Evidence-informed practical recommendations for increasing physical activity among persons living with HIV

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.

Effect of a Supervised Exercise Program on Exercise Self-Efficacy in Aging Adults With and Without HIV: A Secondary Analysis of the Exercise for Healthy Aging Study

With earlier initiation and more effective antiretroviral therapy regimens, people with HIV (PWH) are achieving longer lifespans but with high rates of chronic disease and physical function impairment. Regular exercise can reduce disease burden, but older adults with HIV may experience unique barriers to exercise. Exercise self-efficacy (ESE) is an important component of initiation and continuation of exercise, and ESE measurement may illuminate barriers to exercise. Our goal was to evaluate differences in ESE between older PWH and seronegative participants (controls) prior to exercise initiation and over 24-weeks of a supervised resistance and endurance exercise intervention. Virally suppressed PWH and controls completed 12 weeks of moderate-intensity exercise, followed by randomization to 12 weeks of moderate- or high-intensity exercise. The Self-Efficacy for Exercise survey was completed at weeks 0, 12, and 24. Enrolled participants (PWH = 32, controls = 37) had a median age of 56 years [interquartile range: 52, 62]; 63 (91%) were male, and 23 (33%) identified as ethnic or racial minorities. ESE scores differed by serostatus prior to exercise initiation (PWH: 61.3 [95% confidence interval: 54.5, 68]; controls: 73.8 [67.6, 80.1]; p = 0.01; t = - 2.7). ESE scores did not change over the initial 12 weeks in PWH (4.8 [- 2.1, 11.8]; p = 0.17; t = 1.4) or controls (- 2.3 [- 8.9, 4.4]; p = 0.50; t = - 0.7) or between weeks 13 and 24 (pooled serostatus: - 4.8 [- 9.7, 0.2]; p = 0.06: t = - 1.9). Future interventions should incorporate additional strategies to improve ESE, such as text messaging support, coaching, or external rewards.

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.

Prevalence and Correlates of Physical Inactivity Among Individuals with HIV During the First COVID-19 Wave: A Cross-sectional Survey

Physical activity is associated with improved health outcomes among people with HIV (PWH). In the recent pandemic context, policies designed to mitigate COVID-19 transmission may result in an increase in sedentary lifestyle and decreased physical activity. In this study, we aimed to characterize self-reported physical activity and factors associated with physical inactivity during the first wave of the COVID-19 pandemic among a sample of PWH engaged in care. We also described whether psychological coping strategies measured by the Brief COPE differed based on physical activity levels. Among 260 surveyed PWH in two HIV clinics in the US Northeast, 28.5% (n = 74) met the criteria for being physically active according to the Centers for Disease Control and Prevention (CDC)'s physical activity guidelines. Receiving care in New Haven, CT, presence of a detectable HIV viral load, every day tobacco use, and unhealthy alcohol use were associated with physical inactivity. Problem-focused coping, emotion-focused coping, and avoidance-focused coping strategies were found to be protective against physical inactivity. In adjusted analysis, only problem-focused coping continued to be significantly associated with lower odds of reporting physical inactivity. Efforts are urgently needed to promote physical activity among PWH, including among those without problem-focused coping strategies.

Exploring the Interrelationships Between Physical Function, Functional Exercise Capacity, and Exercise Self-Efficacy in Persons Living with HIV

PURPOSE

To determine if there were differences between the subjective and objective assessments of physical activity while controlling for sociodemographic, anthropometric, and clinical characteristics.

SETTING/SAMPLE

A total of 810 participants across eight sites located in three countries.

MEASURES

Subjective instruments were the two subscales of Self-efficacy for Exercise Behaviors Scale: Making Time for Exercise and Resisting Relapse and Patient-Reported Outcomes Measurement Information System, which measured physical function. The objective measure of functional exercise capacity was the 6-minute Walk Test.

ANALYSIS

Both univariate and multivariant analyses were used.

RESULTS

Physical function was significantly associated with Making Time for Exercise (β = 1.76, p = .039) but not with Resisting Relapse (β = 1.16, p = .168). Age (β = -1.88, p = .001), being employed (β = 16.19, p < .001) and race (βs = 13.84-31.98, p < .001), hip-waist ratio (β = -2.18, p < .001), and comorbidities (β = 7.31, p < .001) were significant predictors of physical functioning. The model predicting physical function accounted for a large amount of variance (adjusted R2 = .938). The patterns of results predicting functional exercise capacity were similar. Making Time for Exercise self-efficacy scores significantly predicted functional exercise capacity (β = 0.14, p = .029), and Resisting Relapse scores again did not (β = -0.10, p = .120). Among the covariates, age (β = -0.16, p < .001), gender (β = -0.43, p < .001), education (β = 0.08, p = .026), and hip-waist ratio (β = 0.09, p = .034) were significant. This model did not account for much of the overall variance in the data (adjusted R2 = .081). We found a modest significant relationship between physical function and functional exercise capacity (r = 0.27).

CONCLUSIONS

Making Time for Exercise Self-efficacy was more significant than Resisting Relapse for both physical function and functional exercise capacity. Interventions to promote achievement of physical activity need to use multiple measurement strategies.

Factors associated with insulin resistance in a longitudinal study of Ugandan youth with and without HIV

Prospective investigations from sub-Saharan Africa on metabolic complications in youth with perinatally acquired HIV (PHIV) are lacking. We investigated the changes in insulin resistance in Ugandan PHIV on ART and uninfected controls and their relationship with inflammation, HIV, and cardiovascular disease (CVD) risk factors. Participants 10-18 years of age were included in a prospective study performed in Kampala, Uganda. We compared baseline and changes in insulin resistance (by HOMA-IR) and in markers of inflammation at baseline and 96 weeks. PHIVs were on ART with HIV-1 RNA level 400 copies/ml or less. Generalized Estimating Equation models were used to assess associations between HOMA-IR, and demographic as well as inflammatory markers. Of the 197 participants recruited at baseline (101 PHIV, 96 HIV-negative), 168 (89 PHIV, 79 HIV-negative) had measurements at 96 weeks. At baseline, median (Q1, Q3) age was 13 years (11,15), 53.5% were women, median CD4 + cell counts were 988 cells/μl (631, 1310). At baseline, HOMA-IR was significantly higher in PHIV than in controls ( P  = 0.03). HOMA-IR did not significantly change by week 96 in either group, and at 96 weeks, was similar between groups ( P  = 0.15). HOMA-IR was not associated with any inflammatory markers, or any specific ART. In longitudinal analysis, age and Tanner stage remained associated with higher HOMA-IR throughout the study period, after adjusting for HIV status. In this longitudinal cohort of virally suppressed PHIV in Uganda, PHIV have decreased insulin sensitivity compared to controls, however this difference does not persist through adolescence. ART and immune activation do not appear to affect glucose homeostasis in this population.

Resistance Exercise Training in Individuals With and Without Cardiovascular Disease: 2023 Update: A Scientific Statement From the American Heart Association

Resistance training not only can improve or maintain muscle mass and strength, but also has favorable physiological and clinical effects on cardiovascular disease and risk factors. This scientific statement is an update of the previous (2007) American Heart Association scientific statement regarding resistance training and cardiovascular disease. Since 2007, accumulating evidence suggests resistance training is a safe and effective approach for improving cardiovascular health in adults with and without cardiovascular disease. This scientific statement summarizes the benefits of resistance training alone or in combination with aerobic training for improving traditional and nontraditional cardiovascular disease risk factors. We also address the utility of resistance training for promoting cardiovascular health in varied healthy and clinical populations. Because less than one-third of US adults report participating in the recommended 2 days per week of resistance training activities, this scientific statement provides practical strategies for the promotion and prescription of resistance training.

