Provider, researcher, and community perspectives on comorbidities affecting the health-related quality of life of people living with HIV in Spain

Abstract

Background

Comorbidities, such as cardiovascular disease, diabetes, kidney disease, liver disease, and mental health issues, negatively impact the health-related quality of life (HRQoL) of people living with HIV (PLHIV). Comorbidities can increase the symptom burden, reduce functional or cognitive capacity, increase psychological distress, and reduce adherence to treatment, which can lead to poor viral suppression and other complications.

Methods

This study aimed to identify and explore comorbidities and related contextual determinants of HRQoL and long-term well-being in PLHIV that could be monitored in routine care in Spain. Seven online focus groups were conducted with 115 participants consisting of members of community advocacy organizations (n = 33, 29%), HIV care providers (n = 78, 68%) and researchers (n = 4, 3%) in seven autonomous communities in Spain with the highest incidence of HIV.

Results

Focus group results revealed a prioritised list of comorbidities to monitor: diabetes, cardiovascular diseases, neurologic diseases, substance use problems, bone diseases, renal diseases, liver diseases, including metabolic dysfunction-associated steatotic liver disease, cancers and neoplasms, mental health problems, and pulmonary diseases.

Conclusions

This study emphasises the impact of comorbidities on PLHIV in Spain and the need for a comprehensive approach to HIV care that addresses comorbidities, including mental health. These data can inform the development of policies and interventions to reduce multimorbidity burden among PLHIV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-26971-8.

Background

Since the introduction of highly effective antiretroviral therapy (ART) in 1996 and its more rapid distribution through test-and-treat and rapid linkage-to-care strategies, the HIV epidemic has shifted from being a terminal illness to a chronic condition for many [1–3]. However, this transformation has also highlighted the need for a more comprehensive approach to the care of people living with HIV (PLHIV) encompassing long-term well-being beyond achieving viral suppression alone.

As PLHIV are now living much longer, addressing comorbidities and providing comprehensive care for overall health and well-being has become a critical component of patient-centered HIV care, particularly given the persistent effects of HIV-related stigma, which can discourage care-seeking and continuity of care and contribute to untreated chronic conditions [4, 5]. In addition to physical comorbidities, mental health conditions commonly associated with HIV, including depression, anxiety, substance use disorders, and HIV-associated neurocognitive disorders, are highly prevalent [6–10]. The management of comorbidities beyond HIV has become increasingly important in improving health and well-being of PLHIV, including health-related quality of life (HRQoL). HRQoL is influenced by both HIV-related and non-HIV-related factors, such as mental health issues, socioeconomic status, and the presence of comorbid conditions. Some common comorbidities in PLHIV include cardiovascular disease [11–15], diabetes, kidney disease [11, 14–16], liver disease, and mental health issues [6, 9, 10, 17, 18]. Comorbidities can impact the HRQoL of PLHIV by increasing the symptom burden (e.g., pain, fatigue, and difficulty breathing) [19–22], reducing functional or cognitive capacity [23, 24], increasing psychological distress [6], and reducing adherence to HIV treatment [8, 25–27] which can lead to poor viral suppression and increased risk of HIV-related complications. Multimorbidity, which is the presence of two or more comorbidities in addition to HIV, also increases healthcare utilization and premature mortality [28, 29].

Therefore, monitoring long-term well-being in HIV care has come to be understood as addressing comorbidities, burdensome symptoms of ageing, and QoL and/or HRQoL. This is particularly true in settings like Spain that have achieved or are near achieving the global 95-95-95 targets which aim for 95% of all PLHIV to know their HIV status, 95% of those diagnosed to receive sustained antiretroviral therapy, and 95% of those on treatment to achieve viral suppression and equating to 86% of all PLHIV reaching viral suppression by 2030 [11–13, 30]. Yet, it is difficult for health systems to monitor all aspects of HIV including the many comorbidities affecting PLHIV. While there is a growing body of literature on comorbidities affecting the HRQoL of PLHIV, there is limited research on the specific comorbidities affecting their HRQoL that should be monitored in the Spanish health system. This study aims to identify and explore the comorbidities and other determinants of long-term well-being that HIV care providers, researchers, and community members perceive as substantially affecting the HRQoL of PLHIV.

