Katherine Promer Flores, MD (she/her) Staff Physician Division of Infectious Diseases and Global Public Health Department of Medicine University of California San Diego

1. HIV & Global Health Rounds
The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease and global public health clinicians,
physicians, and researchers. The goal of these presentations is to
provide the most current research, clinical practices, and trends in HIV,
HBV, HCV, TB, and other infectious diseases of global significance.
The slides from the HIV & Global Health Rounds presentation that you
are about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.

2. Frailty in People Aging with HIV
Katherine Promer, MD
Associate Physician
Division of Infectious Diseases & Global Public Health
UC San Diego Health

3. Learning Objectives
1. Define Frailty
2. Screening for and measuring frailty
3. Prevention of and interventions for frailty

4. Financial Disclosure
• Honorarium through an educational grant from ViiV

5. Frailty Definition
“State of vulnerability to poor resolution of
homoeostasis after a stressor event and is a
consequence of cumulative decline in many
physiological systems during a lifetime”
Clegg et al. Lancet. 2013

6. Adverse Outcomes of Frailty
• Hospitalization
• Falls
• Disability
• Increased Health Care Utilization

7. Falls in Adults 65 Years and Older
• In 2020, 14 million (27.6%) older adults reported falling during the previous year
• 28.9% in women and 26.1% in men
• In 2021, a total of 38,742 (78.0 per 100,000) unintentional fall–related deaths occurred among
older adults.
• 91.4 per 100,000 in men and 68.3 per 100,000 in women
• Attitudes toward fall prevention
• Circumstances leading to fall (ice, snow, ladders, etc)

8. • OR of frailty based on duration of HIV infection
• < 4 years: 3.38 (95% CI 1.25-9.11)
• 4-8 years: 12.95 (95% CI 6.6-25.4)
• 8-12 years: 14.68 (95% CI 7.6-28.35
• Frailty prevalence of men living with HIV aged 55
years comparable to that of seronegative men
aged 65 or older (both 3.4%)
Earlier Onset of Frailty in PLWH
Desquilbet et al. 2007

9. Frailty more prevalent in PLWH
Kooij et al. 2016

10. Maile Young Karris, MD

11. Loneliness and Isolation
• Loneliness: discrepancy between actual and preferred social
relationships
• Social isolation: lack of contact with society
• Affects an estimated 39-58% of older PWH
• Substance use, depression, low quality of life more likely
• Excess inflammation and immunosuppression
Shiau et al. 2020

12. Kehler et al. 2022

13. Kehler et al. 2022

14. Fried Frailty Phenotype (FFP)
Criteria
1. Unintentional weight loss
2. Exhaustion
3. Low physical activity
4. Weakness (handgrip strength)*
5. Slow gait (time to walk 15 feet)*
Classification
0 = Not frail
1-2 = Pre-frail
3-5 = Frail
Fried et al. 2001

15. FFP Validity
Died First
Hospitalization
First Fall Worsening ADL
Disability
Worsening
Mobility
Disability
Frailty Status at
Baseline
(n) 3 yr % 7 yr % 3 yr % 7 yr % 3 yr % 7 yr % 3 yr % 7 yr % 3 yr % 7 yr %
Not Frail (2469) 3 12 33 79 15 27 8 23 23 41
Intermediate (2480) 7 23 43 83 19 33 20 41 40 58
Frail (368) 18 43 59 96 28 41 39 63 51 71
p <.0001 <.0001 <.0001 <.0001 <.0001
Fried et al. 2001

16. FFP Logistical Limitations
Huang et al. 2022
Orkaby et al. 2021
Two trials
Slow > 5 seconds
Two Trials
3 seconds
Adjusted for gender and BMI

17. Modified Fried Phenotype (Mod-FP)
0 = Robust
1-2 = Pre-frail
3-4 = Frail
0 = Robust
1-2 = Pre-frail
3-5 = Frail
Ruderman et al. 2023

