Diagnosis, prevention, and treatment of bone fragility in people living with HIV: a position statement from the Swiss Association against Osteoporosis

Abstract

Life expectancy of people living with HIV (PLWH) is reaching similar length as in the general population. Accordingly, age-related comorbidities, including osteoporosis, are increasing. Fracture risk is higher and increases approximately 10 years earlier in PLWH. Classical risk factors of bone fragility are highly prevalent in PLWH but factors specific for HIV infection itself and the type of antiretroviral therapy (ART) (triple combination antiretroviral therapy) regimen (especially tenofovir and protease inhibitors) also contribute to bone loss. The majority of bone loss occurs during virus activity and at initiation of ART (immune reconstitution) and is associated with an increase of bone resorption (upregulation RANKL). Recent data indicate that calcium and vitamin D supplements as ART initiation lower BMD loss. The reduction of tenofovir plasma concentrations with tenofovir alafenamide attenuates BMD loss but it remains unknown whether it will contribute to reduce fracture risk. Hence, special considerations for the management of bone fragility in PLWH are warranted. Based on the current state of epidemiology and pathophysiology of osteoporosis in PLWH, we provide the consensus of the Swiss Association against Osteoporosis on best practice for diagnosis, prevention, and management of osteoporosis in this population. Periodic assessment of fracture risk is indicated in all HIV patients and general preventive measures should be implemented. All postmenopausal women, men above 50 years of age, and patients with other clinical risk for fragility fractures qualify for BMD measurement. An algorithm clarifies when treatment with bisphosphonates and review of ART regimen in favour of more bone-friendly options are indicated.

Vitamin D and Primary Ciliary Dyskinesia: A Topic to Be Further Explored

“…In addition, vitamin D may have a crucial role in bone osteoporosis, which may be essential in migrants and individuals with HIV infection [39][40][41][42][43]. Child neglect cases discovered in forensic practice and unpublished cases debated only in courts may represent the tip of an iceberg [29,44].…”

Human immunodeficiency virus infection (HIV)–associated rheumatic manifestations in thepre- and post-HAART eras

“…There is no specific guide for the assessment and management of HIV patients with decreased bone density; however, FRAX has been recommended for routine evaluation of fracture risk in PLWH despite the limited predictive value in these patients [54].…”

“…Management of osteoporosis in PLWH should follow the same recommendations for the HIV-negative population, an adequate nutrition including calcium and vitamin D and modification of lifestyles, pharmacological therapy with bisphosphonates, alendronate and zoledronic acid, have been shown to have a positive effect on BMD and tolerability similar to those found in the general population [54][55][56][57]. Currently, other therapeutic options have not been evaluated.…”

Reply to “Antiretroviral therapy options in people living with HIV at risk of or with osteoporosis. Comment on: Diagnosis, prevention, and treatment of bone fragility in people living with HIV: a position statement from the Swiss Association against Osteoporosis” by S. Noe, H. Jaeger, E. Wolf

“…We thank Noe and colleagues for their interest [1] in our position statement of the Swiss Association against Osteoporosis on diagnosis, prevention, and treatment of bone fragility in people living with HIV [2]. We agree that several options exist to avoid tenofovir disoproxil fumarate (TDF)-containing antiretroviral therapy (ART) in patients with established osteoporosis or with a relatively high risk of fracture and significant bone loss associated with high levels of bone resorption markers (CTX).…”