This study aimed to explore the perceptions of older people living with HIV in a semi-rural area regarding physical activity and exercise. Understanding the perceptions of this specific population about physical activity and exercise can be useful in the development of interventions that are context-specific and feasible for OPLWH.
The theme around the motivation for physical activity and exercise highlighted facilitators to exercise and physical activity participation. The OPLWH in our study believed that a recommendation by their health professional was a catalyst to them being physically active. Some men and women reported that, during consultation with their primary healthcare provider, they were advised to participate in some form of generalized physical activity or exercise. The benefits that were communicated by the healthcare provider included delayed progression of the disease and improved quality of life. This compelled them to engage in some form of physical activity or exercise. However, there was no clear guidance offered by the healthcare team with regards to mode, duration, frequency, and intensity of exercise prescription. Current physical activity recommendations, as described by the American College of Sports Medicine (ACSM) Exercise Management for Persons with Chronic Disease and Disabilities, for people living with HIV, suggest a moderate-intensity aerobic and resistance training regimen(21). This includes accumulating a total of 150 minutes of moderate-intensity physical activity a week, as well as two days of full body resistance training, following medical clearance from a primary healthcare provider. The prescription is for people living with HIV, and is not specifically tailored for OPLWH. This could possibly contribute to the hesitancy by healthcare teams to provide clear physical activity and exercise guidelines to this OPLWH population.
Personal gratification from participation in physical activity was commonly reported by the both men and women in our study. Some OPLWH also viewed physical activity as a leisure activity rather than a necessity for healthcare. Both health and well-being are improved in a meaningful, enjoyable, leisure activity, such as physical activity and exercise. It also affords a context for self-validation and expression, self-determination and self-esteem, and creativity; all of which contribute to an improved quality of life and sense of well-being(22–25). Participation in physical activity and exercise acts as a buffer against the adverse effects of stress on mental and physical health, and serves as a restorative mechanism that helps people transcend negative life events(26, 27). Studies examining physical activity and exercise levels among older adults are scarce, and research seems to have generally overlooked people growing older with HIV.
Our paper found that the activities of daily living influenced participation in physical activity. Our study was located in a semi-rural area in South Africa where the essential activities of daily living ranged from cooking and cleaning duties in the home, to farming and taking care of livestock. Yaya et al. (2020) assessed the relationship between self-reported difficulty in performing the activities of daily living (ADL’s), health, and quality of life among community-dwelling populations aged 50 years and over in South Africa and Uganda(28). The study found that only two-fifths of the participants reported having good health, and one-fifth reported enjoying a good quality of life. The analysis revealed disparities of varying degrees in the prevalence of good health and quality of life between participants in both countries, but concluded that having difficulty in the ADL was found to be a significant predictor of poor health and quality of life. Our participants were of the belief that ADLs influenced their participation in physical activity and exercise because it improved their health and overall quality of life.
Religious involvement and family responsibility influenced physical activity in both the men and women in our paper. Other studies in this context highlighted the scarcity of resources, including transportation and lack of employment(29–31). This has an influence on the community, as walking becomes the travel mode of necessity. The benefits are sought-after, but the circumstances around such choices need to be addressed. Older people in a South African context, especially in semi-rural and rural communities, are often responsible for caring for grandchildren while parents work in urban areas(32, 33). Caring for children requires high levels of physical activity, such walking to school, playing and helping with grooming and selfcare(34–36). Another circumstance that often prevails in poorly resourced communities is that parents are separated from their children for financial reasons. This is not often ideal, but within the context of this study, it does lead to the benefits of physical activity for OPLWH.
