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.

Correlation Between Polypharmacy and Frailty Among Thai Older Persons Living with HIV.

Polypharmacy and frailty are correlated in Persons Living with HIV (PLWH) in the United States, but little is known about their correlation in resource-limited settings. Our cross-section study evaluated the correlation between polypharmacy and frailty among Thai 324 virally suppressed PLWH and 132 uninfected patients aged ≥50 between March 2016 and April 2017. The primary predictor was the number of patient-reported non-antiretroviral therapy (ART) medications. The outcome was having additional domain of the five Fried frailty phenotype domains (0 = normal, 1-2 = prefrail, >3 = frail). Most participants were male (63% PLWH, 67% uninfected) with few comorbidities (1.4 PLWH, 0.9 uninfected) and small median number of non-ART medications (2 PLWH, 1 uninfected). Frailty was uncommon (8.6% PLWH, 3.8% uninfected). Each additional non-ART medication correlated with 6% increased likelihood of having additional frailty domain among PLWH (95% CI: 0.002-0.11, p = .04) but not statistically significant among the uninfected. The association between polypharmacy and frailty is more pronounced in Thai PLWH than in participants without HIV. Further study is warranted to confirm this association in other resource-limited settings and explore potential deprescribing practices.

Deterioration of Nutritional Status and Its Negative Association with Depression Among Older HIV-Infected Asian Population: A Four-Year Longitudinal Study.

There is limited evidence about the long-term changes in nutritional status among the elderly people living with human immunodeficiency virus (PLWH). We aimed to investigate the changes in nutritional status and related factors over 4 years in the elderly PLWH. The longitudinal study was conducted prospectively among 250 PLWH, 50 years of age and older, receiving antiretroviral therapy (ART). The Mini Nutritional Assessment (MNA) and Thai Depression Scale (TDS) to assess nutritional status and depression, respectively, were performed at the outpatient clinic both at baseline and 4-year follow-up. Majority were male (60.8%) with median age of 58 years. The median CD4 was 612.5 cells/mm3 and 98% had HIV RNA <50 copies/mL. Median duration of ART was 20 years. Median body mass index was 23.1 kg/m2. The most common ART were rilpivirine (45.2%) and dolutegravir (18.8%). Fifty-one patients (20.4%) deteriorated in nutritional status and mean MNA scores declined (25.8 vs. 24.8, p < .001) at follow-up period. In multivariate analysis, high TDS scores (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.17-1.52), polypharmacy (OR, 1.35; 95% CI, 1.10-1.65), and high-density lipoprotein cholesterol (HDL-C) levels (OR, 1.04; 95% CI, 1.01-1.07) were associated factors of deterioration in nutritional status. In this 4-year longitudinal follow-up, 20% of the aging PLWH have deterioration of nutritional status. High TDS scores (depression), polypharmacy, and high HDL-C were significantly associated with declining nutritional status. Our findings highlight the importance of screening and monitoring nutritional and depression status in routine HIV treatment and care for geriatric HIV-infected population.

HIV and Aging: Overcoming Challenges in Existing HIV Guidelines to Provide Patient-Centered Care for Older People with HIV.

With advances in antiretroviral therapy and subsequent increase in life expectancy, People with HIV (PWH) now experience multiple geriatric syndromes in the setting of advanced aging and increased multimorbidity. HIV clinicians bear the responsibility of delivering geriatric care to this vulnerable population, despite limited geriatric medicine training and limited support from HIV service networks that were not traditionally designed to care for an aging population. Although HIV clinicians reported formal guidelines specific to older PWH to be among the most helpful interventions, current HIV guidelines present multiple issues in their applicability to the care of older PWH, including multifactorial nature of conditions in older adults, difficulty measuring patient-centered outcomes, lack of representation of older PWH in clinical trials, limited guidelines addressing geriatric syndromes, and the use of chronological age as criteria for inclusion despite advanced aging in PWH. Understanding that updated guidelines addressing above challenges may take many years to develop, we offer strategies on the application of current guidelines, including using baseline attributes, time to benefit, and the Geriatrics 5M model to aid in shared decision making and improve outcomes among older PWH.

