Background
Acquired immune deficiency syndrome (AIDS) is an infectious disease caused by Human immunodeficiency virus (HIV), which poses great challenges to global public health [
1]. Antiretroviral therapy (ART) has shown great efficacy in viral suppression, immune function recovery and HIV/AIDS-related mortality reduction, transforming AIDS from a fatal disease into a manageable chronic disease [
2]. With the extension of life expectancy for people living with HIV (PLWH), quality of life (QOL) has become an important topic for PLWH. The Joint United Nations Programme on HIV/AIDS (UNAIDS) considered the QOL to be the ‘fourth 90’ target of HIV/AIDS testing and prevention; that is, 90% of PLWH with viral load suppression remain in a healthy state [
3]. In China, the risk of HIV infection among men who have sex with men (MSM) is growing rapidly, and MSM with HIV/AIDS still have many problems in the physical, psychological and social domains [
4‐
6]. Improving the QOL of MSM patients has become one of the primary goals of patients and their medical service providers.
Among MSM patients, disclosure of HIV status to male sexual partners (“
HIV disclosure” hereafter) was the first step to establishing a supportive relationship with sexual partners. HIV disclosure also played an important role in HIV prevention, which could minimize stigmatization and discrimination against PLWH [
7,
8]. Current studies have indicated that HIV disclosure can reduce the occurrence of high-risk sexual behaviours, such as unprotected anal intercourse (UAI) behaviours and multiple sexual partners, thus decreasing the risk of HIV transmission [
9,
10]. A previous review demonstrated that HIV disclosure of MSM could not only reduce the transmission of HIV from patients to negative partners but also decrease the risk of repeated infection due to reinfection with other viruses in MSM patients [
11]. Mathematical models showed that disclosure of HIV status to sexual partners can reduce the risk of HIV transmission by approximately 40% [
12,
13]. In addition, HIV disclosure was linked to less mortality among HIV-infected individuals on ART and could help MSM patients improve their ART adherence [
14]. Good adherence of those who disclosed HIV infection status was found to be 1.6 times that of those who did not [
15,
16]. In addition to preventing HIV transmission and promoting treatment adherence, HIV disclosure was also related to many positive results, such as increasing social support, reducing psychological distress, and improving happiness [
17‐
19]. However, MSM faced many challenges in disclosing their HIV serostatus to their male partners. Although HIV disclosure was important for MSM to obtain social support, potential risks such as loss of financial support, breakdown of partnership, abuse or fear of discrimination prevented them from disclosing [
20,
21]. There was a difference between regions and countries in terms of HIV disclosure [
22,
23].
The relationship between the disclosure of HIV status and QOL revealed complex and even contradictory results [
24‐
26]. For example, some studies found that MSM patients who were hiding their HIV status were related to poor QOL [
25,
26], but others showed that disclosure was related to poor physical and mental health [
24]. This difference might be related to the various disclosure methods, regions and cultural backgrounds. Although it has been showed that there is a specific correlation between disclosure and QOL, the path of the role of disclosure and the impact on the specific areas of QOL have not been fully explained.
Self-efficacy, as first proposed by Bandura, refers to a person’s confidence in their ability to complete a specific behaviour [
27]. According to social cognitive theory (SCT) [
27,
28], self-efficacy is a promoting factor to take action and one of the four core determinants of health promotion [
27,
28]. People with higher self-efficacy are more likely to engage in health promotion behaviours. Several studies [
29,
30] showed that self-efficacy had an important effect on QOL, indicating that improving HIV treatment self-efficacy was essential to promote QOL in patients with HIV/AIDS. PLWH with high self-efficacy might have more optimistic attitudes and more positive coping strategies, resulting in higher QOL scores in various domains [
30]. Moreover, some studies found a negative correlation between disclosure and HIV treatment self-efficacy due to a lack of economic, emotional or psychological support and poor coping skills in partners [
7,
20]. Some researchers began to explore the impact of self-efficacy as a mediator of the QOL of MSM patients. Although existing studies have demonstrated that self-efficacy was related to HIV disclosure and QOL, few studies on the mediation role of self-efficacy in the relationship between HIV disclosure and QOL in various domains have been conducted [
31,
32].
