ABSTRACT
This study aims to evaluate the prevalence of frailty syndrome and its relationship with lung function, functional capacity, and disease-related variables in HIV-infected patients. This is a cross-sectional and descriptive study, with quantitative data analysis. The sample consisted of individuals diagnosed with HIV/AIDS, without previous locomotion limitations. The frailty syndrome was evaluated by the frailty phenotype, punctuated in the following items: unintentional weight loss, fatigue, reduced gait speed, physical activity level, and hand grip strength. Pulmonary function and ventilatory muscle strength were assessed by spirometry and manovacuometry, while functional capacity was assessed by the six-minute walk test. Data analyses were performed with comparison tests, with a 5% significance level. All patients included in this study were scored on the frailty criterion. In total, 70% were fragile and 30% were classified as pre-fragile. There was a relation between impaired functional capacity, the prevalence of restrictive ventilatory disorder, and comorbidities in the fragile population when compared with the pre-fragile group. The findings of this study conclude that frailty syndrome affects the health of individuals with HIV/AIDS, with spirometry impairment, reduced functional capacity, and presence of comorbidities.
Keywords |
HIV Infections; Frailty;; Spirometry; Walk Test
RESUMO
O objetivo deste estudo foi avaliar a prevalência da síndrome da fragilidade e a sua relação com a função pulmonar, a capacidade funcional e as variáveis relacionadas à pacientes infectados pelo vírus HIV. Trata-se de um estudo transversal e descritivo, com análises quantitativas de dados. A amostra foi composta por indivíduos diagnosticados com HIV/AIDS e sem limitações prévias de locomoção. A síndrome da fragilidade foi avaliada pela aplicação do fenótipo da fragilidade, pontuado nos seguintes itens: perda de peso não intencional, fadiga, redução da velocidade da marcha, redução do nível de atividade física e redução da força de preensão palmar. A função pulmonar e a força muscular ventilatória foram avaliadas por meio de espirometria e manovacuometria. A capacidade funcional foi mensurada pelo teste de caminhada de seis minutos (TC6). A análise dos dados foi realizada com testes estatísticos de comparação, adotando-se o nível de significância de 5%. Todos os pacientes incluídos neste estudo encontravam-se dentro dos critérios de fragilidade. Destes, 70% eram frágeis e 30% pré-frágeis. Verificou-se uma relação entre o comprometimento da capacidade funcional, a prevalência de distúrbio ventilatório restritivo e a presença de comorbidades na população frágil comparado com a pré-frágil. Os achados deste estudo permitem a conclusão de que a síndrome da fragilidade impacta a saúde de indivíduos com HIV/AIDS, com comprometimento da espirometria, redução da capacidade funcional e presença de comorbidades.
Descritores |
Infecções por HIV; Fragilidade; Espirometria; Teste da Caminhada
RESUMEN
El objetivo de este estudio fue evaluar la prevalencia del síndrome de fragilidad y su relación con la capacidad pulmonar, la capacidad funcional y las variables relacionadas a pacientes infectados por el VIH. Este es un estudio transversal y descriptivo, con análisis de datos cuantitativos. La muestra estuvo constituida por personas diagnosticadas con VIH/SIDA y sin limitaciones previas de locomoción. Para evaluar el síndrome de fragilidad, se aplicó el fenotipo de fragilidad, que se puntuó en los siguientes ítems: pérdida de peso involuntaria, fatiga, reducción de la velocidad de la marcha, reducción del nivel de actividad física y reducción de la fuerza de agarre. La capacidad pulmonar y la fuerza de los músculos ventilatorios se evaluaron mediante espirometría y manovacuometría. La capacidad funcional se midió mediante la prueba de caminata de seis minutos (PC6). El análisis de los datos se realizó mediante pruebas de comparación estadística, adoptando un nivel de significancia del 5%. Todos los pacientes incluidos en este estudio se encontraban dentro de los criterios de fragilidad. De estos, el 70% eran frágiles y el 30% prefrágiles. Hubo una relación entre la capacidad funcional deteriorada, la prevalencia de trastorno ventilatorio restrictivo y la presencia de comorbilidades en la población frágil en comparación con la población prefrágil. Los hallazgos de este estudio muestran que el síndrome de fragilidad afecta la salud de las personas con VIH/SIDA, con deterioro de la espirometría, reducción de la capacidad funcional y presencia de comorbilidades.
