{"paper_id":"2dc5fc57-7df4-415b-9e38-b2945e8b7f32","body_text":"NiVEst study: Dimensions of stigma and quality of life in people living with HIV | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article NiVEst study: Dimensions of stigma and quality of life in people living with HIV Carolina Olmos Mata, Álvaro Morales Aser, Adrián Valls Carbó, and 14 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6775249/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: Stigma in people living with HIV (PLHIV) has been found to be negatively associated with quality of life. The study aims to determine whether there are relationships between different dimensions of stigma and quality of life. The secondary objective is to determine associations of stigma with medical variables and to incorporate the use of specific interventions and tools to improve consultation and care for PLHIV. Methods : Cross-sectional, multicentre study involving 144 people living with HIV (PLHIV) on antiretroviral therapy (ART) and prolonged viral suppression. Sociodemographic data were collected through questionnaires, together with the results of the stigma scale adapted to the Spanish population, the quality of life (QoL) scale for people with HIV and clinical data obtained from electronic medical records (EMR). Results : Stigma is negatively associated with QoL (adjusted beta = -0.59 [-0.81; -0.37] p<0.001.There is a negative association between all the subdomains of stigma and overall quality of life, as well as a negative association between all the subdomains of QoL and overall stigma. Total QoL and external perceived stigma have the strongest association (ρ=-0.52, p<0.01) and the stigma related to disclosure concerns and spiritual QoL (p=-0.46 p < 0.001). Total stigma was found to be increased related to lower income (β =-10.30 [-18.40, -2.20], p=0.013), female sex (β =9.64 [1.60, 17.68], p=0.019) and Kaposi's sarcoma (KS) (n=3) during evolution was associated with increased total stigma (β =23.57 [7.26, 39.88], p=0.007) and externalised stigma (β =14.76 [6.12, 23.4], p=0.002). Conclusions : Stigma and quality of life in people living with HIV (PLHIV) are closely related. Our study demonstrates that greater stigma is associated with lower quality of life, particularly in spiritual well-being. The subdomains of both stigma and quality of life show a significant negative relationship. Moreover, higher-risk groups, such as women, individuals with low incomes, or patients with advanced disease, are more vulnerable to stigma, which worsens their quality of life and increases the risk of adverse disease progression. It is crucial to adopt a holistic approach that includes both medical treatment and psychosocial support to improve long-term well-being and quality of life. Health sciences/Diseases/Infectious diseases/Hiv infections Health sciences/Diseases/Infectious diseases/Viral infection Health sciences/Health care/Quality of life HIV stigma quality of life internalised stigma spiritual quality of life Figures Figure 1 Introduction The term stigma has its origins in ancient Greece, where it was used to brand criminals, slaves and traitors as immoral or tainted [ 1 ]. In the context of HIV, stigma refers to negative attitudes and behaviours towards people living with HIV (PLHIV), associated with prejudices about HIV transmission and behaviours perceived as immoral, such as drug use or unsafe sexual practices. Earnshaw and Chaudoir's model of stigma [ 2 ] describes how stigmatisation begins with HIV being seen as a socially devalued ‘brand’, affecting people through prejudice, stereotyping and discrimination. Among HIV-negative people, stigma manifests itself as a psychological reaction that perceives PLHIV as a threat to health or as having moral defects. For PLHIV stigma is expressed in three forms: experienced stigma, when they face actual discrimination; anticipated stigma, based on fear of future discrimination that makes it difficult to disclose their status; and internalised stigma, when they accept negative beliefs about themselves, which affects their psychological well being [ 2 ]. HIV-related stigma negatively impacts the physical health of people living with HIV (PLHIV) by promoting harmful habits such as sedentary lifestyles and substance use. It also generates a fear of disclosing one's HIV status, which can affect sexual intimacy, social interactions, and contribute to mental health issues. Furthermore, HIV-related stigma exacerbates social vulnerability and isolation. This stigma can lead to internalized stigma, where individuals adopt negative societal attitudes towards themselves, manifesting in self-isolation and reduced social engagement, which in turn intensifies feelings of loneliness and depression [ 4 ] Factors such as gender, class and geographic location can intensify stigma. A study in Kenya on Kaposi's sarcoma (KS) showed that patients face multiple forms of discrimination that hinder access to care and affect their well-being [ 5 ]. Stigma not only affects mental health, but also restricts access to medical and social resources, underscoring the need for interventions that address stigma and promote social inclusion [ 6 ]. HIV stigma and discrimination are common barriers to HIV prevention, care and treatment services, including HIV testing, condom use, adherence to antiretroviral therapy (ART), and uptake of prevention-of-mother-to-child transmission services [ 7 ] Furthermore, internalized stigma has a negative impact on overall quality of life (QoL) and psychological quality of life [ 8 ], [ 9 ], [ 10 ]. A study by Fuster et al. [ 11 ]. Identified internalised stigma as the most prevalent dimension among PLHIV. This suggests that stigma comes from the HIV negative society, which imposes norms and prejudices on them [ 11 ]. In the study conducted by Stang et al. [ 7 ], stigma within a single population is examined, distinguishing between PLHIV, members of the general population, and healthcare workers, demonstrating that stigma is pervasive throughout society [ 7 ]. Spirituality can act as a buffer against the psychological distress caused by HIV stigma. Spiritual beliefs significantly moderated the relationship between internalized HIV stigma and depressive symptoms among Black men who have sex with men, suggesting that those with stronger spiritual beliefs experienced lower levels of depression despite high stigma levels [ 12 ]. In the work of Kremer and Ironson [ 13 ], who found that spiritual coping strategies were positively associated with health outcomes over time, reinforcing the notion that spirituality can be a vital resource for PLHIV [ 13 ]. Health-related QoL (HRQoL) is affected by clinical and social factors, with stigma being a central element. The presence of depressive symptoms and poor self-reported health status is associated with lower HRQoL [ 14 ]. Some studies suggest that in addition to clinical factors, psychological well-being is crucial for improving the quality of life of these patients [ 15 ]. Non-adherence to treatment, due to side effects, access barriers or insufficient support, is associated with poorer HRQoL outcomes [ 15 ]. Despite advances in ART, advanced HIV disease continues to significantly affect physical and functional domains of health [ 16 ]. In summary, stigma remains a detrimental factor for the health and quality of life of PLHIV. To improve the HRQoL of PLHIV, it is necessary to adopt a holistic approach that addresses not only the physical dimension of the quality of life of PLHIV, but all domains of quality of life, including strategies that address stigma and the effects that stigma may also have on the psychological, environmental, social or spiritual quality of life of PLHIV. The integration of these strategies can contribute significantly to achieving the UNAIDS 2030 targets, helping to move towards the end of the HIV/AIDS epidemic [ 17 ]. This study hypotheses that externally perceived stigma is related to dimensions of quality of life other than internalised stigma, and the main objective is to describe the levels of stigma and HRQoL in a representative sample of PLHIV in the Community of Madrid in order to generate specific intervention programme Our study’s main objective is to identify the association between stigma and quality of life in PLHIV. It will also determine the relationship between the different domains of stigma and quality of life, as well as assess the association of stigma with medical and socio-demographic variables in a representative sample of PLHIV with good virological control. Methods Study design and population and sample This is a multicentre descriptive and analytical cross-sectional study, conducted in three centres in the Community of Madrid (Spain): H. Clínico San Carlos, H. General Universitario Gregorio Marañón and H. Universitario Infanta Leonor. From 1 August 2023 to 1 July 2024, patients over 18 years of age with documented HIV infection and undetectable viral load in the last 12 months, selected during routine consultations, were invited to participate. Those with acute illness or cognitive impairment that could compromise their ability to respond to questionnaires were excluded. Inclusion was done face-to-face during the medical visit. Patients received three forms that collected sociodemographic variables, the results of the stigma scale adapted to the Spanish population by Fuster-Ruiz et al [11], the WHO quality of life scale for people with HIV (reduced version) [18], and clinical variables obtained through a review of each patient's electronic medical records. The questionnaires were administered via the Research Electronic Data Capture ( REDCap) web platform, ensuring data confidentiality. If a patient did not have access to the platform, a written version was provided, which was then digitised. The estimated time to complete the questionnaires was between 5.75 and 11.2 minutes, with a median of 8 minutes. To protect privacy, a pseudonymisation system was implemented, assigning each patient a unique code with no direct personal information. The correspondence between the code and personal data was securely stored. All data supporting the findings of this study are available in the article and its supplementary information. Data related to sociodemographic variables are described in Table 1, and the relationship between stigma and quality of life obtained from the survey results is shown in Table 2. Table 3 shows the results of the relationship between total stigma and its domains and quality of life related to sociodemographic variables. Statistical analysis Qualitative variables were described by absolute frequencies (n) and percentages (%). Quantitative variables were summarised using different measures of central tendency and dispersion according to their distribution. For normally distributed variables, the mean and standard deviation (SD) were used, while for non-normally distributed variables, the median and interquartile range (IQR) were used. The normality of quantitative variables was previously assessed using the Shapiro-Wilk test. To assess the relationships between the dependent and independent variables, linear models adjusted for the characteristics of the variables included were used. In each linear model, the assumptions of homoscedasticity and normality of the residuals were checked, ensuring the validity of the analysis. The selection of variables for the multivariate model was based on a systematic approach, including those that showed a preliminary association in the univariate analysis with a p-value < 0.1. Additionally, for associations of two quantitative variables, correlation coefficients were calculated using Spearman's rho, to explore relationships between pairs of variables, especially those that did not meet the assumptions of normality or linearity. All hypothesis tests were performed at a significance level of α = 0.05, with results with a p-value below this threshold being considered statistically significant. No adjustments for multiple corrections were applied, as the main focus of the analysis was exploratory. The sample size was determined based on previously published data concerning the correlation between global stigma and QoL, estimated at -0.35 [14]. With a confidence level of 95% and a statistical power of 0.9, an estimated sample size of 86 subjects was required. Based on the sample size achieved during recruitment, minimum correlations of ±0.23 with an alpha level of 0.05 and a statistical power of up to 0.9 could be detected. Ethical approval The study protocol was reviewed and approved by the Ethics Committee for Research with Medicines (CEIm) of the Hospital Clínico San Carlos (Act 12.2/23), ensuring compliance with all applicable ethical and legal regulations. All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by the institutional ethics committee. Written informed consent was obtained from all participants prior to their inclusion in the study. The study did not involve any experiments on humans or the use of human tissue samples; therefore, no additional declarations are required in this regard. Results A total of 144 patients were included, the characteristics of the sample are shown in table 1. 