JournalofPsychosomaticRe

search126(2019)109823

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Review article

Effects of exercise on depression and anxiety in persons living with HIV: A

meta-analysis
⁎
Andreas Heissela, , Philipp Zecha, Michael A. Rappa, Felipe B. Schuchb, Jimmy B. Lawrencea,
Maria Kangasc, Stephan Heinzeld
a
SOCIAL AND Preventive Medicine, DEPARTMENT Exercise AND HEALTH Sciences, University of POTSDAM, GERMANY
b
DEPARTAMENTO de métodos e TÉCNICAS DESPORTIVAS, UNIVERSIDADE FEDERAL de SANTA MARIA, BRAZIL
c
Centre for EMOTIONAL HEALTH, DEPARTMENT of Psychology, MACQUARIE University, Sydney, AUSTRALIA
d
CLINICAL Psychology AND PSYCHOTHERAPY, DEPARTMENT of EDUCATION AND Psychology, Freie Universität Berlin, GERMANY

ARTICLEINFO
ABSTRACT
Keywords:
HIV Objective: The purpose of this systematic review and meta-analysis was to examine the effects of exercise on
Exercise depression and anxiety in people living with HIV (PLWH), and to evaluate, through subgroup analysis, the effects
Depression of exercise type, frequency, supervision by exercise professionals, study quality, and control group conditions on
Anxiety these outcomes.
Meta-analysis Method: A literature search was conducted through four electronic databases from inception to February
Supervision
2019. Considered for inclusion were randomized controlled trials (RCTs) investigating exercise interventions
and depression or anxiety as outcomes in people living with HIV (≥ 18 years of age). Ten studies were
included (n = 479 participants, 49.67% females at baseline), and the standardized mean difference (SMD)
and hetero- geneity were calculated using random-effect models. An additional pre-post meta-analysis was
also conducted. Results: A large effect in favor of exercise when compared to controls was found for
depression (SMD = −0.84, 95%CI = [−1.57, −0.11], p = 0.02) and anxiety (SMD = −1.23, 95%CI
= [−2.42, −0.04], p = 0.04).
Subgroup analyses for depression revealed large effects on depression for aerobic exercise only (SMD =
−0.96, 95%CI = [−1.63, −0.30], p = 0.004), a frequency of ≥3 exercise sessions per week (SMD =
−1.39, 95%CI = [−2.24, −0.54], p < 0.001), professionally supervised exercise (SMD = −1.40, 95%CI
= [−2.46,
−0.17], p = 0.03]), and high-quality studies (SMD = −1.31, 95%CI = [−2.46, −0.17], p = 0.02).
Conclusion: Exercise seems to decrease depressive symptoms and anxiety in PLWH, but other larger and
high- quality studies are needed to verify these effects.

1. Introduction
In 2016, the number of individuals living with the human im-
munodeficiency virus (HIV) as reported by the World Health
Organization (WHO) was estimated to range between 30.8 and 42.9
million people worldwide [1]. People living with HIV (PLWH) face
challenges related to social inclusion, uncertainty, and worrying about
their future, which are linked, to some extent, to mental and physical
impairments associated with HIV, including depressive and anxiety
disorders [2,3].
Although highly active antiretroviral therapy (HAART) has ex-
tended the lifespan of individuals with HIV, it is not without its risks.
Notably, studies have shown that HAART increases the risk of
cardiovascular, kidney, and neurological diseases, as well as metabolic
risk factors [4–6]. Moreover, sleep problems and depression in PLWH
have been associated with higher disability [7].
The prevalence of PLWH experiencing depression and anxiety has
been reported to be two- to fourfold higher than in non-infected in-
dividuals [8]. Among other things, both HIV itself and HAART con-
tribute to this elevated prevalence of depression when compared to
HIV-negative individuals. Depression has been shown to decrease
quality of life (QOL) and negatively affect the HIV disease progression
[9], and can lead to a higher risk of suicide in PLWH than in HIV-
negative individuals [10,11]. Therefore, the improvement of mental
health and QOL in PLWH has become a priority in HIV research [12].
Cluster of differentiation 4 (CD4) cell count and viral load play a key

⁎
Corresponding author at: Social and Preventive Medicine, Department Exercise and Health Sciences, University of Potsdam, Am Neuen Palais 10, Potsdam 14469,
Germany.
E-MAIL ADDRESS: andreas.heissel@uni-potsdam.de (A. Heissel).

https://doi.org/10.1016/j.jpsychores.2019.109823
R00e2ce2i-v3e9d992/6 ©Fe2b0ru1a9ryEl2se0v1i9e;rRInecc.eAivleldriignhtrsevreisseedrvfeodr.m 30 August 2019; Accepted 31 August 2019
A. Heissel, et AL. JourNAlofPsychosomAticRes
eArch126(2019)109823
PERO).
role for PLWH and help estimate individuals' overall health status.
There is evidence for a relationship between CD4 cell count and de-
creased mental health and well-being. A lower CD4 cell count in
PLWH could be an indicator of untreated depression [13]. In other
words, chronic depression could negatively affect the disease process
and lead to a decreased CD4 cell count and an increased viral load
[9,14]. Fur- thermore, a meta-analysis by Gonzales et al. [15] showed
that depres- sion was significantly associated with non-adherence to
HIV-treat- ments. While adherence to HIV medication treatment is
essential for a stable viral load, mental health status is not adequately
treated by medication alone. Research has shown that psychotherapy
treatments such as cognitive behavioral therapy (CBT) increase
adherence to HAART and improve depressive symptoms [16].
However, most coun- tries lack adequate resources for psychotherapy
[17].
Physical activity, defined as any bodily movement produced by
skeletal muscles and which requires energy expenditure [18] has be-
come a topic of great interest for mental health promotion, since
people with higher levels of physical activity are less likely to develop
de- pression [19] and anxiety [20]. Moreover, exercise, a structured
subset of physical activity, has proven to be an effective low-threshold
treat- ment in individuals suffering from depression and other mental
dis- orders [21,22]. Additionally, people with HIV spend more time in
se- dentary behavior and less in physical activity when compared to
other chronic populations [23,24]. In recent years, a growing number
of systematic and meta-analytic reviews have investigated the effects
of exercise in PLWH [23–30]. Although the antidepressant effects of
ex- ercise have been demonstrated in people with mental disorders,
pre- vious reviews of exercise in PLWH have focused mainly on
physiolo- gical outcomes [25–30], with minimal attention given to
mental health outcomes.
In a recent Cochrane review in which the authors investigated the
effectiveness of aerobic exercise for PLWH [31], only two studies
were included which reported the impact of exercise on depressive
symp- toms. Although in another recent study [32] the aim was to
evaluate the effects of various types of interventions on depression for
PLWH in Africa, only one study was included based on an exercise
intervention. Additionally, in a separate recent systematic review [33],
although the aim was to evaluate the effects of exercise and mental
health outcomes for PLWH (which included depression and anxiety
outcomes), the re- sults were restricted to a qualitative analysis of
studies evaluating aerobic and/or resistance exercise; yet, the authors
did not conduct a meta-analysis on any mental health outcomes. A
further shortcoming yet to be addressed in previous meta-analytic
reviews on this topic includes investigating the impact of other forms
of physical exercise (beyond aerobic and resistance exercise), such as
yoga, on mental health outcomes in PLWH. Additionally, none of the
meta-analytic re- views to date have evaluated whether the effects of
exercise for PLWH are influenced by training frequency or
professional supervision, and whether the exercise intervention
condition was compared to a struc-
tured versus non-structured control condition.
Accordingly, the objective of the present systematic and meta-ana-
lytic review is to address these gaps and limitations in this field. In
particular, the aims of this review are twofold: 1) to investigate the
effect of exercise (including other forms of exercise, e.g., yoga, tai chi)
on depression and anxiety in PLWH; and 2) to investigate whether the
effects of exercise are moderated by exercise type, training frequency,
supervision by exercise professionals, study quality, and different con-
trol group conditions (structured and non-structured control groups).

2. Methods

We conducted a systematic review and meta-analysis focusing on

randomized controlled trials (RCTs) according to the Cochrane
Collaboration protocol [34]. The procedure was previously registered
on the international prospective register of systematic reviews (PROS-

