|Year : 2019 | Volume
| Issue : 4 | Page : 146-155
Holistic Humanized Nursing Care Strategies on Physiological and Psychological Parameters Among Adolescents with HIV − An Interventional Study
Jasmine Carlouise1, Judie Arulappan2, Susila Chandrasekaran3, Ganesamurthy4, Anna Samuel5, Starmine Carlouise6, Sowmya Saira Chandy5
1 Officiating Nursing Director, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India
2 Assistant Professor/Head of the Department, Department of Maternal and Child Healthr, College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman
3 Principal/Research Guide Billroth College of Nursing, India
4 Clinical Pharmacist Cum Pharmacy In Charge, Kanchi Kamakoti Childs Trust Hospital, India
5 Nurse Educator Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India
6 Assistant Professor/HOD Department of Mental Health Nursing, St. James College of Nursing, Thrissur, Kerala, India
|Date of Submission||03-Oct-2019|
|Date of Decision||28-Oct-2019|
|Date of Acceptance||06-Nov-2019|
|Date of Web Publication||28-Nov-2019|
Assistant Professor/HoD, Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, Muscat
Sultanate of Oman
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction/Background: Globally, an estimated 30% of new HIV infection occurs among adolescents aged 15–24 years. HIV related mortality increased by 50% between 2005 and 2012. HIV-related deaths have increased more than three times since 2000, ranking it the second in the list of causes of death among adolescents worldwide. Purpose: This study evaluated the efficacy of Holistic Humanized Nursing Care Strategies (HHNCS) on the Body mass index (BMI), Waist Circumference (WC) and self-esteem among adolescents living with HIV. Research Methods: The adolescents who had low and moderate level of self-esteem and all levels of BMI and WC were selected and assigned to experimental (124) and control group (122). The HHNCS was administered to the experimental group and the intervention was continued at home and the reinforcement was given. The control group received NGO’s routine care. The post test was done for both the groups at the end of 3rd and 6th month and the BMI, WC and self-esteem were measured. Results: The mean difference in BMI was 0.32 in experimental and 0.11 in control group. The calculated ‘F’ value in experimental group was 2.94, which was significant at P<0.05. With regard to WC, the mean difference was 0.35 in experimental and 0.10 in control group. The calculated ‘F’ value in experimental group was 0.22, and in control group it was 0.04, which was not statistically significant. In the self-esteem scores, the mean difference was 7.25 in experimental and 0.63 in control group. The calculated ‘F’ value in experimental group was 121.66, which was significant at the level of P<0.00. Conclusion: This study proved that that the HHNCS administered to the adolescents living with HIV were effective in reducing BMI and improved the level of self-esteem.
Keywords: Adolescents living with HIV, body mass index, self-esteem, waist circumference
|How to cite this article:|
Carlouise J, Arulappan J, Chandrasekaran S, Ganesamurthy, Samuel A, Carlouise S, Chandy SS. Holistic Humanized Nursing Care Strategies on Physiological and Psychological Parameters Among Adolescents with HIV − An Interventional Study. Int J Nutr Pharmacol Neurol Dis 2019;9:146-55
|How to cite this URL:|
Carlouise J, Arulappan J, Chandrasekaran S, Ganesamurthy, Samuel A, Carlouise S, Chandy SS. Holistic Humanized Nursing Care Strategies on Physiological and Psychological Parameters Among Adolescents with HIV − An Interventional Study. Int J Nutr Pharmacol Neurol Dis [serial online] 2019 [cited 2020 Sep 18];9:146-55. Available from: http://www.ijnpnd.com/text.asp?2019/9/4/146/271855
| Introduction|| |
Adolescence is the most critical time of life, where they become independent individuals, make new relationships, develop social skills, and learn lifestyles and health behaviors that can last a life time. Adolescents are considered to be the future citizens of any country. Adolescents are a key resource and asset for the social and financial advancement of any nation, with the possibility to make a huge commitment to their families, networks, and nations. Though healthy adolescents are needed for the country, substantial rates of death, illness, and diseases are still found in this age group. Of this, HIV is the most common cause of death.
