High prevalence of and progression to low bone mineral density in HIV-infected patients: a longitudinal cohort study

Decreased serum bone specific alkaline phosphatase and increased urinary N-terminal telopeptide of type I collagen as prognostic markers for bone mineral density loss in HIV patients on cART

OBJECTIVES

Bone mineral density (BMD) loss is a major chronic complication in HIV patients. We performed a prospective study to determine the time course of BMD changes and to find prognostic factors of BMD loss in HIV patients on combination antiretroviral therapy (cART).

PATIENTS AND METHODS

Subjects were 54 male Japanese HIV patients who had been on cART ≥1 year with no therapeutic agents for osteoporosis. Patients were observed for ≥1 year (median 3.1 years) and underwent annual BMD analyses using dual energy X-ray absorptiometry. Changes in BMD at lumbar spine and femoral neck were calculated for each person-year of all the patients. Clinical factors were also collected simultaneously with BMD examinations to determine prognostic factors for BMD loss.

RESULTS

In total, 173 person-years in 54 patients were observed. One third (19, 35.2%) and slightly over half (30, 55.6%) patients showed BMD decreases at lumbar spine and femoral neck, respectively. However, the median BMD changes at lumbar spine and femoral neck were 0.0% and -0.52% per year, respectively. Monovariant and mixed model analyses determined that decreased serum bone specific alkaline phosphatase (BAP, p = 0.0047) and increased urinary N-terminal telopeptide (uNTx, p = 0.0011) were prognostic factors for BMD loss at lumbar spine and femoral neck, respectively.

CONCLUSIONS

BMD at both lumbar spine and femoral neck changed little on average in HIV patients on cART. Decreased serum BAP or increased uNTx may be helpful to predict progressive BMD loss in the following year and to select patients for BMD follow-up or initiation of anti-osteoporosis treatment.

Disrupted trabecular bone micro-architecture in middle-aged male HIV-infected treated patients

OBJECTIVES

HIV-infected individuals are at increased risk of incident fractures. Evaluation of trabecular bone micro-architecture is an important tool to assess bone strength, but its use has not yet been reported in middle-aged HIV-infected male individuals. The aim of the study was to compare bone micro-architecture between HIV-infected and HIV-uninfected men.

METHODS

In this cross-sectional study, 53 HIV-infected male individuals with a mean (± standard deviation) age of 49 ± 9 years who had been receiving antiretroviral therapy including tenofovir disoproxil fumarate (DF) for at least 60 months were compared with 50 HIV-uninfected male controls, matched for age and ethnic origin. We studied the volumetric bone density and micro-architecture of the radius and tibia using high-resolution peripheral quantitative computed tomography (HR-p QCT).

RESULTS

Volumetric trabecular bone density was 17% lower in the tibia (P < 10(-4) ) and 16% lower in the radius (P < 10(-3) ) in HIV-infected patients compared with controls. By contrast, the cortical bone density was normal at both sites. The tibial trabecular micro-architecture differed markedly between patients and controls: bone volume/total volume (BV/TV) and trabecular number were each 13% lower (P < 10(-4) for both). Trabecular separation and inhomogeneity of the network were 18% and 24% higher in HIV-infected patients than in controls, respectively. The radial BV/TV and trabecular thickness were each 13% lower (P < 10(-3) and 10(-2) , respectively). Cortical thickness was not different between the two groups.

CONCLUSIONS

The findings of lower volumetric trabecular bone density and disrupted trabecular micro-architectural parameters in middle-aged male HIV-infected treated patients help to explain bone frailty in these patients.

Bone health and HIV in resource-limited settings: a scoping review

PURPOSE OF REVIEW

Sub-Saharan Africa and other resource-limited settings (RLS) bear the greatest burden of the HIV epidemic globally. Advantageously, the expanding access to antiretroviral therapy (ART) has resulted in increased survival of HIV individuals in the last 2 decades. Data from resource rich settings provide evidence of increased risk of comorbid conditions such as osteoporosis and fragility fractures among HIV-infected populations. We provide the first review of published and presented data synthesizing the current state of knowledge on bone health and HIV in RLS.

RECENT FINDINGS

With few exceptions, we found a high prevalence of low bone mineral density (BMD) and hypovitaminosis D among HIV-infected populations in both RLS and resource rich settings. Although most recognized risk factors for bone loss are similar across settings, in certain RLS there is a high prevalence of both non-HIV-specific risk factors and HIV-specific risk factors, including advanced HIV disease and widespread use of ART, including tenofovir disoproxil fumarate, a non-BMD sparing ART. Of great concern, we neither found published data on the effect of tenofovir disoproxil fumarate initiation on BMD, nor any data on incidence and prevalence of fractures among HIV-infected populations in RLS.

SUMMARY

To date, the prevalence and squeal of metabolic bone diseases in RLS are poorly described. This review highlights important gaps in our knowledge about HIV-associated bone health comorbidities in RLS. This creates an urgent need for targeted research that can inform HIV care and management guidelines in RLS.

Improvement of BMD after Switching from Lopinavir/R Plus Two Nucleos(T)ide Reverse Transcriptase Inhibitors to Lopinavir/R Plus Lamivudine: OLE-LIP Substudy

OBJECTIVE

To compare 48-week changes in bone mineral density (BMD) and body fat distribution between patients continuing lopinavir/ritonavir and two NRTIs and those switching to lopinavir/ritonavir and lamivudine.

METHODS

Substudy of a randomized, open-label, multicenter OLE study was carried out. Adult HIV-infected patients with <50 copies/mL for ≥6 months were randomized (1:1) to continue lopinavir/ritonavir and two NRTIs or switching to lopinavir/ritonavir and lamivudine. Dual-energy X-ray absorptiometry (DXA) was performed at baseline and after 48 weeks to measure bone composition and body fat distribution in both the groups.

RESULTS

Forty-one patients (dual-therapy, n = 23; triple-therapy, n = 18) of 239, who received at least one dose of study medication, completed the study: median age, 42 years, 71% male, 73% Caucasian. At week 48, total BMD increased by 1.04% (95% CI, 0.06 to 2.01%) among patients switching to dual-therapy, whereas no significant changes occurred in patients maintaining triple-therapy. Dual-therapy and older age were independently associated with total BMD increase. Among patients discontinuing tenofovir-DF, a significant increase was seen in total BMD (1.43; 95% CI, -0.04 to 2.91) and total hip (1.33%; 95% CI, 0.44 to 2.22%). A non-statistically significant decrease in femoral and spinal BMD was observed in patients who discontinued abacavir and in those continuing triple-therapy. Regarding fat distribution, no significant changes were seen in both the treatment groups.

DISCUSSION

BMD increased following switching to lopinavir/ritonavir plus lamivudine in HIV-infected patients on suppressive triple-therapy with lopinavir/ritonavir and two NRTIs including tenofovir-DF.

Management of bone mineral density in HIV-infected patients

INTRODUCTION

Loss of bone mineral density is an emerging problem in persons living with HIV infection. Earlier and more rapid bone demineralization has been attributed not only to the high prevalence of traditional risk factors, but also to specific HIV-related factors. The aim of this guidance is to stimulate an appropriate management of osteoporosis in this population, to identify patients at risk and to better manage them.

AREAS COVERED

Appropriate screening of HIV-infected subjects to identify those at risk for bone fractures is described, as well as the recommended interventions. American and European recommendations in HIV-infected and non-infected populations were considered. As the etiology of bone loss is multifactorial, many factors have to be addressed. Overall, recommendations on traditional risk factors are the same for HIV-infected and non-HIV-infected subjects. However, we should consider some specific factors in the HIV-infected population, including an appropriate antiretroviral therapy in patients with low bone mineral density, and probably novel strategies that could provide an additional benefit, such as anti-inflammatory drugs, although data supporting this approach are scant.

EXPERT OPINION

Some personal opinions are highlighted on the management of bone health in HIV-infected subjects, mainly on the use of FRAX(®) score and DXA scans. In addition, the need to implement new strategies to delay demineralization is remarked upon.

Antiretroviral therapy induces a rapid increase in bone resorption that is positively associated with the magnitude of immune reconstitution in HIV infection

OBJECTIVE

Antiretroviral therapy (ART) paradoxically intensifies bone loss in the setting of HIV infection. Although the extent of bone loss varies, it occurs with virtually all ART types, suggesting a common pathway that may be aligned with HIV disease reversal. Using an animal model of immunodeficiency we recently demonstrated that immune activation associated with CD4 T-cell reconstitution induces increased production of the osteoclastogenic cytokines RANKL and TNFα by immune cells, driving enhanced bone resorption and loss in bone mineral density.

