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

Bone mineral density changes in breastfeeding women with HIV on antiretroviral therapy in Eastern and Southern Africa

OBJECTIVE

The aim of this study was to describe postpartum bone mineral density (BMD) change among breastfeeding African women with HIV (WHIV) on life-long antiretroviral therapy (ART).

DESIGN

In IMPAACT P1084 s, postpartum BMD declines were greater in WHIV randomized to ART to prevent breastmilk transmission compared to infant nevirapine prophylaxis. This analysis extends the observation period through entry to a follow-on observational study, PROMOTE.

METHODS

Lumbar spine, total hip, and femoral neck BMD were assessed using dual energy x-ray absorptiometry (DXA) at postpartum weeks 1 and 74 in P1084 s, and at PROMOTE entry. Participants were included if DXA data were available from PROMOTE entry and more than one earlier timepoint. Country-specific Z-scores were created by internal standardization to week 1 values. Linear mixed models, adjusted for country, estimated the average 5-year change in BMD z -scores between postpartum week 1 and PROMOTE entry. Linear regression assessed the association between maternal characteristics and the rate of change in BMD z -score.

RESULTS

We included BMD data from 519 participants between postpartum week 1 through PROMOTE entry [median (IQR) 4.6 (3.5-5.1) years postpartum]. For every 5 years passed, lumbar spine BMD Z -scores increased by + 0.250 units, while total hip and femoral neck BMD z -scores decreased by -0.173 and -0.141 units, respectively. Lumbar spine, total hip, and femoral neck BMD increased between postpartum week 74 and PROMOTE entry, but only lumbar spine BMD fully recovered to week 1 values.

CONCLUSION

Given dampened total hip and femoral neck BMD recovery postbreastfeeding, longer term monitoring is needed to assess peri-/postmenopausal fracture risk, and interventions to optimize bone health among WLHIV on life-long ART.

Combined Sequential Antiretroviral Therapy-Induced Immune Reconstitution Bone Loss and Estrogen Deficiency Bone Loss Are Cumulative in Mice Models

BACKGROUND

Antiretroviral therapy causes osteoporosis and bone fractures, increasing morbidity and mortality in people with HIV (PWH). Antiretroviral therapy induces immune reconstitution bone loss (IRBL), an inflammatory reaction associated with immune system reactivation. Women represent >50% of PWH, and many are now undergoing menopause, a major cause of postmenopausal osteoporosis that also increases fracture risk. However, the interactions between IRBL and postmenopausal bone loss are poorly understood and were investigated in this study.

METHODS

We used a mouse model of IRBL, which was applied simultaneously or sequentially with surgical ovariectomy (Ovx) as a mouse model of postmenopausal osteoporosis. Cortical and trabecular bone in vertebrae and femurs was assessed with micro-computed tomography, and bone turnover was quantified by serum markers of bone resorption and formation via enzyme-linked immunosorbent assay. T-cell production of osteoclastogenic cytokines was analyzed by flow cytometry.

RESULTS

Although simultaneous Ovx and IRBL did not have additive effects, sequential Ovx and IRBL caused cumulative bone loss. Vertebral bone loss from combined Ovx and IRBL (Δ = -42.6 vs control, P < .01) was blunted by the anti-inflammatory agent abatacept (Δ = -13.9 vs control, not significant) and the probiotic Lactobacillus rhamnosus GG (Δ = -8.6 vs control, not significant). Both treatments reduced bone resorption, stimulated formation, and suppressed CD4+ T-cell production of the osteoclastogenic cytokines TNF-α and IL-17A.

CONCLUSIONS

Sequential IRBL and postmenopausal bone loss appear to be cumulative. If validated in humans, early screening and prophylaxis could reduce fracture risk in postmenopausal women with HIV. Probiotic therapy may provide a beneficial alternative to pharmacotherapy.

Bone loss in young adults with HIV following antiretroviral therapy containing tenofovir disoproxil fumarate regimen using machine learning

Objective

Bone mineral density (BMD) monitoring, primarily relying on dual-energy X-ray absorptiometry (DEXA), remains inaccessible in resource-limited regions, making it difficult to promptly address bone loss in people with HIV (PWH) on long-term ART-containing TDF regimens and assess the prevalence of bone loss. Our objective is to identify the frequency of PWH experiencing bone loss after long-term ART with a TDF regimen and to develop a predictive model of HIV-infected high-risk populations containing TDF long-time ART, for providing more appropriate ART regimens for PWH in clinical practice, particularly in resource-limited settings.

Methods

Our study retrospectively screened PWH under long-term follow-up at Peking Union Medical College Hospital (PUMCH) from January 2000 to August 2024. These individuals were either treatment-naive or treatment-experienced and had been on containing TDF ART regimen for over 5 years. BMD was assessed using DEXA every 1-2 years in this center. We selected predictive factors utilizing machine learning methods, including Random Forest, XGBoost, LASSO regression, and logistic regression. The results were visualized using a nomogram.

Results

Our study enrolled a total of 232 PWH who have contained TDF ART regimens for more than 5 years. Twenty-five percent (58/232) of the patients experienced bone loss, primarily including osteopenia and osteoporosis. Further results showed that the LASSO regression model was the most suitable for the current dataset, based on a comparison of LASSO regression, Random Forest, XGBoost, and logistic regression models including age, gender, LPV/r, baseline CD4+ T count, baseline VL, baseline body weight, treatment-naïve TDF, ART duration, percentage of CD38+CD8+T, percentage of HLA-DR+CD8+ T, and CD4+/CD8+ ratio, with AUC values of 0.615, 0.507, 0.593, and 0.588, respectively. We identified age, gender, and LPV/r as the most relevant predictive factors associated with bone loss based on LASSO regression. Then the results were visualized and plotted in a nomogram.

Conclusion

Our study quantified the frequency and established a nomogram based on the LASSO regression model to predict bone loss in PWH on long-term containing TDF ART. The nomogram guides identifying individuals at high risk of bone loss due to prolonged TDF exposure. Clinicians can leverage the predicted risk to design personalized ART regimens at the initiation of therapy or to switch from TDF-containing to TDF-free regimens during treatment. This approach aims to reduce the incidence of bone loss, particularly in resource-limited settings.

