Fuster, Ph.D.

Order of Authors Secondary Information:

Abstract:

In Spain little research has focused on assessment of health indicators, both physical
and psychological, in people living with HIV. The aim of this study is to evaluate a set
of different indicators that allow us to identify psychosocial factors that may be
influencing the quality of life of these people. The sample consist of 744 people
infected with HIV aged between from 18 to 82 years (M=43.04; SD=9.43). Results
show that factors such as self-esteem and leading a healthy lifestyle act as protectors
in both, physical and mental health. On the other hand, financial problems, body
disfigurement, and mood could have harmful effects on both, physical and mental
health. The structural model reveals depressed mood as the factor with greatest
influence upon mental health, which in turn can be largely explained by factors such as
the stress generated by HIV and personal autonomy. This work has allowed us to
identify the vulnerability and protective factors that play a significant role in the physical
and mental HRQOL of persons with HIV, providing guidelines for design and
implementation of psychological intervention programs aimed to improve HRQOL in
this population.

Suggested Reviewers:

Jos P. Espada, Ph.D.

Universidad Miguel Hernandez de Elche
jpespada@umh.es
Large experience in HIV related research
Mireia Orgils, Ph.D.
Universidad Miguel Hernandez de Elche
morgiles@umh.es
Experience in HIV related research
ngel Castro, Ph.D.
Universidad de Zaragoza

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castroa@unizar.es
Experience in QoL related research
Luis M Pascual, Ph.D.
Universidad de Zaragoza
mpo@unizar.es
Large experience in QoL related research

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Cover Letter

Rafael Ballester Arnal

Department of Basic and Clinical Psychology and Psychobiology.
Universitat Jaume I de Castell.
Avda. Vicent Sos Baynat s/n.
12071 Castelln de la Plana (Spain).
April 1, 2015
Dear Dr. Kalichman,

I am forwarding the manuscript entitled is A Spanish study on

psychosocial predictors of quality of life in people with HIV because I would
be pleased if your editorial might examine it and consider its publication in
the Aids and Behavior as an original publication.
This manuscript is not currently under review elsewhere and has not
been previously published in whole or in part. Moreover, meets standards
on the ethical treatment of participants.
I would be pleased to discuss any aspects of our manuscript should
you consider this to be necessary; looking forward to your reply at your
earliest convenience.

Yours sincerely,
Rafael Ballester Arnal, PhD.

Title Page; Acknowledgement - with contact information

A Spanish study on psychosocial predictors of

quality of life in people with HIV.
Rafael Ballester-Arnal1, Sandra Gmez-Martnez1, Carmina R. Fumaz2, Marian
Gonzlez-Garca2, Eduardo Remor3, M Jos Fuster4
1. Departamento de Psicologa Bsica, Clnica y Psicobiologa. Facultad de Ciencias de
la Salud, Universitat Jaume I de Castell, Castell de la Plana, Spain.
2. Fundaci Lluita Contra la Sida, Hospital Germans Trias i Pujol, Barcelona, Spain.
3. Departamento de Psicologa Biolgica y de la Salud, Facultad de Psicologa,
Universidad Autnoma de Madrid, Madrid, Spain.
4. Facultad de Psicologa, Universidad Nacional de Educacin a Distancia, Madrid,
Spain.

*The study was conducted on behalf of the Spanish Group for the Quality of Life
Improvement in HIV or AIDS.

Correspondence address:
Rafael Ballester Arnal
Departamento de Psicologa Bsica, Clnica y Psicobiologa. Facultad de Ciencias de la
Salud.
Universitat Jaume I de Castell
Avda. Sos Baynat, s/n
12071. Castelln de la Plana, Spain.
Phone: 964729726
Email: rballest@uji.es

Suggested running head: A Spanish study on psychosocial predictors of quality of life

in people with HIV

ACKNOWLEDGEMENTS:
This research has been made possible thanks to funding from a FIPSE Espaa (Fundacin Para
La Investigacin y Prevencin del Sida en Espaa) project: 36-0743/09). This paper has been

