Being Alive; March 1994
Richard Cooper, MD

Resistance Exercise

Early studies on exercise (PRE-Progressive Resistance Exercise, i.e., weight lifting and cardiovascular) in HIV+ individuals show that exercise is not only safe and feasible, but that it also has a positive effect on many systems of the body. These benefits have been noted by measuring improvements in psychological, physiological and immunological parameters. In addition, review of long term survival data shows that many of these individuals engage in some sort of physical fitness program.

Physiologically, HIV+ people generally have a high metabolism, not only because of HIV and other infections, but also because of the psychological and physical stressors associated with the disease itself. We know that the HIV+ individual may undergo changes in body composition even without losing weight. With progression through different stages of HIV, people generally experience a decrease in lean body tissue, the metabolically active tissue in the body. Significant loss of lean muscle mass has been shown to correlate with progression to mortality.

In addition, physical inactivity as well as psychological factors contribute to muscle wasting, weakness, and fatigue. The HIV Wasting Syndrome may also be precipitated and/or aggravated by the combination of the body's increase in metabolism (requirements up to 4500-6000 calories in some individuals), the decrease in intake and absorption of nutrients, and the decrease in lean muscle mass over time.

Based on studies of PRE in HIV+ individuals, a carefully monitored exercise program should be considered as part of an overall treatment program. These studies have definitely shown improvements in muscle function, increase in body dimensions and mass, regardless of the degree of HIV involvement in the skeletal muscle and nervous system. In asymptomatic stages of HIV, exercise evokes a positive response in the pathways that activate protein synthesis and hormonal factors that produce an increase in muscle growth and function. Considering the debilitating effect that prolonged bed rest or inactivity has on physical function and the concomitant decline in quality of life, early intervention with PRE may actually slow the rate of muscle atrophy that is associated with this condition.

Anabolic steroids, a hot topic today, are currently being used in clinical practice in the treatment of HIV Wasting Syndrome, as a means of increasing muscle mass and strength. The use of steroids is also playing an increasingly important role in those people experiencing a deficiency in the male hormone, testosterone. This hormone is crucial for normal sexual function, ejaculation and maintenance of male body characteristics. However, the use of anabolic steroids for other purposes remains debatable and controversial.

Aerobic Exercise

Aerobic exercise is still another important aspect of an exercise program. Many short term studies on aerobic exercise in HIV+ individuals have shown that this type of exercise is very beneficial. Recent epidemiologic evidence suggests that cardiovascular fitness is associated with signs of an activated immune system and increased survival time in HIV+ males.

One study from the International Conference in Berlin demonstrated that regular aerobic exercise in HIV+ individuals correlated with stabilization of T4 counts. T-cells have been shown to increase transiently during aerobic exercise, but no study to date has demonstrated statistically significant sustained increases. This study also suggested there were less opportunistic infections in the exercise group vs. the control group. Those people with T4 cells between 200-500 seemed to benefit the most from an exercise program. Another study from Miami suggests that aerobic exercising may enhance certain critical components of the cellular immune system, i.e., increase activity of natural killer cells, T4 and T8 cells.

There is some concern about aerobic exercise increasing the body's metabolic rate and thus increasing additional muscle loss. However, with a balanced high calorie diet geared toward a high metabolic rate and a well monitored exercise program, this should not pose a problem. A supervised training program should be consistent with guidelines by the American College of Sport Medicine. A suggested program, depending on one's ability, is to exercise one hour a day, three days a week. Each session should consist of 20 minutes of stationary bicycling or stairmaster at 60-80% of age estimate heart rate. This should be followed by 10-15 minutes of stretching and then 20-25 minutes of strength training using weights.

Improved Physical Fitness

Other benefits from aerobic exercise and PRE include a reduction in the degree of anxiety and depression associated with HIV disease. In the past, it has been noted that these types of psychological states could lead to further suppression of an already compromised immune system. This may result in increased risk of opportunistic infections and worsening of the overall disease state.

Exercise also improves pulmonary function, which may help prevent pneumonia and other respiratory infections. It also stimulates endorphins (natural pain killers) which may help alleviate or improve pain and neuropathy. Finally, improved physical fitness promotes greater exertional reserves for daily living and leisure activities for HIV+ individuals.

In summary, both aerobic exercise and PRE have been shown to be beneficial in HIV+ individuals. Further long term studies are needed. Based on preliminary results, exercise may be a valuable therapeutic tool to be used in one's overall treatment plan and may be considered depending on one's overall health status.

(Richard Cooper, MD is a member of the Kraus-Beer Medical Group and can be reached at 213.930.2323.)

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