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Hasenmajer V, D'Addario NF, Bonaventura I, Sada V, Nardi C, Jannini EA, D'Ettorre G, Mastroianni C, Gianfrilli D. Breaking Down Bone Disease in People Living with HIV: Pathophysiology, Diagnosis, and Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2025; 1476:87-110. [PMID: 39668274 DOI: 10.1007/5584_2024_831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2024]
Abstract
Bone health in people living with HIV (PLWH) has emerged as a significant concern in the era of effective antiretroviral therapy (ART). While ART has transformed HIV infection into a chronic condition, it has also unmasked long-term health complications, including an increased risk of osteoporosis and fractures. This review aims to elucidate the multifactorial mechanisms contributing to bone health deterioration in PLWH, such as direct viral effects, immune activation, and ART-induced bone metabolism changes. We examine the current evidence on bone mineral density (BMD) reductions and the heightened fracture risk in this population. Furthermore, we evaluate diagnostic and management strategies, including radiological and non-radiological evaluations, vitamin D optimization, bisphosphonates, and other emerging treatments, to provide a comprehensive overview of effective interventions. By synthesizing the latest research, this review seeks to enhance the understanding of bone health issues in PLWH and guide clinicians in implementing strategies to mitigate these risks, ultimately improving patient outcomes.
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Affiliation(s)
- Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | | | - Ilaria Bonaventura
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Valentina Sada
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Christopher Nardi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emmanuele Angelo Jannini
- Endocrinology and Medical Sexology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Gabriella D'Ettorre
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Claudio Mastroianni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
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2
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McGee DM, Cotter AG. HIV and fracture: Risk, assessment and intervention. HIV Med 2024; 25:511-528. [PMID: 38087902 DOI: 10.1111/hiv.13596] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 11/17/2023] [Indexed: 05/09/2024]
Abstract
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.
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Affiliation(s)
- D M McGee
- Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
| | - A G Cotter
- Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
- UCD Centre for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Republic of Ireland
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3
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Walmsley S, Clarke R, Lee T, Singer J, Cheung AM, Smaill F, De Pokomandy A, Trottier S, Messina E, Guaraldi G. BEING: Bone Health in Aging Women with HIV: Impact of Switching Antiretroviral Therapy on Bone Mineral Density During the Perimenopausal Period. AIDS Res Hum Retroviruses 2023; 39:204-210. [PMID: 36511389 DOI: 10.1089/aid.2022.0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Menopause is a high-risk period for osteoporosis, which may be exacerbated by HIV and/or antiretroviral therapy (ART). Our goal was to study the impact of switching from tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide (TAF) on bone mineral density (BMD) in peri- and early postmenopausal women living with HIV. This is a randomized international multicenter study of an early versus delayed (48-week) switch. BMD was measured by dual energy X-ray absorptiometry scan. Thirty-four women were enrolled: 19 in the immediate and 15 in the delayed switch arm from September 2017 to April 2019; 30 completed the 96-week protocol. The study closed for futility during the COVID-19 pandemic. The median (intraquartile range [IQR]) age was 51 years (47, 53), with a median (IQR) of 16.5 years (14, 23) since HIV diagnosis, median (IQR) 14 years (11, 20) of ART, and mean 8.6 years TDF. At enrollment, TDF was used in combination with a boosted protease inhibitor (n = 7), a non-nucleoside reverse transcriptase inhibitor (n = 13), an integrase inhibitor (n = 11), or more than one ART class (n = 3). The median (95% confidence interval [CI]) percentage change in BMD at the lumbar spine from 0 to 48 weeks in the immediate switch group was 1.97% (-1.15 to 5.49) compared with a median (95% CI) decrease of 2.32% (-5.11 to 0.19) in the delayed arm. The median (95% CI) percentage change in BMD from 0 to 96 weeks was 2.33% (0-4.51) in the immediate arm compared with 0.70% (-3.19 to 2.47) in the delayed arm. We demonstrated a trend to increased BMD at the lumbar spine after a switch from TDF to TAF in peri- and early postmenopausal women living with HIV. Clinical Trials.gov: NCT02815566.
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Affiliation(s)
- Sharon Walmsley
- University Health Network, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Terry Lee
- Canadian HIV Trials Network, Vancouver, Canada
| | - Joel Singer
- Canadian HIV Trials Network, Vancouver, Canada
| | - Angela M Cheung
- University Health Network, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Fiona Smaill
- Department of Lab Sciences, Mc Master University, Hamilton, Canada.,Hamilton Health Sciences, Hamilton, Canada
| | | | - Sylvia Trottier
- Department of Medicine, CHU de Québec-Université Laval, Quebec, Canada
| | - Emanuela Messina
- Department of Infectious Diseases, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Giovanni Guaraldi
- Department of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
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Yin MT, Hoover DR, Shi Q, Tien PC, Cohen MH, Kassaye S, Gustafson D, Adimora A, Weitzmann MN, Bolivar H, Warriner A, Bares SH, Sharma A. Hormone therapy and fractures in postmenopausal women. AIDS 2022; 36:1683-1688. [PMID: 35730385 PMCID: PMC9444941 DOI: 10.1097/qad.0000000000003292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Fracture rates have been reported to be higher among older women living with HIV (WLWH) than HIV- women. Hormone therapy with estrogen can reduce vasomotor symptoms (VMS) associated with menopause and prevent fractures. As data are limited on the benefits of hormone therapy use in WLWH, we examined associations of hormone therapy, use and fractures. METHODS A prospective study of 1765 (1350 WLWH and 415 HIV-) postmenopausal Women's Interagency HIV Study (WIHS) participants was performed, including self-reported hormone therapy, use and fracture data from 2003 to 2017. Proportional hazard models determined predictors of new fractures at any site or at typical fragility fracture sites (hip, spine, wrist). RESULTS At the first postmenopausal visit, the median (IQR) age of WLWH was slightly younger than HIV- women [49.8 (46.4-53) vs. 50.7 (47.5-54), P = 0.0002] and a smaller proportion of WLWH reported presence of VMS (17% vs. 26%, P < 0.0001). A greater proportion of WLWH than HIV- women reported hormone therapy use (8% vs. 4%, P = 0.007) at the first postmenopausal visit. In multivariate analyses, white race and smoking were significant predictors of incident fracture at any site but hormone therapy ( P = 0.69) and HIV status ( P = 0.53) were not. CONCLUSION Our study did not find evidence of benefit or harm with regards to fracture outcomes in postmenopausal WLWH receiving hormone therapy. Further research is needed to determine whether hormone therapy has benefits beyond treatment of VMS, such as prevention of adverse aging-associated outcomes.
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Affiliation(s)
- Michael T Yin
- Department of Medicine, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Donald R Hoover
- Department of Statistics and Institute for Health, Healthcare Policy and Aging Research, Rutgers University, Piscataway, NJ
| | - Qiuhu Shi
- School of Health Sciences and Practice, New York Medical College, Valhalla, NY
| | - Phyllis C Tien
- Department of Veterans Affairs Medical Center
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | | | | | | | - Adaora Adimora
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - M Neale Weitzmann
- Department of Medicine, Emory University School of Medicine, Atlanta
- the Atlanta VA Medical Center, Decatur, GA
| | | | - Amy Warriner
- Department of Medicine, University of Alabama, Birmingham AL
| | - Sara H Bares
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Anjali Sharma
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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Mehta CC, Hagen KS, Rubtsova AA, Lahiri CD, Michopoulos V, Moran CA, Haddad LB, Titanji K, Collins LF, Quyyumi AA, Neigh G, Shaw LJ, Weitzmann MN, Waller L, Ofotokun I. Bone, Brain, Heart study protocol: A resilient nested, tripartite prospective cohort study of the role of estrogen depletion on HIV pathology. PLoS One 2022; 17:e0272608. [PMID: 35921353 PMCID: PMC9348736 DOI: 10.1371/journal.pone.0272608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We describe the rationale for and design of an innovative, nested, tripartite prospective observational cohort study examining whether relative estrogen insufficiency-induced inflammation amplifies HIV-induced inflammation to cause end organ damage and worsen age-related co-morbidities affecting the neuro-hypothalamic-pituitary-adrenal axis (Brain), skeletal (Bone), and cardiovascular (Heart/vessels) organ systems (BBH Study). METHODS The BBH parent study is the Multicenter AIDS Cohort/Women's Interagency HIV Study Combined Cohort Study (MWCCS) with participants drawn from the Atlanta MWCCS site. BBH will enroll a single cohort of n = 120 women living with HIV and n = 60 HIV-negative women, equally distributed by menopausal status. The innovative multipart nested study design of BBH, which draws on data collected by the parent study, efficiently leverages resources for maximum research impact and requires extensive oversight and management in addition to careful implementation. The presence of strong infrastructure minimized BBH study disruptions due to changes in the parent study and the COVID-19 pandemic. CONCLUSION BBH is poised to provide insight into sex and HIV associations with the neuro-hypothalamic-pituitary-adrenal axis, skeletal, and cardiovascular systems despite several major, unexpected challenges.
