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E-Module

An HIV and Rehab Resource

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  • About
    • 1 – What is this resource about and who is it for?
    • 2 – Why was this resource created?
    • 3 – How can this resource be used?
    • 4 – Can this resource be used for teaching?
    • 5 – How was this resource developed?
    • 6 – Who contributed to developing this adapted resource?
    • 7 – Who funded the development of this resource?
    • 8 – Disclaimer
  • Section 1
    • 1.1 How is “rehabilitation” defined in this resource?
    • 1.2 How can rehabilitation help people living with HIV?
    • 1.3 How can the World Health Organization’s “ICF” help us think about rehabilitation for people living with HIV?
    • 1.4 How can the Episodic Disability Model help us think about rehabilitation for people living with HIV?
    • 1.5 Who provides rehabilitation for people living with HIV?
    • 1.6 Do rehabilitation providers need special skills or training to care for people living with HIV? If so, what?
    • 1.7 What roles do rehabilitation providers have related to HIV?
    • 1.8 When is rehabilitation clinical intervention useful along the HIV care continuum?
  • Section 2
    • 2.1 What do rehabilitation professionals need to know about the stages of HIV infection?
    • 2.2 What do rehabilitation providers need to know about CD4 count and viral load?
    • 2.3 What is the impact of HIV on body systems and why does this matter for rehabilitation providers?
    • 2.4 Who might rehabilitation providers treat?
    • 2.5 What do rehabilitation providers need to know about antiretroviral therapies?
  • Section 3
    • 3.1 What are the rehabilitation interventions that address impairments common among people living with HIV?
    • 3.2 What are the rehabilitation interventions that can address the activity limitations and participation restrictions common among people living with HIV?
    • 3.3 More information on the rehabilitation interventions available for people living with HIV
    • 3.4 – What do rehabilitation providers need to know about their patients’ beliefs and use of traditional healers, spiritual leaders and alternative therapies outside the formal medical system?
  • Section 4
    • 4.1: Intersectionality Theory in the Context of Rehabilitation
    • 4.2: Children and Youth
    • 4.3: HIV and Aging
    • 4.4: Substance Use
    • 4.5: Trauma
    • 4.6: Racialized Populations
    • 4.7: Indigenous Populations
    • 4.8: HIV, Sex and Gender
    • 4.9: HIV and COVID-19
    • 4.10: Is HIV itself a disability?
  • Section 5
    • 5.1 What are outcome measures?
    • 5.2 Why is it important to use outcome measures during rehabilitation with people living with HIV?
    • 5.3 How do rehabilitation providers know if an outcome measure will be useful in practice?
    • 5.4 What are floor and ceiling effects in outcome measurement?
    • 5.5 What is the difference between generic and HIV-specific outcome measures?
    • 5.6 How should you decide which outcome measures to use?
    • 5.7 How do you access a copy of an outcome measure?
    • 5.8 What are rehabilitation-related outcome measures that can be useful for people living with HIV?
  • Case Studies
    • Case #1 – Acute Care, Cardiorespiratory and Neurological
    • Case #2 – Musculoskeletal – Knee Pain
    • Case #3 – Aging, Cognition, Community, Stroke
    • Case #4 – Complex Case – Musculoskeletal, Episodic, Cardiorespiratory
    • Case #5 – Diabetes, Neuropathy, Substance Use
    • Case #6 – Transition from Paediatric to Adult Care
    • Supplemental Case Studies without Leading Questions
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2.5 What do rehabilitation providers need to know about antiretroviral therapies?

Although rehabilitation providers do not prescribe drugs, the effects of pharmacological treatments (both good and bad) experienced by people living with HIV can impact rehabilitation goals.

The goals of HIV drug therapy are:

  1. maximal and sustained suppression of viral load
  2. reduction of morbidity (illness) and mortality (death)
  3. improvement of quality of life
2.5.1 Benefits of Antiretroviral Therapy (ART)

Advances in the treatment of HIV with effective, more convenient and more tolerable ART have dramatically changed the course of HIV infection. This has led to a sharp reduction in morbidity and mortality among patients who have access to treatment.1

Antiretroviral drugs are not a cure for HIV. However, with lifelong adherence most individuals can achieve close to normal life expectancy.

1 Mocroft A, Ledergerber B, Katlama C, Kirk O, Reiss P, d’Arminio Monforte A, Knysz B, Dietrich M, Phillips AN, Lundgren JD; EuroSIDA study group. Decline in the AIDS and death rates in the EuroSIDA study: an observational study. Lancet. 2003 Jul 5;362(9377):22-9. PubMed PMID: 12853195.