Palabras clave |
Infecciones por VIH; Fragilidad; Espirometría; Prueba de Caminata
INTRODUCTION
The recognition of similarities between the clinical and the biological phenotypes of older adults and individuals infected with the HIV virus has increased the scientific interest in studying frailty syndrome (FS) (11. Desquilbet L, Jacobson LP, Fried LP, Phair JP, Jamieson BD, Holloway M, et al. HIV-1 infection is associated with an earlier occurrence of a phenotype related to frailty. J Gerontol A Biol Sci Med Sci. 2007;62(11):1279-86. doi: 10.1093/gerona/62.11.1279
https://doi.org/10.1093/gerona/62.11.127...
. The literature reports that 19% of HIV-infected patients may develop this syndrome22. Ianas V, Berg E, Mohler MJ, Wendel C, Klotz SA. Antiretroviral therapy protects against frailty in HIV-1 infection. J Int Assoc Provid AIDS Care. 2013;12(1):62-6. doi: 10.1177/1545109712457241
https://doi.org/10.1177/1545109712457241...
. The first study that investigated the relationship of FS with this population observed a strong association of viral infection with frailty11. Desquilbet L, Jacobson LP, Fried LP, Phair JP, Jamieson BD, Holloway M, et al. HIV-1 infection is associated with an earlier occurrence of a phenotype related to frailty. J Gerontol A Biol Sci Med Sci. 2007;62(11):1279-86. doi: 10.1093/gerona/62.11.1279
https://doi.org/10.1093/gerona/62.11.127...
. Subsequent studies showed a significant association with severe HIV infection, specifically related to low levels of CD4 and uncontrolled infection22. Ianas V, Berg E, Mohler MJ, Wendel C, Klotz SA. Antiretroviral therapy protects against frailty in HIV-1 infection. J Int Assoc Provid AIDS Care. 2013;12(1):62-6. doi: 10.1177/1545109712457241
https://doi.org/10.1177/1545109712457241...
),(33. Erlandson KM, Allshouse AA, Jankowski CM, Duong S, MaWhinney S, Kohrt WM, et al. Risk factors for falls in HIV-infected persons. J Acquir Immune Defic Syndr. 2012;61(4):484-9. doi: 10.1097/QAI.0b013e3182716e38
https://doi.org/10.1097/QAI.0b013e318271...
.
Frailty is a syndrome marked by a decrease in physiological reserve and greater vulnerability to stress, predisposing the individual to major adverse outcomes including hospitalization, institutionalization, disability, and death. Although FS is related to aging, it has been characterized as a distinct process from chronological age11. Desquilbet L, Jacobson LP, Fried LP, Phair JP, Jamieson BD, Holloway M, et al. HIV-1 infection is associated with an earlier occurrence of a phenotype related to frailty. J Gerontol A Biol Sci Med Sci. 2007;62(11):1279-86. doi: 10.1093/gerona/62.11.1279
https://doi.org/10.1093/gerona/62.11.127...
),(44. Piggott DA, Erlandson KM, Yarasheski KE. Frailty in HIV: epidemiology, biology, measurement, interventions, and research needs. Curr HIV/AIDS Rep. 2016;13(6):340-8. doi: 10.1007/s11904-016-0334-8
https://doi.org/10.1007/s11904-016-0334-...
)-(66. Richert L, Brault M, Mercié P, Dauchy FA, Bruyand M, Greib C, et al. Decline in locomotor functions over time in HIV-infected patients. AIDS. 2014;28(10):1441-9. doi: 10.1097/QAD.0000000000000246
https://doi.org/10.1097/QAD.000000000000...
.
The pathophysiological mechanisms responsible for the development of FS in HIV-infected patients are not yet clear. Piggott, Erlandson and Yarasheski (44. Piggott DA, Erlandson KM, Yarasheski KE. Frailty in HIV: epidemiology, biology, measurement, interventions, and research needs. Curr HIV/AIDS Rep. 2016;13(6):340-8. doi: 10.1007/s11904-016-0334-8
https://doi.org/10.1007/s11904-016-0334-...
and Walston et al. (55. Walston J, Hadley EC, Ferrucci L, Guralnik JM, Newman AB, Studenski SA, et al. Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. J Am Geriatr Soc. 2006;54(6):991-1001. doi: 10.1111/j.1532-5415.2006.00745.x
https://doi.org/10.1111/j.1532-5415.2006...
