Association Between Frailty and HIV-Associated Neurodegenerative Disorders Among Older Adults Living with HIV

The clinical utility of three frailty measures in identifying HIV-associated neurocognitive disorders

OBJECTIVE

Frailty measures vary widely and the optimal measure for predicting HIV-associated neurocognitive disorders (HAND) is unclear.

DESIGN

A study was conducted to examine the clinical utility of three widely used frailty measures in identifying HIV-associated neurocognitive disorders.

METHODS

The study involved 284 people with HIV (PWH) at least 50 years enrolled at UC San Diego's HIV Neurobehavioral Research Program. Frailty measurements included the Fried Phenotype, the Rockwood Frailty Index, and the Veterans Aging Cohort Study (VACS) Index. HAND was diagnosed according to Frascati criteria. ANOVAs examined differences in frailty severity across HAND conditions. ROC analyses evaluated sensitivity and specificity of each measure to detect symptomatic HAND [mild neurocognitive disorder (MND) and HIV-associated dementia (HAD)] from no HAND.

RESULTS

Across all frailty measures, frailty was found to be higher in HAD compared with no HAND. For Fried and Rockwood (not VACS), frailty was significantly more severe in MND vs. no HAND and in HAD vs. ANI (asymptomatic neurocognitive impairment). For discriminating symptomatic HAND from no HAND, Fried was 37% sensitive and 92% specific, Rockwood was 85% sensitive and 43% specific, and VACS was 58% sensitive and 65% specific.

CONCLUSION

These findings demonstrate that Fried and Rockwood outperform VACS in predicting HAND. However, ROC analyses suggest none of the indices had adequate predictive validity in detecting HAND. The results indicate that the combined use of the Rockwood and Fried indices may be an appropriate alternative.

Frailty and health-related quality of life among older people living with HIV pre- and post-COVID-19 pandemic onset: A cross-sectional study

INTRODUCTION

Antiretroviral therapy increased the survival and life expectancy of People living With HIV (PWH). Frailty-related syndromes among older PWH (aged 50+ years) may affect their Health-related Quality of Life (HQoL). Additionally, the COVID-19 pandemic has impacted health-related outcomes. This study aimed to estimate the prevalence of frailty and pre-frailty among older PWH, and to explore associations of HQoL with the study assessment period and frailty status.

METHODS

Cross-sectional study conducted pre- (23-Mar-2019 to 5-Mar-2020) and post-COVID-19 pandemic onset (23-Jun-2021 to 5-May-2022), among older PWH at INI-Fiocruz, the largest cohort of PWH in Rio de Janeiro, Brazil. We measured frailty using Fried assessment, consisting of five domains: unintentional weight loss; self-reported exhaustion, weakness, slow walking speed, low physical activity. HQoL was assessed using the ACTG SF-21, which contains 21 questions divided into 8 domains. We used Chi-Square test, Fisher's exact test, Kruskal-Wallis and ranksum test for comparisons.

RESULTS

We included 250 older PWH: 109 (43.6 %) pre- and 141 (56.4 %) post-COVID-19 pandemic onset. Median age was 60-years (IQR: 55‒64). Most self-identified as cisgender men 152 (60.8 %), Pardo/Black 146 (58.4 %), with completed secondary education or less 181 (72.7 %) and low income 132 (52.8 %). Overall, prevalence of frailty and pre-frailty were 9.2 % (95 % CI: 8.1‒10.3) and 61.6 % (95 % CI: 54.0‒69.2). Prevalence of frailty in the pre- and pos-COVID-19 pandemic periods were 7.3 % and 10.6 % (p = 0.66). HQoL scores were lower among participants with frailty compared to those with non-frailty and pre-frailty in all eight domains, and among those included in the post-COVID-19 compared to pre-COVID-19 period for four domains.

CONCLUSIONS

We observed low prevalence of frailty, but high prevalence of pre-frailty among older PWH. Frailty status did not differ according to the COVID-19 assessment period. Assessment of frailty and HQoL should be incorporated in clinical practice for older PWH. Programs to reverse or prevent frailty should be implemented within the public health system.

Ongoing Healthcare Disparities in neuroHIV: Addressing Gaps in the Care Continuum

PURPOSE OF REVIEW

We aim to review the neurological complications of HIV and the social, cultural, and economic inequalities that contribute to disparities in neuroHIV care.

RECENT FINDINGS

Disparities in diagnostics and care of patients with neurological infections and non-infectious conditions associated with HIV in both high-income and low-to-middle-income countries (LMIC) are common. The COVID-19 pandemic has exacerbated these disparities. Factors, such as HIV-related stigma, may deter people from accessing HIV treatment. First-line recommended treatments for neurological infections are not available in many LMICs, leading to inadequate treatment and exposure to agents with more harmful side effect profiles. Access-related factors, such as lack of transportation, lack of health insurance, and inadequate telehealth access, may increase the risk of HIV-related neurological complications. Further research is needed to increase awareness of neurological complications among providers and PWH, and regional guidelines should be considered to better address these complications.

