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. Author manuscript; available in PMC: 2025 Dec 30.
Published in final edited form as: AIDS Care. 2025 Dec 4;38(2):388–395. doi: 10.1080/09540121.2025.2596817

The Interplay of HIV, Female Sexual Dysfunction and Quality of Life among Women in North-Western Nigeria: A Comparative Study

Fatima M Damagum 1, Rabiu I Jalo 1,2, Zainab D Ahmed 1,2, Murtala A Muhammad 3, Hamisu M Salihu 3, Baba M Maiyaki 1,2, C William Wester 4, Muktar H Aliyu 4
PMCID: PMC12747149  NIHMSID: NIHMS2132319  PMID: 41343256

Abstract

Background:

Antiretroviral therapy has markedly increased life expectancy among people living with human immunodeficiency virus (HIV), yet the long-term impact of chronic HIV infection on women’s quality of life (QoL) and sexual functioning remains poorly understood. Female sexual dysfunction (FSD) is common in women and may impair psychological well-being and social relationships. Understanding how HIV infection intersects with FSD and QoL could inform holistic care for women in resource-limited settings.

Objective:

To compare QoL and FSD between women living with HIV and HIV-negative women and to identify socio-demographic predictors of poor QoL.

Methods:

We conducted a hospital-based cross-sectional study in 2024 among 200 women on antiretroviral therapy and 200 age-matched HIV-negative women attending the general outpatient clinic at Aminu Kano Teaching Hospital, Kano, Nigeria. Participants were recruited through systematic sampling; research assistants provided study information and obtained written informed consent. Quality of life was assessed with the World Health Organization Quality of Life 26-item Brief questionnaire (WHOQOL-BREF). Female sexual function was screened with the 19-item Female Sexual Function Index (FSFI); a total score ≤26.55 denoted FSD. Data were analyzed using chi-square tests, independent t-tests and multivariable logistic regression.

Results:

The mean (±SD) age of participants was 37.1 ± 9.4 years. Overall QoL was significantly worse among women with HIV than HIV-negative women (53 % vs. 63 % reporting good QoL, respectively, p=0.043). Mean QoL scores were lower in the HIV-positive group for the psychological (61 ± 18 vs. 54 ± 14; p<0.001) and environmental domains (69 ± 20 vs. 65 ± 16; p<0.001), while physical and social domain scores were comparable. FSD was highly prevalent in both groups (96 % in HIV-positive and 98 % in HIV-negative participants; p=0.40), and FSFI scores were not associated with QoL. In multivariable analysis, rural residence (adjusted odds ratio aOR 3.30, 95 % CI 1.31–8.98) and primary-level education (aOR 3.06, 95 % CI 1.50–6.38) independently predicted poor QoL.

Conclusions:

Women living with HIV experience poorer overall QoL than HIV-negative peers, particularly in psychological and environmental domains. Interventions that improve living conditions, strengthen psychosocial support and integrate sexual health and mental health services into HIV care are needed to improve the well-being of women in North-western Nigeria.

Keywords: HIV infection, female sexual dysfunction, quality of life, Nigeria

SUSTAINABLE DEVELOPMENT GOALS: SDG 3: Good Health and Well Being, SDG 5: Gender equality, SDG 10: Reduced Inequalities

Introduction

Human immunodeficiency virus (HIV) infection remains a major public health challenge. In 2023 an estimated 39.9 million people were living with HIV worldwide, 53 % of whom were women and girls.1,2 Sub-Saharan Africa continues to bear the greatest burden of disease; women and girls accounted for 62 % of all new HIV infections in the region.3 Nigeria has one of the largest HIV epidemics globally, with approximately 1.8 million people living with HIV and women disproportionately affected.4 Despite the scale-up of antiretroviral therapy (ART), the socio-economic and psychosocial consequences of chronic HIV infection—particularly its impact on women’s quality of life (QoL) and sexual health—have received limited attention in the Nigerian context.5

The World Health Organization defines quality of life as individuals’ “perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”.6 QoL encompasses physical, psychological, social and environmental dimensions. Sexual health is an important aspect of QoL; it is defined as a state of physical, emotional, mental and social well-being in relation to sexuality, not merely the absence of disease.6,7 Problems with sexual function may negatively affect psychological well-being, self-esteem and intimate relationships.8 Female sexual dysfunction (FSD) refers to persistent difficulties with desire, arousal, orgasm or pain that cause personal distress.9 Global estimates suggest that up to 38 % of women experience some form of sexual dysfunction, with prevalence exceeding 50 % in some Nigerian population.10 FSD remains under-recognized in many cultures because sexuality is a sensitive topic and women may not seek care.

