Peer support and improved quality of life among persons living with HIV on antiretroviral treatment: A randomised controlled trial from north-eastern Vietnam.

Abstract

BACKGROUND: Among people living with HIV (PLHIV) on antiretroviral therapy (ART), it is important to determine how quality of life (QOL) may be improved and HIV-related stigma can be lessened over time. This study assessed the effect of peer support on QOL and internal stigma during the first year after initiating ART among a cohort of PLHIV in north-eastern Vietnam. METHODS: A sub-sample study of a randomised controlled trial was implemented between October 2008 and November 2010 in Quang Ninh, Vietnam. In the intervention group, participants (n=119) received adherence support from trained peer supporters who visited participants' houses biweekly during the first two months, thereafter weekly. In the control group, participants (n=109) were treated according to standard guidelines, including adherence counselling, monthly health check and drug refills. Basic demographics were measured at baseline. QOL and internal stigma were measured using a Vietnamese version of the WHOQOL-HIVBREF and Internal AIDS-related Stigma Scale instruments at baseline and 12 months. T-tests were used to detect the differences between mean values, multilevel linear regressions to determine factors influencing QOL. RESULTS: Overall, QOL improved significantly in the intervention group compared to the control group. Among participants initiating ART at clinical stages 3 and 4, education at high school level or above and having experiences of a family member dying from HIV were also associated with higher reported QOL. Among participants at clinical stage 1 and 2, there was no significant effect of peer support, whereas having children was associated with an increased QOL. Viral hepatitis was associated with a decreased QOL in both groups. Lower perceived stigma correlated significantly but weakly with improved QOL, however, there was no significant relation to peer support. CONCLUSION: The peer support intervention improved QOL after 12 months among ART patients presenting at clinical stages 3 and 4 at baseline, but it had no impact on QOL among ART patients enrolled at clinical stages 1 and 2. The intervention did not have an effect on Internal AIDS-related stigma. To improve QOL for PLHIV on ART, measures to support adherence should be contextualized in accordance with individual clinical and social needs. KEYWORDS: Quality of life, Peer support, HIV, ART, Quang Ninh, Vietnam, randomised controlled trial.

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Peer support and improved quality of life among persons living with HIV on
antiretroviral treatment: A randomised controlled trial from north-eastern
Vietnam
Health and Quality of Life Outcomes 2012, 10:53doi:10.1186/1477-7525-10-53
Tam Van Vu (tamvanvu@yahoo.com)
Mattias Larsson (Mattias.Larsson@ki.se)
Anastasia Pharris (Anastasia.Pharris@ki.se)
Björn Diedrichs (bjorn_diedrichs@hotmail.com)
Hoa Phuong Nguyen (hoatuber@yahoo.com)
Chuc Thi Kim Nguyen (ntkchuc020254@gmail.com)
Phuc Dang Ho (hodang54@yahoo.com)
Gaetano Marrone (Gaetano.Marrone@ki.se)
Anna Thorson (Anna.Thorson@ki.se)
ISSN
1477-7525
Article type
Research
Submission date
30 August 2011
Acceptance date
18 May 2012
Publication date
18 May 2012
Article URL
http://www.hqlo.com/content/10/1/53
This peer-reviewed article was published immediately upon acceptance. It can be downloaded,
printed and distributed freely for any purposes (see copyright notice below).
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Health and Quality of Life
Outcomes
© 2012 Vu et al. ; licensee BioMed Central Ltd.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Peer support and improved quality of life among
persons living with HIV on antiretroviral treatment:
A randomised controlled trial from north-eastern
Vietnam
Vu Van Tam1,2,3*
* Corresponding author
Email: tamvanvu@yahoo.com
Mattias Larsson1,5
Email: Mattias.Larsson@ki.se
Anastasia Pharris1
Email: Anastasia.Pharris@ki.se
Björn Diedrichs6
Email: bjorn_diedrichs@hotmail.com
Hoa Phuong Nguyen2
Email: hoatuber@yahoo.com
Chuc Thi Kim Nguyen2
Email: ntkchuc020254@gmail.com
Phuc Dang Ho4
Email: hodang54@yahoo.com
Gaetano Marrone1
Email: Gaetano.Marrone@ki.se
Anna Thorson1
Email: Anna.Thorson@ki.se
1 Division of Global Health, Department of Public Health Sciences, Karolinska
Institute, Stockholm, Sweden
2 Health System Research Project, Ha Noi Medical University, Ha Noi, Vietnam
3 Department of Infectious diseases, Uong Bi general hospital, Uong Bi, Quang
Ninh, Vietnam
4 Department of Probability and Mathematical Statistics, Institute of
Mathematics, Ha Noi, Vietnam
5 Oxford University Clinical Research Unit, Ha Noi, Vietnam
6 Sundsvall-Härnösand regional hospital, Sundsvall, Sweden

