Question

Subjective

Medical History

Mr. BP, a 42 yr old African American with a seropositive HIV status since 2005, was recently placed on HAART after being hospitalized with bouts of thrush. The HAART regimen consists of Truvada and Kaletra. Shortly after beginning his new pharmacological regimen, the patient began experiencing more fatigue, muscle weakness, and nausea. He came to you seeking help in gaining strength and energy to “get my life back.”

Objective and Laboratory Data

Diagnosis

At the time of hospital admission, the patient’s weight was 187 lb (85 kg), and his blood pressure was 132/90 mmHg.

His laboratory work revealed the following:

• 254 CD4+ cells · mm–3
• 89,650 HIV RNA copies · mL–1
• Total cholesterol = 201 mg · dL–1
• High-density lipoprotein cholesterol = 33 mg · dL–1
• Triglycerides = 140 mg · dL–1

Six months after beginning HAART, his laboratory work was as follows:

• 420 CD4+ cells · mm–3

• 1,009 HIV RNA copies · mL–1
• Total cholesterol = 280 mg · dL–1
• High-density lipoprotein cholesterol = 34 mg · dL–1
• Triglycerides = 160 mg · dL–1

Exercise Test Results

At the time of the exercise evaluation, Mr. BP’s resting vitals were as follows:

• Height = 5 ft 10 in. (1.78 m)
• Weight = 170 lb (77.27 kg)
• BMI = 24.38 kg · m–2
• Heart rate = 72 beats · min–1
• Blood pressure = 146/98 mmHg
• Respiratory rate = 22/min

The graded exercise evaluation resulted in the following values:

• <sb3bl>Peak HR = 184 beats · min–1
• Peak BP = 270/96 mmHg
• Peak respiratory rate = 44/min
• Peak RPE = 19 out of 20
• Peak oxygen consumption = 26 mL · min−1 · kg−1

His resting ECG revealed normal sinus rhythm with nonspecific ST-segment changes. No abnormal ECG changes or arrhythmias were noted during exercise. Before beginning his exercise program, the patient was advised to revisit his primary care provider and have his blood pressure reevaluated. The physician added a diuretic to the patient’s medical regime. When he returned to the exercise facility the next week, his resting blood pressure was 128/90 mmHg.

Assessment and Plan

Exercise Prescription

• Mode: stationary cycling or walking/jogging.
• Frequency: 3 to 5 d/wk.
• Duration: 30 min, not including warm-up and cool-down. Patient may have to begin at 10 min each day and build up to 30.
• Intensity: 40% heart rate reserve, eventually increasing to 60% heart rate reserve.
• Exercise progression: As cardiovascular and muscular adaptations occur in response to training, the workload should be adjusted to maintain the heart rate within the initially prescribed range. Additionally the patient should try increasing the duration by 5 min every other week.

Case Study Discussion Questions

1. What type of exercise increases lean body mass in HIV-infected patients experiencing skeletal muscle wasting?
2. What are the essential elements in an exercise prescription for someone with HIV?
3. What are the common complications of HAART? How can exercise attenuate these effects?
4. What factors are responsible for low CRF in persons with HIV infection?
5. What factors may limit exercise capacity in HIV-infected individuals?
6. What are stages of HIV infection? How are they defined? What are the stage-specific implications for exercise testing and training?
7. What are the common misconceptions about working with persons infected with HIV? What is the risk of contracting HIV during an exercise evaluation?
8. Compare the CD4+ cell counts from the time of admission to 6 mo. What information does this provide regarding the efficacy of the drug regimen?
9. What are the patient’s triglyceride levels? HDL (high-density lipoprotein) levels? How might the exercise prescription alter these markers over time?
10. Compare the exercise prescription with the current ACSM guidelines. Do they differ? If so, how?

Answer 1

Aerobic exercises are good for patients suffering from HIV which starts with walking and slight jogging they can extend it to doing crunches, dumbell punch and weight lifting. But any exercise has to be started according to the strength and repetition of the same has to be done daily.

The exercise prescription will include the start from simple exercises like walking that too only for 10 mins in the beginning and extend it to 30 mins with a frequency of 3-5 days every week

The common complications of HAART are -

Hyperlipidemia , lipodystrophy , insulin resistance and changes in bone density is also observed. The conditions may be associated with coronary heart disease due to long term persistence of hyperlipidemia.

Hence exercise plays a very important role over here helping the patient by treating the issues related with cardiovascular diseases or metabolic syndrome.

The factors responsible for low crf in hiv patients are:

Smoking

High triglycerides

Low high density lipoprotein

High blood pressure

Factors limiting the capacity for exercise in HIV patients are:

1.Structural and inflammatory muscle abnormalities.

2. Nucleoside related mitochondrial toxicity

3. Oxidative phosphorylation