With advances in HIV medication, life expectancy of people living with HIV (PLWH) has been greatly extended. On the other hand, PLWH now suffer from challenges associated with aging, just as in the general population (Greene, Justice, Lampiris, & Valcour, 2013). Survival rate has not been the only concern of PLWH; there was also concern about physical health and the quality of life. PLWH using antiretroviral therapy (ART) might have complications and side effects (Erlandson et al., 2013; Montessori, Press, Harris, Akagi, & Montaner, 2004), including depression, fat maldistribution, dyslipidemia, osteonecrosis, osteoporosis, peripheral neuropathy, sarcopenia, fatigue, and reduced exercise tolerance. A cross-sectional study reported that PLWH suffered from accelerated aging (Khoury et al., 2017), a finding that PLWH had more of a decline in physical function compared to an age- and gender-matched uninfected population despite successful ART. The overall prevalence of major depressive disorder was also found to be higher in PLWH (Owe-Larsson, Sall, Salamon, & Allgulander, 2009). These factors may contribute to poor quality of life of older adults living with HIV.
The benefits of exercise in the general population were well documented (Booth, Roberts, & Laye, 2012; Meyers, 2003; World Health Organization, 2018) and have been shown to maintain a healthy body and reduce age-related diseases (Booth et al., 2012; Pillard et al., 2011). Sufficient amounts of exercise were associated with better physical and mental health in PLWH (Quiles, Ciccolo, & Garber, 2017). Exercise benefits to PLWH have also been shown in studies that demonstrated improved muscle endurance, flexibility, aerobic fitness, pulmonary function, and depression (Aweto, Aiyegbusi, Ugonabo, & Adeyemo, 2016; Farinatti, Borges, Gomes, Lima, & Fleck, 2010; Mabweazara, Leach, Ley, & Smith, 2018; Patil, Shimpi, Rairikar, Shyam, & Sancheti, 2017). Two recently published studies also demonstrated positive physical benefits of exercise in older PLWH (Erlandson et al., 2018; Oursler, Sorkin, Ryan, & Katzel, 2018). However, the effects of exercise in older Chinese PLWH have not been well studied.
Moreover, PLWH were found to be more physically inactive compared to the general population (Vancampfort, Mugisha, et al., 2018). Even with specific physical activity intervention, PLWH had higher dropout rates compared to those living with other chronic diseases, but a lower dropout rate was found if the exercise was supervised or guided by a qualified professional (Vancampfort et al., 2017). Therefore, supervised exercise may help enhance exercise adherence. Our study is a first attempt to pilot a supervised exercise program and test its effect on physical health and quality of life among older PLWH in Hong Kong.
Design and Participants
Twenty-one adults living with HIV (16 men and 5 women) were recruited from a community-based nongovernmental organization (NGO) for HIV-related services. The participants were physically inactive Chinese citizens living in Hong Kong, ranging in age from 56 to 84 years, outdoor walkers, on ART, and without contraindications for exercise. We defined an inactive participant as a person who had not participated in any form of moderate or vigorous intensity exercise for at least once a week in the past year. We excluded participants who were younger than 50 years. Participants who had poor ambulatory function, contraindications for exercise, or regular exercise training were also excluded. All eligible participants provided written, informed consent and were randomized into an exercise group (n = 11) or control group (n = 10) by drawing lots, which contained an equal number of orange balls (exercise) and white balls (control). Demographic information was obtained from all participants. Our study was approved by the Human Research Ethics Committee at the University of Hong Kong. The trial protocol was retrospectively registered in ClinicalTrials.gov (NCT03748797).
Participants in the exercise group participated for 8 weeks (2 sessions per week) in a supervised exercise program in the community day center of the recruiting NGO. Training sessions were organized in groups of two to three participants. All training sessions were performed under the supervision of a registered physiotherapist. Exercise intensity was moderate. Following guidelines from the U.S. Centers for Disease Control and Prevention (2015) for moderate intensity exercise, we monitored the heart rate of participants during exercise and maintained 50–70% of maximum heart rate. Blood pressure and oxygen saturation were also checked for safety purposes. The mode of exercise was combined aerobic and resistance training. It consisted of a warm-up exercise, upper and lower limb cycling, treadmill walking, multigym muscle strengthening, stepper exercise, dumbbell lifting, semisquatting, and cooldown stretching. A detailed exercise program can be viewed on request. The duration of each exercise session was about 45 min. Flexibility on exercise duration and intensity were allowed based on the physical capacity of each participant. In the control group, participants did not have supervised exercises. They were advised to continue routine daily activities, and self-exercise was allowed. The investigator contacted control group participants every week to review any significant change in lifestyle or health condition.