The most at risk group for contracting HIV are adolescents. They can acquire the infection through sexual contact or from birth. HIV can be transmitted from mother to child during pregnancy, delivery, or breastfeeding. This type of transmission is called as mother to child transmission. In the United States, most of the children below 13 years have acquired HIV through mother-child transmission. Children who have perinatally transmitted HIV (PHIV) are surviving through adolescence with antiretroviral therapy; however, they may have variety of impacts on their life. In 2017, most of the young people affected with HIV were between 15 and 19 years. Since most of the adolescents have developed HIV perinatally, the death rate among them has increased drastically.
Though there is no magic potion to facilitate the transition from adolescent to adulthood among HIV positive population, nonetheless, there is new proof that proposes three promising, non-pharmacological methodologies which can assist adolescents with HIV, they are exercise, balanced nutrition, and positive social interaction.
| Background of the study|| |
In 2017, the people living with HIV were 36.9 million globally. Of this, 1.8 million are children below 15 years. The people newly infected with HIV are 1.8 million. People who died from AIDS-related illness are 9,40,000.  The National AIDS Control Organization reported that the total number of people living with HIV in India in 2015 was 21.17 lakhs and children below 15 years are 6.54%. Children are infected perinatally and the immune system is affected early in life. PHIV has been found to affect the normal growth and development. 
In India, a small proportion of people are infected by contaminated needles and unsafe blood transfusion, but mother-to-child transmission of HIV is the most significant route of transmission in children <15 years. Therefore, successful management of the disease in pregnant women is essential for the prevention of HIV transmission to children. There is a need for ongoing psychosocial support to help cope with the illness and associated issues of education, employment, social security, sexuality, and relationships.
Children and adolescents with HIV infection repeatedly face many issues which include illness of the parent, death of a parent, poverty, economic crisis, and disclosure of their parent’s HIV status to others. These issues might influence the adolescents with HIV to have mental health problems as well. The self-esteem of the children with HIV plays a key role in determining the performance in school, peer relationship, and motivation to perform tasks. The development and functioning of the children are affected by low self-esteem. 
It is very difficult for an HIV positive adolescent to mature into an adult due to various reasons. The main reason is the stigma related to HIV infection. The stigma that the adolescent with HIV has can increase the symptoms of the disease and decrease the quality of life. The negative stigma can be minimized by learning the facts about HIV, respecting the people with HIV, and promoting the hope and empowerment. The burden of symptoms such as fatigue, pain, and depression also decrease the daily functioning and quality of life in adolescents living with HIV.
Recently there is a new evidence that suggests and recommends three non-pharmacological methods that can help adolescents living with HIV. It includes increasing the intensity and duration of physical activity. Increasing the physical activity is found improving the cardiovascular health, cognitive functioning, and reducing the symptoms such as fatigue. Though the benefits are numerous with increased physical activity, the HIV positive adolescents do not engage in regular and intense physical activity.
The research studies have proved that aerobic fitness may prevent the adolescents with HIV from developing cardiovascular diseases. The adolescents with HIV infection should be assessed for the waist circumference (WC) as it is an important predictor to assess the cardio metabolic risk. 
The recent evidences suggest that positive social interactions can improve the adherence to HIV treatment, reduce the burden of symptoms, and improves various aspects of quality of life. Hence, the health care team members should recognize that the cure will take a long time unless a positive social environment is created.  Therefore, the quality of life and life expectancy can be improved, if the adolescents comply with anti-retroviral treatment and follow improved lifestyle modifications. 
The adolescents who are perinatally infected with HIV are at greater risks of developing low self-esteem and psychological problems. The strategies should be taken to enhance the self-esteem to overcome the psychological difficulties among the adolescents living with HIV. 
