E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-Module)

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1 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-Module) 2015

2 E-Module for Evidence-Informed HIV Rehabilitation (E-module) Acknowledgements Funders: This e-module was made possible with the support of Health Force Ontario InterprofessionalCare/ Education Fund ICEF Updates to this e-module were made possible through a financial contribution from the Public Health Agency of Canada. The opinions expressed in this publication are those of the authors / researchers & do not necessarily reflect the views of the Public Health Agency of Canada Disclaimer: While the content of this e-module is, to the best of our knowledge, current and reliable, information is not a substitute for actual health care and treatment. Opinions do not necessarily reflect the official policy of CWGHR or any sponsoring organizations. Production of this e-module has been made possible through a financial contribution from the Government of Ontario. The opinions expressed in this publication are those of the authors/ researchers and do not necessarily reflect the views of the funding agencies. The content of this resource module was originally updated from the 1998 publication: A comprehensive guide for the care of persons with HIV disease. Issued also in French under title: Un guide complet de soins aux personnes atteintes d'une infection a VIH. Module 7 publ. by the Wellesley Central Hospital, Toronto, Canada. Includes bibliographical references and index. Partial contents: Module 7. Rehabilitation services. ISBN (Module 7), RC607.A26C '92 C The content of this resource module has been updated from the 2013 publication: Copyright of the 1998 publication was transferred from the Wellesley Institute to the Canadian Working Group on HIV and Rehabilitation in March of The Canadian Working Group on HIV and Rehabilitation (CWGHR) 2015 ISBN CWGHR is a national multi-sector, multi-disciplinary, charitable organization of stakeholders involved in rehabilitation in the context of HIV. CWGHR works to bridge the traditionally separate worlds of HIV, disability and rehabilitation to promote quality of life through research, education, and cross-sector partnerships. Design: Coco* Creative Production: Catherine Nasije - E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION 2015 II

3 PREFACE Introduction With many people with HIV living longer, facing a multitude of health challenges related to HIV, concurrent health conditions, and side effects of treatment, the role for rehabilitation in the context of HIV continues to grow. This E-Module for Evidence- Informed Rehabilitation (e-module) is a comprehensive resource for rehabilitation professionals to respond to the increasing role for rehabilitation in the context of HIV. This e-module is an update of "A Comprehensive Guide for the Care of Persons with HIV Disease (Module 7)", originally published in 1998 by Health Canada and the Wellesley Central Hospital, Toronto, Canada. The changing profile, emerging issues and new evidence related to HIV and rehabilitation prompted the Canadian Working Group on HIV and Rehabilitation (CWGHR) to update this important resource for rehabilitation professionals so that they may better address the current needs of people living with HIV. Rehabilitation Audience In this e-module, CWGHR broadly defines rehabilitation as any services or providers that may address or prevent symptoms and impairments, activity limitations and social participation restrictions experienced by an individual (Worthington et al. 2005). Hence, while the e-module is primarily intended for rehabilitation professionals, other audiences may include other health and social service providers and people living with HIV. Development of the E-Module The aim of this e-module is to enhance knowledge about