Research consultancy

Effects of a Twelve-Week Aerobic Exercise on Functional Work Capacity in HIV Positive Clients on Antiretroviral Therapy at GMH-Bombo Hospital in Uganda

Mwebaze Nicholas¹, Constance A.N. Nsibambi², Edward Ojuka³, Mshilla Maghanga⁴

¹Programme Officer – Quality Improvement, UPDF, Ph.D. Candidate, Kyambogo University

²Department of Sport science, Kyambogo University, Kampala, Uganda (Assc Prof)

³Department of Physiology, Lira University, Lira Uganda (Assc Prof)

⁴Faculty of Business & Development Studies, Gulu University, Gulu City Uganda

Corresponding Author

Mwebaze Nicholas   

Faculty of Sports Science, Kyambogo University

Tel: +256-772924070

nicmwebazeru@yahoo.com

ABSTRACT

Introduction/Background: The implications of aerobic exercise on clinical outcomes of Human Immunodeficiency Virus (HIV) positive clients on Antiretroviral therapy (ART) in Uganda have been established. ART and the efforts to scale it up have significantly improved the quality of life and life expectancy of among people living with HIV.

Purpose of the Study: This study provides useful information to the Ministry of Health of Uganda on the implications of aerobic exercises on Immunological markers as a clinical outcome to HIV positive clients in Uganda. This will help in refining the existing information on aerobic exercises and their relevancy in care and treatment of HIV positive clients in Uganda. This information will in turn support the relevance of exercise scientists in the management of HIV positive clients.

Methodology: A quasi-experimental study was conducted among HIV positive clients who had been on treatment for at least 12 months. Volunteers were randomly assigned o: a control group (Group 1), where no treatment was administered, and an experimental group (Group 2), where a twelve weeks moderate intensity aerobic exercise was administered. Both groups were assessed using a physical activity readiness questionnaire (PAR-Q). Thereafter, assessment of the clinical outcomes that is, immunological measures using CD4. For the experimental group, they were taken through aerobic exercise sessions for a period of twelve weeks. The control group members were called weekly to make a follow up on them during the 12 weeks and to ensure that they did not feel left out of the study. After the12 weeks post-test was done.

Results: The results showed that aerobic exercises significantly decreased CD4 count in both males and females by 29.7% on average (P<0.001).

Conclusion: Aerobic exercise is therefore likely to increase quality of life, reduce mobility and mortality rates in HIV positive clients on ART.

Recommendations: It is therefore recommended that authorities should authorise the use of aerobic exercise as an additional therapy in the care and treatment of HIV positive clients on ART in Uganda.

Key words: Aerobic exercises; HIV/AIDS; CD4 Count; Antiretroviral Therapy; Positive clients; Uganda

Background of the Study

There have been significant changes in the quality of human life since Acquired Immune Deficiency Syndrome (AIDS) was first declared in humans in 1981 in Uganda (Okoroiwu et al., 2022). Bailes et. al., (2011), states that the Human Immunodeficiency Virus (HIV), a retrovirus belonging to the Lentivirus genus, is the cause of the sickness. The virus slowly affects a human body and deprives it of its immunity by seeking to destroy CD4 cells gradually – a type of T-lymphocytes (T-cells) that is critical to the immune system. According to O’Brien et al. (2016), there is a higher chance of opportunistic infections, which can reduce one’s functional work capacity and have other psychological impacts, when the immune system is significantly compromised. According to O’Brien et al. (2016), there is a higher chance of opportunistic infections, which can reduce one’s functional work capacity and have other psychological impacts, when the immune system is significantly compromised

In 2020, the United Nations Programme on HIV & AIDS [UNAIDS] released a report stating that HIV is one of the most serious public health issues facing the world today (UNAIDS, 2020). Of the approximately 37.9 million people living with HIV/AIDS worldwide in 2019, 95.5% were adults and 4.5% were children under the age of 15 years. An estimate of 1.7 million individuals worldwide became newly infected with the virus in 2018 and 94% of these were aged 15 years and above. Africa was the most affected with 25.7 million people living with HIV hence making Africa to account for about two thirds of the global total of new infections in 2018 with about 1.1 million infected (Velavan et al., 2021). In 2021, there were about 1.5 million new infections in the world with the highest infections recorded from Africa (UNAIDS, 2021).  According to a UNAIDS (2022) report, over 2.5 million people have died due to AIDS and more than 1.5 million people live with HIV infection in Uganda.

Scientific breakthroughs in AIDS treatments and efforts to scale up these treatments have significantly improved the quality of life and life expectancy of those infected with the virus. For example, Anti-retroviral Therapy (ART) such as the Highly Active Antiretroviral Therapy (HAART) have reduced hospitalisation rates, lowered mortality, and generally improved the quality of life of patients (Bopp et al 2003). On the other hand, a number of negative side effects are also linked to this treatment, including exhaustion, nausea, pain, anxiety, sadness, a decrease in functional job ability, and low energy (Ibeneme et al., 2022). Therefore, there is still need for multi-sectoral approaches to reduce these side effects and prevent other infections that would increase pill burden and affect the adherence to ART. Other strategies that control the effect of the virus and increase public attention are needed (Uganda AIDS Commission, 2011). Treatment of HIV involves regular visits to the hospital mainly when unstable, that is; when one has low CD4 count 200 copies and below, high viral load and any other opportunistic infection. It is estimated that about 254,000/= to 524,000/= is spent on adults and 190,000/= to 1,869,00= is spent on children in Uganda monthly (Moreland et al. 2013). This cost may be higher, depending on where they get their treatment. Moreover, many PLHIV travel long distances to get services where they are least known this also increases the cost of care.

Aerobic exercise is currently being explored as a means of dealing with symptoms, complications, and unwanted side effects that reduce the quality of life for chronic HIV infection (McIntyre & Puterman, 2020). Aerobic exercise may be a helpful treatment for a variety of ART side effects and symptoms, according to studies from both healthy individuals and those with various chronic illnesses (O’Brien et al., 2016). Therefore, aerobic exercise is now recommended by studies as one of the requirements in managing HIV positive clients. According to O’Brien et al. (2016), exercise therapy should start as soon as possible after an HIV infection diagnosis in an effort to postpone the onset of symptoms, lessen the severity of existing symptoms, and possibly postpone the progression of the disease and the subsequent onset of Non-Communicable Diseases (NCDs).

According to Okechukwu et al. (2022) aerobic exercise is a low- to moderate-intensity physical activity that uses oxygen in the metabolic processes that produce energy during exercise. Patients can engage in these activities for prolonged periods of time. Nystoriak and Bhatnagar (2018) further explained that regular aerobic exercise has several health benefits, including: strengthening muscles, improving circulation efficiency by strengthening heart muscle, and reducing blood pressure. These workouts also contribute to the body’s overall red blood cell count, which facilitates oxygen delivery, lowers stress levels, decreases the risk of depression, and improves cognitive function (Bopp et al., 2003). O’Brien et al. (2016) in a study on the benefits of aerobic exercise for persons living with HIV/AIDS showed improvements in their health, mood, life satisfaction, and quality of life in addition to symptoms of anxiety and sadness.

It was determined that several factors were significant indicators of obesity/overweight, including older age, female sex, early stage of the illness, lower CD4 level, and mild to moderate physical activity. It was noted that as part of standard HIV therapy, doctors should take into account implementing targeted weight management programs and be cognizant of the health consequences associated with obesity (Krupa et al., 2012).

In HIV management, there are key clinical outcomes that show client improvement or deterioration. Such clinical outcomes include the functional work capacity (Vajpayee & Mohan, 2011).  Functional work capacity, which is the measure of a client’s ability to carry out everyday tasks without undue fatigue, is mostly determined by looking at their maximal oxygen consumption or VO₂max (mL/kg/min). As physical fitness increases, VO₂max also increases (Maciejczyk et al., 2014) reflecting a general improvement in patient wellbeing as discussed before.

This study determined how a 12-week aerobic exercise programme affected the functional work capacity of people living with HIV on antiretroviral therapy (ART) in various regions of Uganda. In HIV management, the key clinical outcomes that show client improvement or deterioration include functional work capacity (Vajpayee & Mohan, 2011). This study determined how a 12-week aerobic exercise programme affected the functional work capacity of people living with HIV on antiretroviral therapy (ART) in various regions of Uganda.

Problem Statement

There is no cure yet for HIV infection despite its high level of prevalence and scientific studies done. ARV medications, which prevent the virus from multiplying and spreading among humans, are used to treat it. The present ART makes it possible for an individual’s immune system to fortify. They can combat other illnesses better as a result. Nonetheless, advanced HIV illnesses continue to be a challenge in the HIV response, a sign of subpar clinical results that worsen sickness and mortality in certain HIV-positive individuals, (Tugume et al., 2023). Studies have indicated that the use of antiretroviral therapy (ART) is strongly linked to adverse alterations, specifically morphologic and metabolic abnormalities. These changes are further compounded by obesity brought on by lipodystrophy, nutritional imbalances, and a sedentary lifestyle, (Thet & Siritientong, 2020). The use of aerobic exercise as an adjunct therapy in the treatment of HIV infection symptoms in clients without acute infection or severe wasting can significantly improve the quality of life for clients who are HIV positive (Grace et. al., 2015). Aerobic exercise therapy has the potential to lower the total cost of HIV treatment by prolonging the asymptomatic phase of the illness. This may also lessen the need for additional medications and the burden of those pills, as well as enhance the patients’ overall health, rate of health care utilization, and quality of life (Bopp et al., 2003).

