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Ward KA, Pearse CM, Madanhire T, Wade AN, Fabian J, Micklesfield LK, Gregson CL. Disparities in the Prevalence of Osteoporosis and Osteopenia in Men and Women Living in Sub-Saharan Africa, the UK, and the USA. Curr Osteoporos Rep 2023; 21:360-371. [PMID: 37351757 PMCID: PMC10393839 DOI: 10.1007/s11914-023-00801-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 06/24/2023]
Abstract
PURPOSE To review the rising prevalence of osteopenia and osteoporosis in sub-Saharan Africa and the challenges this poses to governments and healthcare services. Using existing studies, we compare the prevalence of osteopenia and osteoporosis in men and women from sub-Saharan Africa to US and UK cohorts. Context-specific disparities in healthcare are discussed particularly the challenges in diagnosis and treatment of osteoporosis. RECENT FINDINGS There are few epidemiological data describing the burden of osteoporosis in sub-Saharan Africa. In the studies and cohorts presented here, osteoporosis prevalence varies by sex, country and area of residence, but is generally higher in African populations, than has previously been appreciated. Risk factors contributing to poorer bone health include HIV, malnutrition and "inflammaging." Reprioritization towards care of ageing populations is urgently required. Equitable access to implementable preventative strategies, diagnostic services, treatments and pathways of care for bone health (for example embedded within HIV services) need now to be recognized and addressed by policy makers.
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Affiliation(s)
- Kate A Ward
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK.
- MRC Unit The Gambia, London School of Hygiene and Tropical Medicine, Banjul, The Gambia.
| | - Camille M Pearse
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - Tafadzwa Madanhire
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- The Health Research Unit Zimbabwe, Biomedical Research & Training Institute, Harare, Zimbabwe
| | - Alisha N Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - June Fabian
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa K Micklesfield
- SAMRC/Wits Developmental Pathways for Health Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Celia L Gregson
- The Health Research Unit Zimbabwe, Biomedical Research & Training Institute, Harare, Zimbabwe
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
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Mukwasi-Kahari C, Rehman AM, Ó Breasail M, Rukuni R, Madanhire T, Chipanga J, Stranix-Chibanda L, Micklesfield LK, Ferrand RA, Ward KA, Gregson CL. Impaired Bone Architecture in Peripubertal Children With HIV, Despite Treatment With Antiretroviral Therapy: A Cross-Sectional Study From Zimbabwe. J Bone Miner Res 2023; 38:248-260. [PMID: 36426511 PMCID: PMC9996028 DOI: 10.1002/jbmr.4752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/08/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
HIV infection has multi-system adverse effects in children, including on the growing skeleton. We aimed to determine the association between chronic HIV infection and bone architecture (density, size, strength) in peripubertal children. We conducted a cross-sectional study of children aged 8 to 16 years with HIV (CWH) on antiretroviral therapy (ART) and children without HIV (CWOH) recruited from schools and frequency-matched for age strata and sex. Outcomes, measured by tibial peripheral quantitative computed tomography (pQCT), included 4% trabecular and 38% cortical volumetric bone mineral density (vBMD), 4% and 38% cross-sectional area (CSA), and 38% stress-strain index (SSI). Multivariable linear regression tested associations between HIV status and outcomes, stratified by sex and puberty (Tanner 1-2 versus 3-5), adjusting for age, height, fat mass, physical activity, and socioeconomic and orphanhood statuses. We recruited 303 CWH and 306 CWOH; 50% were female. Although CWH were similar in age to CWOH (overall mean ± SD 12.4 ± 2.5 years), more were prepubertal (ie, Tanner 1; 41% versus 23%). Median age at ART initiation was 4 (IQR 2-7) years, whereas median ART duration was 8 (IQR 6-10) years. CWH were more often stunted (height-for-age Z-score <-2) than those without HIV (33% versus 7%). Both male and female CWH in later puberty had lower trabecular vBMD, CSA (4% and 38%), and SSI than those without HIV, whereas cortical density was similar. Adjustment explained some of these differences; however, deficits in bone size persisted in CWH in later puberty (HIV*puberty interaction p = 0.035 [males; 4% CSA] and p = 0.029 [females; 38% CSA]). Similarly, puberty further worsened the inverse association between HIV and bone strength (SSI) in both males (interaction p = 0.008) and females (interaction p = 0.004). Despite long-term ART, we identified deficits in predicted bone strength in those living with HIV, which were more overt in the later stages of puberty. This is concerning, as this may translate to higher fracture risk later in life. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Cynthia Mukwasi-Kahari
- Department of Infectious Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,The Health Research Unit Zimbabwe (THRU-Zim), Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Andrea M Rehman
- Department of Infectious Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mícheál Ó Breasail
- MRC Nutrition and Bone Health Research Group, University of Cambridge, Cambridge, UK.,Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Ruramayi Rukuni
- The Health Research Unit Zimbabwe (THRU-Zim), Biomedical Research and Training Institute, Harare, Zimbabwe.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Tafadzwa Madanhire
- Department of Infectious Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,The Health Research Unit Zimbabwe (THRU-Zim), Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Joseph Chipanga
- The Health Research Unit Zimbabwe (THRU-Zim), Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Lynda Stranix-Chibanda
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Lisa K Micklesfield
- South African Medical Research Council/Wits Developmental Pathways for Health Research Unit (DPHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rashida A Ferrand
- The Health Research Unit Zimbabwe (THRU-Zim), Biomedical Research and Training Institute, Harare, Zimbabwe.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Kate A Ward
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK.,MRC Unit, The Gambia at LSHTM, Banjul, Gambia
| | - Celia L Gregson
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
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Ó Breasail M, Gregson CL, Norris SA, Madanhire T, Jaff N, Crowther NJ, Micklesfield LK, Ward KA. Menopause is associated with bone loss, particularly at the distal radius, in black South African women: Findings from the Study of Women Entering and in Endocrine Transition (SWEET). Bone 2022; 164:116543. [PMID: 36058501 DOI: 10.1016/j.bone.2022.116543] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/17/2022] [Accepted: 08/27/2022] [Indexed: 11/23/2022]
Abstract
UNLABELLED Menopause transition is associated with accelerated bone loss, though data are limited from sub-Saharan African (SSA). Our objective was to describe bone density, geometry and estimated strength in women by menopause status and to explore whether patterns differed within those living with HIV. METHODS Radius and tibia peripheral QCT data were collected for Black South African women (n = 430) aged 40-61 years with verified menopause and HIV status. pQCT outcomes were distal 4 % radius and tibia total cross-sectional area (CSA), total volumetric bone mineral density (vBMD), and compressive bone strength (BSIc); proximal 66 % radius and 38 % tibia cortical vBMD, total CSA, cortical thickness, and Stress-strain Index (SSI). Linear regression assessed associations between pre, peri-, and postmenopausal groups and pQCT outcomes adjusting for age, height, and weight, and then stratified by HIV status. Mean [95%CI] and tests for trend (p-trend) across menopausal groups are presented. RESULTS Women were mean (SD) age 49.2 (5.3) years, with a body mass index (BMI) of 32.4 (6.3) m/kg2, and 18 % were living with HIV. After adjustment, later menopause stage was associated with lower 4 % radius total mean [95%CIs] vBMD (premenopause: 345.7 [335.8,355.5] vs. postmenopause: 330.1 [322.7,337.6] mg/cm3, p-trend = 0.017) and BSIc (premenopause: 0.39 [0.37,0.41] vs. postmenopause: 0.36 [0.35,0.37] g2/cm4; p-trend = 0.012). Similar trends were observed at the 66 % radius for cortical vBMD (premenopause: 1146.8 [1138.9,1154.6] vs. postmenopause: 1136.1 [1130.1,1142.0] mg/cm3; p-trend = 0.028) and cortical thickness (premenopause: 2.01 [1.95,2.06] vs. postmenopause: 1.93 [1.89,1.98] mm; p-trend = 0.036). After stratification by HIV status a similar patten was observed in women with HIV (cortical vBMD premenopause: 1152.9 [1128.5,1177.2] mg/cm3 vs. postmenopause: 1123.6 [1106.0,1141.2] mg/cm3, p-trend = 0.048). Total CSA varied little by menopause or HIV status at either radius sites; few differences were found at the tibia. CONCLUSION In black South African women, menopause is associated with lower bone density and strength at the distal radius, a common site of osteoporotic fracture, in addition to lower cortical density and thickness at the proximal radius. Although the sample size was small, following stratification by HIV, women living with HIV had evidence of lower cortical density across menopause stages, unlike those without HIV. These findings raise concern for the incidence of Colles' fractures in postmenopausal women in South Africa; longitudinal studies of fracture incidence and implications of living with HIV are required.