researched and written by the authors on the half of the Spanish Group for the improvement
of quality of life in HIV/AIDS (Grupo Espaol para la mejora de la Calidad de Vida en VIH/SIDA).
The members of the Spanish Group for the improvement of quality of life in HIV/AIDS are:
Lpez-Ziga, A.M., Santos-Miguel, I. (Asociacin T-4); Albiol-Soto, M. (CESIDA); Ferrer-Lasala,
M.J., Fumaz, C. R., Gonzlez-Garca, M., Tuldr-Nio, A. (Fundaci Lluita contra la Sida. Hospital
Germans Trias i Pujol); Ferrando-Vilalta, R. (Hospital Clnico de Valencia); Santamaria-Jauregui,
J.M. (Hospital de Basurto); Iribarren-Loyarte, J.A. (Hospital de Donostia); Fuster-Ruiz de
Apodaca, R., Pasquau-Liao, F. (Hospital de la Marina Baixa de Villajoyosa); Tornero-Esteban,
C. (Hospital Fco Borja de Ganda); Roca, B. (Hospital General de Castelln, Universitat Jaume I
de Castelln); Cnoves-Martnez, L. (Hospital General de Valencia); Lorenzo-Gonzlez, J.F.
(Hospital General Yage de Burgos); Remor, E. (Universidad Autnoma de Madrid); UbillosLanda, S. (Universidad de Burgos); Ruzafa-Martnez, M. (Universidad de Murcia); AguirrezabalPrado, A., Arnoso-Martnez, A., Larraaga-Eguilegor, M., Mayordomo-Lpez, S. (Universidad
del Pas Vasco); Fuster-Ruiz de Apodaca, M.J., Molero, F., Nouvilas-Pallej, E., Prez-Garn, D.,
Sanjuan-Surez, P. (Universidad Nacional de Educacin a Distancia); Gil-Llario, M.D., MadrigalVilchez, A. (Universitat de Valncia-Estudi General); Ballester-Arnal, R., Gil-Juli, B., GimnezGarca, C., Gmez-Martnez, S., Ruiz-Palomino, E. (Universitat Jaume I de Castell).
We wish to express our most sincere gratitude to the following centers for providing us with
access to the participants in the study: H.U."Marqus de Valdecilla" Santander, Hospital
General de Castelln, Hospital Xeral de Vigo, Hospital General Universitario de Alicante,
Hospital Clnico San Carlos de Madrid, Hospital General Universitario de Elche, Hospital Clnico
Universitario de Valencia, Hospital General Universitario de Valencia, Hospital Clnico
Universitario Santiago de Compostela, Hospital Germans Trias i Pujol (Fundacin Lluita contra
la Sida) de Barcelona, Hospital Comarcal de la Marina Baixa. Villajoyosa, Hospital Infanta
Leonor de Madrid, Hospital de Basurto Bilbao, Hospital la Princesa de Madrid, Hospital de
Burgos, Hospital Ramn y Cajal de Madrid, Hospital de Calella, Hospital Rosell. Murcia, Hospital
de Donostia, Hospital Son Lltzer. Palma. Mallorca, Hospital de Figueres. Girona, Hospital
Universitario Central de Asturias, Hospital de la Santa Creu i Sant Pau de Barcelona, Hospital
Universitario de A Corua, Hospital de Matar (Barcelona), Hospital Universitario Gregorio
Maran, Hospital de Sant Pau i Santa Tecla de Tarragona, Hospital Universitario Miguel
Servet. Zaragoza, Hospital de Vic. Barcelona, Hospital Virgen de las Nieves. Granada, Hospital
Francesc de Borja. Ganda, Residencia Murcia.

BLIND Manuscript--SHOULD NOT CONTAIN AUTHOR INFORMATION

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Abstract:
In Spain little research has focused on assessment of health indicators, both physical and
psychological, in people living with HIV. The aim of this study is to evaluate a set of different
indicators that allow us to identify psychosocial factors that may be influencing the quality of
life of these people. The sample consist of 744 people infected with HIV aged between from 18
to 82 years (M=43.04; SD=9.43). Results show that factors such as self-esteem and leading a
healthy lifestyle act as protectors in both, physical and mental health. On the other hand,
financial problems, body disfigurement, and mood could have harmful effects on both,
physical and mental health. The structural model reveals depressed mood as the factor with
greatest influence upon mental health, which in turn can be largely explained by factors such
as the stress generated by HIV and personal autonomy. This work has allowed us to identify
the vulnerability and protective factors that play a significant role in the physical and mental
HRQOL of persons with HIV, providing guidelines for design and implementation of
psychological intervention programs aimed to improve HRQOL in this population.
Key words: HIV; Quality of life; predictors; physical health; psychological health.

