Relationships Among Trajectories of Sleep Disturbance, Depression, and Antiretroviral Therapy in Persons Newly Diagnosed with HIV: A One-and-a-Half-Year Observational Longitudinal Study.

Purpose: Sleep disturbance is one of the most prevalent symptoms among persons living with HIV (PLWH). However, the trajectory of sleep patterns in persons newly diagnosed with HIV remains underrecognized. The current study aimed to estimate the trajectory of sleep quality and its associated factors among newly diagnosed PLWH. Patients and Methods: A prospective study was conducted in the outpatient clinic of a medical center in southern Taiwan from January 2015 to December 2017. Our primary outcome was sleep quality using the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI). Participants completed the questionnaire at baseline and at four follow-up interval visits: at 3-6, 6-9, 9-12 and 12-15 months. A generalized equation estimation (GEE) model was applied to analyze the relationships among poor sleep quality, depression and antiretroviral therapy among persons newly diagnosed with HIV. Results: A total of 217 PLWH were included. The mean age of the sample was 29.3 years, and males (98.6%) were predominant. A total of 56.2% of HIV-infected persons were considered to have poor sleep quality at baseline. After controlling for the confounding effects of demographic characteristics, the following factors increased the risk of poor sleep quality: older age (ß= 0.07, CI: 0.03-0.11, p=0.001), level of depression (ß= 0.32, CI: 0.27-0.37, p<0.001) and detectable viral load (ß= 0.61, CI: 0.04 - 1.18, p= 0.037). However, there was no significant difference in BMI, CD4 counts, HIV viral load, disclosure status, or highly active antiretroviral therapy (HAART) regimen. Conclusion: Our results demonstrate that one in two persons with newly diagnosed HIV had poor sleep quality. Being older, having higher levels of depression, and having detectable HIV viral loads were identified as risk factors for developing poor sleep quality in persons living with HIV.

Increased repeat syphilis among HIV-infected patients: A nationwide population-based cohort study in Taiwan.

Among human immunodeficiency virus (HIV)-infected individuals, syphilis is an important sexually transmitted infection (STI), and repeat infections are common. Identifying risk factors for delineating the trends in repeat syphilis are essential for STI and HIV prevention.This study is to investigate the dynamic of the syphilis epidemic among HIV-infected patients and to identify the risk factors associated with repeat syphilis.A population-based cohort design was used to analyze claim data between January 2000 and December 2010 using the Taiwan National Health Insurance Research Database. The Poisson regression test was used to identify risk factors for repeat syphilis.Of 13,239 HIV-infected patients, annual syphilis screen tests have been performed in 4,907 (37.1%) of these patients. Syphilis has been diagnosed in 956 (19.5%) patients, and 524 (10.7%) had repeat syphilis. The annual trend in repeat syphilis showed a significant increase in the study period (ß = 0.23, P < .001). Younger age (adjusted incidence rate ratio [aIRR] 1.43; 95% CI 1.11-1.86), male gender (aIRR 11.14, 95% CI 4.16-29.79), a history of STIs (aIRR 1.39, 95% CI 1.21-1.59) were independently associated with repeat syphilis. The retention in HIV care and adherence to antiretroviral therapy ≥85% ([aIRR] 0.77, 95% CI 0.61-0.98; P < .001) were associated with a reduced risk of repeat syphilis.The incidence of repeat syphilis increased during 11 years of follow-up. The screening of syphilis for early diagnosis and retention in HIV care with medication adherence should be encouraged to minimize the risk of repeat syphilis in the targeted population.

HCV co-infection among people living with HIV Is associated with Higher fracture risk.

INTRODUCTION: The purpose of this study was to predict the 10-year risk of fracture among people living with HIV (PLWH) using FRAX™, and to determine the risk factors related to a high probability of fractures. METHODOLOGY: This study consisted of 288 subjects aged 40 years and above. The ten-year probability of major osteoporotic fractures (MOF) and hip fractures was assessed using the FRAX™ algorithm with bone mineral density (BMD) data. A logistic regression was used to determine risk factors related to a high probability of major osteoporotic fracture and hip fracture. RESULTS: The median 10-year probability of fracture was 3.7% (IQR 2.2-6.2) for MOF and 0.8% (IQR 0.3-2.5) for hip fractures. In addition to old age, previous fracture history, and low T-scores, HCV co-infection was associated with a higher risk of hip fractures in PLWH (AOR: 4.3, 95% CI: 1.29-14.33). Old age and low T-scores were also associated with a high probability of MOF. CONCLUSIONS: HCV co-infection among PLWH is associated with a higher risk of hip fracture. Sustained efforts in terms of pharmacologic and non-pharmacologic interventions in PLWH are necessary to prevent osteoporotic fractures, especially in those with HCV co-infections.

