Bone Disease in HIV Infection: A Practical Review and Recommendations for HIV Care Providers

Abstract

Low bone mineral density (BMD) is prevalent in human immunodeficiency virus (HIV)–infected subjects. Initiation of antiretroviral therapy is associated with a 2%–6% decrease in BMD over the first 2 years, a decrease that is similar in magnitude to that sustained during the first 2 years of menopause. Recent studies have also described increased fracture rates in the HIV-infected population. The causes of low BMD in individuals with HIV infection appear to be multifactorial and likely represent a complex interaction between HIV infection, traditional osteoporosis risk factors, and antiretroviral-related factors. In this review, we make the point that HIV infection should be considered as a risk factor for bone disease. We recommend screening patients with fragility fractures, all HIV-infected post-menopausal women, and all HIV-infected men ≥50 years of age. We also discuss the importance of considering secondary causes of osteoporosis. Finally, we discuss treatment of the more severe cases of bone disease, while outlining the caveats and gaps in our knowledge.

An increased risk for fractures: another cause of frailty in HIV-infected subjects

“…The results of the study clearly suggest that the increased risk for fractures seems to be mainly due to HIV-infection and its treatment [10,11]. Several previous studies had shown that bone mineral mass is decreased in a large proportion of the HIV-infected population and therefore it was suggested that subjects living with HIV could be more prone to fractures than non-infected subjects [12]. Nevertheless, until now a few data were available in the literature on this topic.…”

“…Current guidelines on the osteoporosis do not take into account HIV-infection among risk factors that require a screening for osteoporosis in younger subjects [18,19]. HIV should be added to the list of risk factors for osteoporosis and probably a DXA should be performed in all HIV-infected patients 50 years or older, as recently suggested [12]. However, in HIVinfected patients bone mass density, as assessed by DXA scan, may underestimate the risk for fractures, as also seen in other types of secondary osteoporosis [14]; therefore it may be useful to perform not only DXA scan but also a spine radiography [14].…”

HIV infection, bone metabolism, and fractures

“…They did not detect differences in the FRAX score between patients with normal BMD and patients with low BMD; they concluded that the FRAX score does not discriminate between patients with osteopenia and those without osteopenia and thus provides very limited usefulness as a screening tool in the HIV-positive population. In fact, FRAX has not been validated in HIV-infected persons and may underestimate the 10-year risk of fracture in these patients (11).…”

Alta frecuencia de hipovitaminosis D y baja densidad mineral ósea en un grupo de hombres con infección por VIH en Chile

“…También son más frecuentes las fracturas óseas en pacientes con infección por VIH comparado con individuos sanos de la misma edad 4,5 . Algunos factores que se han asociado independientemente con pérdida de densidad mineral en esta población han sido el virus en sí mismo, la edad, tabaquismo, abuso de alcohol, bajo índice de masa corporal y particularmente, el uso de terapia antirretroviral (TARV) [6][7][8][9] . En Latinoamérica no se han publicado datos sobre este tema en pacientes con VIH.…”