Mechanisms underlying HIV-associated cognitive impairment and emerging therapies for its management

People living with HIV are affected by the chronic consequences of neurocognitive impairment (NCI) despite antiretroviral therapies that suppress viral replication, improve health and extend life. Furthermore, viral suppression does not eliminate the virus, and remaining infected cells may continue to produce viral proteins that trigger neurodegeneration. Comorbidities such as diabetes mellitus are likely to contribute substantially to CNS injury in people living with HIV, and some components of antiretroviral therapy exert undesirable side effects on the nervous system. No treatment for HIV-associated NCI has been approved by the European Medicines Agency or the US Food and Drug Administration. Historically, roadblocks to developing effective treatments have included a limited understanding of the pathophysiology of HIV-associated NCI and heterogeneity in its clinical manifestations. This heterogeneity might reflect multiple underlying causes that differ among individuals, rather than a single unifying neuropathogenesis. Despite these complexities, accelerating discoveries in HIV neuropathogenesis are yielding potentially druggable targets, including excessive immune activation, metabolic alterations culminating in mitochondrial dysfunction, dysregulation of metal ion homeostasis and lysosomal function, and microbiome alterations. In addition to drug treatments, we also highlight the importance of non-pharmacological interventions. By revisiting mechanisms implicated in NCI and potential interventions addressing these mechanisms, we hope to supply reasons for optimism in people living with HIV affected by NCI and their care providers.

Physical activity is associated with adiposity in older adults with HIV in the modern HIV era

OBJECTIVES

People with HIV (PWH) are aging and are experiencing higher rates of abdominal adiposity. Physical activity is an effective nonpharmacological strategy to reduce adiposity in the general aging population. Yet, the relationship between physical activity and adiposity in people with well controlled HIV is unclear. Our objective was to describe the association between objectively-measured physical activity and abdominal adiposity in PWH.

METHODS

As part of the multisite, observational PROSPER-HIV study, virologically suppressed, adult PWH wore an Actigraph accelerometer for 7-10 days and completed duplicate waist and hip circumference measures. Demographic and medical characteristics were abstracted from the CFAR Network of Integrated Clinical Systems dataset. Descriptive statistics and multiple linear regressions were used to analyze the data.

RESULTS

On average, our 419 PWH were 58 years of age [interquartile range (IQR): 50, 64], male (77%), Black (54%), and currently taking an integrase inhibitor (78%). PWH completed a mean of 7.06 (±2.74) days of total actigraphy wear time. They took an average of 4905 (3233, 7140) steps per day and engaged in 5.4 h of sedentary time per day. Controlling for age, sex, employment and integrase inhibitor use, the number of steps taken per day was associated with reduced abdominal adiposity ( F  = 3.27; P  < 0.001) and the hours of daily sedentary time was associated with increased abdominal adiposity ( F  = 3.24; P  < 0.001).

CONCLUSIONS

Greater physical activity is associated with reduced abdominal adiposity in aging PWH. Future work should investigate how to tailor the amount, type and intensity of physical activity needed to reduce adiposity in PWH taking contemporary HIV medication.

REGISTRATION NUMBER

NCT03790501.

Understanding Physical Activity Determinants in an HIV Self-Management Intervention: Qualitative Analysis Guided by the Theory of Planned Behavior

BACKGROUND

People living with HIV have long life expectancy and are experiencing more comorbid conditions, being at an increased risk for developing cardiovascular disease (CVD) and diabetes, further exacerbated due to the HIV or inflammatory process. One effective intervention shown to decrease mortality and improve health outcomes related to CVD and diabetes in people living with HIV is increased regular physical activity. However, people living with HIV often fall short of the daily recommended physical activity levels. While studies show that mobile health (mHealth) can potentially help improve people's daily activity levels and reduce mortality rates due to comorbid conditions, these studies do not specifically focus on people living with HIV. As such, it is essential to understand how mHealth interventions, such as wearables, can improve the physical activity of people living with HIV.

OBJECTIVE

This study aimed to understand participants' experiences wearing a fitness tracker and an app to improve their physical activity.

METHODS

In total, 6 focus groups were conducted with participants who completed the control arm of a 6-month randomized controlled trial (ClinicalTrials.gov NCT03205982). The control arm received daily walk step reminders to walk at least 5000 steps per day and focused on the overall wellness of the individual. The analysis of the qualitative focus groups used inductive content analysis using the theory of planned behavior as a framework to guide and organize the analysis.

RESULTS

In total, 41 people living with HIV participated in the focus groups. The majority (n=26, 63%) of participants reported their race as Black or African American, and 32% (n=13) of them identified their ethnicity as Hispanic or Latino. In total, 9 major themes were identified and organized following the theory of planned behavior constructs. Overall, 2 major themes (positive attitude toward tracking steps and tracking steps is motivating) related to attitudes toward the behavior, 2 major themes (social support or motivation from the fitness tracker and app and encouragement from family and friends) related to participant's subjective norms, 1 theme (you can adjust your daily habits with time) related to perceived behavioral control, 2 themes (reach their step goal and have a healthier lifestyle) related to participant's intention, and 2 themes (continuing to walk actively and regularly wearing the fitness tracker) related to participant's changed behavior. Participants highlighted how the mHealth interface with the avatar and daily step tracking motivated them to both begin and continue to engage in physical activity by adjusting their daily routines.

CONCLUSIONS

Findings from this study illustrate how features of mHealth apps may motivate people living with HIV to start and continue sustained engagement in physical activities. This sustained increase in physical activity is crucial for reducing the risk of comorbid conditions such as diabetes or CVD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03205982; https://classic.clinicaltrials.gov/ct2/show/NCT03205982.

Association Between VACS Index and Health-Related Quality of Life in Persons with HIV: Moderating Role of Fruit and Vegetable Consumption

BACKGROUND

The health status of people with HIV (PWH) influences their health-related quality of life (HRQOL). Modifiable lifestyle factors may improve HRQOL. This study (1) explores the association between modifiable lifestyle factors (physical activity and nutrition) and HRQOL and (2) examines if these lifestyle factors moderate the association health status and HRQOL.

METHODS

Participants included 91 community dwelling PWH (age 36-65 years) from the university lab. Participants reported mental and physical HRQOL via the Medical Outcome Study 36-Item Short-Form (SF-36). Physical activity was examined via the International Physical Activity Questionnaire and nutrition (i.e., fruit and vegetable consumption) was assessed with the By-Meal Screener. Health status was ascertained via the Veterans Aging Cohort Study (VACS) Index.

RESULTS

Aim 1 analyses indicated that neither physical activity nor nutrition was related to mental HRQOL (p's > .05). However, greater physical activity (β = .33, p < .01) and nutrition (β = .23, p = .03) were each independently related to better physical HRQOL and remained significant after accounting for co-occurring medical conditions. For aim 2, the interaction between health status and nutrition was statistically significant (β = .24, p = .02), such that the association between worse health status and worse physical HRQOL was weaker with better nutrition. There was not a statistically significant interaction between physical activity and health status on physical HRQOL (p > .05).

CONCLUSION

Physical HRQOL is related to self-reported physical activity and nutrition, with nutrition showing a moderating effect on the association between health status and physical HRQOL. Thus, future interventional studies designed to improve physical HRQOL should target both physical activity and nutrition.

Wireless physical activity monitor use among adults living with HIV in a community-based exercise intervention study: a quantitative, longitudinal, observational study

OBJECTIVES

Our aim was to examine wireless physical activity monitor (WPAM) use and its associations with contextual factors (age, highest education level, social support and mental health) among adults living with HIV engaged in a community-based exercise (CBE) intervention.

