Journal of Clinical Research in HIV AIDS and Prevention
ISSN: 2324-7339
Current Issue
Volume No: 3 Issue No: 1
share this page

Research Article | Open Access
  • Available online freely | Peer Reviewed
  • Disability and Health Outcomes – From a Cohort of People on Long Term ART

    Hellen Myezwa 1       Jill Hanass-Hancock 2 3     Adedayo Tunde Ajidahun 1     Bradley Carpenter 2    

    1Department of Physiotherapy, University of the Witwatersrand, Johannesburg, South Africa

    2Health Economics HIV and AIDS Research Division (HEARD), University of KZN

    3South African Medical Research Council, South Africa

    Abstract

    HIV and AIDS remains a major health problem in South Africa even after two decades since the introduction of antiretroviral therapy. Long term survival with HIV is associated with new health related issues and a risk of functional limitation/disability. The aim of this study was to assess the impact and predictors of functional limitation associated with HIV/AIDS among people living with HIV (PLHIV) in South Africa.

    This study is a cross-sectional survey using a cohort in an urban area in Gauteng province South Africa. Questionnaires that were interview administered were used to collect information on demographics, disability, mental and physical health state, adherence and livelihood.

    A total of 1044 participants with an average age of 42±12 years, were included in the study and 51.9% of the participants reported functional limitation (WHODAS ≥ 2). These were reported mainly in the participation (40.2%) and mobility domains (38.7%). In addition, adherence to ARV, physical health symptoms and depression were strongly associated with functional limitations/disability.

    HIV as a chronic disease is associated with functional limitations that are not addressed and pose a risk of long term disability and negative adherence outcomes. Therefore, wellness for people living with HIV/AIDS (PLHIV) needs to include interventions that can prevent and manage disability.

    Received 29 Jan 2017; Accepted 28 Apr 2017; Published 19 Aug 2017;

    Academic Editor:Denise Evans, Epidemiologist, Clinical HIV Research Unit, Helen Joseph Hospital.

    Checked for plagiarism: Yes

    Review by: Single-blind

    Copyright©  2017 Hellen Myezwa, et al

    License
    Creative Commons License    This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    Competing interests

    The authors have declared that no competing interests exist.

    Citation:

    Hellen Myezwa, Jill Hanass-Hancock, Adedayo Tunde Ajidahun, Bradley Carpenter (2017) Disability and Health Outcomes – From a Cohort of People on Long Term ART. Journal Of Clinical Research In HIV AIDS And Prevention - 3(1):18-30.
    Download as RIS, BibTeX, Text (Include abstract )
    DOI10.14302/issn.2324-7339.jcrhap-17-1430

    Introduction

    Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) remain key priority health areas in HIV-endemic countries in spite of its thirty year trajectory 1. An estimated 7,000,000 people were living with HIV in South Africa in the year 2015 2. Due to life saving antiretroviral treatment (ART) more people survive. As a result, the focus of HIV management has shifted in recent years from that of a deadly disease towards managing a chronic condition 3. Managing chronicity requires a move towards a more integrated approach of treatment, care and support that includes rehabilitation in the continuum of care 3, 4, 5. There is similarity in this approach with the systems thinking proposed by Valdiserri in his call for improved focus on demographic and epidemiological data in order to develop high quality systems of care 1. There is very little understanding of the long term health outcomes of living with chronic HIV in Africa and the related services needed to manage associated health needs after long periods on ART 3, 4, 6. Co morbidities such as TB, cancer and depression have already received some attention 7, 8, 9. We have even less understanding on the long-term effects beyond the investigation of HIV-related conditions and comorbidities.

    Recent evidence has suggested that people living with HIV including those on ART experience a diverse set of disabilities 5, 10, 11, 12, 13. The United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD) has been instrumental in many policy debates including HIV/AIDS. The CRPD offers a tool to protect and promote the rights of people with disability but also those in need of rehabilitation because they are affected by chronicity. The intersection of disability in HIV requires a careful exploration of the impact of the virus and treatment from a multi-systemic perspective. There is however a dearth of empirical information on the intersection of HIV and disability to inform policy and practice. Understanding the scope, types of disabling effects as well as its impact on health outcomes and treatment adherence is crucial to inform management of HIV as a chronic condition (3, 6). Existing literature used the international classification of function (ICF) as a lens to understand the relationship between HIV and disability 5, 6, 10, 11, 13, 14, 15. The ICF is a classification system of health components of function and disability.

    Studies using this lens indicate a high burden of disability with diverse conditions among people living with HIV and those on ART. However, we have little quantitative evidence from representative cohort studies that can predict better the scope and types of disability in populations living with HIV and its impact on health and ART adherence.

