Introduction

The advent of antiretroviral therapy (ART) and effective treatment protocols have provided opportunities for PLWHA to live longer lives; hence, HIV is now perceived as a manageable chronic condition instead of a terminal illness [1]. Indeed, there is conclusive evidence that effective ART reduces the risk of HIV transmission to almost zero when the viral load remains persistently below 1000 copies per ml [2]. The treatment also significantly improves life expectancy and health-related quality of life [3]. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) recently estimated that approximately 39 million people are living with HIV/AIDS worldwide, and 29.8 million out of this number have access to antiretroviral treatment [4]. Adopting and scaling up the most effective strategies to prevent new infections has been central to the HIV/AIDS control strategy [5]. This strategy is aimed at improving the quality of life (QoL) of people battling the infection [5].

Self-disclosure of sensitive information is beneficial for people’s health: lower stress and better psychological well-being [6, 7]. Studies also indicate that individuals who disclosed their results have greater adherence to ART treatments [8–10]. Moreover, disclosure may increase opportunities to receive social support, which may help individuals cope and recover from physical illness and lessen depressive symptoms due to HIV-related physical symptoms [11, 12].

Folasire and colleagues argue that the availability of care and social support from family members and close friends are major determinants of the QoL of PLWHA [13]. Although willing to access this support and care, most PLWHA are concerned about the possibility that disclosing their HIV status to family members and close friends will result in some stigmatization and discrimination, likely affecting their loved ones and personal relationships [14, 15]. The negative attitude of society and HIV-related stigma dissuade PLWHA from disclosing their status, especially in low- and middle-income countries [16, 17]. Stigma has profound implications for HIV prevention, treatment, care, and support [18, 19].

Studies have shown reluctance to disclose HIV status among many sub-Saharan Africans even when they had gone for Voluntary Counselling and Testing, with the few who choose to disclose it being selective in choosing their audience [20–23]. Stigma and discrimination against PLWHA are pervasive and represent significant obstacles to HIV/AIDS prevention efforts, including HIV testing and status disclosure [24, 25]. Internalised and experienced/expected HIV-related stigma, such as guilt, shame, fear of abuse, and rejection, among other things, is a major obstacle to HIV status disclosure in Ghana and some parts of Sub-Saharan Africa [26–28]. In Ghana, HIV status disclosure remains a difficult task for most HIV-positive individuals poses a real challenge in providing treatment and clinical care to PLWHA [29]. Internalised HIV stigma is common among PLWHA in Ghana while community-related stigma has been found to affect HIV status disclosure [30]. Acquiring HIV/AIDS in Ghana is generally considered the result of promiscuity or sexual immorality, so infected individuals are highly discriminated against and stigmatized [31]. PLWHA are subjected to a variety of types of stigmatisations and discrimination, such as rejection from their families and communities, inability to share a meal or a bed, finger-pointing, and exclusion [25, 32]. These discriminations and stigmatization lead to decreased self-esteem, lowered body image, negative feelings about self, depression, anxiety, self-isolation, feelings of guilt and failure to disclose status [33].

Chronic illness has always constituted a barrier to QoL [34, 35]. HIV/AIDS is notorious for hindering the QoL of people [34]. PLWHA face psychological isolation and condemnation from their family, friends, and society because people around them are aware of their HIV status, affecting their physical health even though ARTs help with regaining their strength [36, 37].

Disclosure to family members and friends is indeed necessary to ensure social and/or material support [38], especially when the availability of care and social support from family members and close friends tend to be the major determinants of the QoL of those living with HIV in resource-limited settings [13]. It is also noted that the desire for care and support enforces the willingness to disclose one’s HIV status; however, this is withheld where support is not expected [13].

There is a paucity of information regarding disclosure and QoL among PLWHA in the Obuasi East District of the Ashanti Region. It is therefore of prime importance to know what the effect of HIV status disclosure has been on PLWHA. Therefore, we examined the influence of HIV/AIDS status disclosure on quality of life among PLWHA in the Obuasi East District of the Ashanti Region of Ghana.

