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Nixon et al. Globalization and Health 2011, 7:41
http://www.globalizationandhealth.com/content/7/1/41




 COMMENTARY                                                                                                                                   Open Access

The increasing chronicity of HIV in sub-Saharan
Africa: Re-thinking “HIV as a long-wave event”
in the era of widespread access to ART
Stephanie A Nixon1,2*, Jill Hanass-Hancock2, Alan Whiteside2 and Tony Barnett3,4


  Abstract
  HIV was first described as a “long-wave event” in 1990, well before the advent of antiretroviral therapy (ART). The
  pandemic was then seen as involving three curves: an HIV curve, an AIDS curve and a curve representing societal
  impact. Since the mid-2000’s, free public delivery of life-saving ART has begun shifting HIV from a terminal disease
  to a chronic illness for those who can access and tolerate the medications. This increasing chronicity prompts
  revisiting HIV as a long-wave event. First, with widespread availability of ART, the HIV curve will be higher and last
  longer. Moreover, if patterns in sub-Saharan Africa mirror experiences in the North, people on ART will live far
  longer lives but with new experiences of disability. Disability, broadly defined, can result from HIV, its related
  conditions, and from side effects of medications. Individual experiences of disability will vary. At a population level,
  however, we anticipate that experiences of disability will become a common part of living with HIV and,
  furthermore, may be understood as a variation of the second curve. In the original conceptualization, the second
  curve represented the transition to AIDS; in the era of treatment, we can expect a transition from HIV infection to
  HIV-related disability for people on ART. Many such individuals may eventually develop AIDS as well, but after a
  potentially long life that includes fluctuating episodes of illness, wellness and disability. This shift toward chronicity
  has implications for health and social service delivery, and requires a parallel shift in thinking regarding HIV-related
  disability. A model providing guidance on such a broader understanding of disability is the World Health
  Organization’s International Classification of Functioning, Disability and Health (ICF). In contrast to a biomedical
  approach concerned primarily with diagnoses, the ICF includes attention to the impact of these diagnoses on
  people’s lives and livelihoods. The ICF also focuses on personal and environmental contextual factors. Locating
  disability as a new form of the second curve in the long-wave event calls attention to the new spectrum of needs
  that will face many people living with HIV in the years and decades ahead.


HIV as a long-wave event                                                            until all people who are susceptible have become
“HIV as a long-wave event” was first described by Bar-                              infected. In the final stage of the epidemic (where the S-
nett and Blaikie in 1990 [1]. This idea was developed                               curve flattens at the top), people are either getting better
further by Barnett and Whiteside who conceptualized                                 or the number of deaths exceeds the number of new
the long-wave nature of HIV in the three curves                                     cases such that the total number of people living with
depicted in Figure 1 [2]. In general, epidemics follow an                           the infection passes its peak and begins to decline. This
S-curve (see the S-curve on the left in Figure 1). They                             decline typically occurs rapidly.
start slowly and gradually. When a critical mass of                                   What sets HIV and AIDS apart from other epidemics is
infected people is reached, the growth of new infections                            that there are additional curves to consider. The three
accelerates (see the steep climb in the middle of the S-                            curves in Figure 1 were conceived before the widespread
curve). The epidemic spreads through the population                                 availability of antiretroviral therapy (ART) [1,2]. First is
                                                                                    the HIV curve, which was envisaged to precede a second
* Correspondence: stephanie.nixon@utoronto.ca
1
                                                                                    curve, the AIDS curve, by 8 to 12 years. For the HIV
 Department of Physical Therapy, University of Toronto, 160-500 University
Avenue, Toronto, ON, M5G 1V7, Canada
                                                                                    curve, in the absence of a cure the only way to leave the
Full list of author information is available at the end of the article              pool of people with infections is by dying. The second
                                       © 2011 Nixon et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
                                       Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
                                       any medium, provided the original work is properly cited.
Nixon et al. Globalization and Health 2011, 7:41                                                               Page 2 of 5
http://www.globalizationandhealth.com/content/7/1/41




                                                             dropped by almost one-fifth between 2004 and 2009 [4].