HIV care among rehabilitation professionals so they may better address the needs of people living with HIV. Development of this document involved a multi-staged and interdisciplinary process, led by CWGHR. Notable characteristics of this e- module include the comprehensive review and incorporation of current best evidence on HIV and rehabilitation and the interdisciplinary approach to its development. This document resulted from collaboration among a dedicated team of authors, editors, and external reviewers including people living with HIV, clinicians, researchers, and advocates representing fields spanning medicine (family medicine and physiatry), nursing, occupational therapy, psychology, physical therapy, speech-language pathology, social work, pediatrics, midwifery, and policy. Through the leadership of CWGHR, the e-module team collectively authored, reviewed, and revised the document at multiple stages to ensure the content was comprehensive, relevant, readable, and applicable for rehabilitation professionals and HIV care. We gratefully acknowledge the financial support for the development of this e-module from the Ontario Ministry of Health and Long Term Care and the Public Health Agency of Canada. Content We made a number of revisions to this e-module, building on the original Module 7. We updated sections with current best evidence on HIV and rehabilitation, removed out-of-date sections from the original module, and added content to address current and emerging issues in HIV and rehabilitation. New sections of the e-module worthy of highlighting include aging and concurrent health conditions, cognitive rehabilitation, evidence-informed rehabilitation interventions, information on accessing rehabilitation and advocacy. Another novel component of the e-module includes six comprehensive case studies developed to facilitate learning through the practical application of knowledge in complex clinical scenarios. Case studies include guiding questions to promote critical thinking among rehabilitation professionals about assessment, analysis and treatment interventions that can be addressed independently or as a group. Guiding questions include discussion notes with embedded links that will direct the reader to applicable sections in the e-module that are addressed in each case. This E-Module for Evidence-Informed Rehabilitation is divided into seven chapters. Chapter 1 includes an introduction that reviews current approaches to HIV and rehabilitation, HIV pathogenesis, and epidemiology, interacting with communities affected by HIV, and rehabilitation, including traditional rehabilitation professionals (physical therapy, occupational therapy, speech-language pathology and physiatry), complementary and alternative medicines and therapies, vocational rehabilitation, and psychological rehabilitation. Chapter 2 provides an overview of best practices in rehabilitation. Chapter 3 describes the symptoms and impairments associated with HIV and interventions to address them. Chapter 4 provides an overview of the systemic impacts of HIV. Chapter 5 is dedicated to pediatrics. Chapter 6 provides an overview of interventions (both pharmacological and nonpharmacological) including exercise, modalities, vocational rehabilitation, and self-management. Chapter 7 describes issues related to HIV and rehabilitation such as access to care, advocacy, research priorities, and provides additional resources on national rehabilitation and consumer organizations. Chapter 8 includes six case studies that encourage integration of the e- module content and problem-solving around practical scenarios that rehabilitation professionals may face in clinical practice. Red flags throughout the e-module highlight important clinical symptoms that indicate the need for immediate referral to a physician. E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION 2015 III