    The HIV-Live Study, collaboration between Health, Economics, HIV and AIDS Research Division (HEARD) and University of the Witwatersrand Johannesburg South Africa, sought to address this gap investigating the disabling experiences in three different cohorts and settings. The study investigated the intersection of functional limitation as a proxy for disability, other health outcomes, treatment adherence and livelihood outcomes.

    A recent publication reported the results of HIV disability and associations with health outcomes in the first cohort study (HIV-Live) in a semi-rural area in KwaZulu-Natal considered the epicentre of the pandemic in South Africa 6. The results of the second cohort in the urban setting of Gauteng (second highest prevalence in the country) are presented in this paper. The main aim of the study was to investigate the scope and types of functional limitations/disability and the association with health and adherence outcomes with the specific objectives being to determine socio-demographics, livelihood, and medical history, physical, functional and mental health of the cohort.

    Methods

    A combination of a disability and livelihood framework formed the theoretical basis to investigate the relationship between disability and other outcomes in a cohort of people on ART in South Africa. The overall methodology was developed to include a cross-sectional survey in three cohorts: a semi urban area in KwaZulu-Natal (longitudinal observational study) and two cohorts in the urban area of Gauteng (SA) and United States of America. The cohort in Gauteng was at Helen Joseph Hospital, Themba Lethu HIV clinic where the largest antiretroviral treatment site in the South Africa, operates. Since 2004 over 140,000 patients have been initiated on antiretroviral (ARV) and currently has 8000 patients on treatment.

    Each participant was approached as during their routine visit for treatment review and collection of medication. All patients were routinely screened for height, weight, BMI, blood pressure and are screened further by a doctor. Participants had to be attending the outpatient HIV clinic, be between the ages of 18-65 years and have been on ART for six months or longer. Exclusion criteria included participants with any acute opportunistic infection such as active TB or pneumonia and if the patient was pregnant as this would have impacted the disability measure.

    A trained research assistant who herself was a patient attending this clinic approached the patients during their visit, explained the purpose of the study and sought initial permission to interview the patient. Three trained research assistants including the principle investigator collected data. All three were trained clinicians and could explain the concepts when misunderstanding arose. The questionnaires were translated into isiZulu and the researchers could use the standardised translated questionnaire where needed. The patient file was accessed after permission was granted by the patient. The length of time on ART and the presence of recent opportunistic infections were extracted as well as the most recent CD4 count. The information extracted was verified with the patient in the interview.

    Ethics approval was obtained from the Human and research ethics committee at the University of the Witwatersrand, Johannesburg, South Africa and written informed consent of the participant was obtained.

    The estimated sample size for this study was calculated at 1050 with Stata 12.1 with a one sample comparison of proportions (one sample size computation), a 90% power and two-sided test and alpha level of 5% with a hypothesized 55% of the population with disability. Therefore, the estimated sample size was 1050.

    The data collection tool was developed using literature 4, 5, 6, 13, 14, 15, 16, 17 as well as established and validated scales (see Table 1). Included in the survey tool were demographics, biomarkers and scales for livelihood capitals (human, financial, social, natural and physical capital), patients’ health medical history, functional limitations/disability, depression symptoms and treatment adherence.

    Table 1. Formulas of insulin sensitivity/resistance derived indices from fasting glucose and insulin or OGTT values.
    Element measured Tool Variables Literature Source, reliability and validity Data analysis
    Socio-demographic Socio-demographic questionnaire Age gender and marital status ( * other factors are indicated in the livelihoods section) - Descriptive and correlations
    Livelihood HIV-Live livelihood capitals (self-developed from literature) Education , financial capital, including source of income, physical and natural capital including housing, source of income, water and sanitation, social capital and food security Livelihood-.728Physical & natural capital -.699Social capital - .908Food security - .79021  Descriptive
    Medical history Medical symptoms questionnaire  Confusion, Memory loss, Breathlessness, Fatigue, Diarrhea, Nausea, Stomach Pain, Headache, Change in taste, Change in taste, . Skin itching/ changes. Muscular pain, Heartburn, Sore mouth, Vomiting, Fever, Kidney stones. Included in this section were the patient weight height, CD4 count 22 Overall score converted to a metric of 0- 100% where 100 = full health and 0 experiencing all symptoms.
    Physical and functional health WHODAS World health Organisation disability assessment scale 2.0(5 point Likert scale)  Mobility (standing and walking), Self-care ( washing , getting dressed), Participation ( involvement in life situations), Cognition ( learning concentration and memory),getting along ( dealing with people and maintaining friendship)and life activities (work and education) Internal consistency reliability was 0.94 (Cronbach's alpha).It showed moderate convergent validity with EQ5Dand RAND-12 (0.41-0.76)23  WHO item response theory-scoring and data analysis system was used and the analysis uses overall weighted score of 36, 36 = lowest level of function.
    Mental health CESD-10( 4 point Likert scale)  Ten questions prompting Status as far as depression, level of bother, how fearful, hopeful, happy or lonely one is and the effort required to get going. The CES D -10 showed good internal consistency reliability with the original CES D 20 (α = 0.88 24, 25 A sum of the scores was taken and a cut off of 16 and above was considered at risk of depression. A converted summary score is calculated with a metric of 0-100 (100 is equal to no symptoms of depression and 0 depicts severe symptoms of depression.)
    Adherence CASE adherence index Three unique adherence questions combined to form a composite score CASE adherence index showed strong correlation with the three day self-reported adherence (ROC curve >0.86, p<0.001).26 A sum of the scores was calculated out of 16, with scores below 11 indicating adherence issues.