DESIGN

Quantitative, longitudinal, observational study.

SETTING

Toronto YMCA, Ontario, Canada.

PARTICIPANTS

Eighty adults living with HIV who initiated the CBE intervention.

INTERVENTION

Participants received a WPAM to track physical activity during a 25-week CBE intervention involving thrice-weekly exercise, supervised weekly (phase 1) and a 32-week follow-up involving thrice-weekly exercise with no supervision (phase 2), completed in December 2018.

OUTCOME MEASURES

Uptake was measured as participants who consented to WPAM use at initation of the intervention. Usage was defined as the proportion of days each participant had greater than 0 steps out of the total number of days in the study. We measured contextual factors using a baseline demographic questionnaire (age, highest education level), and median scores from the bimonthly administered Medical Outcomes Study-Social Support Scale and Patient Health Questionnaire (mental health), where higher scores indicated greater social support and mental health concerns, respectively. We calculated Spearman correlations between WPAM usage and contextual factors.

RESULTS

Seventy-six of 80 participants (95%) consented to WPAM use. In phase 1, 66% of participants (n=76) and in phase 2, 61% of participants (n=64) used the WPAM at least 1 day. In phase 1, median WPAM usage was 50% (25th, 75th percentile: 0%, 87%; n=76) of days enrolled and in phase 2, 23% (0%, 76%; n=64) of days. Correlation coefficients with WPAM usage ranged from weak for age (ρ=0.26) and mental health scores (ρ=-0.25) to no correlation (highest education level, social support).

CONCLUSIONS

Most adults living with HIV consented to WPAM use, however, usage declined over time from phase 1 to phase 2. Future implementation of WPAMs should consider factors to promote sustained usage by adults living with HIV.

TRIAL REGISTRATION NUMBER

NCT02794415.

Update in Human Immunodeficiency Virus and Aging

Effective and consistent antiretroviral therapy has enabled people with human immunodeficiency virus (HIV) (PWH) to survive longer than previously encountered earlier in the epidemic. Consequently, PWH are subject to the struggles and clinical conditions typically associated with aging. However, the aging process in PWH is not the same as for those who do not have HIV. There is a complex interplay of molecular, microbiologic, and pharmacologic factors that leads to accelerated aging in PWH; this leads to increased risk for certain age-related comorbidities requiring greater vigilance and interventions in routine care.

Cardiometabolic Diseases and Quality-of-Life Outcomes in Adults With HIV in the Deep South: A Cross-sectional Study

ABSTRACT

The role of cardiometabolic diseases (CMDs) on physical health-related quality of life (P-HRQoL) and quality of sleep was examined among 261 PLWH ≥40 years, recruited from a university-affiliated HIV clinic in the Deep U.S. South. Using a cross-sectional study design, participants completed the Medical Outcomes Study HIV Health Survey (MOS-HIV; P-HRQoL) and Pittsburgh Sleep Quality Index. The overall prevalence of self-reporting ≥1 CMD was 64.4%. P-HRQoL scores were lower in PLWH with ≥1 CMD compared with those with no CMDs (45.53 ± 11.54 vs. 49.67 ± 10.77, p <.01). Poor sleep quality was higher among participants with ≥1 CMD compared with those with no CMDs (9.28 ± 4.42 vs. 7.26 ± 4.17, p <.01). Each additional CMD resulted in a 1.83-point decrease in P-HRQoL and 0.74-point increase in poor sleep quality scores. Interventions that focus on targeting these quality-of-life domains in PLWH with CMDs are needed.

Inflammatory and Cardiovascular Correlates of Physical Activity and Sedentary Behavior in Older Adults Living With HIV

BACKGROUND

Inflammation is an indicator of oxidative stress that may contribute to cardiovascular diseases in older people living with HIV (OPWH). Physical activity (PA) may reduce these biomarkers in OPWH, but little is known about the association of PA with inflammatory and cardiovascular biomarkers. We sought to examine the inflammatory and cardiovascular biomarker correlates of PA and sedentary behavior in OPWH.

METHODS

We included 101 OPWH with complete assessments of PA, sedentary behavior, and biomarker data to examine the association between the volume of PA and inflammatory and cardiovascular biomarkers.

RESULTS

In this cohort of OPWH (mean age 55.9 y), 68% were male and 83% were African American/Black. Among OPWH, greater volume of PA (ie, walking, moderate, vigorous, and/or total) was associated with lower systolic (P < .05) and diastolic blood pressure (P < .05), pulse pressure (P < .05), and tumor necrosis factor-alpha (P < .05). Greater duration of sitting was associated with greater triglycerides, interleukin-6, and tumor necrosis factor-alpha (P < .05).

CONCLUSIONS

Although adherence to regular PA among OPWH is low and sedentary behavior is high, the associations between biomarkers and PA suggest a greater volume of PA could attenuate the inflammatory and cardiovascular derangements experienced by OPWH.

Current Challenges and Solutions for Clinical Management and Care of People with HIV: Findings from the 12th Annual International HIV and Aging Workshop

People with HIV on combination antiretroviral therapy (ART) have longer life expectancy and are increasingly experiencing age-related comorbidities. Thus, aging with HIV has become a central issue in clinical care and research, which has been particularly challenging with the intersection of the ongoing coronavirus (COVID)-19 pandemic. Since 2009, the International Workshop on HIV and Aging has served as a multidisciplinary platform to share research findings from cross-disciplinary fields along with community advocates to address critical issues in HIV and aging. In this article, we summarize the key oral presentations from the 12th Annual International Workshop on HIV and Aging, held virtually on September 23rd and 24th, 2021. The topics ranged from basic science research on biological mechanisms of aging to quality of life and delivery of care under the COVID-19 pandemic. This workshop enriched our understanding of HIV and aging under the COVID-19 pandemic, identified challenges and opportunities to combat the impact of COVID-19 on HIV communities, and also provided updated research and future directions of the field to move HIV and aging research forward, with the ultimate goal of successful aging for older people with HIV.

Effects of Physical Activity Interventions on Health Outcomes among Older Adults Living with HIV: A Systematic Review and Meta-Analysis

There is a lack of evidence regarding the effects of exercise on older individuals living with HIV. This systematic review and meta-analysis examined previous studies on physical activity interventions for people living with HIV aged ≥50 years. The effectiveness of the interventions on various physical and psychological health outcomes was evaluated. Databases used for this review included PubMed, EMBASE, CINAHL, and Cochrane Library CENTRAL. Twelve randomized controlled trials on physical activity interventions for people ≥50 years and living with HIV were included. Standardized mean differences were calculated using random-effect models. All effect sizes were expressed using Cohen's d values and their 95% confidence intervals (CIs). Physical activity interventions had a significant effect on walking capacity (Cohen's d: 0.467; 95% CI [0.069, 0.865]). The effect sizes on cardiorespiratory fitness, weight, and health-related quality of life were not significant. These findings suggest that physical activity interventions for people living with HIV aged ≥50 years are effective for the improvement of walking capacity. Further larger and higher-quality studies are required to determine the full effects of physical activity interventions on various health outcomes among older adults with HIV.