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Affiliation(s)
- C. Christina Mehta
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Kimberly S. Hagen
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Anna A. Rubtsova
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Cecile D. Lahiri
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
- Grady Infectious Diseases Program, Grady Health System, Atlanta, GA, United States of America
| | - Vasiliki Michopoulos
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Caitlin A. Moran
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
- Grady Infectious Diseases Program, Grady Health System, Atlanta, GA, United States of America
| | - Lisa B. Haddad
- Center for Biomedical Research, Population Council, New York, NY, United States of America
| | - Kehmia Titanji
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Lauren F. Collins
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
- Grady Infectious Diseases Program, Grady Health System, Atlanta, GA, United States of America
| | - Arshed A. Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Gretchen Neigh
- Department of Anatomy and Neurobiology, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Leslee J. Shaw
- Blavatnik Women’s Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - M. Neale Weitzmann
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
- Atlanta Veterans Affairs Medical Center, Decatur, GA, United States of America
| | - Lance Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Ighovwerha Ofotokun
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
- Grady Infectious Diseases Program, Grady Health System, Atlanta, GA, United States of America
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Pond RA, Collins LF, Lahiri CD. Sex Differences in Non-AIDS Comorbidities Among People With Human Immunodeficiency Virus. Open Forum Infect Dis 2021; 8:ofab558. [PMID: 34888399 PMCID: PMC8651163 DOI: 10.1093/ofid/ofab558] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022] Open
Abstract
Women are grossly underrepresented in human immunodeficiency virus (HIV) clinical and translational research. This is concerning given that people with HIV (PWH) are living longer, and thus accumulating aging-related non-AIDS comorbidities (NACMs); emerging evidence suggests that women are at higher risk of NACM development and progression compared with men. It is widely recognized that women vs men have greater immune activation in response to many viruses, including HIV-1; this likely influences sex-differential NACM development related to differences in HIV-associated chronic inflammation. Furthermore, many sociobehavioral factors that contribute to aging-related NACMs are known to differ by sex. The objectives of this review were to (1) synthesize sex-stratified data on 4 NACMs among PWH: bone disease, cardiovascular disease, metabolic dysfunction, and neurocognitive impairment; (2) evaluate the characteristics of key studies assessing sex differences in NACMs; and (3) introduce potential biological and psychosocial mechanisms contributing to emerging trends in sex-differential NACM risk and outcomes among PWH.
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Affiliation(s)
- Renee A Pond
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lauren F Collins
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cecile D Lahiri
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
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Battalora L, Armon C, Palella F, Li J, Overton ET, Hammer J, Fuhrer J, Novak RM, Carlson K, Spear JR, Buchacz K. Incident bone fracture and mortality in a large HIV cohort outpatient study, 2000-2017, USA. Arch Osteoporos 2021; 16:117. [PMID: 34337687 DOI: 10.1007/s11657-021-00949-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/03/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED We evaluated the association of bone fracture with mortality among persons with HIV, controlling for sociodemographic, behavioral, and clinical factors. Incident fracture was associated with 48% greater risk of all-cause mortality, underscoring the need for bone mineral density screening and fracture prevention. PURPOSE/INTRODUCTION Low bone mineral density (BMD) and fracture are more common among persons with HIV (PWH) than those without HIV infection. We evaluated the association of bone fracture with mortality among PWH, controlling for sociodemographic, behavioral, and clinical factors. METHODS We analyzed data from HIV Outpatient Study (HOPS) participants seen at nine US HIV clinics during January 1, 2000, through September 30, 2017. Incident fracture rates and post-fracture mortality were compared across four calendar periods. Cox proportional hazards analyses determined factors associated with all-cause mortality among all participants and those with incident fracture. RESULTS Among 6763 HOPS participants, 504 (7.5%) had incident fracture (median age = 47 years) and 719 (10.6%) died. Of fractures, 135 (26.8%) were major osteoporotic (hip/pelvis, wrist, spine, arm/shoulder). During observation, 27 participants with major osteoporotic fractures died (crude mortality 2.97/100 person-years [PY]), and 48 with other site fractures died (crude mortality 2.51/100 PY). Post-fracture, age- and sex-adjusted all-cause mortality rates per 100 PY decreased from 8.5 during 2000-2004 to 1.9 during 2013-2017 (P<0.001 for trend). In multivariable analysis, incident fracture was significantly associated with all-cause mortality (Hazard Ratio 1.48, 95% confidence interval 1.15-1.91). Among 504 participants followed post-fracture, pulmonary, kidney, and cardiovascular disease, hepatitis C virus co-infection, and non-AIDS cancer, remained independently associated with all-cause mortality. CONCLUSIONS Incident fracture was associated with 48% greater risk of all-cause mortality among US PWH in care, underscoring the need for BMD screening and fracture prevention. Although fracture rates among PWH increased during follow-up, post-fracture death rates decreased, likely reflecting advances in HIV care.
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Affiliation(s)
- Linda Battalora
- Colorado School of Mines, 1301 19th St., Golden, CO, 80401, USA. .,Cerner Corporation, Kansas City, MO, USA.
| | - Carl Armon
- Cerner Corporation, Kansas City, MO, USA
| | - Frank Palella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jun Li
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Edgar T Overton
- University of Alabama School of Medicine, Birmingham, AL, USA
| | | | - Jack Fuhrer
- Stony Brook School of Medicine, Stony Brook, NY, USA
| | - Richard M Novak
- University of Illinois College of Medicine, Chicago, IL, USA
| | | | - John R Spear
- Colorado School of Mines, 1301 19th St., Golden, CO, 80401, USA
| | - Kate Buchacz
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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8
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Chang CJ, Chan YL, Pramukti I, Ko NY, Tai TW. People with HIV infection had lower bone mineral density and increased fracture risk: a meta-analysis. Arch Osteoporos 2021; 16:47. [PMID: 33638754 DOI: 10.1007/s11657-021-00903-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/01/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Chao-Jui Chang
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan, 70428, Taiwan
| | - Yi-Lin Chan
- Department of Life Science, Chinese Culture University, Taipei, Taiwan
| | - Iqbal Pramukti
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Faculty of Nursing, Universitas Padjadjaran, , West Java, Bandung, Indonesia
| | - Nai-Ying Ko
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ta-Wei Tai
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan, 70428, Taiwan.
- Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Lam JO, Levine-Hall T, Hood N, Alexeeff SE, Horberg MA, Young-Wolff KC, Sterling SA, Williams A, Weisner C, Satre DD, Silverberg MJ. Smoking and cessation treatment among persons with and without HIV in a U.S. integrated health system. Drug Alcohol Depend 2020; 213:108128. [PMID: 32603975 PMCID: PMC7392076 DOI: 10.1016/j.drugalcdep.2020.108128] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Persons with HIV (PWH) are more likely to smoke and are more susceptible to the harmful effects of smoking than persons without HIV. We examined smoking patterns and use of cessation treatment among PWH and persons without HIV in a U.S. integrated health system. METHODS We identified adults (≥18 years) with HIV and demographically-matched persons without HIV between July 2013 and December 2017. Smoking status and cessation treatment were ascertained from health records. We calculated age-standardized annual prevalence of smoking and evaluated trends using Cochran-Armitage tests and Poisson regression. Factors associated with cessation treatment during the study period, and smoking in the last year of the study, were evaluated by HIV status using multivariable Poisson models. RESULTS The study included 11,235 PWH and 227,320 persons without HIV. Smoking prevalence was higher among PWH across all years but declined for both groups (from 16.6% to 14.6% in PWH and 11.6% to 10.5% in persons without HIV). Among smokers, PWH were more likely to initiate cessation treatment compared to persons without HIV (17.9% vs. 13.3%, covariate-adjusted prevalence ratio of 1.31, 95% CI = 1.15-1.50), with few differences in cessation treatment across subgroups of PWH. In 2017, smoking prevalence remained higher in PWH, especially among those who were younger or who had diagnoses of depression or substance use disorder. CONCLUSION In a setting with access to cessation resources, smoking prevalence decreased both in PWH and persons without HIV. PWH had greater uptake of cessation treatment, which is encouraging for smoking reduction and improved health.
