HIV and musculoskeletal frailty: implications for care, policy and research

指导我们研究的广泛目标是为临床医生和决策者提供重要见解 关于干预措施在诊断、预防和减少身体虚弱（PF）进展方面的价值， 艾滋病毒感染者（PWH）。 在美国，有一百多万人感染艾滋病毒，这种以前致命的感染已经成为一种流行病。 使用抗逆转录病毒疗法可治愈的慢性疾病。威尔斯亲王医院现时的预期寿命 接近一般人群，揭示了比预期更早和日益增长的PF患病率。 带来了巨大的个人和社会负担。如果不加以管理，可能会导致失去独立性，反复发作， 福尔斯、骨折、残疾和死亡。PF的常规筛查和管理尚未成为 治疗指南，而不是在艾滋病毒流行的早期关注机会性感染，以及更多 最近在HCV合并感染，CVD，烟草和其他物质使用障碍。 在威尔斯亲王医院诊断和管理肺纤维化及其相关疾病的挑战进一步加剧 "我们知道的"和"我们做的"之间的差距。有证据表明，前脆弱和早期阶段的PF 通过及时诊断和有效干预是可逆的。然而，这一证据没有被翻译成 常规的艾滋病护理。定期进行虚弱评估对于防止福尔斯、骨折和其他后果至关重要， 然而，大多数PWH尚未进行PF评估。证据还表明，多模式干预，包括 心血管和力量锻炼结合跌倒预防，治疗骨质疏松症，并小心 药物降级可有效减少PF的肌肉骨骼表现。 然而，这一证据尚未转化为常规的艾滋病毒护理。引导选择 在预算有限的情况下，缺乏有效的干预措施，以最大限度地提高PWH的健康效益。 了解这些方案的成本效益（价值）和预算影响将有助于促进 将研究结果应用于威尔斯亲王医院的临床管理。 成本效益分析是一种重要的方法，有助于在多种有效的方法中做出明智的选择。 当包括数据、时间和金钱在内的资源受到限制时，我们建议开发一种计算机 模拟模型，描绘自然历史和治疗的PF在PWH，以缩小差距之间 通过评估预防和减缓疾病进展的三大战略的价值， PWH中的PF：1）及时诊断PF; 2）实施结构化强化和心血管 健身改善运动计划，以减少福尔斯和骨折，预防PF发病率，减缓其 进展;和3）使用跌倒预防计划，包括多种药物降级，骨质疏松症 筛查、诊断和管理，以减少福尔斯和骨折。

The broad objective guiding our research is to provide critical insights to clinicians and decision makers regarding the value of interventions to diagnose, prevent and reduce progression of physical frailty (PF) in people with HIV (PWH). More than a million persons in the United States live with HIV, a previously fatal infection that has become a highly treatable chronic condition with the use of antiretroviral therapy. The life expectancy of PWH now approaches that of the general population, revealing an earlier than expected and growing prevalence of PF. PF carries substantial individual and societal burden. If unmanaged, it may lead to loss of independence, recurrent falls, fractures, disability, and death. Routine screening and management of PF has not been part of the treatment guidelines, which instead focused on opportunistic infections early in the HIV epidemic, and more recently on HCV co-infection, CVD, and tobacco and other substance use disorder. The challenges in diagnosing and managing PF and its associated conditions in PWH are further exacerbated by the gap between ‘what we know’ and ‘what we do.’ Evidence indicates that pre-frailty and early stages of PF are reversible with timely diagnosis and effective interventions. However, this evidence has not been translated to routine HIV care. Regular frailty assessment is essential to prevent falls, fractures and other consequences, yet most PWH have not been assessed for PF. Evidence also suggests that multimodal interventions including cardiovascular and strength exercise in conjunction with fall prevention, treatment of osteoporosis, and careful medication de-escalation are effective in reducing musculoskeletal manifestations of PF. There are similar benefits for PWH, however this evidence has not been translated into routine HIV care. Guidance on choosing among effective interventions to maximize health benefits for PWH with constrained budgets is lacking. Knowledge of the cost-effectiveness (value) and budgetary impact of these programs would help facilitate translation of research findings into clinical management of PWH. Cost-effectiveness analysis is an important methodology that helps to inform choice among multiple efficacious programs when resources including data, time, and money are limited. We propose to develop a computer simulation model that portrays the natural history and treatment of PF in PWH to narrow the gap between evidence and practice by assessing the value of three major strategies to prevent and attenuate progression of PF in PWH: 1) timely diagnosis of PF; 2) implementation of structured strengthening and cardiovascular fitness improvement exercise programs to reduce falls and fractures and prevent PF incidence and slow its progression; and 3) use of fall prevention programs, including polypharmacy de-escalation, osteoporosis screening and diagnosis and management to reduce falls and fractures.