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CONSIDERATIONS & PRECAUTIONS: Exercise Prescription for Health in HIV+ Individuals

Quiles, Norberto Ed.M., M.A., RCEP, CES, HFS, CSCS; Garber, Carol Ewing Ph.D., FACSM, FAHA, RCEP, CPD, HFS

doi: 10.1249/FIT.0000000000000053

LEARNING OBJECTIVE: To provide the health fitness professional with current evidence, considerations, and recommendations for providing exercise prescription for people with the human immunodeficiency virus and its complications.

Individuals with HIV may benefi t from an exercise program that includes cardiorespiratory, resistance, fl exibility, and neuromotor exercise. This article provides an overview on the HIV disease process, its treatment, and associated health complications and reviews the scientific evidence about how exercise can be benefi cial in the management of these health complications and recommendations for exercise prescription.

Norberto Quiles, Ed.M., M.A., RCEP, CES, HFS, CSCS, is a doctoral student in Applied Physiology in the Program in Movement Sciences in the Department of Biobehavioral Sciences and Education at Teacher’s College, Columbia University in New York City, and is an adjunct faculty member in the Department of Family, Nutrition and Exercise Sciences at Queens College of The City University of New York. He holds an Ed.M. in Applied Exercise Physiology and an M.A. in Health Promotion. Norberto is an ACSM Registered Clinical Exercise Physiologist®, ACSM Certified Clinical Exercise SpecialistSM, ACSM Certified Health Fitness SpecialistSM, NSCA Certified Personal Trainer, and NSCA Certified Strength and Conditioning Specialist. His research focus is exercise in individuals with the human immunodeficiency virus.

Carol Ewing Garber, Ph.D., FACSM, FAHA, RCEP, CPD, HFS, is an associate professor of Movement Sciences and Education and the director of the graduate program in applied physiology in Department of Biobehavioral Sciences at Teachers College, Columbia University. She is a clinical exercise physiologist with a research focus in the role of exercise in the treatment and prevention of chronic diseases. Dr. Garber is a fellow of the American College of Sports Medicine and the American Heart Association. She is an ACSM Registered Clinical Exercise Physiologist®, ACSM Certified Preventive and Rehabilitative Exercise Program Director, ACSM Certified Health Fitness SpecialistSM, and ACSM Certified Exercise Test Technologist.

Disclosure: The authors declares no conflict of interest and does not have any financial disclosures.

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According to the World Health Organization, more than 27 million individuals worldwide have died from complications related to the human immunodeficiency virus (HIV) (73). Although the number of new infections has been declining, approximately 34.2 million individuals in the world live with HIV, and recent reports document 2.5 million newly infected individuals in 2011 (72). In the United States alone, there is an estimated 1.2 million individuals who are living with HIV, of which approximately 50,000 people are newly infected each year (61).

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The antiretroviral therapy, commonly abbreviated as ART, is the drug treatment combination used to suppress the replication of the HIV virus. This treatment usually is composed of three or more medications from different antiretroviral drug classes to suppress effectively the replication of the HIV virus at different stages in the cell. Without the use of ART, the estimated life expectancy of an HIV+ person is approximately 10 years. Individuals with a recent diagnosis of HIV who take ART have a life expectancy that is almost the same as that of a person without HIV, given they have access to HIV care and adhere to the treatment (44). With the increased life expectancy with treatment, various cardiometabolic complications associated with exposure to the ART medications and progression of the HIV virus infection have appeared. Exercise may be beneficial in reducing these cardiometabolic complications, increasing physical fitness and ultimately increasing quality of life in people with HIV (23,37,39). Because of the high prevalence of people living with the disease who are battling these health complications, it is imperative that health and fitness professionals have an understanding of the disease and the role that exercise plays in treatment.

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The HIV is a retrovirus that destroys the T-lymphocyte cells (T cells) progressively by using the CD4+ glycoprotein expressed in the lymphocyte cell surface to gain entry into the cell. T cells function as part of the immune system as “helper” white blood cells that are responsible for activating and regulating other immune cells to protect the body from infections. HIV fuses on the T cell and causes a reduction of the number of cells with the CD4+ protein and a loss of immune function. AIDS is the acronym for acquired immune deficiency syndrome, which is the final stage of the infection where the body’s ability to resist infections is decreased markedly, and certain cancers and opportunistic infections could develop, and ultimately the disease can result in death. HIV infection is detected by using the reactive enzyme immunoassay, or EIA test and confirmed by a positive result from a Western Blot method HIV antibody test (64).