2
A. Heissel, et AL. JourNAlofPsychosomAticRes
eArch126(2019)109823
Studies-Depression Scale (CES-D)).
(http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=
CRD42016035798) and refers to the Preferred Reporting Items for 2.3. SEARCH STRATEGY intervention intensity, type of
Systematic Reviews and Meta-Analyses (PRISMA) guidelines [35]. control group, anti-depressants
The literature search was and HAART medication intake,
conducted by two reviewers (PZ supervision of participants, and
2.1. Included studies AND types of interventions
and JL) who first independently peer review or thesis. In the case
screened each title for potential of missing data or unconvertible
Studies were considered for inclusion if they: 1) were RCTs and
relevance as set by the eligibility measuring units in a study, the
exercise interventions were compared to any concurrent structured
criteria described above. If an authors were contacted via email
control condition (defined as any assigned activity except exercise)
article met the title- screening and the missing data or an
and/or non-structured control condition (defined as no assignment, as
process, the abstracts were then adequate conversion of a
usual daily activity or on a waiting list), 2) included at least one ex-
fully screened. For poten- tially measuring unit were requested.
ercise intervention ≥1 time per week, 3) investigated depression and/
eligible studies, full-text papers If two weeks passed with no
or anxiety symptoms pre- to post-intervention using a validated mea-
were obtained and assessed by reply, the author was then kindly
sure, 4) were published in English or German, 5) included adult parti-
the same two independent reminded of the request. When
cipants ≥18 years old, and 6) included people with an HIV-positive
reviewers. In the case of the corresponding author did not
status. For the purposes of this review, exercise was defined as any
disagreement, both authors reply, the co-authors were
“planned, structured and repetitive bodily movement done to improve
discussed their differences until contacted via email as well.
or maintain one or more components of physical fitness” [18]. Ac-
they reached an agreement. If When no email address was
cording to this definition, beyond traditional forms of exercise such as
this was not possible, a third reported, the author was searched
aerobic exercise or strength training, other forms of exercise modes
author (AH) was consulted for via Google and Research Gate,
such as yoga or tai chi were also included, as they qualify as effective
the final decision. and contacted if possible. In
exercise treatments [36,37].
To identify relevant cases where none of the authors
To examine the differences in effects between PLWH who
published trials, as well as replied to any attempts to make
exercised compared to those who did not (i.e., non-exercisers), the
existing systematic reviews, the contact, the study was excluded
control group was defined as performing no exercise at all. Control
following electronic databases from the quantitative synthesis.
groups exercising at different intensity levels or performing any type
were searched to include studies In order to determine the risk of
of exercise were strictly excluded to prevent falsification of the
published up to February 2019: bias of the included studies, the
results regarding the comparison of non-exercising and exercising
Pubmed, Physiotherapy Physiotherapy Evidence
participants because moderate-intensity exercise can have similar
Evidence Database (PEDro), Database (PEDro) scale was
effects on mental health when compared to more intense exercise.
PsycNet, and the Cochrane used. The PEDro scale is based
Therefore, comparing ex- ercise versus exercise may lead to an
Central Register of Controlled upon the Delphi list described
underestimation of the effect size [38]. For trials which included more
Trials (CENTRAL). Search by Verhagen et al. [40].
than one intensity of exercise, we used the exercise arm with the
parameters and syntax were The criteria of the PEDro scale
greatest clinical effect in the review. Similarly, when trials provided
adapted to the requirements of (eligibility criteria (EC))
more than one type of exercise, we used the type of exercise with the
each database. Combined MeSH determine: if the eligibility
greatest clinical effect. However, because this may overestimate the
terms and text words were criteria were specified, 1.
effect of exercise, we used the exercise arm which provides the
related to HIV, exercise, and whether subjects were ran- domly
biggest ‘dose’ of exercise, and performed a sensi- tivity analysis to
depression/ anxiety. In addition, allocated to groups, 2. whether
explore the effect of using the smallest ‘dose’. Control groups were
systematic reviews and cohort the allocation was concealed, 3.
separated into structured and non-structured control conditions. Any
studies were cross- referenced. whether the groups were similar
activity except exercise, e.g. heat therapy, reading a book, were
To identify unpublished or on- at baseline regarding the most
defined as structured control conditions, and non-structured
going studies, clinicaltrials. gov im- portant prognostic indicator,
control conditions were defined as not being involved in any
was searched. Reference lists 4. whether there was blinding of
organized form of activity and free of any form of intervention, e.g.
and tables of contents in relevant all sub- jects, 5. whether there
continuing daily activity or being on a waiting list. A trial was
publications, reviews, and books was blinding of all therapists who
considered an RCT if the allocation of participants was reported as
were also screened. The search administered the therapy, 6.
randomized, and the eligibility criteria had to be specified.
stra- tegies represent the method whether there was blinding of all
used for all databases using the assessors who mea- sured at least
2.2. Outcomes Boolean operators AND/OR and one key outcome, 7. whether the
can be found in detail in the measures of at least one key
The primary outcome was the post-intervention results for depres- Appendix (Table A.1). outcome were obtained from >
sion, and the secondary outcome was anxiety. In cases where a study 85% of the subjects initially allo-
investigated depression or anxiety with more than one assessment tool 2.4. DATA EXTRACTION cated to groups, 8. whether all
[39], separate meta-analyses were conducted. In this review, the spe- subjects for whom outcome
cific focus was on evaluating the effects of exercise on depression and Data were extracted by two measures were available received
anxiety symptoms. Thus, ‘depression’ and ‘anxiety’ was defined in independent reviewers (PZ and the treatment or control condition
terms of symptom severity, not in terms of a clinical diagnosis of a JL) using a standardized data as allocated or, where this was
depressive or anxiety disorder. Studies that only used broad measures abstraction digital form sheet, not the case, data for at least one
of mental health and health-related quality of life (HRQOL) were and included the following: key outcome were analyzed with
excluded, as they were deemed too generic. Any study that used a author, year and country of an “intention to treat,” 9. whether
validated quan- titative self-report measure assessing depression and publication, investigated the results of between- group
anxiety symptoms was considered for inclusion (e.g. State-Trait outcome, exercise method, statistical comparisons are
Anxiety Inventory (STAI), Beck Depression Inventory (BDI), number of participants (% reported for at least one key
General Health Questionnaire (GHQ), Profile of Mood State- women), pre-and post-outcome outcome, and 10. whether the
Depression/Anxiety (POMS-D/A), Hospital An- xiety and Depression measures at baseline for study provided both point
Scale-Depression/Anxiety (HADS-D/A), Centre for Epidemiological intervention and control groups, measures and measures of

3
A. Heissel, et AL.
variability for at least one key
outcome. Two reviewers (PZ
and JL) independently assessed
the risk of bias using the PEDro
scale. Dis- crepancies between
the two reviewers were resolved
by consulting two other authors
(AH and SH). A study with a
PEDro score ≥ 5 was graded
as a high-quality study [41,42].
2.5. DATA ANALYSIS
Review Manager 5.3 was
used for the data analysis.
Different in- struments were
pooled for data analysis if they
measured the same
psychological construct for
depression and anxiety. For the
meta-ana- lysis, the main
outcome of the means, standard
differences, and number of
participants allocated to each
group were used. If different
measuring units were used in
the studies, such as mean ±
standard error or mean ±
change/difference (post minus
pre); these were converted into
the common measuring unit of
mean ± standard difference.
Random-effect models were
used when calculating the
standardized mean differences
(SMD) of the post-treatment
measures comparing exercise
and other forms of exercise
with control groups across all
in- cluded trials [43]. Subgroup
analyses for the different types
of exercise, number of sessions,
professional supervision, and
structured and non- structured
control conditions were
performed whenever possible.
High- quality studies with a low
risk of bias (PEDro score ≥ 5)
were analyzed separately
[41,42]. In line with the
standard analysis procedure in
the Cochrane meta-analyses,
SMDs were calculated using
means, standard differences,
and sample sizes post-
intervention (post-treatment
effect sizes). Due to the
possibility that no
parallelization pre-intervention
between intervention and
(structured) control groups was
assured in the main outcomes at
the starting points, especially in
small sample sizes despite
randomization or due to high
dropout rates, we used an
additional method to compare
the two methods with one
another. Therefore, we
conducted additional meta-
analyses (pre-post analyses).
For the main outcomes, we
calculated new means by
subtracting the post-
intervention means from the
pre-intervention means between
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JourNAlofPsychosomAticRes
eArch126(2019)109823
all groups to determine the cognitive beha- vioral stress
differences. Additionally, a management intervention [58],
pooled standard one study did not include
difference to adjust the exercise in the individual or
differences was used [44], as family activity intervention [59],
was the post-in- tervention and one study had no exercise
sample size. For both groups, included in the positive-affect
these three values were used for skills intervention [60]. For
statistical calculation in Review further information about the
Manager 5.3. We interpreted study selection process, see Fig.
SMD ranges 0.00–0.39 as 1.
small, 0.40–0.70 as moderate,
and above 0.70 as large [45]. A
p value of < 0.05 was
considered statistically
significant. Heterogeneity was
determined by calculating the I2
statistics [46]. We considered
three ranges of heterogeneity: a)
2
I ≤ 25% for low hetero-
geneity, b) I2 > 25–75% for
moderate heterogeneity, and c)
2
I > 75% for considerably high
heterogeneity [46]. The
conducted pre-post analyses
were then compared to the post
analyses to identify possible
differences [44,47]. Assessing
publication bias, Egger's Test
was pre- ferred to Begg's Test
due to its higher sensitivity
[48,49].
3. Results
3.1. CHARACTERISTICS of excluded
studies
As shown in Fig. 1, 4850
studies were identified. After
four dupli- cates were removed,
4814 studies were excluded by
assessing the title. Nine records
needed to be excluded after
reading the abstract. Seven
records did not investigate
depression or anxiety, one study
had a non- exercising control
group by investigating two
different intervention groups,
and one study did not assess
exercise as an intervention.
The full texts of the
remaining 23 studies were
assessed. Twelve additional
studies were then excluded:
Eight studies did not measure
depression or anxiety [36,50–
56], four studies had no
exercise inter- vention or had an
exercise intervention that did
not meet the inclusion criteria,
one study had only two groups
differing in their intensity levels
of exercise (moderate and high
intensity) but no non-exercising
control group [57], in one study
there was no exercise in the
 Fig. 1. PRISMA flow diagram.
3.2. CHARACTERISTICS of studies excluded from the QUANTITATIVE synthesis
One study was excluded due to missing or incomplete data [61]
(see also Appendix Table A.2). The author was contacted twice but the
re- quested data were not made available. Hence, a total of 10 studies
were included in the quantitative analysis.
3.3. CHARACTERISTICS of studies included in the QUANTITATIVE synthesis
Of the 10 included trials, four studies investigated aerobic exercise
(AE) [39,62–64], four investigated aerobic exercise and resistance
training (AERT) [65–69], and two studies investigated a yoga inter-
vention (Y) [68,70]. The duration of the interventions ranged from 4 to
12 weeks, the duration of each exercise session ranged from 45 to
75 min, the sessions per week ranged from 2 to 6 times per week.
Follow-up data were presented in none of the included studies. Parti-
cipants were supervised in six trials, and in five of these studies parti-
cipants were professionally supervised by a yoga trainer [68,70], a
personal trainer [39] or a physiotherapist [64,66]. Two studies did not
report on supervision [62,63]. In two studies the participants were in-
structed to exercise privately in their own at home not being
supervised [65,69]. Participants in 8 studies performed their exercise
intervention stationary. Two studies were conducted in Africa [62,65],
three studies in India [66,68,70], two studies in the USA [39,63], and
one study in Germany [64]. Five studies assessed structured control
groups [62,63,65–67] and five assessed non-structured control groups
[39,64,68–70]. No study assessed two different intensity levels for the
intervention group. Detailed information about supervision, control
group conditions and other study characteristics are available in
Table 1.
3.4. CHARACTERISTICS of PARTICIPANTS
A total of 479 participants for baseline (49.67% females) and 429
participants for post-intervention measures (10.44% withdrawal rate)
were investigated. Four studies reported a nil dropout rate
[63,65,68,70].
Six studies reported ART medication for all participants
[62,64,65,68–70]. One of these six studies that reported ART medica-
tion also made a distinction between the antiretroviral medications
concerning the drug classification [69]. The other four studies did not
report whether participants were on HAART medication [39,63,66,67].
Two studies reported anti-depressant or anti-anxiety medication use
[39,69]. In Neidig et al. [39], twelve out of 60 participants used anti-
depressants (16.70% in the intervention group (IG) and 23.30% in the
control group (CG)) and 10% of the 60 participants used anxiolytics
(10% in the IG and 10% in the CG) at entry. 16.70% of the participants
used antidepressants and 10% of the participants used anti-anxiety
agents. Shah et al. [69] only mentioned in the exclusion criteria that
participants with untreated depression were excluded. Detailed in-
formation about the study characteristics are summarized in Table 1.
Six studies investigated participants who were not diagnosed
with depressive symptoms [39,62–64,66,67]. In four studies, the
authors reported details for depression conditions in the inclusion or
exclusion criteria. Participants in the studies of Naoroibam et al.
[70] n = 14 (n = 9/22 participants in the intervention group and n =
5/22 parti- cipants in the control group) and Daniels et al. [65] n =
8/60 partici- pants were partly diagnosed with depressive
symptoms. 20 participants (n = 12/22 participants in the
intervention group and n = 8/22 in the control group) in the study
by Naoroibam et al. [70] were diagnosed with anxiety symptoms.
The study by Kiloor et al. [68] excluded par- ticipants with
psychiatric illnesses or use of antipsychotic medications.
 A.
Table 1 Heis
Characteristic of studies included in the meta-analysis. sel,
et
Author, Year, AL.

