This section is organized according to the categories of impairment in the World Health Organization’s International Classification of Functioning, Disability and Health1 (see Section 1.3).
- Mental functions
- Sensory functions and pain
- Voice and speech functions
- Functions of the cardiovascular, hematological, immunological and respiratory systems
- Functions of the digestive, metabolic and endocrine systems
- Genitourinary and reproductive functions
- Neuromuscular and movement related structures
- Functions of the skin and related structures
1 World Health Organization: International Classification of Functioning, Disability and Health (ICF) – Geneva. 2001. http://www.who.int/classifications/icf/en
3.1.1 Mental functions
People living with HIV commonly experience changes in mental functions. These include (but are not limited to) difficulties related to consciousness, orientation, intellect, energy and drive, sleep, attention, memory, emotion, perception, cognition and language.
These impairments may be caused by the HIV infection itself, one of the many opportunistic infections associated with HIV or side effects of various HIV-related medications. Pre-existing mental impairments may also be present which further impacts the rehabilitation of people living with HIV.
Rehabilitation interventions for these mental impairments include specific psychosocial techniques as well as general exercise and education. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.
Table 3.1.1: Clinical Aspects of Mental Function Impairments
|
Impairments |
Possible Etiologies |
Rehabilitation Interventions (for details, see Section 3.3) |
|
HIV Cognitive-Motor Complex (also known as AIDS Dementia Complex or HIV Dementia) |
HIV (the virus itself) Opportunistic infections |
Exercise prescription – aerobic |
|
Cognitive impairment (including memory loss) |
Hypoxia Cryptococcal meningitis TB meningitis Syphilis Neurovascular disease (stroke) Focal cerebral disease Vitamin deficiency (e.g., B12, B6) Electrolyte abnormalities Pain-related |
Exercise prescription – aerobic |
|
Psychological disorders (including depression, mood disorders, anxiety and delirium) |
Related to cognitive impairment Side effects of medication Psychosocial factors (e.g., stigma) Premorbid psychiatric disorders Post-traumatic stress disorder Pain-related |
Exercise prescription – aerobic |
|
Substance-related disorders |
Prescription medications (e.g., narcotics) Over-the-counter medications Street drugs: premorbid or current Alcohol: premorbid or current |
Referral to drug or alcohol treatment |
Legend: TB – tuberculosis
3.1.2 Sensory functions and pain
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”1 Pain can be classified temporarily as acute (i.e., pain < 3 months in duration) or chronic (i.e., pain > 3 months in duration). Pain can also be classified through a mechanistic perspective (i.e., nociceptive, neuropathic or nociplastic). In certain circumstances, chronic pain can now be considered a health condition in its own right.2 Pain is commonly experienced by people living with HIV at all stages of the disease process. Pain prevalence in people living with HIV ranges from 54% to 83%. This pain is often of moderate to severe intensity, which has a negative impact on physical functioning and overall quality of life.3
Rehabilitation techniques for pain management can include exercise prescription, self-management support, and pain education as well as electrotherapy modalities, cryotherapy, heat, and massage. Rehabilitation techniques used may vary depending whether pain is acute or chronic in addition to the mechanism of pain. Other sensory impairments, including difficulties related to sight, hearing and vestibular control are also experienced by people living with HIV. These may be managed by environmental modifications, provision of assistive devices and education.
These impairments may be caused by the HIV infection itself, one of the many opportunistic infections associated with HIV, or toxicity or side effects of various HIV-related medications. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.
1 Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982. doi: 10.1097/j.pain.0000000000001939. PMID: 32694387
2 Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019 Jan;160(1):19-27. doi: 10.1097/j.pain.0000000000001384. PMID: 30586067.
