Beyond viral suppression of HIV: quality of life of people living with HIV in the Eastern Cape province, Republic of South Africa

Abstract

The management of HIV has greatly advanced with the introduction of antiretroviral therapy (ART), enabling most individuals living with HIV (PLWH) to achieve viral load suppression. In Africa, the success of treatment programmes is often measured by this essential biomedical indicator. However, the goal of HIV care extends beyond merely reaching undetectable viral loads; it also encompasses the overall health and quality of life (QoL) of individuals. The success of antiretroviral therapy (ART) has transformed HIV from a deadly health condition into a chronic, manageable condition, enabling people living with HIV (PLWH) to achieve viral load suppression (VLS) within a reasonable period, thus saving lives. While VLS is a critical clinical milestone, it does not inherently equate to a high quality of life (QoL). This doctoral research project addresses a pivotal gap in the literature by systematically investigating the multifaceted determinants of QoL among PLWH who are virally suppressed, with a specific focus on the African context. The research moves beyond a purely biomedical model of care to explore the psychological, social, environmental, and behavioural factors that sustain well-being after viral suppression. A mixed-methods study to provide a comprehensive analysis was conducted anchored on three key strands being; A Scoping Review that systematically identified and synthesized existing literature on correlates of QoL for PLWH with VLS in Africa; Quantitative Investigations that utilized validated instruments (WHOQOL-BREF, AUDIT, WHO STEPwise) in a sample of 244 virally suppressed adults in the Eastern Cape, South Africa, to quantitatively assess QoL domains, substance use patterns, and their socio-demographic associations; and Qualitative Enquiry which conducted in-depth interviews with purposively selected PLWH who were virally suppressed to explore the subjective, lived experiences and determinants of self-rated health and excellent QoL. This study yielded several interconnected findings that highlight the complex reality of life after viral suppression. Overall, QoL among virally suppressed individuals was moderate (mean score: 50.5). The environmental domain (access to services, financial resources, physical safety) was consistently the lowest-scoring aspect of QoL, while the physical health domain was rated highest. Key Social Determinants of QoL like socio-economic factors specifically employment, higher education, and income were significantly associated with higher scores across all QoL domains. Conversely, lack of family support, and poor living conditions were strongly correlated with poor QoL. High Prevalence of Substance Use, especially among the female population, undermined gains of viral suppression, with alcohol and tobacco use remaining significant public health concerns. The study found a high prevalence of alcohol dependence, with distinct gendered patterns suggesting that males were more likely to engage in hazardous/harmful drinking, while females constituted a majority of those with likely alcohol dependence. Substance use was significantly linked to employment status, age, and marital status. Subjective Determinants of Excellent Self-Rated Health investigated through qualitatively approach indicated that participants defined excellent self-rated health through psychological resilience (e.g., downward counterfactual thinking), perceived health improvements, and adherence to healthy behaviours (ART, diet, abstinence from substances). Financial stability and good healthcare access were also identified as indispensable enablers of these positive outcomes. This doctoral research project establishes that viral suppression, while a necessary achievement, is an insufficient sole indicator of overall well-being for PLWH. The findings compellingly argue for a paradigm shift in HIV care from a narrow focus on biomedical outcomes to a holistic, person-centred model. The original contribution of this work lies in its integrated evidence that long-term well-being is dependent on addressing the intersecting social, economic, and behavioural determinants of health. It identifies specific, modifiable targets for intervention, including economic empowerment, stigma reduction, and the integration of mental health and substance use services into routine HIV care. Critical reforms in policies and programs designs are needed to deliberately target these broader determinants to sustain the gains of ART. These should include implementing gender-responsive interventions to address substance use; development of multidisciplinary care models that integrate financial counselling, mental health support, and lifestyle modification; advocacy for policies that improve access to education, employment, and social support for PLWH; and incorporating routine screening for QoL and substance use into standard HIV clinical care and practice. By addressing these areas, healthcare systems can better support PLWH who are virally suppressed in achieving not just longer lives, but lives of significantly improved quality and dignity.