The prevalence of co-morbidities in patients  on HAART referred for physiotherapy in three  public hospitals in KwaZulu-Natal, South Africa: a short report

<jats:p>Introduction: The roll-out of Highly Active Antiretroviral Therapy (HAART) to patients infected with the Human Immuno-deficient Virus (HIV) is presenting with co-morbidities as a result of the side effects of the drugs or the prolonged lifespan of the HIV positive individual. This poses a challenge to physiotherapists for rehabilitation which has changed from prophylaxis and management of opportunistic infections to managing the co-morbidities. The aim of this preliminary study was to determine the number of patients on HAART with co-morbidities admitted to three public hospitals in KwaZulu-Natal and referred for physiotherapy.Method: This descriptive epidemiological study used a cross-sectional design to determine the prevalence of co-morbidities associated with HAART. Baseline data of patients and their demographics, AIDS status and clinical co-morbidities were recorded. The sample consisted of 78 patients with an average CD4 count of 338 cells/mm³ and a viral load of 133 copies/mL. Patients were categorised according to their HIV stages: 13 (17%) asymptomatic, 44 (56%) ‘AIDS-related complex’ and 21 (27%) had full blown AIDS.Results: Patients referred for physiotherapy presented with peripheral neuropathy 36 (46%), pulmonary tuberculosis 29 (37%), musculo-skeletal pain 17(22%), myopathies 9 (12%), pneumonia 8 (10%), enthesopathies 4 (5%), cerebral vascular accidents 2 (3%) and abdominal pain 1(1%). Conclusion: To rehabilitate the HIV infected individual successfully physiotherapists should note the side effects and co-morbidities associated with HAART.</jats:p>

section_content: The prevalence of co-morbidities in patients on HAART referred for physiotherapy in three public hospitals in KwaZulu-Natal, South Africa:

A short report Higginson 2001) with comorbidities associated with the side effects of antiretroviral drugs often requiring reha bilitation. Physiotherapists will have to manage HIV related syndromes and comorbidities affecting the respiratory, neurological and musculoskeletal sys tems. Physiotherapy is shown to have beneficial effects on pain reduction and improving the healthrelated quality of life in an HIV affected person (Germaine et al, 2005). To date, Medline, Pubmed, Pedro, Biomed and a wide Google search showed no published studies of comorbidities and the number of patients on HAART referred for physio therapy in South Africa. The purpose of

section_content: Highly Active Antiretroviral Treatment (HAART), a triple combination of antiretroviral drugs (ARVs), has been provided in South Africa since April 2004. Patients with a CD4 count of less than 200 cells/mm³ are eligible for HAART which is prolonging their survival (Wong et al, 2004) with an increase in chronic health problems, impairments and disabilities compared to the preHAART era (Rusch et al, 2003). The infected individual is in transition between an acute terminal and a subacute chronic disease (Brown et al, 2000). Patient care will change from prophylaxis and the management of opportunistic infections to managing comorbidities associated with HAART which will continue to increase beyond 2015 (Dorrington et al, 2004). Health care professionals, social workers and religious leaders enable the HIV infected individuals to have a longer life span (AddingtonHall &
section_name: INTRODUCTION

section_content: Three public hospitals servicing a large proportion of the urban and semi urban population of Durban viz. King Edward VIII, Prince Mshiyeni and R. K. Khans were identified. Each hos pital had an antiretroviral clinic and an efficient crossreferral system. HAART was a combination of at least three antiretroviral drugs that included either a protease inhibitor or a nonnucleoside reverse transcriptase inhibitor as defined by Brown et al (2006).
section_name: Research setting

section_content: The population consisted of HIV/AIDS patients referred for admission. The sample was based on the following. (1992). These were asymptomatic stage (with few outward signs and symptoms), AIDS related complex (the development of one or more opportunistic infections) and AIDS (serious opportunistic infec tions and cancer). Confusing or missing information in the inpatients file was clarified or sourced from the referring medical practitioner, physiotherapist incharge of the unit or the patient. 

graphic characteristics of the sample and Table 2 the HIV profile. The average CD4 count was 338 cells/mm³ (±282) and viral load 132. 69 copies/mL (±309). Category of the HIV stages of the patients were 17% (n=13) asymptomatic, 56% (n=44) AIDS related complex and 27% (n=21) had full blown AIDS. Table 3 illustrates the comorbidities and their ranking. From the patients presenting with musculoskeletal pain (n=17), seven had upper limb and ten lower limb pain; myopathies (n=9) had three upper and six lower limb involvement; enthesopa thies (n=4), were restricted to the lower limbs with three having Achilles tendon and one iliotibial pain.
section_name: Sample

section_content: This study was designed to determine the comorbidities of patients receiving HAART and referred for physiotherapy. 

