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Table 2 Outcomes and Author’s Conclusions of Individual Studies Included in the Aerobic Exercise and HIV Systematic Review

From: Effectiveness of aerobic exercise for adults living with HIV: systematic review and meta-analysis using the Cochrane Collaboration protocol

Study

Immunological/Virological

Cardiorespiratory

Strength

Weight and Body Composition

Psychological

Adverse Events

Authors’ Conclusions

Agostini (2009)a [34]

Not assessed

Not assessed

Not assessed

Body Fat: Decrease in abdominal fat was similar in both groups. There did not appear to be a significant difference between groups.

Not assessed

Not reported

Aerobic exercise and a balanced diet are key pillars in the non-pharmacological treatment of lipodystrophy.

Baigis (2002) [50]

CD4 count: No significant changes.

VO2max: No significant differences between exercisers versus non-exercisers. Results were attributed to the level of intensity and duration of exercise.

Not assessed

Not assessed

Health-related quality of life: Non-significant trend favouring exercisers compared to non-exercisers in HRQL. Significant improvement in overall health subscale of the MOS-HIV found among exercisers compared to non-exercisers.

Not reported

Exercise appeared to be safe in HIV-infected individuals.

Balasubramanyam (2011)a [33]

CD4 count and viral load: No significant differences between groups.

No significant difference between groups for VCO2, VO2, respiratory quotient, resting energy expenditure.

Not assessed

Weight: No statistically significant difference between groups.

Body composition: No significant difference between groups for body mass index (kg/m2), waist circumference, hip circumference, waist to hip ratio, body cell mass, fat mass (kg) and body fat (%). As intended in the Diet and Exercise (weight maintaining lifestyle intervention), there were no significant changes within groups or between groups in weight or BMI.

Not assessed

Adverse events were reported in both groups. Exercise Group: 24 adverse events reported in at least 1 % of participants ranging from (but not limited to) events such as diarrhea, nausea and vomiting, fatigue, dizziness, and headache. Recommendation Group: 20 adverse events reported in at least 1 % of participants ranging from (but not limited to) events such as: triglyceride >1000 mg/dl, elevated bilirubin, abdominal pain.

The combination of niacin and fenofibrate together with diet and exercise (D/E) is more effective than lifestyle change alone or drug monotherapy with lifestyle change in improving HIV associated dyslipidemia. Diet and Exercise intervention alone did not improve lipid levels or adiponectin or induce statistically significant changes in any of the secondary (body composition) outcomes.

Dolan (2006) [51]

CD4 count and viral load: No significant changes.

6MWT: Significant improvements in exercise time as measured by submaximal exercise time and 6MWT distance among exercisers compared with non-exercisers.

VO2max: Significant improvements among exercisers compared with non-exercisers.

Significant improvements in upper and lower extremity strength (7 measures) among exercisers compared with non-exercisers.

Weight: No significant change between groups.

Body Composition: Significant increase in total cross-sectional muscle area and muscle attenuation among exercisers compared with non-exercisers. Significant decrease in waist circumference among exercisers compared with non-exercisers. No significant difference between group for body mass index, abdominal visceral tissue area, subcutaneous adipose tissue area, and total fat.

Not assessed

Authors reported 1 participant who had an exacerbation of asthma, and 1 participant had chest pain but neither were related to exercise.

A 16 week supervised home based PRE and aerobic exercise program improves measures of strength, cardiorespiratory fitness, and body composition among women living with HIV.

Driscoll (2004a) [44]

CD4 count and viral load: No significant changes.

Exercise Time: Significant improvements in endurance time on cycle ergometer during submaximal stress test in the exercise and metformin group compared with the metformin only group.

Significant increases in upper and lower extremity strength (five of six indices) in the exercise and metformin group compared with the metformin only group.

Weight: No significant changes in either group.

Body Composition:

Significant increases in cross-sectional muscle area, and significant decreases in waist-to-hip ratio and abdominal fat area in the exercise and metformin group compared with the metformin only group. No significant changes in body mass index in either group.

