Exercise as a preventive and therapeutic strategy for non-communicable diseases in people living with HIV: evidence, mechanisms and clinical implications

Objective To synthesise evidence on exercise for preventing and managing non-communicable diseases (NCDs) among HIV clients, emphasising sub-Saharan Africa. Design Narrative review. Data sources Meta-analyses, randomised trials, cohort studies, mechanistic investigations and implementation reports involving adolescents and adults aged 15+ Priority was given to cardiometabolic, musculoskeletal, neurocognitive, immunological, behavioural, safety, feasibility and low- and middle-income country outcomes. Rationale People living with HIV face elevated risk of cardiovascular disease, heart failure and type 2 diabetes due to persistent immune activation, chronic inflammation and treatment related metabolic effects. Exercise is a scalable, low-cost intervention with broad benefits. Results Aerobic and combined aerobic plus resistance training performed ≥3 times weekly for ≥5 weeks improves cardiorespiratory fitness and functional capacity with moderate effects, without adverse effects on CD4 or viral load. Resistance and concurrent training increase strength and lean mass and may attenuate bone mineral density loss. Exercise reduces depressive symptoms, improves quality of life and benefits attention and executive function. Mechanistic studies report reduced pro inflammation, improved endothelial function, enhanced mitochondrial capacity and greater antioxidant defence. Feasibility is high with appropriate screening and progression and with adaptations for neuropathy, frailty, pregnancy, low bone density and multimorbidity. Task shifting, digital or community delivery improve uptake despite limited evidence. Conclusions Exercise should be integrated into HIV and NCD care using frequency, intensity, time and type principles. Programmes require risk stratification, age and sex sensitivity and behaviour change support. Further research should evaluate mechanistic endpoints, high-intensity interval training dosing, pragmatic delivery models and economic outcomes in low- and middle-income countries.