Resumen:
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En Espaa son escasos los trabajos que evalan los indicadores de salud, tanto fsica como
psicolgica, en las personas que viven con VIH. El objetivo del trabajo es valorar diferentes
indicadores, que nos permitan conocer los factores psicosociales que influyen en la calidad de
vida de las personas con VIH. Se cont con la participacin de 744 personas con HIV con
edades de entre 18 y 82 aos (M=43.04; DT=9.43). Los resultados muestran que factores como
la autoestima y el mantenimiento de hbitos de vida saludables actan como protectores en la
salud fsica y mental. Por otro lado, los problemas econmicos, la desfiguracin corporal y el
nimo podran vulnerar ambos indicadores de salud. En el modelo estructural encontramos
que el nimo depresivo aparece como el factor que ms peso tiene sobre la salud mental, muy
influido a su vez por el estrs que genera el VIH y la autonoma personal. Este trabajo ha
permitido identificar los factores de vulnerabilidad y proteccin que resultan relevantes para la
CVRS fsica y mental de las personas con VIH, proporcionando directrices para el diseo y la
ejecucin de programas de intervencin psicolgica dirigidos a mejorar la CVRS de esta
poblacin.
Palabras clave: VIH, calidad de vida, predictores, salud fsica, salud mental

Introduction
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The latest treatments for HIV infection have brought about a significant change in the health of
persons with HIV (1), and this change has in turn led to a rethinking of the psychological care
for those with HIV. Until then this had mainly consisted in trying to help the patient to come to
terms with a fatal prognosis. The increased life expectancy resulting from more efficient
treatments meant that efforts could be focused more on studying and improving the healthrelated quality of life (HRQOL) of this population. The HRQOL variable has since been included
in most of the studies carried out on people with HIV.
This study sets out from a multidimensional conceptualization of quality of life, as defining
this concept is a rather complex matter (2). According to Shumaker and Naughton (1995) (3),
HRQOL refers to peoples subjective evaluations of the influences of their current health
status, health care, and health promoting activities on their ability to achieve and maintain a
level of overall functioning that allows them to pursue valued life goals and that is reflected in
their general well-being. Also in 1995 the WHOQOL group established that HRQOL measures
must be subjective, multidimensional, include both positive and negative feelings, and record
variability over time. When it comes to establishing these measures, it must be remembered
that, according to the evidence available, HRQOL is affected not only by factors related to the
progression of HIV, but also by psychosocial factors.
Recent studies suggest that a lack of social support and infrequent contact with the family
seem to be related to a reduction in the number of TCD4 cells (4). In turn, the number of these
cells also seems to be related to psychosocial factors such as having a history of chronic
stressing life events, an avoidance coping style, chronic depression, perceived stress, and
certain dimensions of personality such as neuroticism or openness to experience, among
others (5) (6) (7) (8).

A number of studies have related depressive symptoms with physical health. These symptoms
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could be predicted by the factors emotional loneliness and stigma, which, although not
associated to objective indicators of physical health, were related with the main indicators of
perceived health (9).
Some studies have measured the difference in the self-perceived quality of life of patients
after being diagnosed with HIV. One of them concluded that a third of the patients felt that
their life was better after the diagnosis than before it. In this study, increased
spirituality/religious feelings, one of the factors that has received most attention in recent
years, was associated with a 68.5% increase in the self-perception of a better quality of life
(10). Existential well-being, or personal meaning, has also been studied. Thus, a study
conducted by Dalmida et al. showed a significant positive relationship between this variable
and physical and mental HRQOL (11).
Studies have also been carried out on quality of life and body disfigurement. One recent study
showed that lipodystrophy can affect psychological well-being due its being related to lowered
self-esteem, a negative perception of the body image, and the avoidance of any social contact
(12). Another recent study compared self-perception of the body (in terms of changes in the
amounts of fat: loss on the face and legs, and increase on the abdomen) in persons who were
HIV-positive and HIV-negative. Results showed a significant positive association between the
self-perception of changes in body fat and a lower physical HRQOL in people with HIV (13).
In another study the effect of the work situation on physical and mental HRQOL was evaluated,
the conclusion being that it affected both of them, with a greater influence on physical health
(14).
The effect of modifiable factors such as healthy habits has also been researched. In the study
conducted by Uphold et al. tobacco use, recreational drug use, and high-risk sexual behavior
were not found to be related to the dimensions of HRQOL. Yet drinking alcohol was negatively

