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

HIV and fracture: Risk, assessment and intervention

OBJECTIVES

With management of comorbidity in people living with HIV (PLWH) a key component of clinical care, early loss of bone integrity and clinical fracture are recognized as important issues. This review aims to describe the epidemiology of fracture in PLWH, as well as summarizing the relative balance of factors that contribute to fracture. We also aim to describe fracture risk assessment and interventional strategies to modify the risk of fracture in this population.

RESULTS

Data from recent meta-analyses show that PLWH have significantly more fractures than the general population, with men and injecting drug users at higher risk. Modifiable factors that contribute to fracture risk in this cohort include body mass index (BMI), drug use, concurrent medications, frailty, and hepatitis C virus infection. Relating to antiretroviral therapy, current or ever tenofovir exposure has been identified as predictive of fracture but not cumulative use, and a potentially modest protective effect of efavirenz has been observed. Fracture Risk Assessment Tool scores underestimate fracture risk in PLWH with improved accuracy when HIV is considered a cause of secondary osteoporosis and bone mineral density (BMD) included.

CONCLUSION

Early consideration of risk, prompting evaluation of modifiable risk factors, frailty and falls risk with bone density imaging and prompt intervention may avert fracture in PLWH. Guidance on screening and lifestyle modification is available in international guidelines. Bisphosphonates are safe and effective in PLWH, with limited data for other agents.

Association between frailty phenotype, quantification of plasma HIV-1 RNA, CD4 cell count and HAART in HIV-positive subjects: a systematic review and meta-analysis of observational studies

HIV infection causes a constant activation of the immune system and contributes to an enhanced systemic pro-inflammatory cytokine milieu, which has been associated with premature aging and frailty. We performed a systematic review and meta-analysis to analyze whether the HIV-1 RNA load, CD4+ T-lymphocyte counts and exposure to HAART in HIV-positive subjects are associated with frailty phenotype. Searches were performed in PubMed, SCOPUS, Lilacs, Web of Science, Google Scholar, and OpenThesis databases. We used the odds ratio as a measure of the association. We used either a fixed or random-effects model to pool the results of individual studies depending on the presence of heterogeneity. Eleven studies were included in the review. Data from 8035 HIV-positive subjects were analyzed; 2413 of the subjects had viral load detectable, 981 had a CD4T-cell count <350 cells/μL, and 1342 had HAART exposure information. We found an association between frailty and CD4T-cell count <350 cells/μL (OR 2.68, CI 95% 1.68-4.26, I²= 46%), HIV-1 RNA load detectable (OR 1.71, CI 95% 1.38-2.12, I²= 0%), and protease inhibitor-containing HAART regimen (OR 2.21, CI 95% 1.26-3.89, I² = 0%). Further studies are necessary to evaluate the effects of other factors on the development of clinical features related to frailty.

Insights Into the Coinfections of Human Immunodeficiency Virus-Hepatitis B Virus, Human Immunodeficiency Virus-Hepatitis C Virus, and Hepatitis B Virus-Hepatitis C Virus: Prevalence, Risk Factors, Pathogenesis, Diagnosis, and Treatment

Human immunodeficiency virus, hepatitis B virus, and hepatitis C virus are three blood-borne viruses that can cause major global health issues by increasing severe morbidity. There is a high risk of coinfection with these viruses in individuals because of their same transmission routes through blood using shared needles, syringes, other injection equipment, sexual transmission, or even vertical transmission. Coinfection can cause various liver-related illnesses, non-hepatic organ dysfunction, followed by death compared to any of these single infections. The treatment of coinfected patients is complicated due to the side effects of antiviral medication, resulting in drug resistance, hepatotoxicity, and a lack of required responses. On the other hand, coinfected individuals must be treated with multiple drugs simultaneously, such as for HIV either along with HBV or HCV and HBV and HCV. Therefore, diagnosing, treating, and controlling dual infections with HIV, HBV, or HCV is complicated and needs further investigation. This review focuses on the current prevalence, risk factors, and pathogenesis of dual infections with HIV, HBV, and HCV. We also briefly overviewed the diagnosis and treatment of coinfections of these three blood-borne viruses.

Changes in trabecular bone score and bone mineral density in Chinese HIV-Infected individuals after one year of antiretroviral therapy

OBJECTIVE

Human immunodeficiency virus (HIV) infection and antiretroviral therapy (ART) have been associated with reduced bone mineral density (BMD) in persons with HIV (PWH). BMD provides information only about bone mineral quantity. Trabecular bone score (TBS) is a noninvasive tool that estimates bone microarchitecture. The aim of this study is to measure BMD and TBS of Chinese PWH after one-year ART.

METHODS

We designed a retrospective study of adult Chinese PWH. Patients with a dual-energy X-ray absorptiometry (DXA) scan prior to ART initiation, and again 48 weeks later were included. Information regarding demographic and clinical history, HIV treatment history, BMD and TBS were collected. We analyzed differences in BMD and TBS over 48 weeks and associations between key risk factors and changes in BMD and TBS.

RESULTS

Our study included 233 ​PWH (mean age ​= ​36.6 ​± ​11.1 years). Before ART initiation, 19.3% of PWH had normal BMD but abnormal TBS. Both BMD and TBS decreased after one-year ART. TDF and LPV/r-containing regimens were associated with greater declines in BMD at different site. Traditional risk factors such as old age, low BMI and female sex were associated with lower baseline TBS. Greater change in TBS over one year was associated with lower BMI and lower baseline CD4+ cell count, but unlike BMD measures, it was not correlated with treatment with TDF and LPV/r in our study population.

CONCLUSIONS

We present the first longitudinal analysis of change in TBS over 48 weeks compared with BMD among Asian PWH receiving ART. Before ART initiation, approximately 20% of PWH with impaired bone microarchitecture would not have been identified if DXA were used alone to assess for bone damage. Both BMD and TBS decreased after one-year ART. Change in TBS was not associated with different antiretroviral agents.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

The trabecular microarchitecture measured indirectly by TBS may provide clinicians additional information about bone damage in PWH.

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.

Bone Mineral Density in Antiretroviral Therapy-Naïve HIV-1-Infected Young Adult -Women Using Depot Medroxyprogesterone Acetate or Nonhormonal Contraceptives in Uganda

Most studies evaluating BMD in human immunodeficiency virus (HIV)‐infected populations have focused on antiretroviral therapy (ART)‐experienced patients. In this study, the association between HIV‐1 and/or depot medroxyprogesterone acetate (DMPA) and BMD among untreated HIV‐1–infected women in a resource‐limited setting was assessed before long‐term exposure to ART. The data were then compared with that of the 2005–2008 United States National Health and Nutrition Examination Survey data for non‐Hispanic White and Black women. Women aged 18–35 years, recruited from health facilities in Kampala, Uganda, were classified based on their combination of HIV‐1 status and DMPA use: (i) HIV‐1–infected current DMPA users, (ii) HIV‐1–infected previous DMPA users, (iii) HIV‐1–infected nonhormonal‐contraceptive users, and (iv) HIV‐uninfected nonhormonal‐contraceptive users. All HIV‐1–infected women reported being ART‐naïve at baseline. BMD was measured at the lumbar spine, total hip, and femoral neck using DXA. Multivariate linear regression was used to assess the association between HIV‐1 and/or DMPA and BMD Z‐scores. Baseline data were analyzed for 452 HIV‐1–infected (220 nonhormonal users, and 177 current and 55 previous DMPA users) and 69 HIV‐1–uninfected nonhormonal‐contraceptive users. The mean age was 26.1 years (SD, 4.2) with a median duration of DMPA use among current users of 24.0 months [medians (interquartile range), 12‐48]. A higher proportion of HIV‐1–infected previous (12.7%) or current DMPA users (20.3%) and nonhormonal users (15.0%) had low BMD (Z‐score ≤−2 at any of the three sites) compared with age‐matched HIV‐1–uninfected women (2.9%). HIV‐1 infection and DMPA use were independently associated with significantly lower mean BMD Z‐scores at all sites, with the greatest difference being among HIV‐1–infected current DMPA users (5.6%–8.0%) versus uninfected nonhormonal users. Compared with non‐Hispanic White and Black women, the Ugandan local reference population had generally lower mean BMD at all sites. Newer treatment interventions are needed to mitigate BMD loss in HIV‐1–infected women in resource‐limited settings. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

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.

