Developing an HIV-specific falls risk prediction model with a novel clinical index : a systematic review and meta-analysis method

Abstract

BACKGROUND: Falls are a common problem experienced by people living with HIV yet predictive models specific to this population remain underdeveloped. We aimed to identify, assess and stratify the predictive strength of various physiological, behavioral, and HIV-specific factors associated with falls among people living with HIV and inform a predictive model for fall prevention. METHODS: Systematic review and meta-analysis were conducted to explore predictors of falls in people living with HIV. Data was sourced, screened, extracted, and analyzed by two independent reviewers from eight databases up to January 2nd, 2024, following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol. Evidence quality and bias were assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and the Mixed Method Appraisal Tool (MMAT), respectively. Pooled odds ratios (OR) with 95% confidence intervals (CI) were computed using random-effects models to establish associations between predictors and falls risk. We applied established criteria (Bradford Hill’s criteria, Rothman’s and Nweke’s viewpoints) to stratify risk factors and create a weighted predictive algorithm. RESULTS: This review included 12 studies on falls/balance dysfunction in 117,638 participants (54,513 people living with HIV), with varying ages (45–50 years), sample sizes (32−26,373), study durations (6 months to 15 years), disease stages (CD4+counts 347.2 cells/mm³ to ≥500 cells/µL) and fall definitions (self-reported histories to real-time reporting). Some predictors of falls in people living with HIV including depression, cannabis use, cognitive impairment/ neurocognitive adverse effects (NCAE), hypertension, and stavudine—showed perfect risk responsiveness (Ri=1), indicating their strong association with falls. Notably, cannabis use demonstrated the highest risk weight (Rw=3.0, p<0.05, 95%CI:1.51–5.82), followed by NCAE (Rw=2.3, p<0.05, 95%CI:1.66–3.21) and frailty with a broad confdence interval (Rw=2.2, p<0.05, 95%CI:0.73–14.40). Other significant predictors included hypertension (Rw=1.8, p<0.05, 95%CI:1.33–2.33), depression (Rw=1.6, p<0.05, 95%CI:1.22–2.18), stavudine use (Rw=1.5, p<0.05, 95%CI: 0.95–2.25), neuropathy (Rw=1.3, p<0.05, 95%CI:1.26–2.11), and polypharmacy (Rw=1.2, p<0.05, 95%CI:1.16–1.96). The fall risk threshold score was 12.8, representing the 76th percentile of the specific and sufficient risk weight. CONCLUSION: Our meta-analysis identifies predictors of falls in people living with HIV, emphasizing physiological, behavioral, and HIV-specific factors. Integrating these into clinical practice could mitigate falls-related sequelae. We propose a novel approach to falls risk prediction using a novel clinical index, resulting in a HIV-specific falls risk assessment tool.