Frailty in people 50 years or older living with HIV: A sex perspective

OBJECTIVE

To estimate prefrailty and frailty prevalence and associated factors in people living with HIV (PLHIV) from a sex perspective.

METHODS

Cross-sectional study on PLHIV at specialized public health centres in Brazil. Data were obtained from individuals aged ≥50 years using antiretroviral therapy (ART) and with an undetectable viral load through personal interviews, clinical evaluations and medical records. Frailty and prefrailty were characterized using the Fried Frailty Phenotype tool. Multinomial regression models were performed, and the associated factors were selected through the backward stepwise method.

RESULTS

Among 670 patients, 373 men and 297 women were included. The prevalence of frailty and prefrailty was significantly higher for women (16.2% and 56.2%, respectively) than for men (11.5% and 46.4%, respectively). Low socioeconomic and educational level, multimorbidity, depression, subjective cognitive complaints, and low scores on the Mini-Mental State Exam (MMSE) were associated (P < 0.05) with frailty for both sexes. However, in the sex-specific analysis, while smoking (OR = 3.66, 95% CI: 1.58-8.48) and a history of low adherence to ART (OR = 3.10, 95% CI: 1.33-7.23) were associated with frailty in men, depression (OR = 3.39, 95% CI: 1.36- 8.44) and the absence of functional dentition (OR = 3.77, 95% CI: 1.36- 10.43) were associated with frailty in women.

CONCLUSIONS

This study adds self-reported cognitive complaints as a potential predictor of frailty in both sexes and supports the known deleterious effect of multimorbidity on frailty in adults living with HIV. Furthermore, it suggests that other possible predictors, such as depression, oral health status and adherence to ART, may be sex-specific.

Characterization of data-driven geriatric syndrome clusters in older people with HIV: a Mexican multicenter cross-sectional study

Background

As living with HIV has been proposed as a condition that may accelerate aging, the main objective of this work was to estimate the prevalence of geriatric syndromes (GS) among older Mexicans with HIV dwelling in the community. Secondly, to evaluate whether the accumulation of GS could be associated with an adverse HIV-related clinical profile, independent of chronological age.

Methods

Multicenter, cross-sectional study including 501 community-dwelling people aged ≥50 years with HIV. The overall prevalence of nine selected GS and their cumulative number were estimated. An Age-Independent Cumulative Geriatric Syndromes scale (AICGSs) was constructed, and correlations between the AICGSs and HIV-related parameters assessed. Finally, k-mean clustering analyses were performed to test the secondary objective.

Findings

Median age 56 (IQR: 53-61) years, 81.6% of men. Polypharmacy (74.8%), sensorial deficit (71.2%), cognitive impairment (53.6%), physical disability (41.9%), pre-frailty (27.9%), and falls (29.7%), were the more prevalent GS. A significant negative correlation was found between the AICGSs and normalized values of CD4+ nadir cell counts (r = -0.126; 95%: CI: -0.223 to -0.026, p < 0.05). Similarly, a significant inverse adjusted association between the CD4+ nadir cells and the AICGSs was observed on linear regression analysis (β -0.058; 95%: CI: -0.109 to -0.007, p = 0.03). Cluster analysis identified three differentiated groups varying by age, metabolic comorbidities, AICGSs, and HIV-related parameters.

Interpretation

An elevated prevalence of GS was observed in the studied population. Moreover, the accumulation of GS was associated with adverse HIV-related profiles, independent of age. Thus, early detection and management of GS are crucial to promote healthier aging trajectories in people with HIV.

Funding

This work was funded in part by the National Center for the Prevention and Control of HIV/AIDS in Mexico (CENSIDA)-National Ministry of Health.

Mapping frailty in people living with HIV: A nationwide study in Greece

OBJECTIVES

Frailty is known to affect people living with HIV prematurely, compared to the ageing seronegative population. In this cross-sectional study, we aimed to assess frailty prevalence in people living with HIV in Greece and find associations of frailty criteria with clinical data.

METHODS

Demographic and clinical data were collected from 477 participants in six HIV clinics. Fried's frailty phenotype was used to assess frailty prevalence, and participants were classified as frail, pre-frail or robust. Associations of several factors with overall frailty phenotype, as well as with frailty criteria, were explored.

RESULTS

The median age was 43 years old (IQR = 51.5) and 444/477 (93%) were men. Most of the participants (429/477, 93.5%) had an undetectable HIV viral load, and a CD4 cell count over 500 cells/μl (366/477, 76.7%). Frailty assessment classified 285/477 (62.1%) as robust, 155/477 (33.8%) as pre-frail and 19/477 (4.1%) as frail. Weakness in grip strength was the most prevalent criterion (128/477, 26.8%), followed by exhaustion (46/477, 9.6%). Lower CD4 cell count, history of AIDS diagnosis, CNS disorders, psychiatric diagnoses, and polypharmacy were strongly associated with frailty.

CONCLUSIONS

Although the prevalence of frailty in people living with HIV in Greece is uncommon, when combined with pre-frailty over a third of people are affected, which requires attention in clinical practice. The physical and psychological aspects of frailty highlight the need for a holistic approach to prevent or counteract it. The diverse associations of frailty criteria with HIV-related and non-HIV-related factors suggest a possible variation in people's different healthcare needs.

