Interview data.

We analyzed transcripts using a descriptive thematic analysis informed by Braun and Clarke to classify themes within the data [38]. The interviewer (NSG) transcribed the interview audio files verbatim and reviewed each for accuracy. The interviewer (NSG) created preliminary notes, and drafted participant summaries for each interview embedded with participant’s characteristics and experiences with exercise. The interviewer (NSG) coded all transcripts line-by-line to establish a preliminary coding scheme that pertained to the study objectives. Co-authors (KKO, ML) reviewed a sub-sample of the transcripts and participant summaries. We defined and clustered the codes into broader categories and sub-categories. All authors met on 4 occasions to refine the coding scheme and discuss analytical interpretations.

Questionnaire data.

We downloaded responses from the demographic questionnaire from Qualtrics into Microsoft Excel 2018 [39]. We conducted a descriptive analysis including frequencies (percent) for categorical variables and median (25^th,75^th percentiles) for continuous variables to describe the characteristics of the participants.

Culture.

Women described culture as influencing their attitudes, values and behaviour to exercise. Culture was comprised of i) cultural expectations, ii) intersectionality of women and their social identities, iii) exposure to exercise, and iv) food diversity.

i) Cultural expectations. Participants spoke about the cultural expectations, which influenced their engagement with exercise. Expectations of women were associated with specific responsibilities and customs, specifically those of African and/or Black decent. Participants whom identified as Black or African expressed that their cultural background largely dictated how women engaged and perceived exercise, namely with prioritizing domestic and other cultural responsibilities over their own health. Regardless of living in Canada, one community member expressed that ethnic women may be socially inclined into respecting their native culture, which places boundaries on how exercise is experienced:

Culture, you know, as African woman, there is something I can do, there is something I cannot do because of my culture. To respect also where I come from… we don’t talk about sometime because we are in Canada, we wanted to get this Canadian system, but even in that, there is something I can do, there is something I cannot do. (P2)

This participant further described cultural expectations that required dressing modestly when entering fitness spaces:

Even I go to YMCA, some they put like uh, what, the short-short uh to go to do the gym… But, me for my culture, no, we put the long one… to cover my leg… And there is uh something to cover my-my-my stomach, to cover-not to show my body… because of what? Because of our culture. (P2)

Cultural expectations also included the need to accommodate others by fulfilling domestic responsibilities from cooking to cleaning, leaving no time to participate in exercise:

Especially in the African/Caribbean communities… Yes, yes [self-care] is the last [priority]… because culturally, a woman with her child, there is uh something, she cannot do like exercises, she there just to cook, to go to bring the children to school, to wash clothes, to do that. (P2)

Another participant spoke about putting her nephew’s needs before her own, limiting her engagement with exercise:

I live with my nephew who is new to Canada. So, he still has some culture from back home… last night, I had, uh, prepared everything to do my back exercise but there was no food so I had to make sure I cook and I spend, like uh, 3 hours in the kitchen. So, by the time I finished, I didn’t want to exercise… Men can ignore [chores] but women cannot. (P1)

ii) Intersectionality of women and their social identities. A couple of women expressed that exercising was not important for some women of color who experienced intersectionality, where they faced multiple forms of inequality. Having dealt with challenges such as oppression from others as a racial minority, to experiencing stigma due to their HIV status, exercise as a result, fell to the bottom of some women’s priority list:

I find African women are affected differently than European women based on oppression. There’s just more intersectionality’s with women of colour. We have to deal with oppression… in Canada for women of colour going to the gym is not going to be their priority. It’s not. Especially, if they’re dealing with health, and children, and poverty, and racism and, maybe hiding that they’re gay, or hiding their diagnosis from their family. Like, it just layers up, right? (P3)

Another participant of ethnic minority also spoke about intersectionality in women living with HIV, and how it may limit their exercise experience:

In women it’s so many other issues…the cultural issues, the children, the financial, this-that, the other taboos of allowing-not allowing. Many things play-play a factor… (P9)

iii) Exposure to exercise. Living in Canada also allowed one woman to become exposed to the benefits of exercise, where she was once not privileged in her native country. Having experienced that exercise can be a healthy self-management strategy, she was better able to understand the benefits of exercise, as demonstrated below:

with education now I never talked about it like long time ago…also because of the culture or the exposure to know those benefits… let’s say when I was still in my home country, but uh, since I’ve been in Canada, being exposed it to how exercising will uh, have uh, a positive impact on my immune system, my health. (P1)