The evidences suggest that there are various dimensions in treating an HIV positive child or an adolescent. The holistic humanized health approach involves meeting the needs including physical, psychological, emotional, social, economic, and spiritual needs of a person. Also, it includes helping the person to his or her response to the illness, meeting the self-care needs of the person, and managing the effect of the illness on the ability of the person.
Therefore, an adolescent with a positive HIV should not be treated for the disease alone. The physiological factors such as fatigue, BMI, WC, and psychological factors like self-esteem should be cared for. All the factors should be considered in the management of the child with HIV to bring good change in their health outcomes.
| Research methods|| |
This study protocol was approved by the Institutional Ethics Review committee of International Centre for collaborative Research, Chennai, India (valid from April, 2013 to May, 2018 dated 30.04.2013). The written consent was obtained from the adolescents and mothers by explaining the purpose of the study, type of data, intervention, nature of commitments, right to refuse or withdraw, participation procedures, and potential benefits. Written permission was obtained from the organization for data collection.
In the pretest, the adolescents with HIV were assessed for BMI, WC, and self-esteem. The adolescents with any level of BMI and WC and with low and moderate level of self-esteem were selected for the study.
In the first phase of the study, sample size was calculated using 5% α-error and 90% of power of the study (1-β error). The required sample size was 110 per group. With the expected 10% of dropout rate, final sample was calculated to be 121. However, the rounded sample size was 136 and 133 in experimental and control group respectively and the samples were assigned through block randomization. Single blinding was used in the allocation of samples.
Data were collected from the participants during the period from April 2015 to March 2017. The study included adolescents who were diagnosed to have HIV in primary stage and stage I by screening; between 13 and 18 years of age; diagnosed with HIV within 10 years; with Antiretroviral therapy (ART) and their Cluster of Differentiation 4 (CD4) cell count more than 250; and who had given written consent to participate in the study. The adolescents who were physically challenged, having sensory impairment, who had chronic mental illness, taking treatment other than ART, and having co-morbidity were excluded from the study.
After the pretest, the Holistic Humanized Nursing Care Strategies (HHNCS) were administered along with the non-governmental organizations (NGO) routine care to the adolescents of experimental group for 1 hour 30 minutes. The intervention included multi-faceted teaching for 40 minutes using flash cards and booklets, which included education on overview of the disease, home care management including nutrition, regular exercise of aerobics and its benefits, oral care and dental hygiene, personal care and environmental hygiene, sleep and rest, measures to stop the spread of HIV, consulting the doctor regularly, adherence to ART, support groups, economical support, emotional support including counseling, and spiritual support by using flash cards.
Structured group counseling session for self-esteem was given in various phases that included establishing rapport and relationship building, problem assessment, goal setting, initiating intervention and termination for a maximum of six sessions for a period of six months. Each session of counseling was carried out by the investigator for 30 minutes at 30 days of time interval and each group consisted of 15 adolescents living with HIV.
Aerobic exercises included the demonstration of 10 minutes limbering up exercise which included rotating of neck, shoulders, hip, lifting of knees, toes, step up of legs, 8 minutes of stretching exercise which included stretching of muscles such as calf, hip, harm strings, groin, quadriceps, triceps, chest, neck, back, buttock, and 2 minutes of repeating the limbering up exercise. Return demonstration was done and they were reinforced to do the exercise thrice in a week for the period of six months with the parent’s guidance. Twelve supervised practice sessions were done at 15 days of time interval. Follow up and reinforcement of counseling and aerobic exercise was given every 15 days. The control group received only NGO’s routine care. The post test was done for both the groups at the end of third and sixth months. The adolescents of control group received the same HHNCS after completion of posttest.
Semi-structured interview questionnaire was used to assess the background variables. The formula used for assessing the BMI among adolescents living with HIV was Metric formula. This formula was adopted from Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, 2014 (BMI = (Weight in Kilograms / (Height in Meters x Height in Meters). For boys the values were categorized into underweight (<13.6–<15.6), normal weight (13.6–23.2), overweight (20.4–26.6), and obese (>23.2–>26.6) and for girls, the categories included underweight (<13.8–<15.8), normal weight (13.8–23.2), overweight (21.4–26.6), and obese (>25.2–>26.8).
