Evaluation of a knowledge translation intervention for HIV and rehabilitation advocacy in physiotherapy in three sub-Saharan African countries

PURPOSE

To evaluate a knowledge translation intervention to determine knowledge, attitudes and self-efficacy related to HIV and rehabilitation advocacy in physiotherapy students.

METHODS

A pre and post-test study was conducted at three physiotherapy-training programs in Sub Saharan Africa - the University of the Witwatersrand (Wits), the University of Zambia (UNZA) and Kenya Medical Technical College (KMTC). For each site, the knowledge, attitude and self-efficacy of physiotherapy students were tested pre- and post-intervention using a standardized questionnaire.

RESULTS

Students' knowledge improved with regard to being able to describe the challenges faced by their patients, knowing what resources are available and understanding their role as an advocate. In terms of self-efficacy, they felt more confident clinically, as well as being a resource person to colleagues and an advocate for their patients.

This study highlights the need to contextualize knowledge translation interventions to meet the unique needs of individual academic sites. Students who have clinical experience working with people living with HIV are more likely to embrace their role as advocates in the area of HIV and rehabilitation.Implications for RehabilitationThe knowledge translation process used in this study gives a concrete example of how to use research evidence on HIV knowledge in rehabilitation applied within the advocacy process.Applying the principles of advocacy translates to understanding the management of HIV practically.Clinical experience in managing people living with HIV strengthens knowledge and improves the attitude of physiotherapy studentsPhysiotherapy students need guidance in realizing their potential as advocates for holistic rehabilitation care for people living with HIV.

Long COVID and episodic disability: advancing the conceptualisation, measurement and knowledge of episodic disability among people living with Long COVID - protocol for a mixed-methods study

INTRODUCTION

As the prevalence of Long COVID increases, there is a critical need for a comprehensive assessment of disability. Our aims are to: (1) characterise disability experiences among people living with Long COVID in Canada, UK, USA and Ireland; and (2) develop a patient-reported outcome measure to assess the presence, severity and episodic nature of disability with Long COVID.

METHODS AND ANALYSIS

In phase 1, we will conduct semistructured interviews with adults living with Long COVID to explore experiences of disability (dimensions, uncertainty, trajectories, influencing contextual factors) and establish an episodic disability (ED) framework in the context of Long COVID (n~10 each country). Using the conceptual framework, we will establish the Long COVID Episodic Disability Questionnaire (EDQ). In phase 2, we will examine the validity (construct, structural) and reliability (internal consistency, test-retest) of the EDQ for use in Long COVID. We will electronically administer the EDQ and four health status criterion measures with adults living with Long COVID, and readminister the EDQ 1 week later (n~170 each country). We will use Rasch analysis to refine the EDQ, and confirm structural and cross-cultural validity. We will calculate Cronbach's alphas (internal consistency reliability), and intraclass correlation coefficients (test-retest reliability), and examine correlations for hypotheses theorising relationships between EDQ and criterion measure scores (construct validity). Using phase 2 data, we will characterise the profile of disability using structural equation modelling techniques to examine relationships between dimensions of disability and the influence of intrinsic and extrinsic contextual factors. This research involves an academic-clinical-community partnership building on foundational work in ED measurement, Long COVID and rehabilitation.

ETHICS AND DISSEMINATION

This study was approved by the University of Toronto Research Ethics Board. Knowledge translation will occur with community collaborators in the form of presentations and publications in open access peer-reviewed journals and presentations.

Employment and Occupational Productivity Among Women Living With HIV: A Conceptual Framework

ABSTRACT

Women living with HIV (WLWH) have lower employment rates and more difficulty finding and keeping employment compared with their counterparts without HIV. These disparities affect physical, psychological, and socioeconomic outcomes, and they may compound the disadvantages associated with living with HIV. Although historical literature has emphasized the impact of clinical factors on employment, current evidence suggests that socioeconomic and psychosocial factors associated with HIV should be included for a more comprehensive view. Based on this broader inclusion, a conceptual framework is presented describing how socioeconomic and psychosocial characteristics influence employment acquisition and maintenance among WLWH. The framework posits that there is a reciprocal relationship between employment acquisition and occupational productivity, and psychological health, physical health, social support, and empowerment. Implications for future research and interventions include (a) an extended conceptualization of vocational rehabilitation and (b) the use of peer support groups to increase social capital, empowerment, knowledge, and resources among WLWH.

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.

Exercise and Positive Living in Human Immunodeficiency Virus/AIDS

Evidence would suggest that regardless of disease status, people living with human immunodeficiency virus (HIV)/AIDS can obtain similar health benefits from routine physical activity reported within general populations. Research has shown significant improvements among psychological and physiologic variables within the first 5 to 6 weeks of beginning a routine physical activity program. Daily activity has shown promising results in other clinical populations, but there is still a paucity of research that limits evidence among the HIV population. Additional research is needed to examine the long-term benefits of physical activity, and to discover more practical ways to achieve this lifestyle change.

Calendaring and alarms can improve naturalistic time-based prospective memory for youth infected with HIV

Individuals with HIV disease often evidence deficits in prospective memory (PM), which interfere with daily functioning and increase the risk of suboptimal health behaviours. This study examined the benefits of simple encoding and cueing supports on naturalistic time-based PM in 47 HIV-positive young adults. All participants completed a naturalistic time-based PM task in which they were instructed to text the examiner once per day for seven days at a specified time. Participants were randomised into (1) a Calendaring condition in which they created a calendar event in their mobile telephone for the specified texting time; (2) an Alarm condition in which they programmed an alarm into their mobile telephone for the specified texting time; (3) a Combined calendaring and alarm condition; and (4) a Control condition. Participants in the Combined condition demonstrated significantly better naturalistic PM performance than participants in the Control and Calendaring conditions. Findings indicate that HIV-positive young people may benefit from a combined calendaring and alarm supportive strategy for successful execution of future intentions in daily life.

Designing robot-assisted neurorehabilitation strategies for people with both HIV and stroke

There is increasing evidence that HIV is an independent risk factor for stroke, resulting in an emerging population of people living with both HIV and stroke all over the world. However, neurorehabilitation strategies for the HIV-stroke population are distinctly lacking, which poses an enormous global health challenge. In order to address this gap, a better understanding of the HIV-stroke population is needed, as well as potential approaches to design effective neurorehabilitation strategies for this population. This review goes into the mechanisms, manifestations, and treatment options of neurologic injury in stroke and HIV, the additional challenges posed by the HIV-stroke population, and rehabilitation engineering approaches for both high and low resource areas. The aim of this review is to connect the underlying neurologic properties in both HIV and stroke to rehabilitation engineering. It reviews what is currently known about the association between HIV and stroke and gaps in current treatment strategies for the HIV-stroke population. We highlight relevant current areas of research that can help advance neurorehabilitation strategies specifically for the HIV-stroke population. We then explore how robot-assisted rehabilitation combined with community-based rehabilitation could be used as a potential approach to meet the challenges posed by the HIV-stroke population. We include some of our own work exploring a community-based robotic rehabilitation exercise system. The most relevant strategies will be ones that not only take into account the individual status of the patient but also the cultural and economic considerations of their respective environment.

