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

Urgent focus on enhanced recovery after surgery of AIDS patients with limb fractures

Aims

The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures.

Methods

A total of 120 PLWH with limb fractures, between January 2015 and December 2023, were included in this study. We established a multidisciplinary team to design and implement a standardized ERAS protocol. The demographic, surgical, clinical, and follow-up information of the patients were collected and analyzed retrospectively.

Results

Compared with the control group, the ERAS group had a shorter operating time, hospital stay, preoperative waiting time, postoperative discharge time, less intraoperative blood loss, and higher albumin and haemoglobin on the first postoperative day. The time to removal of the urinary catheter/drainage tube was shortened, and the drainage volume was also significantly reduced in the ERAS group. There was no significant difference in the visual analogue scale (VAS) scores on postoperative return to the ward, but the ERAS group had lower scores on the first, second, and third postoperative days. There were no significant differences in the incidence of complications, other than 10% more nausea and vomiting in the control group. The limb function scores at one-year follow-up were similar between the two groups, but time to radiological fracture union and time to return to physical work and sports were significantly reduced in the ERAS group.

Conclusion

The implementation of a series of perioperative nursing measures based on the concept of ERAS in PLWH with limb fracture can significantly reduce the operating time and intraoperative blood loss, reduce the occurrence of postoperative pain and complications, and accelerate the improvement of the functional status of the affected limb in the early stage, which is worthy of applying in more medical institutions.

Bone Tissue Changes in Individuals Living with HIV/AIDS: The Importance of a Hierarchical Approach in Investigating Bone Fragility

Skeletal alterations and their complications can significantly impact the quality of life and overall prognosis of patients living with HIV (PLWHIV). Considering skeletal alterations are often asymptomatic and unapparent during routine clinical evaluation, these conditions are frequently overlooked in the clinical management of PLWHIV. However, since the use of combined antiretroviral therapy (cART) has increased life expectancy in PLWHIV effectively, osteopenia, osteoporosis, and bone fragility are now considered to have a major health impact, with a substantial increase in healthcare costs. This narrative literature review aimed to provide a comprehensive overview of the contemporary literature related to bone changes in PLWHIV, focusing on the importance of taking a multi-scale approach in the assessment of bone hierarchical organization. Even though a low bone mineral density is frequently reported in PLWHIV, numerous ambiguities still remain to be solved. Recent data suggest that assessment of other bone properties (on various levels of the bone structure) could contribute to our understanding of bone fragility determinants in these individuals. Special attention is needed for women living with HIV/AIDS since a postmenopausal status was described as an important factor that contributes to skeletal alterations in this population. Further research on complex etiopathogenetic mechanisms underlying bone alterations in PLWHIV may lead to the development of new therapeutic approaches specifically designed to reduce the health burden associated with skeletal disorders in this population. A major challenge in the clinical management of PLWHIV lies in the adverse skeletal effects of some frequently prescribed cART regimens (e.g., regimens containing tenofovir disoproxil fumarate), which may require a switch to other pharmacological approaches for maintained HIV infection (e.g., regimens containing tenofovir alafenamide). Taken together, the findings are indicative that the HIV/AIDS status should be taken into consideration when designing new guidelines and strategies for individualized prevention, diagnosis, and treatment of increased bone fragility.

Clinical considerations when switching antiretroviral therapy

INTRODUCTION

Antiretroviral therapy (ART) can be personalized through simple formulations with high resistance barriers, favorable safety profiles, and novel administration routes. Switching treatments has become a key clinical strategy for addressing drug toxicity and interactions and enhancing adherence and convenience. This strategy aims to improve the quality of life and long-term efficacy, even in challenging cases like people living with HIV (PLWH) with multiple comorbidities, prior virological failure, and drug resistance.

AREAS COVERED

The authors reviewed clinical trials and cohort studies providing evidence of benefits and risks of current antiretroviral (ARV) drugs as switching options for PLWH in various scenarios. The literature search included clinical trials, meta-analyses, observational studies, and review articles in English published after 2000, and current HIV treatment guidelines in English and Spanish as of February 2024.

EXPERT OPINION

New ARV drugs offer advantages in efficacy and safety over previous options but may also have adverse effects. Second-generation integrase inhibitors and tenofovir alafenamide show benefits as switching options in various scenarios, though more research is needed on potential weight gain and metabolic issues. Injectable long-acting ART is promising for switching strategies, but finding the optimal combination of new drugs remains challenging.

Cardiometabolic health in people with HIV: expert consensus review

OBJECTIVES

To develop consensus data statements and clinical recommendations to provide guidance for improving cardiometabolic health outcomes in people with HIV based on the knowledge and experience of an international panel of experts.

METHODS

A targeted literature review including 281 conference presentations, peer-reviewed articles, and background references on cardiometabolic health in adults with HIV published between January 2016 and April 2022 was conducted and used to develop draft consensus data statements. Using a modified Delphi method, an international panel of 16 experts convened in workshops and completed surveys to refine consensus data statements and generate clinical recommendations.

RESULTS

Overall, 10 data statements, five data gaps and 14 clinical recommendations achieved consensus. In the data statements, the panel describes increased risk of cardiometabolic health concerns in people with HIV compared with the general population, known risk factors, and the potential impact of antiretroviral therapy. The panel also identified data gaps to inform future research in people with HIV. Finally, in the clinical recommendations, the panel emphasizes the need for a holistic approach to comprehensive care that includes regular assessment of cardiometabolic health, access to cardiometabolic health services, counselling on potential changes in weight after initiating or switching antiretroviral therapy and encouraging a healthy lifestyle to lower cardiometabolic health risk.

CONCLUSIONS

On the basis of available data and expert consensus, an international panel developed clinical recommendations to address the increased risk of cardiometabolic disorders in people with HIV to ensure appropriate cardiometabolic health management for this population.

Bone mass, fracture risk, and associated factors in postmenopausal women living with HIV

OBJECTIVE

The aim of this study was to assess the prevalence of low bone mass (osteopenia/osteoporosis), the factors associated with low bone mass, and the risk of fractures in Brazilian postmenopausal women living with HIV (WLH) in the Amazon region.

METHODS

This is a cohort study with a cross-sectional assessment at baseline conducted between March 2021 to August 2022 with 100 postmenopausal WLH undergoing antiretroviral therapy (ART) between 45 and 60 years of age and 100 age-matched HIV-negative women. Data on bone mineral density in the lumbar spine (LS) and femoral neck (FN) were collected using dual x-ray absorptiometry and the 10-year risk of hip and major osteoporotic fractures was assessed using the Fracture Risk Assessment tool (FRAX).

RESULTS

The age of menopause onset occurred earlier in WLH ( P < 0.001). No differences in prevalence of osteoporosis and osteopenia in LS and FN were observed except for a lower T score in FN in WLH ( P = 0.039). The FRAX for major osteoporotic fracture and hip fracture were low in both groups, despite the mean of both FRAX scores was higher in WLH ( P < 0.001). Multivariate analysis showed that years since menopause onset, higher body mass index and higher FRAX major osteoporotic fracture were associated with the WLH group, while a higher frequency of physical activity was registered in the HIV-negative group. Multivariate analysis also showed that in WLH, a lower T score in FN was associated with years since menopause onset and body mass index and that the number of years since menopause onset was associated with a lower T score in the LS and a higher score in the FRAX hip fracture.

CONCLUSIONS

Our findings show a high prevalence of low bone mass (osteopenia/osteoporosis) in Brazilian postmenopausal women from the Amazon region. Women living with HIV have higher FRAX scores than HIV-negative women and a lower T score in the FN.

Association of a Polygenic Risk Score With Osteoporosis in People Living With HIV: The Swiss HIV Cohort Study

BACKGROUND

Bone mineral density (BMD) loss may be accelerated in people with HIV (PLWH). It is unknown whether a polygenic risk score (PRS) is associated with low BMD in PLWH.

METHODS

Swiss HIV Cohort Study participants of self-reported European descent underwent ≥2 per-protocol dual x-ray absorptiometry (DXA) measurements ≥2 years apart (2011-2020). Univariable and multivariable odds ratios (ORs) for DXA-defined osteoporosis were based on traditional and HIV-related risk factors and a genome-wide PRS built from 9413 single-nucleotide polymorphisms associated with low BMD in the general population. Controls were free from osteoporosis/osteopenia on all DXA measurements.

RESULTS

We included 438 participants: 149 with osteoporosis and 289 controls (median age, 53 years; 82% male, 95% with suppressed HIV RNA). Participants with unfavorable osteoporosis PRS (top vs bottom quintile) had univariable and multivariable-adjusted osteoporosis ORs of 4.76 (95% CI, 2.34-9.67) and 4.13 (1.86-9.18), respectively. For comparison, hepatitis C seropositivity, 5-year tenofovir disoproxil fumarate exposure, and parent history of hip fracture yielded univariable osteoporosis ORs of 2.26 (1.37-3.74), 1.84 (1.40-2.43), and 1.54 (0.82-2.9).

CONCLUSIONS

In PLWH in Switzerland, osteoporosis was independently associated with a BMD-associated PRS after adjustment for established risk factors, including exposure to tenofovir disoproxil fumarate.

Bictegravir/emtricitabine/tenofovir alafenamide plus doravirine in highly treatment-experienced men with multidrug-resistant HIV

OBJECTIVE

To evaluate the safety and efficacy of switching highly treatment-experienced people with HIV (HTE PWH) from rilpivirine/emtricitabine/tenofovir alafenamide (RPV/FTC/TAF) plus dolutegravir (DTG) to bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) plus doravirine (DOR). A pharmacokinetic (PK) analysis was conducted to assess the potential interaction between BIC and DOR.

