AIDS Education and Prevention, 21(2), 104112, 2009

2009 The Guilford Press

SOLOMON ET AL.
QUALITY-OF-LIFE STUDY IN SOUTH INDIA

A Longitudinal Quality-of-Life Study

of HIV-infected persons in South
India: the case for comprehensive
clinical care and support services
Suniti Solomon, Ashita Batavia, Kartik K Venkatesh, Lisanne Brown,
Praneeta Verma, Anitha J. Cecelia, Celine Daly, Vaishali S Mahendra,
N. Kumarasamy, and Kenneth H. Mayer

This study longitudinally assesses the quality of life (QOL) of HIV-infected

individuals in a resource-limited setting prior to the extensive generic roll-
out of highly active antiretroviral therapy. Data was collected on 136 indi-
viduals receiving clinical care at Y.R. Gaitonde Centre for AIDS Research
and Education YRG CARE, a large community-based HIV tertiary care re-
ferral center in Chennai, South India. The QOL questionnaire was adminis-
tered to participants at baseline, 6-months follow-up, and 12-month follow-
up, and analysis of variance was used to assess for significant differences
in mean QOL scores for each of these visits. Study findings showed that
QOL scores significantly improved in all five domains of the questionnaire
between participants baseline visit, second interview, and third interviews
(p < 0.01). We conclude that a multidisciplinary approach to managing HIV
infection can enhance patients QOL, independent of antiretroviral therapy.

It is currently estimated that between 2.1 million and 3.0 million Indians are infected
with HIV (UNAIDS, 2007). Although the epidemic in India was first detected in
populations with a higher HIV exposure risk, such as sex workers, truck drivers,
and injection drug users (IDUs), infection has now spread to the urban and rural
general populations (Gangakhedar et al., 1997; Solomon, Kumarasamy, Ganesh,
& Amalraj, 1998). With the increasing provision of HIV clinical care, HIV-infected
Indians may be able to lead longer and more productive lives, making quality of life

Suniti Solomon, Anitha J. Cecelia, and N. Kumarasamy are with YRG CARE, Chennai, India. Ashita
Batavia is with Weill Cornell Medical College, New York. Kartik K. Venktesh and Kenneth H. Mayer are
with Brown Medical School/Miriam Hospital, Providence, RI. Lisanne Brown is with Tulane University,
New Orleans, LA. Praneeta Verma is with the AIDS Prevention and Control Society, Chennai, India. Ce-
line Daly is with Family Health International, Bangkok, Thailand. Vaishali S. Mahendra is with Horizons/
Population Council, New Delhi, India.
The authors thank the Population Council (Agreement Number AI99.77A) for supporting this study. The
authors are grateful to Isabelle de Zoysa WHO-Geneva (formerly with Horizons/Population Council,
New Delhi) and Christopher Castle UNESCO-Paris (formerly with Horizons/International HIV AIDS
Alliance, Washington DC).
Address correspondence to Kenneth H. Mayer, MD, Brown Medical School/Miriam Hospital, 164 Sum-
mit St., Providence, RI 02906; e-mail: Kenneth_Mayer@Brown.edu

104
QUALITY-OF-LIFE STUDY IN SOUTH INDIA 105

(QOL) an important area of concern for patients and providers of medical and social
services.
QOL is a multidimensional construct generally defined as a subjective evalua-
tion of ones functioning and well-being (Sowell et al., 1997). Incorporating patient-
reported data into the clinical encounter can assist caregivers in optimizing QOL
for patients with HIV (Wu, 2000). In the developed world, both generic health-
related QOL and HIV-specific instruments have been used to measure QOL among
HIV-infected individuals (Cunningham, Crystal, Bozzette, & Hays, 2005; Franchi &
Wenzel, 1998; Liu et al., 2006; Murri et al., 2003; Preau et al., 2007; Saunders &
Burgoyne, 2002; Wu, Hays, Kelly, Malitz, & Bozette, 1997) However, because indi-
vidual lifestyle, social norms, cultural practices, and belief systems vary between dif-
ferent populations, it is imperative to have a deeper understanding of the experiences
of HIV-infected Indians. Despite a few studies that have examined QOL among
HIV-infected Indians (Chanda, Deethivarma, Jairam, & Thomas, 2003; Kohli et
al., 2007; Wig et al., 2006) this is the first longitudinal study of QOL among HIV-
infected Indians to date.
The current study was undertaken to examine changes in QOL after initiat-
ing clinical care over a 12-month period within a resource-limited setting. These
data are derived from a larger prospective cohort study jointly implemented by Y.R.
Gaitonde Centre for AIDS Research and Education (YRG CARE), Horizons/Popula-
tion Council, and International HIV/AIDS Alliance to identify key elements of YRG
CAREs continuum of care program that meet the perceived needs of clients by as-
sessing their satisfactions with services and changes in perceived QOL.