DESIGN

To confirm these findings in humans, we investigated the early kinetics of CD4 T-cell recovery in relation to biomarkers of bone turnover and osteoclastogenic regulators in a prospective 24-week cohort study.

METHODS

Clinical data and blood sampling for HIV-RNA PCR, CD4 T-cell counts, bone turnover biomarkers, and osteoclastogenic regulators were obtained from ART-naïve HIV-infected study participants initiating standard doses of lopinavir/ritonavir plus tenofovir disoproxil fumarate/emtricitabine at baseline and at weeks 2, 8, 12, and 24 post ART.

RESULTS

C-terminal telopeptide of collagen (CTx) a sensitive biomarker of bone resorption rose by 200% above baseline at week 12, remaining elevated through week 24 (α<0.01), and was associated with significant increases in plasma levels of osteoclastogenic regulators [receptor activator of NF-kB ligand (RANKL), tumor necrosis factor alpha, (TNFα)]. Importantly, the magnitude of CD4 T-cell recovery correlated significantly with CTx (rs = 0.387, α=0.01).

CONCLUSION

Our data suggest that ART-induced bone loss occurs early, is aligned with early events of immune reconstitution, and these immune changes provide a unifying mechanism to explain in part the skeletal decline common to all ART.

Perspectives on menopause and women with HIV

Since the implementation of effective combination antiretroviral therapy, HIV infection has been transformed from a life-threatening condition into a chronic disease. As people with HIV are living longer, aging and its associated manifestations have become key priorities as part of HIV care. For women with HIV, menopause is an important part of aging to consider. Women currently represent more than one half of HIV-positive individuals worldwide. Given the vast proportion of women living with HIV who are, and will be, transitioning through age-related life events, the interaction between HIV infection and menopause must be addressed by clinicians and researchers. Menopause is a major clinical event that is universally experienced by women, but affects each individual woman uniquely. This transitional time in women's lives has various clinical implications including physical and psychological symptoms, and accelerated development and progression of other age-related comorbidities, particularly cardiovascular disease, neurocognitive dysfunction, and bone mineral disease; all of which are potentially heightened by HIV or its treatment. Furthermore, within the context of HIV, there are the additional considerations of HIV acquisition and transmission risk, progression of infection, changes in antiretroviral pharmacokinetics, response, and toxicities. These menopausal manifestations and complications must be managed concurrently with HIV, while keeping in mind the potential influence of menopause on the prognosis of HIV infection itself. This results in additional complexity for clinicians caring for women living with HIV, and highlights the shifting paradigm in HIV care that must accompany this aging and evolving population.

High Prevalence of Low Bone Mineral Density and Substantial Bone Loss over 4 Years Among HIV-Infected Persons in the Era of Modern Antiretroviral Therapy

HIV-infected persons are living longer on combination antiretroviral therapy (cART) but experiencing more comorbidities including low bone mineral density (BMD). Using data from the Study to Understand the Natural History of HIV and AIDS in the Era of Effective Therapy (SUN Study), we determined the prevalence of low BMD (T-score below one standard deviation of the reference mean) and compared it with matched controls from the National Health and Nutrition Examination Survey (NHANES). We also assessed 4-year longitudinal BMD changes among participants virologically suppressed on cART. Of 653 participants included in this analysis (77% male, 29% black, median age 41 years, median CD4(+) cell count 464 cells/mm(3), 89% with HIV RNA <400 copies/ml), 51% and 10% had baseline osteopenia and osteoporosis, respectively. Low BMD at the femoral neck was significantly more prevalent than for the NHANES controls (47% versus 29%, p<0.001). Lower body mass index, nonwhite race, longer tenofovir exposure, older age, being unemployed or retired, and lower apolipoprotein E were independently associated with baseline osteoporosis. Among 170 participants virologically suppressed on cART and with longitudinal BMD data, 31% experienced substantial bone loss (≥5% BMD decline from baseline) over 4 years. Female sex, current smoking, and longer stavudine use were more common among participants who had substantial bone loss, although these variables failed to reach statistical significance. Low BMD was highly prevalent among HIV-infected persons. One-third of participants experienced substantial bone loss despite cART, suggesting the need for monitoring and potential clinical interventions.

Role of T-cell reconstitution in HIV-1 antiretroviral therapy-induced bone loss

HIV infection causes bone loss. We previously reported that immunosuppression-mediated B-cell production of receptor activator of NF-κB ligand (RANKL) coupled with decline in osteoprotegerin correlate with decreased bone mineral density (BMD) in untreated HIV infection. Paradoxically, antiretroviral therapy (ART) worsens bone loss although existing data suggest that such loss is largely independent of specific antiretroviral regimen. This led us to hypothesize that skeletal deterioration following HIV disease reversal with ART may be related to T-cell repopulation and/or immune reconstitution. Here we transplant T cells into immunocompromised mice to mimic ART-induced T-cell expansion. T-cell reconstitution elicits RANKL and TNFα production by B cells and/or T cells, accompanied by enhanced bone resorption and BMD loss. Reconstitution of TNFα- or RANKL-null T-cells and pharmacological TNFα antagonist all protect cortical, but not trabecular bone, revealing complex effects of T-cell reconstitution on bone turnover. These findings suggest T-cell repopulation and/or immune reconstitution as putative mechanisms for bone loss following ART initiation.

Vitamin D and Osteoporosis in HIV/HCV Coinfected Patients: A Literature Review

Vitamin D deficiency further increases the risk of osteoporosis in HIV-positive patients coinfected with hepatitis C virus (HCV); however, it is still unclear whether HCV-related increased fracture risk is a function of the severity of liver disease. The aim of this review was to identify studies on associative vitamin D deficiency patterns in high-risk populations such as HIV/HCV coinfected patients. We did this by searching MEDLINE and EMBASE databases, from inception to August 2014, and included bibliographies. The final 12 articles selected are homogeneous in terms of age but heterogeneous in terms of sample size, participant recruitment, and data source. Most of the HIV/HCV coinfected patients have less than adequate levels of vitamin D. After reviewing the selected articles, we concluded that vitamin D deficiency should be regarded as a continuum and that the lower limit of the ideal range is debatable. We found that vitamin D deficiency might influence liver disease progression in HIV/HCV coinfected patients. Methodological issues in evaluating vitamin D supplementation as a relatively inexpensive therapeutic option are discussed, as well as the need for future research, above all on its role in reducing the risk of HCV-related fracture by modifying liver fibrosis progression.

Time trends for risk of severe age-related diseases in individuals with and without HIV infection in Denmark: a nationwide population-based cohort study

BACKGROUND

Whether the reported high risk of age-related diseases in HIV-infected people is caused by biological ageing or HIV-associated risk factors such as chronic immune activation and low-grade inflammation is unknown. We assessed time trends in age-standardised and relative risks of nine serious age-related diseases in a nationwide cohort study of HIV-infected individuals and population controls.

METHODS

We identified all HIV-infected individuals in the Danish HIV Cohort Study who had received HIV care in Denmark between Jan 1, 1995, and June 1, 2014. Population controls were identified from the Danish Civil Registration System and individually matched in a ratio of nine to one to the HIV-infected individuals for year of birth, sex, and date of study inclusion. Individuals were included in the study if they had a Danish personal identification number, were aged 16 years or older, and were living in Denmark at the time of study inclusion. Data for study outcomes were obtained from the Danish National Hospital Registry and the Danish National Registry of Causes of Death and were cardiovascular diseases (myocardial infarction and stroke), cancers (virus associated, smoking related, and other), severe neurocognitive disease, chronic kidney disease, chronic liver disease, and osteoporotic fractures. We calculated excess and age-standardised incidence rates and adjusted incidence rate ratios of outcomes for time after HIV diagnosis, highly active antiretroviral therapy (ART) initiation, and calendar time. The regression analyses were adjusted for age, sex, calendar time, and origin.

FINDINGS

We identified 5897 HIV-infected individuals and 53,073 population controls; median age was 36·8 years (IQR 30·6-44·4), and 76% were men in both cohorts. Dependent on disease, the HIV cohort had 55,050-57,631 person-years of follow-up and the population controls had 638,204-659,237 person-years of follow-up. Compared with the population controls, people with HIV had high excess and relative risk of all age-related diseases except other cancers. Overall, the age-standardised and relative risks of cardiovascular diseases, cancers, and severe neurocognitive disease did not increase substantially with time after HIV diagnosis or ART initiation. Except for chronic kidney diseases, the age-standardised and relative risks of age-related diseases did not increase with calendar time.