Cognitive Deficits: Verbal and Semantic Fluency in People Living with HIV and AIDS

BACKGROUND

Since the beginning of the HIV epidemic, the virus has taken millions of lives worldwide. The United Nations AIDS Fund's statistics reported that deaths caused by HIVrelated conditions and AIDS were about 39 million from the beginning of the epidemic to 2015. The united global efforts to fight the virus are considerably changing the indicators, such as mortality and morbidity, but the challenges remain. The total number of people living with HIV in Bulgaria as of 12th May, 2015, was 2,121. As of 30th November, 2016, the official data reported 2 460 people living with HIV. As of 13th February, 2017, 2 487 individuals were HIV-seropositive. Approximately 60% of people with HIV are prone to developing cognitive impairment due to the infection.

OBJECTIVE

This study aimed to know the level of cognitive deficiency, in particular, the verbal and semantic fluency of people living with HIV and AIDS.

METHODS

In this study, a comparative analysis was carried out. The Stewart test was used to compare the average independent samples. For clarity, the average values, the test statistics, and the estimated significance levels are presented in the tables. Additionally, a statistical mechanism of factor selection was used by the forward stepwise method. The Wilks' Lambda statistic reported values between 0 and 1, with values close to zero indicating good discrimination of the model.

RESULTS

According to this research, the HIV positives participants generated fewer verbs than the ones from the control group. The data were partially confirmed by the present study. There were differences in terms of both adjectives and nouns among people living with HIV and AIDS.

CONCLUSION

The study data proves that language deficits are detectable in neurocognitive testing of HIV. The overall hypothesis of the study has been confirmed. The language impairments are primarily qualitative and can be used as a marker for the initial and subsequent therapy assessment.

A moderated mediation analysis of depression and age on the relationship between resilience and frailty among HIV-positive adults

Background

Given the continuing challenges frailty poses among people living with human immunodeficiency virus (HIV) (PLHIV), accumulating evidence suggests that frailty is linked to psychological factors. However, the mutual influences of resilience, depression, and frailty have not yet been clarified. This study aimed to identify the potential mechanistic pathway through which psychological factors mitigate frailty.

Methods

Data were collected from June to August 2019 by trained investigators through face-to-face interviews with 375 HIV-positive Chinese adults. Each participant completed structured questionnaires to collect data in respect of their socio-demographic characteristics, and levels of frailty, depression, and resilience. These assessment measures included a self-designed questionnaire, the Tilburg Frailty Indicator (TFI), the 10-item Center for Epidemiological Studies Depression Scale (CES-D-10), and the 10-item Connor-Davidson Resilience Scale (CD-RISC-10). SPSS PROCESS macro was used to analyze the mediation and moderated mediation models.

Results

The overall prevalence of frailty was 26.4%, and the prevalence of frailty among older and younger adults living with HIV was 22 and 31.4%, respectively. Mediation analysis showed that an association between resilience and frailty was mediated by depression, whereas resilience did not mediate the relationship between depression and frailty. Compared to physical frailty, depression was a stronger mediator of resilience to psychological frailty. We further found that age moderated the indirect effect of resilience on psychological frailty, with resilience being a stronger negative predictor of depression and depression being a stronger positive predictor of psychological frailty for older PLHIV than for younger PLHIV.

Conclusion

Lower levels of resilience and greater levels of depression may be significant risk factors for frailty among PLHIV. Levels of resilience influenced frailty directly and frailty was indirectly affected by depression. Therefore, it is recommended that PLHIV, especially older patients, should be encouraged to establish positive psychological coping strategies to slow the progression of frailty.

HIV-Associated Dementia: Associated Factors and Characteristics of Cognitive Domain Abnormalities in Elderly People Living with HIV Treated with Highly Active Antiretroviral Therapy

This study aimed to evaluate the prevalence and associated factors of HIV-associated dementia (HAD) in people living with HIV (PLWH) aged ≥ 60 years who are currently treated with highly active antiretroviral therapy. A cross-sectional study was conducted on adult (age ≥ 60 years) PLWH at the infectious clinic, Vajira Hospital, Navamindradhiraj University, Thailand, between August 2019 and March 2021. We collected the patients' characteristics and performed Montreal Cognitive Assessment and Instrumental Activities of Daily Living test to determine whether they have HIV-associated neurocognitive disorders (HAND), which we further classified into asymptomatic neurocognitive impairment (ANI), mild neurocognitive disorder (MND), and HAD. Finally, we evaluated the prevalence, associated factors, and characteristics of cognitive domain abnormalities in these patients. We enrolled 84 elderly PLWH patients consisting of 43 (51.2%) males. The mean patient age was 63 years (SD ± 3.9), and the median duration of HIV infection was 13 (SD ± 5.7) years. All the patients had undetectable HIV viral load. Among them, seven (8.3%) had no neurocognitive impairment, 61 (72.6%) had ANI, three (3.6%) had MND, and 13 (15.5%) had HAD. After confounder adjustment, the patient age of ≥ 65 years was found to be significantly associated with dementia (odds ratio = 5.97, 95% CI: 1.51-23.57). Significant difference in the mean score of all cognitive domains was observed between the patients with HAD and those with normal cognitive status. HAND is common in PLWH. Age older than ≥ 65 years is a risk factor of HAD.

