A new frailty syndrome: central obesity and frailty in older adults with the human immunodeficiency virus

Serum gonadal hormones levels and hypogonadism in ART naïve newly diagnosed HIV infected adult males in Mwanza, Tanzania

BACKGROUND

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is an endemic chronic disease which is characterized with progressive depletion of CD4 T cells and increased susceptibility to opportunistic infections. Previous studies have associated HIV infection with increased hypogonadism. However, the prevalence of hypogonadism remained poorly defined and widely ranging in various studies. This study aims to evaluate the serum gonadal hormonal levels and hypogonadism in antiretroviral therapy (ART) naïve newly diagnosed HIV infected-males in Mwanza, Tanzania.

METHODS

This was a comparison study involving 81 ART naïve newly diagnosed HIV-infected adult males as study group and 81 apparently healthy HIV-negative males as comparison group. The participants in the study group and comparison group were matched by body mass index and age. Serum hormones [Total testosterone (TT), follicle stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E) were estimated. Serum testosterone < 300 ng/dl, or testosterone > 300 ng/dl with high LH and FSH (compensatory hypogonadism) were taken as markers of hypogonadism. Data were analyzed using STATA version 15.

RESULTS

The median serum testosterone level among ART naïve newly diagnosed HIV-infected adult males was significantly lower as compared to their comparison group (447 [259-534] versus 517 [396-605]; p = 0.0074) and shown to decrease with decreasing CD4 level. The median [IQR] serum FSH level among ART naïve newly diagnosed HIV-infected adult males was significantly higher than among their comparison group (3.8 [2.1-6.5] versus 2.6 [1.8-4.2]; p = 0.0086). The differences in serum LH and Estradiol were not statistically significant. Furthermore, the proportion of hypogonadism was significantly higher among ART naïve newly diagnosed HIV-infected adult males than in their comparison group (37.0% [30/81] versus 14.8% [12/81]; p = 0.0006). Out of these 30, 24 HIV-infected males had secondary hypogonadism, one had primary, and the remaining five had compensatory hypogonadism.

CONCLUSION

Serum testosterone was lower and follicle stimulating hormone was higher among ART naïve HIV-infected males as compared to the HIV negative controls. Hypogonadism, mainly secondary, is common endocrine abnormality among ART naïve HIV-infected male patients in this study. HIV is associated with variations in gonadal hormones which may lead to sexual dysfunction in infected individuals.

Prevalence and Factors Associated With Frailty Among Older Adults Living With HIV Compared to Their Uninfected Peers From the Kenyan Coast

Objectives: a) To document the prevalence and correlates of frailty among older adults living with HIV (OALWH) and their uninfected peers, and b) Investigate HIV status as an independent predictor of frailty. Methods: This cross-sectional study was conducted between 2020 and 2021 at the Kenyan coast among 440 older adults aged ≥50 years (257 OALWH). Frailty was assessed using the Reported Edmonton Frail Scale. Logistic regression was used to examine the correlates of frailty. Results: The prevalence of frailty was significantly higher among OALWH (24%) than their uninfected peers (13%). HIV seropositivity was not independently associated with frailty. Sleeping difficulties, ageism, higher waist/hip ratio, visiting traditional healers, HIV treatment change/interruption, prolonged illness following HIV diagnosis, and self-reported diabetes were significantly associated with higher odds of frailty. Residing in larger households, having higher income, having friends, being male and light physical activities were significantly associated with reduced odds of frailty. Conclusion: The prevalence of frailty is elevated among OALWH; however, factors other than HIV are predominant, particularly psychosocial factors. Multicomponent interventions are needed to prevent/delay and manage frailty in this setting.

The use of non-invasive imaging modalities for the assessment of skeletal muscle quantity and quality in people with HIV: A narrative review

BACKGROUND

People with HIV (PWH) are prone to mobility impairments and physical dysfunction, with the loss of skeletal muscle quantity and quality being a major contributor to the dysfunction. Assessment of skeletal muscle is an important component of care for this patient population for early intervention and treatment. The use of non-invasive imaging techniques to evaluate skeletal muscle, such as dual X-ray absorptiometry, computer tomography and magnetic resonance imaging, has increased in popularity in recent years.

PURPOSE

This narrative review synthesizes the use of these techniques and summarizes the associations between outcomes from these imaging modalities and physical function in PWH.

Body mass index and quality of life in people living with HIV

With advances in the treatment of HIV, people living with HIV (PLWH) are now expected to have a near-normal life expectancy, but challenges remain in the form of substantially poorer health-related quality of life (HRQoL) than the general population. Being overweight or obese may pose an additional burden in PLWH, but few studies have evaluated the relationship between body mass index (BMI) and HRQoL in PLWH. This study aimed to evaluate and describe the association between HRQoL and BMI among PLWH in the US. Data were obtained from the 2018 and 2019 US National Health and Wellness Survey, an online, self-reported, general population survey. Analyses included 575 PLWH who self-reported a physician diagnosis and prescription use for the treatment of HIV, as well as 1725 propensity score matched non-HIV controls. After adjusting for age, sex, race, and comorbidities, higher BMI was associated with poorer physical (β =  -0.18, p = 0.005) and general (β =  -0.42, p = 0.014) HRQoL among PLWH. Additionally, PLWH reported poorer mental, physical, and general HRQoL than non-HIV controls; these relationships were not moderated by BMI. The potential negative impact of higher BMI on patients' humanistic outcomes should be considered in HIV management, including selection of treatment.

Mediating effects of resilience on frailty and depression among older Chinese people living with HIV/AIDS: a cross-sectional study in Hunan

BACKGROUND

Little is known about the ambiguous and complex relationship between frailty, resilience and depression in older adults living with HIV (OALHIV). Thus, the current study aimed to further clarify the relationship, as well as to investigate whether resilience plays a mediating role and to quantify the mediating effect.

METHODS

A cross-sectional study was conducted on patients who were aged ≥50 y with HIV/AIDS at the First Hospital of Changsha City from June to August 2019. The sociodemographic characteristics of participants, depression, resilience and frailty were evaluated by the self-developed questionnaire, the 10-item Center for Epidemiological Studies Depression Scale, the 10-item Connor-Davidson Resilience Scale and Tilburg Frailty Indicator, respectively. SPSS macro model 4 was used to analyse the mediation of resilience between frailty and depression.

RESULTS

A total of 175 OALHIV (120 males and 55 females) were investigated in this study. The prevalence of frailty and depression was 31.4% and 30.9%, respectively. Additionally, the mediation analysis model showed that frailty could contribute to depression directly, and that it also affected depression through resilience, suggesting that resilience partially mediated the relationship between frailty and depression among OALHIV.

CONCLUSIONS

Our findings suggest that resilience appears to be a protective factor for depression. Effective and targeted intervention on resilience is available and is crucial to improve the life quality of OALHIV.

Associations between drug and alcohol use, smoking, and frailty among people with HIV across the United States in the current era of antiretroviral treatment

OBJECTIVE

To examine associations between frailty and drug, alcohol, and tobacco use among a large diverse cohort of people with HIV (PWH) in clinical care in the current era.

METHODS

PWH at 7 sites across the United States completed clinical assessments of patient-reported measures and outcomes between 2016 and 2019 as part of routine care including drug and alcohol use, smoking, and other domains. Frailty was assessed using 4 of the 5 components of the Fried frailty phenotype and PWH were categorized as not frail, pre-frail, or frail. Associations of substance use with frailty were assessed with multivariate Poisson regression.

RESULTS

Among 9336 PWH, 43% were not frail, 44% were prefrail, and 13% were frail. Frailty was more prevalent among women, older PWH, and those reporting current use of drugs or cigarettes. Current methamphetamine use (1.26: 95% CI 1.07-1.48), current (1.65: 95% CI 1.39-1.97) and former (1.21:95% CI 1.06-1.36) illicit opioid use, and former cocaine/crack use (1.17: 95% CI 1.01-1.35) were associated with greater risk of being frail in adjusted analyses. Current smoking was associated with a 61% higher risk of being frail vs. not frail (1.61: 95% CI 1.41-1.85) in adjusted analyses.