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

Aims

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

Methods

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

Results

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

Conclusion

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

Prevalence and associated factors of low bone mineral density in people living with HIV: a cross-sectional study

This study examined low bone mineral density (BMD) prevalence and associated factors among Chinese people living with HIV (PLWH), uncovering a persistent high BMD risk in older individuals, even after adjusting for age and body mass index (BMI). Notably, lopinavir/ritonavir (LPV/r) therapy was linked to reduced BMD, highlighting the imperative need for regular BMD monitoring and interventions in older PLWH.

PURPOSE

HIV infection and antiretroviral therapy (ART) have been shown to contribute to lower BMD, resulting in an increased susceptibility to osteopenia and osteoporosis. However, there is limited knowledge about the prevalence of reduced BMD and its associated factors among Chinese PLWH. In this cross-sectional study, we aimed to investigate the prevalence and factors associated with low BMD among PLWH in China.

METHODS

We retrospectively enrolled PLWH and non-HIV volunteers who underwent dual-energy X-ray absorptiometry (DXA) scans to measure bone density. Demographic information, laboratory test results, ART regimens, and treatment duration were collected. Univariate and multiple regression analyses were performed to identify factors influencing abnormal bone mass in PLWH.

RESULTS

A total of 829 individuals were included in this study, comprising the HIV group (n = 706) and the non-HIV group (n = 123). The prevalence of low BMD among all PLWH was found to be 13.88% (98 out of 706). However, among PLWH aged 50 years and above, the prevalence increased to 65.32% (81 out of 124). In contrast, control subjects in the same age group had a prevalence of 38.21% (47 out of 123). After adjusting for age and BMI, older PLWH still demonstrated a higher prevalence of low BMD compared to the non-HIV group (68.24% vs 34.94%, P < 0.001). Multivariate analysis revealed that older age was strongly associated with a higher risk of low BMD among PLWH, with an odds ratio (OR) of 6.28 for every 10-year increase in age in the ART-naïve population (95% confidence intervals [CIs], 3.12-12.65; P < 0.001) and OR of 4.83 in the ART-experienced population (3.20-7.29, P < 0.001). Within the ART-experienced group, current LPV/r treatment was associated with an increased risk of low BMD (OR = 3.55, 1.24-10.14, P < 0.05), along with lower BMI (OR = 0.84, 0.75-0.95, P < 0.05), and elevated alkaline phosphatase (OR = 1.02, 1.01-1.03, P < 0.01).

CONCLUSION

The prevalence of low BMD is higher among PLWH aged 50 years and above compared to non-HIV individuals. The use of LPV/r for ART is associated with reduced BMD. These findings emphasize the importance of regular monitoring of BMD in older PLWH and the need for appropriate interventions to mitigate the risks of osteopenia and osteoporosis in this population.

Clinical considerations when switching antiretroviral therapy

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Cardiometabolic health in people with HIV: expert consensus review

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Tenofovir induced Fanconi syndrome in a middle age African female from Kenya, East Africa: Case report and brief literature review

This case presentation highlights the need to routinely monitor renal function in patients on Tenofovir Disoproxil Fumarate (TDF) due to its side effect of proximal tubule dysfunction.

Abstract

This is a case presentation of a 50-year-old African female who had been on a Tenofovir based regimen for 12 years and developed Fanconi syndrome. She recovered after discontinuation of the Tenofovir Disoproxil Fumarate (TDF).

Unilateral avascular necrosis of the right hip in an HIV patient with tearing of the rectus femoris and adductor longus muscles

A man in his 20s with a medical history of syphilis, chlamydia and HIV presented to the emergency department (ED) with 2 months of right hip pain and was found to have advanced avascular necrosis (AVN) of the right femoral head with secondary haemorrhage. The patient lacked the common risk factors of AVN in patients with HIV (PWH): ≥10 years of HIV diagnosis, extended duration on highly active antiretroviral therapy, trauma, corticosteroid use, alcohol abuse, systemic lupus erythematosus, obesity, smoking and dyslipidaemia. Given the extensive destructive changes in the hip joint and muscles, a right hip resection arthroplasty was performed, and the patient recovered well postoperatively. This case presents a learning opportunity for understanding bone pathologies in PWH and offers clinical guidance for the management of HIV-infected patients with a focus on optimising bone health.

The anti-HIV drug abacavir stimulates β-catenin activity in osteoblast lineage cells

Bone mineral density (BMD) loss in people living with HIV occurs with the initiation of combined antiretroviral therapy (cART), particularly with tenofovir disoproxil fumarate (TDF) containing cART. Switching from TDF to abacavir (ABC) or dolutegravir (DTG) leads to increased BMD. Whether BMD gains are due to cessation of TDF or anabolic effects of ABC or DTG is unclear. We investigated the effects of ABC and DTG on osteoblast lineage cells in vitro and in vivo. Primary human osteoblasts and male C57BL/6 mice were treated with individual antiretrovirals (ARVs) or a combination of ABC/DTG/lamivudine (3TC). Nearly all ARVs and cART inhibited osteogenic activity in vitro. Due to the importance of Wnt/β-catenin in bone formation, we further investigated ARV effects on the Wnt/β-catenin pathway. ABC, alone and as part of ABC/DTG/3TC, increased osteoblastic β-catenin activity as indicated by increased TOPFlash activity, hypo-phosphorylated (active) β-catenin staining, and β-catenin targeted gene expression. Mice treated with TDF had decreased lumbar spine BMD and trabecular connectivity density in the vertebrae, while those treated with ABC/DTG/3TC reduced cortical area and thickness in the femur. Mice treated with ABC alone had no bone structural changes, increased circulating levels of the bone formation marker, P1NP, and elevated expression of the Wnt/β-catenin target gene, Lef1, in osteocyte enriched samples. Further, bones from ARV-treated mice were isolated to evaluate ARV distribution. All ARVs were detected in the bone tissue, which was inclusive of bone marrow, but when bone marrow was removed, only TDF, ABC, and DTG were detected at ~0.1% of the circulating levels. Overall, our findings demonstrate that ABC activates Wnt/β-catenin signaling, but whether this leads to increased bone formation requires further study. Assessing the impact of ARVs on bone is critical to informing ARV selection and/or discovery of regimens that do not negatively impact the skeleton.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Bone mineral density among children living with HIV failing first-line anti-retroviral therapy in Uganda: A sub-study of the CHAPAS-4 trial

BACKGROUND

Children living with perinatally acquired HIV (CLWH) survive into adulthood on antiretroviral therapy (ART). HIV, ART, and malnutrition can all lead to low bone mineral density (BMD). Few studies have described bone health among CLWH in Sub-Saharan Africa. We determined the prevalence and factors associated with low BMD among CLWH switching to second-line ART in the CHAPAS-4 trial (ISRCTN22964075) in Uganda.