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Affiliation(s)
- Jennifer O. Lam
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA
| | - Tory Levine-Hall
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA
| | - Nicole Hood
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA
| | - Stacey E. Alexeeff
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA
| | - Michael A. Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, 2101 East Jefferson Street, 3 East, Rockville, MD, 20852, USA
| | - Kelly C. Young-Wolff
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA,Department of Psychiatry, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Stacy A. Sterling
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA,Department of Psychiatry, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Andrew Williams
- Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA,Department of Psychiatry, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Derek D. Satre
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA,Department of Psychiatry, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Michael J. Silverberg
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA
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Pramukti I, Liu HY, Chen CC, Chen YC, Yeh CY, Fetzer S, Ibrahim K, Tai TW, Ko WC, Ko NY. HCV co-infection among people living with HIV Is associated with Higher fracture risk. J Infect Public Health 2020; 13:1724-1728. [PMID: 32653478 DOI: 10.1016/j.jiph.2020.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/21/2020] [Accepted: 06/14/2020] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Iqbal Pramukti
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Faculty of Nursing, Universitas Padjadjaran, West Java, Indonesia
| | - Hsiao-Ying Liu
- Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chang-Chun Chen
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yen-Chin Chen
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chun-Yin Yeh
- Department of Computer Science and Information Engineering, National Cheng Kung University, Taiwan
| | - Susan Fetzer
- Southern New Hampshire Medical Center, Nashua, New Hampshire, USA
| | - Kusman Ibrahim
- Faculty of Nursing, Universitas Padjadjaran, West Java, Indonesia
| | - Ta-Wei Tai
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Nai-Ying Ko
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan.
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Pramukti I, Lindayani L, Chen YC, Yeh CY, Tai TW, Fetzer S, Ko NY. Bone fracture among people living with HIV: A systematic review and meta-regression of prevalence, incidence, and risk factors. PLoS One 2020; 15:e0233501. [PMID: 32497105 PMCID: PMC7271989 DOI: 10.1371/journal.pone.0233501] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/06/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction People living with HIV (PLWH) had a higher prevalence and incidence rate of bone fracture compared to general population. Although several studies have explored this phenomenon, the prevalence and incidence rate of fracture were varied. Objective The aim of the study is to determine and analyze the pooled prevalence, incidence rate of fracture and fracture risk factors among people living with HIV (PLWH). Methods PubMed, Cochrane Library, CINAHL with full Text, and Medline databases for studies published up to August 2019 were searched. Studies reporting the prevalence or incidence of fracture among PLWH were included. Study quality was assessed using the Joanna Briggs Institute (JBI) appraisal tool. A meta-analysis with random-effects model was performed to determine pooled estimates of prevalence and incidence rates of fracture. A meta-regression was performed to determine the source of heterogeneity. Results The pooled estimated prevalence of fracture among PLWH was 6.6% (95% CI: 3.8–11.1) with pooled odds ratio of 1.9 (95%CI: 1.1–3.2) compared to the general population. The pooled estimates of fracture incidence were 11.3 per 1000 person-years (95% CI: 7.9–14.5) with incidence rate ratio (IRR) of 1.5 (95% CI: 1.3–1.8) compared to the general population. Risk factors for fracture incidence were older age (aHR 1.4, 95% CI: 1.3–1.6), smoking (aHR 1.3, 95% CI: 1.1–1.5), HIV/HCV co-infection (aHR 1.6, 95% CI: 1.3–1.9), and osteoporosis (aHR 3.3, 95% CI: 2.2–5.1). Conclusions Our finding highlights a higher risk of fracture among PLWH compared to the general population. Osteoporosis, smoking and HIV/HCV coinfection as the significant modifiable risk factors should be prioritized by the HIV health providers when care for PLWH.
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Affiliation(s)
- Iqbal Pramukti
- Department of Nursing, International Doctoral Program in Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Faculty of Nursing, Universitas Padjadjaran, West Java, Indonesia
| | - Linlin Lindayani
- Sekolah Tinggi Ilmu Keperawatan PPNI Jawa Barat, Bandung, Indonesia
| | - Yen-Chin Chen
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Yin Yeh
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Ta-Wei Tai
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Susan Fetzer
- Southern New Hampshire Medical Center, Nashua, New Hampshire, United States of America
| | - Nai-Ying Ko
- Department of Nursing, International Doctoral Program in Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- * E-mail:
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Vega LE, Espinoza LR. Human immunodeficiency virus infection (HIV)-associated rheumatic manifestations in thepre- and post-HAART eras. Clin Rheumatol 2020; 39:2515-2522. [PMID: 32297034 PMCID: PMC7159285 DOI: 10.1007/s10067-020-05082-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Luis E Vega
- Section of Rheumatology, Air Force Hospital, Aramburú Ave 2nd block, Lima, Peru.
| | - Luis R Espinoza
- Louisiana State University Health Sciences Center, 433 Bolivar St, New Orleans, LA, 70112, USA
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13
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Kim TW, Ventura AS, Winter MR, Heeren TC, Holick MF, Walley AY, Bryant KJ, Saitz R. Alcohol and Bone Turnover Markers among People Living with HIV and Substance Use Disorder. Alcohol Clin Exp Res 2020; 44:992-1000. [PMID: 32124466 PMCID: PMC7263383 DOI: 10.1111/acer.14303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/27/2020] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Theresa W. Kim
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineBoston Medical CenterBoston University School of MedicineBostonMassachusetts
| | - Alicia S. Ventura
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineBoston Medical CenterBoston University School of MedicineBostonMassachusetts
| | - Michael R. Winter
- Biostatistics and Epidemiology Data Analytics CenterBoston University School Public HealthBostonMassachusetts
| | - Timothy C. Heeren
- Department of BiostatisticsBoston University School Public HealthBostonMassachusetts
| | - Michael F. Holick
- Section of Endocrinology, Diabetes, and NutritionBoston Medical CenterBoston University School of MedicineBostonMassachusetts
| | - Alexander Y. Walley
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineBoston Medical CenterBoston University School of MedicineBostonMassachusetts
| | - Kendall J. Bryant
- HIV/AIDS ResearchNational Institute on Alcohol Abuse and AlcoholismBethesdaMaryland
| | - Richard Saitz
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineBoston Medical CenterBoston University School of MedicineBostonMassachusetts
- Department of Community Health SciencesBoston University School Public HealthBostonMassachusetts
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14
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Quigley A, MacKay-Lyons M. Physical deficits among people living with HIV: a review of the literature and implications for rehabilitation. PHYSICAL THERAPY REVIEWS 2019. [DOI: 10.1080/10833196.2019.1701763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Adria Quigley
- Department of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Marilyn MacKay-Lyons
- Department of Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
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15
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Bedimo RJ, Adams-Huet B, Poindexter J, Brown G, Farukhi I, Castanon R, Turner D, Moore T, Tebas P, Maalouf NM. The Differential Effects of Human Immunodeficiency Virus and Hepatitis C Virus on Bone Microarchitecture and Fracture Risk. Clin Infect Dis 2019; 66:1442-1447. [PMID: 29145609 DOI: 10.1093/cid/cix1011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/13/2017] [Indexed: 01/06/2023] Open
Abstract
Background Human immunodeficiency virus (HIV)/hepatitis C virus (HCV)-coinfected individuals have a significantly greater osteoporotic fracture risk than HIV-monoinfected persons, despite the fact that HIV/HCV coinfection has not been associated with lower bone mineral density (BMD) than HIV or HCV alone. To evaluate if changes in bone microarchitecture, measured by trabecular bone score (TBS), could explain these differences, we performed a prospective, cross-sectional cohort study of virologically suppressed HIV-infected subjects, untreated HCV-infected subjects, HIV/HCV-coinfected subjects, and uninfected controls. Methods We enrolled 532 male subjects: 57 HIV/HCV coinfected, 174 HIV infected, 123 HCV infected, and 178 controls. We conducted analysis of covariance comparing BMD and TBS between groups, controlling for age, race, body mass index, and smoking. We used linear regression to evaluate predictors of BMD and TBS and evaluated the effects of severity of HCV infection and tenofovir disoproxil fumarate use. Results Despite both infections being associated with decreased BMD, only HCV, but not HIV, was associated with lower TBS score. Also, HIV/HCV-coinfected subjects had lower TBS scores than HIV-monoinfected, HCV-monoinfected, and uninfected subjects. Neither the use of TDF or HCV viremia nor the severity of HCV liver disease was associated with lower TBS. Conclusions HCV infection is associated with microarchitectural changes at the lumbar spine as assessed by the low TBS score, suggesting that microstructural abnormalities underlie some of the higher fracture risk in HCV infection. TBS might improve fracture risk prediction in HCV infection.