WC was measured in centimeters among adolescents living with HIV. For boys the values were categorized into underweight (<63.4–<68.4), normal weight (63.4–89.6), overweight (82.3–96.3), and obese (>88.8–>96.3) and for girls, the categories included underweight (<63.6–<67.1), normal weight (63.6–87.4), overweight (82.3–93.3), and obese (>88.3–>93.3). The values were categorized as per Indian Academy of Pediatrics (IAP) growth chart.
Rosenberg self-esteem scale was used to assess the level of self-esteem. The instrument consisted of ten questions, in which five questions were positively scored (1, 3, 4, 7, and 10). The score of 4 for strongly agree, 3 for agree, 2 for disagree, and 1 for strongly disagree was given. And five questions were negatively scored (2, 5, 6, 8, and 9). The score of 4 for strongly agree, 3 for agree, 2 for disagree, and 1 for strongly disagree was given. The r value for the tool was 0.78. The study instrument was found to be sufficiently reliable to proceed further in the data collection process. 
Eleven participants from the control group and twelve from the study group were considered as “Drop outs” as the adolescents could not continue to participate in the study due to school commitments. After considering the drop outs, 124 adolescents with HIV in study group and 122 in control group completed the study. Data entry and data cleaning were carried out before the data were analyzed. Data analysis was done using IBM SPSS version-24.
The CONSORT flow chart shows the flow of the trial [Figure 1].
|Figure 1 CONSORT Flow chart showing the process of enrollment of subjects, allocation to treatment, drop outs and analysis|
Click here to view
| Results|| |
[Table 1] presents the demographic information of adolescents who participated in the study. The chi-square test shows that the distributions of adolescents with HIV were homogenous in both the groups. In both groups, the highest percentage were male adolescents 56.5% and 59.8% respectively, 20.2% and 26.2% belonged to the age of 14 years, 23.4% and 27.9% were studying in ninth grade and 66.9% and 72.1% belonged to Hindu religion respectively. The results show that there were majority of male adolescents who participated in the study. Also, it is noted that most of the participants belong to Hindu religion.
|Table 1 Frequency and percentage distribution of demographic variables of adolescents living with HIV in experimental and control group|
Click here to view
[Table 2] describes about the area of residence, siblings, order of birth, medium of instruction, and type of family of both study and control group. Thus [Table 2] summarizes that most of the adolescents were hailing from Sub-urban region. In most of their families, the number of siblings were three and above. The birth order of most of the children was three and above. Most of the adolescents were studying in Tamil medium. The adolescents were living in joint family in both the groups.
|Table 2 Frequency and percentage distribution of demographic variables of adolescents living with HIV in experimental and control group|
Click here to view
[Table 3] illustrates the education and occupation of father and mother. Majority of mothers completed middle school and fathers completed primary school. Both fathers and mothers were working in private organizations in both study and control group. Thus, both the groups found to be homogenous.
|Table 3 Frequency and percentage distribution of demographic variables of adolescents living with HIV in experimental and control group|
Click here to view
[Table 4] highlights the type of work for the mother and father, health status of mother and father, health status of sibling, parent status, adolescent is living with whom, and information on previous exposure to HIV education. It is reported in the study that most of the adolescents were living with their parents in both the study and control group. Most of the mothers and fathers were performing moderate work in their day to day life. It was interesting to note that in majority of the families the fathers, mothers, and siblings were affected with HIV. In most of the families, the fathers expired and the mothers were alive. The adolescents with HIV were found to be living with their parents. It was told by the adolescents that they gained information on HIV through mass media.