The Ministry of Health (MoH) developed prevention and treatment guidelines of HIV in Uganda in which use of ART is a pillar in management of PLHIV, (MoH, 2020). The guideline points out that PLHIV are more prone to psychological effects, NCDs such as depression that may affect their immunity and functional work capacity and recommends use of aerobic exercise as one of the interventions to prevention and treatment. These recommendations are based on research data and clinical observations mainly from other countries. In addition, sufficient details are not given regarding the specific aerobic exercises to be administered and the benefits they offer. Moreover, the document does not mention exercise as a potent means of treating and preventing depression. The lack of detail about specific aerobic exercises and their benefits is problematic because the majority of practicing clinicians in Uganda are not adequately exposed to the science of exercise physiology and exercise prescription, considering that, the curricula for medical training in Ugandan Medical Schools and institutions hardly covers these disciplines in detail. Furthermore, the MoH HIV Prevention and Treatment Guidelines (2018), recommend the inclusion of exercise in improving psychosocial state in adults and adolescents who are HIV positive. However, it does not also sufficiently guide on the kind, level of intensity, and length of physical activity to be performed. To date, there is no published study on the roles of exercise in enhancing clinical results of HIV positive clients on ART in Uganda.

Specific Objectives

The objective of this study was to evaluate the impact of a 12 weeks aerobic exercise on functional work capacity of HIV positive clients on ART at GMH-Bombo. The corresponding hypotheses was  that “There is no significant effect of aerobic exercise on the functional work capacity of HIV positive clients on ART”.

Conceptual Framework

This study was guided by the conceptual framework presented in Figure 1.

Figure 1: Conceptual Framework

Source: Adopted with modifications from Ann (2014)

The conceptual framework in Figure 1 shows that aerobic exercise performed for 12 weeks (Independent variable) affects clinical outcomes for HIV positive clients on ART in Uganda. The aerobics sessions had five parts to a workout: warm-up (5–10 minutes), stretching and flexibility (5–8 minutes), cardiovascular conditioning (25–30 minutes), muscular strength and conditioning (10–15 minutes) and cool-down (5–8 minutes). The clinical outcomes (dependent variables) under study were functional work capacity measured by, VO₂max (mL/kg/ min) as an assessment of one’s ability to operate at work. The mediating variables for the study were: adherence to ARV intake, nutrition, and social status of the participants. The clinical outcomes (dependent variables) under study were functional work capacity measured by, VO₂max (mL/kg/ min) as an assessment of one’s ability to operate at work

Scope of the Study

The study was limited to one health facility in Uganda located in Bombo Town Council in Katikamu County in Luwero District. This facility was selected because of its ease of accessibility by the researcher and the institutional discipline that would help to ensure commitment of the participants to the study. More importantly the facility cares for individuals from various regions of the nation. The study population included majorly the clients from Bombo Army barracks and the neighbouring communities.  The clients were selected because of the time they have spent on treatment and their age.  The study sought to ascertain the implications of aerobic exercises on functional work capacity of HIV positive clients in Uganda.

LITERATURE REVIEW

Human Immunodeficiency Virus (HIV) and Antiretroviral Therapy (ART)

Antiretroviral Therapy (ART) like the Highly Active Antiretroviral Therapy (HAART), offers benefits to clients that’s to say improved quality and standard of life, reduced hospitalisation and mortality of PLHIV, (Eggleton and Nagalli, 2023). On the other hand, there could be a number of negative side effects connected to this treatment. These include; fatigue, nausea, depression, pain, anxiety, reduction in functional work capacity and reduced energy (Ibeneme et al., 2022). Other side effects are neuropsychiatric, and some of the examples include; peripheral neuropathy, headache, insomnia hepatotoxicity, dizziness, increased appetite, anaemia and bone marrow suppression, myopathy, cardiomyopathy, pancreatitis, hyperpigmentation and alterations in blood lipids, such as triglycerides and cholesterol, that are typically linked to protease inhibitors (PIs) (Eggleton and Nagalli, 2023). Gastrointestinal disturbances, fatigue, vomiting, diarrhoea and raised liver enzyme levels also occur (Talwani et al., 2011). These signs may manifest clinically and the level of their effects can be measured.

Exercises positively impact on many aspects of the physical and mental health of HIV-infected clients as an alternative therapy, the most commonly used of which are aerobic exercises of low intensity and long duration (Jaggers & Hand, 2016). It was discovered that exercise matched the signs and consequences of a long-term HIV infection without having the excruciating side effects (Jaggers & Hand, 2016). Exercise may be a helpful treatment for a variety of symptoms and side effects of ART that HIV-positive people may suffer, according to samples from other chronic diseases (O’Brien et al., 2016). In a study examining the effectiveness of aerobic exercise in adults living with HIV/AIDS, for example, the results of individual studies’ psychological measures showed improvements in general health, mood, life satisfaction, and quality of life among those in the exercise intervention groups, along with a decrease in anxiety and depression (O’Brien et al., 2016).

Significant increases in CD4 counts were observed in the exercise group that was on antiretroviral therapy (ART), suggesting that individuals living with HIV who are on ART might benefit more from adequate exercise than those who are not on ART and do not exercise (Asogwa et. al. 2022). Despite all these studies, in Uganda, aerobic exercises have not been emphasized by clinicians despite being listed as one of the ways in managing HIV positive clients. Currently there is scanty information on the efforts of HIV positive clients utilizing exercise therapy to improve their clinical outcomes while they undergo treatment.

According to Ciccolo and Jowers (2004), ‘’the use of HAART has served to highly reduce the mortality of HIV-infected patients’’. They emphasized that many HIV/AIDS patients are employing aerobic exercise regimens to enhance clinical results while undergoing treatment, as opposed to relying on conventional pharmaceutical treatments for its effects. In order to examine the impact of exercise on the most commonly self-reported clinical outcomes of HIV and AIDS, such as biological measures, psychological markers, functional work capacity, immunological measures, and body composition, O’Brien et al. (2016) have consistently listed aerobic exercise as one of the most popular self-care therapies. Exercise has the potential to be a helpful treatment for a variety of symptoms and side effects that HIV-positive people suffer, according to research done on healthy patients (Agbonlahor & Kubeyinje, 2020). These in turn greatly improves the quality of life of clients living with HIV and are on ART. The other benefits are reduced mortality, morbidity, cost of medication and pill burden.

Alebel et al. (2022), note that poor nutrition also significantly shortens time to develop Opportunistic Infections (OIs) in adults living with HIV. This shows that several affordable nutritional interventions, such regular nutritional assessments and education, can reduce the incidence of OIs in this susceptible population. These OIs affect the wellbeing of individuals living with HIV (Alebel et al., 2022). High viral load is another problem that reduces standard and quality of life; its primary cause is noncompliance with antiretroviral therapy (ART). When someone has a high viral load defined as more than or equal to 1000 Ribose Nucleic Acid (RNA) copies per millilitre and has been receiving treatment for at least six months, the World Health Organization (WHO) suggests enhanced or intense adherence and counselling and repeat the viral load after three consecutive good adherence session scores done a month apart, (Nyagupe et al., 2019). On the other hand, not much is known regarding the results of improved adherence counselling (Alebel et al., 2022).

These studies, however, tended not to indicate instances in which exercise was unable to enhance the quality of life for clients who were HIV positive. In the moderate-intensity exercise group, their higher-intensity group, or the control group, Hand et al. (2009) stated that Terry et al. discovered no significant modifications from baseline CD4+ cell count, CD8+ cell count, leukocytes, or lymphocytes. Additionally, they stated that Zanetti et al. (2020) replicated their protocol in 30 healthy HIV-positive individuals with lipodystrophy and dyslipidemia, and they found that after 12 weeks of aerobic exercise, three days a week for 30 minutes at a maximal heart rate of 70% to 85%, no significant changes in immunological variables were found in any groups.

Exercise is well recognized to boost mitochondrial biogenesis and function. It is also known that regular physical activity improves energy metabolism and general health. Exercise has also been demonstrated to have favorable effects on mental health, such as lowering stress levels, elevating mood via increased serotonin (the happy hormone) secretion, and lowering stress-related cortisol hormone secretion. Exercise can also aid with weight management, which improves the quality of life for clients who are HIV positive by lowering the risk factors for non-communicable diseases (Ferrara et al., 2021).

2.2 Clinical Implications

The use of aerobic exercises as one of the therapies in the management of symptoms of HIV infection is so much recommended. To put it another way, it is recommended that clients who do not have severe infections or wasting start aerobic exercise therapy as soon as they are diagnosed with HIV in an effort to postpone the onset of symptoms, lessen the severity of those that are already present, and possibly postpone the progression of the illness and other comorbidities that may result from ARVs (Grace et al, 2015). By extending the asymptomatic phase of the illness and lowering drug use and healthcare use rates, aerobic exercise therapy lowers the overall cost of treating HIV-positive patients (Bopp, et al. 2003). It is advised that therapeutic aerobic exercise regimens be customized for each HIV-positive client based on their unique symptomology and functional capabilities. Moderate-intensity aerobic exercises involving big muscle groups, such walking, cycling, and rowing, are recommended forms of exercise. The above-described progressive resistance training can be started after five to six weeks of aerobic exercise.