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Based on the U.S. Centers for Disease Control 2008 Surveillance Case Definition for HIV infection for adults and adolescents, there are four stages of HIV infection; the stages mainly are based on CD4+ T-lymphocyte count or percentage because this method is an acceptable predictor for the development of opportunistic infections and malignancies (47,64). Table 1 provides a description of each of the stages of HIV Infection. It is worth noting that immune reconstitution may occur after initiation of an effective ART regimen. This involves the phenomenon of recovery of the CD4+ T-cell count and can complicate the use of the HIV infection staging system for disease state classification. For example, an individual initially meeting the criteria for an HIV infection stage 2 or 3 because of a relatively low CD4+ T-cell count may return to a stage 1 as his or her CD4+ T-cell count increases because of effective treatment (40).

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Although the use of ART to treat HIV has been effective in increasing quality of life and reducing morbidity and mortality in patients who suffer from the disease, a series of adverse metabolic effects have been associated with this prolonged use of drug treatment. Reported side effects of these drugs include disorders of glucose metabolism, dyslipidemia, abnormal fat distribution, hepatotoxicity, lactic acidosis, bone metabolism abnormalities, and an increase in cardiovascular disease (CVD) risk (15,31), all of which could be improved by exercise. Often, the patient is prescribed medications to treat the side effects of ART, which potentially could lead to additional side effects with long-term exposure. Table 2 provides a list of the commonly prescribed drugs to treat HIV, their mechanism of action, and the possible side effects.

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Lipodystrophy Syndrome

Lipodystrophy syndrome is the term used to describe a disorder involving abnormal fat redistribution and metabolic disturbances that develop in people with HIV taking certain antiretroviral medications. The syndrome is characterized by the loss of adipose tissue in the extremities, buttocks, and facial areas (termed lipoatrophy) and the accumulation of fat in the upper torso, dorsocervical region, and intrabdominal or visceral region, although these characteristics can occur independently of each other (33). Fat accumulation is associated with the use of protease inhibitor medications (PI) such as indinavir sulfate, whereas the development of lipoatrophy is associated with nucleoside reverse transcriptase inhibitors (NRTI), especially zidovudine and stavudine. Moreover, it seems that there is a higher risk of developing lipoatrophy with the combination of PI and NRTI (14,15,33,71). Lipodystrophy syndrome is associated with the development of insulin resistance, impaired glucose tolerance, dyslipidemia (14), and metabolic syndrome (52). About 50% of HIV+ patients develop one or more of the metabolic sequelae of lipodystrophy syndrome (14), and the likelihood of metabolic abnormalities increases with longer exposure to ART medications (15,71). Other proposed risk factors for the development of lipodystrophy syndrome include older age, male gender, AIDS diagnosis, high HIV viral load, and low pretreatment CD4+ cell count (14,15,33). Furthermore, the Framingham 10-year risk estimate of Coronary Heart Disease significantly is elevated in HIV-infected patients with fat redistribution, especially among men 29). The use of the skinfold (SKF) methods for estimating body composition is not recommended in people with HIV (with and without lipodystrophy) because they provide inaccurate results; however, the use of individual SKF can be used to track changes in body fat distribution in those with lypodystrophy (32).

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Metabolic Syndrome

The metabolic syndrome is a cluster of risk factors that increases the risk for developing CVD and type 2 diabetes mellitus substantially. According to the Adult Treatment Panel III (ATP III), metabolic syndrome is diagnosed when three or more of the following CVD risk factors are present: abdominal obesity, elevated triglyceride (TG) levels, decreased high-density lipoprotein cholesterol (HDL-C), elevated blood pressure, and hyperglycemia/insulin resistance (27). A recent study reported that the prevalence of metabolic syndrome in HIV+ individuals who take ART is approximately 18% by ATPIII criteria, whereas 49% of the patients presented with at least two components of metabolic syndrome (52).