A study by Myezwa et al (2007), in the preHAART era, reported that 19% (n=139) of the possible 344 HIV patients were considered for physiotherapy of which 2% (n=3) were referred. The res piratory system was the most affected
section_name: DISCUSSION

section_content: The data was analysed using Microsoft Excel and SPSS version 15 and sum marised using descriptive statistics. The comorbidities were classified into eight common conditions. The most common was ranked 1 and the least common 8 (table 3 ). To ensure internal validity regarding sample selection bias only patients referred from the ARV sites who had not defaulted on their antiretroviral regime were selected. Information bias was minimized by transcribing infor mation directly and accurately from the inpatient's file. Patients having two or more comorbidities were analysed individually for statistical purposes.
section_name: Statistical analysis

section_content: A total of 138 patients on HAART were admitted during the study period. From these 60% (n=83) were referred for physiotherapy with 94% (n=78) satisfy ing the inclusion criteria. Five patients were excluded because three files lacked statistical information and two were noncompliant with verbal com munication. Table 1 indicates the demo with pneumonia manifesting in 29% followed by meningitis 25% and gender composition was 57% female and 43% male. In our study from a possible 138 patients on HAART, 60% (n=83) were referred for physiotherapy. The ranking of the comorbidities was 46% peripheral neuropathy, 37% tuberculosis (TB) and 10% pneumonia with 41% female and 59% male. A possible explanation for our findings is that HAART is "changing the profile" of the HIV infected individuals. 

Studies have documented a link between the central or peripheral nervous system, peripheral neuropathy and the HIV dis ease which is associated with antiretro viral therapy (Parry et al, 1997; Moyle & Sadler 1998). Our study supports this as 46% (n=36) presented with periph eral neuropathy and 3% (n=2) cerebral vascular accident. Our data show the lower limbs were more affected (n=19) compared to the upper limbs (n=8) and a combination of upper and lower limbs (n=9). Although the specific patho physiology is not understood (Moyle & Sadler 1998) noted that several nucleoside antiretroviral agents such as zalcitabine, stavudine and didanosine lead to patients developing peripheral neuropathy within three months. This antiretroviral implication for peri pheral neuropathy was supported by Gerschenson and Brinkman (2004) attributing the HIV nucleoside reverse transcriptase inhibitors as a possible antiretroviral therapy and HIV causes mithochondrial toxicities which could lead to myopathies, pain and enthesopa thies. Incidence of comorbid conditions could result in pain (Simpson & Tagliati, 1994) as noted in this study. 

The data indicate that enthesopathies was restricted to the lower limbs with three patients having the Achilles tendon and one iliotibial pain. Musculoskeletal pain and myopathies were more com mon in the lower limbs. It is not clear whether this greater prevalence of lower limb involvement was due to HAART medication or to the functional stress of weight bearing. 

One female patient was referred for abdominal pain because females with pelvic inflammatory pain are requested to be managed by shortwave diathermy. The patient's file however did not con firm the presence or absence of pelvic inflammatory disease.
section_name: RESULTS

section_content: Since no published studies described the comorbidities of patients on HAART referred for physiotherapy in South Africa, this study was an appropriate starting point. The results compared to a similar study in the preHAART era, shows that HAART is changing the profile of the HIV individual. The data indicate that physiotherapy referrals are changing from acute respiratory comorbidities to peripheral neuropathy, myopathies, enthesopathies and mus culoskeletal pain. The lower limbs are more affected compared to upper limbs. As a preliminary study from three public hospitals further research is needed to establish what comorbidities and func tional deficits exist for the physiotherapy profession in the HAARTera.
section_name: CONCLUSION

section_content: The researchers acknowledge that the study was limited to inpatients with referrals based on the medical practi tioner's discretion. As data collectors the researchers could have been bias although case notes were meticulously examined and information transcribed exactly from the patient's files. The authors accept that superficial data ana lysis and generalisation of the findings can be explored with further research. cause of mitochondrial injury to the host cells. 

HIV patients coinfected with TB receiving ARV therapy sometimes have a paradoxical worsening of symptoms. This is due to reconstitution of the immune response to mycobacteria by Rifampicin, an antiTB drug, which metabolises protease inhibitors and nonnucleoside reverse transcriptase inhibitors (McShane 2005). This study did not identify the prevalence of TB before the administration of HAART and the authors assumed their sample probably had TB prior to the commencement of antiretroviral therapy supported by Whalen et al (1995) where coinfection with HIV and mycobacterium tuberculosis results in TB being the commonest coinfection in HIV individuals. Myezwa et al (2007) ranked pneumo nia (29%) the most common diagnosis compared to 10% of our sample could be related to the mean CD4 cell count of 338cells/mm³ for our patients. The AIDS Surveillance Data Project found patients with a CD4 count of less than 200cell/mm³, as in the preHAART era, had a five times greater chance of acquir ing bacterial pneumonia compared to a higher CD4 cell count (CDC, 1992). 

Musculoskeletal pain, myopathies and enthesopathies data from this study are relevant as Gerschenson and Brinkman (2004) report that long term exposure to 'The total exceeds 100% because some patients had two or more co-morbidities
section_name: LIMITATION OF THE STUDY

section_name: ACKNOWLEDGEMENTS

section_content: The authors thank the physiotherapists, medical practitioners and nursing staff from the public hospitals for assisting with the study.
section_name: ACKNOWLEDGEMENTS

section_content: This descriptive epidemiological study used a crosssectional design to deter mine the prevalence of comorbidities associated with HAART during the period June 2007 to July 2008. The ethics committee of the University of KwaZuluNatal approved this study ( FECHS036/07 ). Informed consent was obtained from the patients prior to participation in this study.