Implementation of an online tele-coaching community-based exercise (CBE) intervention among adults living with HIV in Canada: A two-phased intervention study

This two-phased study demonstrates that a 12-month online tele-coaching community-based exercise intervention successfully increased physical activity levels and improved strength, weight, and physical function among adults living with HIV in Canada, with many benefits sustained during a subsequent independent follow-up period.

The Gist

Imagine living with HIV is like driving a car that has a very sensitive engine. Over time, the engine might get a bit rusty, or the car might feel heavier, making it harder to drive smoothly. For many adults living with HIV, staying active is the best way to keep that engine running, but finding the motivation to get behind the wheel every day can be tough.

This study is like a 12-month "Driving School" experiment, but instead of a classroom, it happened entirely online, and instead of a driving instructor, participants had a personal fitness coach on Zoom.

Here is the story of what happened, broken down simply:

The Setup: Building a Digital Gym

The researchers wanted to see if they could help adults living with HIV get moving without them having to leave their homes. They partnered with the Toronto YMCA to create a virtual gym.

• The Participants: 32 adults (mostly men, but also women) who were ready to try.
• The Gear: They sent everyone a "starter pack" that included a Fitbit (to count steps), a yoga mat, resistance bands, and a digital scale.
• The Plan: The year was split into two halves:
  1. The Coaching Phase (First 6 Months): Participants were asked to exercise three times a week. They got a personal "check-in" with a trainer every two weeks via video call to make sure they were doing it right. They also had access to group classes and monthly health talks.
  2. The Solo Drive Phase (Next 6 Months): The trainers stepped back. The participants were on their own, encouraged to keep exercising three times a week using the same online tools, but without the scheduled check-ins.

The Journey: What Happened?

1. The "Check-In" Magic
Think of the bi-weekly coaching sessions as a personal GPS. When the participants had a coach checking in, they stayed on the road. They attended about 77% of their coaching sessions. However, once the "GPS" was turned off in the second half of the year, the group started to drift a bit. They still exercised, but they didn't hit their goals as consistently as they did when someone was watching.

2. The Physical Results: A Stronger Engine
Despite the drop in strict adherence later on, the results were impressive. By the end of the year, the participants were like cars that had been tuned up:

• Weight Loss: They lost about 6 pounds (2.8 kg) on average.
• Stronger Core: They could hold a "plank" (a yoga pose) for nearly 40 seconds longer. That's like going from holding a heavy box for a few seconds to holding it for almost a minute!
• More Push-ups: They could do about 8 more push-ups in a minute.
• Better Flexibility: They could reach further when bending down to touch their toes.
• Heart Health: Their hearts recovered faster after exercise, meaning they were getting fitter.

3. The "Maintenance" Challenge
Here is the tricky part. While they lost weight and got stronger, they actually lost a tiny bit of muscle mass by the end of the year. It's like the car got lighter and faster, but the engine block got slightly smaller. The researchers noted that while the strength went up, the muscle size shrank a little. This suggests that while the program was great for general fitness, it might need more heavy lifting (resistance training) to keep muscle mass from dropping as people age.

The Big Takeaway

This study showed that you don't need a physical gym to get fit, even if you have a chronic condition like HIV. An online coach can be a powerful motivator, acting like a digital cheerleader who keeps you accountable.

However, the study also taught us a valuable lesson about sustainability. When the coach stopped checking in every two weeks, the participants' motivation dipped slightly. It's like trying to learn a new language: you learn the most when you have a teacher, but keeping that skill sharp on your own is much harder.

In short: The online program worked wonders for getting people moving, losing weight, and getting stronger. But to keep that momentum going forever, people might need a little more "nudge" or support than just a one-time sign-up. The future of fitness for people with HIV might look like a mix of high-tech coaching and community support to keep everyone driving smoothly for the long haul.

Technical Summary

1. Problem Statement

Adults living with HIV (PLWH) face chronic health consequences, including accelerated aging, multimorbidity, and disability. While exercise is a proven rehabilitation intervention to improve cardiopulmonary fitness, strength, and mental health in this population, engagement rates remain suboptimal (only ~51% meet physical activity guidelines). Traditional community-based exercise (CBE) programs often face barriers such as geographical constraints, childcare responsibilities, and social stigma, particularly affecting women and those with episodic disabilities. Furthermore, the efficacy of online tele-coaching interventions specifically for PLWH remains under-explored compared to other chronic conditions.

2. Methodology

Study Design:
A longitudinal, two-phased, community-engaged intervention study conducted over 12 months in Toronto, Canada. The study utilized the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to evaluate implementation.

Participants:

• Target: Adults living with HIV in Toronto.
• Inclusion: Medically safe to exercise (PAR-Q), access to technology (smartphone/computer, Wi-Fi, webcam), and home space for exercise.
• Recruitment: Via community organizations, the Ontario HIV Treatment Network Cohort Study (OCS), and previous in-person study participants.
• Sample: 32 participants initiated the study (Median age: 53; 69% male, 31% female/non-binary; 91% undetectable viral load).