Barriers to participation in physical activity and exercise included stigma. Stigma has been recognized as an important barrier to physical activity and exercise in vulnerable groups(13, 37). However, in the specific context of OPLWH, there is a dearth of research to assess the relationship between physical activity and the perception of HIV-related stigma. HIV-related stigma is defined as social discrediting and devaluation associated with HIV against people perceived to have HIV(38). Anticipated stigma, enacted stigma and internalized stigma are all mechanisms through which stigma may be experienced by people living with HIV (PLHIV)(39, 40). Anticipated stigma refers to the expectation of discrimination and prejudice from others, due to one’s HIV status; while enacted stigma refers to experiences of discrimination and prejudice from others due to one’s HIV status(40). Internalized stigma is related to endorsing negative feelings and beliefs associated with HIV and applying them to oneself(39). According to Han et al. (2018), of the three mechanisms, internalized stigma seems to have the most influence on behaviors and attitudes to physical activity(41). This can manifest as a reluctance to engage in specific, public forms of activity (e.g. at gyms, in social sports teams), or as avoidance of any physical activity, such as going for a brisk walk. Our participants cited internalized stigma as a major barrier to engaging in some form of physical activity or exercise, especially in a group setting. Akatukwasa et al. (2021) also advocate for the further exploration of the connection between levels of internalized stigma and physical activity behavior in PLHIV, in order to better inform physical activity interventions for this population(42). Developing and implementing physical activity programmes for OPLWH should include factors to mitigate against such stigma in the community. This could include mixed groups of participants within exercise groups, as well as increasing awareness and fostering understanding within such communities.
Our research found that physical health issues and personal circumstances contributed to poor uptake of physical activity and exercise. The link between a decline in physical health and HIV, as well as personal circumstances as a result of HIV, is well documented. The decline in physical health as a result of HIV may be associated with more musculoskeletal problems and subsequent bodily discomfort during participation in physical activity or exercise(43). This is evident from the experiences of OPLWH in our study. However, it is important to bear in mind that physical activity and exercise enhances physical well-being, which in turn may benefit one’s physical self-perception, especially in HIV populations. Olsen et al. (2015) found that higher HIV loads were associated with less physical activity and participation in exercise (44). The authors agreed that a higher HIV load should not be a contra-indication for physical activity, and recommended that patients with higher HI viral load levels perform moderate, instead of high intensity, physical activity. Despite the medical advances in HIV management with antiretroviral therapy, OPLWH appear to experience age-associated comorbidities at a higher rate than younger adults. The physical barriers attributed by our participants to HIV and medication – fatigue, and chronic musculoskeletal pain – are consistently identified as barriers to exercise(45). To engage OPLWH, exercise interventions must acknowledge and address this issue. The effective management of HIV and support to those infected, together with understanding their personal circumstances, is vital in increasing the opportunity to undertake physical activity.
Other barriers to the uptake of physical activity by the OPLWH in our study included the lack of proper instruction and environmental factors. Many of our OPLWH indicated that they would love to engage in some form of physical activity and exercise, but did not know where, when, or how to begin. One of the men said “That’s my problem. Up until today I love to exercise but I’ve never been instructed thoroughly about it. Yes, that is what is worrying me.” Li et al. (2017) identified instruction and supervision by a suitably qualified health professional as an important factor to consider when developing and implementing community-based exercise programmes for PLHIV(46). This greatly enhanced adherence to physical activity and exercise in PLHIV. The men and women in our study believed that environmental factors such as lack of time, and the lack of a conducive environment and facilities, inhibit them from participating in physical activity and exercise. Similar environmental factors were reported by Wright and colleagues (2020) when investigating physical activity, exercise, and diet among older Ugandans living with, and without, chronic HIV infection(47). Most studies conducted in sub-Saharan Africa, although few, have often cited the lack of facilities in rural and semi-rural areas as a barrier to physical activity and exercise adherence.
The theme regarding the proposed structure of physical activity and exercise focused on the belief of OPLWH that the provision of combined activity in the form of aerobic, resistance, flexibility, and balance exercises could be beneficial and should be encouraged. Most of the men and women also preferred group-based exercise rather than individual exercise regimens. Most highlighted the fact that the benefits from social interaction and peer support during group-based exercise was important to them, as outlined by the statement by one of our most senior participants “Definitely, I prefer to exercise in a group. That’s where we get encouragement and forget about the pain and stresses and we all go on this journey of exercising together.” The frequency, duration, intensity and time of activity requires further exploration in this population. There seemed to lack of understanding around these parameters and/or how they could be used in prescribed physical activity and exercise to improve their health outcomes. Grace et al. (2015) acknowledged that, whilst the primary goals of prescribing exercise in HIV-infected patients are to improve quality of life (QOL), physical tolerance, and neuromuscular function, and to promote long-term exercise compliance, most exercise prescriptions fail to indicate the optimum frequency, duration, intensity and time(48). This advocates for a closer inspection of the exercise dose-response relationship, which is important when prescribing physical activity and exercise for OPLWH.