Disability and health outcomes – from a cohort of people on long-term anti-retroviral therapy

Figures & data

Table 1. Outline of the psychometric properties of instruments used in this study.

Element measured	Tool	Variables	Literature source, reliability and validity	Data analysis
Socio-demographic	Socio-demographic questionnaire	Age gender and marital status (* other factors are indicated in the livelihoods section)	–	Descriptive and correlations
Livelihood	HIV-live livelihood capitals (self-developed from literature)	Education and financial capital, including source of income, physical and natural capital including housing, source of income, water and sanitation, social capital and food security	Livelihood – .728 Physical & natural capital – .699 Social capital – .908 Food security – .790 (Hanass-Hancock, Misselhorn, Carpenter, & Myezwa, 2016)	Descriptive
Medical history	Medical symptoms questionnaire	Confusion, Memory loss, Breathlessness, Fatigue, Diarrhoea, Nausea, Stomach Pain, Headache, Change in taste, Skin itching/changes. Muscular pain, Heartburn, Sore mouth, Vomiting, Fever, Kidney stones. Included in this section were the details of the weight and height of the patient, CD4 count	Duran et al. (2001)	The presence and the absence of each symptom were recorded as ‘Yes’ and ‘No’ respectively. The ‘Yes and ‘No’ responses was coded as ‘1’ and ‘0’, respectively. The sum of the symptoms was converted into percentages. Overall score converted to a metric of 0- 100% where 100 = full health and 0 experiencing all symptoms.
Physical and functional health	WHODAS World Health Organisation: disability assessment scale 2.0 (5 point Likert scale)	Mobility (standing and walking) Self-care (washing, getting dressed) Participation (involvement in life situations) Cognition (learning concentration and memory) Getting along (dealing with people and maintaining friendship) Life activities (work and education)	Internal consistency reliability was 0.94 (Cronbach’s alpha). It showed moderate convergent validity with EQ5D and RAND-12 (0.41–0.76) (Carlozzi et al., 2015)	WHO item response theory-scoring and data analysis system was used and the analysis uses overall weighted score of 36, 36 = lowest level of function. Cut off for presence of disability was set at ≥2 (Hanass-Hancock et al., 2015).
Mental health	CESD-10 (4 point Likert scale)	Ten questions prompting status in terms of: depression, level of bother, how fearful, hopeful, happy or lonely one is and the effort required to get going	The CES D-10 showed good internal consistency reliability with the original CES D 20 (α = 0.88 (Myer et al., 2008; Zhang et al., 2012)	A sum of the scores was taken and a cut off of 16 and above was considered at risk of depression. A converted summary score is calculated with a metric of 0–100 (100 is equal to no symptoms of depression and 0 depicts severe symptoms of depression).
Adherence	CASE adherence index	Three unique adherence questions combined to form a composite score	CASE adherence index showed strong correlation with the three day self-reported adherence (ROC curve >0.86, p < .001) (Mannheimer et al., 2006).	A sum of the scores was calculated out of 16, with scores below 11 indicating adherence issues.

Fig. 1. ICF conceptual framework.

Table 2. Socio-demographic characteristics and clinical outcomes of the participants.