Country Outcome Method/ Participants n n, post (n), Baseline (SD); post (SD); within Intervention Control group Anti- Super-vision Location of Peer
Parameter Intervention (% women) WR%/ group difference post minus condition depressant/ exercise reviewed/
pre, post intention baseline (SD) ART intervention thesis
to treat medication
yes/no Intervention Control M/S S/Wk Wks M/Wk

1 Aweto, 2016,
Nigeria BDI-D: aerobic pre: 40 40, 33, depression: depression: 45 3 6 135 structured: group not mentioned/ not mentioned stationary peer
depression exercise vs. (62.50%), 17.5%/ no 10.33 (6.48); 10.06 (5.96); counselling for on ART reviewed
CG post: 33 3.50 (1.27); 8.33 (5.80); 30 min. Once in two
2 Daniels, 2018, (69.70%) −6.83 (3.88) −1.73 (5.88) weeks.
South Africa BDI-D: aerobic and pre: 60 60, 60, depression: depression: N.A. 2 6 N.A. structured: read the not mentioned/ not supervised home based peer
depression resistance (100%) post: 0%/ no 6.17 (3.97); 4.64 (2.79); prescribed material on ART reviewed
exercise vs. 60 (100%) 4.85 (2.85); 2.75 (2.10);
CG −1.32 (3.41) −1.89 (2.45)
3 Dianatinasab, GHQ- aerobic pre: 40 40, 30, depression: depression: 65 3 12 195 structured: receiving not mentioned/ professionally stationary peer
2018, 28:depression and (100%), post: 25%/ no 4.84 (2.76); 6.60 (4.25); routine educational not mentioned supervised reviewed
Iran anxiety resistance 30 (100%) 2.69 (1.44); 7.60 (5.38); and medical service
exercise vs. −2.15 (2.10) 1.00 (4.82)
CG anxiety: 5.92 anxiety: 6.30
(4.46); (4.19);
3.61 (2.33); 6.20 (4.29);
−2.31 (3.40) −0.1 (4.24)
4 Jaggers, 2014, POMS-D: aerobic and pre: 49 49, 44, depression: depression: 75 2 6 120 structured: sedentary not mentioned/ supervised stationary peer
USA depression resistance (26.50%), 10.2%/ no 14.38 (12.15); 9.39 (9.08); activities not mentioned reviewed
exercise vs. post: 44 (NA) 6.21 (7.35); 8.20 (9.30);
CG −8.17 (9.75) −1.19 (9.19)
5 Kiloor, 2018, HADS-D/A: yoga vs. CG pre: 60 (65%) 60, 60, depression: depression: 60 5 8 300 non-structured: wait not mentioned/ professionally stationary peer
India depression, post: 60 0%/ no 9.16 (2.15); 9.19 (2.04); list, usual activity on ART supervised reviewed
anxiety (65%) 4.74 (1.12); 10.23 (1.93);
−4.42 (1.64) 1.04 (1.99)
anxiety: 11.29 anxiety: 11.45
(2.15); 5.45 (2.17); 12.48
(1.34); −5.84 (2.20); 1.03
(1.75) (2.19)
6 LaPerriere, POMS-D/A: aerobic pre: 17 (0%), 17, 17, depression: depression: 10 45 3 12 135 structured: not mentioned/ not mentioned stationary peer
1990, depression, exercise vs. post: 17 (0%) 0%/ yes 10.90 (1.70); (1.60); 23.80 assessment only not mentioned reviewed
USA anxiety CG 14 (3.70); 3.1 (7.90); 13.80
(2.7) anxiety: (4.75) anxiety:
12.80 (2); 11.30 (1.60);
Jou
12.90 (2.50); 16.30 (3.80); 5 rNAl
0.10 (2.25) (2.70) ofPs
7 Naoroibam, HADS-D/A: yoga vs. CG pre: 44 44, 44, depression: depression: 60 6 4 360 non-structured: not mentioned/ professionally stationary peer ych
2016, India depression, (45.50%), 0%/ no 9.18 (2.95); 9.55 (3.01); routine daily on ART supervised reviewed
oso
activity mAt
anxiety post: 44 7.95 (1.78); 9.59 (3.03);
icRe
(45.50%) −1.23 (2.37) 0.04 (3.02) seAr
anxiety: 10.82 anxiety: 10.14 ch1
(3.86); 9.91 (3.16); 11.45 26(
(3.35); −0.91 (3.36); 1.31 201
(3.61) (3.26) 9)1
098
8 Neidig, 2003, POMS-D, BDI- aerobic pre: 60 60, 48, POMS-D: POMS 60 3 12 180 non-structured: wait (n) 12/60 anti- professionally stationary peer 23
USA D: depression exercise vs. (13%), post: 20%/yes depression: depression: list, usual activity depressants, supervised reviewed
CG 48 (8.30%) 10.90 (11.80); 10.90 (8.50); (n) 9/60 anti-
6.10 (8.90); 10.90 (11.20); anxiety agents/
−4.80 (10.35) 0 not mentioned
BDI-D: (9.85) BDI
depression: depression:
8.90 (5.90);
(continued on next
PAGE)
 description of control group condition. Standard deviation (SD), antiretroviral therapy (ART), withdrawal rate (WR), State-Trait Anxiety
A. Heissel, et AL. JourNAlofPsychosomAticRes
eArch126(2019)109823

Note. Study characteristics presented as author/year of publication, investigated outcome, specific intervention investigated, (n) participants (percentage women) at pre- and post-intervention, withdrawal rate (WR) in percent,
Peer reviewed/ thesis The study of Shah et al. [69] explicitly excluded participants with un-

intention to treat yes/no, baseline measures mean ± SD intervention group, baseline measure mean ± SD control group, minutes per session (M/S), sessions per week (S/Wk), weeks (Wks), minutes per week (M/Wk),
treated depressive symptoms.

peer reviewed
thesis

(GHQ), Profile of Mood State-Depression/Anxiety (POMS-D/A), Hospital Anxiety and Depression Scale-Depression/Anxiety (HADS-D/A), intervention group (IG), control group (CG), not available (N.A.).
3.5. Outcomes of included studies
Location of exercise intervention

home based
Nine studies reported the effects of exercise on depression

stationary
outcomes [39,62,63,65–70], while only five studies reported
anxiety outcomes [63,64,66,68,70]. A summary of the outcome
measures for these stu- dies are summarized in the Appendix (Table

not supervised
professionally supervised

A.3).
Super-vision

3.6. Risk of BIAS

Five studies were graded as having good methodological quality

and low risk of bias with a PEDro score ≥ 5 [39,62,63,68,69]. The
not mentioned/ (n) 15/34

re- maining five studies were rated as low-quality studies (high risk
Anti- depressant/ ART

of bias) [64–67,70]. The risk of bias analysis according to the

PEDro scale is available in the Appendix, Table A.4.

3.7. META-ANALYTIC results

non- structured:routine daily activity
Control group condition

3.7.1. Depression
Nine studies investigated depression (n = 194 in the exercise
group, n = 201 in the control group) and five were of high quality.
An overall standardized mean difference SMD = −0.84 (95% CI
-1.57 to −0.11) in favor of the exercise group was found in the
M/Wk

random-effect model for post-intervention values. There was a

N.A.
120

significant overall effect (Z = 2.27, p = 0.02) of exercise

Wks

compared to the control group at post- treatment. Statistical

10

12

2 2
heterogeneity was high (I = 91%, X = 87.82, df = 8, p < 0.001).
S/Wk
Intervention

N.A.

Measuring tools used from the included studies were: BDI-D, GHQ-
2

28, POMS-D, HADS-D, see Appendix, Table A.3. Table 2 shows all
N.A.
M/S

statistical results of the subgroup analyses for de- pression. The

60

forest plot of the main analysis of depression is shown in Fig. 2.