Strategies to Increase HIV Testing Among MSM: A Synthesis of the Literature

More than 30 years into the HIV epidemic, men who have sex with men (MSM) continue to be disproportionately impacted. It is estimated that worldwide nearly half of MSM infected with HIV are unaware of their status, making HIV testing along with early linkage to care crucial to HIV prevention efforts. However, there remain significant barriers to HIV testing among MSM, due largely to complex issues of layered stigma that deter MSM from accessing traditional, clinic-based testing. We conducted a review and synthesis of the literature on strategies to increase uptake of HIV testing among MSM. We found that social network-based strategies, community-based testing, HIV self-testing, and modifications to the traditional clinic-based model can effectively reach a subset of MSM, but success was often context-specific and there are significant gaps in evidence. We provide recommendations for increasing HIV testing rates and status awareness among MSM.

Supervised Physical Activity and Improved Functional Capacity among Adults Living with HIV: A Systematic Review

Physical activity (PA) combats the effects of multimorbidity and antiretroviral therapy in people living with HIV (PLWH), but PLWH often don't meet recommended PA guidelines. The purpose of our review was to investigate whether supervised PA improved functional capacity in PLWH. Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. Five databases were searched for randomized controlled trials in English, with participants ages 18 years and older, and a supervised PA intervention. A database search yielded 8,267 articles, with 15 eligible for review inclusion. We found a low risk of bias within and across studies. Combined aerobic/progressive resistance training (PRT) improved strength, cardiovascular, and flexibility outcomes; aerobic interventions alone showed no significant improvements; PRT improved strength outcomes; yoga or yoga/meditation showed no outcome differences; and t'ai chi showed cardiovascular and flexibility improvements. We found that supervised PA increased functional capacity in PLWH and that self-report was not a reliable assessment.

Visualisation of future task performance improves naturalistic prospective memory for some younger adults living with HIV disease

Human immunodeficiency virus (HIV) disease is commonly associated with deficits in prospective memory (PM), which increase the risk of suboptimal health behaviours, like medication non-adherence. This study examined the potential benefits of a brief future visualisation exercise during the encoding stage of a naturalistic PM task in 60 young adults (aged 19-24 years) with HIV disease. Participants were administered a brief clinical neuropsychological assessment, which included a standardised performance-based measure of time- and event-based PM. All participants were also given a naturalistic PM task in which they were asked to complete a mock medication management task when the examiner showed them the Grooved Pegboard Test during their neuropsychological evaluation. Participants were randomised into: (1) a visualisation condition in which they spent 30 sec imagining successfully completing the naturalistic PM task; or (2) a control condition in which they repeated the task instructions. Logistic regression analyses revealed significant interactions between clinical neurocognitive functions and visualisation. HIV positive (HIV+) participants with intact retrospective learning and/or low time-based PM demonstrated observable gains from the visualisation technique, while HIV+ participants with impaired learning and/or intact time-based PM did not evidence gains. Findings indicate that individual differences in neurocognitive ability moderate the response to visualisation in HIV+ young adults. The extent to which such cognitive supports improve health-related PM outcomes (e.g., medication adherence) remains to be determined.

Evaluating the Effectiveness of Physical Exercise Interventions in Persons Living With HIV: Overview of Systematic Reviews

Physical exercise (PE) has not been well studied in persons living with HIV (PLHIV). We conducted an overview of systematic reviews to assess the effectiveness of PE and to determine the most appropriate PE regimen for PLHIV. We used the CDC's Prevention Research Synthesis Project's database and manual searches to identify systematic reviews published between 1996 and 2013. We qualitatively synthesized the findings from five reviews to assess the effectiveness of PE and conducted meta-analyses on CD4 counts to identify the best PE regimen. PE is associated with reduced adiposity and depression, but was not associated with a decrease in HIV viral load. CD4 counts were improved by interventions with interval aerobic or 41-50 minutes of exercise three times per week compared with other modes and duration of exercise. PE appears to benefit PLHIV, but more research is needed to help develop appropriate PE strategies specifically for PLHIV.

Experiences participating in a community-based exercise programme from the perspective of people living with HIV: a qualitative study

OBJECTIVES

Our aim was to explore the experiences of engaging in a community-based exercise programme (CBEP) from the perspective of people living with HIV (PLWH).

DESIGN

We conducted a descriptive qualitative study using semistructured interviews.

SETTING

We recruited adults living with HIV who participated in a 16-week CBEP in Toronto, Canada.

PARTICIPANTS

11 participants, the majority men (64%), with a median age of 52 years, and living with a median of 5 concurrent health conditions in addition to HIV participated in the study.

OUTCOME MEASURES

We asked participants about their overall experiences: strengths, limitations and perceived benefits of the CBEP; factors influencing participation and current level of exercise after completion of the CBEP. We administered a self-reported demographic questionnaire followed by the Rapid Assessment of Physical Activity (RAPA) questionnaire. We analysed interview data using thematic analysis.

RESULTS

We developed a framework that describes the experiences before, during and after the CBEP; and the perceived impact of the CBEP on health, which influenced the intent to, engagement in and sustainability of exercise among PLWH. Participants described the positive impact of the CBEP on their physical, mental and social health. Interviews were completed at a median of 6 months after the CBEP, when 9 participants reported ongoing engagement in exercise, but to a lesser extent than during the CBEP. Intrinsic and extrinsic factors facilitated or hindered engagement in exercise throughout all phases of the CBEP. The episodic nature of HIV and multimorbidity influenced engagement in exercise and posed challenges to re-engagement after periods of inactivity.

CONCLUSIONS

CBEPs provide an opportunity to enhance physical activity, perceived health outcomes and knowledge about exercise for PLWH. Community-based exercise is a strategy that may be used by health providers to promote engagement in sustained physical activity for PLWH.

Needs among persons with human immunodeficiency virus and intellectual and developmental disabilities in community mental health care: a cross-sectional study

BACKGROUND

The experience of having human immunodeficiency virus (HIV) is often associated with co-occurring mental health issues. Community mental health services are an important source of support for persons with HIV living in the community. Persons with intellectual disability (ID) are vulnerable to HIV and may have unique support needs beyond those without ID receiving community care. This study compared support needs of men with HIV in community mental health programmes, with and without ID.

METHODS

The sample was composed of 138 HIV-positive men with and without ID receiving mental health case management from one community organisation in Ontario, Canada, on 31 March 2013. Staff-rated needs across 16 domains grouped into four clusters were measured using the Camberwell Assessment of Need: Basic needs (accommodation, food, public transportation, money and benefits); self-care/functional needs (looking after the home, self-care and daytime activities); health/safety needs (physical health, psychological distress, psychotic symptoms, safety to self and safety to others); and social needs (company, intimate relationships and sexual expression). Adjusted logistic regression models examined the association between ID and each need domain.

