HIV infection among children accounts for 3.5% of HIV infected population in India [1]. HIV infection in children is a chronic illness with effect on physical, emotional and social well-being. There is, however paucity of information on assessment of quality of life among HIV infected Indian children [2,3]. The present study was designed to assess the quality of life (QOL) among HIV infected children when compared to children with other chronic diseases and to determine the influence of demographic and clinical factors on quality of life among HIV infected children.

The tool assesses the quality of life in five domains: physical functioning (8 items), psychosocial functioning (sum of emotional, social and school functioning), emotional functioning (5 items), social functioning (5 items) and school (5 items) functioning. The PedsQL scores range from 0 to 100 points with higher scores predicting better quality of life. Baseline demographic factors including age, gender and kuppuswamy’s socioeconomic status of the family were collected [5]. Clinical and immunological staging of HIV infection as per World Health Organization (WHO) guidelines was recorded among the cases [6]. Clinical diagnosis and duration of symptoms of control subjects were also recorded.

The Mean QOL scores were compared among the cases and controls and also among various demographic and clinical variables using a unpaired t test and analysis of variance (ANOVA). All tests were two tailed and P value of less than 0.05 was considered statistically significant.

The mean (SD) age of cases was 8.98 (3.49) years and 70% were males. Diagnosis of children in the control group (n=40) were thalassemia, in 18(45%) epilepsy in 10 (25%), nephrotic syndrome in 7 (17.5%) and one case each of celiac disease, leukemia, chronic liver disease, rheumatic heart disease and juvenile rheumatoid arthritis.

Majority belonged to lower socioeconomic status [23 (57.5%)], seven (17.5%) were orphans, one child above 5 years of age did not attend school, 38 (95%) had acquired infection by vertical transmission and were on ART for median (IQR) duration of 16.5 (7, 48.75) months. Clinical staging of cases at time of assessment were as follows: stage 1, 5 (12.5%); stage 2, 16 (40%), stage 3, 12 (30%) and stage 4, 7 (17.5%). Similarly, immunological staging were: not significant 2 (5%), mild 3 (7.5%), advanced 3 (7.5%) and severe 32 (80%).

In accordance with the child self-report, quality of life among HIV infected children was better compared to controls with significantly better scores in the psychosocial (P=0.008), emotional (P=0.001) and school (P=0.039) functioning among the former. Similarly, a parental proxy report on perceived quality of life of their HIV infected children was better than controls with significant difference in emotional functioning domain (P=0.038) (Table I).

TABLE I Quality Of Life Scores In Cases And Controls

Demographic factors did not significantly influence the total QOL scores among HIV infected children (Table II). In subgroup analysis, it was observed that children with milder clinical stage had significantly better quality of life scores in physical functioning domain (P=0. 021). Similarly, younger aged children performed better QOL scores than their older counterparts in physical functioning domain (P=0.014).

TABLE II	Factors Affecting Quality Of Life Among Cases (N=40)

The present study highlights a better quality of life in HIV infected children especially in psychosocial functioning as compared to other childhood chronic illness. We believe the study provides a further insight into this aspect of care of HIV infected children in the context of developing country.

HIV infection not only affects physical well-being but also compromise emotional and social well-being [7-10]. In addition, school dropouts and school absenteeism are perceived as a major handicap to care of chronic childhood illness like HIV in India [11]. In the present study, performance on emotional, social and psychosocial functioning as per child self-report was interestingly better than those with other chronic ailments. However, Indian studies have demonstrated significantly better scores on physical functioning domain among HIV infected children as compared to emotional, social and school functioning [2,3]. Although, parents of HIV infected perceive significantly lower scores in emotional functioning as compared to parents of uninfected children [12].

We believe the emotional and social components of quality of life largely depend on ethnic origin, local cultural and societal practices. Indian society is largely composed of children who hail from middle socioeconomic status, living in a joint family, a larger number of siblings as compared to their Western counterparts. In India, HIV infected children are largely supported by governmental and non-governmental organizations with access to free supply of drugs. This could probably influence better psychosocial scores when compared to other chronic ailments.

Although male gender and lower socioeconomic status contributed to almost two third of our enrolled cases, interestingly, our study did not find any significant influence of these factors on quality of life. In addition, parental living status also did not influence the overall quality of life in HIV infected children. It has been observed that children living with grandparents and parents who spent more hours with their children have performed better on emotional and psychosocial well-being [14]. Similarly, clinical and immunological staging also did not contribute to effect on quality of life scores. The lack of effect could be the result of small sample size, acknowledged as a limitation of the study.

To conclude, the present study shows overall quality of life in HIV infected children was better when compared to other chronic illness of childhood and that demographic and clinical and immunological severity did not affect the quality of life. However, studies with larger sample size could provide a further insight into factors affecting quality of life in HIV infected children in India.

Contributors: SN: The study was conceived; MG, SN: collected data; JSK, SN and MG: statistical analysis, interpretation and drafting of manuscript. The final version was approved by all authors.

Funding: None; Competing interests: None stated.

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