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My Take: We Must Be Vigilant in Maintaining Bone Health in Patients With HIV

Todd T. Brown, MD, PhD

Professor of Medicine and Epidemiology
Division of Endocrinology, Diabetes and Metabolism
Johns Hopkins University
Baltimore, Maryland


Todd T. Brown, MD, PhD, has disclosed that he has received consulting fees from Gilead Sciences, Janssen, Merck, and ViiV Healthcare.


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Released: September 8, 2020

The population of people with HIV (PWH) is aging. In 2016, the CDC documented that nearly one half of people in the United States and dependent areas with diagnosed HIV were 50 years of age or older. As such, the frequency of aging-related conditions has increased during the last several years and will continue to increase dramatically in the next 10-15 years.

Osteoporosis is a classic disease of aging; we know from multiple studies that the risk of osteopenia, osteoporosis, and fractures related to osteoporosis are all higher in PWH compared with HIV-seronegative people of the same age who share the same demographic factors.

Causes of this increased risk for bone loss and resulting osteoporotic fracture are many. First, HIV-specific factors such as systemic inflammation may affect bone health. Second, PWH have many traditional osteoporosis risk factors. Third, certain ARV agents have been shown to be associated with decreased bone mineral density and fracture. Finally, as stated earlier, the population is aging, so it is important to remain vigilant in trying to reduce fracture risk when possible.

ART is one contributing factor to bone loss in PWH. Two of the main culprits among drugs used in the modern era are tenofovir disoproxil fumarate (TDF) and boosted PIs, both of which have been associated with decreased bone mineral density (BMD) compared with other drugs. However, the use of both TDF and the boosted PI class has decreased during the past 5 years. Although TDF is an excellent NRTI, negative effects on BMD have been observed, especially in people who already have compromised bone heath, and this may increase fracture risk. Fortunately, we know from switch studies in PWH and from assessing TDF as part of PrEP in persons without HIV that TDF cessation is associated with improvements in BMD. Similarly, although more controversial, boosted PI use has been independently associated with lower BMD and, in some studies, fracture. Some of this effect may be due to a combination of boosted PI and TDF, in which TDF levels are raised approximately 30%. Other studies suggest an effect of PIs independent of TDF use (eg, ACTG A5224s). Nevertheless, switching from boosted PI–based therapy may improve bone health of PWH.

Although the issue of ART and bone health has become less of a clinical problem with newer regimens, this does not mean that osteoporosis is not a critical issue in our aging PWH. Therefore, we must monitor our patients regularly to prevent fractures before they happen. Guidelines from the HIV Medicine Association of the Infectious Diseases Society of America recommend that the Fracture Risk Assessment Tool (FRAX) be used to assess risk of fragility fracture in men with HIV aged 40-49 years and women with HIV who are not yet menopausal but 40 years of age or older. Osteoporosis is a silent disease, and the simplest way to screen for it is by performing a dual energy X-ray absorptiometry (DXA) scan. A baseline DXA should be done in all postmenopausal women with HIV and men aged 50 years or older with HIV. The optimal interval between DXA or FRAX screening remains unknown, but a repeat DXA should be considered after 1-2 years for patients with baseline advanced osteopenia and after 5 years for mild to moderate osteopenia. For patients with normal BMD upon baseline screening, data from the general population suggest an interval of up to 15 years between screenings. Unfortunately, DXA screening competes with other health screenings and is not done as widely as recommended. However, this method is inexpensive, noninvasive, and takes less than 30 minutes. Of importance, by identifying people who are at increased risk of fracture, we can intervene with bone-specific treatments—including lifestyle modifications as well as pharmacologic treatments—and reduce the risk of fracture by 40% to 50%. Preventing fractures is a critical goal of caring for aging PWH, and fortunately, with proper screening and management, we can achieve this goal.

Join the Discussion
Do you routinely perform DXA screening on your PWH who fall into the age range for recommended screening? How often are you modifying ART in response to BMD loss in PWH? Please discuss your experiences in the comments section.

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