FRAX assessment in people ageing with HIV

Investigation of Osteoporosis in Persons Living with Human Immunodeficiency Virus: The HOST Study

Bone health is an emerging concern in the aging human immunodeficiency virus (HIV)-infected population. We aimed to investigate bone mineral density (BMD) and bone microarchitecture in persons living with HIV (PLHIV). The study was a cross-sectional study. BMD and bone microarchitecture were investigated by Dual-Energy X-ray Absorptiometry (DXA) at the hip and lumbar spine and High-Resolution peripheral Quantitative Computed Tomography (HRpQCT) at the radius and tibia. Information about risk factors for fracture was obtained from a questionnaire. 183 PLHIV were included, 160 (131 males, 29 females) completed the visit. Age range was 30-78 years and the mean time since first HIV-positive serology was 16.5 years. 47% had low bone density and 6% had osteoporosis. The mean T-score by DXA was - 1.2 (standard deviation (SD) ± 1.0), - 0.7 (SD ± 0.9), and - 0.7 (SD ± 1.3) at the femoral neck, total hip and lumbar spine, respectively. We observed no significant difference in BMD by DXA between participants below or above age 50. BMI was significantly lower in PLHIV with lower BMD (p = 0.001, ANOVA). HRpQCT measurements showed significant differences in cortical area, volumetric BMD, and most microarchitecture parameters between PLHIV with BMD in the normal, low, and osteoporotic ranges measured at the tibia and radius. Our results indicate that bone microarchitecture and BMI vary considerably between PLHIV with normal, low, and osteoporotic BMD. These differences may partly explain the increased fracture risk seen in PLHIV.Trial numbers: Ethics Committee of the Central Denmark Region (case no. 1-10-72-238-17), Danish Data Protection Agency (case no. 1-16-02-708-17).

High prevalence of osteoporosis among virally suppressed older people (≥60 years) living with HIV

OBJECTIVES

Our objective was to evaluate bone mineral density (BMD) among older people living with HIV at the time of enrolment into a clinical trial in Kenya.

METHODS

The bictegravir/emtricitabine/tenofovir alafenamide (BFTAF) Elderly Study is a clinical trial among virally suppressed people living with HIV aged ≥60 years randomized to switch to BFTAF or continue their pre-enrolment regimen. At enrolment, dual-energy x-ray absorptiometry (DXA) of the lumbar spine, total hip, and femoral neck was performed and T-scores calculated for BMD. Osteoporosis was defined as T-score -2.5 or lower and osteopenia as T-score between -1 and -2.5. Fracture risk was calculated based on clinical risk factors (not including BMD), considering HIV as a secondary cause of osteoporosis, and the correlation between FRAX®-HIV and BMD assessed.

RESULTS

Between February and May 2022, a total of 296 participants were enrolled. All were Black African, 147 (49.7%) were female, the median age was 64 years (range 60-77), and 280 (94.6%) were on tenofovir disoproxil fumarate. The median BMD of lumbar spine, total hip, and femoral neck was 0.87 g/cm2 (interquartile range [IQR] 0.78-0.99), 0.89 g/cm2 (IQR 0.79-1.01), and 0.75 g/cm2 (IQR 0.67-0.84), respectively, with median T-scores of -1.9 (IQR -2.8 to -0.7), -1.0 (IQR -1.9 to -0.3), and -1.5 (IQR -2.2 to -0.9), respectively. Osteoporosis and osteopenia were found in 37.5% and 47.3% of participants, respectively. Major osteoporotic fracture and hip fracture 10-year median probabilities using FRAX®-HIV were 3.4% (IQR 2.8-4.6) and 1.0% (IQR 0.7-1.3). Correlation coefficients between these FRAX®-HIV probabilities and femoral neck BMD were -0.204 for major osteoporotic fracture and -0.338 for hip fracture.

CONCLUSIONS

The prevalence of osteoporosis is high among older people living with HIV in Kenya, where DXA is not readily available and risk calculation without BMD had low correlation with measured BMD values. Additional data are required on the impact of investment in fracture risk assessment and treatment, including population-specific risk calculators.