Screening Accuracy of Mini Addenbrooke's Cognitive Examination Test for HIV-Associated Neurocognitive Disorders in People Ageing with HIV

Aging and increased cardiovascular risk are major drivers for HIV-associated neurocognitive disorders (HAND), for which accurate screenings are lacking. Mini-Addenbrooke's Cognitive Examination (MACE) reliably detects vascular and neurodegenerative cognitive decline among HIV-negative patients. We evaluated MACE diagnostic accuracy in detecting HAND in people living with HIV (PLWH) and we compared it with the International HIV Dementia Scale (IHDS). A single-centre double-blind study of diagnostic accuracy on adult outpatient PLWH without neurocognitive confounding was performed. MACE and IHDS were administered in 5 and 10 min by clinicians, followed by the reference standard battery (14 tests) by neuropsychologists. HAND diagnosis was based on the modified version of Frascati's criteria by Gisslén to reduce false positives. Exploratory cut-offs were evaluated for MACE. Diagnostic accuracy and clinical utility parameters were assessed. 231 patients were enrolled. 75.7% men with a median age, education, and length of infection of 54 (48-59), 10 (8-13) and 16 (5-25) years. HAND prevalence was 48.5% (38.9% asymptomatic impairment). Compared to IHDS, MACE sensitivity (89.3% vs 70.5%), specificity (94.1% vs 63.0%), correct classification rate (86.5% vs 66.7%), J index (0.83 vs 0.34), AUROC (0.97 vs 0.79), agreement with the gold standard (k 0.84 vs 0.33) and effect size in distinguishing HAND vs non-HAND (d 2.11 vs 1.15) were higher. Among PLWH aged 65 years and above (n = 37) MACE performance was consistently better than IHDS. The quick and easy-to-perform MACE could possess an accurate and useful screening performance for HAND in otherwise neurocognitively healthy cohorts of PLWH.

Prevalence of Frailty and Prefrailty in People With Human Immunodeficiency Virus Aged 50 or Older: A Systematic Review and Meta-Analysis

Background

With effective antiretroviral therapy, there is an emerging population of adults aged 50 years or older with human immunodeficiency virus (HIV). Frailty is an increasingly recognized clinical state of vulnerability associated with disability, hospitalization, and mortality. However, there is a paucity of large studies assessing its prevalence in people with HIV (PWH) aged 50 or older.

Methods

PubMed was systematically searched for studies published between January 2000 and August 2020 reporting the prevalence of frailty in PWH aged 50 or older. The pooled prevalence of frailty and prefrailty was synthesized using a random-effects meta-analysis.

Results

Of the 425 studies identified, 26 studies were included in the analysis, with a total of 6584 PWH aged 50 or older. The included studies were published between 2012 and 2020, and all studies used the Fried frailty phenotype to define frailty. The overall pooled prevalence of frailty and prefrailty was 10.9% (95% confidence interval [CI], 8.1%–14.2%) and 47.2% (95% CI, 40.1%–54.4%), respectively. A high degree of heterogeneity was observed (I² = 93.2%). In the subgroup analysis, HIV-related variables and other demographic variables were examined, and heterogeneity disappeared only in the group of a longer duration since HIV diagnosis (I² = 0%).

Conclusions

The pooled prevalence of frailty and prefrailty defined by the Fried frailty phenotype was assessed in PWH aged 50 or older. Findings from this study quantified the proportion of this specific population with this common geriatric syndrome. Future studies identifying effective strategies for frailty screening and intervention are required for this vulnerable population.

The association between benzodiazepine use and greater risk of neurocognitive impairment is moderated by medical burden in people with HIV

Benzodiazepine use is linked to neurocognitive impairment (NCI) in the general population and people with HIV (PWH); however, this relationship may depend on age-related factors such as medical comorbidities, which occur at an elevated rate and manifest earlier in PWH. We retrospectively examined whether chronological age or medical burden, a clinical marker for aging, moderated the relationship between benzodiazepine use and NCI in PWH. Participants were 435 PWH on antiretroviral therapy who underwent neurocognitive and medical evaluations, including self-reported current benzodiazepine use. A medical burden index score (proportion of accumulated multisystem deficits) was calculated from 28 medical deficits. Demographically corrected cognitive deficit scores from 15 neuropsychological tests were used to calculate global and domain-specific NCI based on established cut-offs. Logistic regressions separately modeled global and domain-specific NCI as a function of benzodiazepine x age and benzodiazepine x medical burden interactions, adjusting for current affective symptoms and HIV disease characteristics. A statistically significant benzodiazepine x medical burden interaction (p = .006) revealed that current benzodiazepine use increased odds of global NCI only among those who had a high medical burden (index score > 0.3 as indicated by the Johnson–Neyman analysis), which was driven by the domains of processing speed, motor, and verbal fluency. No age x benzodiazepine interactive effects on NCI were present. Findings suggest that the relationship between BZD use and NCI among PWH is specific to those with greater medical burden, which may be a greater risk factor for BZD-related NCI than chronological age.