[Trends in Immunity and Adverse Drug Reactions Among People Newly Diagnosed With HIV].

BACKGROUND: Early antiretroviral therapy (ART) is recommended as an intervention for HIV by the World Health Organization. However, the association between the CD4 count at ART initiation and the risk of adverse drug reactions (ADRs) remains unclear. PURPOSE: This study aimed to describe the trends related to symptom number and intensity among patients newly diagnosed with HIV in three different CD4-count-based groups and then to investigate the ADR trends for these three groups at different points in time. METHODS: This multi-center cohort study recruited newly diagnosed HIV/AIDS patients who had not previously used ART from AIDS-designated hospitals in Taiwan from March 2015 to December 2016. Study measures were assessed at the time of case enrollment (T0) and during the 1st month (T1), 4-6th month (T2), and 7-9th month (T3) of ART treatment. Patients were stratified into three groups according to initial CD4 count: ≤ 350 cells/mm3, >350-500 cells/mm3 and >500 cells/mm3. Repeated measures ANOVA and generalized estimating equations were used to estimate the relationships between the level of initial CD4 count and ADRs. RESULTS: A total of 207 patients completed the study. Mean symptom numbers and symptom intensities decreased significantly over time in all three groups (p < .01). The largest mean reduction in both symptom number and intensity was achieved by the CD4 count >500 cells/mm3 group. Overall, at least one ADR was reported by 85.7% of the participants at the first month of ART use, and the incidence of ADR had decreased by an average of 22% at the 7-9th month assessment (p < .001). ARDs decreased significantly over time in the CD4 count > 500 cells/mm3 group, with the degrees of ADRs in systematic side effect most significantly decreased in this group (p = .03). CONCLUSIONS / IMPLICATIONS FOR PRACTICE: Number and intensity of symptoms significantly improved over time in all three CD4 count groups. The percentage of systematic side effects was most reduced in the CD4 count > 500 cells/mm3 group. The results of this study may be referenced by HIV care providers when discussing with patients the initiation of ART and the potential risks of experiencing ADRs.

[Willingness to Receive Text Message Appointment Reminders Among Patients With HIV Infection].

BACKGROUND: Wireless communication technologies are increasingly being used in the fields of healthcare, with platforms such as mobile health (mHealth) being widely implemented in HIV care. The rapid expansion of mobile technologies, including smartphone applications (apps), provides a unique opportunity to effectively remind patients about regular follow-up appointments, thereby ensuring patient retention and resulting in a higher quality of care for HIV patients. PURPOSE: This study examines mobile phone users' usage patterns, application usage, and challenges associated with the use of a mobile phone reminder system in order to improve retention in HIV care among patients. METHODS: A cross-sectional descriptive study was conducted to collect data on the usage and patterns of communication technologies from 405 patients. RESULTS: This study included 384 of the 405 eligible patients, resulting in a response rate of 94.8%. A majority of participants (73.3%) indicated their willingness to receive reminders via a text message regarding their upcoming HIV clinical appointments. After adjusting for sociodemographic and clinical variables, multiple logistic regression models indicated that the willingness to receive reminder messages was independently associated with having a college-level education (AOR=2.06, 95% CI [1.05, 4.04]) and with having prior experience with using electronic reminders (AOR=4.01, 95% CI [1.51, 10.66]). CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Protection of personal information was identified as the most important factor that must be addressed in order to increase patient willingness to use a cell phone reminder system. Our findings suggest that mobile technologies are a widely used and an acceptable method for improving quality of care for HIV patients.

[Applying the Modified Delphi Technique to Develop the Role of HIV Case Managers and Essential Nursing Competencies in HIV Care].