DESIGN AND METHODS

This open-label switch trial enrolled HTE PWH from a primary care private practice in the United States. Eligible participants were male, aged ≥45 years, with documented viral resistance to protease inhibitors, nucleoside reverse transcriptase inhibitors, and/or nonnucleoside reverse transcriptase inhibitors but no resistance to RPV or DOR, and no K65R or T69 insertion mutations. Virologic suppression (≤50 copies/ml) while on RPV/FTC/TAF plus DTG for ≥6 months was required prior to enrollment. The primary endpoint of the study was virologic suppression (<50 and <200 copies/ml) at 48 weeks. Secondary endpoints included safety, tolerability, changes in body mass index (BMI), and identification of PK parameters of BIC and DOR.

RESULTS

Twenty males [median age: 65 years (range, 46-74), median time since HIV diagnosis: 37 years (range, 12-42)] completed the study. BIC/FTC/TAF plus DOR was well tolerated with no serious or treatment-related adverse events reported and no appreciable changes in BMI from baseline to Week 48. At Week 48, 100% of participants had <50 viral copies/ml. PK parameters for BIC and DOR ( n  = 10) were consistent with published data.

CONCLUSIONS

Switching from RPV/FTC/TAF plus DTG to BIC/FTC/TAF plus DOR was well tolerated and efficacious in HTE men aged ≥45 years with HIV.

Treatment Regimens and Care Models for Older Patients Living with HIV: Are We Doing Enough?

With improved access to antiretroviral therapy throughout the world, people are aging with HIV, and a large portion of the global population of people with HIV (PWH) is now age 50 or older. Older PWH experience more comorbidities, aging-related syndromes, mental health challenges, and difficulties accessing fundamental needs than the population of older adults without HIV. As a result, ensuring that older PWH are receiving comprehensive healthcare can often be overwhelming for both PWH and the providers. Although there is a growing literature addressing the needs of this population, gaps remain in care delivery and research. In this paper, we suggest seven key components to any healthcare program designed to address the needs of older people with HIV: management of HIV, comorbidity screening and treatment, primary care coordination and planning, attention to aging related-syndromes, optimization of functional status, support of behavioral health, and improved access to basic needs and services. We review many of the difficulties and controversies related to the implementation of these components, which include the absence of screening guidelines for this population and the challenges of care integration, and we suggest key next steps.

Impact of Alcohol on Bone Health in People Living With HIV: Integrating Clinical Data From Serum Bone Markers With Morphometric Analysis in a Non-Human Primate Model

People living with HIV (PLWH) represent a vulnerable population to adverse musculoskeletal outcomes due to HIV infection, antiretroviral therapy (ART), and at-risk alcohol use. Developing measures to prevent skeletal degeneration in this group requires a grasp of the relationship between alcohol use and low bone mass in both the PLWH population and its constituents as defined by sex, age, and race. We examined the association of alcohol use with serum biochemical markers of bone health in a diverse cohort of PLWH enrolled in the New Orleans Alcohol Use in HIV (NOAH) study. To explore the effects of alcohol on bone in the context of HIV and ART and the role of estrogen, we conducted a parallel, translational study using simian immunodeficiency virus (SIV)+/ART+ female rhesus macaques divided into four groups: vehicle (Veh)/Sham; chronic binge alcohol (CBA)/Sham; Veh/ovariectomy (OVX); and CBA/OVX. Clinical data showed that both osteocalcin (Ocn) and procollagen type I N-propeptide (PINP) levels were inversely associated with multiple measures of alcohol consumption. Age (>50 years) significantly increased susceptibility to alcohol-associated suppression of bone formation in both female and male PLWH, with postmenopausal status appearing as an additional risk factor in females. Serum sclerostin (Scl) levels correlated positively with measures of alcohol use and negatively with Ocn. Micro-CT analysis of the macaque tibias revealed that although both CBA and OVX independently decreased trabecular number and bone mineral density, only OVX decreased trabecular bone volume fraction and impacted cortical geometry. The clinical data implicate circulating Scl in the pathogenesis of alcohol-induced osteopenia and suggest that bone morphology can be significantly altered in the absence of net change in osteoblast function as measured by serum markers. Inclusion of sophisticated tools to evaluate skeletal strength in clinical populations will be essential to understand the impact of alcohol-induced changes in bone microarchitecture. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Bone mineral density among virologically suppressed Asians older than 50 years old living with and without HIV: A cross-sectional study

There are limited data regarding bone health in older people living with HIV (PWH), especially those of Asian ethnicity. We aimed to determine whether BMD in well-suppressed HIV-infected men and women aged ≥ 50 years are different from HIV-uninfected controls. In a cross-sectional study, BMD by dual-energy X-ray absorptiometry and calciotropic hormones were measured. A total of 481 participants were consecutively enrolled (209 HIV+ men, 88 HIV- men, 126 HIV+ women and 58 HIV- women). PWH were on average 2.5 years younger [men: 55.0 vs. 57.5 yr; women: 54.0 vs. 58.0 yr] and had lower body mass index (BMI) [men: 23.2 vs. 25.1 kg/m2; women: 23.1 vs. 24.7 kg/m2] compared to the controls. The median duration since HIV diagnosis was 19 (IQR 15-21) years in men and 18 (IQR 15-21) years in women. Three-quarters of PWH had been treated with tenofovir disoproxil fumarate-containing antiretroviral therapy for a median time of 7.4 (IQR 4.5-8.9) years in men and 8.2 (IQR 6.1-10) years in women. In an unadjusted model, HIV+men had significantly lower BMD (g/cm2) at the total hip and femoral neck whereas there was a tend toward lower BMD in HIV+women. After adjusting for age, BMI, and other traditional osteoporotic risk factors, BMD of virologically suppressed older PWH did not differ from participants without HIV (P>0.1). PWH had lower serum 25(OH)D levels but this was not correlated with BMD. In conclusion, BMD in well-suppressed PWH is not different from non-HIV people, therefore, effective control of HIV infection and minimization of other traditional osteoporosis risk factors may help maintain good skeletal health and prevent premature bone loss in Asian PWH. Clinical trial registration: Clinicaltrials.gov # NCT00411983.

Vitamin D and Calcium Supplementation Reverses Tenofovir-Caused Bone Mineral Density Loss in People Taking ART or PrEP: A Systematic Review and Meta-Analysis

Background

The decrease of bone mineral density (BMD) after the intake of Tenofovir disoproxil fumarate (TDF)-based drugs in people living with HIV/AIDS (PLWHA) and HIV-negative key populations under pre-exposure prophylaxis (PrEP) regimen raised concerns. Previous findings on the effects of vitamin D (VD) and calcium supplements and the recovery of BMD loss were inconclusive. The optimal doses of VD and calcium and its supplementary duration remained unknown. Therefore, we conducted a systematic review and meta-analysis to synthesize current evidence on VD and calcium supplements to inform clinical practice.

Methods

We searched PubMed, Web of Science, Cochrane library, and EMBASE databases for all placebo-controlled trials and prospective cohort studies published before March 5, 2021 that investigated VD and calcium supplements in participants taking TDF-based drugs. The keywords calcium, vitamin D, Tenofovir, and BMD were used for the searches. The primary outcome was changes of spine and hip BMD. A subgroup analysis was performed to determine the factors that were related to the effects of VD supplements on BMD. Locally weighted regression (loess) was used to determine the relationships of VD supplements, supplementary duration, and changes of BMD. This study was registered at PROSPERO (No. 42021231000).

Findings

Seven eligible studies including 703 participants were included in the analyses. The meta-analysis found that VD and calcium supplementation was related to a significant increase of BMD in the spine and hip [standardized mean difference (SMD) 0.43; 95% CI, 0.25 to 0.61, p = 0.009]. Moreover, positive dose-response relationships were demonstrated between doses of VD and calcium supplements, supplementary duration, and BMD recovery. Patients who took VD with the dose level of 4,000 IU/D obtained the highest BMD improvement (SMD 0.59, 95% CI, 0.43 to 0.74). No side effects were reported on VD and calcium supplementation.

Interpretation

We found the VD and calcium supplementation was associated with increases of BMD in participants taking TDF-based drugs. An optimal supplementary dose of 4,000 IU/D for VD was suggested for clinicians. The findings could be used in clinical practice to improve the BMD outcomes in people who were taking TDF-based drugs.Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/.

The prevalence and associated factors of reduced bone mineral density (BMD) among men with suppressed viral load taking antiretroviral therapy

BACKGROUND

Reduced bone mineral density (BMD) is a frequent comorbidity observed in people living with HIV (PLHIV).

OBJECTIVE

The aim of the study is to determine the prevalence and associated factors of reduced bone mineral density (BMD) among men with suppressed viral load taking antiretroviral therapy.

METHOD

The study was conducted as a cross-sectional study design between January to April 2019. 211 patients were included in the study. Z-score at either body site between -1.0 and -2.0 or -2 or less were defined as osteopenia or osteoporosis, respectively. Multivariate logistic regression analysis was used to evaluate the factors affecting the development of reduced BMD.

RESULTS

The mean age of the patients involved in the study was 34.8 ± 7.6. Osteoporosis was detected in 21.4% and osteopenia in 44.5% of the patients. There was a significant relationship between HIV diagnosis time, ART usage duration, tenofovir disoproxil fumarate (TDF) use, TDF use in the past, total TDF usage time and decreased BMD. Multivariate logistic regression analysis showed that the likelihood of reduced bone marrow density was 67% lower among those with regular milk or dairy product intake compared to those without (OR=0.330; 95% CI = 0.12-0.92, p=0.033 ) Conclusion: There is a high prevalence of reduced BMD among PLHIV aged under 50 which is mainly confounded by HIV diagnosis time, ART usage duration and TDF usage. Although virological control has been achieved, these patients should be followed up, considering that they may have decreased BMD.

Persistently lower bone mass and bone turnover among South African children living with well controlled HIV

OBJECTIVE

We evaluated longitudinal trends and associations between bone mass, bone turnover and inflammatory markers among South African children living with HIV (CLHIV) and controls.

DESIGN

We previously reported decreased bone mass among CLHIV independent of marked inflammation and increased bone turnover. The goal of this study was to evaluate longitudinal changes in bone mass, bone turnover and inflammation over 2 years.