METHODS

BMD was determined using dual-energy X-ray Absorptiometry (DXA). BMD Z-scores were adjusted for age, sex, height and race. Demographic characteristics were summarized using median interquartile range (IQR) for continuous variables and proportions for categorical variables. Logistic regression was used to determine the associations between each variable and low BMD.

RESULTS

A total of 159 children were enrolled (50% male) with median age (IQR) 10 (7-12) years, median duration of first -line ART 5.2(3.3-6.8) years; CD4 count 774 (528-1083) cells/mm3, weight-for-age Z-score -1.36 (-2.19, -0.65) and body mass index Z-score (BMIZ) -1.31 (-2.06, -0.6). Low (Z-score≤ -2) total body less head (TBLH) BMD was observed in 28 (18%) children, 21(13%) had low lumbar spine (LS) BMD, and15 (9%) had both. Low TBLH BMD was associated with increasing age (adjusted odds ratio [aOR] 1.37; 95% CI: 1.13-1.65, p = 0.001), female sex (aOR: 3.8; 95% CL: 1.31-10.81, p = 0.014), low BMI (aOR 0.36:95% CI: 0.21-0.61, p<0.001), and first-line zidovudine exposure (aOR: 3.68; 95% CI: 1.25-10.8, p = 0.018). CD4 count, viral load and first- line ART duration were not associated with TBLH BMD. Low LS BMD was associated with increasing age (aOR 1.42; 95% CI: 1.16-1.74, p = 0.001) and female sex: (aOR 3.41; 95% CI: 1.18-9.8, p = 0.023).

CONCLUSION

Nearly 20% CLWH failing first-line ART had low BMD which was associated with female sex, older age, first-line ZDV exposure, and low BMI. Prevention, monitoring, and implications following transition to adult care should be prioritized to identify poor bone health in HIV+adolescents entering adulthood.

Examination of Risk Factors and Expression Patterns of Atypical Femoral Fractures Using the Japanese Adverse Drug Event Report Database: A Retrospective Pharmacovigilance Study

Atypical femoral fracture (AFF) is a rare complication related to the use of bisphosphonates (BPs). Herein, we analyzed the risk factors and onset patterns of AFF using the Japanese Adverse Drug Event Report database and reported the findings. First, the independent risk factors for AFF were gender (female), high body mass index, and medical history of osteoporosis, arthritis, and systemic lupus erythematosus (SLE). Drug-related risk factors for AFF included BPs (i.e., alendronic acid, ibandronic acid, etidronic acid, zoledronic acid, minodronic acid, risedronic acid), denosumab, prednisolone, lansoprazole, rabeprazole, exemestane, letrozole, eldecalcitol, and menatetrenone. Therefore, it appears that AFF is influenced by a combination of patient backgrounds and drugs, and that the risk of developing AFF is particularly high in patients with fragile bones (e.g., osteoporosis, arthritis, and SLE). Second, in the analysis of AFF onset patterns, the onset of AFF from BPs and denosumab took a long time (>1 year) to develop. Analysis using a Weibull distribution showed wear-out failure-type AFF onset for BPs and denosumab, and both osteoporosis and cancer patients with long-term administration of these drugs showed a tendency to have an increased risk of onset. AFF developed earlier in osteoporosis patients with long-term administration of BPs and denosumab than in cancer patients.

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

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

Prevalence and Risk Factors of Low Bone Mineral Density in HIV/AIDS Patients: A Chinese Cross-Sectional Study

INTRODUCTION

Our study aimed to investigate the prevalence and risk factors of low bone mineral density (BMD) among HIV/AIDS patients in China.

METHODS

We performed a cross-sectional analysis of HIV-infected patients from October 2017 to August 2020. Demographic information, clinical data, and serum parameters were obtained. Univariable and multiple logistic regression analyses were performed.

RESULTS

A total of 1143 patients were included. In the ART-naive group, low BMD was diagnosed in 19.2% (117/608), including osteoporosis in 1.0% (6/608) and osteopenia in 18.3% (111/608). In the ART group, low BMD was diagnosed in 32.2% (231/717), including osteoporosis in 2.4% (17/717) and osteopenia in 29.8% (214/717). Using multivariate analysis, we identified age older than 50 years, body mass index < 18.5 kg/m2, and treatment based on tenofovir disoproxil fumarate as independent risk factors for low BMD. Low high-density lipoprotein cholesterol was a protective factor for low BMD. Among low BMD participants, the most common number of low BMD sites for a patient to have was 4 (33.6%, 117/348).

CONCLUSION

We confirmed a high prevalence of low BMD and osteoporosis in HIV/AIDS patients, and we identified age older than 50 years, low body mass index, and a treatment based on tenofovir disoproxil fumarate as risk factors for low BMD. Low high-density lipoprotein cholesterol had a protective effect against low BMD. Among low BMD patients, patients most commonly had 4 sites with low BMD, which has been associated with fracture risk. In addition, bone changes to L1 can present before low BMD diagnosis and may be a potentially useful indicator that low BMD is developing.

Evaluation of the Effects of Favipiravir Combined with Vitamin C on Alveolar Bone in Rats

Introduction: Favipiravir and Vitamin C (Vit C) were used together in the treatment of the COVID-19 pandemic. However, the effects of favipiravir on the periodontium are still unknown. Therefore, the aim of this study was to investigate the effects of Favipiravir and Vit C treatment on alveolar bone metabolism. Experimental: Fifty healthy adult male Sprague-Dawley rats (2–3 months old) were randomly divided into five equal groups (n = 10): Control, Favi 20, Favi 100, Favi 20+Vit C, Favi 100+Vit C. Favipiravir (20 mg/kg and 100 mg/kg, i.m.) and Vit C (150 mg/kg/day, oral) were administered to the rats for 14 days. Alveolar bone loss (ABL) and histopathological changes were examined using a light microscope. Immunohistochemistry was used to determine levels of receptor activator of nuclear factor kappa-B ligand (RANKL), caspase-3, bone morphogenic protein 2 (BMP-2) and alkaline phosphatase (ALP) in the bone tissues. Results: Favipiravir increased the levels of RANKL and caspase-3 expression but decreased BMP-2 and ALP levels in a dose-dependent manner. Favi 20+Vit C and Favi 100 +Vit C groups showed decreased RANKL and caspase-3 levels in addition to increased BMP-2 and ALP levels. Conclusion: Favipiravir can cause histopathological damage to the periodontium, but administration of favipiravir combined with Vit C can provide a protective effect against this damage.