Control
group difference post minus baseline (SD)

3.7.2. Anxiety
Five studies investigated anxiety (n = 92 in the exercise group,
8.70 (7.10);

n = 93 in the control group), two of which were of high quality. An

overall standardized mean difference SMD = −1.23 (95% CI -2.42
Intervention

to
−0.04) in favor of the exercise group was found in the random-
effect model for post-intervention values. There was a significant
overall ef- fect (Z = 2.03, p = 0.04) of exercise compared to the
control group at post-treatment. Statistical heterogeneity was
high (I2 = 92%, X2 = 48.90, df = 4, p < 0.001). Measuring tools
WR%/

for anxiety used from the included studies were: GHQ-28, POMS-
42 no 42, 34,

11.90%/ 67, 59,

within

A, HADS-A, STAI, see Appendix, Table A.3. Table 2 shows the

post (n),

results of the meta-analysis for anxiety; no subgroup analysis was

(SD);

conducted due to the low number of studies identified. The forest

19%/
post

plot of the main analysis for anxiety is shown in Fig. 3.

postn,

(19%), post: pre:

(SD);pre,
(% women)

3.7.3. Pre-post ANALYSES

The SMD difference in the depression post analysis (−0.84) and
nBaseline

pre-post analysis (−0.91) was 0.07 favoring the pre-post analysis. A

Intervention

aerobic exercise vs. CG

minimal difference in SMD post minus pre-post was found for anxiety
Participants

(0.04) favoring the pre-post analyses. Thereby no substantial differ-

ences between the results and heterogeneity between post and pre-post
Method/

analyses exist. Post analysis vs. pre-post analysis for the outcomes are
STAI: anxiety

presented in Table 3.
depression BDI-D:
Outcome Parameter

3.7.4. Sensitivity ANALYSES

Sensitivity analyses where performed after the main analyses. A
Table 1 (continued)

sensitivity analysis for depression was conducted, excluding the

Schlenzig, 1992,

studies of Daniels et al. [65] and Jaggers et al. [67]; a large

significant effect was found (SMD = −1.19 (95% CI -1.97 to
2 2
−0.40), Z = 2.95 p = 0.003, X = 0.98, df = 6, p < 0.001, I =
89%). The two afore-

6
A. Heissel, et AL. JourNAlofPsychosomAticRes
eArch126(2019)109823
mentioned studies were excluded due to the continuously unequal

10
(large differences) baseline measures in the intervention and control

9
groups ((Daniels et al. [65] IG 6.17 (3.97), CG 4.64 (2.79) at baseline;
Jaggers et al. [67]: IG 14.40 (12.20), CG 9.40 (9.10) at baseline).
Conducting a second sensitivity analysis for depression
(excluding the studies of Shah et al. and Daniels et al. [65,69]), a
large significant effect was found (SMD = −1.21 (95% CI -1.97 to
−0.45), Z = 3.12 (p < 0.01), X2 = 46.95, df = 6, p < 0.01, I2 =
87%). The reason for excluding these studies was due to the
missing information about ex- ercise minutes per session and/or
sessions per week, and the circum- stance that participants were
instructed to perform the instructed ex- ercise at home on their
own.
Conducting a third sensitivity analysis for depression by
excluding the study of LaPerriere [63], a moderate significant effect
was found for depression (SMD = −0.76 (95% CI -1.53 to −0.01).
Excluding the study of Schlenzig et al. [64], a large significant
effect for anxiety was found (SMD = −1.49 (95% CI -2.98 to
−0.01).
3.7.5. PUBLICATION BIAS
According to Egger's test, a publication bias was found for
depres- sion (bias = −8.24, CI 95% 16.41 to −0.06), p = 0.048).
However, no publication bias was found for anxiety (bias = −9.66,
CI 95% -36.97 to 17.64), p = 0.34.
4. Discussion
To our knowledge, this is the first meta-analysis evaluating the ef-
fects of exercise (both traditional and non-traditional forms of activity)
on depression and anxiety outcomes in PLWH. Notably, the results of
the meta-analysis for depression revealed a high and significant effect
of exercise on depressive symptoms (SMD = −0.84). When analyzing
only low-risk-of-bias studies, this effect was found to be even greater
(SMD = −1.31). Importantly, in subgroup analyses testing only ex-
ercise trials with three or more sessions per week (SMD = −1.39) and
professional supervision (SMD = −1.40), significant and large effects
were evident. Although the meta-analysis of O'Brien et al. [31] already
found a significant improvement in depression scores favoring the ex-
ercisers compared to the non-exercisers, the analysis was limited to
two studies (LaPerriere [63] and Smith [71], n = 65; with the study of
La- Perriere [63] being conducted in the pre-ART era). We now can
add
further meaningful evidence to this field.
Given the moderately high methodological heterogeneity between
studies, these findings need to be considered in this context. The
studies were conducted in different countries, such as the USA, Africa,
Germany, and India. Different prevalence rates for depression in
PLWH are reported in China (50.8%) [72], Vietnam [73] (44%),
Africa (9% -
32%) [74] and India (67.3%) [75]. Also, two studies [63,64] were
conducted in the pre-ART era before the year 1995. Depression and
anxiety prevalence and levels for PLWH during the pre-ART era
were higher. In the study of LaPerriere [63], the values for
depression and anxiety in the exercising group (+3.1/ +0.1) did not
decrease com- pared to the non-exercising control group (+13.8/
+5) but was just increasing less.
The study of LaPerriere [63] did not report HAART. In the partici-
pant description in the paper, it was mentioned that the participants did
not know about their HIV status at study entry, which implies that they
were not on HAART at all. In the study by Schlenzig [64], 15 of 34
participants were under anti-retroviral medication and the participants
presented different HIV-specific disease progressions. The circum-
stances for developing depression or anxiety are different compared
with participants of a study conducted in more recent years with a
stable infection and HAART. The two studies in the sub-analysis for
depression investigating yoga only were the same as in the sub-
analysis for HADS only. The comparison between the (commonly
used) post- analyses and the pre-post analyses revealed no differences
in the results and heterogeneity indicating that drop-out after
randomization espe- cially in small samples sizes did not lead to
significant differences in the main outcomes pre- to post intervention.
The present findings are in accordance with previous studies de-
monstrating the beneficial effects of exercise in reducing depressive
symptoms [22], which is also evident for PLWH.
A large and significant effect (SMD = −1.23) for anxiety was
found at post-treatment. However, this finding was based on a
conservative number of studies (n = 5); therefore, these results are
provisional, as more RCTs are clearly needed in this field.
Nonetheless, this effect is also in accordance with previous studies that
have shown the anxiolytic effects of exercise [76]. The current
findings further indicate that ex- ercise is also beneficial in reducing
anxiety symptoms in PLWH.

Table 2
Meta-analytic results – depression, anxiety for post-intervention values.
2 2 2
Effect foci n trials (n participants) SMD (95% CI) Z (p) I (Tau ), Chi , df (p)

Depression
Random-effect model 9 (395) −0.84 [−1.57, −0.11] 2.27 (0.02) 91% 1.11, 87.82, 8 (< 0.001)

Subgroup analysis
1. AE 3 (98) −0.96 [−1.63, −0.30] 2.86 (0.004) 52% 0.18, 4.15, 2 (=0.13)
2. AERT 4 (193) −0.12 [−0.86, 0.62] 0.32 (0.75) 84% 0.47, 18.68, 3 (< 0.001)
3. Yoga 2 (104) −2.03 [−4.76, 0.70] 1.46 (0.15) 97% 3.75, 28.96, 1 (< 0.001)
4. ≥ 3 sessions/week 6 (232) −1.39 [−2.24, −0.54] 3.20 (< 0.001) 87% 0.97, 38.94, 5 (< 0.001)
5. Professional supervision 4 (182) −1.40 [−2.64, −0.17] 2.24 (0.03) 92% 1.45, 38.39, 3 (< 0.001)
6. PEDro score ≥ 5 5 (217) −1.31 [−2.46, −0.17] 2.24 (0.02) 92% 1.56, 52.14, 4 (< 0.001)
7. POMS-D - only 3 (109) −0.60 [−1.23, 0.02] 1.88 (0.06) 55% 0.16, 4.41, 2 (=0.11)
8. BDI - only 4 (200) −0.18 [−0.96, 0.59] 0.46 (0.64) 86% 0.53, 21.00, 3 (=0.001)
9. HADS-D - only 2 (104) −2.03 [−4.76, 0.70] 1.46 (0.15) 1.46 (0.15) 97% 28.96, 1 (< 0.001) 3.75, 28.96, 1 (< 0.001)
10. structured control 5 (184) −0.62 [−1.53, −0.30] 1.32 (0.19) 88% 0.93, 32.59, 4 (< 0.001)
11. non-structured control 4 (211) −1.11 [−2.38, 0.15] 1.73 (0.08) 94% 1.55, 50.16, 3 (< 0.001)

Anxiety
Random-effect model 5 (185) −1.23 [−2.42, −0.04] 2.03 (0.04) 92% 1.67, 48.90, 4 (< 0.001)

Note. Panel includes n trials (n participants), standardized mean difference (SMD), 95% confidence interval (95% CI), Z-score (Z) and significance (p) of
exercise vs. control conditions. Statistical heterogeneity (I2) is tested using the Chi2 statistics, including degree of freedom (df) and significance (p) and Tau2. A

7
A. Heissel, et AL. JourNAlofPsychosomAticRes
eArch126(2019)109823
negative SMD favors the exercise group. Aerobic exercise (AE), aerobic exercise combined with resistance training (AERT), Physiotherapy Evidence Database
(PEDro), Beck Depression Inventory (BDI), Profile of Mood State (POMS), Hospital Anxiety and Depression Scale (HADS).

