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

A novel library screen identifies immunosuppressors that promote osteoblast differentiation

Bone homeostasis can be compromised by an increase in osteoclast-mediated resorption and/or a decrease in osteoblast-mediated bone deposition. While many efforts have focused on treating osteoclast resorption, there has been less emphasis on identifying strategies for promoting osteoblast function. Herein, we describe a high-throughput screening assay to select for small molecules that augment bone morphogenetic protein-2 (BMP-2)-mediated osteoblast lineage commitment. After an initial screen of 5405 compounds; consisting of FDA-approved drugs, known bioactives, and compounds with novel chemical makeup, we identified 45 small molecules that promoted osteoblast commitment. Of the 45 candidates, there was a broad array of classes that included nine retinoid analogs/derivatives and four immunosuppressants, notably rapamycin and FK-506, which were chosen for further study. Treatment of osteoblast precursor cells with rapamycin or FK-506, either alone, or synergistically with BMP-2, increased levels of phospho-Smad 1/5/8 protein and transcription of Runx-2, Osx and Smad-7, consistent with a role in promoting osteoblast differentiation. Only FK-506 was able to enhance osteocalcin transcripts and Alizarin Red staining, both late markers for differentiation. When osteoblast differentiation was suppressed with exogenous TGF-β1 treatment, rapamycin (but not FK-506) was able to rescue expression of differentiation markers, indicating distinct but overlapping activity of these compounds. Collectively, these data add to an understanding of pathways engaged in osteoblastogenesis, support a role for non-redundant immunosuppressant signaling, and provide a novel approach for the discovery of potentially therapeutic compounds that affect bone remodeling.

High frequency of vitamin D deficiency in HIV-infected patients: effects of HIV-related factors and antiretroviral drugs

OBJECTIVES

The aim of this study was to assess 25-hydroxyvitamin D (vitamin D) status in an HIV-infected adult population and to define HIV- and antiretroviral-related factors associated with vitamin D deficiency.

METHODS

Using data from a prospective cohort of HIV-infected adult patients followed in five French centres (Dat'AIDS cohort), we evaluated the prevalence of vitamin D deficiency/insufficiency (<30 ng/mL). A multiple linear regression model was used to examine risk factors for vitamin D deficiency (≤10 ng/mL).

RESULTS

Vitamin D deficiency/insufficiency was observed in 86.7% of the 2994 patients, including 55.6% with vitamin D insufficiency and 31.1% with vitamin D deficiency. In multivariate analysis, factors associated with vitamin D deficiency were current smoking [adjusted OR (aOR) 1.55], estimated glomerular filtration rate ≥90 mL/min/1.73 m(2) (aOR 1.51), vitamin D measurement not performed in summer (aOR 0.27), CD4 <350 cells/mm(3) (aOR 1.37 for CD4 200 to <350 and 1.62 for CD4 <200 cells/mm(3)) and antiretroviral therapy (aOR 2.61). Gender, body mass index, age, coinfection and previous AIDS were not associated factors. In the antiretroviral-treated population (n = 2660), besides the same factors found in the whole population, efavirenz was the only drug to be significantly associated with deficiency, with an aOR of 1.89 (95% CI 1.45-2.47).

CONCLUSIONS

Vitamin D deficiency is frequent in this HIV-infected population. Patients on antiretroviral therapy are at higher risk of vitamin D deficiency than antiretroviral-naive patients, with an increased risk in patients receiving efavirenz. No effect of the other antiretrovirals, including the latest (etravirine, darunavir, raltegravir), was found.

Antihypertensive Drugs in Patients Treated with Antiretroviral

Objective:

To review the literature for information regarding pharmacokinetic interactions between antiretrovirals and antihypertensive agents, evaluate the clinical significance of these interactions, and analyze the effect of antihypertensive drugs on the metabolic complications frequently observed in HIV-infected patients to emphasize the advantages and inconveniences of every class of antihypertensive drugs in association with antiretrovirals.

Data Sources:

A literature search was conducted via PubMed and MEDLINE (1950-November 2011) using the search terms drug interactions, cytochrome P450, names of antiretrovirals, names of commonly prescribed antihypertensive drugs, pharmacokinetics, and metabolic complications. Reference citations from relevant publications, manufacturers’ product information, and www.HIV-druginteracttons.org were also reviewed.

Study Selection And Data Extractions:

All articles with an English abstract identified through the data search were examined. Of these, pharmacologic reviews, studies, and case reports were evaluated.

Data Synthesis:

Antihypertensive drugs interact with several antiretroviral drugs, non nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (Pls) in particular. Pharmacokinetic interactions are less expected with diuretics, jî-blockers excreted by the kidney, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs) other than losartan and irbesartan. Calcium channel blockers (CCBs) are metabolized by CYP3A4, with the potential for interaction with NNRTIs and Pls. Because CCBs do not adversely affect glucose or lipid metabolism or renal function, they may be preferred in patients with such complications. ACE inhibitors and ARBs may exert favorable effects on glucose homeostasis. In addition, they may significantly reduce protein excretion and further slow the progression of renal disease.

Conclusions:

The choice of antihypertensive drugs in HIV-infected patients is complex and must take into account the metabolic pathways of antiretroviral drugs and antihypertensive drugs with the potential of pharmacokinetic interactions, as well as the effect of antihypertensive drugs on some biological parameters.

Osteoporotic fracture risk associated with cumulative exposure to tenofovir and other antiretroviral agents

BACKGROUND

Whereas tenofovir (TDF) exposure has been associated with decreased bone density, it remains unclear whether it is associated with increased risk of osteoporotic fractures.

METHODS

Patients with any osteoporotic fracture (defined as wrist, vertebral or hip fracture) occurring after HIV diagnosis were identified by International Classification of Diseases - 9th Revision (ICD-9) code in the Veterans Affairs' Clinical Case Registry from 1988 to 2009. Osteoporotic fracture risk associated with cumulative exposure to TDF and other antiretrovirals was examined in univariate analysis and multivariate model 1 (MV1 - controlling for race, age, tobacco use, diabetes, body mass index, and hepatitis C status) and model 2 (MV2 - controlling for MV1 variables + concomitant antiretroviral exposures).

RESULTS

Among 56,660 patients evaluated, TDF exposure (total 46,062 person-years) was associated with an osteoporotic fracture hazard ratio of 1.080 [95% confidence interval (CI) 1.02-1.15, P < 0.001] in univariate analysis, 1.06 (0.99-1.12) in MV1 and 1.06 (0.99-1.14) in MV2. Among patients entering the cohort in the highly active antiretroviral therapy (HAART) era (n = 32,439), TDF exposure was associated with a yearly hazard ratio for osteoporotic fracture of 1.16 (95% CI 1.08-1.24, P < 0.001) in univariate model, 1.13 (1.05-1.21, P = 0.001) in MV1 and 1.12 (1.03-1.21, P = 0.011) in MV2. Boosted protease inhibitor exposure was associated with hazard ratio of 1.11 (1.05-1.18, P = 0.001) in univariate model, 1.08 (1.01-1.15, P = 0.026) in MV1 and 1.05 (0.97-1.13, P = 0.237) in MV2. Among protease inhibitors, lopinavir/ritonavir (LPV/RTV) had an osteoporotic fracture hazard ratio of 1.09 (CI 1.00-1.20, P = 0.051) in MV2.

