Nearly one in five older people living with HIV showed signs of frailty in a Canadian study, and being single or lonely—but not having prior advanced immune suppression—increased the odds, according to research published in the journal AIDS.

Compared with their HIV negative peers, people living with HIV are more prone to health problems as they age. Regardless of HIV status, frailty is a common syndrome among older adults that carries an increased risk for poor health outcomes, including falls, cognitive impairment, disability, hospitalization and mortality. Signs of frailty include fatigue, low energy, weakness and reduced activity.

Alice Zhabokritsky, MD, of the University Health Network in Toronto, and colleagues, set out to assess the prevalence of frailty and associated risk factors among older adults living with HIV in Canada.

In particular, they looked at its association with nadir, or lowest-ever, CD4 T-cell count. Persistent immune dysregulation and chronic inflammation seem to play an important role in the development of frailty, the authors noted. Even when they are on effective antiretroviral treatment with viral suppression, people who had advanced immune suppression in the past may have lingering health consequences. Indeed, some prior studies of younger HIV-positive populations have seen a link between greater immune suppression and frailty.

“Advancements in treatment have resulted in improved survival among people living with HIV. However, additional years of life are not necessarily spent in good health, as frailty tends to develop at a younger age among people living with HIV,” the study authors wrote.

The researchers analyzed data from the Correlates of Healthy Aging in Geriatric HIV (CHANGE HIV) study, a Canadian cohort of HIV-positive people ages 65 years and older. Frailty was assessed using the Fried Frailty Phenotype, which includes unintentional weight loss, self-reported exhaustion, poor grip strength, slow walking speed and self-reported low physical activity. People who met three or more criteria were considered frail, and those meeting one or two criteria were deemed “pre-frail.”


The analysis included 439 participants with a median age of 69; 10% were women and 76% were white. All were on antiretroviral therapy, and most had viral suppression. The current median CD4 count was over 500, but the median nadir count was 200—the cutoff for an AIDS diagnosis. About one third were married or partnered, 65% were single (including those who were divorced or widowed) and 57% lived alone. Nearly 20% were living in poverty, and this group was more likely to be frail.

The overall prevalence of frailty was 17%. This is more than double the rate reported in a previous study of HIV-negative Canadians in the same age group, but similar to rates seen in prior studies of older people living with HIV. Another 62% were pre-frail. The likelihood of frailty increased with age, and women had a slightly higher prevalence than men. Time since HIV diagnosis and number of comorbidities were not significant risk factors.

Contrary to their hypothesis, the researchers did not see a significant increase in frailty among people with a lower nadir CD4 count. They acknowledged that “survivorship bias” may have contributed to this finding, meaning people who were more frail may not have lived to age 65.

However, after adjusting for other factors, people who had higher scores on a loneliness scale had a 25% greater likelihood of frailty, and those who were not in a relationship had about double the risk.

“While nadir CD4 count did not correlate with frailty, being single and lonely did, highlighting the importance of recognizing and addressing these social vulnerabilities among people aging with HIV,” the study authors concluded.

“Sadly, many long-term HIV survivors, especially older men who have sex with men, have lost partners during the early days of the HIV epidemic, which has had a long-lasting impact throughout their life course,” they wrote. “As the aging HIV population grows, discussions around where and how people will age with HIV are becoming more important. Recognizing that a large proportion of older adults living with HIV are single, divorced, or widowed (65% of our cohort), it is crucial to develop supports that would address loneliness in this population. This would allow people to age safely in their own homes and create opportunities to make supportive housing and long-term care facilities available and inclusive for persons living with HIV.”

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