Primary outcomes of the study were physical health as measured by grip strength, 30-s chair stand test, 6-min walk test, and quality of life as measured by Short Form-36 (SF-36) scores. Outcomes were measured at baseline and after 8 weeks for both groups. Subjective physical improvement was also measured. All outcomes were evaluated by a research assistant blinded to group allocation. Grip strength was taken by handgrip dynamometer (in kilograms) from the dominant hand of participants (Lam et al., 2016). Three measurements were taken with a 10-s rest between measurements to avoid fatigue. The mean value of all three measurements was calculated. The 30-s chair stand test was used to evaluate leg strength and endurance (Jones, Rikli, & Beam, 1999). Participants were asked to repeatedly stand-up and sit down in a back-supported chair. The number of times the person stood in 30 s was recorded as the result. A 6-min walk test was used to assess functional capacity (Enright et al., 2003). It measured the distance (in meters) a participant was able to walk in 6 min. Health-related quality of life was assessed by the SF-36 questionnaire, which includes 36 items that assess 8 health domains: (a) physical functioning, (b) role limitations due to physical problems, (c) bodily pain, (d) general health perceptions, (e) role limitations due to emotional problems, (f) vitality, (g) mental health, and (h) social functioning (Laucis, Hays, & Bhattacharyya, 2015). Scores in each domain ranged from 0 to 100; a lower score represented greater disability and a higher score represented less disability. Subjective improvement was assessed by a Likert scale, from −100% to +100%, with a 10% interval in each possible response. At the end of the program, all participants from the exercise group were interviewed individually by the principal investigator to allow for feedback. Two standard questions were asked in the interview: Do you have any feedback about this training program? and Was there any change to your health during or after this 8-week training? More comments from participants were allowed after the standard questions.
The change of outcome scores for performance was calculated based on the difference between baseline and post 8-week outcomes. Between-groups differences in outcome change were analyzed by Mann–Whitney U test using IBM SPSS Statistics Version 23. Level of significance was set to be 0.05. Answers to the interview questions were summarized by the principal investigator.
Findings from the pilot study revealed high feasibility to conduct a supervised exercise program for older Chinese PLWH. Figure 1 represents an overview for the study. In the exercise group, one participant dropped out of the program in the second week of training. The other 10 participants completed the 8-week exercise program without serious exercise-related adverse events. Training adherence was excellent in those who completed the program with 96.3% attendance. In the control group, all 10 participants completed data collection. Demographic characteristics of these 20 participants are shown in Table 1.
The results of physical parameters and subjective physical improvement are shown in Table 2. Maximum grip strength increased in the exercise group but not in the control group (exercise: 2.0 ± 2.16 kg; control: −0.3 ± 1.64 kg; p = .019). Improvement was observed in both groups in the 30-s chair stand (exercise: 9.9 ± 4.73; control: 3.0 ± 2.58; p = .002) and 6-min walk test (exercise: 65.9 ± 30.19 m; control: 19.4 ± 49.47 m; p = .035); however, the exercise group showed greater improvement. Participants in the exercise group reported greater subjective physical improvement compared to the control group after 8 weeks (exercise: 37% ± 24.97%; control: 6% ± 14.3%; p = .004). The between-group differences for changes in these outcomes were statistically significant.
Quality of Life
Results of the SF-36 are summarized in Table 2. All eight domain scores in the exercise group were improved, whereas only four domain scores (bodily pain, general health perceptions, mental health, social functioning) in the control group were slightly increased. In statistical analysis, physical functioning (p = .023), role limitations due to physical problems (p = .035), role limitations due to emotional problems (p = .015), and social functioning (p = .043) achieved statistically significant differences in the exercise group compared to the control group.