A list of physical activities and their related metabolic equivalent (MET) levels was compiled by Ainsworth et al. (2000) to illustrate the range of oxygen consumption intensities. A certain activity’s metabolic cost, expressed in millilitres per kilogram of oxygen utilized, can be divided by 3.5 millilitres per kilogram of oxygen at rest to determine the activity’s MET level. Exercise at a three- to six-meter intensity level is recommended for those with HIV/AIDS since even those without symptoms have a decreased functional capacity (VO₂max = 28 mL/kg/min, 8 METs). This intensity range include low-intensity jogging, walking at 3 mph on a level surface, dancing, water aerobics, bicycling at speeds under 10 mph, low-intensity sports like badminton, fencing, and golf, as well as regular gardening (Naura, et al., 2005).

Effects of Exercise on Functional Work Capacity

A typical way to estimate functional work capacity is to use maximal oxygen consumption or VO₂max (mL/kg/min). In healthy persons without HIV infection, VO₂max rises in tandem with physical fitness. A healthy male with no training typically has a V̇O₂ max of 35–40 mL/(kg. min). According to Scribbans et al. (2016), the average untrained healthy female has a V̇O₂ max of about 27–31 mL/(kg. min). Teens living with HIV had average VO₂max values in the upper 20s, placing them in the “well below average” group when compared to age-matched, HIV-negative controls (Keyser et al., 2000). Webel et al. (2019) discovered that HIV-positive patients had lower VO₂max values than an uninfected control group, both at the anaerobic threshold and throughout maximal exercise. This means they needed to aerobic exercise in order to improve their VO₂max values significantly increased in functional capacity following 12 weeks of exercise Bopp et al. (2003) and 24 weeks of aerobic endurance activity. The implications of this improvement in functional capability, however, have scarcely been assessed in Ugandan HIV-positive individuals. According to additional research, patients’ capacity to carry out activities of daily living improved steadily by 40% in a group receiving cardiac rehabilitation (Bopp et al., 2003). Greater functional capacity may lessen HIV-related symptoms and provide a higher quality of life in individuals with HIV infection, if this association is present.

The rating of perceived exertion (RPE), a fifteen-point category scale, is a commonly used method to quantify the level of physical strain encountered during aerobic exercise (Eston and Williams, 1986). The results of studies on effort perception showed that assessments of adults’ exercise intensity were highly correlated with physiological indices that were also collected at the same time, including heart rate, oxygen uptake, and blood lactate build-up (Zinoubi et al., 2018). According to Monoen et al. (2017), the RPE approach was utilized for training load monitoring validity, ecological utility, and affecting factors. With men and women of diverse ages and skill levels, they verified the validity, reliability, and internal consistency of the session RPE approach in sports and physical activities. The conclusion was that, while some suggested integrating it with other physiological indicators like heart rate, this method can be utilized independently for training load monitoring.

Williams (2017), asserts that a “Danish study which looked at the use of the Borg CR10 scale in assessing levels of fatigue at midday and at the end of the shift in workers”. It was shown that during the course of a workday, there was a strong correlation between high felt levels of physical activity and high neck muscular tension. On the Borg CR10 scale, a score of at least four (4) appeared to suggest that there was significant muscle loading taking place. VO₂max has also been predicted using RPE. McCulloch et al. (2015) examined VO₂max in research to validate a submaximal test to predict maximal oxygen consumption for individuals with spinal cord damage. It was found that an RPE-based approach for VO₂max prediction is feasible and can produce VO₂max values in the able-bodied population that can be predicted with accuracy. This study serves as a proof of concept for the use of a whole-body recumbent stepper in a submaximal test protocol to predict VO₂max in healthy adults.

Heart rate may also be determined using RPE. That is to say, the heart rate is calculated as follows: 12 x 10 = 120 beats per minute if the person’s rating of perceived exertion (RPE) is 12. But the heart rate determined by this technique is merely an estimate. Age and physical state can have a significant impact on the real heart rate. For people using drugs that alter heart rate or pulse, the Borg Rating of Perceived Exertion is the recommended way to measure intensity (CDC 2022). A preferred scale is used by the exerciser to rate their effort on a range of either 0–10 (very light effort = 10–20 maximal exertion) or 6–20 (very light effort = 6-9 maximal exertion) (CDC 2022). Engaging in frequent physical activity, your heart becomes more efficient at pumping blood. This increased efficiency means that with each beat, your heart can pump a larger volume of blood, allowing it to beat less frequently while still maintaining an adequate blood flow to meet the body’s demands. VO₂max also increases in healthy adults (Brooks et al., 2005). Overall, basic research on effort perception has shown that adult judgments of exercise intensity are highly correlated with physiological indices that are obtained concurrently, such as heart rate, oxygen uptake, blood lactate accumulation, and others (Zinoubi et. al. 2018).

The exercise group in the systematic review and meta-analysis utilizing the Cochrane Collaboration protocol ended the 20-minute multi-stage shuttle run test (20mMST) with a higher heart rate and rate of perceived exertion (RPE). When compared to non-exercisers, exercisers’ VO₂max significantly improved, as indicated by the results of the 20-meter multi-shuttle run test (MST). The modified Borg Rate of Perceived Exertion (RPE) scale is used to measure the common field measure of VO₂max. The patients showed more progress after a specific load was applied until they felt muscle failure, or were unable to perform any more repetitions (O’Brien et al., 2016). In this study a ten minutes aerobic exercise was used at moderate intensity. Whoever got exhausted was asked to rest and time all the minutes spent which were also recorded on a modified Borg RPE. This was used to assess both pre and post-test to determine the difference in functional work capacity.

The Duke Activity Status Index (DASI), which was created by Ravani, et al. (2012) as a quick and low-cost substitute for VO₂max, measures a person’s capacity for exercise by asking twelve (12) questions about their ability to undertake activities of daily living. Participants in the DASI were expected to select “yes” or “no” for each question. The DASI score is calculated by multiplying the total number of “yes” replies by 0.43, adding 9.6, and calculating the estimated maximum oxygen consumption (VO₂max) with 81% reliability. There is a range of 0 to 58.2 points in the final score. The functional capacity scores improve with higher scores (Tolulope et al 2021). Ferguson and Shulman (2021) found a weak connection between peak VO₂max and the DASI score. The DASI’s predictive power for a peak VO₂ > 15 mL/kg/min is moderate. Four or five questions in a condensed, modified version of the DASI questionnaire (m-DASI) may be sufficient to identify patients with at least modest functional capacity.

The DASI has criterion validity of 0.34 when associated with measured VO₂peak, indicating that it can predict functional capacity in individuals with chronic obstructive pulmonary disease. A small number of studies suggest that there is a moderate link between the VO₂ peak and the DASI in the perioperative context (Riedel et al., 2021). When measuring a patient’s functional capacity for heart failure, DASI scores also showed a strong correlation with peak oxygen uptake (Grodin et al., 2015). In this study the DASI score was associated with improved functional work capacity if the score increases it indicates improvement. Specifically, DASI was used to triangulate the results of functional work capacity in HIV positive people got where RPE was used with an assumption that improvement in oxygen uptake VO₂max will mean improvement functional work capacity.

2.6 Impact of Exercise to HIV-Infected Clients

HIV infection became a chronic condition due to medical advances in the use of HAART to treat it; this has been associated with a number of comorbidities, disability, problems coping with day-to-day living, and a decrease in exercise capacity (Eggleton and Nagalli, 2023). Because of their longer lifespans in the HAART era, HIV-positive patients’ rates of death and morbidity have dramatically dropped. Nsagha et al. (2015) found that although HAART has dramatically reduced the prevalence of immunosuppression and wasting syndrome in HIV patients, it is associated with anthropometric and metabolic abnormalities such as insulin resistance, dyslipidaemia, and aberrant body fat distribution.

Exercise is a critical management strategy employed by rehabilitation health professionals when it comes to HIV/AIDS clients’ rehabilitation and health promotion. Exercise can help reduce a number of HIV-related side effects as well as the cardiometabolic and morphological problems that come with HAART, such as inflammation, oxidative stress, and mitochondrial dysfunction (Grace et al., 2015). Exercising can slow down the disease’s progression, enhance quality of life, increase aerobic capacity, enhance functional ability, improve oxidative stress, improve lipid profiles, improve muscle strength, and lower the cardiovascular disease risk in people living with HIV, according to a substantial body of scientific research. According to Gianluca et al. (2020): (Jaggers & Hand, 2016), it is noteworthy that aerobic exercise is generally recognized as safe and that there is no evidence that regular moderate-intensity exercise would affect immune function in both symptomatic and asymptomatic HIV/AIDS patients. Exercise studies on clients with HIV/AIDS show that aerobic exercise (AE) and progressive resistive exercise (CARE) together enhance a number of health indices in HIV-infected clients more effectively than using either strategy alone (O’Brien et al., 2010). The American College of Sports Medicine has recently used and recommended CARE (Nweke et al., 2022).