Characteristics	Total (n = 1044)	People WHODAS 0–1 (n = 502)	People WHODAS ≥ 2 (n = 542)	p
Age, median (IQR) years	42(12)	42(11)	42(12.3)	.53
Age category, n (%)
18–29	68(6.5)	33(6.6)	35(6.5)
30–39	335(32.1)	164(32.7)	171(31.5)
40–49	459(44)	223(44.4)	236(43.5)
50–59	168(16.1)	76(15.1)	92(17)
60+	14(1.3)	6(1.2)	8(1.5)
*Gender, n (%)				<.001
Men	291(28.2)	164(32.7)	127(23.5)
Women	750(71.8)	337(67.3)	413(76.5)
Marital Status, n (%)				.06
Never married, single,	513(49.1)	235(46.8)	278(51.3)
currently married,	250(23.9)	125(24.9)	125(23.1)
divorced or widowed,	208(19.9)	97(19.3)	111(20.5)
cohabiting	73(7)	45(9)	28(5.2)
*Educational status, n (%)				.14
No formal schooling	17(1.6)	10(2)	7(1.3)
Some primary school	143(13.7)	80(16)	63(11.6)
High school	769(73.7)	367(73.3)	402(74.2)
Post high school	113(10.8)	44(8.8)	69(12.7)
Refused/Don’t know	1(0.1)	–	1(0.2)
*Source of Income, n (%)				.79
Earned Income	604(58.3)	286(57.5)	318(59)
Disability Grant	14(1.4)	–	14(2.6)
Other Grants	77(7.4)	19(3.8)	58(10.8)
No Income	43(4.2)	30(6)	13(2.4)
Refused	197(19)	122(24.5)	75(13.9)
Other income	94(9.1)	38(7.6)	56(10.4)
Gifts	7(0.7)	2(0.4)	5(0.9)
Income, median (IQR)	5260.6(9000)	4500(9000)	3600(6540)
WHODAS weighted score, mean out of 36 (±SD)	0.5(8)	0(0)	8(9)	<.001
CES-10 Score, mean out of 30 (±SD)	11(9)	10(10)	12(10)	<.001
*Adherence score, median (IQR)	16(2.8)	16(1)	14.2(3)	<.001
Adherence score above 10, n (%)	148(14.2)	65(13)	83(15.4)
Adherence score of 10 or less, n (%)	893(85.8)	436(87)	457(84.6)
Health Symptoms, mean out of 16 (±SD)	5(6)	4(5)	6(5)	<.001
*BMI, median (IQR)	25(8.1)	24.9(7.5)	25.2(8.6)	.37
Normal	432(42.7)	245(44.4)	187(40.7)
Underweight	73(7.2)	36(6.5)	37(8)
Overweight	273(27)	155(28.1)	118(25.7)
Obese	234(23.1)	116(21)	118(25.7)
*CD4 Count, n (%)				.25
<200	762(77.5)	366(77.9)	396(77.2)
≥200	221(22.5)	104(22.1)	117(22.8)
*Years of living with HIV since diagnosis, median (IQR)	8(6)	7(6)	9(6)	<.001
*Years on ART, median (IQR)	6(5)	6(5)	7(6)	.01

Fig. 2. Functional limitations in the six domains.

Table 3. Relationship between socio-demographics and health outcome measures.

	WHODAS		Adherence		Mental health
Variable		p		p		p
Age	0.04	.12	0.02	.36	0.10	<.001
Gender	0.10	<.001	0.04	.17	0.09	<.001
Marital status	−0.04	.15	−0.03	.19	0.01	.73
Education	0.05	.05	−0.12	<.001	−0.13	<.001
Income	0.03	.19	−0.00	.90	−0.22	<.001
Years on ARVs	0.07	.01	−0.05	.07	0.04	.06
Years of living with HIV from time of diagnosis	0.07	<.001	−0.05	.05	0.03	.24
Exposure to shock	0.32	<.001	−0.08	.01	0.15	<.001
Mental health	0.19	<.001	0.03	.16	1	−
Adherence	−0.12	<.001	1	−	0.03	.16
Physical health	0.21	<.001	0.01	.82	0.31	<.001
WHODAS	1	–	−0.12	<.001	0.19	<.001
CD4 count	−0.00	.72	0.04	.18	−0.05	.06
BMI	0.01	.54	0.04	.14	−0.02	.41

Table 4. Multivariate linear regression analysis of the health outcome predictors of disability among PLHIV on ARV >6 months using linear regression.

	WHODAS			Adherence			Mental health
	B	95% CI	p	B	95% CI	p	B	95% CI	p
Mental health	0.18	0.16–0.38	<.001	−0.02	−0.04–0.02	<.001	–	–	–
Adherence	−0.13	−0.86–(−0.29)	<.001	–	–	–	−0.02	−0.24–0.15	.64
Physical symptoms	0.11	0.06–0.31	<.001	0.03	−0.02–0.04	.45	0.36	0.32–0.47	<.001
WHODAS	–	–	–	–0.16	−0.06–(−0.02)	<.001	0.18	0.07–0.17	<.001
Age	−0.00	−0.39–0.38	.98	0.07	−0.01–0.19	.08	0.10	0.14–0.65	<.001
Gender	0.06	−0.01–0.14	.08	0.10	0.01–0.04	.01	0.03	−0.03–0.07	.35
Education	0.04	−0.02–0.09	.21	−0.02	−0.02–0.01	.57	−0.03	−0.05–0.02	.39
Marital status	−0.01	−0.04–0.03	.68	−0.02	−0.01–0.01	.60	−0.01	−0.02–0.02	.83
Income	0.13	0.13–0.41	<.001	0.21	0.07–0.14	<.001	−0.07	−0.19–0.00	.05
Exposure to shock	0.28	0.20–0.33	<.001	−0.04	−0.03–(−0.01)	.37	0.06	−0.01–0.08	.10
Number of years living with HIV from time of diagnosis	0.02	−0.14–0.22	.64	−0.08	−0.08–0.01	.15	−0.11	−0.25–(−0.02)	.02
Years on ARVs	0.05	−0.08–0.28	.27	0.00	−0.04–0.05	.94	0.04	−0.06–0.17	.35

