Exercise for People Living with HIV

Introduction[edit | edit source]

Since the introduction of antiviral therapy, the prognosis of people living with Human Immunodeficiency Virus (HIV) has greatly improved[1][2]. This has however led to new challenges relating to the chronicity of HIV with the associated long term effects of the disease and the side-effects of antiretroviral therapy (ART).

Regular physical activity and exercise are part of a healthy lifestyle for everyone, including people living with HIV (PLWH)[3]. In 2020, the World Health Organisation (WHO) released revised physical activity recommendations, with additional considerations for people with chronic conditions, including HIV [4]. These recommendations made it clear that exercise is safe and beneficial for PLWH.

Considerations for People Living with HIV[edit | edit source]

PLWH may have a variety of psychological and physiological symptoms associated with the virus itself, the related medications, or a combination of both[1]. Due to these factors, there is need for special considerations when it comes to physical activity and exercise. PLWH often present with significant reductions in their general well-being and overall quality of life, with an interplay of various complex factors contributing to this.

Health considerations and risks[edit | edit source]

People living with HIV may exhibit various physiological and psychological changes with negative health and functional implications. Some of these changes include:

  • Increased blood lipids, central fat accumulation, lipodystrophy, lipoatrophy[1][5]
  • Decreased aerobic capacity[1]
  • Chronic inflammation[2]
  • Headaches, fatigue, nausea[1][2]
  • Pain - often inflammatory or neuropathic
  • Increased cardiovascular risk factors[2]
    • Exercise-induced pulmonary hypertension: People with HIV infection are at risk of developing pulmonary arterial hypertension (PAH), which can be fatal. Exercise-induced pulmonary hypertension could be the first clinical sign of PAH. This is often tested with stress echocardiogram, and might require special exercise considerations [6].
  • Depression and anxiety[1]
  • Impaired glucose tolerance[1]
  • Impaired activity and social participation[7]

These signs and symptoms are as a result of the multi-systemic changes associated with the virus itself, or ART medication, or both[8]. For more detailed information, read the following pages:

Barriers to Exercise[edit | edit source]

Long-term sustainability, mostly influenced by poor adherence, remains a challenge in exercise interventions for PLWH[2]. Some of the barriers that influence adherence in PLWH include:

  • Social factors: Time constraints, family responsibilities, financial resources, lack of support[2]
  • Behavioural factors: Sedentary habits[2]
  • Personal factors: Stress, lack of motivation, negative physical self-perception, fear of aggravating pain, weakness of the muscles[2][8]
  • Clinical factors: Fatigue, clinical instability[2], impaired physical capacity[9]
  • Environmental factors: Living in unsafe environments, unavailability of leisure spaces[2]

Acknowledgement of these barriers, along with creative solutions to overcome them, may play an important role in ensuring continued engagement in regular physical activity for sustained health benefits.

WHO guidelines[edit | edit source]

People living with HIV can do the same types of physical activity and exercise as individuals who do not have HIV. The WHO guidelines recommends that PLWH should engage in regular physical activity, because:

  • It can improve physical fitness and mental health.
  • It does not have any negative effects on CD-4 counts or body composition [4].

It is recommended that PLWH should:

  • Do at least 150-300min of moderate-intensity aerobic physical activity OR 75-150min of vigorous-intensity aerobic physical activity per week [4].
  • Also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups, 2 or more days per week [4].
  • When not contra-indicated, increase moderate-intensity aerobic physical activity to more than 300min, or vigorous physical activity to more than 150min[4].
  • Older adults should also engage with weekly functional balance and strength training 3 days per week, to prevent falls and improved functional capacity[4].
  • When these guidelines can't be met, PLWH should aim to engage with physical activity to the best of their abilities and follow a process of gradual introduction as health status and capacity allow [4].
  • The WHO also emphasises that the above guidelines are not applicable when undergoing acute treatment, if any contra-indications are present or when not medically stable [10].
WHO physical activity guidelines[11]

Click here to access the booklet: WHO guidelines booklet

Benefits of Physical Activity[edit | edit source]

Psychological benefits[edit | edit source]

Mental Health

A systematic review by Ibeneme et al. (2022), found strong evidence that physical exercise significantly reduces depression in PLWH[8]. Of particular interest is one RCT that was conducted in a low- or liddle-income country (LMIC), found significant reductions in depression and anxiety after a mere 4-week supervised basic aerobic exercise intervention. See Mental Health Interventions for PLWH.

Quality of Life

A recent systematic review[7] found strong evidence that combined aerobic and resistance exercise improves health related quality of life (HRQoL) in PLWH.

A recent RCT[9] investigated the effect of aerobic exercise on the quality of life in people with HIV-associated neurocognitive disorder (HAND), and found significant improvements. These improvements were however not maintained with discontinuation of exercise.