INTERPRETATIONS

Severe age-related diseases are highly prevalent in people with HIV, and continued attention and strategies for risk reduction are needed. The findings from our study do not suggest that accelerated ageing is a major problem in the HIV-infected population.

FUNDING

Preben og Anna Simonsens Fond, Novo Nordisk Foundation, Danish AIDS Foundation, Augustinus Foundation, and Odense University Hospitals Frie Fonds Midler.

Ageing with HIV: a multidisciplinary review

INTRODUCTION

After the introduction of highly active antiretroviral treatment, the course of HIV infection turned into a chronic disease and most of HIV-positive patients will soon be over 50 years old.

MATERIAL AND METHODS

This paper reviews the multiple aspects that physicians have to face while taking care of HIV-positive ageing patients including the definitions of frailty and the prevalence and risk factors of concomitant diseases. From a therapeutic point of view pharmacokinetic changes and antiretroviral-specific toxicities associated with ageing are discussed; finally therapeutic approaches to frailty are reviewed both in HIV-positive and negative patients.

CONCLUSION AND DISCUSSION

We conclude by suggesting that the combined use of drugs with the least toxicity potential and the promotion of healthy behaviours (including appropriate nutrition and exercise) might be the best practice for ageing HIV-positive subjects.

Comparison of two different strategies of treatment with zoledronate in HIV-infected patients with low bone mineral density: single dose versus two doses in 2 years

OBJECTIVES

Given the need for easily managed treatment of osteoporosis in HIV-infected patients, we evaluated the efficacy and tolerability of two doses of zoledronate, by comparing three groups of patients: those with annual administration, those with biennial administration (one dose in 2 years) and a control group with no administration of zoledronate.

METHODS

We randomized (2:1) 31 patients on antiretroviral therapy with low bone mineral density (BMD) to zoledronate (5 mg administered intravenously; 21 patients) plus diet counselling and to a control group (diet counselling; 10 patients). At week 48, patients treated with zoledronate were randomized again to receive a second dose (two-dose group; n = 12) or to continue with diet counselling only (single-dose group; n = 9). Changes in lumbar spine and hip BMD and bone turnover markers were compared.

RESULTS

The median percentage change from baseline to week 96 in L1-L4 BMD was -1.74% [interquartile range (IQR) -2.56, 3.60%], 7.90% (IQR 4.20, 16.57%) and 5.22% (IQR 2.02, 7.28%) in the control, two-dose and single-dose groups, respectively (P < 0.01, control vs. two doses; P = 0.02, control vs. single dose; P = 0.18, two doses vs. single dose). Hip BMD changed by a median of 2.12% (IQR -0.12, 3.08%), 5.16% (IQR 3.06, 6.74%) and 4.47% (IQR 1, 5.58%), respectively (P = 0.04, control vs. two doses; P = 0.34, two doses vs. single dose). No differences between the two-dose and single-dose groups were detected in bone markers at week 96.

CONCLUSIONS

The benefits for BMD of a single dose of zoledronate in 2 years may be comparable to those obtained with two doses of the drug after 96 weeks, although this study is insufficiently powered to exclude a real difference. Future studies should explore whether biennial administration of zoledronate is a useful alternative in the treatment of osteoporosis in HIV-infected patients.

Does HIV infection have an impact upon dental implant osseointegration? A systematic review

OBJECTIVE

A systematic review is made to determine whether human immunodeficiency virus (HIV) infection has an impact upon dental implant osseointegration.

STUDY DESIGN

A PubMed (MEDLINE) literature search was made of articles published up until 14 April 2014. The systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The quality of the studies included in the review was assessed using the Methodological Index for Nonrandomized Studies (MINORS) and levels of evidence (based on the University of Oxford's Center for Evidence Based Medicine criteria).

RESULTS

The combinations of search terms resulted in a list of 132 titles. Nine studies finally met the inclusion criteria and were selected for inclusion in the systematic review. A total of 173 dental implants were placed in 80 patients (135 implants in 56 HIV-positive subjects and 38 implants in 24 HIV-negative patients), and a single loss of dental implant osseointegration was recorded in an HIV-positive patient.

CONCLUSIONS

Our results suggest that dental implant placement in HIV-positive patients does not increase the dental implant failure rate. Prophylactic antibiotic treatment, the administration of highly active antiretroviral therapy, and control of the CD4+ T lymphocyte counts appear to be the main influencing factors in this respect. Given the few studies included in our systematic review, further prospective studies involving larger sample sizes and longer durations of follow-up are required in order to confirm the results obtained.

Effects of Emtricitabine/Tenofovir on Bone Mineral Density in HIV-Negative Persons in a Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Daily preexposure prophylaxis (PrEP) with oral emtricitabine and tenofovir disoproxil fumarate (FTC/TDF) decreases the risk of human immunodeficiency virus (HIV) acquisition. Initiation of TDF decreases bone mineral density (BMD) in HIV-infected people. We report the effect of FTC/TDF on BMD in HIV-seronegative men who have sex with men and in transgender women.

METHODS

Dual-energy X-ray absorptiometry was performed at baseline and 24-week intervals in a substudy of iPrEx, a randomized, double-blind, placebo-controlled trial of FTC/TDF PrEP. Plasma and intracellular tenofovir concentrations were measured in participants randomized to FTC/TDF.

RESULTS

In 498 participants (247 FTC/TDF, 251 placebo), BMD in those randomized to FTC/TDF decreased modestly but statistically significantly by 24 weeks in the spine (net difference, -0.91% [95% confidence interval {CI}, -1.44% to -.38%]; P = .001) and hip (-0.61% [95% CI, -.96% to -.27%], P = .001). Changes within each subsequent 24-week interval were not statistically significant. Changes in BMD by week 24 correlated inversely with intracellular tenofovir diphosphate (TFV-DP), which was detected in 53% of those randomized to FTC/TDF. Net BMD loss by week 24 in participants with TFV-DP levels indicative of consistent dosing averaged -1.42% ± 29% and -0.85% ± 19% in the spine and hip, respectively (P < .001 vs placebo). Spine BMD tended to rebound following discontinuation of FTC/TDF. There were no differences in fractures (P = .62) or incidence of low BMD.

CONCLUSIONS

In HIV-uninfected persons, FTC/TDF PrEP was associated with small but statistically significant decreases in BMD by week 24 that inversely correlated with TFV-DP, with more stable BMD thereafter.

CLINICAL TRIALS REGISTRATION

NCT00458393.

HIV-related metabolic comorbidities in the current ART era

Despite effective antiretroviral therapy (ART), HIV-infected individuals have residual chronic immune activation that contributes to the pathogenesis of HIV infection. This immune system dysregulation is a pathogenic state manifested by very low naïve T-cell numbers and increased terminally differentiated effector cells that generate excessive proinflammatory cytokines with limited functionality. Immune exhaustion leaves an individual at risk for accelerated aging-related diseases, including renal dysfunction, atherosclerosis, diabetes mellitus, and osteoporosis. We highlight research that clarifies the role of HIV, ART, and other factors that contribute to the development of these diseases among HIV-infected persons.

Tenofovir substitution in Namibia based on an analysis of the antiretroviral dispensing database

Objectives

In the management of HIV infection, tenofovir is preferred to its predecessors – zidovudine and stavudine – in the antiretroviral therapy (ART) nucleoside backbone. Tenofovir’s (TDF) preference is based on its safety profile. Nevertheless, TDF causes adverse reactions, some of which warrant its substitution for patients. The rate of TDF-substitution is suggestive of the rate of occurrence of TDF-related adverse reactions. However, the rate of substitution of TDF with another nucleoside reverse transcriptase inhibitor (NRTI) in Namibia was unknown. The objective of this review was to measure the rate of TDF’s substitution for the period of January 1, 2008 to November 30, 2011, and to compare the gender difference in the rates of TDF’s substitution.

Methods

We accessed antiretroviral medicine dispensing records from the national antiretroviral dispensing database (NDB). We selected patients who were started on a TDF-containing conventional ART regimen – 2NRTI+1NNRT. We used the initial and current ART regimens to identify records of TDF’s substitution with another NRTI.

