Our study adds to the growing number of reports on the burden and determinants of frailty in low- and middle-income countries. In this study, the prevalence of frailty was significantly higher in OALWH (23.9%; 95% CI 18.8–29.6) compared to their uninfected peers (12.8%; 95% CI 8.3–18.7); however, HIV seropositivity was not significantly associated with frailty after adjusting for biopsychosocial factors. To our knowledge, there have been only two previous studies of frailty among OALWH in SSA. The first one, a cross-sectional sample of 145 OALWH (67% female) on ART and a median age of 57 years in Tanzania, reported a low prevalence of frailty (2.8%) (48). The other one, a population-based cohort of 614 older adults (292 OALWH) in South Africa, reported a frailty prevalence of 17.7% in OALWH compared to 14.7% in their uninfected peers (49). The variations in frailty prevalence could partly be attributed to differences in frailty measurement and the fact that older adults are a highly heterogeneous group, having different genetic backgrounds, medical profiles, and biological, as well as social environmental factors at different stages of life, thus highlighting the need for country-specific frailty data using tools validated within the country or region of interest. Our finding of a higher prevalence of frailty in OALWH than their uninfected peers is consistent with previous evidence, which has demonstrated both higher frequency of frailty in OALWH and the development of frailty at earlier ages for OALWH than for individuals without HIV (17). Many factors may predispose OALWH to elevated rates of frailty, including the effects of persistent inflammation from HIV (even in well-controlled viraemia), toxic effects of earlier cART regimens, delayed initiation of ART, and higher rates of multimorbidity (50).
Literature suggests that it is a constellation of environmental, disease-specific, and biological factors that contribute to frailty (17, 24–33), though most of the evidence is concentrated in HICs. In the present study, the factors significantly associated with frailty were predominantly psychosocial, many of which are potentially modifiable with appropriate programs and interventions. Consistent with previous studies (33, 51), our study showed that sleeping difficulties were associated with higher odds of frailty in OALWH and their uninfected peers. Sleep problems may impact frailty in numerous ways, including decreased energy expenditure, elevated inflammatory response, disturbed hormonal pathways, tissue growth and repair (51). These mechanisms may explain the associations observed. Interventions targeting sleeping problems – such as exercise and mindfulness-based stress reduction, may have potential clinical implications for both OALWH and their uninfected peers.
Increasing ageism scores were also significantly associated with elevated odds of frailty in OALWH in our study. Ageism, commonly conceptualized as the stereotyping, prejudice and discrimination against people based on age, is becoming increasingly important in older adults (52). Very few studies have examined the possible association between frailty and ageism. Our finding is consistent with the limited previous research that does exist (53). Persistent exposure to ageism could lead to internalization of the ageist messages by the OALWH, thus becoming part of their unconscious beliefs. In some cases, the adults may act subconsciously to fulfil the ageist stereotypes, even if detrimental to their health and wellbeing, e.g., physiologic stress response, physical functioning performance, which may influence frailty.
A higher waist/hip ratio was also significantly associated with elevated odds of frailty among OALWH in our study, consistent with previous findings of a positive association between central/abdominal obesity and frailty (54, 55). As HIV infection has become a manageable chronic illness, it has been progressively accompanied by a growing prevalence of overweight and obesity (56). Moreover, long-term treatment with cART may contribute to lipodystrophy, often characterized by fat redistribution with a relative increase in abdominal fat (57). Lipid depositions and infiltration in muscle fibre may bring about frailty by decreasing mobility and increasing loss of muscle strength. Interventions to minimize obesity and sedentary behaviour could potentially be beneficial in addressing frailty.
Visiting traditional healers was significantly associated with an elevated odds of frailty among OALWH in our study. We are not aware of previous research that has examined this relationship. Plausibly, frail individuals visit the healers to have their frailty symptoms addressed, especially when the primary care services fail to address these concerns. A previous qualitative exploration of the health and wellbeing of OALWH in the study setting has linked seeking help or treatment from traditional and certain faith healers with poor health outcomes, including defaulting HIV treatment and unsuppressed viral load (58). Healthcare providers have a reason to be concerned, given the observed impacts of untreated or improperly treated HIV on the development of frailty among OALWH.