110/129 (85%) were male, 84/129 (65.1%) had a homosexual desire orientation and 15/129 (11.6%) were bisexual. Most patients were in active employment 80/124 (64.5%) and 60/118 (50.8%) had university or post-graduate studies. Of the 105 with information about earnings, 46 (43.8%) had an income of less than 1000 euros, of which 25 (23.8%) had an income of less than 500 euros per month. 14/129 (10.9%) were in an irregular administrative situation, with 12/129 (9.3%) did not have public health insurance. The mean total stigma was 69.9 (SD 16.6), while the median quality of life was 118 (IQR [100; 130]). Table 1. Sociodemographic variables of the study sample. N=144 Age (mean, sd) 45.6 (11.7) Gender (N, %): Male 110/129 (85.3%) Female 18/129 (14.0%) Other (non-binary people, gender fluid, etc.) 1/129 (0.78%) Irregular administrative status 14/129 (10.9%) No health insurance 12/129 (9.30%) Orientation of desire Homosexual 84/129 (65.1%) Heterosexual 29/129 (22.5%) Bisexual 15/129 (11.6%) Other 1/129 (0.78%) Education: University education 42/118 (35.6%) Primary education 19/118 (16.1%) Baccalaureate 22/118 (18.6%) Intermediate studies 17/118 (14.4%) Postgraduate studies 18/118 (15.3%) Employment status: Active 80/124 (64.5%) Unemployed 18/124 (14.5%) Long-term unemployment (+12 months) 9/124 (7.26%) Permanently incapacitated 8/124 (6.45%) Retired 3/124 (2.42%) Temporary incapacity 6/124 (4.84%) Income: 0-500€ 25/105 (23.8%) 501-1000€ 21/105 (20.0%) 1001-1500€ 27/105 (25.7%) 2001-2500€ 11/105 (10.5%) 2501-3000€ 11/105 (10.5%) >3000€ 10/105 (9.52%) Transmission route: Sexual route 101/112 (90.2%) Intravenous substance use 10/112 (8.93%) Vertical transmission (from mother to child) 1/112 (0.89%) Access hospital: Hospital Clínico San Carlos 76/129 (58.9%) HGUGM 30/129 (23.3%) HGUIL 23/129 (17.8%) History of therapeutic failure 15/127 (11.8%) History of AIDS-related events 24/126 (19.0%) Relationship of stigma and quality of life In order to study the relationship between stigma and quality of life, the determinants affecting quality of life were first studied. Table 2 shows the β values for each variable (Table 2). Table 2. Relationship between internalized stigma, externalized stigma, and total stigma with overall quality of life and its different domains. Betas (size of the difference) after adjusting for each of the significant variables. Correlation = Spearman's rho. QoL = quality of life. Internalized stigma Externalized stigma Total stigma Correlation β Adjusted Correlation β Adjusted Correlation β Adjusted Overall QL -0.36 p<0.001 -0.89 [-1.27; -0.52] p<0.001 -0.51 p<0.001 -1.02 [-1.49; -0.56] p<0.001 -0.47 p<0.001 -0.59 [-0.81; -0.37] p<0.001 Independence QL -0.22 p=0.0092 -0.08 [-0.15; -0.02] p=0.011 -0.38 p<0.001 -0.11 [-0.18; -0.04] p=0.003 -0.32 p<0.001 -0.06 [-0.1; -0.02] p=0.002 Spiritual QL -0.51 p<0.001 -0.22 [-0.28; -0.16] p<0.001 -0.46 p<0.001 -0.24 [-0.31; -0.17] p<0.001 -0.54 p<0.001 -0.14 [-0.18; -0.11] p<0.001 Physical QL -0.27 p=0.0017 -0.1 [-0.17; -0.04] p=0.0014 -0.44 p<0.001 -0.16 [-0.23; -0.08] p<0.001 -0.38 p<0.001 -0.08 [-0.12; -0.04] p<0.001 General QL -0.28 p<0.001 -0.06 [-0.1; -0.02] p=0.0064 -0.4 p<0.001 -0.05 [-0.1; 0] p=0.059 -0.37 p<0.001 -0.03 [-0.06; -0.01] p=0.0084 Psychological QL -0.35 p<0.001 -0.17 [-0.24; -0.1] p<0.001 -0.4 p<0.001 -0.15 [-0.24; -0.07] p<0.001 -0.41 p<0.001 -0.11 [-0.15; -0.06] p<0.001 Social QL -0.29 p<0.001 -0.11 [-0.17; -0.04] p=0.0021 -0.44 p<0.001 -0.14 [-0.2 2; -0.06] p<0.001 -0.38 p<0.001 -0.08 [-0.11; -0.04] p<0.001 Environmental QL -0.22 p=0.01 -0.11 [-0.21; -0.02] p=0.017 -0.47 p<0.001 -0.15 [-0.26; -0.04] p=0.0079 -0.37 p<0.001 -0.08 [-0.14; -0.03] p=0.005 Total stigma was negatively associated with quality of life (adjusted beta = -0.59 confidence interval 95% [-0.81; -0.37] p<0.001). This negative association also exists between the different dimensions of quality of life and stigma (figure 1). Among the different associations, the relationship between total stigma and spiritual quality of life (ρ=-0.54), as well as that between external perceived stigma and total quality of life (ρ=-0.52), were the most strongly correlated. The only stigma components that do not affect quality of life are: disclosure concerns, which do not affect independence, physical, general and environmental QoL; total externalised stigma, which does not affect general QoL; and public attitude concerns, which do not affect independence, physical, general, psychological and environmental QoL (supplementary table 1). Additionally, an attempt was made to assess the association between depression and scores on the stigma scales. The depression item on the psychic quality of life scale was positively correlated with total stigma (ρ = 0.45, p<0.001) and with all subdomains of this scale, with the strongest correlation being with perceived external stigma (ρ = 0.48, p<0.001) and external stigma (ρ = 0.47, p<0.001). Relationship of stigma and quality of life with socio-demographic variables Total stigma was found to be increased related to lower income (β =-10.30 CI 95% [-18.40, -2.20], p=0.013), female gender (β =9.64 CI 95% [1.60, 17.68], p=0.019). In the stigma subdomains, internalised stigma was found to be associated with age (β =-0.15 CI 95% [-0.3, -0.01], p=0.044) and with the presence of graduate studies relative to undergraduate studies (β =-5.4 CI 95%[-10.5, -0.27], p=0.039), while externalising stigma was found to be higher in females (β =7.14 CI 95% [3.10, 11.17], p<0.001) and with lower income (β =-7.14 CI 95% [-11.4, -2.9], p=0.001). There was no relationship of stigma with treatment received, time of diagnosis, AIDS events or treatment failure, however, the presence of Kaposi´s sarcoma (KS) (n=3) during evolution was associated with increased total stigma (β =23.57 CI 95% [7.26, 39.88], p=0.007) and externalised stigma (β =14.76 CI 95% [6.12, 23.4], p=0.002). This increase was mainly at the expense of externalised perceived stigma (β =10.9 CI 95% [4.45, 17.36], p = 0.002) and to a lesser extent public attitude concerns (β =3.86 CI 95% [0.24, 7.48], p = 0.038). Additionally, lower income and lower education were associated with lower QoL (table 2). Discussion Our study shows a negative relationship between stigma and the QoL of PLHIV. Specifically, the negative correlation was highest between total stigma and spiritual quality of life. Spirituality has been shown to have a positive effect on the health of PLHIV, both on their mental health and HRQoL, as well as on general health and the acquisition of healthy behaviours after diagnosis [19], [20] Spirituality may function as a protective factor against the psychological distress associated with HIV stigma. Studies have shown that individuals with stronger spiritual beliefs experience lower levels of depression despite high stigma and spiritual coping strategies are positively associated with improved long-term health outcomes [13] Another finding of our study is the negative association between QoL and internalised stigma, especially in the negative self-image subdomain. This internalised stigma, which originates with the diagnosis and develops into distorted self-perception, severely impacts the QoL of PLHIV. Internalised HIV stigma is a predictor of psychological problems such as anxiety, depression or feelings of hopelessness. In addition, environmental factors need to be considered in addressing this phenomenon. [21], [22] The available evidence supports a model of HIV stigma that emphasises that negatively distorted self-perception is not the result of the will of PLHIV, but a process of internalising stigma that originates from factors external to individuals. Thus, HIV stigma cannot be resolved at the individual level alone, but requires structural interventions, such as anti-discrimination laws and the normalisation of HIV as a medical condition. Reducing social stigma, would might reduce its internalisation and improve the quality of life of PLHIV. The scientific community agrees on the need to include specific strategies to address internalised stigma in efforts to improve the quality of life of PLHIV. [23], [24] External perceived stigma is also associated with lower quality of life. Lack of access to health services can be a result of stigma, exacerbating social inequalities and negatively affecting quality of life [25] HIV stigma and discrimination are key barriers that hinder access to crucial HIV services, making it more difficult for individuals to access both healthcare and social services that promote preventive activities. [7]. Socioeconomic inequality is significantly associated with stigma and quality of life, meaning that patients with lower incomes and lower educational levels experience higher levels of stigma and a lower quality of life. In this study, 14/129 (10.9%) of patients were in an irregular situation, and 12/129 (9.3%) did not have public health coverage. Despite the fact that public healthcare in the Community of Madrid guarantees free HIV care, which should, in principle, ensure equitable access to healthcare, notable disparities persist in terms of stigma and quality of life (table 3). Additionally, with regard to gender, women experience higher levels of overall and externalised stigma, despite being an underrepresented group. This suggests that the intersection of HIV-related stigma and gender structures continues to influence patients’ experiences, even within a universal healthcare system. Table 3. Relationship between total stigma and its domains, and overall quality of life with sociodemographic and clinical variables. Stigma Internalized stigma Externalized stigma Overall quality of life Age -0.17 [-0.42, 0.06], p=0.15 -0.15 [-0.3, -0.01], p=0.044 -0.02 [-0.15, 0.1], p=0.679 -0.14 [-0.43; 0.16] p=0.37 Gender (female) 9.64 [1.60, 17.68], p=0.019 2.51 [-2.40, 7.41], p=0.314 7.14 [3.10, 11.17], p<0.001 -5.98 [-16.41; 4.45] p=0.26 Orientation (Heterosexual) 2.35 [-4.60, 9.30], p=0.505 -0.89 [-5.08, 3.29], p=0.673 3.24 [-0.28, 6.77], p=0.071 -3.82 [-12.64; 5.01] p=0.39 Education (universal) p = 0.025 p =0.004 p = 0.295 p<0.001 Primary -1.86 [-10.22, 6.51], p=0.661 -3.15 [-8.18, 1.89], p=0.218 1.29 [-3.10, 5.68], p=0.562 -10.78 [-20.52; -1.04] p=0.03 High school -6.07 [-14.03, 1.89], p=0.133 -3.94 [-8.73, 0.85], p=0.106 -2.14 [-6.31, 2.04], p=0.313 3.11 [-6.06; 12.27] p=0.50 