Turning disability into ability: barriers and facilitators to initiating and maintaining exercise among older men living with HIV

Exercise to Prevent Accelerated Vascular Aging in People Living With HIV

Given advances in antiretroviral therapy, the mortality rate for HIV infection has dropped considerably over recent decades. However, people living with HIV (PLWH) experience longer life spans coupled with persistent immune activation despite viral suppression and potential toxicity from long-term antiretroviral therapy use. Consequently, PLWH face a cardiovascular disease (CVD) risk more than twice that of the general population, making it the leading cause of death among this group. Here, we briefly review the epidemiology of CVD in PLWH highlighting disparities at the intersections of sex and gender, age, race/ethnicity, and the contributions of social determinants of health and psychosocial stress to increased CVD risk among individuals with marginalized identities. We then overview the pathophysiology of HIV and discuss the primary factors implicated as contributors to CVD risk among PLWH on antiretroviral therapy. Subsequently, we highlight the functional evidence of premature vascular dysfunction as an early pathophysiological determinant of CVD risk among PLWH, discuss several mechanisms underlying premature vascular dysfunction in PLWH, and synthesize current research on the pathophysiological mechanisms underlying accelerated vascular aging in PLWH, focusing on immune activation, chronic inflammation, and oxidative stress. We consider understudied aspects such as HIV-related changes to the gut microbiome and psychosocial stress, which may serve as mechanisms through which exercise can abrogate accelerated vascular aging. Emphasizing the significance of exercise, we review various modalities and their impacts on vascular health, proposing a holistic approach to managing CVD risks in PLWH. The discussion extends to critical future study areas related to vascular aging, CVD, and the efficacy of exercise interventions, with a call for more inclusive research that considers the diversity of the PLWH population.

Qualitative Description of Exercise Perceptions and Experiences Among People With Human Immunodeficiency Virus in the High-Intensity Exercise to Attenuate Limitations and Train Habits Study

BACKGROUND

The benefits of physical activity (PA), specifically exercise, among older adults in general are well known. Yet globally, there is concern regarding limited engagement in PA, increased obesity, and frailty among older people with human immunodeficiency virus related to low levels of PA.

METHODS

We conducted in-depth interviews among 30 older, sedentary people with human immunodeficiency virus participating in the ongoing High-Intensity Exercise to Attenuate Limitations and Train Habits (HEALTH study, NCT04550676) between February 2021 and August 2022. A semistructured interview guide, informed by two minds theory, which frames behavior change as an intention-behavior gap between 2 neurocognitive systems, was used to elicit data from participants. Interviews explored general exercise perceptions, self-efficacy for exercise, mobile health intervention tailoring, outcome expectations, and PA goals. Thirty interviews from 33 participants were recorded and transcribed verbatim, and deductive and inductive thematic analysis were used using Dedoose.

RESULTS

Physical activity was defined as maintaining daily living activities and addressing health goals. Previous experiences with PA varied among participants and were influenced by chronic illnesses, including human immunodeficiency virus; motivation; work commitments; interest; and social support. Reported barriers to PA included antiretroviral adverse effects, comorbidities, aging, and the COVID-19 pandemic. Changes in health status, body changes, and relationships were identified as benefits of PA. Conversations with healthcare providers supporting exercise goals were perceived to be important but rarely received by the participants.

CONCLUSION

Understanding how older people with human immunodeficiency virus perceive PA is crucial to developing tailored strategies and structuring service delivery within the healthcare setting to promote a physically active life.

Barriers and Facilitators of Physical Activity in People Living With HIV: A Systematic Review of Qualitative Studies

BACKGROUND

Most people living with HIV (PLWH) are sedentary. This study aimed to synthesize the findings of qualitative studies to understand barriers and facilitators of physical activity (PA) among PLWH, categorized using the Capability, Opportunity, Motivation-Behavior (COM-B) model and Theoretical Domains Framework (TDF).

