Physiotherapy 97 (2011) 17–25

HIV/AIDS: use of the ICF in Brazil and South Africa – comparative data
from four cross-sectional studies
H. Myezwa a,∗ , C.M. Buchalla b , J. Jelsma c , A. Stewart a
a Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Park Town 2093, Johannesburg, South Africa
b School of Public Health, University of Sao Paulo, Sao Paulo, Brazil
c Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

Abstract
Introduction Human immunodeficiency virus (HIV) is a serious disease which can be associated with various activity limitations and
participation restrictions. The aim of this paper was to describe how HIV affects the functioning and health of people within different
environmental contexts, particularly with regard to access to medication.
Method Four cross-sectional studies, three in South Africa and one in Brazil, had applied the International Classification of Functioning,
Disability and Health (ICF) as a classification instrument to participants living with HIV. Each group was at a different stage of the disease.
Only two groups had had continuing access to antiretroviral therapy. The existence of these descriptive sets enabled comparison of the disability
experienced by people living with HIV at different stages of the disease and with differing access to antiretroviral therapy.
Results Common problems experienced in all groups related to weight maintenance, with two-thirds of the sample reporting problems in this
area. Mental functions presented the most problems in all groups, with sleep (50%, 92/185), energy and drive (45%, 83/185), and emotional
functions (49%, 90/185) being the most affected. In those on long-term therapy, body image affected 93% (39/42) and was a major problem.
The other groups reported pain as a problem, and those with limited access to treatment also reported mobility problems. Cardiopulmonary
functions were affected in all groups.
Conclusion Functional problems occurred in the areas of impairment and activity limitation in people at advanced stages of HIV, and more
limitations occurred in the area of participation for those on antiretroviral treatment. The ICF provided a useful framework within which to
describe the functioning of those with HIV and the impact of the environment. Given the wide spectrum of problems found, consideration
could be given to a number of ICF core sets that are relevant to the different stages of HIV disease.
© 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: ICF; HIV/AIDS; Function; Disability

Introduction number of people in Brazil with infection is much lower (esti-

Human immunodeficiency virus (HIV) is a major con-
cern in developing and middle-income countries such as
South Africa and Brazil. In South Africa, the HIV/acquired
immunodeficiency syndrome (AIDS) epidemic has claimed
thousands of lives and continues with little signs of abating.
In 2008, it was estimated that just over 5 million people out of
a population of 46 million were living with HIV, resulting in a
total population prevalence rate of 18% [1]. The large major-
ity of those with HIV/AIDS are heterosexual. In contrast, the
∗ Corresponding author. Tel.: +27 117173702; fax: +27 117173719.
E-mail address: hellen.myezwa@wits.ac.za (H. Myezwa).
mated 630 000 people) and infection is more prevalent within
the homosexual community (21% of those infected) [2]. In
addition, Brazil differs from South Africa in that a very active
free programme to provide antiretroviral therapy was started
in 1991 [3], and this has resulted in the number of deaths
per 100 000 inhabitants decreasing from 9.7 in 1995 to 6.0
in 2005 [2]. In contrast, South Africa only began to roll out
universally available antiretroviral therapy in 2004 [4], and
is still in the process of instituting treatment for those who
are in need.
The virus has many complex effects on the body and can
be expected to have a marked impact on the functioning of
individuals in everyday life [5]. The health-related quality