8
 Fig. 2. Forest plot using random effect model of studies examining the impact of exercise on depression.
Fig. 3. Forest plot using random effect model of studies examining the impact of exercise on anxiety.
Table 3
Pre-post comparison of depression and anxiety.
Outcome Studies (n) Participants (n) Post-analysis
Random effect model
Depression 9 395 −0.84 [−1.57, −0.11]
Anxiety 5 185 −1.23 [−2.42, −0.04]
Note. Panel includes study outcome, studies (n), participants (n), random effect of post analysis, heterogeneity of post analysis (I2), random effect of pre-post analysis,
heterogeneity of pre-post analysis (I2), difference of post minus pre-post analysis of random effect models and heterogeneity (I2).
In this investigation, only two studies [68,69] explicitly excluded
participants with a psychiatric illness, which includes depression and
anxiety. For all other included studies, diagnosed depression was not a
reason for exclusion. Effectively, the baseline scores of the depression
and anxiety measures were under the cut-off values for depression or
anxiety in six studies [39,62–64,66,67]. Overall, 42 (8.8%) of the 479
participants at baseline were diagnosed with depression or anxiety. In
the review by Chaudhury et al. [77], the prevalence of depression was
36% and of anxiety 16% in PLWH. Also, they reported that the pre-
valence of depression and anxiety in PLWH ranged from 7.2% to
71.9% and from 4.5% to 82.3%, respectively. Given the fact that the
pre- valence for depression and anxiety is underrepresented in the
included studies compared to the general HIV population, the effect of
exercise could also be underestimated.
5. Limitations
This review was based explicitly on depression and anxiety out-
comes. Hence, the findings may not generalize to broader QOL out-
comes that are more multidimensional. The results from the current
review need to also be interpreted in the context of several limitations.
First, the findings from the pre-post analysis may have in part been
influenced by the small sample sizes, given that the majority (i.e.,
60%) of included trials was comprised of samples < 50, with a
combined
2 2
I Pre-post analysis I Post minus pre-post
2
Random effect model Diff. random Diff. I
91% −0.91 [−1.51, −0.32] 86% 0.07 5%
92% −1.27 [−2.49, −0.04] 92% 0.04 0%
total sample range of 17 to 67 participants. This wide sampling
varia- bility increases the risk of sample bias among the studies and
can lead to high statistical heterogeneity. Furthermore, across the
ten studies, the participant dropout rate was 10.44% (n = 50). Six
of these studies had a high withdrawal rate according to the quality
assessment from the PEDro scale (≥ 15% of participants dropped
out) [39,62,64,66,67,70]. However, due to the proportionate
dropout rates in the intervention and control groups in these trials,
the migration bias within the studies of participants who dropped
out is minimized. Taken together, this pattern of findings highlights
the need for future RCTs in this field to use larger sample sizes that
comply with the criteria of high-
quality studies, including the blinding of assessors and intention-to-
treat analysis, and involve clinically standardized outcome measures.
As outlined in the participants' characteristics, two of the included
studies included samples taking anti-depressants or anti-anxiety medi-
cations [39,69]. The inclusion of these studies may have partially in-
fluenced the current results of the meta-analyses, as medication use in
combination with exercise may have a potential synergistic effect in
improving well-being. It is unclear, however, whether participants in
the remaining eight studies used anti-depressants or anxiolytics, as
these studies did not report on medication usage. This merits further
investigation in future, larger scale RCTs in this field. Furthermore, it
is known that HAART medication affects physiological parameters
such as muscle tissue, body composition, cardiovascular parameters,
and also
psychological parameters [5,78–80].
Although the medication intake in the studies that reported
HARRT use was similar, the risk of medication bias is still possible
since dif- ferent types of HAART were analyzed. The duration of
HAART intake and the number of therapy changes may also be
different for every HIV- positive participant. These factors may
influence the effect of any type of exercise method investigated.
Further research in a more homo- genous classification for medication
intake is needed.
In addition, the current meta-analysis excluded any control groups
exercising at different intensity levels or performing other forms of
exercise. However, we considered the strict differentiation between
exercising and non-exercising participants as a strength of this study.
The inclusion of an exercising control group would lead to confounded
results regarding the comparison of exercising and non-exercising
PLWH.
This current meta-analysis excluded studies investigating quality of
life. It must be mentioned that the MOS-HIV or the SF-36 are primary
tools of investigation in several excluded studies, e.g. Mutimura et al.
[81], Maharaj et al. [82], Ogalha et al. [83], and Mkandla et al. [84].
These questionnaires also include domains of anxiety and depression
as part of the mental health summary score. The current findings are
re- latively comparable to the findings of Nosrat et al. [33], although
they found positive effects of exercise when comparing exercise to
control groups. The limitation of Nosrat's review [33] is that the results
are not based on meta-analytical findings. In the current meta-analysis,
we used validated specific measures for depression and anxiety.
Regarding the control group conditions, the meta-analysis for
de- pression showed a higher effect in favor of the intervention
group when comparing non-structured vs. structured control
conditions (SMD = 1.11 vs. SMD = −0.62), even though both
analyses are not significant (p = 0.08 vs. p = 0.19). Furthermore,
within a non-struc- tured control condition such as “maintaining
daily activity,” it remains unclear what exactly the participants did
during this time.
5.1. IMPLICATIONS for RESEARCH
It is noteworthy that there was an equal gender distribution in the
included studies, with women comprising 49.7% of the sample
average. This indicates that the findings are applicable across both
genders. This is particularly relevant given that research has shown
that the pre- valence rates for anxiety and depression may be higher in
women versus men [85,86]. However, given that all of included
studies in the current review did not report the depression and anxiety
results sepa- rately for each gender, unfortunately this precluded
conducting sub- analyses according to whether or not the effects of
exercise for de- pression and anxiety were influenced by gender.
Accordingly, future research is needed to specifically test whether
women and men benefit equally from the positive effects of exercise
interventions.
The outcomes of this review identified some additional gaps that
need to be addressed in future research. First, PEDro scale criteria:
blinding subjects (n = 0), and blinding researchers/evaluators (n =
0) were not met from any study. Blinding subject and blinding re-
searchers/evaluators are hardly realizable due to the nature of the
ex- ercise intervention. Some criteria for high methodological
quality were not met by many studies, such as blinding assessors (n
= 7), measuring at least one key outcome obtained from > 85% of
subjects initially al- located to groups (n = 6), and intention-to-treat
analysis (n = 8). Therefore, the methodological quality of studies
needs to be improved in future trials. Second, medication intake,
especially antidepressants, was not specified in the majority of
trials. This information is important to detail in future studies in
order to establish whether or not there is
indeed a synergistic effect when exercise is combined with medication
use. Third, the effect of age regarding the impact of exercise on de-
pression and anxiety status has not been investigated systematically.
Finally, the number of studies investigating exercise beyond the tradi-
tional forms of aerobic and resistance training is small, with only two
studies identified for PLWH. Hence, it is too early to determine
whether the benefits of exercise are equivalent across different forms
of physical activity for PLWH. Further research is clearly needed to
extend this line of research.
With regard to the higher effect in the subgroup analysis of pro-
fessional supervision (SMD = −1.40 [−2.64, −0.17]), these results
are similar to those of Schuch et al.'s [87] meta analyses investigating
exercise in the context of depressed patients also finding large and
higher effects for exercise led by exercise professionals. Another study
in the context of exercise and aging with nearly 500 participants found
that the perceived need support from the exercise professional predicts
depressive symptoms and satisfaction with life [88]. Therefore, further
studies need to control for the effect of the supervision suggesting that
e.g. the competence and empathy of the supervisor influences the
outcomes positively. Also exercising with a training partner or in a
group can have positive effects on the outcomes and therefore should
be controlled and might promote an even greater decrease in
depressive and anxiety symptoms.
5.2. IMPLICATIONS for PRACTICE
PLWH have a higher risk of developing depressive or anxiety
symptoms when compared to HIV negatives. This meta-analysis
showed the benefits of performing exercise for reducing depressive
and anxiety symptoms beyond the well investigated benefits for
physical health in PLWH. Additionally, exercise is generally a fast
reachable and easy accessible option that should be recommended by
physicians to PLWH. Moreover, the results further showed that a high
frequency of training sessions (3 or more per week) may be beneficial
specifically for the reduction of depressive symptoms. Supervision by
qualified exercise professionals also led to greater effects for
depression. This psycho-so- cial component of the involvement of an
exercise professional that might be further increased by exercising
within a group or a partner should be considered in the
recommendations of physicians and out- reach clinics.
6. Conclusion
The present meta-analytic outcomes indicate large effects for the
efficacy of exercise interventions in reducing both depression and an-
xiety symptoms in PLWH. Although these findings are based on a
small number of RCTs, these results suggest that exercise seems to be
mod- erately to largely beneficial for reducing depression and anxiety
in PLWH. Taken together, the results suggest that highly frequent (3 or
more per week), professionally supervised, and aerobic exercise may
lead to the greatest improvements in depressive symptoms for PLWH.
Dclaration of Competing Interests
The authors have no competing interests to report.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
 Appendices

Table A.1
Systematic search strategy.

Database Date Combined terms and text words

Pubmed 13.02.2019 (((((((((HIV[MeSH Terms]) AND physical exercise[MeSH Terms]) OR physical activity[MeSH Terms]) OR yoga[MeSH Terms]) OR tai chi[MeSH
Terms]) OR qigong[MeSH Terms]) AND psychological [MeSH Terms] depression[MeSH Terms]) OR dysthymia[MeSH Terms]) OR anxiety[MeSH
Terms]
Cochrane Cen- 13.02.2019 HIV, exercise, physical activity, depression, anxiety
tral
PsycNet 13.02.2019 “HIV” OR “human immunodeficiency virus”) AND (“exercise” OR “physical activity” OR “aerobic” OR “resistance” OR “strength “OR “fitness “OR
“yoga “OR “tai chi “OR “qigong“) AND (“depression” OR “psychological” OR “depressive” OR “dysthymic” OR “dysthymia” OR “anxiety”)
PEDro 13.02.2019 HIV, exercise, physical activity, depression, anxiety
Clinicaltrials. 13.02.2019 (HIV exercise OR physical activity OR resistance OR aerobic OR yoga OR tai chi OR qigong AND depression OR anxiety or dysthymia)
gov

Note. Scientific databases consulted for the systematic review, with search term combinations and search dates as day, month and year.