RESULTS

One-quarter of the sample (n = 34/138, 24.6%) had co-occurring ID. Those with ID were more likely to have needs in the basic cluster [odds ratios: food 4.05 (1.14, 14.44), P:0.031; benefits 2.58 (1.05, 6.32), P:0.038)] and self-care/functional cluster [looking after the home (2.75 (1.17, 6.49), P:0.021); self-care (2.72 (1.18, 6.27), P:0.019)], but were less likely to have need for sexual expression: 0.35 (0.14,0.90), P:0.030) (social cluster). There were no differences in the domains in the health/safety cluster.

CONCLUSION

Despite elevated cognitive needs in the basic and self-care/functional clusters for the ID group, limited other differences suggest that with moderate additional targeting, community mental health programmes for persons with HIV may be appropriate for men with ID.

Attitudes Toward Addiction, Methadone Treatment, and Recovery Among HIV-Infected Ukrainian Prisoners Who Inject Drugs: Incarceration Effects and Exploration of Mediators

In this study, we use data from a survey conducted in Ukraine among 196 HIV-infected people who inject drugs, to explore attitudes toward drug addiction and methadone maintenance therapy (MMT), and intentions to change drug use during incarceration and after release from prison. Two groups were recruited: Group 1 (n = 99) was currently incarcerated and Group 2 (n = 97) had been recently released from prison. This paper's key finding is that MMT treatment and addiction recovery were predominantly viewed as mutually exclusive processes. Group comparisons showed that participants in Group 1 (pre-release) exhibited higher optimism about changing their drug use, were less likely to endorse methadone, and reported higher intention to recover from their addiction. Group 2 participants (post-release), however, reported higher rates of HIV stigma. Structural equation modeling revealed that in both groups, optimism about recovery and awareness of addiction mediated the effect of drug addiction severity on intentions to recover from their addiction.

CNS Impact of Perinatal HIV Infection and Early Treatment: the Need for Behavioral Rehabilitative Interventions Along with Medical Treatment and Care

There is growing concern that although the more severe forms of HIV-associated neurologic deficits are reduced following highly active anti-retroviral therapy (HAART), mild to moderate cognitive disorders may persist for years after HAART initiation and this may occur despite complete plasma viral suppression. According to the UNAIDS 2014 report, there were 3.2 million children living with HIV around the world at the end of 2013 and 91 % of these resided in sub-Saharan Africa. In the same year, only 24 % of children who needed antiretroviral treatment (ART) received it and 190,000 children died of AIDS-related illnesses. We propose that behavioral interventions are needed in combination with medical treatment and care in order to fully address the needs of children and adolescents in Africa living with HIV. In early childhood, caregiver training programs to enhance the developmental milieu of the child with HIV can enhance their cognitive and social development and that such interventions are both feasible and well-accepted by the local population. For school-age children, computerized cognitive rehabilitation training can be an entertaining and engaging way to improve attention, working memory, and problem solving skills for children with HIV. Further dissemination and implementation science work is needed for arriving at cost-effective strategies for scaling up such behavioral interventions in African resource-constrained settings, given that the vast majority of HIV-affected children and youth worldwide presently live in sub-Saharan Africa.

A Home-Based Rehabilitation Intervention for Adults Living With HIV: A Randomized Controlled Trial

A randomized controlled trial was conducted to investigate the effects of a 16-week home-based rehabilitation (HBR) intervention on the quality of life, functional mobility, and functional capacity of adult people living with HIV (PLWH) on antiretroviral therapy in KwaZulu-Natal, South Africa. The intervention was carried out by community health care workers under the supervision of a qualified physical therapist. Participants in the control group received the standard of care as well as written health advice. While participants in the intervention group showed greater improvements across all outcome measures, between-group differences were nonsignificant. HBR for PLWH is a safe means of addressing the functional deficits experienced by PLWH and appears likely to improve quality of life. A task-shifting approach may be a feasible method of meeting the varied needs of PLWH, while at the same time potentially minimizing costs to already overburdened health care systems.

A Randomized Controlled Trial to Evaluate if Computerized Cognitive Rehabilitation Improves Neurocognition in Ugandan Children with HIV

OBJECTIVES

Clinically stable children with HIV can have neuromotor, attention, memory, visual-spatial, and executive function impairments. We evaluated neuropsychological and behavioral benefits of computerized cognitive rehabilitation training (CCRT) in Ugandan HIV children.

DESIGN

One hundred fifty-nine rural Ugandan children with WHO Stage I or II HIV disease (6 to 12 years; 77 boys, 82 girls; M = 8.9, SD = 1.86 years) were randomized to one of three treatment arms over a 2-month period.

METHODS

The CCRT arm received 24 one-hour sessions over 2 months, using Captain's Log (BrainTrain Corporation) programmed for games targeting working memory, attention, and visual-spatial analysis. These games progressed in difficulty as the child's performance improved. The second arm was a "limited CCRT" with the same games rotated randomly from simple to moderate levels of training. The third arm was a passive control group receiving no training. All children were assessed at enrollment, 2 months (immediately following CCRT), and 3 months after CCRT completion.

RESULTS

The CCRT group had significantly greater gains through 3 months of follow-up compared to passive controls on overall Kaufman Assessment Battery for Children-second edition (KABC-II) mental processing index (p < .01), planning (p = .04), and knowledge (p = .03). The limited CCRT group performed better than controls on learning (p = .05). Both CCRT arms had significant improvements on CogState Groton maze learning (p < .01); although not on CogState attention/memory, TOVA/impulsivity, or behavior rating inventory for executive function and child behavior checklist (psychiatric behavior/symptom problems) ratings by caregiver.

CONCLUSIONS

CCRT intervention can be effective for neurocognitive rehabilitation in children with HIV in low-resource settings, especially in children who are clinically stable on ARV treatment.

[Development of valorization of physical activity: the role of HIV associations]

<ce:para>With the arrival of triple combination therapy in 1996-1997, HIV infection, considered up until then to be a life-threatening condition, changed statuses within the realm of public health actions Progressively likened to a “chronic illness”, the discourse on HIV prevention targeting people living with HIV (PLHIV) began to evolve. A review of the scientific literature and the journals of four national HIV associations published between 1990 and 2010 shows that physical activities, previously discouraged because considered to be dangerous, have become increasingly presented as a means of improving quality of life and are increasingly recommended for PLHIV. This article studies this reconfiguration of the discourse on HIV prevention, as well as its effects on the discourse conveyed by HIV associations. The article shows how the new classification of HIV as a “chronic illness”, on the basis of scientific expertise, has led to a modified discourse on prevention, including the recommendation of regular and controlled physical activity. This new orientation has contributed to the restructuring of HIV associations which relay this discourse and modify their organization and services, increasingly offering access to physical activities. However, this raises the question of the effects of this new representation of physical activities, as there has been little conside-ration of the difficulties encountered by PLHIV to respond to these repeated encouragements to modify their lifestyles in order to be “good” chronically ill patients.<np pagenum="092"/> </ce:para>.

