Prevalence of and risk factors for low bone mineral density in Spanish treated HIV-infected patients

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.

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.

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.

Reconstruction and repair, using mini-plate and bone graft for persons living with HIV with giant cell tumor of long bone: retrospective analysis of a single-center experience

Background

To evaluate the effect of reconstruction and repair, using a mini-plate and bone graft for HIV -positive patients with giant cell tumor of long bone.

Methods

We conducted a retrospective analysis of 12 HIV positive patients with giant cell tumor of long bone. A non-HIV-positive cohort of patients, matched for age, sex, and disease type, was selected as the control group. From June 2012 to August 2020, curettage by ultrasonic scalpel was performed in all patients, combined with min- plate and bone graft treatment. All patients were followed- up for 18 to 60 months. Limb function was evaluated, using the MSTS93 scoring system, and any examples of postoperative recurrence, distant metastasis, complications, MSTS93 score, and fracture prognosis were recorded.

Results

The mean age of HIV group was 43.5 years. The ratio of men to women was 11: 1. In all cases the histopathological diagnosis was clear, except the patients with primary malignant giant cell tumor of bone, including five, three, two, and two cases in the proximal tibia, distal femur, distal tibia, and talus, respectively. Following their surgery, all patients were followed up with an average of 31.24 ± 11.84 months. No local recurrence or pulmonary metastases were observed. Post-surgery, all the 12 patients showed good bone morphologic repair and reconstruction, good bone healing, good joint function, and no pathological fractures around their lesion. In the HIV group, one case of giant cell tumor in the proximal tibia showed mild articular surface collapse and mild valgus deformity of the knee joint but retained good joint function. The MSTS scores of excellent or good in the two groups comprised 83.3%, thus, there was no significant difference between them (P > 0.05). Compared with preoperatively, the MSTS scores in the HIV group were significantly improved, ranging from 7 to 11 points preoperatively to 24 to 27 points postoperatively; this difference was statistically significant (P < 0.05).

Conclusion

Reconstruction and repair, using a mini-plate and bone graft for HIV -positive patients with giant cell tumor of long bone can achieve satisfactory results. The mini- plate requires little space and is flexible during reconstruction and fixation, significantly reducing complications such as surgical site infection, as well as preserving joint function and avoiding amputation; therefore, it is a safe and effective treatment method.

[Prevalence of low bone mass in individuals with HIV infection]

BACKGROUND AND AIMS

There are no population data on bone mass in individuals with HIV in Spain, adjusted for age and sex.

MATERIALS AND METHODS

Bone mineral density (BMD) data were obtained by dual X-ray absorptiometry in a cohort of individuals with HIV infection compared with cohort data from the general population in Spain and the United States of America.

RESULTS

Of 928 individuals (mean 46 years, 25% women), the prevalence of osteoporosis in the lumbar spine/femoral neck was 18%/5% in men, and 17%/10% in women, respectively. The rate increased from the age of 40 in men and from 50 in women (osteoporosis in 20% and 27%, respectively). BMD was lower than that observed in the general population in almost all age groups (mean, -6%; between 0%-11% lower compared to the Spanish cohort, and -8%; between 0%-14% lower than the American cohort).

CONCLUSIONS

Our cohort of individuals with HIV had a lower BMD in all age groups after adjustment for age and sex, compared with the general population. This fact must be considered when making recommendations.

General Practitioners as partners for a shared management of chronic HIV infection: An insight into the perspectives of Italian People Living with HIV

Is it possible to achieve a collaboration between Infectious Diseases (ID) Specialists and General Practitioners (GPs) in the management of chronic HIV infection? A cross sectional survey was conducted among People Living with HIV (PLWHIV) attending the outpatient services of four Italian Infectious Diseases Centers to understand to which extent patients trust their GPs and involve them in the management of their chronic condition. Information about level of communication with GPs, subjective perception of the disease, and presence of co-medications were collected and matched with socio-demographic data using χ2statistics. A p<0.05 was considered statistically significant. From December 2019 to February 2020, 672 patients completed the survey, 59% males and 56% >50 years. Overall, 508 patients (76%) had informed GPs about HIV-positivity. Communication of diagnosis was significantly associated with age >50years, lower education level, history of disease >10 years and residency in Northern Italy. The "Undetectable = Untrasmittable" (U = U) concept was investigated as an indirect measure of perceived stigma. 23% of subjects was unaware of its meaning. Despite undetectable status, 50% of PLWHIV found difficult to communicate their condition to GPs, especially married (52% vs 48% of unmarried, p = 0.003), well-educated patients (51% vs 48, p = 0.007), living in Southern vs Northern Italy (52% vs 46%, p< 0.001). More than 75% of the participants consulted the ID specialist for co-medications and DDIs management, often complaining a lack of communication of the former with GPs. Overall, a good level of communication between PLWHIV and GPs was outlined, even if a wider involvement of the latter in HIV care is desirable.

Negative correlation between bone mineral density and subclinical fractures in patients with human immunodeficiency virus

Background

Although low bone mineral density (BMD) is associated with an increased risk of fracture, few studies have assessed fracture rates in patients with human immunodeficiency virus (HIV).

Methods

The occurrence of subclinical fractures in patients with HIV was assessed. Pearson’s chi-square test was used to analyze the relationship between subclinical fractures and related factors.

Results

Fifty patients with HIV were included, among whom 11 were diagnosed with subclinical fractures. These 11 patients had a mean body mass index of 24.127 ± 3.482 kg/m², smoked a mean of 142.091 ± 3.482 cigarettes/month, drank a mean of 61.545 ± 13.026 mL/day of alcohol, had a mean CD4⁺ T cell count of 247.727 ± 181.679 cells/mm³, had a mean duration of acquired immunodeficiency syndrome (AIDS) of 4.27 ± 0.786 years, and had a mean BMD of the third lumbar spine of 0.810 ± 0.063 g/cm³. The AIDS duration and BMD of the third lumbar spine were significantly associated with subclinical fractures. The BMD of the third lumbar spine was negatively correlated with subclinical fractures.