Methods

Study sample

The study used purposive sampling to recruit expert participants who: (1) provide HIV care in Spain, (2) conduct research on the health and well-being of PLHIV in Spain, or (3) advocate for the HIV community, including key populations at risk for HIV. Two researchers contacted experts in the seven autonomous communities who have published on the topic and used the snowball technique to identify additional colleagues satisfying the inclusion criteria, reaching n = 115 participants recruited. Seven online focus groups were conducted, from 17 May to 9 November 2021, in each of seven regions: Andalusia, Aragon, Basque country, Catalonia, Galicia, Madrid, and Valencia [31].

Data collection & analysis

Each 1.5-hour focus group was held in Spanish with a short presentation to orient participants to the study purpose. Participants were instructed to identify which comorbidities and/or groups of related comorbidities and symptoms they perceive as substantially impacting the HRQoL of their patients with HIV [32]. Two researchers used a semi-structured agenda to facilitate focus group discussion and a closed-ended question asking participants to select three comorbidities from among the group-derived list of ten (Supplemental Material 1). Two other researchers observed and notated the discussions. Audio recordings for each meeting were transcribed using Whisper OpenAI, a sequence-to-sequence speech recognition model [33, 34]. One researcher reviewed the transcripts for accuracy using MAXQDA v12. Two researchers used directed content analysis to independently apply an inductive coding strategy. A third researcher independently repeated these steps for approximately 10% of each transcript to identify potential issues of discrepancy, bias, or misunderstanding. No issues were identified. The three researchers jointly categorised the codes into the derived themes (Table 1). Descriptive statistics were used to analyze the quantitative data collected on comorbidity prioritization, while, the transcripts were analyzed using directed content analysis [35]. A closed-ended item was used to prioritise identified comorbidities and was calculated as simple averages and as weighted averages adjusted for the proportion of the sample size per community.

Table 1.

Themes and codes identified from focus groups

Theme	Codes
Health Conditions and Morbidities	lung problems
	sexual health/STIs
	nervous system illness
	metabolic illness
	neoplasms/cancer
	cardiovascular illness
	hepatitis/liver issues
	mental health
Other Health Issues	drug use
	age-related issues
	frailty
	polypharmacy
	frequency of monitoring
	suggested indicators or other patient-reported outcomes
Access to Healthcare	access to care
	pharmaceutical distribution
Interpersonal and Social Issues	stigma
	discrimination
	interpersonal relationships
	diversity issues
	women/gender issues
	socioeconomic vulnerability
Patient-Provider Relationship	patient-provider relationship
	privacy and confidentiality issues
Public Health and Prevention	public health and prevention
	national AIDS plan or other policies
	COVID-19
	education/knowledge

Results

In total, 115 participants were recruited, ranging from 12 in Valencia to 35 in the Basque country; 50% were women and 68% were healthcare providers (Table 2). The final list of prioritised comorbidities identified from the focus group discussions included mental health problems (selected by 94% of participants), cardiovascular diseases (55%), neurologic and neurodegenerative diseases (43%), substance use (35%), neoplasms (35%), bone diseases (9%), kidney diseases (9%), lung problems (7%), liver diseases (5%), and diabetes (4%) (Table 3). Analyses of focus group discussions on these health conditions and morbidities, as well as other health and healthcare issues, follow.

Table 2.

Participant characteristics by region

	Andalusia	Aragon	Basque country	Catalonia	Galicia	Madrid	Valencia	% of total (n = 115)
Gender
Men	9	4	8	11	8	14	4	50%
Women	3	10	12	4	9	11	8	50%
Sector
Academic	0	0	2	0	0	2 (1 woman)	0	3%
Healthcare provider	8 (2 women)	11 (7 women)	12 (9 women)	11 (2 women)	10 (5 women)	17 (8 women)	9 (6 women)	68%
Community	4 (1 woman)	3 (3 women)	6 (3 women)	4 (2 women)	7 (4 women)	6 (2 women)	3  (2 women)	29%

Table 3.

