Returning to the timeline traced by the International AIDS Conferences, the 2000 meeting was held in Durban, South Africa. This was the first time that a resource-limited country had played host.  It was at this conference that science was met head on by politics.  The focus on HIV treatments that had dominated the previous two meetings was displaced by a new emphasis on a profound global disparity with respect to attention,  resources and research for HIV.  More than 90% of people living with HIV resided in poor settings,  yet access to HIV treatments in those regions was available to only a handful of elites. As such, activists argued that it was unjust for attention at a global meeting to centre on the science behind treatment without simultaneously addressing the vast political chasm of concern between rich and poor countries. 
At that point,  the cost of treatment was so prohibitively high that it precluded serious contemplation of universal coverage in poor countries. However, 2001 saw a dramatic drop in the price of treatment due in large part to the competitive market created by low-cost generic versions of the HIV drugs by Indian pharmaceutical companies that were not limited by World Trade Organization patent regulations. 
In 2002,  the XIV International AIDS Conference in Barcelona,  Spain,  witnessed a shift that reflected newfound commitment to redressing the disparity in access between rich and poor countries with respect to HIV treatment,  as well as other aspects of HIV prevention,  care and support.

The World Health Organization announced its bold “3 by 5” campaign, which promised to have three million people on HIV treatment by 2005. Two years later, the theme of the 2004 conference,  held in Bangkok,  Thailand,  was Access For All.  The question of whether or not universal access was possible had shifted to how best to achieve this goal. Although unforgivably late and tragically slow, the move to deliver HIV treatment to all in need was in motion.
With the arrival of treatment in poor countries, so the issue of rehabilitation in the context of HIV surfaced in these parts of the world. Some issues have mirrored concerns raised in environments like Canada,  such as the challenge of living with an unpredictable and episodic illness when one’s financial safety net is tied to health and employment status [15]. However, new issues have emerged in research, such as paediatric rehabilitation interventions: the number of children living with HIV in high-prevalence countries is significantly higher than in wealthy countries. It is also important to note that issues of disability and rehabilitation are not limited to people on treatment.

Although the advent of treatment has prompted action in this field,  there are concerns and opportunities for intervention for people who either cannot access or tolerate the drug regimens.
Thus, the field of disability and rehabilitation in the context of HIV has gone global, and one may expect that interest in these issues will expand as treatment becomes more of a reality in poor countries. 
A field becomes established
The field of disability, disablement and rehabilitation in the context of HIV has come a long way in just over a decade. Along with the new geographic reach, there are now bodies of research on a range of topics, including: assessment of disablement among people living with HIV [10], HIV and exercise [16],  HIV and rehabilitation best practices [17],  preparedness of rehabilitation professionals to treat people living with HIV [18],  and barriers and facilitators to labour force participation. 
Furthermore,  in 2007,  the Canadian Working Group on HIV and Rehabilitation undertook a scoping review to identify key research priorities in HIV and rehabilitation to advance policy and practice for people living with HIV in Canada. Among the research priorities that emerged were: further exploring the prevalence and impact of disability among people living with HIV; better understanding the episodic nature of disability as it fluctuates over time; and exploring the impact of episodic disability on one’s overall health [12].
It is important to note that the degree of engagement on issues of rehabilitation and disability in the context of HIV described in Canada do not necessarily reflect a general trend worldwide.

There is work to be done in more broadly advancing the issue in other regions. However, it is also noteworthy that the Canadian response has largely been located in a health paradigm, which has resulted in limited collaboration with disability organizations. 
More progressive intersections between the HIV and disability communities can be found in other countries, such as Australia, where the Disability Discrimination Act was passed in 1992.

The Act’s definition of disability included “the presence in the body of organisms capable of causing disease or illness”,  thus including people living with HIV [19].  There have also been notable activists, such as John Campbell of the United Kingdom, who was a person living with HIV and a disability activist. As chair of the British Council of Disabled People and founder of an organization for people who are hearing impaired,  Campbell was visionary in recognizing challenges shared by people with disabilities and people living with HIV [20]. 

