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    Website of the HIV Special Interest Group

    -as part of the College of Occupational Therapists Specialist Section - HIV/AIDs, Oncology & Palliative Care

Individuals with a diagnosis of HIV or AIDS may be admitted to a rehabilitation facility for a variety of reasons. These may be physical, psychological or cognitive in origin, and there may be one predominant reason, or a combination of more than one. 

At present, although all OT services within acute centres offer the opportunity for individuals to engage with rehabilitation services, within London, there is one hospital which offers specific rehabilitation admissions (as well as also offering longer term admissions for assessment and rehabilitation of individuals with a HIV related brain impairment [HRBI] diagnosis, continuing care and terminal care admissions, the Mildmay Mission Hospital. The information which follows relates to this specific facility (which offers admission to adults and adults with children - infected or affected by HIV or AIDS) and the OT service within it (which relates to adults only).

 People may be admitted from home or from an acute centre (the main hospital where they receive their treatment). If admitted from an acute centre they may have been acutely unwell, perhaps with an opportunistic infection related to having their immune system compromised by HIV, or having undergone an operation or received treatment for a health problem unrelated to their diagnosis of HIV or AIDS. Similarly, someone may have had an admission to a psychiatric facility and require a further period of rehabilitation and / or convalescence prior to returning home. For some, an admission to a rehabilitation facility provides a “safety net” which may help to prevent an admission to an acute centre and support them in community based living. Such admissions may be on a “one-off” basis or may be arranged on a more regular basis.

Funding for admission to a rehabilitation facility is usually provided by the person’s health authority, via their HIV and AIDS Clinical Nurse Specialist [CNS]. Each health authority has a budget which they allocate to such admissions, and the rationale for each person to be admitted is closely examined, to ensure that the admission will be beneficial.

 The length of each admission will vary according to the person’s needs, their funding arrangements, and the assessment and opinion of the professionals - both community and hospital - involved in their care. For non-HRBI clients the average is two weeks, with further time (usually of one week, but maybe longer) being available if those involved feel that there are sufficient health related grounds for their admission to be extended. This must be discussed with and agreed by, the funder. For clients admitted to the HRBI unit, the minimum admission for assessment is four weeks, with the norm being that all clients will stay for a greater period of time - the mean length of admission being 7 months.

 The significantly greater length of time required to assess and work with those diagnosed with HRBI reflects both the time that is needed to assess difficulties - which will of course be cognitive, but may also encompass physical and / or psychological aspects of function - as well as establishing whether or not intervention and medication will produce changes.

(The following three sections are to be considered as a guide and are not exhaustive)

Aspects of Intervention related to Physical Function:

Function may be affected by motor or sensory impairment, such as affected balance, power, strength or endurance, increased fatigue or shortness of breath. A person may have a hemiplegia or hemiparesis (mild, moderate or severe), may have a partial or complete visual loss, or altered sensation in upper / lower limbs or both - possibly due to peripheral neuropathy. There may be other medical problems which may be related or unrelated to their HIV or AIDS diagnosis. For example, a person seeking asylum may have been tortured in their home state and as a result, have amputated / partially amputated limbs, burns or visual loss. A person who has misused non-prescribed drugs and / or alcohol may have liver problems, have a diagnosis of Hepatitis or have experienced health problems such as endocarditis. Aside from any HIV or AIDS related difficulties there may be other pre existing or concurrent health problems, which are unrelated, but still have the potential to cause the person difficulties i.e.: arthritis or cardiac problems.

OT intervention in this area will involve assessment, and the selection of an appropriate approach, taking into account all the specific information relating to that person, for example, compensatory. This may involve equipment provision or recommendation for minor or major adaptation (in liaison with OT’s employed by the local authority). Energy conservation advice may also be beneficial, as may re-training in alternative techniques to achieve the activity. OT’s are frequently involved in rehousing and housing assessment and advice in order to promote safe and independent function and reduce the negative or restrictive impact of a particular environment on a person.

Aspects of Intervention related to Psychological Function:

As suggested above, an HIV or AIDS diagnosis may not be the only health problem a person is facing. many clients also have a mental health diagnosis such as anxiety, depression, bi-polar affective disorder, eating disorder or schizophrenia. In such instances, a person will usually have involvement from mental health services at another hospital, and possibly also in the community. Professionals that may be involved include, Psychiatrist, Clinical Psychologist, Registered Mental Health Nurses, Community Psychiatric Nurses, District Nurses, Clinical Nurse Specialist. They may also be able to access Occupational Therapy via a Community Mental Health Team.

Obviously, when considering intervention in a short admission to hospital, the OT needs to be aware of existing services, which may be very longstanding in nature, and to ensure that their intervention does not duplicate or disrupt in any way, intervention from other professionals. Stress management work using formal relaxation techniques may offer the person a means of gaining some “control” over signs and symptoms of anxiety. These may be physiological (e.g: increased heart rate, raised blood pressure, a feeling of “butterflies” in the stomach, muscle tension) or psychological (e.g: difficulties sleeping, reduced appetite, difficulty concentrating) The OT will discuss how the person feels that stress affects them, explore existing coping strategies, and take into account relevant past physical and psychiatric history. Informal relaxation techniques such as socialising with friends / family, gentle exercise, reading or listening to music may be useful, perhaps particularly for clients with family and child care commitments where it may be more practical to build such activities into their day than set aside specific time to practice formal relaxation techniques such as imagery, passive neuromuscular or tense-release styles. One to one sessions using all or a selection of relaxation styles can be offered, with evaluation occurring on an ongoing basis. Some clients will wish to continue using the techniques on discharge, and if so, options such as attending a day care service where this is offered, or using prepared cassettes can be explored.

Aspects of Intervention related to Cognitive Function

Individuals with an HRBI may be affected in terms of memory, attention, concentration, skills such as information processing, information recall, sequencing and structuring of activity may be affected. Levels of insight and judgment may also be impaired. Inevitably any deficit in these areas can lead to significant problems in terms of daily living on both a personal and domestic level. The OT will assess the level of deficit and explore the persons performance in both the hospital and community environment. It may also be beneficial to carry out formal standardised cognitive assessment in conjunction with functional assessment. Both personal and domestic daily living skills are assessed in order to establish what is the nature and level of difficulty as well as what strategies may assist in reducing its impact. The use of medication can often make a significant impact on a persons health and well being in terms of their CD4, viral load and physical function. It may lessen the signs and symptoms of a cognitive impairment to an extent, but it may also make no apparent difference to key aspects of a persons ability to function safely. What are called external cues - such as diaries, timetables, calendars and alarms- may help recall by acting as a prompt, but the person obviously has to be able to connect the fact that an alarm is going off with the activity required, or to remember to read the diary or list. Often in order to promote safe discharge to the community it is necessary for the individual to have not only appropriate housing, but also a care package (often substantial) which provides supervision and support where necessary with daily living skills. Where this is not possible, alternative placement such as a community based group home, residential or nursing care may need to be considered.

Camilla Hawkins Senior I OT Mildmay Hospital, September 2002

Send mail to will.chegwidden@bartsandthelondon.nhs.uk with questions or comments about this web site.                           
Last modified: 16 May 2007