Permit us to take you back in time when virtually all individuals infected with human immunodeficiency virus (HIV) were dying. So many were young and vibrant; yet, they had life-threatening opportunistic infections including Kaposi's sarcoma. HIV, and its assault on the immune system, was essentially a death sentence until the release of the first antiretroviral therapy (ART) in 1986. Prior to then, our patients died within 6 to 12 months of diagnosis. Four decades later, HIV/AIDS is a chronic disease for those successfully treated with ART. Furthermore, since the 1980s, much progress in medicine was made in the context of immunology to spawn the cancer treatments of today.
HIV/AIDS continues to be a major global public health issue, claiming more than 35 million lives thus far.1 Globally, there were approximately 36.9 million people living with HIV at the end of 2017, with 1.8 million people becoming newly infected in 2017.1 Successful management of ART side effects, multimorbidity, impairments, disability, and the effects of aging may be a key to improving quality of life in persons living with HIV (PLHIV).2 The fact that viral load may be suppressed with ART is remarkable; however, episodic disability may emerge in PLHIV as they encounter drug side effects and comorbidities such as neurocognitive changes, cardiovascular diseases (CVD), peripheral neuropathy, and musculoskeletal pain.3
The effect of immune activation on chronic inflammation may lead to premature aging, disability, and HIV-related mortality.4 PLHIV experience excess morbidity and mortality compared with the general population, with an increased prevalence of age-related, non-HIV illnesses, CVD, malignancies, cognitive impairment, and reduced bone mineral density, which impact disability and function.5 The leading causes of death in PLHIV are coronary artery disease, and over the next decade, HIV-associated CVD burden is expected to increase globally.6 As rehabilitation specialists, this is a call to embrace wellness/prevention programs and enhance nutrition and physical activity in PLHIV. The complexity of pain management and mental health considerations alongside the opioid epidemic in America requires us to intervene early in the trajectory of functional decline.
We can apply various cancer rehabilitation models in the context of prospective surveillance of comorbidities, ART side effects, and disability. Management of chronic HIV disease includes addressing pain, balance impairments, frailty, and falls. Furthermore, we need to address prospective routine screening and to validate this model of care. Ongoing assessment can include functional measures and screening consultation at the point of diagnosis and throughout medical treatment in order to trigger appropriate referral to rehabilitation specialists in the context of episodic disability.
This special issue of Rehabilitation Oncology includes several articles that shed light on the important role of the rehabilitation team. The scoping review by Strehlau, van Aswegen, and Potterton addresses pediatric HIV infection by describing interventions that may help mitigate neurodevelopmental delays in children living with HIV. Physical therapists encounter PLHIV across the lifespan, and the scoping review by Dagenais et al describes the use of technology to track physical activity. The perspective paper by Myezwa et al discusses the effect of living with both breast cancer and HIV infection, whereas Dr Myezwa's commentary provides an international discussion of disability and rehabilitation issues faced by PLHIV in Africa. Finally, the case study by Pullen illuminates the interprofessional team's efforts to manage chronic pain and reduce use of opioid medication over time. These contributions widen the scope of physical therapists' practice and the importance of attending to optimal care for PLHIV.
Assessment of functional status by clinicians and incorporation of patient-reported measures across the trajectory of living with HIV disease are a starting point to establish standard models of care to mitigate episodic disability. Regardless of age, suboptimal adherence to ART may lead to increased viral load, immunosuppression, drug-resistant viral strains, comorbidities, and opportunistic infections, thus having an adverse effect on survival.7 Our first role is to educate PLHIV and prepare them for the journey of living well with chronic issues. However, despite the overall health improvement, significant social disparities remain in several health indicators across the globe.8,9 These disparities in various health outcomes indicate the underpinning of social determinants in disease prevention and health promotion and necessitate systematic and continued monitoring of health inequalities. A multisectoral approach is needed to address persistent and increasing health inequalities among PLHIV.9
Thus, the role of rehabilitation must be client-centered and interprofessional. Using the framework designed by DeBoer et al10 as a means of addressing HIV rehabilitation goals that positively influence physical health and social participation may provide meaningful outcomes. This can be used by rehabilitation professionals to help inform their approach for providing client-centered HIV care.10 Furthermore, this may be complemented with psychologically informed physical therapy (PIPT) in the context of episodic disability in addition to living long and well with HIV disease.
It is recognized for many years that patients with chronic disease may present with significant emotional distress including anger, fear, and depression, as well as pain-related disability, and require a physical and psychological approach to intervention or patient treatment.11 Cognitive-behavioral therapy principles are incorporated into clinical practice as part of a biopsychosocial approach to managing chronic disease, especially pain.11,12 Incorporating this HIV framework alongside PIPT with an interprofessional team may provide a context for treating PLHIV across the globe. We have come a long way in the last 4 decades, yet there is much work and needed resources to facilitate healthy aging. Our Academy of Oncology Rehabilitation through the HIV SIG is a place where colleagues may find resources, research, and support—join us in aging gracefully.
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12. Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153.