Functional Limitations and Disability in Persons Living with HIV in South Africa and United States: Similarities and Differences

The association between HIV infection, disability and lifestyle activity among middle-aged and older adults: an analytical cross-sectional study in Ivory Coast (the VIRAGE study)

INTRODUCTION

People living with HIV (PLWH) live longer and face new health challenges resulting from the confluence of chronic HIV infection and the natural effect of aging and comorbidities. However, there is a dearth of information on the long-term impact of HIV infection on the health and wellbeing of PLWH in sub-Saharan Africa. This research aimed to fill this gap by reporting on physical, functional and social outcomes among PLWH treated at a referral center in Abidjan, Ivory Coast, and comparing them with those of a control group.

METHODS

Body composition, functional capacity, sarcopenia, limitations in daily activities and social participation were assessed among 300 PLWH (aged ≥ 30 years) and 200 uninfected adults of similar age and sex. The associations between these outcomes and participants' socioeconomic characteristics, HIV history and physical activity level were assessed using generalized additive models adjusted for age and sex.

RESULTS

The median age was 51 years, and the median antiretroviral therapy duration was 15 years. Compared to controls, PLWH reported higher levels of physical activity (p < 0.0001). They had a lower muscle index (adjusted p < 0.0001) and grip strength (adjusted p < 0.0001) but achieved similar performance on the 6-min walk test (6MWT, p = 0.2). Among PLWH, physical activity level was positively associated with better performance in the 6MWT (p = 0.006) and greater hand grip strength (p = 0.04). The difference in physical performance according to the level of physical activity appeared mainly after the age of 60. PLWH reported similar rates of activity limitations (p = 0.8), lower depression levels and greater scores for social functioning (p = 0.02).

CONCLUSION

In this study, PLWH achieved high levels of physical activity, which may explain why they maintained good physical performance and social functioning despite having a higher risk of sarcopenia. These results have important implications for resource-limited health systems and show avenues for chronic care models.

TRIAL REGISTRATION

This study was registered on the ClinicalTrials.gov website (NCT05199831, first registration the 20/01/2022).

The Social Construction of Aging Among a Clinic-Based Population and Their Healthcare Workers in Zambia

Objectives

We sought to understand the social construction of aging in a clinic-based population, with and without HIV, to address gaps in care for older individuals living with HIV in Zambia.

Methods

Our exploratory qualitative study included 36 in-depth interviews with clinic clients and four focus group discussions with 36 professional and lay healthcare workers providing services to the clients. We identified themes based on social construction theory.

Results

At the individual level, aging was multidimensional, perceived both as an achievement in the HIV era and as a period of cognitive, physical, and economic decline. In social interactions, older individuals were often stereotyped and treated as helpless, poor, and "witches." Those living with HIV faced the additional stigma of being labeled as promiscuous. Some of the participants living without HIV refused to take daily medication for non-communicable diseases to avoid being mistaken for taking antiretroviral therapy for HIV. Older individuals wanted quality healthcare and family support to address the intersectional stigma of aging, poverty, and chronic illness.

Conclusion

Multifaceted interventions are required to combat age-related prejudice, intersectional stigma, and discriminatory practices, particularly for people living with HIV.

The Global Task Force for Chronic Pain in People with HIV (PWH): Developing a research agenda in an emerging field

Chronic pain is a common comorbidity in people with HIV (PWH), with prevalence estimates of 25-85%. Research in this area is growing, but significant gaps remain. A Global Task Force of HIV experts was organized to brainstorm a scientific agenda and identify measurement domains critical to advancing research in this field. Experts were identified through literature searches and snowball sampling. Two online questionnaires were developed by Task Force members. Questionnaire 1 asked participants to identify knowledge gaps in the field of HIV and chronic pain and identify measurement domains in studies of chronic pain in PWH. Responses were ranked in order of importance in Questionnaire 2, which was followed by a group discussion. 29 experts completed Questionnaire 1, 25 completed Questionnaire 2, and 21 participated in the group. Many important clinical and research priorities emerged, including the need to examine etiologies of chronic pain in PWH. Pain-related measurement domains were discussed, with a primary focus on domains that could be assessed in a standardized manner across various cohorts that include PWH in different countries. We collaboratively identified clinical and research priorities, as well as gaps in standardization of measurement domains, that can be used to move the field forward.