18. CFAR Network of Integrated Clinical Systems (CNICS)

19. Subjective Frailty Phenotype Responses
• HIV symptom index
• Fatigue: “I have this symptom and it bothers me [a lot]”
• Weight loss: “I have this symptoms and it bothers me [a little/ a lot]”
• Lipid Research Questionnaire
• Low physical activity: not engaging in strenuous exercise and less active than
peers of comparable age and gender
• EuroQOL Health-Related Quality of Life questionnaire
• Poor mobility: “I have some problems walking about” “I am unable to walk”
Ruderman et al. 2023

20. Ruderman et al. 2023

21. Tilburg Frailty Indicator (TFI)
Self-report questionnaire developed among Dutch community
dwellers aged 75 and older to reflect a multidimensional
approach to frailty

22. TFI Components
Part A: Determinants of Frailty
• Gender, age, marital status
• Birth country, education, income
• Life events in the past year
• Lifestyle, living environment
Part B: Components of Frailty
• Physical
• Psychological
• Social

24. Tilburg Frailty Indicator Validity

25. Tilburg Frailty Indicator Validity

26. Use of TFI in PLWH
• Cross-sectional study of 175 PLWH aged 50 years and older in
Changsha City, China used modeling to show that frailty could directly
contribute to depression (Yao et al. 2023)
• Cross-sectional study of 120 Hispanic PLWH aged 50 years or older
found that higher TFI score was associated with higher depressive
symptoms and higher of comorbidities (Iriate et al. 2023)

27. Frailty Interventions for PLWH
EXERCISE AND
PHYSICAL
ACTIVITY
NUTRITION POLYPHARMACY FALL
PREVENTION
MOOD
DISORDER
TREATMENT
COGNITIVE
IMPAIRMENT
TREATMENT
ADDRESSING SOCIAL
DETERMINANTS OF
HEALTH

28. Exercise and Physical Activity
• DHHS and WHO recommend
150-300 minutes of exercise per
week including balance and
strength training
• WHO recommends limiting
sedentary time, replacing with at
least light activity

29. RCT Assessing Exercise in PWH
• Treatment group: 1-hour supervised gym class (aerobic
and resistance) 3-times weekly plus nutrition counseling
• Control group: 1-hour monthly workshops to discuss
exercise and nutrition
• Significantly better outcomes after 24 weeks in Tx group
• Quality of life, vitality, general health, mental health
• Fat mass, muscle mass, waist circumference
• Resting heart rate
• CD4 count
Ogalha et al. 2011

30. Montoya et al. 2019

31. Montoya et al. 2019

32. Montoya et al. 2019

33. exerciseismedicine.org

34. exerciseismedicine.org

35. exerciseismedicine.org

36. exerciseismedicine.org

37. exerciseismedicine.org

38. Polypharmacy:
5 or more
medications

39. Polypharmacy in Community-Dwelling PWH
60 years or older in San Francisco
Greene et al. 2014

40. Edelman et al. 2020

41. Polypharmacy interventions
Medication reconciliation with review of
indications, risks, interactions, and doses
Non-pharmacologic alternatives
BEERS criteria to identify potentially
inappropriate medications for older adults

42. Non-pharmacologic alternatives
• Sleep aids -> Sleep hygiene, CBT, CPAP
• HTN, HLD, DM prescriptions -> Diet and exercise
• Chronic opiate prescriptions -> Physical therapy and acupuncture
• PPI -> Avoidance of trigger foods and late meals

43. Fall Prevention
• STEADI: Stopping Elderly Accidents, Deaths, and Injuries
1. Screening to identify older adults with an increased falls risk.
2. Assessing to identify modifiable risk factors (e.g., medication review,
functional ability test, measuring visual acuity, orthostatic blood pressure,
podiatry review, and home hazard evaluation).
3. Intervening to reduce fall risk using evidence-based strategies (e.g.,
strength and balance program, medication management, occupational
therapy, and corrective eyewear).
Johnston et al. 2019

44. Common STEADI Interventions
cdc.gov/steadi

45. Summary
HIV is associated with earlier onset and higher prevalence
of frailty
Several screening instruments exist to measure frailty
Several interventions are available to promote resilience
(preventing and treating frailty) in patients aging with HIV