Bilateral symmetrical stress fractures of femoral Neck in HIV patient: Case report and brief review of literature

Osseous changes in HIV(Human immunodeficiency virus) positive patients receiving ART (antiretroviral therapy) are three times greater than in normal individuals.These changes include osteopenia/osteoporosis,stress fractures,fragility fractures and osteonecrosis.On an average,bone mineral density reduces by 2 to 6% in the first two years after commencement of antiretroviral therapy. High risk for stress fractures is observed in these patients.In present article,we report a case of bilateral femoral neck stress fractures in a known HIV patient.

Immune Reconstitution Bone Loss Exacerbates Bone Degeneration Due to Natural Aging in a Mouse Model

BACKGROUND

Immune reconstitution bone loss (IRBL) is a common side-effect of antiretroviral therapy (ART) in people living with HIV (PWH). IRBL acts through CD4 + T-cell/immune reconstitution-induced inflammation and is independent of antiviral regimen. IRBL may contribute to the high rate of bone fracture in PWH, a cause of significant morbidity and mortality. Although IRBL is transient, it remains unclear whether bone recovers, or is permanently denuded and further compounds bone loss associated with natural aging.

METHODS

We utilized a validated IRBL mouse model involving T-cell reconstitution of immunocompromised mice. Mice underwent cross-sectional bone phenotyping of femur and/or vertebrae between 6- and 20-months-of-age by micro-computed tomography (µCT) and quantitative bone histomorphometry. CD4 + T-cells were purified at 20 months to quantify osteoclastogenic/inflammatory cytokine expression.

RESULTS

While cortical IRBL in young animals recovered with time, trabecular bone loss was permanent, and exacerbated skeletal decline associated with natural aging. At 20-months-of-age, reconstituted CD4 + T-cells express enhanced osteoclastogenic cytokines including RANKL, IL-1β, IL-17A and TNFα, consistent with elevated osteoclast numbers.

CONCLUSIONS

IRBL in the trabecular compartment is permanent and further exacerbates bone loss due to natural aging. If validated in humans, interventions to limit IRBL may be important to prevent fractures in aging PWH.

Contributory role of ART in the development of non-AIDS comorbidities in asymptomatic PLWHA

BACKGROUND

Despite the many benefits that follow antiretroviral therapy (ART) initiation, its chronic use contributes to the early aging of people living with HIV/AIDS (PLWHA). The aim of this cross-sectional study was to trace the prevalence of and investigate possible renal, bone and metabolic changes, as well as cardiovascular risk in 94 asymptomatic PLWHA, relating them to the duration of ART use.

METHODS

Four groups were evaluated according to ART use: G1 (n = 21), ART-naïve individuals; G2 (n = 17), <2 years; G3 (n = 40), 2-10 years; and G4 (n = 16) on ART for more than 10 years.

RESULTS

Our results showed a high prevalence of dyslipidemic individuals (64%), especially in those under ART. Lower creatine phosphokinase levels were observed in G1 as compared to the others (p < 0.05). Regarding the Framingham score, 12.1% of PLWHA showed moderate and high risk, and the highest proportion (38.5%) occurred in G4 (p = 0.003). A decrease in glomerular filtration rates occurred in 20% of patients, which was also more significant in G3 and G4 (p = 0.007). High prevalences of osteopenia and osteoporosis (53.2%) were found, especially in G1 and G4; however, G1 showed the lowest means for alkaline phosphatases (AP, p = 0.04 and BAP, p = 0.005) and osteocalcin (p = 0.005), in addition to higher vitamin-D concentrations (p = 0.04).

CONCLUSIONS

Our study showed the possible contributory role of ART in these changes, which leads us to reflect on the need for specific conducts and patient care, pointing out the importance of individualized care in an attempt to increase life expectancy.

Exploring the Mechanisms Underlying Drug-Induced Fractures Using the Japanese Adverse Drug Event Reporting Database

Fractures occur when bones become fragile and are subjected to external forces as occurring during falls. The use of drugs that increase bone fragility or fall risk increases the risk of fracture. This study investigates drug-induced fractures reported in the Japanese Adverse Drug Event Report (JADER) database in patients using 4892 drugs. Atypical femur fracture was the most frequently reported fracture, and 58 other fractures were also reported. Using Volcano plots and multiple logistic regression analysis, we identified the risk factors for drug-induced fractures as being female, of older age, higher body mass index, and using one of 90 drugs. The drug groups significantly associated with drug-induced fractures included bone resorption inhibitors, antiviral drugs, dopaminergic drugs, corticosteroids, and sleep sedatives. Principal component analysis was used to examine the relationship between the use of specific drugs and the site of drug-induced fracture. Bone resorption inhibitors and corticosteroids were associated with atypical femur fractures, jaw fractures, and ulna fractures through an osteoclast-mediated process. Other drugs were found to increase fracture risk via non-osteoclast-mediated mechanisms. These findings suggest that many drugs can result in drug-induced fractures through a variety of mechanisms.

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

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

Menopausal hormone therapy for women living with HIV

People living with HIV are ageing, and a growing number of women living with HIV are entering menopause. Women living with HIV commonly have bothersome vasomotor symptoms and onset of menopause at earlier ages; both factors go on to affect quality of life and systemic health. Vasomotor symptoms and early menopause are both indications for menopausal hormone therapy; however, current evidence suggests that this therapy is seldom offered to women living with HIV. Additionally, women living with HIV have several risks to bone health and are likely to benefit from the bone-strengthening effects of menopausal hormone therapy. We present an assessment of the benefits and risks of menopausal hormone therapy in the context of HIV care and propose a practical approach to its prescription. If considered in the appropriate clinical context with discussion of risks and benefits, menopausal hormone therapy might provide substantial benefits to symptomatic menopausal women living with HIV and improve health-related quality of life.

The benefits of tenofovir discontinuation with or without bisphosphonate therapy in osteoporotic people living with HIV

OBJECTIVES

Treatment with bisphosphonates and discontinuation of tenofovir disoproxil fumarate (TDF) are recommended strategies for managing osteoporosis in people living with HIV (PLHIV). This study aimed to compare the effects on bone mineral density (BMD) of TDF discontinuation with and without bisphosphonate therapy in osteoporotic PLHIV.