All exercise sessions with an HIV-positive client should be supervised by a clinical exercise physiologist with the appropriate training or by other health professionals knowledgeable in exercise until the client shows that they can handle the recommended workload (Fletcher et al., 2001). When recommending exercise to an HIV client, a number of things need to be taken into account, including as the client’s drug regimen, symptoms, functional ability, and disease stage. Enhancing body composition, increasing functional work capacity, and building muscle strength and endurance should all be objectives of the workout regimen (Bopp et al. 2003).

Using the gradual progression approach, the number of weekly exercise sessions should be raised until the client can endure three to five sessions per week. Each session should last longer until the customer is working out for 20 to 60 minutes every time. The client’s sessions may end abruptly if they are incapacitated. For instance, the client could work through three 10-minute sessions until they can finish a 30-minute session in place of just one. Moderate intensity exercise was performed at 50% to 85% of peak heart rate, between 45% – 85% V02max, or between 11 and 14 on the Borg Rating of Perceived Exertion Scale (Turner et al., 2018). It is recommended that the client finish four to six weeks of aerobic training prior to beginning a weight training regimen. This will reduce the likelihood of immunological problems early in the exercise regimen by enhancing fitness and preventing overtraining. Large muscular groups including the chest, biceps, brachia, quadriceps, and hamstrings should be the main emphasis of moderately intense resistance training.

The client should choose a weight that allows them to comfortably complete 8–12 repetitions. More sets of 8 to 12 repetitions should be added as soon as the client is able to tolerate the increased exertion, or resistance should be raised as the 8 to 12 repetitions start to feel less taxing. It is advised against using free weights when doing resistance training due to the higher risk of injury (Bopp et al., 2003). Because HIV clients have a wide range of symptoms, Jaggers et al., (2014) advised that all clients obtain medical clearance from their doctors before starting exercise programs. It is also advised to do an exercise stress test under physician supervision, as there are a number of potential limiting factors that could be present. HIV clients are more likely to experience dehydration and electrolyte abnormalities due to diarrhoea, poor diet, and poor nutrient absorption. These conditions can result in cramping in the muscles and irregular heartbeats. Increased exhaustion and a reduced ability to exercise can result from anaemia and muscle atrophy. Particular care should be taken if a patient has had pneumocystis pneumonia in the past, as residual lung scarring may lower alveolar capacity.

2.7 Related Studies

In order to compare various levels of exercise intensity, the safety and effectiveness of aerobic exercise in older HIV-positive males were investigated in a randomized experiment. Exercise endurance increased in both groups. Changes in VO_{2 peak} was clinically observed in the experimental group. No negative effects linked to exercise were seen (Araujo et al., 2021).

Numerous researches have examined the impact of consistent aerobic exercise training on the immune systems of individuals living with HIV. The duration of most training programs was six to twelve weeks of regular aerobics, bicycle or treadmill exercise. Either moderate or heavy intensity was present (60-80% V02 max). At least three training sessions a week, lasting between fifty and sixty minutes each, were held. For the majority of HIV positive clients, this regular aerobic exercise training program returns the maximal oxygen uptake and lactic acidosis threshold to nearly normal levels. Exercise intensities, thereby reducing one’s capacity for exercise (Bopp et. al., 2003). Diverse range of HIV patients’ symptoms. Furthermore, it was discovered that an appropriately structured aerobic exercise training program improved immune system indices or function. Ultimately, an exercise intervention improved depression symptoms and quality of life (O’Brien et al., 2016).

METHODOLOGY

Research Design

A quasi-experimental research design was used in the study. Quasi-experimental study designs, often known as nonrandomized, pre-post intervention studies, are widely utilized in the medical informatics field (Harris et al., 2006). This is different from experimental design because; experimental design has a high level of controls over the variables. While quasi experimental lacks the same controls and random assignments because often cannot assign participants randomly due to ethical or practical constraints. Like in this case HIV positive clients that may have stigma and need to incur some costs to come to the facility daily for exercises.

To measure the effect of the independent variable (IV) on the dependent variable (DV), the same manipulations as in a real experiment were made. There was a control group, though, and the participants were assigned at random only after being chosen for the study through volunteerism and purposeful selection. The participants were selected according to particularly required characteristics like being on treatment for 12 months or more and being adults who can commit time to participate in the exercise this was necessary in the research situation (Martínez-Mesa & González-Chica, 2016). The age group was selected considering the nature of the participants being HIV positive clients with stigma and the transport cost involved to come to the facility at least three times a week.  This study design consists of studying the experimental and control samples at two different points in time in order to establish change in a phenomenon or variables in order to establish the impact of an intervention (Estrada & Ferrer, 2019). Using one or more experimental variables is what this is all about (Seel and Nobert, 2012). This design provided an opportunity for the variables to be measured at the start of the study and after subjecting the experimental group to a twelve weeks’ aerobic exercise. All groups were given a pre-test, the experimental group underwent aerobic exercise, and there was no treatment given to the control group at all just a follow-up call to ensure they didn’t feel abandoned. After that, each group received a post-test. This provided an opportunity to determine the clinical effects of aerobic exercise on immune markers, psychological indicators, and the ability of HIV-positive clients receiving ART to perform their jobs.

3.2 Location of the Study

The study was conducted at General Military Hospital (GMH) Bombo in Luwero District, central Uganda which is 33.8 kilometre (kms) (21miles) from Kampala the capital city of Uganda. The hospital is situated in Bombo Town Council, on the grounds of Bombo Military Barracks, the Land Forces of the UPDF’s headquarters. It is roughly 32 kilometres north by road of Mulago National Referral Hospital. Bombo Military Hospital’s coordinates are 0°35’11.0″N, 32°32’10.0″E (a longitude: 32.536111; latitude: 0.586389). From mile 21 trading centre one branches to the right at a sign post of Bombo Army Secondary school which is about 800 metres to the facility. The hospital is a military facility that provides referral services to the UPDF’s several medical units. Yet, the hospital treats residents of the surrounding areas due to the great need in those communities.

The district is located between latitudes 20 north of the equator and east between 320 and 330, to the north of Kampala.  The Luwero district encompasses an area of roughly 2577.49 square kilometres.  The district is bounded to the south by Mukono and Wakiso, to the west by Nakaseke, to the north by Nakasongola, and to the east by Kayunga District. The study was conducted in Nyimbwa sub-county Bombo military barracks as indicated.

3.3 Target Population

HIV-positive patients receiving care at General Military Hospital-Bombo made up the target demographic. Particularly, men and women who were receiving care for a minimum of 12 months and were 20 years of age an above. That category of clients formed the majority of the 4150 clients that were receiving ART treatment at GMH, (DHIS2, 2019). The age range was selected with an assumption that majority of them were adults, out of schools and could allocate time for the aerobic exercise classes.

3.3.1 Inclusion and exclusion criteria

The inclusion criteria for this study were: HIV positive clients taking their ART treatment from Bombo Military Hospital, who were on treatment for 12 months and more, without any limitation for exercise, asymptomatic, 20 years of age and above, volunteering to come for aerobic exercise session for 3 times or more a week and adhering to their ART.

Exclusion criteria were: clients with known limitation to exercise, clients with opportunistic infections, those with signs and symptoms of the HIV disease, children, adolescents and new clients less than 12 months on ART treatment.

3.4 Sampling Procedure and Sample Size

3.4.1 Study sample size

After health education sessions that took more than six months about the study, out of 4150 clients 3300 met the inclusion criteria and 135 volunteers were willing participants in the study as per the defined criteria and were enrolled. This gave an adequate sample as compared with Yemen’s formula of determining the sample size using a level of confidence of 10%. The formula is defined as follows:

……………………………………………………………………………………….(1)

Where:

N is the population size

n is the sample size

e Margin of error

the formulae gave the study n = 99 participants.

135 were participants who were involved in the study. This was regarded as a good sample since it was greater than the 99 minimum calculated from Yemen’s formulas. Yemen’s formulas work best when a large population is involved and a representative sample size is desired by the researcher (Chanuan et al., 2021).

3.4.2 Sampling procedure

Purposive sampling procedure was employed, the participants were sampled on the basis of their duration on treatment, and absence of signs and symptoms that would not allow them to take part in exercise. According to Odiya (2009), participants were selected purposively, because they possess the characteristics being sought, or because they were the only ones in their respective categories. That category of clients 20 years and above who formed majority of the 4150 clients on ART care at GMH (DHIS2, 2019). The age range was selected with an assumption that majority of them were out of schools and would allocate time for the aerobic exercise classes. They should have been on care for 12 months and more to select both the experimental and the control groups. Because these clients were expected to be stable on treatment and their schedules would make them reliable to attend the exercise sessions. Volunteerism was used this method was found appropriate because of the stigma associated with HIV infection, time, and money for transport to come for the aerobic exercise sessions. In a related study, Maduagwu et al. (2017) evaluated the effects of volunteering on CD4 cell counts and quality of life in HIV-positive individuals in Nigeria.