associated with HRQOL, especially in the social functioning dimension (15). Likewise, the study
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by Kabali et al. confirmed the absence of any relationship between smoking tobacco and
physical HRQOL, as measured by the CD4 count (16).
Other studies have carried out more general research, focused on predicting the factors that
could be protective and high-risk for the physical and mental quality of life of persons with HIV
infection. Thus, Emlet et al. concluded that an increase in the limitation of activities, that is to
say lower autonomy, and a greater number of comorbid conditions gave rise to a poorer
physical HRQOL. Self-efficacy, however, acted as a protective factor. As regards the risk and
protective factors of mental HRQOL, the same study concluded that both self-efficacy and
social support were associated to improved mental health, whereas comorbid conditions, lack
of autonomy, and victimization, but not the stigma itself, were associated to decreased mental
HRQOL(17).
Despite the number of international studies conducted to date, in Spain little research has
focused on a more comprehensive perspective that takes into account all the relevant
psychosocial factors. In general the few studies that have been carried out have concentrated
on examining the individual effect of psychological indicators on quality of life or health
markers, such as perceived stress (18)(19), social support (20), sexual behavior (21), drug
abuse (22), emotional state (23), and perception of illness (21). Hence, our aim is to go a step
further by assessing a set of different indicators that can enable us to determine which
psychosocial factors may be exerting a predominant influence on how persons with HIV
experience quality of life. The ultimate aim of this approach would be to implement specific
interventions that have been designed bearing in mind the particular needs of these persons
and which, consequently, can be used to improve their quality of life, both physically and
psychologically.
Method:

Participants
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The participants in the study were people of both sexes with a known HIV infection, who were
treated at the hospitals selected for the research and/or who sought help from NonGovernmental Organizations (NGOs). Eligibility criteria for participation were the following:
aged over 18, capable of reading and comprehension, diagnosed with HIV at least six months
before the date of assessment, free from any serious psychiatric disorder, and agrees to
participate in the research by signing the informed consent form.
Instruments:
Three different instruments were used in the present study:
- A Record Sheet, which included questions about demographic, social, and occupational
data, as well as asking for information about their health habits in general (alcohol, drugs,
tobacco). They were also asked about several aspects related to their current status, such
as mode of transmission and the year it had taken place, telling other people about their
condition, whether they were active members of an association, their current CD4 level and
viral load, possible opportunistic diseases, type of treatment they were receiving, and sideeffects they were experiencing.
- The MOS-HIV survey by Wu et al., 1991 (24): a short, self-administered easy-tounderstand questionnaire. The Spanish version of the MOS-HIV questionnaire was
developed by Bada et al. in 1999(25). It consists of 35 questions that refer to 11 dimensions
of health: General Health Perceptions ( =.837), Pain ( =.783), Physical Functioning (
=.862), Role Functioning ( =.695), Social Functioning, Mental Health ( =.841),
Energy/Fatigue ( =.836), Health Distress ( =.909), Cognitive Functioning ( =.860), Quality
of Life, and Health Transition. Moreover, they are quantified in two general indices:
physical health and mental health. The questions refer to the last two weeks and are
answered on different scales with 2, 3, 5 or 6 possible answers.

- Screenphiv: Screening tool for HIV-related psychological issues (26). This battery consists
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of 63 items covering 23 facets depressive mood ( =.83), activism ( =.79), healthy habits
( =.70), information about HIV ( =.73), emotional loneliness ( =.82), satisfactory sexual
activity ( =.78), positive reassessment ( =.90), avoidance coping ( =.75), representation
of the disease ( =.42), social support ( =.78), self-esteem ( =.82), financial problems (
=.80), perceived stigma ( =.61), enacted stigma ( =.64), internalized stigma ( =.77), HIVrelated stress ( =.88), optimism ( =.85), personal meaning ( =.63), change in personal
values ( =.86), personal autonomy ( =.65), satisfaction with body image ( =.90),
disfigurement of body image ( =.61), and problem-focused coping ( =.83). The items are
statements related with the different facets, which are to be answered on an analogical
scale from 0 to 100, where 0 is not at all and 100 is a great deal.
Procedure:
Participants were invited to take part in the study either during a follow-up visit to their doctor
or on seeking help from one of the NGOs that collaborated in the study. The content of the
research was explained to them and they were asked to collaborate on a voluntary basis.
Those who agreed to do so filled in an informed consent sheet and the study assessment
protocol. Finally, after filling in all the data, participants were paid 10 as compensation for the
time spent on the study. The surveys were collected between the months of December 2010
and June 2011.
Statistical analyses:

The descriptive analyses, Pearson correlation analyses, regression analyses, and structural
equations included in this work were performed using the structural equations program EQS.