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Affiliation(s)
- Mícheál Ó Breasail
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; MRC Nutrition and Bone Health Research Group, Clifford Allbutt Building, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 OAH, United Kingdom.
| | - Celia L Gregson
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom; SAMRC/Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Shane A Norris
- SAMRC/Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Global Health Research Institute, School of Human Development and Health, University of Southampton, United Kingdom.
| | - Tafadzwa Madanhire
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom; SAMRC/Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Nicole Jaff
- Department of Chemical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa.
| | - Nigel J Crowther
- Department of Chemical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa.
| | - Lisa K Micklesfield
- SAMRC/Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Kate A Ward
- MRC Nutrition and Bone Health Research Group, Clifford Allbutt Building, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 OAH, United Kingdom; SAMRC/Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom; MRC Unit The Gambia at The London School of Hygiene and Tropical Medicine, United Kingdom.
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Nimitphong H, Sungkanuparph S, Saetung S, Chailurkit LO, Sritara C, Musikarat S, Ongphiphadhanakul B. A Comparison of Bone Mineral Density and Its Predictors in HIV-Infected and HIV-Uninfected Older Men. Endocr Pract 2021; 27:1225-1231. [PMID: 34343711 DOI: 10.1016/j.eprac.2021.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/19/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Bone health in older individuals with HIV infection has not been well studied. This study aimed to compare bone mineral density (BMD), trabecular bone score (TBS), and bone markers between HIV-infected men and age- and body mass index (BMI)-matched HIV-uninfected men aged ≥60 years. We investigated the associations of risk factors related to fracture with BMD, TBS, and bone markers in HIV-infected men. METHODS This cross-sectional study included 45 HIV-infected men receiving antiretroviral therapy and 42 HIV-uninfected men. Medical history, BMD and TBS measurements, and laboratory tests related to bone health were assessed in all the participants. HIV-related factors known to be associated with bone loss were assessed in the HIV-infected men. RESULTS The mean BMD, TBS, and osteopenia or osteoporosis prevalence were similar among the cases and controls. The HIV-infected men had significantly higher mean N-terminal propeptide of type 1 procollagen and C-terminal cross-linking telopeptide of type I collagen levels. Stepwise multiple linear regression analysis demonstrated that low BMI (lumbar spine, P = .015; femoral neck, P = .018; and total hip, P = .005), high C-terminal cross-linking telopeptide of type I collagen concentration (total hip, P = .042; and TBS, P = .010), and low vitamin D supplementation (TBS, P = .035) were independently associated with low BMD and TBS. CONCLUSION In older HIV-infected men with a low fracture risk, the mean BMD and TBS were similar to those of the age- and BMI-matched controls. The mean bone marker levels were higher in the HIV group. Traditional risk factors for fracture, including low BMI, high C-terminal cross-linking telopeptide of type I collagen level, and low vitamin D supplementation, were significant predictors of low BMD and TBS.
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Affiliation(s)
- Hataikarn Nimitphong
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Somnuek Sungkanuparph
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Samut Prakan, Thailand
| | - Sunee Saetung
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - La-Or Chailurkit
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chanika Sritara
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suchawadee Musikarat
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Boonsong Ongphiphadhanakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Ellis C, Kruger HS, Viljoen M, Dave JA, Kruger MC. Factors Associated with Bone Mineral Density and Bone Resorption Markers in Postmenopausal HIV-Infected Women on Antiretroviral Therapy: A Prospective Cohort Study. Nutrients 2021; 13:nu13062090. [PMID: 34207469 PMCID: PMC8234450 DOI: 10.3390/nu13062090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/01/2021] [Accepted: 06/10/2021] [Indexed: 12/20/2022] Open
Abstract
The study aimed to determine factors associated with changes in bone mineral density (BMD) and bone resorption markers over two years in black postmenopausal women living with human immunodeficiency virus (HIV) on antiretroviral therapy (ART). Women (n = 120) aged > 45 years were recruited from Potchefstroom, South Africa. Total lumbar spine and left femoral neck (LFN) BMD were measured with dual energy X-ray absorptiometry. Fasting serum C-Telopeptide of Type I collagen (CTx), vitamin D and parathyroid hormone were measured. Vitamin D insufficiency levels increased from 23% at baseline to 39% at follow up. In mixed linear models serum CTx showed no change from baseline to end (p = 0.363, effect size = 0.09). Total and LFN BMD increased significantly over two years, but effect sizes were small. No significant change in spine BMD over time was detected (p = 0.19, effect size = 0.02). Age was significantly positively associated with CTx over time, and negatively with total and LFN BMD. Physical activity (PA) was positively associated with LFN BMD (p = 0.008). Despite a decrease in serum vitamin D, BMD and CTx showed small or no changes over 2 years. Future studies should investigate PA interventions to maintain BMD in women living with HIV.
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Affiliation(s)
- Christa Ellis
- Centre of Excellence for Nutrition, North-West University, Potchefstroom 2520, South Africa;
- Correspondence: ; Tel.: +27-83-374-9477
| | - Herculina S Kruger
- Centre of Excellence for Nutrition, North-West University, Potchefstroom 2520, South Africa;
- Medical Research Council Hypertension and Cardiovascular Disease Research Unit, North-West University, Potchefstroom 2520, South Africa
| | - Michelle Viljoen
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, University of the Western Cape, Bellville 7535, South Africa;
| | - Joel A Dave
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town 7535, South Africa;
| | - Marlena C Kruger
- School of Health Sciences, Massey University, Palmerston North 0745, New Zealand;
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Matovu FK, Nabwana M, Kiwanuka N, Scholes D, Isingel E, Nolan ML, Fowler MG, Musoke P, Pettifor JM, Brown TT, Beksinska ME. Bone Mineral Density in Antiretroviral Therapy-Naïve HIV-1-Infected Young Adult -Women Using Depot Medroxyprogesterone Acetate or Nonhormonal Contraceptives in Uganda. JBMR Plus 2020; 5:e10446. [PMID: 33615111 PMCID: PMC7872338 DOI: 10.1002/jbm4.10446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/10/2020] [Accepted: 10/27/2020] [Indexed: 12/15/2022] Open
Abstract