4 How to Use the E-Module While the e-module can be read sequentially from start to finish, the online format allows readers to navigate and seek out specific sections of this resource, depending on their specific learning needs and areas of interest. Links to additional resources on topics addressed in the e-module are interspersed throughout so that readers can immediately access further information. How to Cite Resources created by CWGHR are copyrighted. They may be reprinted and distributed in their entirety for non-commercial purposes without prior permission, but permission must be obtained to excerpt and / or edit / adapt their content. CWGHR's resources are intended to be shared with as broad a range of stakeholders as appropriate and the use of these materials is encouraged. For further information on use of resources go to Form.doc Keeping the E-Module Current The e-module was designed to be a living document and it will be updated regularly. Updates are completed by a large team of volunteers who participate as content experts, advisory committee members, writers and reviewers. While we strive to modify key findings that may occur in several places throughout the e-module, readers are also asked to inform us when content between sections seems to be conflicted. For further information, to provide feedback, or to suggest updates for this e-module, please contact the Canadian Working Group on HIV and Rehabilitation (CWGHR) at or Canadian Working Group on HIV and Rehabilitation March 31, 2015 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION 2015 IV

5 National Working Group Management and Editing Committees Update Committee Anne Phillips (Chair) Larry Baxter Larry Baxter Gerry Bally Alan Casey Allana Beavis Alan Craig Will Chegwidden Alan Casey John Flannery Le-Ann Dolan Will Chegwidden Jim O'Neill Sarah Eby Le-Ann Dolan Sheila Thomas Julie Hard Sarah Eby Georgina Veldhorst Ken King Nicole Gervais Kelly O'Brien Julie Hard Rehabilitation Committee Greg Robinson Kelly O'Brien Michael O'Dell (Chair) Sheila Thomas Greg Robinson Ron Bowie Todd Tran Jennifer Siemon Gary Gibson Janet Wu Stephen Tattle Rae Graham Elisse Zack Amanuel Tesfamichael Christine MacDonell Barry Trentham Joann McDermid Co-ordinating team: Janet Wu Bruce Mills Georgina Blanchard Tammy Yates Stephanie Nixon Catherine Nasije Deborah Yoong Lynda Phillips Annette Wilkins Elisse Zack Stan Read Bill Ryan Summer students and project assistance: Stephen Tattle Amanda Himmel (2010) Catherine Nasije Sheila Thomas Md. Shah Newaz (2010) Annette Wilkins Janet Wu Michael Siarkowski (2010) Yalnee Shanthraham (2009) Eamonn Wall (2009) Elizabeth Uleryk, Information Specialist Co-ordinating team: Project Assistance: Rebecca Perlmutar Mary Wilkins Authors: The following people wrote portions of the text: (name, expertise) Gerry Bally Maggie Atkinson, Neurocognitive Stephanie Nixon, Academic Physical Therapy Alan Craig Larry Baxter, Policy & Self Management Kelly O'Brien, Academic Physical Therapy Mary Grondin Allana Beavis, Physical Therapy Brent Oliver, Vocational Rehabilitation John Flannery Georgina Blanchard, Midwifery Melissa Popiel, Vocational Rehabilitation Sean Hosein Alan Casey, Physiatry Greg Robinson, Family Medicine Rodney Kort Will Chegwidden, Occupational Therapy Jennifer Siemon, Occupational Therapy Bruce Mills Sharin Collins, Neurcognitive Interventions Sheila Thomas, Occupational Therapy Christine MacDonell Le-Ann Dolan, Social Work Todd Tran, Occupational Therapy Joann McDermid Marg Dwyer, Self Management Barry Trentham, Occupational Therapy Stephanie Nixon Jacqueline Gahagan, Policy Annette Wilkins, Health Services Research Michael O'Dell Jill Hanass-Hancock, International Policy Janet Wu, Speech-Language Pathology Anne Phillips Julie Hard, Physical Therapy Deborah Yoong, Pharmacy Lindy Samson Hal Huff, Naturopathy Elisse Zack, Policy Stan Read Ken King, Social Work Arn Schilder Monica Khalil, Human Resources Stephen Tattle Sheila Thomas Brenda Merritt, Occupational Therapy Samra Mian, Epidemiology Jimmy Nguyen, Pharmacy Student Lead E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

6 External Reviewers Kevin Barlow Brenda Barr Deborah Barrett Jeanine Bianco Louise Binder Betty Jane Blair Glen Brown Anne Carter Jeff Crowly Anne Gordon Marie Jutras Marshall Kubota Joan Lee Christine Lussier Elaine Marchand Jay Meythaler Brian Ouellette Diana Peabody Elsie Parkinson Marilyn Robertazzi Lindy Samson Anne Strickland Linda Studholme Tracy Xavier Vera Carmini, Pediatric Physical Therapy Sarah Eby, Physical Therapy Alda Fernandes-Penney, Pediatric Psychometry Deirdre Igoe, Pediatric Physical Therapy Carly Mutch, Pediatric Occupational Therapy Shane Patey, Health Promotion Deborah Randall-Wood, Nursing Kirsti Reinikki, Rehabilitation Education Shari Renaud, Pediatric Physical Therapy Mary Lou Smith, Pediatric Psychology Expedited Stakeholder Review John Arenburg Paul Curwin Marg Dwyer David Gee Margaret Lapointe Jean McKellar San Patten (Facilitator) French language reviewers Marie Jutras Sylvie Lemay Consumer Committee Arn Schilder (Chair) Cornelius Baker Alan Craig Anitra Halliday Sean Hosein Rodney Kort Roger LaRade Sylvie Lemay Tom McAulay Gary Murphy Elaine Daniels People living with HIV and AIDS have participated on the planning, development and management committees for this resource. People living with HIV and AIDS have also written sections of this resource and have participated as reviewers and in other capacities. E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