Expert Consensus on the Rehabilitation Framework Guiding a Model of Care for People Living With HIV in a South African Setting

Disabilities and treatments related to HIV are a focus for rehabilitation professionals in HIV-endemic countries, yet these countries lack guidance to integrate rehabilitation into a model of care for people living with HIV. We asked HIV and rehabilitation experts in South Africa to engage in a modified Delphi survey based on findings from (a) an enquiry into stakeholder perspectives of a context-specific rehabilitation framework at a semi-rural setting and (b) an analysis of international models of care-guiding rehabilitation. Consensus was determined by an a priori threshold of 70% of agreement and interquartile range (≤ 1 on criterion) to be included as essential or useful in the model of care framework. Experts agreed that improving access to care, optimal communication between stakeholders, education and training for health care workers, and home-based rehabilitation were essential for the model. Furthermore, task shifting and evidence-based practice were seen as fundamental for optimal care.

Emotional social support and access to care among older people living with HIV in rural China

OBJECTIVES

Globally, the number of older people living with HIV (PLH) is growing. Additionally, older PLH are facing particular challenges related to accessing health care. The objective of this study is to investigate the older PLH's access to care and its relationship to emotional and tangible social support.

METHODS

A cross-sectional study was conducted among 225 PLH who were 50 years of age or older in Anhui, China. A computer-assisted personal interview was used to collect the participants' demographic characteristics, perceived health status, and access to care. The following two dimensions of social support were measured: emotional support and tangible support. The association between emotional/tangible support and access to care was calculated using Pearson's/point-biserial correlations and with multiple linear regression.

RESULTS

Higher tangible support was reported by the participants who were married or living with a partner, those who had higher annual income levels, and those with better perceived health status. Emotional support was correlated with higher education, higher income, and better perceived health status. Multiple regression analyses showed that access to care was significantly associated with emotional support (β = 0.2807, p < 0.0001) but not with tangible support (β = -0.0183, p = 0.7922).

CONCLUSIONS

The study findings point to the importance of providing emotional support for older PLH. It is suggested that emotional support should be provided for older PLH in addition to tangible assistance, in order to engage them in treatment and care.

Interventions for improving employment outcomes for workers with HIV

BACKGROUND

The vast majority of people infected with human immunodeficiency virus (HIV) are adults of working age. Therefore unemployment and job loss resulting from HIV infection are major public health and economic concerns. Return to work (RTW) after diagnosis of HIV is a long and complex process, particularly if the individual has been absent from work for long periods. There have been various efforts to improve the RTW of persons living with HIV (HIV+), and many of these have been assessed formally in intervention studies.

OBJECTIVES

To evaluate the effect of interventions aimed at sustaining and improving employment in HIV+ persons.

SEARCH METHODS

We conducted a comprehensive search from 1981 until December 2014 in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, OSH UPDATE databases (CISDOC, HSELINE, NIOSHTIC, NIOSHTIC-2, RILOSH), and PsycINFO.

SELECTION CRITERIA

We considered for inclusion all randomized controlled trials (RCTs) or controlled before-after (CBA) studies assessing the effectiveness of pharmacological, vocational and psychological interventions with HIV+ working-aged (16 years or older) participants that had used RTW or other indices of employment as outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all potential references for inclusion. We determined final selection of studies by consensus. We performed data extraction and management, as well as Risk of bias assessment, in duplicate. We measured the treatment effect using odds ratio (OR) for binary outcomes and mean difference (MD) for continuous outcomes. We applied the GRADE approach to appraise the quality of the evidence.

MAIN RESULTS

We found one RCT with 174 participants and five CBAs with 48,058 participants assessing the effectiveness of vocational training (n = 1) and antiretroviral therapy (ART) (n = 5). We found no studies assessing psychological interventions. The one RCT was conducted in the United States; the five CBA studies were conducted in South Africa, India, Kenya, and Uganda. We graded all six studies as having a high risk of bias.The effectiveness of vocational intervention was assessed in only one study but we could not infer the intervention effect due to a lack of data.For pharmacological interventions, we found very low-quality evidence for a beneficial effect of ART on employment outcomes in five studies. Due to differences in outcome measurement we could only combine the results of two studies in a meta-analysis.Two studies compared employment outcomes of HIV+ persons on ART therapy to healthy controls. One study found a MD of -1.22 days worked per month (95% confidence interval (CI) -1.74 to -1.07) at 24-months follow-up. The other study found that the likelihood of being employed steadily increased for HIV+ persons compared to healthy individuals from ART initiation (OR 0.35, 95% CI 0.26 to 0.47) to three- to five-years follow-up (OR 0.73, 95% CI 0.42 to 1.28).Three other studies compared HIV+ persons on ART to HIV+ persons not yet on ART. Two studies indicated an increase in the likelihood of employment over time due to the impact of ART for HIV+ persons compared to HIV+ persons pre-ART (OR 1.75, 95% CI 1.44 to 2.12). One study found that the group on ART worked 12.1 hours more (95% CI 6.99 to 17.21) per week at 24-months follow-up than the average of the cohort of ART and pre-ART HIV+ persons which was 20.1 hours.We rated the evidence as very low quality for all comparisons due to a high risk of bias.

AUTHORS' CONCLUSIONS

We found very low-quality evidence showing that ART interventions may improve employment outcomes for HIV+ persons. For vocational interventions, the one included study produced no evidence of an intervention effect. We found no studies that assessed psychological interventions. We need more high-quality, preferably randomized studies to assess the effectiveness of RTW interventions for HIV+ persons.

Collaborative priority setting for human immunodeficiency virus rehabilitation research: A case report

BACKGROUND

The inclusion of community members and other stakeholders in the establishment of research priorities is vital to ensuring that priorities are congruent with the main concerns of affected communities.

PURPOSE

The purpose of this project was to identify priority research topics for addressing the activity and community participation needs of people living with human immunodeficiency virus (HIV) and meaningfully involve multiple stakeholders in the development of those priorities.

METHOD

We invited people living with HIV, researchers, service providers, and policy makers to a 2-day forum. Twenty-six people participated in developing priorities through the application of two methodologies, the World Café and Dotmocracy. We evaluated the forum though immediate dialogue and a postproject survey.

FINDINGS

Participants identified 10 high-priority research topics. Evaluation findings highlighted positive substantive, instrumental, personal, and normative outcomes of stakeholder involvement.

IMPLICATIONS

The identified priority topics can guide future occupational therapy practice and research in this emerging area.

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.

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.

HIV among injection drug users and their intimate partners in Almaty, Kazakhstan

This paper examines prevalence rates of HIV, HCV, and syphilis among a sample of injecting drug users (IDUs) and their heterosexual intimate partners (N = 728) from Almaty, Kazakhstan. The study uses baseline data from Project Renaissance, a couple-based HIV prevention intervention delivered to a couple where one or both partners are IDUs. HIV prevalence rates among female and male IDUs were 28 %. Among the full sample, 75 % had HCV, and 13 % tested positive for the syphilis antibody test. Only 10 % of the sample ever visited a needle exchange program. One-fourth (25.3 %) had never been tested for HIV. One-quarter of those who tested positive were unaware of their status. Being HIV positive was associated with a history of incarceration, being an IDU, and having access to needle exchange programs. The findings call for increasing efforts to improve access to HIV testing, prevention, treatment, and care for IDUs in Almaty, Kazakhstan.