Benefits of Antiretroviral Therapy

Saves lives. Antiretroviral therapy averted almost 8 million AIDS-related deaths globally from the peak in 1995 until 2016.1

Prevents new HIV infections. Antiretroviral therapy reduces the risk of HIV transmission by up to 96%.2

Prevents illness. Antiretroviral therapy reduces the risk of tuberculosis infection among people living with HIV by 65%.3

Saves money and promotes development. HIV treatment can generate economic savings within five years.4 Spending on antiretroviral therapy also generates economic returns of double or more than the initial investment.5

Keeps people productive. Working-age adults living with HIV can return to work earlier when they receive treatment, boosting labour productivity and reducing hardship among affected households.6

1 Our World in Data. HIV and AIDS Deaths and Averted Deaths due to ART (to 2016). 2017.

2 Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011 Aug 11;365(6):493-505. doi: 10.1056/NEJMoa1105243. Epub 2011 Jul 18. PMID: 21767103

3 Suthar AB, Lawn SD, del Amo J, Getahun H, Dye C, et al. Antiretroviral therapy for prevention of tuberculosis in adults with HIV: a systematic review and meta-analysis. PLoS Med. 2012;9(7):e1001270. doi: 10.1371/journal.pmed.1001270. PMID: 22911011

4 Walensky RP, Ross EL, Kumarasamy N, Wood R, Noubary F, et al. Cost-effectiveness of HIV treatment as prevention in serodiscordant couples. N Engl J Med. 2013 Oct 31;369(18):1715-25. doi: 10.1056/NEJMsa1214720. PMID: 24171517

5 Resch S, Korenromp E, Stover J, Blakley M, et al. Economic returns to investment in AIDS treatment in low and middle income countries. PLoS One. 2011;6(10):e25310. doi: 10.1371/journal.pone.0025310. Epub 2011 Oct 5. PMID: 21998648

6Maulsby CH, Ratnayake A, Hesson D, Mugavero MJ, Latkin CA. A Scoping Review of Employment and HIV. AIDS Behav. 2020 Oct;24(10):2942-2955. doi: 10.1007/s10461-020-02845-x. PMID: 32246357; PMCID: PMC7716244.

2.5.2 Treatment Guidelines

The World Health Organization (WHO) publishes recommendations on the diagnosis of HIV, the care of people living with HIV and the use of antiretroviral drugs for treating and preventing HIV infection from a global perspective.

These treatment guidelines address specific populations and provide guidance on how best to use ART to maximize success of drug therapy. A link to the guidelines is available here: Update of recommendations on first- and second-line anti-retroviral regimens.

2.5.3 ART Adherence

For best results, individuals with HIV need to take their medications every single day, in the proper way and at the same time for the rest of their lives.

When there is only partial adherence, an undetectable viral load (or viral load suppression) may not be achieved and there is increased risk of developing drug resistance.

Table 2.5.3: Examples of facilitators and barriers to ART adherence

Facilitators to Adherence Barriers to Adherence
  • Social support
  • Reminders
  • Dosing frequency and pill burden (e.g., one pill per day or less)
  • Experiences with health improvement on treatment
  • Decreased HIV-related stigma and discrimination
  • Positive experiences within the health system and with health providers
  • Unreliable drug supply
  • Transportation cost
  • Access to food and water
  • Polypharmacy (taking multiple treatments at the same time)
  • Homelessness or housing instability
  • Line-ups at clinics
  • Stigma/fear of disclosure
  • Depression
  • Fatigue
  • Other co-morbidities
  • Side effects
2.5.4 Side Effects of ART

As with other medications, antiretroviral medications have both short and long-term side effects. These side effects can affect many different body systems, and can range from bothersome to fatal.

Rehabilitation providers can assist patients with impairments that are the result of side effects of HIV medication. For example, several drugs can cause a condition called distal symmetrical polyneuropathy, which presents as bilateral pain, tingling and numbness in both lower legs and feet.

Other drugs can cause a condition called lipodystrophy, which causes metabolic changes as well as changes in body composition. The body changes can present as reduced fat in arms and legs, and added fat around the waist or back of neck.