3 Parker R, Stein DJ, Jelsma J. Pain in people living with HIV/AIDS: a systematic review. J Int AIDS Soc. 2014 Feb 18;17(1):18719. doi: 10.7448/IAS.17.1.18719. PMID: 24560338
Table 3.1.2: Clinical Aspects of Sensory Impairment
| Impairments | Possible Etiologies | Rehabilitation Interventions |
|---|---|---|
|
Visual loss (including retinitis, retinal detachment, retinal vascular disease and blindness) |
Viral (e.g., CMV, HSV, VSV) Parasitic (e.g., Toxoplasmosis) Fungal (e.g., PCP) Bacterial (e.g., Cryptococcus) Malignancy (e.g., Kaposi’s sarcoma, Burkitt’s lymphoma) Ischemia Cranial nerve involvement Diabetes-related Side effects from medication Pre-existing (e.g., cataracts) |
|
|
Auditory impairments (including hearing loss, tinnitus and otalgia) |
HIV (the virus itself) Opportunistic infections Lesions in the central nervous system Medication-related Pre-existing |
Education on managing conversations and communication, cued speech, use of visual clues, learning strategies |
|
Vestibular impairments (including dizziness and poor balance) |
Otitis media Side effects of medication Visual impairment |
|
|
Pain (acute and chronic) |
Musculoskeletal pain (inflammatory or non- inflammatory) Secondary processes, inactivity or deconditioning Joint pain caused by bacterial infections, arthritis and medication Central nervous system lesions (parasitic, fungal, bacterial, fungal or malignant) Peripheral neuropathy (HIV or medication-related) Myelopathy (e.g., secondary to CMV) Systemic pain (e.g. malignancies, pleurisy, esophagitis, myocarditis, colitis) Exacerbation of pain by lack of sleep, anxiety or depression Impact of life situation (stress, finances, etc.) |
Electrotherapy Modalities (e.g., TENS1, IFC) Exercise prescription – aerobic Exercise prescription – strength Exercise prescription – stretching and passive movement Progressive goal setting Graded physical activity2 Mind-body interventions (e.g., yoga)3 Relaxation techniques (e.g., progressive muscle relaxation) Splinting and joint support Sleep hygiene techniques Cognitive behavioural therapies and insight-oriented focus counselling Return to work and/or activities strategies Self-management support4 Pain education5 |
|
Sensation changes (including numbness, burning or tingling) |
HIV Peripheral neuropathy |
Exercise prescription – aerobic |
Legend: CMV – Cytomegalovirus; HSV – Herpes Simplex Virus; IFT – Interferential Therapy; PCP – Pneumocystis Carinii Pneumonia; TENS – Transcutaneous Electrical Nerve Stimulation; VSV – Varicella-Zoster Virus
1 Dailey DL, Vance CGT, Rakel BA, Zimmerman MB, Embree J, et al. Transcutaneous Electrical Nerve Stimulation Reduces Movement-Evoked Pain and Fatigue: A Randomized, Controlled Trial. Arthritis Rheumatol. 2020 May;72(5):824-836. doi: 10.1002/art.41170. Epub 2020 Mar 18. PMID: 31738014
2 Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther. 2003 Aug;8(3):130-40. doi: 10.1016/s1356-689x(03)00051-1. PMID: 12909433.
3 Morone NE, Greco CM. Mind-body interventions for chronic pain in older adults: a structured review. Pain Med. 2007 May-Jun;8(4):359-75. doi: 10.1111/j.1526-4637.2007.00312.x. PMID: 17610459.
4 Nkhoma K, Norton C, Sabin C, Winston A, Merlin J, Harding R. Self-management Interventions for Pain and Physical Symptoms Among People Living With HIV: A Systematic Review of the Evidence. J Acquir Immune Defic Syndr. 2018 Oct 1;79(2):206-225. doi: 10.1097/QAI.0000000000001785. PMID: 30212435.
5 Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016 Jul;32(5):332-55. doi: 10.1080/09593985.2016.1194646. PMID: 27351541.
3.1.3 Voice and speech functions
People living with HIV experience impairments relating to voice and speech function caused by infection by viral pathogens or secondary sarcomas, and bacterial or fungal infections. In some cases, voice and speech impairments are associated with neurological impairments.
Rehabilitation interventions for voice and speech functions include exercise related to articulation, fluency, resonance, language as well as adaptation of the communication environment. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.
