Gender and sex considerations in HIV and bone health

Abstract

Purpose of reviewPeople with HIV (PWHIV) are at increased risk for osteoporosis and fractures, because of the effects of HIV and inflammation and antiretroviral therapy (ART) initiation as well as traditional risk factors. This review from recent literature focuses on sex differences in rates of bone disease, risk of fractures, and effects of ART. Recent findingsWomen with HIV in resource-constrained settings experience bone loss because of the additive effect of initiating TDF-containing ART during pregnancy, lactation, and menopause. Children and adolescents experience lower bone accrual during the pubertal growth years. There has been less focus on bone health in recent trials of ART containing tenofovir alafenamide and/or integrase inhibitors. Very few clinical trials or studies compare sex-specific changes in inflammation, immune activation, response to ART and bone turnover or change in BMD resulting in significant knowledge gaps. SummaryMore data is needed to determine changes in prevalence of osteopenia, osteoporosis, and fractures in the era of immediate initiation of ART at high CD4 cell counts and the use of more bone-friendly ART. The longterm effects of ART and low bone mass on fractures in the ageing population of PWHIV is yet to be realized. Keywordsantiretroviral therapy, bone mineral density, fracture, gender, HIV BONE HEALTH IN CHILDREN AND ADOLESCENTS WITH HIVOver 90% of children with perinatally acquired HIV live in resource-limited settings, and will experience the highest lifetime exposure to HIV and ART. Peak bone mass accrual occurs around puberty, and lower peak bone mass is a major determinant of subsequent osteoporosis and fractures in adults. ART initiated during growth and reproductive years is therefore a risk factor for osteoporosis. ART containing TDF and/or ritonavir-boosted protease inhibitors has the greatest negative impact on bone accrual in children and adolescents compared with