METHODS

Systematic searches of four databases were conducted to identify eligible studies. Thematic synthesis was used to inductively code, develop, and generate themes from the barriers and facilitators identified. Inductive data-driven themes were deductively categorized using the relevant domains of the COM-B model and the TDF.

RESULTS

Fourteen articles were included. The most prominent TDF domain for barriers was skills, particularly symptoms/health issues such as fatigue and pain, while the most prominent TDF domain for facilitators was reinforcement, particularly experiencing benefits from PA.

CONCLUSION

The breadth of factors identified suggests the need for comprehensive strategies to address these challenges effectively and support PLWH in adopting and sustaining PA routines.

Older Mens' Experiences with and Preferences for Physical Activity

We aim to describe older mens' experiences with physical activity (PA) and their preferences for PA programs. We interviewed 14 men from a Canada-based PA intervention study called Men on the Move, and 5 men from a supplementary sample (who were not intervention participants). Content analysis was used to describe their experiences with PA and program preferences. The socio-ecological perspective and the hegemonic masculinity framework guided the research. PA barriers were low motivation, poor health, lack of time, interests other than PA and a lack of interest in PA, finances, lack of knowledge about PA, injury fear, social influences, inconvenience, weather, caregiving, built/natural environments, low-quality fitness instructors, and program structure. PA facilitators were chores, health, interest, time, motivation, social influences, active transportation, built/natural environments, good weather, program structure, and skilled/knowledgeable fitness instructors. PA program preferences were small group atmosphere, individualized attention/programming, equal number of men and women, sports programming, PA classes, and experienced instructors. Older men have distinct PA experiences. Promoting and designing programs that address their experiences may increase their PA.

Preventing cardiovascular disease in midlife women with HIV: An examination of facilitators and barriers to heart health behaviors

Midlife women with HIV (WWH) are disproportionately impacted by cardiovascular disease (CVD), yet little is known about perceptions of CVD risk and the factors that influence engagement in heart health behaviors in this population. Few (if any) studies have used a qualitative approach to examine these perceptions, which has important implications for minimizing the negative impact of HIV-related noncommunicable diseases, the risk for which increases after midlife. Eighteen midlife WWH (aged 40-59) in Boston, MA, completed semistructured interviews to explore perceptions of CVD, HIV, and barriers and facilitators to healthy lifestyle behaviors. Interviews were analyzed via thematic analysis. Participants viewed heart health as important but were unaware of HIV-associated CVD risk. Facilitators included family and generational influences, social support, and access to resources. Physical symptoms, menopause, mental health challenges, and limited financial resources were barriers. Midlife WWH may benefit from tailored CVD prevention interventions that target their unique motivations and barriers to healthy behaviors.

The Role of the Social Determinants of Health on Engagement in Physical Activity or Exercise among Adults Living with HIV: A Scoping Review

Physical activity (PA) and exercise are an effective rehabilitation strategy to improve health outcomes among people living with HIV (PLWH). However, engagement in exercise among PLWH can vary. Our aim was to characterize the literature on the role of social determinants of health (SDOH) on engagement in PA or exercise among adults living with HIV. We conducted a scoping review using the Arksey and O'Malley Framework. We searched databases between 1996 and 2021. We included articles that examined PA or exercise among adults with HIV and addressed at least one SDOH from the Public Health Agency of Canada Framework. We extracted data from included articles onto a data extraction charting form, and collated results using content analytical techniques. Of the 11,060 citations, we included 41 articles, with 35 studies involving primary data collection 23 (66%) quantitative, 8 (23%) qualitative, and four (11%) mixed methods. Of the 14,835 participants, 6398 (43%) were women. Gender (n = 24 articles), social support (n = 15), and income and social status (n = 14) were the most commonly reported SDOH in the literature with the majority of studies addressing only one SDOH. Future research should consider the intersection between multiple SDOH to better understand their combined impact on engagement in PA or exercise among PLWH.

