Mexican Patients with HIV Have a High Prevalence of Vertebral Fractures

Abstract

Low bone mineral density (BMD) and fragility fractures are common in individuals infected with HIV, who are undergoing antiretroviral therapy (ART). In high-income countries, dual energy X-ray absorptiometrry is typically used to evaluate osteopenia or osteoporosis in HIV infected individuals. However, this technology is unavailable in low andmiddle income countries, so a different approach is needed. The aim of this study was to use X-ray scans of the spine to determine the prevalence of and associated risk factors for vertebral fractures in HIVinfected patients in a tertiary-care hospital in Mexico. We conducted a cross-sectional study of outpatients who were >40 years old and receiving ART at the Hospital de Infectología, La Raza National Medical Center in Mexico City, Mexico. We used semi-quantitative morphometric analysis of centrally digitized X-ray images to assess vertebral deformities in the spine. Anterior, middle and posterior vertebral heights were measured, and height ratios were calculated. For each vertebral body, fractures were graded on the basis of height ratio reductions, and a spine deformity index’ (SDI) value was calculated by summing the grades of the vertebral deformities: An SDI>1 was indicative of a vertebral fracture. We included 104 patients, 87% of whom were men. The median age was 49 years [interquartile range (IQR) 42-52]. The most common stage of HIV infection, as defined by the Centers for Disease Control, was B2 in 40 (39%) of patients. Forty seven (45%) patients were on ART regimens that included protease inhibitors (PIs) and 100 (96%) being treated with tenofovir. The median time of ART was 6.5 years (IQR 1.6-9.0). Of the 104 patients in our study, 83 (80%) had undetectable viral load, as assessed by HIV-1 RNA levels, 32 (31%) showed evidence of a previous fracture, 4 (4%) were co-infected with hepatitis C virus, and 57 (55%) had a history of corticosteroid treatment. The prevalence of vertebral fractures was 25%, 95% confidence interval 17-34%. We assessed whether gender, HCV co-infection, previous corticosteroid use, AIDS, total HIV viral load, and current and previous use of PIs were associated with fractures in our study group, but we did not observe a significant association between any of these factors and vertebral fractures. The prevalence of vertebral fractures was high among HIV-infected patients. We propose that screening for bone disease should be performed in HIV individuals who are at risk of fragility fractures. Furthermore, we suggest that X-ray based assessment of the spine should be considered in patients who are at increased risk of fragility fractures, irrespective of BMD levels, particularly in elderly patients in low and middle income countries.

Incidence of osteoporosis and osteopenia in men with HIV+ and a history of Kaposi sarcoma

“…Osteoporosis and the high risk of fractures has also been reported [7]. In addition, a study conducted in Mexico City investigated the prevalence of vertebral fractures in 104 patients with HIV over 40 years of age (85% men), documenting that 25% had vertebral fractures, and no association was found with ARV drugs or with higher viral loads (> 100,000 copies/mL) [20]. However, the history of fractures in our population was low (1.2%), although the mean follow-up time was 9.7 ± 6.8 years.…”

Prevalence of osteoporosis and osteopenia in a cohort of HIV positive women with a history of treated neoplasms

“…In patients with HIV, many factors are related in the pathogenesis of the decrease in BDM: (1) increased levels of inflammatory cytokines present in chronic HIV infection that may increase bone turnover through osteoclast stimulation; (2) other pathologies can contribute to chronic inflammation, such as co-infection with HCV or HBV, renal disease, and diabetes; (3) factors related with HIV, such as low body weight, estrogen depletion, malabsorption, tobacco use, low CD4+ T cell count, duration of HIV infection, lipodystrophy, low levels of vitamin D, insulin resistance, and hyperlactatemia; and (4) antiretroviral treatment, which is generally associated with bone loss (2%-6% over the first 2 years of therapy). 3,4,7,[13][14][15][16][17][18] Mexican HIV-infected women are facing missing opportunities in medical care such as inadequate screening strategies, in conjunction with fewer opportunities to receive preventive or therapeutic intervention for BMD loss. 19 Considering ARV drugs, TDF and PIs, particularly Lopinavir, have been linked to low BMD.…”

“…1 Over the past two decades, there has been an increase in life expectancy in HIV population with access to cART, which has led to an increase in chronic degenerative diseases, such as osteoporosis. 4…”

“…1 Over the past two decades, there has been an increase in life expectancy in HIV population with access to cART, which has led to an increase in chronic degenerative diseases, such as osteoporosis. 4 However, the patients with a diagnosis of cancer have also a higher risk of bone loss and fractures, due to a combination of factors including their underlying malignancy and therapeutic regimens, particularly chemotherapies, which directly or indirectly affect bone cells. 5,6 The aim of this study was to describe the prevalence of osteopenia and osteoporosis in HIV positive women with a history of treated neoplasms and to compare this population with two control groups: women with cancer non-HIV infected, and women non-HIV and non-cancer diagnosis.…”

Prevalence of and risk factors for vertebral fracture and low bone mineral density among Peruvian women aging with HIV

“…Research focused on the bone health of women with HIV has primarily been carried out in upper-income countries and to a lesser extent in Africa. In contrast, only one study has examined fracture rates among women with HIV in Latin America and the Caribbean (LAC) region [ 10 ]. The aim of the present study was to determine prevalence of VF and measure BMD in a cohort of women aging with and without HIV in Lima, Peru, in order to identify risk factors for osteoporosis and fracture in this population.…”