Breaking Down Bone Disease in People Living with HIV: Pathophysiology, Diagnosis, and Treatment

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.

Bone Loss and Fractures in Post-Menopausal Women Living with HIV: A Narrative Review

INTRODUCTION

Post-menopausal women living with Human Immunodeficiency Virus (WLHIV) face an increased risk of bone fractures due to the relationship between HIV-related factors and menopause. This narrative review aims to summarise the current knowledge about fracture risk among post-menopausal WLHIV in particular looking at hormonal changes, combined antiretroviral therapy (cART), lifestyle factors, and psychosocial implications. We also profiled a summary of the significant, recent studies of post-menopausal WLHIV residing in low-income countries (LIC).

METHODS

A thorough search of the literature was performed across PubMed, Medline, Scopus, and Google Scholar, focussing on studies published between 2000 and 2024. Inclusion criteria entailed original research, reviews, and meta-analyses addressing bone mineral density (BMD), fracture incidence, and related risk factors in post-menopausal WLHIV.

RESULTS

The review identified 223 relevant studies. Post-menopausal WLHIV exhibit significantly lower BMD and higher fracture rates compared to both HIV-negative post-menopausal women and pre-menopausal WLHIV. cART, particularly tenofovir disoproxil fumarate (TDF), contributes to reduced BMD. Menopausal status exacerbates this risk through decreased oestrogen levels, leading to increased bone resorption. Moreover, lifestyle choices such as smoking, alcohol consumption, and low physical activity are more prevalent in PWHIV, which further elevates fracture risk. Different psychosocial factors may make WLWHIV more vulnerable at this stage of their life, such as depression, isolation, stigma, and housing and nutritional issues. Women living in LICs face a variety of challenges in accessing HIV care. There are gaps in research related to the prevalence of osteoporosis and bone loss in post-menopausal WLHIV in LICs.

CONCLUSION

Post-menopausal women living with HIV face a significantly higher risk of bone loss and fractures due to the combined effects of HIV and menopause. Antiretroviral therapy (particularly TDF), lifestyle factors, and psychosocial challenges exacerbate this risk. There is a need for careful selection of cART, hormone replacement therapy (HRT), and emerging treatments such as Abaloparatide. A holistic approach including lifestyle changes and psychosocial support is crucial to reduce fracture risk in WLHIV, especially in low-income countries.

HIV and fracture: Risk, assessment and intervention

OBJECTIVES

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

RESULTS

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

CONCLUSION

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

Bone Disease in HIV: Need for Early Diagnosis and Prevention

The transformation of HIV into a manageable chronic condition has unveiled new clinical challenges associated with aging-related pathologies, including bone disease. This review explores the intricate relationship between HIV, antiretroviral therapy (ART), and bone disease, highlighting the necessity of early diagnosis and preventative strategies to mitigate the increased risk of osteopenia, osteoporosis, and fractures in people living with HIV (PLWHIV). It synthesizes the current literature to elucidate the multifactorial etiology of bone pathology in this population, that includes direct viral effects, chronic immune activation, ART-associated risks, and the impact of traditional risk factors for bone loss. Through a critical examination of modern diagnostic methods, lifestyle modifications, evidence-based preventive actions, and pharmacological treatments, the necessity for comprehensive management is highlighted, along with recommendations for integrated healthcare approaches vital for achieving optimal patient outcomes. By advocating for a proactive, patient-centered, and multidisciplinary strategy, this review proposes a plan to integrate bone health into standard HIV care through active risk identification, vigilant screening, effective preventive measures, tailored treatments, and informed decision-making, in an effort to ultimately enhance the quality of life for PLWHIV.