With readily access to internet in Canada as opposed to her home country, another participant of African-Black decent agreed that offering online exercise classes would be beneficial for women:

Yeah, especially here in Canada ‘cuz most people have access to internet. It’s not like back home, so that-that would be easier. (P5)

iv) Food diversity. Additionally, culture produces diversity in food, with one participant claiming that many ethnic women engage in unhealthy eating habits that are transferred to their children. This should further coerce women into reconsidering their relationship with food and consult one another to gain insight into portioning meals alongside working out to ultimately lead a healthy life:

And a lot of women too, we’re all ethnic a lot of us have diversity in terms of food eating. That’s a large, huge-huge barrier for women who are overweight because we come from [inaudible] were if the plates not full of food, you’re offended…. [Women]have to see how they look at food because not only would it benefit them, it would benefit their children. Women of color are bringing up children that are obese as well. Right, so if they’re working out and they know how to portion food for them properly, and they see their friends doing it the same way and they’re saying it to themselves. You know, Nigerian women are talking to themselves in Nigeria or women from Turkey are talking to themselves in Turkey and telling themselves, ‘‘no, do it this way sis, it really does [inaudible], and your kids will like it too and do smaller portions… (P3)

Another participant of ethnic minority, while not directly driven by culture, also conferred the importance of maintaining a healthy diet alongside exercise:

Exercise also, that’s why I told you, it go together with diet….uh diet and exercise and the treatment because the treatment, diet, the food that we eat is a treatment too. Yeah, treatment. The food we eat is uh treatment for our body. (P2)

Gender.

Identifying as a woman, affected the ways in which some participants viewed and engaged with exercise. Gender was comprised of i) caregiving roles and competing priorities, ii) objectification of women, and iii) social norms that set expectations for women.

i) Caregiving roles and competing priorities. For some participants, competing priorities at some point in their lives, such as work or caregiving (i.e., children) took precedence over exercising:

There was a time in my life where I had to prioritize my kids…‘cuz they were little. So, there’s no way, I was going to say, ‘‘you know what, let me forget—let me just focus on the exercise. I just need to focus on them.” With me, I think the stages in life, that’s how I look at it…every-every person has stages in life… I think there was a time I almost gave up on exercise all together because it wasn’t just working, I was exhausted. You have a full-time job and you have small kids, you’re attending diapers, they’re crying, they’re not well and you have to cook. (P5)

This was similarly expressed by another participant who articulated that some women struggle to engage in exercise because of gendered factors:

Well, women with children, yeah, it’s difficult for them to uh be able to get the time [to exercise].(P10).

Another woman stressed that she was a full-time caregiver to her elderly parents, further limiting her time to exercise:

[my current position] stops me, limits me [to exercise] at this stage of my life because now I’m a caregiver full-time with two-two babies. Yeah, to mama and papa. (P9).

Furthermore, maintaining a working life, while also exercising proved difficult for another participant:

I also have a couple of jobs so I have to work around that as well, right? … I have to work around my-my life, my daily life as well. My responsibilities and stuff, I have to work around that, and my obligations I have. (P6)

ii) Objectification of women. The objectification of women was viewed as the sexualization of women in fitness spaces and at large. One participant voiced her concern over the objectification of women’s bodies in the context of weight-lifting:

Well, especially with weights because I find there’s a lot more- there’s more girls now, but there’s a lot of guys too. So, yeah in that sense, I don’t like being looked at as a piece of meat …and that happens a lot… just getting that look or those cat calls and that kind of crap, I just could knock somebody out. (P8)

Consequently, exercise was viewed as a source of strength, and a means for some women to defend themselves:

you get so strong, you can beat up those-those guys that are getting in the way or bugging down your life. (P8)

Similarly, another woman of racial minority also voiced that exercise gave her the power to defend herself against the threat of misogyny:

As a woman, I’m 40% weaker than men and a lot of us women of color have been abused by misogyny for far too long. And, when you exercise, you build strength where you can take a weapon and balance it out. And, there’s women right now as we speak in India that are learning how to fight with sticks and swords. (P3)

iii) Social norms that set expectations for women. Participants stated that social norms set the tone for body image and beauty standards for women, and consequently encouraged them to engage in exercise to look a certain way. This influenced engagement in exercise as some women claimed to rely on social media to obtain their ideal body standards in hopes of looking like other women who post exercise material:

I’m watching this Instagram; I see some people doing exercise… So, I want to look like them, like this is the motivation. (P7)

This was echoed by another participant about other women in the HIV community:

So, in terms of what motivates me [to exercise], is myself ‘cuz I don’t do social media… people in the community of what we’re discussing. Uh, everyone’s social media based and that’s where they get their culture, that’s where they get their influence, that’s where they get their motivation, right? (P3)

Some participants also described how body image, specifically, ‘looking good’ was important for most women and encouraged them to exercise. For instance, one participant indicated:

I like to look good. I like when I dress, I look good and I don’t like too much fat. You know, and yeah, I like to, you know, fit good in clothes and be happy with what I see in the mirror… us women like to look good. (P5)

Similarly, another participant confirmed that gender influenced their level of engagement with exercise:

“Well, being a woman, I don’t know, we have to look good, right?” (P10)

The social norms geared towards women may also demand a traditionally ‘feminized’ approach to working out. This participant spoke on the negative stereotypes of women in body-building:

Well, the-the-the social norms and bias about gender, about women working out, looking beastly, looking too manly, it’s too unfeminine, it’s unsexy, you know. So, it’s always characterized, especially as looking beastly, you know. And-and-and unattractive. So, I’ve had to break through those norms and stereotypes. (P3)

HIV-related stigma.

Stigma, defined as negative beliefs and attitudes about people living with HIV, influenced participants’ decisions to engage in exercise. For some women, issues related to stigma generated fears which resulted in i) HIV-related stigma as a barrier to exercise, whereas for one woman, it resulted in ii) HIV-related stigma as a motivator to exercise, as a means to alleviate frustration from stigma.

i) HIV-related stigma as a barrier to exercise. Both social and internal stigma around HIV emerged as a challenge, with some women voicing concerns for those who may fear exercising due to their HIV status:

Stigma is very critical in our situations, right? Especially, if it’s known to others, right? So, and people can be very mean… Like, uh even catching [HIV] from kissing, all these myths that they’ve created through the years. It’s just crazy, right? … Some women yeah, because they’re afraid. I’ve seen some people; they get afraid because they sweat and all that stuff. And, people think they’re going to catch [HIV]… The dirty looks, the rudeness, the ignorance as a whole. (P6)

One woman noted that some of her fellow community members avoided exercise programs related to living with HIV due to stigma:

To be honest, if this uh program, you send it, for me I don’t-I don’t mind. For other, all they see is it will help you because you are HIV-positive. Just that word, just that word, finish! It goes inside for that person and say ‘‘no…maybe this person I am living with will know what is happen to me or if I go-mm mm I don’t want.” Stigma is uh something that make people to be dis-, it make people to die. (P2)

Another participant echoed this concern, affirming that women living with HIV are still stigmatized:

I can see why it might be a little bit terrifying for people in my situation to put themselves out there because it’s so stigmatized for what I’m living with… And, even just getting fit, a lot of us feel, you know, ‘‘where do I begin? What do I do? How would that look like?” (P3)

An HIV diagnosis also meant that many women experienced unfavorable symptoms that came with their medical treatment, such as lipodystrophy or atrophy:

I don’t know if it’s medication or HIV itself- uh, some unfortunately, can uh, have like uh, should I call it a deformed body or….? That-that sounds negative. Uh, uh, fat disproportion, like where we find someone with a big chest or uh, or uh big uh, shoulder while their lower part is uh, like muscles are losing on the lower part is losing, kind of extremities or this part is losing muscles things like that, so exercise can help maintain muscles or uh, or uh, yeah prevent it to go bad. (P1)

ii) HIV-related stigma as a motivator to exercise. While participants expressed the negative effects of stigmatization towards women living HIV and its discouraging impact on exercise engagement, one participant also voiced that exercise can be employed to offset the negative effects of stigma, facilitating her engagement in exercise:

[Exercise] helps [women] deal with stigma and everything else that might be happening in their lives, you know? (P6)

Episodic nature of HIV.