Methods and materials

Results

Sociodemographic characteristics of respondents

In all, 124 PLWHA consented to participate, resulting in an 89% response rate. Table 1 shows the sociodemographic characteristics of the respondents. Most of the respondents (54.8%) were males. The mean age of the respondents was 35.38 years. Additionally, 58.0% of the respondents were never married, and 20.2% were divorced/widowed. Most of the respondents (62.1%) were Christians, and 14.5% were Muslims. Furthermore, more than half (72.6%) of the respondents were Akan, and 45.2% had attained secondary education. Almost all (80.6%) of the respondents were urban residents. In addition, more than half (58.9%) were employed. Of those employed, 20.5%, 21.9%, and 19.2% were traders, skilled workers, and artisan miners, respectively.

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Table 1. Sociodemographic characteristics of respondents.

https://doi.org/10.1371/journal.pmen.0000060.t001

Status disclosure and social support availability among PLWHA

Regarding status disclosure, 41.9% of the respondents disclosed their status to another person. Of these, a relative majority (46.2%) disclosed to their spouses, and 13.4% and 23.0% disclosed to children and nonfamily relations, respectively. Additionally, 76.9% of those who disclosed their HIV/AIDS status received a form of social support from such persons. Kinds of support received included support for medical expenses (47.5%), cash for upkeep (55.0%), shelter (52.5%), and emotional support (55.0%). The main sources of emotional support were spouses (60.0%), children (17.5%), parents (7.5%), and nonfamily relations (7.5%). Additionally, 16.9% of the respondents were in peer support groups (Table 2).

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Table 2. Status disclosure and social support availability.

https://doi.org/10.1371/journal.pmen.0000060.t002

Quality of life of people living with HIV/AIDS

This study also assessed the QoL of the respondents in Table 3. The mean QoL was highest within the physical domain (13.3±2.9), while the psychological domain indicated the lowest QoL among the respondents (11.03±3.26). The overall mean QoL score was 73.18, with 47.6% attaining at least this score.

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Table 3. Summary scores of WHOQOL-HIV domains.

https://doi.org/10.1371/journal.pmen.0000060.t003

Table 4 presents the results of a comparison of the means of QoL per background characteristics of the respondents. On average, respondents who were less than thirty years old had higher QoL in the physical, psychological, independence, social and environmental domains, and the difference was statistically significant. This same age group averaged a higher overall QoL, and the difference was statistically significant. Females recorded higher average QoL scores than males in physical, psychological, and independence domains as well as overall QoL, and the difference was statistically significant. Those who were currently married had higher average QoL scores in all domains, including overall QoL, and the difference was statistically significant. Regarding religion, Muslims had higher average QoL scores in all domains, including overall QoL, and the difference was statistically significant. Respondents with tertiary education had a higher average QoL score in all domains, including overall QoL, and the difference was statistically significant. Even though respondents who disclosed their status had higher overall scores for all QoL domains except independence, the difference was not statistically significant.

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Table 4. Comparison of mean QoL scores for background characteristics.

https://doi.org/10.1371/journal.pmen.0000060.t004

Factors influencing quality of life among PLWHA

Table 5 presents the effects of status disclosure and other independent factors on the QoL of PLWHA. The regression model explained 51.5%, 54.0%, 55.6%, 41.2%, 48.7% and 44.4% of the variance in the physical, psychological, independence, social, environmental and spiritual domains, respectively. Overall, the regression model explained 51.8% of the variance in the overall quality of life score. As age increased, overall QoL decreased, and this observation was statistically significant. The QoL of males was significantly lower than that of females in all domains as well as overall QoL. Muslims had significantly higher QoL than Christians in all domains as well as overall QoL. Respondents who had tertiary education had significantly better QoL than those without any education. On the other hand, respondents who had tertiary education recorded lower QoL in the psychological domain than those who had no formal education, and this difference was statistically significant. Respondents who lived in urban areas had better QoL in all domains and overall QoL than those who lived in rural areas, and the difference was statistically significant. Although respondents who disclosed their status recorded better QoL overall than those who did not disclose their status, the difference was not statistically significant.

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Table 5. Effect of status disclosure on factors influencing quality of life among PLHIV.

https://doi.org/10.1371/journal.pmen.0000060.t005

Discussions

We examined HIV/AIDS status disclosure and social support availability and their influence on quality of life among PLWHA in the Obuasi East District of the Ashanti Region, Ghana. We found that less than half of the HIV/AIDS clients had disclosed their status to someone such as a spouse, children, and nonfamily relations. Additionally, most of the clients had moderate quality of life across most of the six domains. We did not find a significant link between HIV/AIDS status disclosure and quality of life in any of the domains.