METHODS

The present study is a retrospective cohort analysis of dual-energy X-ray absorptiometry scan results of PLHIV attending Chelsea and Westminster Hospital HIV clinic between 2009 and 2020. Osteoporotic (T-score < -2.5) patients with ≥ 6 months' TDF exposure were included. Changes in BMD and T-scores at the lumbar spine (LS) and femoral neck (FN) were assessed.

RESULTS

A total of 84 participants were included, of whom 43 discontinued TDF only (TS) and 41 switched from TDF and received bisphosphonates (TS+): 86.9% were male; 77.4% were white; median (interquartile range, IQR) age was 54.8 (51.0-58.5) years; and median (IQR) TDF exposure was 6.5 (3.5-10.4) years. At a median follow-up of 2 years after TDF-discontinuation, mean spine BMD increased significantly in both groups, but bisphosphonate recipients had greater improvements (4.83% vs. 7.79%; P < 0.019); LS T-scores improved significantly but changes were comparable between groups (TS, 0.5 vs. TS+, 0.6; P = 0.270). At the FN, no significant increases in BMD were observed (TS, 3.05% vs. TS+, 2.71%; P = 0.205); T-scores significantly improved in bisphosphonate recipients only (+0.2; P = 0.003). A greater proportion recovered from osteoporosis in the TS+ group (34.9% vs. 43.9%), although differences between groups were not significant (P = 0.503).

CONCLUSIONS

Our real-world data indicate that although TDF discontinuation significantly improved bone health in osteoporotic PLHIV, combining bisphosphonates with TDF discontinuation resulted in greater improvements in BMD.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

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

Multiple vertebral compression fractures in a human immunodeficiency virus-positive patient with glucocorticoid-induced Cushing syndrome treated with percutaneous vertebroplasty: a case report

The authors present a rare case of multiple vertebral compression fractures in a young female with iatrogenic glucocorticoid-induced Cushing syndrome and concomitant human immunodeficiency virus (HIV) infection. Both long-term steroid use and HIV infection may lead to osteopenia or even osteoporosis. Multiple vertebral fractures in young patients are very uncommon and should alert the examiner to investigate any underlying cause. Treatment choices include pharmacological agents such as bisphosphonates or parathyroid hormone and even surgical interventions such as percutaneous vertebroplasty.

Evaluation of Provider Screening Practices for Fracture Risk Assessment among Patients with HIV Disease

People living with HIV are known to have greater risk of low bone mineral density than HIV-negative peers. The reasons for this disparity are multifactorial. To address this increased risk, the Infectious Diseases Society of America (IDSA) released fracture risk screening recommendations in 2015, which differ significantly from recommendations that apply to the general population. A study was conducted at the University of Connecticut to assess for provider awareness and adherence to these recommendations. Electronic surveys were sent to providers, and patients were also surveyed for risk factors and prevalence of low bone mineral density. The results of the provider survey showed low rates of awareness of the IDSA screening recommendations. A substantial proportion of patients surveyed met criteria for low BMD screening but did not have dual-energy X-ray absorptiometry (DXA) ordered by their provider. As an intervention, providers were sent information via e-mail regarding current screening recommendations, as well as notifications if their patient met criteria for DXA screening. A twelve-month follow-up survey showed increased provider knowledge of screening recommendations and improved screening practices. Additionally, the results of a logistic regression analysis of patient factors showed that increasing age and male sex were positively associated with fragility fracture risk. Increased duration of antiretroviral therapy use was associated with a lower likelihood of fragility fracture.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of postpartum tenofovir-based antiretroviral therapy on bone mineral density in breastfeeding women with HIV enrolled in a randomized clinical trial

Objectives

We set out to evaluate the effect of postnatal exposure to tenofovir-containing antiretroviral therapy on bone mineral density among breastfeeding women living with HIV.

Design

IMPAACT P1084s is a sub-study of the PROMISE randomized trial conducted in four African countries (ClinicalTrials.gov number NCT01066858).

Methods

IMPAACT P1084s enrolled eligible mother-infant pairs previously randomised in the PROMISE trial at one week after delivery to receive either maternal antiretroviral therapy (Tenofovir disoproxil fumarate / Emtricitabine + Lopinavir/ritonavir–maternal TDF-ART) or administer infant nevirapine, with no maternal antiretroviral therapy, to prevent breastmilk HIV transmission. Maternal lumbar spine and hip bone mineral density were measured using dual-energy x-ray absorptiometry (DXA) at postpartum weeks 1 and 74. We studied the effect of the postpartum randomization on percent change in maternal bone mineral density in an intention-to-treat analysis with a t-test; mean and 95% confidence interval (95%CI) are presented.

Results

Among 398/400 women included in this analysis, baseline age, body-mass index, CD4 count, mean bone mineral density and alcohol use were comparable between study arms. On average, maternal lumbar spine bone mineral density declined significantly through week 74 in the maternal TDF-ART compared to the infant nevirapine arm; mean difference (95%CI) -2.86 (-4.03, -1.70) percentage points (p-value <0.001). Similarly, maternal hip bone mineral density declined significantly more through week 74 in the maternal TDF-ART compared to the infant nevirapine arm; mean difference -2.29% (-3.20, -1.39) (p-value <0.001). Adjusting for covariates did not change the treatment effect.

Conclusions

Bone mineral density decline through week 74 postpartum was greater among breastfeeding HIV-infected women randomized to receive maternal TDF-ART during breastfeeding compared to those mothers whose infants received nevirapine prophylaxis.

Non-communicable Diseases in Pregnant and Postpartum Women Living with HIV: Implications for Health Throughout the Life Course

PURPOSE OF REVIEW

The development of non-communicable diseases (NCDs) in pregnant women living with HIV can be a harbinger of future NCD-related morbidity and mortality. This review focuses on the NCDs that complicate pregnancy and the postpartum period, including hypertensive complications, hyperglycemic disorders, excessive gestational weight gain, and bone mineral density losses. For each disease process, we explore the role of HIV as a possible driver of excess risk, the immediate consequences of these complications on pregnancy outcomes and maternal and infant health, and possible implications for long-term women's health.

RECENT FINDINGS

Countries with the highest burden of HIV also shoulder a high burden of NCDs that complicate pregnancy, including hypertensive disorders, hyperglycemic disorders, weight gain, and osteopenia. This double burden of disease is a significant public health threat for reproductive-age women, with the potential for serious short- and long-term consequences for both women and their infants. Additionally, as the global first-line antiretroviral therapy regimens increasingly include integrase inhibitors, unhealthy weight gain associated with this drug class poses additional risk for NCD-related pregnancy complications and their persistence postpartum. Further research is needed to better define prevalence of NCD complications in pregnancy, elucidate HIV-specific and traditional factors associated with poor outcomes, and to develop interventions to reduce risk and avoid downstream complications in those at highest risk.