Factors associated with reduced function and quality of life among adult people with HIV with depression and substance use in the Asia-Pacific region

BACKGROUND

Depression and substance use (SU) disorders are prevalent among people with HIV (PWH) and impact health outcomes despite successful antiretroviral therapy (ART). We explored quality of life, functional ability and associated factors among PWH screened positive for depression and/or SU.

METHODS

This cross-sectional study recruited adult PWH during routine follow-up at five HIV clinical sites in the Asia-Pacific region. Participants were screened for depression using Patient Health Questionnaire-9 and SU using Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Quality of life (QoL) was assessed with WHOQOL-HIV BREF and functional ability with World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Factors associated with mean QoL and disability scores were analysed using linear regression.

RESULTS

Of 864 PWH enrolled, 753 screened positive for depression or SU. The median (interquartile range, IQR) age was 38 (31-47) years and 97% were on ART. Overall mean WHOQOL-HIV BREF and WHODAS scores indicated greater impairment with increasing depressive symptom severity and SU risk. In multivariate analysis, PWH reporting previous trauma/stress (difference = 2.7, 95% confidence interval [CI] 1.5-3.9, P  < 0.001) and past mental health diagnosis (difference = 5.0, 95% CI 2.9-7.1, P  < 0.001) were associated with greater disability and poorer QoL scores across multiple domains ( P < 0.01 for all). Higher CD4 T-cell counts was also associated with better QoL scores and functional ability.

CONCLUSION

PWH with depression/SU experienced poorer QoL and function despite routine engagement in HIV care. Efforts to integrate mental health services and interventions addressing disability into HIV management should be prioritized in the region.

A review of the framework and strategy for disability and rehabilitation services in South Africa

Background

Rehabilitation is imperative for the successful integration of persons with disabilities into their social environments. The Framework and strategy for disability and rehabilitation services (FSDR) in South Africa, 2015-2020.was developed to strengthen access to rehabilitation services and ensure the inclusion of persons with disabilities in all aspects of community life. Despite the FSDR being commissioned, access to rehabilitation is a challenge for persons with disabilities and further compounded in rural communities.

Objective

The study aimed to describe the barriers and facilitators that influenced the process of development, implementation and monitoring of the FSDR.

Method

This qualitative study employed a single case study design. Data was collected through document analysis and in-depth interviews utilising the Walt & Gilson policy analysis framework that outlines the context, content, actors and process of policy development and implementation. In-depth interviews were conducted with twelve key informants (N=12) who were selected purposively for the study. Data obtained from the in-depth interviews were analysed using inductive thematic analysis.

Results

We found many factors that influenced the implementation of the framework. Actor dynamics, insufficient resources, the rushed process, poor record-keeping, inappropriate leadership, negative attitudes of staff members and the insufficient monitoring impeded the successful implementation of the framework. While positive attitude, mentorship and support amongst the task team facilitated the implementation process, albeit with challenges.

Conclusion

There is a need to address implementation gaps so that the FSDR is responsive to the current rehabilitation needs of persons with disabilities in South Africa.

Contribution

This study may inform future disability policy, and can be used as a tool to advocate for the rights for persons with disabilities.

Functioning Problems Associated with Health Conditions with Greatest Disease Burden in South Africa: A Scoping Review

A notable rise in health-related disability for which evidence-based rehabilitation is beneficial is evident in low-to-middle income countries. This scoping review aimed to systematically identify and map the most common functioning problems associated with health conditions that contribute most to disability in South Africa using the International Classification of Functioning, Disability and Health (ICF) framework. Peer-reviewed evidence published from January 2006 to December 2021 was systematically searched from five databases. Some 268 studies reporting on functioning problems (impairments, activity limitations, and participation restrictions) in South African adults (>18 years) related to 10 health conditions were included. A total of 130 different functioning problems were mapped to the ICF. The most prevalent problems (top 20) were related to mobility, pain, and mental health but spanned across several ICF domains and were mostly in patients at primary care. The high prevalence and wide range of functioning problems may be particularly burdensome on an already strained primary health care (PHC) system. This points towards targeted planning of innovative strategies towards strengthening rehabilitation service delivery at primary care to address these complexities where there is an inadequate rehabilitation workforce.