Responses to “According to your opinion, select the three comorbidities that you believe should be considered as part of measurement for the Fourth 90”

	Andalusia	Aragon	Basque Country	Catalonia	Galicia	Madrid	Valencia	Simple average	N-adjusted average
Mental health problems	100%	73%	91%	95%	100%	100%	90%	93%	93%
Cardiovascular diseases	73%	55%	77%	74%	50%	28%	40%	57%	55%
Neurologic and neurodegenerative diseases	18%	45%	23%	37%	38%	69%	60%	41%	43%
Substance use problems	73%	18%	18%	42%	44%	34%	30%	37%	35%
Neoplasms	18%	55%	45%	21%	38%	24%	60%	37%	36%
Bone diseases	0%	18%	5%	16%	0%	7%	20%	9%	9%
Kidney diseases	0%	9%	14%	5%	6%	14%	0%	7%	8%
Lung problems	0%	9%	0%	0%	13%	17%	0%	6%	7%
Liver diseases	9%	0%	18%	0%	6%	0%	0%	5%	5%
Diabetes	9%	0%	5%	10%	6%	0%	0%	4%	4%
Others	0%	0%	0%	5%	0%	0%	0%	1%	1%
Respondents (N)	12	14	20	15	17	25	12
N as % of all respondents	10%	12%	17%	13%	15%	22%	10%

Note: Question translated from Spanish, “Bajo su criterio, seleccione las tres comorbilidades que considere que se tengan que tener en consideración para medir el Cuarto 90” 

Bold text indicates averages

Health conditions and morbidities

Participants overwhelmingly highlighted mental health as crucial to monitor in relation to HRQoL, including conditions such as depression, anxiety, and mood disorders, due to their prevalence and profound impact on emotional well-being. Routine screening for mental health disorders utilizing validated assessment tools was recommended alongside comprehensive support and access to mental health resources to enhance HRQoL outcomes, promote overall psychological well-being, and enable referrals when necessary.

“As a very important one: mental health, and, well, all the impact it has, all mental health, right?, from stress, depression, anxiety, the impact on these people’s lives. So, I would highlight it as one of the very important health indicators to consider in this population.” (Healthcare provider, man, Basque Country)

Non-communicable diseases, particularly cardiovascular issues like heart disease and stroke, were raised as prevalent health conditions substantially impacting HRQoL in this population. As well, participants identified neurologic and cognitive disorders, such as HIV-associated neurocognitive disorders (HAND), as important to address as part of long-term well-being promotion. These conditions were distinguished from mental health disorders (e.g., depression, anxiety, and mood disorders), although participants noted that cognitive impairment can exacerbate psychological distress and vice versa. In particular, older individuals were recognised as likely to experience more severe cognitive impairments, highlighting the challenges of aging with HIV as a chronic condition. Participants overwhelmingly agreed that addressing these issues requires a coordinated approach that includes mental health services, psychological support, and integrating cognitive assessments into general consultations and primary care. Thus, both neurologic and mental health conditions were viewed as interconnected but distinct domains affecting quality of life and requiring coordinated assessment and care.

The interrelationship between drug use and mental health was highlighted as an area of concern among PLHIV, emphasizing the need to monitor both aspects. Substance abuse was identified by participants and in the literature as an important compounder of morbidity among PLHIV.

“And moreover, beyond [noncommunicable diseases], we are seeing a lot of drug use, alcohol, substances that are also interfering with the health of our patients.” (Healthcare provider, woman, Valencia)

Participants emphasised the need for increased attention to neoplasms and cancer among PLHIV. Certain types of cancer, such as lung cancer, non-Hodgkin’s lymphoma and colorectal cancer were identified as particularly important. Participants encouraged collaborative efforts between HIV specialists and oncologists to help provide more comprehensive care for people with both HIV and cancer.