METHODS

Study Setting
YRG CARE, a tertiary care facility for HIV/AIDS based in Chennai, India,
has provided comprehensive care for over 10,000 HIV-infected individuals to date.
Patients at YRG CARE are able to access anonymous voluntary counseling and
testing (VCT) services, prevention counseling, medical management including treat-
ment and monitoring, nutrition counseling, and a wide range of other support and
clinical services. Patients are advised to initiate highly active antiretroviral therapy
(HAART) at CD4 counts of less than 200 cells/microliter (L), or with CD4 counts
between 200 and 350 cells/L and an AIDS-defining illness. Patients are scheduled
for medical evaluation every 3 months or as clinically indicated.
The current study was conducted prior to the extensive rollout of HAART by
global funding agencies and the Indian government, at which time antiretroviral
therapy costs remained prohibitively expensive for most HIV-infected patients.

Participants
Enrollment criteria required provision of informed consent from HIV-infected
individuals over 18 years of age. Patients who were pregnant or with any history of
antiretroviral therapy use were excluded. In total, 356 patients were recruited from
YRG CARE from April 2000 to October 2000. All patients were clinically staged at
enrollment as asymptomatic, mild/ moderately symptomatic, or severely symptom-
atic.
106 SOLOMON ET AL.

TABLE 1. Quality of Life Instrument

Domain Items
Physical well-being Rate ability to perform daily activities without assistance
Rate energy for everyday activities
Physical pain prevents performing normal work
Satisfaction with work capacity
Rate ability to concentrate
Rate sleep quality
Rate appetite quality
Comfort with body appearance
Psychological well-being Rate frequency of positive feelings about the future
Rate fear of being alone as the disease progresses
Rate comfort in disclosing HIV status to family and friends
Rate worry about family members ability to cope with your death
Rate ability to remember things
Rate comfort in seeing other patients
Rate fear about being able to care for yourself
Social support Satisfied with support from friends
Satisfaction with support from family members
Sexual well-being Satisfaction with current sex life
Rate fear of initiating/resuming a sexual relationship given HIV status
Relationship with partner Fear that partner will leave as a result of HIV status
Difficulty talking about the future with partner

Clinical Staging
Clinical staging was based on a modification of the WHO Adult Clinical Stag-
ing Guidelines (2003). Asymptomatic patients were defined as being without symp-
toms or with generalized lymphadenopathy only. The criteria for mild/ moderately
symptomatic patients included weight loss, herpes zoster, tinea infection in the skin,
papular pruritic eruptions, oral thrush, over 1 month of diarrhea or unexplained
fever, severe bacterial infections, pulmonary tuberculosis, or acute necrotizing ul-
cerative gingivitis/ periodontitis. Severely symptomatic patients included those pre-
senting with HIV wasting syndrome, extra pulmonary tuberculosis, cryptococcal
meningitis, toxoplasmosis, cytomegalovirus, esophageal thrush, and Pneumocystis
jiroveci pneumonia.

QOL
This study used the WHO Quality of Life (QOL) HIV instrument, Functional
Assessment of Human Immunodeficiency Virus Infection (FAHI) QOL instrument,
and the Medical Outcomes Study (MOS) measures of QOL to develop a QOL ques-
tionnaire appropriate for South Indian populations (Cella, McCain, Peterman, &
Wolen, 1996; World Health Organization HIV/AIDS Quality of Life Group, 1999).
After field-testing with the FAHI QOL instrument and the MOS measures of QOL,
the following five domains were retained and modified for use in this study: physical
well-being, psychological well-being, social support, sexual well-being, and relation-
ship with partner (Table 1). Each domain comprises items scored on a scale between
QUALITY-OF-LIFE STUDY IN SOUTH INDIA 107

1 and 5. A score of 1 on an item indicates a low QOL whereas a score of 5 on an

item indicates a high QOL. For each participant, the average score of all items in a
domain represents his/her QOL for that domain.