Frailty Syndrome Is Associated with Poorer Self-Reported Sleep Quality Among Older Persons with Human Immunodeficiency Virus

Older people with HIV (PWH) experience heightened risk for the acquisition of cumulative, multisystem decline, that is, frailty syndrome. Frailty relates to poorer sleep quality in the general older adult population; however, this association has yet to be explored among PWH. A cross-sectional analysis of 285 PWH ≥50 years of age (mean age 60.5 ± 7.0) examined the relationship between frailty (Fried frailty phenotype) and self-reported sleep quality [Pittsburgh Sleep Quality Index (PSQI)]. Three separate multivariable linear regression models examined global PSQI as a function of (1) frailty phenotype, (2) total number of frailty symptoms, or (3) specific individual frailty symptoms. Models covaried for demographic and biopsychosocial risk factors, including age, sex, race/ethnicity, education, premorbid verbal IQ estimate, current depressive symptoms, and diagnosis of a substance abuse disorder. Compared to nonfrail (B = 0.151; p = .021) and prefrail (B = 0.144; p = .021), frail phenotype was related to poorer sleep quality (increased global PSQI; F(5,278) = 11.34, p < .001; R2 = 0.17). Increased number of frailty symptoms (B = 0.144; p = .019; F(4,276) = 12.719, p < .001; R2 = 0.16) and exhaustion was associated with increased global PSQI scores (B = 0.218, p < .001; F(6,247) = 10.436, p < .001; R2 = 0.19). In all models, older age, female sex, and elevated current depressive symptoms were associated with poorer sleep quality. In older PWH, greater frailty symptoms related to poorer sleep quality, independent of psychosocial risk factors for poor sleep. Frailty and poor sleep individually have adverse effects on health and everyday functioning; thus, establishing this association may better aid providers to screen for and treat problems with sleep quality and/or frailty among PWH.

Predictors of Transition to Frailty in Middle-Aged and Older People With HIV: A Prospective Cohort Study

BACKGROUND

People with HIV (PWH) have increased frailty risk at younger ages compared with the general population. Multimorbidity is associated with frailty, yet effects of specific comorbidities on transition to frailty in PWH are unknown.

SETTING

Prospective study of 219 PWH age 45 years or older in the National NeuroAIDS Tissue Consortium.

METHODS

Frailty status was categorized using Fried frailty phenotype criteria. Comorbidities [bone disease, cardiovascular disease, cerebrovascular disease, liver disease, renal disease, diabetes, chronic obstructive pulmonary disease (COPD), hypertension, obesity, cancers, neuropsychiatric conditions] were assessed from longitudinal data. Associations between baseline comorbidities and transition to frailty within 30 months were analyzed using Kaplan-Meier and Cox regression models. Grip strength was assessed using mixed-effects models.

RESULTS

At baseline, the median age was 61 years, 73% were male 98% were on antiretroviral therapy, 29% had ≥3 comorbidities, 27% were robust, and 73% were pre-frail. Cerebrovascular disease, diabetes, and COPD were independent predictors of transition to frailty within 30 months in models adjusted for age, sex, and multimorbidity (≥3 additional comorbidities) [hazard ratios (95% confidence intervals) 2.52 (1.29 to 4.93), 2.31 (1.12 to 4.76), and 1.82 (0.95 to 3.48), respectively]. Furthermore, cerebrovascular disease, diabetes, COPD, or liver disease co-occurring with multimorbidity was associated with substantially increased frailty hazards compared with multimorbidity alone (hazard ratios 4.75-7.46). Cerebrovascular disease was associated with decreased baseline grip strength (P = 0.0001), whereas multimorbidity, diabetes, and COPD were associated with declining grip strength (P < 0.10).

CONCLUSIONS

In older PWH, cerebrovascular disease, diabetes, COPD, or liver disease co-occurring with multimorbidity is associated with substantially increased risk of becoming frail within 30 months. Interventions targeting these comorbidities may ameliorate frailty and age-related functional decline in PWH.

Characterization of HIV-Associated Neurocognitive Impairment in Middle-Aged and Older Persons With HIV in Lima, Peru

