Prevalence of activity limitation among persons living with HIV/AIDS in British Columbia

The association between HIV infection, disability and lifestyle activity among middle-aged and older adults: an analytical cross-sectional study in Ivory Coast (the VIRAGE study)

INTRODUCTION

People living with HIV (PLWH) live longer and face new health challenges resulting from the confluence of chronic HIV infection and the natural effect of aging and comorbidities. However, there is a dearth of information on the long-term impact of HIV infection on the health and wellbeing of PLWH in sub-Saharan Africa. This research aimed to fill this gap by reporting on physical, functional and social outcomes among PLWH treated at a referral center in Abidjan, Ivory Coast, and comparing them with those of a control group.

METHODS

Body composition, functional capacity, sarcopenia, limitations in daily activities and social participation were assessed among 300 PLWH (aged ≥ 30 years) and 200 uninfected adults of similar age and sex. The associations between these outcomes and participants' socioeconomic characteristics, HIV history and physical activity level were assessed using generalized additive models adjusted for age and sex.

RESULTS

The median age was 51 years, and the median antiretroviral therapy duration was 15 years. Compared to controls, PLWH reported higher levels of physical activity (p < 0.0001). They had a lower muscle index (adjusted p < 0.0001) and grip strength (adjusted p < 0.0001) but achieved similar performance on the 6-min walk test (6MWT, p = 0.2). Among PLWH, physical activity level was positively associated with better performance in the 6MWT (p = 0.006) and greater hand grip strength (p = 0.04). The difference in physical performance according to the level of physical activity appeared mainly after the age of 60. PLWH reported similar rates of activity limitations (p = 0.8), lower depression levels and greater scores for social functioning (p = 0.02).

CONCLUSION

In this study, PLWH achieved high levels of physical activity, which may explain why they maintained good physical performance and social functioning despite having a higher risk of sarcopenia. These results have important implications for resource-limited health systems and show avenues for chronic care models.

TRIAL REGISTRATION

This study was registered on the ClinicalTrials.gov website (NCT05199831, first registration the 20/01/2022).

The multidimensional vulnerability of people with disability to HIV infection: Results from the handiSSR study in Bujumbura, Burundi

BACKGROUND

In resource-limited contexts, available data indicate that people with disability are disproportionally affected by the HIV epidemic. While disability resulting from chronic HIV infection has received some attention, few epidemiologic studies have examined the vulnerability of people with disability to HIV acquisition. The aims of the study were as follows: to estimate and compare HIV prevalence among people with and without disability living in Bujumbura, Burundi; to examine how the interaction among disability, gender and socioeconomic environment shapes vulnerability to HIV; and to identify potential pathways to higher HIV risk.

METHODS

In this cross-sectional population-based study, 623 persons with disability (302 with disability onset ≤10 years ["early disability"]) and 609 persons without disability matched for age, sex and location were randomly selected to be tested for HIV and to participate in an interview about their life history, their social environment and their knowledge of sexual health.

FINDINGS

A total of 68% of men and 75% of women with disability were affected by multidimensional poverty compared to 54% and 46% of their peers without disability (p<0.0001). Higher HIV prevalence was observed among women with disability (12.1% [8.2-16]) than among those without (3.8% [1.7-6], ORa 3.8, p<0.0001), while it was similar among men with disability and those without (p = 0·8). Women with disability were also at higher risk of sexual violence than were those without (ORa 2.7, p<0.0001). The vulnerability of women with early disability to HIV was higher among those who were socially isolated (HIV prevalence in this group: 19% [12-27]). In addition, education level and sexual violence mediated 53% of the association between early disability and HIV (p = 0.001).

INTERPRETATION

This study highlights how the intersection of disability, gender and social environment shapes vulnerability to HIV. It also shows that the vulnerability to HIV of women who grew up with a disability is mediated by sexual violence.

FUNDING

This research was funded by the Netherlands Organization for Scientific Research (Grant W08.560.005) and the Initiative HIV-TB-Malaria (new name of the organisation).