CONCLUSION

Cumulative exposure to TDF and, among protease inhibitors, LPV/RTV was independently predictive of increased risk of osteoporotic fracture in the HAART era.

The frequency of low muscle mass and its overlap with low bone mineral density and lipodystrophy in individuals with HIV--a pilot study using DXA total body composition analysis

As a result of the advances in antiretroviral therapy, the life span of human immunodeficiency virus (HIV)-infected patients has increased dramatically. Attendant to these effects are signs of premature aging with notable changes in the musculoskeletal system. Although changes in bone and fat distribution have been studied extensively, far less is known about changes in muscle. This study examined the extent of low muscle mass (LMM) and its relationship with low bone mineral density (BMD) and lipodystrophy (LD) in HIV-positive males. As such, HIV-positive males on therapy or treatment naive underwent dual-energy X-ray absorptiometry total body composition measurements. Appendicular lean mass/(height)2 and lowest 20% of residuals from regression analysis were used to define LMM. BMD criteria defined osteopenia/osteoporosis, and the percent central fat/percent lower extremity ratio defined LD. Several potential risk factors were assessed through chart review. Sixty-six males (57 with treatment and 9 treatment naive) volunteered. Treated individuals were older than naive (44 vs 34 yr) and had HIV longer (108 vs 14 mo). When definitions for sarcopenia (SP) in elderly individuals were applied, the prevalence of LMM was 21.9% and 18.8% depending on the definition used. Low BMD was present in 68.2% of participants. LD with a cutoff of 1.5 and 1.961 was present in 54.7% and 42.2% of participants, respectively. LMM and LD were negatively associated. In conclusion, this study shows that LMM is common in males with HIV and that SP affecting muscle function could be present in a substantial number of individuals. Future research needs to examine what impact decreased muscle mass and function has on morbidity, physical function, and quality of life in individuals with HIV.

Body fat distribution in HIV-infected patients treated for 96 weeks with darunavir/ritonavir monotherapy versus darunavir/ritonavir plus nucleoside reverse transcriptase inhibitors: the MONOI-ANRS136 substudy

OBJECTIVES

The aim of the study was to evaluate fat tissue distribution in HIV-infected patients with suppressed viraemia treated with darunavir/ritonavir (darunavir/r) monotherapy versus darunavir/r triple therapy.

METHODS

This study was a substudy of the randomized, multicentre, open-label MONOI-ANRS 136 trial. Body fat distribution and metabolic parameters were measured at baseline, week 48 and week 96.

RESULTS

In total, 156 patients of the 225 initially enrolled in the MONOI trial participated in this study, 75 in the darunavir/r monotherapy arm and 81 in the darunavir/r triple-therapy arm. The median limb fat increase from baseline was +0.34 kg [interquartile range (IQR) -0.040 to +1.140 kg; P < 0.001] at week 48 and +0.33 kg (IQR -0.14 to +1.26 kg; P = 0.001) at week 96 in the monotherapy arm, while there was no change (-0.02 kg; IQR -0.53 to +0.52 kg) at week 48 and then an increase of +0.23 kg (IQR -0.45 to +0.87 kg; P = 0.046) at week 96 in the triple-therapy arm. The two arms differed significantly at week 48 (P = 0.001) but not at week 96. The median increase in trunk fat was +0.73 kg (IQR -0.24 to +1.60 kg; P < 0.001) and 0.60 kg (IQR -0.41 to +1.49 kg; P = 0.03) at week 48 and +1.16 kg (IQR -0.17 to +2.75 kg; P < 0.001) and +0.90 kg (IQR -0.51 to +2.34 kg; P = 0.001) at week 96 in the monotherapy and triple-therapy arms, respectively, with no difference between arms. At week 96, the only biological change was a glucose level elevation in the monotherapy arm (median +4.0 mg/dL; IQR -4.0 to +7.0 mg/dL) compared with the triple-therapy arm (P = 0.012).

CONCLUSIONS

Overall, body fat tissue increased in patients on darunavir/r monotherapy and triple therapy, with no difference between the arms over 96 weeks. The only difference found was a delayed increase in limb fat tissue in the triple-therapy arm compared with the monotherapy arm in the first year.

Reduced quantitative ultrasound bone mineral density in HIV-infected patients on antiretroviral therapy in Senegal

BACKGROUND

Bone status in HIV-infected patients on antiretroviral treatment (ART) is poorly documented in resource-limited settings. We compared bone mineral density between HIV-infected patients and control subjects from Dakar, Senegal.

METHODS

A total of 207 (134 women and 73 men) HIV-infected patients from an observational cohort in Dakar (ANRS 1215) and 207 age- and sex-matched controls from the general population were enrolled. Bone mineral density was assessed by quantitative ultrasound (QUS) at the calcaneus, an alternative to the reference method (i.e. dual X-absorptiometry), often not available in resource-limited countries.

RESULTS

Mean age was 47.0 (±8.5) years. Patients had received ART for a median duration of 8.8 years; 45% received a protease inhibitor and 27% tenofovir; 84% had undetectable viral load. Patients had lower body mass index (BMI) than controls (23 versus 26 kg/m(2), P<0.001). In unadjusted analysis, QUS bone mineral density was lower in HIV-infected patients than in controls (difference: -0.36 standard deviation, 95% confidence interval (CI): -0.59;-0.12, P = 0.003). Adjusting for BMI, physical activity, smoking and calcium intake attenuated the difference (-0.27, CI: -0.53;-0.002, P = 0.05). Differences in BMI between patients and controls explained a third of the difference in QUS bone mineral density. Among patients, BMI was independently associated with QUS bone mineral density (P<0.001). An association between undetectable viral load and QUS bone density was also suggested (β = 0.48, CI: 0.02;0.93; P = 0.04). No association between protease inhibitor or tenofovir use and QUS bone mineral density was found.

CONCLUSION

Senegalese HIV-infected patients had reduced QUS bone mineral density in comparison with control subjects, in part related to their lower BMI. Further investigation is needed to clarify the clinical significance of these observations.

Osteoporosis and Vitamin D Deficiency in HIV-Positive Patients

Objective:

To review the epidemiology and pathophysiology of osteoporosis in patients with HIV infection and discuss vitamin D deficiency and the treatment of HIV-positive patients with osteoporosis.

Data Sources:

A search of PubMed (1980–June 2011) was conducted using the terms osteoporosis, HIV, vitamin D deficiency, and treatment.

Study Selection and Data Extraction:

Epidemiologic studies, clinical trials, and meta-analyses published in English were included. A manual review of the bibliographies of available literature was conducted and relevant articles were reviewed for inclusion.

Data Synthesis:

Patients with HIV infection are living longer with the use of potent antiretroviral therapy (ART) and are at increased risk for osteoporosis. Several studies have shown that HIV infection can affect bone health and increase the risk for osteoporosis. In addition, ART, and tenofovir in particular, may affect bone turnover. Studies and meta-analyses have shown an increased prevalence of osteopenia and osteoporosis in HIV-positive patients compared to noninfected controls. Recent reports also show increased prevalence of fractures and low vitamin D concentrations in HIV-positive patients. Osteoporosis treatments used in patients with HIV infection are similar to treatments for noninfected patients. HIV-positive patients should be monitored and treated to prevent the progression and complications of osteoporosis.