Conclusion

A significant negative correlation was found between the BMD of the third lumbar spine and subclinical fractures.

Longitudinal change in bone mineral density among Chinese individuals with HIV after initiation of antiretroviral therapy

This is the first study to report changes in BMD and related risk factors among Chinese patients with HIV after initiation of tenofovir disoproxil fumarate (TDF)-containing antiretroviral therapy. Greater bone mineral density (BMD) loss was observed in patients treated with TDF, compared to those on non-TDF-containing regimens. Our findings provide important knowledge regarding the risk factors in the long-term clinical management of patients with HIV in China.

INTRODUCTION

Persons living with HIV (PLWH) are at increased risk for osteoporosis and fracture. Tenofovir disoproxil fumarate (TDF) has been associated with higher rates of bone mineral density (BMD) loss, osteoporosis, and fracture. Few studies have studied the impact among PLWH in Asia.

METHODS

We analyzed retrospectively patients from the outpatient HIV clinic of a large tertiary hospital in Beijing, China, from March 2007 to May 2016. Patients who had dual-energy X-ray absorptiometry testing prior to antiretroviral initiation and at 48 and/or 96 weeks after initiation were included in this analysis.

RESULTS

A total of 136 patients were included (mean age 36.0 ± 10.6 years) and over 90% participants were male and Han Chinese ethnicity. We observed greater declines in BMD at the spine from baseline to week 48 (-2.94% vs. -0.74%) and at the hip from baseline to week 96 (-4.37% vs. -2.34%) in the TDF group compared with the non-TDF group. With regard to HIV-specific parameters, longer duration since HIV diagnosis and undetectable viral load over time were associated with lower BMD at the hip [relative risk (RR) 0.97, 95% confidence index (CI) (0.95, 0.99) per 1 year increase and RR 0.96, 95%CI (0.94, 0.99), respectively] and femoral neck [RR 0.97, 95%CI (0.95, 0.99) per 1 year increase and RR 0.97, 95%CI (0.95, 0.998), respectively] over 96 weeks.

CONCLUSIONS

This is the first study to report changes in BMD among PLWH after initiation of TDF-based antiretroviral therapy in China. Our findings provide important knowledge for the long-term clinical management of PLWH from this region.

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.

Association of Low Vitamin D with Complications of HIV and AIDS: A literature Review

With the advent of combination antiretroviral therapy (cART), the survival of HIV patients has improved dramatically, but the complications of the disease and treatment have become an important issue in the management of HIV patients. Vitamin-D deficiency is common in HIV patients. Low vitamin-D is associated with different comorbidities in the HIV uninfected general population. In this review, we first briefly describe vitamin D synthesis and mechanism of action and we focus on the epidemiological and clinical data dealing with the relationship between vitamin D deficiency in HIV infection with several comorbidities which has been found to be increasingly common in patients living with HIV infection. We searched the PubMed database using the keywords "HIV," "vitamin D" and other common disorders or conditions that are relatively common in HIV infection. The other conditions included in the search were osteoporosis and fracture, cardiovascular disease, diabetes and insulin resistance, active tuberculosis, hepatitis-C co-infection, and HIV disease progression. Articles presenting original data as well as systematic reviews and met analysis related to HIV population were included in our analysis. Vitamin-D deficiency seems to be associated with several adverse outcomes in HIV patients but a definite cause and effect relationship with vitamin-D is yet to be confirmed in most of the cases. However, the literature supporting the efficacy of vitamin-D supplementation is lacking.

The effect of tenofovir disoproxil fumarate on bone mineral density: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis (CRD#42017070552) to quantify the impact of oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) on bone mineral density (BMD) and the risk of osteoporosis, low bone mass and fractures, among people taking it as pre-exposure prophylaxis (PrEP), HIV treatment and HBV treatment.

METHODS

We searched MEDLINE and EMBASE for randomized controlled trials published from 1997-2018 reporting BMD, osteoporosis, low bone mass and/or fractures in treatment-naive patients taking compared with not taking TDF for 48 ±4 weeks. We pooled outcomes using DerSimonian random-effects models.

RESULTS

Our search yielded 5,178 abstracts, representing 3,865 articles, with 25 meeting the inclusion criteria. TDF was associated with greater BMD decline when taken as PrEP (lumbar spine: mean difference [MD]=-0.82%, 95% CI=-1.28, -0.37%, I²=38%; total hip: MD=-0.81%, 95% CI=-1.22, -0.40%, I²=48%) and HIV treatment (lumbar spine: MD=-1.62%, 95% CI=-2.30, -0.95%, I²=93%; total hip: MD=-1.75%, 95% CI=-2.08, -1.42%, I²=83%; femoral neck: MD=-1.26%, 95% CI=-2.15, -0.38%, I²=43%) in comparison to those not taking TDF. Eight studies reported on incident osteoporosis or low bone mass, with variable results. Pooled results from five PrEP studies showed that TDF was not associated with increased fractures compared with no PrEP (RR=1.12, 95% CI=0.752, 1.74, I²=26%).

CONCLUSIONS

TDF caused greater decreases in BMD than did comparators when used for all three indications and the magnitude of this decrease was larger for HIV treatment compared with PrEP. Fractures were not increased among PrEP patients. The clinically significant BMD decline caused by TDF and current expansion of PrEP use suggest attention to the adverse bone effects of TDF will increase in importance.