CONCLUSIONS

We found a high prevalence of prefrailty and frailty among a nationally distributed cohort of PWH in care. This study identified distinct risk factors that may be associated with frailty among PWH, many of which, such as cigarette smoking and drug use, are potentially modifiable.

Síndrome da fragilidade, capacidade pulmonar e funcional em pacientes infectados pelo HIV/AIDS

RESUMO O objetivo deste estudo foi avaliar a prevalência da síndrome da fragilidade e a sua relação com a função pulmonar, a capacidade funcional e as variáveis relacionadas à pacientes infectados pelo vírus HIV. Trata-se de um estudo transversal e descritivo, com análises quantitativas de dados. A amostra foi composta por indivíduos diagnosticados com HIV/AIDS e sem limitações prévias de locomoção. A síndrome da fragilidade foi avaliada pela aplicação do fenótipo da fragilidade, pontuado nos seguintes itens: perda de peso não intencional, fadiga, redução da velocidade da marcha, redução do nível de atividade física e redução da força de preensão palmar. A função pulmonar e a força muscular ventilatória foram avaliadas por meio de espirometria e manovacuometria. A capacidade funcional foi mensurada pelo teste de caminhada de seis minutos (TC6). A análise dos dados foi realizada com testes estatísticos de comparação, adotando-se o nível de significância de 5%. Todos os pacientes incluídos neste estudo encontravam-se dentro dos critérios de fragilidade. Destes, 70% eram frágeis e 30% pré-frágeis. Verificou-se uma relação entre o comprometimento da capacidade funcional, a prevalência de distúrbio ventilatório restritivo e a presença de comorbidades na população frágil comparado com a pré-frágil. Os achados deste estudo permitem a conclusão de que a síndrome da fragilidade impacta a saúde de indivíduos com HIV/AIDS, com comprometimento da espirometria, redução da capacidade funcional e presença de comorbidades.

Biological Aging and Immune Senescence in Children with Perinatally Acquired HIV

Chronic HIV-infected children suffer from premature aging and aging-related diseases. Viral replication induces an ongoing inflammation process, with the release of pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs), the activation of the immune system, and the production of proinflammatory cytokines. Although combined highly active antiretroviral therapy (ART) has significantly modified the natural course of HIV infection, normalization of T and B cell phenotype is not completely achievable; thus, many HIV-infected children display several phenotypical alterations, including higher percentages of activated cells, that favor an accelerated telomere attrition, and higher percentages of exhausted and senescent cells. All these features ultimately lead to the clinical manifestations related to premature aging and comorbidities typically observed in older general population, including non-AIDS-related malignancies. Therefore, even under effective treatment, the premature aging process of HIV-infected children negatively impacts their quality and length of life. This review examines the available data on the impact of HIV and ART on immune and biological senescence of HIV-infected children.

Frailty, markers of immune activation and oxidative stress in HIV infected elderly

People living with HIV-1 experience an accelerated aging due to the persistent and chronic activation of the immune system. This phenomenon conduces to immune exhaustion and precipitate immunosenescence. In general, frailty is defined as a syndrome of physiological degeneration in the elderly. Circulating naïve and memory T cells were studied by flow cytometry in non-frail and frail HIV-1-infected groups. Thymopoiesis, cell activation, senescence and cell proliferation were analyzed by CD31, HLA-DR/CD38, CD28/CD57 and Ki-67 expression, respectively. Plasma levels of sCD14 and MDA were measured by ELISA. Frail infected individuals showed a reduced number of memory T cells, both CD4+ and CD8+ populations. Activated CD3+CD4+HLA-DR+ T cells were lower in frail individuals, and directly correlated with CD3+CD8+HLA-DR+ and CD8M cells. Senescent CD8+CD28-CD57+ cells were reduced in frail HIV-1 infected individuals and inversely correlated with CD8RTE, CD8N and CD3+CD4+HLA-DR+. Higher plasma levels of sCD14 and MDA were found in HIV-1 infected frail individuals. Our data show association among frailty, markers of immune activation and oxidative stress. Understanding the immune mechanisms underlying frailty status in HIV-1 population is of high relevance not only for the prediction of continuing longevity but also for the identification of potential strategies for the elderly.

Frailty-A promising concept to evaluate disease vulnerability

With the emergence of diseases, people become frailer and are expected to be less tolerant of adverse outcomes. Frailty was first described to explain the variability in life expectancy in individuals of the same age. Nowadays, it is described as a syndrome and as a state. It is used to explain the heterogeneity of people not only in their responses to biological ageing but also in their responses to illness. In this review, we explore the role of frailty both in age-related diseases, including dementia, cancer and cardiovascular disease, and in non-age-related diseases, such as Human Immunodeficiency Virus. We describe how high levels of frailty in such disorders predict worse outcomes and play a direct role in disease progression and in prognostic prediction. Overall, the potential for frailty to predict adverse health outcomes among young people as well as in non-age-related diseases is an evolving topic. Understanding how frailty contributes to poor health and how it can be modified to prevent or delay disease progression will ultimately enhance quality of life in affected individuals.

The Interplay Between Frailty and Intrinsic Capacity in Aging and HIV Infection

In the context of an emerging aging epidemic affecting people living with HIV (PLWH), we critically discuss existing data regarding two different conceptual models of aging-frailty and intrinsic capacity, respectively, both in a clinical and public health perspective. These constructs have not yet been integrated in the general population. Nevertheless, the holistic HIV care, which goes beyond the viro-immunological success, may offer an ideal setting to test a possible integration of these models in older adults living with HIV. We suggest a new framework to assess health in PLWH, shifting from an infectious disease (ID)/internal medicine approach, which includes quality of life in the definition of healthy living with HIV, to an ID/geriatric medicine approach, focused on the maintenance of functional ability in frail and geriatric PLWH.

The Growth Hormone Releasing Hormone Analogue, Tesamorelin, Decreases Muscle Fat and Increases Muscle Area in Adults with HIV

BACKGROUND

Tesamorelin, a growth hormone-releasing hormone analogue, decreases visceral adipose tissue in people living with HIV, however, the effects on skeletal muscle fat and area are unknown.

OBJECTIVES

The goals of this exploratory secondary analysis were to determine the effects of tesamorelin on muscle quality (density) and quantity (area).

DESIGN

Secondary, exploratory analysis of two previously completed randomized (2:1), clinical trials.

SETTING

U.S. and Canadian sites.

PARTICIPANTS

People living with HIV and with abdominal obesity. Tesamorelin participants were restricted to responders (visceral adipose tissue decrease ≥8%).

INTERVENTION

Tesamorelin or placebo.

MEASUREMENTS

Computed tomography scans (at L4-L5) were used to quantify total and lean density (Hounsfield Units, HU) and area (centimeters2) of four trunk muscle groups using a semi-automatic segmentation image analysis program. Differences between muscle area and density before and after 26 weeks of tesamorelin or placebo treatment were compared and linear regression models were adjusted for baseline and treatment arm.

RESULTS

Tesamorelin responders (n=193) and placebo (n=148) participants with available images were similar at baseline; most were Caucasian (83%) and male (87%). In models adjusted for baseline differences and treatment arm, tesamorelin was associated with significantly greater increases in density of four truncal muscle groups (coefficient 1.56-4.86 Hounsfield units; all p<0.005), and the lean anterolateral/abdominal and rectus muscles (1.39 and 1.78 Hounsfield units; both p<0.005) compared to placebo. Significant increases were also seen in total area of the rectus and psoas muscles (0.44 and 0.46 centimeters2; p<0.005), and in the lean muscle area of all four truncal muscle groups (0.64-1.08 centimeters2; p<0.005).

CONCLUSIONS

Among those with clinically significant decrease in visceral adipose tissue on treatment, tesamorelin was effective in increasing skeletal muscle area and density. Long term effectiveness of tesamorelin among people with and without HIV, and the impact of these changes in daily life should be further studied.

