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HIV & Aging Clinical Recommendations
Osteoporotic bone disease affects persons with HIV infection disproportionately when compared with others of similar age. Bone density is lower, and the fracture rate as much as 60% higher, in HIV-infected individuals (Arnsten 2007; Summary 2007; NOF 2013).
This may be explained at least in part by conventional risk factors that are more common among those with HIV, such as low body weight, cigarette smoking, alcoholism, hypogonadism, opiate use, and vitamin D deficiency. The proinflammatory state of HIV infection and direct viral effects on bone formation and resorption, however, play a role as well (Walker 2012). HIV/AIDS has been added to the most recent iteration of the National Osteoporosis Foundation (NOF) Guidelines as a risk factor for osteoporosis (NOF 2013) .
In addition, studies have demonstrated a high rate of secondary causes of osteoporosis in individuals with HIV and antiretroviral medications also lead to a reduction of bone mineral density (Walker 2012). Certain antiretroviral agents, especially tenofovir disoproxil fumarate (TDF), lead to greater bone turnover and reductions in bone mineral density than other medications, and thus increase the risk of osteoporosis (Stellbrink 2010).
With regard to screening for abnormal bone mineral density, the 2013 Primary Care Guidelines for the Management of Persons Infected with HIV recommend dual-X-ray absorptiometry (DXA) scan for all HIV-infected women who are post-menopausal and all HIV-infected men over the age of 50 (Aberg 2004). A set of recommendations for evaluation and management of bone disease for individuals with HIV, developed by a group of experts, similarly advises that all post-menopausal women and men above 50 year of age complete DXA screening (McComsey 2010), although the cost effectiveness of this strategy has not been well defined. These guidelines also recommend DXA screening for individuals with HIV infection who are age 40 to 50 who have a FRAX (Fracture Risk Assessment Tool)-estimated 10-year risk of fracture above 20%, or those individuals who have a history of fragility fracture or chronic corticosteroid use. Screening should be considered for all HIV-infected individuals who fall into these risk groups. Although use of the medication TDF and a history of advanced HIV infection may increase the risk of osteoporosis, there are no concrete guidelines on how to weigh these factors in decisions about osteoporosis screening. Another important note is that studies have demonstrated that the FRAX calculator tools underestimate the prevalence of osteoporosis for individuals with HIV (Yin 2016). An evaluation for secondary causes of osteoporosis is also important to include in the evaluation, including a screen for vitamin D deficiency.
Good bone health depends first and foremost on good nutrition, with adequate intake of calcium and vitamin D, as well as avoidance of serious systemic illness, smoking, and alcohol (McComsey 2010; Qaseem 2008). Patients should receive nutritional counseling if osteoporotic, and vitamin D supplementation if deficient. Weight bearing and strengthening exercise should be advised. Attempts to modify known risk factors should be encouraged.
Androgen supplementation should be an individual decision between patient and provider and was not deliberated by the Panel. Similarly, decisions for changing antiretroviral therapy due to decreased bone mineral density should be individualized. Of note, tenofovir alafenamide (TAF), a prodrug of tenofovir, appears to affect bone mineral density less than TDF; long-term clinical outcomes data is lacking and it is unclear whether use of TAF leads to a lower rate of osteoporotic fracture as compared to TDF (Wang 2016a). For a patient with osteoporosis or osteoporosis risk factors, decisions about antiretroviral therapy should be individualized and TDF should be avoided if effective alternate options are available; the decision to use TAF in place or TDF or to avoid both TAF and TDF in these situations depends on the clinical situation and available antiretroviral options.
Summary AG. Management of osteoporosis: a national clinical guideline. 2007.