Conclusions:

HIV-positive patients are at increased risk for osteoporosis and vitamin D deficiency due to disease and treatment influences on bone health. These patients should be identified and treated to prevent the morbidity and mortality associated with osteoporosis.

Low CD4 count is associated with an increased risk of fragility fracture in HIV-infected patients

BACKGROUND

Low bone mineral density in HIV-infected patients is an increasingly recognized clinical problem. The aim of this study was to determine the incidence, prevalence, and risk factors for development of low trauma or fragility fractures in an HIV-infected population.

METHODS

A 1:2 matched case-control study was performed of HIV-infected patients attending the Alfred Hospital between 1998 and 2009. Controls were matched on gender, age, and duration of HIV infection.

RESULTS

The overall fracture incidence rate was 0.53 per 100 person-years [95% confidence interval (CI): 0.43 to 0.65] and period prevalence of 3.34 per 100 patients (95% CI: 2.66 to 4.13). There were 73 low trauma fractures in 61 patients. Patients were predominantly male (89%) with a mean age of 49.8 years. Independent risk factors for fragility fracture were a CD4 cell count <200 cells per microliter odds ratio (OR): 4.91 (95% CI: 1.78 to 13.57, P = 0.002), corticosteroids OR: 8.96 (95% CI: 1.55 to 51.88, P = 0.014) and anti-epileptic medications OR: 8.88 (95% CI: 1.75 to 44.97, P = 0.008). There were no significant associations between HIV viremia (P = 0.18), use of or class of antiretroviral medication, and risk of fracture. Eighty-eight percent of patients with fracture had established osteopenia or osteoporosis.

CONCLUSION

This is the largest clinical study to date of fragility fractures occurring in an HIV-infected population. The study found that risk of fracture was strongly associated with a low CD4 cell count, use of corticosteroids, and anti-epileptic medications. There were no associations between fracture risk and viral load, use of class, or duration of antiretroviral agent.

Low bone mass prevalence, therapy type, and clinical risk factors in an HIV-infected Brazilian population

Low bone mineral density (BMD) has been described in human immunodeficiency virus (HIV)-infected patients, but data on associated factors are still unclear, and to our knowledge, no reports are available in Brazil. Our goal was to evaluate BMD in HIV patients attending an outpatient clinic in Vitoria, Brazil. A sectional study was performed in 300 HIV-infected patients to measure BMD by dual-energy X-ray absorptiometry (DXA). Age, gender, anthropometric parameters, nadir and current CD4 cell count, HIV viral load, smoking habit, and current antiretroviral therapy (ART) associations were investigated by multivariable analysis. Based on World Health Organization T-score ranges, low BMD (T-score <-1.0 standard deviation [SD] in postmenopausal women and men aged 50 and older or Z-score <- 2.0 SD in premenopausal women and men below the age of 50) was detected in 54.7% (95% confidence interval: 49.1-60.3%) of the 300 enrolled patients. The observed median age was 46 yr (interquartile range: 39-52), 58% were male, 88.5% were on ART, and 21.4% smoked. The following factors were identified, by multiple logistic modeling, as being independently associated with low BMD: (1) male gender (4.6 [1.28-16.39]), (2) body mass index lower than 25 kg/m(2) (2.9 [1.31-6.49]), (3) menopause (13.4 [2.53-71.12]), and (4) HIV-1 undetectable viral load (7.9 [1.96-32.25]). Conversely, zidovudine (0.2 [0.04-0.85]) and nevirapine (0.1 [0.02-0.38]) use were inversely associated with low BMD. Low BMD was frequently found in our cohort of about 300 Brazilian HIV-infected subjects. This study supports the need for periodic DXA testing in HIV outpatient clinics.

Therapy for HIV: past, present, and future

Initial therapies for HIV infection comprised nucleoside analogues, but as single or dual agents, they failed to prevent disease progression. When a new class of drug was introduced, the protease inhibitors, an effective triple therapy became possible-namely, highly active antiretroviral therapy, or HAART. HAART reduced viral replication almost completely and enabled immune system recovery. The probability of classical infections and tumors attributed to HIV were dramatically reduced, and life expectancy correspondingly increased. The initial disadvantages of HAART included the need for strict adherence to prevent drug resistance, the cost that initially precluded their widespread use in the developing world, and the short- and long-term side effects. One of the most disabling long-term complications was HIV lipodystrophy, which in extreme cases lead to severe peripheral fat wasting and central fat gain. In recent years, many of these disadvantages have been addressed: Once-daily drug combinations improve adherence; global access to HAART has been markedly improved; and new drugs enable patients to avoid many of the initial side effects. Future research will determine at what CD4 count HAART should be initiated, and new approaches such as immunotherapeutic HIV vaccines are being tested with the aim to delay or obviate the need for antiretroviral drugs.

Bone mineral density and fractures in antiretroviral-naive persons randomized to receive abacavir-lamivudine or tenofovir disoproxil fumarate-emtricitabine along with efavirenz or atazanavir-ritonavir: Aids Clinical Trials Group A5224s, a substudy of ACTG A5202

BACKGROUND

Long-term effects of abacavir (ABC)-lamivudine (3TC), compared with tenofovir (TDF)-emtricitabine (FTC) with efavirenz (EFV) or atazanavir plus ritonavir (ATV/r), on bone mineral density (BMD) have not been analyzed.

METHODS

A5224s was a substudy of A5202, in which HIV-infected treatment-naive participants were randomized and blinded to receive ABC-3TC or TDF-FTC with open-label EFV or ATV/r. Primary bone end points included Dual-emission X-ray absorbtiometry (DXA)-measured percent changes in spine and hip BMD at week 96. Primary analyses were intent-to-treat. Statistical tests used the factorial design and included linear regression, 2-sample t, log-rank, and Fisher's exact tests.

RESULTS

Two hundred sixty-nine persons randomized to 4 arms of ABC-3TC or TDF-FTC with EFV or ATV/r. At baseline, 85% were male, and 47% were white non-Hispanic; the median HIV-1 RNA load was 4.6 log(10) copies/mL, the median age was 38 years, the median weight was 76 kg, and the median CD4 cell count was 233 cells/μL. At week 96, the mean percentage changes from baseline in spine and hip BMD for ABC-3TC versus TDF-FTC were -1.3% and -3.3% (P = .004) and -2.6% and -4.0% (P = .024), respectively; and for EFV versus ATV/r were -1.7% and -3.1% (P = .035) and -3.1% and -3.4% (P = .61), respectively. Bone fracture was observed in 5.6% of participants. The probability of bone fractures and time to first fracture were not different across components.

CONCLUSIONS

Compared with ABC-3TC, TDF-FTC-treated participants had significantly greater decreases in spine and hip BMD, whereas ATV/r led to more significant losses in spine, but not hip, BMD than EFV. Clinical Trials Registration. NCT00118898.