Results

A total of 84,741 patients were initiated on ART (Jan-1-2008 to Nov-30-2011). A total of 52,612 patient-records were excluded from the analysis because they did not meet the criteria for inclusion. Of the 32,129 included records, 59.4% (n=19 096) and 40.6% (n=13 033) were for female and male patients, respectively. Of these, 1.2% (n=380) of the patients had their TDF substituted with another NRTI. Of the females and males, respectively, 1.1% (95% CI: 0.9-1.3; n=210) and 1.3% (95% CI: 1.1-1.5; n=170) had TDF substituted with another NRTI. No gender difference was observed (p-value = 0.11).

Conclusion

The percentage of patients for whom TDF was substituted with another NRTI, possibly due to TDF-related adverse reactions, was within the current published limits. However, 1.2% is likely not a true representation of the percentage of patients who experience adverse events because some patients could have been maintained on TDF even in the presence of adverse events. Further investigation is required to determine the clinical reasons for TDF’s withdrawal.

Bone Density and Fractures in HIV-infected Postmenopausal Women: A Systematic Review

With the development of effective antiretroviral therapy, HIV-infected women are living longer and transitioning through menopause. The purpose of our study was to systematically examine the evidence that menopause is an additional risk predictor for osteoporosis and fractures in HIV-infected women. Electronic databases were searched for studies of low bone density or fractures in HIV-infected postmenopausal women. Studies that met the inclusion criteria (n = 10) were appraised using a validated quality assessment tool. The majority of studies were rated as good quality and the remaining were fair. The prevalence of osteoporosis reported in these studies ranged from 7.3% to 84% and 0.7% to 23% in HIV-infected and uninfected postmenopausal women, respectively. In the two qualifying studies, postmenopausal status was not a predictor of fractures in HIV-infected women. Findings suggest that HIV care providers should accurately assess postmenopausal status and modifiable risk factors for osteoporosis in all older HIV-infected women.

Prevalence and predictors of low bone mineral density and fragility fractures among HIV-infected patients at one Italian center after universal DXA screening: sensitivity and specificity of current guidelines on bone mineral density management

Low bone mineral density (BMD) is frequent in HIV infection regardless of the use of antiretroviral therapy (ART). Uncertainties remain, however, as to when in HIV infection BMD screening should be performed. We designed a prospective study to estimate the efficacy of universal BMD screening by dual-energy X-ray absorptiometry (DXA). Since April 2009 through March 2011, HIV patients attending our Center were offered femoral/lumbar DXA to screen BMD. Low BMD for chronological age, that is significant osteopenia, was defined as a Z-score ≤ -2.0 at femur and lumbar spine. Nontraumatic bone fractures (NTBFs) were evaluated. The final sample included 163 patients. A Z-score ≤ -2.0 at any site was observed in 19.6% of cases: among these, 18.8% had no indication to DXA using current Italian HIV guidelines for BMD screening. A lower femoral Z-score was independently associated with lower BMI, AIDS diagnosis, HCV co-infection, antiretroviral treatment, and NTBFs; a lower lumbar Z-score with age, BMI, Nadir CD4 T-cell counts, and NTBFs. Prevalence of NTBFs was 27.0%, predictors being male gender, HCV co-infection, and lower femoral Z-scores. Our results suggest that measuring BMD by DXA in all HIV patients regardless of any further specification may help retrieving one-fifth of patients with early BMD disorders not identified using current criteria for selective screening of BMD.

Bone alterations associated with HIV

HIV infection and initiation of antiretroviral therapy (ART) have been consistently associated with decreased bone mineral density (BMD), with growing evidence linking HIV to an increased risk of fracture. This is especially concerning with the expanding number of older persons living with HIV. Interestingly, recent data suggest that HIV-infected children and youth fail to achieve peak BMD, possibly increasing their lifetime risk of fracture. Elucidating the causes of the bone changes in HIV-positive persons is challenging because of the multifactorial nature of bone disease in HIV, including contribution of the virus, immunosuppression, ART toxicity, and traditional osteoporosis risk factors, such as age, lower weight, tobacco, and alcohol use. Thus, practitioners must recognize the risk of low BMD and fractures and appropriately screen patients for osteoporosis if risk factors exist. If fractures do occur or elevated fracture risk is detected through screening, treatment with bisphosphonate medications appears safe and effective in the HIV+population.

Long-term treatment with tenofovir in Asian-American chronic hepatitis B patients is associated with abnormal renal phosphate handling

BACKGROUND

Increased risk of defective urinary phosphate reabsorption and osteoporosis has been reported in HIV and chronic hepatitis B (CHB) patients treated with tenofovir disoproxil fumarate (TDF).

AIMS

Goals of this study were to evaluate the prevalence of renal phosphate wasting and abnormal bone mineral density in CHB patients taking TDF compared to CHB patients treated with entecavir (ETV) and untreated CHB patients.

METHODS

This is a cross-sectional study of 146 consecutive Asian-American CHB patients who were treatment naïve (n = 60) or treated with either TDF (n = 42) or ETV (n = 44). Proximal tubular handling of phosphate was assessed by the maximal rate of tubular reabsorption of phosphate (TmPO4) divided by glomerular filtration rate (GFR) (TmPO4/GFR). Bone mineral density (BMD) was measured using dual X-ray absorptiometry.

RESULTS

TmPO4/GFR was similar among CHB patients treated with TDF compared to untreated patients and patients taking ETV. However, among patients treated with ≥18 months of TDF or ETV, prevalence of abnormal TmPO4/GFR was higher among patients treated with TDF compared to ETV (48.5 % (16/33) vs. 12.5 % (3/24), p = 0.005). Overall prevalence of osteoporosis in this cohort of CHB patients was 14 %, with no significant difference between the three groups. Renal phosphate handling did not correlate with osteoporosis.

CONCLUSIONS

Chronic hepatitis B patients treated with ≥18 months of TDF experienced an increased risk of proximal tubular dysfunction. TDF did not increase the risk of osteoporosis. Longitudinal studies are needed to confirm these findings.

Bone mineral density changes after 2 years of ARV treatment, compared to naive HIV-1-infected patients not on HAART

BACKGROUND

The prevalence of osteopenia and osteoporosis is increased in human immunodeficiency virus (HIV)-infected patients. The pathogenesis of this low bone mineral density (BMD) is multifactorial.

METHODS

We conducted a prospective study over a 2-year period of the BMD in non-treated ARV-naïve HIV-infected-males, in comparison to HIV-infected males commencing a first ARV treatment, and analyzed the evolution of bone turnover markers.

RESULTS

A total of 39 caucasian males (median age 38.6 years) were enrolled, including 10 who started ARV treatment (group 1), and 29 without indications for ARV therapy (group 2). In the latter group, 11 subjects commenced ARV during the study; therefore the remainder of their follow-up was within group 1, which finally consisted of 21 patients. At baseline, 9 patients (19.5%) had osteoporosis at least at 1 site, while 28 (61%) showed osteopenia. Lower BMD was correlated with tobacco use. Lumbar spine and total hip BMD significantly decreased in group 1 patients after 6 months of treatment, then stabilized (2.4% and 4% loss, respectively, at 24 months), while no significant change in BMD was observed in group 2 subjects. At baseline, one patient had an increased CTX (C-terminal cross-linking telopeptide of type 1 collagen) and all BSAP (bone-specific alkaline phosphatase) results were normal. During follow-up, both CTX and BSAP increased in group 1 patients, while they did not change in group 2.

CONCLUSION

Osteoporosis and osteopenia are frequent in HIV-infected males. After ARV initiation, BMD decreased, and bone turnover markers increased, even though the BMD remained stable in non-treated patients. These results underline the impact of HIV treatment on BMD and bone metabolism.

Effect of risedronate in osteoporotic HIV males, according to gonadal status: a pilot study

The aim of the study was to evaluate the effect of risedronate on bone mineral density (BMD) and bone turnover markers in HIV-infected osteoporotic males, according to their gonadal status. HIV patients were followed up for 24 months and divided into two groups: patients with osteoporosis or osteopenia with fractures (group A, n = 20) and those without (group B, n = 21). Group A and B were further divided according to the presence of reduced androgenizations. Both groups were treated with cholecalciferol 800 I.U. and calcium (Ca) 1,000 mg orally every day for the first 12 months. Risedronate 75 mg for two consecutive days a month orally was then added in group A, for another 12 months. Group B continued treatment with Ca and vitamin D. Every 6 months each patient underwent biochemical evaluation, and BMD measurement. A significant increase in lumbar BMD was observed in HIV males with adequate androgenization after 12 months of risedronate treatment in group A together with a reduction of bone turnover markers. BMD remained stable with a concomitant significant slight reduction of bone turnover markers in group B. Risedronate increased BMD and reduced bone turnover markers to a greater extent in patients with adequate androgenization compared to osteoporotic HIV males with symptomatic hypoandrogenization.