Results
Description of the sample used in the study

The sample consisted of a total of 744 persons infected with HIV with ages ranging from 18 to
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82 years (M=43.04; SD=9.43) who sought care from 32 different healthcare centers in Spain
and NGOs. Socio-demographic data can be seen in Table I.
INSERT HERE TABLE I

The relationship between psychological predictors and HRQOL

Pearson correlation indices were calculated among the summations of physical and mental
health and the means in each of the facets. The results can be seen in Table II.
INSERT HERE TABLE II

Practically all the facets correlate in a positive or negative way (in the expected sense) with
both health indices, except for the scores on the facets Change in personal values and "Social
support", which do not correlate with either of the two indices. The facets Enacted stigma:
experience of rejection and Information about the illness", however, correlate with the
mental health index but not with the physical one. And the opposite happens with Activism,
which correlates significantly with the physical health index (albeit with a negative sign) but
not with the mental one.
Regression analyses were later performed to determine the factors (both demographic and
HIV-related) that could act as protectors and non-protectors for the physical and mental
quality of life indices. Accordingly, first of all, stepwise regression analysis was used to
determine which psychosocial factors are capable of predicting the physical state. This resulted
in six regression models, the best of which accounted for 24.4% of the variance. In this model
(Table III), physical health can be explained by a higher score on the factors healthy habits,
self-esteem, and internalized stigma, and also by a lower score on financial problems, body
disfigurement, and depressive mood.

INSERT HERE TABLE III

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On performing the same analysis to determine the predictors of the mental state, we obtained
eight models, the best of them explaining 47.1% of the variance. According to these analyses
(Table IV), the mental health index is predicted by a lower score on depressive mood, HIVrelated stress, financial problems, and body disfigurement, and a higher score on personal
autonomy, healthy habits, personal meaning, and self-esteem.
INSERT HERE TABLE IV

Finally, structural equations were performed using the structural equations program EQS (27)
and by applying the Robust ML method. Accordingly, we used the variables that were found to
be predictors in the regression analysis, and after constructing several models we found that
the one that fit best was one in which five socio-psychological factors had an influence on the
person's mental health, which in turn was affecting physical health. As can be seen in Table V,
in this model the significance value of the Satorra-Bentler 2 (2 corrected for samples that do
not follow the assumption of normality) reaches a value close to 0.05, the criterion that must
be met in order to consider the model fit as satisfactory. Bearing in mind that this statistic is
highly conditioned by the sample size (28) (29) (which in our case easily exceeds the minimum
standard required to be able to perform these analyses (30), we can consider the value
obtained for that index to be satisfactory. If we look at other indices that are less sensitive to
sample size, the relative 2 value (2/DF) for the model is 1.27, values of between 0 and 2
being considered a good fit (31). Another statistic that reflects the model fit well is RMSEA,
which has a value below the 0.05 required by the strictest criteria for a model to be considered
parsimonious. In most fit statistics we obtain values that reflect a good model fit, although in
some cases it is true that they do not exceed the criterion set by the strictest classifications
and remain within acceptable values (32).

INSERT HERE TABLE V

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Figure I shows the standardized values of the model, i.e., correlations among the factors,
factor saturations on the items, and factor saturations on other factors and on the indicators
of mental and physical health. The estimations of the errors have been omitted to make it
easier to interpret. Through financial problems, healthy habits, personal autonomy, HIVrelated stress, but above all depressive mood (which in turn is related to autonomy and stress),
this model can explain 34% of the mental health variance. In turn, this single indicator (mental
health) alone allows us to explain 20% of physical health. As we have pointed out, HIV-related
stress and personal autonomy have a direct influence upon mental health, but also display
indirect effects on it through depressive mood, of which they account for 60% of the variance.
If we examine the factorial weightings of the factors upon the items, most of these values
exceed 0.50 and allow us to explain an important percentage of the variance of each of the
items.
INSERT HERE FIGURE I

Conclusions:
Our results show that certain psychosocial factors act as protectors that help maintain a good
quality of life, in both its physical and mental dimensions. Thus, factors such as self-esteem
and leading a healthy lifestyle have proven to be significant in both cases. There are also other
factors, such as personal autonomy and personal meaning, which are only significant as
protectors of mental health. Conversely, we find internalized stigma as a predictor of better
physical health. Apart from these factors that would provide protection, there are also others
that could have harmful effects on both physical and mental health. This is the case of financial
problems, body disfigurement, and mood. HIV-related stress is also found to be a variable
associated to poorer mental health.