Most studies evaluating BMD in human immunodeficiency virus (HIV)‐infected populations have focused on antiretroviral therapy (ART)‐experienced patients. In this study, the association between HIV‐1 and/or depot medroxyprogesterone acetate (DMPA) and BMD among untreated HIV‐1–infected women in a resource‐limited setting was assessed before long‐term exposure to ART. The data were then compared with that of the 2005–2008 United States National Health and Nutrition Examination Survey data for non‐Hispanic White and Black women. Women aged 18–35 years, recruited from health facilities in Kampala, Uganda, were classified based on their combination of HIV‐1 status and DMPA use: (i) HIV‐1–infected current DMPA users, (ii) HIV‐1–infected previous DMPA users, (iii) HIV‐1–infected nonhormonal‐contraceptive users, and (iv) HIV‐uninfected nonhormonal‐contraceptive users. All HIV‐1–infected women reported being ART‐naïve at baseline. BMD was measured at the lumbar spine, total hip, and femoral neck using DXA. Multivariate linear regression was used to assess the association between HIV‐1 and/or DMPA and BMD Z‐scores. Baseline data were analyzed for 452 HIV‐1–infected (220 nonhormonal users, and 177 current and 55 previous DMPA users) and 69 HIV‐1–uninfected nonhormonal‐contraceptive users. The mean age was 26.1 years (SD, 4.2) with a median duration of DMPA use among current users of 24.0 months [medians (interquartile range), 12‐48]. A higher proportion of HIV‐1–infected previous (12.7%) or current DMPA users (20.3%) and nonhormonal users (15.0%) had low BMD (Z‐score ≤−2 at any of the three sites) compared with age‐matched HIV‐1–uninfected women (2.9%). HIV‐1 infection and DMPA use were independently associated with significantly lower mean BMD Z‐scores at all sites, with the greatest difference being among HIV‐1–infected current DMPA users (5.6%–8.0%) versus uninfected nonhormonal users. Compared with non‐Hispanic White and Black women, the Ugandan local reference population had generally lower mean BMD at all sites. Newer treatment interventions are needed to mitigate BMD loss in HIV‐1–infected women in resource‐limited settings. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Flavia Kiweewa Matovu
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration Kampala Uganda.,Makerere University College of Health Sciences Kampala Uganda
| | - Martin Nabwana
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration Kampala Uganda
| | - Noah Kiwanuka
- Makerere University College of Health Sciences Kampala Uganda
| | - Delia Scholes
- Kaiser Permanente Washington Health Research Institute Seattle WA USA
| | - Esther Isingel
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration Kampala Uganda
| | - Monica L Nolan
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration Kampala Uganda
| | - Mary G Fowler
- Johns Hopkins University School of Medicine Baltimore MD USA
| | - Philippa Musoke
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration Kampala Uganda.,Makerere University College of Health Sciences Kampala Uganda
| | - John M Pettifor
- SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa
| | - Todd T Brown
- Johns Hopkins University School of Medicine Baltimore MD USA
| | - Mags E Beksinska
- Maternal Adolescent & Child Health Research Unit, Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa
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7
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Nabwire F, Prentice A, Hamill MM, Fowler MG, Byamugisha J, Kekitiinwa A, Goldberg GR. Changes in Bone Mineral Density During and After Lactation in Ugandan Women With HIV on Tenofovir-Based Antiretroviral Therapy. J Bone Miner Res 2020; 35:2091-2102. [PMID: 32573842 DOI: 10.1002/jbmr.4121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 06/08/2020] [Accepted: 06/17/2020] [Indexed: 01/08/2023]
Abstract
Antiretroviral therapy (ART) in people living with human immunodeficiency virus (HIV) is associated with bone loss, but data are limited in lactation, when physiological bone mineral mobilization is occurring. This research charted changes in areal bone mineral density (aBMD) during and after lactation in Ugandan women with HIV (WWH) initiated onto ART in pregnancy, compared to women without HIV (REF). One-hundred WWH on tenofovir-based ART and 100 REF were enrolled in pregnancy. Lumbar spine (LS), total hip (TH), and whole-body-less-head (WBLH) aBMD were measured by dual-energy X-ray absorptiometry (DXA) at 2, 14, and 26 weeks of lactation, and at 3 months postlactation. The primary outcome was the difference between groups in mean percent change in LS aBMD between 2 and 14 weeks. Statistical analysis was performed in hierarchical repeated measures ANOVA models that corrected for multiple testing. Median age was 23.4 (IQR, 21.0 to 26.8) years. WWH had lower body weight. aBMD decreased in both groups during lactation, but WWH had greater decreases at TH (2-to-26 weeks: WWH [n = 63] -5.9% [95% CI, -6.4 to -5.4] versus REF [n = 64] -4.3% [95% CI, -4.8 to -3.8]; group*time point interaction p = .008). Decreases in LS aBMD were similar in WWH and REF (2-to-26 weeks: -2.0% [95% CI, -2.5 to -1.5]), although there was a tendency toward a smaller decrease in WWH between 2 and 14 weeks (WWH [n = 77] -1.8% [95% CI, -2.2 to -1.4] versus REF [n = 69] -2.9% [95% CI, -3.3 to -2.5]; group*time point interaction p = .08). Postlactation, LS aBMD was higher relative to week 2 in both groups. TH and WBLH aBMD did not return to week 2 values in WWH but did in REF (TH postlactation versus week 2: WWH [n = 61] -3.1% [95% CI, -3.6 to -2.6]; REF [n = 29] +0.1% [95% CI, -0.9 to +1.1]). These data show accentuated bone loss during lactation and only partial skeletal recovery by 3 months postlactation in Ugandan WWH on tenofovir-based ART. Studies are ongoing to understand longer-term consequences for bone health. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.
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Affiliation(s)
| | - Ann Prentice
- MRC Nutrition and Bone Health Research Group, Cambridge, UK
| | | | | | | | - Adeodata Kekitiinwa
- Baylor College of Medicine Children's Foundation, Uganda (Baylor-Uganda), Kampala, Uganda
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8
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Paruk F, Tsabasvi M, Kalla AA. Osteoporosis in Africa-where are we now. Clin Rheumatol 2020; 40:3419-3428. [PMID: 32797362 DOI: 10.1007/s10067-020-05335-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/20/2020] [Accepted: 08/08/2020] [Indexed: 02/07/2023]
Abstract
Africa is experiencing an exponential increase in the number of older persons. The number of persons surviving with human immunodeficiency virus is simultaneously increasing due to improved availability of anti-retroviral therapy. The burden of non-communicable diseases, in particular, osteoporosis and its consequent fragility fractures, is also predicted to increase. Osteoporosis, however, remains a neglected disease and there are no age-standardized reference data available to accurately screen and diagnose individuals with osteoporosis. Epidemiological studies reporting the incidence of hip fracture or vertebral fractures are limited from Africa, especially Sub-Saharan Africa. The studies are usually limited as they are based on a retrospective data and small study numbers and often from a single study site. However, compared with early initial studies, the more recent studies show that osteoporosis and fractures are increasing across the continent. The overall incidence rates for osteoporosis and fractures still vary greatly between different regions in Africa and ethnic groups. Predisposing factors are similar with those in developed countries, but awareness of osteoporosis is sorely lacking. There is a lack of awareness among the population as well as health authorities, making it extremely difficult to quantify the burden of disease. There is great potential for research into the need and availability of preventive strategies. The FRAX® tool needs to be developed for African populations and may circumvent the shortage of bone densitometry.
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Affiliation(s)
- F Paruk
- Department of Rheumatology, Inkosi Albert Luthuli Central Hospital, School of Clinical Medicine, College of Health Science, University of KwaZulu-Natal, 719 Umbilo Road, eThekwini, Congella, Durban, 4001, South Africa.
