AIDS Behav (2011) 15:1857–1869
DOI 10.1007/s10461-011-9928-8
ORIGINAL PAPER
Gender and Age Differences in Quality of Life and the Impact
of Psychopathological Symptoms Among HIV-Infected Patients
Marco Pereira • Maria Cristina Canavarro
Published online: 23 March 2011
Ó Springer Science+Business Media, LLC 2011
Abstract The purpose of this study was to determine
gender and age differences and interaction effects on the
quality of life (QoL) domains in a sample of Portuguese
HIV-positive patients, and to examine to what degree
psychopathological symptoms are associated with QoL in
addition to sociodemographic and clinical variables. The
sample consisted of 1191 HIV-positive patients, and mea-
sures included the WHOQOL-HIV-Bref and the Brief
Symptom Inventory. Controlling for clinical status, there
was a significant effect of gender on QoL. Women reported
lower scores of Psychological and Spirituality QoL.
Younger patients reported higher scores on Physical and
Level of Independence domains. Age by gender interac-
tions emerged on all domains of QoL except on the Level
of Independence domain. Overall, women over 45 years
old showed lower QoL scores. Psychopathological symp-
toms contributed significantly to the variance of all QoL
domains. Gender differences in the association of HIV
infection with QoL and psychopathological symptoms
seemed to be modulated by age. Understanding gender and
age differences (and their interaction) may provide poten-
tially useful information for planning interventions to
M. Pereira (&)
Foundation for Science and Technology (SFRH/BPD/44435/
2008), Institute of Cognitive Psychology, Vocational and Social
Development, University of Coimbra, Rua do Colégio Novo,
Apartado 6153, 3001-802 Coimbra, Portugal
e-mail: marcopereira@fpce.uc.pt
M. C. Canavarro
Faculty of Psychology and Educational Sciences,
University of Coimbra, Coimbra, Portugal
improve QoL and mental health among people infected
with HIV/AIDS, especially among older women.
Keywords Age
Gender
HIV/AIDS

Psychopathological symptoms
Quality of life
Resumen El objetivo de este estudio fue determinar las
diferencias de género y de edad y los efectos de interacción
en los dominios de la calidad de vida (CdV) en una muestra
de pacientes portugueses VIH-positivos, y examinar en qué
grado los sı́ntomas psicopatológicos están asociados a la
CdV, además de las variables sociodemográficas y clı́nicas.
La muestra consistió en 1191 pacientes VIH-positivos y las
medidas incluyeron el WHOQOL-HIV-Bref y el Brief
Symptom Inventory. Controlando la situación clı́nica, hubo
un efecto significativo del género en la CdV. Las mujeres
reportaron puntuaciones más bajas en los dominios de CdV
Psicológica y Espiritualidad. Los pacientes más jóvenes
reportaron puntaciones más altas en los dominios Fı́sico y
Nivel de Independencia. Las interacciones edad por género
surgieron en todos los dominios de CdV, excepto en el Nivel
de Independencia. En general, las mujeres con más de 45
años mostraron puntuaciones más bajas de CdV. Los
sı́ntomas psicopatológicos contribuyeran significativamente
a la varianza de todos los dominios de la CdV. Las diferencias
de género en la asociación de la infección por el VIH con la
CdV y los sı́ntomas psicopatológicos parecen ser moduladas
por la edad. Entender las diferencias de género y edad (y su
interacción) puede proporcionar información útil para la
planificación de las intervenciones para mejorar la CdV y la
salud mental entre las personas infectadas con el VIH/SIDA,
especialmente entre las mujeres de edad.
Palabras-clave Edad
Género
VIH/SIDA
Sı́ntomas
psicopatológicos
Calidad de vida
123
1858
Introduction
According to recent estimates, around 33.2 million
(30.6–36.1 million) people worldwide are infected with
HIV [1]. In Portugal, at the end of 2009, 37.201 cases of
HIV infection in all stages of infection [2] were officially
notified. This is one of the highest rates in Europe and
strong concerns still exist with respect to its prevention.
Despite progress made over the last decade, the HIV pan-
demic remains the most serious infectious disease chal-
lenge for global public health [3].
Despite the fact that gender and age are important
markers for individual differences in psychosocial and life
situation variables [4, 5], to our knowledge, no published
studies directly compare men’s quality of life (QoL) and
mental health to women’s QoL and mental health, within
the same sample and across age. Therefore, in the current
study we intended to assess QoL gender and age differ-
ences, as well as possible interaction effects of age by
gender, and the additional impact of psychopathological
symptoms on QoL domains.
Quality of life is a concept that has become an increas-
ingly relevant outcome measure in medical practice and
research, acknowledging the emphasis beyond the clinical
aspects of the illness and its treatments. This relevance is
particularly critical in a HIV context. Conceptually, QoL is
characterised as a subjective and multidimensional con-
struct, and was defined as the individual’s perception of their
position in life in the context of the culture and value systems
in which they live and in relation to their goals, expectations,
standards and concerns [6, p. 28]. This broad range defini-
tion reflects the individual’s subjective perception in the
context of the physical and psychological well-being, as well
as the cultural and social environment in which they live.
Therefore, it is possible that QoL might be a result of a
complex interplay between sociodemographic, clinical, and
psychological variables.
Gender, Age and Quality of Life
In HIV literature, although reasonably limited, studies on
QoL and gender have shown some consistency across
countries and continents [7]. Overall, women reported
poorer QoL than men [7–15]. More recently, two studies
reported lower scores among men [16, 17], and a multi-site
study reported similar QoL scores among men and women,
with the exception of physical QoL, in which women
showed significantly higher scores [18]. Some studies
reported, however, no significant differences [19–22].
It has also been observed that age has an influence on
the QoL of HIV-positive patients. Despite the number of
older individuals living with HIV/AIDS, the impact of age
on various dimensions of QoL has been also subject of
123
AIDS Behav (2011) 15:1857–1869
little research [23]. Overall, findings indicated that QoL
scores decreased in higher-age groups [12, 13, 20, 24], and
that decrease was mostly due to age-related physical
decline [25, 26]. Some studies reported, however, contra-
dictory results [15], that is, younger people (\35 years)
reported lower QoL scores. The authors did not present,
however, any rationale for this finding.
A study on the QoL of older ([50 years) versus younger
(\50 years) HIV-positive patients showed that while older
patients were more likely to have co-morbid medical
conditions and more limitations in physical functioning,
they reported similar QoL scores as younger patients [27].
Piette et al. [24] found a decrease on mean scores with age
for physical functioning, social functioning, and health
perceptions, but only where physical functioning is con-
cerned, was the decrease statistically significant. Similar
results were reported by Hays et al. [25]. In the Kovačević
and colleagues’ study [20] older people (\46 years)
reported lower QoL, but the difference was only statisti-
cally significant regarding psychological QoL. In the field
test of WHOQOL-HIV instrument [13] while older people
(\34 years) showed poorer physical and psychological
QoL, younger people reported lower scores for environ-
mental and spiritual facets. The latter was also found in the
pilot test analyses [12].
As mentioned, although the impact of gender and age on
QoL is relatively well documented, little is known to date
about possible gender by age interactions regarding QoL
domains. To our knowledge, only one study conducted in
Sweden reported some associations between age and gen-
der [28]. These authors reported that men exceeded
women’s scores of QoL despite being older than those
women, and even despite being at a more advanced stage
of the disease. In the multivariate analysis, the authors
found that older men rated their QoL lower than younger
men.
Sociodemographic and Clinical Variables
Other sociodemographic determinants (e.g., marital status,
educational attainement, employment) might also be rela-
ted to domain specific QoL. Marital status provided some
inconsistent associations. Most studies reported no differ-
ences [21, 29], and others reported higher QoL among
married patients, specially in the Social relationships
domain [20, 30]. One study [15] reported higher QoL
among single patients. Comparisons between educational
groups showed that those with less education reported
significantly poorer QoL than those with higher education
[8, 13, 15, 16, 26]. Previous research that has incorporated
employment status as a variable of interest verified that
employed individuals generally reported enhanced QoL
[26, 27, 31, 32].
AIDS Behav (2011) 15:1857–1869
Regarding the effects of clinical characteristics on QoL,
previous research has reported an association between HIV
stage and diminished QoL scores. For example, most
studies found that physical QoL of symptomatic and AIDS
patients is significantly poorer than that of patients who are
at a lesser advanced stage of the disease [12, 15, 17, 21, 25,
26, 33–36]. Associations between physical dimensions, but
not psychological dimensions have also been shown in
some studies [21, 25, 37]. Among the biological markers,
higher CD4? T cell count have been found to be associated
with higher QoL scores [17, 19, 38], particularly in the
domains related to physical and independence QoL [25,
37]. Some studies, however, have not reported significant
associations between CD4? T cell count and any QoL
dimensions [21, 39, 40].
Psychopathological Symptoms
Mental health is also a prominent factor affecting patients
QoL [41, 42]. Several studies have reported an association
between increased psychological distress in people living
with HIV/AIDS (PLWHA) and decreased QoL [15, 36, 43,
44]. In terms of psychological variables, several studies
demonstrated significant associations between higher
depressive symptoms and lower scores in multiple
dimensions of QoL among HIV-positive patients [26, 30,
45, 46]. Some studies also revealed that depressive symp-
toms were significantly associated with QoL over and
above other variables, such as demographic and clinical
characteristics [46–48]. Depression is especially relevant
given that several studies suggest that PLWHA are at a
high risk of depressive symptoms [49, 50].
Both HIV-positive men and women have been shown to
have psychological distress associated with HIV infection
[51, 52], and most studies have shown evidence that
women usually reported higher psychopathogical symp-
toms or psycholocical co-morbidity than men [53–55].
According to Vosvick and colleagues [5], across multiple
samples of PLWHA, it is evident that men and women
differ in symptoms, behaviors, and other conditions, which
greatly influences well-being. Nevertheless, studies exam-
ining if gender differences might have an impact on QoL
domains are lacking.
The Present Study
In the current study we examine: (a) gender and age dif-
ferences in QoL domains, as well as their possible inter-
action; and (b) how sociodemographic (e.g., education,
employment status, marital status, age, and gender), clini-
cal (e.g., CD4 count, HIV stage), and psychopathological
variables (somatisation, anxiety, depression) relate to QoL.
Based on the literature review, we hypothesized that men
1859
and women differ in their QoL. Also, in line with previous
studies, we expected older patients to report lower QoL. In
terms of the gender by age interaction we expected lower
QoL among women to be consistent across age-groups.
Finally it was antecipated that higher QoL would be sig-
nificantly explained by lower psychopathlogical symptoms,
especially anxiety and depression.
Method
Participants and Procedures
The current study was part of a larger research project
about the quality of life and mental health of Portuguese
HIV-infected patients. The study sample comprised of
1191 HIV-infected patients attending the main departments
of Infectious Diseases of Portuguese Hospitals (a total of
10 institutions), recruited by convenience sampling. Gen-
eral inclusion criteria were age (18 years or older), diag-
nosis of HIV infection, and sufficient knowledge of
Portuguese to complete the assessment protocol. Trained
researchers (mainly psychologists) were available to pro-
vide assistance in completing the questionnaires for those
who needed.
Patients were invited to participate in the study while
attending the consultation with their infectologist. A total
of 1251 patients were contacted between September 2007
and July 2008. Patients who did not complete the assess-
ment protocol ([20% of missing data; n = 59) were con-
sidered ineligible for the analysis. One participant was
excluded from the study analyses because (s)he self-iden-
tified as transgender. Based on the demographic and HIV-
related characteristics summarised in Table 1, especially
age, gender, route of infection, and HIV status, it appears
that they are representative of the type of people officially
notified with HIV in Portugal [2].
All participants were informed of the purpose of the
study and those who accepted to participate provided a
written informed consent. The study was carried out in
compliance with the Helsinki Declaration. Ethical approval
to conduct the study was obtained from the Ethics Com-
mittee of all the institutions involved.
Measures
Sociodemographic and HIV-Related Characteristics
Information was gathered regarding sex, age, marital sta-
tus, education, the mode of transmission, CD4? T cell
count, HIV stage, and the year of transmission. CD4? T
cell count, based on clinically meaningful cut-off points,
were stratified into three groups: \200 cells/mm3, 201–499
123
1860 AIDS Behav (2011) 15:1857–1869