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Abstract
Background
Among people living with HIV (PLHIV) on antiretroviral therapy (ART), it is important to
determine how quality of life (QOL) may be improved and HIV-related stigma can be
lessened over time. This study assessed the effect of peer support on QOL and internal stigma
during the first year after initiating ART among a cohort of PLHIV in north-eastern Vietnam.
Methods
A sub-sample study of a randomised controlled trial was implemented between October 2008
and November 2010 in Quang Ninh, Vietnam. In the intervention group, participants
(n = 119) received adherence support from trained peer supporters who visited participants’
houses biweekly during the first two months, thereafter weekly. In the control group,
participants (n = 109) were treated according to standard guidelines, including adherence
counselling, monthly health check and drug refills. Basic demographics were measured at
baseline. QOL and internal stigma were measured using a Vietnamese version of the
WHOQOL-HIVBREF and Internal AIDS-related Stigma Scale instruments at baseline and 12
months. T-tests were used to detect the differences between mean values, multilevel linear
regressions to determine factors influencing QOL.
Results
Overall, QOL improved significantly in the intervention group compared to the control
group. Among participants initiating ART at clinical stages 3 and 4, education at high school
level or above and having experiences of a family member dying from HIV were also
associated with higher reported QOL. Among participants at clinical stage 1 and 2, there was
no significant effect of peer support, whereas having children was associated with an
increased QOL. Viral hepatitis was associated with a decreased QOL in both groups. Lower
perceived stigma correlated significantly but weakly with improved QOL, however, there
was no significant relation to peer support.
Conclusion
The peer support intervention improved QOL after 12 months among ART patients
presenting at clinical stages 3 and 4 at baseline, but it had no impact on QOL among ART
patients enrolled at clinical stages 1 and 2. The intervention did not have an effect on Internal
AIDS-related stigma. To improve QOL for PLHIV on ART, measures to support adherence
should be contextualized in accordance with individual clinical and social needs.
Keywords, Quality of life, Peer support, HIV, ART, Quang Ninh, Vietnam, Randomised
controlled trial
Background
The HIV epidemic in Vietnam is in a concentrated stage, with an estimated HIV prevalence
of 0.53 % in 2010 [1]. Antiretroviral therapy (ART) has been scaled-up in Vietnam since late

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2005 with funding through programs such as the US President’s Emergency Plan for AIDS
Relief (PEPFAR) and Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM). By
December 2010, about 49,492 persons living with HIV (PLHIV) in Vietnam had access to
free ART [2].
The world-wide scale-up of ART has decreased the incidence of new HIV infection and
reduced AIDS-related deaths substantially [3]. With an increased prevalence of PLHIV on
life-long ART, it is becoming increasingly important to determine which factors contribute to
a better quality of life (QOL). While people are living longer, they may be living with
increased health-challenges related to HIV disease, the side effects of treatment or emerging
concurrent morbidities related to HIV or aging. Hence, despite living longer, individuals may
not always be ‘living well’. Quality of life has become an essential outcome to consider in the
overall health and well-being of people living with HIV. Whereas it is well documented that
ART improves not only clinical outcomes but also QOL within the first year [4,5],
conclusions on what other factors (besides the ART itself) can contribute to a higher QOL are
diverse [6,7]. Several factors have been identified as contributing to better QOL among
PLHIV, including social support [8,9], spiritual well-being[9], education level [10,11], not
being an injecting drug user [12,13] and having good adherence to ART [14,15]. Meanwhile,
other factors such as HIV-related stigma [16-18], non-disclosure of one’s HIV status have
been reported to negatively affect QOL [19]. Due to the strong relationship between QOL
and many important indicators for treatment success, QOL has been widely applied in
evaluating the impact of HIV-related interventions among different populations [20,21].
In settings with heavy HIV-related stigma and discrimination and limited health care
resources, such as Vietnam [22], scaling up HIV care faces challenges, including shortages of
health care personnel willing to work with HIV-infected individuals resulting in heavy
workloads and constrained support to patient adherence. To counter this, community-based
peer support interventions have sought to improve adherence to ART, to lessen internal HIV-
related stigma as well as to improve treatment outcomes such as QOL [23]. However, to date,
there is no available data evaluating such an intervention in Vietnam.
In this randomized controlled trial, we assess the impact of peer support on QOL and internal
stigma for PLHIV after 12 months on ART.
Methods
General study design
This study focusing on QOL is a sub-sample of a cluster randomized controlled trial aiming
to assess the impact of peer support on viral suppression and resistance development among
patients in Quang Ninh province in north-eastern Vietnam (DOTARV).
Study setting
The study was conducted at four outpatient clinics (OPC) in Quang Ninh, a province in the
northeast of Vietnam with a population of 1.1 million. Quang Ninh’s economy is rapidly
growing and mainly based on industries such as coalmines, cement plants and harbours as
well as tourism within the famous Ha Long Bay. It is also the area that is hardest hit by the