Osteoporosis and fractures in HIV/hepatitis C virus coinfection: a systematic review and meta-analysis

OBJECTIVE

There is growing evidence that fracture risk is increased in individuals with HIV and/or hepatitis C virus (HCV) infection. We systematically reviewed the literature to determine whether prevalence of osteoporosis and incidence of fracture is increased in HIV/HCV-coinfected individuals.

DESIGN

A systematic review and meta-analysis.

METHODS

A search was performed of Medline, Scopus and the Cochrane Library databases, as well as of abstracts from annual retroviral, liver and bone meetings (up to 2013) for studies with bone mineral density (BMD) or bone fracture data for HIV/ HCV-coinfected individuals. Osteoporosis odds ratios (ORs) and fracture incidence rate ratios (IRRs) were estimated from studies with data on HIV-monoinfected or HIV/HCV uninfected comparison groups.

RESULTS

Of 15 included studies, nine reported BMD data and six reported fracture data. For HIV/HCV-coinfected, the estimated osteoporosis prevalence was 22% [95% confidence interval (95% CI) 12–31] and the crude OR for osteoporosis compared with HIV-monoinfected was 1.63 (95% CI 1.27-2.11). The pooled IRR of overall fracture risk for HIV/HCV-coinfected individuals was 1.77 (95% CI 1.44-2.18) compared with HIV-monoinfected and 2.95 (95% CI 2.17-4.01) compared with uninfected individuals. In addition to HIV/HCV-coinfection, older age, lower BMI, smoking, alcohol and substance use were significant predictors of osteoporosis and fractures across studies.

CONCLUSION

HIV/HCV coinfection is associated with a greater risk of osteoporosis and fracture than HIV monoinfection; fracture risk is even greater than uninfected controls. These data suggest that HIV/HCV-coinfected individuals should be targeted for fracture prevention through risk factor modification at all ages and DXA screening at age 50.

Role of bone mineral density in predicting morphometric vertebral fractures in patients with HIV infection

This study investigated the bone of HIV patients both in terms of quantity and quality. It was found that HIV-infected patients did fracture independently of the degree of bone demineralization as in other forms of secondary osteoporosis.

INTRODUCTION

We aimed to determine the prevalence of vertebral fractures (VFs) in HIV patients who were screened by bone mineral density (BMD) and to explore possible factors associated with VFs.

METHODS

This is a cross-sectional study that included HIV-infected patients recruited in the Clinic of Infectious and Tropical Diseases and that underwent BMD measurement by dual-energy X-ray absorptiometry (DXA) at the lumbar spine and hip (Lunar Prodigy, GE Healthcare). For the assessment of VFs, anteroposterior and lateral X-ray examinations of the thoracic and lumbar spines were performed and were centrally digitized. Logistic regression models were used in the statistical analysis of factors associated with VFs.

RESULTS

One hundred thirty-one consecutive patients with HIV infection (93 M, 38 F, median age 51 years; range, 36-75) underwent BMD measurement: 25.2 % of patients showed normal BMD, while 45 % were osteopenic and 29.7 % osteoporotic. Prevalence of low BMD (osteopenia and osteoporosis) was higher in females as compared to males (90 vs 69 %) with no significant correlation with age and body mass index. VFs occurred more frequently in patients with low BMD as compared to patients with normal BMD (88.5 vs. 11.4 %; p < 0.001) without any significant difference between osteopenia and osteoporosis (43 vs. 46 %; p = 0.073). VFs were significantly associated with older age and previous AIDS events.

CONCLUSIONS

These results suggest a BMD <-1 threshold to identify patients at risk of skeletal fragility and, therefore, good candidates for morphometric evaluation of spine X-ray in line with other forms of secondary osteoporosis with impaired bone quality.

Low bone mineral density in patients with well-suppressed HIV infection: association with body weight, smoking, and prior advanced HIV disease

BACKGROUND

Human immunodeficiency virus (HIV) and combination antiretroviral therapy (cART) may both contribute to the higher prevalence of osteoporosis and osteopenia in HIV-infected individuals.

METHODS

Using dual-energy X-ray absorptiometry, we compared lumbar spine, total hip, and femoral neck bone mineral density (BMD) in 581 HIV-positive (94.7% receiving cART) and 520 HIV-negative participants of the AGEhIV Cohort Study, aged ≥45 years. We used multivariable linear regression to investigate independent associations between HIV, HIV disease characteristics, ART, and BMD.

RESULTS

The study population largely consisted of men who have sex with men (MSM). Osteoporosis was significantly more prevalent in those with HIV infection (13.3% vs 6.7%; P<.001). After adjustment for body weight and smoking, being HIV-positive was no longer independently associated with BMD. Low body weight was more strongly negatively associated with BMD in HIV-positive persons with a history of a Centers for Disease Control and Prevention class B or C event. Interestingly, regardless of HIV status, younger MSM had significantly lower BMD than older MSM, heterosexual men, and women.

CONCLUSIONS

The observed lower BMD in treated HIV-positive individuals was largely explained by both lower body weight and more smoking. Having experienced symptomatic HIV disease, often associated with weight loss, was another risk factor. The low BMD observed in younger MSM remains unexplained and needs further study.

Improvement in bone mineral density after switching from tenofovir to abacavir in HIV-1-infected patients with low bone mineral density: two-centre randomized pilot study (OsteoTDF study)

BACKGROUND

Tenofovir has been associated with a decrease in bone mineral density (BMD). However, data on changes in BMD after discontinuing tenofovir are lacking.

METHODS

We performed a two-centre randomized pilot study in virologically suppressed HIV-infected patients receiving tenofovir with osteopenia/osteoporosis (OsteoTDF study, ClinicalTrials.gov number NCT 01153217). Fifty-four patients were randomly assigned to switch from tenofovir to abacavir (n = 26) or to continue with tenofovir (n = 28). Changes in lumbar and total hip BMD were evaluated at Week 48 from baseline.

RESULTS

Five patients discontinued the study (three from the tenofovir group and two from the abacavir group). No significant differences were detected between the groups at Week 48 (P = 0.229 for total hip and P = 0.312 for lumbar spine). However, hip BMD improved by 2.1% (95% CI -0.6 to 4.7) (P = 0.043) in the abacavir group and 0.7% (95% CI -0.9 to 2.4) (P = 0.372) in the tenofovir group. Lumbar spine BMD varied by -0.7% (95% CI -3.8 to 3.3) (P ≤ 0.001) in the abacavir group and -1.2% (95% CI -3.8 to 0.4) (P < 0.001) in the tenofovir group.

CONCLUSIONS

Switching from tenofovir to abacavir led to a slight improvement in femoral BMD although no differences were detected between groups. Larger studies are necessary before firm recommendations can be made on the discontinuation of tenofovir in patients with a low BMD.

Comorbidities among the HIV-infected patients aged 40 years or older in Taiwan

Background

With the widespread use of combination antiretroviral therapy (cART), life expectancy of HIV-infected patients has significantly prolonged. An increasing number of HIV-infected patients are aging and concurrent use of medications are not uncommon for management of metabolic complications and cardiovascular diseases related to aging and prolonged exposure to cART.

Methods

We reviewed medical records of all HIV-infected patients aged 40 years or older who had been followed at a university hospital for HIV care in Taiwan between January and December 2013. A standardized case record form was used to collect information on demographics and clinical characteristics, comorbidity, cART, and concurrent medications.

Results

During the study period, 610 patients aged 40 to 49 years (mean, 44.1) and 310 aged 50 years or older (mean, 58.8) sought HIV care at this hospital. Compared with patients aged 40 to 49 years, those aged 50 years or older were significantly more likely to be female (15.9% vs 3.8%); to have received cART (97.7% vs 94.8%) and a lower plasma HIV RNA load (1.6 vs 1.7 log₁₀ copies/ml); and to have diabetes mellitus (18.4% vs 4.6%), hypertension (31.0% vs 10.8%), hyperlipidemia (29.4% vs 11.6%), coronary artery disease (6.8% vs 0.5%), and an estimated glomerular filtration rate <60 ml/min/1.73 m² (11.5% vs 2.7%); and were significantly less likely to have syphilis. Other than HIV infection, patients aged 50 years or older were more likely to have been receiving two or more concurrent medications than those aged 40 to 49 years (22.9% vs 6.4%).

