Frailty common among HIV-positive patients in South Africa, but early ART may be protective

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 2011.

Frailty was assessed according to an established criteria and was defined as three or more of the following:

• Unintended recent weight loss.

• Low physical activity.

• Exhaustion.

• Weak grip strength.

• Slow walking time.

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 uninfected controls.

“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 antiretroviral therapy.

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 investigators.

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.”

Pathai S et al. Frailty in HIV-infected adults in South Africa. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0b013e318273b631, 2012.