Study Follow-Up
A trained research nurse collected demographic information at the first inter-
view. During the first interview participants also recorded answers to the survey
questionnaire assessing their QOL 6 months prior to coming to YRG CARE and at
the present time. Participants were scheduled for a second interview at 6 months and
a third interview at twelve months. Only the survey questionnaire was administered
at the second and third interview.

Statistical Analysis
Descriptive statistics were used to describe the characteristics of the study popu-
lation. All items in the QOL questionnaire were scored from 1 to 5, with a score of 1
indicating a low QOL and a score of 5 indicating a high QOL. For each participant,
the QOL score for each of the five domains of the questionnaire was calculated by
averaging the score of all items comprising that domain. Composite QOL scores for
each assessment were calculated by averaging the QOL score in each of the 5 study
domains. Clinical differences in the QOL domains were analyzed using ANOVA. A
p value of less than 0.05 was considered to be statistically significant. All statistical
analysis was performed with SPSS software, Version 13.0.

RESULTS

Baseline Demographic and Clinical Characteristics

The demographic characteristics of all participants enrolled in this study (N =
356) and the demographic characteristics of the final study cohort of all participants
that attended all three interviews (baseline interview, second interview at 6 months,
and a third interview 12 months after the baseline interview), are presented in Table
2. In the final study cohort, participants were predominantly employed in unskilled
occupations, which was the only significant difference between all enrolled partici-
pants and the final study cohort.

QOL Scores
For the 136 participants with 12 months of follow-up, the QOL scores signifi-
cantly improved in all five domains between their baseline visit, second interview,
and third interview (p < .01) (Table 3). The only decline in QOL scores longitudi-
nally was between the prior to YRG CARE retrospective assessment and the baseline
assessment in the sexual well-being domain (decline of 0.3) and the relationship
with partner domain (decline of 0.03). However, these declines were not statistically
significant. The greatest improvement in the Composite QOL Scores for the final
study cohort occurred between the baseline assessment and the second interview
(improvement of 0.3).
Overall QOL scores in each domain significantly improved for each clinically
staged group during the 12-month follow-up period (p < .01). The greatest improve-
ment in composite QOL scores for asymptomatic participants (0.24) occurred be-
tween Interview 2 and Interview 3. Both mild/moderately symptomatic and severely
symptomatic participants experienced the greatest improvement in composite QOL
108 SOLOMON ET AL.

TABLE 2. Demographic Characteristics of Study Participants

All Enrolled (N = 356) Final Study Cohort (N = 136)
Male Gender 60.4% 66.2%
Age (mean) in years 31.2 31.6
Location of residence
Rural 33.7% 30.9%
Urban 27.5% 30.1%
Semi urban 38.8% 39.0%
Religion
Hindu 95.8% 96.3%
Muslim 1.7% 0.7%
Christian 2.5% 2.9%
Language
Tamil 48.0% 51.5%
Telugu 44.1% 41.9%
Other 7.8% 6.7%
Education
None 11.8% 7.4%
Primary 14.3% 13.2%
Middle school 18.8% 16.2%
Matric or SSLC 25.8% 33.1%
Higher secondary/Preuniversity College/Intermediate 16.0% 17.6%
Graduate and higher 13.2% 12.5%
Occupation
Unskilled 21.1% 66.9%
Skilled 46.0% 3.0%
Unemployed 6.2% 6.6%
Housewife 26.1% 22.8%
Student 0.6% 0.7%
Marital Status
Living w/Spouse 67.4% 66.9%
Separated/Divorced 2.0% 1.5%
Abandoned 1.1% 1.5%
Widowed 12.6% 14.0%
Living together but unmarried 3.1% 3.7%
Unmarried 13.8% 12.5%
Type of household
Nuclear 40.2% 36.8%
Extended/Joint 58.4% 61.8%
Other 1.4% 1.5%
Severity of disease
Asymptomatic 33% 30.9%
Mild/ Moderate 43% 44.9%
Severe 24% 24.3%
QUALITY-OF-LIFE STUDY IN SOUTH INDIA 109

TABLE 3. Quality of Life for the Final Study Cohort (N = 136)

Prior to YRG Baseline/
CARE Interview 1 Interview 2 Interview 3
Quality of Life Domains Mean (SD) Mean (SD) Mean (SD) Mean (SD) p Value
Physical well-being 3.32 (0.99) 3.65 (0.76) 3.96 (0.60) 4.09 (0.64) < .01
Psychological well-being 3.13 (0.93) 3.33 (0.78) 3.74 (0.60) 3.95 (0.58) < .01
Social support 3.85 (0.53) 3.85 (0.53) 3.91 (0.58) 4.13 (0.65) < .01
Sexual well-being 3.31 (1.09) 3.28 (1.10) 3.71 (0.98) 3.96 (0.91) < .01
Relationship with partner 4.28 (0.89) 4.25 (0.89) 4.53 (0.70) 4.71 (0.59) < .01
Composite QOL score 3.57 3.67 3.97 4.17 -

scores (0.35 and 0.46, respectively) between the baseline assessment and Interview
2. In the four cases in which a domain QOL score decreased for a clinically staged
group between assessment time points, the decline was minimal ranging from 0.01
to 0.17 (Table 4).

