by Jeffrey T. Kirchner, DO, AAHIVS, AAHIVM Chief Medical Officer

October 15, 2019

Featured Literature:

Sean G. Kelly, SG et al. for the ACTG A5332 Study Team. Frailty Is an Independent Risk Factor for Mortality, Cardiovascular Disease, Bone Disease, and Diabetes Among Aging Adults with Human Immunodeficiency Virus. Clin Infect Dis October 15, 2019; 69(8):1370–76.

As the HIV population ages, frailty is a growing concern. In the general population, frailty prevalence is usually observed after age 65. This study attempted to describe any associations between frailty and bone disease (osteopenia or osteoporosis), cardiovascular disease (CVD), diabetes mellitus (DM), and mortality within a cohort of aging persons with HIV (PLWH). Included were 821 men and 195 women from ACTG A5322, a cohort referred to as HAILO – HIV infection, Aging, Immune Function Long-Term Observational Study. Frailty was assessed using the Fried frailty assessment tool, which includes five components: weak grip; slow gait speed on a 4-meter walk; self-reported weight loss, exhaustion, and limitations in ability to undertake physical activity. Frailty was defined as having 3 or more of these criteria. The clinical outcomes noted above, including mortality, were recorded throughout the study from baseline to the most recent clinic visit or the date of a clinical outcome, whichever came first. Regression models were used to evaluate associations between baseline frailty, change in frailty score over 48 weeks, and each clinical outcome. Overall 6% of the patients were found to be frail at the baseline visit. Frailty scores increased by ≥1 component among 19% of patients from baseline to 48 weeks. Baseline frailty was associated with an increased risk of CVD and DM. There was also a trend toward a significant association with bone events.  An increase in frailty from baseline to week 48 was significantly associated with mortality.  The authors believe these data support the incorporation of frailty assessments into the care of PLWH. Addressing this problem may improve functional status and decrease the risk for age-related chronic diseases and death.

Author’s Commentary:

This paper supports the observation from other studies suggesting that PLWH have “accelerated aging.” This remains a debatable point – but is likely impacted by many variables (body mass index, lifestyle, socioeconomic status) besides HIV disease alone. We know that frailty impacts many health outcomes including falls, hospitalizations, and disability. It is worth noting that the patients from ACTG – HAILO had a median age at baseline of only 51 years with (91%) having an undetectable viral load and the median CD4 count of 621. Interventions for frail patients including physical activity training and structured exercise programs have been shown to be effective in improving cardiovascular fitness, weight, and strength and should be encouraged for many if not all of our HIV patients.

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