Fractures in children and adolescents living with perinatally acquired HIV

BACKGROUND

Across numerous settings, bone mineral density for age and sex is lower in children/adolescents living with perinatally-acquired HIV (PHIV) compared to uninfected peers. We assessed incidences of any fracture/any long bone fracture, and osteoporosis prevalence in PHIV and HIV-exposed uninfected (PHEU) participants in the Pediatric HIV/AIDS Cohort Study (PHACS).

METHODOLOGY

Lifetime history of fracture events from birth up to age 20 years was obtained by chart review and/or interview, including age at fracture, mechanism, and bone(s) fractured. Poisson regression models were fit comparing fracture incidence by HIV status adjusted for age, sex, and race, with effect modification by age (<6, ≥6 yr).

RESULTS

PHIV (N = 412) were older (median 17.5 vs 16.7 yr) and more frequently reported black race (72% vs 61%) than PHEU children/adolescents (N = 206). 17% of PHIV and 12% of PHEU ever reported a fracture. Among children <6 yr, the adjusted incidence rate ratio of ≥1 fracture was higher (7.23; 95% CI 0.98, 53.51) in PHIV than PHEU, but similar among children/adolescents ≥6 years (1.20; 95% CI: 0.77, 1.87). Results were similar for long bone fracture. The most common fracture mechanisms were falling to the ground from a standing height (23.6% PHIV vs 8.8% PHEU) and sports injuries (21.3% vs 32.4%), and the most commonly fractured sites were the forearm and small bones of the wrist/hands. None of the children had osteoporosis.

CONCLUSIONS

Among children/adolescents ≥6 yr of age, fractures were similar by perinatal HIV status. Prospective, targeted collection of fracture history will be necessary to determine rates of fracture as PHIV and PHEU age into adulthood.

SUMMARY

Lifetime fracture history was collected in children/adolescents living with perinatally-acquired HIV (PHIV) and HIV-exposed uninfected (PHEU) children from birth up to age 20 years. Fracture incidence was higher in PHIV compared to PHEU among children <6 years old, but not among older children/adolescents.

People living with HIV and fracture risk

PLHIV have an increased risk of osteoporosis and fractures when compared with people of the same age and sex. In this review, we address the epidemiology and the pathophysiology of bone disease and fractures in PLHIV. The assessment of fracture risk and fracture prevention in these subjects is also discussed. The spectrum of HIV-associated disease has changed dramatically since the introduction of potent antiretroviral drugs. Today, the survival of people living with HIV (PLHIV) is close to that of the general population. However, the longer life-span in PLHIV is accompanied by an increased prevalence of chronic diseases. Detrimental effects on bone health are well recognised, with an increased risk of osteoporosis and fractures, including vertebral fractures, compared to the general population. The causes of bone disease in PLHIV are not fully understood, but include HIV-specific risk factors such as use of antiretrovirals and the presence of chronic inflammation, as well as traditional risk factors for fracture. Current guidelines recommend the use of FRAX to assess fracture probability in PLHIV age ≥ 40 years and measurement of bone mineral density in those at increased fracture risk. Vitamin D deficiency, if present, should be treated. Bisphosphonates have been shown to increase bone density in PLHIV although fracture outcomes are not available.

HCV co-infection among people living with HIV Is associated with Higher fracture risk

INTRODUCTION

The purpose of this study was to predict the 10-year risk of fracture among people living with HIV (PLWH) using FRAX™, and to determine the risk factors related to a high probability of fractures.

METHODOLOGY

This study consisted of 288 subjects aged 40 years and above. The ten-year probability of major osteoporotic fractures (MOF) and hip fractures was assessed using the FRAX™ algorithm with bone mineral density (BMD) data. A logistic regression was used to determine risk factors related to a high probability of major osteoporotic fracture and hip fracture.

RESULTS

The median 10-year probability of fracture was 3.7% (IQR 2.2-6.2) for MOF and 0.8% (IQR 0.3-2.5) for hip fractures. In addition to old age, previous fracture history, and low T-scores, HCV co-infection was associated with a higher risk of hip fractures in PLWH (AOR: 4.3, 95% CI: 1.29-14.33). Old age and low T-scores were also associated with a high probability of MOF.

CONCLUSIONS

HCV co-infection among PLWH is associated with a higher risk of hip fracture. Sustained efforts in terms of pharmacologic and non-pharmacologic interventions in PLWH are necessary to prevent osteoporotic fractures, especially in those with HCV co-infections.

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.

Human immunodeficiency virus infection (HIV)-associated rheumatic manifestations in thepre- and post-HAART eras

Rheumatic manifestations remain an important clinical manifestation associated to HIV. To date after 4 decades of the onset of the HIV/AIDS pandemic, almost 37 million individuals are living with the infection, including close to 2 million of newly infected individuals. The status, however, of a considerable proportion of HIV/AIDS patients has changed from a near fatal disorder secondary to opportunistic infections to a chronic disease in which renal cardiovascular, diabetes, malignancy, and autoimmune co-morbid disorders have become prevalent and relevant. In addition, the spectrum of rheumatic disorders also has changed since the introduction of HAART and its diagnosis and treatment represents a challenge. The purpose of this review is to define and discuss the HIV-related rheumatic manifestations in the pre- and post-HAART eras.

Alcohol and Bone Turnover Markers among People Living with HIV and Substance Use Disorder

BACKGROUND

Although unhealthy alcohol use and low bone density are prevalent among people living with HIV (PLWH), it is not clear whether alcohol use is associated with bone turnover markers (BTMs), and if so, at what quantity and frequency. The study objective was to examine the association between alcohol and BTMs in PLWH with substance use disorder.

METHODS

We studied a prospective cohort recruited from 2 HIV clinics who met criteria for DSM-IV substance dependence or reported ever injection drug use. Outcomes were BTM of (i) bone formation (serum procollagen type 1 N-terminal propeptide [P1NP]) and (ii) bone resorption (serum C-telopeptide type 1 collagen [CTx]). Alcohol consumption measures included (i) mean number of drinks/d (Timeline Follow-Back [TLFB]) (primary predictor), (ii) any alcohol use on ≥20 of the past 30 days, and phosphatidylethanol (PEth), a biomarker of recent alcohol consumption. Linear regression analysis examined associations between (i) each alcohol measure and each BTM and (ii) change in alcohol and change in BTM over 12 months.

RESULTS

Among 198 participants, baseline characteristics were as follows: The median age was 50 years; 38% were female; 93% were prescribed antiretroviral medications; 13% had ≥20 drinking days/month; mean drinks/day was 1.93 (SD 3.89); change in mean drinks/day was -0.42 (SD 4.18); mean P1NP was 73.1 ng/ml (SD 34.5); and mean CTx was 0.36 ng/ml (SD 0.34). Higher drinks/day was significantly associated with lower P1NP (slope -1.09 ng/ml; 95% confidence interval [CI] -1.94, -0.23, per each additional drink). On average, those who drank on ≥ 20 days/month had lower P1NP (-15.45 ng/ml; 95% CI: -26.23, -4.67) than those who did not. Similarly, PEth level ≥ 8ng/ml was associated with lower P1NP. An increase in drinks/d was associated with a decrease in P1NP nonsignificantly (-1.14; 95% CI: -2.40, +0.12; p = 0.08, per each additional drink). No significant associations were detected between either alcohol measure and CTx.