Conclusions

Our findings show a significant proportion of the HIV-infected patients aged 50 years or older have multiple comorbidities that may increase the risk for cardiovascular and renal complications. Issues of poly-pharmacy among the HIV-infected patients who are aging should be addressed to ensure adherence and minimize drug-drug interactions.

Is bone loss linked to chronic inflammation in antiretroviral-naive HIV-infected adults? A 48-week matched cohort study

OBJECTIVE

Antiretroviral therapy (ART) has been implicated in bone loss in HIV. The role of inflammation and vitamin D is unclear and better investigated in ART-naive individuals.

DESIGN AND METHODS

This is a 48-week, prospective cohort study to compare baseline and change in hip and spine bone mineral density (BMD) measured by dual-energy X-ray absorptiometry in HIV-infected, ART-naive adults and healthy controls matched by age, sex, and race. We also studied associations between bone loss and inflammation markers and plasma 25-hydroxyvitamin D [25(OH)D] using logistic regression.

RESULTS

Forty-seven HIV-infected adults and 41 controls were included. Baseline 25(OH)D, BMD at total hip, trochanter, and spine, and prevalence of osteopenia and osteoporosis were similar between groups. In the HIV-infected group, total hip and trochanter, but not spine, BMD decreased over 48 weeks [hip -0.005 (-0.026-0.008) g/cm², P = 0.02 within group; trochanter -0.013 (-0.03-0.003), P < 0.01]. BMD did not change at any site within controls. The HIV-infected group was more likely to have bone loss at the trochanter (P = 0.03). This risk persisted after adjustment for age, sex, race, BMI, smoking, and hepatitis C (odds ratio 4, 95% confidence interval 1.2-15.8). In the HIV-infected group, higher interleukin-6 concentrations (P = 0.04) and Caucasian race (P < 0.01) were independently associated with progression to osteopenia or osteoporosis, but not 25(OH)D levels.

CONCLUSION

BMD at the total hip and trochanter sites decreased in the HIV-infected, ART-naive adults, but not controls, over this 48-week study. Higher serum interleukin-6 concentrations were associated with progression to osteopenia or osteoporosis status in the HIV-infected group.

The effects of untreated and treated HIV infection on bone disease

PURPOSE OF REVIEW

Low bone mineral density (BMD) is common in those with HIV, associated with higher bone turnover and a higher prevalence of fractures. This review explores low BMD in HIV, focusing on underlying mechanisms and relationships between low BMD and HIV infection, immune dysfunction, and antiretroviral therapy (ART).

RECENT FINDINGS

Greater reductions in BMD accompanying reductions in HIV viremia at initiation of first-line or second-line ART suggest an important role for immune- or viral-mediated mechanisms in its pathogenesis.

SUMMARY

As bone metabolism is part-regulated by T cells and B cells, we propose that earlier initiation of ART at higher CD4 T-cell counts may attenuate BMD loss by abrogating immune- and viral-mediated disturbances in bone metabolism that accompany ART initiation. Further pathogenesis-based research is required in this field, focusing on the complex interaction between virus, immune system, ART, and bone metabolism.

Long-term use of protease inhibitors is associated with bone mineral density loss

HIV-infected patients are at high risk for bone mineral density (BMD) loss. The present study was designed to provide information on characteristics of BMD abnormalities in Japanese HIV-1-infected patients and risk factors involved in worsening of BMD. A total of 184 Japanese HIV-1-infected men were studied with a dual-energy X-ray absorptiometry scan (DXA) at the lumbar spine and femoral neck. Multivariate logistic regression models were used for comparison of the impact of risk factors on BMD loss. Osteopenia and osteoporosis were diagnosed in 46% and 10% of the patients at lumbar spine, and 54% and 12% at femoral neck, respectively. In logistic analysis, factors associated with low BMD at both lumbar spine and femoral neck were long-term treatment with a protease inhibitor (PI) [odds ratio (OR) 1.100 and 1.187 per 1 year increase of PI use; 95% confidence interval (CI) 1.003-1.207 and 1.043-1.351; p=0.042 and 0.009, respectively] and a low body mass index [OR: 0.938 and 0.852, CI 0.892-0.992 and 0.783-0.927; p=0.024 and <0.001, respectively]. Patients who discontinued PI had a significantly higher BMD than those who currently use PI at lumbar spine (t score -0.8 vs. -1.3, p=0.04) but not at femoral neck (-1.3 vs. -1.5, p=0.38). In HIV-infected Japanese patients, the duration of treatment with PI correlated significantly with BMD loss. Discontinuation of PI is a promising option in the treatment of BMD loss since it allows recovery of BMD, especially in the lumbar spine.

HIV and ageing: what the geriatrician needs to know

The transformation of human immunodeficiency virus (HIV) from a rapidly fatal disease to a chronic manageable illness has resulted in annual increases in the numbers of people living with HIV. The HIV cohort is therefore ageing, with numbers of older adults with HIV climbing, through both prolonged survival and late acquisition of the disease. Associated with ageing is an accumulation of HIV-associated non-AIDS related co-morbidities, creating a complex patient group affected by multi-morbidity along with polypharmacy, functional decline and complex social issues. With this in mind, this review seeks to explore areas where HIV (diagnosed or undetected) may impact on the work of clinical geriatricians.

Bone mass, body composition and vitamin D status of ARV-naïve, urban, black South African women with HIV infection, stratified by CD₄ count

This is the first report examining vitamin D status and bone mass in African women with HIV infection using dual-energy X-ray absorptiometry (DXA) with an appropriate HIV-negative control group. Unlike previous publications, it demonstrates no difference in bone mineral density (BMD) or vitamin D status in HIV-positive patients, at different disease stages, vs. HIV-negative subjects.

INTRODUCTION

Low bone mass and poor vitamin D status have been reported among HIV-positive patients; suggesting HIV or its treatment may increase the risk of osteoporosis, a particular concern for women in countries with high HIV prevalence such as South Africa. We describe bone mass and vitamin D status in urban premenopausal South African women, who were HIV positive but not on antiretroviral therapy (ARV).

METHODS

This study is a cross-sectional measurement of BMD and body composition by DXA and vitamin D status by serum 25-hydroxyvitamin D (25(OH)D) concentration. Subjects were recruited into three groups: HIV negative (n = 98) and HIV positive with preserved CD₄ cell count (non-ARV; n = 74) or low CD₄ cell counts prior to ARV initiation (pre-ARV; n = 75).

RESULTS

The mean (standard deviation (SD)) age of women was 32.1 (7.2) years. Mean CD₄ (SD) counts (×10(6)/l) were 412 (91) and 161 (69) in non-ARV and pre-ARV groups (p < 0.0001). Pre-ARV women were significantly lighter and had lower mean BMI than the other two groups (p < 0.002). The pre-ARV group also had significantly less fat and lean mass compared with non-ARV and HIV-negative subjects (p ≤ 0.05). After full adjustment, there were no significant differences in BMD at any site (p > 0.05) between the groups, nor was vitamin D status significantly different between groups (p > 0.05); the mean (SD) cohort 25(OH)D being 60 (18) nmol/l.

CONCLUSION

Contrary to previous studies, these HIV-positive women did not have lower BMD or 25(OH)D concentrations than HIV-negative controls, despite the pre-ARV group being lighter with lower BMI.

Prevalence and risk factors of osteopenia/osteoporosis in Turkish HIV/AIDS patients

BACKGROUND

Recent studies showed a high frequency of low bone mineral density (BMD) in HIV-infected patients and no reports have been issued in Turkey. Our aim was to evaluate BMD and risk factors for osteopenia/osteoporosis in HIV-infected patients that attended an outpatient clinic in Istanbul, Turkey.

METHOD

In order to determine the prevalence of BMD, 126 HIV-infected patients had been studied with dual energy X-ray absorptiometry (DEXA). The association between BMD and age, gender, body mass index (BMI), habits, 25(OH)vitamin D, HIV RNA, CD4 lymphocyte nadir, using and duration of highly active antiretroviral treatment (HAART) were investigated by using multivariate analysis.