|Table 4 Frequency and percentage distribution of demographic variables of adolescents living with HIV in experimental and control group|
Click here to view
[Table 5] describes the period of diagnosis of HIV, duration of treatment, HB level, and CD4cell count. In both the study and control group, most of the adolescents were diagnosed since 6–10 years. The adolescents were taking treatment for more than 1–3 years. The average HB for majority of the samples was between 13 and 14 gm/dl. The CD4 count for most of the participants was between 501 and 1000.
|Table 5 Frequency and percentage distribution of biophysiological variables of adolescents living with HIV in experimental and control group|
Click here to view
[Table 6] compares pre and posttest mean BMI and WC score. In experimental group, in pretest the adolescents had 20.25 mean score of BMI whereas in posttest third month adolescents had 20.14 with the mean difference was 0.11 and in sixth month adolescents had 19.93, with the mean difference 0.32. The calculated F value was 2.94 which showed that it was statistically significant at the level of P < 0.05. In control group, the calculated F value was 1.59 which showed, it was not statistically significant. Thus, the study reports that HHNCS was effective in bringing changes in BMI in adolescents living with HIV.
|Table 6 Comparison of pre and posttest level of physiological parameters of BMI, waist circumference in experimental and control group|
Click here to view
The mean WC score in experimental group in pretest was 71.21 score whereas in posttest third month, the adolescents had the mean of 71.04, with the mean difference of −0.17 and in sixth months adolescents had the mean of 70.86, with the mean difference of −0.35. The calculated F value was 0.22 which showed that it was not statistically significant. In control group, the calculated F value was 0.04 which showed it was not statistically significant. Thus, it is interpreted that no significant improvement was found in WC in the experimental group.
[Table 7] shows the pre and posttest mean self-esteem score in experimental and control group. In pretest, the adolescents had the mean score of 23.45 whereas in posttest third month adolescents had 27.82, with the mean difference of 4.37 and in sixth months adolescents had 30.70, with the mean difference of 7.25. The calculated F value was 121.66 which showed that it was statistically significant at the level of P < 0.001. In control group, the calculated F value was 3.05 which showed that it was not statistically significant. The study results have proved that HHNCS was highly effective in improving the self-esteem of adolescents living with HIV.
|Table 7 Comparison of pre and posttest level of psychological parameter of self-esteem in experimental and control group|
Click here to view
| Discussion|| |
This study aimed at improving the quality of life of adolescents living with HIV with the strategies that included a holistic approach with proper education, group counseling, aerobic exercise, dietary management, and love and support. The HHNCS was proved to be effective by means of improving the self-esteem and reduction of BMI and WC among adolescents living with HIV.
In this study, most of the adolescents living with HIV were 14 years old, were males, majority were studying in 9th and 11th standards, most of them belonged to Hindu religion, and were living in urban residence. Most of the families had three and above siblings, with the birth order third and above. The medium of instruction was Tamil for the major portion of children. The majority of children were living in joint family and most of the mothers had middle school education, and majority of fathers had primary school education.
With regard to mother’s occupation, most of the mothers were private employees, and fathers also were private employee. Regarding the type of work, most of the mothers were moderate workers, and the fathers also were moderate workers. With regard to the health status of mother, most of the mothers were affected with HIV, and majority of the fathers also were affected with HIV. Few siblings were affected with HIV. In both the groups, most of the adolescent’s mothers were only alive. Majority of the adolescents were living with their parents and most of the adolescents had exposure to HIV education previously. Most of the adolescents were diagnosed to have HIV since 6 to 10 years, and were on treatment for 1 to 3 years. The HB level was almost normal and the CD4cell count was around 501 to 1000.
In our study, it was found that children with lower CD4 count were obese. The results of our study are supported by another study where the children who were HIV positive with lower CD4 counts were found to have higher risks of overweight and obesity. The children with HIV also reported to have high burden of overweight and obesity after they started taking anti-retroviral treatment. It is thus essential that necessary steps should be taken to improve the CD4 count in adolescents with HIV, thereby the risk of developing HIV can be minimized.