                                                             The advent of widespread access to ART in Southern
                                                             Africa marks the dawning of a new era in the history of
                                                             HIV as vast numbers of people living with HIV may
                                                             expect to live far longer [5]. Indeed, the clinical, immuno-
                                                             logic and virologic effects of ART for people living with
                                                             HIV in resource-poor countries are well-documented
                                                             [6-8]. Most people who can access and adhere to treat-
                                                             ment can expect improvements in CD4 count and viral
                                                             load, fewer opportunistic infections and overall reduc-
                                                             tions in HIV-related morbidity and mortality. HIV in
                                                             high-prevalence, resource-poor countries is on the path
                                                             toward becoming a chronic illness [9,10].
                                                                This increasing chronicity prompts revisiting HIV as a
                                                             long-wave event. First, the advent of widespread ART
                                                             means that the HIV curve will be higher and will last
                                                             longer since people continue to become HIV-infected
                                                             but are also living longer on treatment [11]. As a result,
                                                             progression to AIDS on an individual level is far less
                                                             predictable, although estimates can be made of treat-
 Figure 1 The three HIV epidemic curves.                     ment failure at a population level. The advent of better
                                                             drugs at lower prices, especially second-line regimens,
                                                             could further change the shape of the curve.
curve, AIDS, reflected people who were becoming ill and,        If patterns in sub-Saharan Africa mirror experiences in
often, dying. The third curve represented impacts, which     high-income countries, people on ART will live far
included orphaning, food insecurity and other societal       longer lives but with new experiences of disability
concerns.                                                    [12-18]. Disability, broadly defined, can result from HIV,
  The innovation in this multi-curve approach was disag-     its related conditions, and from side effects of the medi-
gregating the idea of a long-wave event into some of its     cations [19]. This shifting experience has stimulated
constituent processes. This orientation drew attention to    innovative responses from rehabilitation, health and
the need for long-term engagement in responding to the       social sectors in many resource-rich countries [20-25].
HIV epidemic. It also indicated an intergenerational pro-    However, it is likely that HIV-related disabilities in
blem because: (a) one outcome of the disease was             resource-poor settings will be more acutely disabling
increased orphaning as parents had children and then         given the limited availability of rehabilitation, chronic
died prematurely, leaving those children to possible         health care services and social support grants.
insufficient socialization, thus breaking the bond between      Individual experiences of disability will vary greatly. At
generations; (b) inadequately socialized children were       a population level, we anticipate that disability will
more likely to adopt risky sexual behaviours, thus replen-   become a common part of living with HIV, and may now
ishing the disease susceptible population age cohort [3].    be understood as a new version of the second curve.
Finally, this conceptualization of HIV as a long-wave        Whereas the second curve in the original conceptualiza-
event cautioned that most standard public health inter-      tion represented the transition to AIDS, in the era of
ventions for communicable diseases would be proble-          treatment we can expect a transition from HIV infection
matic given the ill-fit with funding streams and sheer       to HIV-related disability for people who can access and
magnitude of the problem.                                    tolerate ART. Many of these individuals may eventually
                                                             transition to AIDS as well, but after a potentially long life
HIV in the era of expanded treatment access                  that includes fluctuating experiences of illness, wellness
Free public access to life-saving ART became available in    and disability over time. This shift occurs in a milieu
parts of Africa in the mid-2000’s, in contrast to many       where increased resources are unlikely to be available in
resource-rich countries where ART had been available         significantly greater quantities than they are now to sup-
from 1996. Despite this delayed start, by the end of 2009,   port these elevated demands in terms of health infra-
37% of people eligible for ART in sub-Saharan Africa         structure, rehabilitation and disability services, palliative
were receiving treatment, compared with only 2% in           care provision and/or medications to mitigate the effects