3.5 Research Instruments

The following instruments were employed for data collection:

Modified Physical Activity Readiness Questionnaire (PAR-Q)

The Physical Activity Readiness Questionnaire (PAR-Q) was adapted and used as an instrument to assess physical activity readiness (Appendix VI). This was used to assess the readiness of the participants to take part in aerobic exercise it also helped to eliminate those with exercise limitations. The PAR-Q is a tool that was used to determine whether the participants were healthy to participate in exercise or whether were to consult a doctor to ensure that they are in good health status, (Elizabeth, 2020).

Rate of perceived exhaustion scale

Rate of Perceived Exhaustion scale (RPE), (Appendix VIII) was used to determine maximum oxygen consumption (VO₂max) which is a common measure of functional work capacity. Nystoriak and Bhatnagar (2018), alludes that regular exercise benefits cardiovascular system like, strengthening the heart muscle. It is a fifteen-point category scale introduced by Borg in 1971. In this study a 10-minute moderate intensity aerobic dance at 150 beats per minute was used to check the RPE for clients using the RPE scale by (Eston and Williams, 1986).

Self-report physical activity status

Duke Activity Status Index (DASI) (Appendix IX) was also used to compare with the results of functional work capacity. Another method McCarthy et. al., (2015) uses to test VO₂max in physical activity and functional capacity in women is the DASI. The primary outcome measures included cardiac risk factors, CAD, and functional capacity as assessed by core laboratory-determined parameters during symptom-limited exercise treadmill testing. Measured physical activity using postmenopausal progesterone and oestrogen levels. Functional capacity as determined by the Duke Activity Status Index (DASI) questionnaire was connected with functional capacity as assessed in metabolic equivalents (METS) (McCarthy et. al., 2015). This helped to reinforce the results got from RPE scale.

.

Exercise protocol

Rate of Perceived Exertion (RPE) for functional work capacity

RPE scale (Appendix VIII) is used by YMCA of the USA in predicting VO₂max and access cardiorespiratory endurance see details in (Appendix XX). This test was compared with other laboratory tests and found to give consistence results (Zinoubi et al., 2018). Additionally, it was suggested that RPE be utilized as a rough indicator of exercise intensity. Monoen et al. (2017) have demonstrated that the repeatability of work capacity based upon an RPE at 13 and 17 is as excellent as that based upon a heart rate of 130 and 170 beats/min in both healthy volunteers and cardiac patients. Also, it was noted that HR, RPE, and VO₂max percentage were closely related (Zinoubi et al., 2018). Adult studies have found that, for the majority of participants, an RPE between 12 and 14 corresponds to 60–80% VO₂max (Zinoubi et. al. 2018) when performing running or cycling exercises. In their investigation, comparable RPE levels were noted at 60% VO₂max. This was therefore a useful method to estimate work capacity since it had a linear relationship with VO₂max.

Duke Activity Status Index (DASI) (Appendix IX)

To triangulate the results of functional work capacity DASI was used in this study. DASI determines exercise capacity it uses 12 questions to assess a person’s ability to perform activities of daily living. These questions need a yes or no the participants were asked to answer the questions to ascertain their capacity to do daily work. Several researchers have employed the DASI, such as (McCarthy, et. al., 2015) who measured women’s functional ability and physical activity. The primary outcome measures included cardiac risk factors, CAD, and functional capacity as assessed by core laboratory-determined parameters during symptom-limited exercise treadmill testing. Measured physical activity using postmenopausal progesterone and oestrogen levels. Functional capacity as determined by the Duke Activity Status Index (DASI) questionnaire and the intervention physical activity questionnaire (PEPI-Q) were linked with functional capacity as determined by metabolic equivalents (METS) (McCarthy et al., 2015).

Data Collection Procedure

Eight research assistants were trained on what was involved in the study, and then the participants were selected using appropriate methods as earlier indicated.

Five A’s psychological counselling framework Bardonian model was used to prepare participants for the exercise and also ensure adherence to the aerobic exercise programme (Appendix XIX), (HIV prevention and treatment guideline, 2020). A study risk mitigation plan was developed Appendix XVIII to ensure safety and reduce the risk of Covid-19 transmission.

The clients were briefed on their rights and asked to sign informed consent. They were asked to fill self-administered physical activity readiness questionnaire (PAR-Q) to ascertain their readiness to exercise and if there any exercise limitations.

They were informed about what was involved in the exercise. The exercises included brisk walking, jogging and aerobic dance at moderate intensity. The days that the participants chose to attend, knowing that they would have time, determined how they were grouped. At least three times a week, each subject attended under the careful supervision of the research assistants and the researcher. Water was available for use during the sessions, and for those who needed it afterward, there was a handy restroom. All sessions included 5 minutes of warm up followed by stretching, not less than 25 minutes of exercising (aerobic dance), as well as 5 minutes of relaxation activities to cool down. All types of exercise training were done according to the ACSM guidelines (Colberg, et. al. 2016).

Measuring functional work capacity using rate of perceived exertion (RPE)

This was done by using Borg RPE scale which uses a scale of six to twenty. This was designed to give a fairly good estimate of the actual heart rate and after getting the score you multiply by 10 to get the estimate. The clients were taken through a 10-minute non-stop exercise by the instructors guided by music of 150 beats per minute and then the research assistants helped them to complete the RPE scale. There after the results were kept ready for analysis. The researcher also used the Duke Activity Status Index (DASI) to compare with the results of functional work capacity. DASI a self-administered the clients were provided with this questionnaire and asked to complete it with assistance from the research assistant.

Data Analysis and Presentation

The data collected using a PAR-Q was analysed using predictive analytics to determine the participants’ engagement in physical activities. Where the information given in the questionnaire were categorised, classified, summarised, tabulated and thereafter participants that did not meet the criteria were replaced. Quantitative data was analysed using two sample t-test to compare the means for two different samples namely experimental and control group. A p-value ≤ 0.05 was considered statistically significant. All analysis was performed using the Statistical Package for Social Sciences (SPSS) version 20.0.

RESULTS AND DISCUSSIONS

Demographic Information of Participants

Table 1: Demographic information of participants

Source: Primary Data (2023)

Table 1 shows that the majority (67.3%) of participants in the experimental group were males while the females constituted 32.7%. Similarly, for the control group the males constituted 71.4% and the females 28.6%. This is a fair reflection of the member of the study population (clients attending the ART Clinic at Bombo Military Hospital) where the males are slightly above 2,490 (>60%) and female are slightly below 1,660 (<40%).

The results also show that majority of the participants were between the age of 38-47 years although those in experimental group had a slightly higher number (67.3%) compared to 51% in the control group. This is true because most of the young soldiers are HIV negative since they are recruited when they are negative. The least number of participants (2%) who participated in the survey from the two categories were in different age, the experimental group were in the age bracket of 48-57 years and control group were in the age bracket of 20-27 years. The study furthermore revealed that there were participants who were above the age of 57 years. This therefore implies that all the participants in the study were adults and had knowledge regarding the problem under investigation.

The majority of participants in the control group (77.6%) and experimental group (61.2%) were married.  This is in line with Pettee et al (2006) who established that, married men and women unlike those who were single reported higher median levels of exercise participation than singles.

Regarding education, the majority (51%) of the participants had a secondary education, followed by 30% who had primary education. In this study, the participants ‘ educational background was also deemed to be significant. All these findings imply that all participants had attained some level of formal education and so they were expected to be conversant with aspects to do with physical activity aspects and also to understand the questions given to them during data collection. The fact that all participants had some formal education could partly be explained by the fact that the study was conducted in a military setting whereby academic credentials are necessary for one to be enlisted.

Physical Activity Readiness Questionnaire (PAR-Q)

Data on the study participants ‘ physical activity readiness and any barriers preventing them from engaging in physical exercise were gathered using the Physical Activity Readiness Questionnaire (PAR-Q). The background information included in the data collection is what has been presented in sections 4.3.1 – 4.3.7.

Current engagement in physical exercise and type of exercise

The study sought to establish whether the participants were engaged in any regular physical activity at the time of conducting this study and if so which type of activity. The findings are presented in Table 2.

Table 2: Current Engagement in Physical Activity and Type of Activity

Source: Primary Data (2023)

The test group reported a total of 24.5% (n=12) of regular, non-organized physical activity, compared to 6.1% (n=3) of the control group, according to the results. 84.7% of the participants in the study did not participate in any physical activities at all. The physical activities that those who exercised participated in included roadwork at 6.7%, jumping at 20%, and aerobics at 60%.

As to whether they were engaged in physical exercise prior to joining this study, it was established that the majority of the participants were not engaged in any exercises. The results also show that very few of the experimental group participants and control group participants, engaged in regular an organised physical activity. This, however, was not considered to be a problem as such, since it was a baseline analysis before the experimental group was subjected to the aerobic exercises as was the objective of this study.

The results further show that very few of the experimental and control group members engaged in regular un-structured physical activities, and the few who did, none of them did so for more than 2 hours. Specifically, very few participants engaged in digging, fetching water, jogging, playing football or netball. Apparently, some participants indicated that they last participated in physical activity over a year ago prior to this study.

According to Vancampfort et al. (2018), “Globally, the physical activity status of HIV patients varies between countries, on average 32% fall into the low physical activity category, the moderate and the high category, each accounting for 33%, as defined by the International Physical Activity Questionnaire (IPAQ)” and the results presented show that HIV clients are not very active.