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HIV epidemic in Vietnam, with an estimated HIV prevalence of slightly above 1 % among
15-49-year-olds [24].
Sampling and participants
The study sample was selected from four districts in Quang Ninh province, which consisted
of 71 communes (28 urban and 43 rural). The total population of the 71 communes was
612,541 in 2009. Cluster-based sampling at the level of the commune was employed in order
to minimize contamination between patients living near each other. In cluster sampling, the
71 communes were randomised to either intervention (36 communes) or control (35
communes), after an initial matching according to rural–urban, population and vicinity to
hospital. In both intervention and control communes, all patients who came from the same
commune were then treated similarly in a standardized way according to the study protocol.
The study enrolled HIV positive patients who were ARV-naïve and eligible to initiate ART
according to the Vietnamese national guidelines at the time of the study. Inclusion criteria
were as following: clinical stage 4 of HIV disease (AIDS related illnesses) regardless of
CD4+ count, clinical stage 3 (severe opportunistic infections) with CD4+ <350/µl, clinical
stage 1 and 2 (asymptomatic or mild infection) with CD4+ count of <200/µl [25] . Exclusion
criteria were pregnancy, age under 18 or above 60, mental illness and institutionalization.
While the larger DOTARV study began in 2007, the present sub-study focusing on QOL and
internal stigma included all DOTARV participants recruited from October 2008 to November
2009. Two-hundred seventy-five participants were consecutively selected from both the
intervention and the control groups (i.e. all persons eligible for ART and meeting inclusion
criteria from both intervention and control communes were enrolled in this sub-study).
Among these, 24 died within six months of ART initiation, twelve patients did not come for
the interview at twelve months and eleven dropped out of the study as per compulsory
detoxification or arrested due to heroin trafficking. A total of 228 participants responded to
the interview both at baseline and at twelve months.
Control
Those individuals who were randomized to the control arm of the study received standard
care as per normal government health care standards for patients initiating ART. This
included adherence counselling and readiness training provided by the medical staff of these
OPCs at individual level (three times) and at group level (three times) prior to starting ART.
Health checks, adherence assessment and drug refills were carried out monthly at the
outpatient clinic. All patients would report their obstacles/barriers to ART adherence (if any)
to health staff at the OPCs at monthly visits. In case non-adherence to ART was identified by
health staff, adherence counselling would be provided instantly on location.
The adherence assessment in this study was based on the self-reports from the patients as
well as pills counts. These were both compared to the amount of the pills that should have
been taken using the criteria recommended by WHO [26]. The adherence assessment then
referred to: good adherence (patient forgot to take doses less than four times per month);
moderate adherence (patient forgot to take doses between 4–8 times per month) and poor
adherence (patient forgot to take doses more than 8 times per month).

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Intervention
Individuals in the intervention arm of the study received standard care as described above and
also received peer support from trained PLHIV who were taking ART. These peers
functioned as “external supporters” for patients initiating ART and performed biweekly visits
during the initial two months of ART, when drug-taking habits were being formed. After two
months, the visits were reduced to once per week (if treatment adherence was good) or
intensified to become more frequent (if adherence was poor). To facilitate the peer support
activities and ensure that the adherence support was carried out properly, a standardized
checklist was developed by the research group together with a group of PLHIV who were on
ART. The checklist was used to guide the peer supporter to ask questions in a standardized
order and manner. During each visit, the external supporter went through this standardized
checklist including questions about general well-being, signs/symptoms since the last visit,
psychological problems or adverse drugs reactions as well as adherence to therapy since the
last visit. The checklist was only applied in the intervention group and hence it was not used
for data collection or for monitoring the effects of the intervention. Patients and family
members were encouraged to report all constraints/obstacles to ART adherence. Barriers to
ART adherence identified during the visiting were discussed between the peer supporter, the
patient and family members to determine a feasible solution and (if necessary) health staff at
the outpatient clinic were contacted for advice. Problems identified by peer supporters such
as common barriers, suggestions for changing dose-taking schedules, behaviour of family
member towards peer supporter (if any) were discussed among the research group at monthly
meetings.
Measurement tools
Study tools administered to both intervention and control participants included:

The WHOQOL-HIVBREF includes questions respond to the definition of Quality of
Life as Individuals’ perception of their position in life in the context of the culture and
value system in which they live and in relation to their goals, expectation, standards and
concerns. This measurement produced scores on the patients’ self-reported judgement of
six different domains of QOL including: Physical (4 facets: pain, energy, sleep,
symptoms); Psychological (5 facets: positive feelings, cognitive, self- esteem, bodily
image, negative feelings); Social Relationships (4 facets: personal relationships, social
support, sexual activity, social inclusion); Level of Independence (4 facets: mobility, daily
activities, dependence on medication, work capacity); Environment (8 facets: physical
safety and security, home environment, financial resources, health and social care,
opportunities for acquiring new information, opportunity for leisure activities, physical
environment, transport) and Spirituality/Personal Beliefs (4 facets: forgiveness and blame,
concern about the future, death, spirituality). The patients answered each question using a
5-level Likert scale. Among these, scores of questions with negative direction (negative
feelings, pain and discomfort, dependence on medicine, death) were reversed to make
higher scores generally indicate better QOL. The score of each domain ranged between 4
and 20. These scores could also be added up to produce an overall score. The higher
scores indicated better QOL [27]. The difference between the score at 12 months and the
score at baseline was then used to express the change in QOL (both for each separate
domain and for the overall score). We strictly followed the protocol provided by the
WHOQOL-HIV Group to translate and using forward-backward translation with

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subsequent reviews and discussions within the research groups.
The Internal AIDS-Related stigma questionnaire focused on self-blame and
concealment of HIV status [28]. This measurement assessed if patients agreed with
statements including: It is difficult to tell people about my HIV infection; Being HIV
positive makes me feeling dirty; I feel guilty that I am HIV positive; I am ashamed that I
am HIV positive; I sometimes feel worthless because I am HIV positive; and I hide my
HIV status from others. Participants responded to each question by agree = 1 or
disagree = 0. The total scores ranged from 0 to 6. Lower scores at 12 months means
lessened stigma over time.
Both WHOQOL-HIVBREF and Internal AIDS-related stigma measurement tools were
pre-tested, revised and validated prior to beginning data collection.
Baseline characteristics of the participants were collected through a baseline
questionnaire that included socioeconomic characteristics (age, sex, education level,
occupation, marital status, number of children, housing, income) and HIV-related
characteristics (HIV transmission routes, the duration of knowing their HIV status, other
family member infected with HIV or died from HIV, alcohol and drug use behaviours,
hepatitis co-infection, clinical staging).


Data on QOL and internal AIDS-related stigma were collected in a separate room at the
outpatient clinic through self-administered questionnaires after participants were provided
with instructions on how to fill them in by a member of the health staff. These assessments
were carried out at initiation of treatment and then every four months in connection to the
participants’ scheduled monthly drug pick-up with a planned follow-up time of one year.
Statistical analysis
Data collected were processed and analysed using SPSS version 13 and STATA version 10.
Proportions, means and standard deviations (SDs) were used for the descriptive analysis. Chi-
square tests were performed to examine the difference between proportions (sex, age
distribution, marital status, occupations, education level, current and past IDU, clinical stage,
member of family infected with HIV or died from HIV). WHOQOL-HIVBREF scores and
stigma scale scores were assessed for normal distributions. T-tests were used to detect the
difference between mean values of QOL scores or Stigma scores in both related samples
model and independent samples model. Pearson’s correlation coefficient was used to evaluate
the correlation between quantitative variables[29]. Stepwise multiple linear regression and
multilevel linear regression methods were used to estimate the causal relationship between
QOL change between baseline and 12 months and independent variables. We used default
cut-offs provided by SPSS in stepwise multiple linear regression (0.05 to enter in the model
and 0.10 to be removed from the model) to choose the most influential independent variables.
Then multilevel linear regression was applied to justify the effects of intra cluster correlation.
Intra cluster correlation coefficients (ICCs) were calculated to evaluate the similarity of QOL
within clusters (communes). In all the tests and regression models, p-values less than 5 %
were considered significant. Longitudinal approach was attempted in order to take the values
of the QOL at different time points (baseline, 4 months, 8 months, 12 months) into account.
However, due to the small sample size, the change in QOL during the 4 months intervals was
not significant. Thus, only the results related to QOL at baseline and 12 months are presented
here.