2002. As a result, AIDS-related deaths in Southern Africa    of chronically disabling conditions.
Nixon et al. Globalization and Health 2011, 7:41                                                                  Page 3 of 5
http://www.globalizationandhealth.com/content/7/1/41




HIV-related disability                                          accelerated osteoporosis, and problems with vision or
ART has the potential to change HIV from a terminal dis-        hearing. The strength of the ICF is its concern not only
ease to a chronic, albeit very serious, illness. This shift     with these diagnoses, but with how these conditions
toward chronicity has significant implications for health       affect people’s lives and livelihoods. Disability resulting
and health care, and requires a parallel shift in thinking.     from HIV-related mental health conditions and neuro-
How might we understand and anticipate the second wave          cognitive changes [30] is also becoming better under-
of HIV-related disability? The word disability frequently       stood among people living with HIV in Africa, especially
invokes static and narrowly-conceived stereotypes. A            as it is pertains to elevated rates of depression [31].
broader understanding of disability as far-reaching and         Other mental health conditions with higher prevalence
dynamic reflects a more realistic and constructive sce-         among people living with HIV in some African settings
nario. A widely-accepted model that provides guidance on        include bipolar disorder, schizophrenia, anxiety, post-
such a broader understanding of disability is the World         traumatic stress disorder and sleep disorders [32]. Con-
Health Organization’s International Classification of Func-     siderable disability can also result from the side effects of
tioning, Disability and Health (ICF) (see Figure 2) [26,27].    ART such as peripheral neuropathies linked to some
The ICF describes diverse dimensions of human function-         medications, which can create pain and altered sensation
ing affected by a health condition, including both biomedi-     in people’s legs (impairment), potentially limiting their
cal and social concerns. In contrast to a biomedical            mobility (activity limitation), thus compromising their
approach that centres on diagnoses and symptoms, the            engagement in work or managing a household (participa-
ICF also focuses on the impact of these diagnoses at three      tion restriction). Furthermore, the concept of “environ-
levels: body structure and function (whereby impairments        mental contextual factors” within the ICF offers a link to
are challenges at the level of the body part or structure),     the social, political and economic forces that may shape
activity (whereby activity limitations are challenges at the    an individuals’ experience of HIV-related disability, such
level of the whole person) and participation (whereby par-      as the profoundly important role of stigmatizing attitudes
ticipation restrictions are challenges faced by the person in   in creating and/or exacerbating disability.
her environment or society). Challenges at all of these            The ICF has been used to conceptualize HIV in coun-
levels may be conceptualized as forms of disability. The        tries like Canada since the advent of ART in the late
ICF also understands personal and environmental contex-         1990’s [23,33,34]; however, engagement with this frame-
tual factors as shaping experiences at these three levels.      work for HIV in resource-poor settings has only recently
   The ICF has been widely used in both resource-rich           begun. In 2009, Myezwa and colleagues used the ICF as
and resource-constrained settings for considering the dis-      the basis for a cross-sectional study that demonstrated a
ability dimensions of many health conditions [28,29].           high level of disablement among 80 HIV-positive hospital
Applied to HIV, impairments, activity limitations and           inpatients [35] and among 45 HIV-positive outpatients in
participation restrictions can result from a diverse range      South Africa [36]. Even more recently, Myezwa et al.
of HIV-associated conditions affecting all body systems,        compared data from four cross-sectional studies (3 in
including neurological and neurocognitive conditions            South Africa, 1 in Brazil) that had applied the ICF as a
resulting in brain or spinal cord problems, cardiovascular      classification instrument to people living with various
system changes resulting in strokes or heart attacks,           stages of HIV and unequal access to ART [37]. Issues
musculoskeletal problems related to osteoarthritis and          across all groups included weight maintenance and pro-
                                                                blems with sleep (50%, 92/185), energy and drive (45%,
                                                                83/185), and emotional functions (49%, 90/185). People
                                                                on ART identified body image as a major problem. Other
                                                                groups reported pain as a problem, and those with lim-
                                                                ited access to treatment also reported mobility problems.
                                                                Cardiopulmonary functions were affected in all groups.
                                                                Gaidhane et al. used the ICF to examine self-care among
                                                                194 people living with HIV in a tertiary care hospital in
                                                                rural India, finding that over 65% of participants experi-
                                                                ences one or more impairments [38]. This early evidence
                                                                points to the spectrum of disability that we locate as the
                                                                new second curve in the long-wave event of HIV.