Table 1 Sociodemographic and HIV-related characteristics of the study sample listed in percent
\34 years (n = 305) 35–44 years (n = 558) [45 years (n = 328)
Male Female Male Female Male Female
(n = 188) (n = 117) (n = 385) (n = 173) (n = 230) (n = 98)

Education
Primary school 19.8 12.8 25.8 27.9 45.6 60.2
Basic school 43.4 53.9 52.9 44.2 30.3 29.6
Secondary school 16.6 19.7 12.2 20.9 11.4 5.1
College 10.2 13.7 9.1 7.0 12.7 5.1
Marital status
Single 70.2 50.4 57.3 24.6 28.4 9.3
Married/co-habiting 21.8 40.2 22.7 43.9 45.0 46.4
Separated/divorced 6.9 6.8 19.0 24.6 23.1 25.8
Widowed 1.1 2.6 1.0 7.0 3.5 18.6
Employment status
Employed 57.8 41.8 56.2 45.9 53.3 35.4
Unemployed 29.2 32.7 28.4 24.7 17.9 14.6
Retired 8.1 3.6 13.5 8.8 26.9 28.1
Housewife – 12.7 – 20.0 – 21.8
Student 4.8 9.1 1.1 0.6 – –
Route of infection
Sexual intercourse with man 17.0 76.9 16.4 67.1 14.8 78.6
Sexual intercourse with woman 31.9 – 32.5 0.6 57.0 –
IV Drug use 46.8 10.1 46.0 24.9 18.7 10.2
Blood products 2.7 1.7 1.6 2.3 5.2 6.1
Unknown 1.6 4.3 3.6 5.2 4.3 5.1
HIV stage
Asymptomatic 54.8 62.4 59.5 64.7 66.1 61.2
Symptomatic 14.9 11.1 11.9 11.6 13.0 14.3
AIDS 22.9 13.7 24.7 18.5 16.1 18.4
Unknwon 7.4 12.9 3.9 5.2 4.8 6.1
CD4? count
\200 cells/mm3 28.2 14.5 21.8 15.6 20.4 21.4
201–499 cells/mm3 36.2 37.6 38.7 37.6 37.0 33.7
[500 cells/mm3 27.1 32.5 30.4 34.7 30.9 31.6
Unknown 8.5 15.4 9.1 12.1 11.7 13.3

cells/mm3;[500 cells/mm3. Age was categorised into three
groups: \34 years (below Quartile 25th), 35–44 years
(between Quartile 25th and Quartile 75th), and [45 years
(above Quartile 75th). Age was categorised based on
quartiles in order to assure a similar proportion of partici-
pants in lower and upper age groups.
Quality of Life
The WHOQOL-HIV-Bref is a self-reporting questionnaire
including 31 items that yields a multidimensional profile of
scores across domains and facets [56]. The original English
version of WHOQOL-HIV-Bref consists of six domains:
Physical, Psychological, Level of Independence, Social
relationships, Environment, and Spirituality. These
domains contain 29 specific facets of one question each, for
a total of 29 items. Five facets are specific to PLWHA:
symptoms of PLWHA, social inclusion, forgiveness, fear
of the future, and death and dying. One additional facet (2
items) pertains to global QoL and general health.
The European Portuguese version was developed in
Coimbra, using a detailed research design as part of a
WHO multi-centric initiative to develop a cross-cultural
tool for measuring QoL in HIV infection, and has been
reported elsewhere [57]. Individual items are rated on a
5-point scale in which 1 indicated low, a negative