Table A.2
Study characteristics of studies excluded from quantitative synthesis.
Author,
Outcome Method Participants Baseline Intervention Control Reason for Supervision Peer re-
Year,
Parameters /Intervention group exclusion viewed/
Country Intervention Control M/ S/ Wks M/ thesis
S Wk Wk

1 Galantino,
ML., 2005 POMS aerobic exer- (n) = 38, AE 2 8 non-struc- no baseline not men- peer re-
USA cise vs. tai chi n = 13,TC tured: usual or post tioned viewed
vs. control n = 13, CG daily activity measures
n = 12

Note. Study characteristics presented as author/year of publication, investigated outcome, specific intervention investigated, (n) participants, baseline measures
mean ± SD intervention group, baseline measure mean ± SD control group, minutes per session (M/S), sessions per week (S/Wk), weeks (Wks), minutes per
week (M/Wk), description of control group condition. Profile of Mood State (POMS), aerobic exercise (AE), tai chi (TC), control group (CG).

Table A.3
Outcome measures.

Studies Outcome Measuring tool Number of stu-

dies (%)

(Aweto et al., 2016; Daniels & Van Niekerk 2018; Dianatinasab et al., 2018; Jaggers et al., 2014; Kiloor et al., 2018;
Depression BDI-D, GHQ-28, POMS- 9 (90%)
LaPerriere et al., 1990; Naoroibam et al. 2016; Neidig et al. 2003; Shah et al., 2016)
D, HADS-D
(Dianatinasab et al. 2018; Kiloor et al., 2018; LaPerriere et al., 1990; Naoroibam et al., 2016, Schlenzig et al., 1992) Anxiety (GHQ-28, POMS-A, 5 (50%)
HADS-A, STAI)

Note. Studies: author/year of publication, Outcome: investigated parameter, measuring tool, number of investigating studies (percentage), Beck Depression Inventory-
Depression (BDI-D), General Health Questionnaire −28 (GHQ-28), Profile of Mood State-Depression/Anxiety (POMS-D/A), Hospital Anxiety and Depression Scale
(HADS), State-Trait Anxiety Inventory (STAI), percentage (%).

Table A.4
Risk of bias analysis according to the PEDro scale.

Study E I I III I V VI VII VIII IX X Tota

C I V l

Aweto HA. 2016 Y 1 1 1 0 0 0 0 0 1 1 5

Daniels AK. 2018 Y 1 0 0 0 0 0 1 0 1 1 4
Dianatinasab M. 2016 Y 1 0 1 0 0 0 0 0 1 1 4
Jaggers FR. 2014 Y 1 0 0 0 0 0 0 0 1 1 3
Kiloor A. 2018 Y 1 1 1 0 0 0 1 0 1 1 6
LaPerriere A. 1990 Y 1 0 1 0 0 0 1 1 1 1 6
Naoroibam R. 2016 Y 1 0 1 0 0 0 0 0 1 1 4
Neidig JL. 2003 Y 1 0 1 0 0 1 0 1 1 1 6
Schlenzig C. 1992 Y 1 0 1 0 0 0 0 0 1 1 4
Shah KN. 2016 Y 1 1 1 0 0 1 1 0 1 1 7

Note. EC: eligibility criteria, I: allocated randomization of subjects to groups, II: concealed allocation, III: similarities of groups at baseline, IV: blinding of
subjects, V: blinding of researchers/evaluators, VI: blinding of assessors, VII: measure of at least one key outcome obtained from > 85% of subjects initially
allocated to groups, VIII: intention to treat, IX: statistical comparison of between-group results, X: measured at least one key outcome at two time points, 1:
criteria is present, 0: criteria is missing. *EC does not contribute to the total score, Y: Yes, eligibility criteria present.