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Results
Among 228 ARV-naïve patients recruited to the QOL study within the DOTARV project
from October 2008 to November 2009, there were 119 in the intervention group and 109 in
the control group. Characteristics of the study participants at baseline are described in Table
1. There were no significant differences in these characteristics between the two groups.
Table 1 Baseline characteristics of participants enrolled.
Characteristics
Intervention (n = 119)
%

65.5
34.5

65.5
34.5

45.4
54.6

16
84

12.6
31.1
13.4
42.9

22
78

48.7
51.3

39.5
60.5

26.9
73.1

52.1
36.1
11.8

Control (n = 109)
%

73.4
26.6

70.6
29.4

52.3
47.7

23.9
76.1

15.6
27.5
8.3
48.6

32.1
67.9

54.1
45.9

38.5
61.5

20.2
79.8

52.8
42.2
5.0

p-value*
Age (year)
≤ 35
> 35
Sex
Male
Female
Education
Secondary or less
High school or higher
Occupations
Unemployed
Employed
Marital status
Widow
Single
Divorced/separated
Married
Income/month (USD)
≤ 30 USD
> 30 USD
Having children
Yes
No
Other PLHIV in family
Yes
No
Someone in family died of AIDS
Yes
No
Reported mode of HIV infection
Having sex
IDU
Do not know
History of IDU

0.119


0.410


0.297


0.135


0.490




0.072


0.416


0.882


0.234


0.320

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Yes
No
Current IDU
Yes
No
Hepatitis C and/or B co-infection
Yes
No
Clinical staging
Stage 1 or 2
Stage 3 or 4
*: Chi-square test in proportions comparison
47.1
52.9

9.2
90.8

28.6
71.4

47.1
52.9
45.9
54.1

5.5
94.5

22.9
71.1

48.6
51.4
0.858


0.283


0.332


0.813

QOL in the intervention and control groups
Overall, QOL of the whole cohort seemed to increase over time, with a mean score of 76.5 at
baseline and 77.3 after one year of ART, but this difference was not significant (p = 0.295).
However, stratification by intervention–control groups and clinical stages showed different
patterns.
Table 2 shows the results of the QOL scores that changed over time within each group. In the
intervention group, overall QOL scores and QOL scores of physical and independent capacity
increased mainly among patients who presented at clinical stages 3 and 4. Among patients
who presented at clinical stages 1 and 2, QOL scores increased slightly in independent
capacity (p = 0.033) but decreased in the domain of environment (p = 0.001). In the control
group, QOL increased only in independent capacity among patients presented at clinical
stages 3 and 4.
Table 2 Change in QOL score after 12 months of ART, by QOL domains and
intervention versus control group
QOL by domain
Control group
At baseline
Mean (SD) 12 months
Mean (SD)
Physical 12.87 (2.82) 13.57 (1.65) 0.087
Psychological 12.53 (2.71) 13.05 (1.69) 0.123
Level of Independence 11.93 (2.34) 12.67 (1.72) 0.061
Social Relationships 12.72 (2.44) 12,31 (1.63) 0.166
Environment 12.44 (2.56) 12.24 (2.04) 0.590
Spirituality/Personal
Beliefs
Overall QOL Scores
75.61 (12.65) 77.74 (7.77) 0.337 78.35 (10.62)
Physical 12.76 (2.21) 13.04 (2.08) 0.419
Psychological 13.0 (1.83) 12.26 (2.11) 0.051
Level of Independence 11.71 (1.76) 12.47 (2.10) 0.010
Social Relationships 12.44 (1.92) 12.1 (1.76) 0.491
Clinical
stage
Intervention group
After
12 months
Mean (SD)
13.87 (2.04)
12.93 (1.9)
13.18 (1.93)
12.36 (1.68)
12.19 (1.85)
13 (3.06)
After P-
value*
At baseline
Mean (SD)
P-value*
Clinical
1 & 2
13.45 (2.43)
13.19 (2.13)
12.46 (1.68)
12.79 (2.18)
13.29 (2.31)
13.18 (3.61)
0.274
0.425
0.033
0.206
0.001
0.654 13.11 (3.34) 13.89 (2.89) 0.272
77.53 (9.05)
14.16 (1.90)
12.70 (1.89)
13.29 (2.09)
12.37 (1.29)
0.533
< 0.001
0.970
< 0.001
0.073
Clinical 3
& 4
12.51 (2.56)
12.69 (2.52)
11.52 (2.05)
12.98 (2.45)

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Environment
Spirituality/Personal
Beliefs
Overall QOL Scores 76.82 (8.26)
*: T-test for mean comparison of related samples
Overall QOL score ranged from 24–120
12.44 (1.93)
14.47 (3.17)
11.91 (1.79) 0.107 12.66 (2.31)
13.36 (2.92) 0.107 13.03 (2.85)
12.4 (2.12)
13.78 (2.47) 0.14
0.412
75.36 (9.6)
0.438 75.39 (10.38)
78.69 (8.47) 0.023
Table 3 shows the results of comparison of QOL scores changed over time between groups.
Among participants enrolled with more severe immunosuppression at baseline (clinical stage
3 and 4), there was a significant association between peer support and improved overall QOL
(p = 0.034), more specifically the QOL domains of physical well-being (p = 0.007), level of
independence (p = 0.038) and spirituality (p = 0.029). Meanwhile, among participants those
were less symptomatic when beginning ART (clinical stage 1 or 2), there were no significant
differences between the two groups in overall QOL or in any of the specific domains (Table
3).
Table 3 Mean of difference after 12 months of ART between groups
Clinical 1 & 2
Control
Mean (SD) Mean (SD)