123
AIDS Behav (2011) 15:1857–1869
perception, and 5 indicated high, a positive perception of
QoL. Each scale point was specified with a number and a
verbal descriptor. The four response scales developed were
concerned with Intensity (Not at all–Extremely); Capacity
(Not at all–Completely); Frequency (Never–Always); and
Evaluation (Very dissatisfied–Very satisfied; Very good–
Very poor). All domain scores were transformed to reflect a
0 to 100 scale (a higher score corresponds to a better QoL).
There was no total score for the WHOQOL-HIV-Bref.
Internal consistency in the current sample exceed 0.70 for
all domains, with the exception of Spirituality (a = 0.61).
Psychopathological Symptoms
The Brief Symptom Inventory (BSI), developed by Dero-
gatis [58], is a 53-item self-reporting inventory associated
with psychological distress. In the BSI respondents are
asked to rate to which extent each identified problem has
caused discomfort in the past week on a 5-point scale
ranging from ‘‘Never’’ (0) to ‘‘Very often’’ (4). The BSI
measures nine symptom dimensions including somatisa-
tion, obsessions-compulsions, interpersonal sensitivity,
depression, anxiety, hostility, phobic anxiety, paranoid
ideation and psychoticism; and three global indices. The
Global Severity Index (GSI) and the combination of
somatisation, anxiety and depression ratings are the most
widely used measures of psychological distress. Since the
correlations between GSI and these dimensions were high
(r range from 0.819 to 0.907), only the three dimensions
were used as measures of psychological distress. The
Cronbach’s a in the current sample was 0.97 for all items,
and ranged from 0.84 (Anxiety) to 0.88 (Depression).
Data Analyses
The data were analysed using the Statistical Package for
Social Sciences (SPSS, version 17.0). In order to explore
the characteristics of the sample, analysis of demograph-
ics—including frequencies, mean and standard devia-
tions—were first performed. Independent samples t-test
and chi-square analyses were performed to examine gender
differences among demographic and clinical variables. The
level of significance for all of the statistical tests was set at
0.05 (P \ 0.05). Effect size measures (partial g2) are pre-
sented for all analyses.
Main analyses were multivariate analysis of covariance
(MANCOVA) and multiple linear regressions (MLR).
MANCOVA was used to test for gender and age differ-
ences (as between-subject’s factors) in the different QoL
domains and overall facet, as well as psychopathological
symptoms. The covariates were time since diagnosis, CD4
counts, and HIV stage. Subsequent univariate analyses of
variance (ANOVA) were conducted in order to identify the
1861
source of the significant multivariate effects. MLR was
used to examine the combined contribution of sociode-
mographic and clinical variables, as well as psychopatho-
logical symptoms on QoL domains. In the first step all
sociodemographic and clinical variables were included in
the regression analysis. In the second step, the interaction
gender 9 age was included, and in the final step, the
psychopathological symptoms were included to explore the
additional account of emotional distress variables on these
QoL domains. Following the suggestion of Aiken and West
[59], age was mean centered prior to the computation of
interaction terms to reduce multicollinearity. All predictor
variables were checked for multicollinearity. This was
assessed utilising tolerances, as well as variance inflation
factors (VIF). All reported regression coefficients are
standardized coefficients.
Results
Participant Characteristics
The study sample consisted of 1191 HIV-positive patients.
The demographic and HIV-related characteristics of the
sample are shown in Table 1. Mean age of the participants
was 40.72 years (SD = 9.71; range: 18–81). The majority of
patients were male (67.6%), of lower education (76.1%), and
were employed (51.7%). About half of the sample was single
(44.6%). Regarding the mode of transmission, the analysis
by gender showed that male patients were mostly infected
through sexual contact (56.7%) and IDU (38.8%), while the
majority of female patients were infected through hetero-
sexual transmission (73.7%). No differences were found
regarding age (F(1189) = 3.127, P = 0.077) between men
(M = 41.07; SD = 9.44) and women (M = 40.01; SD =
10.21), or regarding education, F(1172) = 0.015, P = 0.902
(Men: M = 8.02; SD = 4.06; Women: M = 7.98;
SD = 3.97). With respect to age-groups, a significant dif-
ference was found regarding education, F(1166) = 12.549,
P \ 0.001. Younger patients had a higher education (M =
8.82; SD = 3.96) than older groups (35–44: M = 8.02;
SD = 3.85; [ 45: M = 7.21; SD = 4.28). A significant
gender by age interaction was found regarding education
(F(1163) = 6.077, P \ 0.01), with women over 45 years
old reporting significantly lower education levels (M =
6.13; SD = 3.46).
Clinical status was assessed by CD4? T cell count. The
mean CD4? T cell count per mm3 was 405.85 (SD =
273.03) for men and 453.31 (SD = 291.05) for women.
The difference was statistically significant concerning
gender (F(1063) = 6.665, P = 0.010), but no differences
were found regarding age-groups, F(1058) = 0.178,
P = 0.488. Regarding HIV stage, most patients were
123
1862 AIDS Behav (2011) 15:1857–1869

asymptomatic (61.5%). No differences were found between
men and women (v2 = 6.023, P = 0.111), and among age-
groups, v2 = 3.818, P = 0.148. The time since diagnosis
was significantly lower in women (M = 7.46; SD = 5.12)
than in men (M = 8.34; SD = 5.18), F(1063) = 7.516,
P = 0.006. Regarding age-groups, the time since diagnosis
was lower in patients under 34 years old (M = 6.57;
SD = 4.28) and over 45 years old (M = 6.57; SD = 5.55)
than in patients aged 35 to 44 years old (M = 6.57;
SD = 5.16). This difference was statistically significant,
F(1161) = 27.644, P \ 0.001. Seventy-five percent of
patients were receiving highly active anti-retroviral therapy
at the time of enrolment.
Multivariate Analyses
Gender and Age Differences in Quality of Life Domains
Applying MANOVA with gender and age as the between-
subject factors and the different QoL domains as dependent
variables, results showed significant gender differences
(Wilks’ Lambda = 0.965, F(6, 944) = 5.763, P \ 0.001,
partial g2 = 0.035), age-group differences (Wilks’ Lambda =
0.974, F(12, 1888) = 2.076, P = 0.016, partial g2 = 0.013),
and a significant gender by age interaction (Wilks’ Lambda =
0.975, F(12, 1888) = 1.975, P = 0.023, partial g2 = 0.012).
Table 2 displays the mean and standard errors (SE) for gender
and the three age-groups regarding QoL domains.
Subsequent univariate tests indicated significant gender
differences on the Psychological and Spirituality domains
(see Table 3). Overall, women reported significantly lower
scores in all domains (with the exception of Level of
independence). Significant age-group differences emerged
in Physical and Level of independence domains (see
Table 3). Looking at the means, participants over 45 years
of age reported the lowest scores. The differences were
statistically significant only in comparison to patients
below 34 years.
Also, significant gender by age interactions were observed
in five of six domains (see Fig. 1). Compared with men of the
same age-group, women under 34 years old reported higher
scores on five QoL domains, but only a univariate effect was
found on the Social relationships domain, F(1, 240) = 4.151,
P \ 0.05, partial g2 = 0.017. Moreover, men of ages between
35 and 44 years and above 45 years reported higher QoL
scores than women of the same age-groups in all domains.
Among patients of ages between 35 and 44 years old signif-
icant differences were found on Psychological, F(1, 453) =
6.095, P \ 0.05, partial g2 = 0.013, and Spirituality,
F(1, 453) = 22.549, P \ 0.001, partial g2 = 0.047. Women
over 45 years reported significantly lower Physical,
F(1, 250) = 4.931, P \ 0.05, partial g2 = 0.019, Psychological,
F(1, 250) = 9.354, P \ 0.01, partial g2 = 0.017, and
Environment QoL, F(1, 250) = 6.797, P \ 0.01, partial
g2 = 0.026.
Gender and Age Differences in Psychopathological
Symptoms
Using MANOVA with psychopathological symptoms as
dependent variables and gender and age as independent
variables, results showed main multivariate effects for gender

