Risk of falls in HIV-infected patients on ART | HIV – Dove Medical Press


As a result of the widespread use of antiretroviral therapy (ART), people living with HIV (PLHIV) can live longer, survive into older age, and are now approaching the life expectancy of the general population. 1 PLHIV are thought to manifest accelerated aging with an earlier occurrence of many aging diseases than expected. 2 , 3 Geriatric syndromes are common among PLHIV, and they are affected at the younger age group than the common population. 4 , 5 However , the therapy also increases the particular risk associated with several comorbidities, such as cardiovascular and bone disease. 6 , 7 PLHIV have a greater chance of injurious drops or fractures due to low bone density, low body weight, neuropathy, neurocognitive impairment, and frailty. 8 Falls is one of the geriatric syndromes and is a significant public health concern with potentially severe consequences. 9 Falls can result in a severe injury that leads to disability, hospitalization, limitations to activity, and increased mortality risk. 10

In the previous study, 54% of PLHIV were diagnosed with at least two geriatric syndromes, and 26% associated with them reported at minimum one fall in the last 12 months. four The fall rate among middle-aged PLHIV (45–65 years) upon effective ART paralleled along with non-infected elderly population aged 65 years or older. 3 The prevalence of falls among PLHIV has been shown in order to vary from 18% to 41%. 11 , 12 The fear of falling again among older adults who have a history of falls will be associated with poor quality associated with life, developed frailty, plus depression, which leads in order to physical inactivity and weakness that may exacerbate the underlying fall risk. 8

Several factors that are usually known to increase the danger of drops in PLHIV are old age, eleven , 13 , 14 pre-existing comorbidities and complication, a few , 4 , 13 , 14 lower entire body mass index, 8 polypharmacy, three or more , 14 depression status, 3 neurocognitive disability, 8 , thirteen failure, 4 , eight , 11 neuropathy, several , 8 and medication adherence. fourteen As the number of older grown ups living with HIV continues to rise because of enhanced survival plus life expectancy, the particular impact associated with falls and fall-related complications has become increasingly relevant. Due to unique HIV-related characteristics, this study aimed to get the prevalence plus identify the risk of falls in PLHIV on ART and the related aspects of falls to reduce the rate of falls, or even prevent them, amongst older adults with HIV infections.


Study Design

This cross-sectional study was conducted through December 2019 to May 2020.

Study Setting

This study has been conducted at HIV/AIDS Integrated Outpatient Clinic – Cipto Mangunkusumo Hospital, a national referral hospital that provides multidisciplinary HIV care within accordance along with the Indonesian national guideline of HIV/AIDS infection.

Research Participants

Eligible criteria for this study were all PLHIV older ≥40 many years who received ART with regard to at least 6 months in the HIV/AIDS Integrated Outpatient Clinic in Cipto Mangunkusumo Hospital. The particular exclusion criteria were refusal to participate in this research, physical disabilities that caused difficulties with walking or even inability to walk and/or use their dominant hand, and participants with incomplete data. Of the 156 participants screened for eligibility in this study, 54 were declared not eligible because of refusal or inability to walk or use a hand-grip dynamometer due to disability. Thus, 102 individuals completed the study procedures and were included in the final analysis.

Sampling Procedures

PLHIV who came in order to the clinic for regular control were invited to join the research. It had been not based on the medical record, as well as the screening was done daily in order to seek potential participants old a minimum of 40 years who had taken ARTWORK for at least 6 months by the researchers. We consecutively screened the particular patients until the minimum sample size was achieved. The minimal sample dimension was counted by using the two population proportion formula. No incentive was given to the participant within this study.


The socio-demographic information collected included age, gender, marital standing, occupational position, and educational level, habitual history like smoking status and alcohol consumption. Clinical HIV/AIDS information incorporated HIV transmission routes, body mass catalog (BMI), duration of HIV/AIDS diagnosis and ART, recent and nadir CD4 cell count, latest HIV-RNA viral load, ART withdrawal history, opportunistic infection history for example tuberculosis plus central nervous system (CNS) infection, comorbidities (cardiac, lung, liver, and kidney disease, diabetes mellitus, and malignancy), fall background, polypharmacy, type of ART, depression status, the particular severity associated with peripheral neuropathy, frailty plus dementia standing. The outcome of this study is to get the frequency the risk of drop and to identify the risk of falls in PLHIV upon ART and its related factors.