Not assessed

None reported

Exercise training and metformin significantly improve cardiovascular outcomes more than metformin alone in persons living with HIV with fat redistribution and hyperinsulinemia. Exercise training (aerobic and PRE) is well-tolerated and improves muscle strength and size as well as aerobic fitness in persons living with HIV.

Farinatti (2010)a [32]

CD4 count: No significant changes in Cd4 count or CD4 % within or between groups.

Significant improvements within exercisers and significantly greater improvements among exercisers compared with non-exercisers (slope and intercept for HR-workload).

Significant improvement within exercisers and significantly greater improvements in leg press (12-RM) and seated row (12-RM) among exercisers compared with non-exercisers.

Weight: Not assessed

Body Composition: No significant difference within or between groups for body mass index (kg/mg) or body mass (kg).

Not assessed

No adverse events.

HIV infected patients treated with HAART improve their strength and aerobic fitness as a result of a supervised exercise program of aerobic, strength and flexibility exercises with no negative effect on immune function.

Fitch (2012)a [31]

CD4 count and viral load: No significant differences between groups.

VO2max and Endurance Time: Improvements in exercisers compared with non exercisers. No significant effect of metformin on cardiopulmonary measures. Significantly greater improvement in VO2max among the combined Metformin + Exercise group versus the control group. (p = 0.05). Significantly greater improvement in exercise duration (min) among the exercising groups (EXERCISE only group) and (EXERCISE + METFORMIN group) versus control. Significantly greater increase in exercise duration among the EXERCISE only group versus METFORMIN only group. (p = 0.006).

Exercise was associated with improvements in all strength parameters (p < 0.01) compared with non-exercisers. Significantly greater improvement in triceps strength, knee flexor strength, lat pull down, knee extension strength, chest press, leg press, among the exercising groups (EXERCISE only group) and (EXERCISE + METFORMIN group) versus control. Significantly greater increase in triceps strength, knee flexor strength, lat pull down, knee extension strength, chest press, leg press, among the EXERCISE only group versus METFORMIN only group.

Weight: Not assessed

Body Composition: Intramyocellular lipid (IMCL) improved in exercisers compared to non-exercisers. Visceral adipose tissue decreased in participants randomized to metformin only versus control, although this was not significant. Extremity fat did not change significantly in response to exercise or metformin.

Significant between group difference between the exercise and control groups (p < 0.05) whereby the exercise group had greater reduction in tibialis anterior intramyocellular lipid (IMCL) compared with control. Significant difference between the exercise and metformin only group whereby the exercise group had a greater reduction in tibialis anterior IMCL compared with the metformin only group. Assuming that reduction in cellular lipid is a good outcome this suggests exercise had a beneficial effect beyond control and metformin only for reducing cellular lipid. No significant difference between groups for change in body mass index (kg/m2), visceral adipose tissue (cm2), subcutaneous adipose tissue (cm2), total extremity fat (kg), and waist circumference (cm).

Not assessed

Two participants in the EXERCISE group experienced muscle strains related to the resistance training necessitating modification of weights. There were no serious adverse events and the exercise program was well-tolerated.

Metformin participants demonstrated significantly less progression of coronary artery calcification (CAC) whereas the effect of exercise on CAC progression was not significant. Metformin had a significantly greater effect on CAC than exercise.

Exercise participants showed significant improvement in HDL, and cardiorespiratory fitness compared to non-exercisers. Metformin prevents plaque progression in HIV infected individuals with metabolic syndrome. Exercise demonstrates improvements in cardiopulmonary fitness and strength.

Grinspoon (2000) [42]

CD4 count and viral load: No significant changes with exercise or testosterone therapy either alone or together as a co-intervention.

Not assessed

No significant change in strength (note strength was tested isometrically, which may underestimate change in strength).

Weight: No significant changes in either group.

Body Composition: Participants in the exercise only group showed significant increases in lean body mass, arm muscle area, leg muscle area, HDL cholesterol and significant decreases in AST level compared to non-exercising control group. No significant changes in and fat mass in either the exercisers or non-exercising control group.

Not assessed

No deaths or adverse events.

