Effect of calcium and vitamin D supplementation on bone mineral accrual among HIV-infected Thai adolescents with low bone mineral density

Update: Vitamin D3 and calcium carbonate supplementation for adolescents with HIV to reduce musculoskeletal morbidity and immunopathology (VITALITY trial): study protocol for a randomised placebo-controlled trial

BACKGROUND

Of the 2 million children living with HIV globally, 90% live in sub-Saharan Africa. Despite antiretroviral therapy, longstanding HIV infection is associated with several chronic complications in children including growth failure, particularly stunting and delayed puberty. Vitamin D deficiency, which is highly prevalent among children living with HIV in sub-Saharan Africa, has further adverse impact on bone health. This trial aims to establish whether supplementation with vitamin D3 and calcium carbonate improves musculoskeletal health among peripubertal children living with HIV. This paper is an update to an already existing protocol that was previously published in Trials in 2022 and details changes in the trial outcomes.

METHODS/DESIGN

We will conduct an individually randomised, double-blinded, placebo-controlled trial of weekly high-dose vitamin D3 (20,000 IU) plus daily calcium carbonate (500 mg) supplementation for 48 weeks. Eight hundred and forty children living with HIV aged 11-19 years taking ART for ≥ 6 months will be enrolled and followed up for 96 weeks. The primary outcome is DXA-measured total body less-head bone mineral density Z-score (TBLH-BMD) at 48 weeks and is an update to the previous primary outcome total body less-head bone mineral content adjusted for lean mass (TBLH-BMCLBM) Z-score. The primary outcome was updated to address the substantial differences in distributions of TBLH-BMCLBM Z-score between the two sites as a result of software differences of the DXA machines. Secondary outcomes are DXA-measured TBLH-BMD Z-score adjusted for height at 48 weeks a new secondary outcome, lumbar spine bone mineral apparent density Z-score, number of respiratory infections, lean muscle mass and grip-strength at 48 and 96 weeks, and TBLH-BMD Z-score at 96 weeks. Sub-studies will investigate the effect of the intervention on vitamin D3 pathway metabolites and markers of bone turnover, intestinal microbiota, and innate and acquired immune function.

DISCUSSION

This is the largest trial to date of vitamin D supplementation in children living with HIV. Intervening to address deficits in bone accrual through childhood is critical for optimising adolescent and early adult bone health, and prevention of later adult osteoporotic fractures. Trial results will draw attention to the need to screen for and treat long-term comorbidities in children living with HIV in resource-limited settings.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR20200989766029. Registered on September 3, 2020. URL of trial registry record: https://pactr.samrc.ac.za TRIAL STATUS: Participant follow-up completed; data analysis ongoing.

Health-Related Physical Fitness Evaluation in HIV-Diagnosed Children and Adolescents: A Scoping Review

BACKGROUND

Health-related physical fitness has been widely used to investigate the adverse effects of HIV infection/ART in children and adolescents. However, methods/protocols and cut-points applied for investigating health-related physical fitness are not clear. The aim of this scoping review was to map the literature to identify gaps in knowledge regarding the methods/protocols and cut-points.

METHODS

A scoping review, following the Joana Briggs Institute (JBI) guidelines, was conducted through ten major databases. Search followed the PCC strategy to construct block of terms related to population (children and adolescents), concept (health-related physical fitness components) and context (HIV infection).

RESULTS

The search resulted in 7545 studies. After duplicate removal, titles and abstracts reading and full text assessment, 246 studies were included in the scoping review. Body composition was the most investigated component (n = 244), followed by muscular strength/endurance (n = 23), cardiorespiratory fitness (n = 15) and flexibility (n = 4). The World Health Organization growth curves, and nationals' surveys were the most reference values applied to classify body composition (n = 149), followed by internal cut-points (n = 30) and cut-points developed through small populations (n = 16). Cardiorespiratory fitness was classified through cut-points from three different assessment batteries, as well as cut-points developed through studies with small populations, muscular strength/endurance and flexibility were classified through the same cut-points from five different assessment batteries.

CONCLUSIONS

The research on muscular strength/endurance, cardiorespiratory fitness and flexibility has been scarcely explored. The lack of studies that investigated method usability as well as reference values was evidenced.

Prevalence and risk factors of vitamin D deficiency among living with HIV adults receiving antiretroviral treatment in tropical area: Cross-sectional study

Background

There was found HIV infection have a higher rate of vitamin D deficiency (VDD) than the general population, even a slight deficiency, can increase the risk of osteoporosis in adults. This study aimed to determine the prevalence and risk factors of VDD in HIV-infected adults receiving antiretroviral therapy (ART) in a tropical area.

