# Exercise as it relates to Disease/The effects of exercise on immune function and mental health in HIV positive patients

This is a critique of the journal article "The effect of a 12-week combinational exercise program on CD4 count and mental health among HIV infected women: A randomized control trial".

## What is the background to this research?

HIV is a serious disease which affects a persons quality life, damaging their mental health and physical function. Someone with HIV may show no symptoms and feel fine even though their bodies immune system is malfunctioning. The HIV virus attacks the CD4 cells in the body, as the cell numbers decrease this increases the likelihood of patients getting tuberculosis. In clinical terms if someones CD4 count is lowered from 250 to 200 then HIV medication is needed due to the high risk of illness.
In Iran in 2013 there were 26,556 individuals living with HIV and this is thought to be much lower than the actual figure. Due to the importance of this issue in the world and the prevalence in Iran, the authors sought to improve the levels of CD4 count in HIV patients and help to improve their quality of life. The authors aim was to see if exercise could reduce the rate that CD4 count was lowered thereby maintaining immune function. As a secondary aim they sought to find out whether exercise could improve mental health for the women with HIV.

## Where is the research from?

The research was completed in Iran and was funded financially by Shiraz University of Medical Sciences. The authors are professionals in their field; Nursing, Biochemistry, Sports Physiology and Epidemiology. The journal was published from a reputable source under the journal of Exercise science and Fitness.

## What kind of research was this?

The research was designed using a randomised controlled trial. This is an important research method as it established cause and effect. The random allocation ensures that there are no outside factors which may influence the results and prevent the relationship from being cause and effect.

## What did the research involve?

There were 40 participants which passed the inclusion criteria. They were recruited from a centre of behavioural diseases run by the Shiraz University of Medical Sciences. If they had recruited in a wider area potentially they would have had more participants.
Participants were randomly allocate to either a control (20) or exercise group (20). The control group received medical care services and education. The exercise based group completed a 12-week program three times a week, as well as the education and medical care services. Blood samples were taken to find CD4 prior to exercise participation and questionnaires were used before and after to assess psychological health.
Training Sessions
* Warm up; light stretching/ flexibility 20 minutes.
* Aerobic training; Twice a week 45 minute bike at 40-45% HRmax
* Strength training; Once a week at 3x8 at 50-55% increased every 2 weeks by 5%. This involved elbow exercises, shoulder press, bench press, leg extension and abdominal flexion.
* Cool down; 5-15 minutes
Only 30 participants finished the experiment. Six participants in the intervention exercise group did not continue with the exercise and four participants in the control group did not finish the program.
It seems that the exercise protocol did not encourage the participants to continue the study. It is unclear whether the issue with the exercise adherence was the resistance, aerobic or simply the duration of the training. The resistance program may have been more beneficial to the participants if they had used more compound lifts which targeted the major muscle groups. The aerobic exercise may have been boring for the participants as riding on an indoor bike for the same duration and intensity twice a week for 12 weeks can become quite mundane.

## What were the basic results?

The main findings of the research was the improvement in mental health status.This is more of a generalised finding as numerous studies have already explored this link and found that exercise does improve mental health. However there is some clinical importance in these findings and the authors claim to have improved the quality of life for the patients.
The results indicated that there was no significant reduction of the CD4 cell count. The authors seemed to overemphasise the findings of this paper. The results do indicate an improvement in CD4 count though this was not significant as there were small number of participants and exercise compliance was poor.
Change in CD4 Counts and GHQ Components in intervention and control group after 12-week exercise program. :
| Variables | Group | Mean ± SD Post Test | P Value |
| Post-test CD4 Count (cells/mm3) | Experiment Control | 495.57 ± 149.37 491.18 ± 284.48 | 0.33 |
| Somatic symptoms | Experiment Control | 4.00 ± 2.41 6.60 ± 4.22 | 0.02 |
| Anxiety Symptoms | Experiment Control | 3.61 ± 2.33 6.20 ± 4.29 | 0.07 |
| Social Dysfunction | Experiment Control | 7.46 ± 2.60 10.40 ± 3.13 | 0.02 |
| Severe Depression | Experiment Control | 2.69 ± 1.44 7.60 ± 5.38 | 0.008 |
| Total GHQ score | Experiment Control | 17.07 ± 6.71 30.80 ± 14.28 0.73 | 0.005 |

## What conclusions can we take from this research?

One of the strengths from this study was its significant improvement in mental health and thereby quality of life for these women with HIV as the physical activity was able to reduce depression, anxiety and social dysfunction.
The main issues with this research program was the limitations applied to the participant recruitment. There was only a small number of participants included in the research to begin the program. Secondly, the method in physical activity was not designed in a way which made exercise interesting and enjoyable. As a result six participants did not complete the program. Therefore, it is not possible to get a statistically significant improvement in CD4 count.
Similar findings by Perna et al. found that only 61% of the participants with HIV were able to finish their exercise protocol which involved aerobic exercise and one of their major issues was also exercise adherence. It seems the inclusion criteria needs to be improved and the method of exercise improved to maintain exercise protocols for patients with HIV.
Systematic review explored aerobic exercise with HIV patients. They concluded that aerobic exercise is a safe type of physical activity though there seems to be a major issue with sample sizes in this field of research.
Future research in this area may benefit from follow up testing. According to a meta analysis done in 2016 on physical activity in Iran, the estimates for physical inactivity may be as high as 70% of the population. It would be interesting to see if any of the women continued to exercise after the research.

## Practical advice

Physical activity is a great way for those with HIV to improve their quality of life. It is important to emphasise that individuals who have HIV are more prone to fatigue than healthy adults exercising. It is important that they only exercise at a moderate intensity or they may cause further illness. From this research it can be concluded that both aerobic and resistance training needs to be varied to prevent boredom and potentially for shorter duration's in the initial stages of exercise. Further information can be found at these resources;
HIV and Exercise
Nutrition with HIV
Global HIV/Aids Organisations

## References

* 1 2 3 Dianatinasab M, Fararouei M, Padehban V, Dianatinasab A, Alimohamadi Y, Beheshti S et al. The effect of a 12-week combinational exercise program on CD4 count and mental health among HIV infected women: A randomized control trial. Journal of Exercise Science & Fitness. 2018;16(1):21-25.
* 1 2 Hossein Fakhrzadeh, Shirin Djalalinia, Mojdeh Mirarefin, Tahereh Arefirad, Hamid Asayesh et al., Prevalence of physical inactivity in Iran: a systematic review. Journal of cardiovascular and thoracic research. 2016;8(3):92-97.
* ↑ 5. Sedgwick P. Randomised controlled trials: understanding confounding. BMJ. 2015;:h5119.
* ↑ Callaghan P. Exercise: a neglected intervention in mental health care?. Journal of Psychiatric and Mental Health Nursing. 2004;11(4):476-483.
* ↑ Perna F, LaPerriere A, Klimas N, Ironson G, Perry A, Pavone J et al. Cardiopulmonary and CD4 cell changes in response to exercise training in early symptomatic HIV infection. Medicine & Science in Sports & Exercise. 1999;31(7):973-979.
* ↑ 7. O'Brien K, Nixon S, Tynan A, Glazier R. Aerobic exercise interventions for adults living with HIV/AIDS. Cochrane Database of Systematic Reviews. 2010;.