Direct and indirect factors associated with health-related quality of life among PLHIV on second-line antiretroviral therapy at Dessie and Woldia Comprehensive Specialized Hospitals in Ethiopia: application of structural equation modelling

Direct and indirect factors associated with health-related quality of life among PLHIV on second-line antiretroviral therapy at Dessie and Woldia Comprehensive Specialized Hospitals in Ethiopia: application of structural equation modelling | 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 Research Article Direct and indirect factors associated with health-related quality of life among PLHIV on second-line antiretroviral therapy at Dessie and Woldia Comprehensive Specialized Hospitals in Ethiopia: application of structural equation modelling Keleb Takele Tiruneh, Tesfaye Birhane Tegegne, Fikade Demeke Bayou, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6897343/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Feb, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted 14 You are reading this latest preprint version Abstract Background People living with HIV have a longer lifespan and a lower mortality rate due to advancements in antiretroviral therapy. However, the clinical signs of HIV and psychological difficulties continue to impair their health-related quality of life. Therefore, this study aimed to assess health-related quality of life and examine the direct and indirect factors influencing it among people living with HIV on second-line antiretroviral therapy. Method An institutionally based cross-sectional study was conducted from January 13 to April 13, 2025, with 825 people living with HIV on second-line antiretroviral therapy selected through simple random sampling. Data were collected through face-to-face interviews, document reviews, and analyzed with STATA version 17. Quality of life was measured with the WHOQOL-HIV BREF, and depression with the PHQ-9. Structural equation modeling was employed to assess the direct and indirect effects of variables on quality of life. Statistical significance was declared at P < 0.05, and effect sizes are reported with 95% CIs. The findings were presented through text, tables, and graphs. Result The mean quality of life score was 48.7 (95% CI: (47.44, 49.96)). Internalized stigma had a direct [β ̂ = −0.59, (95% CI: -0.80, -0.381)] and indirect [β ̂ = −0.16, (95% CI: -0.249, -0.077)] negative effect on overall quality of life. The absence of opportunistic infection had a direct [β ̂ = 0.14, (95% CI: 0.028–0.248)] positive effect on overall quality of life. Depression had a direct [β ̂ = −0.54, (95% CI: -0.734, -0.339)] negative effect on the physical domain quality of life. Social support had a direct [β ̂ = 0.20, (95% CI: 0.046, 0.337)] positive effect on the social domain quality of life. Conclusion This study revealed that psychosocial factors significantly impacted the quality of people living with HIV on second-line antiretroviral therapy. Social support, depression, perceived stigma, internalized stigma, nonworkable functional status, and opportunistic infections were predictors of quality of life. Hence, healthcare facilities should integrate and strengthen routine mental health screenings and interventions in HIV care programs. Direct and indirect factors structural equation modeling health-related quality of life second-line ART Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Human immunodeficiency virus targets immune cells and impairs their function [ 1 ]. The human immunodeficiency virus/acquired immunodeficiency syndrome pandemic is a serious global challenge [ 2 ]. According to the Joint United Nations Program on HIV/AIDS, of the estimated 37.9 million people living with HIV globally, 67.5% are in Africa [ 3 ]. In addition, by the end of 2021, a total of 36.3 million people worldwide had died from AIDS-related illnesses [ 2 ]. Furthermore, eastern Amhara is a high-burden area for the HIV/AIDS pandemic in the region [ 4 , 5 ]. Second-line antiretroviral therapy (ART) is typically prescribed to people living with HIV when first-line treatment fails often due to poor medication adherence, drug resistance, or adverse drug reactions [ 6 , 7 ]. According to the WHO, quality of life can be defined as individuals' perceptions of their position in life, considering the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns [ 8 ]. When quality of life is considered in the context of health, it is commonly referred to as health-related quality of life to differentiate it from other quality of life [ 8 ]. It encompasses various domains related to physical, mental, emotional, environmental, and social functioning, reflecting how health situations impact people's well-being [ 9 ]. In addition, it encompasses psychological effects of illness, covering a patients state of health, daily functioning, and well-being in everyday life [ 10 ]. For people live with HIV on second-line ART, HRQoL is a key indicator of treatment success, encompassing physical, psychological, and social aspects of their well-being [ 11 ]. Although second-line ART is effective in suppressing the virus and restoring immune function, it poses new challenges for HRQoL [ 12 ]. Moreover, patients on second-line therapy often face increased side effects, more complex treatment regimens, and heightened psychosocial challenges, all of which can negatively impact their QOL [ 12 ]. Even though health-related quality of life is closely linked with HIV, there is limited understanding about it among PLHIV on second-line antiretroviral therapy. Some studies have determined HRQoL among PLHIV, but limitations exist in addressing HRQoL specifically in HIV patients on second-line ART. Prior literatures have been focused on clinical outcomes such as CD4 counts, and viral suppression with limited attention given to psychosocial factors affecting HRQoL. Furthermore, the risk factors influencing these people's quality of life are intricate, and previous research conducted in Ethiopia has not thoroughly examined these interrelated factors [ 1 , 13 ]. Traditional logistic and linear regression analyses were the main focus of these investigations. Nevertheless, these approaches frequently overlook measurement errors in latent variables and are limited in their ability to detect both direct and indirect effects of variables. To address these gaps, an institution-based cross-sectional study was conducted to assess HRQoL and determine associated factors. A structural equation modeling approach was applied to analyze these complex relationships of direct and indirect factors associated with health-related quality of life among PLHIV on second-line ART. Methods Study setting This study was carried out at Dessie and Woldia Comprehensive Specialized Hospital in Ethiopia. These hospitals are the main referral sites for second-line ART in the eastern Amhara region, northeast Ethiopia. Second-line ART is currently administered to 624 HIV-positive patients at Dessie Comprehensive Specialized Hospital and 343 at Woldia Comprehensive Specialized Hospital. According to Ethiopia's national HIV/AIDS guidelines, health centers with more than 200 HIV patients are permitted to start second-line treatment [ 14 ]. A typical second-line antiretroviral therapy regimen consists of three antiretroviral (ARV) medications, including at least two new ones for the patient [ 14 – 16 ]. The backbone of this usually consists of two nucleoside reverse transcriptase inhibitors, such as tenofovir (TDF), zidovudine (ZDV), or lamivudine (3TC) and abacavir (ABC) [ 14 – 16 ]. In addition, one protease inhibitor is included, such as lopinavir/ritonavir (LPV/r) or atazanavir/ritonavir (ATV/r). These PIs are more effective in viral suppression and have a lower risk of resistance [ 14 , 17 , 18 ]. Study design and period An institutional-based cross-sectional study was conducted among second-line ART users at Dessie and Woldia Comprehensive Specialized Hospital from January 13, to April 13, 2025. Source and study population The source of the population for this study consisted of adults receiving second-line antiretroviral therapy at Dessie and Woldia Comprehensive Specialized Hospitals, whereas the study population included those who were available during the data collection period. Variables and measurements The primary outcome of this study was health-related quality of life. Quality of life among people living with HIV on second-line ART was assessed via the WHOQOL-HIV BREF tool. This tool generates scores across six domains and 31 items: physical health (4 items), psychological well-being (5 items), level of independence (4 items), social relationships (4 items), environmental factors (8 items), and spirituality/religion/personal beliefs (4 items) [ 7 ]. Five of these facets are specific to people living with HIV/AIDS: symptoms, social inclusion, forgiveness and blame, concerns about the future, and death and dying. In addition to these 29 facets, two additional questions assess overall quality of life: Question 1, which explores individuals overall perceptions of their quality of life, and Question 2, which evaluates their general health perceptions, resulting in a total of 31 items [ 7 , 11 , 19 ]. The WHOQOL-HIV BREF tool questions were individually scored on a Likert-type scale, where 1 indicates low negative perceptions and 5 indicates high positive perceptions. However, some facets were not formulated positively, meaning that for these facets, higher scores did not denote better QoL and needed to be reversed or recoded during the data analysis. Notably, the questions were organized according to a response scale, i.e., capacity, frequency, intensity or satisfaction and the scores ranged from 4 to 20 points, reflecting the worst and the best QoL, respectively [ 11 ]. Depression was measured via the nine-item Patient Health Questionnaire (PHQ-9) [ 20 ]. Each question required participants to rate the frequency of depressive symptoms experienced in the two weeks prior to the evaluation. The total score ranges from 0–27, with responses ranging from 0–3. A score of 0 indicates that the respondent never experienced depression symptoms in the last two weeks, whereas score of 3 indicates that they experienced depression symptoms almost every day. The PHQ-9 depression screening tool used in this study has been validated in the Ethiopian context [ 14 , 21 ]. Internalized stigma and perceived stigma were measured via eight and six items from the HIV stigma scale, respectively. These items were assessed via a four-point Likert scale (strongly disagree, disagree, agree, and strongly agree), where higher scores indicate higher levels of stigma. The total score for internalized stigma (IS) ranges from 8–32, whereas the total score for perceived stigma (PS) ranges from 6–24 [ 22 ]. Social support was measured via the three-item Oslo scale with one item having a 1-4-point Likert- scale and the rest having a 1-5-point Likert-scale. The total score on the Oslo scale ranges from 3–14, with higher scores indicating stronger social support [ 23 ]. For SEM analysis, the raw social support score was used as a continuous scale [ 14 , 22 , 24 ]. Opportunistic infection was assessed via patient medical record and self-reports. In addition, medication adherence was assessed from patients' medical records. Patients who took at least 95% of their prescribed antiretroviral medication were considered to have optimal adherence, unless classified as nonadherent. Furthermore, patients with a viral load less than 50 copies/mL were categorized as suppressed, patients with a viral load less than 1000 copies/mL were classified as having low viremia, and patients with a viral load greater than or equal to 1000 were considered to have high viremia. Moreover, with respect to CD4 counts, healthy individuals typically have counts between 450 cells/mm3 and 1500 cells/mm3. The risk of opportunistic infections in HIV patients increases when CD4 counts fall below 450cells/mm3. CD4 counts were classified as either above 450 cells/mm 3 normal, or below 450 cells/mm3 indicating exposure to opportunistic infections. Therefore, a CD4 count of 450cells/mm3 was used as the threshold to categorize the most recent CD4 cell measurement [ 14 , 15 ]. Sample size determination A general rule is that the minimum sample size should be 5 ~ 20 times the number of free parameters in structural question modeling [ 14 , 25 ]. As shown in the hypothetical model Fig. 1 , there were 57 factor loadings, 5 latent variable variance, 57 error variance, 4 disturbance, 10 covariance, and 20 regression coefficients. The total free parameter becomes the summation of factor loadings, error variances, latent variances, covariances, and regression coefficients. Therefore, the total free parameter is 153. By using 5 ~ 20 times the number of free parameters, the minimum sample size becomes 153*5 = 765. The total sample size increases to 841 when a 10% nonresponse rate is included. Sampling technique and sampling procedure A simple random sampling method was employed to select study participants, and ART smart care was used as the sampling frame. The total numbers of people living with HIV on second-line ART at Dessie and Woldia Comprehensive Specialized Hospitals were 624 and 343, respectively. First, the sample proportion from each hospital was determined by dividing the number of participants from each hospital by the total number of PLHIV on second-line ART across both hospitals 967 then multiplied by sample population. Subsequently, simple random sampling was applied to select PLHIV from each hospital. As a result, 543 participants were selected from Dessie Comprehensive Specialized Hospital and 298 participants were selected from Woldia Comprehensive Specialized Hospital. Data collection Data were collected by a structured questionnaire through face to face interviews and document reviews by trained health officers' at the ART outpatient department. The questionnaire was prepared in English and then translated to Amharic. Data were collected within three months during patients' routine clinical visits. The data extraction sheet was designed in accordance with the national consolidated antiretroviral guidelines [ 14 , 26 ]. Data quality management and control To ensure data quality, the questionnaire was developed on the basis of the literature and relevant guidelines[ 14 ]. In addition, validated tools were used to measure latent constructs. The questionnaire was pre-tested by 5% of the participants at Dessie Health Center among PLHIV on second-line ART and necessary adjustments were made. The data collectors received 3 days of training on the study's objectives, the questionnaire content, and the overall data collection process. The data collection procedures were closely monitored, with onsite feedback by supervisors and principal investigators provided to ensure accuracy. Data processing, model building and analysis The data were collected by the kobo tool box and then cleaned and exported to Stata Version 17 for further analysis. Descriptive and summary statistics were generated and presented via text, figures, and tables. The means ± standard deviations (SDs) were used for normally distributed continuous variables, medians (interquartile ranges, IQRs) were used for skewed continuous variables, and frequencies (percentages) were used for categorical variables. The hypothesized relationships among the exogenous, endogenous, and mediating variables were analyzed by structural equation modeling. Effect sizes were expressed as standardized and unstandardized beta coefficients, with statistical significance set at P < 0.05. The analysis began with the hypothesized model (Fig. 1 ) and was refined iteratively by evaluating the model fit indices and information criteria. Adjustments were made by adding path links or incorporating mediators when statistically significant and theoretically justified. Ethical consideration Ethical approval was obtained from the ethical review committee of Wollo University, College of Medicine and Health Sciences, School of Public Health. Once ethical clearance was granted, a permission letter was secured from Dessie and Woldia Comprehensive Specialized Hospital. Verbal consent was obtained from all the study participants. Moreover, clinical trial number not applicable. This hypothetical model was