Background: With widespread use of antiretroviral medications, people living with HIV (PWH) are living longer worldwide, increasing their risk of developing neurocognitive impairment (NCI). The proportion of Peruvians over age 60 is expected to increase to 25% of the population by 2050, including PWH. Therefore, the problem of aging and NCI, especially in the setting of HIV infection, is uniquely pressing. We sought to study the rates of and risk factors associated with NCI among middle-aged and older PWH in Lima, Peru. Materials and Methods: Sociodemographic, medical (infectious and non-infectious), and psychiatric comorbidity and laboratory data were collected. We administered a brief neuropsychological battery evaluating seven cognitive domains affected in HIV-associated NCI and a depression screening. Cognitive test raw scores were converted to T-scores that were demographically adjusted. Descriptive statistics were performed together with regression (unadjusted and adjusted) analyses to determine potential risk factors for NCI among PWH. Results: This was a cross-sectional study in which 144 PWH aged ≥40 years attending a large HIV clinic in Lima, Peru, were recruited from September 2019 to March 2020. Mean age was 51.6 ± 7.7 years, and mean years of education were 14.0 ± 3.1 with 15% females. Median [interquartile range (IQR)] current CD4 and nadir CD4 were 554 (371, 723) and 179 (83, 291), respectively, and 10% currently had AIDS. The prevalence of NCI was 28.5%, and many demonstrated difficulty with attention and working memory (70%). One-quarter of PWH had mild depression or worse on Patient Health Questionnaire 9 (PHQ-9 ≥ 5). In bivariate analyses, neither a depression history nor a higher PHQ-9 score correlated with NCI. No other non-communicable medical or psychiatric comorbidity nor HIV characteristic was predictive of NCI. Having a positive lifetime history of hepatitis B infection, pulmonary tuberculosis, or syphilis increased risk of NCI (PR 1.72; 95% CI 1.04-2.86) in unadjusted analyses, but not in adjusted analyses. Conclusions: NCI among older Peruvians with HIV was found to be highly prevalent with levels consistent with prior reports of HIV-associated NCI worldwide. Common latent HIV-associated co-infections, including latent syphilis, hepatitis B infection, or pulmonary tuberculosis, may increase the risk of NCI among middle-aged and older PWH in Peru.

High Prevalence of Frailty and Prefrailty Status in Brazilian Patients Living with HIV

Frailty is associated with an increased probability of serious adverse health outcomes in the geriatric general population. People living with HIV have a higher prevalence of frailty. However, the magnitude of this problem in younger patients in South America is unknown. We aimed to determine the prevalence and factors associated with frailty. This is a cross-sectional study from the Brazilian cohort HIV-AIDS (CoBRA) developed between March and November of 2018, on patients ≥18 years of age. Frailty phenotype was assessed by original Fried criteria. The results were analyzed using descriptive statistics, while identification of factors related to frailty was assessed by using multivariate logistic regression. We enrolled 231 patients; all, but 2 were on antiretroviral therapy (ART). Median age was 45.6 interquartile range (36.7-52.1) years, 136 (58.9%) were male, and 86.7% self-identified as non-white. Mean CD4 count was 660 (±345) cells/mm³ and 83.5% had undetectable HIV plasma viral load (<50 copies/mL). Prevalence of frailty and prefrailty was 10.4% and 52.4%, respectively. A CD4 count <200 cells/mm³, depression, low income, and use of third-line ART were variables significantly associated with a greater risk to present frail or prefrail status. Frailty prevalence increases with age and is an important health problem to health care in HIV aging patients. It requires proper strategies to its early detection, prevention, and management.

Aging with HIV in Latin America and the Caribbean: a Systematic Review

PURPOSE OF REVIEW

With the establishment of antiretroviral treatment (ART) programs in low- and middle-income countries, people with HIV (PWH) in Latin America and the Caribbean (LAC) are living longer, subsequently developing chronic non-communicable diseases (NCDs). Few studies focus on the impact of aging among older LAC PWH. This systematic review aims to fill this information gap and understand the burden of aging with HIV in LAC. We identified peer-reviewed literature published in English, Spanish, or Portuguese from several databases to assess currently available evidence on the burden of aging with HIV in LAC and selected six common NCDs found in older PWH (cardiovascular disease [CVD], bone and musculoskeletal [MSK] disorders, cancer, renal disease, neurocognitive impairment [NCI], and depression).

RECENT FINDINGS

Of the 5942 publications reviewed, only 53 articles were found with populations 40 years and older or age-related findings (27 CVD, 13 NCI or depression, 6 MSK disorders, 4 renal disease, 3 cancer). Most (79%) publications were from Brazil with few longitudinal studies on aging with HIV. Prevalence of illnesses such as CVD, NCI, depression, or osteoporosis varied widely depending on the screening instrument utilized and geographic population surveyed. Age was a significant predictor of comorbidity in nearly all studies. Our results demonstrate the need for longitudinal studies and validated screening instruments appropriate for use among PWH in LAC. Understanding the mechanisms behind aging in HIV and the roles of sociocultural factors and genetic diversity specific to LAC is needed to appropriately manage chronic comorbidities as PWH age.

Dysfunctional Immunometabolism in HIV Infection: Contributing Factors and Implications for Age-Related Comorbid Diseases

PURPOSE OF REVIEW

An increasing body of evidence indicates that persons living with HIV (PLWH) display dysfunctional immunometabolism. Here, we provide an updated review of this topic and its relationship to HIV-associated immune stimuli and age-related disease.

RECENT FINDINGS

HIV infection alters immunometabolism by increasing reliance on aerobic glycolysis for energy and productive infection and repurposing oxidative phosphorylation machinery for immune cell proliferation and survival. Recent studies in PLWH with diabetes mellitus or cardiovascular disease have identified an association with elevated T cell and monocyte glucose metabolism, respectively. Immunometabolic dysfunction has also been observed in PLWH in frailty and additional studies suggest a role for immunometabolism in non-AIDS defining cancers and neurocognitive disease. There is a plethora of HIV-associated immune stimuli that could drive immunometabolic dysfunction and age-related disease in PLWH, but studies directly examining their relationship are lacking. Immunometabolic dysfunction is characteristic of HIV infection and is a potential link between HIV-associated stimuli and age-related comorbidities.

