In 2021, 38.4 million people were living with HIV and 28.7 million were accessing Antiretroviral Therapy (ART) globally.1 Due to the development of more effective and safe antiretroviral drugs as well as ART scale-up, the number of AIDS-related deaths decreased by 52% from 2010 to 2021.1 In Brazil, 960,000 people were living with HIV in 2021, with 700,000 on ART.2 The AIDS detection rate decreased from 22.5 to 16.5 cases per 100,000 inhabitants between 2011 and 2021.2

Although life expectancy has significantly improved for People living With HIV (PWH), disparities remain based on region, education, income level, and access to healthcare.3 Among 30,688 PWH from the Caribbean, Central and South America network for HIV epidemiology (CCASAnet), overall life expectancy increased from 31.0 (95% CI 29.3‒32.8) to 69.5 years (95% CI 67.2‒71.8) from 2003‒2008 to 2013‒2017.4 As a consequence, the older PWH population (defined as those aged 50-years or older) and aging-related health problems are both increasing. Prevalence of multiple comorbid conditions (multimorbidity) among older PWH is considerably higher compared to people of similar age not living with HIV in different cohorts, including in Brazil.5

The development of chronic and acute age-related diseases and physiological decline contribute to frailty.6 Frailty can be defined as a cumulative physiological decline over time, which impacts homeostatic regulation and health status.7 The concept of frailty involves physical, cognitive, social, emotional, and economic aspects.8 As other geriatric-related syndromes, frailty should be screened and assessed during PWH routine clinical care to prevent or reverse frailty process. Frailty-related syndromes among older PWH may impact their quality of life.9

Quality of life comprises several aspects, specifically functional capacity, socioeconomic level, social interaction, intellectual activity, family support and health status.10 Health-related Quality of Life (HQoL) is a dimension of quality of life that reflects the impact of disease and treatment on a person's ability to perform daily activities and affects biological, cognitive, and mental health aspects of wellbeing.

In Brazil, the COVID-19 pandemic has disproportionately impacted sexual and gender minorities, and socioeconomically marginalized populations, impacting health-related outcomes.11,12 We have previously reported that lower educational level and older age were associated with lower HQoL at Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), the largest cohort of PWH in Rio de Janeiro, Brazil.13 Moreover, the COVID-19 pandemic disrupted access to the HIV care continuum for PWH in this cohort, such as adequate care visits, viral load monitoring, and optimal medication possession ratio.14

In this study, we aimed to estimate the prevalence of frailty and pre-frailty among older PWH followed at INI-Fiocruz cohort, and to compare characteristics of this population according to the study assessment period (pre- or post-COVID-19 pandemic onset) and frailty status. Furthermore, we explored associations of HQoL with the study assessment period and frailty status.

From 1986 to 2022, 8998 PWH were included in the INI-Fiocruz cohort (Fig. 1). Of these, 5511 PWH were under follow-up and using ART in 2022; 35.9 % (n = 1979/5511) aged ≥ 50 years. Between March 2019 and May 2022, 252 individuals were evaluated and 250 were included in this study: 109 (43.6 %) pre- and 141 (56.4 %) post-COVID-19 pandemic onset. Two individuals were excluded due to MMSE score < 18 points.

Fig. 1.

Study flow-chart.

(0.16MB).

The median age among participants was 60 years (IQR: 55‒64), with 124 (49.6 %) aged 50‒59 years, 106 (42.4 %) 60‒69 years and 20 (8.0 %) ≥ 70 years (Table 1). Most participants self-identified as cisgender men 152 (60.8 %), while 11 (4.4 %) identified as transgender women. Most were Pardo or Black (n=146; 58.4 %), completed secondary education or less (n=181; 72.7 %), had low income (n=132; 52.8 %), with residence in Rio de Janeiro city (n=161; 64.4 %) and lived with someone (n=154; 61.6 %). Only 8 (3.2 %) participants were underweighting and 52 (20.8 %) were obese. Thirty (12.0 %) participants had cognitive problems according to MMSE score, 124 (49.6 %) reported binge drinking, 9 (3.6 %) any substance use, and 141 (56.7 %) ever smoked. Almost half (n=126; 50.4 %) were in DTG-based regimen and 215 (86.0 %) reported adequate ART adherence. A total of 53 (21.2 %) participants reported unintentional falls in the past 6 months; among them, 17 (32.1 %) reported more than one fall.

Compared to participants included pre-COVID-19 onset, those included post-COVID-19 pandemic were older (median age 61 years [IQR: 56‒65] vs. 57 years [IQR: 53‒62]; p < 0.001) and reported less substance use (1.4% vs. 6.4 %; p = 0.044). More participants were former smokers (45.4% vs. 32.1 %; p = 0.030), were on DTG-based regimen (56.7% vs. 42.2 %; p = 0.019), reported inadequate ART adherence (17.7% vs. 9.2 %; p = 0.053) and unintentional falls (27.0% vs. 13.8 %; p = 0.011).

Prevalence of frailty and pre-frailty were 9.2 % (95 % CI: 8.1‒10.3) and 61.6 % (95 % CI: 54.0‒69.2), respectively. Frailty status did not differ according to the COVID-19 inclusion period. We observed no association of evaluated variables with frailty, except for unintentional fall: 43.5 % for frailty, 20.1 % pre-frailty, and 16.4 % non-frailty (p = 0.019) (Table 2).