The finding that most HIV/AIDS clients did not disclose their status is congruent with many studies across the globe. Our status disclosure of 41.9% is consistent with the argument by Ssali et al. that HIV/AIDS status disclosure ranges from 24–91% [17] and is lower than the 49% reported by the WHO in the developing world [42]. Our finding could be attributed to the high levels of stigma and discrimination [43], fear of severed relationships, abuse [44], and feelings of shame in certain settings [45]. The finding suggests a need for interventions aimed at reducing stigma and discrimination to encourage more individuals to disclose their status, thus potentially improving overall QoL. Strategies for reducing stigma and discrimination among PLWHA may involve community education campaigns, workplace sensitivity training, and legal protections against discrimination based on HIV status.

We found in our study that HIV-positive patients had moderate QoL scores in all domains. This supports the argument that being on ART leads to better QoL, regardless of the duration of the ART [46]. It is therefore expected that most of the clients in this study would have better QoL similar to those in other low-income countries [47–49]. This is because PLWHA attend routine ART clinics for their follow-up and receive counselling, care and treatment, which may have positively impacted all the domains of health-related QoL. Additional support or interventions may thus be needed to enhance QoL beyond medical treatment alone.

Our finding that disclosure of HIV/AIDS status was not a statistically significant predictor of quality of life is supported by a study by Agbeko et al. [50], who found that disclosure status of HIV/AIDS among PLWHA in the Ho municipality of Ghana was not statistically significant, although disclosure improved the overall QoL of PLWHA. Similarly, the findings of Chandra and colleagues that HIV serostatus disclosure was not significantly associated with QoL gives credence to our result [51]. Other studies, by contrast, established a statistically significant relationship between disclosure of HIV/AIDS status and quality of life [46, 52, 53]. Even though our finding was not statistically significant, the fact that disclosure improves the QoL of HIV/AIDS could be explained by the role of supportive relationships minimizing stigmatization and discrimination toward PLWHA, which consequently boosts the QoL of PLWHA. Supportive social networks have been shown to play a crucial role in buffering the negative impact of HIV/AIDS-related stigma and discrimination, thereby promoting psychological well-being and overall QoL among PLWHA. Additionally, policies and interventions aimed at reducing stigma and discrimination within communities could further amplify the positive effects of disclosure on QoL. Thus, while our study did not find a direct statistical link, the broader context suggests that disclosure may indeed contribute to improved QoL through its influence on social support and stigma reduction. Social support networks could be enhanced through establishing peer support groups, providing counselling services, and promoting community engagement through awareness-raising events and activities.

Furthermore, we discovered that age negatively predicted the overall quality of life of PLWHA to a statistically significant degree. In other words, as PLWHA grow older, their QoL becomes poorer. This finding is analogous to a Kazakhstan study that established that increasing age decreases the QoL of PLWHA [54]. In the same vein, Chinese and Pakistani studies found that age was negatively associated with QoL [55, 56]. Some authors have made contradictory findings, however. For instance, studies in Burkina Faso showed that older PLWHA were more likely to have higher QoL than younger PLWHA [49]. There seems to be a logical explanation for our finding on the relationship between age and QoL. As people grow older, they are more exposed to diseases that weaken their immune system, thus compounding their healthcare problems and undercutting their QoL. Likewise, mental health challenges are commonly associated with old age.

We also established that female PLWHA had significantly higher QoL in all domains than their male counterparts. This finding is partially supported by a study that showed that females had significantly higher QoL in the domain of physical well-being than males [57]. Other studies, however, suggest that being a male PLWHA is a positive predictor of QoL [49, 56, 58, 59]. Meanwhile, some researchers did not find a statistically significant relationship between QoL and the sex of PLWHA [13, 50]. There is no consensus in the literature on the influence of sex on the QoL of PLWHA. Both groups of researchers who found opposing relationships between sex and QoL of PLWHA rely on one explanation for their observations: gender roles. Gender roles resign females living with HIV/AIDS to discriminatory behaviour, which could hinder their QoL. Additionally, gender roles limit access to the financial resources of these females, which impedes their ability to fend for themselves and improve their QoL. The same gender roles hurt men living with HIV/AIDS, too, by putting financial stress on men—in their role as breadwinners of the family, which invariably affects their QoL.

