HIV system fight off infections. Untreated, HIV reduces

HIV is one of the highest infection rate diseases
worldwide. In 2014, United States reported 1.1 million people living with HIV
and 26,200 (70%) were among gay and bisexual men. As of December 31st, of this
same year, Puerto Rico reported 47,000 people living with HIV occupying the
tenth position as one of the territories with the highest incidence. HIV stands
for Human Immunodeficiency Virus. It is the virus that can lead to acquired
immunodeficiency syndrome, or AIDS, if not treated. Unlike some other viruses,
the human body can’t get rid of HIV completely, even with treatment. HIV
attacks the body’s immune system, specifically the CD4 cells (T cells), which
help the immune system fight off infections. Untreated, HIV reduces the number
of CD4 cells (T cells) in the body, making the person more likely to get other
infections or infection-related cancers. Over time, HIV can destroy so many of
these cells that the body can’t fight off infections and the disease1. Presentations
associated with chronic HIV infection that eventually lead to disability and
mortality includes muscle wasting, muscle weakness, fatigue, impaired
functional work capacity, depression and decreased quality of life2.

Puerto Rico has an ongoing HIV epidemic, having twice the prevalence of HIV infections that of the
mainland United States. Injection drug use has a leading role in the
transmission of the virus. In Puerto Rico only, 160 persons have been diagnosed
with HIV from January 2017 to May 2017. The estimated HIV prevalence in the general adult noninstitutionalized
population is nearly 1.1%3 and 7.3% among gay, bisexual and other men who
have sex with men4. It is common that people living with HIV/AIDS
(PLWHA) present comorbid mental health issues since 68.3%
of PLWHA perceive some level of stigma
towards them3. Individuals who internalize their
stigmatizing experiences may start to feel anxiety, distress and mood
dysregulation fearing social rejection or discrimination as a result of their
HIV status. This often causes social isolation which commonly leads to

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In a study held in Canada in 2004, Furler et al found that 43% of PLWHA
used marijuana and that 67% of these patients used it for medicinal purposes.
Alleged reasons for medicinal use included appetite stimulation (70%),
sleep/relaxation (37%), nausea/vomiting (33%), pain (20%), anxiety/depression
(20%), and stimulation/energy (10%)6. US recent studies had slightly different
results with only 23% of PLWHA admitting marijuana use and alleging that its
use may alleviate symptoms. The general US population, in contrast, is between
3% and 7% the number of people who admitted to use cannabis7. We have to take in consideration that medical
marijuana has been legal in the whole country of Canada since 1991 versus USA
that only has had medical marijuana legalized in 18 states at the time of the
investigation (29 states, Washington D.C. and Puerto Rico to Nov 2018).

When we talk about insomnia, we are referring to an issue that commonly
affects persons with depressive and anxious symptoms and furthermore it affects
PLWHA. Sleep impairments are common in this sub-group and are related to short
and long-term health consequences including but not limited to more severe
disease symptoms, medication non-adherence, poorer wellbeing, immune impairment
and faster disease progression. Research suggests that the cause of poor sleep
quality in PLWAH is multifactorial. For instance, during early phases of the
HIV infection, the central nervous system may become infected and cause changes
to the way that individuals shift to different stages of sleep5.

Even though PLWAH these days is uncommon for them to suffer from
cachexia, anorexia due to AIDS or other severe illness due to low levels of
CD4+ cells (T cells), its more frequent that they may feel appetite
dysregulation and nauseas or vomiting due to Highly Active Antiretroviral
Therapy. Tetrahydrocannabinol has been studied and related with the
augmentation of Ghrelin levels which is a hormone related to increase of
appetite8. Research suggests a correlation between THC-9
intake and increase in appetite which also benefits PLWHA.