designed on the basis of the literature [ 9 , 11 , 14 , 27 – 33 ]. Results Sociodemographic characteristics Among the 841 eligible patients, 825 (98%) agreed and gave their consent to participate in this study. Of those who provided consent and participated, 622 (75.39%) lived in urban areas, 356 (43.15%) were married, 406 (49.2%) were male, and 249 (30%) participants had not attained formal education. Similarly, of 825 participants, 345 (43%) had independent sources of income. The median (IQR) duration of second-line ART and age were 5 (3–8) and 39 (36–49) years, respectively (Table 1 ). Table 1 Sociodemographic characteristics of PLHIV on second-line ART at DCSH and WCSH in the Eastern Amhara region, Northeast Ethiopia, January 2025–March 2025 (n = 825) Socio‑demographic Characteristics Categories Total (825) N (%) median, (IQR) or mean, (SD) Sex Male 406 (49.21) Female 419 (50.79) Residence Urban 622 (75.39) Rural 203 (24.61) Marital status Married 356 (43.15) Single 250 (30.30) Divorced 145 (17.58) Widowed 74 (8.97) Religion Orthodox 450 (54.55) Muslim 323 (39.15) Protestant 30 (3.64) Catholic 19 (2.30) Other 3 (0.36) Educ. Level No-educated 247 (29.94) Primary 242 (29.33) Secondary 221 (26.79) Tertiary 115 (13.94) Independent source of income Yes 355 (43.03) No 470 (56.97) Age median,(IQR) year 39 (36–49) Dura-second line media,(IQR) year 5 (3–8) DCSH Dessie comprehensive specialized hospital and WCSH Woldia comprehensive specialized hospital Clinical characteristics Out of 825 study participants, 562 (68.12%) had WHO clinical stage one, whereas 708 (85.82%), 72 (8.73%), and 45 (5.45%) participants had viral load measurements less than 50, greater than or equal to 50 and less than 1000, and greater than or equal to 1000 copies/ml, respectively. Similarly, 463 (56%) of the study participants had CD4 less than or equal to 450 cells/mm³, and 529 (64%) of the study participants had a BMI > = 18.5 kg/m² (Table 2 ). Table 2 Clinical characteristics of PLHIV on second-line antiretroviral therapy at DCSH and WCSH in the Eastern Amhara region, Northeast Ethiopia, January 2025–March 2025 (n = 825) Clinical characteristics Categories Total (825) N (%) median, (IQR) or mean, (SD) Functional status Workable 779 (94.42) Nonworkable 46 (5.58) Medication adherence Optimal adherence 780 (94.55) Not optimal adherence 45 (4.45) Second-line ART administration. TDF-3TC-ATV/r 430 (52.12) AZT-3TC-ATV/r 345 (41.81) TDF-3TC-LPV/r 30 (3.64) AZT-3TC-LPV/r 20 (2.42) Viral load Less than 50 (Suppressed) 708 (85.82) 50 to 999 (low viremia) 72 (8.73) 1000 or more high viremia 45 (5.45) WHO clinical stage WHO stage one 562 (68.12) WHO stage two 184 (22.30) WHO stage three 56 (6.79) WHO stage four 23 (2.79) CD4_cat 0-450 463 (56.12) 451 and above 362 (43.88) Opportunistic infection Yes 108 (13.09) No 717 (86.91) BMI Less than 18.5 296 (35.88) 18.5 and above 529 (64.12) Magnitude of health-related quality of life among PLHIV on second-line ART (N = 825) The means (SDs) of six of the domains and overall quality of life scores of World Health Organization Quality of Life HIV-BREF (WHOQOL-HIV BREF) and their respective summary scores were presented. The mean HRQoL score of the participants was 48.7 (25). The domain with the highest HRQoL score was found to be spiritual quality of life, 54(16), whereas the lowest domain score was found to be the social domain, 45.4(19.1) (Table 3 ). Table 3 Magnitude of health-related quality of life of PLHIV on second-line ART at DCSH and WCSH, 2025 (n = 825). Domains of HRQOL Mean with SD out of row score Mean with SD of the transformed score (out 100) Physical 12(0.52) 50(13) Psychological 11.77(0.36) 48.5(9.2) Environmental 11.56(0.75) 47(18) Social relationship Level of independent Spiritual 11.26(0.76) 11.75(0.45) 12.56(0.64) 45.4(19.1) 48(11.4) 54(16) Overall HRQOL 11.8 (0.98) 48.6 (24) Spearman correlations between domains of quality of life, social support, perceived stigma, depression and other covariates (n = 825) The physical quality of life domain was positively correlated with the social, psychological, environmental, independent, and spiritual quality of life domains with Spearman correlation coefficients of r = 0.4, 0.6, 0.61, 0.4, and 0.5, respectively, and p-value < 0.001. Social support was negatively correlated with the viral load (r = -0.02, p-value < 0.001) and directly positively correlated with all domains of quality of life, with a p-value < 0.001 (Table 4 ). Table 4 Spearman’s rank correlation analysis of the domains of quality of life, depression, social support, perceived stigma, and other covariates, (n = 825). Variable 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 1. Dep 1 2. PS 0.8*** 1 3. SS -0.7*** -0.7*** 1 4. VL 0.2*** 0.2*** -0.2*** 1 5. BMI -0.2*** -0.2*** 0.2*** -0.09** 1 6. PQL -0.6*** -0.6*** 0.6*** -0.2*** 0.16* 1 7. PSQL -0.5*** -0.5*** 0.5*** -0.1*** 0.006 0.4*** 1 8. SQL -0.7*** -0.7*** 0.6*** -0.2*** 0.1** 0.6** 0.6*** 1 9. EQL -0.8*** -0.7*** 0.7*** -0.2*** 0.1** 0.6** 0.6*** 0.8** 1 10. LQL -0.5*** -0.5*** 0.4*** -0.1*** 0.1** 0.4** 0.4*** 0.7** 0.7*** 1 11. SRQL -0.6*** -0.5*** 0.4*** -0.3*** 0.1** 0.5*** 0.2*** 0.5** 0.5*** 0.4*** 1 Dep depression, PS perceived stigma, SS social support, VL viral load, BMI body mass index, PQL physical quality of life, PSQL psychological quality of life, SQL social quality of life, EQL environmental quality of life, LQL level of independent quality of life and SRQL spiritual and religious domain quality of life. Measurement model Confirmatory factor analysis revealed that all the factor loadings of the depression, perceived stigma, internalized stigma, social support, and quality of life domains were statistically significant with a P-value less than 0.001. In addition, an evaluation of the CFI, SRMR, RMSEA, and TLI of model fitness was performed. The final model was a good fit with a CFA = 0.913, an RMSEA = 0.08, an SRMR = 0.042, and a TLI = 0.96 for domains of quality of life. Furthermore, the goodness of fit of the CFI, SRMR, RMSEA, and TLI were fit well for depression, perceived stigma, internalized stigma, and social support, revealing that the comparative fit index CFA = 0.97, TLI = 0.97, root mean square error of approximation RMSEA = 0.045, and standardized root mean square residual SRMR = 0.022. Direct and indirect factors associated with overall quality of life among PLHIV on second-line ART Internalized stigma had a direct negative effect on overall quality of life. The direct effect of internalized stigma was that as the internalized stigma score increased by one unit, the participants' overall quality of life score decreased by 0.59 on average provided the effect of other covariates in the model remained constant [ \(\:\widehat{\beta\:}\) = −0.59, (95% CI: -0.80, -0.381)]. In addition, internalized stigma had an indirect effect on overall quality of life mediated through depression [ \(\:\widehat{\beta\:}\) = −0.16, (95% CI: -0.249, -0.077)]. In Summary, as internalized stigma score increased by one unit, the overall quality of life score decreased by 0.75 on average provided that the effects of other variables in the model remain constant [ \(\:\widehat{\beta\:}\) = −0.75, (95% CI: -0.92, -0.58)]. Similarly, patients without opportunistic infection had a 0.14 higher average overall quality of life score than did those with opportunistic infection, the effects of other variables in the model remaining constant [ \(\:\widehat{\beta\:}\) = 0.14, (95% CI: 0.028, 0.248)] (Table 5 ) and (Fig. 2 ). Table 5 Direct and indirect factors associated with overall HRQOL among PLHIV on second-line ART (n = 825). Predictors Estimates ( \(\:\widehat{\varvec{\beta\:}}\) ) SE of \(\:\:\widehat{\varvec{\beta\:}}\) Standardized Estimate 95% CI for Estimates The OQL HRQOL Direct effect SS → OQL 0.23 0. 07 0.17 0.088 to 0.365 Dep → OQL -0.47 0.11 -0.34 -0.677 to -0.26 OI (not having OI) → OQL IS → OQL Indirect effect 0.14 -0.59 0.06 0.11 0.05 -0.41 0.028–0.248 -0.801 to -0.381 SS → IS → OQL 0.47 0.09 0.47 0.302–0.636 SS → IS → Dep → OQL 0.13 0.03 0.13 0.062–0.197 SS → PS → Dep → OQL 0.27 0.06 0.27 0.142 - 0.404 IS → Dep → OQL -0.16 0.04 -0.16 -0.249 to -0.077 PS → Dep → OQL -0.38 0.08 -0.38 -0.560 to -0.197 The total effect SS → OQL 1.1 0.04 1.1 1.02–1.2 IS → OQL -0.75 0.08 -0.75 -0.927 to -0.58 Dep depression, PS perceived stigma, SS social support, OI opportunistic infection, OQL overall quality of life and IS internalized stigma (goodness of fit test CFI = 0.94 SRMR = 0.073 RMSEA = 0.064) as shown at Table 5 and Fig. 2 . Direct and indirect factors associated with physical domain HRQoL among PLHIV on second-line ART Depression had a direct negative effect on the physical domain quality of life score. The direct effect of depression on the physical domain quality of life score was that with a one-unit increase in the depression score, patients' physical domain quality of life score decreased by 0.60 on average, provided that the effects of other covariates in the model remained constant [β ̂ = − 0.60, (95% CI: -0.803, 0.395)]. Similarly, patients with nonworkable functional status had a 0.18 lower physical domain quality of life score on average than did those with workable functional status, with the effects of other covariates in the model remaining constant [β ̂ = −0.18, (95% CI: -0.358, -0.008)] (Table 6 ) and Fig. 3 . Table 6 Direct and indirect factors associated with the physical domain of HRQOL among PLHIV on second-line ART (n = 825). Predictors Estimates ( \(\:\widehat{\varvec{\beta\:}}\) ) SE of \(\:\:\widehat{\varvec{\beta\:}}\) Standardized Estimate 95% CI for Estimates The Physical Domain HRQOL Direct effect FS (not workable) → PQOL -0.18 0. 08 -0.05 -0.358 to -0.008 Dep → PQOL IS → PQOL Indirect effect -0.60 -0.61 0.10 0.11 − .45 -0.43 -0.803 to -0.395 -0.823 to -0.386 SS → Dep → PQOL 0.07 0.028 0.07 0.012–0.122 SS → IS → PQOL 0.48 0.09 0.48 0.304 - 0.651 SS → IS → Dep → PQOL 0.15 0.04 0.15 0.082–0.22 SS → PS → Dep → PQOL 0.31 0.06 0.31 0.184 - 0.42 IS → Dep → PQOL -0.20 0.05 -0.20 -0.281 to -0.103 PS → Dep → PQOL -0.43 0.08 -0.43 -0.59O to -0.258 The total effect SS → PQOL 1.001 0.04 1.001 0.919–1.08 IS → PQOL -0.80 0.09 -0.79 -0.970 to -0.625 Dep depression, perceived PS stigma, SS social support, FS functional status, PQOL physical quality of life and internalized IS stigma. (Goodness of fit test CFI = 0.93 SRMR = 0.08 RMSEA = 0.065), as shown in Table 6 and Fig. 3 . Direct and indirect factors associated with psychological domain HRQoL among PLHIV on second-line ART Perceived stigma had a direct negative effect on the quality of life score in the psychological domain. The direct effect of perceived stigma on the psychological domain quality of life score was that as the perceived stigma score increased by one unit, the psychological domain quality of life score decreased by 0.64 on average, provided that the other covariates in the model remained constant [β ̂ = −0.64, (95% CI: -0.89, 0.40)]. Similarly, depression had a negative direct effect on the psychological domain quality of life score. The direct effect of depression on the psychological domain quality of life score was that with a one-unit increase in the depression score, the psychological domain quality of life score decreased by 0.54 on average, provided that the effects of other variables in the model remained constant [β ̂ = − 0.54, (95% CI: -0.734, 0.339)]. Similarly, patients who did not adhere to their medication had a 0.18 lower psychological domain quality of life score than their counterparts did [β ̂ = −0.18, (95% CI: -0.365, -0.004)] (Table 7 ) and Fig. 4 . Table 7 Direct and indirect factors associated with the psychological domain of HRQOL among PLHIV on second-line ART (n = 825). Predictors Estimates ( \(\:\widehat{\varvec{\beta\:}}\) ) SE of \(\:\:\widehat{\varvec{\beta\:}}\) Standardized Estimate 95% CI for Estimates The Psychological Domain HRQOL Direct effect PS → PSQOL -0.64 0. 12 -0.36 -0.886 to -0.4006 Dep → PSQOL MA (not adhere) → PSQOL -0.54 -0.18 0.10 0.09 -0.28 -0.076 -0.734 to -0.339 -0.365 to -0.004 An indirect effect SS → PS → PSQOL 0.47 0.09 0.47 0.290–0.643 SS → IS → Dep → PSQOL IS → Dep → PSQOL 0.45 -0.55 0.08 0.10 0.45 -0.55 0.284 to 0.618 -0.757 to -0.35 The total effect SS → PSQOL 0.91 0.04 0.91 0.835 to 1.00 Dep depression, PS perceived stigma, SS social support, MA medication adherence, PSQOL physical quality of life and IS internalized stigma. (Goodness of fit test CFI = 0.92 SRMR = 0.07 RMSEA = 0.062), as shown in Table 7 and Fig. 4 . Direct and indirect factors associated with social domain HRQoL among PLHIV on second-line ART Social support had a direct positive effect on the social domain quality of life score. The direct positive effect of social support on the social domain quality of life score was that as the social support score, increased by one unit, the social domain quality of life increased by 0.2 on average, while the effects of the other covariates in the model remained constant [β ̂ = 0.2, (95% CI: 0.046, 0.337)] (Table 8 ) and Fig. 5 . Table 8 Direct and indirect factors associated with social domain HRQOL among PLHIV on second-line ART (n = 825). Predictors Estimates ( \(\:\widehat{\varvec{\beta\:}}\) ) SE of \(\:\:\widehat{\varvec{\beta\:}}\) Standardized Estimate 95% CI for Estimates The Social Domain HRQOL Direct effect SS → SQL 0.2 0.07 0.18 0.046–0.337 Dep → SQL -0.41 0.11 -0.37 -0.638 to -0.192 IS → SQL -0.33 0.10 -0.28 -0.539 to -0.123 An indirect effect SS → PS → Dep → SQL 0.21 0.06 0.21 0.090–0.334 SS → IS → SQL SS → IS → Dep → SQL PS → Dep → SQL SS → Dep → SQL IS → Dep → SQL 0.26 0.11 0.30 0.04 -0.13 0.08 0.033 0.09 0.02 0.26 0.10 0.30 0.04 -0.13 0.097–0.427 0.04–0.171 -0.466 to -0.126 0.001–0.087 -0.216 to − .0515 The total effect SS → SQL 0.82 0.038 0.81 0.74–0.89 IS → SQL -0.47 0.09 -0.46 -0.632 to -0.298 Dep depression, PS perceived stigma, SS social support, SQL social domain quality of life and IS internalized stigma.. (Goodness of fit test CFI = 0.93 SRMR = 0.061 RMSEA = 0.06), as shown in Table 8 and Fig. 5 . Direct and indirect factors associated with environmental domain HRQoL among PLHIV on second-line ART Depression had a direct negative effect on the environmental quality of life score. The direct effect of depression on the environmental domain quality of life score was that with a one-unit increase in the depression score, the environmental domain quality of life score decreased by 0.45 on average, provided that the effects of the other variables in the model remained constant [β ̂ = -0.45, (95% CI: -0.624, 0.278)]. Similarly, perceived stigma had a direct negative effect on environmental quality of life. The direct effect of perceived stigma on the environmental domain quality of life score was that as the patients' perceived stigma score increased one unit, the environmental domain quality of life score decreased by 0.63 on average, provided that the effects of the other covariates in the model remained constant [β ̂ = -0.63, (95% CI: -0.844–0.412)] (Table 9 ) and Fig. 6 . Table 9 Direct and indirect factors associated with the environmental domain of HRQOL among PLHIV on second-line ART (n = 825). Predictors Estimates ( \(\:\widehat{\varvec{\beta\:}}\) ) SE of \(\:\:\widehat{\varvec{\beta\:}}\) Standardized Estimate 95% CI for Estimates The Psychological Domain HRQOL Direct effect PS → EQOL -0.63 0. 