Evidence-Informed Practical Recommendations for Increasing Physical Activity Among Persons Living With HIV

Jessica L. Montoya; Catherine M. Jankowski; Kelly K. O'Brien; Allison R. Webel; Krisann K. Oursler; Brook L. Henry; David J. Moore; Kristine M. Erlandsong


AIDS. 2019;33(6):931-939. 

In This Article

Behaviour Change Strategies for Increasing Engagement in Physical Activity

The American Heart Association recommends the routine assessment and promotion of physical activity as a 'vital sign' with every patient at every visit.[69] Assessment and promotion of physical activity in the healthcare setting has been found to be so effective at improving patient outcomes that some healthcare systems have begun including physical activity as a vital sign in the electronic medical record.[69] The current extensive primary care guidelines for PLWH include detailed screening and management recommendations for hypertension, hyperlipidaemia and other common health conditions but do not mention physical activity assessment or counselling either routinely or in the management of comorbidities. The primary care guidelines for PLWH do recommend healthcare encounters every 3–6 months:[70] these frequent healthcare encounters provide excellent opportunities for healthcare providers to inquire about and promote physical activity among PLWH. A recent review confirms that assessment and promotion of physical activity by healthcare providers has a small to moderate positive effect on increasing physical activity levels, with larger effects observed when multiple behaviour change strategies are implemented.[71]

One simple, effective behaviour change strategy is a physical activity prescription that is collaboratively developed by the patient and provider.[72,73] We adapted the physical activity prescription from the 'Exercise is Medicine' website[74] and included several behaviour change strategies that can be personalized (Figure 1). The adapted physical activity prescription form allows healthcare providers to encourage patients to progress to higher levels of physical activity and/or work towards meeting the HHS recommendations by gradually increasing the amount of time, intensity or number of times a week they are physically active. For sedentary or physically inactive PLWH, prescribing movement breaks or walking may be a practical initial strategy to increase physical activity, as it does not require special skills or equipment.[75]

Figure 1.

Example physical activity prescription.

Effective behaviour change strategies that consider readiness to engage in physical activity in the context of living with a sometimes unpredictable and episodic illness are needed to optimally promote adherence to a physical activity prescription among PLWH.[68] On the basis of HIV-specific literature in combination with existing behaviour change techniques recommended for all persons,[76,77] we recommend adoption of behaviour change strategies, such as self-monitoring of physical activity; goal setting and action planning; prompts, cues or scheduling; and social support. Providing these strategies to patients may increase the likelihood of initiation and maintenance or sustained uptake of physical activity, ultimately leading to improved health and wellness in this population. We briefly summarize the benefits of the following approaches.

Self-monitoring is a useful physical activity behaviour change technique[77] that can include the use of wearable motion-sensing technologies (e.g. pedometers, Fitbit),[78] smartphone applications and online tracking resources such as Go4Life from the National Institute on Aging.[79] Self-monitoring can also occur using low-technology strategies such as a pen and paper diary. Results from a scoping study indicated that wireless activity monitors are increasingly used among PLWH as an outcome measure of physical activity; however, evidence of their effectiveness to enhance physical activity among PLWH is scarce.[80]

Goal setting and action planning are effective behavioural strategies for increasing engagement in physical activity.[81] Goal setting encourages specific behavioural resolution (e.g. engaging in more physical activity this week), while action planning involves detailed planning of what the person will do, when they will engage in the specified behaviour and for how long. Combining behaviour change techniques, a person can self-monitor physical activity (e.g. steps per day) and then set a behavioural goal (e.g. increasing the number of steps by 10% per week). Action planning builds upon goal setting by linking behaviours to situational cues or an existing behaviour (i.e. associative learning). For example, physical activity can be linked with the use of transportation (e.g. exiting one stop early on the subway or bus, parking at the outskirts of a parking lot and taking the stairs), to establish a habit.

Prompts, cues and scheduling that remind PLWH to engage in physical activity may drive habit formation and improve long-term physical activity adherence. Prescheduled activity is more often adhered to than relying on impromptu self-motivation.[82] A calendar, alarms and/or cell phone reminders to set aside a specific time for physical activity can support physical activity scheduling. An ongoing study is evaluating the effectiveness of a novel Short Message Service intervention (iSTEP) to increase moderate physical activity among PLWH.[83,84]

Social support is strongly linked to physical activity engagement. Recent data clearly describe the prominent role that healthcare providers have in integrating health promotion into routine HIV care.[65] Thus, providers can leverage their strong patient relationships to emphasize a holistic concept of well being that includes physical activity.[65] Persons are more likely to engage in physical activity if they are linked to a similarly motivated person with whom they are able to engage in physical activity, creating a 'buddy system' (e.g. making a 'contract' with others to achieve specified levels of physical activity or participating in group exercise).[85] In addition, the social environment of group exercise can enhance motivation and adherence to physical activity among older PLWH.[86]