    The International Classification of Function (ICF) was used as a conceptual framework to define disability. The ICF defines disability as an umbrella term for impairments, activity limitations and participation restrictions. In addition, the interaction between a persons health condition and their context which includes their environmental and personal factors as part of the concept of disability. The central element of disability is therefore the experience of functional or activity limitation on the basis of the interaction between changes in body function (impairment) and unaccommodating environments. As such, scales to investigate function and activity limitations were included in the tool and assessed through the WHODAS 2.0 18. Importantly, their health condition was also measured using health symptoms commonly experienced by people living with HIV/AIDS PLHIV. Adherence was measured using Mannheimers CASE adherence index 19.

    Table 1 outlines the instruments used in this study, the variables measured along with the psychometric properties of the instruments and the data analysis approach. Shapiro Wilk test was conducted and the data were non-linear for the main outcome measures (p<0.001). Subsequently Kendall’s Tau and Mann Whitney U tests were used to examine the relationship between the dependent and independent variables. While Kendall’s Tau is not directly comparable to Pearson’s r, as it provides a smaller coefficient, but it can be converted using a formula from Walker 20.Linear regression was used to determine the predictors of the independent variables. All data analysis was done using the IBM SPSS 22.0.

    Results

    A total of 1044 participants were enrolled, 71.8% were females with an average age of 42±12 years. The average (median) WHODAS weighted score in this population was 0.5±8 and 51.9% (542) of the participants reported disability (WHODAS ≥ 2). Average income was 5260 South African Rand across three months and 84.6% have at least some form of high school education. Only a few participants reported having no source of income (n=43) and no formal schooling (n=17). Socio-demographic characteristics are outlined in Table 2. Functional limitations as a proxy for disability were reported in all the six domains with a higher prevalence in the participation (40.2 %), mobility (38.7 %), cognition (33 %) and the life activity domains (32.9%) as shown in Figure 1.

    Figure 1. Functional limitations in the six domains
    Figure 1.

    Table 2. Socio-demographic characteristics of the participants
    Characteristics Total (n=1044) People WHODAS 0-1 (n =502) People WHODAS 2 (n = 542) P
    Age, median (IQR) years 42(12) 42(11) 42(12.3) 0.53
    Age category, n (%)      
    18-29 68(6.5) 33(6.6) 35(6.5)
    30-39 335(32.1) 164(32.7) 171(31.5)
    40-49 459(44) 223(44.4) 236(43.5)
    50-59 168(16.1) 76(15.1) 92(17)
    60+ 14(1.3) 6(1.2) 8(1.5)
    *Gender, n (%)       0
    Men 291(28.2) 164(32.7) 127(23.5)
    Women 750(71.8) 337(67.3) 413(76.5)
    Marital Status, n (%)       0.06
    Never married, single 513(49.1) 235(46.8) 278(51.3)
    Currently married 250(23.9) 125(24.9) 125(23.1)
    Divorced or Widowed 208(19.9) 97(19.3) 111(20.5)
    Cohabiting 73(7) 45(9) 28(5.2)
    *Education status, n (%)       0.14
    No formal schooling 17(1.6) 10(2) 7(1.3)
    Some primary 143(13.7) 80(16) 63(11.6)
    High school 769(73.7) 367(73.3) 402(74.2)
    Post high school 113(10.8) 44(8.8) 69(12.7)
    Refused/don’t know 1(0.1) - 1(0.2)
    *Source of Income, n (%)       0.79
    Earned Income 604(58.3) 286(57.5) 318(59)
    Disability grant 14(1.4) - 14(2.6)
    Other Grants 77(7.4) 19(3.8) 58(10.8)
    No Income 43(4.2) 30(6) 13(2.4)
    Refused 197(19) 122(24.5) 75(13.9)
    Other income 94(9.1) 38(7.6) 56(10.4)
    Gifts 7(0.7) 2(0.4) 5(0.9)
    Income, median (IQR) 5260.6(9000) 4500(9000) 3600(6540)
    WHODAS weighted score,       0
    mean out of 36 (±SD) 0.5(8) 0(0) 8(9)
    CES-10 Score, 11(9) 10(10) 12(10) 0
    mean out of 30 (±SD)
    *Adherence score, median (IQR) 16(2.8) 16(1) 14.2(3) 0
    Adherence score above 10, n (%) 148(14.2) 65(13) 83(15.4)
    Adherence score of 10 or less, n (%) 893(85.8) 436(87) 457(84.6)
    Health Symptoms,       0
    mean out of 16 (±SD) 5(6) 4(5) 6(5)
    *BMI, median (IQR) 25(8.1) 24.9(7.5) 25.2(8.6) 0.37
    Normal 432(42.7) 245(44.4) 187(40.7)
    Underweight 73(7.2) 36(6.5) 37(8)
    Overweight 273(27) 155(28.1) 118(25.7)
    Obese 234(23.1) 116(21) 118(25.7)
    *CD4 Count, n (%)       0.25
    < 200 762(77.5) 366(77.9) 396(77.2)
    ≥ 200 221(22.5) 104(22.1) 117(22.8)
    *Years of HIV diagnosis, median (IQR) 8(6) 7(6) 9(6) 0
    *Years on ART, median (IQR) 6(5) 6(5) 7(6) 0.01