Participants identified bone diseases such as osteoporosis, osteopenia, and bone fractures as important to monitor in relation to HRQoL. Metrics for pre-frailty and frailty were recommended alongside the regular monitoring of bone mineral density to help ameliorate deteriorating physical dimensions of HRQoL over time. Participants also identified renal diseases as important to monitor in relation to HRQoL, such as chronic kidney disease (CKD), renal insufficiency, and end-stage renal disease (ESRD), given their potential impact on various domains of well-being. Regular monitoring of renal function, such as urinary albumin levels, was recommended alongside the assessment of pre-frailty and frailty metrics to detect early potential impacts on HRQoL.

Participants highlighted hepatitis C as a persistent concern that is growing among people who inject drugs. Co-infections with hepatitis B or C can lead to liver inflammation, which may progress to liver fibrosis, cirrhosis, or liver cancer. Additionally, metabolic dysfunction-associated steatotic liver disease (MASLD), a condition characterised by the accumulation of fat in the liver, was identified as a condition of increasing concern because of its increased risk among PLHIV. Hepatitis C and MASLD were recognised as curable diseases but participants advised that integrated healthcare models that explicitly address HIV, liver steatosis and viral hepatitis can improve HRQoL and ensure optimal liver health.

Diabetes was highlighted by the interviewees as impactful on the quality of life of PLHIV, particularly those over the age of 50. Participants underscore the importance of addressing non-communicable diseases within the HIV care model. From the experts’ perspectives to improve overall well-being, it is crucial to implement comprehensive strategies that encompass lifestyle modifications, regular monitoring, and appropriate medical interventions to manage metabolic conditions effectively.

Other health issues

Among health concerns that are not defined conditions or diseases, psychosocial issues and early aging were predominant. Participants raised the importance of early screening for aging-related comorbidities that impact personal autonomy and quality of life. Fragility and pre-fragility issues were raised by participants, especially for individuals over 50 years old. Menopause in women living with HIV was discussed as having various physical and psychological effects, including insomnia, osteoporosis, and muscle pains, which can exacerbate quality of life deterioration with aging.

“And I think it is very important to emphasise the issue of aging, how to detect it early and how to work with them comprehensively to maintain their autonomy.” (Community, woman, Basque country)

Access to healthcare

Access to healthcare is recognised as a critical aspect of ensuring comprehensive care for PLHIV, and was raised in all focus groups. Discrimination and stigma within healthcare settings were identified as significant barriers to access for PLHIV. Structural barriers, such as long hospital wait lines for medication distribution were also identified. However, some instances of home delivery of medication were reported as contributing to an improved quality of life for those clients. While infectious disease specialists demonstrated knowledge and support, other healthcare professionals were described as lacking awareness of advancements in HIV treatment, sometimes leading to negative experiences and discriminatory practices. Participants emphasised the importance of integrating HIV-positive patients into care provided by non-HIV specialists on a regular basis to ensure comprehensive and inclusive healthcare provision. Additionally, the need for intercultural mediators to overcome cultural and language barriers when working with migrant populations recognises that vulnerability based on socioeconomic and migrant status can impact access to healthcare.

Several participants raised the national shift in medication dispensation from community pharmacies to hospital pharmacies as being driven by economic and service provision factors, while disregarding the needs and preferences of the affected population. Some participants raised the need to implement innovative approaches to improve access to HIV medication, citing a pilot program to evaluate home delivery of ART medication.

“This issue of the pandemic has indeed served, in some cases, to extend the duration of treatment distribution from one month to three months, especially for those with good treatment adherence and undetectable viral loads, which has improved access and reduced the frequency of hospital visits.” (Community, man, Basque country)

This initiative was realised during the pandemic following years of advocacy from NGOs and associations for home dispensing. These participants acknowledged some challenges associated with implementing such a process, including challenges associated with logistics and infrastructure, adherence and monitoring, resource allocation, data management and patient privacy. Similarly, the extension of the duration of treatment distribution from the standard one month to three months was identified as a model to enhance access, suggesting that longer durations could be evaluated. This model was considered particularly for individuals with strong treatment adherence and consistent undetectable viral loads, potentially improving access to treatment and reducing the frequency of hospital visits.