A National Survey of Provider's Preparedness to Care for Persons Living With HIV Aged ≥50 Years.

INTRODUCTION: With increasing longevity among persons living with HIV (PLWH), HIV providers must manage age-related diseases despite limited geriatric training. We surveyed HIV providers to assess perceived preparedness in caring for aging PLWH and knowledge gaps. METHODS: We surveyed HIV providers from October to December 2018 on preparedness (1 = strongly unprepared to 5 = strongly prepared), topics of interest, and participant characteristics including the number of years after training, number of PLWH aged ≥50 years seen/month, degree types (MD/DO versus others), and practice setting (academic versus nonacademic). We grouped "strongly prepared/somewhat prepared" responses as "prepared" and "neutral/somewhat unprepared/strongly unprepared" as "unprepared." The effects of participant characteristics on preparedness were determined using chi-square test. RESULTS: Of 226 participants, 54% were physicians, 27% were NP/PA, 19% were PharmD, and 40% practiced in academic settings. The average preparedness score was 3.37 out of 5.0. Approximately half of participants (56%) were classified as "prepared." The mode number of years in practice was "10 to <20" (22%); mode number of PLWH aged ≥50 years seen/month was "1 to 25" (50%). HIV-associated neurocognitive disorder (73%) and geriatric syndrome screening (63%) were the most chosen areas of interest. Unprepared participants were interested in topics of cardiovascular disease (odds ratio [OR], 2.38; P = .002) and palliative care (OR, 1.92; P = .02). Having >20 years after training increased preparedness ("20 to <30" years versus "none": OR, 3.37; P = .03; "≥30 years" versus "none": OR, 3.66; P = .04). CONCLUSION: Approximately half of the surveyed HIV providers felt prepared to care for aging PLWH. HIV-associated neurocognitive disorder, geriatric syndrome screening, cardiovascular diseases, and palliative care were areas of interest. Having >20 years after training increases preparedness.

Comprehensive Geriatric Assessment in Older Persons With HIV.

With increased longevity related to the advent of antiretroviral therapy, there are increasing proportions of older persons with HIV (PWH). Prior studies have demonstrated increased prevalence of geriatric syndromes in older PWH and recommended the Comprehensive Geriatric Assessment (CGA) in this population. However, there is currently no peer-reviewed literature that outlines how to perform the CGA in PWH in the clinical setting. In this article, we offer a review on how to perform the CGA in PWH, outline domains of the CGA and their importance in PWH, and describe screening tools for each domain focusing on tools that have been validated in PWH, are easy to administer, and/or are already commonly used in the field of geriatrics.

Echocardiographic Findings Among Virally Suppressed HIV-Infected Aging Asians Compared with HIV-Negative Individuals.

OBJECTIVES: Prevalence of cardiovascular disease increases with age. Little is known about the prevalence and risk factors for echocardiographic abnormalities among older people living with HIV (PLHIV) from Asia. DESIGN: A cross-sectional study was conducted among PLHIV aged >50 years (N = 298) on antiretroviral treatment (ART) and HIV-negative controls (N = 100) frequency matched by sex and age in Thailand. METHODS: All participants underwent standard 2-dimensional transthoracic echocardiography performed by trained cardiologists who were blinded to the participant's care and HIV status. Logistic regression was used to examine the association between cardiac abnormalities and risk factors. RESULTS: The median age was 54.7 years (60.8% men) with 37.2% having hypertension and 16.6% having diabetes mellitus. PLHIV was on ART for a median of 16.2 years with current CD4 cell counts of 616 cells per cubic millimeter. Echocardiogram abnormalities did not differ among PLHIV (55%) and the controls (60%). The major abnormalities in PLHIV were following: left ventricular (LV) hypertrophy: 37% men and 42.2% women, LV systolic dysfunction (0.7%), diastolic dysfunction (24.2%), and pulmonary hypertension (3.9%). From the multivariate analyses in PLHIV, being aged >60 years was independently associated with diastolic dysfunction, whereas female sex and left atrial volume index of >34 mL/m were associated with pulmonary hypertension (P < 0.05). None of the ART was significantly associated with any major echocardiographic abnormalities. CONCLUSIONS: In this long-term, well-suppressed, older, Asian PLHIV cohort, the prevalence of asymptomatic LV systolic dysfunction and pulmonary hypertension were relatively low, whereas the diastolic dysfunction and LV hypertrophy were common. Echocardiographic findings did not differ between PLHIV and HIV-uninfected controls.