10 -0.46 -0.844 to -0.412 Dep → EQOL -0.45 0.08 -0.40 -0.624 to -0.278 An indirect effect SS → Dep → EQOL 0.16 0.04 0.15 0.09–0.227 SS → PS→ EQOL IS → Dep→ EQOL SS →IS → Dep→ EQOL 0.46 -0.30 0.24 0.08 0.06 0.05 0.45 0.30 0.24 0.299–0.616 -0.429 to -0.178 0.144–0.344 The total effect SS → EQOL 0.86 0.037 0.86 0.786–0.933 Dep depression, PS perceived stigma, SS social support, EQOL environmental domain quality of life and IS internalized stigma. (Goodness of fit test CFI = 0.94 SRMR = 0.051 RMSEA = 0.05) as shown at (Table 9 ) and Fig. 6 . Direct and indirect factors associated with level of independent domain HRQoL among PLHIV on second-line ART Perceived stigma had a direct negative effect on the level of the independent domain quality of life score. The direct effect of perceived stigma on the independent quality of life score was a one -unit increase in the perceived stigma score, and the independent domain quality of life score decreased by 0.45 on average, provided that the effects of the other variables in the model remained constant [β ̂ = -45, (95% CI: -0.893, 0.002)]. The indirect effect of perceived stigma on the level of the independent domain quality of life score mediated through depression was that with a one-unit increase in the perceived stigma score, the level of independent domain quality of life decreased by 0.45 on average, provided that the effects of the other covariates in the model remained constant [β ̂ = -0.45, (95% CI: -0.742, 0.164)]. Overall, with a one-unit increased in the perceived stigma score, the independent domain quality of life score decreased by 0.90 on average, provided that the effects of the other covariates in the model remained constant [β ̂ = -0.90, (95% CI: -0.9384, 0.067)] (Table 10 ) and Fig. 7 . Table 10 Direct and indirect factors associated with the level of independent domain HRQOL among PLHIV on second-line ART (n = 825). Predictors Estimates ( \(\:\widehat{\varvec{\beta\:}}\) ) SE of \(\:\:\widehat{\varvec{\beta\:}}\) Standardized Estimate 95% CI for Estimates The level of Independent Domain HRQOL Direct effect OI(having opportunistic infection) → LQOL 0.11 0.05 0.05 0.001–0.214 Dep → LQOL PS → LQOL Indirect effect -0.59 -0.45 0.20 0.23 -0.52 -0.34 -0.960 to -0.219 -0.893 to -0.002 SS → PS → LQOL 0.32 0.17 0.32 0.002–0.648 SS → IS → Dep → LQOL 0.18 0.06 0.17 0.053–0.306 SS → PS → Dep → LQOL 0.33 0.11 0.32 0.120–0.537 IS → Dep → LQOL -0.22 0.08 -0.22 -0.384 to -0.066 PS → Dep → LQOL -0.45 0.15 -0.45 -0.742 to -0.164 The total effect SS → LQOL 0.83 0.042 0.82 0.749 - 0.914 PS → LQOL -0.90 0.103 -0.89 -0.9384 to -0.067 Direct and indirect factors associated with spiritual domain HRQoL among PLHIV on second-line ART Depression had a direct negative effect on the spiritual domain quality of life. The direct effect of depression on the spiritual domain quality of life was that with a one-unit increased in the depression score, the spiritual domain quality of life decreased by 0.54 on average, provided that the effects of the other variables in the model remained constant [β ̂ = -0.45, (95% CI: -0.613, 0.456)] (Table 11 ) and Fig. 8 . Table 11 Direct and indirect factors associated with the spiritual domain of HRQOL among PLHIV on second-line ART (n = 825). Predictors Estimates ( \(\:\widehat{\varvec{\beta\:}}\) ) SE of \(\:\:\widehat{\varvec{\beta\:}}\) Standardized Estimate 95% CI for Estimates The Spiritual Domain HRQOL Direct effect Dep → SRQOL -0.54 0.04 -0.64 -0.613 to − 0.456 An indirect effect SS → PS → Dep → SRQOL 0.27 0.034 0.26 0.197–0.329 SS → IS → Dep → SRQOL SS → Dep → SRQOL 0.15 0.06 0.03 0.02 0.15 0.05 0.098–0.194 0.009-0.100 The total effect SS → SRQOL 0.47 0.04 0.46 0.396–0.534 Dep depression, PS perceived stigma, SS social support, SRQOL spiritual domain quality of life and IS internalized stigma. (Goodness of fit test CFI = 0.93 SRMR = 0.07 RMSEA = 0.06) as shown at (Table 11 ) and Fig. 8 . Discussion The purpose of this study was to determine the magnitude of health-related quality and the direct and indirect factors associated with it among PLHIV on second-line ART. In this study, the mean HRQOL was 48.7 (95% CI: (47.44, 49.96)). Depression, opportunistic infection, social support, nonmedication adherence, nonworkable functional status, perceived stigma, and internalized stigma were significant predictors of health-related quality of life. In this study, the mean HRQOL score was lower than studies conducted in Ethiopia, Iran, Botswana, and Thailand [ 1 , 7 , 9 , 11 , 34 , 35 ]. This discrepancy could be attributed to differences in the study population sample size, method of analysis, and study area [ 1 , 7 , 9 , 11 , 34 , 35 ]. In contrast, the results of this study were the same as those of study conducted in northern Shewa, Ethiopia [ 36 ]. Among overall, and the six domains of HRQOL, the highest mean score was reported in the spiritual religion and personal belief domains of quality of life (mean = 54, 95% CI: (52.9, 55.1)). This finding was supported by studies conducted in Iran, Brazil, Ethiopia, and Thailand [ 7 , 9 , 11 , 35 ], respectively. This might be, due to the strong religious and spiritual attachment of the study population [ 7 , 9 , 11 , 35 ]. The mean score of the social domain HRQOL was the lowest (mean = 45, 95% CI: (43.7, 46.3)). This evidence was supported by studies conducted in Thailand [ 35 ], and Ethiopia [ 1 ]. In contrast, a prior study conducted in Ethiopia revealed that the cognitive domain was the lowest [ 37 ]. This could be, due to the stigma and discrimination frequently experienced by people living with HIV [ 37 ]. In this study, social support had both positive direct and indirect effects on all domains of HRQOL [ 38 , 39 ]. This study was supported by a systematic review and meta-analysis [ 40 ], and revealed that social support negatively affects depression [ 41 ], which had a role in enhancing HRQOL [ 42 ]. This study was in line with studies conducted in China, Nepal, and Australia [ 38 , 43 , 44 ]. Social support had an indirect positive effect on the spiritual domain quality of life that was fully mediated through perceived stigma, depression, and internalized stigma with multiple sequential mediations [ 36 , 45 ]. In summary, social support plays a vital role in reducing mental health problems, including depression, and HIV-related stigma, and enhancing social interaction subsequently improves HRQOL [ 36 , 45 ]. Hence, support from friends, family, and non-profitable civic society should be encouraged at the societal level for PLHIV on second-line ART to avert the HROQL problem [ 36 ]. Depression had a direct negative effect on all domains of HRQOL [ 10 , 46 – 48 ]. This study was in line with studies conducted in China, the United States, China, and Africa [ 22 , 39 , 49 , 50 ], which revealed that depression aggravated HIV-related stigma, subsequently affecting HRQOL [ 45 , 51 ]. Moreover, prior literature showed that higher depression score associated with lower quality of life and Vis versa [ 10 , 46 – 48 ]. Hence, healthcare approaches should combine mental health care with social support initiatives to improve HRQOL [ 22 , 39 , 49 , 50 ]. Perceived stigma was found to be, directly and negatively affect all domains of health-related quality of life [ 48 , 52 ]. This finding could be, due to psychological distress, social isolation, or limited healthcare access [ 41 ]. This finding was in line with those of studies conducted in China, and Ethiopia [ 48 , 52 ]. Internalized stigma was the most common direct and indirect negative predictor of all domains of HRQoL [ 45 , 49 ]. This finding was in line with a study conducted in South India [ 45 , 49 ]. This could be because internalized stigma among PLHIV affects their social engagement, mental health, self-efficacy, social support, and positive coping ability and enhances depression scores; subsequently, their HRQOL decreases [ 45 , 53 ]. These results were in line with those of studies conducted in Nepal [ 38 ] and Pakistan [ 53 ]. Moreover, internalized stigma acts as an enhancing negative predictor of health-related quality of life [ 45 , 49 ], which is in line with studies conducted in the United States [ 39 ]. Hence, healthcare settings could systematically assess and address stigma-related challenges faced by PLHIV on second-line ART [ 36 ]. In this study, nonmedication adherence was a negative direct predictor of HRQOL, specifically in the psychological domain [ 36 ]. This finding was supported by a study conducted in India [ 46 ]. This could be because, as patients didn't adhere to their medication, the viral load increased, the CD4 level decreased [ 54 ], psychosocial problems increased, and subsequently decreased QOL [ 55 ]. The presence of opportunistic infection was a negative direct predictor of HRQOL, specifically overall HRQOL [ 50 , 54 ]. This finding was supported by a cohort study conducted in Africa and Ethiopia [ 50 , 54 ]. The reason could be that PLHIV with OIs experience multiple health complications, including prolonged illness, frequent hospitalizations, and side effects of additional medications [ 54 ]. This finding was in line with a study conducted in Kenya [ 56 ]. Hence, early diagnosis and effective management of opportunistic infections should be applied to improve the overall well-being of PLHIV [ 50 , 54 ]. Nonworkable functional status was a negative direct predictor of HRQOL, specifically the physical domain quality of life [ 54 ]. This finding was consistent with those of cross-sectional studies conducted in India [57] and Ethiopia [ 54 ]. In addition, a study conducted in Shewa, Ethiopia, revealed that nonworkable functional status severely negatively affects HRQOL [ 36 ]. The reason could be that individuals who are unable to work due to their health condition experience significantly lower HRQOL than their counterparts who remain functionally active [ 14 , 54 ]. This finding was in line with a study conducted in Northeast China and Ethiopia [ 14 , 54 ]. Therefore, physical rehabilitation, vocational training, and financial assistance could be employed to improve the quality of life for nonworkable individuals [ 54 ]. Strength and Limitations of the study First, to the best of the researcher’s knowledge, this is the first study in Ethiopia to examine the direct and indirect causal pathways of factors influencing health-related quality of life scores, as measured by the WHOQOL-HIV BREF, among PLHIV on second-line ART. Second, this study utilized a structural equation modeling framework, allowing for the simultaneous estimation of direct, indirect, and total effects of predictor variables while accounting for measurement errors in latent variables. Third, this study utilized a large sample size. Fourth, it accounts for both clinical and psychosocial variables simultaneously. Finally, its findings are generalizable to other low-income settings that follow similar WHO HIV treatment guidelines. Although this study utilized an advanced analytical model, it has several limitations. First, the use of self-reported data for most latent constructs may introduce biases such as social desirability and intentional misreporting, potentially affecting accuracy. Future studies should incorporate objective assessments or multiple data sources to enhance reliability. Second, the cross-sectional design limits causal inference, as it cannot determine the direction of relationships between predictor variables and health-related quality of life. Longitudinal studies are recommended to better capture the dynamic interactions among social, clinical, and psychological factors affecting PLHIV on second-line ART. Conclusion This finding revealed that health-related quality of life among PLHIV on second-line ART was highly affected by psychosocial variables. Social support has both direct and indirect positive effects on HRQOL. In most domains of health-related quality of life, depression and perceived and internalized stigma were mediator variables for the association between social support and HRQOL, at the same time as negative direct predictors of the quality of life. The unique finding of this study was the existence of partial, full, parallel, and sequential mediation for the association between social support and domains of HRQOL. Nonworkable functional status, opportunistic infection, depression, social support, nonoptimal medication adherence, perceived stigma, and internalized stigma were significant predictors of health-related quality of life. Abbreviations ART Antiretroviral Therapy BMI Body mass index HAART Highly active antiretroviral therapy HRQoL Health-Related Quality of Life IS Internalized stigma OSSS-3 Oslo Social Support Scale-3 PHQ-9 Patient Health Questionnaire-9 PLHIV people with human immunodeficiency virus PS Perceived stigma QoL Quality of Life SEM Structural equation modeling WHO World Health Organization WHOQoL-HIV BREF World Health Organization Quality of Life HIV BREF Declarations Data availability statement The original contributions presented in the study are included in the article or supplementary material; further inquiries can be directed to the corresponding author. Ethics statement This study was conducted in accordance with the ethical standards of the institutional research committee and the principles outlined in the Declaration of Helsinki. Before the study began, ethical clearance was obtained from the ethical review committee of the College of Medicine and Health Science, Wollo University [Ref. No- WU/CMHS/0003/20/2025]. Verbal informed consent was obtained from all participants before the interview. Privacy, anonymity, and confidentiality were ensured throughout the study process. The participants were informed that refusing consent or withdrawing from the study would not negatively affect their access to healthcare. “Clinical trial number: Not applicable.” Acknowledgments The authors are grateful to all the data collectors, supervisors, study participants, and Wollo University for their creditable contributions to the success of this study. The authors would also like to thank the Dessie Comprehensive Specialised Hospital and Woldia Comprehensive Specialised Hospital for their open contributions to the success of this research. 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Cite Share Download PDF Status: Published Journal Publication published 14 Feb, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 14 Oct, 2025 Reviews received at journal 11 Aug, 2025 Reviews received at journal 09 Aug, 2025 Reviews received at journal 02 Aug, 2025 Reviewers agreed at journal 30 Jul, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers agreed at journal 26 Jul, 2025 Reviews received at journal 23 Jul, 2025 Reviewers agreed at journal 21 Jul, 2025 Reviewers invited by journal 14 Jul, 2025 Editor invited by journal 18 Jun, 2025 Editor assigned by journal 17 Jun, 2025 Submission checks completed at journal 17 Jun, 2025 First submitted to journal 15 Jun, 2025 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6897343","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486263848,"identity":"74c57b3c-68a6-4a5c-bf4f-85147780b739","order_by":0,"name":"Keleb Takele Tiruneh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIie3QPWrDMBiAYQlBsgiyyhjaK6gYNBn7Kp8wpGu7GTpUwSAvga65RNbMMhqymHgNZLEpdC9dBF2qzsV2sxWqd5A06EE/CIVCfzCGiCJ+5miJlg546tdYzRDsCXjiIevL9ZUk6ls7f7Go3mxeH12WrAgxXOou29dWIVceRklMmyrZQSGiagEg9aU4tFLhbXsZJTdM6pgCSbml3HwTYaQiWE+Q26H+pPCc5nb1rqQ+FaIbpknMsCYUrOCE+m9oTSbOM6dEW1nFu/UxYXYhEJQFiPOgmqm3sKNtPh7Sp7uXunrDjme56O6H3pXj5EdS+cH8fr8vv2p3KBQK/Yu+AFY4Wr4VWxa3AAAAAElFTkSuQmCC","orcid":"","institution":"Wollo University","correspondingAuthor":true,"prefix":"","firstName":"Keleb","middleName":"Takele","lastName":"Tiruneh","suffix":""},{"id":486263849,"identity":"a94e33a8-05db-4b41-871d-4395f10d6423","order_by":1,"name":"Tesfaye Birhane Tegegne","email":"","orcid":"","institution":"Wollo University","correspondingAuthor":false,"prefix":"","firstName":"Tesfaye","middleName":"Birhane","lastName":"Tegegne","suffix":""},{"id":486263851,"identity":"e4b1a46c-4350-4629-b4ad-cf1c87f75f44","order_by":2,"name":"Fikade Demeke Bayou","email":"","orcid":"","institution":"Wollo University","correspondingAuthor":false,"prefix":"","firstName":"Fikade","middleName":"Demeke","lastName":"Bayou","suffix":""},{"id":486263855,"identity":"98869745-3e4a-46d0-96fb-cdbfdf96838c","order_by":3,"name":"Yeshewas Abaynew","email":"","orcid":"","institution":"Wollo University","correspondingAuthor":false,"prefix":"","firstName":"Yeshewas","middleName":"","lastName":"Abaynew","suffix":""}],"badges":[],"createdAt":"2025-06-15 08:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6897343/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6897343/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-026-12870-1","type":"published","date":"2026-02-14T15:57:24+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87067868,"identity":"5b492015-70c3-45af-a484-eb59e9c8024a","added_by":"auto","created_at":"2025-07-18 18:58:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":96813,"visible":true,"origin":"","legend":"\u003cp\u003eA hypothetical model for direct and indirect factors associated with health related quality of life among PLHIV who are receiving second-line ART (rectangular and oval shapes represent observed and latent variables), respectively. The solid black lines represent regression and the rest indicate correlation lines.