Associate degree 7.29 [-1.40, 15.99], p=0.099 5.5 [0.27, 10.7], p=0.040 1.79 [-2.77, 6.36], p=0.438 -8.32 [-18.63; 2] p=0.11 Postgraduate -8.29 [-16.80, 0.235], p=0.057 -5.4 [-10.5, -0.27], p=0.039 -2.89 [-7.36, 1.58], p=0.203 12.69 [2.78; 22.61] p=0.01 Income (€) -10.30 [-18.40, -2.20], p=0.013 -3.19 [-8.01, 1.62], p=0.191 -7.14 [-11.4, -2.9], p=0.001 11.91 [1.57; 22.26] p=0.02 Nationality (Spanish) -1.63 [-7.42, 4.17], p=0.580 -1.96 [-5.42, 1.51], p=0.265 0.33 [-2.65, 3.31], p=0.826 -4.76 [-11.9; 2.38] p=0.19 Health card 6.12 [-3.62, 15.86], p=0.216 3.98 [-1.86, 9.83], p=0.180 2.14 [-2.87, 7.14], p=0.400 -0.87 [-12.89; 11.15] p=0.89 Administrative status (irregular) 8.84 [-0.17, 17.85], p=0.054 4.40 [-1.04, 9.84], p=0.112 4.44 [-0.18, 9.06], p=0.059 10 [-21.51; 1.5] p=0.09 Hospital (ref. =HCSC) p = 0.06 p = 0.059 p= 0.154 p= 0.53 HGUGM 1.49 [-5.35, 8.33], p=0.668 1.77 [-2.34, 5.88], p=0.396 -0.28 [-3.8, 3.25], p=0.875 -4.91 [-13.53; 3.7] p=0.26 HUIL 9.12 [1.57, 16.67], p=0.018 5.5 [0.96, 10.03], p=0.018 3.62 [-0.28, 7.52], p=0.069 -0.86 [-10.29; 8.58] p=0.86 Diagnosis duration -0.04 [-0.35, 0.28], p=0.825 -0.12 [-0.31, 0.07], p = 0.212 0.08 [-0.08, 0.25], p=0.302 -0.23 [-0.64; 0.18] p=0.27 Time to undetectable -0.25 [-0.73, 0.22], p=0.299 -0.27 [-0.55, 0.01], p = 0.062 0.02 [-0.23, 0.26], p=0.88 0.47 [-0.16; 1.09] p=0.14 History of therapeutic failure -0.06 [-8.9, 8.79], p = 0.99 -2.04 [-7.35, 3.27], p = 0.448 1.99 [-2.54, 6.52], p=0.387 -5.59 [-17.19; 6.01] p=0.34 AIDS-related events -3.9 [-11.15, 3.35], p=0.289 -1.99 [-6.37, 2.39], p = 0.37 -1.91 [-5.63, 1.81], p=0.312 8.95 [-0.56; 18.46] p=0.06 In assessing HRQoL in PLHIV, recent studies have provided valuable insights into how advanced disease and HIV management affect different aspects of quality of life and stigma. A meta-analysis by Portilla-Tamarit et al. [16], highlights that patients diagnosed with an AIDS event, quality of life deteriorates markedly compared to those without an AIDS diagnosis, especially in terms of physical health [16]. People with KS were more concerned with the public perception of HIV than of cancer and even skin disease. In particular, participants identified HIV as having a “bad name” and being associated with perceived “promiscuous” behaviour. [3] In accordance with the literature, our study shows that people with KS experience higher stigma due to the visibility of the disease, while other AIDS-related events have less stigma. However, this may be due to the small sample size (n < 3). Low quality of life is associated with increased risk of virology failure, highlighting the need to continuously assess the quality of life and adherence [27]. In addition, our results show that achieving an undetectable viral load reduces the stigma associated with negative self-image. The type of ART can also influence the stigma experienced by individuals. Research has shown that regimens designed to minimize side effects and pill burden can help reduce stigma by making it less noticeable when individuals take their medication. [28]. In our study, there has been no significant relationship between quality of life or stigma and the different types of antiretroviral treatment. New injectable treatments (CAB/RPV) do not show a significant association with QoL and stigma, possibly due to the small sample size of patients in this treatment modality. Our study has some limitations that should be considered when interpreting the results. Firstly, the sample size (n) may have influenced the generalisability of the findings to other underrepresented subgroups, the majority of patients being men who have sex with men, which could affect the representativeness of the sample to the general population. One criticism that could be raised is that since the degree of anxiety or depression of the participants was not assessed, it is not possible to completely rule out that these factors influenced the quality of life outcomes. However, the detailed analysis of the specific items in the surveys makes it unlikely that anxiety or depression are the underlying causes of the lower quality of life observed, as these aspects were adequately controlled for in the analyses. Conclusions In conclusion, stigma and quality of life in PLHIV are influenced by multiple factors. Our study demonstrates that stigma is negatively related to quality of life. It is evident that all subdomains of stigma have a negative relationship with quality of life, just as all subdomains of quality of life have a significantly negative relationship with stigma. especially in spiritual QoL, where the negative correlation with overall stigma is most significant. Therefore, it is essential to consider higher-risk groups, such as women, individuals with low incomes, or patients with advanced disease, as these groups are more susceptible to developing significant stigma, leading to poorer quality of life and, consequently, being at higher risk for adverse disease progression. It is also crucial to adopt a holistic approach that includes not only medical treatment but also psychosocial aspects, in order to promote better long-term well-being and QoL. Declarations Conflicts of interest The authors declare that they have no conflicts of interest related to the research, authorship or publication of this article. Author Contribution C.O.M. and A.M.A. conceptualized and designed the study. C.O.M., A.M.A., and M.A.A. collected and analyzed the data. A.V.C. contributed to the methodological design and statistical analysis of the study. C.O.M. and M.A.A. interpreted the results. C.O.M. wrote the main manuscript text. A.M.A., M.A.A., and A.V.C. critically reviewed and revised the manuscript. All authors contributed to the final version of the manuscript and approved its submission. Data Availability All data supporting the findings of this study are available in the article and its supplementary information. Data related to sociodemographic variables are described in Table 1, and the relationship between stigma and quality of life obtained from the survey results is shown in Table 2. Table 3 shows the results of the relationship between total stigma and its domains and quality of life related to sociodemographic variables. References Goffman E. Stigma: Notes on the management of spoiled identity. JASON ARONSON; 1974:147 p. doi:10.2307/2575995. Earnshaw VA, Chaudoir SR. From conceptualizing to measuring HIV stigma: A review of HIV stigma mechanism measures. 2009. doi:10.1007/s10461-009-9593-3. Fragueiro CL. Repercusiones del estigma en la calidad de vida de los adultos con VIH/SIDA: Una revisión sistemática. MLS Psychology Research. 2021;4(1). Kumwenda M, Kamkwamba DB, Chirwa M, et al. Lived experiences of people living with HIV—a qualitative exploration on the manifestation, drivers, and effects of internalized HIV stigma within the Malawian context. PLoS One. 2023;18(4):e0284195. doi:10.1371/journal.pone.0284195. Collier S, et al. Telling the story of intersectional stigma in HIV-associated Kaposi’s sarcoma in western Kenya: A convergent mixed-methods approach. J Int AIDS Soc. 2022;25(S1):e25918. doi:10.1002/jia2.25918. Sarma P, Cassidy R, Corlett S, Katusiime B. Ageing with HIV: Medicine optimisation challenges and support needs for older people living with HIV: A systematic review. 2023. doi:10.1007/s40266-022-01003-3. Stangl AL, Lilleston P, Mathema H, et al. Development of parallel measures to assess HIV stigma and discrimination among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc. 2019;22(12):e25421. Berger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV: Psychometric assessment of the HIV stigma scale. Res Nurs Health. 2001;24(6):518-529. doi:10.1002/nur.10011. Kalichman SC, Simbayi LC, Cloete A, et al. Measuring AIDS stigmas in people living with HIV/AIDS: The Internalized AIDS-Related Stigma Scale. AIDS Care. 2009;21(1):1-13. doi:10.1080/09540120802032627. Visser MJ, Kershaw T, Makin JD, Forsyth BWC. Development of parallel scales to measure HIV-related stigma. AIDS Behav. 2008;12(5):759-767. doi:10.1007/s10461-008-9363-7. Fuster-Ruizdeapodaca MJ, Molero F, Ubillos S. Assessment of an intervention to reduce the impact of stigma on people with HIV, enabling them to cope with it. Anales de Psicología. 2016;32(1):192-201. doi:10.6018/analesps.32.1.192121. Taggart T, Mayer K, Vermund S, et al. Interaction of religion/spirituality with internalized HIV stigma, depression, alcohol use, and sexual risk among black men who have sex with men: The 6 city HPTN 061 study. JAIDS J Acquir Immune Defic Syndr. 2021;87(2):e188-e197. doi:10.1097/qai.0000000000002667. Kremer H, Ironson G. Longitudinal spiritual coping with trauma in people with HIV: Implications for health care. AIDS Patient Care STDS. 2014;28(3):144-154. doi:10.1089/apc.2013.0280. Nguyen AL, McNeil CJ, Han SD, Rhodes SD. Risk and protective factors for health-related quality of life among persons aging with HIV. AIDS Care. 2018;30(4):484-491. doi:10.1080/09540121.2017.1381333. De Oliveira E Silva AC, Reis RK, Nogueira JA, Gir E. Quality of life, clinical characteristics and treatment adherence of people living with HIV/AIDS. Rev Lat Am Enfermagem. 2014;22(6):923-931. doi:10.1590/0104-1169.3534.2508. Portilla-Tamarit J, Reus S, Portilla I, Ruiz-De-apodaca MJF, Portilla J. Impact of advanced HIV disease on quality of life and mortality in the era of combined antiretroviral treatment. J Clin Med. 2021;10(4):716. doi:10.3390/jcm10040716. Coll P, et al. Achieving the UNAIDS goals by 2030 in people living with HIV: A simulation model to support the prioritization of health care interventions. Enferm Infecc Microbiol Clin. 2023;41(10):703-711. doi:10.1016/j.eimc.2022.07.012. Saxena S. WHOQOL-HIV Instrument. World Health Organization; 2012. Cotton S, et al. Spirituality and religion in patients with HIV/AIDS. J Gen Intern Med. 2006;21(Suppl 5):S47-S53. doi:10.1111/j.1525-1497.2006.00642.x. Ironson G, Kremer H. Spiritual transformation, psychological well-being, health, and survival in people with HIV. Int J Psychiatry Med. 2009;39(3):209-219. doi:10.2190/PM.39.3.d. Lee RS, Kochman A, Sikkema KJ. Internalized stigma among people living with HIV-AIDS. AIDS Behav. 2002;6(4):367-374. doi:10.1023/A:1021144511957. Pantelic M, Sprague L, Stangl AL. It’s not ‘all in your head’: Critical knowledge gaps on internalized HIV stigma and a call for integrating social and structural conceptualizations. BMC Infect Dis. 2019;19(1):314. doi:10.1186/s12879-019-3704-1. Simbayi LC, Kalichman SC, Strebel A, et al. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med. 2007;64(9):1823-1831. doi:10.1016/j.socscimed.2007.01.006. Panayi M, Charalambous GK, Jelastopulu E. Enhancing quality of life and medication adherence for people living with HIV: The impact of an information system. J Patient Rep Outcomes. 2024;8(1):1-10. doi:10.1186/s41687-023-00680-x. Sayles JN, Wong MD, Kinsler JJ, Martins D, Cunningham WE. The association of stigma with self-reported access to medical care and antiretroviral therapy adherence in persons living with HIV/AIDS. J Gen Intern Med. 2009;24(10):1068-1074. doi:10.1007/s11606-009-1068-8. Lo T, Fang CT, Lee YY, et al. Early HIV diagnosis enhances quality-adjusted life expectancy of men who have sex with men living with HIV: A population-based cohort study in Taiwan. J Microbiol Immunol Infect. 2024;57(1):52-59. doi:10.1016/j.jmii.2023.11.004. Torres TS, et al. Poor quality of life and incomplete self-reported adherence predict second-line ART virological failure in resource-limited settings. AIDS Care. 2021;33(10):1354-1361. doi:10.1080/09540121.2021.1874275. Jones H, Floyd S, Stangl A, et al. Association between HIV stigma and antiretroviral therapy adherence among adults living with HIV: Baseline findings from the HPTN 071 (PopART) trial in Zambia and South Africa. Trop Med Int Health. 