Functional Limitations and Disability in Persons Living with HIV in South Africa and United States: Similarities and Differences

Persons living with HIV (PLHIV) may experience disability. We compared disability among PLHIV in the United States and South Africa and investigated associations with health and demographic characteristics. Secondary analysis of cross-sectional data using medical records and questionnaires including the World Health Organization Disability Assessment Schedule (WHO-DAS) 2.0 12-item version (range: 0-36, with higher scores indicative of more severe disability). Between-country differences for the presence of disability were assessed with logistic regression and differences in severity using multiple regression. Eighty-six percent of US participants reported disability, compared to 51.3% in South Africa. The mean WHO-DAS score was higher in the United States (12.09 ± 6.96) compared to South Africa (8.3 ± 6.27). Participants with muscle pain, depression, or more years since HIV diagnosis were more likely to report disability. Being female or depressed was associated with more severity. Being adherent to anti-retroviral therapy (ART) and employed were associated with less severity. Because muscle pain and depression were predictive factors for disability, treatment of those problems may help mitigate disability in PLHIV.

Characterizing the disability experience among adults living with HIV: a structural equation model using the HIV disability questionnaire (HDQ) within the HIV, health and rehabilitation survey

BACKGROUND

People aging with HIV can experience a variety of health challenges associated with HIV and multimorbidity, referred to as 'disability'. Our aim was to characterize the disability experience and examine relationships between dimensions of disability among adults living with HIV.

METHODS

We performed a structural equation modeling analysis with data from the Canadian web-based HIV, Health and Rehabilitation Survey. We measured disability using the HIV Disability Questionnaire (HDQ), a patient-reported outcome (69 items) that measures presence, severity and episodic features of disability across six domains: 1) physical symptoms, 2) cognitive symptoms, 3) mental-emotional health symptoms, 4) difficulties carrying out day-to-day activities, 5) uncertainty and worrying about the future, and 6) challenges to social inclusion. We used HDQ severity domain scores to represent disability dimensions and developed a structural model to assess relationships between disability dimensions using path analysis. We determined overall model fit with a Root Mean Square Error of Approximation (RMSEA) of < 0.05. We classified path coefficients of ≥ 0.2-0.5 as a medium (moderate) effect and > 0.5 a large (strong) effect. We used Mplus software for the analysis.

RESULTS

Of the 941 respondents, most (79%) were men, taking combination antiretroviral medications (90%) and living with two or more simultaneous health conditions (72%). Highest HDQ presence and severity scores were in the uncertainty domain. The measurement model had good overall fit (RMSEA= 0.04). Results from the structural model identified physical symptoms as a strong direct predictor of having difficulties carrying out day-to-day activities (standardized path coefficient: 0.54; p < 0.001) and moderate predictor of having mental-emotional health symptoms (0.24; p < 0.001) and uncertainty (0.36; p < 0.001). Uncertainty was a strong direct predictor of having mental-emotional health symptoms (0.53; p < 0.001) and moderate direct predictor of having challenges to social inclusion (0.38; p < 0.001). The relationship from physical and cognitive symptoms to challenges to social inclusion was mediated by uncertainty, mental-emotional health symptoms, and difficulties carrying out day-to-day activities (total indirect effect from physical: 0.22; from cognitive: 0.18; p < 0.001).

CONCLUSIONS

Uncertainty is a principal dimension of disability experienced by adults with HIV. Findings provide a foundation for clinicians and researchers to conceptualize disability and identifying areas to target interventions.

The conceptualization of stigma within a rehabilitation framework using HIV as an example

Stigma theory is concerned with inclusion and opportunities that influence well-being. Rehabilitation is also concerned with social inclusion and well-being. This is a central concern in one of the leading rehabilitation theories, the World Health Organization's International Classification of Functioning, Disability and Health. Despite these shared concerns, the relationship between the fields of stigma and rehabilitation has not been well theorized to date. Using human immunodeficiency virus (HIV) as an example, this article presents an analysis of three ways that stigma may be conceptualized within the context of the International Classification of Functioning, Disability and Health. Three broad spheres of stigma are described: enacted, self, and structural stigma. These three forms of stigma are then aligned in unique ways with three particular constructs of the International Classification of Functioning, Disability and Health: participation restrictions, environmental, and personal contextual factors. This conceptualization illustrates how rehabilitation professionals and other practitioners, policy makers and researchers can better understand the dynamic and nuanced forms of stigma and how they relate to rehabilitation. Implications for rehabilitation This article enables rehabilitation professionals to better understand stigma as it relates to rehabilitation and human immunodeficiency virus. Rehabilitation professionals have the important job of allies and advocates for persons experiencing restrictions in these domains as a result of stigma.