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6897343/v1/529889e78c108c725d5fe449.jpg"},{"id":87068070,"identity":"f60e7d0c-a396-42f9-811c-40af43bc5f5f","added_by":"auto","created_at":"2025-07-18 19:06:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":108921,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation models of direct and indirect factors associated with overall quality of life among PLHIV on second-line ART at DCSH and WCSH Northeast Ethiopia, 2025.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6897343/v1/68baa5284e6a7d154ccd755b.jpg"},{"id":87067870,"identity":"0586d73d-c869-4513-aa00-31a166aaa3f0","added_by":"auto","created_at":"2025-07-18 18:58:31","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":113809,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation models of direct and indirect factors associated with physical domain quality of life among PLHIV on second-line ART at DCSH and WCSH Northeast Ethiopia, 2025.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6897343/v1/b0db5d69a036bd794c465882.jpg"},{"id":87068073,"identity":"34319271-a8a2-41b2-85be-07ec76c646be","added_by":"auto","created_at":"2025-07-18 19:06:31","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":127612,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation models of direct and indirect factors associated with the psychological domain quality of life among PLHIV on second-line ART at DCSH and WCSH in Northeast Ethiopia, 2025.\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6897343/v1/ad797b5b9db2a7a8d9d60831.jpg"},{"id":87068074,"identity":"5b3987a1-4d48-4607-bf1b-bb5898eedbe3","added_by":"auto","created_at":"2025-07-18 19:06:31","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":119650,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation models of direct and indirect factors associated with social domain quality of life among PLHIV on second-line ART at DCSH and WCSH Northeast Ethiopia, 2025.\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6897343/v1/64c64cb987a7fcd0b18ed127.jpg"},{"id":87067874,"identity":"aa62c1a5-8468-4422-9b93-f2aeb174a8cd","added_by":"auto","created_at":"2025-07-18 18:58:31","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":121326,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation models of direct and indirect factors associated with the environmental domain quality of life among PLHIV on second-line ART at DCSH and WCSH in Northeast Ethiopia, 2025.\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6897343/v1/9a6be381da3be4c57adeef02.jpg"},{"id":87068071,"identity":"ecb69800-e1d9-4ad1-b7c4-b8d9295054d1","added_by":"auto","created_at":"2025-07-18 19:06:31","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":101757,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation models of direct and indirect factors associated with the level of independent domain quality of life among PLHIV receiving second-line ART at DCSH and WCSH in Northeast Ethiopia, 2025.\u003c/p\u003e","description":"","filename":"Picture6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6897343/v1/16066f38cc81c8eb43fecb4b.jpg"},{"id":87068076,"identity":"e65cc1fa-989e-4f62-8d4b-509f4198ebdd","added_by":"auto","created_at":"2025-07-18 19:06:31","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":112986,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation models of direct and indirect factors associated with the spiritual domain quality of life among PLHIV on second-line ART at DCSH and WCSH in Northeast Ethiopia, 2025.\u003c/p\u003e","description":"","filename":"Picture7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6897343/v1/81f34be121ec6a2bf230a4b5.jpg"},{"id":102785467,"identity":"d1876625-a61e-4adb-a2e1-abe1446d4f12","added_by":"auto","created_at":"2026-02-16 16:07:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3054293,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6897343/v1/220c2a88-1c43-4fa4-a2b8-ad9b6ee06af3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Direct and indirect factors associated with health-related quality of life among PLHIV on second-line antiretroviral therapy at Dessie and Woldia Comprehensive Specialized Hospitals in Ethiopia: application of structural equation modelling","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHuman immunodeficiency virus targets immune cells and impairs their function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The human immunodeficiency virus/acquired immunodeficiency syndrome pandemic is a serious global challenge [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the Joint United Nations Program on HIV/AIDS, of the estimated 37.9\u0026nbsp;million people living with HIV globally, 67.5% are in Africa [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In addition, by the end of 2021, a total of 36.3\u0026nbsp;million people worldwide had died from AIDS-related illnesses [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Furthermore, eastern Amhara is a high-burden area for the HIV/AIDS pandemic in the region [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Second-line antiretroviral therapy (ART) is typically prescribed to people living with HIV when first-line treatment fails often due to poor medication adherence, drug resistance, or adverse drug reactions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to the WHO, quality of life can be defined as individuals' perceptions of their position in life, considering the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. When quality of life is considered in the context of health, it is commonly referred to as health-related quality of life to differentiate it from other quality of life [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It encompasses various domains related to physical, mental, emotional, environmental, and social functioning, reflecting how health situations impact people's well-being [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In addition, it encompasses psychological effects of illness, covering a patients state of health, daily functioning, and well-being in everyday life [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFor people live with HIV on second-line ART, HRQoL is a key indicator of treatment success, encompassing physical, psychological, and social aspects of their well-being [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Although second-line ART is effective in suppressing the virus and restoring immune function, it poses new challenges for HRQoL [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, patients on second-line therapy often face increased side effects, more complex treatment regimens, and heightened psychosocial challenges, all of which can negatively impact their QOL [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEven though health-related quality of life is closely linked with HIV, there is limited understanding about it among PLHIV on second-line antiretroviral therapy. Some studies have determined HRQoL among PLHIV, but limitations exist in addressing HRQoL specifically in HIV patients on second-line ART. Prior literatures have been focused on clinical outcomes such as CD4 counts, and viral suppression with limited attention given to psychosocial factors affecting HRQoL. Furthermore, the risk factors influencing these people's quality of life are intricate, and previous research conducted in Ethiopia has not thoroughly examined these interrelated factors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Traditional logistic and linear regression analyses were the main focus of these investigations. Nevertheless, these approaches frequently overlook measurement errors in latent variables and are limited in their ability to detect both direct and indirect effects of variables.\u003c/p\u003e\u003cp\u003eTo address these gaps, an institution-based cross-sectional study was conducted to assess HRQoL and determine associated factors. A structural equation modeling approach was applied to analyze these complex relationships of direct and indirect factors associated with health-related quality of life among PLHIV on second-line ART.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy setting\u003c/h2\u003e\u003cp\u003eThis study was carried out at Dessie and Woldia Comprehensive Specialized Hospital in Ethiopia. These hospitals are the main referral sites for second-line ART in the eastern Amhara region, northeast Ethiopia. Second-line ART is currently administered to 624 HIV-positive patients at Dessie Comprehensive Specialized Hospital and 343 at Woldia Comprehensive Specialized Hospital. According to Ethiopia's national HIV/AIDS guidelines, health centers with more than 200 HIV patients are permitted to start second-line treatment [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA typical second-line antiretroviral therapy regimen consists of three antiretroviral (ARV) medications, including at least two new ones for the patient [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The backbone of this usually consists of two nucleoside reverse transcriptase inhibitors, such as tenofovir (TDF), zidovudine (ZDV), or lamivudine (3TC) and abacavir (ABC) [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition, one protease inhibitor is included, such as lopinavir/ritonavir (LPV/r) or atazanavir/ritonavir (ATV/r). These PIs are more effective in viral suppression and have a lower risk of resistance [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy design and period\u003c/h3\u003e\n\u003cp\u003eAn institutional-based cross-sectional study was conducted among second-line ART users at Dessie and Woldia Comprehensive Specialized Hospital from January 13, to April 13, 2025.\u003c/p\u003e\n\u003ch3\u003eSource and study population\u003c/h3\u003e\n\u003cp\u003eThe source of the population for this study consisted of adults receiving second-line antiretroviral therapy at Dessie and Woldia Comprehensive Specialized Hospitals, whereas the study population included those who were available during the data collection period.\u003c/p\u003e\n\u003ch3\u003eVariables and measurements\u003c/h3\u003e\n\u003cp\u003eThe primary outcome of this study was health-related quality of life. Quality of life among people living with HIV on second-line ART was assessed via the WHOQOL-HIV BREF tool. This tool generates scores across six domains and 31 items: physical health (4 items), psychological well-being (5 items), level of independence (4 items), social relationships (4 items), environmental factors (8 items), and spirituality/religion/personal beliefs (4 items) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFive of these facets are specific to people living with HIV/AIDS: symptoms, social inclusion, forgiveness and blame, concerns about the future, and death and dying. In addition to these 29 facets, two additional questions assess overall quality of life: Question 1, which explores individuals overall perceptions of their quality of life, and Question 2, which evaluates their general health perceptions, resulting in a total of 31 items [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe WHOQOL-HIV BREF tool questions were individually scored on a Likert-type scale, where 1 indicates low negative perceptions and 5 indicates high positive perceptions. However, some facets were not formulated positively, meaning that for these facets, higher scores did not denote better QoL and needed to be reversed or recoded during the data analysis. Notably, the questions were organized according to a response scale, i.e., capacity, frequency, intensity or satisfaction and the scores ranged from 4 to 20 points, reflecting the worst and the best QoL, respectively [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDepression was measured via the nine-item Patient Health Questionnaire (PHQ-9) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Each question required participants to rate the frequency of depressive symptoms experienced in the two weeks prior to the evaluation. The total score ranges from 0\u0026ndash;27, with responses ranging from 0\u0026ndash;3. A score of 0 indicates that the respondent never experienced depression symptoms in the last two weeks, whereas score of 3 indicates that they experienced depression symptoms almost every day. The PHQ-9 depression screening tool used in this study has been validated in the Ethiopian context [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInternalized stigma and perceived stigma were measured via eight and six items from the HIV stigma scale, respectively. These items were assessed via a four-point Likert scale (strongly disagree, disagree, agree, and strongly agree), where higher scores indicate higher levels of stigma. The total score for internalized stigma (IS) ranges from 8\u0026ndash;32, whereas the total score for perceived stigma (PS) ranges from 6\u0026ndash;24 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSocial support was measured via the three-item Oslo scale with one item having a 1-4-point Likert- scale and the rest having a 1-5-point Likert-scale. The total score on the Oslo scale ranges from 3\u0026ndash;14, with higher scores indicating stronger social support [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. For SEM analysis, the raw social support score was used as a continuous scale [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOpportunistic infection was assessed via patient medical record and self-reports. In addition, medication adherence was assessed from patients' medical records. Patients who took at least 95% of their prescribed antiretroviral medication were considered to have optimal adherence, unless classified as nonadherent. Furthermore, patients with a viral load less than 50 copies/mL were categorized as suppressed, patients with a viral load less than 1000 copies/mL were classified as having low viremia, and patients with a viral load greater than or equal to 1000 were considered to have high viremia. Moreover, with respect to CD4 counts, healthy individuals typically have counts between 450 cells/mm3 and 1500 cells/mm3. The risk of opportunistic infections in HIV patients increases when CD4 counts fall below 450cells/mm3. CD4 counts were classified as either above 450 cells/mm\u003csup\u003e3\u003c/sup\u003e normal, or below 450 cells/mm3 indicating exposure to opportunistic infections. Therefore, a CD4 count of 450cells/mm3 was used as the threshold to categorize the most recent CD4 cell measurement [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eSample size determination\u003c/h3\u003e\n\u003cp\u003eA general rule is that the minimum sample size should be 5\u0026thinsp;~\u0026thinsp;20 times the number of free parameters in structural question modeling [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. As shown in the hypothetical model Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, there were 57 factor loadings, 5 latent variable variance, 57 error variance, 4 disturbance, 10 covariance, and 20 regression coefficients. The total free parameter becomes the summation of factor loadings, error variances, latent variances, covariances, and regression coefficients. Therefore, the total free parameter is 153. By using 5\u0026thinsp;~\u0026thinsp;20 times the number of free parameters, the minimum sample size becomes 153*5\u0026thinsp;=\u0026thinsp;765. The total sample size increases to 841 when a 10% nonresponse rate is included.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eSampling technique and sampling procedure\u003c/h2\u003e\u003cp\u003eA simple random sampling method was employed to select study participants, and ART smart care was used as the sampling frame. The total numbers of people living with HIV on second-line ART at Dessie and Woldia Comprehensive Specialized Hospitals were 624 and 343, respectively. First, the sample proportion from each hospital was determined by dividing the number of participants from each hospital by the total number of PLHIV on second-line ART across both hospitals 967 then multiplied by sample population. Subsequently, simple random sampling was applied to select PLHIV from each hospital. As a result, 543 participants were selected from Dessie Comprehensive Specialized Hospital and 298 participants were selected from Woldia Comprehensive Specialized Hospital.