) present hypotheses regarding FS in people with HIV, considering that HIV infection and the use of antiretroviral therapy may contribute to the emergence of molecular alterations, comorbidities, psychosocial, and behavioral changes. Such disorders are closely related to altered energy metabolism, chronic inflammation status, immune system activation, and neuroendocrine dysfunction-whose release of inflammatory mediators contribute to the development of insulin resistance, lipodystrophy/obesity, sarcopenia, anorexia, osteoporosis, cognitive impairment, anemia, and thrombophilia44. Piggott DA, Erlandson KM, Yarasheski KE. Frailty in HIV: epidemiology, biology, measurement, interventions, and research needs. Curr HIV/AIDS Rep. 2016;13(6):340-8. doi: 10.1007/s11904-016-0334-8
https://doi.org/10.1007/s11904-016-0334-...
),(55. Walston J, Hadley EC, Ferrucci L, Guralnik JM, Newman AB, Studenski SA, et al. Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. J Am Geriatr Soc. 2006;54(6):991-1001. doi: 10.1111/j.1532-5415.2006.00745.x
https://doi.org/10.1111/j.1532-5415.2006...
.
As a result, these patients may experience reduced gait speed, muscle weakness, weight loss, and fatigue. The set of these aspects may lead to mobility limitations, impairment of functional capacity, increased number of falls, social isolation, and hospitalizations44. Piggott DA, Erlandson KM, Yarasheski KE. Frailty in HIV: epidemiology, biology, measurement, interventions, and research needs. Curr HIV/AIDS Rep. 2016;13(6):340-8. doi: 10.1007/s11904-016-0334-8
https://doi.org/10.1007/s11904-016-0334-...
.
Recent studies have shown a growing interest regarding frailty syndrome in HIV-infected individuals due to the high disability of affected patients11. Desquilbet L, Jacobson LP, Fried LP, Phair JP, Jamieson BD, Holloway M, et al. HIV-1 infection is associated with an earlier occurrence of a phenotype related to frailty. J Gerontol A Biol Sci Med Sci. 2007;62(11):1279-86. doi: 10.1093/gerona/62.11.1279
https://doi.org/10.1093/gerona/62.11.127...
),(55. Walston J, Hadley EC, Ferrucci L, Guralnik JM, Newman AB, Studenski SA, et al. Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. J Am Geriatr Soc. 2006;54(6):991-1001. doi: 10.1111/j.1532-5415.2006.00745.x
https://doi.org/10.1111/j.1532-5415.2006...
. To date, studies relating FS and HIV infection in the Brazilian population are scarce. Most studies only address FS in relation to aspects of the disease, time of diagnosis, CD4 levels, and presence of comorbidities. The influence of frailty on functional capacity and pulmonary function in HIV individuals is still little explored33. Erlandson KM, Allshouse AA, Jankowski CM, Duong S, MaWhinney S, Kohrt WM, et al. Risk factors for falls in HIV-infected persons. J Acquir Immune Defic Syndr. 2012;61(4):484-9. doi: 10.1097/QAI.0b013e3182716e38
https://doi.org/10.1097/QAI.0b013e318271...
),(66. Richert L, Brault M, Mercié P, Dauchy FA, Bruyand M, Greib C, et al. Decline in locomotor functions over time in HIV-infected patients. AIDS. 2014;28(10):1441-9. doi: 10.1097/QAD.0000000000000246
https://doi.org/10.1097/QAD.000000000000...
)-(88. Campo M, Oursler KK, Huang L, Goetz MB, Rimland D, Hoo GS, et al. Association of chronic cough and pulmonary function with 6-minute walk test performance in HIV infection. J Acquir Immune Defic Syndr. 2014;65(5):557-63. doi: 10.1097/QAI.0000000000000086
https://doi.org/10.1097/QAI.000000000000...
.
Thus, this study aims to evaluate the presence of frailty in individuals with HIV/AIDS and to understand its relationship with pulmonary function, functional capacity, and disease-related variables.
METHODOLOGY
This is a cross-sectional and descriptive study conducted at the Infectious Diseases Outpatient Clinic of the Hospital Dia Professora Esterina Corsini da Universidade Federal de Mato Grosso do Sul (UFMS), in Campo Grande (MS), Brazil. This study was approved by the Research Ethics Committee of the Universidade Federal de Mato Grosso do Sul, opinion No. 1.086.017.