The participants were also asked if they played any games, went digging, or went fetching water. The findings as computed from those who responded to the questions posed were as presented in Table 3.

Table 3: Engagement in Digging, Fetching Water, Jogging and other Games

Source: Primary Data (2023)

The aforementioned findings indicate that a relatively small percentage of participants in both the experimental and control groups dug more than three times per week, collected water every day from sources more than one kilometre distant, or participated in jogging, football, or netball for more than three days per week. It appears that only 5.5% (n=96), 2.2% (n=90), and 8.6% (n=93) of the population participated in each of these three categories of physical activity.

The findings above provide additional evidence that HIV-positive clients are typically not active, as reported by Vancampfort et al. (2018) and Tegene et al. (2022). It is evident that the participants performed menial tasks like playing games and jogging, as well as domestic chores like fetching water and general economic activities like digging.

Frequency of engagement in physical exercise, for the participants who indicated that they are currently engaged in any regular physical activity, they were further asked to indicate how many times a week they did so and for how long per day. The findings are presented in Table 4.

Table 4: Frequency of Engagement in Physical Activities

Source: Primary Data (2023)

The results show that, while the majority (58.3%, n=12) of the experimental group engaged in regular un structured physical activities seven times a week, the majority (75.0%, n=4) of the control group did so four times a week. According to these results, the exercises to which the participants engage in being unstructured implies that they may not in the long run be very meaningful in attaining a specific goal. This approach to exercise may be explained by the fact that, according to Tegene et al. (2022), most people living with HIV and receiving ART have low levels of physical activity. The situation is worse among female patients, those living in urban areas, and those undergoing longer treatment durations. The general population is relatively inactive, and this is especially true for HIV positive clients.

4.3.2 Date when last engagement in physical exercises

Participants, who said that they do not do physical exercises regularly, were asked to indicate when they last participated in physical activity. The findings as presented in Table 5

Table 5: Duration When Last Engaged in Exercise

Source: Primary Data (2023)

The majority of those who do not currently participate in physical activity (92.3%, n=13) had not done so for more than a year, according to the results; 7.7% of those who did not participate in physical activity confirmed that they had, but they were unsure of the exact date. Based on the results, it appears that all of these participants were part of the experimental group, and none of the control group indicated that they had ever engaged in physical activity. The majority of those who do not currently participate in physical activity (92.3%, n=13) had not done so for more than a year, according to the results; 7.7% of those who did not participate in physical activity confirmed that they had, but they were unsure of the exact date. Based on the results, it appears that all of these participants were part of the experimental group, and none of the control group indicated that they had ever engaged in physical activity.

4.3.3 Problems experienced upon exercising

The findings on whether participants experienced shortness of breath, fatigue, chest pain, pressure over the heart when exercising such as climbing stairs were as presented in Figure 1.

Figure 1: Problems Experienced by Participants during Exercising

Source: Primary data (2023)

Figure 4.1 shows that majority of the participants from both experimental group and control group considered fatigue to be the major problem experienced by participants during exercising. However, the control group had slightly a higher number (83.7%) as compared to 65.3% of the experimental group. The results also reveal that the least number of participants from both experimental group and control group considered pressure over the heart and they constituted 8.2% and 6.1% respectively. The findings furthermore reveal that there were no participants from the control group that mention other problems experienced by the participants during exercising. The results therefore imply that participants that are always engaged in exercising experience different challenges that are inevitable during the exercising process.

The above results, which can be interpreted negatively for the participants, could be held accountable for the study’s participants’ lack of physical activity. As can be seen, the main complaint from both the experimental and control groups was fatigue, with many of them indicating that they felt they did not have enough energy to participate in any physical activities. This could be the rationale behind the general belief that sick people are frail.

These findings support the findings of Gebreyesus et al. (2020), who demonstrated that fatigue is a common health problem among adult PLHIV and suggested that health care services address the predisposing factors by providing integrated care and promoting physical activity to slow down the disease’s progression and lessen exposure to fatigue. The problems as experienced were not a surprise considering that it was earlier reported that most of the participants were hardly engaged in any physical exercises and so they were physically inactive. To this effect, any exertion would result in one form of pain or discomfort. This being a baseline result was critical as it was expected that after the experiment, there would be a distinction between the two groups upon being exposed to any form of exertion.

Purpose for engaging in exercises

Asked to state what their personal exercise programme goals would be should they engage in physical exercises; the responses of the participants were as shown in Figure 2.

Figure 2: Purpose for Engaging in Physical Exercises

Source: Primary data (2023)

Figure 2 shows that majority of the participants  in both control group and experimental group considered doing exercises to avoid cardiovascular diseases and they were constituting 51% and 30.6% respectively, followed by those who considered weight loss in both control group and experimental with 30.6% and 28.6% respectively, whereas only 2% in the experimental group mentioned other reasons for doing physical exercise and only 8.2% in the control group considered doing physical exercise to become stronger. The results therefore imply that different participants always do physical exercises for different reasons depending on want one would love to achieve.

Based on the results above, it is evident that the participants were aware of the health benefits of exercise. Although they were not questioned about where they learned these benefits, it is possible that they learned them from health professionals who may have encouraged them to maintain their physical fitness or from the general public’s understanding that exercise is beneficial for controlling body weight and maintaining a healthy heart. Going by the above results, it was clear that the participants are knowledgeable about the benefits of exercising and while they weren’t not asked where they got the knowledge from, it is possible that this could have come from the health workers who may have been encouraging them to remain physically fit, or this could have come from the general public domain the exercises are good at helping one have a healthy heart and the control body weight. The results align with the research conducted by Orozco and Rosario (2020), which demonstrated that long-term physical activity can enhance immune system performance, muscular strength, and cardiovascular health in individuals living with HIV.

4.3.5 Number of days per week preferred for exercises

The numbers of days per week participants wished to engage in physical exercises are presented in Figure 3

Figure 3: Number of Days Participants Preferred for Exercises

Source: Primary data (2023)

Figure 3 indicates that the majority of participants in both the experimental and control groups preferred exercising three days a week. The results reveal that all participants in the control group preferred conducting the exercises for three days and 83.7% in experimental group. Only 2% of the participants in the experimental group preferred conducting the exercises for one day. The results furthermore reveal that most participants in both categories preferred conducting exercises for three or more days, implying that for one to be physically fit they must have more days of exercising.

These findings point out to the fact that all participants were keen on engaging in exercises but for only a few days considering that three days may not be adequate to have a great impact on one’s physical wellbeing. The fact that they indicated that they would prefer to do exercises, for whatever period, was considered as a positive point that with encouragement they would be able to practice for a longer period. This short duration could possibly be explained by the fact they had earlier complained of fatigue as being a problem to them.

4.3.6 Preferred Gender of trainers

As far as the preferred sex of the trainer was concerned, the participants gave their opinions and these were as summarised in Figure 4.

Figure 4: Preferred gender of Trainer

Source: Primary data (2023)

Figure 4 shows that majority of the participants, both experimental group and control group preferred both male and female trainers and they composed 55.1% and 77.6% respectively. Those who preferred male were the least participants for both experimental group and control group constituting 24.5% and 6.1% respectively. These results imply that participants that engage in physical exercises always prefer having both male and female trainers at the training ground as opposed to having one gender conducting the training session.

Preference of the training venue

The participants were asked to indicate where they would prefer to conduct their training and the responses were captured as presented in Figure 4.

Figure 5 The preferred training venue for the clients

Source: Primary data (2023)

Figure 5 shows that many of the participants (40.8%) in experimental group considered gym to be the most preferable place for training whereas 38.8% in control group considered both gym and playing field to be the most preferred place for the training. The least number of participants from both experimental group and control group preferred anywhere available and the constituted 4.1% and 2% respectively. The results therefore imply most of the people prefer gazetted sports areas to conduct the trainings of the physical exercises. Their residence in the Army barracks and the hospital, which served as the study site, may be the reason for this. Given that the participants were not questioned about why they favoured working out primarily in a gym or on a playing field, it is likely that they saw working out as a formal activity that was exclusive to these locations. This illustrates how having a designated space for exercise can serve as a motivator for those who would rather engage in physical activity.

Summary on physical activity readiness

The experimental and control groups of participants were found to be physically prepared to participate in the study, which looked at the impact of aerobic exercise on the clinical outcomes of HIV-positive patients receiving antiretroviral therapy (ART) at the General Military Hospital-Bombo in Uganda, based on the previously mentioned PAR-Q results. These results suggest that most of the participants lead relatively sedentary lives, which can be considered a common phenomenon when considering the greater Ugandan population, regardless of whether they have chronic illnesses or not. This is demonstrated by a study conducted in 2019 by Haruna, which found that students at Gulu University did not meet the daily recommended activity threshold for each individual. While exercises are good at keeping the body in a healthy state, this study was of the view that the aerobic exercise can also improve the health status of client on ART. This claim is based on research by Maduagwu et al. (2015), which showed that a 12-week aerobic exercise program increased the participants’ CD4 cell counts. However, the HIV population’s immune system may also benefit from a focus on healthy eating and adherence to antiretroviral therapy. It is to be noted though, that according to (O’Brien, 2010) higher intensity exercise sessions decrease the effectiveness of the immune system, leading to more opportunistic infections among HIV-free individuals. As such, only moderate-intensity aerobic exercise is beneficial.