Exercise has a significant effect on lean body mass and muscle area independent of testosterone. Muscle mass and strength may further increase in response to combined exercise and testosterone therapy. Exercise was associated with an increase in HDL cholesterol whereas testosterone decreased HDL cholesterol. Exercise significantly increases muscle mass and offers cardio protective effects by increasing the HDL cholesterol in men with AIDS wasting. Exercise may be a strategy to reverse muscle loss in this population.

LaPerriere (1990) [35, 36]

CD4 count: Exercisers showed increase in CD4 count. Non-exercising control group showed decrease in CD4 count.

VO2max: No change in V02 max in non-exercising controls. Improvements in fitness level averaged 10 % change in VO2 max in both seronegative and seropositive exercisers.

Not assessed

Not assessed

Depression-Dejection Symptoms: Seropositive non-exercising controls showed significantly larger increases in anxiety and depression than intervention groups as measured by the tension-anxiety subscale and depression-dejection subscale of the profile of mood state (POMS) scale.

Not reported

Aerobic exercise is a beneficial stress management intervention which may be a useful strategy for attenuating an acute stressor such as post-notification of HIV status.

Lindegaard (2008)a [30]

Not reported

VO2max: Significant increase in VO2max by 14.4 % in the aerobic group with no difference in the PRE group. Greater improvement in VO2max in the AEROBIC group versus the PRE group.

Significant increase in strength by 30 % in the PRE group and by 7.8 % in the aerobic group. The increase was more pronounced after strength training than after aerobic training.

Weight and Body Composition: PRE group had significant decrease in body weight, increase in lean body mass, decreased total fat and limb fat mass whereas the AEROBIC group demonstrated no changes in these outcomes.

Not assessed

Not reported

Strength training and endurance training improved insulin mediated glucose uptake but only in the PRE group and not AEROBIC group and caused a reduction in total fat mass. In conclusion, both AEROBIC and PRE training increases insulin sensitivity in HIV-infected patients with lipodystrophy whereas only strength training reduces trunk fat mass. Authors suggest an appropriate exercise program should include PRE and AER training to reduce the risk of cardiovascular disease among people with lipodystrophy.

Lox (1995) [38]

CD4 count and viral load: No significant changes.

VO2max: Significant improvements among exercisers compared to non-exercisers with greater improvements in the aerobic compared to the PRE and non-exercising control groups.

Heart Rate: Non-significant decrease in submaximum HR in the PRE group compared to a non-significant increase in the non-exercising control group.

Significant improvements in the PRE and aerobic exercise groups compared to the non-exercising control groups. Significantly greater improvements as measured by 1-RM in the PRE group compared to the aerobic and non-exercising control groups.

Body Weight: Significant increases in weight among PRE and aerobic exercise groups.

Body Composition: No change among all 3 groups in average body mass index, fat mass, and body fat percentage. Significant increases in lean body mass and sum of chest, arm and thigh circumference among PRE and aerobic exercise groups.

Significant improvements in mood and life satisfaction in both the aerobic and PRE exercise groups compared to the non-exercising control group. Significantly higher life satisfaction in the aerobic group compared with the PRE group.

Not reported

Exercise results in improvements in body composition, strength, cardiopulmonary fitness, and mood and life satisfaction for people living with HIV.

MacArthur (1993) [53]

CD4 count: No significant changes.

The high intensity exercise group may have obtained a greater training effect than the low-intensity group (not significant).

Significant increases in compliant exercisers (n = 6) for V02 max (24 %), minute ventilation (13 %), and oxygen pulse (24 %).

At 12 weeks HR rate pressure product and RPE all decreased significantly in a group of 10 participants.

Not assessed

Not assessed

General health questionnaire scores improved for the 6 compliant participants.

No detrimental hematologic or immunologic effects were noted. One participant in the somewhat compliant group and 3 participants in the non-compliant group died prior to the end of 24 week study (deaths were not attributed to the intervention).

Exercise training is feasible and beneficial for moderate to severely immunocompromised HIV-infected individuals.

Maharaj (2011)a [29]

Not assessed

Not assessed

Not assessed

Not assessed

Quality of Life: Physical and mental health component summary scores of the SF36 questionnaire improved significantly from baseline in the exercise group compared with the non-exercising control group.