2020;25(10):1246-1260. doi:10.1111/tmi.13473. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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09:53:17\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6775249/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6775249/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":85180893,\"identity\":\"7d31de7a-e67f-4310-9b16-1b998eedb892\",\"added_by\":\"auto\",\"created_at\":\"2025-06-23 07:19:55\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":127939,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eScatterplot and linear models of the relationships between the different domains of stigma and QoL. In the upper right corner of each plot it is represented the beta for the unadjusted linear model. It is appreciated how the association is consistent and inverse proportional in all of the cases, but specially strong in the relation between overall stigma and total quality of lifeThe relationship between QoL, total stigma, and the various domains and subdomains.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6775249/v1/0d49632b9cd1ff789c74c4d9.jpg\"},{\"id\":87554046,\"identity\":\"e1fe5473-5f7d-4657-ad4c-b3431efe0291\",\"added_by\":\"auto\",\"created_at\":\"2025-07-25 06:38:59\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":858777,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6775249/v1/c3699349-7d07-4493-a136-9e52442e6bc1.pdf\"},{\"id\":85180900,\"identity\":\"be26c673-36f1-45bf-b7eb-0b2bb69077d3\",\"added_by\":\"auto\",\"created_at\":\"2025-06-23 07:19:55\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":15667,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Supplementarymaterial.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6775249/v1/7eb9eae548a4182416a68968.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"NiVEst study: Dimensions of stigma and quality of life in people living with HIV\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eThe term stigma has its origins in ancient Greece, where it was used to brand criminals, slaves and traitors as immoral or tainted [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. In the context of HIV, stigma refers to negative attitudes and behaviours towards people living with HIV (PLHIV), associated with prejudices about HIV transmission and behaviours perceived as immoral, such as drug use or unsafe sexual practices.\\u003c/p\\u003e \\u003cp\\u003eEarnshaw and Chaudoir's model of stigma [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e] describes how stigmatisation begins with HIV being seen as a socially devalued \\u0026lsquo;brand\\u0026rsquo;, affecting people through prejudice, stereotyping and discrimination. Among HIV-negative people, stigma manifests itself as a psychological reaction that perceives PLHIV as a threat to health or as having moral defects. For PLHIV stigma is expressed in three forms: experienced stigma, when they face actual discrimination; anticipated stigma, based on fear of future discrimination that makes it difficult to disclose their status; and internalised stigma, when they accept negative beliefs about themselves, which affects their psychological well being [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eHIV-related stigma negatively impacts the physical health of people living with HIV (PLHIV) by promoting harmful habits such as sedentary lifestyles and substance use. It also generates a fear of disclosing one's HIV status, which can affect sexual intimacy, social interactions, and contribute to mental health issues. Furthermore, HIV-related stigma exacerbates social vulnerability and isolation. This stigma can lead to internalized stigma, where individuals adopt negative societal attitudes towards themselves, manifesting in self-isolation and reduced social engagement, which in turn intensifies feelings of loneliness and depression [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eFactors such as gender, class and geographic location can intensify stigma. A study in Kenya on Kaposi's sarcoma (KS) showed that patients face multiple forms of discrimination that hinder access to care and affect their well-being [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Stigma not only affects mental health, but also restricts access to medical and social resources, underscoring the need for interventions that address stigma and promote social inclusion [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. HIV stigma and discrimination are common barriers to HIV prevention, care and treatment services, including HIV testing, condom use, adherence to antiretroviral therapy (ART), and uptake of prevention-of-mother-to-child transmission services [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eFurthermore, internalized stigma has a negative impact on overall quality of life (QoL) and psychological quality of life [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e], [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e], [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. A study by Fuster et al. [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Identified internalised stigma as the most prevalent dimension among PLHIV. This suggests that stigma comes from the HIV negative society, which imposes norms and prejudices on them [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. In the study conducted by Stang et al. [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e], stigma within a single population is examined, distinguishing between PLHIV, members of the general population, and healthcare workers, demonstrating that stigma is pervasive throughout society [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eSpirituality can act as a buffer against the psychological distress caused by HIV stigma. Spiritual beliefs significantly moderated the relationship between internalized HIV stigma and depressive symptoms among Black men who have sex with men, suggesting that those with stronger spiritual beliefs experienced lower levels of depression despite high stigma levels [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. In the work of Kremer and Ironson [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e], who found that spiritual coping strategies were positively associated with health outcomes over time, reinforcing the notion that spirituality can be a vital resource for PLHIV [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eHealth-related QoL (HRQoL) is affected by clinical and social factors, with stigma being a central element. The presence of depressive symptoms and poor self-reported health status is associated with lower HRQoL [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. Some studies suggest that in addition to clinical factors, psychological well-being is crucial for improving the quality of life of these patients [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eNon-adherence to treatment, due to side effects, access barriers or insufficient support, is associated with poorer HRQoL outcomes [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. Despite advances in ART, advanced HIV disease continues to significantly affect physical and functional domains of health [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn summary, stigma remains a detrimental factor for the health and quality of life of PLHIV. To improve the HRQoL of PLHIV, it is necessary to adopt a holistic approach that addresses not only the physical dimension of the quality of life of PLHIV, but all domains of quality of life, including strategies that address stigma and the effects that stigma may also have on the psychological, environmental, social or spiritual quality of life of PLHIV. The integration of these strategies can contribute significantly to achieving the UNAIDS 2030 targets, helping to move towards the end of the HIV/AIDS epidemic [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. This study hypotheses that externally perceived stigma is related to dimensions of quality of life other than internalised stigma, and the main objective is to describe the levels of stigma and HRQoL in a representative sample of PLHIV in the Community of Madrid in order to generate specific intervention programme\\u003c/p\\u003e \\u003cp\\u003eOur study\\u0026rsquo;s main objective is to identify the association between stigma and quality of life in PLHIV. It will also determine the relationship between the different domains of stigma and quality of life, as well as assess the association of stigma with medical and socio-demographic variables in a representative sample of PLHIV with good virological control.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eStudy design and population and sample\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis is a multicentre descriptive and analytical cross-sectional study, conducted in three centres in the Community of Madrid (Spain): H. Cl\\u0026iacute;nico San Carlos, H. General Universitario Gregorio Mara\\u0026ntilde;\\u0026oacute;n and H. Universitario Infanta Leonor.\\u003c/p\\u003e\\n\\u003cp\\u003eFrom 1 August 2023 to 1 July 2024, patients over 18 years of age with documented HIV infection and undetectable viral load in the last 12 months, selected during routine consultations, were invited to participate. Those with acute illness or cognitive impairment that could compromise their ability to respond to questionnaires were excluded.\\u003c/p\\u003e\\n\\u003cp\\u003eInclusion was done face-to-face during the medical visit. Patients received three forms that collected sociodemographic variables, the results of the stigma scale adapted to the Spanish population by Fuster-Ruiz et al [11], the WHO quality of life scale for people with HIV (reduced version)\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e[18], and clinical variables obtained through a review of each patient\\u0026apos;s electronic medical records.\\u003c/p\\u003e\\n\\u003cp\\u003eThe questionnaires were administered via the Research Electronic Data Capture ( REDCap) web platform, ensuring data confidentiality. If a patient did not have access to the platform, a written version was provided, which was then digitised.\\u003c/p\\u003e\\n\\u003cp\\u003eThe estimated time to complete the questionnaires was between 5.75 and 11.2 minutes, with a median of 8 minutes.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTo protect privacy, a pseudonymisation system was implemented, assigning each patient a unique code with no direct personal information. The correspondence between the code and personal data was securely stored. All data supporting the findings of this study are available in the article and its supplementary information. Data related to sociodemographic variables are described in Table 1, and the relationship between stigma and quality of life obtained from the survey results is shown in Table 2. Table 3 shows the results of the relationship between total stigma and its domains and quality of life related to sociodemographic variables.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStatistical analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eQualitative variables were described by absolute frequencies (n) and percentages (%). Quantitative variables were summarised using different measures of central tendency and dispersion according to their distribution. For normally distributed variables, the mean and standard deviation (SD) were used, while for non-normally distributed variables, the median and interquartile range (IQR) were used. The normality of quantitative variables was previously assessed using the Shapiro-Wilk test.