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Affiliation(s)
- Roger J Bedimo
- Department of Medicine, Veterans Affairs North Texas Health Care System and the University of Texas Southwestern Medical Center at Dallas
| | - Beverley Adams-Huet
- Department of Clinical Sciences, University of Texas Southwestern Medical Center at Dallas
| | - John Poindexter
- Center for Mineral Metabolism, University of Texas Southwestern Medical Center at Dallas
| | - Geri Brown
- Department of Medicine, Veterans Affairs North Texas Health Care System and the University of Texas Southwestern Medical Center at Dallas
| | - Irfan Farukhi
- Department of Nuclear Medicine, Veterans Affairs North Texas Health Care System and the University of Texas Southwestern Medical Center at Dallas
| | - Rosinda Castanon
- Department of Nuclear Medicine, Veterans Affairs North Texas Health Care System and the University of Texas Southwestern Medical Center at Dallas
| | - Diana Turner
- Department of Medicine, Veterans Affairs North Texas Health Care System, Dallas
| | - Teresa Moore
- Department of Medicine, Veterans Affairs North Texas Health Care System, Dallas
| | - Pablo Tebas
- Department of Medicine, University of Pennsylvania, Philadelphia
| | - Naim M Maalouf
- Department of Medicine, University of Texas Southwestern Medical Center at Dallas
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16
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Abstract
Although HIV diagnoses among women have declined in recent years in the United States (U.S.), women accounted for 19% of new HIV diagnoses in 2016. In addition, women comprise 24% of the 973,846 persons living with HIV infection in the U.S. However, HIV prevention interventions targeting women are limited. We performed a review on HIV infection in women to increase awareness, improve overall care, and inform intervention development. A systematic literature review was conducted using literature published in PubMed, PsychINFO (EBSCO), and Scopus from July 2000 and June 2017. We included studies that: (1) were conducted in the U.S., (2) enrolled at least 50 HIV-positive women, and (3) utilized a case-control, cohort, or surveillance study design. Of 7497 articles, 48 articles met inclusion criteria. HIV diagnoses among women declined 32% between 2001 and 2016. In 2016, 61% of diagnoses in women were among African American women, and 56% were in the South. Women reported barriers to HIV care largely due to psychosocial challenges and social/structural determinants of health (SDH) barriers. Though new diagnoses among women have declined, racial and regional disparities remain. HIV prevention and research efforts with women are vital to inform interventions and reduce disparities.
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Affiliation(s)
- Symone May
- Public Health Summer Intern Program, Leidos Inc, Atlanta, Georgia.,Emory University Rollins School of Public Health, Atlanta, Georgia.,Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ashley Murray
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Madeline Y Sutton
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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17
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Biver E, Calmy A, Aubry-Rozier B, Birkhäuser M, Bischoff-Ferrari HA, Ferrari S, Frey D, Kressig RW, Lamy O, Lippuner K, Suhm N, Meier C. Diagnosis, prevention, and treatment of bone fragility in people living with HIV: a position statement from the Swiss Association against Osteoporosis. Osteoporos Int 2019; 30:1125-1135. [PMID: 30603840 DOI: 10.1007/s00198-018-4794-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/29/2018] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- E Biver
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - A Calmy
- HIV/Aids Unit, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - B Aubry-Rozier
- Center of Bone Diseases, Lausanne University Hospital, Lausanne, Switzerland
| | - M Birkhäuser
- Gynecological Endocrinology and Reproductive Medicine, University of Berne, Basel, Switzerland
| | - H A Bischoff-Ferrari
- Department of Geriatrics and Aging Research, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - S Ferrari
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - D Frey
- Division of Rheumatology, University Hospital Zürich, Zürich, Switzerland
| | - R W Kressig
- University Center for Medicine of Aging, Basel Mobility Center, University of Basel, Basel, Switzerland
| | - O Lamy
- Center of Bone Diseases, Lausanne University Hospital, Lausanne, Switzerland
| | - K Lippuner
- Department of Osteoporosis, University Hospital, University of Berne, Berne, Switzerland
| | - N Suhm
- Department of Orthopedics and Traumatology, Geriatric Fracture Center, University Hospital Basel, Basel, Switzerland
| | - C Meier
- Division of Endocrinology, Diabetology & Metabolism, University Hospital and University of Basel, Missionsstrasse 24, CH-4055, Basel, Switzerland.
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18
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Dalla Grana E, Rigo F, Lanzafame M, Lattuada E, Suardi S, Mottes M, Valenti MT, Dalle Carbonare L. Relationship Between Vertebral Fractures, Bone Mineral Density, and Osteometabolic Profile in HIV and Hepatitis B and C-Infected Patients Treated With ART. Front Endocrinol (Lausanne) 2019; 10:302. [PMID: 31139152 PMCID: PMC6527878 DOI: 10.3389/fendo.2019.00302] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 04/26/2019] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Elisa Dalla Grana
- Internal Medicine Section D, Department of Medicine, University of Verona, Verona, Italy
| | - Fabio Rigo
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | | | - Emanuela Lattuada
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Silvia Suardi
- Internal Medicine Section D, Department of Medicine, University of Verona, Verona, Italy
| | - Monica Mottes
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Maria Teresa Valenti
- Internal Medicine Section D, Department of Medicine, University of Verona, Verona, Italy
| | - Luca Dalle Carbonare
- Internal Medicine Section D, Department of Medicine, University of Verona, Verona, Italy
- *Correspondence: Luca Dalle Carbonare
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Sutton SS, Magagnoli J, Cummings TH, Hardin JW, Edun B, Beaubrun A. Chronic kidney disease, cardiovascular disease, and osteoporotic fractures in patients with and without HIV in the US Veteran's Affairs Administration System. Curr Med Res Opin 2019; 35:117-125. [PMID: 30378450 DOI: 10.1080/03007995.2018.1543183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objective: To evaluate the risk of chronic kidney disease (CKD), cardiovascular disease (CVD), and osteoporotic fractures in human immunodeficiency virus (HIV) patients utilizing data within the Veteran's Affairs (VA) Administration system.Methods: A retrospective cohort study utilizing VA system claims (January 2000-December 2016) were extracted from the VA Informatics and Computing Infrastructure (VINCI). Cases included Veterans with an ICD-9/10 for HIV who had at least one prescription for a complete antiretroviral therapy (ART) regimen. Two non-HIV controls were exactly matched on race, sex, month, and year of birth. All patients were followed until the earliest of the following: first incidence of the outcome (identified based on diagnosis codes or laboratory data), last date of VA activity, death, or December 31, 2016. Relative risks (RR) and odds ratios (ORs) were estimated from multivariable Poisson regression models (CVD and osteoporotic fractures) and multivariable logistic regression models (CKD), respectively. Models were adjusted for demographic factors/comorbidities.Results: A total of 79,578 patients (26,526 HIV and 53,052 non-HIV) met all study criteria. The average age was 49.3 years, 38% were black, 32% were white, and 97% were male for both the HIV and control cohorts. The adjusted models demonstrated that HIV was associated with a 78% increased rate of CKD (OR = 1.78, 95% CI = 1.68-1.89), a 32% increased risk of CVD (RR = 1.32, 95% CI = 1.28-1.37), and a 38% increased risk of fractures (RR = 1.38, 95% CI = 1.23-1.56) compared to non-HIV controls.Conclusions: The risk/rate of the three outcomes were significantly higher in HIV patients compared to controls.
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Affiliation(s)
- S S Sutton
- College of Pharmacy, Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, Columbia, SC, USA
- Dorn Research Institute, WJB Dorn Veterans Affairs Medical Center, Columbia, SC, USA
| | - J Magagnoli
- Dorn Research Institute, WJB Dorn Veterans Affairs Medical Center, Columbia, SC, USA
| | - T H Cummings
- Dorn Research Institute, WJB Dorn Veterans Affairs Medical Center, Columbia, SC, USA
| | - J W Hardin
- Department of Epidemiology & Biostatistics, University of South Carolina, Columbia, SC, USA
| | - B Edun
- Dorn Research Institute, WJB Dorn Veterans Affairs Medical Center, Columbia, SC, USA
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Human Immunodeficiency Virus Infection: Spectrum of Rheumatic Manifestations. INFECTIONS AND THE RHEUMATIC DISEASES 2019. [PMCID: PMC7120519 DOI: 10.1007/978-3-030-23311-2_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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21
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Weitzmann MN, Ofotokun I, Titanji K, Sharma A, Yin MT. Bone Loss Among Women Living With HIV. Curr HIV/AIDS Rep 2017; 13:367-373. [PMID: 27678124 DOI: 10.1007/s11904-016-0336-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Clinical data accumulated over the past two decades attests to a significant decline in bone mineral density (BMD) in patients infected by HIV, which does not remit but may actually intensify with anti-retroviral therapy (ART). Long generally perceived as an aberration without clinical consequences in relatively young HIV-infected cohorts, recent studies have documented marked increases in fracture incidence in HIV-infected men and women over a wide age continuum. Fractures are associated with chronic pain, crippling morbidity, and increased mortality, undermining the gains in quality of life achieved though ART. As bone loss and resulting increases in fracture incidence are a natural consequence of aging, there is now concern regarding the long-term consequences of HIV/ART-associated premature bone loss, given the transition of the HIV/AIDS population into an older age demographic. The development of guidelines for diagnosis and treatment of bone disease within the context of HIV and ART has been an important recent step in raising awareness of the problem and the implications of bone fracture for patient health. Significant progress has also been made in recent years in dissecting the complex and multifactorial mechanisms driving bone loss in HIV/ART and the role of underlying immunological disruption in skeletal dysmorphogenesis. This review examines recent progress in the field and studies by Women's Interagency HIV Study (WIHS)-associated investigators, inside and outside of the WIHS cohort, aimed at identifying skeletal abnormalities, quantifying facture incidence, management, and understanding underlying mechanisms in people living with HIV in the context of chronic ART.