Previous studies have reported that positive sexual health indicators are associated with lower depression and anxiety and higher overall well-being.11 However, data examining the interplay between HIV infection, FSD and QoL in Nigeria are scarce. In addition, many women living with HIV face socio-cultural barriers such as male dominance, child marriage, polygamy and poverty that may impede their agency over sexual and reproductive health.12,13 Understanding how HIV status and these contextual factors impact FSD and QoL is critical for designing gender-responsive interventions. This study therefore sought to compare FSD and QoL between women living with HIV and their HIV-negative peers in North-western Nigeria, and to identify socio-demographic predictors of poor QoL.

Methodology

Study design and setting

We conducted a comparative cross-sectional study at Aminu Kano Teaching Hospital (AKTH), Kano State, Nigeria, between January and March 2024. AKTH is a tertiary-care hospital serving urban and rural populations. Two clinics were selected for recruitment: the HIV/ART clinic and the general outpatient clinic. Ethical approval was by Aminu Kano Teaching Hospital (NHREC/28/01/2020/AKTH/EC/3479) and adhered to the Declaration of Helsinki. All participants provided written informed consent.

Participant recruitment

The target population comprised women aged 18 years and older attending the HIV clinic (cases) or general outpatient clinic (comparison group). Eligible women living with HIV were receiving ART for at least six months. HIV-negative status in the comparison group was verified by reviewing medical records documenting a negative HIV test within the past year; women presenting for routine outpatient consultations were approached consecutively. Exclusion criteria included pregnancy, severe psychiatric illness, current use of medications known to affect sexual function, and inability to provide informed consent.

Potential participants received oral and written information about the study during clinic visits. Research assistants fluent in Hausa and English explained the purpose, procedures and confidentiality assurances. Women willing to participate signed a consent form and were assigned a unique study identification number. Hospital numbers were recorded only to avoid duplication and were removed after data entry; participant names were not collected, and no incentives were offered. We approached 232 women at the HIV clinic and 215 women at the general outpatient clinic; 200 in each clinic (response rates 86 % and 93 %, respectively) met eligibility criteria and consented to participate.

Data collection

In order to maintain confidentiality, standardised questionnaires were given by interviewers in a private setting. Participants were encouraged to speak freely by female research assistants who had received training in sensitive questioning techniques. HIV status, self-reported comorbidities, and sociodemographic details (age, income, education, marital status, parity, occupation, tribe, and place of residence) were all recorded in the questionnaire. Additionally, participants were asked if they were currently on antiretroviral therapy (ART) for the HIV positive group and if they had ever been tested for HIV before for the HIV negative group.

Measures

Female Sexual Function Index (FSFI)

Sexual function was assessed using the 19-item FSFI.14 The FSFI is a screening tool for sexual dysfunction symptoms.14 The instrument covers six domains—desire, arousal, lubrication, orgasm, satisfaction and pain—over the preceding four weeks. Each domain yields a score from 0 or 1 to 6. Domain scores are weighted and summed to generate a total FSFI score ranging from 2 to 36; higher scores indicate better sexual function. A cut-off score ≤ 26.55 is commonly used to screen for FSD.14,15 In our study we considered women with scores ≤ 26.55 to have FSD.

World Health Organization Quality of Life-Brief (WHOQOL-BREF)

QoL was measured with the WHOQOL-BREF, a 26-item questionnaire derived from the WHOQOL-100.16 It covers four domains: physical health (7 items), psychological health (6 items), social relationships (3 items) and environment (8 items). The first two items assess individuals’ overall perception of their quality of life (“How would you rate your quality of life?” with responses ranging from very poor to very good) and their satisfaction with their health (“How satisfied are you with your health?” with responses from very dissatisfied to very satisfied). Responses are scored on a five-point Likert scale; domain scores are transformed to range from 0 to 100, with higher scores indicating better QoL. Domain mean scores and standard deviations were calculated for each group. Overall QoL was based on the response to the first question; we dichotomized responses into “good” (good or very good) and “bad” (very poor, poor or neither good nor poor) for analysis.