Helping people with HIV/AIDS return to work: a randomized clinical trial

OBJECTIVE

New treatments introduced in the mid-1990s led many people with HIV/AIDS who previously had been disabled by their disease to contemplate workforce reentry; many remain unemployed, and little is known concerning interventions that might help them return to work. We report the results of a randomized clinical trial of an intervention designed to help people with HIV/AIDS reenter the workforce.

DESIGN

We tested a mixed (group-individual) modality intervention that incorporated elements of Motivational Interviewing (Miller & Rollnick, 2002), skills building from Dialectical Behavior Therapy (Linehan, 1993), and job-related skills (Price & Vinokur, 1995). A total of 174 individuals participated in either the intervention or in standard of care and were followed for 24 months.

RESULTS

Compared with individuals referred for standard of care, participants in the intervention engaged in more workforce-reentry activities over time and, once employed, were more likely to remain employed. Dose-response analyses revealed that among intervention participants, participants who attended more than 1 individual session engaged in more workforce-reentry activities than individuals who attended 1 or fewer individual sessions, whereas frequency of group session participation did not effect a difference between participants who attended more than 6 group sessions and participants who attended 6 or fewer group sessions.

CONCLUSION

Theoretically based workforce-reentry assistance programs can assist disabled people with HIV/AIDS in their return-to-work efforts.

Nutritional rehabilitation of HIV-exposed infants in Malawi: results from the drug resources enhancement against AIDS and malnutrition program

Infant malnutrition in sub-Saharan Africa is a public health priority and a challenge in high HIV prevalence areas. The Drug Resources Enhancement Against AIDS and Malnutrition program, with multiple medical centers in Sub-Saharan Africa, developed an innovative intervention for the surveillance and control of malnutrition. In a pilot initiative, 36 HIV-exposed children were evaluated at baseline upon presentation for malnutrition and at six months post- treatment. Parameters included HIV-free survival, nutritional status and change in diet. Food diary data was entered and processed using the Nutrisurvey (WHO) software. At 6 months post-intervention, a significant improvement in anthropometric parameters was noted. Slowing of linear growth was observed in patients with malaria with a mean gain in centimetres of 4.4 ± 1.7 as compared to 5.6 ± 1.7 in children with no malaria, p < 0.048 (CL 95%: −2.32, −0.01). Dietary diversity scores increased from 5.3 ± 1.9 to 6.5 ± 1.3, p < 0.01 at 6 months. A significant increase (+25%, p < 0.02) in the number of children eating fish meals was noted. Our pilot data describes positive outcomes from a rehabilitative nutritional approach based on use of local foods, peer education, anthropometric and clinical monitoring in areas of high food insecurity. The relationship between malaria and linear growth retardation requires further investigation.

Semantic cueing improves category verbal fluency in persons living with HIV infection

HIV-associated neurocognitive disorders (HAND) remain highly prevalent in the era of combination antiretroviral therapies, but there are no validated psychological interventions aimed at improving cognitive outcomes. This study sought to determine the potential benefit of semantic cueing on category fluency deficits, which are prevalent in HIV and affect daily functioning. A group of 86 HIV-infected individuals and 87 demographically-matched seronegative participants were administered a standard (i.e., uncued) and a cued category fluency task. Results revealed significant improvements in cued versus uncued performance in HIV, particularly for persons with lower levels of education. The cueing benefit observed may inform rehabilitation efforts aimed at ameliorating HAND.

Enhancing labour force participation for people living with HIV: a multi-perspective summary of the research evidence

Labour force participation has been identified as a critical social and health issue facing people living with HIV/AIDS (PHAs). We conducted a scoping study (a form of literature synthesis that summarizes research findings, research activity, and identifies literature strengths and gaps) on labour force participation for PHAs, guided by a community advisory committee. We summarized information from 243 peer-reviewed articles and 42 reports from the grey literature, and synthesized the evidence into a preliminary conceptual framework with five components: (1) the meaning of work, (2) key factors (barriers and facilitators) influencing labour force participation, (3) factors affecting vulnerable populations, (4) strategies and supports for returning to or sustaining work, and (5) outcomes (benefits and risks) of labour force participation for individuals and employers. The framework supports the development of labour force initiatives requiring collaborative efforts in multiple domains (health, employment, community) by PHAs, rehabilitation professionals, employers, insurers, and policy makers.

Developing clinical practice guidelines in HIV rehabilitation: process recommendations and guiding principles

Our purpose was to develop process recommendations and guiding principles for future clinical practice guidelines in HIV rehabilitation. We conducted a scoping study that included focus group and interview consultations with 28 participants including people living with HIV, researchers, clinicians, educators, and policy stakeholders with expertise in HIV and rehabilitation. We used qualitative content analysis techniques to identify emergent themes related to the development of clinical practice guidelines. Results included seven recommendations for the process of developing clinical practice guidelines in HIV rehabilitation that spanned areas of flexibility, scope, adopting existing evidence from concurrent health conditions, format, interprofessional approach to development and implementation, terminology, and knowledge translation. Three guiding principles emerged to inform the philosophical approach for guideline development. These findings serve as a foundation for the development of clinical practice guidelines in HIV rehabilitation to enhance the care and treatment of people living with HIV.

Inequalities in determinants of health among Aboriginal and Caucasian persons living with HIV/AIDS in Ontario: results from the Positive Spaces, Healthy Places Study

OBJECTIVES

Aboriginal Canadians (i.e., First Nations, Inuit and Métis) are disproportionately affected by HIV/AIDS, and experience greater social and economic marginalization and poorer housing conditions. This study sought to understand the differences in the determinants of health and housing-related characteristics between samples of Aboriginal and Caucasian adults living with HIV/AIDS in Ontario.

METHODS

We analyzed baseline demographic, socio-economic, health, and housing-related data from 521 individuals (79 Aboriginal and 442 Caucasian) living with HIV/AIDS and enrolled in the Positive Spaces, Healthy Places study. We compared the characteristics of Aboriginal and Caucasian participants to identify determinants of health and housing-related characteristics independently associated with Aboriginal ethnicity.

RESULTS

Compared to Caucausian participants living with HIV, Aboriginal participants were more likely to be younger, female or transgender women, less educated, unemployed, and homeless or unstably housed. They were also more likely to have low incomes and to have experienced housing-related discrimination. In a multivariate model, gender, income, and experiences of homelessness were independently associated with Aboriginal ethnicity.

CONCLUSION

Aboriginal individuals living with HIV/AIDS in our sample are coping with significantly worse social and economic conditions and are more likely to experience challenging housing situations than a comparison group of Caucasian individuals living with HIV/AIDS. To develop effective care, treatment and support strategies for Aboriginal peoples with HIV, it is critical to address and improve their socio-economic and housing conditions.

Inequalities in determinants of health among Aboriginal and Caucasian persons living with HIV/AIDS in Ontario: results from the Positive Spaces, Healthy Places Study

OBJECTIVES

Aboriginal Canadians (i.e., First Nations, Inuit and Métis) are disproportionately affected by HIV/AIDS, and experience greater social and economic marginalization and poorer housing conditions. This study sought to understand the differences in the determinants of health and housing-related characteristics between samples of Aboriginal and Caucasian adults living with HIV/AIDS in Ontario.