                                                                Looking ahead
 Figure 2 The World Health Organization’s International         The advent of ART in resource-poor settings has
 Classification of Functioning, Disability and Health (ICF).
                                                                marked a dramatic shift in the epidemic giving rise to
Nixon et al. Globalization and Health 2011, 7:41                                                                                                  Page 4 of 5
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the potential onset of vastly elevated levels of HIV-                        Author details
                                                                             1
                                                                              Department of Physical Therapy, University of Toronto, 160-500 University
related disability. Indeed, clinicians working in HIV may
                                                                             Avenue, Toronto, ON, M5G 1V7, Canada. 2Health Economics and HIV and
be familiar with patients whose clinical markers (e.g.,                      AIDS Research Division (HEARD), University of KwaZulu-Natal, South Africa.
                                                                             3
CD4 count and viral load) indicate that they are doing                        LSE Health, Department of Social Policy, London School of Economics,
                                                                             Houghton St, London WC2A 2AE, UK. 4Department of Global Health and
well, yet they are struggling to manage. The reverse can
                                                                             Development, London School of Hygiene and Tropical Medicine, 15-17
also be true. This disconnect points to the importance                       Tavistock Place, London WC1H 9SH, UK.
of considering not only biomedical concerns (e.g., diag-
                                                                             Authors’ contributions
noses, clinical markers, symptoms, drugs) but also the
                                                                             SN helped conceive the analysis, partially wrote the first draft and wrote the
life-related impacts of HIV and its related conditions,                      final draft.
which we term HIV-related disability. This shift also                        JHH helped conceive the analysis, and wrote portions of the first and final
                                                                             drafts.
occurred in resource-rich countries in the 1990’s upon
                                                                             AW helped conceive the analysis, contributed to writing the first draft and
the advent of treatment in those settings. However, the                      critically reviewed the final draft. TB contributed to the analysis, and critically
experience in Africa will be distinct in at least two                        reviewed the first and final drafts. All authors read and approved the final
                                                                             manuscript.
important ways. First, the scope of the problem in terms
of both absolute numbers and prevalence in many Afri-                        Competing interests
can countries dwarfs the experiences of many resource-                       The authors declare that they have no competing interests.
rich countries. Second, the service delivery models for
                                                                             Received: 8 March 2011 Accepted: 20 October 2011
addressing disability-related concerns are stretched, fra-                   Published: 20 October 2011
gile or non-existent in many African settings.
   This analysis is reminiscent of the policy challenges                     References
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The increasing chronicity of hiv in sub saharan africa 2011

  • 1. Nixon et al. Globalization and Health 2011, 7:41 http://www.globalizationandhealth.com/content/7/1/41 COMMENTARY Open Access The increasing chronicity of HIV in sub-Saharan Africa: Re-thinking “HIV as a long-wave event” in the era of widespread access to ART Stephanie A Nixon1,2*, Jill Hanass-Hancock2, Alan Whiteside2 and Tony Barnett3,4 Abstract HIV was first described as a “long-wave event” in 1990, well before the advent of antiretroviral therapy (ART). The pandemic was then seen as involving three curves: an HIV curve, an AIDS curve and a curve representing societal impact. Since the mid-2000’s, free public delivery of life-saving ART has begun shifting HIV from a terminal disease to a chronic illness for those who can access and tolerate the medications. This increasing chronicity prompts revisiting HIV as a long-wave event. First, with widespread availability of ART, the HIV curve will be higher and last longer. Moreover, if patterns in sub-Saharan Africa mirror experiences in the North, people on ART will live far longer lives but with new experiences of disability. Disability, broadly defined, can result from HIV, its related conditions, and