Keywords

1 Background

Since 1996, the year in which highly active antiretroviral therapy was introduced, the number of patients who died from AIDS and opportunistic infections has significantly decreased (by two-thirds). On the other hand, new health problems including lipids and glucose imbalance and body fat among the patients have gained more attention among physicians and health professionals [1]. In addition, a significant number of newborns who are infected with HIV perinatal infection reach older age causing adolescent HIV epidemics in many parts of the world. Adolescents with congenital HIV cope with several stressors such as other chronic illnesses, ongoing medical treatments, hospitalization, pain, and social problems. In fact, the patients face a wide range of psychosocial problems that are highly stigmatized and may make adolescence a very difficult period for them [2]. Moreover, the HIV-related disabilities are associated with patient’s impairment in daily activities and less exercise. Several scientific findings indicated that exercise training increases aerobic capacity, muscle strength, flexibility, and functional ability in patients with HIV or AIDS [3]. Therefore, as suggested by rehabilitation professionals, keeping up physical activities and regular exercise are key strategies in medical and social care of HIV/AIDS patients. Both symptomatic and asymptomatic HIV-infected patients can develop cardiopulmonary dysfunction characterized by a decrease in both oxygen uptake at submaximal and peak exercise levels and workload capacity. Statistics demonstrated that the most common cardiovascular diseases diagnosed among HIV/AIDS patients were coronary atherosclerosis, angina pectoris, and myocardial infarction. Moreover, HIV patients were more likely to suffer from chronic obstructive pulmonary disease. Patients with HIV-associated pulmonary hypertension had poor prognosis, among whom the vascular endothelial cells were chronically exposed to viral proteins which can be produced by HIV-infected cells in the lung. The loss of skeletal muscle mass and lean tissue mass, known as HIV-associated wasting, is a common disorder among HIV-infected individuals. About 20% of HIV patients with rapid disease progression could suffer from wasting, which is closely related to an increase in morbidity. Metabolic disorders such as dyslipidemia and abnormal glucose metabolism, appear frequently in HIV-infected patients leading to a significant imbalance in body composition and less quality of life [4]. Today, exercise is proven to have a significant role in diseases that are not primarily known as disorders of the locomotive apparatus [5]. Different types of physical exercises are considered as efficient non-pharmacological interventions for patients with chronic diseases [6]. For example, it has been shown that osteoporosis, deterioration of bone tissue, disruption of bone architecture, and compromised bone strength that predispose patients to an increased risk of fracture are common among HIV-infected patients. These conditions are likely to become an important cause of morbidity and mortality alongside of aging process of the HIV-infected people. For example, osteoporosis leads to a higher risk of osteoporosis-related fractures, which might be associated with increased risk for osteonecrosis of the hip and other bones. It has been shown that practicing 30 min of weight-bearing (jogging, dancing, walking) and muscle-strengthening exercises (i.e., weight training) for at least 3 days a week may increase bone density and prevent osteoporosis and its related fractures [7]. In addition, a large number of studies reported that regular aerobic and resistance exercises can promote cardiovascular performance in elderly people by increasing the volume of O2 uptake, reducing blood pressure, improving glucose and lipid metabolism, and decreasing risks of cardiovascular diseases.

Exercise can also prevent osteoporosis and osteoarthritis, and improve neuropsychological health. Resistance exercise also showed beneficial in enhancing muscles strength and function in older HIV patients [4]. The American Psychiatric Association recognizes the diagnosis of a life-threatening illness as a potentially traumatic stressor that may lead to the development of posttraumatic stress disorder (PTSD) [8]. In that regard, it is a truly huge stressful experience to be diagnosed with HIV infection. Kamitani et al. (2017) suggested physical exercise among HIV infected patients as a good strategy to prevent AIDS related complications [9]. Similarly, Quigley et al. (2018) found that physical activity may play an important role in preserving or even improving cognitive performance of people living with HIV [10]. Jaggers (2018) concluded that people living with HIV/AIDS, regardless of disease status, can gain short-term health benefits from routine physical activity. Another study reported that after a moderate level of routine exercise for 5–6 weeks, a significant improvement was obtained in psychological and physiologic statuses of the participants [11]. In an interventional study, a better body image in people living with HIV/AIDS was observed after taking part of a physical exercise program [12]. To define the factors affecting the willingness of patients in doing physical exercise, Mabweazara et al. (2018) evaluated the effects of social support and socioeconomic status of individuals with HIV on their levels of physical activity. In addition, some resources introduced socioeconomic barriers that prevent HIV people from doing physical exercises. It was also reported that social support plays important roles in promoting physical activity and counteracting the other barriers of physical activity in people with low socioeconomic status living with HIV/AIDS [13].