Interpersonal and social issues

Discrimination, stigma, and the burden of psychosocial issues were raised as persistent and significant concerns for the well-being of PLHIV. Participants identified the need to incorporate HIV-related topics more prominently in healthcare education, ensuring that these topics are integrated throughout the curriculum. Addressing discriminatory practices, improving access to insurance, and providing mental health support within healthcare settings are identified as key areas for improvement. Participants recognised that the various monitoring systems that exist to collect information on forms of discrimination, including public stigma and structural discrimination in laws and policies are not present in all communities. Participants raised the issues of discrimination in healthcare settings, when patients may feel poorly treated and requests for outdated medical certificates stating the absence of infectious disease, which serve as barriers to employment and insurance. Participants indicated that some professionals may discriminate against patients who lack documentation or believe they won’t receive payment for treating them. Sensitization and training are necessary across various professions, including medical, nursing, and administration, to address discrimination effectively.

“I understand that the solution is not simple because it involves various sectors, but it is important to address the discrimination faced by people with HIV in the healthcare system. The lack of knowledge about advancements in HIV treatment among healthcare professionals who are not infectious disease specialists can lead to negative experiences and discriminatory practices.” (Healthcare provider, woman, Basque country)

Structural discrimination here refers to systemic and institutional factors contributing to the unequal treatment of PLHIV can further contribute to stigmatization and exclusion. Participants identified several examples of structural discrimination in government policies and job opportunities, including some municipal and firefighting jobs, as well as public job postings that contains non-inclusive language. Other identified forms of structural discrimination included questioning individuals about their HIV status in mortgage agreements, the denial of or increased costs for insurance coverage, the denial of membership to some social or sporting clubs, and bans on blood donation by men who have sex with men, a key population at risk for HIV.

Participants emphasised the role of socioeconomic factors in the quality of life of PLHIV and advocates for a holistic patient-centered approach. Differentiating between social and legal concepts of discrimination was identified as important within national health system monitoring. However, caution was advised against labeling every reported incident as discrimination.

Patient-provider relationship

With respect to the patient-provider relationship, a prominent theme that emerged was the need to address the quality of healthcare and patient treatment. Thus, interpersonal discrimination and stigma towards PLHIV were identified as persistent issues in healthcare settings, though earlier forms of structural (i.e., legal and policy discrimination), it was agreed, had mostly been eliminated.

“Obviously not as much as in the past, thankfully, but there is still interpersonal discrimination in consultations. It is true that structural discrimination has been reduced, but we still hear about some negative attitudes and stigma from some healthcare professionals.” (Healthcare provider, woman, Basque country)

Personalised attention and treatment were recognised as essential elements of the patient-provider relationship. Participants highlighted instances of their patients expressing feeling mistreated, suggesting that these issues are more individual-specific rather than pervasive across the entire healthcare profession. While progress has been made in destigmatizing HIV, there are still areas for improvement in health settings. Suggestions were made to enhance healthcare-related laws, specifically addressing the language and tone used towards patients in primary care settings, as numerous service users have filed complaints. Moreover, participants emphasised the irrelevance of certain questions pertaining to mode of transmission or types of relationships in unrelated medical contexts. The focus should shift towards prioritizing the patient’s well-being and treatment stability.

A notable concern raised by participants was the lack of knowledge about HIV in both private and public healthcare settings. This knowledge gap contributes to the perpetuation of stigmatization, particularly in settings where HIV-related ignorance prevails. Improved education and awareness were identified as crucial strategies for combating discrimination and ensuring appropriate care for marginalised groups.

Public health and prevention

Participants highlight various aspects related to public health and prevention in the context of HIV care, including the promotion of healthy lifestyles, which involves not only controlling or limiting alcohol, toxins, and tobacco use but also encouraging healthy eating habits and physical and social activity, underscoring the importance of addressing behavioral factors that contribute to overall well-being.

“I am very concerned about promoting healthy lifestyles, such as balanced nutrition, regular physical activity, and reducing alcohol and tobacco consumption. These factors are key to improving the overall well-being of people living with HIV.” (Healthcare provider, man, Basque country)

The vulnerability of HIV patients during the COVID-19 pandemic was also raised. Participants described increases in anxiety and depression, including about the potential consequences of contracting COVID-19. Limited access to healthcare services during this time further contributed to their vulnerability. The COVID-19 pandemic further complicated access to medication, with PLHIV being recommended to stay home while needing to go to the hospital for medication.