Frailty among HIV-1 Infected Adults under Antiretroviral Therapy in Indonesia

BACKGROUND

Increasing age of HIV-1 infected population brought about the risk of frailty as comorbidity, whose prevalence is higher in low and middle-income countries (LMICs). Indonesia as an LMIC also bears a major burden of HIV-1 epidemic with a similarly aging population, but the prevalence of frailty and its predictors are unknown.

OBJECTIVES

To identify the prevalence of frailty and analyze its associated factors, among HIV-1 infected adults under antiretroviral therapy in Indonesia.

METHODS

A cross-sectional study was conducted among HIV-infected individuals with inclusion criteria of age ≥30 years old and underwent ART for at least 6 months. The main assessment was done using Fried's frailty phenotype score, which categorizes subjects into non-frail, pre-frail, or frail. Factors associated with frailty were characterized and multiple logistic regression analysis was performed.

RESULTS

A total of 164 subjects were recruited; male subjects were 118 (72%), the median age was 40.5 years old, and the median CD4 nadir was 53 cells/μl. Frailty was identified among 90 (54.9%) subjects with 84 (51.2%) identified as pre-frail and 6 (3.7%) as frail, with dominant frailty phenotype was weakness in grip strength. The multivariate model showed that depression was the only factor significantly correlated with pre-frailty and frailty (OR 2.14; 95% CI 1.04-4.43, p=0.036).

CONCLUSION

Frailty is a common occurrence among HIV-infected patients under ART, with depression as an independent predictive factor.

Abdominal obesity, sarcopenia, and osteoporosis are associated with frailty in men living with and without HIV

OBJECTIVE

The relationships between frailty and body composition in older adults with HIV infection are poorly understood. We sought to describe associations between frailty and measures of body composition among adult men with HIV and without HIV.

DESIGN/METHODS

Men with and without HIV (age 50-69 years) in the Multicenter AIDS Cohort Study (MACS) Bone Strength Substudy were included if evaluated for frailty (by Fried phenotype) and body composition [BMI, waist circumference, abdominal visceral (VAT) and subcutaneous (SAT) adipose tissue, sarcopenia, and osteopenia/osteoporosis]. All participants with HIV infection were on antiretroviral therapy. Multivariate multinomial logistic regression models were used to determine associations of frailty with body composition.

RESULTS

A total of 399 men, including 199 men with HIV and 200 men without HIV, both with median age 60 years, constituted our study population. Frailty prevalence was 16% (men with HIV) vs. 8% (men without HIV). HIV serostatus was associated with a 2.43 times higher odds of frailty (P = 0.01). Higher waist circumference, VAT, sarcopenia, and femoral neck osteoporosis were associated with increased odds of frailty (aOR 4.18, 4.45, 4.15, and 13.6, respectively, and all P < 0.05); BMI and SAT were not. None of these measures presented a differential association with frailty by HIV serostatus (all P > 0.20).

CONCLUSION

Higher abdominal obesity and sarcopenia were associated with frailty among men with and without HIV. Assessment of these body composition parameters may help detect frailty in the clinical setting.

Assessment of sarcopenia in virally suppressed HIV-infected Asians receiving treatment

OBJECTIVES

In a clinic-based, treated HIV-infected cohort, we identified individuals with sarcopenia and compared with age, sex and ethnically matched controls; and investigated associated risk factors and health outcomes.

DESIGN

Sarcopenia (age-related muscle loss) causes significant morbidity to the elderly, leading to frequent hospitalizations, disability and death. Few have characterized sarcopenia in the HIV-infected who experience accelerated aging.

METHODS

Sarcopenia was defined as low muscle mass with weak grip strength and/or slow gait speed using lower 20th percentiles of controls. Multivariate logistic and linear regression analyses were used to explore risk factors and health-related outcomes associated with sarcopenia among HIV-infected individuals.

RESULTS

We recruited 315 HIV-infected individuals aged at least 25 years with at least 1-year history of undetectable viral load on treatment (HIV RNA <50 copies/ml). Percentage of sarcopenia in 315 HIV-infected was 8%. Subsequently, 153 of the 315 were paired with age, sex and ethnically matched HIV-uninfected. The percentage of sarcopenia in the HIV-infected (n = 153) compared with uninfected (n = 153) were 10 vs. 6% (P = 0.193) respectively, whereas of those at least 50 years of age among them were 17% vs. 4% (P = 0.049), respectively. Associated risk factors among the HIV-infected include education level, employment status, BMI, baseline CD4 cell count, duration on NRTIs and GGT levels. Identified negative outcomes include mortality risk scores [5.42; 95% CI 1.46-9.37; P = 0.007) and functional disability (3.95; 95% CI 1.57-9.97; P = 0.004).

CONCLUSION

Sarcopenia is more prevalent in HIV-infected at least 50 years old compared with matched controls. Our findings highlight associations between sarcopenia with loss of independence and greater healthcare burden among treated HIV-infected individuals necessitating early recognition and intervention.

The Fat of the Matter: Obesity and Visceral Adiposity in Treated HIV Infection

PURPOSE OF REVIEW

The aim of this review is to summarize knowledge of the prevalence, relevant physiology, and consequences of obesity and visceral adiposity in HIV-infected adults, including highlighting gaps in current knowledge and future research directions.

RECENT FINDINGS

Similar to the general population, obesity prevalence is increasing among HIV-infected persons, and obesity and visceral adiposity are associated with numerous metabolic and inflammatory sequelae. However, HIV- and antiretroviral therapy (ART)-specific factors may contribute to fat gain and fat quality in treated HIV infection, particularly to the development of visceral adiposity, and sex differences may exist. Obesity and visceral adiposity commonly occur in HIV-infected persons and have significant implications for morbidity and mortality. Future research should aim to better elucidate the HIV- and ART-specific contributors to obesity and visceral adiposity in treated HIV infection, with the goal of developing targeted therapies for the prevention and treatment of obesity and visceral adiposity in the modern ART era.

Integrating Frailty Research into the Medical Specialties-Report from a U13 Conference

Although the field of frailty research has expanded rapidly, it is still a nascent concept within the clinical specialties. Frailty, conceptualized as greater vulnerability to stressors because of significant depletion of physiological reserves, predicts poorer outcomes in several medical specialties, including cardiology, human immunodeficiency virus care, and nephrology, and in the behavioral and social sciences. Lack of a consensus definition, proliferation of measurement tools, inadequate understanding of the biology of frailty, and lack of validated clinical algorithms for frail individuals hinders incorporation of frailty assessment and frailty research into the specialties. In 2015, the American Geriatrics Society, the National Institute on Aging (NIA), and the Alliance for Academic Internal Medicine held a conference for awardees of the NIA-sponsored Grants for Early Medical/Surgical Specialists Transition into Aging Research program to review the current state of knowledge regarding frailty in the subspecialties and to highlight examples of integrating frailty research into the medical specialties. Research questions to advance frailty research into specialty medicine are proposed.

Geriatric syndromes: new frontiers in HIV and sarcopenia

: HIV infection, in many circumstances, can now be managed as a chronic disease due to the marked increase in life expectancy since the introduction of combination antiretroviral therapy (ART). As the patients who first had access to combination ART age into their 50s and 60s, the effects of chronic HIV infection on health have become an important research focus in HIV infection. People living with HIV appear to exhibit an earlier occurrence of some aging-related conditions compared to people without HIV, in part due to higher rates of comorbidities, high-risk behaviors (e.g. smoking, substance use), chronic immune activation, inflammation, and ART-specific factors. Some studies have even suggested an earlier-than-expected appearance of the 'geriatric syndromes,' which are complex medical syndromes of older adults that are associated with morbidity and mortality. The geriatric syndromes include a wide variety of disease processes ranging from incontinence and dementia to impairments in physical function. This review will focus on one geriatric syndrome, sarcopenia, in older HIV-infected populations, and its relation to other aging syndromes, including frailty and falls. The contribution of HIV itself, ART exposure, and specific comorbidities, and the importance of early recognition and prevention of these aging syndromes will be highlighted.

Physical function, grip strength and frailty in people living with HIV in sub-Saharan Africa: systematic review

OBJECTIVE

To present the current knowledge on physical function, grip strength and frailty in HIV-infected patients living in sub-Saharan Africa, where the phenomenon is largely underestimated.