Depression status was measured using the Indonesian version of the particular Beck Depressive disorders Inventory (BDI)-II questionnaire. This particular tool has been reported as an adequate measurement of depressive symptoms among PLHIV and has been translated into Indonesian with good validity plus reliability, with a Cronbach’s alpha of 0. 9. 15 The particular questionnaire used had the 21-item self-reported inventory that asked participants to price each item based on the severity of depressive disorders symptoms they felt during the past week. The test covers cognitive (eg, thought associated with past failure), emotional/affective (eg, sadness), and somatic/vegetative (eg, tiredness or fatigue) symptoms. Each response is scored on a scale from 0 (not) in order to 3 (severe). The scores for each Indo-BDI-II item had been combined to give a total score that will indicated the severity of depression. Scores of 0–13 points were categorized as symptomatic, 14–19 points as mild depression, 20–28 points as moderate depressive disorder, and 29–63 points because severe major depression. 16 Ginting et al showed that the particular receiver operating characteristic (ROC) curve indicated that the cut-off point associated with the Indo BDI-II questionnaire for a mild intensity of despression symptoms in the Indonesian population should be 17. In this particular study, we used ratings below seventeen points since considered not at risk of melancholy. fifteen

The particular Toronto Clinical Scoring System (TCSS) has been used to measure the severity of peripheral neuropathy. This system was first adopted for screening diabetic peripheral neuropathy by a research group in Toronto. The TCSS consists of three parts: symptoms score, reflex rating, and sensory test score. The maximum score is 19 points that divided in to four categories. Quite a few 0–5 points were interpreted as no peripheral neuropathy, 6–8 points because mild peripheral neuropathy, 9–11 points since moderate peripheral neuropathy, plus 12–19 as severe peripheral neuropathy. 17

Fried ainsi que al defined the phenotypes of inadequacy using five criteria: unintentional weight loss, exhaustion, reduced physical activity, slowness of walking speed, and weakness within grip strength. 18 Weight loss was described as the loss associated with 4. 5 kg or even > 5% body weight in the previous year. To measure fatigue and reduced physical activity, participants were asked several questions such as “How often did you feel that will every exercise that you did are tiring? ” and “How often do you are feeling that you could not do any action due in order to your tiredness? ”. The optional responses for those questions are almost always (5–7 days), often (3–4 days), sometimes (1–2 days), or none/rarely (< 1 day within a week). The slowness of strolling speed plus weakness of handgrip strength were objectively measured by observing walking speed across a distance of 15 feet (4. 57 meters) and employing the Jamar Hydraulic Hand Dynamometer. The particular slowness associated with walking speed were defined when time of ≥7 second (men having a height of ≤173 cm or women with a height associated with ≤159 cm) or ≥6 second (men with a height of > 173 centimeter or ladies with an elevation of > 159 cm), while the diagnosis of the weakness of handgrip strength was stratified based on gender and BMI. The weakness associated with handgrip power was described if ≤29 kg grip strength in ≤24 kg/m 2 , ≤30 kg within 24. one kg/m 2 , and ≤32 kg in > 28 kg/m 2 regarding male, while ≤17 kg in ≤23 kg/m 2 , ≤17. 3 or more kg within 23. 1–26 kg/m 2 , ≤18 kilogram in 26. 1–29 kg/m two , plus ≤21 kg in > 29 kg/m 2 for female. Items meeting the criteria intended for frailty had been scored because 1 . Then, each item was calculated as a score to define the stages of vulnerable place by Fried et al. A rating of 0 points means the participant is robust or not frail, 1–2 points is considered pre-frail, and 3–5 points is usually frail. nineteen

The Time Up and Go (TUG) is definitely a tool for testing the danger of drops in inpatient and community settings. In this test, participants are timed while these people rise from an armchair (seat height ±46 cm), walk the distance of 3 meters, then turn and stroll back to the chair and sit down again. Each participant did these tests twice. The first time was a trial to become familiar along with the test, and the second was the particular actual test. During the TUG test, the participants wore their normal footwear plus used any customary strolling that was necessary. 20 A score ≥13. five seconds can be used as a cut-off point to identify those at risk of falls in the particular community. A faster time means the participant has a better functional performance. 21 Nevertheless , reported cut-off values vary from 10 in order to 33 seconds in earlier literature. 22 , 23 In this study, a score ≥10. 0 seconds was utilized to identify those that had a risk of drops.