Physical 0.6792 (2.83) 0.4286 (2.90) 0.649 0.3036 (2.78)
Psychological 0.5585 (2.59) −0.2571 (2.39) 0.090 −0.7571 (2.84) 0.0127 (2.66)
Level of Independence 0.6792 (2.57) 0.7143 (2.44) 0.942 0.8214 (2.28)
Social Relationships −0.5283 (2.73) −0.4286 (2.50) 0.843 −0.2321 (2.5) −0.6190 (2.69)
Environment −0.2170 (2.91) −1.0982 (2.36) 0.085 −0.5089 (2.32) −0.2540 (2.44)
Spirituality/Personal
Beliefs
Overall QOL
1.7377 (13.06) −0.8196 (9.76) 0.248 −1.2482 (11.95) 3.2984 (11.21)
*: T-test for mean comparison of independent samples,
QOL: higher score: better QOL

Clinical 3 &4
Intervention
Mean (SD)
Intervention P-
value*

Control
Mean (SD)

P-value*
QOL

1.6508 (2.58)
0.007
0.130
0.038
0.421
0.562
0.029
1.7619 (2.55)
0.5660 (3.70) −0.1786 (2.96) 0.248 −0.8715 (4.00) 0.7460 (3.96)
0.034
Factors influencing QOL improvement
Table 4 presents factors related to overall QOL by Univariate analysis. All the factors
included in Table 4 which had a p-value < 0.20 (showing a possible correlation with the main
outcome) were added in regression models. After stepwise multiple linear regressions, the
most influencing independent variables were taken into of multilevel linear regression
analysis with individuals as units of level 1 and communes as units of level 2 (Table 5). Intra
cluster correlation coefficients (ICCs) of 12-months changing of overall QOL as well as of all
domains are presented in Table 5.

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Table 4 Changing of Overall QOL Scores after 12 months of ART and influencing
factors by Univariate analysis
Patients at Clinical stage 1 & 2
Mean of difference P value*
Male −1.1149
Female 2.8786
>35 −1.3867
= < 35
1.1114
Occupation
Unemployed 3.3500
Employed −0.1549
Education
Secondary or less 1.7457
High school or higher −0.5413
Having children
Yes 2.5875
No −2.1327
Income/month
≥30USD 3.2469
<30USD −0.9197
Other PLHIV in
the family
No −0.2217
Someone in family
died of AIDS
No 0.3313
Own a house
Yes 3.6938
No −0.6671
Social support
High 0.3203
Low 0.5464
Hepatitis C and/or
B
No 2.3880
Alcohol use
Yes −1.0579
No 1.5386
History IDU
Yes −0.6667
No 1.3828
Current IDU
Yes 1.8875
No 0.3079
Intervention
Yes −0.8196
No 1.7377
*: T-test for mean comparison of independent samples
Factors

Sex

Age

Patients at Clinical stage 3 & 4
Mean of difference P value*
0.2227
3.8161
2.1975
0.6329
1.4333
1.1775
−1.0789
3.2161
1.2738
1.0379
1.2500
1.1220
3.1725
0.078

0.314

0.24

0.3080

0.033

0.086

0.520
0.114

0.495

0.891

0.046

0.913

0.958

0.184 Yes 1.2143

0.882
0.1392
7.4926

0.001
Yes 0.7192

0.069

0.919

0.002
0.7000
3.2419
0.4126
2.3629
−0.1509
−2.3833

0.253

0.245

0.034
Yes −5.9522

0.295

0.356

0.711

0.248

2.6185
0.7488
1.3727
0.0873
2.0797
−1.400
1.3682
3.2984
−1.2482

0.786

0.358

0.499

0.034

Page 12

Table 5 QOL change after 12 months of ART in multilevel linear regression models
Dependent
variable**
Factors
Clinical stage 1 & 2
Unstandardized
Coefficients

