The present study was the first to assess the quality of life in a substantial number of patients living with HIV/AIDS in Iran using a field-tested Farsi version of the standard, complete WHOQOL-HIV 120 instrument. In the event, our Farsi version of the WHOQOL-HIV developed for this study had good reliability and validity. All main domains of questionnaire had Cronbach's α scores of more than 0.6, supporting an acceptable internal consistency for instrument. Structural validity assessed using item/total corrected correlations for association between each domain and their facets were in the range of 0.50–0.91 in all 29 facets with the exception of the energy and fatigue facet of the physical domain, and the correlations between individual domains of instrument were satisfactory with coefficients of more than 0.4.
In our study, employment status showed significant positive correlations with level of independence, spirituality/religion/personal beliefs, overall quality of life, and general health score among participants. Moreover, participants with monthly income reported a better level of independence compared to patients without financial sources in our study. These results underscore the importance of returning HIV/AIDS patients to employment as a significant step in improving their quality of life. In the era of ART, this return should be planned as a long-term one. As suggested by a previous study [4
], working may provide a context for social support, identity, and meaning, accounting for observed better quality of life of employed subjects in our study. Indeed, multiple studies worldwide support our findings in Iran [9
]. However, the current economic environment presents many challenges to full employment in Iran.
The majority of patients in our study had history of imprisonment and/or intravenous substance abuse, with the latter being the route of transmission in the majority of participants as expected by the epidemiology of HIV in Iran [11
]. Intravenous drug users (IDUs) have multiple issues that have a bearing on the quality of life apart from HIV/AIDS that need to be considered in interpreting our results. These include simultaneously experiences such as addiction, poverty, depression, and high stigmatization [13
]. Although previous studies have reported a negative relation between being an IDU and quality of life in HIV/AIDS patients [14
], in our study, we could not show any significant association between intravenous substance abuse and quality of life. This is in line with findings of Astoro et al., who did not find an association between being IDU and quality of life in HIV-positive patients [16
]. The reason for this discrepancy regarding effect of intravenous drug abuse is not clear but could be due to different social profiles of IDUs in various cultures or our inability to discriminate between current and past users in this study.
We found that HIV/AIDS patients older than 35 years reported lower quality of life in the domains of social relationships and spirituality/religion/personal beliefs, as well as overall quality of life and general health. Older age has been shown to be associated with dissatisfaction with one's social relationships [17
], and in a previous study Kalichman et al. suggested that HIV/AIDS patients who are older than 45 years experience significant emotional distress and thoughts of suicide [18
]. Spirituality and social support may influence survival in patients with chronic disease [19
]. Our result can be used to tailor supportive measures to match specific needs of an older subgroup of patients living with HIV/AIDS. Contrary to various studies which have shown better quality of life among HIV patients treated with antiretroviral drugs [20
], this study did not show such an association. Some recent studies have suggested that ART may not affect health-related quality of life early in the course of therapy [6
]. This, as well as relative small number of patients having AIDS and being on ART (17.1%), may be the cause of the observed results in our study.
The design of the present study does not allow us to deduce causality or determine the direction of the observed associations. Furthermore, the degree to which our results are representative of the whole population of Iranian HIV/AIDS patients is limited by the fact that our participants have been selected from a hospital-based consultation center in Tehran. In fact, convenient sampling could have hampered data generalization and, indeed, further limit applications of this instrument in a community-based level. For example, the fact that about 40% of patients were receiving HAART at the time study was conducted could have altered certain results and act as a possible source of bias. These apparent differences due to convenient sampling further increase the level of uncertainty in concluding whether generalization of our results to PLWHA is even plausible. Relative small number of female participants and patients with AIDS in this study should be considered before attributing results of this study to these populations.
To conclude, our study demonstrated that the standard, complete WHOQOL-HIV 120 instrument translated into Farsi and evaluated among Iranian participants provides a reliable and valid basis for future research on quality of life for HIV and other patients in Iran. Furthermore, the present study a significant positive relation between employment and several areas of quality of life and negative relation to older age. Such findings are examples that provide necessary information to take measures either by governmental or nongovernmental institutions to improve patients' quality of life. Although the causal relationship between these factors and the means to intervene need to be confirmed through prospective studies and intervention trials, we believe our study provides an important tool to make progress on improving the quality of life for persons with HIV/AIDS in Iran.