7 ACRONYMS Acronyms will be defined in each subsection to accommodate e-format. Acronyms will not be used in titles. Where the acronym long form only appears once in a section the long form will be maintained. Long form will not be used for Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV). AZT: Botox: BTA: cart: CAD: zidovudine Botulinum toxin type A Botulinum toxin type A Combination anti-retroviral therapy Coronary Artery Disease CAMT: Complementary and Alternative Medicines and Therapies CAS: Canadian AIDS Society CATIE: Canadian AIDS Treatment and Information Exchange CBT: Cognitive Behaviour Therapy CCAC: Community Care Access Centres CES-D: CMV: CNIB: CNS: COPD: ddc: ddi: d4t: DHHS: DNA: DOT: DSP: EDEN: EBV: FES: FET: GI: HAD: Centre for Epidemiological Studies for Depression Scale Cytomegalovirus Canadian National Institute for the Blind Central Nervous System Chronic Obstructive Pulmonary Disease zalcitabine didanosine stavudine Department of Health and Human Services Deoxyribonucleic Acid Directly Observed Therapy Distal Symmetrical Polyneuropathy Episodic Disabilities Employment Network Epstein-Barr Virus Functional Electrical Stimulation Forced Expiry Technique Gastro-Intestinal HIV-Associated Dementia HAART: Highly Active Antiretroviral Therapy HALS: HAND: HBV: HCV: HIV: Highly Active Antiretroviral Therapy-Associated Lipodystrophy Syndrome HIV-Associated Mild Neurocognitive Disorder Hepatitis B Virus Hepatitis C Virus Human Immunodeficiency Virus HIVAN: HIV Associated Nephropathy HIVE: HPV: HSV: HRQL: IBS: ICF: IDP: IDU: IFC: IPV: IRIS: IUD: KS: LBP: LIP: MAC: MDC: MCID: MI: MTCT: HIV Encephalopathy Human Papillomavirus Herpes Simplex Virus Health Related Quality of Life Irritable Bowel Syndrome International Classification of Functioning, Disability and Health Inflammatory Demyelinating Polyneuropathy Injection Drug Use Interferential Current Intimate Partner Violence Immune Reconstitution Inflammatory Syndrome Intrauterine Device Kaposi's Sarcoma Low Back Pain Lymphocytic Interstitial Pneumonitis Mycobacterium Avium Complex Minimal Detectable Change Minimal Clinically Important Difference Myocardial Infarction Mother-to-Child Transmission N/NRTI: Nucleoside/Nucleotide Reverse Transcriptase Inhibitor NNRTI: Non-Nucleoside Reverse-Transcriptase Inhibitor NRRTS: National Registry of Rehabilitation Technology Suppliers NSAID: Non-Steroidal Anti-inflammatory Drug OHL: Oral Hairy Leukoplakia OT: Occupational Therapist PCNSL: Primary Central Nervous System Lymphoma PCP: Pneumocystis Carinii Pneumonia PCP: Phencyclidine PEP: Post-Exposure Prophylaxis PEP Positive Expiratory Pressure Mask mask: PHAs: People Living with HIV or AIDS PML: Progressive Multifocal Leukoencephalopathy PNF: Proprioceptive Neuromuscular Facilitation PSE: Progressive Subacute Encephalopathy E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

8 PSMP: PT: QOL: RCT: RNA: SD: SF-36: SLT/ SLP: SSRIs: STI: TB: TENS: VZV: WHO: Positive Self-Management Program Physical Therapist/Physiotherapist Quality of Life Randomized Controlled Trial(s) Ribonucleic Acid Sexual Dysfunction SF-36 Quality of Life Questionnaire Speech-Language Therapist/Speech-Language Pathologist Selective Serotonin Reuptake Inhibitors Sexually Transmitted Infection Tuberculosis Transcutaneous Electrical Nerve Stimulation Varicella-Zoster Virus World Health Organization Red flags located throughout this module highlight particularly important clinical symptoms that indicate the need for immediate direct contact with a physician. E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

9 TABLE OF CONTENTS E-Module for Evidence-Informed HIV Rehabilitation Acknowledgements Preface Acronyms 3 Table of Contents 5 CHAPTER 1 Introduction 18 1_1 Introduction Current Approaches to HIV and Rehabilitation The Canadian Working Group on HIV and Rehabilitation A New Concept - Episodic Disability Episodic Disability in the Context of HIV The Episodic Disability Framework Contributions of Rehabilitation to HIV Treatment Pathogenesis of HIV Infection HIV Transmission Unprotected Sexual Activities Shared Needles or Equipment Mother-to-Child Transmission Occupational Exposure Blood and Blood Products Pathogenesis Once Transmission has Occurred Viral Load CD4 Count HIV Replication Surrogate Markers Generalized Course of HIV Infection AIDS Defining Illnesses Epidemiology HIV in Canada Canadian Impact Gay Men and Other Men who Have Sex with Men People who Inject Drugs Aboriginal Peoples Prison Inmates Youth at Risk Women People from HIV-Endemic Countries Older Adults 25 1_2 Interacting with Communities Affected by HIV Introduction Turning to Community Resources Affected Communities The Role of Identity in HIV Care 27 I II III E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