| | - M Tsabasvi
- Department of Surgery-Orthopaedics and Traumatology, Harare Central Hospital, Harare, Zimbabwe
| | - A A Kalla
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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9
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Hamill MM, Pettifor JM, Ward KA, Norris SA, Prentice A. Bone Mineral Density, Body Composition, and Mineral Homeostasis Over 24 Months in Urban South African Women With HIV Exposed to Antiretroviral Therapy. JBMR Plus 2020; 4:e10343. [PMID: 32382690 PMCID: PMC7202419 DOI: 10.1002/jbm4.10343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/11/2019] [Accepted: 01/19/2020] [Indexed: 12/17/2022] Open
Abstract
Human immunodeficiency virus- (HIV-) infection and antiretroviral therapy (ART) exposure are associated with bone loss. African data are limited despite the region's HIV burden. Of 247 ART-naïve, premenopausal, urban, black African women aged 33.9 ± 6.6 years from Soweto, South Africa, measured at baseline, 110 underwent anthropometry, DXA, and blood and urine collections at 12 and 24 months; 39 were HIV-negative (Nref), 28 were people with HIV (PWH) not ART-exposed for the duration of the study (ART-N), and 43 were PWH who were ART-exposed within the first 12 months (ART-Y). At baseline, the ART-Y group had lower BMI and fat mass than the Nref group. Within 12 months of ART initiation, areal bone mineral density (aBMD) had decreased at the lumbar spine and at the whole body less head, despite increased weight, and hip aBMD had not increased in line with the Nref group. There was no evidence of further bone changes between 12 and 24 months. By 24 months, the ART-Y women had gained weight and fat mass, but remained lighter with less fat than the Nref women. ART initiation normalized the low serum albumin of the ART-Y group at baseline, but was associated with elevated bone turnover markers at 12 and 24 months. Vitamin D status and renal phosphate handling were normal. ART-N had similar aBMD and other characteristics to the Nref group throughout, except unlike the Nref group, weight and fat mass did not increase and serum albumin decreased. This study in African women of childbearing age demonstrated that the bone loss that had occurred in these PWH after ART initiation did not continue after 12 months and that bone loss did not occur in ART-unexposed PWH over 2 years. At 24 months, despite gains in weight and fat mass, ART-exposed women remained lighter, with lower aBMD, fat mass, and higher bone turnover than women without HIV. More studies are required to establish if the bone loss and fat gain reverse, stabilize, or continue with further ART exposure, particularly during and after menopause. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Matthew M Hamill
- Medical Research Council Elsie Widdowson Laboratory Cambridge UK.,South African Medical Research Council/University of Witwatersrand Developmental Pathways for Health Research Unit, Faculty of Health Sciences University of Witwatersrand Johannesburg South Africa.,Division of Infectious Diseases, Bayview Medical Center Johns Hopkins University School of Medicine Baltimore MD USA
| | - John M Pettifor
- South African Medical Research Council/University of Witwatersrand Developmental Pathways for Health Research Unit, Faculty of Health Sciences University of Witwatersrand Johannesburg South Africa
| | - Kate A Ward
- Medical Research Council Elsie Widdowson Laboratory Cambridge UK
| | - Shane A Norris
- South African Medical Research Council/University of Witwatersrand Developmental Pathways for Health Research Unit, Faculty of Health Sciences University of Witwatersrand Johannesburg South Africa
| | - Ann Prentice
- Medical Research Council Elsie Widdowson Laboratory Cambridge UK.,South African Medical Research Council/University of Witwatersrand Developmental Pathways for Health Research Unit, Faculty of Health Sciences University of Witwatersrand Johannesburg South Africa
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10
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Wattanachanya L, Jantrapakde J, Avihingsanon A, Ramautarsing R, Kerr S, Trachunthong D, Pussadee K, Teeratakulpisarn N, Jadwattanakul T, Chaiwatanarat T, Buranasupkajorn P, Phanuphak N, Sunthornyothin S, Phanuphak P. Antiretroviral-naïve HIV-infected patients had lower bone formation markers than HIV-uninfected adults. AIDS Care 2019; 32:984-993. [PMID: 31137948 DOI: 10.1080/09540121.2019.1622631] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
There are limited studies regarding bone health among people living with HIV (PLHIV) in Asia. We compared bone mineral density (BMD), serum 25-hydroxyvitamin D (25(OH)D) status and bone turnover markers (serum procollagen type1 N-terminal propeptide (P1NP), osteocalcin (OC) and C-terminal cross-linking telopeptide of type1 collagen) among 302 antiretroviral therapy (ART) naive PLHIV compared to 269 HIV-uninfected controls from Thailand. People aged ≥30 years, with and without HIV infection (free of diabetes, hypertension, and active opportunistic infection) were enrolled. BMD at the lumbar spine, total hip, and femoral neck were measured using Hologic DXA at baseline and at 5 years. We analyzed BMD, serum 25(OH)D levels, and bone turnover markers at the patients' baseline visit. PLHIV were 1.5 years younger and had lower BMI. PLHIV had higher mean serum 25(OH)D level and similar BMD to the controls. Interestingly, PLHIV had significantly lower bone formation (serum P1NP and OC), particularly those with low CD4 count. Only a few participants had low bone mass. ARV naïve middle-aged PLHIV did not have lower BMD or lower vitamin D levels compared to the controls. However, PLHIV had lower bone formation markers, particularly those with low CD4 count. This finding supports the benefit of early ART.
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Affiliation(s)
- Lalita Wattanachanya
- Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Anchalee Avihingsanon
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,Tuberculosis Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Stephen Kerr
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Kanitta Pussadee
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | | | | | - Patinut Buranasupkajorn
- Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Sarat Sunthornyothin
- Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Praphan Phanuphak
- Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
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- Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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11
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Wrottesley SV, Ong KK, Pisa PT, Norris SA. Maternal traditional dietary pattern and antiretroviral treatment exposure are associated with neonatal size and adiposity in urban, black South Africans. Br J Nutr 2018; 120:557-566. [PMID: 30058507 PMCID: PMC6773599 DOI: 10.1017/s0007114518001708] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This study examines the associations between maternal Traditional dietary pattern adherence and HIV/treatment with neonatal size and adiposity in urban, black South Africans, as well as how specific maternal factors - that is BMI and gestational weight gain (GWG) - may influence these associations. Multiple linear regression models were used to examine associations among maternal Traditional diet pattern adherence (pattern score), HIV/treatment status (three groups: HIV negative, HIV positive (antenatal antiretroviral treatment (ART) initiation), HIV positive (pre-pregnancy ART initiation)), BMI and GWG (kg/week), and newborn (1) weight:length ratio (WLR, kg/m) in 393 mother-neonate pairs, and (2) Peapod estimated fat mass index (FMI, kg/m3) in a 171-pair subsample. In fully adjusted models, maternal obesity and GWG were associated with 0·25 kg/m (P=0·008) and 0·48 kg/m (P=0·002) higher newborn WLR, whereas Traditional diet pattern score was associated with lower newborn WLR (-0·04 kg/m per +1 sd; P=0·033). In addition, Traditional diet pattern score was associated with 0·13 kg/m3 (P=0·027) and 0·32 kg/m3 (P=0·005) lower FMI in the total sample and in newborns of normal-weight women, respectively. HIV-positive (pre-pregnancy ART) v. HIV-negative (ref) status was associated with 1·11 kg/m3 (P=0·002) higher newborn FMI. Promotion of a Traditional dietary pattern, alongside a healthy maternal pre-conception weight, in South African women may reduce newborn adiposity and metabolic risk profiles. In HIV-positive women, targeted monitoring and management strategies are necessary to limit treatment-associated effects on in utero fat deposition.
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Affiliation(s)
- Stephanie V. Wrottesley
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ken K. Ong
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Pedro T. Pisa
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Shane A. Norris
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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12
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Huis In 't Veld D, Pengpid S, Colebunders R, Peltzer K. Body Mass Index and Waist Circumference in Patients with HIV in South Africa and Associated Socio-demographic, Health Related and Psychosocial Factors. AIDS Behav 2018; 22:1972-1986. [PMID: 28243935 DOI: 10.1007/s10461-017-1737-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A high body mass index (BMI) and high waist circumference are important health risk factors predisposing for cardiovascular and metabolic diseases and certain cancers. Historically, underweight was a diagnostic criterion of HIV-infection. In a cross-sectional study the prevalence of BMI-categories and high waist circumference and its associated factors in patients visiting three outpatient HIV clinics in South Africa were measured with anthropometric measurements and structured questionnaires regarding socio-demographic information, quality of life (QoL), AIDS-related stigma, symptoms of depression, alcohol use, HIV related information and level of adherence to ART. The median age of the 2230 included patients was 37 years, 66.5% were women and 88.6% received antiretroviral therapy. The prevalences of overweight, obesity and high waist circumference were 29.2, 21.9 and 44.6% respectively in women and 12.4, 4.0 and 3.9% respectively in men. Underweight was found in 18.2% of men and 6.3% of women. In multinomial regression analysis compared to a normal BMI, both overweight and obesity were associated with female gender, with being married or cohabiting and with a higher QoL score. Underweight was associated with male gender and tobacco use and negatively associated with being married or cohabiting and the physical domain of the QoL measure. A high waist circumference in men was associated with higher age and negatively associated with tobacco use and stigma score. In women it was negatively associated with never being married. A high prevalence of overweight and obesity was observed in HIV-clinics in South Africa, mainly in women. Since overweight and obesity are important health risk factors, effective weight reduction interventions are desirable.
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Affiliation(s)
- Diana Huis In 't Veld
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium.
- FWO Research Foundation Flanders, Brussels, Belgium.