Table 2 Mean scores and SE on quality of life domains and psychopathological symptoms, by gender and age (adjusted for clinical status and
time since diagnosis)
Women Men
\34 35–44 [45 \34 35–44 [45
Mean (SE) Mean (SE) Mean (SE) Mean (SE) Mean (SE) Mean (SE)

Quality of lifea
Physical 66.89 (2.27) 62.12 (1.81) 56.73 (2.48) 63.20 (1.68) 64.26 (1.18) 63.06 (1.56)
Psychological 60.27 (2.01) 56.14 (1.60) 53.40 (2.20) 56.47 (1.49) 60.89 (1.05) 61.21 (1.38)
Level of independence 68.73 (2.27) 66.36 (1.81) 59.75 (2.48) 64.02 (1.68) 64.40 (1.18) 63.13 (1.56)
Social relationships 64.66 (2.17) 59.84 (1.73) 56.84 (2.37) 58.61 (1.60) 61.50 (1.13) 59.28 (1.49)
Environment 56.84 (1.61) 54.33 (1.29) 52.30 (1.77) 54.68 (1.20) 56.14 (0.84) 58.10 (1.11)
Spirituality 55.98 (2.33) 54.40 (1.86) 56.82 (2.55) 57.06 (1.73) 64.85 (1.22) 62.27 (1.60)
Psychopathological symptomsb
Somatization 0.808 (0.08) 0.961 (0.06) 1.067 (0.08) 0.833 (0.06) 0.757 (0.04) 0.736 (0.05)
Depression 1.142 (0.09) 1.196 (0.07) 1.159 (0.10) 1.173 (0.07) 1.019 (0.05) 0.930 (0.06)
Anxiety 0.918 (0.08) 1.123 (0.06) 1.044 (0.08) 1.027 (0.06) 0.877 (0.04) 0.783 (0.05)
a b
Range 0–100; range 0–4

123
AIDS Behav (2011) 15:1857–1869 1863

Table 3 Gender and age differences including the interaction effect of gender 9 age on quality of life and psychopathological symptoms
(MANOVAs) (adjusted for clinical status and time since diagnosis)
Gender Age-groups Gender 9 age
2 2
F(1, 949) P Partial g F(1, 949) P Partial g F(1, 949) P Partial g2

Quality of life
Physical 1.074 0.300 0.001 3.316 \0.05 0.007 3.115 \0.05 0.007
Psychological 4.614 \0.05 0.005 0.300 0.741 0.001 5.887 \0.01 0.012
Level of independence 0.869 0.352 0.001 3.137 \0.05 0.007 2.251 0.106 0.005
Social relationships 0.195 0.659 0.000 1.846 0.158 0.004 3.241 \0.05 0.007
Environment 2.755 0.097 0.003 0.104 0.902 0.000 3.814 \0.05 0.008
Spirituality 12.834 \0.001 0.013 1.607 0.201 0.003 3.422 \0.05 0.007

Gender Age-groups Gender 9 age

2 2
F(1, 1014) P Partial g F(1, 1014) P Partial g F(1, 1014) P Partial g2

Psychopathological symptoms
Somatization 11.240 \0.01 0.011 0.744 0.476 0.001 3.731 \0.05 0.007
Depression 4.055 \0.05 0.004 0.955 0.385 0.002 1.495 0.225 0.003
Anxiety 5.998 \0.05 0.014 1.062 0.346 0.002 4.843 \0.01 0.009

Physical p < .05 Psychological p < .01 Level of Independence n.s.

Social Relationships p < .05 Environment p < .05 Spirituality p < .05

Fig. 1 Mean differences by gender and age-groups, adjusted for clinical status and time since diagnosis

(Wilks’ Lambda = 0.989, F(3, 1012) = 3.752, P = 0.011,
partial g2 = 0.011), age (Wilks’ Lambda = 0.987, F(6,
2024) = 2.289, P = 0.013, partial g2 = 0.007). The inter-
action effect was also significant (Wilks’ Lambda = 0.988,
F(6, 2024) = 2.107, P = 0.050, partial g2 = 0.006). Table 2
shows mean (and SE) for gender and the three age-groups
regarding psychopathological dimensions.
Follow-up univariate tests showed significant gender
differences for all dimensions of psychopathology. Women
reported significantly higher somatisation, depression, and
anxiety symptoms (see Table 3). With respect to age-
group, no significant differences emerged in the subsequent
univariate tests. Significant age by gender interactions were
observed on somatisation and anxiety. The pattern was
similar to the early reported regarding QoL domains. An
inspection of mean scores showed that women under
34 years old reported lower somatisation and anxiety
symptoms, but no significant differences were found.

123
1864 AIDS Behav (2011) 15:1857–1869

\0.001

\0.001
\0.001
Compared with women of the same age-groups, men of

0.622

0.422
0.922

0.063

0.289

0.346
0.603

0.403
Table 4 Association between demographic and HIV-related variables and QoL domains compared with psychopathological symptoms, controlled for demographic and clinical variables
ages 35 years and above showed significantly lower

P
psychopathology.

DR2 = 0.265
R2 = 0.032
Spirituality

-0.027
-0.003

-0.067

-0.039

-0.052

-0.372
-0.207
Multiple Regression Analyses

0.016

0.166

0.028

0.033
b
Psychopathological Symptoms are Associated with QoL
Domains

\0.001
\0.001

\0.001
\0.001
\0.05

\0.05

\0.01
0.067

0.192
0.202
0.403
To assess the combined contribution of sociodemographic,

P
clinical and psychopathological symptoms on QoL

DR2 = 0.223
Environment

R2 = 0.114
domains, separate MLR analysis were conducted. The

-0.117

-0.075

-0.044

-0.163
-0.253
-0.122
collinearity statistics in the regression models showed that

0.058

0.239

0.046
0.040

0.108
VIF ranged between 1.061 and 3.015, while the tolerance

b
coefficient ranged between 0.332 and 0.942, suggesting no
multicollinearity concerns [60]. The models are presented
in Table 4.

\0.001

\0.001
\0.001
\0.01

\0.05
0.113

0.591

0.151
0.686

0.317

0.173
For the Physical domain, results showed the highest

P
Soc. relationships
regression coefficients for employment, HIV status, and

DR2 = 0.265
age, as well as somatisation and depressive symptoms.