Experiences of People Living With HIV in Community Based Exercise: A Qualitative Longitudinal Study

This qualitative longitudinal study examined the experiences of people living with HIV who engaged in a structured community-based exercise (CBE) program under the supervision of a fitness coach. Twenty people living with HIV were invited to participate in 3 semi-structured interviews over time. Participants engaged in exercise 3 times per week for 6 months with one weekly session supervised by a coach. Interviews were audio-recorded, transcribed verbatim and underwent longitudinal thematic analyses. Eleven participants were included representing a total of 30 interviews. Participants valued their experiences with the CBE program, particularly the motivation provided by the coach. Concerns about the environment, stigma and episodic health challenges affected their overall experience. To foster independence and promote self-management, health providers should consider these findings when encouraging CBE with people living with HIV. It is important to understand their goals and offer a variety of exercise options to meet their needs.

Experiences engaging in a group-based physiotherapist-led exercise programme for adults living with HIV and complex multimorbidity: a qualitative study

OBJECTIVE

To explore experiences participating in a group-based physiotherapist (PT)-led exercise programme among people living with HIV and complex multimorbidity.

DESIGN

We conducted a qualitative descriptive study using semistructured interviews.

RECRUITMENT AND SETTING

We recruited community-dwelling adults living with HIV who engaged in a group-based PT-led exercise programme within an HIV-specialty hospital in Toronto, Canada. Interviews were conducted in-person or by telephone.

PARTICIPANTS

Eight men and two women with a median age of 58 years and median of six concurrent conditions in addition to HIV, who had attended ≥2 classes of the exercise programme.

DATA COLLECTION

Interviews explored (1) reasons for engaging in the programme, (2) experiences with exercise prior to and after joining the programme, (3) facilitators and barriers to engagement and (4) perceived impacts of participation on health and disability. We administered the HIV Disability Questionnaire and a demographic questionnaire.

RESULTS

Experiences spanned perspectives prior to, during and after the PT-led exercise programme. Reasons for engaging in the programme included addressing health-related goals. Participants identified accessibility, the flexible schedule, interprofessional staff and the HIV-specific, group-based environment as facilitators to engagement. Participants reported high attendance rates, but identified episodic health challenges and overcrowded space as potential barriers to attending exercise classes. Perceived impacts on health and disability outcomes included improved physical, mental, social and cognitive health, and activities of daily living. Anticipated or actual experiences transitioning to independent exercise included facilitators (supportive programme leaders) and barriers (challenges motivatiing self to exercise alone).

CONCLUSIONS

Features of the programme that facilitated engagement included the interprofessional, group-based environment that offered tailored exercise in an HIV-specific facility, whereby participants perceived benefits in domains of health and disability. However, challenges transitioning to independent exercise remain. Group-based PT-led exercise programmes may facilitate engagement in exercise among adults living with HIV and complex multimorbidity.

Body Composition Changes in Response to Moderate- or High-Intensity Exercise Among Older Adults With or Without HIV Infection

BACKGROUND

People with HIV (PWH) are at an increased risk for adiposity and sarcopenia, despite effective antiretroviral therapy. Our objective was to compare the effects of prescribed exercise on body composition in older PWH and uninfected controls.

SETTING

Academic medical center.

METHODS

Sedentary PWH (n = 27) and uninfected controls (n = 28) aged 50-75 years completed 24 weeks of cardiovascular and resistance exercise. Participants completed 12 weeks of moderate-intensity exercise and then were randomized to moderate- or high-intensity exercise for 12 additional weeks. Total lean (LEAN) and fat mass (FAT), and visceral adipose tissue area (VAT) were measured using dual-energy x-ray absorptiometry at baseline and 24 weeks; baseline and intervention differences were compared by HIV serostatus using multivariable regression analyses adjusted for baseline values, age, and exercise adherence.