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
- Algemeen inwendige geneeskunde, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Supa Pengpid
- ASEAN Institute for Health Development, Mahidol University, Nakhonpathom, Thailand
- Department of Research and Innovation, University of Limpopo, Sovenga, South Africa
| | - Robert Colebunders
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Karl Peltzer
- ASEAN Institute for Health Development, Mahidol University, Nakhonpathom, Thailand
- HIV/AIDS, STIs & TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, South Africa
- Department of Psychology, University of Limpopo, Sovenga, South Africa
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13
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Boswell MT, Rossouw TM. Approach to acute kidney injury in HIV-infected patients in South Africa. South Afr J HIV Med 2017; 18:714. [PMID: 29568636 PMCID: PMC5843257 DOI: 10.4102/sajhivmed.v18i1.714] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 07/14/2017] [Indexed: 01/25/2023] Open
Abstract
Background HIV-infected patients have an increased risk of renal disease. Current first-line antiretroviral therapy contains tenofovir disoproxil fumarate (TDF), which has nephrotoxic potential, characterised by proximal tubular cell injury. This may result in acute kidney injury, chronic kidney disease or partial or complete Fanconi syndrome. Objectives We reviewed the existing literature on acute kidney injury and TDF-associated nephrotoxicity with the aim of providing an approach to diagnosis and management, which is relevant to a general medical practitioner. Methods We performed a broad literature search of biomedical databases including PubMed and ScienceDirect. Our search terms included, but were not limited to, ‘tenofovir’, ‘nephrotoxicity’, ‘HIV’, ‘acute kidney injury’ and ‘renal tubular acidosis’. Our aim was not to generate a systematic literature review with weighted evidence, but rather to provide a review of best practice from a variety of sources. Where published studies were not available from the above databases, we relied on relevant textbooks and professional guidelines. Results Potential nephrotoxicity is not an impediment to the widespread use of TDF in treating HIV infection, because most patients will tolerate the medication well. However, patients with advanced disease, low body weight, advanced age, pre-existing kidney disease and concomitant use of other nephrotoxic medications are at increased risk of adverse renal events and may develop severe complications if not appropriately managed. These risk factors are unfortunately common in patients initiating antiretroviral therapy in South Africa. Conclusion Prevention of renal damage by means of careful screening and monitoring of high-risk patients is of paramount importance. Increased awareness of this problem and knowledge of how to manage kidney disease should be emphasised for general medical practitioners who work with HIV-infected patients.
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Affiliation(s)
- Michael T Boswell
- Department of Medical Immunology, University of Pretoria, South Africa.,Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Theresa M Rossouw
- Department of Medical Immunology, University of Pretoria, South Africa
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14
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Hoy JF, Grund B, Roediger M, Schwartz AV, Shepherd J, Avihingsanon A, Badal-Faesen S, de Wit S, Jacoby S, La Rosa A, Pujari S, Schechter M, White D, Engen NW, Ensrud K, Aagaard PD, Carr A. Immediate Initiation of Antiretroviral Therapy for HIV Infection Accelerates Bone Loss Relative to Deferring Therapy: Findings from the START Bone Mineral Density Substudy, a Randomized Trial. J Bone Miner Res 2017; 32. [PMID: 28650589 PMCID: PMC5555813 DOI: 10.1002/jbmr.3183] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
UNLABELLED Both HIV infection and antiretroviral therapy (ART) are associated with lower bone mineral density (BMD) and increased fracture risk. Because the relative contributions of ART and untreated HIV to BMD loss are unclear, it is important to quantify the effect of ART on bone. We compared the effect of early ART initiation (CD4 >500 cells/μL) with deferred ART on change in BMD in the START Bone Mineral Density substudy, a randomized trial evaluating the effect of immediate ART initiation versus deferring ART (to CD4 <350 cells/μL). BMD was measured annually at the lumbar spine and hip by dual-energy X-ray absorptiometry (DXA). Percent change in BMD by treatment assignment (intent-to-treat analysis) was estimated using longitudinal mixed models and linear regression. Baseline and follow-up DXA scans were available for 399 (195 immediate, 204 deferred) participants (median age 32 years, 80% non-white, 26% women, median CD4 count 642 cells/μL). ART (most commonly including tenofovir and efavirenz) was used for 95% and 18% of follow-up in the immediate and deferred ART groups, respectively. Through 2.2 years mean follow-up, immediate ART resulted in greater BMD declines than deferred ART at the hip (-2.5% versus -1.0%; difference -1.5%, 95% confidence interval [CI] -2.2 to -0.8, p < 0.001) and spine (-1.9% versus -0.4%; difference -1.6%, 95% CI -2.2 to -1.0, p < 0.001). BMD declines were greatest in the first year of ART. In the immediate ART group, spine BMD stabilized after year 1, whereas hip BMD declined progressively over 2 years. After year 1, BMD changes were similar in the immediate and deferred groups. No clinical, HIV-related, or ART characteristic predicted greater BMD loss in either group. All HIV treatment guidelines now recommend ART initiation at HIV diagnosis because of the reduced risk of serious clinical outcomes. Better understanding of the longer-term consequences of the observed reductions in BMD is needed. CLINICAL TRIALS REGISTRATION NCT00867048. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Jennifer F Hoy
- Monash University and The Alfred Hospital, Melbourne, Australia
| | | | | | - Ann V Schwartz
- University of California San Francisco, San Francisco, CA, USA
| | - John Shepherd
- University of California San Francisco, San Francisco, CA, USA
| | - Anchalee Avihingsanon
- Thai Red Cross AIDS Research Center and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | | | - Simone Jacoby
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Alberto La Rosa
- Asociacion Civil Impacta Salud y Educacion, Barranco, Lima, Peru
| | | | | | - David White
- Heart of England NHS Foundation Trust, Birmingham, UK
| | | | - Kristine Ensrud
- University of Minnesota, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Peer D Aagaard
- INSIGHT START Community Advisory Board, University of Minnesota, Minneapolis, MN, USA
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15
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Hamill MM, Pettifor JM, Ward KA, Norris SA, Prentice A. Changes in Bone Mineral Density, Body Composition, Vitamin D Status, and Mineral Metabolism in Urban HIV-Positive South African Women Over 12 Months. J Bone Miner Res 2017; 32:1615-1624. [PMID: 28370356 PMCID: PMC5753880 DOI: 10.1002/jbmr.3147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 03/07/2017] [Accepted: 03/30/2017] [Indexed: 11/07/2022]
Abstract
Human immunodeficiency virus (HIV) infection and antiretroviral therapy (ART) are associated with bone loss and poor vitamin D status in white populations, though their relative roles are not known. No previous studies have examined longitudinal changes in areal bone mineral density (aBMD), measured by dual-energy X-ray absorptiometry (DXA), or in vitamin D status in HIV-positive African women. Of 247 premenopausal, urban, black African women from Soweto, South Africa, initially recruited, 187 underwent anthropometry, DXA scanning and blood and urine collections at both baseline and 12 months. Of these, 67 were HIV-negative throughout (Nref), 60 were HIV-positive with preserved CD4 counts at baseline (Ppres), and 60 were HIV-positive with low CD4 counts at baseline, eligible for ART by South African standards of care at the time (Plow). No participant had been exposed to ART at baseline. By 12 months, 51 Plow women had initiated ART, >85% of whom took combined tenofovir disoproxil fumarate (TDF), lamivudine, and efavirenz. By 12 months, Plow and Nref, but not Ppres, increased in body weight and fat mass (group-by-timepoint p ≤ 0.001, p = 0.002, respectively). Plow had significant decreases in aBMD of 2% to 3%, before and after size adjustment, at the femoral neck (p ≤ 0.002) and lumbar spine (p ≤ 0.001), despite significant weight gain. These decreases were associated with increased bone turnover but there were no significant differences or changes over time in vitamin D status, serum phosphate concentrations, or renal phosphate handling. Excluding data from nine Plow women unexposed to ART and 11 Ppres women who had initiated ART accentuated these findings, suggesting the bone loss in Plow was related to ART exposure. This is the first study describing DXA-defined bone loss in HIV-positive Sub-Saharan African women in association with ART. Further work is required to establish if bone loss continues with ongoing ART and, if so, whether this results in increased fracture rates. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Matthew M Hamill
- Medical Research Council Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK.,South African Medical Research Council (SAMRC)/University of Witswatersrand Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of Witswatersrand, Johannesburg, South Africa
| | - John M Pettifor
- South African Medical Research Council (SAMRC)/University of Witswatersrand Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of Witswatersrand, Johannesburg, South Africa
| | - Kate A Ward
- Medical Research Council Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
| | - Shane A Norris
- South African Medical Research Council (SAMRC)/University of Witswatersrand Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of Witswatersrand, Johannesburg, South Africa
| | - Ann Prentice
- Medical Research Council Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK.,South African Medical Research Council (SAMRC)/University of Witswatersrand Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of Witswatersrand, Johannesburg, South Africa
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16
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Mutimura E, Shi Q, Hoover DR, Anastos K, Rudakemwa E, Dusingize JC, Sinabye JD, Yin MT. Bone quality assessed using quantitative ultrasound at the distal radius does not differ in antiretroviral therapy-naïve HIV-positive and HIV-negative Rwandan women. HIV Med 2017; 17:724-727. [PMID: 27161586 DOI: 10.1111/hiv.12376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The incidence of fractures appears to be increased in HIV-infected individuals. METHODS We assessed bone quality using quantitative ultrasound (QUS) in HIV-infected and uninfected Rwandan women. A Sunlight Omnisense 7000 QUS was used to measure the speed of ultrasound (SOS) at the distal radius in 646 antiretroviral therapy (ART)-naïve HIV-infected women and 211 HIV-uninfected women. The Z-scores for SOS were based on data for women of the same age from the manufacturer's reference material. RESULTS The mean CD4 cell count was 285 (± 166) cells/μL in the HIV-positive women. SOS Z-scores adjusted and unadjusted for body mass index did not differ between the groups. SOS did not differ by CD4 count (< 200 vs. ≥ 200 cells/μL: 4016 (± 117) vs. 4028 (± 107) m/s, respectively; p=0.19. CONCLUSIONS In HIV-positive ART-naïve Rwandan women with advanced HIV disease, bone quality at the distal radius was similar to that in HIV-negative controls.