METHODS

We analyzed baseline demographic, socio-economic, health, and housing-related data from 521 individuals (79 Aboriginal and 442 Caucasian) living with HIV/AIDS and enrolled in the Positive Spaces, Healthy Places study. We compared the characteristics of Aboriginal and Caucasian participants to identify determinants of health and housing-related characteristics independently associated with Aboriginal ethnicity.

RESULTS

Compared to Caucausian participants living with HIV, Aboriginal participants were more likely to be younger, female or transgender women, less educated, unemployed, and homeless or unstably housed. They were also more likely to have low incomes and to have experienced housing-related discrimination. In a multivariate model, gender, income, and experiences of homelessness were independently associated with Aboriginal ethnicity.

CONCLUSION

Aboriginal individuals living with HIV/AIDS in our sample are coping with significantly worse social and economic conditions and are more likely to experience challenging housing situations than a comparison group of Caucasian individuals living with HIV/AIDS. To develop effective care, treatment and support strategies for Aboriginal peoples with HIV, it is critical to address and improve their socio-economic and housing conditions.

Prospective memory deficits are associated with unemployment in persons living with HIV infection

OBJECTIVE

To determine whether deficits in prospective memory (i.e., "remembering to remember") confer an increased risk of unemployment in individuals living with chronic HIV infection.

METHODS

Fifty-nine Unemployed and 49 Employed individuals with HIV infection underwent comprehensive neuropsychological and medical evaluations, including measures of prospective memory.

RESULTS

The Unemployed participants demonstrated significantly lower performance on time- and event-based prospective memory, which was primarily characterized by errors of omission. Importantly, prospective memory impairment was an independent predictor of unemployment when considered alongside other neurocognitive abilities, mood disturbance, and HIV disease severity.

CONCLUSIONS

Prospective memory impairment is a salient predictor of unemployment in persons living with HIV infection and might be considered in screening for unemployment risk and developing vocational rehabilitation plans.

Psychosocial needs of HIV-positive individuals seeking workforce re-entry

With the advent of more effective treatments and corresponding improvement in morbidity and mortality, people living with HIV and AIDS are increasingly considering a return to the workplace. This study examined subjective and objective indicators of need among a sample of 235 HIV-infected individuals entering a vocational rehabilitation programme for people with HIV. In addition to help with training and job placement, participants indicated a need for assistance with finances, money management, housing access and access to health care, as well as with alcohol or drug problems, legal problems and social relationships. Subsequent to learning of their diagnoses, the sample reported a median decrement in financial resources of 60%. Over half had experienced housing instability in the year prior to entering the study, including 15% who had been homeless, even though most were linked to case management services. A third had used illegal drugs in the prior month, 41% drank to intoxication and 20% lacked even monthly phone contact with friends. Results suggest that back to work programmes for people with HIV and AIDS will need to address a broad range of psychosocial issues beyond job training and placement.

Aerobic exercise interventions for adults living with HIV/AIDS

BACKGROUND

Access to combination antiretroviral therapy has turned HIV into a chronic and manageable disease for many. This increased chronicity has been mirrored by increased prevalence of health-related challenges experienced by people living with HIV (Rusch 2004). Exercise is a key strategy for people living with HIV and by rehabilitation professionals to address these disablements; however, knowledge about the effects of exercise among adults living with HIV still is emerging.

OBJECTIVES

To examine the safety and effectiveness of aerobic exercise interventions on immunologic and virologic, cardiopulmonary, psychologic outcomes and strength, weight, and body composition in adults living with HIV.

SEARCH STRATEGY

Searches of MEDLINE, EMBASE, SCIENCE CITATION INDEX, CINAHL, HEALTHSTAR, PsycINFO, SPORTDISCUS and Cochrane Review Group Databases were conducted between 1980 and June 2009. Searches of published and unpublished abstracts and proceedings from major international and national HIV/AIDS conferences were conducted, as well as a handsearch of reference lists and tables of contents of relevant journals and books.

SELECTION CRITERIA

We included studies of randomised controlled trials (RCTs) comparing aerobic exercise interventions with no aerobic exercise interventions or another exercise or treatment modality, performed at least three times per week for at least four weeks among adults (18 years of age or older) living with HIV.

DATA COLLECTION AND ANALYSIS

Data on study design, participants, interventions, outcomes, and methodological quality were abstracted from included studies by two reviewers. Meta-analyses, using RevMan 5 computer software, were performed on outcomes when possible.

MAIN RESULTS

A total of 14 studies met inclusion criteria for this review and 30 meta-analyses over several updates were performed. Main results indicated that performing constant or interval aerobic exercise, or a combination of constant aerobic exercise and progressive resistive exercise for at least 20 minutes at least three times per week for at least five weeks appears to be safe and may lead to significant improvements in selected outcomes of cardiopulmonary fitness (maximum oxygen consumption), body composition (leg muscle area, percent body fat), and psychological status (depression-dejection symptoms). These findings are limited to participants who continued to exercise and for whom there were adequate follow-up data.

AUTHORS' CONCLUSIONS

Aerobic exercise appears to be safe and may be beneficial for adults living with HIV. These findings are limited by the small sample sizes and large withdrawal rates described in the studies. Future research would benefit from participant follow-up and intention-to-treat analysis. Further research is required to determine the optimal parameters in which aerobic exercise may be most beneficial for adults living with HIV.

AIDS and declining support for dependent elderly people in Africa: retrospective analysis using demographic and health surveys

OBJECTIVES

To determine the relation between the HIV/AIDS epidemic and support for dependent elderly people in Africa.

DESIGN

Retrospective analysis using data from Demographic and Health Surveys.

SETTING

22 African countries between 1991 and 2006.

PARTICIPANTS

123,176 individuals over the age of 60.

MAIN OUTCOME MEASURES

We investigated how three measures of the living arrangements of older people have been affected by the HIV/AIDS epidemic: the number of older individuals living alone (that is, the number of unattended elderly people); the number of older individuals living with only dependent children under the age of 10 (that is, in missing generation households); and the number of adults age 18-59 (that is, prime age adults) per household where an older person lives.

RESULTS

An increase in annual AIDS mortality of one death per 1000 people was associated with a 1.5% increase in the proportion of older individuals living alone (95% CI 1.2% to 1.9%) and a 0.4% increase in the number of older individuals living in missing generation households (95% CI 0.3% to 0.6%). Increases in AIDS mortality were also associated with fewer prime age adults in households with at least one older person and at least one prime age adult (P<0.001). These findings suggest that in our study countries, which encompass 70% of the sub-Saharan population, the HIV/AIDS epidemic could be responsible for 582,200-917,000 older individuals living alone without prime age adults and 141,000-323,100 older individuals being the sole caregivers for young children.

CONCLUSIONS

Africa's HIV/AIDS epidemic might be responsible for a large number of older people losing their support and having to care for young children. This population has previously been under-recognised. Efforts to reduce HIV/AIDS deaths could have large "spillover" benefits for elderly people in Africa.