Prevention of bone loss and management of fracture risk in HIV-infected individuals: case studies and recommendations for different patient subgroups

Increased life-expectancy and the need for long-term antiretroviral therapy have brought new challenges to the clinical management of HIV-infected individuals. While the prevalence of osteoporosis and fractures is probably increased in HIV-infected patients, optimal strategies for risk assessment and treatment in this relatively young population are yet to be defined. Prevention of bone loss is likely to become an important component of HIV care as the HIV-infected patient population grows older. In this article, we present an overview of the literature on bone loss in individuals with HIV and discuss the practical application of the European AIDS Clinical Society (EACS) guidelines to a range of clinical case scenarios.

Endocrine complications of human immunodeficiency virus infection: hypogonadism, bone disease and tenofovir-related toxicity

Treatment with highly active antiretroviral therapy (HAART) has revolutionized care of patients with HIV infection. The cost of increased survival has been antiretroviral toxicity and increasing age-related co-morbidities that include significant metabolic issues. Hypogonadism was first described in the setting of advanced AIDS and can be primary or secondary. Data regarding treatment largely concern patients with wasting. Varied syndromes involving bone have been described in patients with HIV including osteonecrosis, low bone mineral density (BMD) and osteoporosis, and rarely osteomalacia. Low BMD leading to osteoporosis is the most common bone pathology and may be as a result of HIV infection, drug toxicity or co-morbidities. However, increasingly fragility fractures are reported in HIV-infected patients, suggesting bone demineralization in this population is of clinical relevance. Further research is required to understand its pathogenesis and determine effective management; however, initiation of antiretroviral therapy seems to accelerate (in the short-term) bone demineralization. One particular antiretroviral agent, tenofovir is widely used and is potentially implicated as having a greater role in long-term bone and renal dysfunction. As this population ages, screening for low BMD will become increasingly more important.

Osteoimmunopathology in HIV/AIDS: A Translational Evidence-Based Perspective

Infection with the human immunodeficiency virus-1 (HIV) and the resulting acquired immune deficiency syndrome (AIDS) alter not only cellular immune regulation but also the bone metabolism. Since cellular immunity and bone metabolism are intimately intertwined in the osteoimmune network, it is to be expected that bone metabolism is also affected in patients with HIV/AIDS. The concerted evidence points convincingly toward impaired activity of osteoblasts and increased activity of osteoclasts in patients with HIV/AIDS, leading to a significant increase in the prevalence of osteoporosis. Research attributes these outcomes in part at least to the ART, PI, and HAART therapies endured by these patients. We review and discuss these lines of evidence from the perspective of translational clinically relevant complex systematic reviews for comparative effectiveness analysis and evidence-based intervention on a global scale.

Bone mineral density in HIV-infected women taking antiretroviral therapy: a systematic review

There is a high prevalence of osteoporosis in HIV-infected patients. Initially described in HIV-positive men, studies have also demonstrated a high prevalence of osteoporosis in HIV-infected women. It would appear that antiretroviral therapy (ART) plays an important role in the pathogenesis of osteoporosis in HIV-infected patients, although little is known about its importance in relation to osteoporosis and fractures in HIV-positive women. The aim of this systematic review was to evaluate the frequency of bone loss, bone mineral density (BMD) and fractures in HIV-positive women taking ART or protease inhibitors (PI). After screening 597 citations from the databases of PubMed, EMBASE and Lilacs, five studies were selected for the review. A difference was demonstrated of over 3% in the BMD at the femoral neck of HIV-positive women taking PI/ART. No difference was registered in the BMD at the lumbar spine between users and non-users of PI/ART. The lack of studies has made it impossible to reach any conclusion regarding the occurrence of fractures.

Increased risk of abnormal proximal renal tubular function with HIV infection and antiretroviral therapy

Abnormal kidney function is common in the course of human immunodeficiency virus (HIV) infection. Here, we performed a cross-sectional analysis using 399 patients within the Aquitaine cohort (a hospital-based cohort of HIV-1-infected patients receiving routine clinical management) to estimate the prevalence of proximal renal tubular dysfunction (PRTD) associated with HIV infection. These patients did not differ statistically by sociodemographics, median age, years since HIV diagnosis, AIDS stage, or median CD4 cell count from the entire 3080 patient cohort. Antiretroviral therapy was received by 352 patients, with 256 given tenofovir (TDF); 325 had undetectable HIV plasma viral load, and 26 were diagnosed with PRTD. In multivariate analysis, significant independent associations were found between PRTD and age (odds ratio (OR) 1.28 per 5-year increase), atazanavir (OR 1.28 per year of exposure), and TDF (OR 1.23 per year) treatment. Among patients having received TDF-containing regimens over a 5-year period, PRTD remained significantly associated with TDF exposure when treatment was ongoing (OR 5.22) or had been discontinued (OR 11.49). Thus, cumulative exposure to TDF and/or atazanavir was associated with an increased risk of PRTD, with concern about its reversibility in patients with HIV.

Prospective one-year bone loss in treatment-naïve HIV+ men and women on single or multiple drug HIV therapies

Antiretroviral therapy has decreased the rate of HIV-related mortality and extended the life span of HIV patients. Current guidelines recommend the use of a 3-drug regimen, such as two nucleoside reverse transcriptase inhibitors and a protease inhibitor, boosted by ritonavir. Osteoporosis can be associated with the HIV disease itself or with antiretroviral therapy. Many trials have been conducted employing a single drug regimen to simplify antiretroviral therapy but few studies assessed the effect of the single drug regimen on bone mineral density (BMD). The objectives of the study were to assess and compare the relative (%) changes in lumbar spine and hip BMD over 48 weeks in HIV patients treated with mono or triple antiretroviral regimens The study was conducted using data from a randomized trial (MONARK) conducted in 136 antiretroviral-naïve HIV patients (89 men and 47 women) comparing the antiviral efficacy of a single-drug protease inhibitor regimen of lopinavir/ritonavir (LPV/r) versus LPV/r in combination with zidovudine (ZDV) and lamivudine (3TC). Lumbar spine and total hip BMD were assessed in 100 patients by dual-energy X-ray absorptiometry at baseline and 48 weeks. 48 week-BMD data were available for 43 patients (mean age 37years) with a mean baseline lumbar spine Z-score of -0.1 in the LPV/r monotherapy group and for 25 patients (mean age 35.8years) with a mean baseline lumbar spine Z-score of -0.2 in the LPV/r+ZDV+3TC group. After 48weeks, lumbar spine BMD significantly decreased by 4.4% (-5.1% to -2.1%, P≤0.001) in the LPV/r group and by 4.0% (-5.0% to -1.7%, P≤0.0001) in the LPV/r+ZDV+3TC group. There was no significant difference in BMD changes between the two groups. These results suggest that bone loss is observed 48 weeks after the initiation of antiretroviral therapy, whether the patients receive a single- or triple-drug antiretroviral regimen.

Markers of bone turnover are elevated in patients with antiretroviral treatment independent of the substance used

OBJECTIVES

Osteoporosis and bone fractures are correlated to antiretroviral treatment. It is not clear whether some substances comprise greater risks of bone loss than others.

METHODS

We measured pyridinoline, deoxypyridinoline crosslinks, and bone-specific alkaline phosphatase in 113 HIV-positive patients. We compared patients with and without antiretroviral treatment. We then compared patients with versus without tenofovir and patients with protease inhibitor versus nonnucleoside reverse transcriptase inhibitor use.

