According to figures from the World Health Organization, almost 40 million people are living with HIV/AIDS. Although HIV/AIDS was once considered a "gay cancer," the fastest growing populations with this disease in the United States are women and young black males.

Just 15 years ago, most HIV/AIDS sufferers became incapacitated and housebound and died in pain. Fortunately, recent medical treatments are enabling those afflicted to live longer, more productive lives. Although we are far from curing the disease, today many individuals with HIV/AIDS are fully capable of meeting the demands of everyday life.

Working with clients whose health has been compromised by the HIV virus presents an incredible challenge for the fitness professional. Training clients with special needs requires special skills. Some skills may be learned through educational workshops, but others are innate trainer attributes such as patience, sensitivity and a sense of humor. In developing relationships with clients with HIV/AIDS, fitness professionals also somehow must acknowledge (internally at least) that these clients may die.

Just like working with other special population clients, it is critical for trainers who work with HIV/AIDS sufferers to have sufficient knowledge and understanding of this condition to establish safe and effective training programs.

Disease Pathology
HIV/AIDS is a virus that is a microscopic pathogen. These pathogens insert themselves into the cell of a host organism to mature and reproduce. In simpler terms, viruses are such basic life forms that they must set up house inside your cells where they can borrow equipment (your RNA and DNA factories) to replicate themselves. Traditionally, your body has all sorts of "army men" (your white blood cells) floating around looking for these "alien invaders." Unfortunately, one of the favorite places that the HIV virus likes to set up shop is in your white blood cells. As the virus keeps reproducing itself, the host cell reaches a point of critical mass where the cell can no longer physically contain itself, and it explodes.

This causes two things to happen. First, millions of new virus particles are released into the bloodstream to look for new homes. Second, the original white blood cell is totally destroyed. This is why so many people with HIV/AIDS come down with so many unusual illnesses such as pneumocytis carinii pneumonia, cytomegalovirus, toxoplasmosis and cryptosporidiosis.

Disease Transmission
Many trainers fear that working with someone with HIV/AIDS will cause them to become infected. In a traditional health club training setting, there typically is no way for a trainer to pick up the HIV/AIDS virus from her client. Transmission only occurs through:

• Blood to blood contact. For example, your client has a bloody nose, and you have an open wound that comes into contact with his blood.
• Across infected mucous membranes during sexual contact.
• Perinatal contact. This refers to the possibility of transmission from an infected mother to her child before or at the time of birth.

It is important to remember that any discharge of bodily fluids - whether from someone with HIV/AIDS or not - should be handled according to the universal precautions from the U.S. Centers for Disease Control (CDC) or your local American Red Cross.

According to the CDC, four designated stages of AIDS progression exist:

Acute infection - Upon infection, the person suffers a slight fever, rash, general discomfort and weakness. Occasionally, lymph nodes may enlarge, but generally most of the symptoms disappear after a few weeks. Because these symptoms sound similar to many other diseases, only a blood test can confirm if a person has come in contact with the virus.

Asymptomatic HIV infection - During this period, which can last up to 15 to 20 years, the HIV client is basically healthy and symptom free.

Symptomatic HIV infection - Often marked with a visible change in appearance and symptoms such as weight loss, fevers, nausea and diarrhea, this is the stage in which the infected person must make adaptations to her workout routine.

AIDS - Opportunistic infections start to become more and more prevalent, and general health fluctuates widely during this stage. Training programs must be very flexible to accommodate this wide range of functional capacity.

Medical treatment varies but typically includes:

Anti-viral medications - These include some form of nucleoside analog reverse transcriptase inhibitors (NRTIs) such as AZT, Zerit and Epivir. In addition, most doctors will recommend a protease inhibitor (PI) such as Crixivan and Norvir. Always check with the attending physician about what your client is taking.

Medicines for secondary infections - These often include antibiotics, antifungals and hormones.

Alternative modalities - This may include but is not limited to megavitamins, hypnotherapy, possible immune-boosting substances, acupuncture and meditation.