References [1] World Health Organization, Number of People (All Ages) Living with HIV Estimates by WHO
Region [Internet], Available from, 2017. http://apps.who.int/gho/data/
view.main.22100WHO?lang=en.
 [2] Bayoumi A.M. O'Brien, C. Strike, N.L. Young, K. King, A.M. Davis, How do
existing HIV-specific instruments measure up? evaluating the ability of instruments [27]
to de- scribe disability experienced by adults living with HIV, Health Qual. Life
Outcomes
8 (1) (2010) 88.
[3] Bayoumi A.M. O'Brien, C. Strike, N.L. Young, A.M. Davis, Exploring disability
from the perspective of adults living with HIV/AIDS: development of a conceptual
fra- mework, Health Qual. Life Outcomes 6 (1) (2008) 76.
[4] S.G. Deeks, S.R. Lewin, D.V. Havlir, The end of AIDS: HIV infection as a chronic
disease, Lancet 382 (9903) (2013) 1525–1533.
[5] K.M. Erlandson, J.A. Schrack, C.M. Jankowski, T.T. Brown, T.B. Campbell,
Functional impairment, disability, and frailty in adults aging with HIV-infection,
Curr HIV/AIDS Rep. 11 (3) (2014 Sep) 279–290.
[6] A.T. Rodriguez-Penney, J.E. Iudicello, P.K. Riggs, K. Doyle, R.J. Ellis, S.L.
Letendre, et al., Co-morbidities in persons infected with HIV: increased burden with
older age and negative effects on health-related quality of life, AIDS Patient Care
STDs 27 (1)
(2013 Jan) 5–16.
[7] J.O. Mugisha, E.J. Schatz, M. Randell, M. Kuteesa, P. Kowal, J. Negin, et al.,
Chronic disease, risk factors and disability in adults aged 50 and above living with
and without HIV: findings from the wellbeing of older people study in Uganda,
Glob.
Health Action 9 (1) (2016 Dec) 31098.
[8] G. Tesfaw, G. Ayano, T. Awoke, D. Assefa, Z. Birhanu, G. Miheretie, et al.,
Prevalence and correlates of depression and anxiety among patients with HIV on-
follow up at Alert Hospital, Addis Ababa, Ethiopia, BMC Psychiatry [Internet] 16
(368) (2016) 1–7 Dec [cited 2017 Jan 3];16(1). Available from: http://
bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-016-1037-9.
[9] J. Leserman, Role of depression, stress, and trauma in HIV disease progression,
Psychosom Med 70 (5) (2008 Jun) 539–545.
[10] L. Schlebusch, R.D. Govender, Elevated risk of suicidal ideation in HIV-positive
persons, Depress. Res. Treat. 2015 (2015) 1–6.
[11] Y.-L. Wu, H.-Y. Yang, J. Wang, H. Yao, X. Zhao, J. Chen, et al., Prevalence of sui-
cidal ideation and associated factors among HIV-positive MSM in Anhui, China, Int.
J. STD AIDS. 26 (7) (2015 Jun 1) 496–503.
[12] S.A. Nixon, J. Hanass-Hancock, A. Whiteside, T. Barnett, The increasing chronicity
of HIV in sub-Saharan Africa: re-thinking" HIV as a long-wave event" in the era of
widespread access to ART, Glob. Health 7 (1) (2011) 41.
[13] S. Amanor-Boadu, M.S. Hipolito, N. Rai, C.K. McLean, K. Flanagan, F.T.
Hamilton, et al., Poor CD4 count is a predictor of untreated depression in human
im-
munodeficiency virus-positive African-Americans, World J. Psychiatr. 6 (1) (2016)
128.
[14] G. Ironson, C. O'Cleirigh, M.A. Fletcher, J.P. Laurenceau, E. Balbin, N. Klimas, et
al., Psychosocial factors predict CD4 and viral load change in men and women
with
human immunodeficiency virus in the era of highly active antiretroviral treatment,
Psychosom Med. 67 (6) (2005 Nov) 1013–1021.
[15] J.S. Gonzalez, A.W. Batchelder, C. Psaros, S.A. Safren, Depression and HIV/AIDS
treatment nonadherence: a review and meta-analysis, JAIDS J. Acquir. Immune
Defic. Syndr. 58 (2) (2011 Oct) 181–187.
[16] S.A. Safren, C. O'Cleirigh, J.Y. Tan, S.R. Raminani, L.C. Reilly, M.W. Otto, et al.,
A randomized controlled trial of cognitive behavioral therapy for adherence and
de-
pression (CBT-AD) in HIV-infected individuals, Health Psychol. 28 (1) (2009) 1–10.
[17] A. Larisch, G. Heuft, S. Engbrink, E. Brähler, W. Herzog, J. Kruse, Behandlung
psychischer und psychosomatischer Beschwerden-Inanspruchnahme, Erwartungen
und Kenntnisse der Allgemeinbevölkerung in Deutschland, Z Für Psychosom Med
Psychother. 59 (2) (2013) 153–169.
[18] C.J. Caspersen, K.E. Powell, G.M. Christenson, Physical activity, exercise, and
physical fitness: definitions and distinctions for health-related research, Public
Health Rep. 100 (2) (1985) 126.
[19] F.B. Schuch, D. Vancampfort, J. Firth, S. Rosenbaum, P.B. Ward, E.S. Silva, et al.,
Physical activity and incident depression: a Meta-analysis of prospective cohort
studies, Am. J. Psychiatry 175 (7) (2018 Jul) 631–648.
[20] F.B. Schuch, B. Stubbs, J. Meyer, A. Heissel, P. Zech, D. Vancampfort, et al.,
Physical activity protects from incident anxiety: A meta-analysis of prospective
cohort stu- dies: SCHUCH ET AL. Depress Anxiety [Internet], 17 [cited 2019 Jul 17];
Available
from: http://doi.wiley.com/10.1002/da.22915.
[21] G.M. Cooney, K. Dwan, C.A. Greig, D.A. Lawlor, J. Rimer, F.R. Waugh, et al.,
Exercise for depression, The Cochrane Collaboration, Cochrane Database of
Systematic Reviews [Internet], John Wiley & Sons, Ltd, Chichester, UK, 2013, ,
https://doi.org/10.1002/14651858.CD004366.pub6 [cited 2017 Jul 4]. Available
from:.
[22] F.B. Schuch, D. Vancampfort, J. Richards, S. Rosenbaum, P.B. Ward, B. Stubbs,
Exercise as a treatment for depression: a meta-analysis adjusting for publication
bias, J. Psychiatr. Res. 77 (2016 Jun) 42–51.
[23] D. Vancampfort, J. Mugisha, M. De Hert, M. Probst, J. Firth, P. Gorczynski, et al.,
Global physical activity levels among people living with HIV: a systematic review
and meta-analysis, Disabil. Rehabil. 40 (4) (2018 Feb 13) 388–397.
[24] D. Vancampfort, J. Mugisha, M. De Hert, M. Probst, B. Stubbs, Sedentary behavior
in people living with HIV: a systematic review and Meta-analysis, J. Phys. Act.
Health 14 (7) (2017 Mar 14) 571–577.
[25] M. Gomes Neto, C.S. Conceição, V.O. Carvalho, C. Brites, Effects of combined
aerobic and resistance exercise on exercise capacity, muscle strength and quality of
life in HIV-infected patients: a systematic review and meta-analysis. Sacchetti M,
editor, PLOS ONE 10 (9) (2015 Sep 17) e0138066.
[26] M. Gomes-Neto, C. Conceicao, V. Carvalho, C. Brites, A systematic review of the
effects of different types of therapeutic exercise on physiologic and functional
measurements in patients with HIV/AIDS, Clinics. 68 (8) (2013 Aug 30) 1157–
1167.
L.L. Leach, S.H. Bassett, G. Smithdorf, B.S. Andrews, A.L. Travill, Suppl 1: M3: a
systematic review of the effects of exercise interventions on body composition in
HIV+ adults, Open AIDS J. 9 (2015) 66.
[28] K.K. O'Brien, A.M. Tynan, S.A. Nixon, R.H. Glazier, Effectiveness of
Progressive Resistive Exercise (PRE) in the context of HIV: systematic
review and meta-analysis using the Cochrane Collaboration protocol,
BMC Infect Dis. 17 (1) (Apr 12 2017)
268, https://doi.org/10.1186/s12879-017-2342-8.
[29] C.G.A. Pérez Chaparro, P. Zech, F. Schuch, B. Wolfarth, M. Rapp, A.
Heiβel, Effects of aerobic and resistance exercise alone or combined on
strength and hormone outcomes for people living with HIV. A meta-
analysis. Parmenter B, editor, PLOS ONE 13 (9) (2018 Sep 4)
e0203384.
[30] Zech P, Pérez-Chaparro C, Schuch F, Wolfarth B, Rapp M, Heissel A.
Effects of aerobic and resistance exercise on cardiovascular parameters
for people living with
HIV. J. Assoc. Nurses AIDS Care. e-pub ahead;
[31] K.K. O’Brien, A.-M. Tynan, S.A. Nixon, R.H. Glazier, Effectiveness
of aerobic ex- ercise for adults living with HIV: systematic review and
meta-analysis using the Cochrane Collaboration protocol, BMC Infect
Dis. [Internet] 16 (182) (2016 Dec) 1–56 [cited 2017 Mar 29];16(1).
Available from: http://bmcinfectdis.
biomedcentral.com/articles/10.1186/s12879-016-1478-2.
[32] S.M. Lofgren, N. Nakasujja, D.R. Boulware, Systematic review of
interventions for depression for people living with HIV in Africa, AIDS
Behav. 22 (1) (2018 Jan) 1–8.
[33] S. Nosrat, J.W. Whitworth, J.T. Ciccolo, Exercise and mental health of people living
with HIV: a systematic review, Chronic Illn. 13 (4) (2017 Dec) 299–319.
[34] The Cochrane Public Health Group, Guide for developing a Cochrane
protocol [Internet], Available from, 2011.
http://ph.cochrane.org/sites/ph.cochrane.org/
files/public/uploads/Guide%20for%20PH%20protocol_Nov
%202011_final%20for
%20website.pdf.
[35] D. Moher, L. Shamseer, M. Clarke, D. Ghersi, A. Liberati, M.
Petticrew, et al., Preferred reporting items for systematic review
and meta-analysis protocols
(PRISMA-P) 2015 statement, Syst Rev. 4 (1) (2015) 1.
[36] N.L. McCain, D.P. Gray, R.K. Elswick, J.W. Robins, I. Tuck, J.M.
Walter, et al., A randomized clinical trial of alternative stress
management interventions in persons with HIV infection, J. Consult.
Clin. Psychol. 76 (3) (2008) 431–441.
[37] N. Falsafi, A randomized controlled trial of mindfulness versus yoga:
effects on depression and/or anxiety in college students, J. Am.
Psychiatr. Nurses Assoc. 22
(6) (2016) 483–497.
[38] P. Ekkekakis, Honey, I shrunk the pooled SMD! Guide to critical
appraisal of sys- tematic reviews and meta-analyses using the
Cochrane review on exercise for de- pression as example, Ment.
Health Phys. Act. 8 (2015 Mar) 21–36.
[39] J.L. Neidig, B.A. Smith, D.E. Brashers, Aerobic exercise training for depressive
symptom Management in Adults Living with HIV infection, J. Assoc.
[55] A. McDermott, L. Zaporojan, P. McNamara, C.P. Doherty, J. Redmond, C. Forde,
et al., The effects of a 16-week aerobic exercise programme on cognitive function in
people living with HIV, AIDS Care 29 (6) (2017 Jun 3) 667–674.
[56] W.W. Stringer, M. Berezovskaya, W.A. O'Brien, C.K. Beck, R. Casaburi, The effect
of exercise training on aerobic fitness, immune indices, and quality of life in HIV+
patients, Med. Sci. Sports Exerc. 30 (1) (1998) 11–16.
[57] L. Terry, E. Sprinz, J.P. Ribeiro, Moderate and high intensity exercise training in
HIV-1 seropositive individuals: a randomized trial, Int. J. Sports Med. 20 (02)
(1999) 142–146.
[58] S.E. Jensen, D.B. Pereira, N. Whitehead, I. Buscher, J. McCalla, M. Andrasik, et al.,
Cognitive–behavioral stress management and psychological well-being in HIV+
racial/ethnic minority women with human papillomavirus, Health Psychol. 32 (2)
(2013 Feb) 227–230.
[59] L. Li, G. Ji, L.-J. Liang, C. Lin, J. Hsieh, C.-W. Lan, et al., Efficacy of a multilevel
intervention on the mental health of people living with HIV and their family
members in rural China, Health Psychol. 36 (9) (2017 Sep) 863–871.
[60] J.T. Moskowitz, A.W. Carrico, L.G. Duncan, M.A. Cohn, E.O. Cheung, A.
Batchelder, et al., Randomized controlled trial of a positive affect intervention for
people newly diagnosed with HIV, J. Consult. Clin. Psychol. 85 (5) (2017) 409–
