- Since older individuals with HIV, even those on effective ART, may suffer accelerated bone loss, screening for and treatment of osteoporosis should be done.
- Since vitamin D deficiency is prevalent in older HIV-infected persons, screening for vitamin D deficiency is warranted.
Osteoporotic bone disease affects persons with HIV infection disproportionately when compared with others of similar age. Bone density is lower, and the fracture rate as much as 60% higher, in HIV-infected individuals [1-3] .
This may be explained at least in part by conventional risk factors that are more common among those with HIV, such as low body weight, cigarette smoking, alcoholism, hypogonadism, opiate use, and vitamin D deficiency. The proinflammatory state of HIV infection and direct viral effects on bone formation and resorption, however, play a role as well . HIV/AIDS has been added to the most recent iteration of the National Osteoporosis Foundation (NOF) Guidelines as a risk factor for osteoporosis  .
In addition, studies have demonstrated a high rate of secondary causes of osteoporosis in individuals with HIV and antiretroviral medications also lead to a reduction of bone mineral density . Certain antiretroviral agents, especially tenofovir disoproxil fumarate (TDF), lead to greater bone turnover and reductions in bone mineral density than other medications, and thus increase the risk of osteoporosis  .
With regard to screening for abnormal bone mineral density, the 2013 Primary Care Guidelines for the Management of Persons Infected with HIV recommend dual-X-ray absorptiometry (DXA) scan for all HIV-infected women who are post-menopausal and all HIV-infected men over the age of 50 , A set of recommendations for evaluation and management of bone disease for individuals with HIV, developed by a group of experts, similarly advises that all post-menopausal women and men above 50 year of age complete DXA screening  , although the cost effectiveness of this strategy has not been well defined. These guidelines also recommend DXA screening for individuals with HIV infection who are age 40 to 50 who have a FRAX (Fracture Risk Assessment Tool) -estimated 10-year risk of fracture above 20%, or those individuals who have a history of fragility fracture or chronic corticosteroid use. Screening should be considered for all HIV-infected individuals who fall into these risk groups. Although use of the medication TDF and a history of advanced HIV infection may increase the risk of osteoporosis, there are no concrete guidelines on how to weigh these factors in decisions about osteoporosis screening. Another important note is that studies have demonstrated that the FRAX calculator tools underestimate the prevalence of osteoporosis for individuals with HIV  . An evaluation for secondary causes of osteoporosis is also important to include in the evaluation, including a screen for vitamin D deficiency.
Treatment strategies for osteoporosis in HIV-infected persons are similar to those for HIV-uninfected persons.
Good bone health depends first and foremost on good nutrition, with adequate intake of calcium and vitamin D, as well as avoidance of serious systemic illness, smoking, and alcohol [7,9] . Patients should receive nutritional counseling if osteoporotic, and vitamin D supplementation if deficient. Weight bearing and strengthening exercise should be advised. Attempts to modify known risk factors should be encouraged.
Osteoporosis should be treated aggressively with conventional modalities appropriate to the individual patient and as outlined by national guidelines [2, 3, 9] .
Androgen supplementation should be an individual decision between patient and provider and was not deliberated by the Panel. Similarly, decisions for changing antiretroviral therapy due to decreased bone mineral density should be individualized. Of note, tenofovir alafenamide (TAF), a prodrug of tenofovir, appears to affect bone mineral density less than TDF; long-term clinical outcomes data is lacking and it is unclear whether use of TAF leads to a lower rate of osteoporotic fracture as compared to TDF  . For a patient with osteoporosis or osteoporosis risk factors, decisions about antiretroviral therapy should be individualized and TDF should be avoided if effective alternate options are available; the decision to use TAF in place or TDF or to avoid both TAF and TDF in these situations depends on the clinical situation and available antiretroviral options.
Brian Wood MD
- Arnsten JH, Freeman R, Howard AA, Floris-Moore M, Lo Y, Klein RS. Decreased bone mineral density and increased fracture risk in aging men with or at risk for HIV infection. AIDS 2007,21:617-623.
- Summary AG. Management of osteoporosis: a national clinical guideline. 2007.
- http://nof.org/files/nof/public/content/resource/913/files/580.pdf NOF. Clinician’s Guide to Prevention and Treatment of Osteoporosis. 2013.
- Walker Harris V, Brown TT. Bone loss in the HIV-infected patient: evidence, clinical implications, and treatment strategies. J Infect Dis 2012,205 Suppl 3:S391-398.
- Stellbrink H-J, Orkin C, Arribas JR, et al. Comparison of changes in bone density and turnover with abacavir-lamivudine versus tenofovir-emtricitabine in HIV-infected adults: 48-week results from the ASSERT study. Clin Infect Dis 2010;51(8):963-972.
- Aberg JA, Gallant JE, Ghanem KG, Emmanuel P, Zingman BS, Horberg MA, et al. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV medicine association of the Infectious Diseases Society of America. Clin Infect Dis 2014,58:e1-34.
- McComsey GA, Tebas P, Shane E, Yin MT, Overton ET, Huang JS, et al. Bone disease in HIV infection: a practical review and recommendations for HIV care providers. Clin Infect Dis 2010,51:937-946.
- Yin MT, Shiau S, Rimland D, et al. Fracture Prediction With Modified-FRAX in Older HIV-Infected and Uninfected Men. J Acquir Immune Defic Syndr.2016 Aug 15;72(5):513-20.
- Qaseem A, Snow V, Shekelle P, Hopkins R, Jr., Forciea MA, Owens DK, et al. Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008,149:404-415.
- Wang H,Lu X,Yang X, Xu N. The efficacy and safety of tenofovir alafenamide versus tenofovir disoproxil fumarate in antiretroviral regimens for HIV-1 therapy: Meta-analysis. Medicine (Baltimore). 2016 Oct;95(41):e5146.