    Relationship Between Functional Limitations, Health Outcomes and Socio-Demographics

    Gender ( and exposure to shock ( showed significant association with functional limitations. Similarly, duration of HIV and ART was showed significant association with functional limitations (p<0.001). All other socio-demographic variables showed no significant association with functional limitations, Correlation analysis (Kendall Tau b) showed a positive weak correlation between functional limitations and outcome measures of physical health symptoms

    () and mental health scores

    (), whereas, there was a negative weak correlation between adherence score and WHODAS scores (). Table 3 shows the result of the correlation analysis between the dependent and independent variables.

    Table 3. Relationship between socio demographics and health outcome measures
    Variable WHODASrτb(p) Adherence rτb(p) Mental health rτb(p)
    Socio-demographics
    Age 0.04(0.12) 0.02(0.36) 0.10 (0.00)
    Gender 0.10(0.00)** 0.04(0.17) 0.09(0.00)
    Marital status -0.04(0.15) -0.03(0.19) 0.01 (0.73)
    Education 0.05(0.05) -0.12(0.00)** -0.13(0.00)**
    Income 0.03(0.19) -0.00(0.90) -0.22(0.00)**
    Years on ARV 0.07(0.01) -0.05(0.07) 0.04(0.06)
    Years of HIV diagnosis 0.07(0.00) -0.05(0.05) 0.03(0.24)
    Exposure to shock 0.32(0.00) -0.08(0.01)** 0.15(0.00)**
    Clinical outcome measures
    Mental health 0.19(0.00)** 0.03(0.16) 1
    Adherence -0.12(0.00)** 1 0.03(0.16)
    Physical health 0.21(0.00)** 0.01(0.82) 0.31(0.00)**
    WHODAS 1 -0.12(0.00)** 0.19 (0.00)**
    CD4 -0.00(0.72) 0.04(0.18) -0.05(0.06)
    BMI 0.01(0.54) 0.04(0.14) -0.02(0.41)

    Independent variables with p-value ≤0.25 were included in the linear regression model 27. The variables were log transformed to ensure data linearity. Age, gender, income, exposure to shock, adherence, physical health symptoms, education, marital status, duration on ART, duration of HIV diagnosis and mental health score were included in the multivariate regression analysis. Multivariate linear regression showed that mental health, physical health symptoms, income and exposure to shock are stronger predictors of functional limitations. Whereas, the stronger predictors of mental health scores in the study are age, physical health symptoms, functional limitations/disability and duration of HIV diagnosis. Gender, income, disability score and mental health score were stronger predictors of adherence to ARVs. Table 4 shows the multivariate linear regression results of the independent and dependent variables.