RESULTS

Median age was 40.1 years (range, 20-70); 84% were male; 35.7% patients had AIDS, 63.5% were treated with HAART. Osteopenia and osteoporosis were diagnosed in 53.9% and 23.8%, respectively. Mean plasma HIV RNA was 5.2 (SD 1.0) log10 copies/mL and CD4 lymphocyte nadir was 313.8 (SD 226.2)/mm(3). Factors associated with bone loss were high viral load (p=0.034), using (p=0.033) and duration of HAART (p=0.008). No correlation had been seen between sex and osteopenia/osteoporosis (p=0.794). However, males showed higher rates of osteoporosis than females (p=0.042).

CONCLUSIONS

Our results show a very high prevalence of bone mass reduction in Turkish HIV-infected patients. This study supports the importance of both HIV and antiretroviral therapy in low BMD.

Changes in bone mineral density over a 2-year period in HIV-1-infected men under combined antiretroviral therapy with osteopenia

OBJECTIVE

Although osteopenia is common in HIV-infected patients, there is by now limited data on the evolution of bone mineral density in this population. We aimed to evaluate the course of osteopenia over a 2-year period in HIV-1-infected men, and to identify risk factors for abnormal bone mineral density (BMD) decline.

METHODS

HIV-1-infected men on combined antiretroviral therapy (cART) screened in the ANRS 120 Fosivir trial, diagnosed with low BMD (-2.5 ≤T-score <-1), not receiving antiosteoporotic agents, with sequential dual-energy-X ray-absorptiometry (DXA) available at baseline were eligible for this study and had a second DXA performed between months 24 and 36.

RESULTS

We enrolled 94 men with a median age of 46 years [interquartile range (IQR), 41-53], BMI 22 kg/m² (21-25) and a CD4 cell nadir of 164/μl (69-261). They were receiving cART for a median of 7.5 years (5.8-9.5). Over a median interval of 2.6 years (2.3-2.9) between the two DXA tests, the mean change in BMD was -0.5 ± 1.7% per year (P = 0.010) at the lumbar spine and -0.4 ± 1.8% per year (P = 0.033) at the hip. BMD fell by more than the smallest detectable difference (SDD) in, respectively, 25.5 and 27.7% of patients at the lumbar spine and hip. Tenofovir (TDF) exposure was independently associated with a larger decline in BMD at both sites [lumbar spine, OR = 2.4 (1.2-4.9); hip, OR = 2.8 (1.3-5.9)].

CONCLUSION

Although osteopenia overall modestly changes over 2 years in long-term cART-treated patients, a quarter of patients experienced a significant loss (>1 SDD) associated with TDF exposure.

Decline in serum 25 hydroxyvitamin D levels in HIV-HBV-coinfected patients after long-term antiretroviral therapy

BACKGROUND

Vitamin D insufficiency plays an important role in the development of fibrosis in chronic liver disease.

METHODS

This was a cross-sectional study from Thailand. Liver fibrosis was assessed by transient elastography. Serum 25 hydroxyvitamin D (25[OH]D)<30 ng/ml was defined as hypovitaminosis D. 25(OH)D was assessed prior to and following tenofovir disoproxil fumarate (TDF). Factors related to 25(OH)D levels were determined by logistic regression analysis.

RESULTS

A total of 158 HIV-HBV-coinfected patients (32% female, median age 43 years) were included. Overall, liver disease was mild with 13.4% having a fibrosis score (FS) of 7.1-14 kPa and 2% with a FS>14 kPa. Median (IQR) duration on TDF was 5 years (4-7). The median estimated glomerular filtration rate was 96.9 ml/min/1.73 m(2). The median (IQR) serum 25(OH)D levels prior to and following TDF were 24.8 ng/ml (21.3-30.6) and 22.8 ng/ml (18.0-27.7), respectively; P≤0.001). The proportion of patients with hypovitaminosis D significantly increased from 72.2% (95% CI 64.7, 78.6) prior to TDF to 84.2% (95% CI 77.7, 89.0) after taking TDF (P=0.01). Factors associated with hypovitaminosis D by multivariate analysis were female sex (adjusted OR 3.8, 95% CI 1.1, 13.7; P=0.038) and duration of antiretroviral therapy (ART)>5 years (OR 3.3, 95% CI 1.2, 8.8; P=0.017). Vitamin D levels were not associated with significant liver fibrosis.

CONCLUSIONS

Although our HIV-HBV-coinfected patients live in the tropics, there was a high prevalence of hypovitaminosis D, especially in female patients and those receiving prolonged ART. Since HIV-HBV-coinfection requires long-term use of the HBV-active drug, TDF, which can also contribute to bone loss, routine vitamin D assessment and supplementation as necessary should be considered.

Self-management education programs for people living with HIV/AIDS: a systematic review

The effectiveness of self-management programs to improve physical, psychosocial, health knowledge, and behavioral outcomes for adults living with HIV has not been well established. This article reviews the effectiveness of self-management education programs to improve physical, psychosocial, health knowledge, and behavior outcomes for adults living with HIV/AIDS. A systematic review of English articles using CINAHL, MEDLINE, and PsycINFO were used to identify and retrieve relevant studies. Each database was searched from its earliest record to October 2010. Search terms included HIV/AIDS, self-management, self-care, patient education, and education programs. Only studies that (1) reported on a HIV-specific intervention that aimed to increase participants HIV-related knowledge through a self-management component, (2) included a control group, (3) provided skills training or targeted behavior change, and (4) reported clinical outcomes were included. Independent data extraction by one author using the methods described in the Cochrane Handbook for Systematic Reviews. A second reviewer checked the data extraction. Six protocols were reported in eight publications (n=1178), all contained elements of self-management interventions. Effect size calculations were not conducted due to limitations in the available data. The review found randomized controlled trials (RCT) evidence sufficient to infer that self-management programs for people living with HIV/AIDS result in short-term improvements in physical, psychosocial, and health knowledge and behavioral outcomes. Statistically significant improvements were reported for intervention participants compared to control participants across most outcomes. There is insufficient evidence to provide conclusions regarding the long-term outcomes of HIV-specific self-management interventions.

Prevalence and risk factors of low bone mineral density among perinatally HIV-infected Thai adolescents receiving antiretroviral therapy

BACKGROUND

Low bone mineral density (BMD) has been reported among 10%-54% of HIV-infected adolescents in developed countries. We studied the prevalence and predictors of low BMD among HIV-infected Thai adolescents receiving antiretroviral therapy.

METHODS

A cross-sectional study of lumbar spine (L2-L4) BMD as measured by dual-energy X-ray absorptiometry in Thai HIV-infected adolescents aged 12-20 years was performed. The BMD Z score was analyzed using age-matched healthy Thai children as a reference. Serum 25-hydroxyvitamin D was performed. Osteopenia was defined as BMD Z score ≤ -2.

RESULTS

From October 2010 to February 2011, 101 adolescents, 50% male, with a median age of 14.3 (range: 13.0-15.7) years were enrolled. The median [interquartile range (IQR)] current CD4 T-cell count was 646 (506-796) cells per cubic millimeter and 90% had plasma HIV-1 RNA <50 copies per milliliter. The mean BMD among HIV-infected adolescents and controls were 0.855 and 0.980 g/cm (P < 0.001). The median (IQR) L2-L4 spine BMD Z score was -1.0 (-1.9 to -0.1), of which 24% had BMD Z score ≤ -2.0. The median (IQR) of 25-hydroxyvitamin D level was 24.8 (20.0-31.4) ng/mL, of which 25% had vitamin D level < 20 ng/mL. In multivariate analysis, the height for age Z score < -1.5 (adjusted odds ratio: 6.2; 95% confidence interval: 2.2 to 17.7) and history of World Health Organization clinical stage 4 before antiretroviral therapy (adjusted odds ratio: 3.7; 95% confidence interval: 1.3 to 10.7) were significantly associated with osteopenia.

CONCLUSION

One fourth of HIV-infected Thai adolescents have osteopenia. Children with history of advanced-staging or having low height for age are at risk of osteopenia. Preventive measures to prevent osteopenia should be incorporated in routine care for these adolescents.

HIV and its effects on bone: a primer for rheumatologists

PURPOSE OF REVIEW

As patients with HIV are living longer because of effective treatments, rates of comorbid chronic diseases such as bone complications are increasing. There is a growing body of literature showing increased rates of osteopenia and osteporosis in the HIV population. Less is known about the risk of fracture, as well as other bone complications, such as avascular necrosis (AVN).