R2 = 0.044
Gender by age interaction was statistically significant. This

-0.099

-0.019

-0.110

-0.054
-0.341
-0.173
0.129

0.053

0.052
0.013

0.054
interaction between gender and age indicates that, with
b
increasing age, the decline in physical QoL reported
by women was significantly greater than in men. How-
ever, after including psychopathological symptoms, only
\0.001
\0.001

\0.001

\0.001

\0.001
\0.001
\0.05
\0.05

\0.01
0.251

0.127
employment status (b = -0.051; P \ 0.05), HIV stage
P

(b = -0.086; P \ 0.01) and age (b = -0.113; P \ 0.01)

Independence

DR2 = 0.240
remained statistically significant. Being younger, emp-

R2 = 0.141
loyed and asymptomatic as well as having less somatic and
-0.190

-0.144

-0.062
-0.117

-0.218
-0.193
-0.150
0.036

0.114

0.121

0.079
depressive symptoms were associated to a higher physical
b

QoL.
For the Psychological domain results showed significant
coefficients for education, employment, gender, and age.

\0.001
\0.05
\0.01

\0.01
\0.05
\0.05

\0.01
0.056

0.165

0.407

0.380
The interaction gender by age was also statistically sig-
P

nificant, meaning that, with increasing age, women tended

Psychological

DR2 = 0.456
to report significantly lower psychological QoL than men.
R2 = 0.047

Having a higher education, being employed, being younger

-0.104

-0.050

-0.109

-0.029
-0.559
-0.135
0.063

0.087

0.030
0.086

0.108

and being male were related to a better psychological QoL.

b

Anxiety and depressive symptoms added 45.6% of the

variance. After including psychopathological symptoms,
only education (b = 0.100; P \ 0.001) remained statisti-
\0.001

\0.001

\0.001
\0.001
\0.01
\0.05
0.539

0.252

0.368
0.686

0.174

cally significant.
P

For the Level of independence domain, results showed the

DR2 = 0.334

highest regression coefficients for education, employment,

R2 = 0.068
Physical

HIV stage, CD4? T cell count, gender, and age, as well as

-0.020

-0.117

-0.162

-0.178

-0.359
-0.241
-0.058
0.038

0.032
0.013

0.116

less psychopathological symptoms. The gender by age

b

interaction was not statistically significant. After including

psychopathological symptoms, education (b = 0.113;
P \ 0.001), employment status (b = -0.138; P \ 0.001),
partner (no/yes)
Education (years)

HIV stage (b = -0.077; p \ 0.01), CD4? T cell count

Asymptomatic

Gender 9 age

Somatization
Employment
Living with

Depression
CD4 count

(b = 0.122; P \ 0.001) and gender (b = -0.113; P \

(yes/no)

(yes/no)