The study included individuals diagnosed with HIV/AIDS, older than 18 years old, of both sexes, oriented, responsive and clinically stable, without cognitive impairment, without medical contraindication to perform efforts, absence of motor limitations that interfered in locomotion or other clinical conditions that could be worsened by physical exertion. Hospitalized patients and those who were unable to attend the evaluation were excluded.
Initially, the researchers analyzed the patients’ medical records. The individuals were invited to participate in the study, after reading and signing the informed consent form. Next, the evaluations were performed, divided into two moments: at first, anamnesis and anthropometric evaluation were performed; levels of viral load (VL) and CD4 T lymphocytes were collected; the international physical activity questionnaire (IPAQ) and the Center for Epidemiological Studies - Depression (CES-D) scale were applied; pulmonary function and respiratory muscle strength were also evaluated. In the second moment, the six-minute walk test (6MWT), gait speed test, and hand dynamometry were performed. Data collection was divided in these two moments due to the possibility of stress tests causing fatigue and interfering in the results.
References proposed by the Brazilian Ministry of Health99. Ministério da Saúde (BR). Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: Ministério da Saúde, 2013. were used to evaluate viral load and CD4 T-cell count. Regarding the pulmonary function and respiratory muscle strength test, spirometry and manovacuometry were performed (maximal inspiratory pressure, MIP, and maximal expiratory pressure, MEP).
The pulmonary function test was performed using the IQTeQ spirometer®, following the recommendations for test standardization of the American Thoracic Society (ATS) (1010. American Thoracic Society. Lung function testing: selection of reference values and interpretative strategies. Am Rev Respir Dis. 1991;144(5):1202-18. doi: 10.1164/ajrccm/144.5.1202
https://doi.org/10.1164/ajrccm/144.5.120...
. The evaluated parameters were compared with the predicted values for the Brazilian population1111. Duarte AAO, Pereira CAC, Rodrigues SCS. Validation of new brazilian predicted values for forced spirometry in caucasians and comparison with predicted values obtained using other reference equations. J Bras Pneumol. 2007;33(5):527-35.. The evaluation of MIP and MEP (manovacuometry) was performed with the MVD300 - Globalmed®, equipped with a mouth adapter and an escape valve1212. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol. 2002;28(Supl 3):S155-65.. The method and the normality references respected the description of Neder et al. (1313. Neder JA, Andreoni S, Lerario MC, Nery LE. NeryReference values for lung function tests. I. Static volumes. Braz J Med Biol Res. 1999;32(6):703-17.. To evaluate functional capacity (FC), the 6MWT was used, respecting the ATS guideline 1414. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7. doi: 10.1164/ajrccm.166.1.at1102
https://doi.org/10.1164/ajrccm.166.1.at1...
and following the parameters of normality in the Brazilian population1515. Britto RR, Probst VS, Andrade AFD, Samora GAR, Hernandes NA, Marinho PEM, et al. Reference equations for the six-minute walk distance based on a Brazilian multicenter study. Braz J Phys Ther. 2013;17(6):556-63. doi: 10.1590/S1413-35552012005000122
https://doi.org/10.1590/S1413-3555201200...
.
The FS was evaluated by applying the frailty phenotype (FP) (1616. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. doi: 10.1093/gerona/56.3.m146
https://doi.org/10.1093/gerona/56.3.m146...
, in which the following items were verified: unintentional weight loss, muscle weakness, exhaustion report, low level of physical activity, and decreased gait speed. Individuals who presented three or more components of the phenotype were classified as fragile. Those with one or two components were classified as pre-fragile and those with no phenotype components were classified as non-fragile. The item ‘weight loss’ was evaluated by questioning individuals regarding the unintentional loss of 4.5 kg or more than 5% of body weight in the last 12 months (without diet or exercise). To verify exhaustion, two CES-D1717. Batistoni SST, Neri AL, Cupertino AP. Validade e confiabilidade da versão brasileira da center for epidemiological scale - depression (CES-D) em idosos brasileiros. Psico USF. 2010;15(1):13-22.) questions were applied: “I felt that I had to make an effort to do usual tasks” and “I could not carry on my things.” Participants who scored 2 or 3 for either of the two questions, scored on the frailty criterion1616. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. doi: 10.1093/gerona/56.3.m146
https://doi.org/10.1093/gerona/56.3.m146...
