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Multidisciplinary Care Models in HIV/AIDS Care

A Wholistic Approach

Pullen, Sara D., DPT, MPH, CHES

doi: 10.1097/01.REO.0000000000000157
CLINICAL CONVERSATION

This clinical conversation discusses the importance of a wholistic approach to HIV/AIDS care, with physical therapy as a critical part of the care team.

Associate Professor, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA

Correspondence: Sara D. Pullen, DPT, MPH, CHES, Department of Rehabilitation Medicine, Emory University School of Medicine, 1462 Clifton Rd, Ste 312, Atlanta, GA 30322 (sara.pullen@emory.edu).

Grant support: Dr Pullen has grant (P30AI050409) for support of this research, from the National Institutes of Health, Center for AIDS Research at Emory University and National Institutes of Health, National Institute of Drug Abuse, Loan Repayment Program. (L30 DA046878).

The author declares no conflicts of interest.

The term holistic—or wholistic—medicine has been variably defined, with a consensus that it is characterized by the treatment of the whole person, accounting for mental and social factors rather than solely physical injury or disease.1

The past decades have seen numerous crossroads of HIV/AIDS care, with treatment progressing from palliative care in the 1980s to lifesaving and prolonging measures in the late 1990s to chronic HIV/AIDS management in the 2000s.2 Nowadays, people living with HIV (PLHIV) present with comorbidities related to HIV as well as non–HIV- and age-related issues. In fact, recent studies reveal that PLHIV are more likely to present to a medical provider for non–HIV-related issues than for HIV-related morbidities: A 2016 report found that between 84% and 96% of medial visits for PLHIV were for non–HIV-related services in the year after initial diagnosis.3

Around the world, a small but significant body of research is being produced regarding the various roles of physical therapy (PT) in HIV/AIDS. This is creating a quilt of wholistic care models that may be used widely by physical therapists caring for this unique patient population. From functional limitations among PLHIV to a myriad of physical, mental, cognitive, and social challenges that may occur in in this patient population, rehabilitation medicine will inevitably move center stage in the treatment and support of PLHIV.4–6 As the opioid crisis looms above individuals and communities nationwide, PLHIV have been shown to be especially at risk for both chronic pain and opioid dependence.7 Recent literature has shown the unique role of PT in the intersection of HIV/AIDS, chronic pain, and opioid use.8 This Special Issue of Rehabilitation Oncology comes at an ideal time for us, as physical therapists, to recognize our unique role in the support of PLHIV as they age healthily and have increasing rehabilitation needs that may or may not be related to their HIV/AIDS diagnosis.

As physical therapists, we are centered directly in the middle of the wholistic approach to caring for PLHIV. We are trained to address unique musculoskeletal, neuromuscular, and functional impairments that are frequently experienced by this patient population. While we may encounter PLHIV in our clinical practice regardless of setting, this clinical commentary highlights a clinic in Atlanta, Georgia, that has fully incorporated PT into its multidisciplinary AIDS care, recognizing it as an essential part of the care team.

In 2014, I had the unique opportunity to create and implement a PT program at the nation's largest freestanding AIDS clinic, the Grady Ponce de Leon Center in Atlanta, Georgia. After completing a thorough needs assessment of both providers and patients, the Ponce Center has seamlessly incorporated the PT services into its successful, multidisciplinary care team for the past 4 years. The Ponce Center is a 7-story, 90 000-sq ft freestanding building, located in an area of high HIV/AIDS prevalence in Atlanta and is the largest, most comprehensive ambulatory outpatient HIV/AIDS facilities in the nation. The Center provides multidisciplinary medical and support services to nearly 6000 adults, adolescents, and children with HIV/AIDS. More than 70% of HIV-positive individuals residing in Atlanta live within 2 miles of the clinic, making the clinic an essential part of Atlanta's HIV/AIDS epidemic. Founded in 1986, the clinic has been at the forefront of Atlanta's HIV/AIDS epidemic since the earliest days of tragically fast descent from diagnosis to death. As HIV/AIDS has evolved from a fatal to chronic disease, the Ponce Center has kept a brisk pace with meeting the ever-changing needs of PLHIV.