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Affiliation(s)
- M Neale Weitzmann
- The Atlanta Department of Veterans Affairs Medical Center, 1670 Clairmont Road, Decatur, GA, 30033, USA. .,Department of Medicine, Division of Endocrinology and Metabolism and Lipids, Emory University School of Medicine, 101 Woodruff Circle, 1305 WMB, Atlanta, GA, 30322, USA.
| | - Ighovwerha Ofotokun
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr Drive, Atlanta, GA, 30303, USA.,Grady Healthcare System, 80 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA
| | - Kehmia Titanji
- Department of Medicine, Division of Endocrinology and Metabolism and Lipids, Emory University School of Medicine, 101 Woodruff Circle, 1305 WMB, Atlanta, GA, 30322, USA
| | - Anjali Sharma
- Divisions of General Internal Medicine and Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Ave, Block Bldg #305, Bronx, NY, 10461, USA
| | - Michael T Yin
- Division of Infectious Diseases, Columbia University Medical Center, 630 West 168th Street, PH8-876, New York, NY, 10032, USA
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Abstract
OBJECTIVES To determine the incidence of fracture among aging HIV-infected (HIV+) and uninfected men (HIV-). To evaluate factors independently associated with fracture risk. DESIGN Prospective, multicenter cohort study of men with or at risk for HIV. METHODS Outcome measures: all fractures (excluding skull, face and digits) and fragility fractures (vertebral column, femur, wrist and humerus) were collected semiannually in 1221 HIV+ and 1408 HIV- men aged at least 40. Adjusted incident rate ratios (aIRR) with an interaction term for age (40-49, 50-59 and ≥60 years) and HIV serostatus were estimated with Poisson regression models accounting for additional risk factors. RESULTS Fracture incidence increased with age among both HIV+ and HIV- men. Although there was no significant difference in fracture incidence by HIV serostatus among men aged 40-49 years, the HIV+ men aged 50-59 years had a significantly higher incidence of all fractures [aIRR: 2.06 (1.49, 2.84)] and fragility fractures [aIRR: 2.06 (1.21, 3.50)] compared with HIV- participants of similar age. HIV modified the effect of age on all fractures (P = 0.002) but did not significantly modify the effect for fragility fractures (P = 0.135). Hypertension increased the rate of all fractures by 32% after adjustment for covariates [aIRR: 1.32 (1.04, 1.69)]. CONCLUSION Fracture incidence increased with age among HIV+ and HIV- men but was higher among HIV+ men. A significant increase in fracture incidence was found among 50-59-year-old HIV+ men, highlighting the importance of osteoporosis screening for HIV-infected men above the age of 50.
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Fracture Prediction With Modified-FRAX in Older HIV-Infected and Uninfected Men. J Acquir Immune Defic Syndr 2017; 72:513-20. [PMID: 27003493 DOI: 10.1097/qai.0000000000000998] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
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.
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Biver E, Calmy A, Rizzoli R. Bone health in HIV and hepatitis B or C infections. Ther Adv Musculoskelet Dis 2017; 9:22-34. [PMID: 28101146 PMCID: PMC5228639 DOI: 10.1177/1759720x16671927] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Emmanuel Biver
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, HIV Unit, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - René Rizzoli
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Gedmintas L, Wright EA, Dong Y, Lehmann E, Katz JN, Solomon DH, Losina E. Factors associated with fractures in HIV-infected persons: which factors matter? Osteoporos Int 2017; 28:239-244. [PMID: 27421978 PMCID: PMC5480613 DOI: 10.1007/s00198-016-3704-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/06/2016] [Indexed: 02/07/2023]
Abstract
UNLABELLED This study aims to determine what factors are associated with increased risk of fracture among patients with HIV, in particular whether an important medication used to treat HIV, tenofovir, is associated with fracture. Our study found that while co-infection with hepatitis C and markers of HIV severity were associated with fracture, tenofovir was not. INTRODUCTION Growing evidence suggests that tenofovir disoproxil fumarate decreases bone density among patients with HIV, but there are conflicting reports as to whether this decrease in bone density translates to higher fracture risk. We aimed to determine what factors were associated with an increased risk of fracture for patients with HIV, in particular whether tenofovir is associated with elevated fracture risk. METHODS We conducted a retrospective cohort study at two tertiary care hospitals in Boston, MA, between 2001 and 2012 to determine whether tenofovir use is associated with elevated all-site fracture risk, as compared to other antiretroviral medications. We also examined other potential factors associated with fracture among patients with HIV. RESULTS We identified 1981 HIV-infected patients who had at some point used tenofovir and 682 patients who had not. The mean age was 43 years, and 72 % were male. The hepatitis C co-infection rate was 28 %, about 40 % had nadir CD4 count <200, and about 40 % had a history of an AIDS-defining illness. We did not find an association between risk of fracture and tenofovir disoproxil fumarate (TDF) (adjusted RR (aRR) 0.8, 95 % CI 0.6-1.1). However, co-infection with hepatitis C did increase risk of fracture (aRR 1.6, 95 % CI 1.1-2.3), as did nadir CD4 count <200 (aRR 3.1, 95 % CI 1.9-5.0) and history of AIDS-defining illness (aRR 1.6, 95 % CI 1.1-2.2). CONCLUSION There was no association found between fracture and tenofovir use, but there were associations between co-infection with hepatitis C and markers of advanced HIV disease and fracture.
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Affiliation(s)
- L Gedmintas
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - E A Wright
- Department of Orthopedic Surgery, Orthopedic and Arthritis Center for Outcomes Research, Boston, MA, USA
- Harvard School of Public Health, Boston, MA, USA
| | - Y Dong
- Department of Orthopedic Surgery, Orthopedic and Arthritis Center for Outcomes Research, Boston, MA, USA
| | - E Lehmann
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - J N Katz
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopedic Surgery, Orthopedic and Arthritis Center for Outcomes Research, Boston, MA, USA
- Harvard School of Public Health, Boston, MA, USA
| | - D H Solomon
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Boston, MA, USA
| | - E Losina
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopedic Surgery, Orthopedic and Arthritis Center for Outcomes Research, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
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Do people with HIV infection have a higher risk of fracture compared with those without HIV infection? Curr Opin HIV AIDS 2016; 11:301-5. [PMID: 26882459 DOI: 10.1097/coh.0000000000000249] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW This review details recent findings that inform the prevalence and incidence of fractures in people living with HIV (PLWH) and examines the effects of HIV infection and antiretroviral therapy (ART), as well as demographics and traditional risk factors on fractures. As antiretroviral guidelines have recently changed to recommend the introduction of ART at diagnosis of HIV infection, the long-term effects of ART on bone health and fracture risk need to be better understood. RECENT FINDINGS It is apparent that both the effects of HIV infection alone and initiation of ART are associated with significant bone loss in individuals with HIV infection, resulting in osteopenia and osteoporosis. The clinical consequence of low bone mineral density is a greater risk of fragility fractures that are more common in older HIV patients, and those on ART. Frailty occurs at a prevalence of about 10% (about twice that of the general population), and the increased propensity of falls results in greater fracture prevalence, morbidity and mortality. SUMMARY This review examines data from recent cohort studies and clinical trials to inform a better understanding of the complex relationship between the effects of HIV infection, ART and demographics on fractures in PLWH.