The comparison of pretest mean score for physiological parameter of BMI in experimental and control group was 20.25 and 20.14 respectively. In posttest the mean score at third month was 20.14 and 20.07 and in sixth month 19.93 and 20.03 respectively. The mean difference was 0.32 in experimental and 0.11 in control group. The calculated ‘F’ value in experimental group was 2.94, which showed significant at the level of P < 0.05, but the calculated value in control group was 1.59, which was not statistically significant. Thus, it is very evident from the results that the BMI reduced significantly in the participants of experimental group after the administration of HHNCS. We, the authors, recommend continuing HHNCS in adolescents with HIV to reduce the BMI, thereby to improve the physical and physiological wellbeing.
Evidence says that children with HIV in rural areas had a higher physical activity than the children in urban areas. It is also said that the children with HIV having longer duration of ART were less physically active. The participants who received ART regularly were physically active. The study recommended to promote physical activity among people living with HIV in urban areas and to continue ART regularly. The other interventions suggested include the peer support and guidance.  In this study, the HHNCS which included the aerobic exercise improved the physical wellbeing and helped in reducing the BMI in adolescents living with HIV.
The comparison of pretest mean score for physiological parameters of WC in experimental and control group was 71.21 and 71.18 respectively. In posttest, the mean score of third month was 71.04 and 71.11 and of sixth month was 70.86 and 71.08 respectively. The mean difference was 0.35 in experimental and 0.10 in control group. The calculated ‘F’ value in experimental group was 0.22, which was not statistically significant. The calculated’ value in control group was 0.04, which was also not statistically significant. The results inform us that there was not a statistically significant change in the WC. However, significant improvement was found in BMI. The authors hereby state that if HHNCS is continuously provided to adolescents living with HIV, significant improvements could be observed in WC as well.
The comparisons of pretest mean score for psychological parameters of self-esteem in experimental and control group was 23.4 and 22.85 respectively. In posttest the mean score at third month was 27.82 and 23.17 and in sixth month 30.70 and 23.48 respectively. The mean difference was 7.25 in experimental and 0.63 in control group. The calculated ‘F’ value in experimental group was 121.66, which showed significance at the level of P < 0.001, but the calculated value in control group was 3.05, which was not statistically significant.
The self-esteem of the people living with HIV can be improved if a holistic approach is adopted in caring them. A study reported that dignity and spirituality could be seen in the lives of Thai adolescents living with HIV. The researchers could observe the adolescents with HIV in Thai understanding the disease, accepting the truth about their life, hoping for cure, focusing on the purpose of life, making choices for life, caring for themselves, and taking responsibility toward others. These findings have brought significant insights to the health care workers, parents, and nurses to provide holistic, dignified approach and care that includes the dimension of spirituality. This study proved that the self-esteem in the adolescents improved after the administration of HHNCS. Our study emphasizes the need to continuously provide psychological support to adolescents with HIV to improve their psychological wellbeing and self-esteem.
Another study finding reports the psychosocial consequences of adolescents experiencing parental loss due to HIV/AIDS in central China. Individual in-depth interviews were conducted with 47 adolescents (ages 8–17 years) experiencing the loss of one or both parents due to HIV/AIDS in two rural counties of central China. Findings in this study revealed that the majority of the participants reported some level of stigmatization because of their parents’ HIV status. The participants described feelings of sadness, fear, anxiety, anger, loneliness, low self-esteem, social withdrawal, and sleep problems. Implications for intervention programs include the need for psychological support and special counseling services, more public education with accurate knowledge about HIV/AIDS to decrease stigma and discrimination, and financial programs to decrease economic and care giving burdens for these adolescents.
Therefore, the finding of our study reported that the HHNCS were effective in reducing the BMI and improving the self-esteem of adolescents living with HIV in the adolescents of experimental group. We, the authors therefore recommend that HHNCS are an essential nursing intervention that have to be adopted by the community health nurses, community health administrators, nurse educators, nurse practitioners, and researchers.