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.physio.2010.08.015
18 H. Myezwa et al. / Physiotherapy 97 (2011) 17–25
of life (which includes the ability of an individual to func-
tion) of people living with HIV/AIDS in South Africa [6] and
elsewhere [7] has been found to be severely compromised.
The International Classification of Functioning, Disability
and Health (ICF) was published by the World Health Orga-
nization (WHO) in 2001 [8], and has increasingly become
the standard classification of disability and functioning [9].
The ICF, which classifies impairments, activity limitations
and participation restrictions and the environment as compo-
nents that all play an important role in disability, is regarded as
the most comprehensive model available for describing and
understanding disability and functioning [10]. As such, it is
a complex instrument intended to cover all aspects of human
functioning. In principle, it is possible to assign unique codes
to 1424 items [8]. In practice, the entire set of codes is sel-
dom utilised, and WHO has produced a short version of the
ICF [11] which still comprises a large number of codes. It
is expected that a subset of codes will be chosen to meet the
purpose, setting and expertise of the users. The user might,
for example, use the 34 one-digit level codes, the 362 two-
level items or a combination of different levels, with up to
four-level precision for specialist areas. In addition, a check-
list has been developed which presents what is considered to
be the most useful subset of codes for general clinical use
[12].
Physiotherapists are key contributors to understanding
health and disability, and the ICF is used increasingly as a
biopsychosocial framework by this group of professionals.
In addition, the definition of any intervention’s ‘success’ has
changed with this shift to a biopsychosocial approach. It is no
longer enough to reduce impairments with education, med-
ication and exercise regimens at the level of body structure
and function. It is therefore important to utilise the ICF to
frame problems experienced not only at an impairment level
but also at an activity and participation level, as well as to
interpret the effect of all interventions.
As an important function of a classification system is to
provide comparable data across settings, clients and coun-
tries, it would seem necessary to use a similar set of codes
during data collection in order to allow comparisons. In
Table 1
Demographic characteristics of the study samples.
Demographics South Africa, Sample 1
n = 12
WHO Stage of disease II/III
Males 2 50
Females 10
Age in years, median (range) 31 (20 to 49)
Description of patient setting Outpatients attending an
HIV clinic
Antiretroviral therapy No
WHO, World Health Organization; HIV, human immunodeficiency virus.
response to the need for abbreviated but standard ‘core sets’
for specific conditions, several papers have been published
detailing the process and final identification of core sets, such
as those for chronic widespread pain [13], depression [14] and
rheumatoid arthritis [15]. An attempt has also been made to
identify a generic core set based on the regression analysis
of data collected from 1039 patients using the ICF checklist
[16]. It appears that there is a need to develop an ICF core
set for documenting the health and functional consequences
of HIV.
Three studies in South Africa [17–19] and a study in Brazil
[3] applied the ICF as a classification instrument to partic-
ipants living with HIV. Although the studies did not follow
a standard format, the amalgamation of the data gave the
researchers a unique opportunity to compare the functioning
of people living with HIV across different settings and dif-
ferent stages of the disease. This data set may also form the
basis of further studies to identify basic core sets for HIV.
Within the context of HIV, this paper presents an example
of how the ICF can be used to describe health and health-
related states, and is an example of a pragmatic starting point
for physiotherapists.
The specific objectives of this study were to present a
preliminary set of codes which encompass the functional lim-
itations of those living with HIV, and to investigate how these
functional limitations vary within very different contexts.
Methods
The methods of the four studies have been published else-
where and are briefly described below. The specific objectives
of each of the four studies are not outlined in this paper;
however, the common methodology of each study entailed a
description of health and health-related states using the ICF.
The results of the four studies have been amalgamated into a
single data set (Tables 1–4). The WHO classification [20] of
the different stages of disease impact was used post hoc to cat-
egorise the different groups into an asymptomatic group (in
terms of AIDS-defining diseases) (I/II), a symptomatic group
South Africa, Sample 2 South Africa, Sample 3 Brazil, Sample 4
n = 51 n = 80 n = 42
I/II Ill/IV Post long-term
antiretroviral
treatment
23 28
1 57 14
45 (32 to 52) 37 (28 to 46) 38 (29 to 52)
Employed by a mining Inpatients in a general Outpatients
company hospital attending an HIV
clinic
Yes, if necessary Mixed Yes, 59% for >4
years
Table 2
Participants reporting problems in the domain of body functions.
Domain Sample 1 Sample 2 Sample 3 Sample 4 Total of all four
n = 12 n = 51 n = 80 n = 42 samples n = 185%
(n)
All categories under domains expressed as n in Samples 1 to 4
Mental functions (b1) % (n) reporting problems in most affected category of 50 (6) 35 (18) 74 (59) 93 (39)
the four samples
b130 Energy and drive functions 6 18 59 nc 45 (83)
b134 Sleep functions 0 12 56 24 50 (92)
b144 Memory 5 11 24 nc 22 (40)
b152 Emotional functions 6 10 49 25 49 (90)
b1801 Body image nc nc 39 21 (39)
Sensory functions and pain (b2) % (n) reporting problems in most affected category 67 55 80 0
b280 Pain 8 28 64 nc 54 (100)
Functions of cardiovascular and respiratory systems (b4) % (n) reporting problems in most affected category 58 (7) 33 (17) 58 (46) 55 (23)