METHODS

Longitudinal analyses were conducted among 220 CLHIV and 220 controls. Anthropometric measurements, physical activity, antiretroviral regimen, virologic and immunologic status, whole body (WB) and lumbar spine (LS) bone mineral content (BMC) and bone mineral density (BMD) were collected (enrollment, 12 and 24 months). Bone turnover markers including C-telopeptide of type I collagen (CTx) and procollagen type I N-terminal propeptide (P1NP) and inflammatory markers including interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), soluble CD14 and high-sensitivity C-reactive protein (hsCRP) were collected at enrollment and 24 months.

RESULTS

Compared with controls, CLHIV had significantly lower mean WB-BMC, WB-BMD, WB-BMC z scores, LS-BMC and LS-BMD as well as lower bone formation (P1NP) and resorption (CTx), and higher hsCRP and soluble CD14 over 24 months. CLHIV on efavirenz (EFV) had consistently lower TNF-alpha and IL-6 compared with those on ritonavir-boosted lopinavir (LPV/r) at all time points.

CONCLUSION

Over 2 years of follow-up, South African CLHIV had persistently lower bone mass, bone turnover, and macrophage activation. Lower bone mass and higher pro-inflammatory cytokine profiles were consistently observed among those on LPV/r-based compared with EFV-based regimens.

Sirtuins as Interesting Players in the Course of HIV Infection and Comorbidities

The sirtuins (SIRTs) are a family of enzymes from the group of NAD⁺-dependent deacetylases. Through the reaction of splitting the acetyl group of various transcription factors and histones they regulate many processes in the organism. The activity of sirtuins is linked to metabolic control, oxidative stress, inflammation and apoptosis, and they also affect the course of viral infections. For this reason, they may participate in the pathogenesis and development of many diseases, but little is known about their role in the course of human immunodeficiency virus (HIV) infection, which is the subject of this review. In the course of HIV infection, comorbidities such as: neurodegenerative disorders, obesity, insulin resistance and diabetes, lipid disorders and cardiovascular diseases, renal and bone diseases developed more frequently and faster compared to the general population. The role of sirtuins in the development of accompanying diseases in the course of HIV infection may also be interesting. There is still a lack of detailed information on this subject. The role of sirtuins, especially SIRT1, SIRT3, SIRT6, are indicated to be of great importance in the course of HIV infection and the development of the abovementioned comorbidities.

Antiretroviral therapy in older people with HIV

PURPOSE OF REVIEW

The age of people with HIV) continues to rise, and yet older people have tended to be under-represented or excluded from premarketing studies of antiretroviral therapy (ART). In this review, we highlight special considerations for the use of ART in older people with HIV, with a focus on toxicities associated with specific antiretroviral agents or drug classes as well as key research questions moving forward.

RECENT FINDINGS

Like all people with HIV, older people with HIV should be started on ART as soon as possible, regardless of CD4 count, and with a regimen that includes an integrase strand transfer inhibitor (INSTI) and two nucleoside reverse transcriptase inhibitors. Important toxicities to consider when choosing an ART regimen include bone and renal effects related to tenofovir, weight gain related to INSTIs and tenofovir alafenamide, neurocognitive and neuropsychiatric toxicities related to efavirenz, and increased cardiovascular risk associated with abacavir and boosted protease inhibitors. With the ongoing importance of INSTIs as a component of preferred ART regimens, further characterization of INSTI-related weight gain is a critical current research priority in understanding ART toxicity.

SUMMARY

There are multiple potential toxicities of ART to consider when selecting a regimen for older people. Specific agents or drug classes have been implicated in adverse bone or renal effects, weight gain, neuropsychiatric and neurocognitive effects, and cardiovascular risk.

Timing, Dosage, and Adherence of Antiretroviral Therapy and Risk of Osteoporosis in Patients With Human Immunodeficiency Virus Infection in Taiwan: A Nested Case-Control Study

The progression of acquired immunodeficiency syndrome is delayed in patients with human immunodeficiency virus (HIV) infection receiving antiretroviral therapy (ART). However, long-term ART is associated with adverse effects. Osteoporosis is one of the adverse effects and is a multifactorial systemic skeletal disease associated with bone fragility and an increased risk of fracture. We performed a longitudinal, comprehensive, nested case-control study to explore the effect of ART on the risk of osteoporosis in 104 osteoporotic and 416 non-osteoporotic patients with HIV infection at their average age about 29 years old in Taiwan. Patients with history of ART, current exposure to ART, higher cumulative defined daily doses (DDDs), or higher ART adherence were at a higher risk of osteoporosis (p < 0.05). Patients receiving nucleoside/nucleotide reverse transcriptase inhibitor (NRTI)-containing regimen (zidovudine-lamivudine combination, lamivudine-abacavir combination, and abacavir alone) and protease inhibitor (PI)-containing regimen (lopinavir-ritonavir combination, ritonavir, and atazanavir) had a higher risk of osteoporosis (p < 0.05). Especially, patients receiving high doses of the PIs lopinavir-ritonavir combination had an increased risk of osteoporosis (p < 0.05). In conclusion, history of ART, current exposure to ART, higher cumulative DDDs, and higher ART adherence were associated with an increased risk of osteoporosis. Furthermore, NRTI- and PI-containing regimens and high doses of PIs lopinavir-ritonavir combination may be associated with an increased risk of osteoporosis in patients with HIV infection in Taiwan.

Chinese Herbal Medicine Usage Reduces Overall Mortality in HIV-Infected Patients With Osteoporosis or Fractures

The survival of patients with HIV has greatly improved, due to Anti-Retroviral Therapy (ART). However, long-term HIV survivors often develop serious bone abnormalities, possibly due to the interplay of osteoblasts, osteoclasts, HIV ad ART. We evaluated in a nation-wide study in Taiwan the effect of Chinese herbal medicine (CHM) on overall mortality in HIV patients with osteoporosis or fractures. Enrollment period was between 1998 and 2011. Patients with osteoporosis or fractures before the HIV infection, and those with less than 14 days CHM use, were excluded. This left 498 patients, 160 CHM users, 338 without CHM. Univariate Kaplan-Meier and multivariate Cox regression analysis were used to compare the overall mortality in these 2 groups. Due to the nature of Chinese medicine, CHMs inevitably varied. We therefore also used rule mining and network analysis to determine which major CHM clusters were prescribed to the patients. CHM users had a much Lower mortality (hazard ratio (HR) = 0.43, 95% confidence interval (CI): 0.24–0.77, p < 0.005) and higher survival (p = 0.004, log-rank test). Although the CHMs greatly varied, network analysis identified one main cluster of strongly related CHM combinations (Chuan-Xiong-Cha-Tiao-San (CXCTS), Gan-Cao (GC; Glycyrrhiza uralensis Fisch.), Liu-He-Tang (LHT), Huang-Qin-Tang (HQT), Jia-Wei-Ping-Wei-San (JWPWS), and Dang-Gui-Long-Hui-Wan (DGLHuiW)). CHM as an additional treatment strongly improves overall survival in HIV-infected patients with osteoporosis and fractures.

People with HIV infection had lower bone mineral density and increased fracture risk: a meta-analysis

A meta-analysis to investigate the difference in fracture risk between individuals with and without HIV infection was performed. People living with HIV had lower bone mineral density (BMD) and greater risks of overall fractures and fragility fractures. Reducing fragility and maintaining skeletal strength for PLWH are urgently needed for this population.

PURPOSE

The introduction of effective antiretroviral therapy increased the life expectancy of people living with HIV (PLWH). This population now faces problems related to aging such as decreased bone mineral density (BMD) and increased fracture risk. Some antiretroviral therapies may also negatively impact bone health. We performed a meta-analysis to investigate the difference in the fracture risk between individuals with and without HIV infection.

METHODS

We compared BMD, risk of fragility fracture, and risk of all fracture between the two groups. This study included 35 articles with 106,994 PLWH and 228,794,335 controls.

RESULTS

PLWH had lower lumbar spine and hip BMD than controls. PLWH had a higher prevalence of all fracture events (4.08% versus 0.44%) and fragility fractures (2.66% versus 2.19%). The relative risks of all and fragility fractures of PLWH were 1.91 (95% confidence interval (CI), 1.46-2.49; p < 0.001) and 1.68 (95% CI: 1.40-2.01; p < 0.001). PLWH also had more vertebral fractures (1.26% versus 0.37%; RR, 1.97; 95% CI: 1.22-3.2; p < 0.05), hip fractures (1.38% versus 0.81%; RR, 1.88; 95% CI: 0.99-3.57; p = 0.05), and wrist fractures (1.38% versus 1.29%; RR, 1.67; 95% CI: 1.13-2.45; p < 0.05) than healthy controls. The pooled incidence of fractures was 1.72 per 100 person-years in PLWH and 1.29 in healthy controls.

CONCLUSION

PLWH had lower BMD and greater risks of all fractures and fragility fractures. Reducing fragility and maintaining skeletal strength for PLWH are urgently needed for this population.

Calcaneal Quantitative Ultrasonography and Urinary Retinol-Binding Protein in Antiretroviral-Treated Patients With Human Immunodeficiency Virus in Uganda: A Pilot Study

BACKGROUND

Data on bone health and renal impairment in people with human immunodeficiency virus (HIV) in resource-limited settings are limited. The primary aim of this study was to investigate the potential role of calcaneal quantitative ultrasonography (QUS) in predicting bone mineral density (BMD) reduction in a population of Ugandan HIV-infected  individuals receiving long-term antiretroviral therapy; the secondary end point was to assess the prevalence of proximal tubular dysfunction and the correlation between elevated urinary retinol-binding protein-urinary creatinine ratio (uRBP/uCr) and reduced BMD.

METHODS

We conducted a cross-sectional study at the Infectious Diseases Institute, Kampala, Uganda. We included 101 HIV-infected adults who had been receiving continuous antiretroviral therapy for ≥10 years and had undergone dual-energy x-ray absorptiometry (DXA) during the previous 12 months. All patients underwent calcaneal QUS evaluation and urine sample collection.