DISCUSSION

In the era of increasing access to HAART, growing numbers of HIV-infected Indians

are able to lead longer, healthier, and more productive lives (Kumarasamy et al.,
2003). Enrollment for this study occurred between April 2000 and October 2000,
at the beginning of extensive generic HAART roll-out in resource-limited settings,
when the costs of HAART were still prohibitive for most patients (Duraisamy et al.,
2006). In the present treatment scenario of increasing access to generic HAART, it is
no longer ethically permissible to conduct a longitudinal study assessing the impact
of only providing treatment for symptoms and opportunistic infections on the QOL
of HIV-infected patients. Studies in the developed world conducted in the era prior
to HAART showed decrements in QOL over the follow-up period, especially among
patients with AIDS-defining illnesses (Lubeck & Fries, 1992, 1997). However, this
study, similar to many recent studies conducted in the era of HAART (Saunders &
Burgoyne, 2002), demonstrated consistent increases across all physical and psycho-
social domains over time.
This study demonstrated significant improvements over the 12-month follow-up
in the QOL of the final study cohort. These improvements diminished with time and
the greatest gains occurred between the baseline assessment and the second inter-
view. Importantly, the current study suggests HIV-infected individuals that are clini-
cally staged as being severely symptomatic can perceive improvements in their QOL
over time with high-quality clinical care alone. It is likely that providing HAART as
part of clinical care would have led to even greater improvements in their physical
well-being of symptomatic patients as a consequence of their improved immunologi-
cal status and the resolution of opportunistic infections.
The physical well-being domain indicated marked improvements in QOL after
enrollment into clinical care at YRG CARE. Another study conducted in India re-
ported a similar gain in physical well-being (Kohli et al., 2005). It has been suggested
that physical domain scores can be an important prognostic predictor, of even great-
er value than CD4 cell count and CDC staging criteria (Cunningham et al., 2005). In
110 SOLOMON ET AL.

TABLE 4. Quality of Life for the Final Study Cohort (N = 136)

Clinical Stage at Baseline Assessment
Asymptomatic Mild/ Moderate Severe
N = 42 N = 61 N = 33
Mean (SD) Mean (SD) Mean (SD) p Value
Prior to YRG CARE
Physical well-being 4.05 (0.62) 3.31 (0.78) 2.40 (0.94) <.01
Psychological well-being 3.40 (0.84) 3.17 (0.90) 2.74 (1.01) <.01
Social support 3.91 (0.37) 3.79 (0.60) 3.89 (0.56) <.01
Sexual well-being 3.46 (0.99) 3.28 (1.14) 3.15 (1.11) <.01
Relationship with partner 4.48 (0.70) 4.27 (0.90) 4.07 (1.07) <.01
Composite QOL Score 3.86 3.56 3.25 --
Baseline/ Interview 1
Physical well-being 4.15 (0.55) 3.57 (0.69) 3.16 (0.75) <.01
Psychological well-being 3.57 (0.69) 3.27 (0.83) 3.12 (0.76) <.01
Social support 3.87 (0.35) 3.80 (0.61) 3.89 (0.56) <.01
Sexual well-being 3.62 (0.97) 3.11 (1.18)* 3.14 (1.03)* <.01
Relationship with partner 4.50 (0.68) 4.17 (1.01)* 4.09 (0.84) <.01
Composite QOL Score 3.94 3.58 3.48 --
Interview 2
Physical well-being 4.27 (0.47) 3.86 (0.64) 3.89 (0.57) <.01
Psychological well-being 3.90 (0.61) 3.62 (0.59) 3.83 (0.59) <.01
Social Support 4.00 (0.52) 3.90 (0.67) 3.87 (0.45) <.01
Sexual well-being 3.60 (0.95)* 3.80 (0.93) 3.64 (1.08) <.01
Relationship with partner 4.74 (0.52) 4.46 (0.74) 4.48 (0.74) <.01
Composite QOL Score 4.10 3.93 3.94 --
Interview 3
Physical well-being 4.51 (0.45) 4.06 (0.60) 3.92 (0.72) <.01
Psychological well-being 4.23 (0.48) 3.86 (0.58) 3.99 (0.59) <.01
Social support 4.18 (0.57) 4.19 (0.59) 3.97 (0.78) <.01
Sexual well-being 3.89 (0.92) 4.05 (0.87) 3.83 (1.00) <.01
Relationship with partner 4.89 (0.40) 4.67 (0.65) 4.69 (0.55) <0.01
Composite QOL Score 4.34 4.17 4.08 --
*Domain QOL score declines from value recorded at previous QOL assessment.