Our study also pointed to the influence of geographic location on the QoL of PLWHA. Urban residency is a positive predictor of HIV/AIDS. Although studies are largely silent on the impact of geographical location on the QoL of PLWHA, the study by Shriharsha and Rentala [58] found that PLWHA in urban areas had significantly higher QoL, supporting our findings. Urban locations, especially in developing settings such as Ghana, provide an advantage regarding physical access to ART services, which empowers PLWHA and puts them in a better position to cope with the disease than their colleagues in rural areas. Improving access to healthcare services for PLWHA in different demographic groups may require initiatives such as mobile clinics for rural areas, transportation subsidies, and culturally sensitive healthcare provider training programs.

In addition to the geographical area, our findings revealed the influence of religion on the QoL of PLWHA. Belonging to the Islamic religion was a positive predictor of quality of life. The influence of religion on the QoL of PLWHA is an established concept [60, 61]. Religious bodies present an opportunity for social support for PLWHA. However, the particular reason for the advantage that the Islamic religion gives to PLWHA is unclear. Perhaps Islamic practices are more collegial and community-centred than Christian practices.

Moreover, the intersectionality of sociodemographic factors, including age, gender, geographic location, and religion, presents a complex interplay that influences the quality of life of PLWHA. In the Ghanaian context, cultural norms, access to resources, and community support systems may interact with these sociodemographic factors to shape the experiences and well-being of PLWHA. For example, older PLWHA in rural areas may face compounded challenges due to limited access to healthcare services and social support networks, leading to a significant impact on their QoL compared to younger counterparts in urban settings. Gender dynamics further complicate this scenario, as cultural norms and expectations may influence access to employment opportunities and financial resources differently for men and women living with HIV/AIDS. Additionally, geographic location plays a pivotal role; while urban areas typically offer better access to healthcare facilities and support services, factors such as stigma and discrimination may still persist, particularly affecting QoL among PLWHA in densely populated urban centres. Moreover, religious affiliation can influence social support structures and coping mechanisms, with religious communities often providing essential support networks for PLWHA. For instance, mosques and churches may serve as hubs for community gatherings and support groups, facilitating emotional support and enhancing QoL for PLWHA. Understanding these complex interactions is crucial for tailoring targeted interventions and policies to address the diverse needs of PLWHA across different sociodemographic groups. Exploring potential barriers or challenges to implementing these interventions could involve assessing cultural beliefs, addressing healthcare infrastructure limitations, and overcoming financial constraints for both individuals and healthcare systems. Collaborating with local community leaders, leveraging technology for remote healthcare delivery, and advocating for policy changes to support comprehensive HIV/AIDS care can help overcome these barriers.

Conclusions

The finding that less than half of the PLWHA disclosed their HIV/AIDS status implies that most of their sexual and nonsexual relations are at risk of infection. Additionally, this suggests that persistent stigma and discrimination may contribute to the reluctance of most PLWHA to disclose their status. This may affect the fight to reduce the infection and improve the quality of life for PLWHA.

Moreover, the finding that most PLWHA had moderate quality of life implies that ART services likely have a positive impact on the clients’ well-being. A good quality of life suggests improvement in the overall health of HIV/AIDS patients, potentially reducing morbidity and mortality associated with the disease. Ghana’s chances of attaining goal 3.3 of the Sustainable Development Goals, which seeks to end the HIV/AIDS epidemic and reduce mortality associated with the condition, could be increased by stakeholders through initiatives that target and limit the influence of negative predictors of the quality of life of PLWHA.

Based on the implications of these findings, we recommend that the Ghana AIDS Commission and the Ghana Health Service intensify efforts to reduce discrimination and stigmatization associated with HIV/AIDS. Furthermore, stakeholders in AIDS prevention in Ghana should employ innovative methods such as peer support to encourage status disclosure and provide education on the provision of social and emotional support for PLWHA.

Supporting information