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

OBJECTIVES

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

DESIGN

Cross-sectional analysis.

METHODS

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

RESULT

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

CONCLUSION

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

Changes in Bone Mineral Density During and After Lactation in Ugandan Women With HIV on Tenofovir-Based Antiretroviral Therapy

Antiretroviral therapy (ART) in people living with human immunodeficiency virus (HIV) is associated with bone loss, but data are limited in lactation, when physiological bone mineral mobilization is occurring. This research charted changes in areal bone mineral density (aBMD) during and after lactation in Ugandan women with HIV (WWH) initiated onto ART in pregnancy, compared to women without HIV (REF). One-hundred WWH on tenofovir-based ART and 100 REF were enrolled in pregnancy. Lumbar spine (LS), total hip (TH), and whole-body-less-head (WBLH) aBMD were measured by dual-energy X-ray absorptiometry (DXA) at 2, 14, and 26 weeks of lactation, and at 3 months postlactation. The primary outcome was the difference between groups in mean percent change in LS aBMD between 2 and 14 weeks. Statistical analysis was performed in hierarchical repeated measures ANOVA models that corrected for multiple testing. Median age was 23.4 (IQR, 21.0 to 26.8) years. WWH had lower body weight. aBMD decreased in both groups during lactation, but WWH had greater decreases at TH (2-to-26 weeks: WWH [n = 63] -5.9% [95% CI, -6.4 to -5.4] versus REF [n = 64] -4.3% [95% CI, -4.8 to -3.8]; group*time point interaction p = .008). Decreases in LS aBMD were similar in WWH and REF (2-to-26 weeks: -2.0% [95% CI, -2.5 to -1.5]), although there was a tendency toward a smaller decrease in WWH between 2 and 14 weeks (WWH [n = 77] -1.8% [95% CI, -2.2 to -1.4] versus REF [n = 69] -2.9% [95% CI, -3.3 to -2.5]; group*time point interaction p = .08). Postlactation, LS aBMD was higher relative to week 2 in both groups. TH and WBLH aBMD did not return to week 2 values in WWH but did in REF (TH postlactation versus week 2: WWH [n = 61] -3.1% [95% CI, -3.6 to -2.6]; REF [n = 29] +0.1% [95% CI, -0.9 to +1.1]). These data show accentuated bone loss during lactation and only partial skeletal recovery by 3 months postlactation in Ugandan WWH on tenofovir-based ART. Studies are ongoing to understand longer-term consequences for bone health. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fractures in children and adolescents living with perinatally acquired HIV

BACKGROUND

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

SUMMARY

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

Influence of HIV Infection and Antiretroviral Therapy on Bone Homeostasis

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

Inflammation status in HIV-positive individuals correlates with changes in bone tissue quality after initiation of ART

BACKGROUND

The mechanisms behind ART-induced bone changes in HIV-infected patients are poorly known. We aimed to analyse changes in inflammatory and bone markers in HIV after tenofovir disoproxil fumarate initiation, and the associations with changes in the bone strength parameters.

METHODS

HIV-positive participants starting tenofovir disoproxil fumarate-based ART underwent dual-energy X-ray absorptiometry (QDR 4500 SL®, Hologic, Waltham, MA, USA) for bone mineral density (BMD), a microindentation test (OsteoProbe®, Active Life Scientific, Santa Barbara, CA, USA) for bone quality [bone material strength index (BMSi)] and phlebotomy at baseline and 48 weeks after ART. A panel of inflammatory biomarkers and bone turnover markers were measured by ELISA. HIV-negative controls underwent identical procedures once. Values are expressed as medians and IQRs, and non-parametric tests were used to perform the analysis.

RESULTS

Twenty HIV-infected individuals and 20 HIV-negative control individuals were matched in terms of age and gender. HIV individuals showed higher levels of inflammatory markers. We found no differences in bone turnover markers. HIV-positive individuals presented lower BMSi values at baseline compared with controls [86 (83-90) versus 89 (88-93), respectively; P = 0.034]. We found no difference in BMD (at either of the sites evaluated). BMSi tended to increase with treatment. IL-1β at baseline was positively correlated with changes in BMSi after ART (rho = 0.564, P = 0.014). Baseline levels of sclerostin tended to be negatively correlated with changes in BMSi (rho = -0.402, P = 0.097). We found a negative correlation between time since HIV diagnosis and changes in BMSi (rho = -0.466, P = 0.04).

CONCLUSIONS

We observed a correlation between changes in bone quality and the inflammatory environment in HIV-positive individuals. Moreover, among the underlying mechanisms we highlight the Wnt pathway as having a potentially significant role in ART bone quality recovery.

HIV Care Among Elderly Population: Systematic Review and Meta-Analysis

Elderly people living with HIV are increasing. At present in the United States, nearly half of newly diagnosed HIV-infected people are aged >50 years. Diagnosis and treatment of HIV-infected elderly patients tends to be delayed by several health care factors as several life-threatening diseases are common in elderly people. This study aimed to find the pooled HIV prevalence in elderly population and the present situation of continuum care for the elderly HIV patients through systematic review and meta-analysis. All previously published articles from 2000 to 2018 are retrieved using MEDLINE, PUBMED, Cochrane Library, EMBASE, and Google Scholar. DerSimonian and Laird Random Effects model are used to critically appraise articles. STATA 13.0 is used to perform the meta-analysis and quantum-geographic information system (Q-GIS) is used to prepare desired map. I² statistics has been used to test heterogeneity and publication biases. Results have been presented using forest plots. A total of 28 studies are included in this meta-analysis. Present analysis revealed pooled prevalence of HIV in elderly population as 15.79% with a lower rate of viral suppression as 11.524% (95% confidence interval, CI: 11.199-11.855), where a moderate number 38.643% (95% CI: 38.289-38.997) of elderly patients received antiretroviral therapy (ART) globally. The ART retention rate was 12.769% (95% CI: 12.540-13.001) with 6.15% (95% CI: 6.089-6.212) mortality. Despite successful administration of ART in developing part of the world that have relatively higher retention rates among HIV-infected elderly patients only a small percentage are virally suppressed, largely due to elderly drugs interact with ART and several comorbidities reduce the life span of the elderly people.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Clinicaltrials.gov: NCT01634607

Serum extracellular vesicles expressing bone activity markers associate with bone loss after HIV antiretroviral therapy

OBJECTIVE

We tested whether bone-related extracellular vesicle phenotypes changed after initiating antiretroviral therapy (ART) and determined whether changes in levels of extracellular vesicles correlated with changes in bone mineral density (BMD).

