CATIE News

14 November 2019 

Interventions against frailty may improve the health of HIV-positive people

  • Frailty can sometimes occur early in HIV-positive people
  • In a recent study, frailty was linked to an increased risk for heart disease and diabetes
  • Research suggests that frailty can be halted or reversed in some HIV-positive people

The widespread availability of potent HIV treatment (ART) in Canada and other high-income countries has had a tremendous impact on the health of HIV-positive people. Scientists predict that many ART users will have a near-normal life expectancy.

As HIV-positive ART users approach and enter their senior years, issues that are related to aging have become more important. Health issues such as persistently elevated levels of bad cholesterol, blood pressure and blood sugar, increased weight and thinning bones are becoming the focus of routine care appointments in this population. If left untreated, these issues can contribute to disability and premature death.

A team of scientists in the United States has been studying frailty—a syndrome of age-related conditions that they say “leads to physical weakness and functional decline.” Among HIV-negative people, frailty becomes more common after age 65.

The scientists have been monitoring the health of 1,016 HIV-positive people for an average of four years. At the time of entering the study, about 6% of participants were considered frail. However, over the course of the study, about 20% of participants developed increasing signs of frailty. The scientists found that being frail was statistically linked to an increased risk for developing cardiovascular disease and type 2 diabetes. Also, people who were frail or pre-frail seemed more likely to develop thinner-than-normal bones.

The scientists called for annual frailty assessments for older HIV-positive people.

Although the scientists did not study interventions for frail HIV-positive people, they underscored the beneficial effects of strategies used with aging HIV-negative people to halt frailty and improve health outcomes.

Study details

Research assistants recruited people for a study called HAILO, operated under the aegis of the U.S. government-funded AIDS Clinical Trials Group (ACTG). The study was designed to monitor changes in HIV-positive people as they age.

The average profile of participants upon entering the study was as follows:

  • 81% men, 19% women
  • age distributions: less than 50 years – 44%; between 50 and 59 years – 40%; more than 60 years – 16%
  • major ethno-racial groups: white – 48%; black – 29%; Hispanic and other groups – 23%
  • CD4+ count – 621 cells/mm3
  • having a viral load less than 50 copies/mL – 91%
  • smoking status: never smoked – 41%; prior smoker – 34%; current smoker – 25%
  • frailty status: non-frail – 56%; pre-frail – 38%; frail – 6%
  • the presence of elevated blood pressure and abnormal cholesterol levels was relatively common

Assessing frailty

Frailty assessment has been well validated both among HIV-positive and HIV-negative people. Key criteria for frailty assessment are as follows:

  • the strength of a person’s grip (using a dynamometer)
  • how fast or slow they walked for a distance of four metres (this is called gait speed)
  • self-reported unintentional weight loss
  • self-reported exhaustion
  • self-reported limitations in various physical activities

Assessment of each of these criteria is used to develop a score, which is then used to group people as follows:

  • meeting between three and five of the criteria – frail
  • meeting between one and two of the criteria – pre-frail
  • meeting none of the criteria – non-frail

Results

Over the course of the study, scientists found that being frail at the start of the study was statistically linked to an increased risk for subsequently developing the following:

  • a nearly four-fold increased risk for cardiovascular disease (this term encompassed a range of conditions—heart attack, stroke, abnormal heart rhythm, clogged arteries, heart pain, heart failure, excessive formation of blood clots)
  • a more than two-fold increased risk for type 2 diabetes
  • there was a trend for an increased risk for decreasing bone density, however, this approached but did not achieve statistical significance

Frailty and dying

A total of 27 people died over the course of the study. Participants who became more frail in the first year of the study had a nearly four-fold increased risk of death.

A study published in 2007 by a different team of scientists compared the onset of frailty in HIV-negative and HIV-positive men. The scientists found that frailty could occur up to a decade earlier in the HIV-positive men. Furthermore, frailty among HIV-positive men was linked to a greater risk for deteriorating health and dying.

Why does frailty lead to other problems?

The scientists are not certain as to how frailty leads to poorer health. Although their study was not designed to explore the mechanism connecting frailty and poor health, they suggested that the excess inflammation that is a hallmark of HIV may play some role in frailty. They also suggested that excess weight gain in the form of fat mass and loss of muscle tissue (and therefore strength) may be accelerated in HIV-positive people. They stated that these two factors “may contribute to a sedentary lifestyle, thereby hastening metabolic derangements [such as pre-diabetes] and contributing to chronic disease development.”

Possible solutions

Although the scientists did not test interventions to improve the physical resiliency of participants, they stated the following:

“Once identified, frailty development may be halted or reduced by physical activity training. Such programs have been shown to increase strength, balance, and physical activity among elderly HIV-negative participants, ultimately leading to reduction in frailty. For aging people with HIV, structured exercise programs have been shown to improve weight, strength, and cardiorespiratory fitness and to even reduce the number of frailty criteria. Such interventions are low risk and, at a minimum, may improve health outcomes directly consequent to frailty.”

The scientists encourage clinics to routinely incorporate “annual frailty assessments in the care of people with HIV (perhaps beginning in as early as the sixth decade of life).”

Bear in mind

The present study was observational in design. Such studies cannot prove what scientists refer to as “cause and effect.” In this case, the study cannot prove that being frail leads to more serious health problems over time. There was also no comparison group of participants, such as a cohort of HIV-negative people with similar age distribution and socio-demographic factors. However, at least in the group of HIV-positive people studied in HAILO, frailty is an issue that can have serious health consequences. Other observational studies have also found trends similar to those seen in the present study.

Resources

Frailty, nerve injury and falls in middle-aged and older HIV-positive peopleCATIE News

Factors linked to falling in HIV-positive womenTreatmentUpdate 218

Nerve pain and numbness from A Practical Guide to HIV Drug Side Effects

Italian and U.S. researchers look to the future and explore aging-related issuesCATIE News

U.S. researchers look at chronic conditions in HIV-positive people over the age of 65CATIE News

Older people with HIV face different long-term health challengesCATIE News

Unravelling the complexity of HIV and fatigueCATIE News

Inflammation and HIVTreatmentUpdate 223

Emerging issues in older HIV-positive peopleTreatmentUpdate 214

Denmark—unexpected trends in use of psychotropic medicinesTreatmentUpdate 204

—Sean R. Hosein

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