2 Immune Function and Exercise

Exercise is known to have a profound effect on the functioning of the immune system. It is generally believed that prolonged periods of intensive exercise training can depress function of the immune system, whereas, exercise with regular to moderate intensity is beneficial to the immune system. Regular moderate-intensity exercises are “immuno-enhancing” and have been used to effectively increase vaccine responses in immune-compromised patients. The observed improvements in the functioning of the immune system after regular exercise of moderate intensity may be explained by significant reduction in the levels of inflammatory factors, maintenance of thymic mass, alterations in the composition of “older” and “younger” immune cells, enhanced immune surveillance, and/or the amelioration of psychological stress. Indeed, exercise is a powerful behavioral intervention that has the potential to improve immune and health outcomes in the elderly, the obese, and patients living with chronic viral infections such as HIV [14]. However, when it turns to HIV positive patients, there are conflicting results regarding the effects of exercise on the immune function. Neto et al. (2015) demonstrated that the stability of immunological and virological measures during regular exercise can be seen as evidence for the safety of these types of interventions [6]. According to Kamitani et al. (2017), CD4 counts were better improved by interventions with interval aerobic or 41–50 min of exercise three times per week compared with other types and durations of exercises [9]. On the other hand, in a study on the impact of a 12-week aerobic and resistance exercise training program on mental health and CD4 counts among female HIV+ patients, Dianatinasab et al. (2018) found no significant change in CD4 cell counts after the intervention program. In contrary, according to a pre-post analysis study, although both intervention and control groups experienced a decline in CD4 count over time, patients who practiced a 12-week exercise experienced less decrease in CD4 count. High variation and small sample size were possible reasons that the rate of reduction in CD4 counts in the intervention group was not statistically significant [15]. In another study, a combined (resistance plus aerobic) exercise training program completed by ten HIV infected sedentary adults induced a significant increase in the number of TCD4+ cells as well as CD4+/CD8+ ratio reflecting an important benefit to the immune system of HIV+ participants. However, no effect of training on viral load of the participants was detected. These findings strongly suggest that exercise training programs improve the efficiency of immune defense system with no apparent risk to the patients [16]. Interestingly, no study has shown any exercise-induced reduction in immune cell count or function at any exercise intensity when looking specifically in HIV-infected patients. Jaggers and Hand (2016) suggested that aerobic and/or resistance exercise at any intensity neither helps nor hinders immune function or viral load for people living with HIV/AIDS at any stage of HIV infection [17]. However, it is believed that while moderate-intensity physical activities improve the immune function in people with HIV/AIDS, high-intensity exercise may have immunosuppressive effects in people living with HIV/AIDS [12].