DESIGN

Extracellular vesicle phenotypes were measured in blinded serum samples from 15 adults with HIV at baseline, 1, 3, 6 and 12 months after ART initiation. Not all samples were available at each time point so we averaged early (TP1, 1-3 months) and late (TP2, 6-12 months) time points.

METHODS

Extracellular vesicles were stained for osteocalcin (OC), RANKL (CD254), RANK (CD265), M-CSF (macrophage colony stimulating factor), and CD34. Serum OC, procollagen type I N-terminal propeptide (P1NP), and C-terminal telopeptide of type 1 collagen (CTx) were also measured.

RESULTS

BMD significantly decreased from baseline to 12 months. Levels of OC+EVs, serum OC, serum P1NP, and CTx were significantly higher at early and late time points compared with baseline. Increases in EVs expressing OC, RANKL, RANK, and CD34 from baseline to TP1 were associated with decreases in total hip BMD from baseline to 12 months. Change in serum OC, P1NP, and CTx from baseline to TP1 or TP2 did not correlate with change in BMD.

CONCLUSION

Early changes in extracellular vesicles expressing markers of bone activity were associated with total hip bone loss 12 months after ART initiation. These data suggest that serum extracellular vesicles may serve as novel biomarkers of bone remodeling. Future studies are required to determine if extracellular vesicles contribute to the effects of ART on changes in bone turnover markers and BMD.

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

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

Individualized Protease Inhibitor Monotherapy: The Role of Pharmacokinetics and Pharmacogenetics in an Aged and Heavily Treated HIV-Infected Patient

Antiretroviral therapy has changed the history of HIV infection from a lethal disease to a chronic infection, with the emergence of long-term adverse effects. Herein we present a case of a heavily treated HIV-infected man in whom antiretroviral toxicity had been observed. The lopinavir/ritonavir plasma concentrations at standard doses were significantly above the recommended levels. Pharmacogenetic analysis revealed a polymorphism in the DRD3 gene associated with a decrease in the rate of drug metabolism. Additionally, the patient's low body mass index could have contributed to a greater degree of patient exposure to the drug. After the withdrawal of tenofovir disoproxil and the establishment of individualized protease inhibitor monotherapy at reduced doses, a decrease in the intensity of adverse events was observed, while the clinical outcomes were maintained. The pharmacokinetic-pharmacogenetic analysis was shown to be a tool of huge interest for the management and durability of antiretroviral therapy.

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

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

Vitamin D3 Supplementation Increases Spine Bone Mineral Density in Adolescents and Young Adults With Human Immunodeficiency Virus Infection Being Treated With Tenofovir Disoproxil Fumarate: A Randomized, Placebo-Controlled Trial

Background

Tenofovir disoproxil fumarate (TDF) decreases bone mineral density (BMD). We hypothesized that vitamin D3 (VITD3) would increase BMD in youth receiving TDF.

Methods

This was a randomized, double-blind, placebo-controlled trial of directly observed VITD3 vs placebo every 4 weeks for 48 weeks in youth aged 16-24 years with HIV, RNA load <200 copies/mL, taking TDF-containing combination antiretroviral therapy (TDF-cART) for ≥180 days. Participants (N = 214) received a daily multivitamin containing VITD3 400 IU and calcium 162 mg, plus monthly randomized VITD3 50000 IU (n = 109) or placebo (n = 105). Outcome was change from baseline to week 48 in lumbar spine BMD (LSBMD). Data presented are median (Q1, Q3).

Results

Participants were aged 22.0 (21.0, 23.0) years, 84% were male, and 74% were black/African American. At baseline, 62% had 25-hydroxy vitamin D (25-OHD) <20 ng/mL. Multivitamin adherence was 49% (29%, 69%), and VITD3/placebo adherence 100% (100%, 100%). Vitamin D intake was 2020 (1914, 2168) and 284 (179, 394) IU/day, and serum 25-OHD concentration was 36.9 (30.5, 42.4) and 20.6 (14.4, 25.8) ng/mL at 48 weeks in VITD3 and placebo groups, respectively (P < .001). From baseline to week 48, LSBMD increased by 1.15% (-0.75% to 2.74%) in the VITD3 group (n = 99; P < .001) and 0.09% (-1.49% to 2.61%) in the placebo group (n = 89; P = .25), without between-group difference (P = .12). VITD3 group changes occurred with baseline 25-OHD <20 ng/mL (1.17% [-.82% to 2.90%]; P = .004) and ≥20 ng/mL (0.93% [-.26% to 2.15%]; P = .033).

Conclusions

For youth taking TDF-cART, LSBMD increased through 48 weeks with VITD3 plus multivitamin, but not with placebo plus multivitamin, independent of baseline vitamin D status.

Clinical Trials Registration

NCT01751646.

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

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

Two-drug regimens with dolutegravir plus rilpivirine or lamivudine in HIV-1 treatment-naïve, virologically-suppressed patients: Latest evidence from the literature on their efficacy and safety

OBJECTIVES

In the HIV-1-positive population, a paradigm shift from three-drug regimens (3DRs) to dolutegravir-based two-drug regimens (2DRs) both as initial and switch treatment is beginning to take place, supported virologically by the availability of new potent drugs with high genetic barrier to overcome, at least in certain conditions, the dogma of 3DRs in effective HIV-1 therapy. This manuscript reviews the increasing evidence on their excellent and sustained long-term effectiveness and safety.

METHODS

This review includes the most recent results on dolutegravir plus rilpivirine or lamivudine 2DRs from randomised clinical trials, meta-analyses and real-life studies, including relevant data presented at international conferences up to August 2019.

RESULTS

As an initial treatment strategy, dolutegravir plus lamivudine showed high efficacy and safety over 96 weeks in 1441 patients from the GEMINI-1&2 phase III non-inferiority trials. In the SWORD 1&2 trials in virologically-suppressed patients, switching to once-daily dolutegravir plus rilpivirine maintained efficacy over 148 weeks. Similarly, in the TANGO trial, no confirmed virological withdrawals were observed with dolutegravir/lamivudine through Week 48. Consistent results were observed in real-life cohorts. No emergent dolutegravir-resistant virus has ever been reported in a patient in whom dolutegravir was prescribed in the context of such 2DRs. Switching to once-daily dolutegravir plus rilpivirine or lamivudine was generally well tolerated and was associated with favourable renal and bone safety.