CONCLUSIONS

In this sample of PLWH with substance use disorder, greater alcohol consumption was associated with lower serum levels of bone formation markers.

Assessment of trabecular bone score, an index of bone microarchitecture, in HIV positive and HIV negative persons within the HIV UPBEAT cohort

Introduction

Increased prevalence of low bone mineral density (BMD) and increased fracture incidence are observed in persons living with HIV (PLWH). The trabecular bone score (TBS) is a novel index of bone microarchitecture which improves fracture prediction independent of BMD.

Methods

The HIV UPBEAT study is a single centre, prospective cohort study that enrolled subjects with and without HIV from similar sociodemographic backgrounds for annual assessments of bone health. TBS was derived from lumbar spine (LS) dual-energy X-ray absorptiometry images. Univariate and multivariable linear regression was used to assess relationships between baseline TBS, BMD, sociodemographic and clinical factors.

Results

463 subjects (201 HIV positive) were included; PLWH were younger and more likely male, of non-African ethnicity and current smokers. HIV was associated with a mean reduction of 0.037 [-0.060, -0.013] (p = 0.002) in TBS. Lower TBS was also associated with male gender, non-African ethnicity, current smoking status and lower LS BMD. HIV remained associated with lower TBS after adjustment for LS BMD, age, gender and ethnicity. However, adjustment for current smoking significantly attenuated the association between HIV and TBS, with further adjustment for higher bone turnover markers largely explaining any residual association. Among the sub-group of PLWH, exposure to protease inhibitors and lower nadir CD4+ T-cell counts were both predictors of lower TBS.

Conclusions

PLWH have lower TBS independent of LS BMD. However, this is largely explained by higher current smoking rates and higher bone turnover in those with HIV. Exposure to PI, but not tenofovir disproxil fumarate, also contributed to lower TBS in those with HIV.

Relationship Between Vertebral Fractures, Bone Mineral Density, and Osteometabolic Profile in HIV and Hepatitis B and C-Infected Patients Treated With ART

Objective: The purpose of our study was to evaluate the alterations of bone metabolism and the prevalence of vertebral fractures in the population with HIV and hepatitis B and C seropositivity in treatment with antiretroviral drugs (HAART). Methods: We selected 83 patients with diagnosis of HIV, HBV, HCV infection. In all these patients biochemical examinations of phospho-calcium metabolism and a densitometry of lumbar spine were performed. We also evaluated lateral spine X-rays in order to analyze the presence of vertebral deformities and to define their severity. As a control group we analyzed the prevalence of vertebral fractures in a group of 40 non-infectious patients. Results: We selected 82 seropositive patients, 46 males and 37 females, with a median age of 55 ± 10 years. Out of these patients, 55 were infected by HIV, 12 were infected by HBV, 11 presented HIV and HCV co-infection and 4 were HCV+. The prevalence of hypovitaminosis D in the studied population was 53%, while the prevalence of osteoporosis and osteopenia was 14 and 48%, respectively. The average T-score in the fractured population was -1.9 SD. The viral load and the CD4+ cell count were respectively, directly, and inversely correlated with the number and severity of vertebral fractures. Antiretroviral therapy regimen containing TDF and PI was a significant determinant of the presence of vertebral deformities. The use of these drugs was also associated with lower levels of vitamin D and higher bone turnover levels compared to other antiretroviral drugs. Conclusions: HIV patients suffer from bone fragility, particularly at spine, independently by the level of bone mineral density. In this population, the T-score threshold for the risk of fracture is higher than that usually used in general population. For this reason, it would be indicated to perform an X-ray of the spine in order to detect vertebral deformities even in patients with a normal or slighlty reduced bone mineral density.

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.

Human Immunodeficiency Virus Infection: Spectrum of Rheumatic Manifestations

Emerging and reemerging viral infections have been a characteristic feature of the past several decades, with HIV infection being the most important example of an emergent viral infection. To date, the status of a considerable proportion of HIV/AIDS patients has changed from a near-fatal disorder secondary to opportunistic infections to a chronic disease in which a variety of co-morbid conditions have become prevalent and relevant. Arthralgia and myalgias are the most common symptoms. The rate of spondyloarthritis varies according to the geographic area, genetic and mode of transmission. Most RA and SLE patients might go into remission after the development of AIDS, but also there are patients that continue with active disease. Prevalence of DILS is highest among African Americans in less advanced stages. PAN is clinically less aggressive and peripheral neuropathy is the most common clinical manifestation. Anti-phospholipid syndrome (APS), systemic sclerosis and poly-dermatomyositis are uncommon. After the introduction of combination antiretroviral therapy (cART), a decline of spondyloarthritis disorders and of DILS and development of new syndromes such as IRIS, osteoporosis and avascular bone necrosis have occurred. The treatment of patients with rheumatic diseases and HIV infection remains a challenge.

The Hidden Burden of Fractures in People Living With HIV

The survival of people living with human immunodeficiency virus (HIV) has increased markedly since the advent of antiretroviral therapy (ART). However, other morbidities have emerged, including osteoporosis. The estimated incidence of fractures at any site in people living with HIV ranges from 0.1 per 1000 person‐years to 8.4 per 1000 person‐years: at least twice that of people without HIV. This increased risk seems to be related to HIV itself and its treatment. Risk factors for bone disease in HIV‐positive (HIV⁺) subjects include both classical risk factors for osteoporosis and fracture and factors linked to HIV itself, such as inflammation, reconstitution syndrome, low CD4, ART, and co‐infection with hepatitis B and C viruses. The risk of fractures in these individuals can be at least partially assessed by measurement of BMD and the Fracture Risk Assessment Tool (FRAX™). Only alendronate and zoledronic acid have been studied in HIV⁺ individuals; both show beneficial effects on BMD, although data on fracture reduction are not available. © 2018 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

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.

HIV and Vertebral Fractures: a Systematic Review and Metanalysis

The survival of HIV-infected patients has increased with the advent of antiretroviral therapy with the emergence of new comorbidities. Vertebral fracture is a manifestation of reduced bone strength and osteoporosis. This study aims to assess the frequency of spine fractures in HIV-positive men and women aged over 18 years. We performed a systematic review of randomized controlled trials, cohort studies, cross-sectional studies, and case-control studies. Studies that evaluated morphometric and/or clinical vertebral fracture were included. In total 488 studies were found, of which 53 had their full texts evaluated. A total of 85,411 HIV positive individuals were identified in 26 studies. The meta-analysis of the prevalence of vertebral fractures included 12 studies with 10,593 subjects. The prevalence was 11.1% [95% confidence interval (95% CI) 4.5%, 25.0%, I² 98.2% p < 0.00001]. When we evaluated independently studies of clinical vertebral fracture and morphometric vertebral fracture, the prevalence was 3.9% (95% CI 0.9, 15.8, I² 96.4% p < 0.00001) and 20.2% (95% CI 15.7%, 25.6%, I² 69.9% p = 0.003) respectively. HIV-infected individuals had an odds ratio of vertebral fractures of 2.3 (95% CI 1.37, 3.85, I² 98.2% p < 0.00001) when compared with HIV-uninfected patients (n = 9 studies). In conclusion, HIV-positive subjects had a higher risk of vertebral fractures when compared with HIV-negative subjects.