RESULTS

At baseline, PWH had significantly lower FAT (P = 0.003), but no significant differences in LEAN or VAT compared with controls (P > 0.20). Changes over 24 weeks were not significantly different by HIV serostatus, although controls tended to gain more LEAN (0.8 kg; range, 0-1.6 kg; P = 0.04] than PWH (0.6 kg; range, -0.2 to 1.4 kg; P = 0.12) and lose less FAT and VAT (controls: (-0.9 kg; range, -1.8 to 0.0 kg and -10.3 cm; range, -19.6, 1.0) cm; both P = 0.03 vs PWH: -2.0 kg; range, -2.9 to -1.1 kg and -17.7 cm; range, -27.1 to -8.2 cm; both P < 0.001). Exercise intensity differences were not apparent for LEAN, FAT, or VAT.

CONCLUSIONS

Exercise reduced total and visceral fat in older PWH and controls. Minimal gains in lean mass suggest that greater emphasis on resistance exercise may be needed to more effectively increase muscle in PWH.

Ageism in the Fitness and Health Industry: A Review of the Literature

This review aims to understand how age-related stereotypes against older adults' physical capabilities influence their ability to engage in regular physical activity. The authors wanted to know how people construe ageism in the fitness and health arena, how ageism manifests in this field, and how ageism influences older adults' learning and practicing physical activity. Data was extracted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Twenty-two empirical studies met the selection criteria. The findings revealed that the attributes of ageism fell into either self-imposed or other-directed ageism categories and manifested as implicit or explicit ageism. The study also identified the following four themes: (a) perceptions of aging and exercise, (b) exercise motivation, (c) opportunities for older adults, and (d) ambiguous positionality as older exercisers. The research provides evidence for the existence of ageism against older exercisers. Further research considering the implication of ageism within the exercising industry is necessary.

HIV and Aging: Reconsidering the Approach to Management of Comorbidities

Health care for older adults with human immunodeficiency virus can be highly complex, resource intensive, and carry a high administrative burden. Data from aging longitudinal cohorts and feedback from the human immunodeficiency virus community suggest that the current model is not meeting the needs of these older adults. We introduce the 6 Ms approach, which acknowledges the multicomplexity of older adults with human immunodeficiency virus, simplifies geriatric principles for non-geriatrics-trained providers, and minimizes extensive training and specialized screening tests or tools. Implementing novel approaches to care requires support at local/national levels.

A supervised exercise intervention fails to improve depressive symptoms and quality of life among sedentary older adults with HIV infection

Older people living with HIV (PLWH) experience multimorbidity that can negatively impact quality of life (QoL). Exercise can improve physical function, but effects on QoL are not well understood. 32 PLWH and 37 controls aged 50-75 completed 12-weeks of moderate-intensity exercise, then were randomized to moderate or high-intensity for 12 additional weeks. Depressive symptoms (CES-D scores) were significantly greater and QOL (SF-36 mental and physical summary scores) significantly lower among PLWH at baseline (all p < 0.05). PLWH had significantly greater worsening in CES-D scores compared to controls (3.4 [0.7, 6.0]; p = 0.01) between 13and 24 weeks. Mental QoL changed minimally, with no significant difference in changes by serostatus between weeks 0 and 12 or weeks 13 and 24 (p ≤ 0.22). Changes in physical function summary scores were similar by serostatus between 0 and 12 weeks (1.5 [-1.6, 4.6], p = 0.35), but declined significantly more among PLWH between 13 and 24 weeks (-4.1 [-7.2,-1], p = 0.01). Exercise intensity had no significant effect on changes in CES-D or SF-36 summary scores; high-intensity exercise was associated with greater improvements in vitality/fatigue (4.1 [0.8, 7.3], p = 0.02), compared to moderate-intensity. Exercise initiation failed to improve depressive symptoms or QoL among PLWH. Additional interventions may be needed to maximize these patient-reported outcomes among older PLWH initiating an exercise program.