The Prevalence of Frascati-Criteria-Based HIV-Associated Neurocognitive Disorder (HAND) in HIV-Infected Adults: A Systematic Review and Meta-Analysis

Background: The HIV associated mortality is decreasing in most countries due to the widespread use of antiretroviral therapy. However, HIV-associated neurocognitive disorder (HAND) remains a problematic issue that lowers the quality of life and increases the public health burden among people living with HIV. The prevalence of HAND varies across studies and selected samples. Therefore, we aimed to quantitatively summarize the pooled prevalence of Frascati-criteria-based HAND and to explore the potential demographic, clinical, and immunological factors. Methods: A comprehensive literature search in PubMed/Medline, Web of Science, Embase, and PsycINFO was performed. A random-effects meta-analysis was conducted using the event rate (ER) for the estimation of the incidence of HAND. Subgroup meta-analyses were used to evaluate between-group differences in categorical variables. Meta-regression with the unrestricted maximum likelihood (ML) method was used to evaluate associations of continuous variables. Results: Eighteen studies whose sample sizes ranged from 206 to 1555 were included in the final analyses. The estimated prevalence of HAND, ANI, MND and HAD were 44.9% (95% CI 37.4-52.7%), 26.2% (95% CI 20.7-32.7%), 8.5% (95% CI 5.6-12.7%), 2.1% (95% CI 1.2-3.7%), respectively. Factors associated with HAND were percent female, current CD4 count, education level and country development level (all ps < 0.05). Conclusion: Longitudinal cohort and multimodal neuroimaging studies are needed to verify the clinical prognosis and the underlying neurocognitive mechanism of HAND. In addition, it is urgently necessary to establish a standardized HAND diagnostic process.

Frailty in People Living with HIV

PURPOSE OF REVIEW

Different factors contribute to the decreased overall long-term survival in treated people living with HIV (PLWH). This paper will review the state of physical frailty which limits successful aging in PLWH.

RECENT FINDINGS

Identifiable events on the continuum from clinical normality to heightened risk of adverse health outcomes contribute to frailty. These center on chronic inflammation leading to destabilization of autoregulated physiologic systems challenged by environmental and biologic challenges. Frailty assessment can inform the profile of aging PLWH at increased risk of common age-related disorders and geriatric syndromes. Biologic and psychosocial risk factors promoting progression to and reversion from a dynamic state of frailty are being investigated, allowing for preventative interventions to be considered. Insights gained from studying frail PLWH will help adapt an interdisciplinary geriatric model of health care for selected PLWH. This will improve the health and well-being of aging PLWH.

Frequency of non-communicable diseases in people 50 years of age and older receiving HIV care in Latin America

BACKGROUND

A growing population of older adults with HIV will increase demands on HIV-related healthcare. Nearly a quarter of people receiving care for HIV in Latin America are currently 50 years or older, yet little is known about the frequency of comorbidities in this population. We estimated the prevalence and incidence of non-communicable diseases (NCDs) among people 50 years of age or older (≥50yo) receiving HIV care during 2000-2015 in six centers affiliated with the Caribbean, Central and South American network for HIV epidemiology (CCASAnet).

METHODS

We estimated the annual prevalence, and overall prevalence and incidence of cardiovascular diseases, diabetes, hypertension, dyslipidemia, psychiatric disorders, chronic liver and renal diseases, and non-AIDS-defining cancers, and multimorbidity (more than one NCD) of people ≥50yo receiving care for HIV. Analyses were performed according to age at enrollment into HIV care (<50yo and ≥50yo).

RESULTS

We included 3,415 patients ≥50yo, of whom 1,487(43%) were enrolled at age ≥50 years. The annual prevalence of NCDs increased from 32% to 68% and multimorbidity from 30% to 40% during 2000-2015. At the last registered visit, 53% of patients enrolled <50yo and 50% of those enrolled ≥50yo had at least one NCD. Most common NCDs at the last visit in each age-group at enrollment were dyslipidemia (36% in <50yo and 28% in ≥50yo), hypertension (17% and 18%), psychiatric disorders (15% and 10%), and diabetes (11% and 12%).

CONCLUSIONS

The prevalence of NCDs and multimorbidity in people ≥50 years receiving care for HIV in CCASAnet centers in Latin America increased substantially in the last 15 years. Our results make evident the need of planning for provision of complex, primary care for aging adults living with HIV.