Working status and seasonal meteorological conditions predict physical activity levels in people living with HIV

Little is known about how demographic, employment and meteorological factors impact physical activity. We conducted an analysis to explore these associations from participants (N = 447) from six cities in the United States and matched their activity data with abstracted local meteorological data from National Oceanic and Atmospheric Administration (NOAA) weather reports. Participants were purposively recruited in 3-month blocks, from December 2015 to October 2017, to reflect physical activity engagement across the seasons. We calculated total physical activity (minutes/week) based on 7-day physical activity recall. Mild correlations were observed between meteorological factors and correlated with lower physical activity. Participants were least active in autumn (Median = 220 min/week) and most active in spring (Median = 375 min/week). In addition to level of education and total hours of work, maximum temperature, relative humidity, heating degree day, precipitation and sunset time together explained 17.6% of variance in total physical activity. Programs assisting in employment for PLHIV and those that promote indoor physical activity during more strenuous seasons are needed. Additional research to better understand the selection, preferences, and impact of indoor environments on physical activity is warranted.

Recruitment and retention in mobile application-based intervention studies: a critical synopsis of challenges and opportunities

Use of mobile health applications (mHealth apps) is becoming increasingly popular for the management of chronic illnesses, but mHealth-based intervention studies often have limitations associated with subject recruitment and retention. In this synopsis, we focus on targeted aspects of mHealth-based intervention studies, specifically: (i) subject recruitment, (ii) cohort sizes, and (iii) retention rates. We used the Google Scholar (meta-search) and Galileo search engines to identify sample articles focusing on mHealth apps and interventions published between 2010 and 2020 and selected 21 papers for detailed review. Most studies recruited relatively small cohorts (minimum: 20, maximum: 510). Retention rates had high variance with only five studies managing >80% subject retention throughout the study duration, 10.4% being the lowest. Eighty-five percent of the studies expressed concerns regarding study duration, app usage, and lack of proper implementation. The use of mHealth interventions generally yielded positive outcomes, but most studies discussed facing challenges associated with recruitment and retention. There is a clear need to identify strategies for recruiting larger cohorts and improving retention rates, and ultimately increasing the reliability of mHealth app-based intervention studies. We advise that potential underutilized opportunities lie at the intersection of mHealth and social media to address the limitations identified in the synopsis.

Low- and High-Intensity Physical Activity Among People with HIV: Multilevel Modeling Analysis Using Sensor- and Survey-Based Predictors

Background

High-intensity physical activity improves the health of people with HIV. Even when people have good intentions to engage in physical activity, they often find it difficult to maintain physical activity behavior in the long term. Two Minds Theory is a neurocognitive model that explains gaps between people’s intentions and behaviors based on the operations of 2 independent mental systems. This model predicts that everyday experiences will affect physical activity and that factors outside people’s awareness, such as sleep and stress, can have particularly strong effects on physical activity behaviors.

Objective

We designed this study to test the effects of daily experiences on physical activity among people with HIV, including measures of people’s conscious experiences using daily electronic surveys and measures of nonconscious influences using sensor devices.

Methods

In this study, 55 people with HIV wore a Fitbit Alta for 30 days to monitor their physical activity, sleep, and heart rate variability (HRV) as a physiological indicator of stress. Participants also used their smartphones to complete daily electronic surveys for the same 30 days about fatigue, self-efficacy, mood, stress, coping, motivation, and barriers to self-care. Time-lagged, within-person, multilevel models were used to identify the best prospective predictors of physical activity, considering the daily survey responses of people with HIV and sensor data as predictors of their physical activity the following day. We also tested baseline surveys as predictors of physical activity for comparison with daily variables.

Results

Different people had different average levels of physical activity; however, physical activity also varied substantially from day to day, and daily measures were more predictive than baseline surveys. This suggests a chance to intervene based on day-to-day variations in physical activity. High-intensity physical activity was more likely when people with HIV reported less subjective fatigue on the prior day (r=−0.48) but was unrelated to actual sleep based on objective sensor data. High-intensity physical activity was also predicted by higher HRV (r=0.56), indicating less stress, lower HIV-related stigma (r=−0.21), fewer barriers to self-care (r=−0.34), and less approach coping (r=−0.34). Similar variables predicted lower-level physical activity measured based on the number of steps per day of people with HIV.

Conclusions

Some predictors of physical activity, such as HRV, were only apparent based on sensor data, whereas others, such as fatigue, could be measured via self-report. Findings about coping were unexpected; however, other findings were in line with the literature. This study extends our prior knowledge on physical activity by demonstrating a prospective effect of everyday experiences on physical activity behavior, which is in line with the predictions of Two Minds Theory. Clinicians can support the physical activity of people with HIV by helping their patients reduce their daily stress, fatigue, and barriers to self-care.

Diabetes mellitus is associated with declines in physical function among men with and without HIV

OBJECTIVE

To determine the longitudinal relationships between abnormal glucose metabolism and physical function in persons with HIV (PWH) and without HIV.

DESIGN

Prospective cohort study of men with or at risk for HIV in four United States cities between 2006 and 2018.

METHODS

Men with or at risk for HIV from the Multicenter AIDS Cohort Study (MACS) had semi-annual assessments of glycemic status, grip strength, and gait speed. We used linear mixed models with random intercept to assess associations between glycemic status and physical function. Glycemic status was categorized as normal, impaired fasting glucose (IFG), controlled diabetes mellitus [hemoglobin A1C (HbA1C) <7.5%], or uncontrolled diabetes mellitus (HbA1C ≥ 7.5%).

RESULTS

Of 2240 men, 52% were PWH. Diabetes mellitus was similar among PWH (7.7%) vs. persons without HIV (6.7%, P = 0.36) at baseline. PWH had slower gait speed (1.17 vs. 1.20 m/s, P < 0.01) but similar grip strength (40.1 vs. 39.8 kg, P = 0.76) compared with persons without HIV at baseline. In multivariate models, gait speed decline was greater with controlled diabetes mellitus [-0.018 m/s (-0.032 to -0.005), P = 0.01] and grip strength decline was greater with controlled [-0.560 kg (-1.096 to -0.024), P = 0.04] and uncontrolled diabetes mellitus [-0.937 kg (-1.684 to -0.190), P = 0.01), regardless of HIV serostatus compared with normoglycemic individuals.

DISCUSSION

Abnormal glucose metabolism was associated with declines in gait speed and grip strength regardless of HIV serostatus. These data suggest that improvement in glucose control should be investigated as an intervenable target to prevent progression of physical function limitations among PWH.

Sarcopenia Related to Human Immunodeficiency Virus: Protective Effects of Exercise

We discuss recent evidence supporting the hypothesis that sarcopenia is an emerging health concern among people with human immunodeficiency virus (HIV) because of increasing life expectancy and HIV- and treatment-related comorbidities. We also hypothesize that combined exercise at higher intensity has a key role in managing sarcopenia in this population because it directly (increases muscle strength and stimulates hypertrophy) and indirectly (prevents mitochondrial dysfunction, oxidative stress, and persistent inflammation) counteracts sarcopenia hallmarks.

Multimorbidity networks associated with frailty among middle-aged and older people with HIV

OBJECTIVE

People with HIV (PWH) have increased prevalence of multimorbidity and frailty at younger ages compared with the general population. This study investigated individual and combinatorial effects of neuropsychiatric and medical comorbidities as predictors of frailty in PWH.

DESIGN

Analysis of data from the National NeuroAIDS Tissue Consortium, a longitudinal observational cohort.

METHODS

Five hundred and twenty-four PWH over age 40 years were classified using Fried's Frailty criteria. Twelve comorbidities were documented from longitudinal data and associations between individual and co-occurring comorbidities with frailty were assessed using weighted network and logistic regression analyses.