Only two HIV-related factors were associated with elevated odds of frailty in our sample: a history of cART regimen change/interruption and prolonged illness following HIV diagnosis. These factors may be indicators of virological failure, ART toxicity or late HIV diagnosis, commonly associated with poorer health outcomes and risk of severe disease. Indeed, previous research has revealed an independent positive association between AIDS diagnosis, viral-load non-suppression, low CD4 count and frailty (17, 59). Many of the OALWH who have lived with HIV for several years may be significantly impacted by the legacy of the early years of the epidemic, thus predisposing them to a heightened risk of frailty. These adults will more likely require additional support to successfully manage the challenges of ageing with HIV.
Several social factors, e.g. social isolation, social networks, socioeconomic status, social support, social engagement, and social capital, have the potential to influence the health of older adults (60). In our study, higher monthly household income, residence in a larger household, and having a social network of close friends were all associated with reduced odds of frailty among OALWH, thus confirming previous research (17, 31) and highlighting the importance of promoting positive social factors to aid healthy ageing in older adults living with HIV. These factors may have both direct and indirect effects on frailty, e.g., food security, energy expenditure, and better health-seeking behaviours.
Physical activities have the potential to promote physical function, prevent falls and improve general health, hence delaying the onset and progression of frailty. In our study, participating in light physical activities such as walking was associated with reduced odds of frailty among OALWH, confirming previous research [88]. Exercise may also have positive effects on obesity, stress, loneliness in the case of group activities and muscular strength, which have been identified as potential risk factors for incidence of frailty. However, light physical activities were associated with elevated odds of frailty among the HIV uninfected older adults in our study. This was a surprise finding, inconsistent with previous investigations (61–63). This warrants more exploration in the study setting.
Self-reported diabetes was also associated with higher odds of frailty among HIV uninfected older adults in our study, consistent with previous reports (64). Prospective evidence suggests that unhealthy behaviours and obesity may partly explain the association, and to a larger extent, by poor glucose control and altered serum lipid profile among individuals with diabetes, suggesting that diabetes nutritional therapy may reduce the risk of frailty (64). Individuals with diabetic neuropathy are particularly at an increased risk of early onset frailty (65). Prevention programmes in the pre-frail states through appropriate exercise, nutrition and glycemic control may delay the development of frailty in these adults.
Similar to previous studies, this study showed that males are less likely to be frail than females, suggesting that being male is a protective factor against frailty (24). Differences in physical activity, muscle mass and higher fat percentages may explain gender discrepancies in frailty. Still, our observation may be related to social stigma of males appearing/acting/reporting weakness, that is social preference bias, given the self-reported nature of the construct.
Implications
The prevalence of frailty in this study was relatively high for both OALWH and their uninfected peers. Preventing, delaying, or treating frailty is more critical in this setting, given its high burden and the fact that frailty is a known predictor of future disability and dependency. Within the clinical practice, an easy-to-use frailty score will allow the easy identification of those at risk, thus allowing planning of future health and social care needs of these adults. Our study also highlighted some of the correlates of frailty in this setting. Many of the factors identified, such as sleeping difficulties, social engagement, ageism, and visiting traditional healers, are potentially modifiable with appropriate programs. Our findings provide the foundation needed for developing culturally appropriate interventions and healthcare strategies to prevent, delay and manage frailty and its consequences to improve the health and functional status of older adults at risk of frailty. Individual, community-based, or clinic-based interventions such as comprehensive geriatric assessment, physical activity, promoting social engagement, addressing discrimination, and proper management of comorbidities, e.g., diabetes may benefit older adults. Wider public health approaches, including proactive testing of older adults to avoid late diagnosis and advanced immunosuppression, will benefit OALWH. Our results also highlight the need for well-designed prospective studies to establish the incidence, pathophysiology, predictors of transition and outcomes of frailty in this population and assess potential interventions.
Strengths and limitations
Our study is among the very few reports on frailty in SSA and the first one in Kenya. It extends the existing evidence base regarding the prevalence and correlates of frailty in low-resource settings like Kenya. A further strength is the use of a relatively large sample size of people ≥ 50 years living with HIV and the inclusion of a community-based comparison group which enabled us to give a detailed profile of frailty in this population. We also collected detailed information on sociodemographic, physical, lifestyle and psychological factors, which helped us examine the correlates of frailty in this population. The primary limitation, nonetheless, was the use of a cross-sectional design, which precludes any conclusions on causality. Besides, our sample was predominantly from a rural setting; thus, our participants’ experiences may differ from those in urban places. Also, the OALWH were invited to participate from a health facility (ie not a population-based sample) and may not be completely representative of all OALWH in this area. For instance, the sample of OALWH in the study had very high levels of cART treatment and viral suppression and our observations would probably be different in individuals not seeking care (either because they are unaware of their status or don’t believe they need treatment).