RESULTS

Bone-specific alkaline phosphatase, pyridinoline, and deoxypyridinoline crosslinks were significantly higher in patients with antiretroviral treatment compared with patients without antiretroviral treatment: 24.5 versus 13.04 pg/L (P < 0.001), 82.73 versus 51.93 nmol/mmol (P < 0.001), and 16.56 versus 9.94 nmol/mmol (P < 0.001), respectively. In contrast, no difference was found between patients with and without tenofovir: 25.38 versus 20.02 pg/l (P = 0.1); 79.85 versus 83.95 nmol/mmol (P = 0.64), and 19.12 versus 14.00 nmol/mmol (P = 0.14), respectively. Comparison between patients with protease inhibitor versus nonnucleoside reverse transcriptase inhibitor yielded no difference either: 23.07 versus 27.18 pg/L (P = 0.24), 92.96 versus 80.73 nmol/mmol (P = 0.36), and 18.22 versus 16.39 nmol/mmol (P = 0.55).

CONCLUSION

Markers for bone turnover are higher in treated compared with untreated patients. No difference concerning tenofovir use or protease inhibitor versus nonnucleoside reverse transcriptase inhibitor use could be found.

High frequency of poor locomotor performance in HIV-infected patients

OBJECTIVES

To provide up-to-date assessments of locomotor function in HIV-infected patients and to identify potential determinants of impaired function.

DESIGN

Cross-sectional study in 324 HIV-1-infected adults from the French Agency for AIDS and Hepatitis Research (ANRS) CO3 Aquitaine Cohort using standardized locomotor tests.

METHODS

Patients underwent standardized testing assessing balance, walking ability, functional capacity and lower limb muscle performance. Poor test performance was defined by cut-offs based on age-specific data of the general population. Factors associated with poor test performance were studied by logistic regression.

RESULTS

Median age was 48 years, 80% were men and 89% were on antiretroviral treatment. The most frequently altered locomotor test was the five-times sit-to-stand (5STS) test, assessing lower limb muscle performance (poor performance: 53%). In multivariable analysis, time since HIV diagnosis was associated with poor 5STS performance [odds ratio (OR) = 1.08 per year; 95% confidence interval (CI): 1.03, 1.13]. In patients below 30 years, elevated BMI was associated with higher likelihood of good performance (OR = 0.81 per kg/m(2); 95% CI: 0.69, 0.93), whereas in those above 70 years this association was reversed (OR = 1.30 per kg/m(2); 95% CI: 1.10, 1.53; P < 10(-3) for interaction). We found no association with antiretroviral treatment.

CONCLUSION

One of two adults with controlled HIV infection had poor lower limb muscle performance, which might put this population at risk of falls and fracture. The 5STS test is a simple test that should be recommended to assess muscular performance in HIV care.

Increased risk of fragility fractures among HIV infected compared to uninfected male veterans

Background

HIV infection has been associated with an increased risk of fragility fracture. We explored whether or not this increased risk persisted in HIV infected and uninfected men when controlling for traditional fragility fracture risk factors.

Methodology/Principal Findings

Cox regression models were used to assess the association of HIV infection with the risk for incident hip, vertebral, or upper arm fracture in male Veterans enrolled in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC). We calculated adjusted hazard ratios comparing HIV status and controlling for demographics and other established risk factors. The sample consisted of 119,318 men, 33% of whom were HIV infected (34% aged 50 years or older at baseline, and 55% black or Hispanic). Median body mass index (BMI) was lower in HIV infected compared with uninfected men (25 vs. 28 kg/m²; p<0.0001). Unadjusted risk for fracture was higher among HIV infected compared with uninfected men [HR: 1.32 (95% CI: 1.20, 1.47)]. After adjusting for demographics, comorbid disease, smoking and alcohol abuse, HIV infection remained associated with an increased fracture risk [HR: 1.24 (95% CI: 1.11, 1.39)]. However, adjusting for BMI attenuated this association [HR: 1.10 (95% CI: 0.97, 1.25)]. The only HIV-specific factor associated with fragility fracture was current protease inhibitor use [HR: 1.41 (95% CI: 1.16, 1.70)].

Conclusions/Significance

HIV infection is associated with fragility fracture risk. This risk is attenuated by BMI.

Hypovitaminosis D and bone mineral density in human immunodeficiency virus-infected men from India, with or without antiretroviral therapy

OBJECTIVE

To study the vitamin D status and bone mineral density (BMD) in men infected with human immunodeficiency virus (HIV) in a tertiary care center from southern India.

METHODS

We conducted a cross-sectional study of 35 HIV-infected men (between 20 and 50 years old) receiving highly active antiretroviral therapy (HAART) (group 1) in comparison with 35 age- and body mass index-matched HIV-positive antiretroviral therapy-naïve men (group 2) and 35 HIV-negative healthy control subjects (group 3).

RESULTS

A significantly greater proportion (P = .002) of patients (74%) in the HAART group had vitamin D deficiency (<20 ng/mL) in comparison with the other 2 groups (37% in each group). The mean intact parathyroid hormone level was higher (P<.001) and the mean duration of exposure to sunlight was lower (P = .001) in the HAART group than in the other 2 groups. By logistic regression analysis, HAART was found to be significantly associated with vitamin D deficiency. The BMD in the femoral neck was significantly lower in men with HIV infection who were receiving HAART in comparison with the other 2 groups (P = .006). On multivariate logistic regression, older age, low body mass index, and high parathyroid hormone levels emerged as factors significantly associated with decreased BMD at the femoral neck.

CONCLUSION

A significant proportion of patients receiving HAART had vitamin D deficiency. The secondary hyperparathyroidism probably due to vitamin D deficiency is an important contributing factor for the observed changes in BMD. Vitamin D deficiency noted in this group is probably multifactorial, and further research is needed to determine whether the effect of HAART on vitamin D metabolism is an additional causative factor and what benefit vitamin D supplementation might confer in these patients.

HIV and bone loss

The use of antiretroviral therapy has significantly reduced the number of deaths due to HIV/AIDS. However, no current therapy can suppress the virus completely, and as the HIV-infected population continues to live longer new complications are emerging from the persistence of the virus and use of antiretroviral therapy. This review summarizes the clinical evidence linking HIV-associated osteoporosis to direct infection and antiretroviral therapy (ART) use. The purported molecular mechanisms involved in bone loss are also reviewed. Additionally, recommendations regarding the pharmacologic management of HIV/ART-related osteoporosis are given.

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

BACKGROUND

Low bone mineral density (BMD) is an emerging metabolic condition in HIV-infected patients; however, data on progression of this disease are scarce.

METHODS

We studied 671 patients with at least one dual-energy X-ray absorptiometry scan (391 of them ≥2 scans) to determine the prevalence and progression of BMD and establish related factors. Linear regression and logistic polytomic regression were used for the cross-sectional study and mixed effects and generalized estimating equations were used for the longitudinal study.