Data Analysis

Data were analysed using Stata version 17.17 Categorical variables were summarized using frequencies and percentages and compared between groups using chi-square or Fisher’s exact tests. Continuous variables were summarized using means (±SD) and compared using independent t-tests when normally distributed or Mann–Whitney U tests otherwise. Logistic regression models were fitted to estimate predictors of poor overall QoL (bad vs good) with independent variables including age, income, employment, religion, marital status, residence, education, parity, tribe, HIV status and presence of FSD. Variables with p <0.20 in univariable analysis were included in the multivariable model. Adjusted odds ratios (aORs) and 95 % confidence intervals (CIs) were reported. All tests were two-sided and p < 0.05 was considered statistically significant.

Results

A total of 400 women were included, comprising 200 women living with HIV and 200 HIV-negative women. The median age was 38 years (interquartile range 30–45 years); 69 % were of Hausa ethnicity and 92 % were unemployed. The majority were married (76 % overall), although HIV-positive women were more likely to be married (92 %) than HIV-negative women (59 %, p < 0.001). Women with HIV were also more likely to be aged 18–24 years and less likely to be divorced. Most participants (94 % of HIV-negative and 88 % of HIV-positive women) reported monthly incomes below ₦29,000. About half had secondary education, while 21 % of HIV-positive and 26 % of HIV-negative women had only primary education.

Table 1 presents the mean QoL domain scores by HIV status. The physical and social domain scores were similar between groups. However, psychological health scores were significantly lower among HIV-positive women than HIV-negative women (61 ± 18 vs 54 ± 14; p < 0.001), as were environment scores (69 ± 20 vs 65 ± 16; p < 0.001). Overall, 106 (53 %) HIV-negative women reported good QoL compared with 74 (37 %) HIV-positive women (p = 0.043). The mean overall QoL scores (not shown) indicated moderate QoL (mean 58 ± 13) for the cohort.

Table 1.

Mean and standard deviations of each quality-of-life domain by HIV status (n = 400).

Quality of life domain HIV-negative (n = 200)
Mean ± SD		 HIV-positive (n = 200)
Mean ± SD		 p-value
Physical health 61 ± 13 63 ± 21 0.007
Psychological health 54 ± 14 61 ± 18 <0.001
Social relationships 72 ± 14 72 ± 26 0.041
Environment 65 ± 16 69 ± 20 <0.001
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The prevalence of FSD was extremely high in both groups. Using an FSFI cut-off of 26.55, 192 (96 %) HIV-positive women and 195 (98 %) HIV-negative women met the threshold for FSD (p = 0.40). Domain-specific FSFI scores were uniformly low (data not shown). FSD prevalence did not differ by age or marital status. No significant associations were observed between FSD and overall QoL categories.

Table 2 summarizes the distribution of socio-demographic variables, overall QoL and FSD prevalence by HIV status, while Table 3 presents the multivariable logistic regression results. In unadjusted analyses, poor QoL was associated with lower education, unemployment, being divorced or widowed, rural residence and low income. After adjusting for covariates, only rural residence (aOR 3.30; 95 % CI 1.31–8.98; p = 0.011) and primary education (aOR 3.06; 95 % CI 1.50–6.38; p < 0.001) remained significant predictors of poor QoL. HIV status and FSD were not independently associated with QoL.

Table 2.

HIV status comparisons on socio-demographics, overall quality of life and female sexual dysfunction (n = 400).