RESULTS

DXA BMD measurements were significantly associated (P < .01) with calcaneal speed of sound, broadband ultrasound attenuation, and QUS index. Forty-seven individuals (47%) had abnormal uRBP/uCr values. A significant inverse correlation was observed between uRBP/uCr and DXA T scores (lumbar [P = .03], femoral neck [P < .001], and total hip [P = .002]).

CONCLUSIONS

Calcaneal QUS results showed a moderate correlation with DXA outputs. The identified high prevalence of subclinical tubular impairment also highlights the importance of expanding access to tenofovir disoproxil fumarate-sparing regimens in resource-limited settings.

Low bone mass in people living with HIV on long-term anti-retroviral therapy: A single center study in Uganda

BACKGROUND

This study set out to determine the prevalence of low bone mass following long-term exposure to antiretroviral therapy in Ugandan people living with HIV.

METHODS

A cross-sectional study was conducted among 199 people living with HIV that had been on anti-retroviral therapy for at least 10 years. All participants had dual X-ray absorptiometry to determine their bone mineral density. The data collected included antiretroviral drug history and behavioral risk data Descriptive statistics were used to summarize the data. Inferential statistics were analyzed using multilevel binomial longitudinal Markov chain Monte Carlo mixed multivariate regression modelling using the rstanarm package.

RESULTS

One hundred ninety nine adults were enrolled with equal representation of males and females. The mean age was 39.5 (SD 8.5) years. Mean durations on anti-retroviral treatment was 12.1 (SD 1.44) years, CD4 cell count was 563.9 cells/mm3. 178 (89.5%) had viral suppression with <50 viral copies/ml. There were 4 (2.0%) and 36 (18%) participants with low bone mass of the hip and lumbar spine respectively. Each unit increase in body mass index was associated with a significant reduction in the odds for low bone mineral density of the hip and lumbar spine. The duration on and exposure to the various antiretroviral medications had no significant effect on the participant's odds for developing low bone mass. All the coefficients of the variables in a multivariable model for either hip or lumbar spine bone mass were not significant.

CONCLUSION

These results provide additional evidence that patients on long term ART achieve bone mass stabilization. Maintaining adequate body weight is important in maintaining good bone health in people on antiretroviral therapy.

Prevalence and predictors of bone health among perinatally HIV-infected adolescents

OBJECTIVES

Long-term complications of HIV including low bone mineral density remain a concern. We studied the prevalence and predictors of low bone mineral density among South African perinatally HIV-infected adolescents (PHIVA) on antiretroviral therapy (ART).

DESIGN

Cross-sectional analysis.

METHODS

Bone health was evaluated by measuring the calcaneus stiffness index among PHIVA on ART. Low stiffness index was defined as z-score less than -2 SD compared with age-matched and sex-matched HIV-uninfected adolescents (HIV-).

RESULT

Overall, 407 PHIVA (median age: 14 years; 50.4% female; median age at ART initiation: 4.2 years) and 92 HIV- (median age: 13.7 years; 54.4% female) were included. Median duration on ART was 9.8 years (interquartile range 6.8-11.5) with 38% initiating ART at 2 years or less of age. Stiffness index was lower in PHIVA (-0.19 vs. 0.43, P ≤ 0.001), respectively. During puberty, mean stiffness index increased with Tanner Stage in both PHIVA and HIV- but these increases were larger among HIV-; Tanner Stage II-III (96 vs. 101, P = 0.009) and Tanner Stage IV-V (104 vs. 112, P = 0.001). Among PHIVA, 52 (13%) had low stiffness index. After adjusting for age, sex and Tanner Stage, use of lopinavir/ritonavir [odds ratio (OR) = 2.31, P = 0.012] and viral load more than 50 copies/ml (OR = 2.06, P = 0.023) were associated with increased risk of low stiffness index, while use of efavirenz (OR = 0.41, P = 0.009) was associated with decreased risk of low stiffness index.

CONCLUSION

Stiffness index was a significantly lower in PHIVA than in HIV-, especially during puberty. Among PHIVA, detectable viral load and use of lopinavir/ritonavir were risk factors for low stiffness index. Further longitudinal studies are important to determine the clinical implications.

Prolonged Amenorrhea and Low Hip Bone Mineral Density in Women Living With HIV-A Controlled Cross-sectional Study

BACKGROUND

Women living with HIV (WLWH) have higher rates of prolonged secondary amenorrhea (no flow for ≥1 year) than HIV-negative women. Both having amenorrhea and being HIV positive are associated with lower areal bone mineral density (BMD). However, their combined BMD effects remain unclear. Therefore, we investigated prolonged amenorrhea and BMD in WLWH and controls.

METHODS

This cross-sectional study enrolled WLWH and HIV-negative control women aged 19-68 years of similar backgrounds. We assessed BMD (Hologic; as age- and ethnicity-matched Z-scores) in the Children and women: AntiRetrovirals and Markers of Aging cohort. Participants were stratified by amenorrhea history defined as past/present lack of menses for ≥1 year at age 45 and younger and not because of surgery, breastfeeding, pregnancy, or hormonal contraception. Hip and spine Z-scores by amenorrhea/no amenorrhea used linear models with multivariable analysis for relationships within WLWH.

RESULTS

WLWH (N = 129) were similar to controls (N = 129) in age, body mass index, ethnicity, and substance use. Among WLWH, 21% experienced prolonged amenorrhea vs. 9% in controls. WLWH had significantly lower total hip (mean ± SD: -0.4 ± 0.9 vs. 0.3 ± 1.1; P < 0.001) and spine (-0.5 ± 1.3 vs. 0.2 ± 1.3; P = 0.001) Z-scores than controls. Amenorrhea was independently associated with hip (P = 0.01) but not spine (P = 0.94) BMD by multivariable linear regression. WLWH with amenorrhea had lower hip Z-scores (-0.8 ± 0.9) than those without (-0.3 ± 0.8; P = 0.01). They also had higher rates of substance use, smoking, opioid therapy, hepatitis C coinfection, and lower CD4 nadir.

CONCLUSIONS

WLWH had higher rates of prolonged amenorrhea and lower BMD than controls. WLWH with amenorrhea experienced lower hip BMD Z-scores than those without. Prolonged amenorrhea is an added osteoporosis risk in WLWH.

Effects of maximal strength training on bone mineral density in people living with HIV and receiving anti-retroviral therapy: a pilot study

BACKGROUND

Anti-retroviral therapy (ART) is associated with low bone mineral density (BMD) among people living with HIV (PLWHIV). Although physical activity is recommended for improving bone health in patients with reduced BMD, data on effects of strength exercises on low BMD among PLWHIV is scarce. This study therefore aimed to determine the effects of a 12 weeks maximal strength training (MST) on BMD among PLWHIV in Blantyre, Malawi.

METHODS

Twenty-six PLWHIV with reduced BMD were randomised into a training group (TG, n = 15) and control group (CG, n = 11). The TG underwent 12 weeks of MST consisting of 4 sets of 3 to 5 repetitions at 85-90% of one repetition maximum (1RM) 3 times per week. The CG was advised to maintain their usual lifestyle. Measurements of BMD using dual-energy X-ray absorptiometry, 1RM using a squat machine, heart rate using a heart rate monitor, weight, height and body mass index were obtained before and after the intervention in the TG and CG. Descriptive statistics and student's t - tests were used to analyse data.

RESULTS

The study was conducted for 12 weeks. Data of 24 participants [14 (TG) and 10 (CG)] were analysed. At base line, there were no significant differences in age (p = 0.34), height (p = 0.91), weight (p = 0.43) and body mass index (p = 0.34) between participants in the TG and the CG. After the intervention, there were significant improvements in lumbar BMD (p < 0.001) and resting heart rate (p = 0.03) in the TG compared to the CG. There were significant improvements in muscle strength (1 RM) in both the TG (p < 0.001) and the CG (p = 0.01).

CONCLUSIONS

MST improves lumbar BMD and strength in PLWHIV receiving ART in Blantyre, Malawi. MST with a shorter exercise duration of 12 weeks seem to have the potential in treating reduced BMD in PLWHIV.

TRIAL REGISTRATION

PACTR201712002889203. Registered with the Pan African Clinical Trial Registry on 22nd December, 2017 at www. pactr.org.

Increase in bone turnover markers in HIV patients treated with tenofovir disoproxil fumarate combined with raltegravir or efavirenz

Introduction

Accelerated bone loss and osteoporosis are multifactorial comorbidities related to HIV and its treatments; however, their mechanisms remain elusive. Identifying HIV treatments that are differentially linked to osteoporosis risk, and clinical factors associated with HIV-related osteoporosis may enable optimizing anti-retroviral treatment (ART) and anti-osteoporosis therapy in preventing or treating this debilitating complication. This study aims to evaluate the dynamics of bone turnover markers after initiation of two commonly used antiretroviral regimens.

Methods

A prospective matched cohort study. Thirty treatment-naïve male patients (mean age 40 ± 10y) who initiated treatment with truvada (tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC)) + raltegravir or TDF/FTC + efavirenz were included in the study. Control group included 15 treatment-naive HIV patients. Serum morning fasting level of P1NP and CTX were measured 0, 1, 6, and 12 months after treatment initiation in the two study groups, and at 0, 6 and 12 months in the control group.

Results

In both treatment groups, but not in the control group, both markers increased significantly over time with no difference in BTM between patients treated with raltegravir or efavirenz. Levels of P1NP were statistically higher at 6 and 12 months after treatment initiation in both treatment groups compared to the controls, while CTX during treatment increased in both treatment groups but was significantly higher only in the raltegravir treatment group after 12 months. The ratio of area under the curve of P1NP/CTX correlated with CD4 increment.

Conclusions

Treatment initiation with raltegravir or efavirenz combined with TDF/FTC is associated with increased bone turnover. Thus, therapy that optimize bone turnover is needed to reduce bone loss at this vulnerable period and improve long-term bone health.