MSM with HIV/AIDS face the double stigma of having sex with males and their HIV infection status. Compared with promoting disclosure to the general population, disclosing HIV serostatus to male sexual partners was considered a promising behaviour index, which could be changed through behavioural intervention. In this way, we could prevent HIV transmission, improve the QOL of MSM patients and promote a good outcome [
33,
34]. Therefore, we conducted this study to explore whether HIV disclosure among MSM patients had an impact on QOL and its various domains, and whether HIV treatment self-efficacy played a mediating role.
Discussion
In this study we explored the mediating role of HIV treatment self-efficacy between HIV disclosure and QOL among MSM with HIV/AIDS. The findings demonstrated that HIV disclosure was positively associated with self-efficacy, which was related to a better QOL, including the physical, psychological, social relationships, independence and environment domains. The mediation analyses indicated that self-efficacy played an important role in the relationship between HIV disclosure and QOL [
25,
45‐
47]. Consistent with the results of a meta-analysis, the proportion of individuals disclosing their HIV infection status to sexual partners was very low (12–53%) and varied according to personal and situational factors [
48]. For most MSM patients, it is a great challenge to disclose their HIV infection status. Our study showed that only 16.06% of participants disclosed their HIV infection status to their male sexual partners. Disclosure of HIV infection status is clearly related to reducing HIV transmission, promoting treatment adherence and promting good health [
8]. In this study, the QOL scores and its domains of participants with HIV disclosure were higher than those who did not disclose. Although the differences in some domains were not statistically significant, it also showed that HIV disclosure has a positive impact on most domains of QOL. Unlike the general disclosure of previous studies, HIV disclosure makes it easier to obtain understanding, emotional support and positive response. It will increase MSM patients’ belief in fighting disease, improve their self-efficacy, help them actively seek medical treatment strategies, and reduce the probability of missing drugs or hindering their access to medical services [
49,
50]. In addition, disclosure behaviour is a positive and reinforcing experience that helps patients accept their disease condition. The encouragement of male sexual partners is combined with their own expectations, which enhances their treatment motivation and confidence. Improving self-efficacy in turn can reduce the expected pressure and promote mental health while improving social relationships. This finding is aligned with the results that the positive rate of depression and other negative results of those who refuse to disclose their HIV status were higher than those who disclose their HIV status [
51]. HIV disclosure is an important contributing factor to mental health. Moreover, disclosure behaviour is affected by the surroundings but also affects the surrounding people and environment. We found that disclosure was an important predictor in domains of good social relationships and environment, which was consistent with previous results [
26]. We found that disclosure did not have a significant impact on the spirituality domain, either as a direct effect or an indirect effect, which was consistent with a previous study [
6].
Our study revealed the mediation mechanism that explained the impact of HIV disclosure on the QOL of MSM with HIV/AIDS. The results showed that self-efficacy was an important mediator that was related to the overall QOL and its physical, psychological, social relationships, independence and environment domains. Self-efficacy was considered to be the key determinant of health promotion behaviour based on social cognitive theory (SCT) [
52]. As noted in the study by Jiang, MSM patients with higher self-efficacy were usually more able to accept the reality of the illness and their own health status, had a better mentality and positively sought medical treatment [
30]. Therefore, self-efficacy can not only improve their physical health and enhance their autonomy but also enable them to access a good psychological state by reducing anxiety and depression. Previous studies in China also have shown that self-efficacy can help MSM patients make use of various resources to manage disease conditions and reduce the negative impact on their health [
31,
53]. Self-efficacy has been shown to be a predictor of health behaviours, such as promoting treatment adherence, and it plays an important role in improving the QOL of MSM patients [
54].
This study has some limitations. First, it was a cross-sectional study, which limited the ability to infer the causal and temporal relationships between variables. Future studies should use longitudinal and intervention designs to validate our findings and explore the long-term outcomes of disclosure. Second, the participants were recruited through convenience sampling, which may not fully represent all MSM patients, and selection bias cannot be excluded. Third, self-report measurement may induce social desirability bias, and future research must evaluate the research variables more objectively. Despite these limitations, our results increase the current understanding of the potential path of HIV on QOL and its impact on various domains in MSM patients.
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