BACKGROUND: Since 2005, the Taiwan Centers for Disease Control (Taiwan CDC) initiated an HIV case management program in AIDS-designated hospitals to provide integrative services and risk-reduction counseling for HIV-infected individuals. In light of the increasingly complex and highly specialized nature of clinical care, expanding and improving competency-based professional education is important to enhance the quality of HIV/AIDS care. PURPOSE: The aim of this study was to develop the essential competency framework for HIV care for HIV case managers in Taiwan. METHODS: We reviewed essential competencies of HIV care from Canada, the United Kingdom, and several African countries and devised descriptions of the roles of case managers and of the associated core competencies for HIV care in Taiwan. The modified Delphi technique was used to evaluate the draft framework of these roles and core competencies. A total of 15 HIV care experts were invited to join the expert panel to review and rank the draft framework. RESULTS: The final framework consisted of 7 roles and 27 competencies for HIV case managers. In Round 1, only 3 items did not receive consensus approval from the experts. After modification based on opinions of the experts, 7 roles and 27 competencies received 97.06% consensus approval in Round 2 and were organized into the final framework for HIV case managers. These roles and associated core competencies were: HIV Care Expert (9 competencies), Communicator (1 competency), Collaborator (4 competencies), Navigator (2 competencies), Manager (4 competencies), Advocate (2 competencies), and Professional (5 competencies). CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The authors developed an essential competency framework for HIV care using the consensus of a multidisciplinary expert panel. Curriculum developers and advanced nurses and practitioners may use this framework to support developments and to ensure a high quality of HIV care.

The rising trend of sexually transmitted infections among HIV-infected persons: a population-based cohort study in Taiwan, 2000 through 2010.

OBJECTIVE: Positive prevention interventions for patients living with the HIV include the early detection and treatment of sexually transmitted infections (STIs). This study aimed to determine the incidence of selected STIs, including syphilis, genital warts, gonorrhea, chlamydial infection, and trichomoniasis, in a population-based cohort of individuals living with HIV. METHODS: Clinical data from 2000 to 2010 were obtained from the Taiwan National Health Insurance Research Database identified 15,123 patients with HIV infection. The incidence rates were standardized by age and sex using the direct method that was based on the 2000 World Health Organization world standard population. RESULTS: The overall rate ratio of STI episodes significantly increased [rate ratio: 34.0, 95% confidence interval (CI): 24.3 to 47.6, P < 0.01]. After an HIV diagnosis, 15.9% of patients with HIV had at least 1 of these 5 STIs. An incidence rate of 503.0 STI episodes/10,000 person-years (PYs) (95% CI: 487.1 to 519.5) was detected during the 11-year follow-up period. The most common STIs after an HIV diagnosis were syphilis (381.9 episodes/10,000 PYs; 95% CI: 368.0 to 396.3), followed by genital warts (138.9 episodes/10,000 PYs; 95% CI: 130.6 to 147.6). The incidence of STIs varied significantly according to gender. In women, the annual incidence of STIs remained stable. However, the annual incidence of syphilis, genital warts, and chlamydial infection increased in young men. CONCLUSIONS: An increase in STIs among HIV-positive persons highlights the need to identify the causal factors of these co-infections. Routine STI screenings and early preventive interventions against STIs in HIV-infected persons are crucial.

[The impact of nurse-led case management on the quality of HIV care].

BACKGROUND: Monitoring the quality of human immunodeficiency virus (HIV) care and evaluating the effectiveness of HIV case management programs (CMPs) as approaches to raising the rate of HIV care retention and to improving the efficacy of viral suppression after the initiation of highly active antiretroviral therapy (HAART) are important focuses of research worldwide. PURPOSE: This study describes the trends and evaluates the influence of CMPs on retention in care and viral suppression among patients in Taiwan diagnosed with HIV from 2008 to 2010. METHODS: This retrospective study enrolled 1,302 HIV-positive individuals who had visited at least one outpatient clinic between 2008 and 2012. Of these patients, 715 (54.9%) were enrolled in an HIV CMP. Trend analysis and logistic regression were applied to investigate longitudinal trends and the impact of CMPs on the quality of HIV care. RESULTS: Retention in care improved substantially from 44.5% in 2008 to 57.3% in 2012. The percentage of viral suppression within 12 months of the initiation of HAART increased from 88.4% in 2008 to 93.5% in 2012. Of the patients who were in HIV CMPs, 73.6% were retained in care, which was significantly higher than the 31.7% among those who were not enrolled in CMPs (p<.001). Among the patients who received HAART for more than 180 days, those who achieved viral suppression within 12 months were significantly more likely to be retained in care (adjusted odds ratio=5.36, 95% CI=2.6-10.9, p<.001). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Nurse-led case management programs play a role in improving HIV-related health outcomes. HIV CMPs are beneficial to HIV-infected patients by improving retention in care and are indirectly associated with successful viral suppression.