H. Myezwa et al. / Physiotherapy 97 (2011) 17–25

b410 Heart functions nc 6 31 14 28 (51)
b420 Blood pressure functions nc 9 27 20 30 (56)
b430 Haematological system functions nc 17 46 23 47 (86)
b435 Immunological system functions nc 6 13 17 20 (36)
b440 Respiration (breathing) 7 14 46 nc 36 (60)
b4552 Fatigability nc nc nc 8 4 (8)
Functions of the digestive system (b5) % (n) reporting problems in most affected category 58 (7) 63 (32) 75 (60) 57 (24)
b515 Digestive 4 8 34 18 35 (64)
b5153 Tolerance to food nc nc nc 7 4 (7)
b525 Defaecation 4 6 36 12 31 (56)
b530 Weight maintenance 7 32 60 24 67 (123)
b535 Sensations associated with the digestive system 0 6 13 19 21 (38)
b5350 Sensation of nausea nc nc nc 15 28 (15)
b540 General metabolic functions nc nc nc 18 10 (18)
b5403 Fat metabolism nc nc nc 16 9 (16)
b555 Endocrine gland functions nc 0 8 20 15 (28)
Reproductive functions (b6) % (n) reporting problems in most affected category 8 (1) 22 (11) 16 (13) 76 (32)
b640 Sexual functions 1 11 13 32 31 (57)
b650 Menstruation functions nc nc nc 13 7 (13)
b6500 Regularity of menstrual cycle nc nc nc 5 3 (5)
b670 Sensations associated with genital and nc nc nc 11 6 (11)
reproductive functions
b6700 Discomfort associated with sexual intercourse nc nc nc 26 14 (26)
Neuromusculoskeletal and movement related functions (b7) % (n) reporting problems in most affected category 42 (4) 24 (12) 75 (60) 0
b710 Mobility of joint 5 3 23 nc 17 (31)
b730 Muscle power 4 12 60 nc 41 (76)
Functions of the skin (b8) % (n) reporting problems in most affected category 42 (5) 18 (9) 38 (30) 38 (16)
b8 Skin functions 5 9 30 nc 24 (43)
b840 Sensation related to the skin nc nc nc 16 9 (16)
nc, data not collected under this code.

19
 20
Table 3
Participants reporting problems with either activities or participation.
Domain Sample 1 Sample 2 Sample 3 Sample 4 Total
n = 12 n = 51 n = 80 n = 42 % (n)
All categories under domains expressed as n in Samples 1 to 4 % (n) reporting problems in most affected category 17 (2) 2 (1) 55 (44) 0
Mobility (d4) d430 Lifting and carrying objects 2 1 10 nc 7 (13)
d440 Fine hand use 0 0 7 nc 4 (7)
d450 Walking 1 1 44 nc 25 (46)
d465 Moving around using equipment 0 0 8 nc 4 (8)
d470 Using transportation 1 0 21 nc 12 (22)
d475 Driving 0 0 4 nc 2 (4)
Self-care (d5) % (n) reporting problems in most affected category 0 0 35 (28) 0
d510 Washing oneself 0 0 28 0 15 (28)
d520 Caring for body parts 0 0 13 0 7 (13)