Mexican patients with HIV have a high prevalence of vertebral fractures

Low bone mineral density (BMD) and fragility fractures are common in individuals infected with HIV, who are undergoing antiretroviral therapy (ART). In high-income countries, dual energy X-ray absorptiometrry is typically used to evaluate osteopenia or osteoporosis in HIV infected individuals. However, this technology is unavailable in low andmiddle income countries, so a different approach is needed. The aim of this study was to use X-ray scans of the spine to determine the prevalence of and associated risk factors for vertebral fractures in HIVinfected patients in a tertiary-care hospital in Mexico. We conducted a cross-sectional study of outpatients who were >40 years old and receiving ART at the Hospital de Infectología, La Raza National Medical Center in Mexico City, Mexico. We used semi-quantitative morphometric analysis of centrally digitized X-ray images to assess vertebral deformities in the spine. Anterior, middle and posterior vertebral heights were measured, and height ratios were calculated. For each vertebral body, fractures were graded on the basis of height ratio reductions, and a spine deformity index’ (SDI) value was calculated by summing the grades of the vertebral deformities: An SDI>1 was indicative of a vertebral fracture. We included 104 patients, 87% of whom were men. The median age was 49 years [interquartile range (IQR) 42-52]. The most common stage of HIV infection, as defined by the Centers for Disease Control, was B2 in 40 (39%) of patients. Forty seven (45%) patients were on ART regimens that included protease inhibitors (PIs) and 100 (96%) being treated with tenofovir. The median time of ART was 6.5 years (IQR 1.6-9.0). Of the 104 patients in our study, 83 (80%) had undetectable viral load, as assessed by HIV-1 RNA levels, 32 (31%) showed evidence of a previous fracture, 4 (4%) were co-infected with hepatitis C virus, and 57 (55%) had a history of corticosteroid treatment. The prevalence of vertebral fractures was 25%, 95% confidence interval 17-34%. We assessed whether gender, HCV co-infection, previous corticosteroid use, AIDS, total HIV viral load, and current and previous use of PIs were associated with fractures in our study group, but we did not observe a significant association between any of these factors and vertebral fractures. The prevalence of vertebral fractures was high among HIV-infected patients. We propose that screening for bone disease should be performed in HIV individuals who are at risk of fragility fractures. Furthermore, we suggest that X-ray based assessment of the spine should be considered in patients who are at increased risk of fragility fractures, irrespective of BMD levels, particularly in elderly patients in low and middle income countries.

Vitamin D Status and the Relationship with Bone Fragility Fractures in HIV-Infected Patients: A Case Control Study

HIV-infected patients show high risk of fracture. The aims of our study were to determine the prevalence of vertebral fractures (VFs) and their associations with vitamin D in HIV patients. 100 patients with HIV infection and 100 healthy age- and sex-matched controls were studied. Bone mineral density was measured by quantitative ultrasound at the non-dominant heel. Serum osteocalcin and C-terminal telopeptide of collagen type 1 served as bone turnover markers. Bone ultrasound measurements were significantly lower in patients compared with controls (Stiffness Index (SI): 80.58 ± 19.95% vs. 93.80 ± 7.10%, respectively, p < 0.001). VFs were found in 16 patients and in 2 controls. HIV patients with vertebral fractures showed lower stiffness index (SI) (70.75 ± 10.63 vs. 83.36 ± 16.19, respectively, p = 0.045) and lower vitamin D levels (16.20 ± 5.62 vs. 28.14 ± 11.94, respectively, p < 0.02). The majority of VFs (87.5%) were observed in HIV-infected patients with vitamin D insufficiency, and regression analysis showed that vitamin D insufficiency was significantly associated with vertebral fractures (OR 9.15; 95% CI 0.18–0.52, p < 0.04). VFs and are a frequent occurrence in HIV-infected patients and may be associated with vitamin D insufficiency.

Insulin Resistance in HIV-Patients: Causes and Consequences

Here we review how immune activation and insulin resistance contribute to the metabolic alterations observed in HIV-infected patients, and how these alterations increase the risk of developing CVD. The introduction and evolution of antiretroviral drugs over the past 25 years has completely changed the clinical prognosis of HIV-infected patients. The deaths of these individuals are now related to atherosclerotic CVDs, rather than from the viral infection itself. However, HIV infection, cART, and intestinal microbiota are associated with immune activation and insulin resistance, which can lead to the development of a variety of diseases and disorders, especially with regards to CVDs. The increase in LPS and proinflammatory cytokines circulating levels and intracellular mechanisms activate serine kinases, resulting in insulin receptor substrate-1 (IRS-1) serine phosphorylation and consequently a down regulation in insulin signaling. While lifestyle modifications and pharmaceutical interventions can be employed to treat these altered metabolic functions, the mechanisms involved in the development of these chronic complications remain largely unresolved. The elucidation and understanding of these mechanisms will give rise to new classes of drugs that will further improve the quality of life of HIV-infected patients, over the age of 50.

Protecting bone in long-term HIV positive patients receiving antiretrovirals

INTRODUCTION

As the population of people living with HIV ages, the increase in non-AIDs morbidities is expected to increase in parallel. Maintaining bone health in those with HIV will be an important area of focus for the HIV clinician to prevent the morbidity and mortality associated with fragility fractures, the principal clinical sequela of low bone mineral density (BMD). Rates of fractures and prevalence of low bone mineral density, a risk factor for future fragility fractures, are already increased in the HIV positive population.

AREAS COVERED

This review examines the strategies to maintain bone health in those living with HIV from screening through to managing those with established low BMD or fracture, including the role for choice of or modification of antiretroviral therapy to maintain bone health. Expert commentary: The increasing complexity of managing bone health in the age of succesful antiretroviral therapy and an aging patient population as well as future perspectives which may help achieve the long term aim of minimising the impact of low BMD in those with HIV are discussed and explored.

Fracture Prediction With Modified-FRAX in Older HIV-Infected and Uninfected Men

BACKGROUND

FRAX is a validated, computer-based clinical fracture risk calculator that estimates the 10-year risk of major osteoporotic (clinical spine, forearm, hip, or shoulder) fracture, and hip fracture alone. It is widely used for decision making in fracture prevention, but it may underestimate the risk in HIV-infected individuals. Some experts recommend considering HIV as a cause of secondary osteoporosis when calculating FRAX in HIV-infected individuals.

METHODS

From the Veterans Aging Cohort Study Virtual Cohort, we included 24,451 HIV-infected and uninfected men aged 50-70 years with complete data in the year 2000 to approximate all but 2 factors (ie, history of secondary osteoporosis and parental hip fracture) for modified-FRAX calculation without bone density and 10-year observational data for incident fragility fracture. The accuracy of the modified-FRAX calculation was compared by the observed/estimated (O/E) ratios of fracture by HIV status.

RESULTS

The accuracy of modified-FRAX was less for HIV-infected [O/E = 1.62, 95% confidence interval (CI) 1.45 to 1.81] than uninfected men (O/E = 1.29, 95% CI: 1.19 to 1.40), but improved when HIV was included as a cause of secondary osteoporosis (O/E = 1.20, 95% CI: 1.08 to 1.34). However, only 3%-6% of men with incident fractures were correctly identified by the modified-FRAX using accepted FRAX thresholds for pharmacologic therapy.

CONCLUSIONS

Modified-FRAX underestimated the fracture rates more in older HIV-infected than in otherwise similar uninfected men. The accuracy improved when HIV was included as a cause of secondary osteoporosis, but it still performed poorly for case finding. Further studies are necessary to determine how to use FRAX or define an HIV-specific index to risk stratify for screening and treatment in older HIV-infected individuals.