clinical settings with infrequent lab-based testing, clinicians may also be able to use
QOL domain scores to access prognosis and plan clinical management.
Participants experienced significant improvements in their psychological well-
being and social support after accessing medical support for HIV. Data from sexual
well-being and relationship with partner domains indicate that patients perceived
improvements in these QOL areas after participating in counseling services made
available through YRG CARE. The current study suggests that providing a con-
tinuum of care that includes counseling services in addition to clinical care can sig-
nificantly improve the QOL of a patient population in a resource-limited setting.
The YRG CARE model of providing a continuum of care to HIV-infected pa-
tients was unique at the time this study was conducted. Participants in the final study
cohort reported a decline in QOL in the psychological well-being, sexual well-being,
QUALITY-OF-LIFE STUDY IN SOUTH INDIA 111

and relationship with partner domains between prior to YRG CARE and baseline
assessments. After accessing counseling services at YRG CARE, patients reported
QOL improvements in the aforementioned domains and the social support domain.
Our data suggests that providing counseling services that broadly address patient
concerns can impact patients composite QOL scores, and hence any treatment pro-
gram should combine a robust counseling program at every patient encounter as
part of comprehensive clinical care.
In conclusion, it is advisable that identifying modifiable determinants of low
quality of life of HIV-infected patients at different disease stage can lead to the de-
velopment of effective interventions within clinical care settings. This baseline data
may be useful in assessing improvement in QOL in light of the increasing role out
of HAART across the developing world. In consideration of the fact that this study
excluded patients receiving HAART, the results suggest that timely management of
symptoms and opportunistic infections alone in HIV-infected South Indians can have
a positive effect on their QOL.

Limitations
This is the first longitudinal study to date from an Indian setting reporting
changes in QOL over time. However, the final study cohort at 12 months represents
only 38.2% of the patients initially enrolled in this study. Explanations for this low
retention rate include the fact that 24 patients classified as clinically asymptomatic
on the baseline assessment missed the second interview but attended the third inter-
view and were excluded from the final study cohort. Participants were scheduled for
their second and third interviews over a two-week window period, and those unable
to follow-up at YRG CARE during this interval were excluded from the final study
cohort. This narrow follow-up interview interval may have been difficult for partici-
pants to accommodate because of travel costs, physical illness, or other limitations
within a resource-limited setting. The demographic characteristics of the final study
cohort are representative of all originally enrolled participants, with the exception of
the percent of unskilled workers. Unskilled workers may have been over-represented
in the final study cohort because they had the job-related flexibility to attend follow-
up interviews in the time period specified.