H. Myezwa et al. / Physiotherapy 97 (2011) 17–25

d530 Toileting 2 0 20 0 12 (22)
d540 Dressing 0 0 27 0 15 (27)
d550 Eating 0 0 14 0 8 (14)
d560 Drinking 1 0 7 0 4 (8)
d570 Looking after one’s health 0 0 21 0 11 (21)
d5701 Managing diet and fitness 0 0 0 21 11 (21)
Domestic life (d6) % (n) reporting problems in most affected category 17 (2) 39 (26) 64 (51) 0
d620 Acquisition of goods and services 1 20 51 0 39 (72)
d630 Preparation of meals 1 0 47 0 26 (48)
d640 Doing housework 2 3 50 0 30 (52)
d660 Assisting others 1 0 25 0 14 (26)
Interpersonal interactions and relationships (d7) % (n) reporting problems in most affected category 33 (4) 10 (5) 25 (19) 64 (27)
d710 Basic interpersonal interactions 3 0 20 0 12 (23)
d720 Complex interpersonal interactions 3 0 19 0 12 (21)
d760 Family relationships 4 5 19 0 15 (28)
d770 Intimate relationships 3 5 10 24 23 (42)
d7702 Sexual relationships nc nc nc 27 15 (27)
Major life areas (d8) % (n) reporting problems in most affected category 33 (4) 12 (6) 50 (40) 43 (18)
d845 Acquiring, keeping and terminating a job nc nc nc 5 3 (5)
d850 Remunerative employment 4 6 40 27 (50)
d870 Economic self-sufficiency nc 0 38 18 30 (56)
Community, social and civic life (d9) % (n) reporting problems in most affected category 0 10 (5) 54 (43) 52 (22)
d920 Recreation and leisure nc 5 36 6 25 (47)
d9201 Sports nc nc nc 21 11 (21)
d930 Religion and spirituality nc 1 43 22 36 (66)
d950 Political life and citizenship nc 0 21 13 18 (34)
d999 Community, social and civic life, unspecified nc nc nc 11 6 (11)
nc, data not collected under this digit level code.
Table 4
Participants reporting barriers or facilitators in the environmental domain.
Code Sample 1 Sample 2 Sample 3 Sample 4 Total
n = 12 n = 51 n = 80 n = 42 n = 185
% (n)
Barriers Facilitators Barriers Facilitators Barriers Facilitators Barriers Facilitators Barriers Facilitators
All categories under domains expressed as n in Samples 1 to 4
Products and technology (e1) e110 Products and technology for 0- 0 1 *32 11 21 nc nc 6 (13) 29 (53)
personal consumption
e120 Products and technology for use 0 0 2 30 17 23 nc nc 10 (19) 29 (53)
in indoor and outdoor mobility
Domain e250 Sound 4 0 9 5 27 0 nc nc 22 (38) 3 (5)
Natural environment and human made
changes to environment (e2)
Domain e310 Immediate family 0 12 3 27 10 *58 nc nc 7 (13) 52 (97)
Support and relationships (e3)
e320 Friends 2 7 1 12 15 *57 nc nc 10 (18) 41 (76)

H. Myezwa et al. / Physiotherapy 97 (2011) 17–25

e325 Acquaintances, peers, 3 5 1 11 14 *34 nc nc 10 (18) 27 (50)
colleagues, neighbours and
community members
e330 People in position of authority 0 11 4 *26 10 18 nc nc 8 (14) 30 (55)
e340 Personal care providers and 0 9 1 *35 5 12 nc nc 3 (6) 30 (56)
personal assistants
e355 Health professionals 0 12 1 47 5 *66 nc nc 3 (6) 68 (125)
e360 Health-related professionals 0 12 2 *44 6 27 nc nc 4 (8) 45 (83)
Domain e410 Individual attitudes of 0 11 2 28 6 *58 nc nc 4 (8) 52 (97)
Attitudes (e4) immediate family members
% reporting barriers or facilitators in
most affected category
e420 Individual attitudes of friends 3 7 1 16 18 *48 nc nc 12 (22) 38 (71)
e440 Individual attitudes of personal 0 10 0 *16 5 14 nc nc 3 (5) 22 (40)
care providers and personal assistants
e445 Individual attitudes of strangers 0 0 4 nc nc nc 9 nc 9 (9) 0
e450 Individual attitudes of health 0 11 1 46 5 *59 nc nc 3 (6) 63 (116)
professionals
e455 Individual attitudes of 0 11 1 47 7 *24 nc nc 4 (8) 44 (82)
health-related professionals
e460 Societal attitudes 1 7 4 *39 38 16 14 nc 31 (57) 34 (62)
Domain e5550 Associations and nc nc nc nc nc nc 10 nc 5 (10) 0
Services, systems and policies organisational services
e570 Social security services, nc nc 7 *37 23 27 18 nc 26 (48) 35 (64)
systems and policies
e575 General social support services, nc nc 1 *33 23 23 13 nc 20 (37) 30 (56)
system and policies
e580 Health services, systems and nc nc 2 *42 27 30 9 nc 21 (38) 39 (72)
policies
e590 Labour and employment nc nc 3 24 *45 3 15 nc 34 (63) 15 (27)
services, systems and policies