Women living with HIV revealed that they experienced episodic disability, characterized by fluctuating periods of feeling healthy and unwell which influenced their experiences with exercise. Living with HIV was viewed as having its own set of consequences related to i) symptoms and treatments that occasionally resulted in difficulties when trying to perform daily tasks. A majority of the women also revealed that in addition to living with HIV, ii) they were living with other concurrent health conditions, such as diabetes and COPD, which further contributed to their episodic disability.

i) Symptoms and treatments of HIV. Despite the women actively making efforts to take their daily HIV medication and maintain their health, adverse effects occasionally took a toll on some of their physical and mental well-being. For instance:

there’s a huge correlation between the medication they put us on and depression. (P3)

Because of this, some women faced difficulty finding motivation to exercise. For example:

Anything that discourages me [from exercising]? Uh, I don’t know, just I guess, my-my uh like depression… just feeling down … being HIV, you know… it’s depressing. (P10)

HIV and medication also caused a shift in their body, specifically with weight. For instance, experiencing lipodystrophy left this woman limited with how much she engaged with exercise:

I can do a 2.5 hour walk, nice hike, consistent pace, but not running. My body can’t do it… I’m like pineapple on popsicle sticks, where my body’s kind of deformed with over lipodystrophy and years of whatever. And uh, but my legs are really thin, my ankles are really tiny just like my—but, anyways, the lipodystrophy…So, all the time those popsicle sticks crack and I would fall because of my ankles. (P9)

Other women spoke about the importance of exercise for the health of adults living with HIV and the effects of lipodystrophy. For example:

[Exercise] is very important because the medication, first of all, they make you gain weight in the wrong places… so if you’re not careful and you’re just eating and eating, you find yourself with a big stomach and your bum is small… already that-that’s not proportional, like it’s disproportional… [the medication] causes that. It’s called lipodystrophy or something like that. (P5)

One participant noted that their medication resulted in fatigue, which sometimes affected their ability to exercise:

Because of my medication, I get tired and uh so I might not have a good day with exercise. (P6)

Another participant highlighted the uncertainty associated to HIV and aging. Lack of knowledge had produced a degree of uncertainty living with HIV, which influenced engagement in exercise:

As we get older, there’s not a whole lot of studies. I mean, this disease has only been around for… 50–60 years since the cases… We don’t know how all the men are aging, they’re just starting to age now, let alone women … so I got to make sure I got some sort of regime in place now while I can before-before it gets the better of me. (P4)

ii) Concurrent health conditions. The majority of the women in this study were living with other chronic health conditions in addition to HIV. Living with multi-morbidity interrupted certain participants from engaging in exercise as it put strain on their bodies, which further had the potential to exacerbate episodic disability living with HIV. For instance, one participant noted:

I’ve had a lobectomy in my left lung, I had lung cancer so I have respiratory problems, I get a lot of pneumonia and I also have lymphedema …it’s just really hard for me to breath and aerobics it’s just too much… as recently I’ve even gotten worse because now, I’ve had an exacerbation… of COPD… I’ve had lymphedema uh so, uh and that’s just impossible to breath. It’s impossible to walk from like 3 feet. (P8)

Similarly, another woman described her experience living with asthma and how its limited her exercise:

I have uh negative exercise because uh, sometime, because of my condition… I’m like asthmatic. So, I needed to, at that, I don’t need to do more than as usual-as I’m supposed to do for my health because if I do that, maybe that problem will come back. (P2)

Other chronic conditions, such as diabetes, also affected exercise engagement among women in the study:

[I exercise] depend[-ing] on how I feel when I wake because I also have diabetes as well… (P6)

Sense of belonging.

