Our study highlights the high level of impairments of up to 43% among persons living with HIV. However, very few people reported activity limitations which were mainly in the area of mobility (3%) and interpersonal interactions and relationships (4%). Our findings indicate that as with many chronic conditions, rehabilitation will become an important part of HIV care. High prevalence of impairments of body functions and variability reported in this study were also reported other studies,,. Mental functions (43%), sensory functions and pain (40%) and functions of the cardiovascular, hematological, immunological and respiratory systems (24%) were the most affected body functions. Mental function impairments, sleep disturbances, lack of energy and drive were very common among the study participants. Similar results have also been reported by Myezwa et al in a South African HIV outpatient population, however our results indicate an average of 20% less impairments compared to those reported in South Africa. Furthermore, among our study participants, pain experience (20%) and vestibular functions impairments (19%) were some of the most reported impairments of body functions. These results highlight the need to comprehensively review and manage HIV patients beyond the routine HIV markers of viral load, CD4 count to including individual functional assessments.
Digestion (11%) and weight maintenance (13%) were the most common reported impairments within the domain of the functions of the digestive, metabolic and endocrine systems which was prevalent in 25% of our study participants. However, Myezwa et al in 2008 reported 2 times more impairments at 44% prevalence related to this domain among South African outpatient HIV positive patients. Myezwa et al in 2009 further reported among HIV positive inpatients 3 times more impairments (84%) related to functions of digestive, metabolic and endocrine systems. This variation could be explained by the self-report illness and disability experience as the concept of illness varies depending on how the individual understands it. These variations in proportions affected are reflected in impairments related to the Neuromusculoskeletal systems, Myezwa et al in 2009 reported a 74% prevalence among HIV positive in patients and 27% prevalence among outpatients compared to the 18% reported in our study.
Compared to impairments of body functions, activity limitations and participation restrictions were less common among persons living with HIV attending out-patient clinics in urban Blantyre. In our study, interpersonal interactions and relations (4%) and mobility (3%) were the most reported activity limitations and participation restriction. Mental function impairments, genitourinary and reproductive functions impairments and functions of the digestive, metabolic and endocrine systems impairments were the significant body impairments associated with the limitations in functions indicated above. A similar study conducted among children at the Malawi Baylor College of Medicine reported a higher prevalence of disability among HIV positive children (33%) compared to HIV negative control (7%), however it is important to note that most of the children in this study were also reported to have comorbid conditions that may have influenced the finding.
Despite the variations in prevalence of disability on different domains from different settings, our estimates are relatively low compared to those reported in India and South Africa,,. A recent assessment of disability in a cohort of people living with HIV in South Africa and United States using the WHODAS questionnaire reported a 52% prevalence of disability among people living with HIV compared to what we are reporting in this study. Across all these settings, the variability is high in terms of impairments in body functions and activity limitations and participation restrictions, measurement differences within the individual studies need to be considered as the studies used different tools, setting of the studies need to also be considered as it varies significantly in terms of health services organisation and patient socio-demographic profiles all of which may affect the individual study estimates. We have noted a growing adult population living with HIV among our study participants, mean, 37 years (std. dev 9.5) and the oldest was at 78 years old. These results agree with estimates reported from recent studies which have seen a significant increase in the number of older adults living with HIV.
Our study adds to the body of knowledge for HIV care in Malawi highlighting emerging issues to improve care for people living with HIV. It further highlights the need to look beyond limited clinical markers like CD4 counts, viral load and symptoms of HIV disease towards a comprehensive functional assessment and management to improve quality of life among HIV patients. The findings agree with findings from the HIV disability study conducted among children living with HIV in Lilongwe, Malawi where a high magnitude of disability was reported demonstrating the need for rehabilitation services among people living with HIV in the era of improved longevity.
At macro level, HIV policy implications are important to also consider. The Malawi national strategic plans recognize that HIV remains a significant challenge in the country and requires a revision of strategies based on both emerging and best evidence instituting multidisciplinary approach towards HIV response. Similarly, with the emergency of HIV long terms survivors, the South African national strategic plan on HIV/TB/STI 2017—2022 duly recognize the need to address health needs of this population and have included rehabilitation as a critical component in HIV care. The aging HIV population with new disability experiences and impairments will require particular attention to address chronic HIV syndrome in the face of comorbidities that increase with age such as hypertension and diabetes. Recently, population level interventions including exercise have become popular interventions to avert some of the HIV associated impairments and limitations. Researchers in Canada are evaluating the impact of community based exercise program with the aim of reducing disability and enhancing health living.