21
*Most affected category. nc, data not collected under this digit level code.
22 H. Myezwa et al. / Physiotherapy 97 (2011) 17–25
(III) and a group who were acutely ill (IV). WHO does not
include a post-antiretroviral therapy group and, consequently,
the Brazilian sample, all of whom were receiving antiretro-
viral therapy, did not fit into this classification system.
Sample 1: South Africa, Stage II/III [17]
A small self-selected convenience sample of people living
with HIV (n = 12) and attending an HIV clinic was used. All
subjects who could speak English and who were prepared
to be interviewed by researchers who were not members of
their clinical management team were included in the study.
The five researchers attended a 2-day training workshop on
use of the ICF. An expanded English version of the ICF check-
list was used. The section on impairments of body structures
was not included, although body function impairments were
included. Piloting of the procedure was undertaken, and the
initial interviews were conducted in the presence of all the
interviewers in order to standardise the manner in which ques-
tions were asked. After piloting, an expanded version of the
ICF checklist questionnaire was drawn up in order to stan-
dardise the way the questions were asked by each interviewer.
Interviews were conducted in a private venue within the
clinic. Interviews lasted between 45 and 60 minutes depend-
ing on the amount of information disclosed by the patient.
Sample 2: South Africa, Stage I/II [18]
A cross-sectional study design was used and the par-
ticipants consisted of 51 outpatients working for a mining
company. A professional translation company was contracted
to translate the ICF checklist into SeSotho and isiZulu,
two local and commonly understood languages in Gauteng
Province. The full checklist was used with its codes and
qualifiers. Training was undertaken for two researchers. The
training aimed to specify how each area was coded and sub-
sequently qualified. The two researchers collected the data
for this study. A combination of interviews and examinations
was used to complete the ICF checklist. Impairments were
determined by direct observation and questioning the patient,
and were assessed through standardised tests.
Although qualifiers were used to describe the different
components, for the purpose of this paper, only the pres-
ence or absence of the component was noted. Performance
(functioning within the participants’ personal context) was
analysed. Body structure and function was coded using three
qualifiers (extent, nature and location of the impairment) and
then scaled. Environmental factors were coded as facilitators
or barriers.
Sample 3: South Africa, Stages III/IV [19]
The study design was the same as that for Sample 2
except that the participants were 80 hospitalised patients with
HIV. Data collection involved evaluation and interviews as
above.
Sample 4: Brazil, post long-term antiretroviral treatment
[3]
The sample consisted of volunteers who were patients at a
reference centre for sexually transmitted diseases and AIDS
in Sao Paulo, Brazil. There were 42 participants, 28 of whom
were men. Their ages ranged from 29 to 52 years, with a
median of 38 years. The time on antiretroviral therapy ranged
from 1.2 to 13 years, with 24/42 (59%) receiving therapy for
more than 4 years. A systematic review was conducted as
the preparatory phase to develop an AIDS core set, following
the methodology of Stucki et al. (2002) [21]. The systematic
review, which included the key words ‘HAART’ and ‘quality
of life’, identified a total of 31 studies. An analysis of these
studies identified 87 concepts; 66 of which could be identified
as ICF categories. These comprised the interview questions.
Data analysis
Descriptive statistics were used to describe the data. Per-
centages, means and ranges for the different domains and
subdomains were calculated. A comparison of the different
groups from the studies was made in a table format.
Ethical considerations
For each study, ethical permission was obtained from the
relevant authorities in each country.
Results
Table 1 summarises the demographic profiles of the
different samples. A wide spectrum of participants was rep-
resented, from those attending outpatient clinics or recruited
from a work site to those hospitalised as a result of HIV. Sam-
ple 1 had not had access to antiretroviral treatment as it had
not yet been made available. Participants in Sample 2 were
receiving antiretroviral drugs from the mining company if
their CD4 count warranted treatment. Sample 3 would have
had access to antiretroviral treatment if necessary, and all
of Sample 4 were receiving treatment and had done so for
periods ranging from 1.2 to 13 years.
The lists of problems reported in the tables are not strictly
comparable as, in some instances, the Brazilian study allowed
for the use of three digit codes. The number of participants
reporting problems in the body function domain is listed in
Table 2. For the categories, the data given are the actual num-
bers. Percentages are given for the most affected categories