Characteristic HIV-negative (n = 200) HIV-positive (n = 200) p-value
Age (years) 18–24: 15 (8 %)
25–34: 57 (29 %)
35–44: 82 (41 %)
45–55: 42 (21 %)
>55: 4 (2 %)		 18–24: 36 (18 %)
25–34: 55 (28 %)
35–44: 52 (26 %)
45–55: 47 (24 %)
>55: 10 (5 %)		 0.001
Income (₦ per month) 0–29 000: 188 (94 %)
30 000–59 000: 11 (5.5 %)
60 000–89 000: 1 (0.5 %)
≥90 000: 0 (0 %)		 0–29 000: 176 (88 %)
30 000–59 000: 15 (7.5 %)
60 000–89 000: 2 (1.0 %)
≥90 000: 7 (3.5 %)		 0.020
Employment Employed: 17 (8.5 %)
Unemployed: 183 (92 %)		 Employed: 18 (9.0 %)
Unemployed: 182 (91 %)		 0.900
Religion Islam: 190 (95 %)
Christianity: 8 (4 %)
Others: 2 (1 %)		 Islam: 191 (96 %)
Christianity: 7 (3.5 %)
Others: 2 (1 %)		 >0.900
Marital status Single: 10 (5 %)
Divorced: 36 (18 %)
Married: 118 (59 %)
Widowed: 36 (18 %)		 Single: 2 (1 %)
Divorced: 2 (1 %)
Married: 183 (92 %)
Widowed: 13 (6.5 %)		 <0.001
Residence Urban: 190 (95 %)
Rural: 10 (5 %)		 Urban: 185 (93 %)
Rural: 15 (7.5 %)		 0.300
Education Primary: 52 (26 %)
Secondary: 84 (42 %)
Tertiary: 39 (20 %)
Other: 25 (13 %)		 Primary: 41 (21 %)
Secondary: 87 (44 %)
Tertiary: 55 (28 %)
Other: 17 (9 %)		 0.130
Parity Nulliparous: 26 (13 %)
Multiparous: 117 (59 %)
Grand-multiparous: 57 (29 %)		 Nulliparous: 39 (20 %)
Multiparous: 78 (39 %)
Grand-multiparous: 83 (42 %)		 <0.001
Tribe Hausa: 137 (69 %)
Fulani: 40 (20 %)
Yoruba: 4 (2 %)
Igbo: 2 (1 %)
Other: 17 (8.5 %)		 Hausa: 132 (66 %)
Fulani: 47 (24 %)
Yoruba: 5 (2.5 %)
Igbo: 1 (0.5 %)
Other: 15 (7.5 %)		 0.900
Overall quality of life Good: 106 (53 %)
Bad: 94 (47 %)		 Good: 74 (37 %)
Bad: 126 (63 %)		 0.043
Female sexual dysfunction Absent: 5 (2.5 %)
Present: 195 (97.5 %)		 Absent: 8 (4 %)
Present: 192 (96 %)		 0.400
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Table 3.

Adjusted logistic regression for predictors of poor quality of life among women (n = 400).

Variable Adjusted OR (95 % CI) p-value
Age (reference: >55 years) 18–24: 1.06 (0.24–4.95)
25–34: 1.24 (0.32–5.16)
35–44: 1.05 (0.28–4.18)
45–55: 1.07 (0.29–4.20)		 0.980
Income (reference: ≥90 000) 0–29 000: 1.43 (0.25–11.62)
30 000–59 000: 0.46 (0.07–4.14)
60 000–89 000: 0.95 (0.03–20.58)		 0.218
Employment (reference: Employed) Unemployed: 0.58 (0.22–1.53) 0.269
Religion (reference: Islam) Christianity: 1.67 (0.39–7.47)
Other: 4.24 (0.49–89.71)		 0.355
Marital status (reference: Married) Single: 2.30 (0.55–9.68)
Divorced: 1.60 (0.73–3.54)
Widowed: 1.18 (0.54–2.59)		 0.464
Residence (reference: Urban) Rural: 3.30 (1.31–8.98) 0.011
Education (reference: Tertiary) Primary: 3.06 (1.50–6.38)
Secondary: 1.34 (0.73–2.54)
Other: 0.44 (0.16–1.13)		 <0.001
Parity (reference: Nulliparous) Multiparous: 1.55 (0.72–3.42)
Grand-multiparous: 2.05 (0.89–4.85)		 0.225
Tribe (reference: Hausa) Fulani: 0.84 (0.49–1.44)
Yoruba: 0.52 (0.08–2.60)
Igbo: 0.44 (0.01–7.99)
Other: 0.75 (0.30–1.79)		 0.872
HIV status (reference: HIV-negative) HIV-positive: 0.73 (0.45–1.19) 0.211
Female sexual dysfunction (reference: Present) Absent: 1.30 (0.39–4.30) 0.660
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Discussion

This study looked at the connections between quality of life, female sexual dysfunction, and HIV infection in women who were visiting a tertiary hospital in Northwestern Nigeria. A number of important conclusions were drawn. First, compared to HIV-negative women, women with HIV reported a substantially lower overall quality of life, especially in the psychological and environmental domains. This is consistent with earlier studies showing that long-term HIV infection and its management can negatively impact social functioning, mental health, and perceptions of safety and financial stability.18–20 Secondly, more than 95% of participants in both groups had FSD. Despite being widely used, neither univariate nor multivariable analyses found a correlation between FSD and QoL. The overwhelming prevalence of FSD in this population or cultural factors that influence reporting of FSD could be the reason for the lack of an association.