Empirical Study Findings

The empirical findings are presented here in accordance with the study objective which was about assessing the impact of aerobic exercise on clients’ functional work capacity while on ART. The results, both descriptive and inferential, are presented.

Effect of aerobic exercise on functional work capacity

The second objective of the study was to establish the effect of aerobic exercises on functional work capacity of HIV positive clients on ART. Functional work capacity was measured using the seven-point Borg Rate of Perceived Exertion (RPE) see details in (Appendix XX) Scale and Duke Activity Status Index (DASI). The results are presented in the following sub-sections. The aerobic exercises considered included the intensity of the exercise, the duration and the type using a 5 phase of aerobics classes. This objective was guided by the hypothesis that, “there is no significant effect of aerobic exercise on the functional work capacity of HIV positive clients on ART”.

Rate of Perceived Exertion Findings – descriptive and inferential

The study participants were subjected to a 10 minutes aerobic exercise at 150bpm. They were asked to rate how difficult the exercise was at each stage of exercise using the seven-point Borg RPE Scale. The scale rates feeling of exertion under the continuum, very very light; very light; fairly light, somewhat hard; hard; very hard; and very very hard. The findings by segregating the experimental group from the control group before the exertion (pre-test) are presented in Figure 4.6 and those after the exertion (post-test) in Figure 4.7.

To assess the parameters of the aerobic exercise as conducted, the Rating of Perceived Exertion (RPE) scale was utilized. This scale has been presented differently by different scholars although with the same message. For instance, Lee et. al. (2022) used it to study the convergent of ratings of perceived exertion during resistance exercise in healthy participants.

The results upon conducting the ten minutes exercise were clear that the post-test scores for the experimental group of the perceived exertion shifted the higher scales of ‘hard to very hard’ to the lower part of the scale of ‘very light to fairly light’ expressing that the subject were more physically fit than before. This was confirmed by the fact that the pre-test and post-test results of the control group remained fairly the same.

Figure 6: Pre-test Results of Perceived Exertion Rate

Source: Primary data (2023)

Figure 6 shows pre-test results it was found out that majority of the participants about (33%) in experimental considered exertion rate to be very very hard and majority (30.6%) in control group considered the exertion rate to be both very hard and very very hard. The least number of participants in both the experimental group and control group considered the exertion rate to be very light and they constituted 2% and 8.2% respectively.

On comparing the findings of the experimental group and those of the control group after the physical exercises, the results were as presented in Figure 4.7

Figure 7: Post-test Results of Perceived Exertion Rate

Source: Primary data (2023)

Figure 7 shows that the experimental group ratings shifted more towards the left indicating that the participants rated the exertion to be much lighter than before the exercises. The post-test results revealed that majority of the participants (49%) from experimental group were perceived to give very light ratings whereas 40.8% from the control group were perceived to give very hard.  Only 4.1% of them gave a rating of “Hard” while none gave a rating of either “very hard” or “very, very hard” for the experimental group while only 6.1% gave ratings of very light and fairly light for the control group.

The scale shows either 1-10 1-10 being very, very light meaning the exercise was simple, and 10 being maximum effort or being very light, 10-20 being maximal exertion very, very hard (CDC 2022). Figure 7 shows there was a shift for the experimental group from the side of very, very hard to very, very light. This indicates there was improvement in VO₂max hence improved performance.

Figure 8: Scale Converter Borg 1-10 scale to Borg 6-20 scale

Source: Panzak, (2012)

Figure 8 shows that on converting the readings from the 1-10 scale to 6-20 scale and multiplying with 10 to establish the approximate heart rate, the following graph was developed (The workout is appended; appendix III). Figure 9 shows how the heart varied for both the control and experimental groups. The right side shows control group while the left side shows experimental group while the blue line shows pre-test and red shows post-test results.

Figure 9 showing the results of the heart beat

Source: Primary Data (2023)

Figure 9 shows that on the left side are results of the experimental group and the right-side control group. The results indicate that there was a lowered heart rate for the experimental group in post-test compared to control group. Nystoriak and Bhatnagar (2018), alludes that regular exercise has numerous benefits for the cardiovascular system, including strengthening the heart muscle. Engaging in regular physical activity, makes the heart become more efficient at pumping blood. This increased efficiency means that with each beat, the heart can pump a larger volume of blood, allowing it to beat less frequently while still maintaining an adequate blood flow to meet the body’s demands. What should be noted is that, a strong heart muscle is a crucial component in improving oxygen uptake and VO₂max it pumps more blood that makes oxygen delivery better, (Zheng et al., 2022).

Inferential statistical test which involved conducting a paired-sample t-test was conducted to test the hypothesis of the second objective of this study that:

Ho₂                 There is no significant effect of aerobic exercise on the functional work capacity of HIV positive clients on ART.

The findings of this test were Table 4.10, table 4.11 and Table 4.12 which were about paired samples statistics. The first one was the Paired samples statistics and the second was the Paired sample test results.

Table 4.10: Paired Samples Statistical Results

Source: Primary Data, 2023

The results of the experimental group show a significant difference between the mean of the post-test to the pre-test of -3.222 (2.53 – 5.76) compared to that of the control group of only 0.21 (5.51 – 5.30). There were also variations in the standard deviations of the results of the two groups.

The paired samples correlation findings were as presented in Table 4.11

Table 4.11: Paired Samples Correlation

Source: Primary Data (2023)

According to the pre-test and post-test functional work capacity results in both the experimental and control groups were found not to be correlated. This indicates that there is no linear relationship between the pre-test and post results.Next it was important to establish whether the calculated sample mean falls into the confidence interval. The results for this are as presented in Table 4.12.

Table 4.12: Paired Samples Results

Source: Primary Data, 2023

Table 4.12 reveals that the calculated mean of the experimental group was -3.222 while the 95% confidence interval of the difference ranged from -3.7705 to -2.739. This shows that the calculated mean indeed falls within the confidence interval. The calculated mean for the control group was equally within the 95% confidence interval considering that it was 0.213 and the interval ranged from -0.432 to 0.858. The t-test of the experimental group was established to be statistically significant as the p-value of <0.001 is less than 0.05. The results are: t(44) = -13.442, p < 0.001. The t-test of the control group was, however, not statistically significant as the results were: t(46) = 0.664, p = .510 which is > 0.05. Considering that the p-value of the experimental group in this case was. <0.001 which was less than the alpha level (.005) since a 95% level of significance was considered in this test, the null hypothesis that, “There is no significant effect of aerobic exercise on the functional work capacity of HIV positive clients on ART”, is rejected. These results support the fact that the two sets of results (pre- and post-test) are different and that the mean of the post-test as relates to perceived exertion decreased the functional work capacity improved.

These results imply that the aerobic exercises indeed improve the functional work capacity of HIV positive clients on ART. This was comparable to research that examined the efficacy of aerobic exercise for adults living with HIV: a systematic review and meta-analysis employing the Cochrane Collaboration protocol exercise group ended the 20-minute multi-stage shuttle run test (20mMST) with a higher heart rate and rate of perceived exertion (RPE). According to the 20mMST, VO₂max significantly improved among exercisers as compared to non-exercisers. The modified Borg Rate of Perceived Exertion (RPE) scale was used to gauge intensity. PRE: 45–50 minutes were spent on resistive exercises, which consisted of three sets of 8–12 repetitions with a one to three minute rest period in between each set and a 5–10 minutes cool-down. Intensity: Bench press and leg press: 60–80% of maximal repetitions (1 RM). After a given weight was lifted 8-12 times until muscular failure (unable to complete additional repetitions), the participants exhibited a greater improvement, (O’Brien et al., 2016).

Duke Activity Status Index (DASI) Results – descriptive and inferential

To further assess whether exercise had an effect on VO₂ max, the DASI was used. The participants were required to rate DASI questions using the scale: Extremely Difficult or unable to perform activities = (0); Quite a bit difficulty = (1); Moderate difficulty = (2); A little a bit of difficulty = (3); and No difficulty at all = (4). The findings were as presented in Table 4.13 shows the results of the DASI rating

The descriptive results using the percentage responses were as presented in Table 4.13.

Table 4.13: Duke Activity Status Index (DASI)

Scale: (0) = Extremely Difficult or unable to perform activities; (1) = Quite a bit difficulty; (2) = Moderate difficulty; (3) = A little a bit of difficulty; and (4) = No difficulty at all

Source: Primary Data, 2023

Table 4.13 confirms that the participants in DASI were expected to select “yes” or “no” for each question. The DASI score is calculated by multiplying the total number of “yes” replies by 0.43, adding 9.6, and calculating the estimated maximum oxygen consumption (VO₂ max). There is a range of 0 to 58.2 points in the final score. The functional capacity scores improve with higher scores (Tolulope et al 2021). Total of the questionnaire answers equals DASI. (mL/kg/min) x VO₂ max = 0.43 x DASI + 9.6. METs (in metabolic equivalents) = VO₂ max / 3.5. This study considered the middle points to determine improvement in functional work capacity.