\\u003c/p\\u003e\\n\\u003cp\\u003eTo assess the relationships between the dependent and independent variables, linear models adjusted for the characteristics of the variables included were used. In each linear model, the assumptions of homoscedasticity and normality of the residuals were checked, ensuring the validity of the analysis. The selection of variables for the multivariate model was based on a systematic approach, including those that showed a preliminary association in the univariate analysis with a p-value \\u0026lt; 0.1.\\u003c/p\\u003e\\n\\u003cp\\u003eAdditionally, for associations of two quantitative variables, correlation coefficients were calculated using Spearman\\u0026apos;s rho, to explore relationships between pairs of variables, especially those that did not meet the assumptions of normality or linearity.\\u003c/p\\u003e\\n\\u003cp\\u003eAll hypothesis tests were performed at a significance level of \\u0026alpha; = 0.05, with results with a p-value below this threshold being considered statistically significant. No adjustments for multiple corrections were applied, as the main focus of the analysis was exploratory.\\u003c/p\\u003e\\n\\u003cp\\u003eThe sample size was determined based on previously published data concerning the correlation between global stigma and QoL, estimated at -0.35 [14]. With a confidence level of 95% and a statistical power of 0.9, an estimated sample size of 86 subjects was required. Based on the sample size achieved during recruitment, minimum correlations of \\u0026plusmn;0.23 with an alpha level of 0.05 and a statistical power of up to 0.9 could be detected.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical approval\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study protocol was reviewed and approved by the Ethics Committee for Research with Medicines (CEIm) of the Hospital Cl\\u0026iacute;nico San Carlos (Act 12.2/23), ensuring compliance with all applicable ethical and legal regulations. All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by the institutional ethics committee. Written informed consent was obtained from all participants prior to their inclusion in the study. The study did not involve any experiments on humans or the use of human tissue samples; therefore, no additional declarations are required in this regard.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eA total of 144 patients were included, the characteristics of the sample are shown in table 1. 110/129 (85%) were male, 84/129 (65.1%) had a homosexual desire orientation and 15/129 (11.6%) were bisexual. Most patients were in active employment 80/124 (64.5%) and 60/118 (50.8%) had university or post-graduate studies. Of the 105 with information about earnings, 46 (43.8%) had an income of less than 1000 euros, of which 25 (23.8%) had an income of less than 500 euros per month. 14/129 (10.9%) were in an irregular administrative situation, with 12/129 (9.3%) did not have public health insurance.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe mean total stigma was 69.9 (SD 16.6), while the median quality of life was 118 (IQR [100; 130]).\\u003c/p\\u003e\\n\\u003cp\\u003eTable 1. Sociodemographic variables of the study sample.\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" align=\\\"\\\" width=\\\"388\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003eN=144\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eAge (mean, sd)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 45.6 (11.7) \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eGender (N, %):\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eMale\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 110/129 (85.3%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;18/129 (14.0%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eOther (non-binary people, gender fluid, etc.)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;1/129 (0.78%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eIrregular administrative status\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;14/129 (10.9%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eNo health insurance\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;12/129 (9.30%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eOrientation of desire\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eHomosexual\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;84/129 (65.1%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Heterosexual\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;29/129 (22.5%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eBisexual\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;15/129 (11.6%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eOther\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;1/129 (0.78%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eEducation:\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eUniversity education\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;42/118 (35.6%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003ePrimary education\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;19/118 (16.1%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;Baccalaureate\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;22/118 (18.6%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eIntermediate studies\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;17/118 (14.4%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003ePostgraduate studies\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;18/118 (15.3%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eEmployment status:\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eActive\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;80/124 (64.5%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eUnemployed\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;18/124 (14.5%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eLong-term unemployment (+12 months)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;9/124 (7.26%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003ePermanently incapacitated\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;8/124 (6.45%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eRetired\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;3/124 (2.42%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eTemporary incapacity\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;6/124 (4.84%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eIncome:\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003e0-500\\u0026euro;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;25/105 (23.8%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003e501-1000\\u0026euro;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;21/105 (20.0%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003e1001-1500\\u0026euro;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;27/105 (25.7%)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003e2001-2500\\u0026euro;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;11/105 (10.5%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003e2501-3000\\u0026euro;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;11/105 (10.5%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026gt;3000\\u0026euro;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;10/105 (9.52%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eTransmission route:\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eSexual route\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 101/112 (90.2%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eIntravenous substance use\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;10/112 (8.93%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eVertical transmission (from mother to child)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;1/112 (0.89%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eAccess hospital:\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eHospital Cl\\u0026iacute;nico San Carlos\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;76/129 (58.9%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eHGUGM\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;30/129 (23.3%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eHGUIL\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;23/129 (17.8%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eHistory of therapeutic failure\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e15/127 (11.8%) \\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 71.9072%;\\\"\\u003e\\n \\u003cp\\u003eHistory of AIDS-related events\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 28.0928%;\\\"\\u003e\\n \\u003cp\\u003e24/126 (19.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eRelationship of stigma and quality of life\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn order to study the relationship between stigma and quality of life, the determinants affecting quality of life were first studied. Table 2 shows the \\u0026beta; values for each variable (Table 2).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Table 2. Relationship between internalized stigma, externalized stigma, and total stigma with overall quality of life and its different domains. Betas (size of the difference) after adjusting for each of the significant variables. Correlation = Spearman\\u0026apos;s rho. QoL = quality of life.\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" align=\\\"\\\" width=\\\"560\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.3214%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 24.2857%;\\\"\\u003e\\n \\u003cp\\u003eInternalized stigma\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 29.6429%;\\\"\\u003e\\n \\u003cp\\u003eExternalized stigma\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 28.75%;\\\"\\u003e\\n \\u003cp\\u003eTotal stigma\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.3214%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 9.46429%;\\\"\\u003e\\n \\u003cp\\u003eCorrelation\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.8214%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026beta; Adjusted\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 12.1429%;\\\"\\u003e\\n \\u003cp\\u003eCorrelation\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.5%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026beta; Adjusted\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.0357%;\\\"\\u003e\\n \\u003cp\\u003eCorrelation\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 15.7143%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026beta; Adjusted\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.3214%;\\\"\\u003e\\n \\u003cp\\u003eOverall QL\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 9.46429%;\\\"\\u003e\\n \\u003cp\\u003e-0.36 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.8214%;\\\"\\u003e\\n \\u003cp\\u003e-0.89 [-1.27; -0.52] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 12.1429%;\\\"\\u003e\\n \\u003cp\\u003e-0.51 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.5%;\\\"\\u003e\\n \\u003cp\\u003e-1.02 [-1.49; -0.56] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.0357%;\\\"\\u003e\\n \\u003cp\\u003e-0.47 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 15.7143%;\\\"\\u003e\\n \\u003cp\\u003e-0.59 [-0.81; -0.37] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.3214%;\\\"\\u003e\\n \\u003cp\\u003eIndependence QL\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 9.46429%;\\\"\\u003e\\n \\u003cp\\u003e-0.22 p=0.0092\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.8214%;\\\"\\u003e\\n \\u003cp\\u003e-0.08 [-0.15; -0.02] p=0.011\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 12.1429%;\\\"\\u003e\\n \\u003cp\\u003e-0.38 