Advanced HIV disease alone can increase blood triglyceride levels and decrease HDL-C levels, and ART medications, especially PI and NNRTI, can result in increased total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and TG and a decrease in the levels of HDL-C (24,71). HIV+ individuals also are at increased risk of developing diabetes mellitus (51), which has been associated with the use of ART medications (19). Low HDL-C levels are one of the most common lipid disorders in HIV+ persons taking antiretroviral medications (71). Higher levels of HDL-C are known to have a cardioprotective effect and have been associated with a decreased risk of CVD and coronary heart disease mortality (18). Insulin resistance and glucose intolerance often occur concurrently in HIV+ patients who take ART medications, especially in those who take PI (28). Prolonged use of ART also has been linked to the development of systolic hypertension (53), but some studies have suggested that this may be explained by age, race, and body mass index (BMI), rather than medication use (24).

Obesity and being overweight have become another burden for HIV+ individuals in the United States, in stark contrast to the wasting syndrome commonly observed before the advent of ART. Increasing numbers of HIV+ individuals are overweight or obese; it is estimated that about 31% are overweight (BMI, 25–29.9 kg/m2) and 14% are obese (BMI, >30.0 kg/m2) (10). In addition, as with the general population, higher BMI is associated with higher levels of total cholesterol, triglycerides, and glucose levels (10).

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Cardiovascular Disease Risk

HIV+ individuals, particularly those receiving antiretroviral therapy, display multiple risk factors associated with the development of cardiovascular disease (24). Traditional risk factors for CVD such as genetic predisposition, diabetes mellitus, dyslipidemia, lifestyle behaviors, and older age compound the risk already imposed by the HIV infection and the antiretroviral medications (60). Individuals with HIV also tend to have lower cardiorespiratory fitness levels compared with healthy individuals (12,46). Therefore, exercise training may be an effective tool in reducing the risk of developing CVD disease in HIV+ persons by increasing cardiorespiratory fitness, improving blood lipid levels, glucose control, and other known risk factors for CVD (37,43,58).

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Cardiorespiratory training and resistance training have beneficial effects on persons with HIV. Multiple studies have shown that aerobic exercise training programs ranging from 12 weeks to 6 months have beneficial effects on BMI, waist-to-hip ratio, waist circumference, total and visceral fat, and body fat percentage in people with HIV with and without lipodystrophy (38,43,54,59). On the other hand, resistance exercise training in programs lasting 6 to 16 weeks have resulted in increased arm and thigh girth, lean body mass, and muscle strength (4,11,26,37,38,55,75) and decreased fat mass (4,37). Studies in overweight and obese persons without HIV have demonstrated a decrease in total body fat and in abdominal visceral fat, even without weight loss (13,21). These effects suggest that aerobic and resistance exercise could have an impact on morphological changes associated with lipodystrophy syndrome by decreasing the fat mass in the areas where it tends to accumulate, particularly in the abdominal and trunk area. In individuals experiencing AIDS-related muscle wasting, resistance training can be effective in increasing lean body mass, muscle cross-sectional area, muscular strength, and body weight (11,55).

Anabolic androgenic steroid medications have been used clinically and in various studies of persons with HIV+ both in combination with resistance exercise or alone (11,26). In one study, the combination of resistance exercise and testosterone enanthate was shown to promote increases in lean body mass and strength in HIV+ men with low testosterone levels and weight loss, but similar results were found in those who performed resistance exercise alone (11). Likewise, the use of testosterone alone increased leg and arm muscle cross-sectional area in HIV+ men with AIDS-related wasting, but resistance training alone promoted similar effects. Furthermore, in this study, it was reported that in those who took the anabolic steroids, HDL-C levels were decreased toward the end of the 12-week intervention (26), which is a commonly reported side effect of this class of drugs that may increase CVD risk (69). It seems evident from these studies that positive results in various parameters of body composition and strength can be achieved in HIV+ persons with resistance training without the use of anabolic steroids and the possible associated side effects. However, there may be clinical reasons that an individual is prescribed anabolic steroid treatment. In the presence of steroid medications, particularly when combined with PI or CVD risk factors, close monitoring of signs and symptoms of CVD is warranted (33).