.
The level of physical activity of the participants was measured using the short version of the IPAQ questionnaire1818. Benedetti TRB, Antunes PC, Rodriguez-Añez CR, Mazo GZ, Petroski EL. Reprodutibilidade e validade do Questionário Internacional de Atividade Física (IPAQ) em homens idosos. Rev Bras Med Esporte. 2007;13(1):11-6.. Individuals classified as sedentary or insufficiently active scored on the frailty criterion.
Muscle strength was evaluated by measuring hand grip strength, in Kgf, with a Saehan® dynamometer. The test was performed according to the method proposed by Fess1919. Fess, EE. Documentation: essential elements of an upper extremity assessment battery. In: Hunter JM, Mackin EJ, Callahan AD. Rehabilitation of the hand: surgery and therapy. 4th ed. St. Louis: Mosby; 1995.. The final result was obtained by calculating the arithmetic mean of the three recorded values and comparing them with the reference value, according to sex and age2020. Bohannon, RW. Dynamometer measurements of hand-grip strength predict multiple outcomes. Percept Mot Skills. 2002;93(2):323-8. doi: 10.2466/pms.2001.93.2.323
https://doi.org/10.2466/pms.2001.93.2.32...
. The walking speed was evaluated by the time the patient spent to travel the distance of 4.6m on flat ground. Speed greater than 0.80m/s was considered “preserved gait speed2121. Abellan van Kan G, Rolland Y, Andrieu S, Bauer J, Beauchet O, Bonnefoy M, et al. Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an international academy on nutrition and aging (IANA) task force. J Nutr Health Aging. 2009;13(10):881-9. doi: 10.1007/s12603-009-0246-z
https://doi.org/10.1007/s12603-009-0246-...
.”
This study was carried out in compliance with the guidelines of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) (2222. Malta M, Cardoso LO, Bastos FI, Magnanini MMF, da Silva CMFP. Iniciativa STROBE: subsídios para a comunicação de estudos observacionais. Rev Saúde Pública. 2010;44(3):559-65. - as appropriate for cross-sectional observational epidemiological studies. For result analysis, data were submitted to descriptive statistical analysis, followed by tests of association with the chi-square test for categorical variables; Student’s t-test or Mann-Whitney test were used to compare the continuous variables. The adopted significance level was 5% (p<0.05).
RESULTS
In total, 35 patients were screened in the study. Out of these, five were excluded: four did not show up at the second moment of evaluation and one presented difficulty in locomotion. Out of the 30 patients who completed the study, 27 were male and three female, with a mean age of 41±11 years. Table 1 presents the sample characterization.
Regarding viral load and CD4 T levels, visualized in Table 2, the groups showed similar results.
Regarding the spirometry report, the two groups were statistically different, with predominance of restrictive ventilatory defect (RVD) in fragile individuals. The mean MIP value in the pre-fragile group was −103.5±33.45cmH2O and, in the fragile group, −103.28±46.67cmH2O. The MEP values between groups were, respectively, 110.5±26.5cmH2O and 97.5±27.5cmH20. In this comparison, there was no statistically significant difference between the two studied groups. When analyzing FC, the groups were different: a greater impairment was found in individuals considered fragile (Table 3).
DISCUSSION
A high prevalence of frailty was observed in the studied individuals. To date, few studies address frailty in the Brazilian population with HIV/AIDS. Recent studies suggest that HIV-infected individuals have reduced physical function and are at higher risk of frailty2323. Shah K, Hilton TN, Myers L, Pinto JF, Luque AE, Hall WJ. A new frailty syndrome: Central obesity and frailty in older adults with the human immunodeficiency virus. J Am Geriatr Soc. 2012;60(3):545-9. doi: 10.1111/j.1532-5415.2011.03819.x
https://doi.org/10.1111/j.1532-5415.2011...
),(2424. Righetto RC, Reis RK, Reinato LAF, Gir E. Comorbidades e coinfecções em pessoas vivendo com HIV/Aids. Rev Rene. 2014;15(6):942-8. doi: 10.15253/2175-6783.2014000600006
https://doi.org/10.15253/2175-6783.20140...