Authors reported that all SF36 domain scores improved significantly greater for the exercise group compared with the control group (general health, mental health, role physical, role emotional, pain, physical functioning, social functioning, and energy).

None of the participants showed any adverse effects on their clinical status of CD4 counts, viral load, or increase in opportunistic infections, heart, respiratory and blood pressure either during or after the exercises.

Results support the positive benefits of a rehabilitation program of moderate intensity and home program of exercises for patients on HAART. Results show a significant increase in all domains of quality of life with a possible achievement of an increase in the function and participation of ADLs.

Mutimura (2008a) [45]

CD4 count: No significant differences between groups.

Exercise group achieved a higher heart rate and rate of perceived exertion (RPE) at the end of the 20 m multi-stage shuttle run test (20mMST).

V02max: Significant improvements among exercisers compared with non-exercisers as measured by the 20mMST.

Not assessed

Weight: Not assessed

Body Composition: Significant decrease in body mass index (BMI), percent body fat mas (BFM), waist circumference, and waist-to-hip ratio among exercisers whereas these outcomes remained unchanged or increased among non-exercisers.

Significant decrease in sum of skim folds, and percent body fat mass (%) and total body fat redistribution score (BFR) among exercisers compared with non-exercisers.

Significant decrease in triceps, biceps, subscapular, suprailiac, and sum of skinfold thickness decreased more in the exercisers compared with non-exercisers. No change in hip circumference in either group.

Quality of Life: Significant improvements in quality of life (QOL) on the psychological, independence, social relationships, HIV+ HAART-specific domains of QOL, and overall QOL score as measured by the World Health Organization Quality of Life HIV Instrument (WHOQOL-BREF) for exercisers compared with non-exercisers.

No difference between groups on the physical QOL domain score.

Not reported

Exercise training positively improves body composition, cardiorespiratory fitness and several components of QOL in HAART-treated HIV+ African participants with Body Fat Redistribution. Results imply that exercise training is a safe, inexpensive, practical and effective treatment for evolving metabolic and cardiovascular syndromes associated with HIV and HAART exposure in resource-limited settings such as Su-Saharan Africa.

Ogalha (2011)a [28]

CD4 count: Significant improvement in CD4 count in both groups.

VO2max: ‘Marginally’ significant (p = 0.05) improvement in VO2max for exercisers only.

Statistically significant improvement (reduction) in resting heart rate in the exercise group only (within group difference).

Not assessed

Weight: No significant within or between group differences for body weight.

Body Composition: Statistically significant improvement in muscle mass, resting heart rate, body fat percent, hip circumference (decrease) among the exercisers (within group difference only). Statistically significant improvement in BMI, and hip circumference (decrease) among the control group (within group difference). No significant difference within or between groups for waist circumference or waist to hip ratio.

Quality of Life: All SF36 domain scores improved significantly similarly for all domains in both groups except for the pain domain (whereby the control group was the only group to show significant improvement). Improvements in QOL were significantly greater for the exercise group compared with the control group for general health, vitality, and mental health.

None reported

Regular exercise coupled with nutritional guidance in people living with HIV significantly improves quality of life. Main findings suggest that the intervention promoted significant modifications in increase in muscle mass and reduction in fasting glucose, BMI, body fat, and hip circumference.

Perez-Moreno (2007)a [27]

CD4 count: Significant increase in CD4 count among exercisers (within group only).

Statistically significant improvement in peak workload (Watts) among exercisers whereas there was a significant decrease (worsening) in the control group.

HRmax: Significant improvement in heart rate peak (bpm) among exercisers. A significant combined effect of group and time was found for peak-completed workload (W), HRpeak, and rate of HR decrease at 1-min post exercise compared to attained HRpeak among exercisers.

Significant improvement among exercisers for strength whereas no change among non-exercisers.

Significant improvement in the upper and lower body dynamic strength endurance (6RM) among exercisers (bench press, knee extensor strength) compared with non-exercisers.

Body Composition: No significant changes within groups for body mass. Mean estimated muscle mass significantly increased in the exercise group (within group only) with no change in the control group.

Quality of Life: Statistically significant improvement in QOL as measured by the QOL Assessment with a Scale from Spain in the exercise group (p < 0.01) whereas no change occurred in the control group.