We received feedback about the exercise training arm of our study in interviews with the 10 participants who completed the 8-week exercise program. All of the participants agreed that training under supervision improved their confidence in exercise because they would be corrected if they were doing it wrong; 8 of 10 of the participants felt safer because vital signs were checked and monitored. By building rapport with the therapist, 7 of 10 of the participants felt more encouraged to adhere to the program. Four of 10 of the participants reported that training as a group was more fun and less boring compared to training alone. Participants could talk to each other during exercise, leading to a better atmosphere. When we asked for the change in health condition, improved walking speed and endurance (8 of 10 of the participants) were the most common responses. Half of the participants reported better quality of sleep, and 4 of 10 of the participants reported stress reduction.
Overall, we found that the 8-week, moderate-intensity, supervised exercise intervention was feasible for older Chinese PLWH. It improved physical health and some aspects of health-related quality of life. The moderate intensity training was well tolerated by our participants with an inactive lifestyle. Participants in the exercise group showed excellent exercise adherence with only one dropout from the program.
In terms of the exercise group, there were significant improvements in grip strength and 30-s chair stand tests. Improvement in lower limbs was greater than upper limbs. The exact mechanism of greater improvement in lower limbs was unknown and deserves further study. Significant improvement in the 30-s chair stand and 6-min walk tests indicated better lower limb muscle strength, endurance, and functional capacity.
Physical impairment has been associated with self-stigmatization and withdrawal of social linkage in PLWH (Mo & Ng, 2017). Improved physical function may result in better self-image and confidence in social life. These were also reflected in the improvement in role limitations and social function domain scores in SF-36 in our study. In the result of health-related quality of life, the exercise group had significant differences in two physical domains (physical functioning, role limitations due to physical problems) and two mental domains (role limitations due to emotional problems, social functioning) compared to controls, which supported our hypothesis that supervised exercise would improve physical and mental quality of life among older PLWH to some extent. A recent systematic review also found that aerobic exercise might reduce depression and improve psychological quality of life, self-esteem, body image, and emotional stress in PLWH who also had mental health problems (Vancampfort, Stubbs, Probst, & Mugisha, 2018). Although general health perceptions, mental health, and vitality domains did not achieve significant differences in our trial, better walking endurance and stress reduction were reported by exercise participants during their interviews. Combined aerobic and resistance exercise was found to improve general health, vitality, and physical function domains of quality of life in PLWH (Neto, Conceição, Carvalho, & Brites, 2015), results that were different from our study, but studies involved in that meta-analysis were not focused on older adults or the Chinese population. Further studies are suggested using larger sample sizes.
Lack of motivation, self-confidence, and exercise knowledge have been found to be barriers of exercise in older PLWH (Neff et al., 2019). Based on feedback from our exercise participants, support from physiotherapists or exercise professionals could be helpful to enhance exercise motivation. Thus, we recommend supervised exercise for older PLWH in the community setting.
Small sample size was the major limitation of our study. Hong Kong citizens were recruited from a single NGO, which may decrease generalization. Short study duration without a follow-up assessment also limited our results. Due to the selection criteria, we excluded those who had poor ambulatory function or were at risk from exercise. Thus, we have no information on the effect of exercise on PLWH with severe impairments. Further research with a larger sample size and multiple organization involvement would be required for generalizable evidence. Recruiting participants with physical impairments may also help to determine suitable exercises for different PLWH.
High-intensity training was not tested in our study, but it has been found to have greater physical benefits compared to moderate-intensity exercise (Erlandson et al., 2018; Oursler et al., 2018). Erlandson et al. (2018) found that PLWH using high-intensity exercise gained significantly more muscle strength than those using moderate-intensity exercise. In Oursler et al. (2018), only the high-intensity training group showed better improvement in terms of exercise tolerance and walking distance compared to the moderate intensity group. However, there is not much information about the effects of high-intensity training on the quality of life of older PLWH, and further study could be done.
An 8-week moderate-intensity supervised exercise program may feasibly improve physical health and some aspects of health-related quality of life in older Chinese PLWH. Our study supports efficacy of moderate-intensity supervised training, which is recommended to promote successful aging with HIV.
The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest.
The authors' appreciation is given to all participants for their participation. The authors acknowledge Alice Chan and Lawrence Leung for their general support and assisting data collection. The research abstract was accepted by Asia Pacific AIDS & Co-infections Conference (APACC) 2018 in Hong Kong for poster presentation; June 28–30, 2018.
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