Optimism alongside new challenges: using a rehabilitation framework to explore experiences of a qualitative longitudinal cohort of people living with HIV on antiretroviral treatment in Lusaka, Zambia

Previous research has demonstrated increased comorbidities related to the chronic effects of HIV. Rehabilitation science offers a useful approach for studying chronic illness. This longitudinal qualitative study used a rehabilitation science approach to explore the experiences over time of women and men living with HIV and on antiretroviral therapy (ART) in the high HIV-prevalence setting of Lusaka, Zambia. Thirty-five participants participated in a total of 99 in-depth interviews from 2012 to 2015. The central pattern that emerged across the participants' narratives was the paradoxical experience of profound optimism alongside significant new challenges. Participants' stories of hopefulness in the face of ongoing struggles played out in three interconnected themes: (1) impacts on my body and life; (2) interventions I am grateful to have and new interventions I need; and (3) stigma reduced and created by ART. Results reflected the ups and downs of life with HIV as a chronic illness. Participants, whilst committed to and healthier on ART, typically experienced multiple physical, psychological and sensory impairments that varied in type, severity and trajectory. Participants valued improved relationships enabled by ART, but yearned for support for living long-term with HIV. Frequently participants reflected that their needs were overlooked related to managing side-effects, exercise, family planning and healthy sexuality. ART strengthened acceptance by self and others through improved health and productivity and through becoming a source of support for others. However, being on ART also led to stigma, driven by persistent associations with sickness, death, lack of productivity and uncertainty. This study points to shortcomings in the current focus of HIV care in Zambia and the region, which centres on initiating and adhering to ART. Findings call for evolution of the HIV care continuum to embrace a more holistic and long-term approach to living with HIV as a chronic and episodic condition.

Research on rehabilitation interventions for adults living with HIV: a scoping review

The aim of this paper is to use a scoping review to investigate the extent, range, and nature of research on rehabilitation interventions for adults living with HIV. Electronic databases (MEDLINE, EMBASE, CINAHL, AMED, and PsychINFO) and reference lists of the included articles were searched. Authors were emailed when possible for unavailable articles. A total of 897 titles and abstracts were retrieved. Thirty-three articles were included. There were 27 different rehabilitation interventions delivered by 18 professions. The studies were completed in four different countries. Most studies were published in 2008. A randomized-controlled trial was the most used method. The nature of the studies was analyzed according to the three-core concepts of the International Classification of Functioning, Disability and Health: 28 studies addressed impairments; six studies addressed activity limitations; and 14 studies addressed participation restrictions. This scoping study advances the knowledge of research on rehabilitation interventions for adults living with HIV. More research on rehabilitation interventions is needed in sub-Saharan Africa and other low-income and middle-income countries to ensure that these individuals are receiving the best possible care. There is a need for the HIV field to recognize the important contribution of rehabilitation toward the HIV care continuum.

Advancing research and practice in HIV and rehabilitation: a framework of research priorities in HIV, disability and rehabilitation

BACKGROUND

HIV increasingly is experienced as a complex chronic illness where individuals are living longer with a range of physical, cognitive, mental and social health-related challenges associated with HIV, comorbidities and aging, a concept that may be termed 'disability'. Rehabilitation such as physical therapy and occupational therapy can help address disability and has the potential to improve quality of life in people living with HIV. Hence, the role for rehabilitation in the context of HIV, aging and comorbidities is emerging. Our aim was to establish a framework of research priorities in HIV, disability and rehabilitation.

METHODS

We convened people living with HIV, clinicians, researchers, service providers, representatives from community-based organizations and policy and funding stakeholders to participate in the first International Forum on HIV and Rehabilitation Research. We conducted a multi-stakeholder consultation to identify current and emerging issues in HIV, disability and rehabilitation. Data were collated and analyzed using content analytical techniques.

RESULTS

Ninety-two participants attended the Forum from Canada, United Kingdom (UK), Ireland and the United States. Situated within three overarching themes (episodic health and disability across the life course; rehabilitation; and methodological advances), the Framework of Research Priorities in HIV, Disability and Rehabilitation includes six research priorities: 1) episodic health and disability; 2) aging with HIV across the life course; 3) concurrent health conditions; 4) access to rehabilitation and models of rehabilitation service provision; 5) effectiveness of rehabilitation interventions; and 6) enhancing outcome measurement in HIV and rehabilitation research. The Framework includes methodological considerations and environmental and personal contextual factors (or lenses) through which to approach research in the field. Knowledge translation should be implemented throughout the development and application of research knowledge to inform HIV clinical practice, programming and policy.