Antiretroviral Therapy-Associated Metabolic Complications: Review of the Recent Studies

The extensive utilization of antiretroviral therapy (ART) has successfully improved human immunodeficiency virus (HIV)-associated complications. The incidence of opportunistic infections is decreased by the viral load suppression and the CD4 count promotion. However, metabolic complications, commonly bone demineralization, lipodystrophy, and lactic acidosis, are arising following the adaptation of long-term ART. The events are not drug-specific, but the severity and incidence individually vary depending upon classes of drugs. Such concerning occurrences may lead to discontinuation of current therapy or switching to another regimen with fewer adverse effects. The purpose of this review is to demonstrate the common metabolic abnormalities associated with each class of widely used ART in people living with HIV (PLHIV). Electronic databases such as PubMed, ScienceDirect, Scopus, Google Scholar, SciFinder, and Web of Science were used for the literature search. A better understanding of ART-associated metabolic adverse effects is helpful in various clinical settings so that therapists may optimize treatments in this population.

Influence of HIV Infection and Antiretroviral Therapy on Bone Homeostasis

The human immunodeficiency virus type 1 (HIV)/AIDS pandemic represents the most significant global health challenge in modern history. This infection leads toward an inflammatory state associated with chronic immune dysregulation activation that tilts the immune-skeletal interface and its deep integration between cell types and cytokines with a strong influence on skeletal renewal and exacerbated bone loss. Hence, reduced bone mineral density is a complication among HIV-infected individuals that may progress to osteoporosis, thus increasing their prevalence of fractures. Highly active antiretroviral therapy (HAART) can effectively control HIV replication but the regimens, that include tenofovir disoproxil fumarate (TDF), may accelerate bone mass density loss. Molecular mechanisms of HIV-associated bone disease include the OPG/RANKL/RANK system dysregulation. Thereby, osteoclastogenesis and osteolytic activity are promoted after the osteoclast precursor infection, accompanied by a deleterious effect on osteoblast and its precursor cells, with exacerbated senescence of mesenchymal stem cells (MSCs). This review summarizes recent basic research data on HIV pathogenesis and its relation to bone quality. It also sheds light on HAART-related detrimental effects on bone metabolism, providing a better understanding of the molecular mechanisms involved in bone dysfunction and damage as well as how the HIV-associated imbalance on the gut microbiome may contribute to bone disease.

Physical activity levels among Malawian adults living with HIV and receiving anti-retroviral therapy

Introduction

Despite increasing life expectancy among people living with HIV (PLWHIV), anti-retroviral therapy (ART) side effects, HIV chronic inflammation and co-morbidities may limit functional abilities and reduced participation in exercises and physical activity (PA). PA improves wellbeing and overall quality of life of PLWHIV. In Malawi, there is paucity of information regarding PA levels among Malawians living with HIV and receiving ART. Therefore, this study aimed at determining PA levels among PLWHIV and receiving ART in Malawi.

Methods

A quantitative cross-sectional design was employed. Eligible participants were male and female adults aged 18–45 years living with HIV receiving ART for at least 1 year. The participants were recruited from Limbe Health Center, Gateway Health Center and Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi. The International Physical Activity Questionnaire (IPAQ) was used to assess the PA levels. A Stadiometer (HS-DBS00361, Model: 1127154) was used to measure weight (kg) and height (cm) of the participants.

Results

A total of 213 participants were recruited. There were more females than male participants (n=132 females). Overall, the mean age of all participants was 37±6.5 years and they were within normal body weight (BMI=23±4.0). Many participants (n=85, 40%) had low PA levels followed by those who were moderately physically active (n=75, 36%). A larger proportion of the female participants (51%) had low PA levels compared to males (22%). Forty-two percent of participants with 1–3 years of ART had low PA whereas 39% with >3 years ART had low PA.

Conclusion

Most PLWHIV and receiving ART in the sample have low PA levels. The study has also revealed that proportionally more females than males had low PA levels.

Osteopenia and osteoporosis among treatment-experienced people living with HIV

Introduction

Life expectancy of people living with human immunodeficiency (PLHIV) has increased mainly due to the accessibility and effectiveness of antiretroviral therapy (ART). However, adverse effects from long-term use of antiretrovirals, and the physiological changes associated with aging, may compromise the quality of life of PLHIV, in addition to causing new demands on the healthcare system.

Objectives

Estimate the frequency of osteoporosis and osteopenia in patients on prolonged ART and to verify their associated factors.

Methods

A cross-sectional study was conducted in Belo Horizonte, Minas Gerais, Brazil, from August 2017 to June 2018, in a sample of PLHIV (age ≥ 18 years) who started ART between 2001 and 2005. Data were collected through face-to-face interviews, physical evaluation, laboratory tests, and Dual-Energy X-Ray Absorptiometry Screening (DEXA). The outcome of interest was presence of bone alteration, defined as presence of osteopenia or osteoporosis in DEXA. The association between the explanatory variables and the event was assessed through odds ratio (OR) estimate, with 95% confidence interval (CI). Multiple logistic regression was performed to evaluate factors independently associated with bone alteration.

Results

Among 92 participants, 47.8% presented bone alteration (19.6% osteoporosis and 28.2% osteopenia). The variables that remained in the final logistic regression model were age ≥ 50 years (OR: 12.53; 95% CI: 4.37–35.90) and current alcohol use (OR: 2.63; 95% CI: 0.94–7.37).

Conclusions

This study showed a high frequency of bone changes, especially in PLHIV older than 50 years. This information is useful to stimulate the screening and timely intervention of this comorbidity of PLHIV on prolonged use of ART in order to prevent or minimize complications and new demands on the healthcare system.

Nevirapine Use Is Associated with Higher Bone Mineral Density in HIV-1 Positive Subjects on Long-Term Antiretroviral Therapy

We assessed bone mineral density (BMD) in a cohort of human immunodeficiency virus (HIV)-positive patients after a median of 11 years of combination antiretroviral therapy (cART) and evaluated the respective role of HIV infection and antiretroviral drugs (ARVs). A cross-sectional study of 162 participants (131 male) from the ANRS-C08 cohort was performed with bone dual-energy X-ray absorptiometry (DXA) scans and renal assessment. The window of exposure to ARVs was defined as an exposure of more than six cumulative months during the last 3 years before the DXA evaluation to account for a cumulative exposure that could affect bone remodeling. The association with low BMD (Z-score < -2) was assessed by a multiple logistic regression model. The study population was 50 years (median), hepatitis C virus (HCV) (18%), and hepatitis B virus (HBV) (8%) coinfection with HIV-RNA <50 c/mL in 89%, median CD4 of 619/mm³. Prevalence of low BMD was 18% in males and 6% in females. The factors associated with a Z-score < -2 in males were uric acid renal loss [adjusted odds ratio (aOR): 6.1; 95% confidence interval (CI): 1.2-31.5; p = .03], HCV coinfection (aOR: 4.0; 95% CI: 1.3-12.2; p = .02), and less frequent window of exposure to nevirapine (NVP) (aOR: 0.1; 95% CI: 0.02-0.6; p = .01). For the full study sample, there was a strong positive association between duration of exposure to NVP and lumbar spine Z-score (p = .004). HIV-positive patients exposed to long-term cART have a high incidence of low BMD. Tenofovir disoproxil fumarate and ritonavir-boosted protease inhibitors did not seem to be associated with increased risk of low BMD, whereas NVP exposure appeared to have an independent positive association.

Evaluation of screening practices for low bone mass and prevalence of osteoporosis and fractures in people living with human immunodeficiency virus attending a sexual health clinic

BACKGROUND

Adults with human immunodeficiency virus (HIV) infection commonly experience fractures and have a high prevalence of osteoporosis. The reasons for low bone mineral density (BMD) in HIV patients are multifactorial and there are now guidelines for screening.

AIMS

The aims of this study were to determine the screening practices for osteoporosis at this sexual health clinic, the prevalence of osteoporosis and to examine the risk factors for bone disease.

METHODS

We performed a retrospective cohort study of all HIV patients attending the Sunshine Coast Health Service District Sexual Health Clinic. Through chart review we collected the following details: patient demographics, co-morbid conditions, HIV status and anti-retroviral therapy, BMD screening, fractures, screening for secondary causes of bone disease and treatment interventions for osteoporosis.

RESULTS

A total of 243 patients with HIV attended the sexual health clinic. Of these, 149 met screening criteria for BMD assessment and 93 (61%) of those eligible underwent BMD examination. In those who had a BMD performed, 13 (19%) had sustained a previous fracture, 28 (30%) had osteoporosis and 42 (45%) had osteopenia. In the osteoporosis group, 21 (78%) were treated with vitamin D and calcium, 7 (26%) had a change in ART, 19 (68%) were treated with anti-resorptive therapy and 9 received testosterone replacement.

CONCLUSIONS

In this cohort, there was a high prevalence of low bone mass and BMD screening rates of 60%. Our results highlight the importance of this condition and the need to improve screening and availability of BMD assessment.