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Affiliation(s)
- E Mutimura
- Regional Alliance for Sustainable Development (RASD), Kigali, Rwanda.
| | - Q Shi
- New York Medical College, Valhalla, NY, USA
| | - D R Hoover
- The State University of New Jersey, New Brunswick, NJ, USA
| | - K Anastos
- Albert Einstein College of Medicine and Montefiore Medical Center, New York, NY, USA
| | | | - J C Dusingize
- Regional Alliance for Sustainable Development (RASD), Kigali, Rwanda
| | - J D Sinabye
- Regional Alliance for Sustainable Development (RASD), Kigali, Rwanda
| | - M T Yin
- Columbia University Medical Center, New York, NY, USA
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17
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Vitamin D Status and Its Consequences for Health in South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13101019. [PMID: 27763570 PMCID: PMC5086758 DOI: 10.3390/ijerph13101019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/10/2016] [Accepted: 10/10/2016] [Indexed: 12/14/2022]
Abstract
In this review, reports were retrieved in which vitamin D status, as assessed by serum 25-hydroxyvitamin D [25(OH)D] levels, was measured in South African population groups with varied skin colours and ethnicities. Healthy children and adults were generally vitamin D-sufficient [25(OH)D level >50 nmol/L] but the majority of those aged above 65 years were deficient. A major role for exposure to solar ultraviolet radiation (UVR) in determining 25(OH)D levels was apparent, with the dietary contribution being minor. Limited data exist regarding the impact of recent changes in lifestyles on vitamin D status, such as urbanisation. With regard to disease susceptibility, 11 of 22 relevant publications indicated association between low 25(OH)D levels and disease, with deficiency most notably found in individuals with tuberculosis and HIV-1. Information on the relationship between vitamin D receptor variants and ethnicity, disease or treatment response in the South African population groups demonstrated complex interactions between genetics, epigenetics and the environment. Whether vitamin D plays an important role in protection against the range of diseases that currently constitute a large burden on the health services in South Africa requires further investigation. Only then can accurate advice be given about personal sun exposure or dietary vitamin D supplementation.
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18
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Abstract
The success of antiretroviral therapy in treating HIV infection has greatly prolonged life expectancy in affected individuals, transforming the disease into a chronic condition. A number of HIV-associated non-AIDS comorbidities have emerged in the ageing HIV-infected population, including osteoporosis and increased risk of fracture. The pathogenesis of fracture is multifactorial with contributions from both traditional and HIV-specific risk factors. Significant bone loss occurs on initiation of antiretroviral therapy but stabilizes on long-term therapy. Fracture risk assessment should be performed in HIV-infected individuals and bone mineral density measured when indicated. Lifestyle measures to optimize bone health should be advised and, in individuals at high risk of fracture, treatment with bisphosphonates considered.
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Affiliation(s)
- J Compston
- Dept of Medicine, Cambridge Biomedical Campus Francis Crick Ave, Cambridge CB2 0SL, UK.
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19
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Mouton JP, Cohen K, Maartens G. Key toxicity issues with the WHO-recommended first-line antiretroviral therapy regimen. Expert Rev Clin Pharmacol 2016; 9:1493-1503. [PMID: 27498720 DOI: 10.1080/17512433.2016.1221760] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION WHO recommends tenofovir, efavirenz, and lamivudine or emtricitabine for first-line antiretroviral therapy (ART) in adults, which replaced more toxic regimens using stavudine, zidovudine or nevirapine. Areas covered: We searched Pubmed to identify observational studies and randomized controlled trials reporting toxicity of these antiretrovirals published between 2011 and 2016, and hand-searched abstracts presented at major HIV conferences in 2015 and 2016, focusing on data from sub-Saharan Africa. Tenofovir's nephrotoxicity manifests as mild renal tubular dysfunction (common and of uncertain clinical significance), acute kidney injury (rare), and chronic declining glomerular filtration rate (common). African studies, which include high proportions of patients with renal dysfunction from opportunistic diseases, report population improvement in renal function after starting tenofovir-based ART. Tenofovir modestly decreases bone mineral density, and there is emerging data that this increases fracture risk. Efavirenz commonly causes early self-limiting neuropsychiatric toxicity and hypersensitivity rashes. Recent studies have highlighted its long-term neuropsychiatric effects, notably suicidality and neurocognitive impairment, and metabolic toxicities (dyslipidemia, dysglycemia, and lipoatrophy). We point out the challenges clinicians face in the recognition and attribution of adverse drug reactions. Expert commentary: Tenofovir and efavirenz are generally well tolerated, but both are associated with potentially serious toxicities. Pharmacovigilance systems in resource-limited settings with high HIV burden should be strengthened.
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Affiliation(s)
- Johannes P Mouton
- a Division of Clinical Pharmacology, Department of Medicine , University of Cape Town , Cape Town , South Africa
| | - Karen Cohen
- a Division of Clinical Pharmacology, Department of Medicine , University of Cape Town , Cape Town , South Africa
| | - Gary Maartens
- a Division of Clinical Pharmacology, Department of Medicine , University of Cape Town , Cape Town , South Africa
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Matovu FK, Wattanachanya L, Beksinska M, Pettifor JM, Ruxrungtham K. Bone health and HIV in resource-limited settings: a scoping review. Curr Opin HIV AIDS 2016; 11:306-25. [PMID: 27023284 PMCID: PMC5578733 DOI: 10.1097/coh.0000000000000274] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Sub-Saharan Africa and other resource-limited settings (RLS) bear the greatest burden of the HIV epidemic globally. Advantageously, the expanding access to antiretroviral therapy (ART) has resulted in increased survival of HIV individuals in the last 2 decades. Data from resource rich settings provide evidence of increased risk of comorbid conditions such as osteoporosis and fragility fractures among HIV-infected populations. We provide the first review of published and presented data synthesizing the current state of knowledge on bone health and HIV in RLS. RECENT FINDINGS With few exceptions, we found a high prevalence of low bone mineral density (BMD) and hypovitaminosis D among HIV-infected populations in both RLS and resource rich settings. Although most recognized risk factors for bone loss are similar across settings, in certain RLS there is a high prevalence of both non-HIV-specific risk factors and HIV-specific risk factors, including advanced HIV disease and widespread use of ART, including tenofovir disoproxil fumarate, a non-BMD sparing ART. Of great concern, we neither found published data on the effect of tenofovir disoproxil fumarate initiation on BMD, nor any data on incidence and prevalence of fractures among HIV-infected populations in RLS. SUMMARY To date, the prevalence and squeal of metabolic bone diseases in RLS are poorly described. This review highlights important gaps in our knowledge about HIV-associated bone health comorbidities in RLS. This creates an urgent need for targeted research that can inform HIV care and management guidelines in RLS.