10 1.2.5 Identity and the Client-Provider Relationship Age Chosen Family Ethnicity and Culture "Hard to Serve" or "Hard to reach" For Whom? 28 1_3 Introduction to Rehabilitation For Clients, Families and Other Care Providers Introduction: What is Rehabilitation? Physical Rehabilitation Physical Therapist Occupational Therapist Speech-Language Pathologist Physiatrist Complementary and Alternative Medicines and Therapies Vocational Rehabilitation Participation Assistance Rehabilitation Nurses Vocational and Rehabilitation Counsellors Occupational Therapists Psychological Rehabilitation Mental Health Promotion and Support Basic Components of a Rehabilitation Program Where Are Rehabilitation Services Provided? How Can People Living with HIV Access Rehabilitation Services? Who Pays for Rehabilitation Services? Provincial Health Plan or Hospital Program Funding Private Insurers Sliding Fee Scales and Payments Over Time AIDS Service Organizations One Stop Resource 33 CHAPTER 2 Rehabilitation Best Practices 34 2_1 Current Issues in Evidence-Based Rehabilitation and Interprofessional Learning Building Evidence Across Study Designs 34 2_2 Outcomes and Measurement in Rehabilitation Practice What is Measurement? Why Should Rehabilitation Providers Use Outcome Measures? Why Do Rehabilitation Providers Use Measures in Practice? Descriptive Predictive Evaluative How Do Rehabilitation Providers Know if a Measure Is Useful in Practice? Reliability Validity Responsiveness Interpretability Other Measurement Characteristics to Consider Floor effect Ceiling effect 36 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

11 2.2.6 Generic versus HIV-Specific Measures Steps to Consider in HIV and Rehabilitation Measurement Obtaining a Copy of the Desired Measure Summary 37 Table 2.2 Examples of Outcome Measures Used in HIV Rehabilitation Practice and Research 37 2_3 Guiding Principles for Best Practices in HIV and Rehabilitation Guiding Principles Theme One Theme Two Theme Three Additional Considerations The Importance of Interprofessionalism in HIV Care Practitioner-Client Relationship History-Taking and Assessment Medical History Cognitive Assessment Substance Use History Sexual History Information About Support Networks Activity and Social Participation Restrictions 42 2_4 International Forum on HIV and Rehabilitation Research 43 CHAPTER 3 Symptoms and Impairments 44 3_1 Introduction 44 Table 3.1 Examples of Rehabilitation Intervention Categories Concurrent Medical and Neurological Diagnoses Episodic and Ultimately Progressive Disease Course Parallel Primary and Secondary Prevention Efforts Uniqueness of Persons Served Importance of Psychological Impairments Importance of Community Resources in HIV Rehabilitation How to Use this Section 47 3_2 Pain 47 Table 3.2 Clinical Aspects of Pain Rehabilitation Interventions Peripheral Neuropathic Pain Physical Modalities Adaptive Equipment Desensitization Techniques Psychological Counselling and Interventions Environmental Assessment Medication Management Miscellaneous Musculoskeletal and Joint Pain Exercise Positioning Physical Modalities Medications Management 49 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

12 3.2.4 Psychological Counselling and Techniques Miscellaneous Community Resources 49 3_3 Weakness and Coordination 49 Table 3.3 Clinical Aspects of Weakness and Coordination Impairments Rehabilitation Interventions General Guidelines Enhancing Mobility Problems with Activities of Daily Living General Guidelines Adaptive Equipment to Enhance Independence Decrease the Risk of Falls Community Resources 51 3_4 Fatigue 51 Table 3.4 Clinical Aspects of Fatigue Rehabilitation Interventions Energy Management Environmental Exercise Nutrition Medications Psychosocial Community Resources 52 3_5 Weight Management 52 Table 3.5 Clinical Aspects of Weight Loss Rehabilitation Interventions Nutritional General Guidelines Anorexia and Early Satiety Alterations in Taste (Dysgeusia) Pain and Inflammation in the Mouth (Mucositis) / Pain on Swallowing (Odynophagia) Difficulty Swallowing (Dysphagia) Dyspnea while Eating Malabsorption and Diarrhea Nausea and Vomiting Abdominal Cramping and Bloating Dehydration Constipation Physical Medications Miscellaneous Community Resources 54 3_6 Cognitive Impairments 54 Table 3.6 Clinical Aspects of Cognitive Impairments Rehabilitation Interventions Managing Complex and Simultaneous Tasks Maximize Safety General Cognitive Deficits 56 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

