The results of this study documents that in a cohort of patients with different chronic pathologies with comparable characteristics of chronicity, followed in the same hospital care setting, albeit by different doctors, over the same period, PLWH have a better self-reported state of health than people living with other chronic pathologies such as diabetes mellitus type I, rheumatoid arthritis, breast carcinoma in hormone therapy. This difference is reported for most of the quality-of-life domains analyzed.
Each domain examined in our study showed how PLWH outcome results in being the most satisfying compared to all other chronic diseases considered, while people living with RA resulted as the worst outcome group primarily in domains related to physical functioning, physical pain, and limitation related to emotional factors.
The only domain in which PLWH did not have the best outcome is the mental health in which, however, PLWH reported scores perfectly comparable with patients affected by other diseases. Our results in such sphere are concordant with the findings of Miners et al., that highlighted how PLWH have frequent mental health disturbances, due to depression and anxiety [11]. A peculiar role in mental health of PLWH is potentially attributable to the social stigma: in the work of Nobre et al., the social dimension is crucial in determining the experience of a worse perception of illness related to HIV infection, and the multidimensional phenomenon of self-stigma [28], which is a direct consequence of the stigmatization of the illness in the society, can lead to a discrediting self-perception and guilt that easily flow into psychiatric disorders. The introduction of routinely QoL questionnaires and PRO assessment in clinical practice for PLWH and its continuous monitoring, results have proved to be extremely useful not only in providing a prompt detection and intervention on such mental disturbances, but also in serving as a sort of snapshot of the social stigma and its perception. The trajectories designed by such studies involving PRO could help in defining areas of intervention for future global health programs aimed to break the social barriers.
According to our results, another factor related to an impaired quality of life is polypharmacy, which also has an impact on mental health. Efforts in minimizing the burden of pills in PLWH must be concordant with the increment of life-expectancy in such patients, where HIV infection overlaps with other clinical conditions requiring daily medications. When possible, treatment simplification strategies in viro-immunologically stable individuals can have a key role in improving health perception in PLWH, although the impact of the drugs used for the comorbidities that may afflict the HIV patient may have a greater impact on the drug burden than the burden of the antiretroviral therapy itself [29, 30].
In the years 1990–2000, several scientific works compared patient outcomes in terms of health-related quality of life in HIV infection and other chronic conditions [30,31,32,33]. However, although they represent fundamental works for the application and dissemination of PROMS in clinical practice, especially with regard to the management of PLWH, they refer to a very different historical period from the current one in which the focus on PLWH in patients regularly taking antiretroviral therapy has shifted mostly from issues related to acuity (clinical progression, survival, side effects of drugs…) to issues related to long-term chronic management (comorbidity, long-term adherence, degree of satisfaction with treatment, disease burden, etc.). Hays et al. [33] reported how patients with AIDS had worse physical functioning and partially emotional functioning, than those with other chronic diseases such as epilepsy, gastroesophageal reflux disease, clinically localized prostate cancer, clinical depression, diabetes.
To our knowledge, the comparison in terms of self-reported health outcomes between patients with HIV infection and other chronic diseases has not been frequently explored in the era of combined antiretroviral therapy. The work of Engelhard et al. [12] has been the first study in literature aimed to analyze health-related QoL in PLWH comparing it to other chronic conditions in the ART era, relying on the previously dominant thought that health-related QoL of PLWH is lower than the one in general population. The study’s results revealed how PLWH experience a worsening of QoL related to mental health directly connected with the patient’s immunological status, while people with AIDS experience a worse QoL related to health condition connected to prolonged life therapy and the presence of comorbidity. Although representing a fundamental study, the main limitation of Engelhard et al. lies in the collection of the information regarding people with chronic conditions, which have been obtained by previous studies [34,35,36,37] and not by direct enrollment from the same center, thus including different patients in different time frames and geographical locations, and distinct healthcare contexts. By consequence, alterations encountered may not only be reflection of the disease itself, but it may be connected to factors regarding place, time and healthcare assistance. Differently from what reported by Engelhard et al. study, the cohort of patients in our study has been actively recruited, and it is homogeneous both in time frame and healthcare facility. Our study gathered information on patients treated between March 2019 and January 2020 in the same hospital thus minimizing the variability related to healthcare assistance, patients’ management, and logistic differences.
Although consecutively observed patients were enrolled in our study, the proportion of PLWH with complicated disease (defined as a previous diagnosis of AIDS) was significantly higher than for other diseases. Although the CDC classification of 1993 appears to be rather outdated and does not reflect the current clinical reality of HIV infection, we do not currently have any other standardized definition of a complicated patient. It is certainly not possible to standardize the definitions of complicated disease among such different diseases, but it can be excluded that the better health-related quality of life reported by PLWH compared to other diseases is due to the selection of an "easier" population to manage. What emerges from this consideration is that the determinants of health-related quality of life for PLWH today may not be related to previous history of disease, but rather to the difficult handling of current therapy and advancing age.
We can obviously highlight some limitations in our study. First of all, the necessity of using generic questionnaire, non-HIV specific, aimed at identifying comparable items for each disease due to the willingness of including clinical conditions other that HIV in our study population, could have led to an overestimation of health-related QoL in PLWH [38, 39]. Moreover, despite the strenuous attempt of homogeneity in our study population demographic characters, PLWH were found to be globally younger, thus probably affecting positively the perception of health-status comparing to other clinical conditions. We are aware that HIV infection has its own peculiarities as a chronic pathology that make it difficult to compare with the others, but the criteria for inclusion in the study have been selected with the objective of balancing the potential differences inherent in the individual pathologies.
Notwithstanding our University Hospital is a reference one for many acute and chronic pathologies in central-southern Italy, in particular for those considered in the present manuscript, it is not possible to exclude a priori a selection bias whereby more severe patients may be followed at the center. For these reasons it cannot be excluded the possibility that in other care systems, where some chronic diseases have a different severity, the results may be different.