The truly unique aspect of the Ponce Center is its wholistic approach to HIV/AIDS care and the effect that has on patient health, retention, and positive outcomes. Primary HIV/AIDS care providers refer patients to PT, often consulting with the therapist on appropriate plans of care and providing thorough medical histories. A key example of this wholistic, multidisciplinary approach is highlighted with the following brief patient case:

A 50 year-old patient was referred to PT for chronic, worsening neck and jaw pain. While we had some success with decreasing muscle tension and improving neck posture, his persistent lower jaw pain limited his success. In conversation at one session as I performed soft tissue mobilization to his neck, he mentioned that he struggled with methamphetamine use. Upon examination, his upper and lower molars were decayed and painful, a result of “meth mouth”: the oral effects of methamphetamine use can be one of the most common, visible, and distressing consequences of this drug use.9 In addition, methamphetamine abuse has been widely associated with grinding/clenching of the teeth and jaw, temporomandibular joint disorders, and myofacial pain.10

At that same appointment, I called his primary provider to consult regarding the best plan of care for this individual patient. We agreed that he would make an appointment at the on-site dental clinic to address his teeth. In addition, the patient was agreeable to seeing an on-site mental health counselor to address some addiction-related struggles, as well as the anxiety, depression, and living situation stressors that were causing him to increase his drug use. We agreed that he would continue PT, keep his mental health appointments, and receive necessary dental work for his meth-related tooth and gum decay, all with the aim of improving his interrelated stress, drug use, and neck/jaw pain. The result for this patient was improvement in all areas: although his teeth were irreversibly damaged by years of drug use, the dentist was able to put him on a regimen of oral health care to prevent further decay and tooth loss. His visits with his mental health provider focused on his drug use as well as his overall anxiety and depression and stressful living situation. His primary care provider continued to not only follow him for his HIV/AIDS and primary care needs but also communicate frequently with the PT to assess his progress. Once his dental and mental health concerns were being addressed, the patient progressed beautifully in PT. By the time I discharged him from PT 8 weeks after the initial evaluation, his neck was pain-free. This could only be achieved by focusing on all factors of aspects of his pain and by having all providers involved and in close communication. At the time of publication, this patient is still keeping his mental health appointments and is faithful to his dental regimen. His primary care provider reports that he is retained well in care and is fully compliant with his antiretroviral medications.

As with the essence of wholistic health care, physical therapists must be concerned with the whole person, accounting for the potential social and mental factors of a patient's situation rather than only the physiological symptoms of his or her presenting diagnosis. Our clinical skills may not be enough to successfully manage what seems on the surface to be simple neck pain. We must reach out to our peers in other specialty areas and maintain open, honest communication among providers and patient. As physical therapists, we must think wholistically as we treat the unique needs of PLHIV.

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REFERENCES

1. Cambridge Dictionary. Holistic. https://dictionary.cambridge.org/us/dictionary/english/holistic. Accessed October 15, 2018.
2. US Department of Health and Human Services. A timeline of HIV and AIDS. https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline. Accessed October 14, 2018.
3. Lourenco L, Nohpal A, Shopin D, et al Non-HIV related healthcare utilization, demographic, clinical, and laboratory factors associated with time-to-initial retention in HIV care among HIV-positive individuals linked to HIV care. HIV Med. 2016;17(4):269–279.
4. Johs NA, Wu K, Tassiopoulos K, et al Disability among middle-aged and older persons with human immunodeficiency virus infection. Clin Infect Dis. 2017;65(1):83–91.
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6. Richert L, Brault M, Mercie P, et al Decline in locomotor functions over time in HIV-infected patients. AIDS. 2014;28(10):1441–1449.
7. Bruce DR, Merlin J, Lum PJ, et al 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV. Clin Infect Dis. 2017;65(10):e1–e37.
8. Pullen S. Physical therapy as non-pharmacological chronic pain management of adults living with HIV: self-reported pain scores and analgesic use. HIV AIDS (Auckl). 2017;9:177–182.
9. American Dental Association. Methamphetamine. https://www.ada.org/en/member-center/oral-health-topics/methamphetamine. Accessed October 14, 2018.
10. National Institute on Drug Abuse. Research Report Series: Methamphetamine. Washington, DC: National Institutes of Health. https://www.drugabuse.gov/publications/research-reports/methamphetamine/letter-director. Accessed August 23, 2016.
Keywords:

HIV; AIDS; Multidisciplinary

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