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected by a structured questionnaire through face to face interviews and document reviews by trained health officers' at the ART outpatient department. The questionnaire was prepared in English and then translated to Amharic. Data were collected within three months during patients' routine clinical visits. The data extraction sheet was designed in accordance with the national consolidated antiretroviral guidelines [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eData quality management and control\u003c/h3\u003e\n\u003cp\u003eTo ensure data quality, the questionnaire was developed on the basis of the literature and relevant guidelines[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition, validated tools were used to measure latent constructs. The questionnaire was pre-tested by 5% of the participants at Dessie Health Center among PLHIV on second-line ART and necessary adjustments were made. The data collectors received 3 days of training on the study's objectives, the questionnaire content, and the overall data collection process. The data collection procedures were closely monitored, with onsite feedback by supervisors and principal investigators provided to ensure accuracy.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData processing, model building and analysis\u003c/h2\u003e\u003cp\u003eThe data were collected by the kobo tool box and then cleaned and exported to Stata Version 17 for further analysis. Descriptive and summary statistics were generated and presented via text, figures, and tables. The means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SDs) were used for normally distributed continuous variables, medians (interquartile ranges, IQRs) were used for skewed continuous variables, and frequencies (percentages) were used for categorical variables.\u003c/p\u003e\u003cp\u003eThe hypothesized relationships among the exogenous, endogenous, and mediating variables were analyzed by structural equation modeling. Effect sizes were expressed as standardized and unstandardized beta coefficients, with statistical significance set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The analysis began with the hypothesized model (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and was refined iteratively by evaluating the model fit indices and information criteria. Adjustments were made by adding path links or incorporating mediators when statistically significant and theoretically justified.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eEthical consideration\u003c/h2\u003e\u003cp\u003eEthical approval was obtained from the ethical review committee of Wollo University, College of Medicine and Health Sciences, School of Public Health. Once ethical clearance was granted, a permission letter was secured from Dessie and Woldia Comprehensive Specialized Hospital. Verbal consent was obtained from all the study participants. Moreover, clinical trial number not applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eThis hypothetical model was designed on the basis of the literature [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31 CR32\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eSociodemographic characteristics\u003c/h2\u003e\u003cp\u003eAmong the 841 eligible patients, 825 (98%) agreed and gave their consent to participate in this study. Of those who provided consent and participated, 622 (75.39%) lived in urban areas, 356 (43.15%) were married, 406 (49.2%) were male, and 249 (30%) participants had not attained formal education. Similarly, of 825 participants, 345 (43%) had independent sources of income. The median (IQR) duration of second-line ART and age were 5 (3\u0026ndash;8) and 39 (36\u0026ndash;49) years, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic characteristics of PLHIV on second-line ART at DCSH and WCSH in the Eastern Amhara region, Northeast Ethiopia, January 2025\u0026ndash;March 2025 (n\u0026thinsp;=\u0026thinsp;825)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocio‑demographic Characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal (825) N (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003emedian, (IQR) or mean, (SD)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e406 (49.21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e419 (50.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e622 (75.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e203 (24.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e356 (43.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e250 (30.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e145 (17.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74 (8.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eReligion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrthodox\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e450 (54.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMuslim\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e323 (39.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProtestant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30 (3.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCatholic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19 (2.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (0.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEduc. Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo-educated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e247 (29.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e242 (29.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e221 (26.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e115 (13.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eIndependent source of income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e355 (43.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e470 (56.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge median,(IQR) year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39 (36\u0026ndash;49)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDura-second line media,(IQR) year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (3\u0026ndash;8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDCSH Dessie comprehensive specialized hospital and WCSH Woldia comprehensive specialized hospital\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eClinical characteristics\u003c/h2\u003e\u003cp\u003eOut of 825 study participants, 562 (68.12%) had WHO clinical stage one, whereas 708 (85.82%), 72 (8.73%), and 45 (5.45%) participants had viral load measurements less than 50, greater than or equal to 50 and less than 1000, and greater than or equal to 1000 copies/ml, respectively. Similarly, 463 (56%) of the study participants had CD4 less than or equal to 450 cells/mm\u0026sup3;, and 529 (64%) of the study participants had a BMI\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;18.5 kg/m\u0026sup2; (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical characteristics of PLHIV on second-line antiretroviral therapy at DCSH and WCSH in the Eastern Amhara region, Northeast Ethiopia, January 2025\u0026ndash;March 2025 (n\u0026thinsp;=\u0026thinsp;825)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal (825) N (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003emedian, (IQR) or mean, (SD)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFunctional status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWorkable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e779 (94.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNonworkable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e46 (5.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMedication adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOptimal adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e780 (94.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot optimal adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45 (4.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eSecond-line ART administration.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTDF-3TC-ATV/r\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e430 (52.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAZT-3TC-ATV/r\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e345 (41.81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTDF-3TC-LPV/r\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30 (3.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAZT-3TC-LPV/r\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20 (2.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eViral load\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLess than 50 (Suppressed)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e708 (85.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 to 999 (low viremia)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72 (8.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1000 or more high viremia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45 (5.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eWHO clinical stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWHO stage one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e562 (68.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWHO stage two\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e184 (22.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWHO stage three\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56 (6.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWHO stage four\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23 (2.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCD4_cat\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0-450\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e463 (56.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e451 and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e362 (43.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOpportunistic infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e108 (13.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e717 (86.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLess than 18.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e296 (35.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.5 and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e529 (64.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eMagnitude of health-related quality of life among PLHIV on second-line ART (N\u0026thinsp;=\u0026thinsp;825)\u003c/h2\u003e\u003cp\u003eThe means (SDs) of six of the domains and overall quality of life scores of World Health Organization Quality of Life HIV-BREF (WHOQOL-HIV BREF) and their respective summary scores were presented. The mean HRQoL score of the participants was 48.7 (25). The domain with the highest HRQoL score was found to be spiritual quality of life, 54(16), whereas the lowest domain score was found to be the social domain, 45.4(19.1) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMagnitude of health-related quality of life of PLHIV on second-line ART at DCSH and WCSH, 2025 (n\u0026thinsp;=\u0026thinsp;825).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomains of HRQOL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean with SD out of row score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean with SD of the transformed score (out 100)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12(0.52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50(13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.77(0.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.5(9.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnvironmental\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.56(0.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47(18)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial relationship\u003c/p\u003e\u003cp\u003eLevel of independent\u003c/p\u003e\u003cp\u003eSpiritual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.26(0.76)\u003c/p\u003e\u003cp\u003e11.75(0.45)\u003c/p\u003e\u003cp\u003e12.56(0.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45.4(19.1)\u003c/p\u003e\u003cp\u003e48(11.4)\u003c/p\u003e\u003cp\u003e54(16)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall HRQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.8 (0.98)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.6 (24)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSpearman correlations between domains of quality of life, social support, perceived stigma, depression and other covariates (n\u0026thinsp;=\u0026thinsp;825)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe physical quality of life domain was positively correlated with the social, psychological, environmental, independent, and spiritual quality of life domains with Spearman correlation coefficients of r\u0026thinsp;=\u0026thinsp;0.4, 0.6, 0.61, 0.4, and 0.5, respectively, and p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Social support was negatively correlated with the viral load (r = -0.02, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and directly positively correlated with all domains of quality of life, with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001 (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSpearman\u0026rsquo;s rank correlation analysis of the domains of quality of life, depression, social support, perceived stigma, and other covariates, (n\u0026thinsp;=\u0026thinsp;825).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e7.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e8.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003e9.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003e10.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003e11.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Dep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. PS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.8***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. SS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.7***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.7***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. VL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.2***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.2***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.2***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. BMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.2***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.2***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.09**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. PQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.6***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.6***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.2***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.16*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. PSQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.5***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.5***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.1***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.4***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. SQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.7***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.7***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.2***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.1**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.6**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.6***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9. EQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.8***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.7***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.2***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.1**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.6**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.6***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.8**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10. LQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.5***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.5***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.4***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.1***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.1**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.4**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.4***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.7**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.7***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11. SRQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.6***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.5***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.4***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.3***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.1**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.5***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.2***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.5**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.5***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.4***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDep depression, PS perceived stigma, SS social support, VL viral load, BMI body mass index, PQL physical quality of life, PSQL psychological quality of life, SQL social quality of life, EQL environmental quality of life, LQL level of independent quality of life and SRQL spiritual and religious domain quality of life.