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HIV Linked to Frailty in Middle-Aged IDUs, Especially With Poor HIV Control
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2nd International Workshop on HIV and Aging, October 27-28, 2011, Baltimore, Maryland
Mark Mascolini
Comparing HIV-positive and negative injection drug users (IDUs) in a large Baltimore cohort, researchers determined that HIV infection independently raised the risk of objectively defined frailty and prefrailty [1]. Frailty and prefrailty risks were highest in people with a CD4 count below 350 and a detectable viral load.
Frailty boosts chances of hospital admission, disability, and death in older people without HIV.
In the Multicenter AIDS Cohort Study of HIV-positive and negative gay men. HIV infection raised the odds of earlier frailty [2], and frailty before combination antiretroviral therapy begins independently predicted AIDS or death [3]. But the impact of HIV on frailty risk and clinical outcomes is still in an early phase of study.
In this analysis Johns Hopkins University researchers focused on 1206 current or former IDUs with or without HIV infection seen from 2005 through 2009 in a prospective observational cohort. All cohort members were at least 18 years old and made twice-yearly visits for follow-up. The Hopkins team defined frailty (by the Fried system) as meeting 3 or more of 5 criteria: weakness determined by grip strength, slowed walking speed, weight loss, low physical activity, and exhaustion. They defined prefrailty as one or two of these criteria.
Of the 1206 IDUs assessed, 345 (29%) had HIV infection. Median age stood at 48 years, and one third in both the HIV-positive and negative groups were women. Higher proportions in the HIV group were African American (95.7% versus 87.6%), had less than a high school education (65.2% versus 57.0%), and were hepatitis C positive (93.3% versus 81.0%) (P < 0.05 for all comparisons). Lower proportions of HIV-positive cohort members were recent injectors (36.2% versus 47.4%), actively used alcohol (48.3% versus 56.8%), abused prescription drugs (6.4% versus 12.9%), or had a spouse or common-law partner (4.7% versus 8.8%) (P < 0.05 for all).
HIV-positive people had a median CD4 count of 290, a median CD4 nadir of 138, and a median viral load of 3.1 log (about 1250 copies). Half (51%) were taking combination antiretrovirals, and 21.7% had an AIDS diagnosis.
Overall frailty prevalence stood at 8.3%, with rates of 10.7% in the HIV group and 7.3% in the HIV-negative group; 59% of cohort members met prefrailty criteria. Through 4652 person-visits, both frailty and prefrailty proved more common in older IDUs, women, those with less than a high school education, people without a spouse or partner, those who abused prescription drugs, and those with depressive symptoms. African-American cohort members had a lower risk of prefrailty. Adjusting for all these factors, the researchers determined that HIV infection raised the prefrailty risk 28% (adjusted odds ratio [AOR] 1.28, 95% confidence interval [CI] 1.06 to 1.53), while raising the frailty risk 75% (AOR 1.75, 95% CI 1.27 to 2.39).
Compared with HIV-negative IDUs, HIV-positive cohort members had a higher risk of prefrailty or frailty with worse HIV disease status, as noted by the following AORs (and 95% CIs):
-- CD4s above 349, undetectable viral load: prefrailty 1.14 (0.81 to 1.62), frailty 1.13 (0.65 to 1.97)
-- CD4s below 350, undetectable viral load: prefrailty 1.37 (0.97 to 1.95), frailty 1.75 (1.02 to 2.98)
-- CD4s above 349, detectable viral load: prefrailty 1.14 (0.79 to 1.63), frailty 1.8 (1.00 to 3.21)
-- CD4s below 350, detectable viral load: prefrailty 1.49 (1.17 to 1.89), frailty 2.26 (1.51 to 3.39)
The Hopkins teams evaluated frailty as a predictor of new hospital admissions in all 1206 cohort members from July 2005 through December 2009. During that time there were 374 hospital admissions, and the admission rate was significantly greater in frail than in nonfrail people (P = 0.006).
Compared with nonfrail cohort members, prefrail people did not have an independently higher risk of hospital admission, but frail people had a 60% higher risk (adjusted hazard ratio [AHR] 1.59, 95% CI 1.10 to 2.30). Female gender made hospital admission 66% more likely, homelessness raised the odds by 42%, active alcohol use by 32%, hepatitis C by 90%, and prescription drug use by 56%. Compared with HIV-negative people, HIV-positive people with a CD4 count under 350 and a detectable viral load had a doubled risk of hospital admission (AHR 2.12, 95% CI 1.61 to 2.79).
The Johns Hopkins investigators concluded that HIV infection boosts the risk of prefrailty and frailty in current and former IDUs. They proposed that "early identification of frail and prefrail IDUs may provide opportunities for arresting progression to adverse clinical states."
References
1. Piggott D, Muzaale A, Mehta S, Brown T, Leng S, Kirk G. Frailty and incident hospitalization in a cohort of HIV-infected and uninfected injection drug users (IDUs). 2nd International Workshop on HIV and Aging. October 27-28, 2011. Baltimore, Maryland. Abstract O_06.
2. Desquilbet L, Jacobson LP, Fried LP, et al. HIV-1 infection is associated with an earlier occurrence of a phenotype related to frailty. J Gerontol A Biol Sci Med Sci. 2007;62:1279-1286.
3. Desquilbet L, Jacobson LP, Fried LP, et al. A frailty-related phenotype before HAART initiation as an independent risk factor for AIDS or death after HAART among HIV-infected men. J Gerontol A Biol Sci Med Sci. 2011;66:1030-1038.
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