from side effects of medications. Individual experiences of disability will vary. At a population level, however, we anticipate that experiences of disability will become a common part of living with HIV and, furthermore, may be understood as a variation of the second curve. In the original conceptualization, the second curve represented the transition to AIDS; in the era of treatment, we can expect a transition from HIV infection to HIV-related disability for people on ART. Many such individuals may eventually develop AIDS as well, but after a potentially long life that includes fluctuating episodes of illness, wellness and disability. This shift toward chronicity has implications for health and social service delivery, and requires a parallel shift in thinking regarding HIV-related disability. A model providing guidance on such a broader understanding of disability is the World Health Organization’s International Classification of Functioning, Disability and Health (ICF). In contrast to a biomedical approach concerned primarily with diagnoses, the ICF includes attention to the impact of these diagnoses on people’s lives and livelihoods. The ICF also focuses on personal and environmental contextual factors. Locating disability as a new form of the second curve in the long-wave event calls attention to the new spectrum of needs that will face many people living with HIV in the years and decades ahead. HIV as a long-wave event until all people who are susceptible have become “HIV as a long-wave event” was first described by Bar- infected. In the final stage of the epidemic (where the S- nett and Blaikie in 1990 [1]. This idea was developed curve flattens at the top), people are either getting better further by Barnett and Whiteside who conceptualized or the number of deaths exceeds the number of new the long-wave nature of HIV in the three curves cases such that the total number of people living with depicted in Figure 1 [2]. In general, epidemics follow an the infection passes its peak and begins to decline. This S-curve (see the S-curve on the left in Figure 1). They decline typically occurs rapidly. start slowly and gradually. When a critical mass of What sets HIV and AIDS apart from other epidemics is infected people is reached, the growth of new infections that there are additional curves to consider. The three accelerates (see the steep climb in the middle of the S- curves in Figure 1 were conceived before the widespread curve). The epidemic spreads through the population availability of antiretroviral therapy (ART) [1,2]. First is the HIV curve, which was envisaged to precede a second * Correspondence: stephanie.nixon@utoronto.ca 1 curve, the AIDS curve, by 8 to 12 years. For the HIV Department of Physical Therapy, University of Toronto, 160-500 University Avenue, Toronto, ON, M5G 1V7, Canada curve, in the absence of a cure the only way to leave the Full list of author information is available at the end of the article pool of people with infections is by dying. The second © 2011 Nixon et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
  • 2. Nixon et al. Globalization and Health 2011, 7:41 Page 2 of 5 http://www.globalizationandhealth.com/content/7/1/41 dropped by almost one-fifth between 2004 and 2009 [4]. The advent of widespread access to ART in Southern Africa marks the dawning of a new era in the history of HIV as vast numbers of people living with HIV may expect to live far longer [5]. Indeed, the clinical, immuno- logic and virologic effects of ART for people living with HIV in resource-poor countries are well-documented [6-8]. Most people who can access and adhere to treat- ment can expect improvements in CD4 count and viral load, fewer opportunistic infections and overall reduc- tions in HIV-related morbidity and mortality. HIV in high-prevalence, resource-poor countries is on the path toward becoming a chronic illness [9,10]. This increasing chronicity prompts revisiting HIV as a long-wave event. First, the advent of widespread ART means that the HIV curve will be higher and will last longer since people continue to become HIV-infected but are also living longer on treatment [11]. As a result, progression to AIDS on an individual level is far less predictable, although estimates can be made of treat- Figure 1 The three HIV epidemic curves. ment failure at a population level. The advent of better drugs at lower prices, especially second-line regimens, could further change the shape of the curve. curve, AIDS, reflected people who were becoming ill and, If patterns in sub-Saharan Africa mirror experiences in often, dying. The third curve represented impacts, which high-income countries, people on ART will live far included orphaning, food insecurity and other societal longer lives but with new experiences of disability concerns. [12-18]. Disability, broadly defined, can result from HIV, The innovation in this multi-curve approach was disag- its related conditions, and from side effects of the medi- gregating the idea of a long-wave event into some of its cations [19]. This shifting experience has stimulated constituent processes. This orientation drew attention to innovative responses from rehabilitation, health and the need for