Lifetime and recent alcohol use and bone mineral density in adults with HIV infection and substance dependence

Low bone mineral density (BMD) is common in people living with HIV infection (PLWH), increasing fracture risk. Alcohol use is also common in PLWH and is a modifiable risk factor for both HIV disease progression and low BMD. In PLWH, alcohol's effect on BMD is not well understood.We studied adult PLWH with substance dependence. We measured lifetime alcohol use (kg) and recent (i.e., past 30-day) alcohol use (categorized as: abstinent, low risk, or high risk). In adjusted multivariable regression analyses, we tested associations between lifetime and recent alcohol use and (i) mean BMD (g/cm) at the femoral neck, total hip, and lumbar spine and (ii) low BMD diagnosis (i.e., osteopenia or osteoporosis). We also examined associations between 2 measures of past alcohol use (i.e., total consumption [kg] and drinking intensity [kg/year]) and BMD outcome measures during 3 periods of the HIV care continuum: (i) period before first positive HIV test, (ii) period from first positive HIV test to antiretroviral therapy (ART) initiation, and (iii) period following ART initiation.We found no significant associations between lifetime alcohol use and mean femoral neck (β -0.000, P = .62), total hip (β -0.000, P = .83) or lumbar spine (β 0.001, P = .65) BMD (g/cm), or low BMD diagnosis (adjusted odds ratio [aOR] = 0.98, 95% Confidence Interval [CI]: 0.95-1.01). There was no significant correlation between past 30-day alcohol use and mean BMD (g/cm). Past 30-day alcohol use was associated with low BMD diagnosis (P = .04); compared to abstainers, the aOR for high risk alcohol use was 1.94 (95% CI: 0.91-4.12), the aOR for low risk alcohol use was 4.32 (95% CI: 1.30-14.33). Drinking intensity (kg/year) between first positive HIV test and ART initiation was associated with lower mean BMD (g/cm) at the femoral neck (β -0.006, P = .04) and total hip (β -0.007, P = .02) and increased odds of low BMD (aOR = 1.18, 95% CI = 1.03-1.36).In this sample of PLWH, we detected no association between lifetime alcohol use and BMD. However, recent drinking was associated with low BMD diagnosis, as was drinking intensity between first positive HIV test and ART initiation. Longitudinal studies should confirm these associations.

Bone health in HIV and hepatitis B or C infections

Chronic infections with human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) add to age-dependent bone loss and may contribute to lower bone strength in the elderly. In this review, we report recent highlights on the epidemiology of bone fragility in chronic viral infections with HIV, HCV and HBV, its physiopathology and discuss the interference of antiviral therapies with bone metabolism. Chronic infections influence bone through the interactions between risk factors for bone fragility and falls (which are highly prevalent in infected patients), virus activity and antiviral drugs. HIV-infected patients are at increased risk of fracture and the risk is higher in cases of co-infection with HIV and untreated chronic viral hepatitis. In HIV patients, the majority of bone loss occurs during virus activity and at initiation of antiretroviral therapy (ART). However, long-term elderly HIV-infected patients on successful ART display bone microstructure alterations only partially captured by dual energy X-ray absorptiometry (DXA). Bone loss is associated with an increase of bone resorption, reflecting the upregulation of the receptor activator of nuclear factor-kappaB ligand (RANKL) and osteoprotegerin (OPG) pathways via a crosstalk between virus activity, inflammation and the immune system. The use of some antiviral drugs, such as tenofovir (controlling both HBV and HIV infections) or protease inhibitors, may be associated with higher bone toxicity. The reduction of tenofovir plasma concentrations with the implementation of tenofovir alafenamide (TAF) attenuates bone mineral density (BMD) loss but it remains unknown whether it will contribute to reducing fracture risk in long-term HIV-treated patients. Moreover, to what extent the new direct-acting agents for treatment of HCV, including nucleotide inhibitors and protease inhibitors, may affect bone health similarly as ART in HIV should be investigated.

Does systemic inflammation and immune activation contribute to fracture risk in HIV?

PURPOSE OF REVIEW

There is increasing evidence pointing toward an important role of heightened immune activation and inflammation in people living with HIV contributing to the development of non-AIDS comorbidities. This review aims to explore low bone mineral density (BMD) in HIV with a focus on the underlying mechanisms and relationships between the immune and skeletal systems.

RECENT FINDINGS

Baseline immune activation and inflammation negatively impact BMD at antiretroviral therapy (ART) initiation. B- and T-cell alterations in HIV lead to an imbalance in the osteoblastic osteoprotegerin (OPG) and osteoclastic receptor activator of NF-κB ligand (RANKL) cytokines which favours osteoclastogenesis and bone resorption. These findings suggest an important role for immune-mediated mechanisms in the pathogenesis of low BMD in HIV.

SUMMARY

Bone homeostasis is in part regulated by cells of the immune system through complex interactions with the RANK/RANKL/OPG axis. Disturbances in the normal functioning of T, B cells, and monocytes in HIV and the resulting proinflammatory state may contribute to dysregulation of this finely controlled balance leading to increased bone loss. Pre-ART levels of immune activation and inflammation have a consistently negative effect on BMD and further suggest the immunocentric basis of bone loss in HIV alongside supporting the benefits of earlier ART initiation. Further longitudinal studies will help determine the effect this will have on fracture risk in people living with HIV.

HIV and Bone Complications: Understudied Populations and New Management Strategies

The higher risk of osteoporosis and fracture associated with HIV infection and certain antiretrovirals has been well established and the need for risk stratification among older adults increasingly recognized. This review focuses upon emerging data on bone complications with HIV/HCV coinfection, in children and adolescents, and with pre-exposure prophylaxis (PrEP), as well as new management strategies to minimize the negative effects of ART on bone.

Ageing and inflammation in patients with HIV infection

Nowadays, HIV⁺ patients have an expected lifespan that is only slightly shorter than healthy individuals. For this reason, along with the fact that infection can be acquired at a relatively advanced age, the effects of ageing on HIV⁺ people have begun to be evident. Successful anti-viral treatment is, on one hand, responsible for the development of side effects related to drug toxicity; on the other hand, it is not able to inhibit the onset of several complications caused by persistent immune activation and chronic inflammation. Therefore, patients with a relatively advanced age, i.e. aged more than 50 years, can experience pathologies that affect much older citizens. HIV⁺ individuals with non-AIDS-related complications can thus come to the attention of clinicians because of the presence of neurocognitive disorders, cardiovascular diseases, metabolic syndrome, bone abnormalities and non-HIV-associated cancers. Chronic inflammation and immune activation, observed typically in elderly people and defined as 'inflammaging', can be present in HIV⁺ patients who experience a type of premature ageing, which affects the quality of life significantly. This relatively new condition is extremely complex, and important factors have been identified as well as the traditional behavioural risk factors, e.g. the toxicity of anti-retroviral treatments and the above-mentioned chronic inflammation leading to a functional decline and a vulnerability to injury or pathologies. Here, we discuss the role of inflammation and immune activation on the most important non-AIDS-related complications of chronic HIV infection, and the contribution of aging per se to this scenario.

Falls among middle-aged women in the Women's Interagency HIV Study

BACKGROUND

To determine the frequency and risk factors for falls among middle-aged HIV+ and HIV- women in the Women's Interagency HIV Study (WIHS).

METHODS

We quantified self-report of any and multiple (≥2) falls in the prior 6 months among 1,412 HIV+ and 650 HIV- women with mean age 48 years. Logistic regression was used to evaluate associations of demographics, behavioural factors, comorbid conditions and medications with odds of any fall (versus none) and multiple falls (versus ≤1 fall).

RESULTS

At least one fall was reported in 263 HIV+ (19%) versus 119 HIV- (18%) women, and ≥2 falls reported in 133 HIV+ (9%) versus 65 HIV- (10%) women. HIV infection was not associated with falls in multivariate analyses. Factors independently associated with any fall included age (adjusted odds ratio [aOR] 1.71, 95% CI 1.17, 2.49 age 50-59 versus <39 years; aOR 2.26, 95% CI 1.38, 3.71 age ≥60 versus <39), current marijuana use (aOR 2.19, 95% CI 1.53, 3.13) depressive symptoms (aOR 1.57, 95% CI 1.21, 2.05 for Center for Epidemiology Studies Depression score ≥16), subjective cognitive complaints (aOR 2.19, 95% CI 1.56, 3.08), neuropathy (aOR 1.59, 95% CI 1.19, 2.13), obesity (aOR 1.39, 95% CI 1.08, 1.80), number of central nervous system active agents (aOR 2.98, 95% CI 1.90, 4.68 for ≥3 agents versus 0) and WIHS site. Factors associated with ≥2 falls included age, marijuana use, number of central nervous system active agents, subjective cognitive complaints, depressive symptoms, neuropathy and study site.

