Physical Therapy and the Global HIV/AIDS Pandemic

The upcoming 2017 World Confederation of Physical Therapy (WCPT) Congress in Cape Town, South Africa, is special because it will be the first time that a WCPT Congress has ever been held in the Africa Region of WCPT. In planning what will be my first trip to South Africa, I have been trying to learn more about the region, its people, some of the health challenges they face, and the role of physical therapy there. My reading immediately alerted me that South Africa's 54 million people are living at the epicenter of the ongoing global HIV/AIDs pandemic. South Africans are experiencing the biggest and most high-profile HIV epidemic in the world. With an estimated 7 million people living with HIV and 380,000 new HIV infections in 2015, South Africa carries 17% of the global burden of HIV infection.1,2 Although South Africa has the largest antiretroviral treatment (ART) program in the world, HIV prevalence remains high (19%) among the general population, and most people (52%) living with HIV do not receive ART.1 In 2013, about 360,000 children up to 14 years of age were living with HIV in South Africa; however, since 2002, HIV prevalence declined among children, primarily because of programs launched to prevent mother-to-child transmission of HIV.3 The scaling up of ART has reduced child mortality by 20%, and, although life expectancy of the South African population from birth remains low at 60 years (as of 2012), it has increased from 54 years in 2005 largely because of increases in survival of young adults and children.4 The prevalence and devastating impact of HIV/AIDS in South Africa is multifactorial and was exacerbated by the pre-2005 AIDS denialism of the government led by President Thabo Mbeki. An estimated 2.2 million person-years were lost due to the failure to implement a feasible and timely ART program.4 With the introduction of an ambitious program to provide ART to all people with HIV in 2003, adults who are HIV-positive in South Africa now have a near-normal life expectancy, provided they start ART before their CD4 count drops below 200 cells per cubic millimeter.5 Primary prevention remains the most cost-effective strategy to curtail the HIV epidemic; however, with the establishment of successful ART in South Africa and globally, HIV now is increasingly becoming a chronic illness, with accompanying periods of exacerbation and remission of symptoms6 that need to be managed. As this transformation continues, physical therapists and other rehabilitation professionals will have a crucial role to play in helping people with HIV/AIDS manage their condition and live a normal life.7 As Cade and colleagues7 noted in a PTJ Update on this topic in 2004, “Exercise and activity intolerance in people with HIV has been manifested as decreased peak aerobic capacity, ventilatory threshold ­occurring during MET [metabolic equivalents] levels associated with instrumental activities of daily living, and prolonged oxygen on-kinetics… These impairments may have important implications for physical disability in this population.”7(p660) In July 2017, Dr. Stephanie Nixon, associate professor in the Department of Physical Therapy at the University of Toronto, Ontario, will lead a timely symposium on physical therapy and HIV at the WCPT Congress in Cape Town. She and her colleagues on the panel will highlight examples of the success of rehabilitation intervention in people living with HIV from around the globe—even though, in general, rehabilitation is not yet viewed as a mainstream part of the HIV care continuum. Nixon and colleagues will call for a paradigm shift toward viewing HIV as a chronic manageable illness, requiring a rehabilitation focus on the good health and well-being of people living with HIV. This shift is a much-needed corrective to an overly narrow biomedical focus on HIV testing and ART in the current global HIV response.8 Fortunately, the evidence-base to support a paradigm shift—especially toward the use of exercise to improve or sustain the health and well-being of people with HIV—is growing.9 And resources are increasingly becoming available to assist rehabilitation professionals who work with people living with HIV.10 A recent systematic review and meta-analysis, using the Cochrane Collaboration protocol to search databases up to April 2013, identified 24 randomized trials that met the study criteria.11 This systematic review concluded that performing aerobic exercise or a combination of aerobic exercise and resistance exercise at least 3 times per week for at least 5 weeks is not only safe but can lead to significant improvements in cardiorespiratory fitness, strength, body composition, and quality of life for adults with HIV. No significant change in CD4 or viral load were found among exercisers who were medically stable.11 Unique challenges face those who seek to improve the health of people in South Africa. But the local challenges and successful local interventions are a microcosm of both the impediments and the promise for population health globally. I look forward to learning much more when I travel to Cape Town in July to learn from my physical therapist colleagues from around the world who are attending WCPT. I hope to meet many of you there.

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