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HIV and Rehabilitation: What’s it all about?

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For those with access to antiretroviral therapy the life expectancy for people living with HIV is now approaching that similar to the general population (Weber et al 2013). HIV is increasingly considered a chronic illness as people are living longer and now aging with HIV.  As a result, more individuals may be living with an increasing number of concurrent health conditions related to HIV as well as the normal effects of aging.  For instance, over 34% of people living with HIV in Ontario were living with at least one other physical condition, and 39% were living with a mental health condition (Kendall et al, 2014).   In the HIV, Health and Rehabilitation Survey, an online web-based survey with adults living with HIV in Canada, 72% of respondents stated they were living with two or more health conditions in addition to HIV; the most common conditions included mental health issues (42%), muscle pain (33%), and joint pain (30%). Collectively, these health-related challenges associated with HIV and concurrent health conditions may be termed, disability.  The Episodic Disability Framework was derived from the perspectives of people living with HIV as a way to think about the health-challenges experienced by adults living with HIV.  Episodic disability can include any physical, cognitive, mental and emotional symptoms and impairments, difficulties carrying out day-to-day activities, challenges to social inclusion, and uncertainty or worrying about future health that can fluctuate on a daily basis and over the entire course of living with HIV (O’Brien et al, 2008).

Rehabilitation is recommended to address or prevent the health-related challenges of HIV and multi-morbidity and improve health for adults aging with HIV.  Rehabilitation can be defined as any services or activities that address or prevent impairments, activity limitations, or participation restrictions experienced by an individual (Worthington et al, 2005).  Rehabilitation services such as physiotherapy and occupational therapy can help to address side effects of medications, fatigue, pain, cognitive problems, and issues related to income and vocational support and have the potential to improve health and quality of life for people living with HIV.  The E-module for Evidence Informed HIV Rehabilitation was developed by realize (formerly the Canadian Working Group on HIV and Rehabilitation) to provide a comprehensive overview about up-to-date evidence and overview of the role of rehabilitation for people living with HIV.  Nevertheless, few people with HIV access formal rehabilitation services through the health system.  Only 17% and 6% of respondents in the HIV Health and Rehabilitation Survey accessed a physiotherapist or occupational therapist in the past year respectively, leaving individuals likely to access complementary and alternative therapies and services offered at community-based organizations, as well as take up individual self-management or wellness living strategies to deal with their daily health challenges.

Exercise is one strategy that can be individually employed by people living with HIV in order to address or prevent disability.  Results from a systematic review comprised of 24 randomized controlled trials concluded that exercising at least three times a week for at least five weeks is safe and can lead to improvements in cardiopulmonary fitness, strength, weight and body composition, and quality of life (O’Brien et al; 2016).  Adults living with HIV who attended a twice weekly physiotherapy-led group exercise and self-management sessions in the United Kingdom demonstrated improvements in mobility, cardiorespiratory fitness, strength, flexibility and health-related quality of life (Brown et al, 2016).

The Canadian Physical Activity Guidelines (CPAG) state that adults aged 18-64 years should engage in at least 150 minutes of moderate to vigorous aerobic physical activity per week in bouts of 10 or more minutes and that it is beneficial to incorporate bone and muscle strengthening activities with major muscle groups at least twice weekly (Canadian Society for Exercise Physiology, 2017).  However, few routinely engage in exercise (Schuelter-Trevisol et al, 2012) placing people living with HIV with lower cardiorespiratory fitness levels at risk for cardiovascular disease and mortality (Vancampfort et al, 2016).

Community Based Exercise (CBE) is an ideal strategy for enhancing the health of people living with HIV within a self-management framework.  CBE can foster social interaction, support and encouragement to exercise, and promote emotional, cognitive and behavioural self-management strategies to help independently manage health challenges associated with chronic conditions.

The Toronto PWA Foundation and Casey House, along with the Toronto Central YMCA are actively involved collaborating with the Department of Physical Therapy at the University of Toronto on research examining community-based exercise for people living with HIV.  A group of MScPT students examined readiness to exercise by conducting 14 one-on-one interviews with adults living with HIV in Toronto. Results indicated that readiness to exercise can involve a dynamic and fluctuating spectrum ranging from not thinking about exercise to routinely taking part in daily activity (Simonik et al, 2016). Tailoring exercise to individual goals, preferences, and abilities of the individual, offering a combination of individual and group-based exercise that can provide social interaction and support, offering accessible places to engage in exercise, and providing access to knowledgeable health care or fitness professionals can help to promote participation in CBE for people living with HIV (Li et al, 2017).  A current research study is underway funded by the Canadian Institutes of Health Research, HIV/AIDS Research Initiative examining the impact of a CBE programme with adults living with HIV in Toronto (O’Brien et al, 2016).

As more individuals age with HIV, rehabilitation interventions, including exercise can offer ways to enhance health outcomes for people living with HIV.

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Kelly O’Brien is a physical therapist and Assistant Professor in the Department of Physical Therapy University of Toronto. Her research focuses on disability and rehabilitation in the context of HIV and chronic disease. Currently she is working with a team to examine the translation of a community-based exercise intervention for people living with HIV in the community. Kelly is also a founding member of the Canada-United Kingdom (now International) HIV and Rehabilitation Research Collaborative (@cihrrc).  She is also Board Member of the PWA