Table 3.1.3: Clinical Aspects of Voice and Speech Impairments
| Impairments | Possible Etiologies | Rehabilitation Interventions |
|---|---|---|
|
Dysphagia |
Kaposi’s sarcoma of mouth, pharynx, larynx Viral, bacterial or fungal infection |
Articulation, fluency, resonance, language advice and exercises Swallowing studies and trial feeding Alternative feeding options e.g. percutaneous gastronomy tubes |
|
Phonatory dysfunction |
Kaposi’s sarcoma of mouth, pharynx, larynx Viral, bacterial or fungal infection |
Articulation, fluency, resonance, language advice and exercises Sound amplification devices |
|
Dysarthria |
Viral pathogen Neurogenic anomalies of viral infection |
Articulation, fluency, resonance, language advice and exercises Augmentative communication devices e.g., text-to-voice output device |
3.1.4 Functions of the cardiovascular, hematological, immunological and respiratory systems
People living with HIV experience impairments related to the heart, blood pressure, hematological system (blood), immune system (including allergies, hypersensitivities) and respiration (breathing).
Possible causes of these impairments include primary HIV infection or secondary bacterial and fungal infections such as cytomegalovirus, Pneumocystis Jirovecii Pneumonia (PJP) or Tuberculosis (TB).
Malignancy such as Kaposi’s sarcoma and Non-Hodgkin’s Lymphoma are also secondary complications which affect the cardiovascular, hematological, immunological and respiratory systems. These impairments can also be caused by side effects of medications.
Rehabilitation interventions include chest physiotherapy, aerobic and strength exercise, pain management and adaptation of environment. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.
Table 3.1.4: Clinical Aspects of Cardiovascular, Hematological, Immunological and Respiratory Impairments
| Impairments | Possible Etiologies | Rehabilitation Interventions |
|---|---|---|
|
Impairments related to cardiac dysfunction (e.g., angina pain, anxiety, decreased endurance) |
Myocarditis or endocarditis (e.g., from bacterial or fungal infection) Cardiomyopathy (e.g., from viral pathogens or side effects of medication) Pericarditis or pericardial effusion (e.g., resulting from infections from multiple pathogens) Coronary artery disease (e.g., resulting from side effects of medication) Peripheral vascular disease (e.g., resulting from viral pathogens) |
Exercise prescription – aerobic Exercise prescription – strength Return to work and/or activities strategies Formal referral for cardiac rehabilitation |
|
Shortness of breath and other respiratory impairments |
Acute lung disease (e.g., pneumonia) Malignancies (e.g., Kaposi’s sarcoma, Non-Hodgkins Lymphoma) |
Chest physiotherapy techniques Exercise prescription – aerobic |
3.1.5 Functions of the digestive, metabolic and endocrine systems
People living with HIV may have impairments related to digestion, endocrine function and weight maintenance (both excessive weight loss and weight gain). These impairments may be caused by the HIV infection itself, one of the many opportunistic infections associated with HIV, or side effects of various HIV-related medications.
Dietary advice and exercise prescription can be utilized as methods to assist people living with HIV with both weight gain and weight loss. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.
Table 3.1.5: Clinical Aspects of Digestive, Metabolic and Endocrine Impairments
| Impairments | Possible Etiologies | Rehabilitation Interventions |
|---|---|---|
|
Digestive dysfunction |
HIV enteropathy Secondary infections (e.g., MAC, cryptosporidium) Obstruction (e.g., tumour) Food intolerances Medication-related |
|
|
Endocrine dysfunction |
Malignancy Adrenal insufficiency Hypogonadism Hypothyroidism Medication-related Food intolerances |
|
|
Weight loss |
Anorexia secondary to physiological (e.g., esophagitis, candida) or psychological causes Dysphagia (e.g., due to candida, KS or CMV) Malnutrition Malabsorption Malignancy Infection and fever-related Side effects of medication |
Exercise prescription – aerobic |
|
Weight gain |
Inactivity and deconditioning Constipation Side effects of medication |
Exercise prescription – aerobic Exercise prescription – strength |
|
Weight redistribution |
HIV-infection Side effects of medication Lipodystrophy |
Exercise prescription – aerobic |
Legend: CMV – Cytomegalovirus; KS – Kaposi’s Sarcoma; MAC – Mycobacterium Avium Complex
3.1.6 Genitourinary and reproductive functions
People living with HIV can experience impairments of genitourinary and reproductive functions. These impairments are related to urination functions and sexual functions and may be directly caused by the viral pathogen or secondary bacterial and fungal infection. Side effects of medications also have an effect on urinary and sexual functions. Sexual impairments can also result from psychosocial etiologies.