    Table 4. Multivariate linear regression analysis of the health outcome predictors of disability among PLHIV on ARV > 6 months using linear regression
      WHODAS Adherence Mental health            
      B 95%CI p B 95%CI p B 95%CI p
    Mental health 0.18 0.16 – 0.38 0.00 -0.02 -0.04 – 0.02 0.00 - - -
    Adherence -0.13 -0.86 – (-0.29) 0.00 - - - -0.02 -0.24 – 0.15 0.64
    Physical symptoms 0.11 0.06 – 0.31 0.00 0.03 -0.02 – 0.04 0.45 0.36 0.32 – 0.47 0.00
    WHODAS - - - -0.16 -0.06 – (-0.02) 0.00 0.18 0.07 – 0.17 0.00
    Age -0.00 -0.39 – 0.38 0.98 0.07 -0.01 – 0.19 0.08 0.10 0.14 – 0.65 0.00
    Gender 0.06 -0.01 – 0.14 0.08 0.10 0.01 – 0.04 0.01 0.03 -0.03 – 0.07 0.35
    Education 0.04 -0.02 – 0.09 0.21 -0.02 -0.02 – 0.01 0.57 -0.03 -0.05 – 0.02 0.39
    Marital status -0.01 -0.04 – 0.03 0.68 -0.02 -0.01 – 0.01 0.60 -0.01 -0.02 – 0.02 0.83
    Income 0.13 0.13 – 0.41 0.00 0.21 0.07 – 0.14 0.00 -0.07 -0.19 – 0.00 0.05
    Exposure to shock 0.28 0.20 – 0.33 0.00 -0.04 -0.03 – (-0.01) 0.37 0.06 -0.01 – 0.08 0.10
    HIV diagnosis 0.02 -0.14 – 0.22 0.64 -0.08 -0.08 – 0.01 0.15 -0.11 -0.25 – (-0.02) 0.02
    Years on ARV 0.05 -0.08 – 0.28 0.27 0.00 -0.04 – 0.05 0.94 0.04 -0.06 – 0.17 0.35

    Furthermore, the multivariate results in Table 5 shows the health predictors of functional limitation in the six domains, mobility, cognition, self-care, life activity, getting along and participation after adjusting for age, gender, education, marital status, income, exposure to shock, duration of HIV diagnosis and duration on ART.

    Table 5. Multivariate regression analysis of health outcome predictors of disability among PLHIV on ARV > 6 months using linear regression with respect to the WHODAS domains
      Adherence Mental health Physical health symptoms
      B 95%CI p B 95%CI P B 95%CI p
    WHODAS score -0.13 -0.87-(-0.30) 0.00 0.18 0.16 – 0.38 0.00 0.11 0.06 – 0.30 0.00
    Mobility -0.09 -0.45 – (-0.06) 0.01 0.19 0.11 – 0.26 0.00 0.10 0.02 – 0.18 0.01
    Cognition -0.10 -0.38 – (-0.07) 0.01 0.17 0.07 – 0.19 0.00 0.12 0.04 – 0.17 0.00
    Participation -0.07 -0.35 – (-0.01) 0.04 0.16 0.07 – 0.20 0.00 0.09 0.01 – 0.16 0.02
    Self-care -0.13 -0.28 – (-0.08) 0.00 0.10 0.01 – 0.08 0.02 -0.03 -0.05 – 0.03 0.55
    Getting along -0.28 -0.58 – (-0.35) 0.00 0.09 0.01 – 0.09 0.02 0.08 -0.00 – 0.09 0.06
    Life activity -0.11 -0.34 – (-0.08) 0.00 0.19 0.07 – 0.17 0.00 0.06 -0.01 – 0.10 0.11

    A one unit increase in mental health and physical health score increased WHODAS score (functional limitation) by 0.18 and 0.11 respectively. In the specific domains, a unit increase in mental health score increased WHODAS score in the mobility, cognition and participation domain by 0.19, 0.17 and 0.16 respectively. Likewise, a unit increase in physical health symptoms score increased the WHODAS score by 0.11. In the specific domains, a unit increase in physical health score increased WHODAS score in the cognition and mobility domains by 0.12 and 0.11 respectively.

    Also, a one unit decrease in adherence score reduces the WHODAS score by 0.13. In the specific domains, a unit increase in adherence score reduced WHODAS score in the getting along, self-care and life activity domains by 0.28, 0.13 and 0.11 respectively.

    Discussion

    This study assessed the impact and predictors of HIV-related functional limitations/disability and health outcomes in a cohort of PLHIV on ART for more than six months. In this cohort 51.9% of the participants scored 2 or more on the WHODAS 2.0 using the adjusted measure 14, 28, 29. This is higher than in the sister study in KZN 6 and suggest a high prevalene of functional limitations that if not addressed may be a risk of disability. In many studies, disability is described differently and often interchangeably between functional and activity limitation, disability and functioning 5, 28, 29, 30. Current measures of disability such as the WHODAS 2.0 or the Washington set of questions 31 make use of this understanding and measure functional limitations to understand disability. This method identifies people with more moderate conditions that can be addressed with therapeutic interventions to severe conditions that need complex rehabilitative interventions. In this cohort the levels of functional limitation/disability remain high, and a large part of this population has more moderate limitations that are also less visible One difference with existing studies is that previous studies are focused on older people (28-30) living with HIV while 99.7% of this cohort were an economically able age group (20-60). Comparably, Rusch, Nixon 32 reported a higher prevalence of disability in their study with an HIV population. There is also a difference in the gender distribution of functional limitations/disability in this cohort and this is consistent with other studies, females are prone to report more disability than males 6, 10, 11, 29, 33.