Table 4.14 VO₂max values calculated from DASI

Source: Primary Data, 2023

For the Experimental Group, the VO₂ max (in mL/kg/min) significantly improved from 25.13 to 34.19 mL/kg/min while that of the control group only changed slightly from 18.51 to 22.26 mL/kg/min. As indicated the DASI score ranges from 0 to 58.2 points, the higher the scores, the better the functional work capacity. Table 4.14. Figure 4.10 shows a clear variation the pre-and post-test result of experimental group. The results show an improvement in oxygen consumption as indicate on the left side of Figure 4.10 where the experimental group are on the left and the control group on the right. The blue line on figure 4.10 is pre-test while the pink is post-test. These findings are consistent with those of O’Brien et al. (2016), who discovered that engaging in aerobic exercise, or a mix of aerobic and resistive exercise, three times a week for five weeks or more, is safe and can enhance the quality of life, strength, body composition, and cardiorespiratory fitness in adults living with HIV.

Figure 4.10 showing VO₂max results

Source: Primary Data (2023)

The inferential analysis on DASI was conducted by undertaking a paired-sample T-test using the SPSS version 20 and the results were as presented in the next two subsequent tables.

Table 4.15: Paired Samples Statistical Results

Source: Primary Data (2023)

The first thing to check was whether there was a difference in the mean values of the pre-test results compared to the post-test results. The results of the experimental group show a significant difference between the mean of the post-test to the pre-test of 1.26 (3.88 – 2.62) compared to that of the control group of only 0.17 (2.53 – 2.36) as shown in table 4.15. The paired correlations results were as shown in Table 4.16

Table 4.16: Paired Samples Correlation

Source: Primary Data (2023)

According to the pre-test and post-test Duke results in both the experimental and control groups were found not to be correlated. This indicates that there is no linear relationship between the pre-test and post results in that, the post-test Duke results for any given subject was not related to the corresponding pre-test reading. Following the above test, next it was important to establish whether the calculated sample mean falls into the confidence interval and whether the results are statistically significant or not. The results were as presented in Table 4.17

Table 4.17: Paired Samples Results

Source: Primary Data, 2023

As shown in Table 4.17, the calculated mean of the experimental group was 1.257 while the 95% confidence interval of the difference ranged from 1.069 to 1.445. This shows that the calculated mean indeed falls within the confidence interval. The calculated mean for the control group was equally within the 95% confidence interval considering that it was 0.163 and the interval ranged from -0.088 to 0.414. The t-test of the experimental group was established to be statistically significant as the p-value of <0.001 is less than 0.05. The results are: t(47) = 13.457, p < 0.001. The t-test of the control group was, however, not statistically significant as the results were: t(40) = 1.309, p = .198 which is > 0.05

Considering that the p-value of the experimental group in this case was <.001 which was less than the alpha level (.005) since a 95% level of significance was considered in this test, the null hypothesis that, “There is no significant effect of aerobic exercise on the functional work capacity of HIV positive clients on ART”, is rejected and this means that the aerobic exercises statistically significantly increased oxygen consumption (functional work) capacity of the HIV positive clients.  The results imply that oxygen consumption in the experimental group increased and therefore the functional work capacity. The clients living on HIV in the experimental group found the post-test exercise easy despite the fact that it was the same intensity compared to the clients in the control group. Therefore, well-structured aerobic exercises improve functional work capacity for HIV positive clients on ART in Uganda.  It is known that oxygen uptake kinetics determines exercise tolerance by determining the rate of carbohydrate (CHO) oxidation and/or the rate of heat storage in exercise, (Burnley & Jones 2007). This clearly explains how oxygen consumption improves functional work capacity. These results agree with a study of Riedel et al. (2021), where there was an improvement in functional work capacity measured using the DASI, and that of (O’Brien et al., 2016).  Where the participants exhibited a greater improvement in functional work capacity.

The study’s findings, which as summarized, are consistent with those of O’Brien et al. (2016), who found that doing aerobic exercise three times a week for at least five weeks can improve an adult with HIV’s strength, body composition, cardiorespiratory fitness, and quality of life. The findings corroborate previous findings by Warburton et al. (2006) and Penedo (2005) that exercise does, in fact, have a good effect on strength, cardiovascular function, and psychological status even in non-patients. In a similar vein, O’Brien et al. (2008) had also shown that persons with HIV could benefit from aerobic exercise.

The results of this study were also consistent with those of Stanley et al. (2017), who also showed that exercise improves the general health and wellbeing of the HIV population, and of Jaggers et al., (2014), who found that exercise and physical activity are safe and effective ways to improve the metabolic profile, cardiorespiratory fitness, and quality of life in people living with HIV. The argument of O’Brein et al. (2016) based on other studies as a concern exercising is that the exercise does not positively restrict viral replication or improve the immune system of PLHIV, but instead, it can elicit improvements in cardiorespiratory fitness, strength, body composition, and overall quality of life. In fact, according to Aweto et al. (2016), aerobic exercise improves the functioning of the pulmonary system and also alleviates respiratory and depressive symptoms in younger HIV positive clients. Apparently though, in 2017 Stanley et al. (2017) in their study to examine the effectiveness of a 12-weeks exercise on quality of life and CD4 cells of HIV population established that there was an insignificant change in the quality of life of the HIV positive clients. At the same time, according to Stanley et al., (2017), there seems to be no study that has indicated that moderate intensity exercise can lead to deterioration in the health status of HIV sero-positives on HAART.

Table 4.38: Summary Results of Hypotheses Testing

Source: Primary Data (2023)

The results above show that all the study hypotheses were rejected implying that aerobic exercises according to this study were very useful in HIV positive clients on ARVs. In summary, therefore, aerobic exercise significantly improves the functional work capacity of HIV positive clients on ART.

CONCLUSIONS AND RECOMMENDATIONS

Effect of aerobic exercise on functional work capacity of HIV+ Clients on ART

The results show that before the physical exercises, the rate of perceived exertion was the same across the two groups. However, the experimental group participants rated the exertion to be much lighter than before taking part in aerobic exercise sessions. The results of the experimental group show a significant difference between the mean of the post-test to the pre-test compared to that of the control group. The t-test of the experimental group was established to be statistically significant while that of the control group was not. Indicating the 12 weeks moderate intensity aerobic exercise improved functional work capacity in clients living with HIV on ART.

Going by these results, it follows that the functional work capacity of HIV positive patients can indeed benefit from well organised, timed, and moderated aerobic exercises. This is significant in that such patients may be enjoying themselves while keeping physically fit and at the same time improving their functional work capacity. This would mean that they can be in a position to be self-dependent in any chores as opposed to them feeling “week” and incapable of being active without undue fatigue.

The study established an improvement in the VO_2max for participants in the experimental group compared to the control group. As oxygen is the fuel of the body it can be concluded that the functional work capacity of the participants improved after the aerobic exercise intervention.

It was also found out that the clients in the experimental group had their heart rate lower when exposed to the same exercise intensity as in the pre-test. This is true because as one exercises the heart becomes stronger and it is able to pump enough blood and therefore no need of pumping many times. This therefore means the blood supply the muscles can be adequate hence improved functional work capacity.

Conclusions

Conclusions on the effect of aerobic exercise on functional work capacity

1. The results were clear in all the two tests done that, HIV positive clients on ART had a significant improvement after an exercise intervention. Given aerobic exercise clients will be more productive and continue doing their work without undue fatigue like their HIV negative counterparts.
2. The use of RPE and DASI give almost the same results when measuring oxygen consumption to determine functional work capacity. RPE there was a clear shift to a score below ten indicating the exercise was very simple for the experimental group in the post test. With DASI there was an increase from 19.9 to 48.68 scores which indicated a significant improvement in functional work capacity.

5.6 Recommendations

the following recommendations were made:

• MoH should authorise the use of aerobic exercise as an additional therapy in the care and treatment of HIV positive clients on ART in Uganda to improve their quality of life.
• MoH should skill clinicians in the prescription of exercise to HIV positive clients on ART in Uganda
• MoH should add details of recommended exercises in the HIV prevention and treatment guidelines    of Uganda
• HIV positive clients should regularly participate in aerobic exercise. This can further be of help in weight management, help to reduce pre-disposing factors of none communicable disease in HIV positive clients and improve their quality of life.
• Ministry of Education and sports should add exercise physiology in the training of clinicians and counsellors since they are the ones who handle HIV positive clients.
• Implementing partners should support advocacy concerning the benefits of aerobic exercise on improving the quality of life of PLHIV.
• Exercise scientists should promote policies and programmes that gear-up to the promotion of aerobic exercise to all PLHIV.
• MoH should include exercise scientist in the care and management team of HIV positive clients
• Academic institutions should add exercise counselling as a course unit which will promote exercise adherence.
• Mental health experts should promote Aerobic exercise training which can be made part of health care service in HIV positive clients in order to improve their mental health
• Health promotion policy maker’s arm of the government and Healthcare givers should integrate and enforce the use of exercises either as a single regimen or combined exercises into the management plan of PLHIV for greater boost in absolute CD4 count, functional work capacity and mental health bearing in mind that both have positive effects.
• Health care providers should advocate for the integration of physiotherapists in the managements of PLHIV for appropriate prescription and education of therapeutic exercises for body weight.

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