Bone mineral density changes among people living with HIV who have started with TDF-containing regimen: A five-year prospective study

There are limited data regarding long-term BMD changes over time among treatment-naïve people living with HIV (PLHIV) after initiating combined antiretroviral therapy (cART) in Asia. We aimed to study bone mineral density (BMD) changes among treatment-naïve PLHIV started treatment with tenofovir disoproxil fumarate (TDF)- or non-TDF-containing regimen and HIV-uninfected controls in an Asian setting. The study was a five-year prospective study. BMD at lumbar spine (LS) (L1 to L4), total hip (TH), and femoral neck (FN) were measured by dual energy X-ray absorptiometry (DEXA) scans at baseline, months 12, 24 and 60. Multivariate logistic regression models were used to explore factors associated with mean BMD ≥5% reduction after 5 years of cART. A total of 106 PLHIV (75 and 31 started TDF- and non-TDF-containing regimen, respectively) and 66 HIV-uninfected individuals were enrolled. The mean percent changes of BMD were significantly different longitudinally between TDF and non-TDF users (p<0.001 for LS, p = 0.006 for TH and p = 0.02 for FN). HIV-positive status and on TDF-containing regimen was independently associated with BMD loss ≥5% at month 60 (adjusted odds ratio [aOR] 7.0, 95% confidence interval [95%CI] 2.3–21.0, P = 0.001 for LS; aOR 4.9, 95%CI 1.7–14.3, P = 0.003 for TH and aOR 4.3, 95%CI 1.6–11.2, P = 0.003 for FN) compared to HIV-uninfected individuals. In a multivariate model for PLHIV only, TDF use (vs. non-TDF, P = 0.005) and pre-treatment CD4+ count <350 cells/mm³ (vs. ≥350 cells/mm³, P = 0.02) were independently associated with ≥5% BMD loss in TH at month 60. Treatment-naïve PLHIV initiating treatment with TDF-containing regimen have higher BMD loss in a Thai cohort. TDF use and low pre-treatment CD4 count were independently associated with BMD loss at month 60 at TH. Earlier treatment initiation and interventions to prevent bone loss could improve skeletal health among PLHIV.

Clinicaltrials.gov: NCT01634607

Alendronate/Vitamin D for attenuating bone mineral density loss during antiretroviral initiation: a pilot randomized controlled trial

Background: Antiretroviral therapy (ART) initiation is associated with decreases in bone mineral density (BMD).Objectives: To plan for a larger trial, we sought to obtain preliminary estimates for the difference in the change in BMD at 48 weeks achieved with 24 weeks of prophylactic alendronate/vitamin D during ART initiation compared to no intervention, the within-group standard deviation of this change, and intra-patient correlation coefficient for repeated BMDs. Secondary objectives included assessing enrollment feasibility, treatment acceptability, adherence and safety.Methods: We randomized treatment-naïve HIV-positive adults initiating tenofovir disoproxil fumarate/emtricitabine/elvitegravir/cobicistat or abacavir/lamivudine/dolutegravir 1:1:1 to immediate alendronate/vitamin D3 70 mg/5600 IU for 24 weeks (concomitant treatment arm, CTA), the same intervention starting 24 weeks after study entry (delayed treatment arm, DTA), or no bone anti-resorptive therapy (standard of care, SOC). We assessed BMD, acceptability, adverse events and drug adherence at baseline, week 24 and week 48.Results: Of 29 included participants, 72% initiated TDF/FTC/ELV/c and 28% initiated ABC/3TC/DTG. Median (IQR) CD4 count was 388 (303,525) cells/mm³ and median plasma HIV RNA was 4.45 (2.26, 4.84) log₁₀ copies/mL. The mean (SD) percentage change in BMD for the CTA and DTA combined was 1.95% (2.53%), 0.38% (3.34%), and -0.57% (3.50%) at the lumbar spine, femoral neck and total hip respectively at 48 weeks. The ICC among repeated measurements of BMD was 0.978, 0.964, and 0.967 at these sites, respectively. Enrollment feasibility, drug acceptability, adherence, and tolerability were good.Conclusions: Our findings inform the sample size for a larger trial of bone anti-resorptive therapy during ART initiation and support feasibility.

Reduced bone mineral density among HIV infected patients on anti-retroviral therapy in Blantyre, Malawi: Prevalence and associated factors

INTRODUCTION

Use of tenofovir based anti-retroviral therapy (ART) in HIV patients is associated with low bone mineral density (BMD). Low BMD predisposes people living with HIV (PLWHIV) to fractures thereby increasing morbidity and mortality. Since the introduction of tenofovir based ARV regimens in 2011, information on the prevalence of low BMD in PLWHIV and receiving ART is still scarce in Malawi. This study aimed to determine the prevalence and associated factors of low BMD among adults living with HIV and receiving ART in Blantyre, Malawi.

METHODOLOGY

This was a cross sectional study involving 282 HIV-positive adults of whom 102 (36%) were males. The participants aged 18-45 years were recruited from three primary and one tertiary health care facilities. Patients with no other comorbidities or conditions associated with low BMD and on ART >12 months were included. Data on BMD (femoral neck and lumbar spine) were collected using Dual-Energy X-ray Absorptiometry (DEXA). The International Physical Activity Questionnaire (IPAQ) was used to assess the physical activity (PA) levels. Participants' body weight (kg) and height (m) were also measured. Descriptive statistics, Chi-Square test and multivariable logistic regression were used to analyse data.

RESULTS

Mean age of participants was 37(± 6.4) years, mean duration on ART was 5(± 3.5) years and mean body mass index (BMI) was 23(± 4.5) kg/m2. Twenty percent (55) had reduced BMD. More males (28%) had reduced BMD than females (14%) (p = 0.04). There was a significant association between lumbar BMD and femoral neck BMD (r = 0.66,p<0.001). However, on average, lumbar BMD (g/cm2) was significantly lower than the femoral BMD (p < 0.001). Participants with low PA level (OR 1.23,p = 0.6) had higher odds of having reduced BMD compared to those with high PA level.

CONCLUSIONS AND RECOMMENDATION

Prevalence of reduced BMD is high among PLWHIV in Malawi especially male Malawian adults. Occurrence of low BMD is associated with low PA level. There is need for health care providers to routinely monitor BMD and PA levels of this population.

Long-Term Impact of Calcium and Vitamin D Supplementation on Bone Density in HIV+ Patients with Documented Deficiencies

To assess the efficacy of long-term calcium and vitamin D treatment on bone mineral density (BMD) in HIV⁺ patients on combined antiretroviral therapy (cART). A retrospective, single-center cohort study. Between March 2010 and July 2012, 268 HIV⁺ patients were screened for vitamin D and calcium deficiency. Those with proven vitamin D or calcium deficiency received supplementation according to a predefined protocol, and were offered further evaluation of BMD by dual-energy X-ray absorptiometry (DEXA). Calcium and vitamin D status and BMD were assessed at baseline (T₀) and approximately one (T₁) and 4-6 years (T₂) later. Percentual change in BMD of the lumbar spine and hip was compared with reported rates of change in HIV⁺ patients on cART without standard calcium and vitamin D treatment. The prevalence of vitamin D deficiency and calcium deficiency was 46% and 43%, respectively. Thirteen percent of patients had secondary hyperparathyroidism at baseline. DEXA performed in patients with a deficiency revealed osteopenia in 40% and osteoporosis in 8% of patients. The expected long-term change in lumbar spine and hip BMDs at T₂ was -0.7%, -1.5%, and -1.5%, respectively. The measured changes were +2.3%, -0.6%, and -0.6%, respectively. The difference between measured and expected rate of change was significant for the lumbar spine (3.0%, p < .05), but not for the hip. Long-term vitamin D and calcium supplementation improves lumbar spine BMD of HIV⁺ patients with osteopenia or osteoporosis and with proven calcium and/or vitamin D deficiencies. Screening and treatment are recommended to become part of regular care.

Vitamin D and Calcium Supplement Attenuate Bone Loss among HIVInfected Patients Receiving Tenofovir Disoproxil Fumarate/Emtricitabine/ Efavirenz: An Open-Label, Randomized Controlled Trial

BACKGROUND

Antiretroviral therapy (ART), especially with tenofovir disoproxil fumarate (TDF), has been associated with accelerated bone turnover and leads to significant bone loss.

OBJECTIVE

We aimed to determine the effect of vitamin D2 and calcium on bone mineral density (BMD) in HIV-infected patients receiving TDF/emtricitabine (FTC)/efavirenz (EFV).

METHODS

A prospective, open-label, randomized controlled study was conducted. Eligible patients were ART naïve HIV individuals who initiated TDF/FTC/EFV. The study group received supplementation with vitamin D2 and calcium carbonate, whereas the control group was administered only ART. The primary outcome was the percentage change in total hip BMD at week 24 compared with baseline.

RESULTS

A total of 18 patients were randomized (9 in each group). The mean (standard deviation; SD) total hip BMD significantly decreased from baseline in both groups, from 0.96 (0.14) g/cm2 to 0.93 (0.13) g/cm2 in the study group (p = 0.006) and from 0.87 (0.11) g/cm2 to 0.84 (0.11) g/cm2 in the control group (p = 0.004). The mean (SD) lumbar spine BMD significantly decreased from baseline in both groups, from 1.00 (0.13) g/cm2 to 0.97 (0.13) g/cm2 (p = 0.004) in the study group and from 0.90 (0.09) g/cm3 to 0.86 (0.08) g/cm2 in the control group (p = 0.006). At week 24, the mean (SD) lumbar spine BMD was significantly greater in the study group than in the control group (p = 0.042). However, there were no significant differences in the percentage change of total hip, lumbar spine, and femoral neck BMD between both groups. No adverse events were reported. In conclusion, as early as 24 weeks after TDF initiation, a significant decline in BMD was detected.

CONCLUSION

Vitamin D2 and calcium supplements should be considered for HIV-infected patients receiving TDF/FTC/EFV in a resource-limited setting where there are limited ART options (Clinicaltrials. gov NCT0287643).

Impact of Antiretroviral Drugs on Fracture Risk in HIV-Infected Individuals: A Case-Control Study Nested Within the French Hospital Database on HIV (FHDH-ANRS CO4)

BACKGROUND

HIV-infected patients have lower bone mineral density and a higher incidence of fractures than the general population of the same age and sex. To assess the impact of antiretroviral (ARV) drugs exposure on the risk of osteoporotic fractures, we conducted a nested case-control study.

METHODS

Cases were individuals enrolled while ARV-naive, with a first prospectively recorded fracture between 2000 and 2010. Controls were randomly selected after matching for sex, age (±3 years), period of HIV diagnosis (<1997/≥1997), and clinical center. The risk of fracture was analyzed with conditional logistic regression models, using different ways to model ARV exposure. All exposure variables and potential confounders were included in multivariable models.