    Our study showed levels of functional limitations/disability are higher in the areas of mobility, cognition and participation and life activity domains. Similarly, Nyirenda, Chatterji 28 reported mobility as well as participation and household activities as the most affected domains in their study with an older population with HIV. Difficulties in mobility are anticipated as HIV is known to affect the musculoskeletal system negatively for example, peripheral neuropathy with direct effects on muscle function as well as aptotic effects on muscle cells 34, 35. Clearly, a large number of our cohort reported mobility limitations.

    In our study, adherence to ARV was a strongly associated with overall disability and this is true in all six WHODAS 2.0 domains. Similar results were reported in the sister cohort study in KZN. The HIV live study is the first study to measure the direct association between disability (as functional limitation) and adherence. The role of adherence to ARV in the progression of HIV and occurrence of related comorbidities has been reported in several studies 36, 37, 38. Adherence to ARV therapy reduces or delays the progression of HIV to AIDS and reduces the risk of comorbidities 36, 38. At this point we are unable to fully understand the direction of this relationship. It is however plausible that the lack of adherence increases the risk of opportunistic infections and comorbidities and therefore disability. It is also plausible that disability negatively impacts health seeking behaviour and therefore adherence to treatment. Much work has been done on adherence to ARVs however no study has been conducted to examine to what extent adherence is related to the onset of disability.

    The physical health state of participants was also associated with disability in the mobility, cognition and participation domains. A poorer state of health is often directly associated with a decreased level of function in the general population 39, 40. In addition, adherence to ARVs has been shown to improve overall health status of PLHIV 36, 38. In this cohort as well as its sister study 6, there is an relationship between adherence and functional limitations/disability. Similarly, in both studies depression correlated with increasing disability and all the subcategories of the WHODAS2.0 scores. A discussion on the implication of depression and disability is beyond scope of this paper, but a matter for further analysis and publication.

    Preventing and managing disability is important as it impacts the productivity of a community, function and health related quality of life (HRQOL) 41. In practice, the management of disability is both multi-sectoral and person centred 41. The response to needs of PLHIV could be divided into micro (person), meso (community) and macro (policy). At person level, functional limitations can be managed to mitigate the impact on individuals’ function in their daily life through interventions with a rehabilitation team, including physiotherapy, occupational, speech therapy and social workers. At meso level further studies are needed to explore the specific details of mobility, cognition and life participation. At the meso level, community based interventions are implemented through specific evidence based interventions to mitigate functional limitations experienced by people living with HIV and is important for effectiveness. The results reflect nuanced effects of functional limitations/disability that have similarities with disability in the general population but also exhibit important differences peculiar to HIV. Of interest is the relationship between functional limitations, adherence and mental health and participation related problems.

    Finally, at macro level, the impact of HIV-related disability on policy is important to consider. The last South African National Strategic Plan for STIs HIV and TB for 2012-2016 related to disability in two areas of wellness and health and the provision of services to people with disability (PWD). There was however no mention of the need to include rehabilitative services. The new South African National Strategic Plan on HIV/TB/STIs 2017-202242 has recently recognised the need to address the new health related needs of people living long term with chronic HIV or TB and therefore included rehabilitation into the framework.

    The results of this study can be used to inform the implementation of the ambitious new plan through providing a better understanding of the link between disability, adherence and mental health (depression). In a similar vein the new South African Framework and Strategy for Disability and Rehabilitations Services (2015) 43clearly identifies HIV as major cause of increased disability prevalence in South Africa and calls for integration of services. The results of this study could provide a starting point to discuss potential needed services.

    The relationship between HIV and disability also has the potential to impact the current targeted outcomes in important policy statements such as the 90:90:90 UN statements if disability is excluded 2. The need to integrate services therefore has been recognised by the WHO consolidated guidelines on antiretroviral treatment (2016). These guidelines acknowledge the need to integrate palliative and rehabilitative services. How this can be implemented within the global response to HIV and AIDS still needs to be outlined better.

    Limitations of Study

    A limitation in this study was the inclusion criteria which included people on ART for six months or longer. The line of ART therapy was not considered and this could affect the prevalence and the intensity of disability in the study population.

    Conclusions

    The large number of people on ART experiencing functional limitations and its impact on other health outcomes in this cohort highlights the need of a continuum of HIV care that prevents and mitigates disability. Wellness for PLHIV will not be complete without the inclusion of rehabilitative services that can prevent and manage known disability. Conversely, the provision of services for people with disabilities (e.g. assistive devices, therapy, and environmental accessibility) is closely tied to these efforts of addressing disability among PLHIV as a consequence of HIV. Hence prevention and accommodating disability need to become a central part of managing living with HIV over a life-time. In addition, impact of HIV on PWD where they are like any other population group impacted by HIV and may suffer a double burden of HIV disability.

    Acknowledgements

    The authors would like to acknowledge all the people that participated in the study.