Massage therapy for people with HIV/AIDS

BACKGROUND

Infection with human immunodeficency virus (HIV) and acquired immunodeficency syndrome (AIDS) is a pandemic that has affected millions of people globally. Although major research and clinical initiatives are addressing prevention and cure strategies, issues of quality of life for survivors have received less attention. Massage therapy is proposed to have a positive effect on quality of life and may also have a positive effect on immune function through stress mediation.

OBJECTIVES

The objective of this systematic review was to examine the safety and effectiveness of massage therapy on quality of life, pain and immune system parameters in people living with HIV/AIDS.

SEARCH STRATEGY

A comprehensive search strategy was devised incorporating appropriate terms for HIV/AIDS, randomised controlled trials (RCTs), massage therapy and the pertinent measures of benefit. All electronic databases identified were searched in November 2008, including Cochrane Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, SCIENCE CITATION INDEX, AIDSLINE, AIDSearch, CINAHL, HEALTHSTAR, PsycLIT, AMED, Current Contents, AMI, NLM GATEWAY, LILACS, IndMed, SOCIOFILE, SCI, SSCI, ERIC and DAI. We also reviewed relevant published and unpublished conference abstracts and proceedings and scrutinised reference lists from pertinent journals. There were no language or date restrictions.

SELECTION CRITERIA

Studies were identified by two reviewers based on trial design (RCTs) and participants (ie, people of any age with HIV/AIDS, at any stage of the disease) who had undergone an intervention that included massage therapy for the identified aims of improving quality of life and activity and participation levels, improving immune function, reducing pain and improving other physiological or psychological impairments.

DATA COLLECTION AND ANALYSIS

Two reviewers independently identified included studies and extracted relevant data. Two other reviewers independently reviewed the included studies for risk of bias. All data and risk of bias judgements were entered into Revman (v5) and meta-analyses were conducted where appropriate.

MAIN RESULTS

Twelve papers were identified, from which four were included. The remaining eight papers were excluded predominantly due to inappropriate methodology. The four included studies were highly clinically heterogenous, investigating a range of age groups (ie, children, adolescents and adults) across the disease spectrum from early HIV through late-stage AIDS. The settings were either community or palliative care, and the outcome measures were a combination of quality of life and immunological function. The trials were judged to be at moderate risk of bias mostly because of incomplete reporting. For quality of life measures, the studies reported that massage therapy in combination with other modalities, such as meditation and stress reduction, are superior to massage therapy alone or to the other modalities alone. The quality of life domains with significant effect sizes included self-reported reduced use of health care resources, improvement in self-perceived spiritual quality of life and improvement in total quality of life scores. One study also reported positive changes in immune function, in particular CD4+ cell count and natural killer cell counts, due to massage therapy, and one study reported no difference between people given massage therapy and controls in immune parameters. Adverse or harmful effects were not well reported.

AUTHORS' CONCLUSIONS

There is some evidence to support the use of massage therapy to improve quality of life for people living with HIV/AIDS (PLWHA), particularly in combination with other stress-management modalities, and that massage therapy may have a positive effect on immunological function. The trials are small, however, and at moderate risk of bias. Further studies are needed using larger sample sizes and rigorous design/reporting before massage therapy can be strongly recommended for PLWHA.

[The usefulness of a genogram as a tool in therapeutic patient education: an exploratory study of parents of children living with HIV/AIDS in Benin]

Understanding family dynamics and relationship is an important facet of care, therapeutic education and psychosocial support. As part of a therapeutic education program organized within a pediatric service in Cotonou, Benin, we have experimented with the genogram at the time of diagnosis and tested it as an educational tool. This study evaluates the usefulness of the genogram for therapeutic patient education, and its capacity to serve as an aid to better understand family structure and dynamics. The study was conducted in 2007 with 29 parents of children living with HIV / AIDS. Six professionals observed the conditions for the development and application of the genograms their effects on the production of information of an educational nature. The results indicate that it can provide families and caregivers benchmarks essential for understanding the role of the family and community in which the child-patient is situated and how they function. It facilitates the identification of key resource persons for the child and selfcare to be mobilized and fostered within the family.

Rehabilitation in the context of HIV: an interprofessional multi-stakeholder process for curriculum development

With longer survival, individuals living with human immunodeficiency virus (HIV) infection are facing a multitude of health-related challenges due to HIV, its associated concurrent health conditions, and treatments. Despite the need for rehabilitation, few rehabilitation professionals work with people living with HIV, with many feeling they lack adequate knowledge and skills to assess and treat this population.

PURPOSE

We describe a national multi-stakeholder consultation used to inform the development of an interprofessional curriculum for rehabilitation professionals on HIV/AIDS.

METHODS

We conducted a series of focus groups and key informant interviews (either in person or by telephone) with people living with HIV, rehabilitation professionals, physicians, curriculum experts, and other HIV stakeholders. Participants were asked to describe their perceived learning needs of rehabilitation professionals and to identify relevant content and delivery methods for a future interprofessional HIV/AIDS curriculum.

RESULTS

Seven focus groups and 31 interviews with a total of 74 key informants were conducted, resulting in recommendations for content to include in HIV rehabilitation professional curricula and ways to deliver these curricula effectively.

CONCLUSIONS

A national multi-stakeholder environmental scan was a useful preliminary step to inform the development of an interprofessional curriculum for rehabilitation professionals on HIV/AIDS. Recommendations serve as scaffold from which to build content and delivery of future curricula.

Pairing HIV-positive prisoners with volunteer life coaches to maintain health-promoting behavior upon release: a mixed-methods needs analysis and pilot study

Drawing on individuals who volunteer in US prisons to mentor HIV-infected inmates returning to the community may promote successful transitions. Evaluations published in the scientific literature of such community linkage programs are scant. Our quantitative and qualitative methods needs analysis and pilot study entailed interviewing convenience samples of 24 HIV-positive persons recently released from Georgia correctional facilities and 12 potential volunteer mentors. Both releasees and potential mentors were open to the establishment of a mentoring program. Releasees wanted nonjudgmental mentors. Releasees and volunteers had statistically significant differences in marital status, education, current employment, and possession of a driver's license but not in degree of religious involvement and attitudes toward condom use. A volunteer-staffed program, perhaps more aptly named "life coaching" than mentoring, to help HIV-infected persons to transition from prison to the community may be feasible. Success will require adequately trained volunteers and a straightforward program.

Post-traumatic stress disorder (PTSD) after stigma related events in HIV infected individuals in Nigeria

BACKGROUND

One of the most distressing concerns of many people living with HIV in sub-Saharan Africa is the stigma. Intense stigma may be traumatic. This study aimed to investigate the probability and correlates of Posttraumatic stress disorder (PTSD) following intense stigmatizing events and situations in HIV infected individuals in Nigeria.

METHODS

Adult sero-positive attendees of an HIV care centre (N = 190) completed questionnaires regarding sociodemographic and clinical details; the 12-item General Health Questionnaire (GHQ-12) and the Rosenberg's Self-Esteem Scale. The clients were then interviewed for the presence of stigma related PTSD with a modified version of the mini international neuropsychiatry interview (MINI).