METHODS

A systematic search was conducted on MEDLINE, Scopus and African Index Medicus. We reviewed articles on sub-Saharan African people living with HIV (PLHIV) >18 years old, published until November 2016.

RESULTS

Of 537 articles, 12 were conducted in six African countries and included in this review. Five articles reported information on functional limitation and one on disability. Two of these five articles reported functional limitation (low gait speed) in PLHIV. Disability was observed in 27% and 3% of PLHIV living in rural and urban places, respectively. Two of three studies reporting grip strength reported lower grip strength (nearly 4 kg) in PLHIV in comparison with uninfected patients. One study reported that PLHIV were more likely to be frail than HIV-uninfected individuals (19.4% vs. 13.3%), whereas another reported no statistical difference.

CONCLUSION

Decline in physical function, grip strength and frailty are now part of the burden of PLHIV living in SSA countries, but current data are insufficient to characterise the real public health dimension of these impairments. Further studies are needed to depict this major public health challenge. As this is likely to contribute to a significant burden on the African healthcare systems and human resources in the near future, a holistic care approach should be developed to inform guidelines.

Frailty Syndrome: Visceral Adipose Tissue and Frailty in Patients with Symptomatic Severe Aortic Stenosis

BACKGROUND/OBJECTIVES

In patients with severe aortic stenosis (AS), frailty is a clinically relevant measure of increased vulnerability that should be included in the preoperative risk assessment. Bioelectrical impedance analysis (BIA) derived phase angle (PA) reflects cell membrane integrity and function. Few studies are available on the relative contribution of adiposity distribution on frailty, and about the influences of frailty and visceral obesity in PA value. Therefore, we aimed to evaluate associations among frailty, visceral fat depots and PA in patients with symptomatic severe AS.

METHODS

In a cohort of patients with symptomatic severe AS and preserved ejection fraction, we examined the associations between frailty, visceral fat depots and bioelectrical impedance analysis (BIA) derived phase angle (PA); and between visceral fat and PA. Frailty was defined according the Fried et al. scale criteria and the body fat distribution was determined by multidetector computed tomography and by BIA.

RESULTS

Of the fifty-five included patients, 26 were frail (47%). Adjusting for age and gender, frailty was associated with indexed epicardial adipose tissue volume (EATVi) (the odds of frailty increased 4.1-fold per additional 100 cm3/m2 of EAT [95% confidence interval (CI) of 1.03 to 16.40, p=0.04] and with PA (OR of 0.50, 95% CI, 0.26 to 0.97, p=0.04), but not with body mass index (BMI), waist circumference (WC), indexed total, visceral and subcutaneous abdominal fat areas (TAFAi, VAFAi and SAFAi) nor with indexed mediastinal adipose tissue volume (MATVi). In an age and gender adjusted linear model, PA was inversely correlated with EATVi (β=-0.008, 95% CI, -0.016 to -0.001, p=0.03), but not with BMI, WC, nor with MATVi, VAFAi, SAFAi and TAFAi.

CONCLUSIONS

In patients with symptomatic severe AS, EATVi is associated with frailty, independently of age and gender, but not with MAFVi or VAFAi. Moreover, frailty and EATVi are associated with impaired cell membrane integrity and function assessed by PA.

Fat Matters: Understanding the Role of Adipose Tissue in Health in HIV Infection

More than one-third of adults in the USA are obese and obesity-related disease accounts for some of the leading causes of preventable death. Mid-life obesity may be a strong predictor of physical function impairment later in life regardless of body mass index (BMI) in older age, highlighting the benefits of obesity prevention on health throughout the lifespan. Adipose tissue disturbances including lipodystrophy and obesity are prevalent in the setting of treated and untreated HIV infection. This article will review current knowledge on fat disturbances in HIV-infected persons, including therapeutic options and future directions.

Long-term body composition changes in antiretroviral-treated HIV-infected individuals

OBJECTIVE

Body composition impacts physical function and mortality. We compared long-term body composition changes after antiretroviral therapy (ART) initiation in HIV-infected individuals to that in HIV-uninfected controls.

DESIGN

Prospective observational study.

METHODS

We performed dual-energy x-ray absorptiometry (DXA) approximately 7.5 years after initial DXA in available HIV-infected individuals who received DXAs during the randomized treatment trial AIDS Clinical Trials Group A5202. For controls, we used DXA results from HIV-uninfected participants in the Boston Area Community Health/Bone and Women's Interagency HIV Study cohorts. Repeated measures analyses compared adjusted body composition changes between HIV-infected and HIV-uninfected individuals. Multivariable analyses evaluated factors associated with body composition change in HIV-infected individuals.

RESULTS

We obtained DXA results in 97 HIV-infected and 614 HIV-uninfected participants. Compared with controls, HIV-infected individuals had greater adjusted lean mass and total, trunk, and limb fat gain during the first 96 weeks of ART. Subsequently, HIV-infected individuals lost lean mass compared with controls. Total, trunk, and limb fat gains after 96 weeks of ART slowed in HIV-infected individuals but remained greater than in controls. Lower CD4 T-cell count was associated with lean mass and fat gain during the initial 96 weeks of ART, but subsequently no HIV-related characteristic was associated with body composition change.

CONCLUSION

Consistent with a 'return to health effect', HIV-infected individuals, especially those with lower baseline CD4 T-cell counts, gained more lean mass and fat during the first 96 weeks of ART than HIV-uninfected individuals. Continued fat gain and lean mass loss after 96 weeks may predispose HIV-infected individuals to obesity-related diseases and physical function impairment.

Effect of HIV-infection and cumulative viral load on age-related decline in grip strength

OBJECTIVE

Grip strength predicts functional decline and death, and is regarded as a biomarker of biological aging. The primary objective of this manuscript was to assess differences in the rate of decline in grip strength in persons aging with and without HIV.

DESIGN

Grip strength was assessed in 1552 (716 HIV+ and 836 HIV-) men aged at least 50 years participating in the Multicenter AIDS Cohort Study between 2007 and 2014.

METHODS

Grip strength decline was modeled longitudinally, adjusting for serostatus, demographics, comorbidities, and conditions. In HIV-specific models, coefficients were included for cumulative viral load and history of AIDS.

RESULTS

Grip strength at the age of 50 years averaged 37.9 and 38.2 kg for HIV+ and HIV- men, respectively (P = 0.70). In fully adjusted models, grip strength declined 0.33 kg/year in HIV- men (P < 0.001) and 0.42 kg/year in HIV+ men (P = 0.01). In HIV-stratified models, higher cumulative viral load indicated greater strength decline (-0.884 kg for 3.1-4.0 log10 copies-years/ml and -1.077 kg for ≥4.1 log10 copies-years/ml) relative to men with consistently low viral load (≤3.0 log10 copies-years/ml). Adjusted Cox proportional hazard models revealed a 70% greater risk of clinically weak grip strength in HIV+ men (adjusted hazard ratio 1.70; 95% confidence interval, 1.22-2.40).

CONCLUSION

Grip strength decline is accelerated in HIV-infected men, which may contribute to decreased life expectancy and lower quality of life with aging. Greater cumulative viral load exposure appears to be an important driver of this decline and underscores the importance of early initiation of therapy.

Obesity in patients with HIV infection: epidemiology, consequences and treatment options

Even though wasting used to characterize patients with HIV infection prior to the antiretroviral therapy (ART) era, obesity is becoming increasingly prevalent in this population. Areas covered: In the present review, we discuss the epidemiology, consequences and treatment options for obesity in patients with HIV infection. Expert commentary: Obesity exerts a multitude of detrimental cardiometabolic effects and appears to contribute to the increasing cardiovascular mortality of this population. However, there are very limited data on the optimal management of obesity in patients with HIV infection. Given the potential for interactions between antiobesity agents and ART that might compromise viral control, lifestyle changes should represent the cornerstone for the prevention and management of obesity in HIV infection.