There is limited evidence showing that cardiorespiratory exercise training for durations ranging from 4 to 6 months can result in reductions in TC, LDL-C, TG, and fasting glucose levels, with concomitant increases in HDL-C and enhanced glucose uptake in people with HIV with and without lipodystrophy (36,40,58). Additional studies have shown that resistance training exercise also may help to reduce LDL-C levels and triglycerides levels (75) and increase HDL-C levels and glucose uptake (37) in people with HIV, but these findings are not conclusive because of the limited number of published studies available. The possible positive effects in lipid and glucose metabolism in conjunction with reduced trunk and abdominal fat support the potential role for exercise training as a safe and effective complementary treatment for these cardiometabolic risk factors in people with HIV.

Individuals who are HIV+ with and without lipodystrophy syndrome seem to respond well to aerobic exercise training, demonstrating gains in cardiorespiratory fitness (CRF). Numerous controlled and uncontrolled trials have reported improvements in CRF ranging from 1.5 mL · kg · min−1 to 8.0 mL · kg · min−1 with programs of aerobic exercise or a combination of aerobic and resistance exercise for a total duration between 6 weeks and 6 months (20,37,38,43,49,54–58). Some studies of people with HIV have suggested that higher-intensity cardiorespiratory exercise (∼75% V˙O2max) provides greater improvements in CRF than does moderate-intensity exercise, with no detrimental health effects associated with the higher-intensity exercise programs (49,56,57).

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Before initiating an exercise program, consultation with the primary care or specialist physician is advisable because HIV is a chronic infectious disease. The preparticipation screening should include a medical history questionnaire that details any existing comorbidities (e.g., diabetes mellitus, cardiovascular disease, etc.), cardiovascular disease risk factors, signs and symptoms suggestive of disease, musculoskeletal injuries, and current medication usage (2). A physical activity and lifestyle questionnaire also is valuable in identifying health-related behaviors, physical activity, smoking, stress levels, and unhealthy dietary patterns.

Testing of CD4+ cell count and viral load should be performed before starting the exercise program and then every 3 to 6 months thereafter to assess disease status and to guide modifications in exercise intensity and duration appropriate for those with lower CD4+ cell counts. Although an exact cutoff point has not been established for a CD4+ cell count at which exercise is contraindicated, safety experts recommend decreasing the intensity and duration of the exercise session when CD4+ T-cell count is less than 200 cells μL-1 because immune function is depressed severely. In addition, because of the prevalence of metabolic disorders in HIV+ patients, particularly in those who take ART medications, blood test results that include glucose and a blood lipid profile should be available to the health and fitness professional so that the exercise program is adjusted as needed to address these cardiometabolic abnormalities. The increased risk of CVD in this population warrants the assessment of resting heart rate and blood pressure before initiating an exercise program and consideration of diagnostic exercise testing as per the ACSM guidelines (2). CVD risk stratification should be done according to ACSM guidelines (2), although it is unclear whether the impact of risk factors are similar to that of the general population or greater in HIV+ individuals.

Regular health monitoring of individuals with HIV is encouraged throughout the exercise program, as generally is recommended for persons with chronic diseases (2), because health may change as the person ages and the disease progresses. Questions should be asked about any changes in health and disease status, including HIV viral load, CD4+ count, and comorbidities. HIV treatment, CVD risk factors, and signs and symptoms of coronary heart disease should be assessed, and monitoring of resting heart rate and blood pressure should be performed when indicated.

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The risk of transmission of HIV is relatively low in the health and fitness setting, because transmission of HIV occurs primarily through contact with blood, semen, preseminal and vaginal fluids, and breast milk (67). Coming in contact with sweat from an HIV+ person is not a risk of infection with HIV (34). Moreover, the risk of transmission of the virus is extremely low in individuals with an undetectable viral load (62). Coinfection with hepatitis B and C is common in people with HIV (63), and consideration of hepatitis B vaccination and other precautions should be discussed with a health care provider or occupational health office, according the U.S. Centers for Disease Control and Prevention recommendations 65).