Another aspect recognised as crucial is the importance of addressing social and legal issues to increase participation in HIV-related interventions. Discrimination monitoring systems play a role in collecting information on structural discrimination and discriminatory laws and policies. Such discrimination, participants discussed, can hinder access to care and support for individuals living with HIV, and addressing these issues is essential to promote inclusivity and ensure the effective implementation of HIV interventions. Several comments underscore the importance of implementing preventive measures, such as vaccinations, regular screenings, and lifestyle modifications, to address these health conditions and comorbidities among PLHIV and emphasise the need for integrated healthcare models that consider both HIV and other health issues, such as hepatitis C and non-communicable diseases.

Prioritisation of comorbidities affecting HRQoL

The prioritisation of comorbidities perceived as most important in terms of affecting HRQoL were mental health, cardiovascular disease, neurologic/neurodegenerative conditions, substance use problems, and neoplasms (Table 3). Participants explained during focus groups that these five were viewed as most urgent because they either directly limit functional capacity and autonomy (e.g., cardiovascular, neurologic), or because they strongly affect mental and emotional well-being (e.g., depression, substance use). The lower-ranking conditions, such as diabetes, liver, and kidney disease, were still acknowledged as medically important but were viewed as being better controlled within the current HIV care system or less visible in daily practice.

Regional differences were modest but informative. For example, Aragon and Madrid assigned higher priority to neurologic disorders, while Andalusia and Valencia gave greater weight to substance use problems, reflecting local epidemiologic trends and service needs. Providers tended to emphasise clinical comorbidities (e.g., cardiovascular, neurologic, renal), whereas community advocates prioritised mental health and substance use problems, which they linked to stigma and social isolation.

Discussion

This study prioritises the comorbidities most affecting the health-related quality of life (HRQoL) of people living with HIV (PLHIV) that could be addressed in routine HIV care in Spain, underscoring the need to move beyond viral suppression toward comprehensive long-term well-being as a health system objective for this population. Although Spain provides free and universal access to health services, including for HIV [36], PLHIV continue to face a high burden of a range of other health conditions and comorbidities, or multimorbidity as well as obstacles such as healthcare-related stigma and fragmented care can hinder timely and appropriate management of co-occurring chronic conditions. In Spain, HIV care is primarily provided through the public health system at hospital-based outpatient clinics, with referrals to psychiatrists, cardiologists, and other specialists typically coordinated through the same hospitals [37, 38]. Integration varies by region; mental health and other specialty services are generally accessible but not systematically embedded within HIV units. The European AIDS Clinical Society (EACS) guidelines recommend regular screening for mental health, cardiovascular, metabolic, renal, and hepatic comorbidities among PLHIV [39, 40]. Participants noted that while Spanish HIV services broadly follow these recommendations, implementation remains uneven across regions and between hospitals, particularly for mental health screening and referrals. Specific areas of concern identified in this study, including, lung problems, sexual health/STIs, nervous system illness, metabolic illness, neoplasms/cancer, cardiovascular illness, hepatitis/liver issues, and mental health comorbidities, and the problems associated with them while aging, such as polypharmacy and frailty [41, 42], can have a substantial impact on the quality of life and overall health outcomes for PLHIV. While many of the comorbidities discussed have been previously reported among PLHIV, this study provides a novel contribution by systematically prioritizing them based on the perspectives of healthcare providers, researchers, and community members across seven autonomous communities in Spain—an approach not previously applied in this context. These findings echo recent efforts to incorporate multidimensional well-being measures into HIV care, such as a long-term well-being metric that integrates comorbidity, discrimination, and HRQoL into a single composite score and could allow clinicians to identify PLHIV at risk for poor outcomes [42]. However, recent qualitative research highlights major gaps in Spain’s health information systems, noting the absence of standardised indicators for multimorbidity and HRQoL as a barrier to integrating long-term well-being measures into routine HIV care [37].