2.1 Exercise and CD4/CD8

The effect of exercise on CD4 count is still under debate. This is because few studies suggested that exercise programs may increase CD4 count [17], whereas others found no significant association [15]. Kamitani et al. (2017) suggested that regular aerobic exercise, up to 50 min, three times per week, appears to positively affect CD4 counts among people living with HIV [9]. After summering several studies on effects of any type/intensity of exercise on CD4+ counts, Jaggers and Hand (2016) conducted that there is a potential benefit in maintaining CD4+ cell count when routine moderate-intensity aerobic exercise is done while HIV/AIDS patients were taking ART [17]. In a Nigerian study, 45–60 min, 3 times/week for 8 weeks of moderate intensity exercise resulted in an increase in CD4 cells versus conventional therapy involving ART only [18]. Ten sedentary adult participants with HIV exhibited a significant improvement in several important immunological indexes after completing a 20-week combined resistance–aerobic exercise training program. Although the participants’ serum viral load remained unaltered throughout the period of the exercise program, the number of TCD4+ cells increased by 31% and a significant augmentation in CD4+/CD8+ ratio was observed. The improvement in the number of TCD4+ lymphocyte and CD4+/CD8+ ratio highlights the importance of combined exercise training program in the functioning of immune system among HIV positive participants [16]. Another study on people living with HIV/AIDS, who were receiving ART treatment, revealed a significant decrease in systolic blood pressure, diastolic blood pressure and increase in CD4 count and maximum O2 volume uptake (VO2 max) after aerobic exercise with moderate intensity (between 60 and 79% of heart rate reserve) quantified by jogging on a treadmill. Furthermore, the results indicated a significant positive correlation between change in VO2 max and change in CD4 count. These findings suggest that moderate intensity aerobic exercise is an effective complementary therapy in lowering blood pressure and increasing CD4 cell count in people living with HIV/AIDS [19]. From a different point of view, Grace et al. (2015) noted that considering the stage of HIV/AIDS disease is critical not only for tracking and monitoring the HIV epidemic but also for the clinical management of the disease. Physical exercise therapists should therefore be aware of the stages and the varying needs of the HIV patients in order to prescribe the effective exercise. For the aerobic exercise for HIV-positive individuals, the researchers recommend 40–60% of exercise intensity of VO2R (difference between VO2max and resting VO2) or heart rate reserve. Progressive resistive exercise intensity can be measured as percentage of 1RM (1 Repetition Maximum: maximum amount of weight that a person can lift for one repetition). Intensities of the exercises prescribed to HIV-infected individuals most often include progressive resistive exercise start at moderate intensity of 50–60% 1 RM, and then gradually to higher level of intensity (75–80% 1 RM) after 4–12 weeks of training. Although training at higher intensities of up to 85% 1 RM reported no adverse effects, a progressive resistive exercise at 60–80% of 1 RM for 2–3 sets of 8–10 repetitions are recommended. For HIV-infected individuals, 20 min of steady-state exercise has been suggested to gain positive results though, with a longer session of up to 1 h also showing positive results. In most observational studies, regular training that included alternate moderate-and high-intensity exercises were also associated with improved CD4 counts [20].