Geriatric syndromes: How to treat

The survival of HIV-infected persons has been increasing over the last years, thanks to the implementation of more effective pharmacological and non-pharmacological interventions. Nevertheless, HIV-infected persons are often "biologically" older than their "chronological" age due to multiple clinical, social, and behavioral conditions of risk. The detection in this population of specific biological features and syndromic conditions typical of advanced age has made the HIV infection an interesting research model of accelerated and accentuated aging. Given such commonalities, it is possible that "biologically aged" HIV-positive persons might benefit from models of adapted and integrated care developed over the years by geriatricians for the management of their frail and complex patients. In this article, possible strategies to face the increasingly prevalent geriatric syndromes in HIV-infected persons are discussed. In particular, it is explained the importance of shifting from the traditional disease-oriented approach into models of care facilitating a multidisciplinary management of frailty.

Ageing and inflammation in patients with HIV infection

Nowadays, HIV⁺ patients have an expected lifespan that is only slightly shorter than healthy individuals. For this reason, along with the fact that infection can be acquired at a relatively advanced age, the effects of ageing on HIV⁺ people have begun to be evident. Successful anti-viral treatment is, on one hand, responsible for the development of side effects related to drug toxicity; on the other hand, it is not able to inhibit the onset of several complications caused by persistent immune activation and chronic inflammation. Therefore, patients with a relatively advanced age, i.e. aged more than 50 years, can experience pathologies that affect much older citizens. HIV⁺ individuals with non-AIDS-related complications can thus come to the attention of clinicians because of the presence of neurocognitive disorders, cardiovascular diseases, metabolic syndrome, bone abnormalities and non-HIV-associated cancers. Chronic inflammation and immune activation, observed typically in elderly people and defined as 'inflammaging', can be present in HIV⁺ patients who experience a type of premature ageing, which affects the quality of life significantly. This relatively new condition is extremely complex, and important factors have been identified as well as the traditional behavioural risk factors, e.g. the toxicity of anti-retroviral treatments and the above-mentioned chronic inflammation leading to a functional decline and a vulnerability to injury or pathologies. Here, we discuss the role of inflammation and immune activation on the most important non-AIDS-related complications of chronic HIV infection, and the contribution of aging per se to this scenario.

Enhancing physical function in HIV-infected older adults: A randomized controlled clinical trial

OBJECTIVE

HIV-infected older adults (HOA) are at risk of functional decline. Interventions promoting physical activity that can attenuate functional decline and are easily translated into the HOA community are of high priority. We conducted a randomized, controlled clinical trial to evaluate whether a physical activity counseling intervention based on self-determination theory (SDT) improves physical function, autonomous motivation, depression and the quality of life (QOL) in HOA.

METHOD

In total, 67 community-dwelling HOA with mild-to-moderate functional limitations were randomized to 1 of 2 groups: a physical activity counseling group or the usual care control group. We used SDT to guide the development of the experimental intervention. Outcome measures that were collected at baseline and final study visits included a battery of physical function tests, levels of physical activity, autonomous motivation, depression, and QOL.

RESULTS

The study participants were similar in their demographic and clinical characteristics in both the treatment and control groups. Overall physical performance, gait speed, measures of endurance and strength, and levels of physical activity improved in the treatment group compared to the control group (p < .05). Measures of autonomous regulation such as identified regulation, and measures of depression and QOL improved significantly in the treatment group compared with the control group (p < .05). Across the groups, improvement in intrinsic regulation and QOL correlated with an improvement in physical function (p < .05).

CONCLUSION

Our findings suggest that a physical activity counseling program grounded in SDT can improve physical function, autonomous motivation, depression, and QOL in HOA with functional limitations. (PsycINFO Database Record

More than osteoporosis: age-specific issues in bone health

PURPOSE OF REVIEW

The interaction between fall and fracture risk factors is an area of increasing clinical relevance, but little information is known about the age-specific issues in bone health unique to HIV-infected adults. The present review will focus on what is known about falls and fall risk factors among HIV-infected adults, and then review the association between decreased muscle, increased adiposity, and frailty with both low bone mineral density (BMD) and falls.

RECENT FINDINGS

The rate of falls among middle-aged HIV-infected adults is similar to that of HIV-uninfected adults 65 years and older. Many of the clinical factors that contribute to low BMD overlap with risk factors for falls, resulting in a high risk of a serious fall among older adults with the greatest risk for a fracture. Low muscle mass, increased adiposity and metabolic syndrome, physical function impairment and frailty, common among older HIV-infected adults, contribute to an increased risk for low BMD and falls, and subsequently, may increase the risk of fracture among HIV-infected older adults.

SUMMARY

Interventions with dual benefit on reducing fall risk and improving BMD are likely to have the greatest impact on fracture prevention in the older, HIV-infected adult.

FRAILTY, FOOD INSECURITY, AND NUTRITIONAL STATUS IN PEOPLE LIVING WITH HIV

BACKGROUND

Nutritional status and food insecurity are associated with frailty in the general U.S. population, yet little is known about this in the aging population of people living with HIV (PLWH).

OBJECTIVES

Given the potential importance of nutrition and the amenability to intervention, we examined the association between nutritional status, food insecurity, and frailty in PLWH.

DESIGN

Cross sectional study.

SETTING

Boston, Massachusetts, U.S.A.

PARTICIPANTS

50 PLWH, age ≥45 years, recruited from a cohort study examining risk factors for cardiovascular disease.

MEASUREMENTS

Frailty, duration of HIV, use of antiretroviral therapy, disease history, food insecurity, physical function, and physical activity were assessed by questionnaire. Dietary intake was assessed using 3-day food records. Blood was drawn for CD4+ cell count, hemoglobin, hematocrit, and lipid levels. Physical measurements included height, weight, and skinfold thickness.

RESULTS

The prevalence of frailty was 16% (n=8), 44% were pre-frail (n=22) and 40% were not frail (n=20). The number of reported difficulties with 20 activities of daily living was highest in frail (mean 10.4±3.9 SD), followed by pre-frail (6.5±4.6), and lowest in not frail participants (2.0±2.3). Seven (88%) of the frail PLWH lost weight with an average weight loss of 22.9 pounds; 6 (75%) reported unintentional weight loss, and all 6 of these met the frailty criteria for weight loss of 10 or more pounds. Nine (45%) of the not frail PLWH reported losing weight with an average weight loss of 6.2 pounds; 5 (23%) reported unintentional weight loss of <10 pounds. Frail PLWH were more likely to report being food insecure than not frail PLWH (63% vs. 10%, p=0.02), and tended to have lower energy intake than not frail PLWH.

CONCLUSION

Research is needed on targeted interventions to improve food security and activities of daily living in PLWH for both the prevention and improvement of frailty.

The Silent Epidemic - Frailty and Aging with HIV

As the number of older adults with HIV increases, this population is experiencing an increased risk for frailty. While there is no single definition or diagnostic criteria for frailty, it is generally recognized as an accumulation of deficits in functional capacity and ability to perform activities of daily living. Frailty may be present in up to half of older adults living with HIV, and is associated with significant morbidity and mortality risk in this group. Frailty in HIV can either be transient, and linked to the status of HIV infection, or resemble a more typical gradual decline in functional capacity. Frailty risk in HIV may be exacerbated by mitochondrial dysfunction, chronic inflammation, and oxidative stress. Several tools have been developed and adapted to assess different domains of frailty, yet medical treatment of this condition can be complex and should consider management of polypharmacy as well as nutrition and exercise interventions. However, few concrete strategies have been developed to prevent or treat frailty in the context of HIV infection. This review summarizes what is currently known about the prevalence, diagnosis, and management of frailty among older adults living with HIV.

HIV infection is independently associated with frailty in middle-aged HIV type 1-infected individuals compared with similar but uninfected controls

BACKGROUND

Frailty is an age-related syndrome of decreased physiological reserve and resistance to stressors, associated with increased morbidity and mortality in the general elderly population. An increased prevalence of frailty has been reported amongst HIV-infected individuals.