CONCLUSION

The results available so far support dolutegravir-based 2DRs as excellent treatment options for adults with HIV-1 infection, either naïve or already virologically suppressed on their current antiretroviral regimen.

Tenofovir Has Minimal Effect on Biomarkers of Bone Health in Youth with HIV Receiving Initial Antiretroviral Therapy

Both HIV infection and tenofovir disoproxil fumarate (TDF) treatment adversely impact bone metabolism and may lead to osteopenia, which has critical implications for youth with HIV (YWH). This study evaluates changes in the biomarkers of bone metabolism and inflammation among YWH receiving initial treatment with TDF- and non-TDF-containing antiretroviral therapies (ARTs). YWH [n = 23, median age 21 years (range 18-24), 87% male, 61% African American] were assessed for inflammatory and bone metabolism biomarkers at enrollment, after 48 weeks of TDF-containing ART, and 96 weeks of ART without TDF with continued viral suppression. Spearman's rank correlation evaluated biomarker associations. Bone alkaline phosphatase, parathyroid hormone, and osteopontin increased after TDF treatment. All fell after TDF was discontinued. Levels of RANKL and osteoprotegerin did not change throughout the study. There was little correlation between biomarkers of bone metabolism and either macrophage or lymphocyte activation at any time point. Our results establish baseline associations between bone metabolism and immune biomarkers for this population, and find that before CD4 T cell decline chronic inflammation does not perturb biomarkers of bone metabolism among YWH. The adverse effects of TDF on bone health may be marginal for YWH at the early stages of disease.

Performance of fracture risk assessment tool in HIV-positive male individuals aged ≥45 years on suppressive antiretroviral therapy

INTRODUCTION

An age-specific evaluation and management algorithm for reduced bone mineral density (BMD) is suggested for HIV-positive patients without major risk factors. Whether combination of BMD and the Fracture Risk Assessment Tool (FRAX) may detect more individuals for therapeutic interventions remains unclear. We aimed to determine the prevalence of middle-aged or older HIV-positive males fitting the criteria of therapeutic interventions with different approaches.

METHODS

From July 2016 to February 2018, HIV-positive male patients aged ≥45 years receiving suppressive antiretroviral therapy were recruited in a cross-sectional study, at two designated hospitals for HIV care in northern Taiwan. Patients with malignancy, AIDS, pre-existing bone disease or immobilization were excluded. Information on clinical and demographic characteristics, FRAX questionnaire, activity questionnaire, BMD and serum 25(OH)D was obtained. FRAX scores combined with BMD (FRAX/BMD) and without BMD (FRAX) were calculated. The data were analysed on the basis of major risk factors for fragility fracture and age stratification, FRAX score and BMD results respectively.

RESULTS

We enrolled 330 patients with a mean age of 51.6 years and CD4 610 cells/μL, in whom 98.1% (n = 324) underwent BMD assessment of one site or more. By FRAX, 6.7% (n = 22) reached treatment thresholds (10-year risk of major osteoporotic fracture ≥20% and/or hip fracture ≥3%). The prevalence of osteopenia (-2.5

CONCLUSIONS

With FRAX as a screening approach among HIV-positive male patients aged ≥45 years, addition of BMD assessment may detect more candidates for therapeutic management.

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Key Words

• ageing
• bone mineral density
• combination antiretroviral therapy
• osteopenia
• osteoporosis

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MESH Headings

• Adult
• Algorithms
• Anti-HIV Agents/therapeutic use
• Bone Density
• Cross-Sectional Studies
• Fractures, Bone/etiology
• HIV Seropositivity/complications
• HIV Seropositivity/drug therapy
• HIV Seropositivity/epidemiology
• Hip Fractures/etiology
• Humans
• Male
• Middle Aged
• Osteoporosis/etiology
• Osteoporotic Fractures/etiology
• Prevalence
• Risk Factors
• Surveys and Questionnaires
• Taiwan/epidemiology

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Affiliation(s)

Mao‐Song Tsai Department of Internal MedicineFar Eastern Memorial HospitalNew Taipei CityTaiwan School of MedicineCollege of MedicineFu Jen Catholic UniversityNew Taipei CityTaiwan
Jun‐Yu Zhang Center of Infection ControlNational Taiwan University HospitalTaipeiTaiwan
Hsin‐Yun Sun Department of Internal MedicineNational Taiwan University Hospital and NationalTaiwan University College of MedicineTaipeiTaiwan
Wen‐Chun Liu Department of Internal MedicineNational Taiwan University Hospital and NationalTaiwan University College of MedicineTaipeiTaiwan
Pei‐Ying Wu Center of Infection ControlNational Taiwan University HospitalTaipeiTaiwan
Chia‐Jui Yang Department of Internal MedicineFar Eastern Memorial HospitalNew Taipei CityTaiwan School of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
Chien‐Ching Hung Department of Internal MedicineNational Taiwan University Hospital and NationalTaiwan University College of MedicineTaipeiTaiwan Department of Tropical Medicine and ParasitologyNational Taiwan University College of MedicineTaipeiTaiwan

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Continued Interest and Controversy: Vitamin D in HIV

PURPOSE OF REVIEW

Vitamin D (VitD) deficiency is highly prevalent among HIV-infected individuals. Given the overlapping risk for several chronic disease and immunomodulatory outcomes from both long-standing HIV and VitD deficiency, there is great interest in clarifying the clinical role of VitD for this population.

RECENT FINDINGS

Recent studies have expanded our knowledge regarding the epidemiology and mechanisms of VitD deficiency-associated outcomes in the setting of HIV. Clinical trials focusing on VitD supplementation have demonstrated a positive impact on bone mineral density in subgroups of HIV-infected individuals initiating ART or on suppressive ART regimens; however, significant heterogeneity exists between studies and data are less consistent with other clinical outcomes. Further research is needed to clarify uncertainly in several domains, including identifying patients at greatest risk for poor outcomes from VitD deficiency, standardizing definitions and measurement techniques, and better quantifying the benefits and risks of VitD supplementation across different demographic strata for skeletal and extra-skeletal outcomes.