0.979
−2.537
1.762
4.561
−6.460
−1.001

0.557
−0.767
−0.175
0.840
−0.204
0.223

0.384
−0.392
0.722
0.800
−1.199
−0.495

Clinical stage 3 & 4
Unstandardized
Coefficients

−4.690
5.311
8.776
−0.486
−2.764
4.156

0.420
0.556
1.204
−0.497
−1.229
1.359

−1.221
1.013
1.411
−0.354
−0.540
0.641

ICC
(%)
28.6






32.2






27.6






26.1
Standardized
Coefficients


−0.109
0.066
0.199
−0.230
−0.044


−0.133
−0.026
0.148
−0.029
0.039


−0.077
0.123
0.160
−0.196
−0.099

P
value*

0.672
0.254
0.487
0.036
0.017
0.689

0.376
0.181
0.789
0.132
0.773
0.758

0.415
0.420
0.195
0.091
0.043
0.414

ICC
(%)
42.7






44.7






40.9






37.7
Standardized
Coefficients


0.226928
0.314378
−0.02076
−0.10861
0.177439


0.101
0.184
−0.091
−0.206
0.247


0.184
0.214
−0.064
−0.090
0.116

P
value*

0.074
0.010
0.000
0.810
0.214
0.080

0.497
0.258
0.037
0.304
0.021
0.014

0.037
0.044
0.018
0.478
0.322
0.232

Overall QOL






Physical






Psychological






Level of
independence



Constant
High school or higher education
Someone in family died of AIDS
Having children
Hepatitis C and/or B co-infection
Intervention

Constant
High school or higher education
Someone in family died of AIDS
Having children
Hepatitis C and/or B co-infection
Intervention

Constant
High school or higher education
Someone in family died of AIDS
Having children
Hepatitis C and/or B co-infection
Intervention

Constant
High school or higher education


0.969
−0.798
0.056
0.103


1.420
−0.286

0.010
0.532 −0.158 −0.058

Page 13

Social relation






Environment






Spirituality/personal
beliefs





*: Test to compare regression coefficient to 0,
**: Difference between 12-month score and baseline score,
ICC: Intra cluster (commune) correlation
Someone in family died of AIDS
Having children
Hepatitis C and/or B co-infection
Intervention

Constant
High school or higher education
Someone in family died of AIDS
Having children
Hepatitis C and/or B co-infection
Intervention

Constant
High school or higher education
Someone in family died of AIDS
Having children
Hepatitis C and/or B co-infection
Intervention

Constant
High school or higher education
Someone in family died of AIDS
Having children
Hepatitis C and/or B co-infection
Intervention