CONCLUSIONS

Falls were associated with factors affecting cognition, but not HIV status in this large cohort of women. Longitudinal studies are needed to determine the incidence and consequences of falls by HIV status as women age.

Learning from the experiences of people with HIV using general practitioner services in London: a qualitative study

Aim To explore the experiences of people with HIV (PWHIV) using general practitioner (GP) services in order to identify barriers to use.

BACKGROUND

Traditionally, GPs have little involvement in the care of PWHIV. However, as HIV becomes a chronic condition and the population of PWHIV ages, there is a need to increase this involvement. Despite high levels of GP registration, the majority of PWHIV in London report that their GP is not involved in their HIV care.

METHODS

This paper presents qualitative findings from a mixed method study of PWHIV's experiences of clinical services. Survey respondents were purposively sampled to recruit 51 PWHIV who took part in eight focus groups. Participants were asked about their experience of using GP services. Findings Three factors emerged which mediated experiences of GP care. Competence: respondents were concerned about the potential for misdiagnosis of symptoms, lack of awareness of the health needs of PWHIV and experiences of prescribing, which could lead to drug interactions. Continuity: not being able to get appointments quickly enough, not being able to see the same doctor twice and not being able to keep the same GP when one changed address were experienced as impediments to use. Communication: lack of communication between GPs and HIV specialists led to what participants called 'patient ping-pong' where they found themselves acting as a go-between for different clinical specialists trying to make sense of their care.

CONCLUSION

Meaningful contact between HIV specialists and GPs is likely to allay concerns about competency as treatment and care decisions can be taken collaboratively between the GP, HIV specialist and patient. A key component of acceptable GP care for PWHIV is likely to be the application of long-term condition management approaches, which includes empowered patient self-management.

Perspectives on menopause and women with HIV

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

Epidemiology of Vertebral Fractures

Vertebral fractures are one of the most common fractures associated with skeletal fragility and can cause as much morbidity as hip fractures. However, the epidemiology of vertebral fractures differs from that of osteoporotic fractures at other skeletal sites in important ways, largely because only one quarter to one-third of vertebral fractures are recognized clinically at the time of their occurrence and otherwise require lateral spine imaging to be recognized. This article first reviews the prevalence and incidence of clinical and radiographic vertebral fractures in populations across the globe and secular trends in the incidence of vertebral fracture over time. Next, associations of vertebral fractures with measures of bone mineral density and bone microarchitecture are reviewed followed by associations of vertebral fracture with various textural measures of trabecular bone, including trabecular bone score. Finally, the article reviews clinical risk factors for vertebral fracture and the association of vertebral fractures with morbidity, mortality, and other subsequent adverse health outcomes.

Increased Fracture Incidence in Middle-Aged HIV-Infected and HIV-Uninfected Women: Updated Results From the Women's Interagency HIV Study

BACKGROUND

We previously reported that fracture incidence rates did not differ by HIV status among predominantly premenopausal Women's Interagency HIV Study participants. We now conduct a follow-up study with 5 additional observation years to further characterize fracture risk associated with HIV infection in women as they age.

METHODS

We measured time to first new fracture at any site in 2375 (1713 HIV-infected and 662 HIV-uninfected) Women's Interagency HIV Study participants, with median 10-year follow-up. Fractures were self-reported semiannually. Proportional hazards models assessed predictors of incident fracture.

RESULTS

At index visit, HIV-infected women were older [median age of 40 years (IQR: 34-46) vs. 35 (27-43), P < 0.0001] and more likely to be postmenopausal, hepatitis C virus infected, and weigh less than HIV-uninfected women. Among HIV-infected women, mean CD4 count was 480 cells per microliter and 63% were taking highly active antiretroviral therapy. Unadjusted incidence rates of any fracture were higher in HIV-infected than in HIV-uninfected women [2.19/100 person-years (py) vs. 1.54/100 py, P = 0.002]. In multivariate models, HIV status, older age, white (vs. black) race, prior fracture, history of cocaine use, and history of injection drug use were significant predictors of incident fracture. Among HIV-infected women, age, white race, prior fracture, smoking, and prior AIDS were predictors of new fracture.

CONCLUSIONS

Middle-aged HIV-infected women had a higher adjusted fracture rate than HIV-uninfected women. Cocaine use and injection drug use were also associated with a greater risk of incident fracture. Further research is needed to understand whether the risk of fracture associated with cocaine use relates to increased rate of falls or direct effects on bone metabolism.

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

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

Hepatitis C

Hepatitis C virus (HCV) infection is a major health problem worldwide. The effects of chronic infection include cirrhosis, end-stage liver disease, and hepatocellular carcinoma. As a result of shared routes of transmission, co-infection with HIV is a substantial problem, and individuals infected with both viruses have poorer outcomes than do peers infected with one virus. No effective vaccine exists, although persistent HCV infection is potentially curable. The standard of care has been subcutaneous interferon alfa and oral ribavirin for 24-72 weeks. This treatment results in a sustained virological response in around 50% of individuals, and is complicated by clinically significant adverse events. In the past 10 years, advances in HCV cell culture have enabled an improved understanding of HCV virology, which has led to development of many new direct-acting antiviral drugs that target key components of virus replication. These direct-acting drugs allow for simplified and shortened treatments for HCV that can be given as oral regimens with increased tolerability and efficacy than interferon and ribavirin. Remaining obstacles include access to appropriate care and treatment, and development of a vaccine.

Skeletal health in adults with HIV infection

Concern has been raised that HIV infection, its treatment, or both adversely affect skeletal health. Cross-sectional studies show that bone mineral density (BMD) is 3-5% lower in patients infected with HIV than in uninfected controls, but patients with HIV infection are, on average, 5 kg lighter than uninfected people. After this weight difference is accounted for, BMD differences are smaller and not clinically relevant. Longitudinal studies show short-term BMD loss of 2-4% over 1-2 years when antiretroviral therapy is started, followed by longer periods of BMD increase or stability. Losses are greatest with treatment regimens that contain tenofovir. Patients infected with HIV have slightly higher fracture rates than controls, but the increased risk of fracture is substantially attenuated by adjustment for traditional risk factors for fracture. These reassuring findings suggest that management of skeletal health in HIV should follow guidelines for the general population. In general, effective antiretroviral treatment and avoidance of undernutrition are the two most important factors for maintenance of skeletal health in patients infected with HIV.

Current and future treatments of secondary osteoporosis

Osteoporosis is commonly associated with menopause and ageing. It can, however, also be caused by diseases, lifestyle, genetic diseases, drug therapies and other therapeutic interventions. In cases of secondary osteoporosis, a common rule is the management of the underlying condition. Healthy habits and calcium and vitamin D supplementation are also generally advised. In cases of high risk of fracture, specific antiosteoporosis medications should be prescribed. For most conditions, the available evidence is limited. Special attention should be paid to possible contraindications of drugs used for the treatment of postmenopausal or senile osteoporosis. Bisphosphonates are the most widely used drugs in secondary osteoporosis, and denosumab or teriparatide have been also assessed in some cases. Important research is needed to develop more tailored strategies, specific to the peculiarities of the different types of secondary osteoporosis.