Higher Proportion of Abnormal Nutritional Status Among Well-Suppressed HIV-Infected Elderly Asians Compared to HIV-Negative Individuals.

Older adults face physiological, psychological, social, and economic changes, which may impair nutritional status, making the body vulnerable to illness and adverse clinical outcomes. Little is known regarding the nutritional status among elderly people living with HIV (PLHIV). We aimed to study the prevalence of malnutrition and the associated factors in a Thai aging cohort. A cross-sectional study was conducted among PLHIV >50 years of age on long-term antiretroviral therapy and HIV-negative controls, frequency matched by sex and age in Bangkok, Thailand. Nutritional status was assessed by the Mini Nutrition Assessment (MNA) tool. Abnormal nutritional status was defined as MNA score <24 (malnutrition and at risk of malnutrition). Body composition was measured by bioelectrical impedance analysis using Body Composition Analyzer. Demographic and disease-related factors were assessed for their association with abnormal nutrition status using multivariable logistic regression. There were 349 PLHIV and 103 HIV-uninfected controls, with median age 55 years. The majority were male (63%) with median body mass index (BMI) of 23.4 kg/m2. PLHIV had lower BMI [median, 23.1 (IQR, 20.8-25.2) vs. 25.3 (22.3-28.7) kg/m2, p < .001], lower fat percent [22.8% vs. 26.3%, p < .001] and lower fat mass [14.2 vs. 16.9 kg, p < .001] and higher abnormal nutritional status (18.05% vs. 6.8%, p = .005) than controls. In the multivariate model, older age (adjusted odds ratio [aOR], 1.06, 95% confident interval [CI]: 1.01-1.12, p = .03), positive HIV status (aOR, 2.67, 95% CI: 1.07-6.65, p = .036), diabetes mellitus (aOR, 2.21, 95% CI: 1.003-4.87, p = .049), lower fat mass (aOR, 0.70, 95%CI: 0.57-0.86, p < .001), and lower BMI (aOR, 0.63, 95% CI: 0.51-0.78, p < .001) were independently associated with abnormal nutritional status. PLHIV had higher risks for abnormal nutritional status compared with HIV-uninfected individuals. Regular screening and monitoring of nutritional status among PLHIV may promote better health outcomes.

Short Communication: Carotid Intima-Media Thickness Is Not Associated with Neurocognitive Impairment Among People Older than 50 Years With and Without HIV Infection from Thailand.

Neurocognitive impairment (NCI) contributes to poor quality of life among HIV-positive individuals. Cardiovascular risk factors, including the predictor of subclinical atherosclerosis, carotid intima-media thickness (cIMT), are reported to be associated with NCI. Data on NCI and its association with cIMT among HIV positive are limited, especially in Asian populations. We aimed to determine the prevalence of NCI and its association with cIMT among HIV-positive and HIV-negative aging Thai individuals. Cognitive performance was evaluated by the Thai version of Montreal Cognitive Assessment (MoCA) with a cutoff of <25/30 for diagnosis of NCI. Depression was evaluated by PHQ-9 Patient Depression Questionnaire, with scores ≥5 indicating depression. cIMT measurement was performed by experienced neurologists, and abnormal cIMT was defined as cIMT ≥0.9 mm or presence of carotid plaques. Among 340 well suppressed and aging HIV-positive and 102 HIV-negative matched participants, the median age (interquartile range) was 55 (52-59) years and 61.5% were males. For HIV positive group, the median duration on antiretroviral therapy was 18.3 years with median CD4 of 615.5 cells/mm3, and 97.4% had current plasma HIV RNA <50 copies/mL. The most common antiretroviral agents used were tenofovir disoproxil fumarate (76.8%), lamivudine (70.3%), efavirenz (26.7%), and emtricitabine (23.8%). HIV-positive and HIV-negative participants performed comparably between each domain and had comparable prevalence of NCI (59.4% vs. 61.7%, p = .69). However, the HIV-positive group had a high prevalence of depression (24.71% vs. 13.73%, p = .019). HIV-positive status [adjusted odd ratio (aOR) 0.91; 95% confidence interval (CI) 0.57-1.47, p = .71] and cIMT (aOR 1.17; 95% CI 0.77-1.79, p = .47) were not significantly associated with NCI. Given the high prevalence of NCI and depression among aging HIV-positive individuals, routine screening for NCI and depression should be integrated into the HIV care services.