Improved self-efficacy

A 4-week physiotherapist-supervised aerobic exercise program performed in a LMIC resulted in significant improvements in self-efficacy[12]. Earlier studies, with more long term interventions, also indicated positive effects on self-efficacy[13].

Social Engagement

A systematic review by Ibeneme et al. (2022), reported significant improvements in social participation after exercise interventions - This was found particularly in interventions that included a combination of aerobic and strengthening exercises[8].

Cardiorespiratory benefits[edit | edit source]

  • Improved aerobic capacity[14] [7] - combined aerobic and resistance exercises are the most effective in improving maximal oxygen consumption (VO2 max)
  • Improved lung function [14]

Haemodynamic effects[edit | edit source]

Regular exercise can also reduce the risk of cardiovascular disease, high blood pressure and type 2 diabetes by altering blood lipid profiles and insulin resistance[2]

Immunological effects[edit | edit source]

Cluster of Differentiation 4 (CD4) count

  • The evidence regarding the effect of exercise on CD4 is not yet conclusive. One systematic review by Zanetti et al (2021) found that resistance training can improve CD4 counts[15], while another systematic review found no significant improvements[14].
  • Although the benefits remain uncertain, the evidence is clear on the fact that exercise does not have an adverse effect on CD4 counts


  • PLWH often have elevated cytokine/inflammatory markers, and exercise has been shown to reduce the levels of various cytokines (IL-5, IL-8, IL-10) in those infected with HIV under ART[7].

Physical benefits[edit | edit source]

  • Maintains or builds muscle mass, with improved muscular strength[15]
  • Improved body composition and body weight[15]- such outcomes do however need to be viewed with caution in PLWH on ART, as reduced body fat might be as a result of lipoatrophy associated with ARV toxicity, rather than being a direct result of exercise[2].
  • Improved bone mineral density[16]
  • Exercise is associated with a trend of improved physical activity levels, but the evidence is still lacking[8]. Exercise can at the very least prevent deterioration of physical activity levels.

Improved ART adherence[edit | edit source]

A systematic review conducted by SantaBarbara et al. (2022), found a significant positive relationship between exercise and ART adherence[2]. This could be explained by the ability of exercise to reduce depressive symptoms, as well as potential reduction in the negative symptoms associated with treatment-related side effects [3]. Improved adherence can in turn result in improvements in other health outcomes[8].

Types of Exercise[edit | edit source]


The type of aerobic exercise use in research studies vary. No one form of aerobic exercise has been shown to be more beneficial than another. Since adherence can be a significant barrier, it may therefore be most important to consider practicality, resources and enjoyment when choosing aerobic exercises. Examples of exercise strategies:

  • Stationary cycling
  • Treadmill walking/running
  • Light jogging or brisk walking
  • Jogging on the spot or jumping jacks

Strengthening and resistance training

In most studies this involved the use of gym equipment/machines. In low resource setting the use of weights and resistance bands would be more feasible, but evidence of effectiveness is lacking.

Balance and functional strengthening

Yoga as a form of exercise for PLWH has been investigated in various studies[7] and resulted in benefits relating to aerobic capacity and HRQoL. Balance training is especially important for elderly PLWH, and specific functional exercises can be included for all PLWH based on individual goals.

Frequency and Type of Exercise[edit | edit source]

The frequency and intensity of prescribed exercises in studies vary, but the following can be used as a guideline:

  • Type of exercise: Aerobic or resistance exercise alone result in significant benefits; a combination of aerobic and resistance exercise might result in a wider range of/compounded benefits[7]
  • Frequency: 40-60min, 2-3times per week, for 6-24 weeks[8]
  • Intensity: 50-85% of max HR for aerobic exercises, 60-80% of 1RM 3 sets of 8-10 repetitions for strengthening exercises[2]

Low-resource settings[edit | edit source]

HIV is most prevalent in low- and middle income countries. The WHO (African Region), reported that in 2018, almost two thirds of the global total of new HIV infections occur in Africa[17]. Despite this, most of the current literature on exercise for PLWH is based on research studies conducted in high-income settings. Many studies use gym equipment and stationary bicycles for the exercise regimes, which is not feasible in LMICs. Home based interventions could present a possible solution to address adherence and resource constraints in these settings[2].

The high infectious disease risk and other social determinants of health in LMICs, could also change the average baseline health status and abilities of PLWH. It is possible that exercise could have even more dramatic benefits in LMICs, but affordable and health-appropriate exercise interventions will need to be considered.