    Noleen Ndlovu who assisted and was instrumental with data collection, Sister Vicky with the phlebotomy, Dr Mashmaite and Dr Itumeleng Motloung and all the patients who agreed to participate in this study.

    References

    1.Valdiserri R O. (2011) Commentary: thirty years of AIDS in America: a story of infinite hope. , AIDS Education and Prevention 23(6), 479.
    2. (2014) . UNAIDS.Country report[Online].[cited 23/08/2015 ].Available from: http://www.unaids.org/en/regionscountries/countries/southafrica
    3.Deeks S G, Lewin S R, Havlir D V. (2013) The end of AIDS: HIV infection as a chronic disease. The Lancet. 382(9903), 1525-33.
    4.Nixon S A, Hanass-Hancock J, Whiteside A, Barnett T. (2011) The increasing chronicity of HIV in sub-Saharan Africa: Re-thinking&quot; HIV as a long-wave event” in the era of widespread access to ART. Globalization and health. 7(1), 1.
    5.Myezwa H, Stewart A, Musenge E, Nesara P. (2009) Assessment of HIV-positive in-patients using the international classification of functioning, disability and health (ICF) at Chris Hani Baragwanath Hospital. , Johannesburg, African Journal of AIDS Research 8(1), 93-105.
    6.Hanass-Hancock J, Myezwa H, Carpenter B. (2015) Disability and Living with HIV: Baseline from a Cohort of People on Long Term ART in South Africa. , PloS one 10(12), 0143936.
    7.Robbins H A, Shiels M S, Pfeiffer R M, Engels E A. (2014) Epidemiologic contributions to recent cancer trends among HIV-infected people in the United States. , AIDS (London, England) 28(6), 881.
    8.Gonzalez J S, Batchelder A W, Psaros C, Safren S A. (2011) Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. Journal of acquired immune deficiency syndromes.(1999).58(2).
    9.Pawlowski A, Jansson M, Sköld M, Rottenberg M E, Källenius G. (2012) Tuberculosis and HIV co-infection. PLoS Pathog. 8(2):e1002464
    10.Banks L M, Zuurmond M, Ferrand R, Kuper H. (2015) The relationship between HIV and prevalence of disabilities in sub‐Saharan Africa: systematic review (FA). , Tropical Medicine & International Health 20(4), 411-29.
    11.Hanass-Hancock J, Regondi I, L Van Egeraat, Nixon S. (2013) HIV-related disability in HIV hyper-endemic countries: a scoping review. , World Journal of AIDS 3(03), 257.
    12. (2009) . Health Canada.HIV/AIDS and Disability:Final Report of the 4th International Policy Dialogue International Affairs Directorate. Canada:Health , Canada .
    13.Myezwa H, Buchalla C, Jelsma J, Stewart A. (2011) HIV/AIDS: use of the ICF in Brazil and South Africa–comparative data from four cross-sectional studies. , Physiotherapy 97(1), 17-25.
    14.Hanass-Hancock J, Nixon S A. (2009) The fields of HIV and disability: past, present and future. , Journal of the International AIDS Society 12(1), 1.
    15.M Van As, Myezwa H, Stewart A, Maleka D, Musenge E. (2009) The International Classification of Function Disability and Health (ICF) in adults visiting the HIV outpatient clinic at a regional hospital in Johannesburg, South Africa. AIDS care. 21(1), 50-8.
    16.Petersen I, Hancock J H, Bhana A, Govender K. (2013) Closing the treatment gap for depression co-morbid with HIV in South Africa: Voices of afflicted women.
    17.Petersen I, Hancock J H, Bhana A, Govender K. (2014) A group-based counselling intervention for depression comorbid with HIV/AIDS using a task shifting approach in South Africa: a randomized controlled pilot study. , Journal of affective disorders 158, 78-84.
    18.Üstün T B, Chatterji S, Bickenbach J, Kostanjsek N, Schneider M. (2003) The International Classification of Functioning, Disability and Health: a new tool for understanding disability and health. Disability and rehabilitation. 25-11.
    19.Mannheimer S, Thackeray L, Huppler Hullsiek K, Chesney M, Gardner E et al. (2008) A randomized comparison of two instruments for measuring self-reported antiretroviral adherence. , AIDS care 20(2), 161-9.
    20.Walker D A. (2003) JMASM9: converting Kendall’s tau for correlational or meta-analytic analyses. , Journal of Modern Applied Statistical Methods 2(2), 26.
    21.Hanass-Hancock J, Misselhorn A, Carpenter B, Myezwa H. (2016) Determinants of livelihood in the era of widespread access to ART. AIDS. 1-8.
    22.Duran S, Spire B, Raffi F, Walter V, Bouhour D et al. (2001) Self-reported symptoms after initiation of a protease inhibitor in HIV-infected patients and their impact on adherence to HAART. HIV clinical trials. 2(1), 38-45.