RESULTS

Among 861 reviewed cases, 261 fractures were osteoporotic and 254 of cases were matched to at least one control (376 controls). The median year of fracture diagnosis was 2007 (interquartile range 2004-2009): 49% of patients had been exposed to tenofovir disoproxil fumarate (TDF) and 82% to protease inhibitors (PIs). After taking into account the transmission group, AIDS status, geographic origin, body mass index, current smoking status, alcohol consumption, exposure to systemic glucocorticoids, and the period of enrollment, there was no association between the risk of fracture and exposure to TDF [odds ratio for cumulative exposure: 1.04 (0.86-1.27), similar results for ever-exposed subjects], to nucleoside reverse transcriptase inhibitors, or to PIs [odds ratio for cumulative PI exposure: 1.02 (0.92-1.12)].

CONCLUSIONS

We found no evidence of an excess risk of fracture after exposure to TDF or PIs. This has important implications for the debate concerning tenofovir alafenamide versus generic TDF.

The rate of bone loss slows after 1-2 years of initial antiretroviral therapy: final results of the Strategic Timing of Antiretroviral Therapy (START) bone mineral density substudy

OBJECTIVES

Initial antiretroviral therapy (ART) causes loss of bone mineral density (BMD) over the first 1-2 years. Whether this loss continues with longer therapy is unclear. We determined changes in bone and spine BMD over 5 years in adults receiving immediate or deferred initial ART.

METHODS

In the Strategic Timing of Antiretroviral Therapy (START) BMD substudy, ART-naïve adults with CD4 counts > 500 cells/μL were randomized to immediate or deferred ART. Deferred group participants not yet on ART were offered ART after May 2015. Mean per cent changes in total hip and lumbar spine BMD (measured annually by dual-energy X-ray absorptiometry) were compared between groups using longitudinal mixed models. Fracture rates were also compared between groups for all START participants.

RESULTS

Substudy participants (immediate group, n = 201; deferred group, n = 210; median age 32 years; 80% non-white; 24% female) were followed for a mean 4.5 years until December 2016. In the immediate group, > 96% used ART throughout. In the deferred group, 16%, 58% and 94% used ART at years 1, 3 and 5, respectively. BMD decreased more in the immediate group initially; groups had converged by year 3 at the spine and year 4 at the hip by intent-to-treat (ITT). BMD changes after year 1 were similar in the immediate group and in those off ART in the deferred group [mean difference: spine, 0.03% per year; 95% confidence interval (CI) -0.4, 0.4; P = 0.88; hip, -0.2% per year; 95% CI -0.7, 0.3; P = 0.37]. Fracture incidence did not differ significantly between groups (immediate group, 0.86/100 person-years versus deferred group, 0.85/100 person-years; hazard ratio 1.01; 95% CI 0.76, 1.35; P = 0.98).

CONCLUSIONS

Significant ART-induced bone loss slowed after the first year of ART and became similar to that in untreated HIV infection.

Treatment of Human Immunodeficiency Virus Infection With Tenofovir Disoproxil Fumarate-Containing Antiretrovirals Maintains Low Bone Formation Rate, But Increases Osteoid Volume on Bone Histomorphometry

Bone mineral density (BMD) loss is a known complication of human immunodeficiency virus (HIV) infection and its treatment, particularly with tenofovir disoproxil fumarate (TDF)-containing antiretroviral regimens. Although renal proximal tubular dysfunction and phosphaturia is common with TDF, it is unknown whether BMD loss results from inadequate mineralization. We evaluated change in BMD by dual-energy X-ray absorptiometry (DXA) and bone histomorphometry by tetracycline double-labeled transiliac crest biopsies in young men living with HIV before (n = 20) and 12 months after (n = 16) initiating TDF/lamivudine/efavirenz. We examined relationships between calciotropic hormones, urinary phosphate excretion, pro-inflammatory and pro-resorptive cytokines, and bone remodeling-related proteins with changes in BMD and histomorphometry. Mean age was 29.6 ± 5.5 years, with mean CD4 + T cell count of 473 ± 196 cells/mm³ . At baseline, decreased bone formation rate and increased mineralization lag time were identified in 16 (80%) and 12 (60%) patients, respectively. After 12 months, we detected a 2% to 3% decrease in lumbar spine and hip BMD by DXA. By histomorphometry, we observed no change in bone volume/total volume (BV/TV) and trabecular parameters, but rather, increases in cortical thickness, osteoid volume, and osteoblast and osteoclast surfaces. We did not observe significant worsening of renal phosphate excretion or mineralization parameters. Increases in PTH correlated with decreased BMD but not histomorphometric parameters. Overall, these data suggest abnormalities in bone formation and mineralization occur with HIV infection and are evident at early stages. With TDF-containing antiretroviral therapy (ART), there is an increase in bone remodeling, reflected by increased osteoblast and osteoclast surfaces, but a persistence in mineralization defect, resulting in increased osteoid volume. © 2019 American Society for Bone and Mineral Research.

Diagnosis, prevention, and treatment of bone fragility in people living with HIV: a position statement from the Swiss Association against Osteoporosis

Life expectancy of people living with HIV (PLWH) is reaching similar length as in the general population. Accordingly, age-related comorbidities, including osteoporosis, are increasing. Fracture risk is higher and increases approximately 10 years earlier in PLWH. Classical risk factors of bone fragility are highly prevalent in PLWH but factors specific for HIV infection itself and the type of antiretroviral therapy (ART) (triple combination antiretroviral therapy) regimen (especially tenofovir and protease inhibitors) also contribute to bone loss. The majority of bone loss occurs during virus activity and at initiation of ART (immune reconstitution) and is associated with an increase of bone resorption (upregulation RANKL). Recent data indicate that calcium and vitamin D supplements as ART initiation lower BMD loss. The reduction of tenofovir plasma concentrations with tenofovir alafenamide attenuates BMD loss but it remains unknown whether it will contribute to reduce fracture risk. Hence, special considerations for the management of bone fragility in PLWH are warranted. Based on the current state of epidemiology and pathophysiology of osteoporosis in PLWH, we provide the consensus of the Swiss Association against Osteoporosis on best practice for diagnosis, prevention, and management of osteoporosis in this population. Periodic assessment of fracture risk is indicated in all HIV patients and general preventive measures should be implemented. All postmenopausal women, men above 50 years of age, and patients with other clinical risk for fragility fractures qualify for BMD measurement. An algorithm clarifies when treatment with bisphosphonates and review of ART regimen in favour of more bone-friendly options are indicated.

Antiretroviral Therapy and Bone Health

Objective: To determine the incidence of osteopenia and osteoporosis in Bulgarian human immunodeficiency virus (HIV)-infected patients.

Methods: Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry in 41 Bulgarian HIV-infected patients.

Results: Overall, 27% of patients had reduced BMD (7% osteoporosis and 20% osteopenia). There was a significant correlation between low BMD and increasing age and between low BMD and duration of antiretroviral therapy (ART) but no correlation with gender, therapy regimen or serum calcium or phosphate levels. Seventy-one percent had elevated serum cystatin C levels but there was no correlation between BMD and cystatin C levels. Serum calcium, phosphate, cystatin C and creatinine levels and the T- and Z-scores were tested for dependence on duration of therapy. Dependence was found for T- and Z-scores, (p = 0.048 and p = 0.038) but not for calcium, phosphate, cystatin C or creatinine levels. These variables were subsequently tested by means of cross-tabulation tables for correlations between pairs of parameters; no significant correlation was found between any pairs (R > 0.5 for all comparisons).

Conclusions: Significant correlations were observed between low BMD and increasing age and longer duration of ART but no relationship was observed with gender or therapy regimen.

Efficacy and Safety of Tenofovir Disoproxil Fumarate Versus Low-Dose Stavudine Over 96 Weeks: A Multicountry Randomized, Noninferiority Trial

BACKGROUND

Reducing doses of antiretroviral drugs, including stavudine (d4T), may lower toxicity, while preserving efficacy. There are substantial concerns about renal and bone toxicities of tenofovir disoproxil fumarate (TDF).

SETTING

HIV-1-infected treatment-naive adults in India, South Africa, and Uganda.

METHODS

A phase-4, 96-week, randomized, double-blind, noninferiority trial compared d4T 20 mg twice daily and TDF, taken in combination with lamivudine (3TC) and efavirenz (EFV). The primary endpoint was the proportion of participants with HIV-1 RNA <50 copies per milliliter at 48 weeks. Adverse events assessments included measures of bone density and body fat. The trial is registered on Clinicaltrials.gov (NCT02670772).

RESULTS

Between 2012 and 2014, 536 participants were recruited per arm. At week 96, trial completion rates were 75.7% with d4T/3TC/EFV (n = 406) and 82.1% with TDF/3TC/EFV (n = 440, P = 0.011). Noncompletion was largely due to virological failure [6.2% (33) with d4T/3TC/EFV versus 5.4% (29) with TDF/3TC/EFV; P = 0.60]. For the primary endpoint, d4T/3TC/EFV was noninferior to TDF/3TC/EFV (79.3%, 425/536 versus 80.8% 433/536; difference = -1.49%, 95% CI: -6.3 to 3.3; P < 0.001). Drug-related adverse event discontinuations were higher with d4T (6.7%, 36), than TDF (1.1%, 6; P < 0.001). Lipodystrophy was more common with d4T (5.6%, 30) than TDF (0.2%, 1; P < 0.001). Creatinine clearance increased in both arms, by 18.1 mL/min in the d4T arm and 14.2 mL/min with TDF (P = 0.03). Hip bone density measures, however, showed greater loss with TDF.

CONCLUSIONS

Low-dose d4T combined with 3TC/EFV demonstrated noninferior virological efficacy compared with TDF/3TC/EFV, but mitochondrial toxicity remained high. Little renal toxicity occurred in either arm. Implications of bone mineral density changes with TDF warrant investigation.