CONCLUSIONS

These priorities highlight the emerging priorities of living long-term with HIV and outline a plan for HIV and rehabilitation research in resource-rich countries such as the UK and Canada.

The impact of engagement in street-based income generation activities on stimulant drug use cessation among people who inject drugs

BACKGROUND

Despite the growing prevalence of illicit stimulant drug use internationally, and the widespread involvement of people who inject drugs (IDU) within street-based drug markets, little is known about the impact of different types of street-based income generation activities on the cessation of stimulant use among IDU.

METHODS

Data were derived from an open prospective cohort of IDU in Vancouver, Canada. We used Kaplan-Meier methods and Cox proportional hazards regression to examine the effect of different types of street-based income generation activities (e.g., sex work, drug dealing, and scavenging) on time to cessation of stimulant use.

RESULTS

Between December, 2005 and November, 2012, 887 IDU who use stimulant drugs (cocaine, crack cocaine, or crystal methamphetamine) were prospectively followed-up for a median duration of 47 months. In Kaplan-Meier analyses, compared to those who did not engage in street-based income generation activities, participants who reported sex work, drug dealing, scavenging, or more than one of these activities were significantly less likely to report stimulant drug use cessation (all p<0.001). When considered as time-updated variables and adjusted for potential confounders in a multivariable model, each type of street-based income generation activity remained significantly associated with a slower time to stimulant drug cessation (all p<0.005).

CONCLUSIONS

Our findings highlight the urgent need for strategies to address stimulant dependence, including novel pharmacotherapies. Also important, structural interventions, such as low-threshold employment opportunities, availability of supportive housing, legal reforms regarding drug use, and evidence-based approaches that reduce harm among IDU are urgently required.

Evidence-informed recommendations for rehabilitation with older adults living with HIV: a knowledge synthesis

OBJECTIVE

Our aim was to develop evidence-informed recommendations for rehabilitation with older adults living with HIV.

DESIGN

We conducted a knowledge synthesis, combining research evidence specific to HIV, rehabilitation and ageing, with evidence on rehabilitation interventions for common comorbidities experienced by older adults with HIV.

METHODS

We included highly relevant HIV-specific research addressing rehabilitation and ageing (stream A) and high-quality evidence on the effectiveness of rehabilitation interventions for common comorbidities experienced by older adults ageing with HIV (stream B). We extracted and synthesised relevant data from the evidence to draft evidence-informed recommendations for rehabilitation. Draft recommendations were refined based on people living with HIV (PLHIV) and clinician experience, values and preferences, reviewed by an interprofessional team for Grading of Recommendations Assessment, Development, and Evaluation (GRADE) (quality) rating and revision and then circulated to PLHIV and clinicians for external endorsement and final refinement. We then devised overarching recommendations to broadly guide rehabilitation with older adults living with HIV.

RESULTS

This synthesis yielded 8 overarching and 52 specific recommendations. Thirty-six specific recommendations were derived from 108 moderate-level or high-level research articles (meta-analyses and systematic reviews) that described the effectiveness of rehabilitation interventions for comorbidities that may be experienced by older adults with HIV. Recommendations addressed rehabilitation interventions across eight health conditions: bone and joint disorders, cancer, stroke, cardiovascular disease, mental health challenges, cognitive impairments, chronic obstructive pulmonary disease and diabetes. Sixteen specific recommendations were derived from 42 research articles specific to rehabilitation with older adults with HIV. The quality of evidence from which these recommendations were derived was either low or very low, consisting primarily of narrative reviews or descriptive studies with small sample sizes. Recommendations addressed approaches to rehabilitation assessment and interventions, and contextual factors to consider for rehabilitation with older adults living with HIV.

CONCLUSIONS

These evidence-informed recommendations provide a guide for rehabilitation with older adults living with HIV.

Self-management interventions for people living with human immunodeficiency virus: a scoping review

BACKGROUND

Self-management is an important emerging intervention for people with human immunodeficiency virus (PHAs). The principles of self-management are consistent with the principles of client-centred occupational therapy.

PURPOSE

This scoping review addressed three questions about self-management interventions for PHAs: (a) What knowledge, skills, and attitudes are taught? (b) What outcomes are intended? (c) What are the participation experiences of PHAs?

METHOD

Questions were searched in six databases. Two researchers independently reviewed abstracts and articles before inclusion. Extracted data were iteratively themed.