Participants overwhelmingly noted the importance of considering mental health and the diverse aspects of individuals, particularly among migrants, acknowledging the impact of intersectional factors such as sexual orientation, gender identity, and cultural and social diversities on disease management and quality of life. Mental health disorders, such as depression, anxiety, substance abuse and neurocognitive disorder are prevalent among PLHIV in Spain and in Europe [43–50]. Such disorders can negatively impact HRQoL by, for example, reducing the capacity to perform daily activities and limit social interactions. These disorders can be exacerbated by HIV-related stigma and social isolation, reported by many PLHIV.

Stigma can take many forms, and its impact on PLHIV can manifest as social exclusion, negative attitudes or beliefs, discrimination, or even violence towards individuals or groups [51]. HIV-related stigma can have significant psychological and social impacts on PLHIV that negatively affect their quality of life [10, 52]. Stigmatised individuals may experience internalised stigma that yields or exacerbates depression, anxiety, low self-esteem, and social isolation [53, 54]. In some individuals, stigma can also impact social relationships, leading to feelings of rejection, marginalization, and loss of social support. It can also discourage people from seeking testing, treatment, and care, which can have serious consequences for their health and well-being [55].

Participants repeatedly raised the need to address both internalised stigma and stigma enacted through discrimination by considering the perspectives and experiences of PLHIV. Structural discrimination was raised in all focus groups and included examples of disparate access to medication delivery, non-adherence by medical staff to standard operating room protocols, and lack of access to aesthetic interventions for PLHIV. These findings echo European data indicating that stigma and misinformation persist in healthcare settings: a majority of healthcare workers lacked knowledge of key HIV prevention concepts, and substantial proportions reported discriminatory behaviours such as wearing double gloves (26%) or avoiding physical contact (8%) when treating people with HIV, while nearly one-third had witnessed discriminatory remarks or breaches of confidentiality in their workplaces [56]. Meanwhile, the World Health Organization set milestones that countries should achieve less than 10% of PLHIV experiencing stigma or discrimination by 2030 and that less than 10% of countries have HIV-punitive laws [57].

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in PLHIV, who have a higher risk of CVD due to a combination of traditional risk factors, such as smoking, hypertension, and hyperlipidemia, and HIV-specific factors, such as chronic inflammation [14]. Prevalence for CVD in samples in Spain ranged from 4.7% in 2019 to 52.7% in 2020 [58–60]. Ischemic heart disease was estimated at 1% in a national sample (n = 4798) in 2023 [61]. CVD can reduce physical function, affect mental health, impair social well-being, and limit overall well-being, including HRQoL [62, 63]. Physical limitations, such as reduced capacity for exercise and daily activities, along with the emotional burden of managing a chronic condition, may lead to depression, anxiety, and decreased mental well-being in some persons [62, 64]. Social interactions may also be affected due to restrictions on physical activities and lifestyle changes that may result in social isolation and reduced support.

Liver disease can negatively impact HRQoL by reducing physical function and increasing overall morbidity [65]. MASLD is prevalent among an estimated 38% of PLHIV globally and is strongly associated with obesity, insulin resistance, and metabolic syndrome [66]. MASLD, and the more advanced pathology of metabolic dysfunction-associated steatohepatitis (MASH), may be more common among PLHIV, and both can increase symptoms, such as fatigue and discomfort, and reduce HRQoL [65, 67]. MASLD was included in the EACS clinical guidelines in October 2025 [68]. Despite these burdens, a study estimated a 28.9% MASLD prevalence among a sample of 38 children and adolescents with HIV in Madrid [69]. PLHIV have an increased risk of developing MASLD/MASH due to multiple factors, such as the use of certain ART medications, chronic inflammation, and metabolic changes associated with HIV infection [67]. Future research involving PLHIV should include clinical trials and cohort studies investigating liver steatosis [70].

Hepatitis B and C infection, also prevalent among PLHIV [71, 72], are blood-borne viral diseases often transmitted through similar routes as HIV, such as unprotected sex and sharing needles for injection drug use, leading to an increased risk of co-infection [71, 72]. Co-infected individuals may experience more severe liver disease progression and an increased risk of liver-related morbidity and mortality compared to mono-infected individuals. Proper diagnosis, monitoring, and management of viral hepatitis and HIV are crucial in co-infected individuals to ensure optimal health outcomes and mitigate the progression to, for example, liver failure and hepatocellular carcinoma [71, 72]. Regular monitoring of liver function, for example through non-invasive imaging, may also be necessary to detect and manage any liver damage among this population.