Table 5. Multivariate regression analysis of health outcome predictors of disability among PLHIV on ARV >6 months using linear regression with respect to the WHODAS domains.

	Adherence			Mental health
	B	95% CI	p	B	95% CI	p
WHODAS score	−0.13	−0.87–(−0.30)	<.001	0.18	0.16–0.38	<.001
Mobility	−0.09	−0.45–(−0.06)	.01	0.19	0.11–0.26	<.001
Cognition	−0.10	−0.38–(−0.07)	.01	0.17	0.07–0.19	<.001
Participation	−0.07	−0.35–(−0.01)	.04	0.16	0.07–0.20	<.001
Self-care	−0.13	−0.28–(−0.08)	<.001	0.10	0.01–0.08	.02
Getting along	−0.28	−0.58–(−0.35)	<.001	0.09	0.01–0.09	.02
Life activity	−0.11	−0.34–(−0.08)	<.001	0.19	0.07–0.17	<.001

Hanass-Hancock, J., Misselhorn, A., Carpenter, B., & Myezwa, H. (2016). Determinants of livelihood in the era of widespread access to ART. AIDS Care, 29(1), 1–8.

 PubMed Web of Science ®Google Scholar

Duran, S., Spire, B., Raffi, F., Walter, V., Bouhour, D., Journot, V., … Moatti, J. P. (2001). Self-reported symptoms after initiation of a protease inhibitor in HIV-infected patients and their impact on adherence to HAART. HIV Clinical Trials, 2(1), 38–45. doi: 10.1310/R8M7-EQ0M-CNPW-39FC

 PubMedGoogle Scholar

Carlozzi, N. E., Kratz, A. L., Downing, N. R., Goodnight, S., Miner, J. A., Migliore, N., & Paulsen, J. S. (2015). Validity of the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in individuals with Huntington disease (HD). Quality of Life Research, 24(8), 1963–1971. doi: 10.1007/s11136-015-0930-x

 PubMed Web of Science ®Google Scholar

Hanass-Hancock, J., Myezwa, H., & Carpenter, B. (2015). Disability and living with HIV: Baseline from a cohort of people on long term ART in South Africa. PloS One, 10(12), e0143936. doi: 10.1371/journal.pone.0143936

 PubMed Web of Science ®Google Scholar

Myer, L., Smit, J., Roux, L. L., Parker, S., Stein, D. J., & Seedat, S. (2008). Common mental disorders among HIV-infected individuals in South Africa: Prevalence, predictors, and validation of brief psychiatric rating scales. AIDS Patient Care and STDs, 22(2), 147–158. doi: 10.1089/apc.2007.0102

 PubMed Web of Science ®Google Scholar

Zhang, W., O’Brien, N., Forrest, J. I., Salters, K. A., Patterson, T. L., Montaner, J. S., … Lima, V. D. (2012). Validating a shortened depression scale (10 item CES-D) among HIV-positive people in British Columbia, Canada. PLoS One, 7(7), e40793. doi: 10.1371/journal.pone.0040793

 PubMed Web of Science ®Google Scholar

Mannheimer, S., Mukherjee, R., Hirschhorn, L., Dougherty, J., Celano, S., Ciccarone, D., … Eldred, L. (2006). The CASE adherence index: A novel method for measuring adherence to antiretroviral therapy. AIDS Care, 18(7), 853–861. doi: 10.1080/09540120500465160

 PubMed Web of Science ®Google Scholar