Mediating effects of social support on depression and quality of life among patients with HIV infection in Taiwan.

Few empirical studies have evaluated the mediating effects of quality of life (QoL) among people living with HIV/AIDS (PLWHA). The purposes of this study were to identify the predictors of QoL and to test the mediating effects of social support on depression and QoL among patients enrolled in an HIV case-management program in Taiwan. A cross-sectional, descriptive correlation design collected data from 108 HIV-infected individuals. Individuals were assessed using the Beck Depression Inventory II, the short version of the World Health Organization Quality of Life Assessment (WHOQOL-BREF), and the Multidimensional Scale of Perceived Social Support between September 2007 and April 2010. After adjusting for sociodemographic characteristics (including age, gender, and mode of transmission) and clinical information (including CD4 count and time since diagnosis with HIV), the study findings showed that QoL was significantly and positively correlated with both social support and the initiation of highly active antiretroviral therapy (HAART), and was negatively correlated with depression and time since diagnosis with HIV. The strongest predictors for QoL were depression followed by the initiation of HAART and social support, with an R(2) of 0.40. Social support partially mediated the relationship between depression and QoL. Health professionals should enhance HIV-infected individuals' social support to alleviate the level of depression and further increase the QoL among PLWHA.

Effect of antiretroviral therapy on the incidence of cervical neoplasia among HIV-infected women: a population-based cohort study in Taiwan.

OBJECTIVE: Cervical cancer has been recognized as one of the AIDS-defining cancers since 1993. Receipt of HAART has been shown to reduce the risk of opportunistic infection and AIDS-defining malignancies. However, findings concerning the effect of HAART on cervical neoplasia have been inconsistent. DESIGN: A population-based cohort design was used, in which 1360 HIV-infected women were compared to the general population (HIV-negative women). The comparison population included 358 141 HIV-negative women randomly selected from among all insured persons in Taiwan in 2000. Data from HIV-infected and uninfected women were analyzed through 2008. METHODS: The age and calendar year-standardized incidence ratio was calculated to estimate the relative risk of cervical neoplasia, and Cox proportional hazards models were used to assess the effect of HAART on the incidence of cervical neoplasia. RESULTS: The incidence of cervical neoplasia was four times higher in the HIV-infected women than in the general population [standardized incidence ratio 4.0, 95% confidence interval (CI) 2.16-6.95]. The most increased risk was noted in HIV-infected women aged 40-59 years. Receipt of HAART was associated with a significantly reduced risk of cervical neoplasia (0.20, 0.05-0.77). The most evident protective effect was noted in adherent to HAART at least 85%, and those treated with HAART for more than 3 years (0.01, 0.00-0.47). CONCLUSIONS: HIV-infected women have a substantially increased risk of cervical neoplasia. Adherent to HAART and prolonged HAART for more than 3 years may contribute to a reduction risk of cervical neoplasia.

Case management interventions for HIV-infected individuals.

Engagement of HIV-positive persons into care and achieving optimal antiretroviral treatment outcomes is a fundamental HIV prevention strategy. Case management model was recommended as a beneficial model of care for patients with a new HIV diagnosis, focusing on individuals with unmet needs, and linking them with the coordinated health and social services to achieve desired outcomes. HIV case management is population-driven and programs are designed to respond to the unique needs of the client population they serve, such as substance users, homeless, youth, and prison inmates. This view found 28 studies addressing effectiveness and impacts of case management intervention for people living with or at risk of HIV/AIDS. Effectiveness of case management intervention was categorized as follows: decreased mortality and improve health outcomes, linkage to and retention in care, decreased unmet needs, and reducing risky behaviors.