Frailty and Neurocognitive Impairment: Impacts on Quality of Life in HIV

Little is known about the effects of aging-related conditions on health-related quality of life (HRQOL) among people living with HIV (PLWH). The purpose of our study was to examine the independent effects of neurocognitive impairment (NCI) and frailty and the interactive effects with HIV serostatus on HRQOL. Our sample consisted of 121 adults (63 PLWH and 58 HIV-uninfected) participating in the Multi-Dimensional Successful Aging among HIV-Infected Adults study at the University of California, San Diego. HRQOL was measured with the Medical Outcome Study 36-Item Short Form Health Survey scale. We found that frailty was significantly associated with HRQOL (p < .001) in the overall sample, and this effect was significantly stronger for PLWH than HIV-uninfected adults. NCI was not significantly associated with HRQOL in our sample. Frailty may be a particularly important factor in HRQOL for PLWH, highlighting the need for prevention and intervention strategies to mitigate the risks for frailty.

Frailty in medically complex individuals with chronic HIV

OBJECTIVES

Multimorbidity and frailty are consequences of aging with HIV, yet not everyone with medical disease is frail. Our objective was to identify factors associated with frailty in a multimorbid HIV-infected cohort.

DESIGN

Analysis of a prospective, observational, longitudinal cohort.

METHODS

Three hundred and thirty-two participants in the medically advanced National NeuroAIDS Tissue Consortium (NNTC) study were categorized as frail, prefrail, or robust with the Fried Frailty Index. A series of logistic regression analyses (first univariate, then multivariable) were conducted to determine whether medical comorbidities, immunologic and virologic parameters, and/or neuropsychiatric variables predicted increased odds of frailty.

RESULTS

The mean number of medical comorbidities per participant was 2.7, mean CD4 T-cell count was 530 cells/μl, and 77% had undetectable HIV RNA in blood. Twenty-two percent were frail, 55% prefrail, and 23% robust. Significant predictors of frailty in multivariable analysis were cognitive diagnosis rendered by Frascati criteria, depressive symptoms, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and sex. Men were less likely to be frail than women. Higher odds of frailty were seen with: symptomatic, but not asymptomatic, cognitive impairment (compared with cognitive normals); more depressive symptoms; diabetes mellitus; and COPD.

CONCLUSION

Neuropsychiatric illness increased odds of being frail on a predominantly physical/motoric measure, but only when symptomatic. Lack of association with asymptomatic impairment may reflect the importance of functional limitation to frailty, or possibly a unique resilience phenotype. Understanding why sex and symptomatic neuropsychiatric illness are associated with frailty will be important in managing HIV-associated morbidity in aging populations.

Geriatric Syndromes in People Living with HIV Associated with Ageing and Increasing Comorbidities: Implications for Neurocognitive Complications of HIV Infection

Long-term survival of treated people living with HIV (PLWH) currently approaches that of the general population. The average age of PLWH is currently in the mid-50s in resource-rich countries and is predicted that over 40% of PLWH will be older than 60 within a decade. Similar trends have been confirmed in all communities of PLWH with access to antiretroviral therapies. However, the positive impact on survival has been challenged by several developments. Ageing PLWH have clinical features similar to the general population about 5-10 years older. In addition to the earlier occurrence of common age-related conditions common geriatric syndromes have also impacted this population prematurely. These are often difficult to evaluate and manage conditions usually of multifactorial aetiology. They include polypharmacy, frailty, impaired mobility and falls, sarcopenia, sensory impairment, and increasingly, non-dementing cognitive decline. Cognitive decline is of particular concern to PLWH and their care providers. In the general geriatric population cognitive impairment increases with age and occurs in all populations with a prevalence of over 25% in people over 80. Effective treatments are lacking and therefore minimizing risk factors plays an important role in maintaining healthspan. In the general population geriatric syndromes may increase the risk of cognitive decline. The corollary is that decreasing the risk of their development may limit cognitive impairment. Whether a similar status holds in PLWH is uncertain. This chapter will address the question of whether common geriatric syndromes in PLWH contribute to cognitive impairment. Common risk factors may provide clues to limit or delay cognitive decline.

Frailty in people living with HIV

The life expectancy of people living with HIV (PLHIV) has dramatically improved with effective and well-tolerated antiretroviral therapy. This presents a new challenge in caring for this patient population, with up to 28% of older PLHIV being identified as frail. Studies suggest that the prevalence of frailty is higher in PLHIV compared to the general population, and that the onset of frailty occurs at an earlier age. Frail individuals often present with multiple and non-specific health complaints, fluctuating disability, falls and delirium, and are at higher risk for multiple adverse outcomes, post-operative complications, poor responses to vaccination and functional decline. They tend to require longer hospital admissions, are more likely to require nursing home care, and are at greater risk of mortality. The degree of frailty can fluctuate over time. Limited evidence exists to support the reversal of frailty, but epidemiological evidence suggests that interventions to assess and manage co-morbidities, reducing risk factors such as smoking, increasing exercise and optimising BMI, and improving personal and community resources, are all likely to reduce the risk of frailty. Physicians who care for PLHIV need to recognise and manage frailty in this patient population. This includes an understanding of: when to intervene aggressively in the management of an older patient with a new HIV diagnosis to delay or prevent permanent debility and frailty; when to acknowledge that the patient has become frail; and the role of geriatric medicine in addressing the specific issues and needs of this patient, such as maximising functional ability, preventing falls, reducing social isolation and improving quality of life.