. In fact, some patients infected with the virus manifested characteristics of frailty at a much younger age compared with non-infected patients2323. Shah K, Hilton TN, Myers L, Pinto JF, Luque AE, Hall WJ. A new frailty syndrome: Central obesity and frailty in older adults with the human immunodeficiency virus. J Am Geriatr Soc. 2012;60(3):545-9. doi: 10.1111/j.1532-5415.2011.03819.x
https://doi.org/10.1111/j.1532-5415.2011...
.
The presence of co-infections and comorbidities was higher in fragile individuals in our study. The statistical difference, however, remained only in the comorbidity variable. Some studies have shown that such complications can occur both in young patients and older adults2424. Righetto RC, Reis RK, Reinato LAF, Gir E. Comorbidades e coinfecções em pessoas vivendo com HIV/Aids. Rev Rene. 2014;15(6):942-8. doi: 10.15253/2175-6783.2014000600006
https://doi.org/10.15253/2175-6783.20140...
),(2525. John M. The clinical implications of HIV infection and aging. Oral Dis. 2016;22(Suppl 1):79-86. doi: 10.1111/odi.12473
https://doi.org/10.1111/odi.12473...
.
Although the literature has associated the occurrence of frailty in HIV with low levels of CD4, clinical control of the disease, and high levels of CV22. Ianas V, Berg E, Mohler MJ, Wendel C, Klotz SA. Antiretroviral therapy protects against frailty in HIV-1 infection. J Int Assoc Provid AIDS Care. 2013;12(1):62-6. doi: 10.1177/1545109712457241
https://doi.org/10.1177/1545109712457241...
, this association between physical function and CD4+ lymphocyte count may be controversial. Some suggest that clinical classification is more important than laboratory classification to determine physical disability in AIDS2626. O'Dell MW, Crawford A, Bohi ES, Bonner FJ Jr. Disability in persons hospitalized with AIDS. Am J Phys Med Rehabil. 1991;70(2):91-5. doi: 10.1097/00002060-199104000-00008
https://doi.org/10.1097/00002060-1991040...
.
Since the introduction of ART, some studies have reported predominance of chronic respiratory diseases. However, it is difficult to determine to what extent HIV infection interferes with this finding; it may be due to patients’ longevity increase, since the introduction of ART. The association of HIV with smoking can also contribute to the increased prevalence of respiratory diseases77. Gingo MR, George MP, Kessinger CJ, Lucht L, Rissler B, Weinman R, et al. Pulmonary function abnormalities in HIV-infected patients during the current antiretroviral therapy era. Am J Respir Crit Care Med. 2010;182(6):790-6. doi: 10.1164/rccm.200912-1858OC
https://doi.org/10.1164/rccm.200912-1858...
.
Restrictive ventilatory disorders were predominant. The findings in the literature regarding pulmonary function of people with HIV are limited in relation to the extent and types of abnormalities77. Gingo MR, George MP, Kessinger CJ, Lucht L, Rissler B, Weinman R, et al. Pulmonary function abnormalities in HIV-infected patients during the current antiretroviral therapy era. Am J Respir Crit Care Med. 2010;182(6):790-6. doi: 10.1164/rccm.200912-1858OC
https://doi.org/10.1164/rccm.200912-1858...
, still, most studies report a predominance of obstructive ventilatory disorders88. Campo M, Oursler KK, Huang L, Goetz MB, Rimland D, Hoo GS, et al. Association of chronic cough and pulmonary function with 6-minute walk test performance in HIV infection. J Acquir Immune Defic Syndr. 2014;65(5):557-63. doi: 10.1097/QAI.0000000000000086
https://doi.org/10.1097/QAI.000000000000...
),(2727. Crothers K, Butt AA, Gibert CL, Rodriguez-Barradas MC, Crystal S, Justice AC, et al. Increased COPD among HIV-positive compared to HIV-negative veterans. Chest. 2006;130(5):1326-33. doi: 10.1378/chest.130.5.1326
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),(2828. George MP, Kannass M, Huang L, Sciurba FC, Morris A. Respiratory symptoms and airway obstruction in HIV-infected subjects in the HAART era. PLoS One. 2009;4(7):e6328. doi: 10.1371/journal.pone.0006328
https://doi.org/10.1371/journal.pone.000...
. However, due to the high occurrence of respiratory co-infections in people with AIDS and the simultaneous existence of chronic respiratory diseases and/or smoking, it is difficult to describe the real respiratory effects of HIV infection. A probable explanation for our findings was the low prevalence of smokers in the studied sample.