    23.Carlozzi N E, Kratz A L, Downing N R, Goodnight S, Miner J A et al. (2015) . Validity of the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in individuals with Huntington disease (HD). Quality of Life Research 24(8), 1963-71.
    24.Myer L, Smit J, Roux L L, Parker S, Stein D J et al. (2008) Common mental disorders among HIV-infected individuals in South Africa: prevalence, predictors, and validation of brief psychiatric rating scales. AIDS patient care and STDs. 22(2), 147-58.
    25.Zhang W, O’Brien N, Forrest J I, Salters K A, Patterson T L et al. (2012) Validating a shortened depression scale (10 item CES-D) among HIV-positive people in British Columbia. , Canada. PLoS One 7(7), 40793.
    26.Mannheimer S, Mukherjee R, Hirschhorn L, Dougherty J, Celano S et al. (2006) The CASE adherence index: A novel method for measuring adherence to antiretroviral therapy. , AIDS care 18(7), 853-61.
    27.Bursac Z, Gauss C H, Williams D K, Hosmer D W. (2008) Purposeful selection of variables in logistic regression. Source code for biology and medicine. 3(1), 1.
    28.Nyirenda M, Chatterji S, Falkingham J, Mutevedzi P, Hosegood V et al. (2012) An investigation of factors associated with the health and well-being of HIV-infected or HIV-affected older people in rural South Africa. , BMC Public Health 12(1), 1.
    29.Scholten F, Mugisha J, Seeley J, Kinyanda E, Nakubukwa S et al.(2011)Health and functional status among older people with HIV/AIDS in Uganda. , BMC Public Health 11(1), 1.
    30.Peltzer K, Phaswana-Mafuya N. (2008) Health-related quality of life in a sample of HIV-infected South Africans. , African Journal of AIDS Research 7(2), 209-18.
    31.Center forDisease Control and Prevention. Analysis Plan for Pre-testing the WG Short Measurement. Set on Disability Atlanta2006[updated(March312010)cited(2017 April 6].Available from: https://www.cdc.gov/nchs/data/washington_group/meeting6/appendix6_analytic_plan.pdf .
    32.Rusch M, Nixon S, Schilder A, Braitstein P, Chan K et al. (2004) Impairments, activity limitations and participation restrictions: prevalence and associations among persons living with HIV/AIDS. in British Columbia. Health and Quality of Life Outcomes 2(1), 1.
    33.Olley B, Seedat S, Nei D, Stein D. (2004) Predictors of major depression in recently diagnosed patients with HIV/AIDS in South Africa. AIDS patient care and STDs. 18(8), 481-7.
    34.Goletz T J, Klimpel K R, Arora N, Leppla S H, Keith J M et al. (1997) Targeting HIV proteins to the major histocompatibility complex class I processing pathway with a novel gp120-anthrax toxin fusion protein. Proceedings of the National Academy of Sciences 94(22), 12059-64.
    35.Miró Ò, López S, Fernández-Solà J, Garrabou G, Pedrol E et al. (2005) Short communication: HIV infection, antiretrovirals, and apoptosis: studies on skeletal muscle. , AIDS Research & Human Retroviruses 21(8), 702-5.
    36.Lima V D, Geller J, Bangsberg D R, Patterson T L, Daniel M et al. (2007) The effect of adherence on the association between depressive symptoms and mortality among HIV-infected individuals first initiating HAART. , Aids 21(9), 1175-83.
    37.Tantisiriwat W, Zolopa A, Andersen J, Powderly W, Sanchez A et al. (2009) Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. , Journal of Infectious Diseases and Antimicrobial Agents 26(3), 135-6.
    38.Zolopa A R, Andersen J, Komarow L, Sanne I, Sanchez A et al. (2009) Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. , PloS one 4(5), 5575.
    39.Geyh S, Cieza A, Kollerits B, Grimby G, Stucki G. (2007) Content comparison of health-related quality of life measures used in stroke based on the international classification of functioning, disability and health (ICF): a systematic review. , Quality of Life Research 16(5), 833-51.
    40.Woby S R, Roach N K, Urmston M, Watson P J. (2007) The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy. European journal of pain. 11(8), 869-77.
    41.Chetty V, Hanass-Hancock J, Myezwa H. (2016) Expert consensus on the rehabilitation framework guiding a model of care for people living with HIV in a South African setting. , Journal of the Association of Nurses in AIDS Care 27(1), 77-88.
    42.Health S, Trust. (2017) . National Strategic Plan on HIV, TB and STIs2017-2022.Available from: 2017-2022.
    43.DOH Framework.and Strategy for Disability and Rehabilitation Services in2016. Available from:ilifalabantwana.co.za/wp-content/uploads/2016/07/Framework-25-may_1_3.docx.