RESULTS

Osteopenia and osteoporosis were diagnosed in 47.5 and 23%, respectively. Progression to bone demineralization was observed in 28% of the patients over a median of 2.5 years (12.5% progressed to osteopenia and 15.6% to osteoporosis). In the 105 patients with at least 5 years of follow-up, progression was 47% (18% to osteopenia; 29% to osteoporosis). Factors associated with bone loss and progression were age [odds ratio (OR) 1.07; 95% confidence interval (CI) 1.05-1.08; P < 0.0001], male sex (OR 2.23; 95% CI 1.77-2.8; P < 0.0001), low body mass index (OR 1.14; 95% CI 1.11-1.17; P < 0.0001), time on protease inhibitor (OR 1.18; 95% CI 1.12-1.24; P < 0.0001), time on tenofovir (OR 1.08; 95% CI 1.03-1.14; P < 0.0019), and current use of protease inhibitors (OR 1.64; 95% CI 1.35-2.04; P < 0.0001).

CONCLUSIONS

Our results show a high prevalence of and considerable progression to osteopenia/osteoporosis in our cohort. Our findings support the importance of applying adequate strategies to prevent bone demineralization and of close monitoring of BMD in HIV-infected patients, specifically in at-risk patients who are taking antiretrovirals that affect bone mineralization.

Prevalence of bone mineral density abnormalities and related risk factors in an ambulatory HIV clinic population

Bone mineral density (BMD) abnormalities are observed frequently among human immunodeficiency virus (HIV)-infected patients. Risk factors for reduced BMD in the setting of HIV have been previously studied, but detailed antiretroviral treatment history is often not available. A cross-sectional observational study was conducted between 2005 and 2007 among unselected HIV-infected adults attending an ambulatory urban HIV clinic. Dual-energy X-ray absorptiometry (DXA) scans of lumbar spine and femoral neck, full laboratory profile, detailed questionnaire, and antiretroviral history were obtained. Univariate and multivariate logistic regression analyses were performed to investigate factors associated with BMD below the expected range for age. Two hundred ninety patients completed the study: 80% Caucasians, 89% males, with median age of 49 yr. Low BMD as assessed by Z-score was present in 19.7% of the patients. By multivariate analysis, only lower body mass index (BMI) was an independent risk factor for low BMD. Cumulative exposure to protease inhibitors, non-nucleosides, and individual nucleoside and nucleotide analogs were not independently associated with low BMD. In conclusion, a 19.7% prevalence of abnormal BMD by DXA scan was identified in an unselected group of HIV-infected adults. Lower BMI was independently associated with low BMD. No correlation was found between abnormal BMD and cumulative exposure to any antiretroviral agents.

High prevalence of reduced bone mineral density in primary HIV-1-infected men

OBJECTIVE

To assess the bone mineral density (BMD) in a cohort of men with primary HIV-1 infection (PHI).

METHODS

Thirty-three men with PHI had a dual-energy X-ray absorptiometry (DXA) of the lumbar spine, femoral neck and total hip. Osteopenia and osteoporosis were defined according to WHO criteria as T-scores between -1 and -2.5 and -2.5 or less, respectively. The association between clinical and laboratory parameters and BMD was investigated using multivariable linear regression analysis.

RESULTS

Mean age was 38 (SD 9) years and mean body mass index (BMI) 22.7 (SD 3.3) kg/m. Twenty-four men (73%) had a negative or indeterminate Western blot, 32 men (97%) were combination antiretroviral therapy-naive. Mean plasma HIV-1 RNA was 5.0 (SD 1.2) log10 copies/ml. Mean lumbar spine T (-0.8, SD 1.3, P = 0.001) and Z-scores (-0.7, SD 1.3, P = 0.004) and femoral neck T-score (-0.5, SD 0.9, P = 0.003) were significantly lower compared to the reference population. 15/33 men (45%) had osteopenia and 2/33 (6%) osteoporosis. Markers of bone turnover did not differ between patients with or without osteopenia/osteoporosis. Age was negatively associated with femoral neck (beta-coefficient = -0.05, P < 0.001) and total hip T-scores (beta = -0.03, P = 0.04). BMI was associated with lumbar spine (beta = 0.3), femoral neck (beta = 0.2) and total hip (beta = 0.2) T-scores (P < 0.001) and thyroid-stimulating hormone (TSH) with lumbar spine (beta = 0.5, P = 0.045) and femoral neck T-scores (beta = 0.4, P = 0.005). Increased plasma viral load was associated with lower total hip T-scores (beta = -0.2, P = 0.02).

CONCLUSIONS

Reduced BMD was prevalent in PHI men and was associated with increased age, lower BMI and TSH levels, and higher levels of HIV-1 viremia.

Antiretroviral therapy and bone mineral measurements in HIV-infected youths

Reduced bone mass measurements are often found in HIV-infected youths. Both in vitro and human studies demonstrated a role of antiretroviral treatment in determining bone mass alteration. Nevertheless, the data regarding the responsibility of different antiretroviral drugs on bone health in children and adolescents are highly controversial. The purpose of the current study was to relate antiretroviral treatment to bone mass measurements in a large cohort of HIV-infected children and adolescents. Bone mineral content (BMC) was measured in 86 HIV-infected youths (aged 4.8-22.1 years), and in 194 healthy controls (aged 4.9-21.9 years). Fifteen patients were naive to antiretroviral treatment, 11 were receiving a dual nucleoside reverse transcriptase inhibitor (NRTIs) combination, 32 a protease inhibitor (PI)-based antiretroviral treatment, and 28 a non-nucleoside reverse transcriptase inhibitor (NNRTIs)-based regimen. Comparisons between healthy and HIV-infected children and adolescents have been performed by multiple regression analyses to correct for differences in age, sex, and anthropometric measurements. Patients receiving a PI-based treatment had lumbar spine and whole body BMC values significantly lower than healthy children (P<0.05). BMC measurements of patients on other therapeutic regimens or naive to antiretroviral treatment did not differ significantly from those of healthy children. Among patients receiving a PI-based regimen, those receiving full dose Ritonavir had significantly lower lumbar spine BMC values compared to other patients. Lumbar spine and whole body BMC measurements of patients receiving a Stavudine-containing regimen were lower compared to healthy controls, naive patients, and patients on other antiretroviral regimens. Multivariate analyses showed that patients receiving both Stavudine and full dose Ritonavir had significantly lower BMC values both at the lumbar spine (P=0.0033), and in the whole skeleton (P=0.05). In conclusion, antiretroviral treatment may have a detrimental effect on bone health of HIV-infected youths: the use of Ritonavir full dose alone or in combination with Stavudine is associated to lower bone mass measurements. The use of antiretroviral regimens including these drugs should thus be monitored closely in HIV-infected youths.

[Adverse reactions of atazanavir, fosamprenavir and tipranavir in "real life"]

OBJECTIVE

To precise adverse effects of atazanavir, fosamprenavir and tipranavir "in real life".

METHOD

Descriptive study of 3 protease inhibitor adverse effects stored in the French Bank of Pharmacovigilance.

RESULTS

Nineteen adverse effects having at least possible links with antiretroviral drugs studied were reported. It was essentially hepatobiliary (atazanavir: 29/59, tipranavir: 4/6) and skin (fosamprenavir: 10/20) adverse reactions. These reactions, relatively "serious" (35.1%) led to the interruption of the person (or persons) medication (s) suspected (s) in 69 folds (82.1%) and evolved to healing without sequelae in 68 folds (81%).

CONCLUSION

The drug side effects were for the most expected. However, their frequency and their seriously underline the interest of a post-AMM monitoring to reassess the drugs risk-benefit report.

