Exercise as medicine

The widespread availability of potent HIV treatment (ART) in Canada and other high-income countries has largely transformed HIV infection into a chronic condition. The benefits of ART are so profound that scientists and doctors increasingly expect that many ART users will have a near-normal life expectancy.

As people with HIV age, issues associated with growing older will become the focus of their overall care and treatment. Such issues can include higher-than-normal blood pressure, excessive weight, pre-diabetes and type 2 diabetes, cardiovascular disease and so on. Some researchers in Canada propose that by helping people engage in more healthy behaviours, particularly exercise, they can help prevent or minimize the impact of some conditions associated with aging. These researchers have formulated evidence-based recommendations for the type and amount of exercise that can be prescribed for HIV-positive people.

Evidence-based findings and recommendations

Studies have generally found a relatively low rate of physical activity (exercise is a subset of this) among HIV-positive people. To help remedy this situation, a team of scientists in Canada and the U.S. collaborated to review exercise-related studies with HIV-positive people over the past decade. After reviewing the studies, the scientists developed recommendations to help healthcare providers and counsellors “prescribe and support physical activity engagement” among HIV-positive people.

These recommendations are important because studies suggest that issues such as being overweight and obese are more common in the average HIV-positive person today than they were earlier on in the pandemic. A future issue of TreatmentUpdate will delve into studies about factors affecting body weight and report on trends in body weight and obesity among HIV-positive people over the past four decades.

How much and what kind of exercise?

The team of scientists noted that the U.S. Department of Health and Human Services (DHHS) has proposed “that adults—even those with chronic conditions and disability—engage in 150 to 300 minutes of moderate-intensity exercise or 75 to 150 minutes of vigorous-intensity aerobic physical activity each week.”

The scientists stated that “for sedentary or physically inactive [HIV-positive people], prescribing movement breaks or walking may be a practical strategy to increase physical activity, as it does not require special skills or equipment.”

Additionally, the scientists noted that the DHHS recommends the following measures:

• “muscle-strengthening activity on two or more days per week”
• “balance training…as part of older adults’ weekly physical activity to reduce fall risk”
• “moving more and sitting less will benefit nearly everyone”

The team of scientists stated that “although some people with HIV may have unique physical limitations that must be accommodated in order for them to safely engage in physical activity, the take-home recommendation is that physical activity participation is key to maximizing health and function.”

Types of physical activity

The scientists pointed out that in addition to traditional aerobic (walking, biking and swimming) and resistance (weight-bearing) exercises, there is “lower-intensity physical activity” that can be considered, such as the following:

• yoga – the team noted that among HIV-positive people, yoga is associated with the following benefits: “improvement in quality of life; reduction in depressive symptoms and reduction of blood pressure”
• Tai Chi – according to the scientists, this form of activity “was associated with improved [sense of] wellbeing and balance” in HIV-positive people

Intensity of activity

The scientists stated that studies with HIV-positive people have found that “high-intensity aerobic and resistance exercise (based on target heart rate and resistance load) improved endurance and strength to a similar, if not greater, extent than moderate-intensity exercise.” Such gains were also found among older HIV-positive people.

Taking this and other exercise-related findings into account, the scientists made the following statement:

“These studies of high-intensity exercise have indicated no reason to dissuade [HIV-positive people]—young or old—from progressing to high-intensity exercise, following several weeks of moderate-intensity exercise training.”

Identifying and overcoming barriers

Intrapersonal barriers

The scientists reviewed many studies and found that there were “intrapersonal barriers” to engagement in exercise, including the following:

• “worries about HIV disclosure and stigma”
• “a lack of social support”

However, they found that there was at least one study in which “participants found the [exercise environment] less stigmatizing than they initially feared.”

The researchers also stated that “health care providers’ recommendations can also play a key role in perceptions and engagement in physical activity [among HIV-positive people].”

Environmental barriers

The scientists stated that there may also be “environmental barriers” to physical activity among HIV-positive people, including the following:

• “concerns about physical safety”
• “physical and financial accessibility”

They encouraged healthcare providers and community workers to take such issues into account when developing “a physical activity plan” for HIV-positive people. One potential solution from the scientists to help overcome environmental barriers is to encourage HIV-positive people to walk “in a shopping mall or to engage in short bouts of physical activity throughout the day that do not require gym access or equipment.” (Note that some gyms and community organizations offer subsidized access to athletic facilities.)

Changing behaviours

The researchers encouraged primary care providers to periodically “enquire about and promote physical activity among [HIV-positive people].”

One strategy they suggested for helping HIV-positive people engage in more physical activity is for healthcare providers to collaborate with patients to jointly develop a “physical activity prescription.” The scientists pointed out the non-profit website Exercise is Medicine (https://exerciseismedicine.org/), which can be very useful for healthcare providers and has suggestions for effecting simple behavioural changes.

Based on studies, the scientists recommended that the following behaviour change strategies be adopted:

Self monitoring

This can be done with wearable technology such as a pedometer, Fitbit, smartphone apps or online tools (the scientists recommended https://go4life.nia.nih.gov/ from the U.S. National Institutes of Health) or simply pen and paper.

Goal setting and action planning

The scientists stated that “goal setting encourages specific behaviour resolution (eg. engaging in more physical activity this week), while action planning involves detailed planning of what the person will do, when they will engage in the specified behaviour and for how long.”

Prompts, cues and scheduling

Prompts can be used to remind people to engage in physical activity. The scientists stated that these reminders “may drive habit formation and improve long-term physical activity adherence.” They also said that “a calendar, alarms…cell phone reminders” can be used to set aside time for physical activity. They found research that suggested that “pre-scheduled activity is often more adhered to than relying on impromptu self-motivation.”

Social support

The research team stated that there is evidence for the “prominent role that healthcare providers have in integrating health promotion into routine HIV care. Thus, providers can leverage their strong patient relationships to emphasize a holistic concept of well-being that includes physical activity. Persons are more likely to engage in physical activity if they are linked to a similarly motivated person with whom they are able to engage in physical activity, creating a ‘buddy system’…. In addition, the social environment of group exercise can enhance motivation and adherence to physical activity among older [HIV-positive people].”

Bear in mind

The team of scientists has put forward a set of useful, evidence-informed and practical recommendations for increasing physical activity among HIV-positive people. Hopefully these recommendations will be increasingly implemented over the coming years.

Resources

Pilot study finds intense exercise is good for older HIV-positive men – TreatmentUpdate 228

Exercise—Potential impact on inflammation and mood – TreatmentUpdate 205

Exercise and the brain – TreatmentUpdate 203

Exercise found to improve memory – TreatmentUpdate 186

—Sean R. Hosein

REFERENCE:

Montoya JL, Jankowski CM, O’Brien KK, et al. Evidence-informed practical recommendations for increasing physical activity among persons living with HIV. AIDS. 2019 May 1;33(6):931-939.