FINDINGS

Thirty-five articles were included. Interventions taught self-care, interpersonal skills, technical knowledge, cognitive skills, positive attitudes, planning for the future, and role management. Outcomes included well-being, health and illness management, and health services use. Participation experiences reflected social experiences, needs of PHAs, specific needs of women, participation, empowerment, intervention importance, and experiences with service delivery.

IMPLICATIONS

Self-management interventions are a promising approach for occupational therapists to enable PHAs' occupational performance goals.

Rehabilitation interventions for children living with HIV: a scoping review

PURPOSE

To report the extent (how many), range (variation) and nature (qualities) of rehabilitation interventions for children living with HIV.

METHOD

Electronic databases, reference lists of included articles, and grey literature were searched. Title and abstract and full text review were completed independently by two reviewers. Each study's location, research methodology, interventions, the age of the participants, whether participants were receiving antiretroviral therapy (ART), the health professions delivering the interventions, when the study was conducted and the composition of the research team were documented. The nature of the intervention goals was organized into qualitative categories.

RESULTS

The 17 included studies were conducted in seven countries. Seven rehabilitation professions were involved with the interventions. The age of the participants ranged from 3 months to 24 years. The year in which the study was conducted and whether children were receiving ART were rarely specified. Studies focused on impairments. There were no studies on activity limitations and only two studies on participation restrictions. Alternative and complementary therapies were the most common interventions.

CONCLUSIONS

Research in this area is limited. More rehabilitation research is needed especially in areas where the burden of the disease is highest and for those children receiving ART. Implications for Rehabilitation Many low-and-middle-income countries (LMICs) struggle with an undersupply of trained rehabilitation professionals. Due to the large number of children living with HIV in LMICs, and as more continue to receive life-saving treatment, the need will grow for more rehabilitation professionals to work with this population to address HIV-related disability. This scoping review indicates that there is a dearth of research on interventions provided by allied health professionals, including physiotherapists, occupational therapists and speech language pathologists for children living with HIV. There is a moderate literature base supporting the use of alternative and complementary therapies for children living with HIV.

The impact of highly active antiretroviral therapy on activities of daily living in HIV-infected adults in South Africa

This study investigated the relationship between highly active antiretroviral therapy (HAART) and instrumental activities of daily living (IADLs) among two clinical cohorts in South Africa. Between 2003 and 2008 structured questionnaires were administered to HIV-positive patients attending outpatient clinics at an urban hospital (Soweto, n = 3,081) and a rural hospital (Acornhoek, n = 1,247). Among those receiving help, an average of 4.8 and 5.1 h of assistance with IADLs daily was reported (rural and urban participants, respectively), with the patient's mother and children assisting the most. Participants on HAART were 17 and 41% less likely to receive assistance with IADLs in the rural and urban cohorts, respectively, after adjusting for demographic characteristics, healthcare utilization, and CD4 counts. HAART significantly decreased the IADL assistance among patients in South Africa. Alongside clinical benefits, HAART has the potential to reduce the burden of HIV-related care, potentially extending wider social and economic gains to other family members.

Factors associated with employment among a cohort of injection drug users

INTRODUCTION AND AIMS

One of the most substantial costs of drug use is lost productivity and social functioning, including holding of a regular job. However, little is known about employment patterns of injection drug users (IDU). We sought to identify factors that were associated with legal employment among IDU.

DESIGN AND METHODS

We describe the employment patterns of participants of a longitudinal cohort study of IDU in Vancouver, Canada. We then use generalised estimating equations (GEE) to determine statistical associations between legal employment and various intrinsic, acquired, behavioural and circumstantial factors.

RESULTS

From 1 June 1999 to 30 November 2003, 330 (27.7%) of 1190 participants reported having a job at some point during follow up. Employment rates remain somewhat stable throughout the study period (9-12.4%). Factors positively and significantly associated with legal employment in multivariate analysis were male gender (adjusted odds ratio [AOR] = 2.78) and living outside the Downtown Eastside (AOR = 1.85). Factors negatively and significantly associated with legal employment included older age (AOR = 0.97); Aboriginal ethnicity (AOR = 0.72); HIV-positive serostatus (AOR = 0.32); HCV-positive serostatus (AOR = 0.46); daily heroin injection (AOR = 0.73); daily crack use (AOR = 0.77); public injecting (AOR = 0.50); sex trade involvement (AOR = 0.49); recent incarceration (AOR = 0.56); and unstable housing (AOR = 0.57).

