Association of Marital Status and HIV infection

CHAPTER FIVE DISCUSSION

5.1 Association of Marital Status and HIV infection

In this study, 64.9% of respondent are married. This figure leaves us wondering the effects of HIV spread in marriages in The Gambia where polygyny is commonly practiced. There are numerous studies have studied the association of concurrency in marriages and or multiple partners and the spread of HIV in sub-Saharan Africa. Many of them have established and supported that multiple concurrent partnerships significantly increase exposure to HIV infection (Helleringer et al., 2009; Epstein & Morris, 2010; Mah, 2010; Mah & Halperin, 2010; Goodreau, 2010). This position has been used with effect among other strategies by the Joint United Nation Program on HIV/AIDS and the Southern African Development Community to curb the spread of the infection. However their work was subject to much criticism by Sawers and Stillwaggon (2010) and Murray and Burnham (2009). Sawers and Stillwaggon conducted systematic review of published literature and asserted that concurrent sexual partnership do not explain the spread of HIV in Africa. Lagarde and his co-researchers (2001) studied ‘concurrent sexual partnerships and HIV prevalence in five urban communities of sub-Saharan Africa’ and found no evidence to support that concurrency is the driving force for African HIV epidemic. Ecological studies by Reiners and Watkins (2010) failed to provide evidence to support that concurrent sexual partnership is linked to the spread of HIV in Africa. They studied polygyny the type of concurrent sexual partnership found in The Gambia and concluded that it may have some beneficial effects.

Although both positions used methods and data available to them and both are have been subject of so much critique, it is important to look at the evidence presented in the context of Gambia. Most of the studies that support the position that concurrent partner is linked with the

52 spread of HIV were conducted in Eastern and Southern Africa where there HIV infection prevalence was highest. Secondly there are cultural differences between the studied areas and The Gambia, as culture influence human sexual behavior. Reiners and Watkins also found out that HIV prevalence was lowest in region where the practice of polygyny is common between countries and within country. Therefore the role of polygny should be carefully studies to determine its contribution to the spread or control of HIV in The Gambia.

In the multiple regressions married and living as married had positive effect on the changes on quality of life (β=0.158 and β=0.017) respectively as compared to the negative changes of separated and divorced (β= -0.041 and β= -0.01) respectively. Subramanian, et al. (2009) in their study of ‘psycho-social impact and quality of life of people living with HIV/AIDS in South India’

showed that marital status had significant association with quality of life. Nojomi, Anbary, &

Ranjbar, (2008) yielded similar results. However Tiwari et al. (2009) conducted another study of HIV infected patient in India using the WHOQOL-26 BREF Hindi version found no association between marital status and quality of life.

Although standardized beta coefficient in the multiple point to a beneficial effect of being married and living with HIV/AIDS in The Gambia, it is not conclusive and therefore , a study need to be conducted to explore the role of marriage in the quality of life of people living with HIV/AIDS in The Gambia.

53 5.2 Gender and its association with Quality of life

From the one way ANOVA results (Table 4), females demonstrated higher quality of life than males. The significance of this result was further highlighted by the multiple regression output (Table 5).This findings in however not in agreement with the earlier findings of Mrus et al. (2005) Mast et al. (2004) and Cederfjall et al. (2001). These studies reported that women HIV had lower quality of life compared to men. However the study by Chandra et al. (2009) in southern India showed that women had higher score in some facets of the WHO Quality of Life Instrument for HIV (WHOQOL-HIV120) and in spirituality and personal beliefs domain.

Nonetheless, Mayo (2002) in her study found no gender difference in quality of life of people living with HIV in the US. The gender differences in quality of life do not only reflects disease status, but also the prevailing socio-economic condition of the given society. For instance in the studies of Mast et al in Uganda, attention need to be paid to the prevalence of the disease, the plethora of orphanages that wrecked those societies and those who are left with the burden of care of orphans.

A study in Malawi, Zambia and Zimbabwe (SADC/FA, 2003, cited in de Wagt & Connolly, 2005) reported that 20 percent of household are caring for orphans and it is often the female-headed households that care for orphans. Gilborn et al. (2001) in their study found out that 40 percent of adults looking after orphans were HIV positive. Therefore it is necessary to put the result of this study in its context. In the Gambia, HIV has not reached the above devastation and therefore women would not have been subjected to such situations. The strong social solidarity may also help explain why females with HIV have better quality of life compare to males.