Limitations of the study
As the study is limited to one year of data collection, and the sample size is limited, the possibility of generalization of the study findings would be minimal.
| Conclusion|| |
The finding of this study reported that the HHNCS that were administered to the adolescents living with HIV were effective in reducing the BMI and improved the psychological parameter of self-esteem.
Financial support and sponsorship
Conflicts of interest
The data set(s) supporting the conclusion of this article are available upon request.
| References|| |
Balthip K, McSherry W, Nilmanat K. Spirituality and dignity of Thai adolescents living with HIV. Religions, 2017;8:1-18.
Izudi J, Mugenyi J, Mugabekazi M, Muwanika B, Tumukunde SV, Katawera A, Kekitiinwa A. Retention of HIV-positive adolescents in care: a quality improvement intervention in mid-Western Uganda. BioMed Research International, 2018;2018. Article ID 1524016, 8 pages.
Murthy VS, Nayak AS, Joshi MK, Ninawe K. A study of neuropsychological profile of human immunodeficiency virus-positive children and adolescents on antiretroviral therapy. Indian Journal of Psychiatry 2018;60:114.
Wal N, Venkatesh V, Agarwal GG, Kumar A, Tripathi AK, Singh M, Singh RK. Unsafe injections: a potential risk for HIV transmission in India. Biomedical Research 2012;23.
Naswa S, Marfatia YS. Adolescent HIV/AIDS: issues and challenges. Indian Journal of Sexually Transmitted Diseases 2010;31:1.
UNAIDS. Agenda for zero discrimination in health-care settings. 12–14 December 2017. Geneva, Switzerland. UNAIDS Programme Coordinating Board Issue date: 17 November 2017.
Grace JM, Semple SJ, Combrink S. Exercise therapy for human immunodeficiency virus/AIDS patients: Guidelines for clinical exercise therapists. Journal of Exercise Science & Fitness 2015;13:49-56.
Triant VA. Cardiovascular disease and HIV infection. Current HIV/AIDS Reports 2013;10:199-206.
Hadigan C, Meigs JB, Corcoran C, Rietschel P, Piecuch S, Basgoz N, Davis B, Sax P, Stanley T, Wilson PW, D’agostino RB. Metabolic abnormalities and cardiovascular disease risk factors in adults with human immunodeficiency virus infection and lipodystrophy. Clinical Infectious Diseases 2001;32:130-9.
Enriquez M, McKinsey DS. Strategies to improve HIV treatment adherence in developed countries: clinical management at the individual level. HIV/AIDS 2011;3:45-51. http://doi.org/10.2147/HIV.S8993
Marcus JL, Chao C, Leyden W, Xu L, Quesenberry CP, Klein DB, Silverberg MJ. Narrowing the gap in life expectancy for HIV+ compared with HIV-individuals. Conference on Retroviruses and Opportunistic Infections, Boston 2016.
Kirkcaldy BD, Shephard RJ, Siefen RG. The relationship between physical activity and self-image and problem behaviour among adolescents. Social Psychiatry and Psychiatric Epidemiology 2002;37:544-50.
Fillipas S, Cherry CL, Cicuttini F, Smirneos L, Holland AE. The effects of exercise training on metabolic and morphological outcomes for people living with HIV: a systematic review of randomised controlled trials. HIV Clinical Trials 2010;11:270-82.
Rosenberg M. Society and the adolescent self-image. Princeton, NJ: Princeton University Press, 1965.
Dang AK, Nguyen LH, Nguyen AQ, Tran BX, Tran TT, Latkin CA, Ho RC. Physical activity among HIV-positive patients receiving antiretroviral therapy in Hanoi and Nam Dinh, Vietnam: a cross-sectional study. BMJ Open 2018;8:e020688.
Zhao G. Stop AIDS: keep the promise-from stigma and silence to dignity and solidarity. The Nurse Practitioner 2009;19:26-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]