REFERENCES

Cella, D., McCain, N.L., Peterman, A.H., & Wo-
len D. (1996). Development and validation
of the Functional Assessment of Human
Immunodeficiency Virus Infection (FAHI)
quality of life instrument. Quality of Life
Research, 5, 450-463.
Chanda, P., Deepthivarma, S., Jairam, K.R., &
Thomas, T. (2003). Relationship of psy-
chological morbidity and quality of life in
illness-related disclosure among HIV-infect-
ed persons. Journal of Psychosomatic Re-
search, 54, 199-203.
Cunningham, W., Crystal, S., Bozzette, S., & Hays,
R.D. (2005). The association of health-
related quality of life with survival among
persons with HIV infection in the United
States. Journal of General Internal Medi-
cine, 20, 21-27.
Duraisamy, P., Ganesh, A.K., Homan, R., Ku-
marasamy, N., Castle ,C., Sripriya, P. et al.
(2006). Costs and financial burden of care
and support services to PLHA and house-
holds in South India. AIDS Care, 18(2),
121-127.
Franchi, D. & Wenzel, R.P. (1998). Measuring
health-related quality of life among patients
infected with human immunodeficiency vi-
rus. Clinical Infectious Disease, 26, 20-26.
Gangakhedkar, R., Bentley, M.E., Divekar, A.D.,
Gadkari, D., Mehendale, S.M., Shepherd,
M.E., et al. (1997). Spread of HIV infection
in married monogamous women in India.
112 SOLOMON ET AL.
Journal of the American Medical Associa-
tion, 278(23), 2090-2092.
Kohli, R., Sane, S., Kumar, K., Ramesh, S., Paran-
jape, R.S., & Mehendale, S.M. (2005).
Assessment of quality of life among HIV-
infected persons in Pune, India. Quality of
Life Research, 14, 1641-1647.
Kumarasamy, N., Solomon, S., Chaguturu, S.K.,
Mahajan, A.P., Flanigan, T.P., Balakrishnan
P. et al. (2003). The safety, tolerability, and
effectiveness of generic antiretroviral drug
regimens for HIV-infected patients in south
India. AIDS, 17, 2265-2271.
Liu, C., Johnson, L., Ostrow, D., Silvestre, A., Viss-
cher, B., & Jacobson, L.P. (2006). Predic-
tors for lower quality of life in the HAART
era among HIV-infected men. Journal of
Acquired Immune Deficiency Syndrome,
42, 470-477.
Lubeck, D. & Fries, J.F. (1992). Changes in quality
of life among persons with HIV infection.
Quality of Life Research, 1(6), 359-366.
Lubeck, D. & Fries, J.F. (1997). Assessment of
quality of life in early stage HIV-infected
persons: Data from the AIDS Time-Orient-
ed Health Outcome Study (ATHOS). Qual-
ity of Life Research, 6(6), 494-506.
Murri, R., Fantoni, M., Del Borgo, C., Visona, R.,
Barracco, A., Zambelli, A., et al. (2003).
Determinants of health-related quality of
life in HIV-infected patients. AIDS Care,
15(4), 581-590.
Preau, M., Marcellina, F., Carrieria, M.P., Lertd,
F., Obadiaa, Y., & Spirea, B. (2007). VESPA
Study Group. Health-related quality of life
in French people living with HIV in 2003:
Results from the national ANRS-EN12-
VESPA Study. AIDS, 21, S19-S27.
Saunders, D., & Burgoyne, R.W. (2002). Evalu-
ating health-related wellbeing outcomes
among outpatient adults with human immu-
nodeficiency virus infection in the HAART
era. International Journal of STD & AIDS,
13, 683-690.
Solomon, S., Kumarasamy, N., Ganesh, A.K., &
Amalraj, R.E. (1998). Prevalence and risk
factors of HIV-1 and HIV-2 infection in ur-
ban and rural areas in Tamil Nadu, India.
International Journal of STD & AIDS, 9,
98-103.
Sowell, R., Seals, B.F., Moneyham, L., Demi, A.,
Cohen, L., & Brake, S. (1997). Quality of
life in HIV-infected women in the south-
eastern United States. AIDS Care, 9(5),
501-12.
UNAIDS. (2007). UNAIDS/WHO AIDS epidemic
update, 2007 [cited November 5, 2007];
Available from: http://www.unaids.org/
epidemic-update/
WHO HIV/AIDS Quality of Life HIV/AIDS
Group. (1999). Development of the WHO-
QOL-HIV instrument for Field Testing:
Summary analysis of the pilot HIV/AIDS
data. Geneva, Switzerland: World Health
Organization.
Wig, N., Lekshmi, R., Pal, H., Ahuja, V., Mital,
C.M., & Agarwal, S.K. (2006). The impact
of HIV/AIDS on the quality of life: a cross-
sectional study in North India. Indian Jour-
nal of Medical Sciences, 60, 3-12.
Wu, A. (2000). Quality of life assessment comes of
age in the age of highly active antiretroviral
therapy. AIDS, 14, 1449-1451.
Wu, A., Hays, R.D., Kelly, S., Malitz, F., & Boz-
zette, S.A. (1997). Applications of the medi-
cal outcomes study health-related quality of
life measures of HIV/AIDS. Quality of Life
Research, 6, 531-554.
WHO. (2003). Scaling up anti-retroviral therapy in
resource-limited settings: Treatment guide-
lines for a public health approach. Geneva,
Switzerland: World Health Organization.
http://www.who.int/3by5/publications/doc-
uments/avv-guidelines/en/index.html