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Resurrecting the ‘fourth 90’: towards a definition of health-related quality of life in HIV care

09 June 2022
16 min read
Volume 31 · Issue 11


Medical advancements in the treatment of HIV continue to return ever more impressive medical results; increasing life expectancy and reducing negative symptoms (either disease-related or medically-induced). Physical wellness, however, is only one of the many facets of human life. It has been 5 years since Lazarus et al proposed we should be looking towards a fourth 90—good health-related quality of life (QoL)—yet little has been done to take up this task within a coherent approach. We suggest that one of the barriers to this is a lack of definition about what we mean by ‘good health-related quality of life’ (HRQoL) for people living with HIV. This article considers existing definitions of this, and related terms, and the difficulties in finding a universal definition. It goes on to suggest a way to a conceptual HRQoL in people living with HIV based on the biopsychosocial model. It is proposed that by doing it this way, practitioners can assess HRQoL in a comprehensive way, and focus on the things that matter to the individual.

Historically, HIV care focused on quality of life (QoL), in part due to the limited treatment options available for people living with HIV at the time and on a strong humanistic desire from clinicians to provide optimum care for people living with HIV. Over the past 30 years there have been significant advances in HIV treatment, which have led the pendulum to swing back to a more medical focus in HIV care. The impact of being diagnosed and living with the condition, however, still has a significant impact on many across all aspects of their life. In 2014, UNAIDS (2014) launched its ambitious treatment project: 90-90-90. The aim of this was to ensure that by 2020, 90% of those living with HIV worldwide were aware of their status, 90% of those who know they were living with HIV were on treatment, and 90% of those on treatment were virally suppressed. The overall goal behind these targets is to eradicate HIV, based on the concept that, if more people living with HIV are aware of their diagnosis and are virally suppressed, new infection rates will be lower.

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