3 Exercise and Quality of Life in HIV Positive People

It has been shown that HIV declines muscle function and reduces physical activity, so maintaining muscle strength via adequate physical activity is of crucial importance for people living with HIV/AIDS [18]. People of all ages infected with HIV have abnormally lower level of cardiorespiratory fitness, a reduction in which sedentary lifestyle should have a significant effect [11]. Several experts declared that HIV-infected adults seem to experience aging faster at earlier age compared to the general population. Despite adequate ART, the life expectancy of infected individuals is still lower than that of the general population. This means that HIV infected people can have declined health and physical function and experience higher prevalence of physical frailty at younger age compared to healthy individuals. Some of the functional impairments seen in HIV-infected individuals are similar to a physiological sense with those sometimes seen in 10–15 years older people who are uninfected. It is well known that even moderate physical activity can enhance physical function and quality of life among older adults. However, the majority of older adults do not exert physical activity enough to gain its benefits. Documented scientific findings suggest that physical frailty in HIV-infected patients is potentially reversible and it is believed that low physical activity is positively associated with depression [21]. This may suggest the positive effect of increasing physical activity on control of depression among patients. Moreover, most of the side effects attributable to HIV medication/treatment are associated with metabolic processes, which lead to the risk of metabolic syndromes, lipodystrophy, insulin resistance, hyperglycemia, and redistribution of body fat as well as diarrhea, nauseas, vomit, agitation, and insomnia. However, regarding thermos regulation hypothesis (the increase in body temperature facilitates the sleep induction), regular physical exercise, provides better sleeping. In addition, physical exercise improves energy conservation in order to get a positive energetic balance, preparing a normal sleeping cycle condition and thereby a well-being enhancement [22]. Additionally, as the life expectancy of HIV infected individuals increases, aging is going to become a factor affecting brain structure and its function. In addition, aging causes neurocognitive impairment, which influence the sense of well-being [23]. DuFour et al. (2013) have conducted a research that, based on self-reported activities (with increased heart rate in the last 72 h), the HIV adult participants were divided in to “exercise” and “no exercise” groups. The researchers conducted comprehensive standardized neurocognitive test battery that covers seven cognitive domains commonly affected by AIDS. The domains included, verbal fluency, working memory, speed of information processing, learning, recall, executive function, and motor function neurocognitive impairment. The results indicated that HIV infected adults in the exercise group had approximately half the chance to show neurocognitive impairment as compared to those in the no exercise group [24]. Resistance training, aerobic exercise, and concurrent training are proven to be incontestably associated with improvements in body composition, muscle strength, and cardiopulmonary fitness in adults living with HIV/AIDS. Short-term resistance exercise has shown to have physiologic benefits and has positive effects on body composition and musculoskeletal health. In addition, aerobic exercise and concurrent training increase aerobic capacity and have a positive effect on body composition, muscle strength, and quality of life. In addition to reduction in body weight, resistance exercise training improves outcomes related to body composition by increasing the lean body mass, mid-thigh cross-sectional muscle area, muscle strength, and bone mineral density. These parameters might have positive impacts on the individual’s quality of life. Aerobic exercise training improves body composition by balancing body weight, total body fat and the waist-to-hip circumferences ratio (WHR). Aerobic exercise also increases aerobic capacity, measured as maximum/peak volume of O2 uptake (VO2max/VO2peak) or time on treadmill. Similarly, concurrent training positively alters body composition by increasing lean body mass, muscle thigh volume, and mid-thigh cross-sectional muscle area. Additionally, this type of training seems to reduce thigh muscle adiposity, the percentage of body fat and WHR. Thereby, concurrent training provides significant improvement in all evaluated outcomes, making it as the best type of exercise in patients with disabilities and problems related to HIV infection/treatment [3]. It is reported that a 6-month supervised exercise program (90 min, 3 times per week) at a fitness club, caused better social relationships, better quality of life, better self-esteem, better body image and less emotional stress [18]. Kamitani et al. (2017) found that physical exercise is associated with improvements in physiological and psychological health. Moreover, researchers claimed that like aerobic exercise, progressive resistance exercise appears to reduce adiposity and increase body weight and muscle mass in HIV/AIDS patient living with wasting syndrome. Moreover, aerobic exercise with or without progressive resistance exercises appears to improve patients’ anaerobic capacity, depression, and mood [9]. As a result, as a structured form of self-management strategy of physical activity, physical exercise can address different types of mental, physical, and social problems in people with HIV/AIDS.

The exercises also optimized lipid profile and glucose tolerance in HIV/AIDS patients. Progressive resistive exercise are shown to be especially beneficial in medically stable adults living with HIV. This kind of exercise can increase body weight, peripheral girth and interestingly can reverse muscular atrophy process. These effects can undoubtedly cause a better psychological status and better quality of life and lipid profile (by lowering triglycerides) [20]. These benefits also include positive effects on HIV infection and the treatment-related toxicities, (i.e., impaired glucose tolerance, fatigue, increased blood lipid profile, chronic inflammation, anxiety, depression, circulating cortisol). Obviously, the response and adaptation to exercise training vary depending on several factors including current fitness level, disease status and whether or not the patient is currently on an ART [17]. Safeek et al. (2018) reported that regular physical activity may improve the function of cardiorespiratory system and functional independence in people living with HIV/AIDS. Also, researchers have found an association between inactivity and poor physical function in older patients [25]. According to a notable number of observational studies, more physically active persons living with HIV/AIDS have significantly better sleep quality, total sleep time, efficiency of sleep, decreased number of awakenings and improvement of sleeping disorders (insomnia), disorders which significantly deteriorate the patient’s health and consequently their quality of life [22]. In that regard, Neto et al. (2015) suggested that combined aerobic and resistance exercise should be considered as a component of care of HIV-infected individuals [6]. Physical activities in HIV patients are able to improve the quality of life by attenuating anxiety and depression [15].