Low Papanicolaou smear screening rate of women with HIV infection: a nationwide population-based study in Taiwan, 2000-2010.

BACKGROUND: Women infected by human immunodeficiency virus (HIV) have a higher risk of contracting cervical cancer. Recent guidelines recommend that all HIV-positive women should receive two Pap smears in the first year after their HIV diagnosis. METHODS: This was a population-based cohort study, and the National Health Insurance Research Database (NHIRD) in Taiwan was used to estimate the Pap smear screening rate for 1449 HIV-infected women aged 18 years and over from 2000 to 2010. A multiple logistic regression analysis was used to identify factors associated with HIV-infected women who had received Pap smears. RESULTS: Of 1449 women, 618 (43%) women received at least one Pap smear. Only 14.7% of the HIV-infected women received Pap smears within one year after being diagnosed with HIV. A logistic regression analysis showed that the factors associated with receiving at least one Pap smear after HIV diagnosis were increasing age (AOR 1.04, 95% CI 1.03-1.05), high monthly income (AOR 1.83, 95% CI 1.51-2.23), any history of antiretroviral therapy (AOR 1.78, 95% CI 1.38-2.29), retention in HIV care (AOR 1.36, 95% CI 1.04-1.77), a history of sexually transmitted diseases (AOR 1.96, 95% CI 1.50-2.56), and any history of treatment for opportunistic infections (AOR 2.46, 95% CI 1.91-3.16). CONCLUSIONS: A great need exists to develop strategies for promoting receipt of Pap smear screening services that specifically target severely disadvantaged women with HIV, particularly younger, lower income women and those in an asymptomatic phase.

High prevalence of anal human papillomavirus infection and associated risky behaviors in men infected with human immunodeficiency virus in Taiwan.

A cross-sectional study was conducted to investigate the prevalence, types, and risk factors associated with anal HPV infection among HIV-infected men in outpatient clinics at an AIDS designated hospital in Taiwan. Anal swabs were collect and PCR (polymerase chain reaction) was used to analyze the types of anal HPV infection. HPV DNA was detected in 74.2% of the 198 participants, including high-risk types (40.4%), low-risk types (18.2%) and multiple-types (6%). The most common types were HPV 16 (13.1%), 6 (10.4%), 11 (7.1%) and 18 (6.1%). The significant risk factor for being infected with any type or a high-risk type of HPV was having sexual partners (>3) in the preceding 6 months. Low-risk type of anal HPV infection was associated with a history of anal lesions. Our findings support the need for regular follow-up of all HIV/HPV coinfected patients and their partners to allow early detection of anal intraepithelial neoplasia.

Impact of the nurse-led case management program with retention in care on mortality among people with HIV-1 infection: a prospective cohort study.

BACKGROUND: Long-term retention of patients in care is emerging as an important factor for the mortality among persons with human immunodeficiency virus (HIV) infection. OBJECTIVES: The study was to determine the impact of the case management with retention in care on mortality among HIV infected patients. DESIGN AND SETTINGS: A longitudinal prospective cohort study was conducted at a tertiary referral HIV-designated hospital in Taiwan. PARTICIPANTS: Charts from 1040 patients who had made at least one visit for HIV care at the HIV Clinic in the study hospital in 2009 were abstracted. METHODS: A computerized data collection form was used to retrospectively retrieve the electronic demographic and clinical data generated during each clinic visit. Follow-up ended at death or at the last clinic visit as of December 31, 2009. RESULTS: Less than half (44.2%) of 961 HIV-infected patients were retained for follow-up from 2005 to 2009. Patients who received case management were 4.78 times more likely to remain consistently in care than those who did not receive case management, after controlling for other confounding variables. In the Cox proportional hazard analysis, higher hazards of death were independently associated with older age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.026-1.055), entering care before 2005 (HR: 1.73; 95% CI: 1.035-2.885), low baseline CD4 cell count (HR: 0.997; 95% CI: 0.995-0.998), without antiretroviral therapy (HR: 0.55; 95% CI: 0.334-0.909), irregular attendance of HIV care or loss to follow-up (HR: 0.058; 95% CI: 0.023-0.148), acquisition of HIV infection through sexual contact (HR: 2.95; 95% CI: 1.517-5.746), and irregular attendance or lost to follow-up and did not enrolled in the case management program (HR: 3.76; 95% CI: 1.015-14.777). CONCLUSION: Retention in care is independently predictive of survival, and case management is a mediator affecting retention on survival. Case managers need to identify high risk patients for irregular attendance and to retain them in HIV care in order to maximize their health outcomes.