Another conceptual leap,  however,  involves people with pre-existing disabilities and their vulnerability to HIV; it is the history of this movement that forms Part 2 of this article.

Jill Hanass-Hancock and Stephanie A Nixon

Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, South Africa
Department of Physical Therapy, University of Toronto, Canada, and Research Associate, HEARD, University of KwaZulu-Natal, South Africa

Journal of the International AIDS Society 2009, 2:3   doi:10.1186/1758-2652-2-3
Jill Hanass-Hancock (.(JavaScript must be enabled to view this email address))
Stephanie A Nixon (.(JavaScript must be enabled to view this email address))

References

1.      United Nations: UN convention on the rights of persons with disabilities.  2008. [http://www.un.org/disabilities/default.asp?id=150]
2.      Brashers DE, Neidig JL, Cardillo LW, Dobbs LK, Russell JA, Haas SM: “In an important way, I did die’: uncertainty and revival in persons living with HIV or AIDS. AIDS Care 1999, 11:201-219.
3.      Nokes KM: Revisiting how the chronic illness trajectory framework can be applied to persons living with HIV/AIDS. Scholarly Inquiry for Nursing Practice 1998, 12:27-31.
4.      Philips A, O’Dell MW, Mills B: Comprehensive guide for the care of persons with HIV disease: Module 7-HIV rehabilitation services. Ottawa, Canada: Health Canada; 1998.
5.      World Health Organization (WHO): International Classification of Functioning Disability and Health Geneva: WHO, [http://www.who.int/classifications/icf/en/] 2001.
6.      Nixon S, Cott C: Shifting perspectives: reconceptualizing HIV disease in a rehabilitation framework. Physiotherapy Canada 2000, 52:189–197.
7.      Rusch M, Nixon S, Schilder A, Braitstain P, Chan K, Hogg R: Impairments, activity limitations and participation restrictions: Prevalence among persons living with HIV/AIDS in British Columbia Health and Quality of Life Outcomes 2004, 2:46.
8.      The Cross Cluster Initiative on Home-Based Long-Term Care, The Department of HIV/AIDS and Family and Community Health of the World Health Organisation: Community home-based care in resource-limited settings. A framework for action. World Health Organisation, Geneva; 2002.
9.      Worthington C, Myers T, O’Brien K, Nixon S, Cockerill R: Rehabilitation in HIV/AIDS: development of an expanded conceptual framework. AIDS Patient Care and STDs 2005, 19:258-271.
10.    Myezwa H, Stewart A, Musenge E, Nesara P: Assessment of HIV-positive in-patients using the International Classification of Functioning, Disability and Health (ICF), at Chris Hani Baragwanath Hospital, Johannesburg. African Journal of AIDS Research 2009, 8:93-106.
11.    Canadian Working Group on HIV and Rehabilitation: Resources on Episodic Disability [http://www.hivandrehab.ca/EN/resources/episodic_disabilities.php]
12.    O’Brien K, Wilkins A, Zack E, Solomon P: Scoping the field: Identifying key research priorities in HIV and rehabilitation. AIDS and behavior. March 2009. DOI 10.1007/s10461-009-9528-z. 2009.
13.    O’Brien K, Bayoumi AM, Strike C, Young N, Davis AM: Exploring disability from the perspective of adults living with HIV/AIDS: Development of a conceptual framework. Health and Quality of Life Outcomes 2008, 6:76.
14.    Ernst J, Hufnagle KS, Shippy A: HIV and Older Adults. New York: AIDS Community Research Initiative of America; 2008.
15.    Booysen F: Social grants as safety nets for HIV/AIDS-affected households in South Africa1(1). SAHARA Journal 2004, 1:45-56.

Full references

The complete article is available as a provisional PDF.