13 Cognitive Stimulation Behavioural Motor Memory Physical Environment Other Community Resources 58 3_7 Cardiac and Respiratory Impairments 58 Table 3.7 Clinical Aspects of Cardiac and Respiratory Impairments Rehabilitation Interventions Mobilize Secretions and Improve Lung Ventilation Traditional Manual Physiotherapy Techniques Strategies a Client can Perform Independently Aspiration Shortness of Breath and Associated Anxiety Exercise Oxygen Requirements Community Resources 59 3_8 Sensory Loss Visual Loss 59 Table 3.8 Clinical Aspects of Visual Loss Referrals Rehabilitation Interventions Mobility Activities of Daily Living Enhancing Vision Finances Environment Meal Preparation Shopping Medications Other Psychosocial Community Resources Hearing Loss Referrals 61 3_9 Mental Health Prevalence of Mental Illness with HIV Mood Disorders as a Primary Complaint HIV Can Cause Mood Disorders Impact of HIV Medications on Mood Disorders Mood Disorders as a Risk Factor for Acquiring HIV Living with Mood Disorders in the Context of Living with HIV Role for Rehabilitation 63 3_10 Substance Abuse Introduction Harm Reduction Versus Abstinence The Harm Reduction Model 63 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

14 The Practitioner-Client Relationship History-Taking and Assessment Medical History Cognitive Assessment Substance Use History Substances Used Routes of Administration Pattern of Use Drug Treatment History Sexual History Information About Support Networks Behaviour Change Stages of Change Theory Detoxification Smoking Cessation Coordination of Care 67 CHAPTER 4 Systemic Impacts 68 4_1 Introduction 68 4_2 Cardiovascular Myocarditis and Endocarditis Dilated Cardiomyopathy Pericardial Effusion Coronary Artery Disease Peripheral Vascular Disease Stroke 69 4_3 Gastrointestinal 69 4_4 Malignancy Epstein-Barr Virus Human Herpes Virus Human Papillomavirus 69 4_5 Metabolic and Endocrine 70 4_6 Musculoskeletal Arthropathies and Arthralgias Myopathies and Myalgias Osteopenia and Osteoporosis Osteonecrosis 71 4_7 Neurocognitive HIV-Associated Neurocognitive Disorders 71 4_8 Neurological Autonomic Nervous System Central Nervous System HIV-Associated Dementia Toxoplasmosis Progressive Multifocal Leukoencephalopathy Cryptococcosis Primary Central Nervous System Lymphoma Vacuolar Myelopathy 73 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

15 4.8.9 Peripheral Nervous System Distal Symmetrical Polyneuropathy Inflammatory Demyelinating Polyneuropathy 73 4_9 Pulmonary Pneumocystis Carinii Pneumonia Tuberculosis Cytomegalovirus Histoplasmosis 74 4_10 Renal HIV-associated Nephropathy 74 4_11 Hepatic 74 4_12 Aging Introduction Navigation and Advocacy for Older People Living with HIV or AIDS Normal Aging Aging with HIV Increased Risk of Concurrent Conditions Immune System and Immune Response Response to Antiretroviral Medication in Older People Metabolic and Cardiovascular Changes Cholesterol and Triglycerides Cardiovascular Risk Lipodystrophy Diabetes Mellitus Hepatic Function Renal Function Respiratory Function Chronic Obstructive Pulmonary Disease and Lung Cancer Gastrointestinal System Skeletal System and Bone Health Osteoporosis and Osteopenia Joint Disease Rehabilitation Interventions Visual System Rehabilitation Interventions Central Nervous System - Neurocognitive Functioning HIV-Associated Dementia HIV-Associated Mild Neurocognitive Disorder Asymptomatic Neurocognitive Impairment Interventions for Those with Recognized Cognitive Challenges Interventions for Anticipated Functional Neurocognitive Impairment Cortical versus Subcortical Dementia Cancer and Malignancies Sexual Health, Sexual Behaviour and Sexual Well-Being Menopause and Sex Hormone Changes Menopause and Sex Hormone Changes in Women Sex Hormone Changes in Men Adherence 83 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