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Yin MT, Brown TT. HIV and Bone Complications: Understudied Populations and New Management Strategies. Curr HIV/AIDS Rep 2016; 13:349-358. [PMID: 27730445 DOI: 10.1007/s11904-016-0341-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Michael T Yin
- Division of Infectious Diseases, Columbia University Medical Center, 630 w168th street PH8-876, New York, NY, 10032, USA.
| | - Todd T Brown
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA
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Abstract
Osteoporosis develops when the rate of osteoclastic bone breakdown (resorption) exceeds that of osteoblastic bone formation, which leads to loss of BMD and deterioration of bone structure and strength. Osteoporosis increases the risk of fragility fractures, a cause of substantial morbidity and mortality, especially in elderly patients. This imbalance between bone formation and bone resorption is brought about by natural ageing processes, but is frequently exacerbated by a number of pathological conditions. Of importance to the aetiology of osteoporosis are findings over the past two decades attesting to a deep integration of the skeletal system with the immune system (the immuno-skeletal interface (ISI)). Although protective of the skeleton under physiological conditions, the ISI might contribute to bone destruction in a growing number of pathophysiological states. Although numerous research groups have investigated how the immune system affects basal and pathological osteoclastic bone resorption, recent findings suggest that the reach of the adaptive immune response extends to the regulation of osteoblastic bone formation. This Review examines the evolution of the field of osteoimmunology and how advances in our understanding of the ISI might lead to novel approaches to prevent and treat bone loss, and avert fractures.
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Affiliation(s)
- M Neale Weitzmann
- The Atlanta Department of Veterans Affairs Medical Center, 1670 Clairmont Road, Decatur, Georgia, 30033, USA
- Department of Medicine, Division of Endocrinology and Metabolism and Lipids, Emory University School of Medicine, 101 Woodruff Circle, 1305 WMB, Atlanta, Georgia 30322, USA
| | - Ighovwerha Ofotokun
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, 49 Jesse Hill Jr Drive, Atlanta, Georgia 30303, USA
- Grady Healthcare System, 80 Jesse Hill Jr Drive SE, Atlanta, Georgia, 30303, USA
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Kalapila AG, Marrazzo J. Antiretroviral Therapy for Prevention of Human Immunodeficiency Virus Infection. Med Clin North Am 2016; 100:927-50. [PMID: 27235622 DOI: 10.1016/j.mcna.2016.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Human immunodeficiency virus (HIV) infection is considered a chronic medical condition. Several new drugs are available, including fixed-dose combination tablets, that have greatly simplified combination antiretroviral therapy (ART) regimens to treat HIV, while increasing the life-expectancy of infected individuals. In the last decade, multiple well-regarded studies have established the benefits of using ART in high-risk, HIV-negative persons to prevent HIV acquisition. The primary care provider must not only understand commonly encountered issues pertaining to ART, such as toxicities and drug interactions, but also needs to be aware of using ART for HIV prevention.
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Affiliation(s)
- Aley G Kalapila
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Jeanne Marrazzo
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
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Bedimo R, Maalouf NM, Re VL. Hepatitis C virus coinfection as a risk factor for osteoporosis and fracture. Curr Opin HIV AIDS 2016; 11:285-93. [PMID: 26890206 PMCID: PMC6161492 DOI: 10.1097/coh.0000000000000259] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW With increased survival of HIV-infected patients, osteoporotic fractures have developed as a major cause of morbidity in these patients, and chronic hepatitis C virus (HCV) coinfection has emerged as a significant contributor to this increased fracture risk. The present article reviews the epidemiologic and clinical evidence for osteoporosis and increased fracture risk among HIV/HCV coinfected patients, and potential mechanisms for these outcomes with HCV coinfection. RECENT FINDINGS Epidemiologic studies suggest that HIV/HCV coinfected patients exhibit a three-fold increased fracture incidence compared with uninfected controls, and 1.2-2.4-fold increased fracture risk compared with HIV monoinfected patients. Recent reports suggest that chronic HCV coinfection is independently associated with reduced bone mineral density in HIV, but that it is not associated with significantly increased bone turnover. The deleterious impact of chronic HCV on BMD and fracture risk occurs even in the absence of advanced liver fibrosis or cirrhosis. New tools to assess bone quality, including the trabecular bone score, high-resolution peripheral quantitative computed tomography, and in-vivo microindentation, may help improve understanding of the mechanisms of HCV-associated skeletal fragility. The impact of approved antiosteoporosis medications and direct-acting antivirals for the treatment of chronic HCV infection on patients' bone health remain to be studied. SUMMARY Chronic HCV infection is an independent risk factor for osteoporosis and fractures among HIV-infected patients, even before the development of cirrhosis. The underlying mechanisms are being unraveled, but major questions persist regarding the optimal evaluation and management of bone health in HIV/HCV coinfected patients.
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Affiliation(s)
- Roger Bedimo
- Infectious Diseases Section, Medical Service, Veterans Affairs North Texas Healthcare System, Dallas, TX, USA
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Naim M. Maalouf
- Endocrine Section, Medical Service, Veterans Affairs North Texas Healthcare System, Dallas, TX, USA
- Department of Internal Medicine, Division of Mineral Metabolism, and the Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Klassen KM, Kimlin MG, Fairley CK, Emery S, Anderson PH, Ebeling PR. Associations between vitamin D metabolites, antiretroviral therapy and bone mineral density in people with HIV. Osteoporos Int 2016; 27:1737-45. [PMID: 26659069 DOI: 10.1007/s00198-015-3432-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 11/16/2015] [Indexed: 11/27/2022]
Abstract
RATIONALE To see if vitamin D and antiretroviral therapy are associated with bone mineral density (BMD) in people with HIV. RESULT Lower hip BMD was associated with tenofovir (an antiretroviral medicine) in those with 25(OH)D ≥50 nmol/L. SIGNIFICANCE The relationship between antiretroviral therapy and hip BMD differs depending on vitamin D status. INTRODUCTION People with HIV have an increased risk of low BMD and fractures. Antiretroviral therapy contributes to this increased risk. The aim of this study was to evaluate associations between vitamin D metabolites and antiretroviral therapy on BMD. METHODS The simplification of antiretroviral therapy with tenofovir-emtricitabine or abacavir-lamivudine trial (STEAL) was an open-label, prospective randomised non-inferiority study that compared simplification of current nucleoside reverse transcriptase inhibitors (NRTIs) to fixed-dose combination tenofovir-emtricitabine (TDF-FTC) or abacavir-lamivudine. Serum 25(OH)D and 1,25(OH)2D were measured in 160 individuals (90 receiving TDF-FTC, 70 receiving other NRTIs) at baseline from this study. Multivariable linear regression models were constructed to evaluate the covariates of 1,25(OH)2D and BMD. RESULTS Protease inhibitor use (p = 0.02) and higher body mass index (BMI) (p = 0.002) were associated with lower 1,25(OH)2D levels in those with 25(OH)D <50 nmol/L. However, TDF-FTC use (p = 0.01) was associated with higher 1,25(OH)2D levels, but only in those with 25(OH)D ≥50 nmol/L. White ethnicity (p = 0.02) and lower BMI (p < 0.001) in those with 25(OH)D <50 nmol/L and with TDF-FTC use (p = 0.008) in those with 25(OH)D ≥50 nmol/L were associated with lower hip BMD. TDF-FTC use, higher serum calcium and serum βCTX, winter, and lower bone-specific alkaline phosphatase (BALP) and BMI were associated with lower lumbar spine BMD. CONCLUSION TDF-FTC use (versus non-TDF-FTC use) was associated with lower hip BMD, and this difference was more pronounced in those with 25(OH)D ≥50 nmol/L. Serum 25(OH)D <50 nmol/L was associated with lower hip BMD in all participants. Therefore, the associations between antiretroviral therapy and hip BMD differ depending on vitamin D status.
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Affiliation(s)
- K M Klassen
- Department of Medicine, University of Melbourne, Victoria, 3021, Australia.
