HIV & Aging Clinical Recommendations

Chapter 14

Osteoporosis in HIV and Aging

  • Since older individuals with HIV, even those on effective ART, may suffer accelerated bone loss, screening for and treatment of osteoporosis should be done.
  • Since vitamin D deficiency is prevalent in older HIV-infected persons, screening for vitamin D deficiency is warranted.

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.

Treatment strategies for osteoporosis in HIV-infected persons are similar to those for HIV-uninfected persons.

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.

Osteoporosis should be treated aggressively with conventional modalities appropriate to the individual patient and as outlined by national guidelines (Summary 2007; NOF 2013; Qaseem 2008).

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.

Updated on: 
Sunday, November 19, 2017
Updated by: 
Brian Wood MD


Purpose of this Program: The AAHIVM, ACRIA and AGS (collectively, the “Sponsors,” “we” or “us”) are sponsors of this Website and through it seek to address the unique needs and challenges that older adults of diverse populations living with HIV face as they age. However, the information in this Website is not meant to supplant the advice provided in a doctor-patient relationship.

General Disclaimer: is designed for educational purposes only and is not engaged in rendering medical advice or professional services. The information provided through should not be used for diagnosing or treating a health problem or a disease. It is not a substitute for professional care. If you have or suspect you may have a health problem, consult your health care provider.



Phone: 202-659-0699
Fax: 202-659-0976


AAHIVM National Office
1627 Eye St NW Suite 835
Washington, D.C. 20006


The American Academy of HIV Medicine is a professional organization that supports the HIV practitioner and promotes accessible, quality care for all Americans living with HIV disease. Our membership of HIV practitioners and credentialed HIV Specialists™, HIV Experts™, and HIV Pharmacists™ provide direct care to the majority of HIV patients in the US.