DISCUSSION AND CONCLUSIONS

Our results suggest a stabilising effect of employment for IDU and socio-demographic, drug use and risk-related barriers to employment. There is a strong case to address these barriers and to develop innovative employment programming for high-risk drug users.

Scoping the field: identifying key research priorities in HIV and rehabilitation

The purpose of this project was to identify key research priorities related to HIV and rehabilitation. We conducted a scoping study which included a literature review of published and grey literature, followed by focus group and interview consultations with 28 participants including people living with HIV, researchers, educators, clinicians, and policy makers with expertise in HIV and rehabilitation. Qualitative content analysis was used to identify emergent themes related to research priorities in HIV and rehabilitation. The resulting Framework of HIV and Rehabilitation Research provided an outline for approaching research in the field. The framework included three overlapping research priorities: (a) living with HIV across the lifespan, (b) disability, and (c) rehabilitation that should be viewed through environmental and/or personal contextual lenses, using different methodological approaches. Six key research priorities from this framework were identified through additional consultation with new and returning participants including: (1) disability and episodic disability, (2) concurrent health conditions aging with HIV, (3) HIV and the brain, (4) labour force and income support, (5) access to and effectiveness of rehabilitation, and (6) development and evaluation of outcome measurement tools. These priorities inform a future plan for HIV and rehabilitation research that will increase our knowledge to enhance practice, programming and policy for people living with HIV.

Treatment, care and support for people co-infected with HIV and hepatitis C: a scoping review

BACKGROUND

Providing care for people who are co-infected with both HIV and hepatitis C virus (HCV) is becoming increasingly complex and requires integrated prevention, screening, support and programming efforts. We undertook a scoping review to provide a summary of the existing evidence base and to identify and assess the quality of treatment guidelines and systematic reviews related to 3 domains of interest: treatment; epidemiology; and care, support, programming and prevention.

METHODS

We searched 7 databases, hand-searched 8 journals and contacted key informants to identify relevant literature. We included all primary research (including systematic reviews and meta-analyses) or treatment guidelines that assessed pegylated interferon and ribavirin for HCV or highly active antiretroviral therapy for HIV treatment, or both. In the epidemiology domain, we included all primary research (including systematic reviews and meta-analyses). Studies that included only people with hemophilia and those conducted in developing countries were excluded. In the care, support, programming and prevention domain, we included all studies and reports that focused on co-infection. Two reviewers independently applied coding criteria and assessed the quality of the treatment guidelines and systematic reviews using the Appraisal of Guidelines Research and Evaluation and A MeaSurement Tool to Assess Reviews instruments.

RESULTS

Our search strategy yielded 1633 unique references. Of these, 227 references met the final inclusion criteria: 114 addressed treatment, 52 epidemiology and 79 care, support, programming or prevention. The references included 9 treatment guidelines: 4 were assessed as "strongly recommend," 3 as "recommend (with provisos or alterations)" and 1 as "would not recommend" (1 could not be located). Of 10 systematic reviews that were located, 7 were assessed as being high quality, 2 as medium quality and 1 as low quality.

CONCLUSION

This quality-assessed inventory of treatment guidelines and systematic reviews can be used by physicians and service providers to rapidly locate research about HIV-HCV co-infection. However, many treatment guidelines and reviews often indicate that treatment of current injection drug users and/or people with mental health issues should proceed on a "case-by-case basis." Therefore, much of the evidence (particularly in the treatment literature) is limited in its scope and applicability to important populations that are vulnerable to HIV or HCV infection or co-infection.

Ankle mobility in relation to chronic venous insufficiency in HIV-positive persons with and without a history of injection drug use

The purpose of this study was to examine ankle mobility in relation to chronic venous insufficiency (CVI) in HIV-positive persons with and without a history of injection drug use (IDU) and to examine the extent to which peripheral neuropathy further reduced ankle mobility. A cross-sectional, stratified design with quota sampling was used to recruit 27 persons with no history of IDU and 46 with a history of IDU from an infectious diseases clinic. Goniometric measurements of forefoot inversion-eversion and dorsiflexion-plantar flexion were obtained. CVI was assessed on a clinical scale. Peripheral neuropathy was identified from chart review and self-report. Injection drug users had less ankle flexion-extension right, inversion-eversion left and right, and total ankle motion than those who did not inject drugs (p < .05). Neuropathy was not associated with less mobility of the ankle joint (p < .01). A causal model supported the hypothesis of ankle mobility as a mediator of the effect of IDU on CVI.