Pain is another disturbing and common outcome of AIDS, such that severe pain would be experienced by 80–98% of those with advanced HIV. Expectedly, disturbances in physical, psychological, and social functioning have been found to be greater in patients experiencing pain compared to pain-free patients. Several studies demonstrated the adverse impact of pain on the patient’s sense of well-being [26]. Training via increasing muscle strength and stability and the irritant that induces the pain would be reduced [5]. After undergoing a 12-week progressive resistance exercise trial involving HIV infected participants with moderate-to-severe neuropathy, a significant improvement was observed in the quality of life of the intervention group when compared to the control group. As a result, it was suggested that progressive resisted exercise have some positive effects on the health-related quality of life in subjects with HIV/AIDS-related distal symmetrical polyneuropathy [27]. Dudgeon et al. (2012) designed a 6-week moderate-intensity combined aerobic and resistance exercise for HIV+ men participants and observed a significant improvement in salivary cortisol levels, physical performance, and body composition. The researchers showed that the exercise caused transient increase in anabolic factors (Growth Hormone) and decreased catabolic factors (salivary cortisol). These changes led to a significant increase in lean tissue mass in the exercise group, with no changes in total body mass or fat mass. In addition, significant improvement was observed in muscle strength within the exercise group [28]. It is shown that moderate to high-intensity physical activities such as walking, cycling, swimming, stair climbing and rowing are the most beneficial types of exercise for HIV populations. To achieve the most benefits, a 6 weeks aerobic training at least 3 days per week for 20–40 min is recommended. Also, 5–10 min of stretching major muscle groups are necessary before and after aerobic exercise. The appropriate heart rate during exercise is between 70 and 80% of the estimated maximum heart rate. Patients are suggested to begin at a lower intensity, and gradually increase the intensity of the exercise to a higher level. For muscle strength training, patients are recommended to start with 1–2 sets of 6–8 repetitions at 60% of the maximum weight, including knee extension, grip strength, shoulder flexion, and chest press. Later, patients may lift for only one repetition (1-RM) and progressively increase to 3 sets of 8–10 repetitions at 80–90% of 1-RM. It is important that prolonged intensive exercise are probably to have negative effects on HIV patients. Statistics from the American College of Sports Medicine (2003) reported that exercise for more than 90 min in healthy adults may alter the circulating levels of inflammatory cytokines and decrease the function of natural killer cells which target HIV-infected cells in the body [29]. Thus, prolonged exercise may also increase the patients’ susceptibility to the virus, especially among immune-compromised HIV patients. Moreover, patients are recommended to exercise with a group of training partners which help to increase motivation [4]. The functional impairments of a patient should determine the type of exercises and activities prescribed. In fact, the use of multiple conditioning components to address both neuromuscular strength and cardiovascular health has become an important part of most recommended exercise programs. It is important to emphasize that qualified professionals should supervise the exercise training in order to prevent any injury and to optimize the benefits. Exercise prescription is defined by several factors including: frequency, intensity, duration of the training, the type of exercise, and the initial functional status. Determining the appropriate type of exercise also depends on patient health status and safety issues regarding the stage of the disease. A minimal intensity level is likely required to gain any benefit. There is no exact or absolute value and the minimal intensity level may vary from one person to another. Although the optimal intensity cannot be defined based on available information, most of the observed exercises, which were associated with good health, were at least at moderate intensity. Resistance training, at a moderate intensity (set at 60–80% of the 1RM) and progressively increasing, would be the most efficient type of exercise if one is focusing on large muscle groups such as the chest, brachial biceps, quadriceps, and hamstrings. Overload should be adjusted according to a level at which a patient can safely and comfortably perform 8–12 repetitions. For people who wish to focus on improving muscular endurance, a lower intensity (i.e., 50% of the 1RM; light to moderate intensity) would be appropriate to complete 15–25 repetitions per set, with the number of sets not exceeding two. Aerobic exercises are preferred to be practiced at a moderate intensity that would be 50–85% of the maximum heart rate, or 45–85% of the VO2max/peak, from 11 to 14 based on the Borg Rating of Perceived Exertion Scale. The frequency of exercise should be increased until the patient can tolerate three to five sessions weekly for 30–60 min per session. For the best result, sessions need to be started with a warm-up period and finished with a cooldown period [3]. Clinical exercise therapists are needed to consider various factors when prescribing an exercise program for HIV-infected individuals. Considerations supported by the American College of Sports Medicine (ACSM) for the general population are also applicable to those HIV patients who experiencing additional medication-related physical and psychological problems such as gastrointestinal disfunction (especially diarrhea), neurological complications (i.e., peripheral neuropathy), lethargy, malaise, fatigue, anemia, mitochondrial toxicity, and myopathy. In addition, designing any physical exercise, the following factors are recommended to be taken in to account: (1) the functional limitations and likes/dislikes of the individual, (2) availability of time and required equipment, (3) exercise parameters (e.g., desired effect, type of exercise, (4) intensity, duration, and frequency of training) and (5) coordination among members of the multidisciplinary training team [20].