Highly prevalent vitamin D deficiency and insufficiency in an urban cohort of HIV-infected men under care

Vitamin D deficiency and insufficiency are often unappreciated in men. This cross-sectional period-prevalence study was conducted in private practice between November 20, 2008 and January 22, 2009 at latitude N 40, 46 minutes. HIV-infected men presenting for routine care without clinical disease or use of medications known to interfere with vitamin D metabolism were evaluated. Current receipt protease inhibitor (PI) and non-nucleoside reverse transcriptase inhibitor (NNRTI) were determined. Vitamin D deficiency was defined as 25-[OH] D less than 50 nmol/L, severe deficiency as less than 25 nmol/L, and insufficiency as greater than 50 nmol/L but less than 75 nmol/L. Sixty-two men, median CD4 count 541 cells per microliter, 85.5% viral load less than 200 copies per milliliter, were evaluated. A total of 30.7% were receiving a NNRTI and 59.7% a PI; 41.9% were vitamin D-deficient (11.3% severe deficiency), 33.9% insufficient, and 24.2% sufficient, p = < 0.0001. Median vitamin D: 42.4 versus 64.9 nmol/L NNRTI and PI recipients, respectively, p = 0.0017. Percentage deficient: 73.7 (14/19) NNRTI versus 29.7 (11/37) PI recipients, p = 0.0017 OR 6.62 (95% confidence interval [CI] 1.91-22.89). Tobacco use correlated with severe deficiency, p = 0.032. In conclusion, vitamin D deficiency and insufficiency were highly prevalent in these urban men irrespective of stable viral suppression. NNRTI receipt and tobacco use may be associated with lower vitamin D levels and greater risk of deficiency, and severe deficiency, respectively.

Longitudinal study of body composition of 101 HIV men with lipodystrophy: dual-energy X-ray criteria for lipodystrophy evolution

The aim of this study was to define evolution profiles of body composition among human immunodeficiency virus (HIV)-infected men with lipodystrophy. The design is a retrospective analysis using observational data collected longitudinally. We included 101 HIV-infected men with lipodystrophy managed in routine practice and who had 2 dual energy X-ray absorptiometry scans within a minimum interval of 18 mo. Lipodystrophy was defined as a fat mass ratio (FMR, defined as the ratio of the percentage of the trunk fat mass over the percentage of the lower limbs fat mass) equal or superior to 1.5. Patients were classified in "improved" group (IG: increase of lower limbs fat mass >/= 10%) or "nonimproved" group (NIG). Body composition, immunovirological and epidemiological data were collected and compared between the 2 groups. In the whole population, over a 4-yr period, a significant increase was observed for total fat mass, trunk fat mass, and lower limbs fat mass, whereas total lean mass was stable. Total body mineral density decreased. Fifty-nine patients (IG), less exposed to zidovudine than the NIG, had an increase of lower limbs fat mass higher than 10%. But only 13 (22%) regained a normal distribution of fat mass (FMR < 1.5), showing that lipodystrophy was slowly reversible. Among the NIG, 5 patients (11.9%), less exposed to zidovudine and with a higher mean of viral load, reached an FMR below 1.5. It was mainly because of a loss of trunk fat mass, which could be the sign of a lipodystrophy worsening. Lipodystrophy improved for 58.4% of men. The improvement was very slow. Recovery was observed only in patients with an earlier intervention. No correlation was observed between lipodystrophy and total body bone mineral density. The loss of trunk fat mass without gain of lower limbs fat mass may indicate a worsening of HIV disease.

Total body and spinal bone mineral density across Tanner stage in perinatally HIV-infected and uninfected children and youth in PACTG 1045

OBJECTIVE

To characterize total body bone mineral content (BMC) and total body and spinal bone mineral density (BMD) in perinatally HIV-infected and uninfected children/youth across puberty.

DESIGN

HIV-infected (7-24 years) were randomly selected from six strata based on Tanner stage/protease inhibitor use. HIV-uninfected were frequency-matched by Tanner group and sociodemographic background to the HIV-infected.

METHODS

Dual-energy X-ray absorptiometry (DXA) measured BMC and BMD. Linear regression models tested differences in bone outcomes by HIV and the interaction of HIV by Tanner group (1-2, 3-4, 5). Models were performed separately by sex and adjusted for DXA scanner, race/ethnicity, height, age and lean body mass.

RESULTS

HIV-infected (N = 236) and uninfected (N = 143) were comparable on sex and race/ethnicity. HIV-infected were slightly older (median 12.6 versus 11.9 years). In adjusted models, HIV-infected males had significantly lower total body BMC and total body and spinal BMD at Tanner 5, lower BMC at Tanner 3-4 and similar BMC and BMD at Tanner 1-2, compared to HIV-uninfected males. HIV-infected and uninfected girls did not differ significantly on any bone outcome, but there was a marginally significant interaction of HIV and Tanner group for spinal BMD. Kaletra/ritonavir was associated with lower BMC and total body BMD and nevirapine was associated with higher spinal BMD in a model with all HIV-infected.

CONCLUSIONS

Perinatally HIV-infected males showed more evidence of lower bone density especially in the final stage of pubertal development than HIV-infected girls and they may be at increased risk for bone disease during adulthood.

Human immunodeficiency virus and highly active antiretroviral therapy-associated metabolic disorders and risk factors for cardiovascular disease

The successful introduction of highly active antiretroviral therapy (HAART), a combination of potent antiretroviral agents, including protease inhibitors, nucleoside reverse transcriptase inhibitors, and nonnucleoside reverse transcriptase inhibitors, has impacted positively on morbidity and mortality among human immunodeficiency virus (HIV)-positive patients. Over time, HAART has been associated with a number of metabolic and anthropometric abnormalities, including dyslipidemia and insulin resistance as well as subcutaneous fat loss and abdominal obesity, potentially contributing to cardiovascular risk. Recent studies have more firmly established that both HIV infection and HAART might increase the risk of clinical cardiovascular events. Furthermore, whereas HIV/HAART is associated with multiple aspects of endocrine dysfunction, there has been less focus on bone disease, although some studies indicate a higher prevalence of osteoporosis among HIV-positive subjects compared to HIV-negative controls. The relationship between bone and fat metabolism under HIV-positive conditions deserves further attention, and available data suggest the possibility of an intriguing connection. In the future, an increasing population of aging HIV-positive patients with a spectrum of antiretroviral therapies and accumulation of endocrine abnormalities and conventional cardiovascular risk factors will present preventive and therapeutic challenges to our health-care system.

Loss of bone mineral density after antiretroviral therapy initiation, independent of antiretroviral regimen

BACKGROUND

Decreased bone mineral density (BMD) has been described in HIV-infected patients initiating antiretroviral therapy (ART), but the contributions of ART and immunologic and/or virologic factors remain unclear.

METHODS

We compared total BMD changes over 96 weeks in 106 ART-naive HIV-infected subjects who were randomized to receive efavirenz (EFV) + zidovudine/lamivudine (n = 32) or lopinavir/ritonavir (LPV/r) + zidovudine/lamivudine induction (n = 74) for 24-48 weeks followed by LPV/r monotherapy. We also sought to identify factors associated with BMD loss, including markers of systemic inflammation [soluble tumor necrosis factor-alpha receptors (sTNFR I and II)].