and for the problem out of the total sample in the last column.
The most commonly experienced problem in all groups
related to weight maintenance, with two-thirds of the sam-
ple reporting problems in this area. Other common domains
in which problems were encountered included pain, sleep,
energy and drive functions, and muscle power. Mental func-
tions presented the most problems in all groups, with sleep
 H. Myezwa et al. / Physiotherapy 97 (2011) 17–25
(50%, 92/185), energy and drive (45%, 83/185) and emo-
tional functions (49%, 90/185) being the most affected. In
those on long-term therapy, body image affected 93% (39/42)
and was a major problem. All of the groups in Stages II to IV
reported that pain was a problem, whereas Sample 4 did not
seem to have a problem in this area. Cardiopulmonary func-
tions were affected in all groups, being the least affected in
Sample 1. A similar percentage of each group reported prob-
lems with the digestive system (range 57 to 62%), apart from
Sample 3 who had a 75% prevalence of problems in this area.
Sample 4 reported more problems than the other groups with
reproductive functions, and Sample 3 were the most affected
with regard to neuromuscular functions. Those groups likely
to be receiving antiretroviral drugs reported more problems
with regard to skin functions.
With the exception of Sample 3, few subjects reported
problems in the domains of mobility (d4) and self-care (d5).
With regard to major life areas (d6), Sample 3 reported the
most problems, although the 20 respondents in Sample 2
reported problems with acquisition of goods and services.
All groups reported problems with interpersonal interactions
and relationships (d7), with more than 60% of Sample 4
reporting problems with sexual and intimate relationships,
and Sample 3 reporting the most problems with interper-
sonal interaction and family relationships. With regard to
major life areas (d8), remunerative employment and eco-
nomic self-sufficiency emerged as the major area of concern,
particularly for Sample 3. (It is to be noted that Sample 2 were
all employed.) In the domain of community, social and civic
life (d9), Sample 3 reported the most problems with recre-
ation, religion and political life, followed by Sample 4 who
reported the most problems with recreation, sport, religion
and spirituality.
Samples 2 and 3 reported products and technology (e1)
to be facilitators, as illustrated by the results in e110 and
e120 codes (these groups had some access to medication),
but Sample 3 reported barriers in this domain (access was
not universal). These samples also reported support and rela-
tionships (e3) to be a facilitator of function, particularly the
support received from immediate family (e310) (72%, 58)
and health-care professionals (e355) (87%). The similar cat-
egories in the attitudes (e4) domain were also seen to provide
facilitation. Sound emerged as a barrier to function in the
South African samples.
Seventy-three codes with three digits or more are pre-
sented in Tables 1 to 3. As the full checklist has a total of
128 codes, this represents 57% of the ICF checklist codes.
Discussion
Previous studies that have aimed to identify categories
that pertain to areas of difficulty in impairments, activ-
ity and participation used retrospective data or literature
reviews to identify categories that could be related to the
ICF [22–24]. In contrast, this paper is based on prospec-
23
tively gathered data and compares the results of studies
that sought to describe and identify the problems experi-
enced by people living with HIV using the ICF. Although
the different methods and settings of data collection make
strict comparability across the groups impossible, the use
of ICF codes allowed for the amalgamation of the results.
The researchers could then produce a description of both
the problems across different stages of HIV and different
geographical settings.
The ICF model emphasises the importance of contextual
factors in mediating and altering the functional impact of any
health conditions [25]. This stance is well supported by the
results of this paper. It is obvious that at each stage of the
disease, the picture presented by the participants was very
different, and these differences arose directly out of the dif-
ferent environmental factors which were brought to bear on
each group. As a result of these environmental factors, par-
ticularly the availability of antiretroviral therapy, the groups
were at different stages of the continuum of an episodic dis-
ability framework, and the majority of the checklist codes
were utilised. The number of second-level categories used
(i.e. 73) is comparable to that for core sets for low back pain
(78 second-level categories) [26] and rheumatoid arthritis (76
second-level categories) [27], and considerably less than the
130 second-level categories identified for stroke patients. It
would therefore appear that the production of a core ICF set
for HIV is feasible, although the possibility of producing dif-
ferent core sets for different stages of HIV (acute episodic