As physical function is a predictor of quality of life regardless of age, comorbidities, and immune function, the promotion of physical activity has become a public health priority worldwide. However, since HIV-infected patients, particularly HIV-infected older adults, tend to be socioeconomically disadvantaged and live in isolation because of the stigma, they more suffer from depression, negative perceptions, and multiple comorbidities. Interventions aimed at measuring the effects of increasing physical activity on emotional well-being are seriously needed to control physical frailty and depression in this target population. Interventions are needed to raise the needed psychological satisfaction from physical activity. This can boost emotional well-being and help in alleviating some of the emotional barriers that would normally prevent HIV-infected adults from engaging in physical activity. Improvements in self-guarded motivation can not only contribute to maintaining physical activity but also can potentially provide improvements in physical activity-related physiologic outcomes [21].

4 Exercise and Mental Health in HIV-Positive People

Exercise is a regular activity that can start a positive cycle, that is, a person engaging in physical exercise is more likely to feel physically and psychologically normal. Being occupied by physical activity at a relatively high-intensity level makes a simultaneously negative and stressful emotion more difficult. This is because physical activity can act as a healthy efficient distraction from sad thoughts. In addition, depressed people often suffer from fatigue and the feeling that life is insurmountable, which can lead to a sedentary behavior and lifestyle. As a result, they face loss of fitness and increased fatigue. On the other hand, regular exercise increases aerobic capacity and muscle strength, self-confidence, and physical well-being. There are also various theories that hormonal changes occurring during physical activity can have positive effects on mood via altering beta-endorphin and monoamine concentrations [5]. People living with HIV/AIDS suffer from a wide variety of psychological issues associated with the virus itself, the related medications, or a combination of both. The common symptoms of HIV which being experienced by the patients reduce their quality of life and well-being. The frequency and severity of the symptoms are affected by disease progression, functional capacity, adherence to pharmacological treatment, self-medication, psychological distress as well as anxiety and depression [17]. Long-term HIV survivors and perinatal HIV infected individuals are known to be at higher risk of mental health complications because of exposure to biomedical, family, and environmental factors. For example, significant and subtle neurocognitive deficits are reported in perinatal HIV+ children. These defects affect the children’s school achievement, social relationship and autonomy. The suggested mechanism is the possible effect of HIV on subcortical white matter and front striatal systems involved in the regulation of emotion and behavior. This further place the patient at higher risk of mental problems during adolescence. For youths experiencing severe HIV symptoms, hospitalizations, perceived risk of mortality, missing school and social opportunities, and delayed puberty, the mental pressure is huge, and the risk of mental issues is significant. The permanent impact of these experiences and deficits, even though the immune system is reconstituted, may affect the ability of HIV-infected youths in completion of the mandatory education, finding job, and doing social activities. These stressful conditions may have a reciprocal influence on mental health and well-being of the patients [2]. In that regard, properly designed exercises, which can affect psychological complications like anxiety or stress are recommended [30]. For example, a recently published meta-analysis suggested that exercise have beneficial effects on reducing both depression and anxiety symptoms in people living with HIV/AIDS [31]. The authors of this review recommended that professionally guided aerobic exercises for three or more times a week can improve the symptoms in those living with HIV/AIDS [31].