Anxiety
Gender

0.001) remained significant. Having more education, being

Age

employed, being asymptomatic and having higher CD4? T

123
AIDS Behav (2011) 15:1857–1869
cell count, and being female, as well as having less somatic,
depressive, and anxiety symptoms were related to higher
independence.
For the Social relationships domain, significant regression
coefficients were found for marital status, employment and
age. The gender by age interaction was not statistically sig-
nificant. After adding psychopathological symptoms, marital
status (b = 0.122; P \ 0.001) and age (b = -0.096; P \
0.05) remained significant and education (b = 0.060;
P \ 0.05) became statistically significant. Having a partner,
having more education, and being younger, plus being less
depressed and anxious were significantly associated to a better
social QoL.
For the Environmental domain, results showed significant
regression coefficients for the demographic variables educa-
tion and employment, and for the clinical variable HIV status.
Also a significant gender by age interaction was found.
The interaction pattern was similar to that reported earlier
regarding psychological QoL: with increasing age, HIV-
infected women reported significantly lower environmental
QoL, whilst men’s scores on this domain improved with
increasing age. After adding psychopathological symptoms,
education (b = 0.238; P \ 0.001) and employment status
(b = -0.074; P \ 0.01) remained significant and marital
status (b = 0.068; P \ 0.05) became statistically significant.
In addition to having less psychopathological symptoms,
having more education, being employed, and having a partner
were related to a better environmental QoL.
Finally, for the Spirituality domain, significant regression
coefficients were found only for gender, and the interaction
term was not significant. The R2 change was 0.265 when the
psychopathological symptoms were added. After adding
psychopathological symptoms, gender (b = 0.116; P \
0.001) remained statistically significant. Being male, being
less depressed and less anxious were associated to a better
spiritual QoL.
Discussion
In the current study we analysed gender and age differ-
ences in QoL domains, and also the relative associational
strength of sociodemographic (e.g., age, education, marital
status, and employment status), clinical variables (e.g.,
HIV stage, and CD4? T cell count), and psychopatho-
logical symptoms (somatisation, depression, and anxiety)
with QoL domains.
If one of the main purposes of health care is to improve
QoL, then it is important to understand not only how HIV
infection has an effect on QoL, but also differences exist-
ing between QoL domains of HIV-positive men and
women and across different life stages. In fact, a major
finding in our study was that QoL and mental health of men
1865
and women in different age-groups are affected differently
by the HIV infection.
Consistent with the first research hypothesis, our findings
suggest that women have lower QoL on several domains
compared to men. These findings are coherent with other
studies from developing and developed countries [7–13,
15]. Gender differences emerged significantly on Psycho-
logical and Spirituality domains. The finding that HIV-
positive men report greater psychological well-being is
consistent with the literature, which indicates that emotional
distress tend to be more common among HIV-positive
women [14]. Indeed, also consistent with prior research [28,
53], in our study women living with HIV showed higher
scores of psychopathological symptoms than men.
Moreover, the result of differences between sexes was
similar to those of the WHOQOL-HIV’s field test [13], in
which women reported poorer QoL in terms of psycho-
socio-spiritual aspects of well-being, although no gender
effects were found on the Social relationships domain. The
importance of spirituality has also been progressively
acknowledged in HIV literature [61–63], however, it might
need further considerations. Contrary to the study of
Chandra et al. [7] women revealed significantly lower
scores than men on two specific facets (fear of the future,
and death and dying) but no differences were found
regarding forgiveness, and spirituality, religion and per-
sonal beliefs. Future research is needed to understand the
predictors of Spiritual QoL and its association with other
QoL domains.
Several studies have found that Physical QoL is worse
among older patients compared to younger patients [13, 24,
25, 28]. Consistent with this prior work, we have also
found that older age was associated with worse scores on
Physical and Level of independence domains, and that
association remained significant in regression models (even
when we take the account of psychological variables). An
interesting finding reported by Cederfjäll et al. [28] was
that men exceeded women’s QoL scores despite being
older, and even despite a more advanced stage of the dis-
ease. Our results only partially confirm this finding, given
that younger women (\34 years) tended to report better
QoL than men of the same age group.
Our results showed that gender differences in the asso-
ciation of HIV infection with QoL and psychopathological
symptoms are modulated by age. In the younger age group
(\34 years), women reported higher QoL than men on
most domains, but only a significant effect of gender on
Social relationships domain was found. Compared to men,
older women ([45 years) reported the worst QoL scores,
mainly in Physical, Psychological, and Environment
domains. Due to the general lack of awareness of HIV
infection in older adults, and in particular among women,
this segment of the population, for the most part, has been
123
1866
omitted from research and intervention efforts. The find-
ings of our study highlight that older patients, and espe-
cially women, must not be ignored. In 1996, HIV in older
adults was referred to as the ‘‘overlooked epidemic’’ [64].
Although a important amount of research has been con-
ducted in the last 10 years [65], the need for additional
research is still much warranted [66].
With respect to gender by age interaction, we were not
able to identify a typical pattern in the majority of QoL
domains. Overall, HIV-positive women had better ‘‘starting
conditions’’ on most domains, but with increasing age,
women’s QoL tended to decrease, while men’s QoL tended
to increase. This difference was more pronounced in Psy-
chological and Environmental domains. These findings
may be due to the fact that women with increasing age
differ from their male counterparts in several factors,
including education and employment status (in our study,
women over 45 years old were significantly less edu-
cated—about 60% only had basic school). Additionally,
this might be explained by the fact that with increasing age
women tended to be confronted with the dual challenge of
being both a patient and caregiver [67]. All these factors
may serve as additional stressors, and dealing with these
cumulative effects might be psychologically demanding for
most HIV-infected women. Also, the power imbalance, the
poverty environment and economic dependence of male
partners might explain the significant decline in Environ-
mental QoL. Further studies are needed to explore age and
gender differences in QoL between different cultures in
more detail.
Among the sociodemographic variables, younger age,
higher education and being employed were significantly
associated with higher QoL on most domains, and living
with partner was significantly associated to a better Social
relationships QoL. The importance of these demographic
variables has been widely documented [25, 30], and our
results are in agreement with those studies. Interestingly,
and yet not surprising, being unemployed (or not currently
working) was associated with poorer QoL in all domains,
with the exception of Spirituality. This finding is consistent
with Swindells and colleagues’ study [32] that suggests that
employment may provide more than just financial benefits
for PLWHA. Also consistent with prior work [7–9, 18, 26,
35], clinical variables (CD4? T cell count and HIV stage)
were mostly associated with Physical and Independence
domains.
As expected, in our study psychopathological symptoms
accounted for the major variance of QoL scores. Overall,
the strong predictor of decreased QoL domains was
depression, and the most affected was the Psychological
domain. Overall, this association between emotional dis-
tress and a broad range of QoL domains supports the evi-
dence that emotional status might play a major role in the
123
AIDS Behav (2011) 15:1857–1869
QoL [41, 68]. These findings are in line with several
studies [44, 47, 48]. In the Level of Independence and
Environment domains the contribution of psychological
variables was lower than the contribution of clinical and
demographic variables. These findings might be related to
the specific facets included in these domains. Specifically,
Level of Independence concerns mainly with daily living
activities, work capacity, and dependence on medication
and treatment, and Environment includes data regarding