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.5%;\\\"\\u003e\\n \\u003cp\\u003e-0.11 [-0.18; -0.04] p=0.003\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.0357%;\\\"\\u003e\\n \\u003cp\\u003e-0.32 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 15.7143%;\\\"\\u003e\\n \\u003cp\\u003e-0.06 [-0.1; -0.02] p=0.002\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.3214%;\\\"\\u003e\\n \\u003cp\\u003eSpiritual QL\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 9.46429%;\\\"\\u003e\\n \\u003cp\\u003e-0.51 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.8214%;\\\"\\u003e\\n \\u003cp\\u003e-0.22 [-0.28; -0.16] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 12.1429%;\\\"\\u003e\\n \\u003cp\\u003e-0.46 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.5%;\\\"\\u003e\\n \\u003cp\\u003e-0.24 [-0.31; -0.17] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.0357%;\\\"\\u003e\\n \\u003cp\\u003e-0.54 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 15.7143%;\\\"\\u003e\\n \\u003cp\\u003e-0.14 [-0.18; -0.11] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.3214%;\\\"\\u003e\\n \\u003cp\\u003ePhysical QL\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 9.46429%;\\\"\\u003e\\n \\u003cp\\u003e-0.27 p=0.0017\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.8214%;\\\"\\u003e\\n \\u003cp\\u003e-0.1 [-0.17; -0.04] p=0.0014\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 12.1429%;\\\"\\u003e\\n \\u003cp\\u003e-0.44 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.5%;\\\"\\u003e\\n \\u003cp\\u003e-0.16 [-0.23; -0.08] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.0357%;\\\"\\u003e\\n \\u003cp\\u003e-0.38 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 15.7143%;\\\"\\u003e\\n \\u003cp\\u003e-0.08 [-0.12; -0.04] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.3214%;\\\"\\u003e\\n \\u003cp\\u003eGeneral QL\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 9.46429%;\\\"\\u003e\\n \\u003cp\\u003e-0.28 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.8214%;\\\"\\u003e\\n \\u003cp\\u003e-0.06 [-0.1; -0.02] p=0.0064\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 12.1429%;\\\"\\u003e\\n \\u003cp\\u003e-0.4 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.5%;\\\"\\u003e\\n \\u003cp\\u003e-0.05 [-0.1; 0] p=0.059\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.0357%;\\\"\\u003e\\n \\u003cp\\u003e-0.37 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 15.7143%;\\\"\\u003e\\n \\u003cp\\u003e-0.03 [-0.06; -0.01] p=0.0084\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.3214%;\\\"\\u003e\\n \\u003cp\\u003ePsychological QL\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 9.46429%;\\\"\\u003e\\n \\u003cp\\u003e-0.35 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.8214%;\\\"\\u003e\\n \\u003cp\\u003e-0.17 [-0.24; -0.1] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 12.1429%;\\\"\\u003e\\n \\u003cp\\u003e-0.4 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.5%;\\\"\\u003e\\n \\u003cp\\u003e-0.15 [-0.24; -0.07] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.0357%;\\\"\\u003e\\n \\u003cp\\u003e-0.41 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 15.7143%;\\\"\\u003e\\n \\u003cp\\u003e-0.11 [-0.15; -0.06] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.3214%;\\\"\\u003e\\n \\u003cp\\u003eSocial QL\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 9.46429%;\\\"\\u003e\\n \\u003cp\\u003e-0.29 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.8214%;\\\"\\u003e\\n \\u003cp\\u003e-0.11 [-0.17; -0.04] p=0.0021\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 12.1429%;\\\"\\u003e\\n \\u003cp\\u003e-0.44 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.5%;\\\"\\u003e\\n \\u003cp\\u003e-0.14 [-0.2\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e2; -0.06] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.0357%;\\\"\\u003e\\n \\u003cp\\u003e-0.38 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 15.7143%;\\\"\\u003e\\n \\u003cp\\u003e-0.08 [-0.11; -0.04] p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.3214%;\\\"\\u003e\\n \\u003cp\\u003eEnvironmental QL\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 9.46429%;\\\"\\u003e\\n \\u003cp\\u003e-0.22 p=0.01\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.8214%;\\\"\\u003e\\n \\u003cp\\u003e-0.11 [-0.21; -0.02] p=0.017\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 12.1429%;\\\"\\u003e\\n \\u003cp\\u003e-0.47 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 17.5%;\\\"\\u003e\\n \\u003cp\\u003e-0.15 [-0.26; -0.04] p=0.0079\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.0357%;\\\"\\u003e\\n \\u003cp\\u003e-0.37 p\\u0026lt;0.001\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 15.7143%;\\\"\\u003e\\n \\u003cp\\u003e-0.08 [-0.14; -0.03] p=0.005\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eTotal stigma was negatively associated with quality of life (adjusted beta = -0.59 confidence interval 95% [-0.81; -0.37] p\\u0026lt;0.001). This negative association also exists between the different dimensions of quality of life and stigma (figure 1). Among the different associations, the relationship between total stigma and spiritual quality of life (\\u0026rho;=-0.54), as well as that between external perceived stigma and total quality of life (\\u0026rho;=-0.52), were the most strongly correlated. The only stigma components that do not affect quality of life are: disclosure concerns, which do not affect independence, physical, general and environmental QoL; total externalised stigma, which does not affect general QoL; and public attitude concerns, which do not affect independence, physical, general, psychological and environmental QoL (supplementary table 1).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAdditionally, an attempt was made to assess the association between depression and scores on the stigma scales. The depression item on the psychic quality of life scale was positively correlated with total stigma (\\u0026rho; = 0.45, p\\u0026lt;0.001) and with all subdomains of this scale, with the strongest correlation being with perceived external stigma (\\u0026rho; = 0.48, p\\u0026lt;0.001) and external stigma (\\u0026rho; = 0.47, p\\u0026lt;0.001).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eRelationship of stigma and quality of life with socio-demographic variables\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTotal stigma was found to be increased related to lower income (\\u0026beta; =-10.30 CI 95% [-18.40, -2.20], p=0.013), female gender (\\u0026beta; =9.64 CI 95% [1.60, 17.68], p=0.019). In the stigma subdomains, internalised stigma was found to be associated with age (\\u0026beta; =-0.15 CI 95% [-0.3, -0.01], p=0.044) and with the presence of graduate studies relative to undergraduate studies (\\u0026beta; =-5.4 CI 95%[-10.5, -0.27], p=0.039), while externalising stigma was found to be higher in females (\\u0026beta; =7.14 CI 95% [3.10, 11.17], p\\u0026lt;0.001) and with lower income (\\u0026beta; =-7.14 CI 95% [-11.4, -2.9], p=0.001).\\u003c/p\\u003e\\n\\u003cp\\u003eThere was no relationship of stigma with treatment received, time of diagnosis, AIDS events or treatment failure, however, the presence of Kaposi\\u0026acute;s sarcoma (KS) (n=3) during evolution was associated with increased total stigma (\\u0026beta; =23.57 CI 95% [7.26, 39.88], p=0.007) and externalised stigma (\\u0026beta; =14.76 CI 95% [6.12, 23.4], p=0.002). This increase was mainly at the expense of externalised perceived stigma (\\u0026beta; =10.9 CI 95% [4.45, 17.36], p = 0.002) and to a lesser extent public attitude concerns (\\u0026beta; =3.86 CI 95% [0.24, 7.48], p = 0.038). Additionally, lower income and lower education were associated with lower QoL (table 2).\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eOur study shows a negative relationship between stigma and the QoL of PLHIV. Specifically, the negative correlation was highest between total stigma and spiritual quality of life. Spirituality has been shown to have a positive effect on the health of PLHIV, both on their mental health and HRQoL, as well as on general health and the acquisition of healthy behaviours after diagnosis\\u0026nbsp;[19], [20] Spirituality may function as a protective factor against the psychological distress associated with HIV stigma. Studies have shown that individuals with stronger spiritual beliefs experience lower levels of depression despite high stigma and spiritual coping strategies are positively associated with improved long-term health outcomes [13]\\u003c/p\\u003e\\n\\u003cp\\u003eAnother finding of our study is the negative association between QoL and internalised stigma, especially in the negative self-image subdomain. This internalised stigma, which originates with the diagnosis and develops into distorted self-perception, severely impacts the QoL of PLHIV.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eInternalised HIV stigma is a predictor of psychological problems such as anxiety, depression or feelings of hopelessness. In addition, environmental factors need to be considered in addressing this phenomenon. [21], [22]\\u003c/p\\u003e\\n\\u003cp\\u003eThe available evidence supports a model of HIV stigma that emphasises that negatively distorted self-perception is not the result of the will of PLHIV, but a process of internalising stigma that originates from factors external to individuals. Thus, HIV stigma cannot be resolved at the individual level alone, but requires structural interventions, such as anti-discrimination laws and the normalisation of HIV as a medical condition.\\u003c/p\\u003e\\n\\u003cp\\u003eReducing social stigma, would might reduce its internalisation and improve the quality of life of PLHIV. The scientific community agrees on the need to include specific strategies to address internalised stigma in efforts to improve the quality of life of PLHIV.\\u0026nbsp;[23], [24]\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eExternal perceived stigma is also associated with lower quality of life. Lack of access to health services can be a result of stigma, exacerbating social inequalities and negatively affecting quality of life [25] HIV stigma and discrimination are key barriers that hinder access to crucial HIV services, making it more difficult for individuals to access both healthcare and social services that promote preventive activities. [7].\\u003c/p\\u003e\\n\\u003cp\\u003eSocioeconomic inequality is significantly associated with stigma and quality of life, meaning that patients with lower incomes and lower educational levels experience higher levels of stigma and a lower quality of life. In this study, 14/129 (10.9%) of patients were in an irregular situation, and 12/129 (9.3%) did not have public health coverage. Despite the fact that public healthcare in the Community of Madrid guarantees free HIV care, which should, in principle, ensure equitable access to healthcare, notable disparities persist in terms of stigma and quality of life (table 3). Additionally, with regard to gender, women experience higher levels of overall and externalised stigma, despite being an underrepresented group. This suggests that the intersection of HIV-related stigma and gender structures continues to influence patients\\u0026rsquo; experiences, even within a universal healthcare system.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTable 3. Relationship between total stigma and its domains, and overall quality of life with sociodemographic and clinical variables.