Cancer is a substantial concern for PLHIV, who have a high risk for non-Hodgkin’s lymphoma, lung cancer, and anal cancer [73–76]. Cancer can negatively impact HRQoL by reducing physical and cognitive function, and may lead to other symptomologies such as frailty [77]. A 2023 study of PLHIV over age 50 estimated current prevalence of any cancer type to be 6.9% while prevalence of any history of cancer was 7.4% [48]. It is therefore important to prioritise cancer screenings, including for women testing positive for human papilloma virus and among MSM, who have higher rates of anal cancer [78, 79]. Early detection and immediate access to appropriate treatment options are critical within the HIV care framework [80].

Integrated, patient-centered care can help improve health outcomes among PLHIV by coordinating the delivery of medical, behavioral, and social services to meet complex care needs associated with chronic comorbidities and ensure the timely screening, diagnosis and treatment of common comorbidities [81–83]. Integrated care may thereby help identify opportunities to slow physical deterioration among people with chronic conditions [84]. Moreover, integrated care can help address the emotional and psychological stress associated with some comorbidities via mental health support and counseling services and with an equity-focused approach, whereby multimorbidity challenges among key populations (e.g., migrants, men who have sex with men (MSM), the transgender community) are considered [85].

This study identified a prioritised list of types of comorbidities affecting the health-related quality of life (HRQoL) of people living with HIV (PLHIV) in Spain, which included mental health problems, cardiovascular diseases, neurologic and neurodegenerative diseases, substance use problems, and neoplasms among other, non-communicable diseases. Overall, these findings underscore the need to better monitor these comorbidities and incorporate their screening in the management and care of PLHIV as part of more holistic care focused on long-term well-being.

Abbreviations

ART

Antiretroviral therapy

PLHIV

People living with hiv

HRQoL

Health-related quality of life

CKD

Chronic kidney disease

ESRD

End-stage renal disease

MASLD

Metabolic dysfunction-associated steatotic liver disease

NASH

Non-alcoholic steatohepatitis

QoL

Quality of life

PrEP

Pre-exposure prophylaxis

PEP

Post-exposure prophylaxis

STIs

Sexually transmitted infections

NGOs

Non-governmental organizations

MSM

Men who have sex with men

Authors’ contributions

JVL and MJF-R conceptualised the study and facilitated participant focus groups. TMW analysed the focus group transcriptions and drafted the article. CP-S, LvS, and CI validated focus group analyses. All authors reviewed, edited, and approved the final article.

Funding

HIV Outcomes Spain funded the Spanish Interdisciplinary AIDS Society (SEISIDA) for this study. The funder had no involvement in the study design, interpretation of results, nor drafting nor finalization of the manuscript.

Data availability

All relevant data are within the manuscript and its supporting files.

Declarations

Ethics approval and consent to participate

This study was approved by the Research Ethics Committee of the Hospital Clínic (CEIm), Barcelona, Spain, registered under number HCB/2023/0788. Verbal, recorded informed consent was obtained for all participants. All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

MJF-R and CI are members of the Spanish Interdisciplinary AIDS Society (SEISIDA) Executive Board. SEISIDA has received grants from Gilead, Janssen, MSD and ViiV, outside of the submitted work. MJF-R has provided consultancy services to Gilead, Janssen, MSD, ViiV and Theratechnologies, and has received payments for lectures or educational presentations from Gilead, Janssen, MSD and ViiV, outside of the submitted work. JVL reports grants and speaker fees from Gilead Sciences and MSD and speaker fees from AbbVie, Echosens, GSK, Moderna, Novo Nordisk and ViiV, outside of the submitted work, and an institutional grant to ISGlobal from Gilead Sciences for other work packages of the comprehensive study of which the present research is a part. All other authors report no conflicts of interest.