RESULTS

At frailty assessment between 2015 and 2020, median age was 61 years, 76% were men, 94% were on antiretroviral therapy (ART), 73% had two or more comorbidities, 24% were frail, and 52% were prefrail. Among individual comorbidities, highest odds of frailty were in participants with depressive symptoms [adjusted odds ratio (aOR), 95% confidence interval (CI) 3.48 (2.22-5.46)], followed by bone disease and chronic obstructive pulmonary disease (COPD) [2.47 (1.28-4.72) and 2.13 (1.36-3.34), respectively]. Among co-occurring comorbidities, highest odds of frailty were in participants having depressive symptoms with diabetes, hypertension, or obesity [aORs (95% CIs) 5.29 (2.32-12.08), 5.21 (2.65-10.40), 4.85 (2.39-9.95), respectively], cognitive impairment with diabetes or renal disease [2.81 (1.38-5.68) and 2.53 (1.26-5.03), respectively], renal disease with cardiovascular disease [2.81 (1.32-6.01)], and diabetes with obesity [2.76 (1.39-5.45)].

CONCLUSION

Co-occurrence of depressive symptoms, cognitive impairment, diabetes, or renal disease with other medical conditions substantially increases odds of frailty in older PWH. Identifying and treating these comorbidities may help to reduce functional decline with aging in PWH.

Effect of Training and Detraining in the Components of Physical Fitness in People Living With HIV/AIDS

The aim of the study was to evaluate the effect of training and detraining on the physical fitness components of people living with HIV/AIDS (PLHA). The study was characterized as experimental with a sample composed of 21 people divided into two groups: 11 volunteers (PLHA, 46.9 ± 8.0 years, 63.8 ± 12.7 kg, 161.7 ± 8.7 cm, 7 men, and 4 women), using antiretroviral therapy (ART) and 10 people without HIV/AIDS in the control group (CG, 43.8 ± 13.8 years, 75.2 ± 11.2 kg, 163.3 ± 7.8 cm, 3 men, and 7 women), with the same average age and level of physical activity. The intervention, applied to both groups, consisted of combined training for 15 weeks, followed by detraining for 5 weeks. Before and after the training and detraining period the following parameters were evaluated: body composition by dual energy radiological absorptiometry (DXA), cardiorespiratory fitness by ergospirometer, and strength of upper and lower limbs by isometric dynamometer. The results show the effect of the intervention moments on the strength and oxygen consumption variables (time factor), considering the two study groups. Regarding the analysis of the interaction (group vs. time), there was a significant effect on the isometric extension strength of the left (p = 0.019) and right (p = 0.030) knees, with training (left: 10.4%; right: 12.4%) and detraining (left: −10.8%; right: −12.1%) effect in PLHA, when compared with the control group (left: 8.1 and 3.9%, respectively; right: 11.5 and −0.2%, respectively). In addition, there was a significant interaction on ventilatory threshold 1 (p = 0.002), indicating a significantly greater increase with training (27.3%) and decrease with detraining (−22.7%) in the PLHA group compared with the Control group (19.9 and −6.7%, respectively). In conclusion, combined training and the subsequent period of detraining caused similar responses in body composition, isometric strength, and cardiorespiratory fitness of PLHA and CG, except for the extensor strength of the lower limbs and ventilatory threshold 1, which presented positive effects on training and negative effects on detraining for PLHA.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03075332.

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.

Concurrent training remodels the subcutaneous adipose tissue extracellular matrix of people living with HIV: a non-randomized clinical trial

Evaluate the effect of 12wks of concurrent training (CT) in extracellular matrix (ECM) of subcutaneous adipose tissue (SAT) in people living with HIV/aids (PLWHA). To the non-randomized clinical trial 19 participants, 11 healthy (HIV-) and 18 PLWHA under the use of highly active antiretroviral therapy (HAART) for at least 1 year (HIV+). All participants engaged in a moderate-intensity CT program for 12 weeks, three times a week. Before and after CT, aerobic and strength performance were assessed, as well as anthropometry and biochemical blood profile. Also, SAT biopsies were carried out for histologic and morphometric analysis. The statistical analysis was carried out with R Studio, using descriptive and inferential analysis, ANOVA test and mixed-effect model were utilized (P<0.05). HIV+ showed higher levels of VLDL, TGL, and lower levels of HDL in baseline than HIV- (P<0.05). All groups improved aerobic and strength performance (P<0.05). Both groups presented reduced adipocyte sizes after CT (P<0,05). Lastly, HIV+ presented smaller adipocytes and higher elastic fiber deposition in baseline and decreased after training only in HIV+, matching similarly to HIV- group. Thus, CT in PLWHA promoted a decrease in size heterogeneity of adipocytes and elastic fiber deposition, remodeling ECM and improving SAT fibrosis profile. Brazilian Clinical Trials Registry (UTN: U1111-1214-3022) Novelty • Adipose tissue fibrosis is improved by training in people living with HIV. • Concurrent training remodels adipose tissue extracellular matrix.

Incorporating physical activity in the comprehensive care of people living with HIV starting antiretroviral therapy: Insights from a specialized care setting in São Paulo, Brazil

BACKGROUND

Managing HIV infection as a chronic condition includes encouraging adoption of healthy behaviors and promotion of physical activity (PA). However, people living with HIV (PLH) are often under social and programmatic vulnerability that may compromise behavior change. Understanding such barriers is crucial for successful incorporation of PA in their comprehensive care.

METHODS AND FINDINGS

In this study, we describe PA, energy intake from diet, and anthropometry of a cohort of PLH starting antiretroviral therapy (ART) at a Brazilian reference clinic, report how PA was addressed in routine care and investigate association between PA, energy intake and psychosocial constructs that may facilitate PA (social support and self-efficacy for PA). Among 61 PLH (86.9% males, mean age = 32.5 years) anthropometry was normal, but 47.5% reported PA below recommendations. Despite presenting high social support scores, family encouragement for PA was low, and self-efficacy classified as medium. Chart reviews yielded infrequent reports concerning PA. After adjusting for gender and age, we found a negative association between energy intake from diet and self-efficacy, but none between PA and energy intake or between PA and psychosocial constructs.

CONCLUSIONS

We conclude that patients in our cohort were insufficiently active when starting ART, and that PA was poorly addressed by caretakers in routine HIV care. Nevertheless, social support and self-efficacy scores suggest potential for behavioral change. Caregivers should therefore start considering patients' vulnerabilities and establishing strategies to help them overcome barriers to incorporate PA in their comprehensive care effectively.

Daily Cannabis Use is Associated With Lower CNS Inflammation in People With HIV

OBJECTIVE

Recent cannabis exposure has been associated with lower rates of neurocognitive impairment in people with HIV (PWH). Cannabis's anti-inflammatory properties may underlie this relationship by reducing chronic neuroinflammation in PWH. This study examined relations between cannabis use and inflammatory biomarkers in cerebrospinal fluid (CSF) and plasma, and cognitive correlates of these biomarkers within a community-based sample of PWH.

METHODS

263 individuals were categorized into four groups: HIV- non-cannabis users (n = 65), HIV+ non-cannabis users (n = 105), HIV+ moderate cannabis users (n = 62), and HIV+ daily cannabis users (n = 31). Differences in pro-inflammatory biomarkers (IL-6, MCP-1/CCL2, IP-10/CXCL10, sCD14, sTNFR-II, TNF-α) by study group were determined by Kruskal-Wallis tests. Multivariable linear regressions examined relationships between biomarkers and seven cognitive domains, adjusting for age, sex/gender, race, education, and current CD4 count.

RESULTS

HIV+ daily cannabis users showed lower MCP-1 and IP-10 levels in CSF compared to HIV+ non-cannabis users (p = .015; p = .039) and were similar to HIV- non-cannabis users. Plasma biomarkers showed no differences by cannabis use. Among PWH, lower CSF MCP-1 and lower CSF IP-10 were associated with better learning performance (all ps < .05).