When Patients Mentor Doctors: The Story Of One Vital Bond.

A physician reconnects with the patient who mentored her as a medical student and helps him make a final care decision.

Application of Geriatric Principles and Care Models in HIV and Aging.

People aging with HIV present a unique challenge for providers. HIV-infected patients experience accentuated aging and multimorbidity, but are typically disconnected from geriatric care, which is limited by a shortage of geriatric providers worldwide. Consequently, HIV providers are tasked with managing multiple age-related illnesses, within service networks that are historically not designed to care for aging patients. While comfortable with the management of antiretroviral therapy, HIV providers may have limited training on how to recognize or manage geriatric syndromes, especially in the context of multimorbidity. The result is an emerging, vulnerable population, and the question is how to best care for them. As part of the answer, we offer examples of how providers can use geriatric principles to improve the care of aging HIV-infected patients. We begin by describing basic geriatric concepts and examples of care models, and subsequently use a patient case to illustrate their applications at the patient level. At the system level, we discuss how HIV service networks can use components of geriatric care models to meet the needs of aging HIV-infected patients. Lastly, we identify aging-specific guidelines and service integration as important areas for future endeavors.

Caring for Older Adults with the Human Immunodeficiency Virus.

Increasing proportions of older adults are living with the human immunodeficiency virus (HIV). It is estimated that more than 50% of individuals with HIV in the United States are aged 50 and older. Part of this group consists of individuals who have aged with chronic HIV infection, but a large proportion also results from new HIV diagnosis, with approximately 17% of new HIV diagnoses in 2013 occurring in individuals aged 50 and older. Although many of the recommendations on management of HIV infection are not age-specific, individuals with HIV aged 50 and older differ from their younger counterparts in many aspects, including immune response to antiretroviral therapy, multimorbidity, antiretroviral toxicities, and diagnostic considerations. This article outline these differences, offers a strategy on how to care for this unique population, and provides special considerations for problem-based management of individuals with HIV aged 50 and older.

Advance Care Planning and HIV Infection in the Era of Antiretroviral Therapy: A Review.

In the era of antiretroviral therapy, HIV infection has become a chronic illness with associated multimorbidity, and practitioners are faced with an emerging population of HIV-infected patients with evolving needs for advance care planning (ACP), defined as communication between individuals and their proxies to plan for future health care decisions. This article provides a review of original research studies on ACP in HIV-infected adults in the era of antiretroviral therapy (1996-present) from PubMed, EMBASE, and PsycINFO. Eleven studies conducted between 1996 and 2015 met the selection criteria, with study sizes ranging from 9 to 2864 participants. Most studies consisted of white men in outpatient settings and had poorly defined definitions of ACP. Prevalence of ACP was variable (36%-54% had end-of-life communication, 8%-47% had advance directives). Lack of ACP was most commonly associated with low income, followed by lower severity of illness, low education level, black or Hispanic race, female sex, younger age, injection drug use, and social isolation. Practitioners reported limited time or energy and inadequate preparation or training as barriers to ACP. Existing literature on ACP in the era of antiretroviral therapy is limited, but shows that ACP prevalence in HIV-infected individuals is variable depending on socioeconomic factors, severity of illness, and practitioner resources and training. More research is needed to increase ACP among HIV-infected individuals.