Frailty is common among HIV-positive people in South Africa, investigators report in the online edition of the Journal of Acquired Immune Deficiency
Syndromes. A low CD4 cell count was associated with an increased risk of
frailty, and women were especially likely to become frail as they aged.
“This study provides clear evidence that
HIV infection is strongly associated with a two-fold risk of premature frailty
in this African population,” comment the authors. “These findings have potentially
important implications for long-term morbidity among the millions of patients
receiving ART [antiretroviral therapy] long-term in Africa, and may have an
important bearing on the optimum timing of ART.”
There have been major falls in rates of HIV-related
illness and death as a result of the introduction of effective antiretroviral
therapy. There is, however, accumulating evidence that HIV-positive people
develop conditions associated with ageing more rapidly than their HIV-negative peers. The exact reasons for this are
uncertain, but possible explanations include the damage caused by HIV
infection, lifestyle factors and the side-effects of some anti-HIV drugs.
Frailty is common in older people. It is
characterised by multiple problems such as slow walking speed, unintended
weight loss and excessive tiredness.
Because of the rate of ageing of their patients, investigators
in South Africa wanted to establish the prevalence of frailty and its risk
factors among HIV-positive people receiving routine HIV care in Cape Town.
They designed a study involving 248
HIV-positive people aged over 30 who were matched with 256 HIV-negative age-
and gender-matched controls. The study was conducted between March and December
Frailty was assessed according to an
established criteria and was defined as three or more of the following:
- Unintended recent weight loss.
The mean age of the HIV-positive participants
was 41 years, compared to 43 years for the controls. The HIV-positive participants
had higher levels of education (p = 0.05) and reported lower levels of alcohol
use and smoking (p < 0.05) than the HIV-negative individuals. However, body
mass index (BMI) was lower in those with HIV compared to the controls (28 kg/m2
vs 31 kg/m2, p < 0.0001).
Overall, 73% of HIV-positive participants had
been diagnosed with AIDS and 87% were taking antiretroviral therapy. The
people who were taking HIV treatment had an average current CD4 cell count of 468
cells/mm3 and 84% had an undetectable viral load.
There was a 19% prevalence of frailty among
the HIV-positive participants overall. This compared to a prevalence of 14% in the
“Our HIV-related frailty prevalence of
19.4% is higher than estimates from other regions,” note the investigators. A
study conducted among HIV-positive women in the US found a prevalence of 12%,
and separate research found that, depending on age and duration of HIV
infection, between 5 and 14% of HIV-positive men were frail.
After adjusting for potential confounders,
the investigators found infection with HIV doubled the risk of frailty (OR =
2.14; 95% CI, 1.06-3.92; p = 0.01).
The investigators looked at the risk
factors for frailty in the HIV-positive people according to their use of
The prevalence of frailty among the
participants taking antiretroviral therapy was 18%. Old age was a significant risk
factor for frailty for these people This was especially the case for women,
each ten-year increase in age more than doubling the risk of frailty (p =
0.01). Low BMI was also a risk factor (p = 0.01). A CD4 cell count below 500
cells/mm3 was associated with a substantial increase in the risk of frailty
(OR = 2.84; 95% CI, 1.02-7.92).
“The best way to prevent frailty may be to
maintain high CD4 cell counts through early initiation of ART,” write the
There was a 28% prevalence of frailty in
the participants who were not taking antiretroviral therapy. The only predictor of
frailty for these people was an AIDS diagnosis.
“HIV is an important predictor of frailty
in this African population,” the researchers conclude. “Early initiation of ART
at higher CD4 counts may maintain CD4 counts at higher levels and protect
against development of the frailty phenotype. As access to ART expands, and
patients continue to age and live with HIV infection, longitudinal studies are
needed to assess the evolution of frailty within HIV-infected populations and
its impact on morbidity and mortality.”