BONE QUALITY IN A YOUNG COHORT OF HIV-POSITIVE PATIENTS

Context

In HIV+ patients, several factors related to patient and antiretroviral therapy (ART) could determine early onset of bone mineral density (BMD) disturbances.

Objective

Evaluation of bone quality according to gender in patients from the HIV Romanian cohort.

Design

A cross-sectional study in "Prof. Dr. Matei Balş" National Institute for Infectious Diseases, Bucharest between 2016-2018.

Subject and Methods

We collected data regarding HIV infection, ART history, viral hepatitis co-infections and we calculated patients body mass index (BMI). CD4 cell count, HIV viral load (VL), vitamin-D levels were determined. Dual-energy X-ray absorptiometry (DXA) scans were used to evaluate BMD.

Results

We enrolled 97 patients with the median age of 26 years. According to the DXA T-scores, 10 males and 8 females had osteopenia and 4 males and 4 females had osteoporosis. According to Z-scores 2 males and 1 female had osteoporosis. Hip DXA T-scores revealed osteopenia in 6 males and 9 females, whereas T and Z-scores showed osteoporosis in 2 males and 3 females. Lumbar spine (LS) T-score diagnosed osteopenia in 9 males and 6 females, while T and Z-scores revealed osteoporosis in 3 males and females. In males, low T-scores were associated with decreased BMI; low LS DXA Z-scores with low vitamin-D levels; low T and Z-scores and LS-BMD with high VL.

Conclusions

Evaluating bone quality in patients with a long history of HIV infection, multiple factors should be taken into account.

Women have enhanced bone loss associated with phosphaturia and CD4+ cell restoration during initial antiretroviral therapy

OBJECTIVE

We compared bone mineral density (BMD) changes and their correlates, between men and women participating in two randomized trials of initial [antiretroviral therapy (ART)] regimens, with or without tenofovir disoproxil fumarate (TDF).

METHODS

Covariates in linear regression models of 48-week hip and spine %BMD changes, by dual energy X-ray absorptiometry, included baseline and 48-week changes in plasma viral load, CD4 cells, plasma C-terminal telopeptide, procollagen 1 N-terminal propeptide and glomerular filtration rates, and the 48-week area under the curve of fractional excretion of phosphate.

RESULTS

Despite overall hip and spine BMD declines of 2.8 and 2.9%, respectively, plasma viral load suppression to less than 50 vs. at least 50 copies/ml was associated 1.0% (P = 0.02) and 0.8% (P = 0.01) less BMD decline. Women had lower baseline spine (P = 0.04; n = 59 women, 418 men) and hip BMD (P = 0.01) in adjusted models, with 1.7% more hip decline on ART than men (P = 0.001). Serum phosphate was positively associated with baseline spine BMD in women (P = 0.03) but not men, and area under the curve of fractional excretion of phosphate was negatively associated with spine BMD changes, particularly in women randomized to TDF regimens (P = 0.03 and 0.054 for interactions by sex, and randomization to TDF vs. non-TDF regimens, respectively; n = 44 women, 326 men). Women also had 0.6% (P = 0.004) more hip BMD decline than men associated with each 100 CD4 cells/μl increase on ART (P = 0.02; n = 49 women, 379 men).

CONCLUSION

Women randomized to TDF-containing ART had accentuated spine loss associated with phosphaturia, and accentuated hip loss associated with CD4 restoration, regardless of TDF exposure. Viral load suppression reduced bone loss.

Inhibition of osteoblast differentiation by ritonavir

Osteoporosis is one of the chronic complications seen in human immunodeficiency virus (HIV)-infected patients, and affects patients at high prevalence. The causes of osteoporosis in HIV-infected patients are multiple, and include chronic HIV infection, living habits such as smoking and alcohol consumption, and antiretroviral drug use. Among antiretroviral drugs, protease inhibitors have been reported to be associated with osteoporosis. However, it remains to be determined how anti-HIV drugs affect osteoblast differentiation. In the current study, MC3T3-E1 cells, a mouse osteoblastic cell line, were cultured in osteoblast differentiation medium with or without different protease inhibitors (ritonavir, lopinavir, darunavir or atazanavir), and alkaline phosphatase (ALP) activity and the expression of Runt-related transcription factor 2 (Runx2) were analyzed. The ALP activity in MC3T3-E1 cells cultured with ritonavir was significantly reduced compared with that in cells in only osteoblast inducer reagent, indicating that ritonavir inhibited osteoblast differentiation. Meanwhile, ALP activity was not reduced in cells cultured with any of the other inhibitors. In addition, ritonavir inhibited the expression of Runx2, a key regulator of osteoblast differentiation, in the early period of osteoblast differentiation. To the best of our knowledge, this is the first study to demonstrate that ritonavir inhibits osteoblast differentiation in vitro. The present findings may explain the mechanism of osteopenia induced by combination antiretroviral therapy involving protease inhibitors.

Management of Reduced Bone Mineral Density in HIV: Pharmacological Challenges and the Role of Exercise

Low bone mineral density is becoming more common among people living with HIV following the use of current antiretroviral therapy drugs such as tenofovir. Although pharmacological therapies used to treat low bone mineral density are associated with adverse effects and may increase the pill burden in people living with HIV who are already burdened by antiretroviral therapy drugs, non-pharmacological strategies to prevent and treat reduced bone mineral density resulting from antiretroviral therapy drugs in people living with HIV have not been fully explored. Despite evidence that exercise is effective in increasing bone mineral density, effects of exercise on low bone mineral density resulting from antiretroviral therapy drugs in HIV infected individuals are still unknown. This review highlights gaps in the strategies used to manage reduced bone mineral density resulting from antiretroviral therapy drugs and focuses on exercise as an alternative or adjunctive strategy.

Relationships Between Physical Activity and Bone Density in People Living with HIV: Results from the SATURN-HIV Study

We conducted a cross-sectional secondary analysis of baseline data from the SATURN-HIV study (N = 147; 78% male, 68% Black, median body mass index [BMI] 26.72 kg/m2, 13% with osteopenia, HIV-1 RNA < 1,000 copies/mL, stable antiretroviral therapy [ART]) to explore the relationship between physical activity (PA) and bone mineral density (BMD). We measured self-reported minutes of PA and BMD in the overall sample and subgroups based on national recommendations (≥150 minutes/week). Forty-one (28%) participants met recommended PA levels. Higher intensity PA was associated with higher BMD at the total hip (r = 0.27, p = .09; n = 41; 28%) and lumbar spine (r = 0.32, p < .05), and predicted higher BMD at the hip (p < .01; controlling for age, BMI, ART). Lumbar spine BMD did not retain significance in the regression model. Moderate-to-high intensity PA could prevent or mitigate excessive bone loss in people living with HIV.

Alcohol Consumption and Bone Mineral Density in People with HIV and Substance Use Disorder: A Prospective Cohort Study

BACKGROUND

People living with HIV (PLWH) commonly have low bone mineral density (BMD) (low bone mass and osteoporosis) and are at high risk for fractures. Fractures and low BMD are significant causes of morbidity and mortality, increasingly relevant as PLWH age. Alcohol use is common among PLWH and known to affect bone health. The association between alcohol use and changes in BMD among PLWH is not well understood.

METHODS

We conducted a 3.5-year prospective cohort study of 250 PLWH with substance use disorder or ever injection drug use. Annual alcohol consumption was measured as a mean of grams per day of alcohol, mean number of heavy drinking days per month, mean number of days abstinent per month, and any heavy drinking, using the 30-day Timeline Followback method twice each year. The primary outcome was annual change in BMD measured each year by dual energy X-ray absorptiometry in grams per square centimeter (g/cm2 ) at the femoral neck. Additional dependent variables included annual change in total hip and lumbar spine BMD, >6% annual decrease in BMD at any site, and incident fractures in the past year. Regression models adjusted for relevant covariates.

RESULTS

The median age of participants was 50 years. The median duration of HIV infection was 16.5 years and the mean time since antiretroviral therapy initiation was 12.3 years. At study entry, 67% of participants met criteria for low BMD (46% low bone mass, 21% osteoporosis). Median follow-up was 24 months. We found no significant associations between any measure of alcohol consumption and changes in BMD (g/cm2 ) at the femoral neck (adjusted β for g/d of alcohol = -0.0032, p = 0.7487), total hip, or lumbar spine. There was no significant association between any measure of alcohol consumption and >6% annual decrease in BMD at any site, or incident fractures.

CONCLUSIONS

In this sample of PLWH and substance use disorders or ever injection drug use, we detected no association between any of the alcohol measures used in the study and changes in BMD or incident fractures.

Prevalence of and risk factors for low bone mineral density in Spanish treated HIV-infected patients

Objectives

Several studies have involved antiretroviral therapy in the pathogenesis of low bone mineral density (BMD), while others have not confirmed this association. In this study we analyze the impact of HIV status, traditional risk factors and antiretroviral therapy in BMD in an HIV-infected population living in Madrid.

Material and methods

We performed a cross-sectional analysis of 107 individuals infected with HIV and exposed to antiretroviral treatment to estimate the prevalence of decreased BMD. Bone mineral density of lumbar spine and femoral neck was measured by dual-energy X-ray absorptiometry. In a multivariate analysis variables related with HIV status, antiretroviral drugs and traditional risk factors were included.

Results

Low BMD was diagnosed in 63 participants (58.9%), including osteoporosis in 11 (10%). At least one cause of osteoporosis was identified in 43 patients (40%), with a deficiency of vitamin D in 86 (89%) and secondary hyperparathyroidism in 30 (28%). In multivariate analysis, increasing age, a treatment based on boosted PI and tenofovir DF, and previous exposure to tenofovir were identified as independent risk factors for a decreased BMD in both lumbar spine and femoral neck.

Conclusions

We have confirmed a high prevalence of reduced BMD, which is favoured by ritonavir-boosted PI and TDF. Bone safety should continue to be evaluated in clinical trials and cohort studies in order to demonstrate that the new drugs offer additional advantages regarding the impact on BMD.