Rehabilitation interventions include psychosocial rehabilitation, electrotherapy modalities and exercise. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.
Table 3.1.6: Clinical Aspects of Genitourinary and Reproductive Impairments
| Impairments | Possible Etiologies | Rehabilitation Interventions |
|---|---|---|
|
Urination dysfunction |
Urinary tract infection Viral pathogen affecting the nervous system Side effects of medication Opportunistic infections Other fungal or bacterial infections |
|
|
Sexual impairments including loss of libido, pain during sex and male erectile problems |
Viral pathogen Emotional issues (e.g., anxiety, stress, grief and depression) Smoking Side effect of medication Alcohol use Recreational drug use Hormone dysfunction (e.g., testosterone deficiency and thyroid dysfunction in men and women, early menopause in women with HIV) Autonomic and/or peripheral neuropathy Sexually transmitted infections |
Exercise prescription – aerobic Exercise prescription – strength Referral to sex therapy |
3.1.7 Neuromuscular and movement related structures
People living with HIV commonly experience neuromuscular and movement-related impairments. These impairments include (but are not limited to) difficulties related to joint mobility, muscle power and involuntary movements.
These impairments may be caused by pathology in the central nervous system, spinal cord or peripheral nervous system. Neuromuscular rehabilitation techniques include massage therapy, passive movements, proprioceptive neuromuscular facilitation (PNF) and Bobath techniques, and exercise prescription. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.
Table 3.1.7: Clinical Aspects of Neuromuscular and Movement Related Impairments
| Impairments | Possible Etiologies | Rehabilitation Interventions |
|---|---|---|
|
Reduced joint mobility |
Disuse Inflammation Fluid retention |
Exercise prescription – aerobic Exercise prescription – strength |
|
Muscle tone (increased or decreased tone including flaccidity, spasticity and rigidity) |
Deconditioning Central nervous system lesions (including stroke, malignancy or infection) Spinal cord pathology (including myelitis, TB) Lower motor neuron lesions |
Exercise prescription – aerobic Exercise prescription – strength Exercise prescription – stretching and passive movement Functional electrical stimulation Casting/tone-inhibiting orthoses via static splinting |
|
Reduced muscle strength, power and endurance |
Inactivity or deconditioning due to prolonged bed rest or illness Central nervous system lesions (including stroke, malignancy or infection) Spinal cord pathology (including myelitis, TB spine) Acute inflammatory demyelinating polyneuropathy Inadequate nutritional intake Anemia Electrolyte abnormalities |
Exercise prescription – aerobic |
|
Involuntary movements (including dystonia and ataxia) |
Central nervous system lesions Side effects of medication Electrolyte abnormalities |
|
|
Decreased bone density (including osteoporosis and osteopenia) |
Inactivity or deconditioning Severe weight loss Malnutrition Hormonal imbalances |
Exercise prescription – aerobic Exercise prescription – strength Postural re-education Environmental assessment for fall injury risk reduction |
|
Osteonecrosis (avascular necrosis) |
Etiology unknown but associated with HIV infection |
Exercise prescription – aerobic |
Legend: TB – tuberculosis
3.1.8 Functions of the skin and related structures
People living with HIV may experience impairments related to the skin and related structures. Impairments may be caused by viral, fungal or bacterial infections. Kaposi’s sarcoma commonly affects the skin.
Rehabilitation interventions include psychosocial rehabilitation, advice on skin care and exercises. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.
Table 3.1.8: Clinical Aspects of Skin Impairments
| Impairment | Possible Etiologies | Rehabilitation Interventions |
|---|---|---|
|
Skin lesions (including cold sores, rashes, and warts) |
Herpes simplex and other viral infections Kaposi’s sarcoma |
|
|
Skin infections |
Molluscum contagiosum, folliculitis, seborrheic dermatitis, psoriasis and tinea, caused by viral, bacterial and fungal infections |