54 5.3 Association of Quality of life and use of HAART

The independent sample t-test showed no significant differences in the quality of life of respondents on HAART and those not on HAART (Table 4). This result is however not consistent with numerous other studies (Stangl et al., 2007; Louwagie, et al., 2007; Jelsma et al., 2005;

Manheimer et al., 2005; Yen et al., 2004). These studies established the value of HAART in improving quality of life of recipients. The result is likely due two factors. The first factor is emanates from the time of starting patients on HAART therapy. In the Gambia, HIV patients are started on HAART when they are in WHO stage III and IV of the disease (MOH, 2009). This is due to the fact that there is no universal coverage of HAART for all persons living with HIV. Therefore potential gains of starting on HAART therapy at this stage of the disease when compared with those on stage I and II of the disease would diminish. Therefore the need for universal coverage for HAART for people living with the HIV/AIDS in The Gambia is important not only to improve quality of life but to reduce transmission to the virus to sexual partners. In a study by the National Institute of Health in the United States published by UNIADS (2011) press release, ‘adhering to effective antiretroviral treatment reduces the risk of transmitting the virus to an uninfected sexual partner by 96%’.

The second factor relates to the study design. To properly evaluate the potential benefits of HAART for this group of recipients, it will be appropriate to collect data at two (Jelsma, et al., 2005) points in time or more. Therefore, a prospective study design would be appropriate. Hence, it would be inappropriate to state that HAART therapy has no value in improving the quality of life of people living with HIV/AIDS.

55 5.4 Association of quality of life with the six independent variables

Table 3 shows that physical, psychological, level of independence; social relationship environment and spirituality/religious domains had varying strengths of association with quality.

Hasanah, Zaliha & Mahiran (2010) assessed factors influencing the quality of life in patients with HIV in Malaysia. They showed that patient functioned satisfactorily in the physical domain and were impaired in the social domain. However, other studies have shown that in the social relationship domain, social support for patients with HIV/AIDS has shown a strong potential to influence health related quality of life (Badia et al., 1999; Anderson et al., 1998, Wu et al., 1998). In the domain of spirituality, creating meaning and purpose to life was found to correlate with psychological well-being in a large sample of African American men and women with HIV/AIDS (Coleman &

Holzemer, 1999). Adewuya et al. (2008) in their study showed that poor social support correlated with poor quality of life scores on the domain of physical health and social relationship.

Although correlation of the domains with quality of life is not significance in the multiple regression output, it would be appropriate to put this result in the context of the clinic setting.

Physicians, nurses, health counselors and other professionals caring for people living with HIV/AIDS need to pay attention to patients’ physical, psychological and emotional health, their need for independence from use of medication, the environment in which they live and their spiritual needs. The social relationship and level of independence domains show less strong correlation with improved quality of life. Therefore, awareness of the concerns of people living with HIV/AIDS have for being accepted, sexual functional ability and support they get from those around them will be a crucial in improving their quality of life. In the level of independence and spirituality domains, it will imperative to improves patients’ capacity to work, and their satisfaction with the performance of

56 the activities of daily living, to probe into the meaning they attach to purpose of life, concerns for stigma attached to living with the virus, their fears about the future and worries about death.

57 5.5 Conclusion

The findings of this study support the incorporation of quality life assessment into the HIV/AIDS care program at Royal Victoria Teaching Hospital and in The Gambia and the need to expand access to anti-retroviral therapy to all people living with the virus.. In this effect, assessing patient health status and satisfaction with their health can constitute important yardsticks to measure the response to care. Since HIV is a chronic illness, attention needs to be paid to the spiritual needs of patients, their concerns and fears for stigma and the environments in which they live.

58 5.6 Recommendations

Care Giver. Physicians, nurses, health counselors caring for people living with HIV/AIDS should pay greater attention the social relationship and level of independence domain that show less strong positive correlation with quality of life. It will be important to periodically evaluate their patient’s health status and satisfaction with health as these influences patients’ quality of life.

Policy makers. The weak correlation in the level of independent domain and social relationship domain with quality of life means that additional resources are needed to tackle stigma and discrimination, improve patient work capacity and performance of the activities of daily living.

The need for patients to be free from medication should be supported by proper nutrition program.

There is need for universal coverage with HAART to improve quality of life and reduce transmission of the virus to uninfected sexual partners.

Future study directions. A prospective study design should to be conducted to evaluate the potential benefit use of HAART in people living on HIV/AIDS in the Gambia.

59 5.7 Limitations of the study

As noted by Sey-Sawo et al. (2011), there were problems of interpreting some terms in the questionnaire, and therefore data collectors used approximation to describe the terms. Similar difficulties in the interpretation of English term related to the concept of health were noted by Kenyan field workers (Allen et al., 1997). Although, the instrument has been validated in multicultural settings (WHO, 1997), this difficulty requires the tool to be validated if future studies using the instrument are to be free from this problem.

Furthermore, ten respondents failed to answer the question on satisfaction with sex.

Therefore in the future it will be important to conduct a study to evaluate the appropriateness of inclusion of this statement in the questionnaire for use in The Gambia.

Moreover, adults patients with HIV/AIDS are the subjects of study, and thus the results cannot be applied to population of other HIV/AIDS patients less than 18 years.

60

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