long-term engagement in responding to the social sectors in many resource-rich countries [20-25]. HIV epidemic. It also indicated an intergenerational pro- However, it is likely that HIV-related disabilities in blem because: (a) one outcome of the disease was resource-poor settings will be more acutely disabling increased orphaning as parents had children and then given the limited availability of rehabilitation, chronic died prematurely, leaving those children to possible health care services and social support grants. insufficient socialization, thus breaking the bond between Individual experiences of disability will vary greatly. At generations; (b) inadequately socialized children were a population level, we anticipate that disability will more likely to adopt risky sexual behaviours, thus replen- become a common part of living with HIV, and may now ishing the disease susceptible population age cohort [3]. be understood as a new version of the second curve. Finally, this conceptualization of HIV as a long-wave Whereas the second curve in the original conceptualiza- event cautioned that most standard public health inter- tion represented the transition to AIDS, in the era of ventions for communicable diseases would be proble- treatment we can expect a transition from HIV infection matic given the ill-fit with funding streams and sheer to HIV-related disability for people who can access and magnitude of the problem. tolerate ART. Many of these individuals may eventually transition to AIDS as well, but after a potentially long life HIV in the era of expanded treatment access that includes fluctuating experiences of illness, wellness Free public access to life-saving ART became available in and disability over time. This shift occurs in a milieu parts of Africa in the mid-2000’s, in contrast to many where increased resources are unlikely to be available in resource-rich countries where ART had been available significantly greater quantities than they are now to sup- from 1996. Despite this delayed start, by the end of 2009, port these elevated demands in terms of health infra- 37% of people eligible for ART in sub-Saharan Africa structure, rehabilitation and disability services, palliative were receiving treatment, compared with only 2% in care provision and/or medications to mitigate the effects 2002. As a result, AIDS-related deaths in Southern Africa of chronically disabling conditions.
  • 3. Nixon et al. Globalization and Health 2011, 7:41 Page 3 of 5 http://www.globalizationandhealth.com/content/7/1/41 HIV-related disability accelerated osteoporosis, and problems with vision or ART has the potential to change HIV from a terminal dis- hearing. The strength of the ICF is its concern not only ease to a chronic, albeit very serious, illness. This shift with these diagnoses, but with how these conditions toward chronicity has significant implications for health affect people’s lives and livelihoods. Disability resulting and health care, and requires a parallel shift in thinking. from HIV-related mental health conditions and neuro- How might we understand and anticipate the second wave cognitive changes [30] is also becoming better under- of HIV-related disability? The word disability frequently stood among people living with HIV in Africa, especially invokes static and narrowly-conceived stereotypes. A as it is pertains to elevated rates of depression [31]. broader understanding of disability as far-reaching and Other mental health conditions with higher prevalence dynamic reflects a more realistic and constructive sce- among people living with HIV in some African settings nario. A widely-accepted model that provides guidance on include bipolar disorder, schizophrenia, anxiety, post- such a broader understanding of disability is the World traumatic stress disorder and sleep disorders [32]. Con- Health Organization’s International Classification of Func- siderable disability can also result from the side effects of tioning, Disability and Health (ICF) (see Figure 2) [26,27]. ART such as peripheral neuropathies linked to some The ICF describes diverse dimensions of human function- medications, which can create pain and altered sensation ing affected by a health condition, including both biomedi- in people’s legs (impairment), potentially limiting their cal and social concerns. In contrast to a biomedical mobility (activity limitation), thus compromising their approach that centres on diagnoses and symptoms, the engagement in work or managing a household (participa- ICF also focuses on the impact of these diagnoses at three tion restriction). Furthermore, the concept of “environ- levels: body structure and function (whereby impairments mental contextual factors” within the ICF offers a link to are challenges at the level of the body part or structure), the social, political and economic forces that may shape activity (whereby activity limitations are challenges at the an individuals’ experience of HIV-related disability, such level of the whole person) and participation (whereby par- as the profoundly important role of stigmatizing attitudes ticipation restrictions are challenges faced by the person in in creating and/or exacerbating disability. her environment