0.509
0.433
−1.470
0.347

−0.516
−0.304
−0.148
0.313
−1.622
0.418

−0.182
−0.219
0.213
0.442
−2.315
−0.315

−0.530
−0.051
0.324
1.865
0.348
−0.778
0.087
0.087
−0.241
0.070


−0.058
−0.024
0.060
−0.255
0.080


−0.041
0.034
0.083
−0.355
−0.059


−0.008
0.041
0.279
0.043
−0.116
0.363
0.364
0.014
0.564

0.377
0.561
0.840
0.539
0.011
0.472

0.737
0.657
0.705
0.358
0.000
0.602

0.444
0.939
0.671
0.004
0.670
0.327




0.431
−0.551
−0.789
0.806

−1.012
0.733
1.297
0.354
−0.261
−0.414

−1.155
0.849
1.096
0.114
−0.276
0.174

−3.215
2.215
3.337
0.524
0.522
1.705
0.073
−0.112
−0.147
0.164


0.141
0.210
0.069
−0.046
−0.080


0.179
0.194
0.024
−0.053
0.037


0.275
0.347
0.065
0.059
0.211
0.429
0.226
0.113
0.097

0.070
0.125
0.023
0.456
0.615
0.417

0.040
0.065
0.038
0.799
0.576
0.761

0.000
0.001
0.000
0.446
0.487
0.026
21.5






31.2






22.3






33.5






32.4






32.0

Page 14

Results among patients presented at Clinical stages 3 and 4
Participants had significant improvement in overall QOL after 12 months if they had higher
education (p = 0.01), previously had an experience of a family member dying from HIV
(p < 0.001) or received peer support (“borderline” p = 0.080). The influences of intervention
and other factors to specific domains are also described in Table 5. People with higher
education had significant improvement in Psychological wellbeing (p = 0.044) and
Spirituality/personal beliefs (p = 0.001). Meanwhile, experience of a family member dying
from HIV gave positive contributions for almost all domains of QOL Conversely, Hepatitis C
and/or B co-infection was significantly associated with decreased Physical wellbeing
(p = 0.021).
Results among patients presenting at clinical stages 1 and 2
Peer support did not appear to have any impact (Table 5). In this group, for those with
hepatitis B and/or C co-infection, overall QOL decreased significantly (p = 0.017) after 12
months of follow-up, specifically for the QOL domains of psychological well-being
(p = 0.043), level of independence (p = 0.014), social relations (p = 0.011) and environment
aspect (p < 0.001). Whilst, having children in family can help to have better
Spirituality/personal beliefs (p = 0.004) and then to improve QOL (p = 0.036).
QOL and internal AIDS-related stigma
The average internal AIDS-related stigma scores for both intervention and control groups) at
baseline and after 12 months were 3.21 (SD = 1.96) and 3.27 (SD = 1.80) respectively. The
internal AIDS-related stigma did not differ between the intervention and control groups or
between the different clinical stage groups after 12 months. There was a significant
association between value of QOL change over time and changes in internal AIDS-related
stigma (p < 0.001). However, this is not a strong correlation with a correlation coefficient of
−0.36. Patients who reported improved QOL after 12 months on ART also reported decreased
stigma and vice versa.
Discussion
This is the first study, to our knowledge, that shows a positive effect of peer support on QOL
among severely immunosuppressed patients initiating ART in the context of a randomised
controlled trial. We found that peer support had a very different effect on QOL depending on
the patient’s clinical condition when starting ART. Those with severe immunosuppression
and opportunistic infections (clinical stages 3 or 4) who received extra adherence support
from a trained peer supporter reported significantly improved QOL after 12 months on ART
compared to a control group who received standard care. This improvement in the
intervention group was not found among patients who were asymptomatic or who had mild
symptoms (clinical stage 1 or 2) when ART was initiated.
QOL was particularly improved among severely immunosuppressed intervention-group
patients in the domains that relate to the clinical condition such as physical well-being, level
of independence and spirituality (perceptions about the future or worrying about death). For
other QOL domains (psychology, social relationships and environment) improvement
appeared to depend on individual factors such as level of education and earlier experience of

Page 15

a family member dying from HIV rather than on contact with a peer supporter. The
improvement in QOL in some segments of the intervention group might have been because
the peer supporters were able to utilise their own experiences as PLHIV to empathically
listen, understand, advise and assist the patients to problem-solve. In addition, as the peer
supporters had received training, they could act as intermediaries between patients and health
care providers [30], giving information, counselling and assisting patients to contact health
staff when needed [23], particularly in cases the patients experienced severe symptoms that
could influence QOL negatively [31].
While QOL became better over time among patients started ART in advanced stage of
HIV/AIDS (clinical stage 3 or 4), the patients who had not experienced AIDS and
opportunistic infections (clinical stage 1 or 2) often showed a decline QOL after baseline
[32]. They might have perceived the regular visits of the external supporters as annoying or
threatening due to the risk of involuntary disclosure to neighbours, which might have reduced
some aspects of QOL [19]. Other explanations such as challenges with starting ART per se,
including the treatment associated stigma we found in an earlier study [23] and the issue of
being dependent on life-long regular medicine intake while not being physically very sick,
might also play a role. As opposed to the patients in stage 3 or 4, who experienced physical
improvement, these patients have less clear evidence of the positive side of the medication.
Alternatively, one might perceive that there could be a ceiling effect with the WHOQOL-
HIVBREF that might occur in the stage 1 and 2 group, with baseline high QOL. However,
we were surprised that QOL was not higher among this group at baseline and do not think
that there was a significant “ceiling effect” in play during this evaluation.
Meanwhile the intervention improved QOL among participants in the group with severe
immunosuppression and opportunistic infections, there were no changes regarding internal
AIDS-related stigma scores neither in the intervention nor in the subgroup with different
clinical stages. Stigma might be not directly influenced by adherence support measures. In
Vietnam there is a strong association between HIV and “social evils” including IDU and sex
work as well as fear of HIV transmission [33]. A study carried out in Ho Chi Minh City,
Vietnam revealed that PLHIV often faced problems getting a job, perceived unfair treatment
in the work place and experienced discrimination from health care providers [34].
The decision to use peer support as an intervention was taken as a result of focus group
discussions with patients on ART [23] when ART was newly implemented in Vietnam and
the majority of the participants had been or were severely immunosuppressed with
opportunistic infections. The effect of peer support on QOL improvement depends on the
clinical stages of patients as shown by this study. This randomized controlled trial
implemented a common standardized intervention for all patients, independent of clinical
staging and severity of disease and, therefore, may have some limitations. However, the
findings indicate a need to develop appropriate intervention tools tailored according to the
severity of disease at ART initiation to enable contextualization of the support to different
strata of the patient population. Based on our results, we cannot recommend a general peer
support intervention but rather an intervention targeted to patients with advanced stages of
HIV infection. While there seem to have been benefits for the patients in stage 3 and 4, there
were no such effects on the patients with less advanced disease. Possibly similar positive
effects could be achieved by support to HIV positive clubs of various kinds, encouraging
twinning of patients for those who wish, group support meetings at the hospital etc, rather
than organized as the individual resource-intensive process presented in this study. With such
an approach, patients’ needs could be revaluated on a regular basis. For patients who initiate