423.
[61] M.L. Galantino, K. Shepard, L. Krafft, A. Laperriere, J. Ducette, A. Sorbello, et al.,
The effect of group aerobic exercise and t'ai chi on functional outcomes and quality
of life for persons living with acquired immunodeficiency syndrome, J. Altern.
Complem. Med. Res. Paradigm Pract. Policy. 11 (6) (2005) 1085–1092.
[62] H.A. Aweto, A.I. Aiyegbusi, A.J. Ugonabo, T.A. Adeyemo, Effects of aerobic
exercise on the pulmonary functions, respiratory symptoms and psychological status
of people living with HIV, J. Res. Health Sci. 16 (1) (2016) 17–21.
[63] A.R. LaPerriere, M.H. Antoni, N. Schneiderman, G. Ironson, N. Klimas, P. Caralis,
et al., Exercise intervention attenuates emotional distress and natural killer cell
decrements following notification of positive serologic status for HIV-1,
Biofeedback Self-Regul. 15 (3) (1990) 229–242.
[64] C. Schlenzig, Reaktionen des Immunsystems und der Psyche HIV-Infizierter und
AIDS-Patienten auf kontrollierte sporttherapeutische Langzeitbehandlung,
[Heidelberg]: Ruprecht-Karls-Universität Heidelberg (1992).
[65] A.K. Daniels, R.L. Van Niekerk, The impact of a therapeutic exercise intervention
on depression and body self-image in HIV-positive women in sub-Saharan Africa,
HIVAIDS – Res. Palliat. Care. 10 (2018 Jul) 133–144.
[66] M. Dianatinasab, M. Fararouei, V. Padehban, A. Dianatinasab, Y. Alimohamadi,
S. Beheshti, et al., The effect of a 12-week combinational exercise program on
Nurses AIDS Care. 14 (2) (2003 Mar) 30–40.
[40] A.P. Verhagen, H.C.W. de Vet, R.A. de Bie, A.G.H. Kessels, M. Boers, L.M.
Bouter, et al., The Delphi list: a criteria list for quality assessment of randomized
clinical
trials for conducting systematic reviews developed by Delphi consensus, J. Clin.
Epidemiol. 51 (12) (1998 Dec 1) 1235–1241.
[41] A.M. Moseley, R.D. Herbert, C. Sherrington, C.G. Maher, Evidence for phy-
siotherapy practice: a survey of the physiotherapy evidence database (PEDro),
Aust. J. Physiother. 48 (1) (2002) 43–49.
[42] C. Sherrington, R.D. Herbert, C.G. Maher, A.M. Moseley, PEDro. A database of
randomized trials and systematic reviews in physiotherapy, Man. Ther. 5 (4) (2000
Nov) 223–226.
[43] M. Borenstein, L. Hedges, H. Rothstein, Meta-analysis: Fixed effect vs. random ef-
fects, Meta-Anal Com [Internet] (2007) 1–162 [cited 2017 Jan 3]; Available from
https://www.meta-analysis.com/downloads/Meta-analysis%20fixed%20effect
%20vs%20random%20effects%20072607.pdf.
[44] S.V. Faraone, Interpreting estimates of treatment effects: implications for managed
care, Pharm Ther. 33 (12) (2008) 700.
[45] H.J. Schünemann, A.D. Oxman, G.E. Vist, J.P. Higgins, J.J. Deeks, P. Glasziou, et
al., Interpreting results and drawing conclusions, in: J.P. Higgins, S. Green (Eds.),
Cochrane Handbook for Systematic Reviews of Interventions [Internet], John Wiley
& Sons, Ltd, Chichester, UK, 2008, , https://doi.org/10.1002/9780470712184.ch12
[cited 2017 Jul 14]. p. 359–87. Available from:.
[46] J.P. Higgins, S.G. Thompson, J.J. Deeks, D.G. Altman, Measuring inconsistency in
meta-analyses, Bmj. 327 (7414) (2003) 557–560.
[47] S.B. Morris, Estimating effect sizes from Pretest-Posttest-control group designs,
Organ. Res. Methods 11 (2) (2008 Apr) 364–386.
[48] X. Shi, C. Nie, S. Shi, T. Wang, H. Yang, Y. Zhou, et al., Effect comparison
between Egger's Test and Begg's Test in publication bias diagnosis in meta-analyses:
evidence
from a pilot survey, Int. J. Res. Stud. Biosci. [Internet] 5 (5) (2017) 14–20 [cited
2019 Jul 17];5(5). Available from: https://www.arcjournals.org/pdfs/ijrsb/v5-i5/
3.pdf.
[49] K.L. Soeken, A. Sripusanapan, Assessing publication bias in meta-analysis, Nurs.
Res. 52 (1) (2003 Jan) 57–60.
[50] J. Baigis, D.M. Korniewicz, G. Chase, A. Butz, D. Jacobson, A.W. Wu,
Effectiveness of a home-based exercise intervention for HIV-infected adults: a
randomized trial, J.
Assoc. Nurses AIDS Care. 13 (2) (2002) 33–45.
[51] S. Fillipas, L.B. Oldmeadow, M.J. Bailey, C.L. Cherry, A six-month, supervised,
aerobic and resistance exercise program improves self-efficacy in people with
human immunodeficiency virus: a randomised controlled trial, Aust. J. Physiother.
52 (2006) 185–190.
[52] C.L. Lox, E. McAuley, R.S. Tucker, Exercise as an intervention for enhancing sub-
jective well-being in an HIV-1 population, J. Sport Exerc. Psychol. 17 (4) (1995)
345–362.
[53] R.D. MacArthur, S. Levine, T. Birk, Supervised exercise training improves cardio-
pulmonary fitness in HIV-infected persons, Med. Sci. Sports Exerc. 25 (6) (1993 Jun
1) 684–688.
[54] B.T. Mausbach, S.J. Semple, S.A. Strathdee, J. Zians, Effectiveness of a Behavioral
Intervention for Increasing Safer Sex Behaviors in HIV-positive MSM
Methamphetamine Users: Results from the EDGE Study, 16 (2008).
CD4 count and mental health among HIV infected women: a randomized control trial, J.
Exerc. Sci. Fit. 16 (1) (2018 Apr) 21–25.
[67] J. Jaggers, G. Hand, W. Dudgeon, S. Burgess, K. Phillips, J. Durstine, et al., Aerobic and
resistance training improves mood state among adults living with HIV, Int. J.
Sports Med. 36 (02) (2014 Oct 16) 175–181.
[68] A. Kiloor, Metri K. Sonykumari, Impact of yoga on psychopathologies and QoLin persons with
HIV: A randomized controlled study, J. Bodyw. Mov. Ther. [Internet]. 23 (2) (2018) 278–283
Oct [cited 2018 Nov 7]; Available from: https://linkinghub.
elsevier.com/retrieve/pii/S1360859218304467.
[69] K.N. Shah, Z. Majeed, Y.B. Yoruk, H. Yang, T.N. Hilton, J.M. McMahon, et al., Enhancing physical
function in HIV-infected older adults: a randomized controlled
clinical trial, Health Psychol. 35 (6) (2016) 563–573.
[70] R. Naoroibam, K.G. Metri, R. Nagaranta, H.R. Nagendra, Effect of integrated yoga (IY) on
psychological states and CD4 counts of HIV-1 infected patients: a rando- mized controll pilot
study, Int. J. Yoga. 9 (1) (2016) 57–61.
[71] B.A. Smith, J.L. Neidig, J.T. Nickel, G.L. Mitchell, M.F. Para, R.J. Fass, Aerobic exercise:
effects on parameters related to fatigue, dyspnea, weight and body com- position in HIV-
infected adults, Aids. 15 (6) (2001) 693–701.
[72] T. Wang, H. Fu, A.C. Kaminga, Z. Li, G. Guo, L. Chen, et al., Prevalence of de- pression or
depressive symptoms among people living with HIV/AIDS in China: a systematic review and
meta-analysis, BMC Psychiatr. [Internet] 18 (160) (2018)
 1–14 Dec [cited 2019 Jul 17];18(1). Available from:
https://bmcpsychiatry.
biomedcentral.com/articles/10.1186/s12888-018-1741-8.
[73] S.N. Levintow, B.W. Pence, T.V. Ha, N.L. Minh, T. Sripaipan, C.A.
Latkin, et al., Prevalence and predictors of depressive symptoms
among HIV-positive men who
inject drugs in Vietnam. Moitra E, editor, PLOS ONE 13 (1) (2018
Jan 24) e0191548.
[74] C. Bernard, F. Dabis, N. de Rekeneire, Prevalence and factors
associated with de- pression in people living with HIV in sub-Saharan
Africa: A systematic review and meta-analysis. Seedat S, editor, PLOS
ONE 12 (8) (2017 Aug 4) e0181960.
[75] P. Rai, B.L. Verma, A study on depression in people living with
HIV/AIDS in south- west part of Uttar Pradesh, India, South East Asia
J. Public Health. 5 (1) (2015 Sep
13) 12–17.
[76] B. Stubbs, D. Vancampfort, S. Rosenbaum, J. Firth, T. Cosco, N.
Veronese, et al., An examination of the anxiolytic effects of exercise
for people with anxiety and stress- related disorders: a meta-analysis,
Psychiatry Res. 249 (2017 Mar 1) 102–108.
[77] S. Chaudhury, A. Bakhla, R. Saini, Prevalence, impact, and
management of de- pression and anxiety in patients with HIV: a
review, Neurobehav. HIV Med. 15 (2016 May).
[78] J. Price, J. Hoy, E. Ridley, I. Nyulasi, E. Paul, I. Woolley, Changes in
the prevalence of lipodystrophy, metabolic syndrome and
cardiovascular disease risk in HIV-in-
fected men*, Sex Health [Internet] 12 (3) (2015) 240–248 [cited
2017 Jan 3]; Available from: http://www.publish.csiro.au/?
paper=SH14084.
[79] J.R. Kingery, Y. Alfred, L.R. Smart, E. Nash, J. Todd, M.R. Naguib, et
al., Short-term and long-term cardiovascular risk, metabolic syndrome
and HIV in Tanzania, Heart.
102 (15) (2016 Aug 1) 1200–1205.
[80] D.H. Akena, S. Musisi, E. Kinyanda, A comparison of the clinical
features of de- pression in HIV-positive and HIV-negative patients
in Uganda, Afr. J. Psychiatr. [Internet] 13 (2010) 43–51 [cited 2017
Jan 3];13(1). Available from: http://www.
ajol.info/index.php/ajpsy/article/view/53429.
[81] E. Mutimura, A. Stewart, N.J. Crowther, K.E. Yarasheski, W.T. Cade, The
effects of exercise training on quality of life in HAART-treated HIV-
positive Rwandan subjects
with body fat redistribution, Qual. Life Res. 17 (3) (2008 Apr) 377–385.
[82] S.S. Maharaj, V. Chetty, Rehabilitation program for the quality of life
for individuals on highly active antiretroviral therapy in KwaZulu-
Natal, South Africa: a short re- port, Int. J. Rehabil. Res. 34 (4) (2011
Dec) 360–365.
[83] C. Ogalha, E. Luz, E. Sampaio, R. Souza, A. Zarife, M.G. Neto, et al.,
A randomized, clinical trial to evaluate the impact of regular physical
activity on the quality of life, body morphology and metabolic
parameters of patients with AIDS in Salvador,
Brazil, JAIDS J. Acquir. Immune Defic. Syndr. 57 (2011) S179–S185.
[84] K. Mkandla, H. Myezwa, E. Musenge, The effects of progressive-
resisted exercises on muscle strength and health-related quality of life
in persons with HIV-related poly- neuropathy in Zimbabwe, AIDS
Care 28 (5) (2016 May 3) 639–643.
[85] K. Aljassem, J.M. Raboud, T.A. Hart, A. Benoit, D. Su, S.L.
Margolese, et al., Gender differences in severity and correlates of
depression symptoms in people living with
HIV in Ontario, Canada, J. Int. Assoc. Provid. AIDS Care JIAPAC. 15
(1) (2016 Jan) 23–35.
[86] N.P. Caballero-Suárez, E. Rodríguez Estrada, M. Candela-Iglesias, G. Reyes-Terán,
Centro de Investigación de Enfermedades Infecciosas (CIENI),
Instituto Nacional de Enfermedades Respiratorias (INER). Comparison
of levels of anxiety and depression
between women and men living with HIV of a Mexico City clinic,
Salud Ment. 40 (1) (2017 Jan 31) 15–22.
[87] F.B. Schuch, D. Vancampfort, J. Richards, S. Rosenbaum, P.B.
Ward, B. Stubbs, Exercise as a treatment for depression: a meta-
analysis adjusting for publication
bias, J. Psychiatr. Res. 77 (2016 Jun) 42–51.
[88] A. Heissel, A. Pietrek, M. Rapp, S. Heinzel, G. Williams, Perceived
health care cli- mate of older people attending an exercise program:
validation of the German short version of the modified health care
climate questionnaire, J Aging Phys Act. (2019) [epub ahead].