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Melbourne, Victoria, Australia.
| | - M G Kimlin
- AusSun Research Lab, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - C K Fairley
- Central Clinical School, Alfred Centre, Monash University, Melbourne, 3004, Australia
| | - S Emery
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - P H Anderson
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - P R Ebeling
- Department of Medicine, University of Melbourne, Victoria, 3021, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Monash Health, Clayton, 3168, Victoria, Australia
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Bates J, Fodeh SJ, Brandt CA, Womack JA. Classification of radiology reports for falls in an HIV study cohort. J Am Med Inform Assoc 2016; 23:e113-7. [PMID: 26567329 PMCID: PMC4954638 DOI: 10.1093/jamia/ocv155] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/14/2015] [Accepted: 09/08/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To identify patients in a human immunodeficiency virus (HIV) study cohort who have fallen by applying supervised machine learning methods to radiology reports of the cohort. METHODS We used the Veterans Aging Cohort Study Virtual Cohort (VACS-VC), an electronic health record-based cohort of 146 530 veterans for whom radiology reports were available (N=2 977 739). We created a reference standard of radiology reports, represented each report by a feature set of words and Unified Medical Language System concepts, and then developed several support vector machine (SVM) classifiers for falls. We compared mutual information (MI) ranking and embedded feature selection approaches. The SVM classifier with MI feature selection was chosen to classify all radiology reports in VACS-VC. RESULTS Our SVM classifier with MI feature selection achieved an area under the curve score of 97.04 on the test set. When applied to all the radiology reports in VACS-VC, 80 416 of these reports were classified as positive for a fall. Of these, 11 484 were associated with a fall-related external cause of injury code (E-code) and 68 932 were not, corresponding to 29 280 patients with potential fall-related injuries who could not have been found using E-codes. DISCUSSION Feature selection was crucial to improving the classifier's performance. Feature selection with MI allowed us to select the number of discriminative features to use for classification, in contrast to the embedded feature selection method, in which the number of features is chosen automatically. CONCLUSION Machine learning is an effective method of identifying patients who have suffered a fall. The development of this classifier supplements the clinical researcher's toolkit and reduces dependence on under-coded structured electronic health record data.
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Affiliation(s)
- Jonathan Bates
- Yale School of Medicine, New Haven, CT VA Connecticut Healthcare System, West Haven, CT
| | | | - Cynthia A Brandt
- Yale School of Medicine, New Haven, CT VA Connecticut Healthcare System, West Haven, CT
| | - Julie A Womack
- Yale School of Nursing, West Haven, CT VA Connecticut Healthcare System, West Haven, CT
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Abstract
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.
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Affiliation(s)
- Nisha Andany
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - V Logan Kennedy
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Muna Aden
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Mona Loutfy
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
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Increased Fracture Incidence in Middle-Aged HIV-Infected and HIV-Uninfected Women: Updated Results From the Women's Interagency HIV Study. J Acquir Immune Defic Syndr 2015; 70:54-61. [PMID: 26322667 DOI: 10.1097/qai.0000000000000674] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Battalora L, Buchacz K, Armon C, Overton ET, Hammer J, Patel P, Chmiel JS, Wood K, Bush TJ, Spear JR, Brooks JT, Young B. Low bone mineral density and risk of incident fracture in HIV-infected adults. Antivir Ther 2015; 21:45-54. [PMID: 26194468 DOI: 10.3851/imp2979] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Prevalence rates of low bone mineral density (BMD) and bone fractures are higher among HIV-infected adults compared with the general United States (US) population, but the relationship between BMD and incident fractures in HIV-infected persons has not been well described. METHODS Dual energy X-ray absorptiometry (DXA) results of the femoral neck of the hip and clinical data were obtained prospectively during 2004-2012 from participants in two HIV cohort studies. Low BMD was defined by a T-score in the interval >-2.5 to <-1.0 (osteopenia) or ≤-2.5 (osteoporosis). We analysed the association of low BMD with risk of subsequent incident fractures, adjusted for sociodemographics, other risk factors and covariables, using multivariable proportional hazards regression. RESULTS Among 1,006 participants analysed (median age 43 years [IQR 36-49], 83% male, 67% non-Hispanic white, median CD4(+) T-cell count 461 cells/mm(3) [IQR 311-658]), 36% (n=358) had osteopenia and 4% (n=37) osteoporosis; 67 had a prior fracture documented. During 4,068 person-years of observation after DXA scanning, 85 incident fractures occurred, predominantly rib/sternum (n=18), hand (n=14), foot (n=13) and wrist (n=11). In multivariable analyses, osteoporosis (adjusted hazard ratio [aHR] 4.02, 95% CI 2.02, 8.01) and current/prior tobacco use (aHR 1.59, 95% CI 1.02, 2.50) were associated with incident fracture. CONCLUSIONS In this large sample of HIV-infected adults in the US, low baseline BMD was significantly associated with elevated risk of incident fracture. There is potential value of DXA screening in this population.
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Bone Density and Fractures in HIV-infected Postmenopausal Women: A Systematic Review. J Assoc Nurses AIDS Care 2015; 26:387-98. [PMID: 26066693 DOI: 10.1016/j.jana.2015.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 03/31/2015] [Indexed: 01/28/2023]
Abstract
With the development of effective antiretroviral therapy, HIV-infected women are living longer and transitioning through menopause. The purpose of our study was to systematically examine the evidence that menopause is an additional risk predictor for osteoporosis and fractures in HIV-infected women. Electronic databases were searched for studies of low bone density or fractures in HIV-infected postmenopausal women. Studies that met the inclusion criteria (n = 10) were appraised using a validated quality assessment tool. The majority of studies were rated as good quality and the remaining were fair. The prevalence of osteoporosis reported in these studies ranged from 7.3% to 84% and 0.7% to 23% in HIV-infected and uninfected postmenopausal women, respectively. In the two qualifying studies, postmenopausal status was not a predictor of fractures in HIV-infected women. Findings suggest that HIV care providers should accurately assess postmenopausal status and modifiable risk factors for osteoporosis in all older HIV-infected women.
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Abstract
HIV infection and initiation of antiretroviral therapy (ART) have been consistently associated with decreased bone mineral density (BMD), with growing evidence linking HIV to an increased risk of fracture. This is especially concerning with the expanding number of older persons living with HIV. Interestingly, recent data suggest that HIV-infected children and youth fail to achieve peak BMD, possibly increasing their lifetime risk of fracture. Elucidating the causes of the bone changes in HIV-positive persons is challenging because of the multifactorial nature of bone disease in HIV, including contribution of the virus, immunosuppression, ART toxicity, and traditional osteoporosis risk factors, such as age, lower weight, tobacco, and alcohol use. Thus, practitioners must recognize the risk of low BMD and fractures and appropriately screen patients for osteoporosis if risk factors exist. If fractures do occur or elevated fracture risk is detected through screening, treatment with bisphosphonate medications appears safe and effective in the HIV+population.
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Affiliation(s)
- Amy H Warriner
- Division of Endocrinology, Metabolism and Diabetes, University of Alabama at Birmingham, FOT 702, 2000 6th Avenue South, Birmingham, AL, 35233-0271, USA,
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Abstract
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.
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Affiliation(s)
- Mark J Bolland
- Department of Medicine, University of Auckland, Auckland, New Zealand.
| | - Andrew Grey
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Ian R Reid
- Department of Medicine, University of Auckland, Auckland, New Zealand
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Osteoporosis and fractures in HIV/hepatitis C virus coinfection: a systematic review and meta-analysis. AIDS 2014; 28:2119-31. [PMID: 24977441 DOI: 10.1097/qad.0000000000000363] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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.
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Escota GV, Cross S, Powderly WG. Vitamin D and calcium abnormalities in the HIV-infected population. Endocrinol Metab Clin North Am 2014; 43:743-67. [PMID: 25169565 DOI: 10.1016/j.ecl.2014.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of vitamin D deficiency among HIV-infected persons is substantial and comparable to the general population. The factors associated with vitamin D deficiency are similar for both populations but additional factors (ie, use of certain antiretroviral agents) also contribute to vitamin D deficiency among HIV-infected persons. The adverse outcomes associated with vitamin D deficiency considerably overlap with non-AIDS defining illnesses (NADIs) that are increasingly becoming widespread in the aging HIV-infected population. However, there is scant evidence to support any causal inference. Further studies are warranted as efforts to identify and address modifiable risk factors contributing to NADIs continue.
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Affiliation(s)
- Gerome V Escota
- Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid, St Louis, MO 63110, USA
| | - Sara Cross
- Division of Infectious Diseases, University of Tennessee Health Sciences Center, 956 Court Avenue, E336 Coleman Building, Memphis, TN 38163, USA
| | - William G Powderly
- Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid, St Louis, MO 63110, USA.
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Compston J. Osteoporosis and fracture risk associated with HIV infection and treatment. Endocrinol Metab Clin North Am 2014; 43:769-80. [PMID: 25169566 DOI: 10.1016/j.ecl.2014.05.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Osteoporosis has emerged as an important co-morbidity of HIV infection and a modest increase in fracture risk has been documented. Bone loss from the spine and hip occurs after initiation of antiretroviral therapy but most data indicate that bone mineral density is stable in HIV-infected individuals established on long-term antiretroviral therapy. Assessment of fracture probability should be performed in individuals who have clinical risk factors for fracture. Adequate dietary calcium intake and vitamin D status should be ensured and in individuals with a high fracture probability, bisphosphonate therapy may be appropriate.
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Affiliation(s)
- Juliet Compston
- Department of Medicine, Addenbrookes Hospital, Cambridge Biomedical Campus, Box 157, Cambridge CB2 0QQ, UK.
