HIV and fracture: Risk, assessment and intervention

An explainable web application based on machine learning for predicting fragility fracture in people living with HIV: data from Beijing Ditan Hospital, China

Purpose

This study aimed to develop and validate a novel web-based calculator using machine learning algorithms to predict fragility fracture risk in People living with HIV (PLWH), who face increased morbidity and mortality from such fractures.

Method

We retrospectively analyzed clinical data from Beijing Ditan Hospital orthopedic department between 2015 and September 2023. The dataset included 1045 patients (2015-2021) for training and 450 patients (2021-September 2023) for external testing. Feature selection was performed using multivariable logistic regression, LASSO, Boruta, and RFE-RF. Six machine learning models (logistic regression, decision trees, SVM, KNN, random forest, and XGBoost) were trained with 10-fold cross-validation and hyperparameter tuning. Model performance was assessed with ROC curves, Decision Curve Analysis, and other metrics. The optimal model was integrated into an online risk assessment calculator.

Results

The XGBoost model showed the highest predictive performance, with key features including age, smoking, fall history, TDF use, HIV viral load, vitamin D, hemoglobin, albumin, CD4 count, and lumbar spine BMD. It achieved an ROC-AUC of 0.984 (95% CI: 0.977-0.99) in the training set and 0.979 (95% CI: 0.965-0.992) in the external test set. Decision Curve Analysis indicated clinical utility across various threshold probabilities, with calibration curves showing high concordance between predicted and observed risks. SHAP values explained individual risk profiles. The XGBoostpowered web calculator (https://sydtliubo.shinyapps.io/cls2shiny/) enables clinicians and patients to assess fragility fracture risk in PLWH.

Conclusion

We developed a web-based risk assessment tool using the XGBoost algorithm for predicting fragility fractures in HIV-positive patients. This tool, with its high accuracy and interpretability, aids in fracture risk stratification and management, potentially reducing the burden of fragility fractures in the HIV population.

Do Nurse Practitioners Deliver? A Retrospective Self-audit Comparing Nurse Practitioner Care for People With HIV in Australia to Screening and Monitoring Guidelines

ABSTRACT

In Australia, nurse practitioners (NPs) provide care to people with HIV (PWH) in hospital and community settings. We describe a national audit evaluating NP care for PWH, assessing adherence to 2 HIV monitoring guidelines. Five NPs conducted a retrospective case note self-audit. Deidentified data were collected, pooled, and analyzed using Microsoft Excel and compared with HIV monitoring guideline targets. The review was undertaken for 212 NP patients, the majority being cisgendered men (86%), ages 45-49 years, identifying as gay (65%). The majority (95%) of PWH were on an appropriate HIV treatment, meeting the United Nations Programme on HIV/AIDS target of 95%. HIV viral load testing was current for 211 (99%) individuals. Of 138 individuals eligible for cardiovascular screening, 84 (60%) were screened, below a guideline target of 90%. Compliance with HIV monitoring guidelines exceeded targets in most areas. Our audit demonstrates that NPs provide effective and guideline compliant HIV care to PWH in Australia.

Challenges of HIV Management in an Aging Population

PURPOSE OF REVIEW

Potent, well tolerated and simple to administer antiretroviral therapy (ART) has resulted in significant improvement in life expectancy for people with HIV. The increased lifespan does not necessarily equate to improved healthspan with increased rates of comorbidities, frailty and geriatric syndrome experienced by older people with HIV. This review explores the challenges in prevention and management of multimorbidity and geriatric syndrome with the ultimate goal of improving health and quality of life through holistic care.

RECENT FINDINGS

Recent studies have drawn attention to the multifactorial nature of most comorbidities experienced by people with HIV. Adverse effects of contemporary ART, combined with lifestyle factors of smoking, excess alcohol and other substance use, chronic immune activation and inflammation associated with chronic HIV infection and other co-infections, all impact multimorbidity and geriatric syndromes. The complex healthcare needs of the aging population of people with HIV will require comprehensive, multidisciplinary integrated models of care.

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.

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

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

Detection of HIV-1 DNA/RNA in Peripheral Blood, Bone Marrow and Femoral Head of Patients with Osteonecrosis of the Femoral Head

Background

With the increasing life expectancy of people living with HIV (PLWH) following antiretroviral therapy (ART), there is a growing prevalence of chronic diseases such as osteonecrosis of the femoral head (ONFH). Compared with the more accessible blood, the viral infection profile in bone marrow and necrotic femoral heads in PLWH remains inadequately characterized.

Methods

Femoral head and bone marrow were collected from 15 PLWH undergoing total hip arthroplasty. For each femoral head, samples were obtained from the subchondral, necrotic, sclerotic, and normal areas. HIV DNA and HIV RNA assays were employed to evaluate disparities in viral load and reservoir between bone marrow and blood, as well as to quantify viral infection in distinct regions of the necrotic femoral head.

Results

Blood HIV RNA dropped below detectable levels in 8 patients (below 20 copies/mL). The median of bone marrow HIV RNA was 255.89 copies/mL. HIV DNA in blood and bone marrow was 296.35 and 454.31 copies/106 cells. HIV DNA in necrotic area was about half that in sclerotic area, HIV RNA was about twice that in normal area, the difference was statistically significant.

Conclusion

Despite using ART, there is still substantial active HIV and a potential reservoir in the bone marrow. Viral transcription was most active in the necrotic area of the femoral head, which may indicate that HIV itself is directly involved in ONFH.