Prevalence, severity, and risk factors of disability among adults living with HIV accessing routine outpatient HIV care in London, United Kingdom (UK): A cross-sectional self-report study

BACKGROUND

The study objectives were to measure disability prevalence and severity, and examine disability risk factors, among adults living with HIV in London, United Kingdom (UK).

METHODS

Self-reported questionnaires were administered: World Health Organization Disability Assessment Schedule 2.0 (WHODAS), HIV Disability Questionnaire (HDQ), Equality Act disability definition (EADD), and demographic questionnaire. We calculated proportion (95% Confidence Interval; CI) of "severe" and "moderate" disability measured using EADD and WHODAS scores ≥2 respectively. We measured disability severity with HDQ domain severity scores. We used demographic questionnaire responses to assess risk factors of "severe" and "moderate" disability using logistic regression analysis, and HDQ severity domain scores using linear regression analysis.

RESULTS

Of 201 participants, 176 (87.6%) identified as men, median age 47 years, and 194 (96.5%) virologically suppressed. Severe disability prevalence was 39.5% (n = 79/201), 95% CI [32.5%, 46.4%]. Moderate disability prevalence was 70.5% (n = 141/200), 95% CI [64.2%, 76.8%]. Uncertainty was the most severe HDQ disability domain. Late HIV diagnosis was a risk factor for severe disability [Odds Ratio (OR) 2.71; CI 1.25, 5.87]. Social determinants of health, economic inactivity [OR 2.79; CI 1.08, 7.21] and receiving benefits [OR 2.87; CI 1.05, 7.83], were risk factors for "severe" disability. Economic inactivity [OR 3.14; CI 1.00, 9.98] was a risk factor for "moderate" disability. Economic inactivity, receiving benefits, and having no fixed abode were risk factors (P≤0.05) for higher HDQ severity scores in physical, mental and emotional, difficulty with day-to-day activities, and challenges to social participation domains. Personal factors, identifying as a woman and being aged <50 years, were risk factors (P≤0.05) for higher HDQ severity scores in mental and emotional, uncertainty, and challenges with social participation domains.

CONCLUSIONS

People living with well-controlled HIV in London UK experienced multi-dimensional and episodic disability. Results help to better understand the prevalence, severity, and risk factors of disability experienced by adults living with HIV, identify areas to target interventions, and optimise health and functioning.

Examining the Utility of the HIV Disability Questionnaire (HDQ) in Clinical Practice: Perspectives of People Living with HIV and Healthcare Providers

Our aim was to examine the utility of the HIV Disability Questionnaire (HDQ), a patient-reported outcome measure for use in clinical practice from the perspectives of people living with HIV (PLWH) and healthcare providers. We conducted a qualitative descriptive study. Fifteen PLWH and five healthcare providers participated in an interview, of which ten PLWH participated in a follow-up focus group discussion. The HDQ has value in clinical practice, including its role in assessing disability, facilitating communication, tailoring treatments, and guiding referrals. Strengths of the HDQ included its comprehensiveness, relevance of domains, and importance of specific items. Concerns related to length of the HDQ, the potential for some items to trigger emotional response, and negative connotations with the term ‘disability.’ Recommendations for HDQ implementation included the importance of score interpretability, shortening the questionnaire, and tailoring administration to the individual. Results suggest the HDQ possesses clinical utility with PLWH and healthcare providers.

Tobacco Use and Health-Related Quality of Life Among Individuals with Depression Who Are Receiving Treatment for HIV in Cape Town, South Africa

BACKGROUND

Tobacco use is the leading cause of preventable death worldwide, and prevalence rates are high among people living with HIV (PLWH), particularly in men. Depression is also common among PLWH, especially among smokers, who may use tobacco to manage mood. Although HIV and depression have been linked to functional impairment and poor health-related quality of life (HRQOL), little research has examined the degree to which smoking impacts these relationships in low- and middle-income countries with high HIV burden.

METHOD

Participants (N = 289) were people living with HIV (PLWH) who were being assessed for inclusion in a study targeting depression as a barrier to HIV medication adherence. Linear regression models measured the effect of gender on tobacco use (assessed by the WHO-ASSIST) and on each of the five HRQOL functional impairment domains (assessed by the SF-21). Separate multivariable regression models examined the relationships between habitual tobacco use, defined as daily, almost daily, or weekly use, and the HRQOL domains.

