The functional outcomes of stroke patients who are HIV positive, HIV negative and HIV undiagnosed, following rehabilitation: a descriptive study

[摘要] ENGLISH SUMMARY : Background: With the increase in human immunodeficiency virus (HIV) and non-communicable diseases in low to middle-income countries, the rise in HIV-related stroke incidences is becoming a concern. The sub-Saharan region is where the majority of the global HIV population reside. This places an even greater burden on an already strained healthcare system and economy, as HIV-infected people may have an increased chance of stroke and tend to be significantly younger than the conventional stroke population. With the physical and cognitive deficits that may occur due to HIV infection, along with the neurological deficits caused by stroke, this young population now becomes more dependent, increasing the number of unproductive members of society. Hence, it is important to know whether the combination of stroke and HIV further impairs the function of these individuals. Previous studies assessing the function of HIV-infected patients post stroke focused on mortality rather than the morbidity of HIV+ stroke patients. Furthermore, the outcomes measures used to assess their function were global and not specific enough to describe function adequately.Aim: The primary aim of this thesis is to describe the functional outcomes of HIV positive, HIV negative and HIV undiagnosed patients post stroke following inpatient rehabilitation using various outcome measures. Secondary aims include describing demographics, risk factors, length of stay and patient perception. Setting: The Western Cape Rehabilitation Centre (WCRC), situated in Cape Town, South Africa. Study design: A prospective descriptive cohort study.Methods: Approval for conducting the study was obtained from the Committee of Human Research (HREC) at Stellenbosch University (S15/10/232). From July to December 2016, patients who were admitted to the WCRC post stroke were recruited for the study. Written informed consent was obtained from all eligible participants. Data were collected on admission and just prior to discharge, using the Modified Rankin Scale for stroke severity; the Barthel Index and use of assistive devices to assess function in activities of daily living, level of independence and mobility; the Berg Balance Scale and MatScan (pressure mapping) to assess balance. Data on HIV and immune status, demographics, risk factors and length of stay were also collected. The EQ5D was used to assess participant's perception of health related quality of life. All data were entered into an Excel spreadsheet, coded and analysed. Continuous data including mRS, BI, BBS and pressure mapping were summarised using median and range. Categorical data were represented as proportions and graphically displayed using a histogram. Statistical analysis was performed using STATA version 14.2 (Statacorp, 2015). Association between categorical variables was assessed using the chi-squared or Fisher's exact test. Differences in distribution of continuous variables over different levels of a categorical variable were evaluated using the Kruskal-Wallis test, and where differences were detected, the Dunn's test was used for pairwise comparisons. Relationships between patient characteristics and pain and anxiety were evaluated using ordinal logistic regression. The Kaplan-Meier curve was used to describe the length of stay. Statistical significance was assessed at 5%.Results: Out of 54 potential participants, 49 met the inclusion criteria and were recruited; 9 HIV positive (+), 17 HIV negative (-) and 23 HIV undiagnosed participants. The study sample had 51.02% (n = 25) females and 48.98% (n = 24) males. The majority of the sample were mixed race (53.06%, n = 34), 34.69% (n = 17) were of black ethnicity, 10.20% (n = 5) were white and 2.04% (n = 1) were Indian. A significant difference was found with regard to age. The median age for the HIV+ groups was 30 years, and 50 and 51 years for the other groups, respectively (p = 0.0046). The more common risk factors for the HIV- and undiagnosed groups were hypertension and diabetes (p = 0.001 and p = 0.042) respectively. Substance abuse (p = 0.038) and opportunistic infections (p = 0.005) were more prevalent in the HIV+ group. The median CD4 count was 130 (54-883). All groups showed significant improvements in all functional outcome assessments. The HIV+ group had a higher percentage of participants who scored in the higher percentiles for each functional outcome, but no significant results were seen among groups with regard to change in score in stroke severity (mRS p = 0.748), ADLs, independence and mobility (BI p = 0.886; use of assistive devices p = 0. 722) balance and risk of falling (BBS p = 0.4170 and MatScan results). The HIV+ group scored themselves lower than the other groups on the EQ5D VAS scale. This may have been attributed to their age as they were younger and possibly more functionally abled than their older counterparts, but no significant differences were seen among groups (EQ5D p = 0.805). The HIV+ group had a median length of stay of 45 days, while the HIV- and undiagnosed groups stayed for 55 and 53 days respectively. This difference was not statistically significant (p = 0.0671).Conclusion: Even though the HIV+ group was significantly younger and had fewer risk factors, no statistical significant differences were seen with regard to functional outcome. Functional outcome could be affected by a number of variables. In this sample, HIV status did not seem to affect functional outcome negatively. Larger cohorts are required for more generalisable results, to give a better understanding of the functional outcomes of HIV+ stroke patients.

[发布机构] Stellenbosch University