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eMeasurement model\u003c/h2\u003e\u003cp\u003eConfirmatory factor analysis revealed that all the factor loadings of the depression, perceived stigma, internalized stigma, social support, and quality of life domains were statistically significant with a P-value less than 0.001. In addition, an evaluation of the CFI, SRMR, RMSEA, and TLI of model fitness was performed. The final model was a good fit with a CFA\u0026thinsp;=\u0026thinsp;0.913, an RMSEA\u0026thinsp;=\u0026thinsp;0.08, an SRMR\u0026thinsp;=\u0026thinsp;0.042, and a TLI\u0026thinsp;=\u0026thinsp;0.96 for domains of quality of life.\u003c/p\u003e\u003cp\u003eFurthermore, the goodness of fit of the CFI, SRMR, RMSEA, and TLI were fit well for depression, perceived stigma, internalized stigma, and social support, revealing that the comparative fit index CFA\u0026thinsp;=\u0026thinsp;0.97, TLI\u0026thinsp;=\u0026thinsp;0.97, root mean square error of approximation RMSEA\u0026thinsp;=\u0026thinsp;0.045, and standardized root mean square residual SRMR\u0026thinsp;=\u0026thinsp;0.022.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eDirect and indirect factors associated with overall quality of life among PLHIV on second-line ART\u003c/h2\u003e\u003cp\u003eInternalized stigma had a direct negative effect on overall quality of life. The direct effect of internalized stigma was that as the internalized stigma score increased by one unit, the participants' overall quality of life score decreased by 0.59 on average provided the effect of other covariates in the model remained constant [\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\beta\\:}\\)\u003c/span\u003e\u003c/span\u003e = \u0026minus;0.59, (95% CI: -0.80, -0.381)]. In addition, internalized stigma had an indirect effect on overall quality of life mediated through depression [\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\beta\\:}\\)\u003c/span\u003e\u003c/span\u003e = \u0026minus;0.16, (95% CI: -0.249, -0.077)]. In Summary, as internalized stigma score increased by one unit, the overall quality of life score decreased by 0.75 on average provided that the effects of other variables in the model remain constant \u003cb\u003e[\u003c/b\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\beta\\:}\\)\u003c/span\u003e\u003c/span\u003e = \u0026minus;0.75, (95% CI: -0.92, -0.58)]. Similarly, patients without opportunistic infection had a 0.14 higher average overall quality of life score than did those with opportunistic infection, the effects of other variables in the model remaining constant [\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\beta\\:}\\)\u003c/span\u003e\u003c/span\u003e = 0.14, (95% CI: 0.028, 0.248)] (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) and (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDirect and indirect factors associated with overall HRQOL among PLHIV on second-line ART (n\u0026thinsp;=\u0026thinsp;825).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstimates (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSE of\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStandardized Estimate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI for Estimates\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eThe OQL HRQOL\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eDirect effect\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; OQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0. 07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.088 to 0.365\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDep \u0026rarr; OQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.677 to -0.26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOI (not having OI) \u0026rarr; OQL\u003c/p\u003e\u003cp\u003eIS \u0026rarr; OQL\u003c/p\u003e\u003cp\u003e\u003cb\u003eIndirect effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.14\u003c/p\u003e\u003cp\u003e-0.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003cp\u003e-0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.028\u0026ndash;0.248\u003c/p\u003e\u003cp\u003e-0.801 to -0.381\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; IS \u0026rarr; OQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.302\u0026ndash;0.636\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; IS \u0026rarr; Dep \u0026rarr; OQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.062\u0026ndash;0.197\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; PS \u0026rarr; Dep \u0026rarr; OQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.142 - 0.404\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIS \u0026rarr; Dep \u0026rarr; OQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.249 to -0.077\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePS \u0026rarr; Dep \u0026rarr; OQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.560 to -0.197\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe total effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; OQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.02\u0026ndash;1.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIS \u0026rarr; OQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.927 to -0.58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDep depression, PS perceived stigma, SS social support, OI opportunistic infection, OQL overall quality of life and IS internalized stigma (goodness of fit test CFI\u0026thinsp;=\u0026thinsp;0.94 SRMR\u0026thinsp;=\u0026thinsp;0.073 RMSEA\u0026thinsp;=\u0026thinsp;0.064) as shown at Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eDirect and indirect factors associated with physical domain HRQoL among PLHIV on second-line ART\u003c/h2\u003e\u003cp\u003eDepression had a direct negative effect on the physical domain quality of life score. The direct effect of depression on the physical domain quality of life score was that with a one-unit increase in the depression score, patients' physical domain quality of life score decreased by 0.60 on average, provided that the effects of other covariates in the model remained constant [β ̂ = \u0026minus; 0.60, (95% CI: -0.803, 0.395)]. Similarly, patients with nonworkable functional status had a 0.18 lower physical domain quality of life score on average than did those with workable functional status, with the effects of other covariates in the model remaining constant [β ̂ = \u0026minus;0.18, (95% CI: -0.358, -0.008)] (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDirect and indirect factors associated with the physical domain of HRQOL among PLHIV on second-line ART (n\u0026thinsp;=\u0026thinsp;825).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstimates (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSE of\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eStandardized Estimate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI for Estimates\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eThe Physical Domain HRQOL\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eDirect effect\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFS (not workable) \u0026rarr; PQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0. 08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e-0.358 to -0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDep \u0026rarr; PQOL\u003c/p\u003e\u003cp\u003eIS \u0026rarr; PQOL\u003c/p\u003e\u003cp\u003e\u003cb\u003eIndirect effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.60\u003c/p\u003e\u003cp\u003e-0.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.45\u003c/p\u003e\u003cp\u003e-0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e-0.803 to -0.395\u003c/p\u003e\u003cp\u003e-0.823 to -0.386\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; Dep \u0026rarr; PQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.012\u0026ndash;0.122\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; IS \u0026rarr; PQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.304 - 0.651\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; IS \u0026rarr; Dep \u0026rarr; PQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.082\u0026ndash;0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; PS \u0026rarr; Dep \u0026rarr; PQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.184 - 0.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIS \u0026rarr; Dep \u0026rarr; PQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e-0.281 to -0.103\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePS \u0026rarr; Dep \u0026rarr; PQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e-0.59O to -0.258\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe total effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; PQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.919\u0026ndash;1.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIS \u0026rarr; PQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e-0.970 to -0.625\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDep depression, perceived PS stigma, SS social support, FS functional status, PQOL physical quality of life and internalized IS stigma. (Goodness of fit test CFI\u0026thinsp;=\u0026thinsp;0.93 SRMR\u0026thinsp;=\u0026thinsp;0.08 RMSEA\u0026thinsp;=\u0026thinsp;0.065), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eDirect and indirect factors associated with psychological domain HRQoL among PLHIV on second-line ART\u003c/h2\u003e\u003cp\u003ePerceived stigma had a direct negative effect on the quality of life score in the psychological domain. The direct effect of perceived stigma on the psychological domain quality of life score was that as the perceived stigma score increased by one unit, the psychological domain quality of life score decreased by 0.64 on average, provided that the other covariates in the model remained constant [β ̂ = \u0026minus;0.64, (95% CI: -0.89, 0.40)]. Similarly, depression had a negative direct effect on the psychological domain quality of life score. The direct effect of depression on the psychological domain quality of life score was that with a one-unit increase in the depression score, the psychological domain quality of life score decreased by 0.54 on average, provided that the effects of other variables in the model remained constant [β ̂ = \u0026minus; 0.54, (95% CI: -0.734, 0.339)]. Similarly, patients who did not adhere to their medication had a 0.18 lower psychological domain quality of life score than their counterparts did [β ̂ = \u0026minus;0.18, (95% CI: -0.365, -0.004)] (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e) and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDirect and indirect factors associated with the psychological domain of HRQOL among PLHIV on second-line ART (n\u0026thinsp;=\u0026thinsp;825).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstimates (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSE of\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStandardized Estimate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI for Estimates\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eThe Psychological Domain HRQOL\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eDirect effect\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePS \u0026rarr; PSQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0. 12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.886 to -0.4006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDep \u0026rarr; PSQOL\u003c/p\u003e\u003cp\u003eMA (not adhere) \u0026rarr; PSQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.54\u003c/p\u003e\u003cp\u003e-0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.28\u003c/p\u003e\u003cp\u003e-0.076\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.734 to -0.339\u003c/p\u003e\u003cp\u003e-0.365 to -0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAn indirect effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; PS \u0026rarr; PSQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.290\u0026ndash;0.643\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; IS \u0026rarr; Dep \u0026rarr; PSQOL\u003c/p\u003e\u003cp\u003eIS \u0026rarr; Dep \u0026rarr; PSQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003cp\u003e-0.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003cp\u003e-0.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.284 to 0.618\u003c/p\u003e\u003cp\u003e-0.757 to -0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe total effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; PSQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.835 to 1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDep depression, PS perceived stigma, SS social support, MA medication adherence, PSQOL physical quality of life and IS internalized stigma. (Goodness of fit test CFI\u0026thinsp;=\u0026thinsp;0.92 SRMR\u0026thinsp;=\u0026thinsp;0.07 RMSEA\u0026thinsp;=\u0026thinsp;0.062), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eDirect and indirect factors associated with social domain HRQoL among PLHIV on second-line ART\u003c/h2\u003e\u003cp\u003eSocial support had a direct positive effect on the social domain quality of life score. The direct positive effect of social support on the social domain quality of life score was that as the social support score, increased by one unit, the social domain quality of life increased by 0.2 on average, while the effects of the other covariates in the model remained constant [β ̂ = 0.2, (95% CI: 0.046, 0.337)] (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e) and Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDirect and indirect factors associated with social domain HRQOL among PLHIV on second-line ART (n\u0026thinsp;=\u0026thinsp;825).