Dysregulated B cell expression of RANKL and OPG correlates with loss of bone mineral density in HIV infection

HIV infection is associated with high rates of osteopenia and osteoporosis, but the mechanisms involved are unclear. We recently reported that bone loss in the HIV transgenic rat model was associated with upregulation of B cell expression of the key osteoclastogenic cytokine receptor-activator of NF-κB ligand (RANKL), compounded by a simultaneous decline in expression of its physiological moderator, osteoprotegerin (OPG). To clinically translate these findings we performed cross-sectional immuno-skeletal profiling of HIV-uninfected and antiretroviral therapy-naïve HIV-infected individuals. Bone resorption and osteopenia were significantly higher in HIV-infected individuals. B cell expression of RANKL was significantly increased, while B cell expression of OPG was significantly diminished, conditions favoring osteoclastic bone resorption. The B cell RANKL/OPG ratio correlated significantly with total hip and femoral neck bone mineral density (BMD), T- and/or Z-scores in HIV infected subjects, but revealed no association at the lumbar spine. B cell subset analyses revealed significant HIV-related increases in RANKL-expressing naïve, resting memory and exhausted tissue-like memory B cells. By contrast, the net B cell OPG decrease in HIV-infected individuals resulted from a significant decline in resting memory B cells, a population containing a high frequency of OPG-expressing cells, concurrent with a significant increase in exhausted tissue-like memory B cells, a population with a lower frequency of OPG-expressing cells. These data validate our pre-clinical findings of an immuno-centric mechanism for accelerated HIV-induced bone loss, aligned with B cell dysfunction.

HIV infection causes significant bone loss and skeletal deterioration, leading to fractures that are often devastating and incur significant financial burden on patients and their families. HIV-infected individuals have up to a five-fold higher risk of bone fractures, and the increasing average age of people living with HIV/AIDS has triggered fears of an impending epidemic of bone fractures in this population. Antiretroviral therapy, used to manage HIV infection, fails to prevent, but rather paradoxically accelerates skeletal decline. The underlying mechanisms of HIV-induced bone loss are poorly understood. The aim of this study was to clarify the mechanisms of bone loss in HIV-infected patients, in an effort to better understand how bone loss and fractures occur, and consequently how it can be prevented in this population. The cytokine RANKL (Receptor Activator of Nuclear Factor kappa-B Ligand) helps induce bone loss. We show that RANKL expression was increased in immune cells in HIV-infected individuals. Another cytokine, osteoprotegerin (OPG), counteracts the activity of RANKL, and therefor helps prevent bone loss. OPG expression by the same immune cells was decreased in HIV-infected individuals. We conclude that disrupted immune cell expression of RANKL and OPG in HIV-infected patients contributes to bone loss.

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

OBJECTIVE

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

DESIGN

A systematic review and meta-analysis.

METHODS

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

RESULTS

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

CONCLUSION

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

The effect of HIV-hepatitis C co-infection on bone mineral density and fracture: a meta-analysis

OBJECTIVE

There is a variable body of evidence on adverse bone outcomes in HIV patients co-infected with hepatitis C virus (HCV). We examined the association of HIV/HCV co-infection on osteoporosis or osteopenia (reduced bone mineral density; BMD) and fracture.

DESIGN

Systematic review and random effects meta-analyses.

METHODS

A systematic literature search was conducted for articles published in English up to 1 April 2013. All studies reporting either BMD (g/cm2, or as a T-score) or incident fractures in HIV/HCV co-infected patients compared to either HIV mono-infected or HIV/HCV uninfected/seronegative controls were included. Random effects meta-analyses estimated the pooled odds ratio (OR) and the relative risk (RR) and associated 95% confidence intervals (CI).

RESULTS

Thirteen eligible publications (BMD N = 6; Fracture = 7) of 2,064 identified were included with a total of 427,352 subjects. No publications reported data on HCV mono-infected controls. Meta-analysis of cross-sectional studies confirmed that low bone mineral density was increasingly prevalent among co-infected patients compared to HIV mono-infected controls (pooled OR 1.98, 95% CI 1.18, 3.31) but not those uninfected (pooled OR 1.47, 95% CI 0.78, 2.78). Significant association between co-infection and fracture was found compared to HIV mono-infected from cohort and case-control studies (pooled RR 1.57, 95% CI 1.33, 1.86) and compared to HIV/HCV uninfected from cohort (pooled RR 2.46, 95% CI 1.03, 3.88) and cross-sectional studies (pooled OR 2.30, 95% CI 2.09, 2.23).

CONCLUSIONS

The associations of co-infection with prevalent low BMD and risk of fracture are confirmed in this meta-analysis. Although the mechanisms of HIV/HCV co-infection's effect on BMD and fracture are not well understood, there is evidence to suggest that adverse outcomes among HIV/HCV co-infected patients are substantial.

HIV infection, bone metabolism, and fractures

With the advent of high active antiretroviral therapy there was a significant improvement on HIV subjects survival. Thus, bone changes related to HIV became an important aspect of these individuals. HIV affects bone remodeling causing bone fragility. In addition, antiretroviral therapy may also negatively affect bone metabolism. Several studies describe an increased incidence of fractures in these patients when compared with controls without the disease. The European Society of AIDS (EACS), and other societies, have included guidance on management of osteoporosis in HIV-infected patients emphasizing the identification of patients with low bone mass. Supplementation of calcium and vitamin D and the use of alendronate in these individuals should be recommended on a case base.

Osteoporosis in Human Immunodeficiency Virus Patients - An Emerging Clinical Concern

The advent of highly active anti-retroviral therapy (HAART) has significantly improved the survival of human immunodeficiency virus (HIV)-infected patients transforming the HIV infection from a fatal illness into a manageable chronic disease. As the number of older HIV-infected individuals increases, several ageing-related co-morbidities including osteopenia/osteoporosis and fractures have emerged. Patients exposed to HIV infection and its treatment may develop fragility fractures with potential significant impact on quality of life and survival. However, the awareness of HIV-related skeletal fragility is still relatively low and most HIV-infected patients are not investigated for osteoporosis and treated with anti-osteoporotic drugs in daily clinical practice. This article reviews the literature data on osteoporosis and osteopenia in HIV infection, focusing on the pathophysiological, clinical and therapeutic aspects of fragility fractures.

Comparative risk of fracture in men and women with HIV

CONTEXT

Men and women with HIV have an increased risk of fracture compared with individuals without HIV; however, it is unknown if women with HIV fracture at higher rates than men.

OBJECTIVE

We aimed to compare the incidence rates (IR) of fractures between men and women with HIV.

DESIGN

The study was designed as a cohort study, examining medical records from November 2001 to August 2012.

SETTING

The study was performed using records from two tertiary-care hospitals in Boston, Massachusetts.

PATIENTS

The study patients were adults with HIV: this was defined by diagnosis codes for HIV on two visits, at least one prescription for antiretroviral therapy, and at least 18 years of age.

INTERVENTION

IRs per 1000 person-years of all fractures and fractures at osteoporotic sites were calculated. We calculated IRs within age and gender strata and estimated IR ratios (IRR) between men and women.

MAIN OUTCOME MEASURE

The main outcome measure was fracture at any site.

RESULTS

We identified a cohort of 3161 HIV-infected patients (869 women and 2292 men) with a total of 587 fractures. The IRR of all fractures was 1.00 (95% confidence interval [CI] 0.83-1.19) between men and women. The IR of fractures at osteoporotic sites among men was 15.2 (95% CI 12.7-17.6) per 1000 person-years compared with 12.1 (95% CI 8.6-15.6) in women, with IRR of 1.26 (95% CI 0.90-1.75). Men had similar or higher IRs than women for osteoporotic site fractures across most age groups.

CONCLUSIONS

This study found similar rates of fracture in men and women with HIV. Further studies validating these findings are required to determine whether men with HIV should be screened for osteoporosis.