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Affiliation(s)
- Flavia Kiweewa Matovu
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Flavia Kiweewa Matovu and Lalita Wattanachanya contributed equally to the writing of this article
| | - Lalita Wattanachanya
- Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Flavia Kiweewa Matovu and Lalita Wattanachanya contributed equally to the writing of this article
| | - Mags Beksinska
- Maternal, Adolescent and Child Health (MatCH) Research, University of the Witwatersrand, Faculty of Health Sciences, Department of Obstetrics and Gynaecology
| | - John M. Pettifor
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kiat Ruxrungtham
- Department of Medicine, Faculty of Medicine, Chulalongkorn University
- HIV-NAT, Thai Red Cross AIDS Research Center, Thai Red Cross Society, Bangkok, Thailand
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Shivakoti R, Christian P, Yang WT, Gupte N, Mwelase N, Kanyama C, Pillay S, Samaneka W, Santos B, Poongulali S, Tripathy S, Riviere C, Berendes S, Lama JR, Cardoso SW, Sugandhavesa P, Tang AM, Semba RD, Campbell TB, Gupta A. Prevalence and risk factors of micronutrient deficiencies pre- and post-antiretroviral therapy (ART) among a diverse multicountry cohort of HIV-infected adults. Clin Nutr 2016; 35:183-189. [PMID: 25703452 PMCID: PMC4531105 DOI: 10.1016/j.clnu.2015.02.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 12/30/2014] [Accepted: 02/03/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS HIV-infected adults have increased risk of several individual micronutrient deficiencies. However, the prevalence and risk factors of concurrent and multiple micronutrient deficiencies and whether micronutrient concentrations change after antiretroviral therapy (ART) initiation have not been well described. The objective of this study was to determine the prevalence and risk factors of individual, concurrent and multiple micronutrient deficiencies among ART-naïve HIV-infected adults from nine countries and assess change in micronutrient status 48 weeks post-ART initiation. METHODS A random sub-cohort (n = 270) stratified by country was selected from the multinational PEARLS clinical trial (n = 1571 ART-naïve, HIV-infected adults). We measured serum concentrations of vitamins A, D (25-hydroxyvitamin), E, carotenoids and selenium pre-ART and 48 weeks post-ART initiation, and measured vitamins B6, B12, ferritin and soluble transferrin receptor at baseline only. Prevalence of single micronutrient deficiencies, concurrent (2 coexisting) or conditional (a deficiency in one micronutrient given a deficiency in another) and multiple (≥3) were determined using defined serum concentration cutoffs. We assessed mean changes in micronutrient concentrations from pre-ART to week 48 post-ART initiation using multivariable random effects models. RESULTS Of 270 participants, 13.9%, 29.2%, 24.5% and 32.4% had 0, 1, 2 and multiple deficiencies, respectively. Pre-ART prevalence was the highest for single deficiencies of selenium (53.2%), vitamin D (42.4%), and B6 (37.3%) with 12.1% having concurrent deficiencies of all three micronutrients. Deficiency prevalence varied widely by country. 48 weeks post-ART initiation, mean vitamin A concentration increased (p < 0.001) corresponding to a 9% decrease in deficiency. Mean concentrations also increased for other micronutrients assessed 48 weeks post-ART (p < 0.001) but with minimal change in deficiency status. CONCLUSIONS Single and multiple micronutrient deficiencies are common among HIV-infected adults pre-ART initiation but vary between countries. Importantly, despite increases in micronutrient concentrations, prevalence of individual deficiencies remains largely unchanged after 48 weeks on ART. Our results suggest that ART alone is not sufficient to improve micronutrient deficiency.
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Affiliation(s)
- Rupak Shivakoti
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | - Wei-Teng Yang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Nikhil Gupte
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Noluthando Mwelase
- Department of Medicine, University of Witwatersrand, Johannesburg, 2050, South Africa.
| | | | - Sandy Pillay
- Durban International Clinical Research Site, Durban University of Technology, Durban, 4001, South Africa.
| | - Wadzanai Samaneka
- University of Zimbabwe Clinical Research Centre, Harare, 999, Zimbabwe.
| | - Breno Santos
- Hospital Nossa Senhora de Conceição, Porto Alegre, 91350-200, Brazil.
| | | | | | | | - Sima Berendes
- Malawi College of Medicine-Johns Hopkins University Research Project, Blantyre, Malawi.
| | - Javier R Lama
- Asociacion Civil Impacta Salud y Educacion, Lima, 4, Peru.
| | - Sandra W Cardoso
- STD/AIDS Clinical Research Laboratory, Instituto de Pesquisa Clinica Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, 21045-900, Brazil.
| | | | - Alice M Tang
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, 02111, MA, USA.
| | - Richard D Semba
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA.
| | - Thomas B Campbell
- Department of Medicine, Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, 80045, USA.
| | - Amita Gupta
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Antiretroviral Therapy, Especially Efavirenz, Is Associated with Low Bone Mineral Density in HIV-Infected South Africans. PLoS One 2015; 10:e0144286. [PMID: 26633015 PMCID: PMC4669137 DOI: 10.1371/journal.pone.0144286] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 11/15/2015] [Indexed: 12/12/2022] Open
Abstract
Purpose We determined the prevalence and correlates of low bone mineral density (BMD) in HIV-infected South Africans as there is a paucity of such data from Africa. Methods BMD and serum 25-hydroxyvitamin D were measured in HIV-positive participants on antiretroviral therapy (ART) and in those not yet on ART (ART-naïve). Results We enrolled 444 participants [median age 35(IQR: 30, 40) years; 77% women]. BMD was low (z score <-2SD) in 17% and 5% of participants at the lumbar spine and total hip, respectively. Total hip [0.909 (SD 0.123) vs 0.956 (SD 0.124) g/cm2, p = 0.0001] and neck of femur BMD [0.796 (SD 0.130) vs 0.844 (SD 0.120) g/cm2, p = 0.0001] were lower in the ART, compared to the ART-naïve group. Vitamin D deficiency was present in 15% of participants and was associated with efavirenz use [adjusted OR 2.04 (95% CI 1.01 to 4.13)]. In a multivariate linear regression, exposure to efavirenz or lopinavir-based ART was associated with lower total hip BMD, whereas higher weight, being male and higher vitamin D concentration were associated with higher total hip BMD (adjusted R2 = 0.28). Age, weight, sex, and the use of efavirenz-based ART were independently associated with lumbar spine BMD (adjusted R2 = 0.13). Conclusions Vitamin D status, use of efavirenz or lopinavir/ritonavir, weight, age and sex are significantly associated with lower BMD in this young cohort of HIV-infected South Africans.
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Abstract
PURPOSE OF REVIEW Because of antiretroviral therapy (ART), people are living with HIV infection longer than ever before. As this patient group ages, it is expected that medical comorbidities such as osteoporosis and fragility fractures will increase. The purpose of this review is to address the epidemiology and what is known regarding the pathogenesis of bone loss in people living with HIV infection with a focus on recently published literature. RECENT FINDINGS HIV-infected individuals are at increased risk for low bone mineral density and bone fractures. The cause of bone loss in HIV is multifactorial including traditional risk factors some of which disproportionately affect HIV-infected individuals and alterations in bone metabolism due to ART, HIV viral proteins and chronic inflammation. Lifestyle modification, changing ART, calcium and vitamin D supplementation and pharmacologic treatment for osteoporosis may all be employed to abrogate bone loss in this patient group. SUMMARY Clinicians should be aware of the contributors to bone loss in people living with HIV in order to recognize high-risk individuals and to take appropriate steps to address modifiable risk factors to prevent future fracture.