RECENT FINDINGS

Increased rates of osteopenia and osteoporosis are seen in the HIV population, likely secondary to an interaction of traditional osteoporotic and HIV-specific risk factors, and possibly the effect of antiretroviral therapy (ART). There are conflicting recent data as to whether the decrease in bone mineral density seen in the HIV population, specifically with particular ART regimens, translates into an increased risk of fracture. Conflicting evidence emerges from recent studies exploring whether supplementation of vitamin D and calcium can prevent the bone loss seen with specific ART regimens.

SUMMARY

Bone disease is common in the HIV population, and will likely be a medical problem increasingly seen by rheumatologists. The role of ART regimens on bone complications such as fracture and AVN is unclear, and further research in this area as well as possible prevention strategies are needed.

Interventions to address chronic disease and HIV: strategies to promote exercise and nutrition among HIV-infected individuals

Food insecurity, micronutrient deficits, dyslipidemia, insulin resistance, obesity, cardiovascular disease, and bone disorders complicate the treatment of HIV infection. Nutrition and exercise interventions can be effective in ameliorating these symptoms that are associated with HIV and antiretroviral therapy (ART). In this literature review, we examine the most recent nutrition and exercise interventions for HIV-infected patients. Macronutrient supplementation can be useful in treating malnutrition and wasting. Multivitamin (vitamin B complex, vitamin C, and vitamin E) supplements and vitamin D may improve quality of life and decrease morbidity and mortality. Nutritional counseling and exercise interventions are effective for treating obesity, fat redistribution, and metabolic abnormalities. Physical activity interventions improve body composition, strength, and fitness in HIV-infected individuals. Taken collectively, the evidence suggests that a proactive approach to nutrition and physical activity guidance and interventions can improve outcomes and help abrogate the adverse metabolic, cardiovascular, and psychological consequences of HIV and its treatments.

Similarly high prevalence of hypovitaminosis D in HIV-infected subjects with and without low bone mineral density

Background: Hypovitaminosis D is highly prevalent among HIV-infected patients. Since hypovitaminosis D is a secondary cause of low bone mineral density (BMD), we assessed its prevalence and associated factors in HIV-infected patients with osteopenia/osteoporosis, compared with HIV-infected patients with normal BMD. Materials & methods: Serum 25-hydroxy vitamin D (25[OH]D) concentration were collected from 149 HIV-infected subjects with low BMD and 36 with normal BMD from April to October, 2010. Regression analyses were fitted to predict the probability of hypovitaminosis D in all patients. Results: Of the 149 patients with low BMD (51.8 ± 8 years old, 76.5% men), 83% had vitamin D insufficiency (<30 ng/ml) and 7.4% had severe deficiency (<10 ng/ml). In comparison, insufficiency was present in 75% of subjects from the group with normal BMD (p = 0.60) and no subject was severely deficient (p = 0.13). Among subjects with low BMD, 1.8% of men had low levels of testosterone, 5.4% of patients had high levels of thyroid-stimulating hormone, (all with normal free thyroxine levels) and 14.6% had high levels of parathyroid hormone. Univariate analysis showed significant associations between hypovitaminosis D and the current use of non-nucleosides (β-coefficient: -3.797; standard deviation: 1.538; p = 0.015), whereas protease inhibitors were associated with higher levels of vitamin D (β-coefficient: 4.640; standard deviation: 1.673; p = 0.006). Conclusion: Hypovitaminosis D was highly prevalent in our patients with low BMD but also in those with normal bone dual x-ray energy absorptionmetry scan. 25(OH)D should be periodically monitored, although the benefit of vitamin D and calcium supplements on bone mineralization has not yet been investigated in this population.

Reduced bone mineral density among HIV-infected patients in Taiwan: prevalence and associated factors

BACKGROUND

Reduced bone mineral density (BMD) is an emerging threat to the successful long-term management of human immunodeficiency virus (HIV) infection among patients with access to combination antiretroviral therapy (cART). Data on the prevalence and associated factors of reduced BMD in Asian populations remain scarce.

METHODS

From March 2002 to April 2006, a cross-sectional survey was conducted among HIV-infected patients aged ≥ 20 years at the National Taiwan University Hospital. BMD of the lumbar spine was measured with the use of dual-energy X-ray absorptiometry. Osteopenia was defined as a BMD T-score between -1.0 and -2.5, and osteoporosis was defined as a BMD T-score ≤ -2.5. Linear and ordinal logistic regression analyses were performed.

RESULTS

Among 320 patients with a median age of 37.3 years, body mass index (BMI) of 21.4kg/m(2) and 94.4% on cART, osteopenia and osteoporosis were diagnosed in 35.6% and 3.8%, respectively. On multivariate linear analysis, factors associated with reduced BMD were increasing age (p=0.006), longer duration on antiretroviral therapy (p=0.007), and a decreasing BMI (p=0.002). Using ordinal logistic regression, being underweight with a body mass index (BMI)<18.5kg/m(2) was independently associated with reduced BMD (proportional odds ratio, 4.12; 95% confidence interval, 1.93-8.82).

CONCLUSION

Reduced BMD was prevalent among HIV-infected Taiwanese adults on cART. Increased age, lower BMI, and exposure to antiretroviral therapy were significantly associated with decrease of BMD.

Time of progression to osteopenia/osteoporosis in chronically HIV-infected patients: screening DXA scan

BACKGROUND

Algorithms for bone mineral density (BMD) management in HIV-infected patients are lacking. Our objective was to assess how often a dual-energy x-ray absorptiometry (DXA) scan should be performed by assessing time of progression to osteopenia/osteoporosis.

METHODS

All DXA scans performed between 2000 and 2009 from HIV-infected patients with at least two DXA were included. Time to an event (osteopenia and osteoporosis) was assessed using the Kaplan-Meier method. Strata (tertiles) were defined using baseline minimum T scores. Differences between strata in time to an event were compared with the log-rank test.

RESULTS

Of 391 patients (1,639 DXAs), 49.6% had osteopenia and 21.7% osteoporosis at their first DXA scan. Of the 112 (28.6%) with normal BMD, 35.7% progressed to osteopenia; median progression time was 6.7 years. These patients were stratified: "low-risk" (baseline minimum T score >-0.2 SD), "middle-risk" (between -0.2 and -0.6 SD), and "high-risk" (from -0.6 to -1 SD); median progression time to osteopenia was 8.7, >7.2, and 1.7 years, respectively (p<0.0001). Of patients with osteopenia, 23.7% progressed to osteoporosis; median progression time was >8.5 years. Progression time was >8.2 years in "low-risk" tertile (T score between -1.1 and -1.6 SD), >8.5 years in "middle-risk" (between -1.6 and -2), and 3.2 years in "high-risk" (from -2 to -2.4) (p<0.0001).

CONCLUSIONS

Our results may help to define the BMD testing interval. The lowest T score tertiles would suggest recommending a subsequent DXA in 1-2 years; in the highest tertiles, ≥6 years. Early intervention in patients with bone demineralization could reduce fracture-related morbidity/mortality.

Prevalence of low bone mineral density in men and women infected with human immunodeficiency virus 1 and a proposal for screening strategy

We analyzed data collected during screening for eligibility in the ANRS-120 FOSIVIR clinical trial to estimate the prevalence of osteoporosis in patients infected with human immunodeficiency virus 1 (HIV-1), to study its risk factors, and to develop a screening strategy. McNemar test was used to compare the estimated prevalence of osteoporosis, using 3 different definitions. We then derived a screening strategy for HIV-infected men. We analyzed data for 700 men and 192 women. The prevalence of osteoporosis differed markedly according to the definition used. Based on the "T-score ≤ -2.5" definition, 14.9% of men and 1.0% of women had osteoporosis. Factors associated with low bone mineral density comprised not only classical risk factors for osteoporosis such as low body mass index (BMI) or older age but also factors associated with HIV infection such as lower CD4 T-cell nadir in men and AIDS in women, and with antiretroviral treatment such as recent tenofovir therapy. In addition to postmenopausal women, we recommend osteoporosis screening for HIV-infected men older than 60 yr, men younger than 60 yr with BMI < 20 kg/m(2), and men younger than 60 yr with both BMI 20-23 kg/m(2) and a CD4 T-cell nadir ≤ 200/mm(3).