Having a sense of belonging within the HIV community, or lack thereof, could encourage or deter a woman from engaging in exercise. Women expressed the importance of finding a sense of belonging within a community when dealing with the challenges related to HIV. Sense of belonging was comprised of i) a lack of community that discouraged women to exercise, ii) a racial divide within certain spaces, and iii) having a support network that garnered motivation to exercise.

i) Lack of community. One participant agreed that being part of a group would motivate her to exercise, but she struggled to find a community group within the multiple sub-groups of people living with HIV:

Even looking for a support group, again, everything is male-based… racially I don’t fit in the demographics of people living with AIDS as women. So, it’s even harder, ‘cuz then they get segregated down by their races… But, then even the women that I’ve met, there’s subgroups for them. But, there’s not someone that’s like, you know, old ladies who are white that, you know, get together and exercise…I just don’t feel comfortable bombing their like group or whatever. So, it’s hard to find that right group… (P4)

Another woman described her experiences as a long-time survivor of HIV as ‘othered’ due to her identity:

A lot of women like myself, won’t go to these socials because we’re the odd man out … a lot of women that feel very uh othered because of it… it’s only a certain type of woman that will access these programs … women that are been diagnosed for 20–30 years are not accessing anything, anymore …Like myself, I don’t access any of these organizations… there’s no contingencies for women like us, there’s no support for women like us. (P3)

Similarly, this participant was discouraged from continuing her exercise group (non-HIV related) as she felt unwelcomed and overwhelmed by the intensity level:

I managed to get into that meet up group for hiking and walking in my area… as soon as they started, they were like 500 million miles ahead of me. I couldn’t keep up… Inconsiderate to the person that I’m new… you didn’t even care to see if I existed or not. So, I don’t know if it was a racial thing or if I was just paranoid or whatever. But, as soon as I noticed that happening before the trail got too far in, I decided a smart thing is to turn around…that was not a good experience so I never went again for a meet up. (P9)

ii) Racial divide. One participant, who represents a racial minority, described a sense of intolerance she experienced within the gym space. This resulted in her to feel discomfort when trying to engage in exercise:

You know, going to the gym, it’s 90% Caucasian. You know, 40%-30% women, 60% men, you know? Even going to those environments, people look at you like ‘‘what are you doing here?” Like, Toronto’s racist as hell. And so, when you’re stepping out of your comfort zone and you get these micro-aggressions, working out, which should be a priority, becomes an invasion of privacy because of these micro-aggressions. (P3)

This was echoed by another participant:

The color of the skin, the some of the people, sorry to say this, the color of the skin, “oh I don’t want to be the part of this because it’s just, I see uh black women, some black men. I don’t want to be part of that. ‘‘ … ‘‘I don’t want to go to gym, uh with-with black people, maybe- I don’t know” there are some people like that. (P2)

iii) Support network. Conversely, some women claimed they found a support network (i.e., fitness instructor and/or exercise class) who encouraged them to get involved and remain consistent with exercise:

by yourself, it’s hard [to exercise consistently]. But, with a teacher, that is the reality. With a teacher, you go there and let’s go! Put the music and everyone is doing and there is different level, but your power, you have to do it. (P7)

The role of support as promoting engagement in exercise was reiterated by another participant:

I maintain that one-day a week [of group-based exercise] ‘cuz I know that there’s somebody else that I can go with and things like that, it’s accountability. (P4)

Perceptions of exercise.

Each participant had different perceptions of exercise, which influenced the role it played in their life. Perceptions of exercise was comprised of i) exercise as a priority, ii) exercise as health promotion that could prevent secondary disease with aging and multi-morbidity, and iii) understanding the terminology between ‘physical activity’ and ‘exercise’ can promote exercise among women living with HIV.