16 Psychosocial Issues Interventions Stigma Disclosure and Stigma Management Interventions Services and Physical Environments for People Aging with HIV Infection Evidence-Informed Recommendations for Rehabilitation with Older Adults Living with HIV 84 4_13 Sexual Health and Dysfunction Introduction Reasons for Sexual Dysfunction in People Living with HIV or AIDS Ascertaining the Specific Type of Sexual Dysfunction Some Questions to Ask: Addressing Solutions to Sexual Dysfunction Consider General Health A word of caution Resources 87 4_14 Female Reproductive Health Global Context Women, Substance Abuse and Mood Disorders Violence Against Girls and Women and Intimate Partner Violence Prevention Strategies for Women Post Exposure Prophylaxis Female Condom Microbicides Education and Knowledge Pregnancy, Birth and Breastfeeding Mode of Delivery 90 4_15 People with Pre-Existing Disabilities and HIV 90 CHAPTER 5 Pediatrics 91 5_1 Introduction Disclosure Adherence Means to Determine Adherence Levels Strategies to Facilitate Adherence Strategies to Assist in Persistent Adherence Problems 92 5_2 Feeding Problems and Poor Growth Breastfeeding Feeding Problems and Poor Growth 93 Table 5.2 Clinical Aspects of Feeding Problems and Poor Growth Rehabilitation Interventions Inadequate Feeding Self-Feeding Problems Difficulty Swallowing Poor Appetite Diarrhea Increased Caloric Demands 95 5_3 Movement and Coordination Impairments 95 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

17 Table 5.3 Clinical Aspects of Movement and Coordination Impairments Rehabilitation Interventions Generalized Hypotonia and Delayed Achievement of Motor Milestones from Static Encephalopathy Hypertonicity from Progressive Encephalopathy Problems of Limited Mobility from Encephalopathy or Neuropathy Loss of Independence in Self-Care 96 5_4 Behaviour, Memory, and Learning Impairments 96 Table 5.4 Clinical Aspects of Behaviour, Memory, and Learning Impairments Rehabilitation Interventions Infants Slow Acquisition of Developmental Milestones Poor or Absent Expressive Language Children Poor Memory Attention and Learning 97 5_5 Respiratory Impairments 97 Table 5.5 Clinical Aspects of Respiratory Impairments Rehabilitation Interventions General Deep Breathing Exercises Manual Techniques Expiratory Techniques 98 5_6 Pain Nonpharmacological Interventions for Pain Pharmacological Interventions for Pain 99 5_7 Adolescents and Young Adults 99 CHAPTER 6 Overview of Interventions 100 6_1 Preventive Rehabilitation Introduction Exercise Nutrition Key Strategies for Optimal Nutrition Achieve and Maintain Nutritional Adequacy Monitor Nutritional Status Implement Safe Food, Water and Sanitation Practices Establish a Reliable Supply and Variety of Food Explore Use of Nutrition-Based Complementary Therapies Risk Reduction / Risk Management General Transmission Reduction Education Psychosocial Implications for Risk Reduction and Management Emerging Issues: HIV and Aging Emerging Issues: The Importance of Stable Housing Emerging Research Advances Guidelines for Primary and Secondary Prevention 104 6_2 Pharmacologic Interventions Background Online Open Access Treatment Guidelines 104 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

