Background: People living with HIV (PLWH) are now anticipated to have near-normal life expectancies. With increased longevity comes the higher burden of non-infectious comorbidities related to the chronic immune activation and premature telomere shortening in PLWH, ranging from dyslipidemia to osteoporosis [1]. Increased comorbidity burden can lead to polypharmacy, defined as the concurrent use of more than five medications, with the incidence rate of 15 to 39% among PLWH [2]. Frailty has also been shown to correlate with polypharmacy among PLWH in the US, with a possibility that polypharmacy may be a modifiable risk factor for frailty in this population [3]. Polypharmacy and frailty are correlated in persons living with HIV (PLWH) in the US, but little is known about their correlation in resource-limited settings. This study aims to examine the correlation between polypharmacy and frailty in an older Thai population of PLWH.
Methods: Our cross-sectional study evaluated the correlation between polypharmacy and frailty among Thai 324 virally-suppressed PLWH and 132 uninfected patients aged 50 and above between March 2016 and April 2017. PLWH were recruited from two HIV care centers in Bangkok, Thailand, while the uninfected population was recruited from a hospital center in Bangkok. Participants were all aged 50 or older and PLWH had been on ART for at least one year with a viral load less than 50 copies/mL and no active opportunistic infections.The primary predictor was the number of patient-reported non-ART medications at the time participants entered the study as identified by clinic electronic medical record and patient report. The outcome was having additional domains of the 5 Fried frailty phenotypes: grip strength, gait speed, unintentional weight loss, exhaustion, and decreased physical activity (0=normal, 1-2=pre-frail, >3=frail).
Results: Most participants were male (63% PLWH, 67% uninfected) with few comorbidities (1.4 for PLWH, 0.9 for uninfected) and small median number of non-ART medications (2 for PLWH, 1 for uninfected). Frailty was uncommon (8.6% PLWH, 3.8% uninfected). Each additional non-ART medication conferred 8% increased likelihood of having additional frailty domain among PLWH (95%CI: 0.03, 0.14, p=0.002) but was not statistically significant among the uninfected.
Conclusions: Even in relatively healthy older Thai PLWH, the association between polypharmacy and frailty remains at a similar magnitude found in patients with higher levels of multimorbidity in the US. Some limitations of the study include the possibility that the more frail PLWH were unable to be assessed in an ambulatory setting and underestimation of medications, as this was primarily assessed by self-report. The effect of polypharmacy was more pronounced in PLWH compared to those uninfected. With the pervasiveness of polypharmacy and frailty, future research should explore evidence-based guidelines towards systematic and safe deprescribing that may limit both polypharmacy and frailty among older PLWH.