or society). Challenges at all of these The ICF has been used to conceptualize HIV in coun- levels may be conceptualized as forms of disability. The tries like Canada since the advent of ART in the late ICF also understands personal and environmental contex- 1990’s [23,33,34]; however, engagement with this frame- tual factors as shaping experiences at these three levels. work for HIV in resource-poor settings has only recently The ICF has been widely used in both resource-rich begun. In 2009, Myezwa and colleagues used the ICF as and resource-constrained settings for considering the dis- the basis for a cross-sectional study that demonstrated a ability dimensions of many health conditions [28,29]. high level of disablement among 80 HIV-positive hospital Applied to HIV, impairments, activity limitations and inpatients [35] and among 45 HIV-positive outpatients in participation restrictions can result from a diverse range South Africa [36]. Even more recently, Myezwa et al. of HIV-associated conditions affecting all body systems, compared data from four cross-sectional studies (3 in including neurological and neurocognitive conditions South Africa, 1 in Brazil) that had applied the ICF as a resulting in brain or spinal cord problems, cardiovascular classification instrument to people living with various system changes resulting in strokes or heart attacks, stages of HIV and unequal access to ART [37]. Issues musculoskeletal problems related to osteoarthritis and across all groups included weight maintenance and pro- blems with sleep (50%, 92/185), energy and drive (45%, 83/185), and emotional functions (49%, 90/185). People on ART identified body image as a major problem. Other groups reported pain as a problem, and those with lim- ited access to treatment also reported mobility problems. Cardiopulmonary functions were affected in all groups. Gaidhane et al. used the ICF to examine self-care among 194 people living with HIV in a tertiary care hospital in rural India, finding that over 65% of participants experi- ences one or more impairments [38]. This early evidence points to the spectrum of disability that we locate as the new second curve in the long-wave event of HIV. Looking ahead Figure 2 The World Health Organization’s International The advent of ART in resource-poor settings has Classification of Functioning, Disability and Health (ICF). marked a dramatic shift in the epidemic giving rise to
  • 4. Nixon et al. Globalization and Health 2011, 7:41 Page 4 of 5 http://www.globalizationandhealth.com/content/7/1/41 the potential onset of vastly elevated levels of HIV- Author details 1 Department of Physical Therapy, University of Toronto, 160-500 University related disability. Indeed, clinicians working in HIV may Avenue, Toronto, ON, M5G 1V7, Canada. 2Health Economics and HIV and be familiar with patients whose clinical markers (e.g., AIDS Research Division (HEARD), University of KwaZulu-Natal, South Africa. 3 CD4 count and viral load) indicate that they are doing LSE Health, Department of Social Policy, London School of Economics, Houghton St, London WC2A 2AE, UK. 4Department of Global Health and well, yet they are struggling to manage. The reverse can Development, London School of Hygiene and Tropical Medicine, 15-17 also be true. This disconnect points to the importance Tavistock Place, London WC1H 9SH, UK. of considering not only biomedical concerns (e.g., diag- Authors’ contributions noses, clinical markers, symptoms, drugs) but also the SN helped conceive the analysis, partially wrote the first draft and wrote the life-related impacts of HIV and its related conditions, final draft. which we term HIV-related disability. This shift also JHH helped conceive the analysis, and wrote portions of the first and final drafts. occurred in resource-rich countries in the 1990’s upon AW helped conceive the analysis, contributed to writing the first draft and the advent of treatment in those settings. However, the critically reviewed the final draft. TB contributed to the analysis, and critically experience in Africa will be distinct in at least two reviewed the first and final drafts. All authors read and approved the final manuscript. important ways. First, the scope of the problem in terms of both absolute numbers and prevalence in many Afri- Competing interests can countries dwarfs the experiences of many resource- The authors declare that they have no competing interests. rich countries. Second, the service delivery models for Received: 8 March 2011 Accepted: 20 October 2011 addressing disability-related concerns are stretched, fra- Published: 20 October 2011 gile or non-existent in many African settings. This analysis is reminiscent of the policy challenges References 1. Barnett AS, Blaikie P: AIDS in Africa: Its Present and Future Impact London: flagged by Barnett and Blaikie in 1990 regarding the mag- John Wiley and Co; 1990. nitude of the problem and the insufficient preparedness of 2. Barnett AS, Whiteside A: AIDS in the Twenty-First Century: Disease and the health system for responding to impending needs. Globalization Hampshire, UK: Palgrave MacMillan; 2002. 3. Barnett AS: A long-wave event. 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