METHODS

Fried frailty phenotype was systematically assessed in predominantly virologically suppressed HIV type 1 (HIV-1)-infected and otherwise comparable HIV-uninfected participants aged at least 45 at enrollment into the AGEhIV Cohort Study. Multivariable ordinal logistic regression was used to investigate associations between HIV- and antiretroviral therapy-related covariates, markers of inflammation and body composition and prefrailty/frailty.

RESULTS

Data were available for 521 HIV-infected and 513 HIV-uninfected individuals. Prevalence of frailty (10.6 versus 2.7%) and prefrailty (50.7 versus 36.3%) were significantly higher in HIV-infected individuals (Ptrend < 0.001). HIV infection remained statistically significantly associated with prefrailty/frailty after adjustment for age, sex, race/ethnicity, smoking, hepatitis C infection, comorbidities and depression [adjusted odds ratio (ORadj) 2.16, P < 0.001]. A higher waist-to-hip ratio attenuated the coefficient of HIV-infected status (ORadj 1.93, P < 0.001), but not waist- or hip-circumference individually or markers of inflammation. Within the HIV-infected group, parameters related to body composition were most strongly and independently associated with prefrailty/frailty: current BMI less than 20 kg/m2 (OR 2.83, P = 0.01), nadir BMI less than 20 kg/m2 (OR 2.51, P = 0.001) and waist-to-hip ratio (OR 1.79 per 0.1 higher, P < 0.001).

CONCLUSION

HIV infection was independently associated with prefrailty/frailty in middle-aged HIV-infected patients compared with HIV-uninfected controls. This partly may be mediated by the higher waist- and lower hip-circumference in the HIV-infected individuals, potentially partially caused by lipodystrophy, and in part be a consequence of historic weight loss associated with advanced HIV-disease.

Accelerated Longitudinal Gait Speed Decline in HIV-Infected Older Men

BACKGROUND

Gait speed predicts functional decline, disability, and death and is considered a biomarker of biological aging. Changes in gait speed in persons aging with HIV may provide an important method of gauging health and longevity in an under assessed population. The objective of this study was to evaluate and quantify the rate of gait speed decline in HIV-infected (HIV⁺) men compared with HIV-uninfected (HIV⁻) men.

METHODS

The study was nested in the Multicenter AIDS Cohort Study. The primary outcome was usual gait speed in meters per second measured between 2007 and 2013. Differences in the rate of gait speed decline and the incidence of clinically slow gait (<1.0 m/s) were assessed using multivariate linear regression models and Cox proportional hazards models, respectively.

RESULTS

A total of 2025 men (973 HIV⁺ and 1052 HIV⁻) aged 40 years and older contributed 21,187 person-visits (9955 HIV⁺ and 11,232 HIV⁻) to the analysis. Average gait speeds at the age 50 years were 1.24 and 1.19 m/s in HIV⁻ and HIV⁺ men, respectively (P < 0.001). In fully adjusted models, gait speed decline averaged 0.009 m/s per year after age 50 years (P < 0.001); this decline was 0.025 m/s per year greater in HIV⁺ men (P < 0.001). Moreover, HIV⁺ men had a 57% greater risk of developing clinically slow gait (adjusted hazard ratio = 1.57, 95% confidence interval: 1.27 to 1.91).

CONCLUSIONS

These findings indicate a faster rate of functional decline in HIV-infected men, suggesting greater risks of disability and death with advancing age.

Predictors of Treatment Response to Tesamorelin, a Growth Hormone-Releasing Factor Analog, in HIV-Infected Patients with Excess Abdominal Fat

BACKGROUND

Tesamorelin, a synthetic analog of human growth hormone-releasing factor, decreases visceral adipose tissue (VAT) in human immunodeficiency virus (HIV)-infected patients with lipodystrophy.

OBJECTIVES

1) To evaluate the utility of patient characteristics and validated disease-risk scores, namely indicator variables for the metabolic syndrome defined by the International Diabetes Federation (MetS-IDF) or the National Cholesterol Education Program (MetS-NCEP) and the Framingham Risk Score (FRS), as predictors of VAT reduction during tesamorelin therapy at 3 and 6 months, and 2) To explore the characteristics of patients who reached a threshold of VAT <140 cm2, a level associated with lower risk of adverse health outcomes, after 6 months of treatment with tesamorelin.

METHODS

Data were analyzed from two Phase 3 studies in which HIV-infected patients with excess abdominal fat were randomized in a 2:1 ratio to receive tesamorelin 2 mg (n = 543) or placebo (n = 263) subcutaneously daily for 6 months, using ANOVA and ANCOVA models.

RESULTS

Metabolic syndrome (MetS-IDF or MetS-NCEP) and FRS were significantly associated with VAT at baseline. Presence of metabolic syndrome ([MetS-NCEP), triglyceride levels >1.7 mmol/L, and white race had a significant impact on likelihood of response to tesamorelin after 6 months of therapy (interaction p-values 0.054, 0.063, and 0.025, respectively). No predictive factors were identified at 3 months. The odds of a VAT reduction to <140 cm2 for subjects treated with tesamorelin was 3.9 times greater than that of subjects randomized to placebo after controlling for study, gender, baseline body mass index (BMI) and baseline VAT (95% confidence interval [CI] 2.03; 7.44).

CONCLUSIONS

Individuals with baseline MetS-NCEP, elevated triglyceride levels, or white race were most likely to experience reductions in VAT after 6 months of tesamorelin treatment. The odds of response of VAT <140 cm2 was 3.9 times greater for tesamorelin-treated patients than that of patients receiving placebo.

Association between Frailty, Osteoporosis, Falls and Hip Fractures among Community-Dwelling People Aged 50 Years and Older in Taiwan: Results from I-Lan Longitudinal Aging Study

Background

Association of frailty with adverse clinical outcomes has been reported in Western countries, but data from the Asian population are scarce. This study aimed to evaluate the epidemiology of frailty among community-dwelling middle-aged and elderly population and to explore its association with musculoskeletal health in Taiwan.

Methods

I-Lan Longitudinal Aging Study (ILAS) data were retrieved for this study. Frailty was defined by the Fried’s criteria; a comparison of demographic characteristics, physical performance, and body composition, including skeletal muscle mass and bone mineral density (BMD), as well as recent falls, history of hip fractures and the functional status of subjects with different frailty statuses were accomplished.

Results

Overall, the data of 1,839 participants (mean age: 63.9±9.3 years, male 47.5%) were obtained for analysis. The prevalence of pre-frailty was 42.3% in men and 38.8% in women, whereas the prevalence of frailty was 6.9% and 6.7% in men and women, respectively. Frailty was significantly associated with older age, the male gender, larger waist circumference, lower skeletal muscle index, lower hip BMD, poorer physical function, poorer nutritional status, and poorer cognitive function. Also, frailty was significantly associated with osteoporosis (OR: 7.73, 95% CI: 5.01–11.90, p<0.001), history of hip fractures (OR: 8.66, 95% CI: 2.47–30.40, p = 0.001), and recent falls (O.R: 2.53, 95% CI: 1.35–4.76, p = 0.004).

Conclusions

Frailty and pre-frailty, in Taiwan, was closely associated with recent falls, history of hip fractures and osteoporosis among community-dwelling people 50 years of age and older. Furthermore, frailty intervention programs should take an integrated approach towards strengthening both and muscle mass, as well as prevention of falls.

Functional impairment, disability, and frailty in adults aging with HIV-infection

The integration of antiretroviral therapy (i.e., ART) into HIV care has dramatically extended the life expectancy of those living with HIV. However, in comparison to similar HIV-uninfected populations, HIV-infected persons experience an excess of morbidity and mortality with an early onset of aging complications including neurocognitive decline, osteoporosis, impaired physical function, frailty, and falls. Recent consensus guidelines encourage clinicians and researchers to consider functional impairment of HIV-infected adults as a measure to understand the impact of aging across a range of abilities. Despite the importance of assessing function in persons aging with HIV infection, a lack of consistent terminology and standardization of assessment tools has limited the application of functional assessments in clinical or research settings. Herein, we distinguish between different approaches used to assess function, describe what is known about function in the aging HIV population, and consider directions for future research.