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O’Neill TJ, Rivera L, Struchkov V, Zaheen A, Thein HH. The effect of HIV-hepatitis C co-infection on bone mineral density and fracture: a meta-analysis. PLoS One 2014; 9:e101493. [PMID: 25033046 PMCID: PMC4102482 DOI: 10.1371/journal.pone.0101493] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 06/06/2014] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Tyler J. O’Neill
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
| | - Laura Rivera
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Vladi Struchkov
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ahmad Zaheen
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hla-Hla Thein
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Ontario Institute for Cancer Research/Cancer Care Ontario, Toronto, Ontario, Canada
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Fracture risk in hepatitis C virus infected persons: results from the DANVIR cohort study. J Hepatol 2014; 61:15-21. [PMID: 24650694 DOI: 10.1016/j.jhep.2014.03.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 03/06/2014] [Accepted: 03/07/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The association between Hepatitis C virus (HCV)-infection and fracture risk is not well characterized. We compared fracture risk between HCV-seropositive (HCV-exposed) patients and the general population and between patients with cleared and chronic HCV-infection. METHODS Outcome measures were time to first fracture at any site, time to first low-energy and first non-low-energy (other) fracture in 12,013 HCV-exposed patients from the DANVIR cohort compared with a general population control cohort (n=60,065) matched by sex and age. Within DANVIR, 4500 patients with chronic HCV-infection and 2656 patients with cleared HCV-infection were studied. RESULTS Compared with population controls, HCV-exposed patients had increased overall risk of fracture [adjusted incidence rate ratio (aIRR) 2.15, 95% Confidence Interval (CI) 2.03-2.28], increased risk of low-energy fracture (aIRR 2.13, 95% CI: 1.93-2.35) and of other fracture (aIRR 2.18, 95% CI: 2.02-2.34). Compared with cleared HCV-infection, chronic HCV-infection was not associated with increased risk of fracture at any site (aIRR 1.08, 95% CI: 0.97-1.20), or other fracture (aIRR 1.04, 95% CI: 0.91-1.19). The aIRR for low-energy fracture was 1.20 (95% CI: 0.99-1.44). CONCLUSIONS HCV-exposed patients had increased risk of all fracture types. In contrast, overall risk of fracture did not differ between patients with chronic vs. cleared HCV-infection, although chronic HCV-infection might be associated with a small excess risk of low-energy fractures. Our study suggests that fracture risk in HCV-infected patients is multi-factorial and mainly determined by lifestyle-related factors associated with HCV-exposure.
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Güerri-Fernández R, Villar-García J, Díez-Pérez A, Prieto-Alhambra D. HIV infection, bone metabolism, and fractures. ACTA ACUST UNITED AC 2014; 58:478-83. [DOI: 10.1590/0004-2730000003323] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 05/12/2014] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Daniel Prieto-Alhambra
- University of Oxford, UK; University of Southampton, UK; Universitat Autònoma de Barcelona, Spain
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Maffezzoni F, Porcelli T, Karamouzis I, Quiros-Roldan E, Castelli F, Mazziotti G, Giustina A. Osteoporosis in Human Immunodeficiency Virus Patients - An Emerging Clinical Concern. EUROPEAN ENDOCRINOLOGY 2014; 10:79-83. [PMID: 29872469 DOI: 10.17925/ee.2014.10.01.79] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 03/06/2014] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Andrea Giustina
- Full Professor, Division of Endocrinology, Department of Clinical and Experimental Sciences, University of Brescia, Italy
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Piso RJ, Rothen M, Rothen JP, Stahl M, Fux C. Per oral substitution with 300000 IU vitamin D (Cholecalciferol) reduces bone turnover markers in HIV-infected patients. BMC Infect Dis 2013; 13:577. [PMID: 24314015 PMCID: PMC4029316 DOI: 10.1186/1471-2334-13-577] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 12/02/2013] [Indexed: 12/31/2022] Open
Abstract
Background Osteoporosis and bone fractures seem to be higher in HIV-infected Patients compared to the general populations. Moreover, bone turnover markers are increased in patients on antiretroviral therapy and vitamin D deficiency is prevalent in HIV-infected patients. However, the influence of per oral cholecalciferol on bone metabolism in HIV infected patients is not well understood. Methods We measured the bone turnover markers in 96 HIV-infected patients: Bone specific alkaline phosphatase (BSAP), Pyridinoline (PYR), Desoxypyridinoline (DPD) and 25-OH vitamin D. If 25-OH vitamin D was below 75 nnol/L (87/96 patients), 300000 IU cholecalciferol was given per os. 25OH-vitamin D and bone turn over markers were determinded 3 month later. 25 OH-vitamin D was corrected for circannual rythm y'=y+17.875*sin2π365*day+2.06, whereas bone turnover markers were not corrected. The paired students t-Test was used to compare the two periods. No calcium supplementation or biphosphonate therapy was given. Results Corrected 25OH-vitamin D levels increased significantly after supplementation (42.7 ± 26.61 vs. 52.85 ± 21.8 nmol/L, p < 0.001). After supplementation, bone turnover markers were significantly lower. The values decreased for BSAP from 21.31 ± 14.32 to 17.53 ± 8.17 μg/L (p < 0.001), PYR from 74.57 ± 36.83 to 54.82 ± 21.43 nmol/mmol creatinine (p < 0.001) and DPD from 15.17 ± 8.34 to 12.61 ± 5.02 nmol/mmol creatinine (p = 0.01). Conclusions After per oral substitution with cholecalciferol, bone formation as well as bone resorption markers decreased significant. We postulate a protective effect on bone structure with cholecalciferol supplementation.
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Affiliation(s)
- Rein Jan Piso
- Department of Medicine, Kantonsspital, Olten, Switzerland.
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49
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Abstract
OBJECTIVE(S) Some but not all studies indicate that individuals with HIV infection are at an increased risk of fracture. We systematically reviewed the literature to investigate whether incidence of fracture (both overall and fragility) differs between individuals with and without HIV. DESIGN A systematic review and meta-analysis. METHODS Medline, Scopus and the Cochrane Library databases for all studies ever published up to 28 September 2012 and electronically available conference abstracts from CROI, ASBMR, IAS and AIDS were searched. All studies reporting incidence of all fracture and fragility fracture in HIV-infected adults were included. A random effects model was used to calculate pooled estimates of incidence rate ratios (IRRs) for studies that presented data for HIV-infected and controls. For all studies, incidence rates of fracture and predictors of fracture among HIV-infected individuals were summarized. RESULTS Thirteen eligible studies were analysed, of which seven included controls. Nine studies reported all incident fractures and 10 presented incident fragility fractures. The pooled IRR was 1.58 [95% confidence interval (CI) 1.25-2.00] for all fracture and 1.35 (95% CI 1.10-1.65) for fragility fracture. Smoking, white race and older age were consistent predictors for fragility fractures. CONCLUSION Our results indicate that HIV infection is associated with a modest increase in incident fracture. Future research should focus on clarifying risk factors, designing appropriate interventions and the long-term implications of this increased risk for an ageing HIV-infected population.
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Puthanakit T, Siberry GK. Bone health in children and adolescents with perinatal HIV infection. J Int AIDS Soc 2013; 16:18575. [PMID: 23782476 PMCID: PMC3687077 DOI: 10.7448/ias.16.1.18575] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 04/10/2013] [Accepted: 04/16/2013] [Indexed: 01/02/2023] Open
Abstract
The long-term impact on bone health of lifelong HIV infection and prolonged ART in growing and developing children is not yet known. Measures of bone health in youth must be interpreted in the context of expected developmental and physiologic changes in bone mass, size, density and strength that occur from fetal through adult life. Low bone mineral density (BMD) appears to be common in perinatally HIV-infected youth, especially outside of high-income settings, but data are limited and interpretation complicated by the need for better pediatric norms. The potential negative effects of tenofovir on BMD and bone mass accrual are of particular concern as this drug may be used more widely in younger children. Emphasizing good nutrition, calcium and vitamin D sufficiency, weight-bearing exercise and avoidance of alcohol and smoking are effective and available approaches to maintain and improve bone health in all settings. More data are needed to inform therapies and monitoring for HIV-infected youth with proven bone fragility. While very limited data suggest lack of marked increase in fracture risk for youth with perinatal HIV infection, the looming concern for these children is that they may fail to attain their expected peak bone mass in early adulthood which could increase their risk for fractures and osteoporosis later in adulthood.
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Affiliation(s)
- Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- HIVNAT, Thai Red Cross AIDS Research Center, Bangkok, Thailand
| | - George K Siberry
- Maternal and Pediatric Infectious Disease (MPID) Branch, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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