CONCLUSIONS

Current daily cannabis use was associated with lower levels of pro-inflammatory chemokines implicated in HIV pathogenesis and these chemokines were linked to the cognitive domain of learning which is commonly impaired in PWH. Cannabinoid-related reductions of MCP-1 and IP-10, if confirmed, suggest a role for medicinal cannabis in the mitigation of persistent inflammation and cognitive impacts of HIV.

Frailty and HIV: Moving from Characterization to Intervention

PURPOSE OF REVIEW

While the characteristics associated with frailty in people with HIV (PWH) have been well described, little is known regarding interventions to slow or reverse frailty. Here we review interventions to prevent or treat frailty in the general population and in people with HIV (PWH).

RECENT FINDINGS

Frailty interventions have primarily relied on nonpharmacologic interventions (e.g., exercise and nutrition). Although few have addressed frailty, many of these therapies have shown benefit on components of frailty including gait speed, strength, and low activity among PWH. When nonpharmacologic interventions are insufficient, pharmacologic interventions may be necessary. Many interventions have been tested in preclinical models, but few have been tested or shown benefit among older adults with or without HIV. Ultimately, pharmacologic and nonpharmacologic interventions have the potential to improve vulnerability that underlies frailty in PWH, though clinical data is currently sparse.

A Review of Chronic Comorbidities in Adults Living With HIV: State of the Science

ABSTRACT

People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings.

Factors related to functional exercise capacity amongst people with HIV in Durban, South Africa

BACKGROUND

People with HIV (PWH), who engage in regular physical activity, have improved fitness, muscular strength, body composition, health-related quality of life and mental health symptoms, but PWH have amongst the lowest physical activity levels of those with any chronic health condition. Furthermore, there is scant evidence examining these relationships in PWH in Africa.

AIM

To address these critical gaps, this cross-sectional descriptive research study examined the relationships between demographic, HIV-related, anthropometric factors, neighbourhood walkability and physical activity, amongst PWH in Durban, South Africa.

SETTING

Respondents (N = 100) were receiving primary healthcare in six eThekwini nurse-run municipal clinics.

METHODS

Self-reported socio-demographic data were collected, and HIV-related medical data were extracted from respondent's medical charts. Height and weight were measured to calculate the body mass index (BMI, kg/m2); neighbourhood walkability was measured on the Neighbourhood Environment scale; and physical activity, specifically functional exercise capacity, was measured by the 6-min walk test (6MWT).

RESULTS

On average, respondents were black African, female, approximately 38 years old and unemployed; men were of normal weight whilst women were overweight. Only 65% of the respondents reached the age- and sex-predicted distance during the 6MWT. Correlational analyses did not reveal any significant relationships between the functional exercise capacity and socio-demographic, HIV-related factors or anthropometric measures.

CONCLUSION

South African PWH do not reach their predicated walking distance on the 6MWT. Engaging community agencies to promote walking as both a means of transportation and leisure physical activity may decrease the risks of a sedentary lifestyle and improve progression towards recommended physical activity targets.

Weight Gain Following Initiation of Antiretroviral Therapy: Risk Factors in Randomized Comparative Clinical Trials

Background

Initiation of antiretroviral therapy (ART) often leads to weight gain. While some of this weight gain may be an appropriate return-to-health effect, excessive increases in weight may lead to obesity. We sought to explore factors associated with weight gain in several randomized comparative clinical trials of ART initiation.

Methods

We performed a pooled analysis of weight gain in 8 randomized controlled clinical trials of treatment-naive people living with human immunodeficiency virus (HIV) initiating ART between 2003 and 2015, comprising >5000 participants and 10 000 person-years of follow-up. We used multivariate modeling to explore relationships between demographic factors, HIV disease characteristics, and ART components and weight change following ART initiation.

Results

Weight gain was greater in more recent trials and with the use of newer ART regimens. Pooled analysis revealed baseline demographic factors associated with weight gain including lower CD4 cell count, higher HIV type 1 RNA, no injection drug use, female sex, and black race. Integrase strand transfer inhibitor use was associated with more weight gain than were protease inhibitors or nonnucleoside reverse transcriptase inhibitors (NNRTIs), with dolutegravir and bictegravir associated with more weight gain than elvitegravir/cobicistat. Among the NNRTIs, rilpivirine was associated with more weight gain than efavirenz. Among nucleoside/nucleotide reverse transcriptase inhibitors, tenofovir alafenamide was associated with more weight gain than tenofovir disoproxil fumarate, abacavir, or zidovudine.

Conclusions

Weight gain is ubiquitous in clinical trials of ART initiation and is multifactorial in nature, with demographic factors, HIV-related factors, and the composition of ART regimens as contributors. The mechanisms by which certain ART agents differentially contribute to weight gain are unknown.

Reasoned Action Approach Correlates of Physical Activity Among African American Men Living With HIV: A Cross-Sectional Study

ABSTRACT

Physical activity (PA) is associated with a reduced incidence of chronic diseases. However, little is known about the predictors of PA among African American men living with HIV. We report secondary analyses examining the strength of the relationships between the reasoned action approach constructs, attitude, subjective norm, descriptive norm, and self-efficacy and intention to exercise and self-reported adherence to Department of Health and Human Services PA guidelines using baseline data from a trial of a PA intervention with 302 African American men, between 40 and 88 years of age (M = 53.9; SD = 7.2) living with HIV. Multiple regression revealed that attitude, subjective norm, and self-efficacy were positively associated with intention. Logistic regression revealed higher odds of meeting PA guidelines as self-efficacy increased. Self-efficacy and descriptive norm predicted meeting the aerobic guideline. Self-efficacy predicted meeting the muscle-strengthening guideline. Interventions targeting reasoned action approach variables may contribute to efforts to improve PA among African American men living with HIV.

Physical Function and Frailty in HIV

Aging is associated with declines in physical function that can be influenced by many factors, including HIV. These limitations may manifest as increased vulnerability to stressors, or frailty. Functional limitations and frailty can be used to guide clinical decisions, protect people from harm, and avoid strategies that are not likely to provide benefits. Such limitations could also serve as clinically relevant endpoints for some clinical trials. Interventions should ideally focus on early impairments that begin to occur in midlife, well before an individual becomes frail or experiences disabilities. Overall, physical activity is safe and effective in improving physical function, and counseling about physical activity should be a routine component of HIV care to increase the lifespan and healthspan of individuals with HIV. There are some promising pharmaceutical options, but more research is needed to determine the safety and long-term efficacy. This article summarizes an International Antiviral Society-USA (IAS-USA) webinar presented by Kristine M. Erlandson, MD, MS, on July 24, 2020. This webinar is available on demand at https://www.iasusa.org/courses/on-demand-webinar-2020-erlandson/.

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.

Feasibility and effects of high-intensity interval training in older adults living with HIV

Adults with HIV on therapy can live a normal lifespan but exhibit advanced ageing which includes reduced cardiorespiratory fitness. Our objective was to determine the feasibility and effects of high-intensity interval training (HIIT) combined with resistance training (RT) in older adults with HIV. We conducted a cross-over pilot study within a randomized exercise trial in sedentary adults with HIV ≥50 years of age. First, participants were randomized to 4 months of continuous high-intensity aerobic exercise (AEX) and RT 3x/week or standard of care control. Then, the control group completed 4 months of HIIT + RT (3x/week). Among the 32 individuals enrolled, 26 eligible participants were randomized. Most participants were African American (63%) and male (95%) with a mean (SD) age of 61.5 (6.7) years and VO₂peak of 24.5 (4.9) ml/kg/min. Attendance and adherence to both exercise training interventions were high. The clinically significant increases in VO₂peak (ml/kg/min) after HIIT (3.09 ±1.04, p=0.02) and AEX (2.09 ±0.72, p=0.01) represented improvements of 17.1% and 7.7%, respectively. Both groups had improvements in exercise endurance (time on the treadmill) and strength (all p< 0.01). This pilot study supports HIIT as an efficient means to deliver high-intensity AEX to improve cardiorespiratory fitness toward the goal of attenuating the accelerated ageing process in adults with HIV.