Although previous research concluded that men who had more contact with the family and
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were socially more active had a greater half-life of CD4 lymphocytes (4), in our study no
relationship was found between physical health and social support. One possible explanation
for these results may be that personality traits, rather than social support, would have a
positive influence on disease management. This was suggested by Ironson et al. on showing
that the facet of opening up to the experience is significantly related to a slow progression of
the disease (5). Hence, people with these personality traits would be more proactive and
would search for information that they could use to learn more about treatments and facilitate
management of HIV. Moreover, these people would be more sensitive to their surroundings,
and would appreciate transcendental experiences, which is in line with our findings on how
psychological health may be predicted by personal meaning (5).
As regards predictors of physical health, our findings largely coincide with those in the
literature, since they reveal healthy lifestyles, together with self-esteem and internalized
stigma, as the main protective factors. According to Gielen et al. there is a strong relationship
between keeping healthy habits and better physical and mental health (33). Manhas, on the
other hand, suggested that self-esteem is positively related to the general perception of
quality of life and more particularly to the dimensions of mental health, the level of
independence, and the surroundings (34). Since physical health is an important factor for the
quality of life of persons with HIV, our findings underline the importance of fostering a healthy
lifestyle and self-esteem within this social group. With regard to the third factor that was
detected as a protector of physical health, internalized stigma, previous studies obtained
results that contrast with ours. Hence, any kind of stigma can have an impact upon physical
and mental health (35) (36). In the same way, Earnshaw et al. detected a significant association
between internalized stigma and effective indicators of well-being and health, and between
perceived and anticipated stigmata and physical health (37). We believe there are two possible
explanations for these results. One of them may be that internalized stigma has an indirect

influence upon the improvement in physical health. The other would be that those people who
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consider the stigma to be of greater importance are precisely the ones who take most care to
try to conceal the signs of their disease and therefore avoid the social stigma.
Factors that predict a worsening in physical health were found to include financial problems,
body disfigurement, and depressive mood, in order of importance. These results reflect the
importance of social policies implemented to ensure that the basic economic conditions
required by these people are covered, and the important role played by social workers when it
comes to facilitating access to social resources and programs. Furthermore, our findings also
highlight the importance of working with patients in psychological intervention programs on
both body acceptance (lipodystrophies being considered part of the illness) and depressive
mood. This would be worked on alongside other aspects, since several different factors such as
self-esteem or social support are involved in depression.
As regards mental health, our findings show that autonomy, healthy lifestyle, personal
meaning, and self-esteem, in that order of importance, are all positively involved. Turning our
attention to those factors that have not been commented on with respect to physical health, it
seems that enhancing autonomy and personal meaning in these persons is especially
important. Personal meaning, which can be worked on by means of life review therapy, is an
important factor, as some studies carried out on other populations have determined that an
increase in this factor helps to relieve depressive symptoms(38). Depressive mood is the most
important negative factor affecting the mental health of our participants, followed by stress,
financial problems, and body disfigurement. Some studies show that the prevalence of
depression in people with HIV is up to 15% higher than among the general population and
often goes unnoticed, is not treated or is treated in an unsuitable way(39)(40)(41). Our studies
agree with previous work such as that by Gibson et al., who found a significant inverse
association between life stressor factors and both physical and mental HRQOL(42).