Overall, median HQoL scores varied from 66.7 for pain domain to 100 for labor functioning and social functioning (Table 3). Compared to participants included pre-COVID-19, those included post-COVID-19 had lower scores for general health perception (p = 0.002), physical functioning (p < 0.001), cognitive functioning (p = 0.010) and pain (p < 0.001).

Participants with frailty had lower HQoL scores compared to those with pre-frailty and non-frailty in all eight domains (p < 0.001) (Table 4). For participants with frailty, median HQoL scores varied from 37.5 (physical functioning) to 66.7 (social functioning and cognitive functioning). For participants with non-frailty, median HQoL scores varied from 75 (general health perception) to 100 (labor functioning and social functioning).

In this study, we estimated the prevalence of frailty and pre-frailty among older PWH in a large cohort from Rio de Janeiro, Brazil. HQoL was lower among older PWH with frailty compared to those with non-frailty and pre-frailty. HQoL was also lower among older PWH included in post-COVID-19 compared to pre-COVID-19 pandemic period for four out of eight HQoL domains. Our study increases the body of knowledge about aging and HIV and reinforces the importance of including frailty and HQoL during clinical assessment of older PWH.

The prevalence of frailty among older PWH in our study was similar to that estimated among 8556 older Brazilians included in the ELSI-Brasil study (9.0 %; 95 % CI: 8.0‒10.1)19 which also used Fried methodology to assess frailty.17 This result suggests similarities in the aging process of PWH being followed in our cohort compared to the overall population. Importantly, PWH followed at INI-Fiocruz have access to multidisciplinary care, including cardiology, neurology, physiotherapist, nutritionist, and social services. Previous studies among older PWH conducted in Brazil, France, Mexico and United States estimated frailty ranging from 2.9 % to 19.4 %.20,21,30,31 However, comparisons with other studies should take into consideration differences in methodologies to assess frailty, aging strata, and local settings. Frailty is potentially reversible if treated promptly when detected.32 Prevention of frailty among older PWH is paramount, especially among those with pre-frailty, which represented more than 60 % of our study population. Therefore, efforts to reverse or prevent frailty should be encouraged by health professionals. Public health systems should incorporate programs to promote lifestyle modifications encompassing more physical activities in daily routines including regular exercise and nutritional education among the aging population. Food insecurity, also shown to be associated with frailty among PWH33 and poor adherence to ART,34 should be taken into account by public health policy makers as well.

Our study confirmed the association between worse HQoL and frailty among PWH, as reported previously.20,35,36 The ACTG SF-21 instrument used measured eight HQoL domains.27 Other studies have also shown associations of frailty with the domains of HQoL evaluated here, including neurocognitive impairment association with increased risk of frailty in an observational cohort evaluating aging and HIV, the ACTG A5322 study.37 In a study conducted in Uganda, major depressive disorder was associated with decreasing mean grip strength,38 one of the domains used by Fried to estimate frailty. In another study conducted in France, pain was associated with frailty and pre-frailty.39

We observed worse HQoL among older PWH included post-COVID-19 compared to the pre-COVID-19 pandemic period in four QoL domains: general health perception, physical functioning, cognitive functioning, and pain. Although data were not collected longitudinally, some hypotheses can be inferred. First, individuals included in the post-pandemic period were older than those included pre-pandemic (median 61 [IQR: 56‒65] vs. 57 [IQR: 53‒62]), which may explain lower physical functioning and cognitive functioning. The COVID-19 pandemic led to an increase in psychological distress and negative emotions such as pessimism, which could have impacted participants’ perception of health and pain. These results underscore the importance of HQoL screening among older PWH, especially after the COVID-19 pandemic onset.

This study has limitations. We included a convenience sample of older PWH followed in an HIV cohort. However, our sample size (n = 237) was based on 2019 data showing that 35.5 % (n = 1615/4547) of PWH under follow-up at INI-Fiocruz cohort were 50 years or older and estimated the overall prevalence of frailty among older PWH as 19 %, as reported in a study conducted in Salvador, Brazil.40 Due to the cross-sectional design, causality and directionality could not be inferred. Most variables were self-reported, thus potentially subject to social desirability and recall biases.

Low prevalence of frailty and high prevalence of pre-frailty were observed among older PWH in our cohort. Frailty status did not differ according to the COVID-19 inclusion period. HQoL was lower among older PWH with frailty compared to those with non-frailty and pre-frailty, and among participants included post-COVID-19 compared to those pre-COVID-19. Assessment of frailty and HQoL should be incorporated in clinical practice for older PWH. Programs to reverse or prevent frailty should be implemented within the public health system.

BG, VGV and SWC are responsible for the INI-Fiocruz Cohort of People Living with HIV. TST, RE and SWC conceived and designed this study. TST, LG, LDF, RE and SWC designed the case report forms. DA, JSJ and FAM collected study data and performed frailty assessments. FL supervised data entry. TST did the statistical analyses and drafted this manuscript. SWC supervised the analysis and manuscript preparation. DA, JSJ, FAM, LG, LDF, RE, VGV, BG and SWC revised the manuscript for important intellectual content. All authors read and approved the final manuscript.

A complete deidentified dataset sufficient to reproduce the primary study findings will be made available upon request to the corresponding author, following approval of a concept sheet summarizing the analyses to be done.