The Impact of Moderate or High-Intensity Combined Exercise on Systemic Inflammation Among Older Persons With and Without HIV

BACKGROUND

We investigated whether higher-intensity exercise provided greater decrease in markers of inflammation, and whether responses differed by HIV serostatus.

METHODS

People with HIV (PWH; n = 32) and controls (n = 37) aged 50-75 years completed 12 weeks moderate-intensity exercise, then were randomized to moderate- or high-intensity exercise for 12 additional weeks (n = 27 and 29, respectively). Inflammation biomarkers were measured at 0, 12, 24 weeks. Mixed and multiple regression models were adjusted for baseline inflammation, age, and body mass index.

RESULTS

Baseline tumor necrosis factor-α (TNF-α), soluble TNF receptor 2 (sTNFR2), and soluble CD14 (sCD14) were significantly higher among PWH than controls (P < .04). From week 0-12, changes in interleukin-6 (IL-6), TNF-α, and sTNFR1 were not significantly different by HIV serostatus. We found no significant interaction between HIV serostatus/exercise intensity on week 12-24 changes in IL-6, TNF-α, and sTNFR1. Among high-intensity exercisers, PWH and controls had significant increases in sCD14 (P ≤ .003), controls significant increases in IL-10 (P = .01), and PWH nonsignificant decrease in highly sensitive C-reactive protein (P = .07). Other markers were not significantly different by serostatus or intensity.

CONCLUSIONS

Moderate and high-intensity exercise elicited similar effects on inflammation among PWH and controls, with additional beneficial effects seen among high-intensity exercisers. Increase in sCD14 and attenuated IL-10 increase (PWH only) merit further study.

CLINICAL TRIALS REGISTRATION

NCT02404792.

The Relationship Between Physical Activity and Cardiorespiratory Fitness Among People Living With Human Immunodeficiency Virus Throughout the Life Span

BACKGROUND

People living with human immunodeficiency virus (PLHIV) are at an increased risk for developing cardiovascular disease (CVD). Physical activity and cardiorespiratory fitness in PLHIV are poorly understood.

OBJECTIVE

The aims of this study were to describe physical activity and cardiorespiratory fitness by sex and age and to examine the association between physical activity and cardiorespiratory fitness in PLHIV, controlling for covariates.

METHODS

Seven hundred two PLHIV participated in a cross-sectional study and completed validated measures of self-reported physical activity (7-day Physical Activity Recall) and cardiorespiratory fitness (6-minute walk test). Participants were recruited from 7 diverse sites in the United States and Thailand, and data were analyzed using descriptive statistics and multiple regression to examine the relationship between physical activity and cardiorespiratory fitness.

RESULTS

On average, participants self-reported engaging in 115 minutes of, mostly light (75%), physical activity. Men reported twice the amount of physical activity as women (155 vs 73 minutes, P = .01). Participants' ability to achieve their predicted 6-minute walk test distances was similar between men (68%) and women (69%) (P > .01). For women, vigorous physical activity was associated with a 6.6% increase in cardiorespiratory fitness and being temporarily unemployed was associated with an 18% decline in cardiorespiratory fitness. Cardiorespiratory fitness increased with age (P < .01).

CONCLUSIONS

Weekly physical activity of people living with human immunodeficiency virus averaged 85 minutes of mostly light activity, well below the recommended 150 minutes of moderate activity. Vigorous physical activity was associated with improved cardiorespiratory fitness in women, but not men. Although PLHIV would benefit from interventions to increase physical activity, our data suggest a need to develop sex-specific physical activity strategies.

Physical Function Impairment and Frailty in Middle-Aged People Living With Human Immunodeficiency Virus in the REPRIEVE Trial Ancillary Study PREPARE

BACKGROUND

People with human immunodeficiency virus (PWH) are at risk for accelerated development of physical function impairment and frailty; both associated with increased risk of falls, hospitalizations, and death. Identifying factors associated with physical function impairment and frailty can help target interventions.

METHODS

The REPRIEVE trial enrolled participants 40-75 years of age, receiving stable antiretroviral therapy with CD4+ T-cell count >100 cells/mm3, and with low to moderate cardiovascular disease risk. We conducted a cross-sectional analysis of those concurrently enrolled in the ancillary study PREPARE at enrollment.

RESULTS

Among the 266 participants, the median age was 51 years; 81% were male, and 45% were black, and 28% had hypertension. Body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) was 25 to <30 in 38% and ≥30 in 30%, 33% had a high waist circumference, 89% were physically inactive, 37% (95% confidence interval, 31%, 43%) had physical function impairment (Short Physical Performance Battery score ≤10), and 6% (4%, 9%) were frail and 42% prefrail. In the adjusted analyses, older age, black race, greater BMI, and physical inactivity were associated with physical function impairment; depression and hypertension were associated with frailty or prefrailty.

CONCLUSIONS

Physical function impairment was common among middle-aged PWH; greater BMI and physical inactivity are important modifiable factors that may prevent further decline in physical function with aging.

CLINICAL TRIALS REGISTRATION

NCT02344290.

Pre-frailty predicts cognitive decline at 2-year follow-up in persons living with HIV

Both HIV disease and frailty syndrome are risk factors for neurocognitive impairment. Longitudinal research among individuals of the general population suggests that frailty predicts future cognitive decline; however, there is limited evidence for these longitudinal relationships among people living with HIV (PLWH). The current study evaluated and compared rates of cognitive decline over 2 years among HIV serostatus and frailty status groups. Participants included 50 PLWH and 60 HIV-uninfected (HIV-) participants who were evaluated at baseline and 2-year follow-up visits. Baseline frailty status (non-frail, pre-frail, and frail) was determined using fried frailty phenotype criteria. Neurocognitive functioning was measured using practice-effect corrected scaled scores derived from a comprehensive neuropsychological battery covering seven cognitive domains. Repeated measures analysis was used to estimate rates of global and domain-specific cognitive change from baseline to 2-year follow-up among each of six HIV/frailty status groups. Among PLWH, the pre-frail group demonstrated consistent declines in global cognitive functioning (B = - 0.029, p = 0.034), processing speed (B = - 0.047, p = 0.031), and motor functioning (B = - 0.048, p = 0.038). Among HIV- participants, pre-frail individuals also declined in global cognitive functioning and processing speed (ps ≤ 0.05). HIV- non-frail participants also declined in the cognitive domains of learning, delayed recall, and motor functioning; however, these declines appeared to be driven by relatively higher baseline scores among this group. Notably, 38% of PLWH changed in frailty status from baseline to follow-up, and those with stable pre-frailty demonstrated higher likelihood for cognitive decline; change in depressive symptoms did not relate to change in frailty status. Current findings highlight pre-frailty as an important clinical syndrome that may be predictive of cognitive decline among PLWH. Interventions to prevent or reduce frailty among vulnerable PLWH are needed to maintain optimal cognitive health.