A healthy sexual life is a major component of well-being and quality of life. Overall quality of life was significantly associated with HIV status. Women living with HIV scored lower than the median cutoff point of QOL compared with women who were HIV negative, signifying a poorer quality of life. Of the 200 women living with HIV, only 53% (106) had a good quality of life compared to 63% (126) of women living without HIV, and the study revealed that psychological and environmental health domains of HRQOL were significantly associated with HIV status (p < 0.001). This is similar to the study by Suleiman et al., who also revealed higher mean scores of HRQOL in the environment domain, followed by the social relationship domain, and then the level of independence domain.21 But unlike our findings, in their own study, they recorded lower scores in the psychological and physical domains. In this study, despite having an overall lower QOL, the social relations domain showed equal mean scores (72) in both the groups. These findings suggest that HIV-positive individuals may have stronger coping mechanisms, social support, and access to healthcare services, contributing to their relatively higher QOL scores in Kano, Nigeria.

Similar findings have been reported from Kogi state, north-central Nigeria, in which the participants reported better QOL scores in the psychological, physical, and spirituality domains, but lower scores in the environment and social domains.22 Folasire in Ibadan reported higher mean scores in the physical, psychological, and environment domains and lower scores in the social domain.23 In a Bangladesh study, the highest proportion of individuals had low HRQOL in the physical and spirituality/religion domains.24 In Nepal and Ghana studies, they found their lowest scores to be in the psychological domain.25,26 Report from Henan province, China showed higher mean scores in the social and environment domains followed by the psychological domains.27 These findings show that the scores of the individual domains of QOL differ across the globe and that patients living with HIV still experience some level of derogation, stigmatization, discrimination, and marginalization.

In addition, as found in several studies, individuals in committed relationships, such as those married, cohabiting, or living with a partner, were found to exhibit higher levels of QOL (social and psychological domain) than those who were single, separated, widowed, or divorced.28–31

The prevalence of female sexual dysfunction (FSD) in this study was 96% (192) among women with HIV and 98% (195) among HIV-negative women. This finding is much higher than other studies in Nigeria (Ezechi et al., who found a prevalence of 71.4%, Agaba found 89.2%, Abiodun reported 77.29%, and Oyedokun found 61%).32,19,18 It is also much higher than the rates reported among HIV-positive women in India and Europe.30,33 The high prevalence in this study can be attributed to cultural taboos and lack of sexual education as well as high rates of early and forced marriages, obstetric complications, and intimate partner violence. Although female sexual dysfunction is a widespread health condition, there are many controversies regarding the burden of female sexual dysfunction, with vast differences being reported within and between countries.

However, despite the high prevalence of FSD among both HIV-positive and HIV-negative women, this study found no association between FSD and QOL in HIV-positive and HIV-negative patients. This means that although many women, both with and without HIV Infection, experience sexual problems (FSD), this study found no connection between these problems and their overall quality of life (QOL). Unfortunately, few studies have investigated the relationship between FSD and QOL in PLWHIV patients.

The present study has several limitations. Its cross-sectional design precludes causal inferences. Self-reported measures may be subject to recall or social desirability bias, particularly for sensitive topics such as sexuality. Because the study was hospital-based, findings may not generalise to women who do not attend health facilities. We did not assess male partners’ sexual function or relationship quality, which could influence women’s sexual satisfaction. Despite these limitations, this study provides novel insights into the intersection of HIV, FSD and QoL in Nigerian women.

Conclusion

Women living with HIV in North-western Nigeria experience poorer quality of life than HIV-negative peers, notably in psychological and environmental domains. While female sexual dysfunction is ubiquitous in this cohort, it does not explain QoL differences. Rather, socio-economic determinants—particularly rural residence and low education—emerge as key predictors of poor QoL. Programs aimed at improving women’s well-being should integrate psychosocial and sexual health services into HIV care, address structural inequalities and provide targeted support for rural and less educated women.

Funding

This work is supported by the Fogarty International Center (FIC) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the U.S. National Institutes of Health (NIH) award number 1D43TW011544. The findings and conclusions are those of the authors and do not necessarily represent the official position of the FIC, NIAAA, NIH, the Department of Health and Human Services, or the government of the United States of America.

Footnotes

Conflict of Interest

The authors declare no potential conflicts of interest.

Ethical approval and Consent to Participate

The study protocol was approved by the Aminu Kano Teaching Hospital ethics committee (NHREC/28/01/2020/AKTH/EC/3479). All participants provided written informed consent. Participation was voluntary and no incentives were offered. Personal identifiers were removed after data collection.

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