Bone Loss in HIV Infection

Abstract

Opinion Statement Human immunodeficiency virus (HIV) infection is an established risk factor for low bone mineral density (BMD) and subsequent fracture, and treatment with combination antiretroviral therapy (cART) leads to additional BMD loss, particularly in the first 1–2 years of therapy. The prevalence of low BMD and fragility fracture is expected to increase as the HIV-infected population ages with successful treatment with cART. Mechanisms of bone loss in the setting of HIV infection are likely multifactorial, and include viral, host, and immune effects, as well as direct and indirect effects of cART, particularly tenofovir disoproxil fumarate (TDF) and the protease inhibitors (PIs). Emerging data indicate that BMD loss following cART initiation can be mitigated by prophylaxis with either long-acting bisphosphonates or vitamin D and calcium supplementation. In addition, newer antiretrovirals, particularly the integrase strand transfer inhibitors and tenofovir alafenamide (TAF), are associated with less intense bone loss than PIs and TDF. However, further studies are needed to establish optimal bone sparing cART regimens, appropriate screening intervals, and preventive measures to address the rising prevalence of fragility bone disease in the HIV population.

Trends and predictors of non‐communicable disease multimorbidity among adults living with HIV and receiving antiretroviral therapy in Brazil

“…Screening was not uniform across sites and was often limited, particularly in public health settings. Additionally, an increasing proportion of patients in the cohort in later years received tenofovir (the median calendar year for patients who initiated zidovudine was 2007 vs. 2010 for those who initiated tenofovir), which has also been associated with osteoporosis risk . The rise in osteoporosis incidence in our cohort most likely reflects introduction of even limited screening and ageing.…”

Ovariectomy Activates Chronic Low-Grade Inflammation Mediated by Memory T Cells, Which Promotes Osteoporosis in Mice

“…Together, these results suggest that low‐grade inflammation promotes or is associated with bone loss in some postmenopausal women. Consistent with these findings, men and women with chronic inflammatory diseases such as rheumatoid arthritis (RA), Crohn's disease, and some viral (ie, human immunodeficiency virus [HIV]) infections develop osteoporosis . Despite these observations, questions as to the nature and the contribution of inflammation to postmenopausal osteoporosis have lingered.…”

Antiretroviral Therapy and Bone Health

“…HIV-infected patients are at risk for the development of osteopenia and osteoporosis as a result of many factors, including HIV infection itself, immune suppression, life-long ART, vitamin D deficiency and hypogonadism [3,4,12,26,27,28,38]. To the best of our knowledge, this study is the first investigation of the incidence of osteopenia and osteoporosis to be undertaken in a Bulgarian HIV population.…”

“…Data from a number of cross-sectional studies involving both young and elderly HIV-infected patients showed a high incidence of reduced BMD [3,4,16,24,26]. According to one study, osteoporosis is three times more common among HIV-infected patients compared with HIV-negative controls, especially in patients receiving anti-retroviral therapy (ART) [3].…”

“…The causes of low BMD in HIV-infected patients are multifactorial and constitute a complex of interactions between the HIV infection itself, traditional osteoporosis risk factors (poor diet and low weight, smoking, alcohol use and low vitamin D levels) and ART [3,4,24,26,38]. Osteopenia is also commonly found in ART-naive patients, indicating that uncontrolled viraemia may affect BMD, possibly mediated by the effect of systemic inflammation on bone remodelling [26]. HIV proteins increase the resorptive activity of osteoclasts and decrease bone formation by promoting osteoblast apoptosis [25].…”