\\u003c/p\\u003e\\n\\u003cdiv align=\\\"\\\"\\u003e\\n \\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"611\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003eStigma\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003eInternalized stigma\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003eExternalized stigma\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003eOverall quality of life\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eAge\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-0.17 [-0.42, 0.06], p=0.15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-0.15 [-0.3, -0.01], p=0.044\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-0.02 [-0.15, 0.1], p=0.679\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-0.14 [-0.43; 0.16] p=0.37\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eGender (female)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e9.64 [1.60, 17.68], p=0.019\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e2.51 [-2.40, 7.41], p=0.314\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e7.14 [3.10, 11.17], p\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-5.98 [-16.41; 4.45] p=0.26\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eOrientation (Heterosexual)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e2.35 [-4.60, 9.30], p=0.505\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-0.89 [-5.08, 3.29], p=0.673\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e3.24 [-0.28, 6.77], p=0.071\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-3.82 [-12.64; 5.01] p=0.39\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eEducation (universal)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003ep = 0.025\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003ep =0.004\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003ep = 0.295\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;p\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ePrimary\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-1.86 [-10.22, 6.51], p=0.661\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-3.15 [-8.18, 1.89], p=0.218\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e1.29 [-3.10, 5.68], p=0.562\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-10.78 [-20.52; -1.04] p=0.03\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eHigh school\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-6.07 [-14.03, 1.89], p=0.133\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-3.94 [-8.73, 0.85], p=0.106\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-2.14 [-6.31, 2.04], p=0.313\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e3.11 [-6.06; 12.27] p=0.50\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eAssociate degree\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e7.29 [-1.40, 15.99], p=0.099\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e5.5 [0.27, 10.7], p=0.040\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e1.79 [-2.77, 6.36], p=0.438\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-8.32 [-18.63; 2] p=0.11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ePostgraduate\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-8.29 [-16.80, 0.235], p=0.057\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-5.4 [-10.5, -0.27], p=0.039\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-2.89 [-7.36, 1.58], p=0.203\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e12.69 [2.78; 22.61] p=0.01\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eIncome (\\u0026euro;)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-10.30 [-18.40, -2.20], p=0.013\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-3.19 [-8.01, 1.62], p=0.191\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-7.14 [-11.4, -2.9], p=0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e11.91 [1.57; 22.26] p=0.02\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eNationality (Spanish)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-1.63 [-7.42, 4.17], p=0.580\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-1.96 [-5.42, 1.51], p=0.265\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e0.33 [-2.65, 3.31], p=0.826\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-4.76 [-11.9; 2.38] p=0.19\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eHealth card\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e6.12 [-3.62, 15.86], p=0.216\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e3.98 [-1.86, 9.83], p=0.180\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e2.14 [-2.87, 7.14], p=0.400\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-0.87 [-12.89; 11.15] p=0.89\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eAdministrative status\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e(irregular)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e8.84 [-0.17, 17.85], p=0.054\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e4.40 [-1.04, 9.84], p=0.112\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e4.44 [-0.18, 9.06], p=0.059\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e10 [-21.51; 1.5] p=0.09\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eHospital (ref. =HCSC)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003ep = 0.06\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003ep = 0.059\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003ep= 0.154\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003ep= 0.53\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eHGUGM\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e1.49 [-5.35, 8.33], p=0.668\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e1.77 [-2.34, 5.88], p=0.396\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-0.28 [-3.8, 3.25], p=0.875\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-4.91 [-13.53; 3.7] p=0.26\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eHUIL\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e9.12 [1.57, 16.67], p=0.018\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e5.5 [0.96, 10.03], p=0.018\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e3.62 [-0.28, 7.52], p=0.069\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-0.86 [-10.29; 8.58] p=0.86\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eDiagnosis duration\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-0.04 [-0.35, 0.28], p=0.825\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-0.12 [-0.31, 0.07], p = 0.212\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e0.08 [-0.08, 0.25], p=0.302\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-0.23 [-0.64; 0.18] p=0.27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eTime to undetectable\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-0.25 [-0.73, 0.22], p=0.299\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-0.27 [-0.55, 0.01], p = 0.062\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e0.02 [-0.23, 0.26], p=0.88\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e0.47 [-0.16; 1.09] p=0.14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eHistory of therapeutic failure\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-0.06 [-8.9, 8.79], p = 0.99\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-2.04 [-7.35, 3.27], p = 0.448\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e1.99 [-2.54, 6.52], p=0.387\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-5.59 [-17.19; 6.01] p=0.34\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 18.1669%;\\\"\\u003e\\n \\u003cp\\u003eAIDS-related events\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-3.9 [-11.15, 3.35], p=0.289\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 21.9313%;\\\"\\u003e\\n \\u003cp\\u003e-1.99 [-6.37, 2.39], p = 0.37\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e-1.91 [-5.63, 1.81], p=0.312\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 19.9673%;\\\"\\u003e\\n \\u003cp\\u003e8.95 [-0.56; 18.46] p=0.06\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eIn assessing HRQoL in PLHIV, recent studies have provided valuable insights into how advanced disease and HIV management affect different aspects of quality of life and stigma. A meta-analysis by Portilla-Tamarit et al. [16], highlights that patients diagnosed with an AIDS event, quality of life deteriorates markedly compared to those without an AIDS diagnosis, especially in terms of physical health [16].\\u0026nbsp;People with KS were more concerned with the public perception of HIV than of cancer and even skin disease. In particular, participants identified HIV as having a \\u0026ldquo;bad name\\u0026rdquo; and being associated with perceived \\u0026ldquo;promiscuous\\u0026rdquo; behaviour. [3]\\u0026nbsp;In accordance with the literature, our study shows that people with KS experience higher stigma due to the visibility of the disease, while other AIDS-related events have less stigma. However, this may be due to the small sample size (n \\u0026lt; 3).\\u003c/p\\u003e\\n\\u003cp\\u003eLow quality of life is associated with increased risk of virology failure, highlighting the need to continuously assess the quality of life and adherence [27]. In addition, our results show that achieving an undetectable viral load reduces the stigma associated with negative self-image.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe type of ART can also influence the stigma experienced by individuals. Research has shown that regimens designed to minimize side effects and pill burden can help reduce stigma by making it less noticeable when individuals take their medication. [28]. In our study, there has been no significant relationship between quality of life or stigma and the different types of antiretroviral treatment. New injectable treatments (CAB/RPV) do not show a significant association with QoL and stigma, possibly due to the small sample size of patients in this treatment modality.\\u003c/p\\u003e\\n\\u003cp\\u003eOur study has some limitations that should be considered when interpreting the results. Firstly, the sample size (n) may have influenced the generalisability of the findings to other underrepresented subgroups, the majority of patients being men who have sex with men, which could affect the representativeness of the sample to the general population.\\u003c/p\\u003e\\n\\u003cp\\u003eOne criticism that could be raised is that since the degree of anxiety or depression of the participants was not assessed, it is not possible to completely rule out that these factors influenced the quality of life outcomes. However, the detailed analysis of the specific items in the surveys makes it unlikely that anxiety or depression are the underlying causes of the lower quality of life observed, as these aspects were adequately controlled for in the analyses.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eIn conclusion, stigma and quality of life in PLHIV are influenced by multiple factors. Our study demonstrates that stigma is negatively related to quality of life. It is evident that all subdomains of stigma have a negative relationship with quality of life, just as all subdomains of quality of life have a significantly negative relationship with stigma.\\u003c/p\\u003e\\n\\u003cp\\u003eespecially in spiritual QoL, where the negative correlation with overall stigma is most significant.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTherefore, it is essential to consider higher-risk groups, such as women, individuals with low incomes, or patients with advanced disease, as these groups are more susceptible to developing significant stigma, leading to poorer quality of life and, consequently, being at higher risk for adverse disease progression.\\u003c/p\\u003e\\n\\u003cp\\u003eIt is also crucial to adopt a holistic approach that includes not only medical treatment but also psychosocial aspects, in order to promote better long-term well-being and QoL.