No major adverse effects and no major health problems were noted in the participants from both groups over the training period.

A combination of cardiorespiratory and resistance training produces significant gains in cardiorespiratory capacity and dynamic strength endurance of incarcerated men who are HIV-HepC co-infected and enrolled in a methadone maintenance program for the treatment of opioid dependency.

Perna (1999) [48]

CD4 count: Adherent exercisers (attending >50 % of exercise sessions) increased CD4 count by 13 % whereas non-adherent exercisers decreased CD4 count by 18 %. Control participants showed a decreasing trend of CD4 count by 10 %.

VO2max and other Cardiopulmonary Outcomes: Significant increase in V02 max (12 %), 02 pulse (13 %), maximum tidal volume (8 %), and minute ventilation (VE) (17 %) among adherence exercisers. No significant differences were found in non-adherent exercisers and non-exercising control groups.

Significant increase in leg power by 25 % adherent exercisers and no change in non-adherent exercisers or non-exercising controls.

Weight: Not assessed

Body Composition: Significant increase in body mass index among adherent exercisers.

Physician-Rated Health Status: No significant differences were noted of physician-rated health status (note this outcome was not considered a true measure of psychological status because it was not completed by patient self-report).

One hospitalization was reported during the course of the study.

Aerobic exercise may significantly increase CD4 count among symptomatic HIV+ individuals.

Rigsby (1992) [47]

CD4 count: No significant changes.

Aerobic Capacity: Significant increases in aerobic capacity were shown in the exercise group with no change in non-exercising control group.

Heart Rate and Total Time to Voluntary Exhaustion: Significant decreases in HR and increases in total time exercise to voluntary exhaustion

Significant increases in chest press and leg extension in the exercise group.

Not assessed

Not assessed

One death reported in the counselling group during the course of the study and one death one month after the study. Of the 4 participants who dropped out of the exercise group, one died immediately after the study conclusion.

HIV+ men can experience significant increases in neuromuscular strength and cardiorespiratory fitness when prescribed and monitored in accordance with ACSM guidelines for healthy adults. Increased fitness may occur without negative effects on immune status.

Smith (2001) [40]

CD4 count and Viral Load: No significant changes in CD4 cell count, CD4+ percentage, and viral load in either group.

Fatigue: Significant decrease in exercisers compared with non-exercisers as exercisers were able to stay on the treadmill 1 min longer compared to non-exercising control group (significant decrease in fatigue).

Rate of Perceived Exertion (RPE): No significant effect on RPE or FEV1 in either group (dyspnea). Significant improvements in V02max in the experimental group (2.6 ml/kg per min) compared with the non-exercising control group (1.0 ml/kg per min).

Not assessed

Body Weight: Exercise group showed significant decreasing trends in weight.

Body Composition: Significant decrease in waist-to-hip ratio among exercisers (note many participants were above ideal body weight prior to exercise; thus decreases in both weight and body composition were considered favourable outcomes).

Exercise group showed significant decreasing trends in BMI, triceps, central and peripheral skin folds, abdominal girth and waist-to-hip ratio.

Depression: Significant improvements in Centre for Epidemiological Studies Depression Scale (CES-D), Profile of Mood State and Depression-dejection subscale of POMS scale, and non-significant trend to improvement in Beck Depression Inventory in the exercise group compared to non-exercising control group (reported in Neidig 2003).

No adverse events reported

Supervised aerobic exercise training safely decreases fatigue, weight, BMI, subcutaneous fat and central fat in HIV-infected individuals. [Neidig 2003]: Exercisers showed reductions in depressive symptoms.

Stringer (1998) [49]

CD4 count and Viral Load: No significant changes in all three groups.

Aerobic Capacity: An intensity-related aerobic training effect was seen (heavy > moderate) relative to the non-exercising control group.

VO2max and Work Rate Max and Lactic Acid Threshold: Significant increases in V02 max and Work Rate max in the heavy exercise group. LAT increased significantly in both intervention groups.

Not assessed

Not assessed

Quality of Life: Significant improvements in both exercise groups on the QOL questionnaire relative to the non-exercising control group. No significant differences in QOL between the two intervention groups.