home environment, financial resources, and health and
social care.
Overall, these findings support the evidence that links
emotional distress with QoL [43, 44], suggesting that
effective clinical management of psychopathological
symptoms may improve functioning and well-being in
HIV-patients. Actually, in an effort to minimise the effects
of psychopathological symptoms on QoL, a recognition
and effective management of these symptoms (and espe-
cially depressive symptoms) in HIV infection is crucial,
especially because of the importance of adherence to
antiretroviral treatments [69, 70], the association of higher
levels of stress and depression with faster disease pro-
gression [71], and because depression in patients with HIV
is still often under-diagnosed [72].
There are a number of limitations in this study that
should be acknowledged. Firstly, potential limitations
imposed by a sample of convenience and a cross-sectional
study design must also be considered when generalising
these results. Specifically, all participants were recruited
from health settings and accordingly, were actively
engaged in health care. Also, conclusions about the direc-
tion of associations among psychological variables are
preliminary, awaiting replication by longitudinal studies.
Secondly, patients’ co-morbidity was unknown. It is more
likely that patients over 45 years old present a higher
degree of associated co-morbidities, which could explain
the lower QoL scores. Therefore, the differences we
reported may reflect other factors apart from those asses-
sed. Thirdly, clinical data, such as CD4? T cells count,
were self-reported, and about 11% could not recall their
most recent CD4? T cells count. Also, 5.4% of patients did
not know their disease status. Perhaps this means that they
did not know the difference between being symptomatic
and having full-blown AIDS or it could be related to their
low level of education. This is an issue that deserves fur-
ther attention.
Despite these limitations, our study contributes to the
literature on QoL among PLWHA. This study also pro-
vides evidence that among men and women living with
HIV, QoL and psychological distress differ between gen-
ders and across age, and bridges a knowledge gap on age
and gender differences in QoL in HIV-infected patients.
Another major strength of this study was that it was based
AIDS Behav (2011) 15:1857–1869
on data from a large sample recruited from the country’s
main departments of infectious diseases (the main 10
hospitals), which is a more accurate reflection of a cross-
section of the type of people officially notified with HIV in
Portugal [2]. Also, our study contribute to the limited lit-
erature in Portugal that examine the association of soci-
odemographic, clinical, and psychological variables and
QoL domains, which is relevant because of the increasing
importance of QoL in health care and policies.
In conclusion, our findings illustrate the need to recognize
such gender and age differences, and to take them into
consideration when caring and treating for patients with HIV
infection. Additionally, as also pointed out by Chandra et al.
[7], the basis for poorer QoL among HIV-infected women
(and especially among women over 45 years old) in most
areas of life need to be examined as part of a structured and
systematic intervention plan. Considering other demo-
graphic, clinical, and relational variables will add elucida-
tion to our understanding of the complexities of the HIV
infection.
Acknowledgments This study was supported by Coordenação
Nacional para a Infecção VIH/sida (Ref. 5-1.8.4/2007) and was
developed within the ‘‘Relationships, Development & Health’’
research line of the Institute of Cognitive Psychology, Vocational and
Social Development, R&D Unit of the University of Coimbra
(FEDER/POCTI-SFA-160-192).
References
1. UNAIDS. AIDS epidemic update. Geneva: Joint United Nations
Programme on HIV/AIDS; 2009.
2. DID-URES. Infecção VIH/SIDA: A situação em Portugal a 31 de
Dezembro de 2009 [HIV/AIDS Infection: The situation in Por-
tugal on December 31 2009]. Lisbon: Department of Infectious
Diseases—Unit of Reference and Epidemiological Surveillance;
2009.
3. WHO. Towards universal access: scaling up priority HIV/AIDS
intervention in the health sector. Progress report 2009. World
Health Organization; 2009.
4. Nokes KM, Coleman CL, Hamilton MJ, et al. Age-related effects
on symptom status and health-related quality of life in persons with
HIV/AIDS. Appl Nurs Res. 2009. doi:10.1016/j.apnr.2009.03.002.
5. Vosvick M, Martin LA, Smith NG, Jenkins SR. Gender differ-
ences in HIV-related coping and depression. AIDS Behav. 2010;
14:390–400. doi:10.1007/s10461-008-9490-1.
6. WHOQOL Group. Development of the WHOQOL: rationale and
current status. Int J Ment Health. 1994;23(3):24–56. doi:10.1016/
j.socscimed.2005.08.001.
7. Chandra PS, Satyanarayana VA, Satishchandra P, Satish KS,
Kumar M. Do men and women with HIV differ in their quality of
life? A study from South India. AIDS Behav. 2009;13:110–7. doi:
10-1007/s10461-008-9434-9.
8. Campsmith ML, Nakashima AK, Davidson AJ. Self-reported
health-related quality of life in persons with HIV infection: results
from a multi-site interview project. Health Qual Life Outcomes.
2003;1:12. Available at www.hqol.com/content/1/1/12.
9. Kohli RM, Sane S, Kumar K, Paranjape RS, Mehendale SM.
Assessment of quality of life among HIV-infected persons in Pune,
1867
India. Qual Life Res. 2005;14:1641–7. doi:10.1007/s11136-004-
7082-4.
10. Mrus JM, Williams PL, Tsevat J, Cohn SE, Wu AW. Gender
differences in health-related quality of life in patients with HIV/
AIDS. Qual Life Res. 2005;14:479–91. doi:10.1007/s11136-
004-4693-z.
11. Solomon S, Venkatesh KK, Brown L, et al. Gender-related dif-
ferences in quality of life domains of persons living with HIV/
AIDS in South India in the Era prior to greater access to anti-
retroviral therapy. AIDS Patient Care STDS. 2008;22:999–1005.
doi:10.1089/apc.2008.0040.
12. WHOQOL-HIV Group. Preliminary development of the World
Health Organization’s quality of life HIV instrument (WHO-
QOL-HIV): analysis of the pilot version. Soc Sci Med. 2003;
57:1259–75. doi:10.1016/S0277-9536(02)00506-3.
13. 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;16:882–9. doi:10.1080/09540
120412331290194.
14. Wisniewski AB, Apel S, Selnes OA, Nath A, McArthur JC, Dobs
AS. Depressive symptoms, quality of life, and neuropsychologi-
cal performance in HIV/AIDS: the impact of gender and injection
drug use. J Neurovirol. 2005;11:138–43. doi:10.1080/13550280
590922748.
15. Zimpel RR, Fleck MP. Quality of life in HIV-positive Brazilians:
application and validation of the WHOQOL-HIV, Brazilian version.
AIDS Care. 2007;19:923–30. doi:10.1080/09540120701213765.
16. Peltzer K, Phaswana-Mafuya N. Health-related quality of life in a
sample of HIV-infected South Africans. Afr J AIDS Res.
2008;7:209–18. doi:10.2989/AJAR.2008.7.2.6.523.
17. Rüütel K, Uusküla A, Minossenko A, Loit H-M. Quality of life of
people living with HIV and AIDS in Estonia. Cent Eur J Public
Health. 2008;16:111–5.
18. Skevington SM, Norweg S, Standage M, The WHOQOL HIV
Group. Predicting quality of life for people living with HIV:
international evidence from seven cultures. AIDS Care. 2010.
doi:10.1080/09540120903311466.
19. Kemmler G, Schmied B, Shetty-Lee A, et al. Quality of life of
HIV-infected patients: psychometric properties and validation of
the German version of the MQOL-HIV. Qual Life Res.
2003;12:1037–50. doi:10.1023/A:1026114004548.
20. Kovačević SB, Vurusić T, Duvančić K, Maček M. Quality of life of
HIV-infected persons in Croatia. Coll Antropol. 2006; 30(Suppl. 2):
79–84. Retrieved from http://hrcak.srce.hr/file/43662.
21. Starace F, Cafaro L, Abrescia N, et al. Quality of life assessment
in HIV-positive persons: application and validation of the
WHOQOL-HIV, Italian version. AIDS Care. 2002;14:405–15.
doi:10.1080/09540120220123793.
22. Wig N, Lekshmi R, Pal H, Ahuja V, Mittal CM, Agarwarl SK.
The impact of HIV/AIDS in the quality of life: a cross sectional
study in north India. Indian J Med Sci. 2006;60:3–12. doi:10.4103/
0019-5359.19670.
23. Crystal S, Akincigil A, Sambamoorthi U, et al. The diverse older
HIV-positive population: a national profile of economic circum-
stances, social support, and quality of life. J Acquir Immune
Defic Syndr. 2003;33:S76–83.
24. Piette J, Wachtel TJ, Mori V, Mayer K. The impact of age on the
quality of life in persons with HIV infection. J Aging Health.
1995;7:163–78. doi:10.1177/089826439500700201.
25. Hays RD, Cunningham WE, Sherbourne CD, et al. Health-related
quality of life in patients with human immunodeficiency virus
infection in the United States: results from the HIV Cost and
Services Utilization Study. Am J Med. 2000;108:714–22. doi:
10.1016/S0002-9343(00)00387-9.
26. Liu C, Johnson L, Ostrow D, Silvestre A, Visscher B, Jacobson
LP. Predictors for lower quality of life in the HAART era among
123
1868
HIV-infected men. J Acquir Immune Defic Syndr. 2006;42:
470–7. doi:10.1097/01.qai.0000225730.79610.61.
27. Zingmond D, Kilbourne A, Justice A, et al. Differences in