Special Topics in the Care of Older People with HIV

PURPOSE OF REVIEW

Antiretroviral therapy has enabled many people with HIV to live long lives with their infection, but the literature suggests that long term survivors are developing comorbidities and aging-related syndromes at earlier ages than their non-infected counterparts. In addition, there is evidence or sex-based differences in comorbidity risk.

RECENT FINDINGS

How to best care for people aging with HIV is not known, but the tools of comprehensive geriatric assessment can identify people at risk for decline. Newer antiretroviral therapies offer promise of fewer side effects and drug interactions. We will also discuss special needs of women aging with HIV.

SUMMARY

People with HIV and their providers are often unprepared to confront issues of aging, and each clinical program must develop methods to assess older patient and manage age-related complications and syndromes.

Gait Speed Decline Is Associated with Hemoglobin A1C, Neurocognitive Impairment, and Black Race in Persons with HIV

Gait speed declines at a faster rate in persons with HIV (PWH) than in the general population but the risk factors associated with this decline are not well understood. In the AIDS Clinical Trials Group (ACTG) A5322 (HAILO, HIV Infection, Aging, and Immune Function Long-term Observational Study), an observational cohort study of PWH ≥40 years of age, those who developed slow gait during the first 3 years of follow-up were compared with persons who maintained normal speed. Associations with demographic and clinical covariates were assessed using multivariable logistic regression. Of 929 participants, 81% were men, 31% Black, and 20% Hispanic. Median age was 51 years [interquartile range (IQR) = 46-56]. At study entry, 92% had plasma HIV RNA <50 copies/mL with median CD4 count 631 cells/mm³ (IQR = 458-840). At study entry, 7% of participants had slow gait, 16% had neurocognitive impairment (NCI), and 12% had diabetes. Over 3 years, 87% maintained normal gait speed, 3% maintained a slow gait, 6% developed a slow gait, and 4% improved from slow to normal gait speed. In multivariable models, hemoglobin A1C (HbA1C) percentage, per one unit increase [odds ratio (OR) = 1.36; 95% confidence interval (CI) = 1.03-1.81; p = .033], NCI (OR = 3.47; 95% CI = 1.57-7.69 p = .002), and black versus white race (OR = 2.45; 95% CI = 1.08-5.59; p = .032) at entry were significantly associated with development of slow gait compared with those maintaining normal gait speed. The association between baseline HbA1C and development of slow gait speed highlights an intervenable target to prevent progression of physical function limitations.

The Interplay Between Frailty and Intrinsic Capacity in Aging and HIV Infection

In the context of an emerging aging epidemic affecting people living with HIV (PLWH), we critically discuss existing data regarding two different conceptual models of aging-frailty and intrinsic capacity, respectively, both in a clinical and public health perspective. These constructs have not yet been integrated in the general population. Nevertheless, the holistic HIV care, which goes beyond the viro-immunological success, may offer an ideal setting to test a possible integration of these models in older adults living with HIV. We suggest a new framework to assess health in PLWH, shifting from an infectious disease (ID)/internal medicine approach, which includes quality of life in the definition of healthy living with HIV, to an ID/geriatric medicine approach, focused on the maintenance of functional ability in frail and geriatric PLWH.

Improvement in Muscular Strength in HIV-Infected Individuals Receiving Antiretroviral Therapy

PURPOSE

This study investigated (1) the effect of a progressive resistance training (PRT) program and whey protein intake on maximal muscle strength in human immunodeficiency virus (HIV)-infected individuals receiving antiretroviral therapy (ART) and (2) alterations in maximal strength 12 wks after the cessation of PRT with continued supplementation.

METHODS

Sixty HIV-infected individuals were recruited. Whole body PRT was performed twice weekly for 12 wks. Participants received, in a double-blind placebo controlled manner, either 20 g whey or placebo (maltodextrin) before and immediately after each session. Both PRT groups continued to take either whey protein or placebo for a further 12 wks following the exercise intervention to examine the effects of detraining.

RESULTS

Forty participants (mean and standard deviation (SD) age 40.8 (±7.7) years, weight 70.8 (±16) kg, body mass index (BMI) 30.9 (±7.2) kg m2); whey protein /PRT (n = 13), placebo/PRT (n = 17), and a control group (n = 10) completed the study. A significant main effect for time occurred for the bench press (p = 0.02), the squat (p < 0.0001), the deadlift (p = 0.001) and the shoulder press (p = 0.02) one-repetition maximum (1RM) in the intervention groups.

CONCLUSION

The PRT program increased maximal strength regardless of whey protein intake. The detraining period demonstrated minimal strength loss, which is beneficial to this population.

Current Challenges and Solutions in Research and Clinical Care of Older Persons Living with HIV: Findings Presented at the 9th International Workshop on HIV and Aging

In the era of effective antiretroviral therapy, the number of older people with HIV (PWH) is increasing, and those aging with HIV are experiencing an increasing burden of age-associated comorbidities. Life expectancy among older PWH is approaching that of demographically comparable HIV-uninfected (HIV-) adults. With this changing demographic of PWH come new challenges for researchers and clinicians in how to identify, address, and manage the complex interplay of treated HIV infection and aging-associated factors. In response to these challenges, the annual International Workshop on HIV and Aging was initiated in 2009 as a multidisciplinary platform for scientific discourse on the research and clinical complications arising from the aging population of PWH. The multidisciplinary nature of the workshop has resulted in a wide range of topics addressed over the past 9 years, from basic mechanisms in aging and HIV pathogenesis, to epidemiology of aging within large cohorts, interventions, and implementation of clinical programs. Herein, we summarize the key topics discussed at the 9th Annual International Workshop on HIV and Aging 2018, including "inflammaging," mitochondrial dysfunction, exercise interventions, HIV-associated neurocognitive impairment, metabolic dysfunction, menopause, and polypharmacy. In addition to recent developments in research and clinical care, we discuss open questions and future research directions required to better understand the interaction of HIV and aging.

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.

High prevalence of insulin resistance and occurrence prior to hyperinsulinemia threshold among people living with HIV in Pune, India

BACKGROUND

Diabetes prevalence in HIV is not well characterized for India, despite the high burden of both individual diseases. Epidemiology of insulin resistance (IR): a precursor to diabetes, and its associated risk factors are also poorly understood in Asian Indian people living with HIV (PLHIV). We assessed the prevalence of diabetes and IR in Pune, India and the associated risk factors for IR.

METHODS

Cross-sectional analysis of adult (≥18 years) PLHIV receiving care at Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospitals, Pune, India (BJGMC- SGH). Proportions and medians of PLHIV characteristics by diabetes status and IR were described. Homeostatic Model Assessment (HOMA) index value ≥2 was used to define IR. Line of least squares assessed the relationship between IR and hyperinsulinemia. Association between sociodemographic, clinical factors with IR was determined using logistic regression.

RESULTS

Of 485 enrollees, 47% were men, median age was 40 years (IQR: 35-46), median CD4 counts were 389 cells/mm³ (246-609). Thirty-five percent were centrally obese, 75% were adherent to WHO recommended physical activity guidelines. Prevalence of diabetes, prediabetes, IR were 9%, 16% and 38%, respectively. Twenty-nine percent non-diabetics had IR and it occurred much prior to the threshold for hyperinsulinemia. IR was associated with the use of ART drugs (OR: 6.6, 95% CI: 2.9-15.2 and 5.4, 95% CI: 2.2-13.6 for first- and second line ART respectively) and central obesity (OR:1.9, 95% CI: 1.1-3.4).

CONCLUSIONS

One fourth of the study population was diabetic or prediabetic and more than a third had IR. Better understanding of diabetes disease progression in relation to IR and the effect of physical activity on central obesity among Asian Indian PLHIV is mandated.