Regarding respiratory muscle strength, no statistically significant difference was observed between the groups. However, studies suggest that respiratory muscle impairment in HIV can occur due to three main factors: (1) HIV infection itself; (2) side effects caused by prolonged ART use; or (3) metabolic and infectious processes, and vasculitis 2929. Fernandes TAB, Trombeta A, Fraga JCS, Vieira RC Jr, Prestes J, et al. Efeitos do treinamento físico combinado realizado na intensidade do limiar anaeróbio sobre a composição corporal e sistema imune de sujeitos com HIV. Rev Bras Ciênc Mo-v. 2013;21(4):5-12.),(3030. Brito CJ, Mendes EL, Bastos AA, Nóbrega OT, Paula SO, Córdova C. O papel do exercício na era da terapia anti-retroviral fortemente ativa. Rev Bras Ciênc Mov. 2010;18(4):109-16.. Of the three mentioned hypotheses, mitochondrial toxicity, reduced oxidative enzyme activity, increased production of reactive oxygen species and lipodystrophy occurrence directly interfere with cardiorespiratory function2929. Fernandes TAB, Trombeta A, Fraga JCS, Vieira RC Jr, Prestes J, et al. Efeitos do treinamento físico combinado realizado na intensidade do limiar anaeróbio sobre a composição corporal e sistema imune de sujeitos com HIV. Rev Bras Ciênc Mo-v. 2013;21(4):5-12.)-(3131. Ortmeyer HK, Ryan AS, Hafer-Macko C, Oursler KK. Skeletal muscle cellular metab-olism in older HIV-infected men. Physiol Rep. 2016;4(9):e12794. doi: 10.14814/phy2.12794
https://doi.org/10.14814/phy2.12794...
. The sample size of this research may have been a limiting factor to study muscle impairment related to HIV infection.
The FC (assessed through the 6MWT) was more clearly compromised in the fragile group. HIV infection is prone to involve multiple organs and systems, producing a wide variety of debilitating conditions that can compromise patients’ functional independence-this is especially true when considering the number of neurological, neuromuscular, cardiac and pulmonary complications associated with symptomatic HIV infection2626. O'Dell MW, Crawford A, Bohi ES, Bonner FJ Jr. Disability in persons hospitalized with AIDS. Am J Phys Med Rehabil. 1991;70(2):91-5. doi: 10.1097/00002060-199104000-00008
https://doi.org/10.1097/00002060-1991040...
.
The physical weakness resulting from the disease can compromise the patients’ independence, their professional life and productivity, generating social and economic problems2626. O'Dell MW, Crawford A, Bohi ES, Bonner FJ Jr. Disability in persons hospitalized with AIDS. Am J Phys Med Rehabil. 1991;70(2):91-5. doi: 10.1097/00002060-199104000-00008
https://doi.org/10.1097/00002060-1991040...
. However, few studies have addressed functional disability and/or the evolution of functional performance according to the time since diagnosis3232. Terzian AS, Holman S, Nathwani N, Robison E, Weber K, Young M, et al. Factors associated with preclinical disability and frailty among HIV-infected and HIV-uninfected women in the era of cART. J Womens Health (Larchmt). 2009;18(12):1965-74. doi: 10.1089/jwh.2008.1090
https://doi.org/10.1089/jwh.2008.1090...
)-(3434. Richert L, Dehail P, Mercié P, Dauchy FA, Bruyand M, Greib C, et al. High frequency of poor locomotor performance in HIV-infected patients. AIDS. 2011;25(6):797-805. doi: 10.1097/QAD.0b013e3283455dff
https://doi.org/10.1097/QAD.0b013e328345...
. Richert et al. (66. Richert L, Brault M, Mercié P, Dauchy FA, Bruyand M, Greib C, et al. Decline in locomotor functions over time in HIV-infected patients. AIDS. 2014;28(10):1441-9. doi: 10.1097/QAD.0000000000000246
https://doi.org/10.1097/QAD.000000000000...
longitudinally evaluated FC, locomotion, and muscle performance of the lower limbs of 354 people with HIV. The authors concluded that lower limbs muscle performance and functional capacity were compromised and associated with falls. These results suggest that motor alterations are of clinical relevance in the studied profile; however, unlike our study, these individuals were not evaluated by the frailty phenotype.