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Affiliation(s)
- Corrilynn O Hileman
- Metrohealth Medical Center, Cleveland, Ohio, USA
- Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | | | - Grace A McComsey
- Case Western Reserve School of Medicine, Cleveland, Ohio, USA
- University Hospitals Case Medical Center, Cleveland, Ohio, USA
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Carr A, Grund B, Neuhaus J, Schwartz A, Bernardino JI, White D, Badel-Faesen S, Avihingsanon A, Ensrud K, Hoy J. Prevalence of and risk factors for low bone mineral density in untreated HIV infection: a substudy of the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial. HIV Med 2015; 16 Suppl 1:137-46. [PMID: 25711332 DOI: 10.1111/hiv.12242] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES HIV infection is associated with a higher prevalence of low bone mineral density (BMD) and fractures than that found in the general population. There are limited data in HIV-positive adults, naïve to antiretroviral therapy (ART), with which to estimate the relative contribution of untreated HIV infection to bone loss. METHODS The primary objective of the Strategic Timing of AntiRetroviral Treatment (START) Bone Mineral Density Substudy is to compare the effect of immediate versus deferred initial ART on bone. We evaluated traditional, demographic, HIV-related and immunological factors for their associations with baseline hip and lumbar spine BMD, measured by dual-energy X-ray absorptiometry, using multiple regression. RESULTS A total of 424 ART-naïve participants were enrolled at 33 sites on six continents; the mean age was 34 years [standard deviation (SD) 10.1 years], 79.0% were nonwhite, 26.0% were women, and 12.5% had a body mass index (BMI) < 20 kg/m(2) . Mean (SD) Z-scores were -0.41 (0.94) at the spine and -0.36 (0.88) for total hip; 1.9% had osteoporosis and 35.1% had low BMD (hip or spine T-score < -1.0). Factors independently associated with lower BMD at the hip and spine were female sex, Latino/Hispanic ethnicity, lower BMI and higher estimated glomerular filtration rate. Longer time since HIV diagnosis was associated with lower hip BMD. Current or nadir CD4 cell count and HIV viral load were not associated with BMD. CONCLUSIONS In this geographically and racially diverse population of ART-naïve adults with normal CD4 cell counts, low BMD was common, but osteoporosis was rare. Lower BMD was significantly associated with traditional risk factors but not with CD4 cell count or viral load.
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Affiliation(s)
- A Carr
- Centre for Applied Medical Research, St Vincent's Hospital, Sydney, Australia
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25
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Association between HIV infection and bone mineral density in climacteric women. Arch Osteoporos 2015; 10:33. [PMID: 26420601 DOI: 10.1007/s11657-015-0238-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 09/17/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED A cross-sectional study was conducted with the purpose of evaluating bone mineral density in HIV seropositive and seronegative climacteric women. HIV infection was negatively associated with bone mineral density in the lumbar spine PURPOSE To assess bone mineral density (BMD) and its associated factors in HIV seropositive and seronegative climacteric women METHODS A cross-sectional study with 537 women (273 HIV seropositive and 264 HIV seronegative) aged between 40 and 60 years old receiving follow-up care at two hospitals in Brazil. A questionnaire on clinical and sociodemographic characteristics was completed. Laboratory tests were performed, and BMD was measured at the lumbar spine and hip. Statistical analysis was carried out by Yates and Pearson chi-squared tests, Mann-Whitney test, and multiple linear regression. RESULTS The mean age was 47.7 years in HIV-seropositive women, and 75 % had nadir CD4 above 200, and 77.8 % had viral load below the detection limit. The mean age in the HIV-seronegative women was 49.8 years. The prevalence of low spinal BMD was 14.6 % in the HIV-seropositive and 4.6 % in the HIV-seronegative women (p < 0.01). The prevalence of low BMD at the femoral neck was 5.6 % in HIV-seropositive and 3.3 % in the HIV-seronegative women (p = 0.38). Multiple analyses showed that the factors associated with lower BMD at the spine were being postmenopausal and being HIV-seropositive. Being overweight was associated with a higher BMD. At the femoral neck, factors associated with lower BMD were being postmenopausal and being white. Being overweight and having a greater number of pregnancies were associated with higher BMD CONCLUSIONS: HIV-seropositive women on long-term antiretroviral treatment and in good immunological conditions exhibited low BMD in the spine (L1-L4). However, BMD in the femoral neck was similar to non-infected women.
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Vitamin D Status in South Africa and Tuberculosis. Lung 2015; 193:975-84. [DOI: 10.1007/s00408-015-9789-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 08/19/2015] [Indexed: 12/11/2022]
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Abstract
HIV infection and initiation of antiretroviral therapy (ART) have been consistently associated with decreased bone mineral density (BMD), with growing evidence linking HIV to an increased risk of fracture. This is especially concerning with the expanding number of older persons living with HIV. Interestingly, recent data suggest that HIV-infected children and youth fail to achieve peak BMD, possibly increasing their lifetime risk of fracture. Elucidating the causes of the bone changes in HIV-positive persons is challenging because of the multifactorial nature of bone disease in HIV, including contribution of the virus, immunosuppression, ART toxicity, and traditional osteoporosis risk factors, such as age, lower weight, tobacco, and alcohol use. Thus, practitioners must recognize the risk of low BMD and fractures and appropriately screen patients for osteoporosis if risk factors exist. If fractures do occur or elevated fracture risk is detected through screening, treatment with bisphosphonate medications appears safe and effective in the HIV+population.
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Affiliation(s)
- Amy H Warriner
- Division of Endocrinology, Metabolism and Diabetes, University of Alabama at Birmingham, FOT 702, 2000 6th Avenue South, Birmingham, AL, 35233-0271, USA,
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28
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Compston J. HIV infection and osteoporosis. BONEKEY REPORTS 2015; 4:636. [PMID: 25709813 PMCID: PMC4325555 DOI: 10.1038/bonekey.2015.3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 01/07/2015] [Indexed: 01/05/2023]
Abstract
In the past two decades, the life expectancy of people living with HIV infection has increased significantly, and osteoporosis has emerged as a significant comorbidity. In addition to traditional risk factors for fracture, specific factors related to HIV infection are also likely to contribute, including antiretroviral therapy. The heterogeneity of the HIV-infected population in terms of age and ethnicity presents many challenges to the prevention and management of bone disease, and further studies are required to establish optimal approaches to risk assessment and treatment.
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Affiliation(s)
- Juliet Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
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Hearps AC, Martin GE, Rajasuriar R, Crowe SM. Inflammatory co-morbidities in HIV+ individuals: learning lessons from healthy ageing. Curr HIV/AIDS Rep 2014; 11:20-34. [PMID: 24414166 DOI: 10.1007/s11904-013-0190-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Increased life expectancy due to improved efficacy of cART has uncovered an increased risk of age-related morbidities in HIV+ individuals and catalyzed significant research into mechanisms driving these diseases. HIV infection increases the risk of non-communicable diseases common in the aged, including cardiovascular disease, neurocognitive decline, non-AIDS malignancies, osteoporosis, and frailty. These observations suggest that HIV accelerates immunological ageing, and there are many immunological similarities with the aged, including shortened telomeres, accumulation of senescent T cells and altered monocyte phenotype/function. However, the most critical similarity between HIV+ individuals and the elderly, which most likely underpins the heightened risk of non-communicable diseases, is chronic inflammation and associated immune activation. Here, we review the similarities between HIV+ individuals and the aged regarding the pathogenesis of inflammatory diseases, the current evidence for mechanisms driving these processes and discuss current and potential therapeutic strategies for addressing inflammatory co-morbidity in HIV+ infection.
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Affiliation(s)
- Anna C Hearps
- Centre for Biomedical Research, Burnet Institute, GPO Box 2248, Melbourne, VIC, 3001, Australia,
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Dietary intake and body composition in HIV-positive and -negative South African women. Public Health Nutr 2013; 17:1603-13. [PMID: 23835214 DOI: 10.1017/s1368980013001808] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The present paper examines dietary intake and body composition in antiretroviral (ARV)-naïve HIV-positive compared with HIV-negative South African women, as well as the impact of disease severity on these variables. DESIGN Baseline data from a longitudinal study assessing bone health in HIV-negative and HIV-positive premenopausal South African women over 18 years of age were used. Anthropometry and body composition, measured by dual energy X-ray absorptiometry, were analysed together with dietary intake data assessed using an interviewer-based quantitative FFQ. SETTING Soweto, Johannesburg, South Africa. SUBJECTS Black, urban South African women were divided into three groups: (i) HIV-negative (HIV-; n 98); (ii) HIV-positive with preserved CD4 counts (HIV+ non-ARV; n 74); and (iii) HIV-positive with low CD4 counts and due to start ARV treatment (HIV+ pre-ARV; n 75). RESULTS The prevalence of overweight and obesity was high in this population (59 %). The HIV+ pre-ARV group was lighter and had a lower BMI than the other two groups (all P < 0·001). HIV+ pre-ARV women also had lower fat and lean masses and percentage body fat than their HIV- and HIV+ non-ARV counterparts. After adjustment, there were no differences in macronutrient intakes across study groups; however, fat and sugar intakes were high and consumption of predominantly refined food items was common overall. CONCLUSION HIV-associated immunosuppression may be a key determinant of body composition in HIV-positive women. However, in populations with high obesity prevalence, these differences become evident only at advanced stages of infection.
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