HIV and aging: a clinical journey from Koch's postulate to the chronic disease model and the contribution of geriatric syndromes

PURPOSE OF REVIEW

With the discovery and widespread use of antiretroviral therapies, growing numbers of individuals with HIV are now able to live into advanced age. Nevertheless, growing evidence indicates that these dramatic gains in longevity have also resulted in increased prevalence among the survivors of non-AIDS morbidity and disability, together with acceleration of many underlying aging processes. As a result, individuals involved in HIV care, policy, and research have increasingly had to refocus their efforts from a traditional infectious disease emphasis toward conceptual models grounded in the management of common chronic diseases and geriatric syndromes.

RECENT FINDINGS

It has been estimated that by 2015, one-half of all Americans with HIV will be 50  years or older. Such individuals are likely to develop chronic diseases typically seen in their older HIV-negative counterparts. Moreover, the presence of multiple coexisting chronic conditions together with polypharmacy and acceleration of varied age-related physiological changes renders many older HIV-positive individuals more vulnerable to becoming disabled or dying from conditions that are not immediately linked to HIV.

SUMMARY

As growing numbers of individuals confront the prospect of a life with HIV, both they and their providers will need to shift their focus toward a broader and more encompassing perspective that considers the impact of multiple coexisting conditions and age-related changes on outcome measures associated with function, independence, and quality of life. To that end, there is an urgent need for increased dialog between different disciplines, ensuring that the care of older HIV-positive individuals is guided by research that incorporates relevant functional outcome measures.

FUNCTIONAL LIMITATIONS AND ADIPOKINES IN HIV-INFECTED OLDER ADULTS

BACKGROUND

There is a significant increase in the number of HIV-infected older adults (HOA). This population may experience functional decline at a much younger age. Little is known about the relationship between functional limitations and systemic adipokines in HOA.

OBJECTIVE

Our study aimed to evaluate the relationship between functional limitations and systemic adipokine levels in HOA population.

DESIGN

Cross-sectional.

SETTING

Academic hospital-based infectious disease clinic.

PARTICIPANTS

The study investigated community-dwelling HIV-infected adults >50 years old and compared this group with age, gender and BMI comparable healthy controls.

MEASUREMENTS

We measured functional status, body composition and plasma concentrations of adipokines.

RESULTS

Fifty-four HOA were studied (mean: age 57 years, BMI 29 kg/m2, CD4 604, duration of HIV 17 years) and compared with thirty-two age, gender and BMI comparable healthy controls. The HOA group showed significantly higher functional limitations compared to the age, gender and BMI comparable controls (p<0.05). Levels of adipokines were significantly different between the two groups (p<0.05). Multiple regression analyses indicated that adiponectin and visfatin were significantly correlated with several physical function measures after controlling for age, sex, and metabolic comorbidities. Adiponectin was negatively correlated with functional limitations, and this relationship was stronger in the control group compared to the HOA group. Conversely, visfatin was positively correlated with functional limitations only in the HOA group.

CONCLUSION

HOA have significant functional limitations and alteration in adipokine levels compared to controls. Adiponectin and visfatin were associated with functional limitations. Visfatin was a correlate of physical function only in the HOA group. Prospective longitudinal studies could provide further insight on the role of adipokines in HIV-related functional decline.

Self-reported body fat change in HIV-infected men is a marker of decline in physical health-related quality of life with aging, independent of co-morbidity

OBJECTIVE

Self-perception of changes in body fat among HIV+ persons is associated with decreased health related quality of life in cross-sectional studies. The longitudinal impact of body fat changes on health related quality of life, while accounting for comorbidity and anatomic location or severity of body fat changes, is unknown.

DESIGN

This was a longitudinal analysis of HIV+ and HIV- Multicenter AIDS Cohort Study (MACS) participants who completed questionnaires assessing self-perceived body fat changes (baseline visit) and a health related quality of life (Short Form-36) at baseline and then ≥5 years later.

METHODS

Relationships between body fat changes and change in Short Form-36 Physical and Mental Component Summary scores were investigated using mixed-model regression.

RESULTS

We studied 270 HIV+ and 247 HIV- men. At baseline, ≥50% of HIV+ men reported body fat changes; physical component but not mental component summary scores were lower among HIV+ men who reported moderate/severe leg or abdominal fat changes (p<0.05). At follow-up, physical component summary scores were significantly lower among men with face, leg, or abdominal fat changes compared to men without perceived fat changes (p<0.05). No significant changes were seen in mental component scores by fat change location or severity. In the final model, body fat changes at any site or severity were significant predictors of a decline in physical component summary score (p<0.05), independent of demographics or comorbidities. Mental component summary score was not associated with body fat changes, but higher mental component summary score was associated with increasing age and time.

CONCLUSIONS

Negative self-perceived body fat changes were associated with decline in physical health related quality of life, independent of comorbidities, and may be a marker of an increased risk for physical function decline with aging.

Brain morphometric correlates of metabolic variables in HIV: the CHARTER study

Obesity and other metabolic variables are associated with abnormal brain structural volumes and cognitive dysfunction in HIV-uninfected populations. Since individuals with HIV infection on combined antiretroviral therapy (CART) often have systemic metabolic abnormalities and changes in brain morphology and function, we examined associations among brain volumes and metabolic factors in the multisite CNS HIV AntiRetroviral Therapy Effects Research (CHARTER) cohort, cross-sectional study of 222 HIV-infected individuals. Metabolic variables included body mass index (BMI), total blood cholesterol (C), low- and high-density lipoprotein C (LDL-C and HDL-C), blood pressure, random blood glucose, and diabetes. MRI measured volumes of cerebral white matter, abnormal white matter, cortical and subcortical gray matter, and ventricular and sulcal CSF. Multiple linear regression models allowed us to examine metabolic variables separately and in combination to predict each regional volume. Greater BMI was associated with smaller cortical gray and larger white matter volumes. Higher total cholesterol (C) levels were associated with smaller cortex volumes; higher LDL-C was associated with larger cerebral white matter volumes, while higher HDL-C levels were associated with larger sulci. Higher blood glucose levels and diabetes were associated with more abnormal white matter. Multiple atherogenic metabolic factors contribute to regional brain volumes in HIV-infected, CART-treated patients, reflecting associations similar to those found in HIV-uninfected individuals. These risk factors may accelerate cerebral atherosclerosis and consequent brain alterations and cognitive dysfunction.

An adapted frailty-related phenotype and the VACS index as predictors of hospitalization and mortality in HIV-infected and uninfected individuals

BACKGROUND

Frailty is a geriatric syndrome of decreased physiologic reserve and a risk factor for hospitalization and mortality. We hypothesized that an adapted survey-based frailty-related phenotype (aFRP) predicts hospitalization and mortality among HIV-infected and uninfected individuals in adjusted models but is uncommon among those achieving undetectable HIV-1 RNA.

METHODS

Defined from self-reported domains of physical shrinking, exhaustion, slowness, and low physical activity in Veterans Aging Cohort Study (VACS) participants, aFRP was considered present with ≥3 domains and prefrailty with 1-2 domains. Cox survival analysis determined hazard ratios (HRs) for 5-year hospitalization and mortality risk adjusting for frailty states, demographics, health behaviors, comorbidities, and a validated risk index incorporating HIV-specific and general organ system biomarkers, the VACS Index. Model discrimination was assessed.

RESULTS

Participants with complete data were included [6515/7324 (89%)]. Of these, 3.9% of HIV-infected individuals with HIV-1 RNA >400 copies per milliliter; 2.0% of HIV-infected individuals with HIV-1 RNA ≤400 copies per milliliter; and 2.8% of uninfected individuals met aFRP criteria (P = 0.01). After adjustment for other covariates, aFRP was associated with hospitalization (HR = 1.78; 95% confidence interval: 1.48 to 2.13) and mortality (HR = 1.75; 95% confidence interval: 1.28 to 2.40). C-statistics for the VACS Index for hospitalization (0.633) and for mortality (0.756) were higher than for aFRP (0.565 and 0.584, respectively). C-statistic for hospitalization improved modestly when VACS Index and aFRP were both included (0.646) and minimally for mortality (0.761).