There are many drugs used to treat HIV, and therefore many different types of side effects. For side effects associated with specific drugs, see up-to-date websites such as:

  • HIV Medicines and Side Effects
  • Adverse Effects of Antiretroviral Agents
2.5.5 ART for Prevention

Emerging pharmacologic advances include the use of ART for prevention.1 This includes use of pre-exposure prophylaxis (PREP) with oral or mucosally delivered antiretroviral medications to reduce an individual’s risk of acquiring HIV infection.2

Microbicides are products that may reduce HIV risk when applied vaginally. Although there seems to be an overall acceptance by women of microbicides, they are not yet available on the market.3

While significant research has been completed on HIV vaccines, the development of a safe and effective vaccine remains a medium to long-term prospect.4

1 Delva W, Eaton JW, Meng F, Fraser C, White RG, et al. HIV treatment as prevention: optimising the impact of expanded HIV treatment programs. PLoS Med. 2012;9(7):e1001258. doi: 10.1371/journal.pmed.1001258. PMID: 22802738

2 Desai M, Field N, Grant R, McCormack S. Recent advances in pre-exposure prophylaxis for HIV. BMJ.

2017 Dec 11;359:j5011. doi: 10.1136/bmj.j5011. PMID: 29229609

3 Notario-Pérez F, Galante J, Martín-Illana A, Cazorla-Luna R, et al. Development of pH-sensitive vaginal films based on methacrylate copolymers for topical HIV-1 pre-exposure prophylaxis. Acta Biomater. 2021 Feb;121:316-327. doi: 10.1016/j.actbio.2020.12.019. PMID: 33333257.

4 Jones LD, Moody MA, Thompson AB. Innovations in HIV-1 Vaccine Design. Clin Ther. 2020 Mar;42(3):499514. doi: 10.1016/j.clinthera.2020.01.009. Epub 2020 Feb 5. PMID: 32035643

2.5.6 What are the precautions that all rehabilitation providers should take regarding HIV and other related co-infections?

When working with people living with HIV, like any other patient, standard precautions (often called universal precautions) should be used.

  • Standard precautions require frequent hand washing between all client interactions.
  • Standard precautions also include using a barrier device (e.g. gloves) whenever contact with blood or body fluids is anticipated.
  • When handling clients whose skin is intact, gloves are not needed. However, if there are open lesions or breaks in the skin and/or contact with bodily fluids is likely, gloves and long-sleeved gowns are appropriate.
  • Use needles and other sharps safely, and dispose of them safely in a sharps disposal container (without any attempt to recap them).

These are the same precautions that should be used with all patients, regardless of whether or not they are HIV-positive.

Table 2.5.6: Which body fluids are infectious for HIV?

Body Fluids Potentially Infectious for HIV Body Fluids Not Infectious for HIV
  • Blood
  • Cerebrospinal
  • Amniotic
  • Pericardial
  • Peritoneal
  • Pleural
  • Synovial
  • Seminal
  • Vaginal
  • Penile secretions
  • Breast milk
  • Inflammatory exudate
  • Human tissue
  • Any other body fluids which contain visible blood
  • Stool
  • Urine
  • Tears
  • Saliva
  • However, if these non-infectious body fluids contain blood, they may be infectious.

While universal precautions are appropriate for protecting oneself from HIV, a person living with HIV without consistent access to ART may also have other diseases that require a higher level of precaution, such as:

  • Pulmonary Tuberculosis (TB) – precautions would include wearing an appropriate personal protective equipment
  • Hepatitis B – precautions would include vaccination

Health care workers are at increased risk of occupational exposure to blood borne diseases for a number of reasons, which make adherence to universal precautions even more important. Reasons for increased risk of occupational exposure include:1

  • Increased disease prevalence in the patient population
  • Greater disease severity of patients seeking care
  • Higher number of needle stick injuries
  • Culture of using injections versus other methods
  • Use of hazardous equipment and procedures (e.g., glass capillary tubes, non-retracting finger stick lancets)
  • Number of informal workers
  • Lack of vaccination coverage against hepatitis B
  • Lack of adherence to standard precautions

1 Canadian Public Health Association. Do you consistently use universal precautions?  https://www.cpha.ca/do-you-consistently-use-universal-precautions

2.5.7 Post-exposure prophylaxis (PEP)

In the case of a significant occupational exposure (e.g., exposure to blood or bloody body fluids through a hollow bore needle which has been in an artery or vein of a person known to be infected with HIV), individuals should immediately wash the area with warm soapy water and directly seek medical care (e.g., at an emergency department).

Significant exposure may require post-exposure prophylaxis (PEP), which is a form of antiretroviral treatment that is most effective when taken within 72 hours of exposure. Although reasonably successful, PEP is not a guaranteed prophylaxis and should only be used in extreme cases.1

1 Centers for Disease Control. Post-Exposure Prophylaxis.

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