illness, remission and chronic HIV disease with people on
antiretroviral drugs) could be explored. It would be necessary
to establish which categories are common across the differ-
ent stages of a patient’s health status and which categories
are peculiar to each stage.
Subjects in Sample 3 were at Stages II and III, and were
clearly the most affected at an impairment and activity limita-
tion level. Many of these subjects did not have prior access to
antiretroviral drugs, due in part to the South African Govern-
ment’s prior policy of restricting antiretroviral drugs and only
providing treatment to those who had a very low CD4 count.
The majority of these participants reported problems with
energy, drive, pain and muscle weakness. These impairments
are commonly treated with physiotherapy interventions. The
subjects in Sample 2, who were at Stage I/II, were all in full-
time employment and receiving free antiretroviral drugs from
the mining company. Although many reported impairments
of function, these impairments did not appear to affect their
activity and participation levels. With regard to participa-
tion and environmental factors, this group appeared to suffer
the least from the impact of the disease. In contrast, eco-
nomic self-sufficiency and participation in community life
were reported as problems in almost equal numbers by both
Sample 3 and Sample 4. Sample 4 reported relatively more
problems in the area of participation; a finding that concurs
with other studies [28], and particularly with Dos Santos et al.
(2007) [29] who stated that although the health-related qual-
ity of life of people living with AIDS was better than that of
24 H. Myezwa et al. / Physiotherapy 97 (2011) 17–25
other patients, their social relationships were most affected
by the stigma of the disease.
The limited and recent accessibility to antiretroviral
therapy in South Africa was reflected particularly in the envi-
ronment factors, in the facilitation of functioning reported in
products and technology, and in the attitude of health pro-
fessionals, who were very supportive of the antiretroviral
therapy roll-out in South Africa. It was noteworthy that gen-
erally more people in South Africa reported that support,
relationships and attitudes, particularly those of family and
friends, were facilitatory. All samples experienced these bar-
riers with societal attitudes. Sample 4, however, reported
more problems with intimate relationships and with body
image, and it is not clear if this is an artefact of cultural dif-
ference or the effect of long-term use of antiretroviral drugs
(which does result in lipodystrophy and alteration in the dis-
tribution of body fat [30]). With regard to the concern with
body image, healthcare providers may need to pay attention to
interventions for cosmetic purposes, especially where facial
lipodystrophy is common.
These results will help physiotherapists to understand HIV
within a biopsychosocial framework, and illustrate that the
role of physiotherapists will change and is dependent on the
state of the immune system. By using the ICF, physiother-
apists can better define the points in episodic HIV disease
at which they can intervene. Specific problems that mani-
fest due to a myriad of effects that are pathophysiological-,
environment- and person-related become easier to define and
relate to the philosophy of treatment used by physiotherapists.
Physiotherapists therefore need to be aware of the spectrum
of problems and plan holistic interventions which address not
only impairments, but also the other components of the ICF.
Furthermore, use of the ICF to code data provides an opportu-
nity for the examination of common global population health
issues through an international lens.
Conclusion
In summary, the spectrum of functional problems moved
from problems in the areas of impairment and activity limita-
tion in those at the more advanced stages of HIV, through to
more limitations in the area of participation in those on treat-
ment. The ICF provides a useful framework within which to
describe the functioning of those with HIV and the impact of
the environment. In addition, as the classification is presented
in codes, it becomes possible to compare results directly
across different languages and cultures.
A single core set for the ICF may be a viable option.
Consideration could be given to a number of core sets
collected under the ICF that are relevant to the different
stages of HIV disease. Clarity on linking the data to existing
measures and how to take account of different contexts are
areas for further study.
Ethical approval: Samples 2 and 3, University of the Wit-
watersrand Human Research Ethics Committee (Medical)
(Ref. No. M050206); Sample 1, University of Cape Town
Medical Research Ethics Committee (Ref. No. 051/2002);
Sample 4, School of Public Health, University of Sao Paulo
Human Research Ethics Committee (Ref. No. 1193).
Funding: Samples 2 and 3, Carnegie Foundation and Medical
Research Council of South Africa.
Conflict of interest: None declared.
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