Successful Human Immunodeficiency Virus (HIV) treatment through antiretroviral therapy (ART) is known to significantly contribute to viral suppression and consequently quality of life (QoL) improvements in people living with HIV. Existing research evidence has linked HIV treatment success and viral load suppression (VLS) to several benefits, including increased life expectancy, increased productivity and improved QoL domains - physical health, psychological, social relationships and environment domains. ^{1, 2}

According to UNAIDS, VLS is a significant indicator of ART treatment success, characterised by a reduction of viral load to undetectable levels (<1000 copies/mL) in HIV infected individuals. ^{3, 4} The VLS results in reduced viral transmission, improved immunity, and increased life expectancy among HIV-infected individuals, thereby implying better productivity and better QoL across all domains. ^{1, 2, 5}

According to the World Health Organization (WHO), QoL is a multidimensional measurement of an individual’s perceived well-being on several dimensions, including their physical and psychological health, environment, and social relationships. ^{2, 6} The World Health Organisation Quality of Life Brief Version (WHOQOL-BREF) is a cross-culturally applicable and validated measurement tool that assesses QoL using 26 standardised questions on the four QoL domains, namely physical health, psychological, social relationships and environment, with 5-point Likert scale responses per question. ^{1, 6, 7}

An estimated 30.7 million people out of 39.9 million PLH were accessing ART globally, and 72% of them were virally suppressed. ^{8, 9} Sub-Saharan Africa is the region with the highest numbers of PLHIV (20.8 million out of 39.9 million), PLH on ART (84%) and viral suppression rate (76%), relative to other regions. ^{8, 9} South Africa has been ranked among the top 5 countries with the highest HIV prevalence in the world, with 18.8% of the population living with HIV and 81.2% of those virally suppressed. ^{8, 9} The Eastern Cape Province (ECP), where this study was conducted, is among the top 4 provinces with the highest HIV prevalence rate (18.8%) and highest HIV viral suppression rate (80.2%). ¹⁰

During the 2014 International AIDS Conference held in Melbourne, the Joint United Nations Programme on HIV/AIDS introduced the 90–90-90 targets aimed at speeding up initiatives to eliminate the AIDS epidemic by the year 2030. These targets were reviewed in 2018 by the United Nations. ¹¹ The 90–90-90 and 95–95-95 initiatives establish targeted health goals to be realized by the years 2020 and 2030, respectively. The aim is to ensure that by this time, at least 90% of individuals living with HIV (PLWH) will be diagnosed, a minimum of 90% of those diagnosed will be on antiretroviral therapy (ART), and at least 90% of those undergoing treatment will attain viral suppression. The WHO (2016), however, admits that this technique falls short of establishing a clear aim for quality of life. Therefore, it fails to address the needs of PLH who have achieved viral suppression yet continue to confront substantial non-communicable diseases, psychological distress, feelings of hopelessness, economic difficulties, and experiences or fears associated with HIV-related discrimination ¹² Despite the high rates of viral suppression, research evidence on QoL of PLHIV following viral suppression is generally limited in South Africa and none in the Eastern Cape province. The study sought to evaluate Quality of Life (QoL) domains namely, physical health, psychological, social relationships and environment, using the World Health Organization Quality of Life Brief Version (WHOQOL-BREF) among PLH who achieved VL in South Africa.

The study revealed a moderate overall quality of life, with an average score of 50.2% across the four domains, which was consistent with participants’ moderate self-rated health. This overall picture, however, was strongly influenced by socioeconomic factors. Specifically, individuals with higher levels of education, those who were employed, and those with higher incomes reported significantly better outcomes in each of the four QoL domains: physical health, psychological well-being, social relationships, and environmental functioning.

Accompanied by a moderate self-rated health status, participants reported a moderate quality of life across all domains, as measured by their perceptions. Although significant variations were noted between domains, the domain scores for physical health, psychological, social, and environmental domains remained moderate. It was also found that level of education, employment status, and income were significant factors influencing the perception of quality of life for most of the QoL domains. The observed study findings are similar to the results of other studies that have shown that education, employment and income are key determinants of quality of life, as well as principal enabling factors for affording lifestyle choices such as health seeking, use of tobacco products, alcohol intake, physical activity and diet. ^{7, 15– 17}

Higher level of education is known to improve personal health risk perception and knowledge about disease causation and healthier treatment options, hence greater control over health. ^{18, 19} Better education can also increase competitive advantage in securing higher income employment opportunities, consequently, higher disposable income for funding lifestyle choices. ^{17– 20} This may, in part, explain the findings from this study where higher levels of education, employed status and higher income were linked to higher self-rated quality of life domains together with reduced alcohol-and tobacco-use behaviours. With more disposable outcome, people with high income can afford lifestyle behaviours such as a better diet and harmful use of alcohol and tobacco as observed in this study. ^{5, 17}

Participants’ dual engagement in both healthier behaviours (such as better diet and physical activity) and counterproductive health behaviours could have a neutralising effect, possibly explaining the observed moderate QoL and SRH scores. In other similar studies where good and very good QoL and SRH scores were observed, higher levels of healthy behaviours and none or very low levels of counterproductive health behaviours were also reported among the participants, in contrast to the present study findings. ^{5, 7, 15, 16, 18} This study further highlights that socioeconomic status significantly influences all domains of QoL. The socioeconomic hardships not only lead to physical illnesses but also negatively impact mental health and put a strain on social connections. ²¹ This gives a broader perspective on how inequality harms human well-being. This study was conducted over a brief period; thus, longitudinal studies could aid in monitoring the disconnect between behaviour, socioeconomic status, and quality of life.

This study addresses a critical issue in HIV care, emphasizing that while antiretroviral therapy (ART) effectively reduces viral levels, it does not guarantee a good quality of life for people living with HIV in the Eastern Cape Province. Despite improved physical health scores, mental health, social relationships, and environmental conditions remain significant challenges, particularly due to psychological and structural issues. The lowest scores were linked to environmental factors like financial resources and access to services. Additionally, socioeconomic factors such as education, employment, and income are strongly associated with quality of life, indicating that financial stability is vital for the well-being of individuals even after achieving viral suppression.

To optimise viral suppression benefits, public health policies must address the social determinants of health impacting quality of life and lifestyle behaviours. This requires a shift from a biomedical to a socio-ecological model. Key strategies include implementing economic empowerment programs to combat poverty and food insecurity, ensuring housing security for stable care engagement, and integrating mental health into HIV care. By supporting these social factors, policies can help people living with HIV not only survive but thrive, enhancing both individual and public health outcomes.

The study’s ethical principles were guided by the Helsinki Declaration. Ethical approval (Ref. no. 093/2022) was issued on 20 October 2022 by the Walter Sisulu University Faculty of Medicine and Health Sciences Human Research Ethics Committee.

All participants signed a written informed consent prior to all data collection.