1. i) Exercise as a priority. Some participants expressed exercise as a luxury (i.e., financial, time, energy) rather than a priority, which largely became non-attainable to them. This meant some participants rarely, if at all, engaged in exercise or were limited in how much or how often they could exercise. As one woman expressed, some did not view exercise as an important factor in their life:

Working out is not… it’s a luxury. It’s not a privilege. It’s a luxury. And, because of that, a lot of people don’t work out. (P3)

Living with a mental health condition, such as depression, made exercising difficult to achieve for some women. Lacking motivation to become active resulted in this participant avoiding exercise:

I’m lazy and I need some motivation…. I have depression issues and it’s kind of hard to snap out of and go think about going to work out… (P10)

Alternatively, those who viewed exercise as an integral part of their life, made exercise a priority. Some participants expressed they were self-motivated, and refused to accept excuses for not exercising; irrespective of environmental or personal factors, they engaged with exercise to remain healthy. For instance, one woman stated:

Like, you have time to check your email, you can have time to do some exercise if you want. Even if you have a kid, I saw millions of girls doing exercise with kid in the house if they wanted… if you really want to do, you-you-you can find it, you can find time. (P7)

1. ii) Exercise as a health promotion. Regardless of their exercise status, women perceived exercise as important for health promotion that could prevent secondary disease with aging and multi-morbidity. Participants described some form of improvement, from breathing better or losing weight, to enhancing health when they engaged with exercise at some point in life:

After I discovered, the-the benefits from movement and walking, in my personal growth in one year. I think [exercise] is extremely, extremely, extremely, extremely, extremely beneficial because it helps mental health and it also helps physical health. It helps you get alive again. (P9)

Another example of exercise conceptualized as a health promotion strategy included:

the reason of exercise and then the important as a women living with HIV, maybe aging also is to reduce some mental health issues… And then, they also reduce some risk of-of sickness. For example, diabetes, for example, heart attack, for example reduce cholesterol. So, all kind of important to do exercises that is most important for. (P2)

1. iii) Terminology. Women’s perceptions of exercise revealed that the majority had variable perceptions of the distinctions between ‘exercise’, as planned and structured and ‘physical activity’, as encompassing daily activities. For example:

I didn’t know the difference [between the terms], but uh I think it’s good that there’s a difference because there is. Because in exercise, you get other kinds of movements happen, right? In exercise, you have these movements that are essential for all the growth that I talked about earlier…. And, you get movement with physical activity too, but I think it’s a different kind when you know you got the heart happening, this happening. Mind you, I do get it when I run up and down the stairs too. (P9)

Participants had varying views on the differences between the term’s ‘exercise’ and ‘physical activity’ and their respective meanings, for instance:

I feel like exercise is more like voluntary, where you actually have to tell yourself you have to do this. But physical activity is where you’re just doing it because you have to. (P5)

Some women also considered themselves ‘exercisers’ even though they did not achieve the CSEP guidelines. This woman, for instance, after being informed of the terms, realized this during the interview: just when I was thinking I was exercising, I wasn’t really. (P10)

However, participants stated that knowing the differences between the terms ‘exercise’ and ‘physical’ activity could help when recommending exercise for women living with HIV, and provide direction on how to achieve the physical activity guidelines

Yes, it’s good to know the term[s] and to know which is—what is because it’s make more clearly for you what you need to do. (P7)

Facilitators and barriers to exercise.

Facilitators and barriers included factors that influenced engagement with exercise among women living with HIV. Facilitators to exercise included: 1) aspirations to achieve a healthy lifestyle, 2) using exercise as a mental diversion from stressors in life, 3) having an exercise companion, 4) and receiving financial support from community-based organizations to facilitate engagement in exercise. Conversely, barriers to exercise included: 1) limited resources, such as lack of mental-health support and fitness resources, 2) financial limitations, 3) time and gym restrictions, and 4) cold winter weather conditions. See Table 3 for a description of the facilitators and barriers with supporting quotes.

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Table 3. Facilitators and barriers to exercise among women living with HIV.

https://doi.org/10.1371/journal.pone.0286542.t003

Strategies for uptake of exercise.

Participants described personal and organizational strategies to facilitate the uptake and sustainability of exercise among women living with HIV. Personal strategies included: 1) creating social interactions through classes to help women maintain their exercise routine and maintain accountability by having their peers to exercise along with; and organizational strategies included: 2) provision of online exercise classes, 3) raising awareness and educating the population to make informed health decisions, and 4) offering practical support, such as child-care and financial support. See Table 4 for a description of the strategies with supporting quotes.

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Table 4. Strategies for engaging in exercise among women living with HIV.

https://doi.org/10.1371/journal.pone.0286542.t004