Comparison of peripheral forearm DXA and clinical risk factor screening using FRAX® to assess the risk of HIV-associated low bone mass: a cross-sectional study

There is growing awareness that HIV infection is associated with low bone mass and fracture. DXA is a relatively scarce resource. Therefore, we evaluated two tools: peripheral DXA (pDXA) at the forearm and Fracture Risk Assessment Tool (FRAX®) to see which performed best at identifying men who should undergo DXA. In this setting, neither pDXA nor FRAX® showed good sensitivity and specificity for DXA.

PURPOSE

Infection with human immunodeficiency virus (HIV) is associated with an increased risk of low bone mineral density (BMD) and fractures. European guidance advocates screening using the FRAX® tool at diagnosis, on initiation of antiretroviral therapy and biannually thereafter in order to decide the need for DXA scanning. This cross-sectional study evaluates the performance of FRAX® and compares its sensitivity and specificity with that of another screening tool, peripheral forearm DXA (pDXA).

METHODS

HIV-infected men with varying exposure to antiretroviral therapies were recruited. FRAX® scores were calculated for all participants and everybody underwent pDXA scanning. Femoral neck and lumbar spine BMD was acquired on a Hologic QDR machine by an assessor blinded to the results of the FRAX® and pDXA.

RESULTS

One hundred and sixty-eight men (median age 45 years) were recruited with a median duration since HIV diagnosis of 74 months. In total, 21 % of subjects had either osteoporosis (aged ≥50 years) or BMD lower than expected for age (aged <50 years), according to axial DXA. Using a pDXA screening threshold of T ≤ -0.9, sensitivity was high (91 %) in defining those with the worst BMD on axial DXA but with poorer specificity (33 %). Alternately, using a threshold of T ≤ -2.7 reduced sensitivity (34 %) with an increase in specificity (91 %). FRAX® with HIV included as a secondary risk factor had poor sensitivity (31 %) and specificity (74 %) for detecting those with the poorest BMD on axial DXA.

CONCLUSION

In this setting, neither pDXA scanning nor FRAX® was sensitive and specific for low bone mass on DXA and neither was performance much improved by using both screening tools. Prospective studies with fracture as an outcome are required in HIV.

Hepatitis C co-infection and severity of liver disease as risk factors for osteoporotic fractures among HIV-infected patients

Osteoporosis is increasingly reported in the aging HIV-positive population, and co-infection with hepatitis C virus (HCV) may further increase the risk of osteoporosis. However, it remains unclear whether HCV-related increased fracture risk is a function of the severity of liver disease. We calculated the time-updated alanine aminotransferase to platelet ratio index (APRI) score (an indirect marker of hepatic fibrosis) in all HIV-infected patients enrolled in the Veterans Affairs' Clinical Case Registry between 1984 and 2009. The association between HCV co-infection and incident osteoporotic fracture (defined as closed wrist, vertebral, or hip fracture) was assessed in univariate and multivariate Cox survival models adjusting for traditional risk factors for osteoporosis and APRI score or the presence of cirrhosis. A total of 772 osteoporotic fractures were identified among 56,660 HIV-infected patients (98.1% male; 31.3% HCV co-infected; median age 44.0 years) contributing 305,237 patient-years of follow-up. Fracture rates were significantly higher among HIV/HCV patients than HIV-only patients (2.57 versus 2.07/1000 patient-years, relative risk = 1.24, p < 0.0001). In a Cox multivariable model including age, race, smoking, drug use, body mass index, and antiretroviral therapy, HCV co-infection remained an independent predictor of osteoporotic fractures after controlling for presence of cirrhosis (hazard ratio [HR] = 1.32; p <0.001) or APRI score (HR = 1.30; p = 0.003). Among HIV/HCV co-infected patients, cirrhosis strongly predicted osteoporotic fractures (HR = 1.65; 95% confidence interval [CI] 1.11-2.44; p = 0.012), but APRI score was a weaker predictor (HR = 1.008; 95% CI 1.002-1.014; p = 0.015). In conclusion, among HIV-infected patients, severity of liver disease partly explains the HCV-associated increased risk of osteoporotic fractures. Other determinants of this increased risk remain to be defined.

Chronic viral hepatitis is associated with low bone mineral density in HIV-infected patients, ANRS CO 3 Aquitaine Cohort

BACKGROUND

High prevalence rates of low bone mineral density (BMD) have been reported in people living with HIV infection. We aimed to investigate the association of chronic viral hepatitis with low BMD in HIV-infected patients.

METHODS

A hospital-based cohort of HIV-infected patients was screened for hepatitis B and C coinfection. BMD was measured by dual energy x-ray absorptiometry. T-score was used to define bone status according to the World Health Organization's classification; moreover, each observed BMD value was compared with reference to an average person of the same age and gender as a Z-score <-2.0 allow the diagnosis of patients having less bone mass and/or losing bone material more rapidly than expected. A polytomial logistic regression was performed by gender to investigate the association between chronic viral hepatitis and low BMD (osteopenia and osteoporosis) in HIV-infected patients.

RESULTS

A total of 626 patients (166 females of whom 52 postmenopausal) were recruited: 357 HIV monoinfected, and 269 HIV-coinfected with chronic viral hepatitis, among whom 61 with a diagnosis of cirrhosis. Osteopenia was present in 320 patients (51.1%) and osteoporosis in 187 (29.9%). After adjustment, osteoporosis was associated with older age and low body mass index in both genders. The association between chronic viral hepatitis B or C and osteoporosis was found in women only (odds ratio: 19.0; P value: 0.047).

CONCLUSIONS

We found a high prevalence of low BMD overall, but chronic viral hepatitis was independently associated with osteoporosis only in female participants. Our data confirm the need of BMD evaluations for patients living with HIV.

Prevalence of abnormal bone mineral density in hiv-positive patients in ibadan, Nigeria

BACKGROUND

There have been reports of high rate of abnormal bone mineral densities (BMD) among people living with HIV. Following the introduction of combination antiretroviral therapy (CART) into Nigeria, the country is now home to increasing population of HIV positive patients. There is paucity of data about osteoporosis/osteopaenia and bone mineral density in this population.

AIM AND OBJECTIVES

The aim of the study was to determine the prevalence and determinants of osteopaenia/osteoporosis in a cohort of HIV-positive patients in Nigeria.

PATIENTS AND METHODS

The BMD of a group of patients attending the outpatient clinic of the University of Ibadan, Nigeria was assessed using a DXA machine. The relationship of bone mineral density to body weight, CART status, protease inhibitor use, and gender was investigated. Their CD4 counts and viral load were also estimated.

RESULTS

A total of 1005 patients participated with a mean age of 41.3 ± 10 years. There were 724 females (72.0%) and 29.7% were single. The median length of diagnosis was 2 years (Range 1-18 years). The Median CD4 count was 371cells/ml and Median viral load was 200 copies/ml. Of this sample, 785 (78.1%) were on CART with 99 (12.6%) on protease inhibitor. The mean body mass index (BMI) was 23.7±4.7 with 9.2% underweight and 10% obese. The prevalence of osteopaenia and osteoporosis were 46.6% and 31.9% respectively, while 19.6% had normal bone mineral density (BMD). Osteoporosis was significantly higher in those aged above 40 years (p= 0.00001), the females (p= 0.022), the single (p=0.028) and the underweight (p=0.0001). There was no significant difference in BMD of those with or without protease inhibitor containing medications as well as treatment naïve patients.

CONCLUSION

A high prevalence of abnormal bone mineral density was found in HIV positive patients in Nigeria. Patient age above 40 years and a body mass index class of underweight were significant associated factors. Routine bone mineral density assessment is recommended as an adjunct in the evaluation of HIV positive patients in Nigeria.