The guided Mini-Cog test was used for dementia screening in this study. The particular Mini-Cog check has 2 components: the three-word recall task to assess memory and a clock drawing test in order to assess cognitive function, language, visual-motor skills, and executive function. In the 1st part, which is the three-word recall task, the scoring system is certainly in line with the correct recall associated with 0–3 words (1 point per word), as the clock drawing test is obtained as normal or abnormal. A positive Mini-Cog test result indicates the possible diagnosis of dementia, whereas a negative test outcome indicates a lack of dementia. The positive test result is a delayed word recall rating of 0 out associated with 3 or even a score of 1–2 with an abnormal time clock drawing check result. A negative test result is really a score of 3 on the delayed term recall or a score associated with 1–2 using a normal clock drawing check result. 24

Statistical Analysis

Data were analyzed making use of STATA edition 12. 0 (StataCorp, College Station, TX, USA). Bivariate and multivariate analyses had been performed using Poisson regression with the robust estimator to determine the elements associated with the danger of falls among Indonesian PLHIV. Descriptive characteristics were summarized with mean and standard deviation (SD) or median plus interquartile range (IQR Q1-Q3) for continuous variables and frequency along with percentage to get categorical variables. We entered all bivariate correlates (p< 0. 25) into multivariate analyses making use of Poisson regression with a robust estimator test. The results are presented as prevalence ratio (PR) and 95% confidence intervals (95% CI). The level of significance was set at p< 0. 05.

Ethical Considerations

This study was approved by the Health Research Ethics Committee, Faculty of Medicine, Universitas Indonesia–Cipto Mangunkusumo Medical center (0702/UN2. F1/ETIK/2018). After explaining the study procedures and purpose, all individuals who agreed to participate signed the particular informed consent form. All data obtained guaranteed confidentiality. All methods in this particular study had been conducted in accordance with the Declaration of Helsinki, as revised in 2013.


Socio-Demographic and Medical Characteristic of HIV Infection

Most of the individuals were male (83. 3%) with a median age of 45 (IQR 43–48) years. The mean associated with HIV analysis and ARTWORK use duration was 99. 9 weeks (8. 3 years) plus 93. 7 months (7. 8 years), respectively. Intravenous drug make use of (IVDU) (41. 2%) had been the most transmission route of HIV infection, followed by multiple sexual partners (39. 2%), and men that have sex along with men (MSM) (18. 6%). More than half from the participants experienced well-suppressed HIV-RNA viral load (60. 8%) with the median of current plus nadir CD4 counts were 495. 5 (IQR 368. 8–729. 8) and 71. 5 (IQR 26. 0–246. 5) cells/mm a few , respectively ( Table 1 ).

Table one Characteristics associated with Study Individuals (n=102)

Prevalence and Factors Associated with Danger of Falls in PLHIV

With this research, the chance of fall was detected in 52% of the participants. PLHIV with a pre-frail and foible status based on Fried criteria had 2 . 4-fold higher risk of fall than PLHIV with strong status. PLHIV with current CD4 < 200 cells/mm three or more had one 6-fold, whilst history of falls within the past was found to have a 1. 4-fold greater risk associated with along with the particular future. However , age, peripheral neuropathy, and dementia did not significantly relate to the risk of drop. This study also demonstrated that use of a PI-based regimen is a protective factor against falls amongst PLHIV. Nutritional status plus comorbidities were not associated along with the danger of drops among PLHIV in our study ( Table 2 ).

Desk 2 Aspects Associated with the Risk of Drops in PLHIV


Within this research, less compared to one-fourth of the participants were woman. This result was in line with the real situation within Indonesia, the number of the woman above fifteen years residing with HIV is 190, 000 associated with 540, 000 PLHIV. 25 The particular factors related to the risk of falls in PLHIV there are usually history of drops, a current CD4 < 200 cells/mm 3 , and have pre-frail and frail status.

