is also associated with a possible increase in upper res-
piratory tract infections (Mackinnon, 2000).EXERCISE AND THEIMMUNERESPONSE INHIV
POSITIVEATHLETES
- There is a definite link between moderate exercise and
a strengthened immune response in HIV positive sub-
jects. Increases in CD4 levels caused by aerobic exer-
cise have been shown in asymptomatic patients with
HIV. Exercise has also been shown to lower anxiety
and tension levels in HIV positive individuals
(LaPerriere et al, 1991). Evidence also indicates that
even individuals with advanced HIV infection (AIDS-
related symptoms or AIDS-defining opportunistic
infections) respond to an exercise regimen with
increased CD4 counts and an increased CD4:CD8
ratio (Eichner and Calabrese, 1994).
•However, with intense exercise, HIV-infected subjects
may have an impaired ability to mobilize neutrophils
and natural killer cells. This has been shown in
response to 1 h of exercise at 75% VO2max(Ullum
et al, 1994).
•Weight training may enhance muscle strength, bulk,
and function in HIV+ individuals. It may therefore
mitigate AIDS-related muscle wasting (Feller and
Flanigan, 1997). - Nonimmunologic effects of HIV on the athlete
include—cardiac effects (a decreased VO2maxdue to
deconditioning, which may be reversible with aerobic
training), pulmonary effects (certain infectious dis-
eases like PCP may have restrictive ventilatory
effects), hematologic effects (anemia may be a pri-
mary manifestation of HIV disease or may be a side
effect of antiretroviral therapy and could cause a
reduction in maximal oxygen uptake and lower the
lactic acidosis threshold impairing physical perform-
ance), and muscular effects (some retrovirals may
induce mitochondrial myopathies or severe resting
lactic acidosis) (Stringer, 2000).
•Exercise recommendations for HIV positive athletes:
Moderate exercise may be beneficial both physically
and psychologically, but strenuous exercise may be
detrimental (Feller and Flanigan, 1997). Additionally,
although the exercise demands of high-level and pro-
fessional athletics may be safe and beneficial, the pos-
sible detrimental effects of psychologic stress must be
assessed on an individual basis (Eichner and
Calabrese, 1994).
•Exercise is safe and beneficial for the HIV-infected
person. HIV-infected individuals should begin exer-
cising while healthy, and attempt to maintain their
exercise program through the course of their illness.
HIV-infected persons can use exercise to help manage
their illness and improve their quality of life.
•For healthy, asymptomatic HIV positive individuals,
unrestricted exercise is acceptable. Avoidance of over-
training should be emphasized. Stress related to com-
petition should be minimized. Moderate exercise
(40–60% VO2max) or heavy aerobic exercise (60–80%
VO2max) can be recommended depending on patient
preference and motivation. An exercise program pre-
scription should be 1h/day, 3×/week, for 6–12 weeks.
•For individuals with advanced HIV infection with
mild to moderate symptoms or lower CD4 counts
(<200), competition, restrictive training schedules,
and exhaustive exercise should be avoided. Physical
activity and moderate exercise training should be
encouraged under close supervision.- Athletes with frank AIDS may remain active on a
symptom-related basis but should avoid strenuous exer-
cise and reduce or stop training during acute illness.
•Caveats: A complete physical examination should be
undergone to assess the overall health and status of
HIV infection before beginning an exercise program.
Cardiopulmonary exercise testing with gas exchange
measurements (to exclude subtle cardiopulmonary
markers of occult infection, anemia, myopathies, and
the like) should be performed before determining an
exercise prescription, especially in patients with low
CD4 counts or high viral loads (Eichner and
Calabrese, 1994; Stringer, 2000).
TREATMENT•Treatment goals should include attempts to—suppress
viral replication, suppress evolution of resistant
strains, increase CD4 cell counts, prevent disease pro-
gression, improve energy levels, decrease weight loss,
promote weight gain, and preserve quality of life and
prolong survival.- Antiretroviral medications: Include nucleoside
reverse transcriptase inhibitors (RTIs), nonnucleoside
reverse transcriptase inhibitors (NTRIs), and pro-
tease inhibitors (PIs). - Recommendations on treatment regimens are constantly
changing as a result of finding the correct balance
between optimizing the patient’s immunologic/viro-
logic outcome versus reducing the toxicity of antiretro-
viral therapy and the development of drug resistant HIV
strains. - Current recommendations suggest that highly active
antiretroviral therapy (HAART) should be started
when CD4 counts drop to 200 cells/uL or the HIV viral
load is >55,000 copies/mL. Earlier treatment may
improve immunologic/virologic outcomes, but it
increases drug toxicity and the development of resist-
ance. Patients must strive for perfect adherence to
604 SECTION 7 • SPECIAL POPULATIONS