Comorbidities and menopause assessment in women living with HIV: a survey of healthcare providers across the WHO European region

ABSTRACTWomen living with HIV are reaching older age and experiencing menopause and age-related comorbidities. Data suggest that women living with HIV experience earlier menopause and more menopausal symptoms and age-related comorbidities compared to women without HIV. However, there are no guidelines on the screening for and management of age-related comorbidities and events in women living with HIV. Moreover, little is known about provision of care to this population across Europe. We surveyed 121 HIV healthcare providers in 25 World Health Organization European countries to ascertain screening practices for, and management of, menopause, psychosocial and sexual well-being and age-related comorbidities in women with HIV. Most respondents screened for diabetes, cardiovascular disease (CVD) risk factors and poor mental health at least annually. Low bone mineral density (BMD) was regularly checked but less than once a year. Fewer regularly screened for sexual well-being and intimate partner violence. Menstrual pattern and menopausal symptoms in women aged 45-54 were assessed by 67% and 59% of respondents. 44% stated that they were not confident assessing menopausal status and/or symptoms. CVD, diabetes, low BMD and poor mental health were managed mainly within HIV clinics, whereas menopause care was mainly provided by gynaecology or primary care. Most respondents stated a need for HIV and menopause guidelines. In conclusion, we found that whilst metabolic risk factors and poor mental health are regularly screened for, psychosocial and sexual well-being and menopausal symptoms could be improved. This highlights the need for international recommendations and clinician training to ensure the health of this population.

Performance of a modified fracture risk assessment tool for fragility fracture prediction among older veterans living with HIV

OBJECTIVE

Fragility fractures (fractures) are a critical outcome for persons aging with HIV (PAH). Research suggests that the fracture risk assessment tool (FRAX) only modestly estimates fracture risk among PAH. We provide an updated evaluation of how well a 'modified FRAX' identifies PAH at risk for fractures in a contemporary HIV cohort.

DESIGN

Cohort study.

METHODS

We used data from the Veterans Aging Cohort Study to evaluate veterans living with HIV, aged 50+ years, for the occurrence of fractures from 1 January 2010 through 31 December 2019. Data from 2009 were used to evaluate the eight FRAX predictors available to us: age, sex, BMI, history of previous fracture, glucocorticoid use, rheumatoid arthritis, alcohol use, and smoking status. These predictor values were then used to estimate participant risk for each of two types of fractures (major osteoporotic and hip) over the subsequent 10 years in strata defined by race/ethnicity using multivariable logistic regression.

RESULTS

Discrimination for major osteoporotic fracture was modest [Blacks: area under the curve (AUC) 0.62; 95% confidence interval (CI) 0.62, 0.63; Whites: AUC 0.61; 95% CI 0.60, 0.61; Hispanic: AUC 0.63; 95% CI 0.62, 0.65]. For hip fractures, discrimination was modest to good (Blacks: AUC 0.70; 95% CI 0.69, 0.71; Whites: AUC 0.68; 95% CI 0.67, 0.69]. Calibration was good in all models across all racial/ethnic groups.

CONCLUSION

Our 'modified FRAX' exhibited modest discrimination for predicting major osteoporotic fracture and slightly better discrimination for hip fracture. Future studies should explore whether augmentation of this subset of FRAX predictors results in enhanced prediction of fractures among PAH.

Living with HIV and Getting Vaccinated: A Narrative Review

After 40 years of its appearance, human immunodeficiency virus (HIV) infection remains a leading public health challenge worldwide. Since the introduction of antiretroviral treatment (ART), HIV infection has become a chronic condition, and people living with HIV could have life expectancies close to those of the general population. People with HIV often have an increased risk of infection or experience more severe morbidity following exposure to vaccine-preventable diseases. Nowadays, several vaccines are available against bacteria and viruses. However, national and international vaccination guidelines for people with HIV are heterogeneous, and not every vaccine is included. For these reasons, we aimed to perform a narrative review about the vaccinations available for adults living with HIV, reporting the most updated studies performed for each vaccine among this population. We performed a comprehensive literature search through electronic databases (Pubmed-MEDLINE and Embase) and search engines (Google Scholar). We included English peer-reviewed publications (articles and reviews) on HIV and vaccination. Despite widespread use and guideline recommendations, few vaccine trials have been conducted in people with HIV. In addition, not all vaccines are recommended for people with HIV, especially for those with low CD4 cells count. Clinicians should carefully collect the history of vaccinations and patients' acceptance and preferences and regularly check the presence of antibodies for vaccine-preventable pathogens.