Gender differences in HIV manifestations at presentation to care and continuity of care among HIV-infected persons in Taiwan.

The study aimed to compare the gender difference in clinical manifestations at time of HIV diagnosis and after one year of antiretroviral therapy, and to determine the influence of gender on HIV care continuity. A retrospective study was conducted using chart review of adults diagnosed with HIV infection from 1993-2008 at a university-affiliated AIDS-designated hospital in Taiwan. Men who acknowledged having sex with men were excluded in order to compare the gender differences among patients with similar routes of HIV transmission and social context. Of the 682 patients with HIV, 86.6% were men. There were no significant gender differences in clinical, immunological or virological parameters at baseline. After one year of antiretroviral therapy, the curves of changes in CD4 cell counts in men and women were parallel over time. Continuity of care, referring to at least one appointment in each six-month window during 2005-2008, was significantly associated with age >50 years (OR = 2.54, 95% CI: 1.04-6.16), being enrolled in the case management programme (OR = 4.93, 95% CI: 2.53-9.62), acquisition of HIV via heterosexual contact (OR = 3.63, 95% CI: 1.38-9.55), CD4 lymphocyte count <200 counts/mm(3) at baseline (OR = 3.09, 95% CI: 1.38-6.96), being on highly active antiretroviral therapy (OR = 4.77, 95% CI: 2.37-9.59), and with sero-discordant partners (OR = 2.51, 95% CI: 1.07-5.87). The findings indicate that gender does not appear to be associated with HIV disease manifestations and continuity of care. Further research to develop optimal methods to retain patients in HIV care is needed.

One-year follow-up of relapse to risky behaviors and incidence of syphilis among patients enrolled in the HIV case management program.

A longitudinal prospective study was conducted at an AIDS designated hospital in Taiwan. The study aimed to determine the incidence of syphilis and to identify risk factors predicting new onset syphilis and relapse into risky behaviors among 117 patients enrolled in the HIV case management program for 1 year. Having a new episode of syphilis was defined as patients had a fourfold increase of serum rapid plasma reagin titers from baseline to 12-month follow-up. After enrollment, 17% relapsed in unprotected sexual intercourse. New onset syphilis was noted in ten (10.4%) participants, and all were men having sex with men. The incidence of syphilis was 5.8 per 100 person-years. Predictors of a new episode of syphilis were higher CD4 cell counts [hazard ratio (HR), 1.003; 95% confidence interval (CI), 1.00-1.006], and recreational drug use (HR, 18.89; 95% CI, 2.78-128.15). Regular screening for syphilis among patients retaining in HIV care remains necessary.

[HIV-related symptoms in patients with HIV infection enrolled in an HIV case management program in Taiwan].

Patients with HIV (human immunodeficiency virus) experience multiple signs and symptoms that accompany the progress of HIV-related diseases. HIV-related symptoms are associated with side effects and HAART (highly active antiretroviral therapy) complications. The purposes of this study were to estimate the frequency and intensity of HIV-related signs and symptoms in patients with HIV infection and to explore relationships between HIV-related symptoms and the HAART regimen. Data on a total of 172 HIV-positive patients enrolled in an HIV case management program were analyzed for this study. Participants experienced an average of 9.73+/-7.27 symptoms, with fatigue, dry mouth and weakness the most frequently reported. Average mean symptom intensity among participants was 13.24+/-11.48. Insomnia, depression and disorientation were the most severe symptoms. No differences were recorded between HIV-related symptoms and disease progression. Fatigue intensity showed significant differences between NRTI (nucleoside reverse transcriptase inhibitors), +NNRTI (non-nucleoside reverse transcriptase inhibitors) and NRTI+PI (protease inhibitors) based regimens (p=.03). In addition, cluster symptoms of confusion/distress among participants without HAART had a significantly higher mean intensity than those with HAART (t=2.0, df=1, p=.04). Our study indicated that symptom management for fatigue and early detection of psychological distress is needed to improve quality of life for people living with HIV/AIDS.