RESULTS

After 96 weeks, the mean percent change from baseline in total BMD was -2.5% (LPV/r) and -2.3% (EFV) (P < 0.01 for within-group changes in either arm; P = 0.86 for between-group differences). No alteration in the rate of BMD change was observed upon simplification to LPV/r monotherapy. Although soluble tumor necrosis factor-alpha receptor II concentrations at baseline and 24 weeks were at least marginally associated with subsequent changes in BMD (P = 0.06 and P = 0.028, respectively), these associations were no longer significant after adjustment for CD4 T cell count. Subjects with lower baseline CD4 T cell count, non-black race, and higher baseline glucose demonstrated a higher risk for >5% decrease in BMD.

CONCLUSIONS

Similar decreases in BMD over 96 weeks occurred in ART-naive subjects receiving either EFV-based regimen or LPV/r-based regimen, which was not altered by simplification to LPV/r monotherapy and was unrelated to markers of tumor necrosis factor-alpha activity.

Continuous antiretroviral therapy decreases bone mineral density

OBJECTIVES

To assess the effects of antiretroviral therapy (ART) on bone mineral density (BMD) DESIGN: Randomized comparison of continuous ART (viral suppression group; VS) with intermittent ART (drug conservation group; DC) SETTING: Outpatient clinics in the United States, Australia, and Spain.

PARTICIPANTS

Participants in the Strategies for Management of Antiretroviral Therapy (SMART) Body Composition substudy.

MAIN OUTCOME MEASURES

Annual hip and spine BMD by dual-energy radiographic absorptiometry (DXA) and spine BMD by quantitative computed tomography (qCT).

METHODS

Comparisons were by intention-to-treat analysis, using longitudinal models for change in BMD. Risk factors for BMD loss were evaluated.

RESULTS

The 214 participants (median 44 years, 19% female participants, 73% on ART; median T-scores -0.5 total hip, -0.7 spine DXA, -0.9 spine qCT; 98 randomized to VS and 116 to DC) were followed for a mean 2.4 years. With continuous ART, BMD declined per year by 0.8% (hip), 0.4% (spine DXA), and 2.4% (spine qCT). BMD declined significantly less with intermittent ART. Estimated DC minus VS group differences in mean BMD change through follow-up were 1.4% [hip; 95% confidence interval (CI) 0.6-2.3; P = 0.002], 1.3% (spine DXA; 95% CI 0.1-2.4, P = 0.03), and 3.0% (spine qCT; 95% CI 0.8-5.2, P = 0.007). No consistent drug-specific association with BMD decline was found. In the parent study, 10 of 2753 participants in the VS group and two of 2720 in the DC group reported serious fractures (hazard ratio 4.9; 95% CI 1.1-22.5; P = 0.04).

CONCLUSION

Continuous ART is associated with decline in BMD and possibly more fractures relative to intermittent, CD4 cell count-guided ART.

Ten-year incidence and risk factors of bone fractures in a cohort of treated HIV1-infected adults

In the ANRS CO8 APROCO-COPILOTE cohort of patients treated with combination antiretroviral therapy since 1997-1999, the incidence density of bone fractures was 3.3 for 1000 patient-years [95% confidence interval (CI) = 2.0-4.6]. The rate was 2.9-fold (95% CI = 1.3-6.5) higher among patients with excessive alcohol consumption and 3.6-fold (95% CI = 1.6-8.1) higher in those with hepatitis C virus (HCV) coinfection. Specific monitoring of HCV/HIV-coinfected patients and active promotion of alcohol cessation should be recommended for the prevention of bone fractures.

Greater decrease in bone mineral density with protease inhibitor regimens compared with nonnucleoside reverse transcriptase inhibitor regimens in HIV-1 infected naive patients

OBJECTIVE

To evaluate the change in bone mineral density (BMD) at specific sites in patients initiating antiretroviral therapy in a substudy of the ANRS 121 trial.

METHODS

Antiretroviral-naive patients were randomized (2: 1: 1) into three treatment strategy arms: a nonnucleoside reverse transcriptase inhibitor (NNRTI) and a boosted protease inhibitor (PI/r), a PI/r and two nucleoside reverse transcriptase inhibitors (NRTIs) or an NNRTI and NRTIs. Hip and lumbar spine standardized BMD were evaluated at baseline and week 48 by dual X-ray absorptiometry by a central reading laboratory.

RESULTS

Seventy-one patients were enrolled: 36 in the PI/r and NNRTI, 19 in the PI/r and NRTIs and 16 in the NNRTI and NRTIs arms. Baseline characteristics were [median (interquartile range)]: male (77%), age 40 years (33-49), 69% white, 58% smokers, BMI 23 kg/m2 (21-24), CD4 cell count 219 cells/microl (144-285). In the arms with NRTIs, 86% of patients received zidovudine/lamivudine. At baseline, 31% had osteopenia and 3% had osteoporosis. At week 48, there was a mean change in BMD of -4.1 +/- 3.9% at lumbar spine and -2.8 +/- 4.7% at hip (both P< or = 0.001). The decrease of BMD at lumbar spine was significantly worse in the PI/r and NNRTI arm (-4.4 +/- 3.4%) and in the PI/r and NRTIs arm (-5.8 +/- 4.5%) compared with the NNRTI and NRTIs arm (-1.5 +/- 2.9%), P = 0.007 and P = 0.001, respectively.

CONCLUSION

BMD was impaired in 34% of patients, before starting any antiretrovirals. After 1 year, the decrease in lumbar spine BMD was more pronounced in patients receiving either PI/r-containing regimen compared with NNRTI and NRTIs. BMD at specific sites should be monitored during lifelong antiretroviral therapy.

Women facing HIV. Key question on women with HIV infection: Italian consensus workshop

A panel of leading Italian specialists in infectious diseases, obstetrics and gynaecology met in a national consensus workshop on women facing HIV to review critical aspects and discuss recommendations for selected key questions on four issues: (1) women and highly active antiretroviral therapy (HAART): access to care and adherence to therapy, side effects and drug-drug interaction; (2) HIV-infected pregnant women: prevention of mother to child transmission; (3) desire for children among women living with HIV: assisted reproduction; (4) sexually transmitted diseases and genital disturbances. The method of a nominal group meeting was used, and recommendations were graded for their strength and quality of evidence using a system based on the one adopted by the Infectious Diseases Society of America. Main conclusions are summarized and critically discussed, and some of the most recent data supporting recommendations are provided.

Considerations for the antiretroviral management of women in 2008

Clinicians should be familiar with sex-specific considerations when managing antiretroviral (ARV) treatment among women. Pregnancy is a critical influence on when to start treatment and what ARVs should be included in a regimen. Sex, pregnancy and hormonal contraceptive therapies can each influence ARV pharmacokinetic profiles. Women may be prone to have higher serum levels with selected ARV treatments, which may improve potency but also increase the risk for toxicities. Several studies have demonstrated that women do have higher frequencies of selected ARV-associated adverse events when compared with men. Although HIV treatment guidelines for nonpregnant women do not differ from men, clinicians should be aware of the high potential for certain ARV-related toxicities and follow suggestions in order to decrease the risk of side effects.