RESULTS

The prevalence of habitual tobacco use was 23.9% (48.1% among men, 15.5% among women). Habitual tobacco use was associated with decreased cognitive functioning for the whole sample (B = - 8.99, p < 0.05) and with lower levels of pain-related impairment for men (B = 18.1, p < 0.05). Although men reported more tobacco use (B = 8.50, p < 0.001), they reported less pain-related limitations than women (B = 8.70, p < 0.05).

CONCLUSIONS

In our sample, men reported higher rates of habitual tobacco use than women. Smoking was associated with cognitive impairment and with less pain-related impairment among men. Future smoking cessation treatments tailored to PLWH who have symptoms of depression may benefit from strategies that consider pain management as a pathway to habitual smoking and recognize that motivations for use may differ by gender.

Physical outcomes of patients infected with HIV requiring intensive care unit admission for mechanical ventilation at one South African hospital: a pilot study

Patients with life-threatening illnesses in intensive care receive management that improves their chances for survival. The physical outcomes of individuals infected with HIV who survive an intensive care unit (ICU) stay are not well known. The purpose was to describe the physical outcomes of ICU survivors in a high HIV prevalent area and highlight challenges as it relates to study feasibility. A pilot study at a tertiary-care university-affiliated hospital was done. Participants were assessed at ICU and ward admission, hospital discharge, three and six months following discharge. The profile and physical function, assessed with the ICU Mobility Scale, Karnofsky Performance Status Scale and six-minute walk test, of participants was determined. The EQ-5D-3 L provides information on participants' health-related quality of life (HRQOL). The pilot study consists of five patients (n = 173 screened). All were independently mobile and on antiretroviral therapy prior to hospital admission. Respiratory and peripheral muscle weakness were present with variable performance in physical function across participants. Improvement in function occurred over time but participants still had physical dysfunction at six months. Pain/physical discomfort and anxiety/depression were common complaints influencing HRQOL. ICU survivors, who are HIV-positive, present with significant physical dysfunction who require rehabilitation to reduce disability.

Efavirenz, atazanavir, and ritonavir disrupt sarcoplasmic reticulum Ca2+ homeostasis in skeletal muscles

While muscle fatigue, pain and weakness are common co-morbidities in HIV-1 infected people, their underlying cause remain poorly defined. To this end, we evaluated whether the common antiretroviral drugs efavirenz (EFV), atazanavir (ATV) and ritonavir (RTV) could be a contributing factor by pertubating sarcoplasmic reticulum (SR) Ca²⁺ cycling. In live-cell imaging, EFV (6.0 μM), ATV (6.0 μM), and RTV (3.0 μM) elicited Ca²⁺ transients and blebbing of the plasma membranes of C2C12 skeletal muscle myotubes. Pretreating C2C12 skeletal muscle myotubes with the SR Ca²⁺ release channel blocker ryanodine (50 μM), slowed the rate and amplitude of Ca²⁺ release from and reuptake of Ca²⁺ into the SR. EFV, ATV and RTV (1 nM - 20 μM) potentiated and then displaced [³H] ryanodine binding to rabbit skeletal muscle ryanodine receptor Ca²⁺ release channel (RyR1). These drugs at concentrations 0.25-31.2 μM also increased and or decreased the open probability of RyR1 by altering its gating and conductance. ATV (≤5 μM) potentiated and >5μM inhibited the ability of sarco (endo)plasmic reticulum Ca²⁺-ATPase (SERCA1) to hydrolyze ATP and transport Ca²⁺. RTV (2.5-31.5 μM) dose-dependently inhibited SERCA1-mediated, ATP-dependent Ca²⁺ transport. EFV (0.25-31.5 μM) had no measurable effect on SERCA1's ability to hydrolyze ATP and transport Ca²⁺. These data support the notion that EFV, ATV and RTV could be contributing to skeletal muscle co-morbidities in PLWH by modulating SR Ca²⁺ homeostasis.

Self-Reported Disability in Persons With HIV-Related Neuropathy Is Mediated by Pain Interference and Depression

OBJECTIVE

The purpose of this study was to compare disability in people with HIV and peripheral neuropathy with those without neuropathy and explore how neuropathy and other relevant factors are associated with disability.

