Speaker: Dr Kristine Erlandson and Jules Levin
Moderators: Jeff Taylor
Tuesday 22 February 2022
The third session of the Margarita/Breakfast Community Club brought together 76 community members to focus on the implications of ageing with HIV and the concept of frailty. Kristine Erlandson presented the importance of incorporating frailty in study interventions and in the clinic as a clinically relevant “biomarker” of ageing among people living with HIV.
Many of the same factors that contribute to ageing (e.g., epigenetic alterations, DNA damage, inflammation, senescence and stem cell exhaustion, as well as environmental factors such as smoking and socio-economic status) lead to the development of frailty and physical function impairment. Frailty may occur even earlier in people living with HIV as HIV can speed up some of the determining factors. There are some indications of certain ARVs contributing to frailty but there is not much evidence available, so this needs further attention.
Furthermore, frailty and physical function impairment are a major predictor of independent living and have a strong association with mortality, falls and fracture and an increased risk of comorbidities such as diabetes and cardiovascular diseases. Additionally, difficulties in performing daily activities and instances of cognitive impairment (e.g., brain fog, short term memory, verbal fluency, processing speed, attention) show how frailty particularly limits the existence of people living with HIV over the years.
As far as interventional studies are concerned, frailty and physical function impairment can be included as secondary endpoints (e.g., as is the case in the REPRIEVE study). Including these endpoints allows the possibility to check if frailty and physical function modify how an intervention might work (e.g., how different age-groups respond to the same treatment) and ultimately to improve outcomes in people who are frail in the attempt to decrease their frailty (e.g., specific chemotherapy).
Considering that measuring frailty takes different amounts of time, some faster tests can be performed in clinical settings to be more congenial to the clinic schedule. An example is the Clinical Frailty Scale (CFS) that can quickly help health care providers identify where a patient might line up with these measures. This information could be used to treat and manage frailty by referring people to appropriate resources (e.g., nutrition and physical therapy) and thus decrease medications that might contribute to frailty, to inform general care and help to prioritise advanced care planning, identify patients for geriatric referral, determine frequency of clinic visits and to guide treatment decisions (e.g., inform risk/benefit of preventive care, ART choice). Some of these measures have already been included by some HIV-geriatric clinics, but a lot remains to be explored in regards to the implementation of screenings (i.e., what is efficient for patients, what patients like, their time limitations). The direct consequence of having in place instruments and systems that measure frailty will help deliver effective patient-centred care solutions for older people living with HIV.
Jules Levin led a panel discussion on the topic of ageing with HIV, given that it remains a widely and commonly under-recognised and underestimated issue, the impact of ageing on the 65+ population of people living with HIV tends to be rendered invisible. The ageing population tend to feel abandoned and experience loneliness and lack of social engagement as their situation is not often recognised by an HIV healthcare system that are mostly not prepared for this.
The lack of infrastructure to address ageing in people living with HIV is an issue that transcends borders and that happens to be magnified in realities where medical infrastructures are insufficient and the access to drugs is limited (i.e., Africa and India). Some key populations ageing with HIV also report a more severe range of multiple comorbidities, particularly among African-American, Latinos, women and trans people. A new model of care is needed to address intersecting problems, including better communication between specialists.
Further attention should be specifically dedicated to ageing women living with HIV, whose lower mortality rates converge into worse physical function and worse mental and emotional impairments. Reproductive health issues such as for cervical cancer and the menopause and related treatments should be paid attention to, for example if hormone replacement therapy interacts with ARVs.
There are certain barriers to including frail people in clinical studies, however. For example, as many studies are linked to exercise as an intervention to improve or even reverse frailty, it can be difficult to recruit people who are experiencing mobility issues. Long Covid is another factor that now needs to be taken into consideration when studying those considered frail.
A call for global advocacy was made to ensure that leadership, governments and the research community are aware of the needs linked to ageing and frailty and to prioritise the concerns about care, research and services. It is therefore crucial to come together as a community of advocates and work jointly to ignite an open public discussion that combines the voices of those who are speaking up.
Resources
Click here to watch the recording of the session!
More about the MBCs: https://www.eatg.org/events/margarita-breakfast-clubs-at-croi-2022/
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