symptom expression in older HIV-positive patients: The Veterans
Aging Cohort 3 Site Study and HIV Cost and Service Utilization
Study experience. J Acquir Immune Defic Syndr. 2003;33(Suppl. 2):
S84–92.
28. Cederfjäll C, Langius-Eklöf A, Lidman K, Wredling R. Gender
differences in perceived health-related quality of life among
patients with HIV infection. AIDS Patient Care STDS. 2001;15:
31–9. doi:10.1089/108729101460083.
29. Stangl AL, Wamai N, Mermin J, Awor, AC, Bunnell, RE. Trends
and predictors of quality of life among HIV-infected adults taking
highly active antiretroviral therapy in rural Uganda. AIDS
Care;19:626–36. doi:10.1080/09540120701203915.
30. Marcelin F, Préau M, Ravaux I, Dellamonica P, Spire B, Carrieri
MP. Self-reported fatigue and depressive symptoms as main
indicators of the quality of life (QOL) of patients living with HIV
and Hepatitis C: implications for clinical management and future
research. HIV Clin Trials. 2007;8:320–7. doi:10.1310/hct0
805-320.
31. Blalock AC, McDaniel JS, Farber EW. Effect of employment on
quality of life and psychological functioning in patients with
HIV/AIDS. Psychosomatics. 2002;43:400–4.
32. Swindells S, Mohr J, Justis JC, et al. Quality of life in patients with
human immuno-deficiency virus infection: impact of social sup-
port, coping style, and hopelessness. Int J STD AIDS. 1999;10:
383–91.
33. Bing EG, Hays RD, Jacobson LP, et al. Health-related quality of
life among people with HIV disease: results from the Multicenter
AIDS Cohort Study. Qual Life Res. 2000;9:55–63. doi:10.1023/
A:1008919227665.
34. Gill CJ, Griffith JL, Jacobson D, et al. Relationship with HIV
viral loads, CD4 counts, and HAART use to health-related quality
of life. JAIDS. 2002;30:485–92. doi:10.1097/01.QAI.0000024372.
97844.B4.
35. Rai Y, Dutta T, Gulati AK. Quality of life of HIV-infected people
across different stages of infection. J Happiness Stud. 2010;11:
61–9. doi:10.1007/s10902-008-9122-5.
36. Ruiz Perez I, Rodriguez Bano J, Lopez Ruz MA, et al. Health-
related quality of life of patients with HIV: impact of sociode-
mographic, clinical, and psychosocial factors. Qual Life Res.
2005;14:1301–10. doi:10.1007/s11136-004-4715-x.
37. Préau M, Apostolidis T, Francois C, Raffi F, Spire B. Time
perspective and quality of life among HIV-infected patients in the
context of HAART. AIDS Care. 2007;19:449–58. doi:10.1080/09540
120601017464.
38. Call SA, Klapow JC, Stewart KE, et al. Health-related quality of
life and virologic outcomes in an HIV clinic. Qual Life Res.
2000;9:977–85. doi:10.1023/A:1016668802328.
39. Badia X, Podzamczer D, Garcı́a M, et al. A randomised study
comparing instruments for measuring health-related quality of
life in HIV-infected patients. AIDS. 1999;13:1727–35.
40. Murri R, Fantoni M, Del Borgo C, et al. Determinants of health-
related quality of life in HIV-infected patients. AIDS Care.
2003;15:581–90. doi:10.1080/0954012031000134818.
41. Aranda-Naranjo B. Quality of life in the HIV-positive patient:
implications and consequences. J Assoc Nurses AIDS Care. 2004;
15:20S–7S. doi:10.1177/1055329004269183.
42. Kowal J, Overduin LY, Balfour L, Tasca GA, Corace K,
Cameron DW. The role of psychological and behavioral variables
in quality of life and the experience of bodily pain among persons
living with HIV. J Pain Symptom Manage. 2008;36:247–58. doi:
10.1016/j.jpainsymman.2007.10.012.
43. Canavarro MC, Pereira M, Simões MR, Pintassilgo AL. Quality
of life assessment of HIV-infected patients: development and
123
AIDS Behav (2011) 15:1857–1869
application of the Portuguese (from Portugal) version of WHO-
QOL-HIV. AIDS Care. 2011;23:187–94. doi:10.1080/09540
121.2010.498870.
44. Eller LS, Mahat G. Predictors of life satisfaction in HIV-positive
Nepali women. J Assoc Nurses AIDS Care. 2007;18:17–26. doi:
10.1016/jana.2007.07.002.
45. Pereira M, Canavarro MC, Simões MR, Pintassilgo AL, Ferreira
A, Nunes, I. Quality of life, depression and psychopathology in
HIV infected patients. Available at www.isoqol.org/2007mtga
bstracts.pdf (2007). Accessed 16 May 2010.
46. Tate D, Paul RH, Flanigan TP, et al. The impact of apathy and
depression on quality of life in patients infected with HIV. AIDS
Patient Care STDS. 2003;17:115–20. doi:10.1089/1087291037
63807936.
47. Kemppainen JK. Predictors of quality of life in AIDS patients.
J Assoc Nurses AIDS Care. 2001;12:61–70. doi:10.1016/S1055-3290
(06)60171-4.
48. Pereira M, Canavarro MC. Quality of life in women living with
HIV infection. Available at www.isoqol.org/pdfs/AbstractsFor
Booklet_2008v3.pdf (2008). Accessed 16 May 2010.
49. Ciesta JA, Roberts JE. Meta-analysis of the relationship between
HIV infection and risk for depressive disorders. Am J Psychiatry.
2001;158:725–30.
50. Prachakul W, Grant JS, Keltner NL. Relationships among func-
tional social support, HIV-related stigma, social problem solving,
and depressive symptoms in people living with HIV: a pilot
study. J Assoc Nurses AIDS Care. 2007;18:67–76. doi:10.1016/jana.
2007.08.002.
51. Kagee A, Martin L. Symptoms of depression and anxiety among
a sample of South Africans living with HIV. AIDS Care.
2010;22:159–65. doi:10.1080/09540120903111445.
52. Shacham E, Reece M, Ong’or WO, Omollo O, Basta TB. A
cross-cultural comparison of psychological distress among indi-
viduals living with HIV in Atlanta, Georgia, and Eldoret, Kenya.
J Int Assoc Physicians AIDS Care. 2010;9:162–9. doi:10.1177/
1545109710367960.
53. Gordillo V, Fekete EM, Platteau T, et al. Emotional support and
gender in people living with HIV: effects on psychological well-
being. J Behav Med. 2009. doi:10.1007/s10865-009-9222-7.
54. Haugh NA, Sorensen JL, Lollo ND, Gruber VA, Delucchi K, Hall
SM. Gender differences among HIV-positive methadone main-
tenance patients enrolled in a medication adherence trial. AIDS
Care. 2005;17:1022–9. doi:10.1080/09540120500100882.
55. Kennedy CA, Skurnick JH, Foley M, Luria DB. Gender differ-
ences in HIV-related psychological distress in heterosexual
couples. AIDS Care. 1995;7:S33–8. doi:10.1080/09540129550
126803.
56. Canavarro MC, Vaz Serra A, Simões MR, et al. Development and
general psychometric properties of the Portuguese from Portugal
version of the World Health Organization quality of life assess-
ment (WHOQOL-100). Int J Behav Med. 2009;16:116–24. doi:
10.1007/s12529-008-9024-2.
57. WHO. WHOQOL-HIV BREF. World Health Organization; 2002.
Available at www.who.int/mental_health/evidence/WHOQOL-
HIV%20BREF.pdf. Accessed 24 Nov 2010.
58. Derogatis LR. BSI: Brief Symptom Inventory: administration,
scoring and procedures manual. Minneapolis: Natural Computers
System; 1993.
59. Aiken LS, West SG. Multiple regression: testing and interpreting
interactions. Newbury Park: Sage Publications; 1991.
60. Field A. Discovering statistics using SPSS. 2nd ed. London: Sage
Publications; 2005.
61. Cotton S, Tsevat J, Szaflarski M, et al. Changes in religiousness
and spirituality attributed to HIV/AIDS: are there sex and race
differences? J Gen Intern Med. 2006;21:S14–20. doi:10.1111/
j.1525-1497.2006.00641.x.
AIDS Behav (2011) 15:1857–1869
62. Litwinczuk KM, Groh CJ. The relationhip between spirituality,
purpose in life, and well-being in HIV-positive persons. J Assoc
Nurses AIDS Care. 2007;18:13–22. doi:10.1016/j.jana.2007.03.
004.
63. WHOQOL-SRPB Group. A cross-cultural study of spirituality,
religion, and personal beliefs as components of quality of life.
Soc Sci Med. 2006;62:1486–97. doi:10.1016/j.socscimed.2005.
08.001.
64. Whipple B, Scura K. The overlooked epidemic: HIV in older
adults. Am J Nurs. 1996;96:23–8.
65. Nokes KM, Coleman CL, Hamilton MJ, Corless IB, Sefcik E,
Kirksey KM, et al. Age-related effects on symptom status and
health-related quality of life in persons with HIV/AIDS. Appl
Nurs Res. 2009. doi:10.1016/j.apnr.2009.03.002.
66. Martin CP, Fain MJ, Klotz SA. The older HIV-positive adult: a
critical review of the medical literature. Am J Med. 2008;121:
1032–7. doi:10.1016/j.amjmed.2008.08.009.
67. Hackl KL, Somlai AM, Kelly JA, Kalichman SC. Women living
with HIV/AIDS: the dual challenge of being a patient and care-
giver. Health Soc Work. 1997;22:53–62.
1869
68. Heinonen H, Aro AR, Aalto A-M, Uutela A. Is the evaluation of
the global quality of life determined by emotional status? Qual
Life Res. 2004;13:1347–56. doi:10.1023/B:QURE.0000040788.
12947.b9.
69. Elliott AJ, Russo J, Roy-Byrne PP. The effect of changes in
depression on health related quality of life (HRQoL) in HIV
infection. Gen Hosp Psychiatry. 2002;24:43–7. doi:10.1016/S0163-
8343(01)00174-8.
70. Bouhnik AD, Préau M, Vincent E, et al. Depression and clinical
progression in HIV-infected drug users treated with highly active
antiretroviral therapy. Antiviral Ther. 2005;10:53–61.
71. Leserman J. Role of depression, stress, and trauma in HIV disease
progression. Psychosom Med. 2008;70:539–45. doi:10.1097/PSY.
0b013e3181777a5f.
72. Rodkjaer L, Laursen T, Balle N, Sodemann M. Depression in
patients with HIV is under-diagnosed: a cross-sectional study in
Denmark. HIV Med. 2010;11:46–53. doi:10.1111/j.1468-1293.
2009.00741x.
123
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.