Intervention Protocol:
The study consisted of two distinct 6-month phases:

1. Phase 1 (Intervention): Participants exercised 3 times/week.
   • Biweekly Coaching: 60-minute online personal training sessions with certified YMCA trainers (13 sessions total) to monitor and progress intensity.
   • Weekly Classes: Access to synchronous/asynchronous YMCA group exercise classes.
   • Education: Monthly online self-management sessions (e.g., sleep, diet, pain).
   • Monitoring: Use of Fitbit Inspire 2® for self-monitoring steps and active minutes.
2. Phase 2 (Follow-up/Maintenance): Participants continued exercising 3 times/week independently.
   • Retained access to YMCA online membership and group classes.
   • No personal coaching sessions.

Data Collection & Analysis:

• Primary Outcome: Engagement in physical activity (days/week of ≥30 min moderate/vigorous activity).
• Secondary Outcomes: Cardiopulmonary fitness (heart rate recovery), body composition (weight, BMI, fat/muscle mass), strength (push-ups, plank), physical function (sit-to-stand), and flexibility (sit-and-reach).
• Frequency: Physical activity assessed weekly; fitness assessments conducted bimonthly (7 time points) remotely via Zoom.
• Statistical Analysis: Segmented regression using linear mixed-effects models (continuous outcomes) and generalized linear mixed-effects models (binary outcomes) to assess changes within and between phases.

3. Key Contributions

• Implementation Science: This is one of the first studies to apply the RE-AIM framework to an online tele-coaching CBE specifically for PLWH, addressing the gap in digital rehabilitation for this demographic.
• Community-Engaged Approach: The study was co-developed with PLWH, community organizations (YMCA), and clinicians, ensuring the intervention addressed real-world barriers (e.g., providing equipment and flexible scheduling).
• Feasibility of Remote Assessment: Demonstrated the viability of conducting rigorous, bimonthly fitness assessments (including strength and body composition) remotely via Zoom and home-based equipment.
• Retention Strategies: Highlighted the importance of one-on-one supervision for adherence, noting that while group classes were available, individual coaching drove engagement.

4. Key Results

Reach and Adoption:

• Retention: 69% (22/32) completed the 6-month intervention; 56% (18/32) completed the 12-month follow-up.
• Adherence: Median attendance for biweekly coaching was 10/13 sessions (77%). Only 41% registered for group classes, suggesting a preference for individualized support.
• Technology: 56% of participants utilized the provided Fitbit device consistently.

Effectiveness (Physical Activity & Health Outcomes):

• Physical Activity: Significant increase in days/week of moderate/vigorous activity during the intervention (+0.12 days/week). This gain was largely maintained during the follow-up phase, resulting in an overall increase of 0.11 days/week over 12 months.
• Guideline Achievement: The probability of meeting aerobic guidelines increased significantly during intervention (61% → 91%) but dropped during follow-up (65%). Resistance guideline adherence did not significantly change during intervention but dropped significantly during follow-up.
• Body Composition:
  • Weight/BMI: Significant reductions in body weight (-2.83 kg total) and BMI (-0.90 kg/m² total) sustained over 12 months.
  • Waist Circumference: Significant reduction (-4.01 cm total).
  • Muscle/Fat Mass: While body fat % decreased, there were statistically significant decreases in fat-free mass (-0.80 kg) and muscle mass (-0.65 kg) by the end of the study, though the rate of change (slope) was not significant across phases.
• Strength & Function:
  • Push-ups: Significant increase (+8.61 reps/min over 12 months).
  • Plank Time: Significant increase (+40.88 seconds).
  • Sit-to-Stand: Significant increase (+4.38 reps/30 sec), surpassing the Minimum Clinically Important Difference (MCID) established for chronic conditions.
  • Flexibility: Significant improvement in sit-and-reach (+4.52 cm).
• Cardiopulmonary Fitness: Resting heart rate increased during intervention but decreased during follow-up, resulting in no net change. Recovery heart rate showed a significant overall improvement (-7.37 bpm).

5. Significance and Implications

• Clinical Impact: The intervention successfully improved strength, physical function, and body composition in PLWH, outcomes critical for managing sarcopenia, frailty, and metabolic syndrome associated with aging and antiretroviral therapy.
• Scalability: The study suggests that biweekly tele-coaching is a resource-efficient model that can yield significant health benefits compared to weekly supervision, making it scalable for broader populations.
• Maintenance Challenge: While the intervention phase was highly effective, the drop in adherence to aerobic/resistance guidelines during the independent follow-up phase highlights that ongoing supervision (even if reduced frequency) is crucial for sustaining behavior change in PLWH.
• Future Directions: Future interventions should focus on strategies to maintain engagement post-intervention, potentially leveraging peer support or less costly self-management features, and addressing the specific needs of women and those with episodic disabilities to improve retention.

Limitations: The study was a pilot with a small sample size, limiting power for sex-specific analyses. Retention was lower than in-person historical controls, potentially due to the pandemic and the 12-month commitment. Self-reported physical activity data may be subject to bias.