The Impact of Human Immunodeficiency Virus and Menopause on Bone Mineral Density: A Longitudinal Study of Urban-Dwelling South African Women

Abstract

An estimated 25% of South African women live with human immunodeficiency virus (HIV). Antiretroviral therapy roll-out has improved life expectancy, so many more women now reach menopause. We aimed to quantify changes in bone mineral density (BMD) during the menopausal transition in urban-dwelling South African women with and without HIV and determine whether HIV infection modified the effect of menopause on BMD changes. A 5-year population-based longitudinal study recruited women aged 40-60 years residing in Soweto and collected demographic and clinical data, including HIV status, anthropometry, and BMD, at baseline and at 5-year follow-up. All women were staged as pre-, peri-, or postmenopausal at both time points. Multivariable linear regression assessed relationships and interactions between HIV infection, menopause, and change in BMD. At baseline, 450 women had mean age 49.5 (SD 5.7) years, 65 (14.4%) had HIV, and 140 (31.1%), 119 (26.4%), and 191 (42.4%) were pre-, peri-, and postmenopausal, respectively; 34/205 (13.6%) women ≥50 years had a total hip (TH) or lumbar spine (LS) T-score ≤ À2.5. At follow-up 38 (8.4%), 84 (18.7%), and 328 (72.9%) were pre-, peri-, and postmenopausal. Those with HIV at baseline lost more total body (TB) BMD (mean difference À0.013 [95% confidence interval À0.026, À0.001] g/cm 2 , p = 0.040) and gained more weight 1. 96 [0.32, 3.60] kg; p = 0.019 than HIV-uninfected women. After adjusting for age, baseline weight, weight change, and follow-up time, the transition from pre-to postmenopause was associated with greater TB BMD losses in women with HIV (À0.092 [À0.042, À0.142] g/cm 2 ; p = 0.001) than without HIV (À0.038 [À0.016, À0.060] g/cm 2 , p = 0.001; interaction p = 0.034). Similarly, in women who were postmenopausal at both time points, those with HIV lost more TB BMD (À0.070 [À0.031, À0.108], p = 0.001) than women without HIV (À0.036 [À0.015, À0.057], p = 0.001, interaction p = 0.049). Findings were consistent but weaker at the LS and TH. Menopause-related bone loss is greater in women with HIV, suggesting women with HIV may be at greater risk of osteoporotic fractures. HIV services should consider routine bone health assessment in midlife women as part of long-term HIV care delivery.

Cardiometabolic health in people with HIV: expert consensus review

“… 84 Compared with women without HIV, women with HIV had lower BMD in a cross-sectional study 85 and greater bone loss in a prospective study. 86 …”

“…Summary of evidence: Traditional risk factors for reduced BMD and fractures apply to people with HIV and include demographic characteristics such as older age 82 , 87–93 and female sex, 89 , 92 , 94 , 95 vitamin D deficiency, 92 , 96 , 97 and hypogonadal states (e.g. lower testosterone levels in men 92 , 96 , 98 and menopause in women 85 , 86 , 92 ). Notably, one study reported greater risk of BMD loss in people with versus without HIV who transitioned from pre- to post-menopause.…”

“…Notably, one study reported greater risk of BMD loss in people with versus without HIV who transitioned from pre- to post-menopause. 86 Modifiable risk factors associated with lower BMD include tobacco use 88 , 90 , 96 , 97 and heavy alcohol consumption. 96 , 97 Additional factors or conditions associated with reduced BMD and/or increased fracture risk in people with HIV and the general population include adrenal insufficiency, haemophilia, gastrointestinal malabsorption, glucocorticoid use, emphysema, opiate use, dietary calcium deficiency, primary hyperparathyroidism, Cushing’s syndrome, renal phosphate wasting, idiopathic hypercalciuria, celiac sprue, multiple myeloma and mastocytosis.…”

HIV and Bone Health: Considerations for Menopausal Women Living with HIV in Sub-Saharan Africa

“…In this issue of the Journal of Bone and Mineral Research , Madanhire et al ( 16 ) provide data on BMD changes during the menopausal transition in urban‐dwelling South African women with and without HIV and investigate whether HIV infection modifies the effect of menopause on these changes. The authors conducted a 5‐year population‐based longitudinal study among 450 women aged 40 to 60 years in Soweto, South Africa.…”