CONCLUSIONS

aFRP was independently associated with adverse health outcomes among HIV-infected and uninfected individuals. aFRP modestly improved prediction for hospitalization. However, the aFRP is rare among HIV-infected individuals with undetectable HIV-1 RNA.

Lean tissue imaging: a new era for nutritional assessment and intervention

Body composition refers to the amount of fat and lean tissues in our body; it is a science that looks beyond a unit of body weight, accounting for the proportion of different tissues and its relationship to health. Although body weight and body mass index are well-known indexes of health status, most researchers agree that they are rather inaccurate measures, especially for elderly individuals and those patients with specific clinical conditions. The emerging use of imaging techniques such as dual energy x-ray absorptiometry, computerized tomography, magnetic resonance imaging, and ultrasound imaging in the clinical setting have highlighted the importance of lean soft tissue (LST) as an independent predictor of morbidity and mortality. It is clear from emerging studies that body composition health will be vital in treatment decisions, prognostic outcomes, and quality of life in several nonclinical and clinical states. This review explores the methodologies and the emerging value of imaging techniques in the assessment of body composition, focusing on the value of LST to predict nutrition status.

Association of chronic cough and pulmonary function with 6-minute walk test performance in HIV infection

OBJECTIVE

Chronic lung disease has been associated with greater impairment in self-reported physical function in HIV-infected patients. We sought to study this association using objective measures of physical function and pulmonary function.

DESIGN

Baseline data from the Examinations of HIV Associated Lung Emphysema study, a multicenter observational cohort of HIV-infected and uninfected veterans.

METHODS

We assessed the association between clinical, laboratory, and pulmonary function measures with 6-minute walk test (6-MWT). Multivariable linear regression models were generated to identify factors associated with 6-MWT performance.

RESULTS

Three hundred forty participants completed 6-MWT (mean age 55 years), with 68% blacks, 94% men, and 62% current smokers. Overall, 180 (53%) were HIV-infected and 63 (19%) had spirometry-defined chronic obstructive pulmonary disease. In a multivariable model, age, current smoking, and obesity (body mass index > 30) were independently associated with lower 6-MWT performance, but HIV infection was not; there was a significant interaction between HIV and chronic cough, such that distance walked among HIV-infected participants with chronic cough was 51.76 m less (P = 0.04) compared with those without cough or HIV. Among HIV-infected participants, the forced expiratory volume in 1 second (FEV1, percent predicted), to a greater extent than total lung capacity or diffusing capacity, attenuated the association with chronic cough; decreased FEV1 was independently associated with lower 6-MWT performance in those with HIV.

CONCLUSIONS

Older age, current smoking, and airflow limitation were important determinants of 6-MWT performance in the HIV-infected participants. These findings suggest that potential interventions to improve physical function may include early management of respiratory symptoms and airflow limitation.

Frailty in people aging with human immunodeficiency virus (HIV) infection

The increasing life spans of people infected with human immunodeficiency virus (HIV) reflect enormous treatment successes and present new challenges related to aging. Even with suppression of viral loads and immune reconstitution, HIV-positive individuals exhibit excess vulnerability to multiple health problems that are not AIDS-defining. With the accumulation of multiple health problems, it is likely that many people aging with treated HIV infection may be identified as frail. Studies of frailty in people with HIV are currently limited but suggest that frailty might be feasible and useful as an integrative marker of multisystem vulnerability, for organizing care and for comprehensively measuring the impact of illness and treatment on overall health status. This review explains how frailty has been conceptualized and measured in the general population, critically reviews emerging data on frailty in people with HIV infection, and explores how the concept of frailty might inform HIV research and care.

Development of a frailty framework among vulnerable populations

Frailty is a public health issue that is experienced by homeless and other vulnerable populations; to date, a frailty framework has not been proposed to guide researchers who study hard-to-reach populations. The Frailty Framework among Vulnerable Populations has been developed from empirical research and consultation with frailty experts in an effort to characterize antecedents, that is, situational, health-related, behavioral, resource, biological, and environmental factors that contribute to physical, psychological, and social frailty domains and impact adverse outcomes. As vulnerable populations continue to age, a greater understanding of frailty will enable the development of nursing interventions.

Relationship between poor physical function, inflammatory markers, and comorbidities in HIV-infected women on antiretroviral therapy

BACKGROUND

HIV-infected individuals may be at increased risk of poor physical function. Chronic inflammation has been associated with decreased physical function in the elderly and may also influence physical function in HIV-infected individuals.

METHODS

This cross-sectional study assessed physical function in 65 HIV-infected women aged 40 and older on stable antiretroviral treatment using the Short Physical Performance Battery (SPPB): a standardized test of balance, walking speed, and lower- extremity strength developed for elderly populations. The relationship between low SPPB score, selected demographic and medical characteristics, and high inflammatory biomarker profile was analyzed using Fisher's exact test and Wilcoxon rank sum test.

RESULTS

The median age of subjects was 49 years (interquartile range [IQR] 45-55), and the median CD4 T-cell count was 675 cells/mm(3) (IQR 436-828). Thirteen subjects (20%) had a low SPPB score. Subjects with a low SPPB score were more likely to be cigarette smokers (p=0.03), had more medical comorbidities (p=0.01), and had higher levels of interleukin-6 (IL-6) (p<0.05). They also tended to be older (median age 55 vs. 48, p=0.06), more likely to have diabetes (p=0.07), and have higher levels of soluble tumor necrosis factor-1 (p=0.09).

CONCLUSIONS

Twenty percent of women aged 40 and older with well-treated HIV had poor physical-function performance, which was associated with the high burden of comorbidities in this population and with increased IL-6. However, it is unclear from this cross-sectional study whether increased inflammation was related to poor physical function or to other factors, such as age and medical comorbidities.

The end of AIDS: HIV infection as a chronic disease

The success of antiretroviral therapy has led some people to now ask whether the end of AIDS is possible. For patients who are motivated to take therapy and who have access to lifelong treatment, AIDS-related illnesses are no longer the primary threat, but a new set of HIV-associated complications have emerged, resulting in a novel chronic disease that for many will span several decades of life. Treatment does not fully restore immune health; as a result, several inflammation-associated or immunodeficiency complications such as cardiovascular disease and cancer are increasing in importance. Cumulative toxic effects from exposure to antiretroviral drugs for decades can cause clinically-relevant metabolic disturbances and end-organ damage. Concerns are growing that the multimorbidity associated with HIV disease could affect healthy ageing and overwhelm some health-care systems, particularly those in resource-limited regions that have yet to develop a chronic care model fully. In view of the problems inherent in the treatment and care for patients with a chronic disease that might persist for several decades, a global effort to identify a cure is now underway.

Is HIV a model of accelerated or accentuated aging?

BACKGROUND

Antiretroviral therapy has reduced the incidence of adverse events and early mortality in HIV-infected persons. Despite these benefits, important comorbidities that increase with age (eg, diabetes, cardiovascular disease, cancer, liver disease, and neurocognitive impairment) are more prevalent in HIV-infected persons than in HIV-uninfected persons at every age, and geriatric syndromes such as falls and frailty occur earlier in HIV-infected persons. This raises a critical research question: Does HIV accelerate aging through pathways and mechanisms common to the aging process or is HIV simply an additional risk factor for a wide number of chronic conditions, thus accentuating aging?

METHODS

Extensive literature review.

RESULTS

The purpose of this review is to briefly outline the evidence that age-related clinical syndromes are exacerbated by HIV, examine the ways in which HIV is similar, and dissimilar from natural aging, and assess the validity of HIV as a model of premature aging. Specific biomarkers of aging are limited in HIV-infected hosts and impacted by antiretroviral therapy, and a high rate of modifiable life style confounders (eg, smoking, substance abuse, alcohol) and coinfections (eg, hepatitis) in HIV-infected participants.

CONCLUSIONS

There is a need for validated biomarkers of aging in the context of HIV. Despite these differences, welldesigned studies of HIV-infected participants are likely to provide new opportunities to better understand the mechanisms that lead to aging and age-related diseases.