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eConflicts of interest\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors declare that they have no conflicts of interest related to the research, authorship or publication of this article.\\u003c/p\\u003e\\n\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\n\\u003cp\\u003eC.O.M. and A.M.A. conceptualized and designed the study. C.O.M., A.M.A., and M.A.A. collected and analyzed the data. A.V.C. contributed to the methodological design and statistical analysis of the study. C.O.M. and M.A.A. interpreted the results. C.O.M. wrote the main manuscript text. A.M.A., M.A.A., and A.V.C. critically reviewed and revised the manuscript. All authors contributed to the final version of the manuscript and approved its submission.\\u003c/p\\u003e\\n\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\n\\u003cp\\u003eAll data supporting the findings of this study are available in the article and its supplementary information. Data related to sociodemographic variables are described in Table 1, and the relationship between stigma and quality of life obtained from the survey results is shown in Table 2. Table 3 shows the results of the relationship between total stigma and its domains and quality of life related to sociodemographic variables.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eGoffman E. Stigma: Notes on the management of spoiled identity. JASON ARONSON; 1974:147 p. doi:10.2307/2575995.\\u003c/li\\u003e\\n \\u003cli\\u003eEarnshaw VA, Chaudoir SR. From conceptualizing to measuring HIV stigma: A review of HIV stigma mechanism measures. 2009. doi:10.1007/s10461-009-9593-3.\\u003c/li\\u003e\\n \\u003cli\\u003eFragueiro CL. Repercusiones del estigma en la calidad de vida de los adultos con VIH/SIDA: Una revisi\\u0026oacute;n sistem\\u0026aacute;tica. MLS Psychology Research. 2021;4(1).\\u003c/li\\u003e\\n \\u003cli\\u003eKumwenda M, Kamkwamba DB, Chirwa M, et al. Lived experiences of people living with HIV\\u0026mdash;a qualitative exploration on the manifestation, drivers, and effects of internalized HIV stigma within the Malawian context. PLoS One. 2023;18(4):e0284195. doi:10.1371/journal.pone.0284195.\\u003c/li\\u003e\\n \\u003cli\\u003eCollier S, et al. Telling the story of intersectional stigma in HIV-associated Kaposi\\u0026rsquo;s sarcoma in western Kenya: A convergent mixed-methods approach. J Int AIDS Soc. 2022;25(S1):e25918. doi:10.1002/jia2.25918.\\u003c/li\\u003e\\n \\u003cli\\u003eSarma P, Cassidy R, Corlett S, Katusiime B. Ageing with HIV: Medicine optimisation challenges and support needs for older people living with HIV: A systematic review. 2023. doi:10.1007/s40266-022-01003-3.\\u003c/li\\u003e\\n \\u003cli\\u003eStangl AL, Lilleston P, Mathema H, et al. Development of parallel measures to assess HIV stigma and discrimination among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc. 2019;22(12):e25421.\\u003c/li\\u003e\\n \\u003cli\\u003eBerger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV: Psychometric assessment of the HIV stigma scale. Res Nurs Health. 2001;24(6):518-529. doi:10.1002/nur.10011.\\u003c/li\\u003e\\n \\u003cli\\u003eKalichman SC, Simbayi LC, Cloete A, et al. Measuring AIDS stigmas in people living with HIV/AIDS: The Internalized AIDS-Related Stigma Scale. AIDS Care. 2009;21(1):1-13. doi:10.1080/09540120802032627.\\u003c/li\\u003e\\n \\u003cli\\u003eVisser MJ, Kershaw T, Makin JD, Forsyth BWC. Development of parallel scales to measure HIV-related stigma. AIDS Behav. 2008;12(5):759-767. doi:10.1007/s10461-008-9363-7.\\u003c/li\\u003e\\n \\u003cli\\u003eFuster-Ruizdeapodaca MJ, Molero F, Ubillos S. Assessment of an intervention to reduce the impact of stigma on people with HIV, enabling them to cope with it. Anales de Psicolog\\u0026iacute;a. 2016;32(1):192-201. doi:10.6018/analesps.32.1.192121.\\u003c/li\\u003e\\n \\u003cli\\u003eTaggart T, Mayer K, Vermund S, et al. Interaction of religion/spirituality with internalized HIV stigma, depression, alcohol use, and sexual risk among black men who have sex with men: The 6 city HPTN 061 study. JAIDS J Acquir Immune Defic Syndr. 2021;87(2):e188-e197. doi:10.1097/qai.0000000000002667.\\u003c/li\\u003e\\n \\u003cli\\u003eKremer H, Ironson G. Longitudinal spiritual coping with trauma in people with HIV: Implications for health care. AIDS Patient Care STDS. 2014;28(3):144-154. doi:10.1089/apc.2013.0280.\\u003c/li\\u003e\\n \\u003cli\\u003eNguyen AL, McNeil CJ, Han SD, Rhodes SD. Risk and protective factors for health-related quality of life among persons aging with HIV. AIDS Care. 2018;30(4):484-491. doi:10.1080/09540121.2017.1381333.\\u003c/li\\u003e\\n \\u003cli\\u003eDe Oliveira E Silva AC, Reis RK, Nogueira JA, Gir E. Quality of life, clinical characteristics and treatment adherence of people living with HIV/AIDS. Rev Lat Am Enfermagem. 2014;22(6):923-931. doi:10.1590/0104-1169.3534.2508.\\u003c/li\\u003e\\n \\u003cli\\u003ePortilla-Tamarit J, Reus S, Portilla I, Ruiz-De-apodaca MJF, Portilla J. Impact of advanced HIV disease on quality of life and mortality in the era of combined antiretroviral treatment. J Clin Med. 2021;10(4):716. doi:10.3390/jcm10040716.\\u003c/li\\u003e\\n \\u003cli\\u003eColl P, et al. Achieving the UNAIDS goals by 2030 in people living with HIV: A simulation model to support the prioritization of health care interventions. Enferm Infecc Microbiol Clin. 2023;41(10):703-711. doi:10.1016/j.eimc.2022.07.012.\\u003c/li\\u003e\\n \\u003cli\\u003eSaxena S. WHOQOL-HIV Instrument. World Health Organization; 2012.\\u003c/li\\u003e\\n \\u003cli\\u003eCotton S, et al. Spirituality and religion in patients with HIV/AIDS. J Gen Intern Med. 2006;21(Suppl 5):S47-S53. doi:10.1111/j.1525-1497.2006.00642.x.\\u003c/li\\u003e\\n \\u003cli\\u003eIronson G, Kremer H. Spiritual transformation, psychological well-being, health, and survival in people with HIV. Int J Psychiatry Med. 2009;39(3):209-219. doi:10.2190/PM.39.3.d.\\u003c/li\\u003e\\n \\u003cli\\u003eLee RS, Kochman A, Sikkema KJ. Internalized stigma among people living with HIV-AIDS. AIDS Behav. 2002;6(4):367-374. doi:10.1023/A:1021144511957.\\u003c/li\\u003e\\n \\u003cli\\u003ePantelic M, Sprague L, Stangl AL. It\\u0026rsquo;s not \\u0026lsquo;all in your head\\u0026rsquo;: Critical knowledge gaps on internalized HIV stigma and a call for integrating social and structural conceptualizations. BMC Infect Dis. 2019;19(1):314. doi:10.1186/s12879-019-3704-1.\\u003c/li\\u003e\\n \\u003cli\\u003eSimbayi LC, Kalichman SC, Strebel A, et al. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med. 2007;64(9):1823-1831. doi:10.1016/j.socscimed.2007.01.006.\\u003c/li\\u003e\\n \\u003cli\\u003ePanayi M, Charalambous GK, Jelastopulu E. Enhancing quality of life and medication adherence for people living with HIV: The impact of an information system. J Patient Rep Outcomes. 2024;8(1):1-10. doi:10.1186/s41687-023-00680-x.\\u003c/li\\u003e\\n \\u003cli\\u003eSayles JN, Wong MD, Kinsler JJ, Martins D, Cunningham WE. The association of stigma with self-reported access to medical care and antiretroviral therapy adherence in persons living with HIV/AIDS. J Gen Intern Med. 2009;24(10):1068-1074. doi:10.1007/s11606-009-1068-8.\\u003c/li\\u003e\\n \\u003cli\\u003eLo T, Fang CT, Lee YY, et al. Early HIV diagnosis enhances quality-adjusted life expectancy of men who have sex with men living with HIV: A population-based cohort study in Taiwan. J Microbiol Immunol Infect. 2024;57(1):52-59. doi:10.1016/j.jmii.2023.11.004.\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eTorres TS, et al. Poor quality of life and incomplete self-reported adherence predict second-line ART virological failure in resource-limited settings. AIDS Care. 2021;33(10):1354-1361. doi:10.1080/09540121.2021.1874275.\\u003c/li\\u003e\\n \\u003cli\\u003eJones H, Floyd S, Stangl A, et al. Association between HIV stigma and antiretroviral therapy adherence among adults living with HIV: Baseline findings from the HPTN 071 (PopART) trial in Zambia and South Africa. Trop Med Int Health. 2020;25(10):1246-1260. doi:10.1111/tmi.13473.\\u0026nbsp;\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"HIV, stigma, quality of life, internalised stigma, spiritual quality of life\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6775249/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6775249/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eObjective: \\u003c/strong\\u003eStigma in people living with HIV (PLHIV) has been found to be negatively associated with quality of life. The study aims to determine whether there are relationships between different dimensions of stigma and quality of life. The secondary objective is to determine associations of stigma with medical variables and to incorporate the use of specific interventions and tools to improve consultation and care for PLHIV.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e: Cross-sectional, multicentre study involving 144 people living with HIV (PLHIV) on antiretroviral therapy (ART) and prolonged viral suppression. Sociodemographic data were collected through questionnaires, together with the results of the stigma scale adapted to the Spanish population, the quality of life (QoL) scale for people with HIV and clinical data obtained from electronic medical records (EMR).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e: Stigma is negatively associated with QoL (adjusted beta = -0.59 [-0.81; -0.37] p\\u0026lt;0.001.There is a negative association between all the subdomains of stigma and overall quality of life, as well as a negative association between all the subdomains of QoL and overall stigma. Total QoL and external perceived stigma have the strongest association (ρ=-0.52, p\\u0026lt;0.01) and the stigma related to disclosure concerns and spiritual QoL (p=-0.46 p \\u0026lt; 0.001). Total stigma was found to be increased related to lower income (β =-10.30 [-18.40, -2.20], p=0.013), female sex (β =9.64 [1.60, 17.68], p=0.019) and Kaposi's sarcoma (KS) (n=3) during evolution was associated with increased total stigma (β =23.57 [7.26, 39.88], p=0.007) and externalised stigma (β =14.76 [6.12, 23.4], p=0.002).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions\\u003c/strong\\u003e: Stigma and quality of life in people living with HIV (PLHIV) are closely related. Our study demonstrates that greater stigma is associated with lower quality of life, particularly in spiritual well-being. The subdomains of both stigma and quality of life show a significant negative relationship. Moreover, higher-risk groups, such as women, individuals with low incomes, or patients with advanced disease, are more vulnerable to stigma, which worsens their quality of life and increases the risk of adverse disease progression. It is crucial to adopt a holistic approach that includes both medical treatment and psychosocial support to improve long-term well-being and quality of life.\\u003c/p\\u003e\",\"manuscriptTitle\":\"NiVEst study: Dimensions of stigma and quality of life in people living with HIV\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-06-23 07:19:51\",\"doi\":\"10.21203/rs.3.rs-6775249/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"d3fe94e3-a0ba-4d8e-b02e-ea0fa8f85422\",\"owner\":[],\"postedDate\":\"June 23rd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":50260068,\"name\":\"Health sciences/Diseases/Infectious diseases/Hiv infections\"},{\"id\":50260069,\"name\":\"Health sciences/Diseases/Infectious diseases/Viral infection\"},{\"id\":50260070,\"name\":\"Health sciences/Health care/Quality of life\"}],\"tags\":[],\"updatedAt\":\"2025-07-25T06:38:39+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-06-23 07:19:51\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6775249\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6775249\",\"identity\":\"rs-6775249\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}