A qualitative focus group study of perceived barriers and benefits to exercise by self-described exercise status among older adults living with HIV

OBJECTIVES

Although exercise interventions have been shown to improve health outcomes among older people with HIV (PLWH), this population remains highly sedentary. The purpose of this study was to examine the differences in perceived barriers and benefits of exercise among older PLWH by self-identified exercise status.

DESIGN

Five focus groups were formed among PLWH: two groups of exercising men, two groups of non-exercising men and one group of women (mixed exercisers and non-exercisers). Themes were analysed in relation to the social-ecological model, utilising the constant comparative approach.

SETTING

Patients were recruited from an academic medical centre, HIV clinic and community locations.

PARTICIPANTS

PLWH aged 50 or older, diagnosed with HIV for at least 2 years, with no other health conditions that would preclude exercise.

PRIMARY AND SECONDARY OUTCOME MEASURES

Determine facilitators, barriers and the ideal environment for exercise or physical activity and determine whether these differ between older PLWH who self-identify as exercisers or non-exercisers.

RESULTS

Among 25 men (11 exercisers and 14 non-exercisers) and four women (three non-exercisers and one exerciser), non-exercisers mentioned fewer benefits of exercise (n=46) than exercisers (n=75). Exercisers emphasised positive reinforcement, positive mood change and increased energy as benefits of exercise; interpersonal benefits of exercise were also discussed twice as often by exercisers than by non-exercisers. Non-exercisers emphasised barriers to exercise including lack of motivation, lack of self-efficacy and a negative perception of gym culture. Non-exercisers identified the need for age-appropriate activities as a feature of an ideal exercise environment. Both groups identified time, cost and health-related challenges as barriers to exercise.

CONCLUSIONS

Unique exercise barriers and benefits by self-identified exercise status provide important insights into the design of future interventions to initiate and maintain exercise.

TRIAL REGISTRATION NUMBER

NCT02404792; Results.

Middle-Aged Men With HIV Have Diminished Accelerometry-Based Activity Profiles Despite Similar Lab-Measured Gait Speed: Pilot Study

BACKGROUND

People aging with HIV are living with increased risk for functional decline compared with uninfected adults of the same age. Early preclinical changes in biomarkers in middle-aged individuals at risk for mobility and functional decline are needed.

OBJECTIVE

This pilot study aims to compare measures of free-living activity with lab-based measures. In addition, we aim to examine differences in the activity level and patterns by HIV status.

METHODS

Forty-six men (23 HIV+, 23 HIV-) currently in the MATCH (Muscle and Aging Treated Chronic HIV) cohort study wore a consumer-grade wristband accelerometer continuously for 3 weeks. We used free-living activity to calculate the gait speed and time spent at different activity intensities. Accelerometer data were compared with lab-based gait speed using the 6-minute walk test (6-MWT). Plasma biomarkers were measured and biobehavioral questionnaires were administered.

RESULTS

HIV+ men more often lived alone (P=.02), reported more pain (P=.02), and fatigue (P=.048). In addition, HIV+ men had lower blood CD4/CD8 ratios (P<.001) and higher Veterans Aging Cohort Study Index scores (P=.04) and T-cell activation (P<.001) but did not differ in levels of inflammation (P=.30) or testosterone (P=.83). For all participants, accelerometer-based gait speed was significantly lower than the lab-based 6-MWT gait speed (P<.001). Moreover, accelerometer-based gait speed was significantly lower in HIV+ participants (P=.04) despite the absence of differences in the lab-based 6-MWT (P=.39). HIV+ participants spent more time in the lowest quartile of activity compared with uninfected (P=.01), who spent more time in the middle quartiles of activity (P=.02).

CONCLUSIONS

Accelerometer-based assessment of gait speed and activity patterns are lower for asymptomatic men living with HIV compared with uninfected controls and may be useful as preclinical digital biomarkers that precede differences captured in lab-based measures.