METHODS

In this cross-sectional study, participants completed the Brief pain inventory, Beck Depression Inventory II, World Health Organization Disability Assessment Schedule (WHODAS 2.0), and a health and demographic questionnaire. Additional data were extracted from the medical record. A raw score of ≥1 on the Subjective Peripheral Neuropathy Screen questions about lower extremity numbness or paresthesia was used to identify peripheral neuropathy. Predictors of disability (as determined by association with World Health Organization Disability Assessment Schedule 2.0 scores) were evaluated bivariately and in a multivariable model. Path modeling was used to identify a parsimonious model to elucidate the mediated effects of peripheral neuropathy on disability.

RESULTS

Participants with peripheral neuropathy had more depression symptoms, more pain (severity and interference), and higher disability scores compared with participants without neuropathy. The relationship between neuropathy and disability was mediated by pain interference and depression (standardized root mean residual = .056).

CONCLUSION

In this sample of people with HIV, those with lower extremity peripheral neuropathy reported more severe disability, worse pain, and more depression symptoms than those without neuropathy. The relationship between peripheral neuropathy and disability may be mediated though pain interference and depression.

IMPACT

Distal sensory polyneuropathy is a common comorbidity experienced by people living with HIV and frequently causes pain. This study can help providers direct care toward lessening disability experienced among people with HIV and peripheral neuropathy by targeting interventions for treatment of pain and depression.

LAY SUMMARY

People living with HIV may experience disabling painful neuropathy. Treatment for pain and depression may help reduce the disability associated with painful neuropathy.

The multidimensional vulnerability of people with disability to HIV infection: Results from the handiSSR study in Bujumbura, Burundi

BACKGROUND

In resource-limited contexts, available data indicate that people with disability are disproportionally affected by the HIV epidemic. While disability resulting from chronic HIV infection has received some attention, few epidemiologic studies have examined the vulnerability of people with disability to HIV acquisition. The aims of the study were as follows: to estimate and compare HIV prevalence among people with and without disability living in Bujumbura, Burundi; to examine how the interaction among disability, gender and socioeconomic environment shapes vulnerability to HIV; and to identify potential pathways to higher HIV risk.

METHODS

In this cross-sectional population-based study, 623 persons with disability (302 with disability onset ≤10 years ["early disability"]) and 609 persons without disability matched for age, sex and location were randomly selected to be tested for HIV and to participate in an interview about their life history, their social environment and their knowledge of sexual health.

FINDINGS

A total of 68% of men and 75% of women with disability were affected by multidimensional poverty compared to 54% and 46% of their peers without disability (p<0.0001). Higher HIV prevalence was observed among women with disability (12.1% [8.2-16]) than among those without (3.8% [1.7-6], ORa 3.8, p<0.0001), while it was similar among men with disability and those without (p = 0·8). Women with disability were also at higher risk of sexual violence than were those without (ORa 2.7, p<0.0001). The vulnerability of women with early disability to HIV was higher among those who were socially isolated (HIV prevalence in this group: 19% [12-27]). In addition, education level and sexual violence mediated 53% of the association between early disability and HIV (p = 0.001).

INTERPRETATION

This study highlights how the intersection of disability, gender and social environment shapes vulnerability to HIV. It also shows that the vulnerability to HIV of women who grew up with a disability is mediated by sexual violence.

FUNDING

This research was funded by the Netherlands Organization for Scientific Research (Grant W08.560.005) and the Initiative HIV-TB-Malaria (new name of the organisation).

Reliability and Validity of the HIV Disability Questionnaire (HDQ) with Adults Living with HIV in the United States

OBJECTIVES

To assess measurement properties of the HIV Disability Questionnaire (HDQ) among adults with HIV in the United States.

METHODS

We administered the HDQ, World Health Organization Disability Assessment Schedule II (WHODAS 2.0), and a demographic questionnaire. For internal consistency reliability, we calculated Cronbach α and Kuder-Richardson-20 (KR-20) statistics for disability and episodic scores, respectively (≥0.80 acceptable). For test-retest reliability, we calculated intraclass correlation coefficients (>0.8 acceptable). For construct validity, we tested 15 a priori hypotheses assessing correlations between HDQ and WHODAS 2.0 scores.