Program Goals and Recommendations
In working with a client with HIV/AIDS, be sure to clearly identify and agree upon goals. Of course, some of these goals may differ from those of your healthy clients. In my experience, the following goals are important to clients with HIV/AIDS:

• Offset the future effects of wasting by increasing lean muscle mass through a progressive resistance routine.
• Strengthen the client's immune function. This can be accomplished by engaging in a three times weekly cardiovascular workout that eventually elevates the client's heart rate to no more than 70% of the maximum heart rate (MHR) for a maximum of 45 minutes. You may have to start much lower than this, but the research indicates that this is where you should move toward if possible.
• Manage pain control potentially with the use of mind-body techniques. Modalities such as yoga, tai chi chuan and deep breathing during passive stretching can be very beneficial to help offset the debilitating pain that seems to flare up during stage four.
• Reinforce the importance of the client's regular participation in all manners of healthy behavior including everything from following proper eating and hydration habits, maintaining a positive outlook and managing stress levels.
• Do no further harm. Always remember that you are a trainer, not a medical professional. Your client's health and well being supercedes any workout goal, such as lifting more weight or walking for a few more minutes. Due to the nature of this disease, you may need to modify your client's workouts frequently. Don't get frustrated if the client isn't progressing as much as you had hoped.

The program you develop for your client is dependent on her condition and most likely will change if your client's health declines. Listed below are sample programs, which, again may vary according to your client's goals. Progression and variation also will depend on results from the training program and your client's health. The key is to be flexible and have lots of options at all times - don't be rigidly tied to a workout card with this population, or you and your client may end up disappointed.

Example # 1: HIV positive, no medical complications, new to exercise Three times/week workouts, 30 to 35 minutes progressing to 60 minutes.
Cardi 15 minutes on recumbent bike at moderate pace; progress to 45 minutes at 70% MHR.
Strength: Single set of 12 reps of exercises for the major muscle groups using selectorized equipment.
Flexibility: Sun salutations from yoga to stretch and introduce mind-body discipline.

Example #2: HIV positive, some medical complications, some exercise experience Five times/week workouts, 60 minutes.
Cardi three times/week, 45 minutes on cardiovascular machine or outdoors (jog, cycle, swim) up to 70% MHR. Cross train using 15 minutes of each modality or change modalities each workout.
Strength: two times/week, two to three sets of 12 to 15 reps of exercises for the major muscle groups using selectorized equipment; progress to eight to 10 reps of heavier weights for hypertrophy.
Flexibility: 10 to 15 minutes of sun salutations from yoga, other stretches for major muscle groups, tai chi chuan, relaxation exercises; teach how these can help with pain control management.

Example #3: Client has AIDS with medical complications, moderate discomfort but capable of daily functional activities Three to five times/week workouts, 15 to 30 minutes.
Cardi Slow, brief walk during which trainer informally assesses client's condition.
Strength: Most likely not applicable here, although light resistance work with dumbbells or elastic tubes occasionally may provide variety.
Flexibility: Yoga, Pilates or stretching, deep breathing/relaxation and positive imaging.

• Profuse night sweating
• Swollen joints
• Vomiting
• Open sores or oozing lesions
• Severe dizziness
• Bleeding gums
• Pain on bottoms of feet or in hands
• Blood in urine or stool
• Diarrhea
• Severe pain at night

In addition, it is advisable to tell clients to avoid the sauna, steamroom and Jacuzzi, as these environments are not ideal for people with suppressed immune function.

Working with people with HIV/AIDS can be the most challenging - as well as a tremendously rewarding - experience. One of my many triumphs was working with a man we'll call Joe Smith.

In the mid-1980s, Joe was a fitness professional who taught about 10 classes each week and trained about 15 hours a week. When he eventually got sick with HIV/AIDS, he was forced to give up teaching his group fitness classes and personal training.

Joe wanted me to train him. A former dancer with the Martha Graham Dance Company, Joe had two catheters in his lungs, had lost 25% of his body mass and was housebound for more than two months before we started to work. After speaking with Joe's physician and performing an informal fitness evaluation, we began.

Because Joe had rarely been out of the house, I set the goal of walking down five flights of stairs to the local food market to purchase and carry home several days of food. Although this may not sound challenging for most people, it took almost five weeks of emotionally draining, physically challenging work to try this with Joe. I kept telling Joe he was training for the Olympics, and when he would ask me what event, I said the rat race - the daily grind that everyone takes for granted until it becomes almost impossible.

Upon our return trip from the grocery store, we were met by scores of Joe's clients and friends all waving Olympic-like banners and cheering him on. It was a really magical moment when we presented him with his gold medal for achieving his goal.

Working with clients with HIV/AIDS is unique but well worth it. For every trainer who takes it on, I know that Joe is giving her a thumbs up.

Michael Youssouf, MA, MES, is the recipient of the IDEA/Life Fitness 2000 Personal Trainer of the Year award. A 26-year veteran of the fitness industry, Youssouf is the manager of trainer education at the Sports Center at Chelsea Piers in New York City. He can be reached by email at pcp@msn.com.