18 Canadian HIV/AIDS Pharmacists Network International Antiviral Society USA Panel and the Department of Health and Human Services European AIDS Clinical Society World Health Organization Consolidated Guidelines for Treating and Preventing HIV Infection Current Challenges: HIV, Aging and Polypharmacy Current Challenges: Adherence Online Open Access Resources for Clients 105 6_3 Evidence-Informed Rehabilitation Interventions for HIV Introduction Objectives 105 Table 6.3: Inclusion Criteria for identification of relevant articles Findings Phase 1 (October 2008-January 2009) Phase 2 (January 2009-September 2009) E-Module Updates 107 6_4 Exercise Aerobic Exercise Resistance Exercise The FITT Principle Frequency How often should a person exercise? Intensity How strenuous should the exercise be? Time How long should a person exercise? Type What type of exercise should a person do? Research on the Impact of Exercise for Adults Living with HIV Exercise and Lipodystrophy Exercise and Other Co-Interventions Women and Exercise Exercise and Developing Countries Other Forms of Exercise: Tai Chi and Yoga Exercise with Older Adults Living with HIV Summary 110 Table 6.4 Summary of Findings from the Research Evidence from Two Systematic Reviews on Aerobic and Resistive Exercise 110 6_5 Modalities Acu-TENS/TENS Arts Based Therapy Botulinum Toxin Therapies Cannabinoids Topical Capsaicin, e.g. Patch Cognitive Behaviour Therapy Cryotherapy Dental Care Functional Electrical Stimulation Facet Joint Interventions Manipulation Orthoses and Prosetheses Osteopathy Prolotherapy 113 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

19 Sleep Hygiene Techniques Trigger Point Needling Water Based Therapies 114 6_6 Assistive Devices Introduction Resources on the Net for Rehabilitation Providers 114 6_7 Vocational Rehabilitation Introduction HIV and Employment The Significance of Employment for People Living with HIV and AIDs Factors that might Facilitate Employment/ Return-to-Work Barriers to Employment or Return-to-Work Other Potential Barriers General Factors to Consider Physical Health Factors Cognitive and Behavioural Health Factors Psychosocial Health Factors Return-to-Work Principles Creating a Network of Support Accommodation Options in the Workplace Income Security and Health and Disability Insurance Vocational Rehabilitation Programming Basic Tenets of Vocational Rehabilitation Effective Vocational Rehabilitation Alternatives to Paid Employment Summary Retirement on a Low Income 122 6_8 Self-Management Strategies Complementary and Alternative Medicines and Therapies Introduction What are Complementary and Alternative Medicines and Therapies? How are Complementary and Alternative Medicines and Therapies Used? Examples of Complementary and Alternative Medicines and Therapies Aboriginal Healing Traditions Acupuncture Affirmations and Visualization Aromatherapy Ayurvedic Medicine Dietary and Other Supplements (Including Vitamins and Minerals) Herbal Medicine Homeopathy Massage and Touch Therapies Meditation Mind-Body Approaches Naturopathy Reflexology Shiatsu Stress Management Techniques 127 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

20 Tai Chi Therapeutic Touch Traditional Medicine Systems Yoga How to Access and Pay for Complementary and Alternative Medicines and Therapies Considerations for Health Care Providers 128 6_9 Theory-Based Patient Activation Interventions 129 6_10 Palliative Care Introduction What is the Role of Rehabilitation in the Context of Palliative Care? Rehabilitation Interventions for Palliative/End-of-Life Care Physical Modalities for Pain Management Role for Speech-Language Pathology Addressing the Emotional and Spiritual Programs Casey House Palliative/End-of-Life Care AIDS Bereavement Project of Ontario Canadian Hospice Palliative Care Association 132 CHAPTER 7 Current Issues in HIV Rehabilitation in Canada 133 7_1 Access to Care Demand for Rehabilitation Services Rehabiliation as Prevention Rehabilitation as Palliative Care Changes in Health Service Delivery Models 133 7_2 Navigation and Advocacy Background Sensitive Practice within Client-Centred Care Client- or Patient-Centred Care Tips on Client Engagement Navigation Advocacy Looking Ahead 137 7_3 Identifying Key Research Priorities in HIV and Rehabilitation National Consensus Statement on Women, Trans People and Girls and HIV Research in Canada 138 7_4 Occupational Exposure / Universal Precautions General Information Body Fluids Potentially Infectious for HIV Body Fluids Not Infectious for HIV Reducing Occupational Exposure to Infections Guidelines for Management of Occupational Exposure 139 7_5 Privacy, Disclosure and the Law 139 7_6 Resources National Rehabilitation Associations Canada United States National ASO/CBO Organizations Canada 140 E-MODULE FOR EVIDENCE-INFORMED HIV REHABILITATION (E-MODULE) CANADIAN WORKING GROUP ON HIV AND REHABILITATION

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