In the physical area, the neuropathic pain and chronic pain occurs
commonly in PLWHA due to Highly Active Antiretroviral Therapy (HAART) and avascular
necrosis. In a study held in 2016, a randomized control trial compared
neuropathic pain relief in smoked cannabis versus placebo and the results
demonstrated that pain decreased twice as much in the cannabis group compared
to placebo group9. Emerging evidence suggests that chronic pain
among some patients is associated with suboptimal retention in HIV primary care,
concluding in serious health consequences, including 10 times greater odds of
functional impairment9. These issues related to HIV primary treatment
also has repercussions in the ART treatment which is supposed to be provided at
these centers for HIV Primary Care. Mi Salud contracted the delivery of mental
health services, including most substance use disorders services, to APS Healthcare
Puerto Rico (APS-PR). Mi Salud is financed by federal Medicaid allocations to
Puerto Rico and Puerto Rico government funds. Future Puerto Rico government
funding is uncertain as the local economy and the government’s financial
condition worsen. All these factors are detrimental to HIV primary care and as
shown in research previously mentioned, this may have repercutions in PLWHA

As if HIV status by itself isn’t enough distress for a person, physical
symptoms mentioned before are also triggers to cause psychological mood and
anxiety disorders. Is common in PLWHA to suffer from anxiety and depressive
symptoms, affecting their daily routines, emotional status and social
interactions. All this areas are essential for a person’s wellbeing11

According to the World Health Organization,
quality of life in general is a broad multidimensional concept that includes
subjective evaluations of different aspects of life. Quality of life (QoL) has
different domains which includes jobs, housing, schools, the neighborhood,
culture, values, spirituality and health. Not just the absence of the disease
should be considered, but the physical, mental and social well-being. The
interpretation of facts and events explains how some disabled people can report
an excellent quality of life while others cannot. Finally, the level of
acceptance of their current condition of a person and his ability to regulate
negative thoughts and emotions about that condition makes people with similar
condition experience different perspectives in QoL.

 Different tools have been developed to help
conceptualize and measure all different domains and how they relate to each
other. Health-related quality of life (HRQoL) refers to the physical and mental
health perceptions and their correlates, including health risks and conditions,
functional status, social support and socioeconomic status. On the basis of a
synthesis of the scientific literature, the Center for Disease Control and
Prevention has defined HRQoL as “an individual’s perceived physical and mental
health over time”. This variable has been measured in Colombia with instruments
validated for Spanish speaking PLWHA like the WHOQOL-HIV-BREF12.

Focusing on HRQoL as an outcome can help disciplines to understand one
another and between social, mental and medical services. Analysis of HRQoL data
can identify subgroups with relatively poor perceived health and help to guide
interventions to avert more serious consequences. In Puerto Rico, research has
been done addressing the poor management of symptoms which has concluded that
better management and treatment of HIV-related symptoms may have a higher
impact on PLWHA perceiving quality of life11. Researchers have to take in consideration
that in Puerto Rico, since July 2016, medical marijuana has been legalized for
certain conditions and illnesses including; cancer, nausea/vomits, anxiety
disorders, HIV/AIDS, cachexia, anorexia nervosa, etc. Since then, 106 medical
marijuana licenses have been expedited to HIV/AIDS patients until November
2017. These statistics doesn’t include PLWHA who use marijuana recreationally
which are not registered in the Medical Marijuana Program with the Department
of Health of PR. The motives for marijuana usage in PLWHA in Puerto Rico still
unclear since the legality and viability of this sort of investigation in our
country was complicated until last year. In Canada and Australia, as in
California state, research focused on finding motives for marijuana users and
effectiveness of the strains for different symptoms, has shown a correlation in
having HIV/AIDS and the high percentage of users inside that sub-group.

The gap that this investigation intends to address is the shortage of
research in the field of medical marijuana in Puerto Rico, focusing in HIV/AIDS
sub-group. PLWHA present a broad variety of symptoms depending virus strain,
HAART adherence and coping, virus progression and environment. Most of these
symptoms can be evaluated within the quality of life perception of PLWHA in
Puerto Rico. The aim of this investigation is to compare HRQoL in PLWHA which
are non-marijuana users with PLWHA who are medical marijuana patients enrolled
in the Medical Marijuana Program. A goal is to investigate if marijuana
consumption improves HRQoL in PLWHA in PR compared to non-users taking in
considerations all the benefits exposed by previous research in other countries
with PLWHA whom also use medical marijuana to deal with HIV-related symptoms. The
purpose of this research is to foment medical marijuana treatment in HIV/AIDS +
patients if its shown to be beneficial and positive to improve quality of life