Depression affects adherence to ART, CD4 counts, and serum viral load of the patients. Yoga, as a physical exercise, augment current treatment modalities of HIV infected patients Yoga helps in improving many psychological conditions such as anxiety, depression, schizophrenia, and overall well-being and quality of life in many chronic diseases. Several studies reported the potential role of yoga in controlling disorders of cellular immunity, regarding all these significant reduction in depression and improvement in CD4 counts was observed at the end of one month of integrated yoga practice, as compared to the control group [32]. Physical exercise has a positive impact on depression, which is of the most common psychological impairments among people living with HIV/AIDS. It has been shown that, aerobic exercise can eliminate depression symptoms in general population. It might therefor be an efficient intervention if manage depression symptoms among HIV individuals [9]. Many studies demonstrated that HIV stigma may also cause various psychological problems among people living with HIV/AIDS. These problems include depression, hopelessness, anxiety, low self-esteem, and perceived lack of social support. In a study, by controlling perceived stigma the association of self-stigma with depressive symptoms was reduced to a nonsignificant level [33]. It seems that the perceived-stigma mediated the relationship between distress and HIV-related changes in physical appearance [33]. Jaggers and Hand (2016) found that 60 min of moderate intensity (60–80%VO2 peak) aerobic exercise conducted 3 days a week can be suggested as an effective method for improving the psychological disturbances experienced by people living with HIV/AIDS [17]. In addition, Vancampfort et al. (2018) suggested that more physical activity may raise self-efficacy, perceived physical functioning and general health. In their research, higher levels of depressive symptoms, and pain were reported among those with no physical activity when compared to physically active patients. However, the patients’ emotional functioning was unrelated to the physical activity levels. Owing to physical manifestations of AIDS including lipodystrophy which is viewed as a visible marker of the disease progress might on its turn cause stigmatization and social isolation. Positive experiences when being physically active can improve the physical comfort and body satisfaction in people living with HIV/AIDS [12]. In a cross-sectional study, Fazeli et al. (2015) showed that greater levels of moderate physical activity is associated with less neurocognitive and better physical functioning among older adults living with HIV. The researchers suggested that moderate physical activities come with better neurologic outcomes. They also suggested that the underlying effects of physical activity on neurocognitive functioning is possibly due to changes in the brain activity (e.g., via neuroplasticity, neurogenesis, and/or increased cerebral blood flow) and indirect effect via physical activity reduced cardiovascular comorbidities (e.g., diabetes, hypertension), or a combination of both direct and indirect mechanisms [23]. In addition, Monroe et al. (2017) suggested that physical activity have therapeutic effects on psychomotor speed performance in HIV-infected individuals [34]. After 12-week aerobic and resistance exercise, Dianatinasab et al. (2018) observed significant improvement in all psychological subscales including anxiety disorder, social function, depression, and mental health in the exercise group compared to the control group. The researchers concluded that exercise training can be included in all health care programs in order to improve the mental health status of women with HIV infection [15]. Both aerobic and resistance exercises found to have independent and combined positive effects on various indicators of mental health in people living with HIV [35]. As recommended by the American College of Sports Medicine’s Exercise Management for Persons with Chronic Disease and Disabilities (4th edition) exercise programs for people living with HIV/AIDS are similar to those recommended for the general population. These recommendations area moderate-intensity aerobic and resistance training regimen with 150 min of moderate-intensity physical activity throughout a week, as well as 2 days of full-body resistance training at approximately 60% of 1 repetition maximum intensity. Although this recommendation is known to be safe for anyone without underlying heart problems, it may not necessarily be practical for someone with HIV [11]. A descriptive qualitative study on adult participants living with HIV conducted by Simonik et al. (2016) developed a framework to describe readiness to be engaged in physical exercises and the interaction of some other factors with readiness among adults with HIV and the related morbidities. Accordingly, personal perceptions and beliefs about physical exercise, personal experience with exercise, and financial accessibility, readiness was found to be influenced by the complexity and episodic nature of HIV and its related morbidities including physical impairments, mental problems, and other health conditions. The authors suggested that any successful measure to increase readiness to physical exercise should consider the importance of social and financial factors as well as AIDS related symptoms and morbidities [36]. As conclusion, it is proven that in addition to medical treatments and social support, physical exercise is beneficial to HIV/AIDS patient’s clinical status. Physical exercise also improves physiological/psychological and social status of the patients. Physical exercise is beneficial to self-management, functional capacity, and perceived well-being of the patients. Physical exercise is necessary and urgently needed to be prescribed for HIV/AIDS patients in order to let them have a more healthy and efficient life. To become a routine care for the HIV/AIDS patients, physical exercise requires global and governmental support.