In addition to all the predictors that were found, we also developed a structural model in
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which to integrate them, so as to know how they relate with each other and the effect they
have upon physical health. Consequently, in a far more parsimonious manner, taking into
account the measurement errors of the different scales and evaluating everything through
goodness of fit indices of the model, mental health can be explained by means of five factors.
Moreover, we explain the physical health index only by means of the influence that mental
health has upon it. Through the model obtained we can observe that the factor that has the
greatest influence upon mental health is depressive mood, which in turn can be largely
explained by factors such as the stress generated by HIV and personal autonomy. Fortunately,
it is possible to act upon these factors with the aim of diminishing the negative effect that they
can have upon patients HRQOL.
But our findings suggest that to improve the quality of life of persons with HIV, not only is it
necessary to work with them but also with the population in general and more particularly
with healthcare professionals. HIV-related stress and internalized stigma therefore often stem
from a lack of information, internalized stigma being a result of social stigmatization. Hence, in
our opinion, better social education with regard to what HIV actually is, as well as an
improvement in the quality of the information given to persons with HIV about the infection,
its development, and the care they need would help to reduce the negative effect of these
factors upon their health. To achieve this, it is necessary to normalize the situation of HIV in
the general population by means of awareness-raising workshops in educational centers and
also with parents, since they are the most easily accessible source of information available to
their children. Furthermore, the role of healthcare professionals is crucial for patients to
achieve an adequate awareness of what being infected by HIV will require of them. In this
sense we consider that the healthcare professionals who care for persons with HIV should be a
source of information, understanding, and help for each of their patients, because going about

the relationship in a suitable manner would probably result in a better HRQOL for their
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patients.
In sum, this work has allowed us to identify the vulnerability and protective factors that play a
significant role in the physical and mental HRQOL of persons with HIV. This may be used to
provide us with guidelines for the design and implementation of psychological intervention
programs aimed at improving the HRQOL of this population. It seems there is still a lot of work
to be done both on the psychological treatment aimed at these people and on raising the
awareness of the general population.

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Figure I
Click here to download Figure: 2015-03-29. A Spanish study on psychosocial predictors of quality of life in people with HIV- FIGURE I.

Figure I. Standardized solution for the five-factor model

HS1
.80

HS2
.80

HS3

PA2

PA3

.79

.87

HS

PA

-.15

DM2
.72

.61

DM3

DM5
-.13

.86

.85

.59
.29

DM

.35

.18
-.35

FP1

HH2
.68

FP2

FP3

.89

.42
-.13

FP

HH

.83

HH3

.80

.61

HH4
.10

.18

Mental health

.41

Physical health
Note:
HS= HIV-related stress

FP= Financial problems

DM= Depressive mood

HH=

PA= Personal autonomy

Healthy

habits

Table I
Click here to download Table: 2015-03-29. A Spanish study on psychosocial predictors of quality of life in people with HIV- TABLE I.do

Table I. Summary of the participants socio-demographic data

Socio-demographic information
Gender
Sexual orientation
Level of education

Work situation

Financial aid

Type of financial aid

Active member of an
association
Counseling

Mode of transmission

Opportunistic disease
Knows viral load
Viral load

Takes treatment
Type of treatment
Existence of side effects

Males
72.1%
Transgender
Females
27.8%
Heterosexual
62.7%
Bisexual
Homosexual
28.7%
Prefers not to answer
No education
5.40%
Higher
Primary
43.60%
Other
Secondary
33.20%
Employment with work
36.20%
Occupational disability
contract
Employment without
Employment without work
8.30%
work contract
contract + disability
Unemployed
27.30%
Retired
YES
44.5%
No opinion/No reply
NO
53.8%
Total permanent
Temporary occupational
14.1%
disability
disability
Contributory pension
4.9 %
Unemployment benefit
Non-contributory
13.9%
Other type of allowance
pension
YES
6.7%
No reply
NO
92.5%
YES
13%
No reply
NO
78.9%
Information about infection
Unprotected sexual
51.1%
Mother-child
intercourse
Sharing hypodermic
25.7%
Dont know
needles
Other types of transmission
By transfusion
1.1%
(condom breakage, abortion,
tattoo, etc.)
Yes
39.11%
Dont know
No
41.4%
No reply
YES
88%
NO
Detectable
56.6%
Mean viral load
Undetectable
43.4%
Mean CD4
Information about treatment
Yes
95.6%
No reply
No
3.4%
For HIV
78.9%
Other treatments
For hepatitis
0.8%
Yes
36.1%
No reply
No
60.6%

0.1%
3.9%
4.6%
17%
0.70%
27.70%
0.10%
0.30%
1.7%
1.3%
12.2%
53.6%
0.5%
8.1%

0.8%
19.9%
1.5%
17.7%
1.7%
12%
9732.4
495.45
1.1%
20.2%
3.4%

Table II
Click here to download Table: 2015-03-29. A Spanish study on psychosocial predictors of quality of life in people with HIV- TABLE II.d