An intervention study3535. Brown D, Claffey A, Harding R. Evaluation of a physiotherapy-led group rehabilitation intervention for adults living with HIV: referrals, adherence and outcomes. AIDS Care. 2016;28(12):1495-505. doi: 10.1080/09540121.2016.1191611
https://doi.org/10.1080/09540121.2016.11...
, performed in a rehabilitation program for HIV patients, evaluated the performance in the 6MWT, flexibility, upper limbs strength, and quality of life upon admission. Out of the 20, seven (35% of the sample) were unable to complete the 6MWT.
Erlandson et al. (3636. Erlandson KM, Allshouse AA, Jankowski CM, MaWhinney S, Kohrt WM, Campbell TB. Functional impairment is associated with low bone and muscle mass among persons aging with HIV-Infection. J Acquir Immune Defic Syndr. 2013;63(2):209-15. doi: 10.1097/QAI.0b013e318289bb7e
https://doi.org/10.1097/QAI.0b013e318289...
) reported that moderate functional impairment is common among middle-aged HIV-infected individuals. The FC was analyzed with three instruments: (1) evaluation of the frailty phenotype, (2) physical performance test and (3) the 400m walking test. Another study3737. Sims Sanyahumbi AE, Hosseinipour MC, Guffey D, Hoffman I, Kazembe PN, McCrary M, et al. HIV-infected children in Malawi have decreased performance on the 6-minute walk test with preserved cardiac mechanics regardless of antiretroviral treatment status. Pediatr Infect Dis J. 2017;36(7):659-64. doi: 10.1097/INF.0000000000001540
https://doi.org/10.1097/INF.000000000000...
with HIV-infected children, resulted in a worst performance in the 6MWT when compared with non-infected children, and the highest percentage of CD4 was associated with longer distances covered in the test.
Our study has limitations, such as the small sample. Data collection presented some issues due to the need to perform the tests at two different moments, the specificity of the population, and a short collection period. However, it is worth mentioning that this study was one of the first to investigate the association between HIV infection and frailty syndrome in a Brazilian sample.
CONCLUSION
Frailty syndrome affected all HIV-infected individuals. Fragile participants had greater impact on spirometry, functional capacity, and comorbidities, without association with the variables related to HIV infection.
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32Terzian AS, Holman S, Nathwani N, Robison E, Weber K, Young M, et al. Factors associated with preclinical disability and frailty among HIV-infected and HIV-uninfected women in the era of cART. J Womens Health (Larchmt). 2009;18(12):1965-74. doi: 10.1089/jwh.2008.1090
» https://doi.org/10.1089/jwh.2008.1090 -
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34Richert L, Dehail P, Mercié P, Dauchy FA, Bruyand M, Greib C, et al. High frequency of poor locomotor performance in HIV-infected patients. AIDS. 2011;25(6):797-805. doi: 10.1097/QAD.0b013e3283455dff
» https://doi.org/10.1097/QAD.0b013e3283455dff -
35Brown D, Claffey A, Harding R. Evaluation of a physiotherapy-led group rehabilitation intervention for adults living with HIV: referrals, adherence and outcomes. AIDS Care. 2016;28(12):1495-505. doi: 10.1080/09540121.2016.1191611
» https://doi.org/10.1080/09540121.2016.1191611 -
36Erlandson KM, Allshouse AA, Jankowski CM, MaWhinney S, Kohrt WM, Campbell TB. Functional impairment is associated with low bone and muscle mass among persons aging with HIV-Infection. J Acquir Immune Defic Syndr. 2013;63(2):209-15. doi: 10.1097/QAI.0b013e318289bb7e
» https://doi.org/10.1097/QAI.0b013e318289bb7e -
37Sims Sanyahumbi AE, Hosseinipour MC, Guffey D, Hoffman I, Kazembe PN, McCrary M, et al. HIV-infected children in Malawi have decreased performance on the 6-minute walk test with preserved cardiac mechanics regardless of antiretroviral treatment status. Pediatr Infect Dis J. 2017;36(7):659-64. doi: 10.1097/INF.0000000000001540
» https://doi.org/10.1097/INF.0000000000001540
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3
Funding source: nothing to declare
Publication Dates
-
Publication in this collection
18 June 2021 -
Date of issue
Jan-Mar 2021
History
-
Received
19 Sept 2019 -
Accepted
05 Feb 2020