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eEstimates (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSE of\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eStandardized Estimate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e95% CI for Estimates\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003eThe Social Domain HRQOL\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003eDirect effect\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; SQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.046\u0026ndash;0.337\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDep \u0026rarr; SQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e-0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.638 to -0.192\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIS \u0026rarr; SQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.539 to -0.123\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAn indirect effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; PS \u0026rarr; Dep \u0026rarr; SQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.090\u0026ndash;0.334\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; IS \u0026rarr; SQL\u003c/p\u003e\u003cp\u003eSS \u0026rarr; IS \u0026rarr; Dep \u0026rarr; SQL\u003c/p\u003e\u003cp\u003ePS \u0026rarr; Dep \u0026rarr; SQL\u003c/p\u003e\u003cp\u003eSS \u0026rarr; Dep \u0026rarr; SQL\u003c/p\u003e\u003cp\u003eIS \u0026rarr; Dep \u0026rarr; SQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003cp\u003e0.11\u003c/p\u003e\u003cp\u003e0.30\u003c/p\u003e\u003cp\u003e0.04\u003c/p\u003e\u003cp\u003e-0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003cp\u003e0.033\u003c/p\u003e\u003cp\u003e0.09\u003c/p\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003cp\u003e0.10\u003c/p\u003e\u003cp\u003e0.30\u003c/p\u003e\u003cp\u003e0.04\u003c/p\u003e\u003cp\u003e-0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.097\u0026ndash;0.427\u003c/p\u003e\u003cp\u003e0.04\u0026ndash;0.171\u003c/p\u003e\u003cp\u003e-0.466 to -0.126\u003c/p\u003e\u003cp\u003e0.001\u0026ndash;0.087\u003c/p\u003e\u003cp\u003e-0.216 to \u0026minus;\u0026thinsp;.0515\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe total effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; SQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.038\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.74\u0026ndash;0.89\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIS \u0026rarr; SQL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.47\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e-0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.632 to -0.298\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eDep depression, PS perceived stigma, SS social support, SQL social domain quality of life and IS internalized stigma.. (Goodness of fit test CFI\u0026thinsp;=\u0026thinsp;0.93 SRMR\u0026thinsp;=\u0026thinsp;0.061 RMSEA\u0026thinsp;=\u0026thinsp;0.06), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eDirect and indirect factors associated with environmental domain HRQoL among PLHIV on second-line ART\u003c/h2\u003e\u003cp\u003eDepression had a direct negative effect on the environmental quality of life score. The direct effect of depression on the environmental domain quality of life score was that with a one-unit increase in the depression score, the environmental domain quality of life score decreased by 0.45 on average, provided that the effects of the other variables in the model remained constant [β ̂ = -0.45, (95% CI: -0.624, 0.278)]. Similarly, perceived stigma had a direct negative effect on environmental quality of life. The direct effect of perceived stigma on the environmental domain quality of life score was that as the patients' perceived stigma score increased one unit, the environmental domain quality of life score decreased by 0.63 on average, provided that the effects of the other covariates in the model remained constant [β ̂ = -0.63, (95% CI: -0.844\u0026ndash;0.412)] (Table\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e) and Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDirect and indirect factors associated with the environmental domain of HRQOL among PLHIV on second-line ART (n\u0026thinsp;=\u0026thinsp;825).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstimates (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSE of\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStandardized Estimate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI for Estimates\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eThe Psychological Domain HRQOL\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eDirect effect\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePS \u0026rarr; EQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0. 10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.844 to -0.412\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDep \u0026rarr; EQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.624 to -0.278\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAn indirect effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; Dep \u0026rarr; EQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.09\u0026ndash;0.227\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; PS\u0026rarr; EQOL\u003c/p\u003e\u003cp\u003eIS \u0026rarr; Dep\u0026rarr; EQOL\u003c/p\u003e\u003cp\u003eSS \u0026rarr;IS \u0026rarr; Dep\u0026rarr; EQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003cp\u003e-0.30\u003c/p\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003cp\u003e0.06\u003c/p\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003cp\u003e0.30\u003c/p\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.299\u0026ndash;0.616\u003c/p\u003e\u003cp\u003e-0.429 to -0.178\u003c/p\u003e\u003cp\u003e0.144\u0026ndash;0.344\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe total effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; EQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.037\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.786\u0026ndash;0.933\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDep depression, PS perceived stigma, SS social support, EQOL environmental domain quality of life and IS internalized stigma. (Goodness of fit test CFI\u0026thinsp;=\u0026thinsp;0.94 SRMR\u0026thinsp;=\u0026thinsp;0.051 RMSEA\u0026thinsp;=\u0026thinsp;0.05) as shown at (Table\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e) and Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDirect and indirect factors associated with level of independent domain HRQoL among PLHIV on second-line ART\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePerceived stigma had a direct negative effect on the level of the independent domain quality of life score. The direct effect of perceived stigma on the independent quality of life score was a one -unit increase in the perceived stigma score, and the independent domain quality of life score decreased by 0.45 on average, provided that the effects of the other variables in the model remained constant [β ̂ = -45, (95% CI: -0.893, 0.002)]. The indirect effect of perceived stigma on the level of the independent domain quality of life score mediated through depression was that with a one-unit increase in the perceived stigma score, the level of independent domain quality of life decreased by 0.45 on average, provided that the effects of the other covariates in the model remained constant [β ̂ = -0.45, (95% CI: -0.742, 0.164)]. Overall, with a one-unit increased in the perceived stigma score, the independent domain quality of life score decreased by 0.90 on average, provided that the effects of the other covariates in the model remained constant [β ̂ = -0.90, (95% CI: -0.9384, 0.067)] (Table\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e) and Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDirect and indirect factors associated with the level of independent domain HRQOL among PLHIV on second-line ART (n\u0026thinsp;=\u0026thinsp;825).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eEstimates (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSE of\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStandardized Estimate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI for Estimates\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eThe level of Independent Domain HRQOL\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eDirect effect\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOI(having opportunistic infection) \u0026rarr; LQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u0026ndash;0.214\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDep \u0026rarr; LQOL\u003c/p\u003e\u003cp\u003ePS \u0026rarr; LQOL\u003c/p\u003e\u003cp\u003e\u003cb\u003eIndirect effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.59\u003c/p\u003e\u003cp\u003e-0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.52\u003c/p\u003e\u003cp\u003e-0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.960 to -0.219\u003c/p\u003e\u003cp\u003e-0.893 to -0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; PS \u0026rarr; LQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.002\u0026ndash;0.648\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; IS \u0026rarr; Dep \u0026rarr; LQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.053\u0026ndash;0.306\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; PS \u0026rarr; Dep \u0026rarr; LQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.120\u0026ndash;0.537\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIS \u0026rarr; Dep \u0026rarr; LQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.384 to -0.066\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePS \u0026rarr; Dep \u0026rarr; LQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.45\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.45\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.742 to -0.164\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe total effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; LQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.042\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.749 - 0.914\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePS \u0026rarr; LQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.9384 to -0.067\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eDirect and indirect factors associated with spiritual domain HRQoL among PLHIV on second-line ART\u003c/h2\u003e\u003cp\u003eDepression had a direct negative effect on the spiritual domain quality of life. The direct effect of depression on the spiritual domain quality of life was that with a one-unit increased in the depression score, the spiritual domain quality of life decreased by 0.54 on average, provided that the effects of the other variables in the model remained constant [β ̂ = -0.45, (95% CI: -0.613, 0.456)] (Table\u0026nbsp;\u003cspan refid=\"Tab11\" class=\"InternalRef\"\u003e11\u003c/span\u003e) and Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab11\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 11\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDirect and indirect factors associated with the spiritual domain of HRQOL among PLHIV on second-line ART (n\u0026thinsp;=\u0026thinsp;825).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstimates (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSE of\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\:\\widehat{\\varvec{\\beta\\:}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStandardized Estimate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI for Estimates\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eThe Spiritual Domain HRQOL\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eDirect effect\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDep \u0026rarr; SRQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.613 to \u0026minus;\u0026thinsp;0.456\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAn indirect effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; PS \u0026rarr; Dep \u0026rarr; SRQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.197\u0026ndash;0.329\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; IS \u0026rarr; Dep \u0026rarr; SRQOL\u003c/p\u003e\u003cp\u003eSS \u0026rarr; Dep \u0026rarr; SRQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.098\u0026ndash;0.194\u003c/p\u003e\u003cp\u003e0.009-0.100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe total effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS \u0026rarr; SRQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.396\u0026ndash;0.534\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDep depression, PS perceived stigma, SS social support, SRQOL spiritual domain quality of life and IS internalized stigma. (Goodness of fit test CFI\u0026thinsp;=\u0026thinsp;0.93 SRMR\u0026thinsp;=\u0026thinsp;0.07 RMSEA\u0026thinsp;=\u0026thinsp;0.06) as shown at (Table\u0026nbsp;\u003cspan refid=\"Tab11\" class=\"InternalRef\"\u003e11\u003c/span\u003e) and Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe purpose of this study was to determine the magnitude of health-related quality and the direct and indirect factors associated with it among PLHIV on second-line ART. In this study, the mean HRQOL was 48.7 (95% CI: (47.44, 49.96)). Depression, opportunistic infection, social support, nonmedication adherence, nonworkable functional status, perceived stigma, and internalized stigma were significant predictors of health-related quality of life. In this study, the mean HRQOL score was lower than studies conducted in Ethiopia, Iran, Botswana, and Thailand [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This discrepancy could be attributed to differences in the study population sample size, method of analysis, and study area [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In contrast, the results of this study were the same as those of study conducted in northern Shewa, Ethiopia [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAmong overall, and the six domains of HRQOL, the highest mean score was reported in the spiritual religion and personal belief domains of quality of life (mean\u0026thinsp;=\u0026thinsp;54, 95% CI: (52.9, 55.1)). This finding was supported by studies conducted in Iran, Brazil, Ethiopia, and Thailand [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], respectively. This might be, due to the strong religious and spiritual attachment of the study population [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe mean score of the social domain HRQOL was the lowest (mean\u0026thinsp;=\u0026thinsp;45, 95% CI: (43.7, 46.3)). This evidence was supported by studies conducted in Thailand [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], and Ethiopia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In contrast, a prior study conducted in Ethiopia revealed that the cognitive domain was the lowest [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This could be, due to the stigma and discrimination frequently experienced by people living with HIV [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, social support had both positive direct and indirect effects on all domains of HRQOL [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This study was supported by a systematic review and meta-analysis [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], and revealed that social support negatively affects depression [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], which had a role in enhancing HRQOL [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. This study was in line with studies conducted in China, Nepal, and Australia [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Social support had an indirect positive effect on the spiritual domain quality of life that was fully mediated through perceived stigma, depression, and internalized stigma with multiple sequential mediations [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In summary, social support plays a vital role in reducing mental health problems, including depression, and HIV-related stigma, and enhancing social interaction subsequently improves HRQOL [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Hence, support from friends, family, and non-profitable civic society should be encouraged at the societal level for PLHIV on second-line ART to avert the HROQL problem [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDepression had a direct negative effect on all domains of HRQOL [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. This study was in line with studies conducted in China, the United States, China, and Africa [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], which revealed that depression aggravated HIV-related stigma, subsequently affecting HRQOL [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Moreover, prior literature showed that higher depression score associated with lower quality of life and Vis versa [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Hence, healthcare approaches should combine mental health care with social support initiatives to improve HRQOL [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePerceived stigma was found to be, directly and negatively affect all domains of health-related quality of life [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. This finding could be, due to psychological distress, social isolation, or limited healthcare access [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. This finding was in line with those of studies conducted in China, and Ethiopia [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInternalized stigma