No adverse events reported

Exercise training resulted in a substantial improvement in aerobic function (heavy > moderate group) while immune indices were essentially unchanged. QOL markers improved significantly with exercise. Exercise training is safe and effective in this group and should be promoted for HIV+ individuals.

Terry (1999) [54]

CD4 count: No significant changes.

HRMax: Peak HR was unchanged for both groups; peak systolic BP increased significantly only in high intensity group.

Not assessed

Body Composition: No significant change in body mass, body fat percentage, and body density in either intensity exercise group.

Depression: No significant changes detected in depression scores of the Montgomery-Asberg Depression Scale.

Not reported

HIV+ individuals can increase fitness levels with aerobic exercise at a range of intensities. HIV+ individuals can obtain cardiorespiratory benefits of exercise similar to seronegative individuals. Moderate exercise was not associated with an improvement in immunologic markers. High intensity had no shown harmful effects. Short term aerobic exercise programs may be safely recommended to HIV+ individuals for improvement in functional capacity.

Terry (2006) [52]

CD4 count and Viral Load: No significant changes.

VO2max: Significant improvements in exercise capacity as measured by VO2max on the maximal treadmill test for the combined exercise and diet group and no change seen in the diet only group.

HRmax: No significant changes in either group.

Not assessed

Body Weight: Significant decreases in weight in both groups.

Body Composition: Significant decreases in body mass index, waist-to-hip ratio, and percentage of body fat in both groups. Significant increases in body density in both groups. No difference between groups.

Not assessed

No participants withdrew from the study due to infection or illness.

HIV positive adults with hyperlipidemia, when engage in 3 months of aerobic exercise and a low lipid diet do not experience significant changes in triglycerides, total cholesterol, or HDL cholesterol levels (not shown here) but they do improve functional exercise capacity.

Tiozzo (2011) [26]a

CD4 count and Viral Load: Significant decrease in CD4 count among non-exercisers (control group) whereas CD4 count remained the same in the exercise group. Exercisers had significantly greater CD4 count at study completion compared with non-exercisers. No significant changes in viral load in either group.

VO2max: Significant increase (improvement) in VO2max compared with non-exercisers.

HRmax: No difference in heart rate or diastolic blood pressure within or between groups. Significant difference between groups at baseline for systolic blood pressure - the exercise group had lower systolic blood pressure at baseline but at study completion the control group had significantly lowered their systolic blood pressure.

Significant difference within exercisers who demonstrated an increase in 1RM chest and 1 RM legs whereas there was no change in the control group. Significantly greater improvement in 1RM chest among exercisers compared with control.

Body Weight: No significant changes.

Body Composition: No significant changes in hip circumference or waist-to-hip ratio in either the exercise or control group. Significant reduction in waist circumference among exercisers whereas the non-exercisers waist circumference increased.

Quality of Life: Exercisers had significant improvements in SF36 physical function sub scale and mental health sub scale, compared with non-exercisers who demonstrated a significant worsening from baseline.

Not reported

A three month supervised, and moderate intensity cardiorespiratory and resistance exercise training program performed three times a week, can result in significant improvements in physical characteristics and physical fitness and QOL among people living with HIV.

Yarasheski (2011)a [25]

CD4 count and Viral Load: No significant changes.

Not assessed

Not assessed

Body Composition: Significant increase in thigh muscle area among exercisers compared with non-exercisers (within and between group difference) and non-exercisers had a decrease in thigh muscle area.

No other significant within or between group differences in other body composition outcomes: body mass index, fat mass, fat free mass, trunk fat mass, limb fat mass, visceral adipose tissue, abdominal adipose tissue, right and left thigh subcutaneous fat, total hip bone mineral density, lumbar spine bone mineral density, hip or lumbar z-score.

Not assessed

No serious adverse events or complications reported

Overall, combined exercise intervention for diabetes prevention that includes diet and exercise is more effective than medication interventions alone.

  1. HRQL health-related quality of life, QOL quality of life, MOS-HIV Medical Outcomes Study HIV Scale, VO2max maximum oxygen consumption, 6MWT 6 min walk test, BMI body mass index
  2. astudy included in this recent update of the systematic review