Table II. Pearson correlations of the physical and mental health index (MOS-HIV) and the means in the different
facets of the predictor questionnaire
Pearsons correlations

Physical health
index

Mental health
index

Physical health

Mental health

.516 (p=.000)***

Self-esteem

.232 (p=.000)***

.331 (p=.000)***

Body image: satisfaction

.239 (p=.000)***

.315 (p=.000)***

Body image: disfigurement

-.257 (p=.000)***

-.278 (p=.000)***

.086 (p=.019)*

.194 (p=.019)***

Optimism

.170 (p=.000)***

.406 (p=.000)***

Personal meaning

.144 (p=.000)***

.302 (p=.000)***

-.046 (p=.206)

-.005 (p=.896)

.174 (p=.000)***

.390 (p=.000)***

.053 (p=.147)

.190 (p=.147)

Emotional loneliness

-.200 (p=.000)***

-.453 (p=.000)***

Satisfactory sexual activity

-.147 (p=.000)***

-.299 (p=.000)***

Representation of the illness

-.219 (p=.000)***

-.357 (p=.000)***

Avoidance coping

-.072 (p=.049)*

-.174 (p=.000)***

Financial problems

-.412 (p=.000)***

-.378 (p=.000)***

Enacted stigma: experience of rejection

-.282 (p=.000)***

-.321 (p=.000)***

Enacted stigma: perception of rejection

-.056 (p=.126)

-.187 (p=.000)***

Internalized stigma

-.155 (p=.000)***

-.427 (p=.000)***

HIV-related stress

-.211 (p=.000)***

-.551 (p=.000)***

Depressive mood

-.293 (p=.000)***

-.565 (p=.000)***

-.095 (p=.009)*

-.057 (p=.117)

.220 (p=.000)***

.288 (p=.000)***

.064 (p=.083)

.165 (p=.000)***

.126 (p=.001)***

.256 (p=.000)***

Problem-focused coping

Change in personal values

Personal autonomy
Social support

Activism
Healthy habits
Information about the illness
Positive reassessment
* Significant with scores below .05
*** Significant with scores below .001

Table III
Click here to download Table: 2015-03-29. A Spanish study on psychosocial predictors of quality of life in people with HIV- TABLE III.d

Table III. Regression analyses for the physical health index

Confidence interval
Predictive variables

Beta

Sig.

Error

Explained variance
Min.

Max.

Financial problems

-.035

.000

.011

-.043

-.028

16.9%

Healthy habits

.020

.000

.014

.011

.029

20,4%

CI body
disfigurement

-.016

.000

.013

-.024

-.007

22.1%

Self-esteem

.021

.002

.013

.008

.034

23.2%

Depressive mood

-.015

.001

.013

-.024

-.006

23.7%

Internalized stigma

.012

.005

.013

.004

.020

24.4%

Table IV
Click here to download Table: 2015-03-29. A Spanish study on psychosocial predictors of quality of life in people with HIV- TABLE IV.d

Table IV. Regression analyses for the mental health index

Confidence interval
Predictive variables

Beta

Sig.

Min.

Max.

Explained
variance

Error

Depressive mood

-.020

.000

.012

-.028

-.013

31.8%

HIV-related stress

-.025

.000

.011

-.032

-.018

36.9%

Personal autonomy

.022

.000

.012

.010

.034

40.7%

Financial problems

-.015

.000

.008

-.020

-.009

43.1%

Healthy habits

.015

.000

.010

.008

.021

45%

Personal meaning

.011

.004

.012

.004

.019

45.8%

CI body
disfigurement

-.008

.016

.010

-.014

-.001

Self-esteem

.012

.026

.011

.001

.023

46.2%
46.5%

Table V
Click here to download Table: 2015-03-29. A Spanish study on psychosocial predictors of quality of life in people with HIV- TABLE V.d

Table V. Goodness of fit indices for the five-factor model

DF

114.585

90

p
.0412

2/DF

GFI

AGFI

RMSEA

CFI

IFI

1.27

.950

.924

.022

.966

.967

Note: = Satorra-Bentlers ; /DF= relative ; GFI= Goodness of fit statistic; AGFI= adjusted goodness of fit index;
RMSEA= root mean square error of approximation; CFI= Comparative fit index; IFI= Incremental fit index;
2