RESULTS

Of the 128 participants, the majority were males (68%), median age 51 years, taking antiretroviral therapy (96%). Cronbach α ranged from 0.88 (social inclusion) to 0.93 (uncertainty). The KR-20 ranged from 0.86 (cognitive) to 0.96 (uncertainty). Intraclass correlation coefficients ranged from 0.88 (physical, cognitive, social inclusion) to 0.92 (mental-emotional). Of the 15 hypotheses, 13 (87%) were confirmed.

CONCLUSIONS

The HDQ demonstrates internal consistency reliability, test-retest reliability, and construct validity when administered to a sample of adults with HIV in the United States.

Physical Rehabilitation Needs in the BRICS Nations from 1990 to 2017: Cross-National Analyses Using Data from the Global Burden of Disease Study

Background: This study analyzes the current and evolving physical rehabilitation needs of BRICS nations (Brazil, Russian Federation, India, China, South Africa), a coalition of large emergent economies increasingly important for global health. Methods: Secondary, cross-national analyses of data on Years Lived with Disability (YLDs) were extracted from the Global Burden of Disease Study 2017. Total physical rehabilitation needs, and those stratified per major condition groups are analyzed for the year 2017 (current needs), and for every year since 1990 (evolution over time). ANOVAs are used to detect significant yearly changes. Results: Total physical rehabilitation needs have increased significantly from 1990 to 2017 in each of the BRICS nations, in every metric analyzed (YLD Counts, YLDs per 100,000 people, and percentage of YLDs relevant to physical rehabilitation; all p < 0.01). Musculoskeletal & pain conditions were leading cause of physical rehabilitation needs across the BRICS nations but to varying degrees: from 36% in South Africa to 60% in Brazil. Country-specific trends include: 25% of South African needs were from HIV-related conditions (no other BRICS nation had more than 1%); India had both absolute and relative growths of pediatric rehabilitation needs (p < 0.01); China had an exponential growth in the per-capita needs from neurological and neoplastic conditions (p < 0.01; r2 = 0.97); Brazil had a both absolute and relative growth of needs coming from musculoskeletal & pain conditions (p < 0.01); and the Russian Federation had the highest neurological rehabilitation needs per capita in 2017 (over than three times those of India, South Africa or Brazil). Conclusions: total physical rehabilitation needs have been increasing in each of the BRICS nations, both in absolute and relative values. Apart from the common growing trend, each of the BRICS nations had own patterns for the amount, typology, and evolution of their physical rehabilitation needs, which must be taken into account while planning for health and physical rehabilitation programs, policies and resources.

Trends in health and disability in Botswana. An analysis of the global burden of disease study

Purpose: Globally, years of life lost are declining, while years lived with disability are increasing. In high socio-demographic index countries, this trend has been attributed to an overall ageing population and rehabilitation services have begun to adjust to this change. In low- and middle-income countries, this trend is less well understood. Hence, the WHO's 'Rehabilitation 2030 Call for Action' and 'Rehabilitation in Health Systems Guide' call for better assessment of the situation. In order to understand trends and causes in middle income countries such as Botswana, we examine the change over time in causes and number of years lived with disability and years of life lost.Methods: We conducted a secondary analysis of the Global Burden of Disease 2017 data, exploring the change over time in Disability Adjusted Life Years per 100 000 people over the period 1990-2016. The descriptive analysis focuses on the contribution of years lived with disability towards the burden of disease within Botswana compared with the world, sub-Saharan Africa, and high-income countries.Results: Our results show that Botswana's top causes of years of life lost are HIV and other sexually transmitted infections, cardiovascular diseases, maternal and neonatal disorders, respiratory infections and tuberculosis, and neoplasms. Years lived with disability have increased over time, which is driven by mental disorders, HIV and other sexually transmitted infections, musculoskeletal disorders, neurological disorders, and skin and subcutaneous diseases.Conclusions: Botswana needs better data to prepare its emerging health systems to accommodate the increased need for disability support and rehabilitation services caused by communicable and non-communicable diseases.Implications for RehabilitationBotswana has an increase in disability prevalence over time that requires the development of disability and rehabilitation services.The greatest contributors towards disability adjusted life years in Botswana are currently mental disorders (13.7%), HIV and other sexual transmitted diseases, (13.0%), musculoskeletal disorders (9.9%), neurological disorders (8.0%), and sense organ diseases (6.2%).This requires strengthen of services such as mental health interventions, physiotherapy, optometry and audiology as well as linkages from major disease clusters such as HIV to rehabilitation services.