Health and fitness professionals should understand and implement universal biosafety precautions (66) to maintain a safe environment when performing exercise testing and supervising the exercise program with individuals with and without HIV. A key precaution to remember is to don vinyl or latex gloves when the possibility of contact with blood exists and to dispose of materials with blood or other body fluids properly.

The risk of opportunistic infections that can be acquired by the individual with HIV because of their depressed immune function is an important consideration in the health and fitness setting. Infections that may have minor effects in healthy persons can be very serious for a person with HIV, especially in those with reduced CD4+ lymphocyte counts (68). Therefore, the health fitness professional should pay particular attention to maintaining a hygienic environment, including the general practice of using disinfecting wipes on equipment.

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Individuals with HIV may suffer from various complications that may limit their ability or willingness to exercise, and the health and fitness professional will need to make the appropriate modifications to the exercise program to promote adoption and adherence to exercise and to maximize safety. Fatigue is rather prevalent in people with HIV (45,48), and individuals with HIV may have an early onset of fatigue during exercise, likely, in part, caused by their poorer fitness levels and reduced muscle mass. Symptomatic individuals and those who have developed AIDS often encounter symptoms of weakness, exercise intolerance, and fatigue (45,48), which may affect their ability to perform more vigorous activities, so exercise intensity may need to be reduced (50). Symptoms of fatigue also are associated with more advanced disease progression, ART medication usage, and common mental health comorbidities, such as depression and anxiety (35). Aerobic and resistance exercise may reduce fatigue (54) and improve fatigue symptoms in HIV+ individuals (39). In people presenting with symptoms of fatigue during exercise (i.e., tiredness and exhaustion), it is appropriate to reduce the intensity and duration of exercise to decrease the chance of the patient dropping out of the program while maintaining the health benefits associated with exercise. A more gradual progression of exercise program also may be helpful.

Some people with HIV who are taking ART medications may experience side effects such as nausea, vomiting, and diarrhea, especially when starting a new drug regime. The health and fitness professional should be aware if the person is experiencing these symptoms because they could become dehydrated and experience loss of electrolytes, which could become a medical emergency. Persons with HIV also may experience bouts of fever, especially during the acute infection phase, which is considered an absolute contraindication to exercise. In cases of acute diarrhea, vomiting, or fever, the exercise session should be postponed until these symptoms have been resolved.

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Given the increased risk for developing type 2 diabetes mellitus among HIV+ individuals (51), appropriate measures should be taken during exercise in those presenting with this disease. In accordance with recommendations for exercise for people with diabetes mellitus, blood glucose should be monitored before and after exercise to prevent a hypoglycemic event during and after the exercise session (5). People who present with blood glucose levels greater than 300 mg · dL−1 without ketosis may perform exercise with caution, given they are feeling well enough that day to perform physical activities (6). In addition, adequate hydration should be maintained with diabetic patients who present with polyuria because they may develop dehydration while exercising. In those taking hypoglycemic agents or insulin, exercise should not be performed during the peak action of these medications to prevent hypoglycemia (6). Monitoring for the symptoms of hypoglycemia during and after exercise is important (6). As a general practice, it is prudent to have simple carbohydrate snacks (15–20 g) available in case hypoglycemia occurs; these include raisins (2 tablespoons), juice (4 oz), nonfat or low-fat milk (8 oz), or candy (hard candy, jellybeans, gumdrops) (9).

Autonomic and peripheral neuropathy is somewhat prevalent in HIV+ individuals and is associated with more advanced disease progression and use of certain NRTI (i.e., didadosine and stavudine) (16,33). Peripheral neuropathy is the term for the damage to the peripheral motor and sensory nerves (i.e., arms and legs) that can cause pain, weakness, loss of function, numbness, and gait abnormalities. Autonomic neuropathy is a group of symptoms associated with damage of the nerves innervating the heart and gastrointestinal and genitourinary tracts.