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Jaggers JR, Hand GA. Health Benefits of Exercise for People Living With HIV: A Review of the Literature. Am J Lifestyle Med. 2014;10(3):184-192. Published 2014 Jun 16. doi:10.1177/1559827614538750
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 Dos Santos EC, de Lima LR, Yoong S, Guerra PH, Segurado AC. Home-based interventions to promote physical activity for people living with HIV–a systematic review. AIDS care. 2022 Jun 23:1-0.
  3. 3.0 3.1 MHAF. Exercise and Physical Activity. Available from: .https://www.hiv.gov/hiv-basics/living-well-with-hiv/taking-care-of-yourself/exercise-and-physical-activity (updated 28 April 2022)
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Dempsey, P. C., Friedenreich, C. M., Leitzmann, M. F., Buman, M. P., Lambert, E., Willumsen, J., & Bull, F. (2021). Global public health guidelines on physical activity and sedentary behavior for people living with chronic conditions: A call to action. Journal of Physical Activity and Health, 18(1), 76–85. https://doi.org/10.1123/JPAH.2020-0525
  5. Hand GA, Lyerly GW, Jaggers JR, Dudgeon WD. Impact of Aerobic and Resistance Exercise on the Health of HIV-Infected Persons. Am J Lifestyle Med. 2009;3(6):489-499.
  6. Madonna R, Fabiani S, Morganti R, Forniti A, Mazzola M, Menichetti F, De Caterina R. Exercise-induced pulmonary hypertension in HIV patients: Association with poor clinical and immunological status. Vascular Pharmacology. 2021 Aug 1;139:106888.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 Gomes-Neto M, Saquetto MB, Alves IG, Martinez BP, Vieira JP, Brites C. Effects of exercise interventions on aerobic capacity and health-related quality of life in people living with HIV/AIDS: Systematic review and network meta-analysis. Physical therapy. 2021 Jul;101(7):pzab092.
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 Ibeneme SC, Uwakwe VC, Myezwa H, Irem FO, Ezenwankwo FE, Ajidahun TA, Ezuma AD, Okonkwo UP, Fortwengel G. Impact of exercise training on symptoms of depression, physical activity level and social participation in people living with HIV/AIDS: a systematic review and meta-analysis. BMC Infectious Diseases. 2022 Dec;22(1):1-25.
  9. 9.0 9.1 Nweke M, Nombeko M, Govender N, Akinpelu AO, Ogunniyi A. Effects of aerobic exercise on quality of life of people with HIV-associated neurocognitive disorder on antiretroviral therapy: a randomised controlled trial. BMC Infectious Diseases. 2022 Dec;22(1):1-1.
  10. WHO Guidelines on Physical Activity and Sedentary Behaviour. Geneva: World Health Organization; 2020. EXECUTIVE SUMMARY. Available from: https://www.ncbi.nlm.nih.gov/books/NBK566048/
  11. WHO. 2021, June 7. WHO guidelines on physical activity and sedentary behaviour. Available from: https://www.who.int/multi-media/details/who-guidelines-on-physical-activity-and-sedentary-behaviour
  12. Odunaiya NA, Agbaje SA, Adegoke OM, Oguntibeju OO. Effects of a four-week aerobic exercise programme on depression, anxiety and general self-efficacy in people living with HIV on highly active anti-retroviral therapy. AIDS care. 2022 Feb 1;34(2):173-81.
  13. Fillipas S, Oldmeadow LB, Bailey MJ, Cherry CL. A six-month, supervised, aerobic and resistance exercise program improves self-efficacy in people with human immunodeficiency virus: a randomised controlled trial. Aust J Physiother. 2006;52(3):185-90.
  14. 14.0 14.1 14.2 Kalatzi P, Dinas PC, Chryssanthopoulos C, Karatzanos E, Nanas S, Philippou A. Impact of supervised aerobic exercise on clinical physiological and mental parameters of people living with HIV: a systematic review and meta-analyses of randomized controlled trials. HIV Research & Clinical Practice. 2022 Dec 31;23(1):107-19.
  15. 15.0 15.1 15.2 Zanetti HR, Lopes LT, Gonçalves A, Soares VL, Soares WF, Hernandez AV, Tse G, Liu T, Biondi-Zoccai G, Roever L, Mendes EL. Effects of resistance training on muscle strength, body composition and immune-inflammatory markers in people living with HIV: a systematic review and Meta-analysis of randomized controlled trials. HIV Research & Clinical Practice. 2021 Nov 4;22(5):119-27.
  16. Ghayomzadeh M, Earnest CP, Hackett D, SeyedAlinaghi S, Navalta JW, Gholami M, Hosseini Rouzbahani N, Mohraz M, Voltarelli FA. Combination of resistance and aerobic exercise for six months improves bone mass and physical function in HIV infected individuals: a randomized controlled trial. Scandinavian Journal of Medicine & Science in Sports. 2021 Mar;31(3):720-32.
  17. WHO Africa. HIV/AIDS. Available from: https://www.afro.who.int/health-topics/hivaids (accessed 15 April 2023)