First, a history of falls was linked to the danger of falls among PLHIV. Berner ou al showed that 34% of PLHIV have a history of fall in the previous year, both single fall or multiple falls. The most common reasons documented for falling were tripping (41. 2%), dizziness (29. 4%), and slipping (11. 8%). twenty six

Second, our own study reported that present CD4 count less than two hundred cells/mm 3 has been associated with a higher risk associated with falls among PLHIV. We suggest it is because the lower CD4 count number in PLHIV will tend to get a higher risk of opportunistic infection that can lead to the flaw condition. In some cases, low CD4 counts may be associated with increased HIV-RNA viral weight levels that will impaired neuromotor performance, and even low levels of the detectable virus have been related to higher immune activation levels, virological failure, plus poorer clinical outcomes. 27 , 28 Our finding was different from other previous studies that demonstrated there will be no association with CD4 count along with risk of falls amongst PLHIV. 6

The final factor associated with the risk associated with falls among PLHIV is usually a pre-frail–frail status. The results of this study are in line with the particular findings of Erlandson et al, who else reported that frailty position increases the 9. 5-fold risk of drops among PLHIV, and an one -point decrease in Deep-fried criteria improved the several. 1-fold danger of drop. 3 Another study also documented that pre-frail and foible status increased 1 ) 5-fold and two. 4-fold risk of single falls amongst PLHIV, compared with powerful participants; however , this research stated that these findings are not statistically significant. 11 The some other reason for the strong organization of frailty status and falls is definitely that PLHIV in the study has multimorbidities that will affect their own risk associated with falls through different mechanisms, like balance impairment, neuropathy, polypharmacy, plus weakness. Determining frailty since a factor associated with the danger of falling is essential because failure can be modified, although perhaps not ultimately returned in order to normal state. Intervention targeting frailty can be expected to minimize the risk of falls. Currently, there is no management guidelines regarding the pre-frail or frail status of PLHIV. The review associated with existing literature indicates that nutritional improvement by assessing nutritional status and individual needs and programmed bodily exercise can improve inadequacy status. 29

In our study, all of us also found that will the utilization of a PI-based regimen was the protective factor of drops in PLHIV. This is certainly the most interesting because it has not been previously reported in low-middle-income countries (LMIC). All of us assumed this is because the PI-based regimen offers a lower penetrating effect on the central nervous system (CNS) or even peripheral anxious system toxicity compared in order to other ART. This outcome was similar to the particular prior study in high-income countries (HIC) that showed PI-based regimen has a protective effect of falls among PLHIV. 8 The higher CNS penetration score (CPE Score) means that the ARV drugs have great penetration directly into the cerebrospinal fluid (CSF). A increased CPE score is likely to possess a higher neurocognitive enhancement due to higher effectiveness in suppressed viral replication within the CNS and decreased neurotoxins plus neuro-inflammation production. 30–36 An LPV/r has a lower CPE rating compared to NVP, but it provides the same score as EFV. In our study, a good EFV includes a protective element of risk of drops, but not really statistically substantial. We hypothesized that this higher CPE score will increase the particular risk of CNS adverse effects and peripheral nervous system degree of toxicity that lead to a better risk associated with falls among PLHIV.

Falls in PLHIV can lead to because serious effects that may boost the morbidity and mortality. The fall prevalence in our sample may thus not be generalized to the population of PLHIV within Indonesia. Nevertheless , this research showed us that the risk associated with fall amongst PLHIV is high. Assessment from the danger of falls screening among PLHIV will be important to prevent the drop incident in the future.


This study does have some restrictions. First, remember bias might affect the particular accuracy of self-reported questionnaires, and individuals may also have got given inaccurate information throughout data collection. In addition , this particular study is usually limited simply by its cross-sectional design, meaning that the definitive cause plus effect associations cannot be determined. The particular fall frequency within our sample can thus not have to get generalized towards the population of PLHIV in Indonesia. The sex bias can also affect the result associated with this study because more than third-quarter of total participants had been male.


The risk of falls is typical among PLHIV. History of drops, current CD4 counts below 200 cells/mm 3 or more , and pre-frail plus frail status were identified as factors related in order to a higher risk of falls amongst PLHIV. Therefore, it is important pertaining to clinicians to increase the awareness associated with the risk of dropping and conduct the chance of fall screening among PLHIV in order to reduce morbidity and fatality due to falls-related.

Data Sharing Statement

The data can be acquired by request to author’s email ( [email protected] ).

Consent meant for Publication

Written informed permission for publication can become obtained through all participants.


We all thank all the patients which participated with this study.

Author Contributions

Almost all authors made a substantial contribution in order to the work reported, whether that is definitely in the conception, study design, execution, acquisition of data, analysis and interpretation, or in almost all these areas; took part in drafting, revising or even critically reviewing the article; gave final approval of the version to be published; have decided on the particular journal to which the article continues to be submitted; and agree to end up being accountable designed for all aspects of the work.


The authors declare no competing interests for this study.


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