Treatment and comorbidity burden among people living with HIV: a review of systematic literature reviews

Background

As the human immunodeficiency virus (HIV) treatment landscape continues to evolve, the prolonged life expectancy and long-term exposure to antiretroviral drugs have modified the burden associated with living with HIV.

Objective

To better understand the current treatment and comorbidity burden in people living with HIV (PLWH).

Methods

Peer-reviewed systematic literature reviews (SLRs) between 2017 and 2020 that included US studies and examined drug adherence/pill burden, resistance burden, or comorbidities in PLWH were identified. Methods and findings were extracted for the overall studies and examined in the subset of US studies.

Results

Among 665 publications identified, 47 met the inclusion criteria (drug adherence/pill burden: 5; resistance: 3; comorbidities: 40). While antiretroviral drug adherence levels varied across SLRs, single-tablet regimens (STR) were associated with higher adherence versus multiple-tablet regimens. STRs were also associated with lower risk of treatment discontinuation, higher cost-effectiveness, and lower risk of hospitalization. Longer survival resulted in a high comorbidity burden, with non-AIDS causes accounting for 47% of deaths among PLWH in the US. HIV doubled the risk of cardiovascular disease and was associated with other health problems, including bone and muscle diseases, depression, and cancers. Several antiretroviral regimens were associated with chronic diseases, including cardiometabolic conditions. Lifetime HIV costs are substantially increasing, driven by antiretroviral, adverse event, and comorbidity treatment costs cumulated due to longer survival times.

Conclusions

There is a considerable burden associated with HIV and antiretroviral treatment, highlighting the benefits of less complex and safer regimens, and the unmet need for effective preventative interventions.

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.

Selection of risk assessment methods for osteoporosis screening in postmenopausal women with low-energy fractures: A comparison of fracture risk assessment tool, digital X-ray radiogrammetry, and dual-energy X-ray absorptiometry

Objectives:

Fracture liaison services are designed to identify patients needing osteoporosis treatment after a fracture. Some fracture liaison service designs involve a prescreening step, for example, fracture risk assessment tool (FRAX^®). Another possible prescreening tools are bone mass density assessment in the acute setting. The aim of this study was to assess the effectiveness of prescreening tools.

Methods:

In the present prospective cohort study, women aged >55 years with a radius fracture were included. Patients were recruited at the emergency department after experiencing their fracture. All patients performed fracture risk assessment by fracture risk assessment tool, and bone mass density assessment by digital X-ray radiogrammetry and dual-energy X-ray absorptiometry (prescreening steps) as well as full routine evaluation at the osteoporosis unit (endpoint). The main outcome measures were sensitivity, specificity, predictive values, and area under the curve.

Results:

Forty-one women were recruited (mean age: 70 ± 8 years). Of these, 54% fulfilled the treatment indication criteria of osteoporosis after a full examination. Fracture risk assessment tool without bone mass density (cutoff ⩾ 15%) for prescreening patients had a high sensitivity (90%) but a low area under the curve (0.50) and specificity (16%). The highest area under the curve (0.73) was found prescreening with bone mass density assessment (dual-energy X-ray absorptiometry or digital X-ray radiogrammetry) having a sensitivity of 59%–86% and specificity of 61%–90%.

Conclusion:

This study, though small, raises questions regarding the effectiveness of using a prescreening step in fracture liaison services for high-risk individuals. In this cohort, FRAX^® without bone mass density had a low precision, with a risk of both underestimating and overestimating patients requiring treatment. Bone mass density assessment in the acute setting could improve the precision of prescreening. Further investigations on the effectiveness and health economics of prescreening steps in fracture liaison services are needed.