In people with peripheral neuropathy, modifications to the exercise program may be needed to address problems with balance and falls and injury risks that may result from this complication. An example of this would be for an individual with balance problems to perform the aerobic exercise portion on a cycle ergometer or a treadmill with handheld or body supports instead of walking on a track. In the presence of autonomic neuropathy, the ratings of perceived exertion (RPE) may be a preferred measure of intensity, rather than heart rate monitoring, because of attenuated responses of the heart rate associated with autonomic neuropathy. However, this is controversial because research in persons with diabetic neuropathy showed that standard heart rate and oxygen uptake reserve methods can be used (17). Furthermore, the mechanisms whereby neuropathy affects balance is not known, and clinical studies have shown that there may be beneficial effects of weight-supported activity (42). In addition, maintaining adequate hydration and exercising in a place with a comfortable temperature and good ventilation are important because of potential problems with sweating and temperature regulation that can occur with autonomic dysfunction (3).

Table 3 summarizes special considerations and precautions for exercise in individuals with HIV.

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Cardiorespiratory Exercise

Exercise prescription principles used for healthy adults generally can apply to persons with HIV+, with some modifications according to their health status (7,8). Although studies have shown beneficial effects of exercise in persons with HIV, optimal exercise regimens have not been identified to date. In research studies, various different methods were used for the cardiorespiratory exercise prescription, but all of the studies have used exercise intensities ranging from 50% to 75% of the heart rate reserve (HRR), without complications. Exercise duration typically has been 30 to 60 minutes per session. Most of these studies used continuous exercise, with a frequency of at least 3 days per week using equipment including treadmills, cycle ergometers, stair climbers, and elliptical trainers (37,38,43,54,56–58). One study reported gains in cardiorespiratory fitness when using interval training with intensities raging from moderate to more vigorous (∼75% V˙O2max), without any reported adverse events (37). High-intensity exercise has been suggested by some as a way to improve cardiorespiratory fitness to a greater extent than with moderate-intensity exercise alone and without additional detrimental health effects (49,56,57). Although high-intensity training seems to be a promising exercise approach to increase cardiorespiratory fitness in HIV+ individuals, the data are very limited to make any definitive suggestions. A concern is that exercise training at more vigorous intensities can have a transient suppressive effect on the person’s immune system: decreasing natural killer cells and cytotoxicity and increasing the risk of upper respiratory tract infections (70). Therefore, it may be prudent to keep exercise intensity within ranges (≤75% HRR) that are unlikely to have adverse effects on immune function until further research evaluating the safety of exercising at high intensity, especially for prolonged durations, is conducted. On the other hand, a study by Farinatti et al (22). evaluating a 12-week comprehensive exercise program in middle-aged individuals with HIV+ showed no significant decrements in relative or absolute CD4 lymphocyte counts with cardiorespiratory exercise done at 50% greater than the physical work capacity at baseline combined with standard resistance and flexibility training.

Results from available research indicate that current physical activity guidelines for Americans (1) and the ACSM recommendations for apparently healthy adults (2,8) are appropriate for the development of CRF and to attain health benefits in this patient population. The program design should take into consideration the FITT-VP principle for exercise prescription of frequency, intensity, time and type, volume, and progression as recommended by ACSM (2,8). Individuals with low baseline cardiorespiratory fitness or who present with fatigue during exercise can benefit from lower-intensity exercise and volume and then they can progress gradually on these variables across time as tolerated. Table 4 provides a summary of the recommendations for cardiorespiratory exercise in persons with HIV+.

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Resistance Exercise

General principles for resistance exercise training also apply to persons with HIV (7,8) Most research studies have employed resistance training on 3 days per week, using a range of 8 to 15 repetitions accompanied by a an exercise intensity in the range of 60% to 80% of the 1-RM for 1 to 4 sets per exercise (4,11,20,26,37,38,55). Some of these studies effectively used a progressive resistance exercise approach in which the exercise intensity and/or volume was increased in a stepwise manner at the beginning or for the duration of the intervention (8,15,20,30,60). One study in particular used a program of 4 to 5 sets of 4 to 6 repetitions with an intensity range of 70% of the 1-RM for “light”-intensity days of the training week, 80% of the 1-RM for the “medium”-intensity days, and 90% of the 1-RM for the “heavy” days, producing increases in body weight, fat-free mass, thigh muscle volume, and 1-RM of upper and lower body exercises without any major adverse outcomes in persons with HIV+ (11).