was the most common direct and indirect negative predictor of all domains of HRQoL [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. This finding was in line with a study conducted in South India [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. This could be because internalized stigma among PLHIV affects their social engagement, mental health, self-efficacy, social support, and positive coping ability and enhances depression scores; subsequently, their HRQOL decreases [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. These results were in line with those of studies conducted in Nepal [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] and Pakistan [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Moreover, internalized stigma acts as an enhancing negative predictor of health-related quality of life [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], which is in line with studies conducted in the United States [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Hence, healthcare settings could systematically assess and address stigma-related challenges faced by PLHIV on second-line ART [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, nonmedication adherence was a negative direct predictor of HRQOL, specifically in the psychological domain [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This finding was supported by a study conducted in India [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. This could be because, as patients didn't adhere to their medication, the viral load increased, the CD4 level decreased [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], psychosocial problems increased, and subsequently decreased QOL [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe presence of opportunistic infection was a negative direct predictor of HRQOL, specifically overall HRQOL [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. This finding was supported by a cohort study conducted in Africa and Ethiopia [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. The reason could be that PLHIV with OIs experience multiple health complications, including prolonged illness, frequent hospitalizations, and side effects of additional medications [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. This finding was in line with a study conducted in Kenya [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Hence, early diagnosis and effective management of opportunistic infections should be applied to improve the overall well-being of PLHIV [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNonworkable functional status was a negative direct predictor of HRQOL, specifically the physical domain quality of life [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. This finding was consistent with those of cross-sectional studies conducted in India [57] and Ethiopia [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. In addition, a study conducted in Shewa, Ethiopia, revealed that nonworkable functional status severely negatively affects HRQOL [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The reason could be that individuals who are unable to work due to their health condition experience significantly lower HRQOL than their counterparts who remain functionally active [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. This finding was in line with a study conducted in Northeast China and Ethiopia [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Therefore, physical rehabilitation, vocational training, and financial assistance could be employed to improve the quality of life for nonworkable individuals [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003eStrength and Limitations of the study\u003c/h2\u003e\u003cp\u003eFirst, to the best of the researcher\u0026rsquo;s knowledge, this is the first study in Ethiopia to examine the direct and indirect causal pathways of factors influencing health-related quality of life scores, as measured by the WHOQOL-HIV BREF, among PLHIV on second-line ART. Second, this study utilized a structural equation modeling framework, allowing for the simultaneous estimation of direct, indirect, and total effects of predictor variables while accounting for measurement errors in latent variables. Third, this study utilized a large sample size. Fourth, it accounts for both clinical and psychosocial variables simultaneously. Finally, its findings are generalizable to other low-income settings that follow similar WHO HIV treatment guidelines.\u003c/p\u003e\u003cp\u003eAlthough this study utilized an advanced analytical model, it has several limitations. First, the use of self-reported data for most latent constructs may introduce biases such as social desirability and intentional misreporting, potentially affecting accuracy. Future studies should incorporate objective assessments or multiple data sources to enhance reliability. Second, the cross-sectional design limits causal inference, as it cannot determine the direction of relationships between predictor variables and health-related quality of life. Longitudinal studies are recommended to better capture the dynamic interactions among social, clinical, and psychological factors affecting PLHIV on second-line ART.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis finding revealed that health-related quality of life among PLHIV on second-line ART was highly affected by psychosocial variables. Social support has both direct and indirect positive effects on HRQOL. In most domains of health-related quality of life, depression and perceived and internalized stigma were mediator variables for the association between social support and HRQOL, at the same time as negative direct predictors of the quality of life. The unique finding of this study was the existence of partial, full, parallel, and sequential mediation for the association between social support and domains of HRQOL. Nonworkable functional status, opportunistic infection, depression, social support, nonoptimal medication adherence, perceived stigma, and internalized stigma were significant predictors of health-related quality of life.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eART\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAntiretroviral Therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody mass index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHAART\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHighly active antiretroviral therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHRQoL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth-Related Quality of Life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternalized stigma\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOSSS-3\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOslo Social Support Scale-3\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePHQ-9\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePatient Health Questionnaire-9\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePLHIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epeople with human immunodeficiency virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePerceived stigma\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQoL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality of Life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSEM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStructural equation modeling\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHOQoL-HIV BREF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization Quality of Life HIV BREF\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article or supplementary material; further inquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical standards of the institutional research committee and the principles outlined in the Declaration of Helsinki. Before the study began, ethical clearance was obtained from the ethical review committee of the College of Medicine and Health Science, Wollo University [Ref. No- WU/CMHS/0003/20/2025]. Verbal informed consent was obtained from all participants before the interview. Privacy, anonymity, and confidentiality were ensured throughout the study process. The participants were informed that refusing consent or withdrawing from the study would not negatively affect their access to healthcare. \u0026ldquo;Clinical trial number: Not applicable.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to all the data collectors, supervisors, study participants, and Wollo University for their creditable contributions to the success of this study. The authors would also like to thank the Dessie Comprehensive Specialised Hospital and Woldia Comprehensive Specialised Hospital for their open contributions to the success of this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKeleb Takele Tiruneh, \u0026nbsp; conceptualization, data curation, formal analysis, investigation, methodology, software, supervision, validation, visualization, writing original draft, and writing review \u0026amp; editing. Yeshewas Abaynew, Tesfaye Birhane Tegegne, and Fikade Demeke Bayou conceptualization, data curation, formal analysis, investigation, methodology, and supervision.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDinsa Ayeno H, Megersa Atomsa K, Melesie G, Taye. Assessment of Health-Related Quality of Life and Associated Factors Among HIV/AIDS Patients on Highly Active Antiretroviral Therapy (HAART) at Ambo General Hospital, West Shewa, Ethiopia. Volume 12. HIV AIDS (Auckl); 2020. pp. 467\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhong H, et al. Health-related quality of life and associated factors among people living with HIV/AIDS in Sichuan, China: A cross-sectional study. Front Public Health. 2023;11:1133657.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRuiz-Robledillo N, et al. 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Behavioral and psychosocial factors of quality of life among adult people living with HIV on Highly Active Antiretroviral Therapy. public Hosp Southwest Ethiopia. 2022;2(8):e0000822.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu X, et al. Perceived stigma, medical social support and quality of life among people living with HIV/AIDS in Hunan. China. 2015;28(2):169\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNoor A, V.J.H.N.J.o.S S, Earnshaw. \u003cem\u003eInternalized HIV Stigma, Psychological Distress, and Quality of Life in a Collectivist Culture.\u003c/em\u003e 2023. 4(1): pp. 414\u0026ndash;423.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTegegne A. S.J.P.p. and adherence, \u003cem\u003eQuality of life and associated factors of HIV patients under treatment with first line regimens in public hospitals in Amhara Region\u003c/em\u003e. North-West Ethiopia 2023: pp. 1347\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSukartini T, Abdullah KL, I.J.E.J.o.G M, Hasanah. Factors related ART adherence and quality of life in PLHIV: Mediating role of positive self-care management and brain gym. 2024. 21(3).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNyongesa MK et al. Correlates of health-related quality of life among adults receiving combination antiretroviral therapy in coastal Kenya. 2020. 18: pp. 1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGautam A, kleu BR. A cross-sectional study on predictors of quality of life of persons living with human immunodeficiency virus. 2021. 14(3): pp. 334\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Direct and indirect factors, structural equation modeling, health-related quality of life, second-line ART","lastPublishedDoi":"10.21203/rs.3.rs-6897343/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6897343/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePeople living with HIV have a longer lifespan and a lower mortality rate due to advancements in antiretroviral therapy. However, the clinical signs of HIV and psychological difficulties continue to impair their health-related quality of life. Therefore, this study aimed to assess health-related quality of life and examine the direct and indirect factors influencing it among people living with HIV on second-line antiretroviral therapy.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eAn institutionally based cross-sectional study was conducted from January 13 to April 13, 2025, with 825 people living with HIV on second-line antiretroviral therapy selected through simple random sampling. Data were collected through face-to-face interviews, document reviews, and analyzed with STATA version 17. Quality of life was measured with the WHOQOL-HIV BREF, and depression with the PHQ-9. Structural equation modeling was employed to assess the direct and indirect effects of variables on quality of life. Statistical significance was declared at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, and effect sizes are reported with 95% CIs. The findings were presented through text, tables, and graphs.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e\u003cp\u003eThe mean quality of life score was 48.7 (95% CI: (47.44, 49.96)). Internalized stigma had a direct [β ̂ = \u0026minus;0.59, (95% CI: -0.80, -0.381)] and indirect [β ̂ = \u0026minus;0.16, (95% CI: -0.249, -0.077)] negative effect on overall quality of life. The absence of opportunistic infection had a direct [β ̂ = 0.14, (95% CI: 0.028\u0026ndash;0.248)] positive effect on overall quality of life. Depression had a direct [β ̂ = \u0026minus;0.54, (95% CI: -0.734, -0.339)] negative effect on the physical domain quality of life. Social support had a direct [β ̂ = 0.20, (95% CI: 0.046, 0.337)] positive effect on the social domain quality of life.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis study revealed that psychosocial factors significantly impacted the quality of people living with HIV on second-line antiretroviral therapy. Social support, depression, perceived stigma, internalized stigma, nonworkable functional status, and opportunistic infections were predictors of quality of life. Hence, healthcare facilities should integrate and strengthen routine mental health screenings and interventions in HIV care programs.\u003c/p\u003e","manuscriptTitle":"Direct and indirect factors associated with health-related quality of life among PLHIV on second-line antiretroviral therapy at Dessie and Woldia Comprehensive Specialized Hospitals in Ethiopia: application of structural equation modelling","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 18:58:26","doi":"10.21203/rs.3.rs-6897343/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-14T19:44:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-11T06:54:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-09T16:16:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-02T19:47:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274554937172830849993131395118037645008","date":"2025-07-30T15:01:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151376226313549755421006255106370210070","date":"2025-07-28T13:04:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69830301286678155677085789437233345842","date":"2025-07-26T09:11:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-23T18:22:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151258251341427956921381274359488746389","date":"2025-07-21T08:50:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-14T10:06:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-18T10:53:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-18T01:15:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-18T01:14:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-06-15T08:51:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ad1bbfed-e016-4570-80d6-3ad033642fdb","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:04:30+00:00","versionOfRecord":{"articleIdentity":"rs-6897343","link":"https://doi.org/10.1186/s12879-026-12870-1","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2026-02-14 15:57:24","publishedOnDateReadable":"February 14th, 2026"},"versionCreatedAt":"2025-07-18 18:58:26","video":"","vorDoi":"10.1186/s12879-026-12870-1","vorDoiUrl":"https://doi.org/10.1186/s12879-026-12870-1","workflowStages":[]},"version":"v1","identity":"rs-6897343","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6897343","identity":"rs-6897343","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}