RESULTS

About 2/3 of the participants had experienced at least an intense HIV-related stigmatizing event or situation. The rate of HIV-stigma related PTSD was 27.4%. Independent predictors of HIV stigma-related PTSD included past history of traumatic events (Single event, OR 2.28, 95% CI 1.08-4.73; Multiple events, OR 9.47, 95% CI 2.97-32.20), low self esteem (OR 6.52, 95% CI 2.59-16.55), poor level of social support (OR 3.33, 95% CI 1.24-9.79) and presence of general psychopathology (OR 2.18, 95% CI 1.07-4.44).

CONCLUSION

PTSD may not be specific to traumatic events alone. There is a possibility of PTSD after an intense stigmatizing event or situation. While the validity for the validity of HIV-stigma related PTSD warrants further investigation, stigma needs to be considered when planning rehabilitation strategies for HIV infected individuals in sub-Saharan Africa. A closer attention to self esteem, level of social support and presence of psychopathology is needed in these individuals.

Strengthening families to support children affected by HIV and AIDS

This paper provides an overview of the arguments for the central role of families, defined very broadly, and we emphasise the importance of efforts to strengthen families to support children affected by HIV and AIDS. We draw on work conducted in the Joint Learning Initiative on Children and AIDS's Learning Group 1: Strengthening Families, as well as published data and empirical literature to provide the rationale for family strengthening. We close with the following recommendations for strengthening families to ameliorate the effects of HIV and AIDS on children. Firstly, a developmental approach to poverty is an essential feature of responses to protect children affected by HIV and AIDS, necessary to safeguard their human capital. For this reason, access to essential services, such as health and education, as well as basic income security, must be at the heart of national strategic approaches. Secondly, we need to ensure that support garnered for children is directed to families. Unless we adopt a family oriented approach, we will not be in a position to interrupt the cycle of infection, provide treatment to all who need it and enable affected individuals to be cared for by those who love and feel responsible for them. Thirdly, income transfers, in a variety of forms, are desperately needed and positively indicated by available research. Basic economic security will relieve the worst distress experienced by families and enable them to continue to invest in the health care and education of their children. Lastly, interventions are needed to support distressed families and prevent knock-on negative outcomes through programmes such as home visiting, and protection and enhancement of children's potential through early child development efforts.

Progressive resistance training in elderly HIV-positive patients: does it work?

BACKGROUND

Elderly people present alterations in body composition and physical fitness, compromising their quality of life. Chronic diseases, including HIV/AIDS, worsen this situation. Resistance exercises are prescribed to improve fitness and promote healthier and independent aging. Recovery of strength and physical fitness is the goal of exercise in AIDS wasting syndrome.

OBJECTIVE

This study describes a case series of HIV-positive elderly patients who participated in a progressive resistance training program and evaluates their body composition, muscular strength, physical fitness and the evolution of CD4+ and CD8+ cell counts.

METHODS

Subjects were prospectively recruited for nine months. The training program consisted of three sets of 8-12 repetitions of leg press, seated row, lumbar extension and chest press, performed with free weight machines hts, twice/week for one year. Infectious disease physicians followed patients and reported all relevant clinical data. Body composition was assessed by anthropometric measures and dual-energy x-ray absorptiometry before and after the training program.

RESULTS

Fourteen patients, aged 62-71 years old, of both genders, without regular physical activity who had an average of nine years of HIV/AIDS history were enrolled. The strengths of major muscle groups increased (74%-122%, p=0.003-0.021) with a corresponding improvement in sit-standing and walking 2.4 m tests (p=0.003). There were no changes in clinical conditions and body composition measures, but triceps and thigh skinfolds were significantly reduced (p=0.037). In addition, there were significant increases in the CD4+ counts (N=151 cells; p=0.008) and the CD4+/CD8+ ratio (0.63 to 0.81, p=0.009).

CONCLUSION

Resistance training increased strength, improved physical fitness, reduced upper and lower limb skinfolds, and were associated with an improvement in the CD4+ and CD4+/CD8+ counts in HIV positive elderly patients without significant side effects.

The impact of HIV on mortality during in-patient rehabilitation of severely malnourished children in Malawi

A prospective cohort study measured mortality during nutritional rehabilitation among HIV-infected and uninfected children, aged 6-59 months, with severe acute malnutrition (SAM). Children were tested for HIV and CD4% on admission to the nutrition rehabilitation unit (NRU). Mortality was assessed by following children to 4 months post discharge from the NRU or death if earlier. Overall mortality was 14.8% (67/454) and HIV prevalence was 17.4% (79/454). HIV-infected children were significantly more likely to die than uninfected children [35.4% (28/79) vs. 10.4% (39/375), P<0.001], and 85.7% of deaths occurred in children with a CD4% less than 20. Forty percent (18/45) of HIV-infected children with a CD4% <20 died, in contrast to 15% (3/20) of HIV-infected children with a CD4% >20 (P=0.05). Routine testing and treatment for HIV among all malnourished children is necessary to improve quality of care and reduce mortality among children with SAM.

[Spectrum, clinical features, diagnosis of opportunistic and comorbid pathology in HIV-infected patients admitted to infection hospital of Moscow]

AIM

To analyse structure, clinical features, diagnosis of opportunistic and concomitant diseases in patients with HIV infection admitted to infection hospital of Moscow.

MATERIAL AND METHODS

A total of 4155 patients with HIV infection (1518 of them with AIDS) most of them (89%) at the age of 20-39 years were treated in Moscow AIDS hospital in 2006-2007. The examination included standard blood and urine tests, device diagnosis, immunological, bacteriological and molecular investigations of biological materials for detection of opportunistic infections. Cell-mediated immunity was also studied. HIV infection resulted in a lethal outcome in 255 (6.1%) inpatients.

RESULTS

Leading causes of hospitalization of patients at early stages of HIV infection were bacterial bronchitis or pneumonia, hepatic pathology (chronic viral hepatitides, alcohol-associated diseases), sepsis. One-third of the inpatients were at AIDS stage characterized by tuberculosis (66.3%), visceral candidosis (12%), manifest cytomegalovirus infection (10.1%), cerebral toxoplasmosis (9.2%), pneumocystic pneumonia (5.5%). The number of HIV-infected persons with atypical mycobacteriosis, lymphoproliferative diseases, brain tumors increased. Chronic hepatitis C prevailed among liver damage cause in HIV infection, it also often caused hospitalization and death of patients. 60.3% patients having HIV infection who died without AIDS stage had hepatic cirrhosis. Tuberculosis was a leading cause of severe pulmonary pathology, most frequent opportunistic disease, main cause of death in patients with HIV infection. One-third of patients had generalized tuberculosis. Tuberculosis was diagnosed in more than 40% HIV-infected patients with pulmonary lesion, in 65% AIDS patients, 36% dead AIDS patients.

CONCLUSION

To render effective anti-HIV treatment, infection hospital must be equipped with facilities providing device tests, molecular diagnosis, modern etiotropic and pathogenetic medication.