The ACSM recommendations for muscular fitness in an apparently healthy population (2,8) and the results from these studies seem to be in agreement. The resistance exercise program initially should include at least one exercise for each major muscle group for one to four sets, with preference toward multijointed exercises (2,8). To maximize increases in muscular fitness, it may be necessary to increase progressively the intensity and volume of resistance training over time, especially in the more advanced trainees, as recommended by ACSM (7). A progressive overload approach to resistance exercise consisting of increases in volume or intensity for weeks seems to be safe and effective in the HIV+ population (1120,26,37,75). Table 5 provides a summary of the recommendations for resistance exercise prescription in persons with HIV.

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Flexibility Training

HIV+ patients who include a flexibility exercise component to their program may benefit from an increased range of motion (22,41). One program included static stretches held for 30 seconds for each of 8 major muscle groups with beneficial effects (22), which is consistent with the ACSM recommendations for the prescription of flexibility exercise in apparently healthy populations (2,8). Multimodal exercise programs that include Tai Chi or yoga, which typically include a slow sequence of movements that emphasize a natural range of motion, also may prove beneficial in increasing range of motion (and other fitness attributes) in HIV+ individuals (25). As in the apparently healthy people, flexibility exercise should be performed at least 2 to 3 days per week for at least 10 minutes for the major muscle tendon groups of the body, most effectively after a warm-up or conditioning phase. Static stretches should be held for 10 to 30 seconds for each exercise, whereas a proprioceptive neuromuscular facilitation (PNF) stretching technique using a 3- to 6-second contractions followed by a 10- to 30-second assisted stretch also can be recommended (2). Table 6 provides a summary of the recommendations for flexibility exercise prescription in persons with HIV.

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Neuromotor Exercise

Neuromotor exercise training involves exercises that include balance, agility, coordination, and proprioceptive training, and it is recommended for older adults and younger individuals (2,8). In older people with HIV+, neuromotor exercise also may aid in the prevention of falls (8,34), which could be a particular problem in individuals with muscle wasting and atrophy, or peripheral neuropathies, although this has not been studied in people with HIV. ACSM recommends that all adults engage in neuromotor exercise training on 2 to 3 days a week. This can include multimodal exercise activities such as yoga, Pilates, and Tai Chi (2,8). High-intensity yoga or “hot yoga” and other high-intensity martial arts-derived exercise programs may not be advisable for people with HIV because of the potential suppression of immune function or because of the presence of autonomic dysfunction- associated thermoregulatory abnormalities (see discussions above on these topics). There have been no studies of neuromotor exercise training in persons with HIV, so following the recommendations for apparently healthy adults probably is reasonable. Safety precautions should be taken with neuromotor training particularly in the presence of deficits in motor function (e.g., balance and agility) because there is an increased risk of falling or injury when engaging in some of these types of exercises. Table 7 provides a summary of the recommendations for neuromotor exercise prescription in persons with HIV.

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Although ART medications have helped extend the life expectancy of people with HIV+, they also have been associated with various cardiometabolic health complications that increase the risk for cardiometabolic diseases. In addition, the low cardiorespiratory fitness levels and increased central fat accumulation seen in this patient population may increase further the risk of CVD and diabetes mellitus. Cardiorespiratory and resistance exercise can help improve cardiorespiratory fitness, muscular strength, body fat distribution, and body composition and may result in improved blood lipoprotein and glucose profiles in HIV+ patients. In conclusion, HIV+ patients can perform exercise safely without the fear of developing any further negative health effects when appropriate care is taken according to their health status.

Because of space constraints, the complete list of references will appear online at

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Human immunodeficiency virus (HIV) infection causes the destruction of CD4+ cells of the immune system and the progressive weakening of the body’s immune system. The HIV infection and the antiretroviral medications used to treat the disease can cause a series of metabolic disorders, redistribution of body fat in unusual places, and may increase the risk of cardiovascular disease. Cardiorespiratory and resistance exercise training have been shown to increase cardiorespiratory fitness, improve lipid and glucose levels, and help decrease the accumulation of fat in the trunk in HIV+ individuals. Current exercise recommendations for adults may be used in the prescription of exercise in individuals with HIV+, with appropriate modifications depending on disease status and other comorbidities.

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Immune Disease; Physical Activity; Exercise Training; Cardiometabolic Health; Metabolic Syndrome

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