Methods

A cross-sectional study of an HIV-clinical population-based cohort was conducted at Police General Hospital (PGH), from 1st August 2020 to 31st July 2021, in Bangkok, Thailand. Serum 25(OH)D level was measured using ECLIA. All other laboratory investigations were conducted at the PGH's central lab center. The descriptive analysis utilized frequency (percentages) and mean (SD) as appropriate variable types. Chi-square tests (χ2) and independent samples t-tests were used to differentiate between VDD and non-VDD groups. To determine the association between VDD and non-VDD, gender, age (years), BMI discrepancy, ART regimens, ART-duration (years), HIV viral load, and CD4 count (cells/mm3). Univariate and multivariable logistics regression was conducted, respectively.

Results

Of 602 patients, 66.4% were females with mean age of 45.22 ± 10.23 years. The average serum 25(OH)D level was 18.69 ± 7.23 ng/ml. The prevalence of VDD (<20 ng/ml) and insufficiency (VDI) (20-29.9 ng/ml) was 58.5% and 35.2%, respectively. Risk factors associated with vitamin D inadequacy were increasing age (AOR = 1.05, 95%CI = 1.03-1.07, P < .001), efavirenz (EFV-based) use (AOR = 6.07, 95%CI = 3.57-10.31, P < .001), while male (AOR = 0.44, 95%CI = 0.29-0.66, P < .001), body mass index (BMI) lower than 18.5 (AOR = 0.26; 95% CI, 0.11-0.62, P = .002), protease Inhibitors (PIs-based) use (AOR = 0.18, 95%CI = 0.11-0.30, P < .001),and CD4 count <200 cells/mm3 (AOR = 0.41; 95% CI, 0.20-0.85, P = .017) were associated with less VDD.

Conclusion

The implementation of focused strategies for vitamin D supplementation, specifically targeting older patients and patients undergoing EFV-based ART regimen, can serve as a valuable addition to comprehensive HIV management. By optimizing vitamin D levels, there is a potential to improve health outcomes and enhance overall well-being for individuals living with HIV.

Vitamin D and Calcium Supplementation Reverses Tenofovir-Caused Bone Mineral Density Loss in People Taking ART or PrEP: A Systematic Review and Meta-Analysis

Background

The decrease of bone mineral density (BMD) after the intake of Tenofovir disoproxil fumarate (TDF)-based drugs in people living with HIV/AIDS (PLWHA) and HIV-negative key populations under pre-exposure prophylaxis (PrEP) regimen raised concerns. Previous findings on the effects of vitamin D (VD) and calcium supplements and the recovery of BMD loss were inconclusive. The optimal doses of VD and calcium and its supplementary duration remained unknown. Therefore, we conducted a systematic review and meta-analysis to synthesize current evidence on VD and calcium supplements to inform clinical practice.

Methods

We searched PubMed, Web of Science, Cochrane library, and EMBASE databases for all placebo-controlled trials and prospective cohort studies published before March 5, 2021 that investigated VD and calcium supplements in participants taking TDF-based drugs. The keywords calcium, vitamin D, Tenofovir, and BMD were used for the searches. The primary outcome was changes of spine and hip BMD. A subgroup analysis was performed to determine the factors that were related to the effects of VD supplements on BMD. Locally weighted regression (loess) was used to determine the relationships of VD supplements, supplementary duration, and changes of BMD. This study was registered at PROSPERO (No. 42021231000).

Findings

Seven eligible studies including 703 participants were included in the analyses. The meta-analysis found that VD and calcium supplementation was related to a significant increase of BMD in the spine and hip [standardized mean difference (SMD) 0.43; 95% CI, 0.25 to 0.61, p = 0.009]. Moreover, positive dose-response relationships were demonstrated between doses of VD and calcium supplements, supplementary duration, and BMD recovery. Patients who took VD with the dose level of 4,000 IU/D obtained the highest BMD improvement (SMD 0.59, 95% CI, 0.43 to 0.74). No side effects were reported on VD and calcium supplementation.

Interpretation

We found the VD and calcium supplementation was associated with increases of BMD in participants taking TDF-based drugs. An optimal supplementary dose of 4,000 IU/D for VD was suggested for clinicians. The findings could be used in clinical practice to improve the BMD outcomes in people who were taking TDF-based drugs.Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/.

Vitamin D3 and calcium carbonate supplementation for adolescents with HIV to reduce musculoskeletal morbidity and immunopathology (VITALITY trial): study protocol for a randomised placebo-controlled trial

BACKGROUND

Of the 2 million children living with HIV globally, 90% live in sub-Saharan Africa. Despite antiretroviral therapy, longstanding HIV infection is associated with several chronic complications in children including growth failure, particularly stunting and delayed puberty. Vitamin D deficiency, which is highly prevalent among children living with HIV in sub-Saharan Africa, has a further adverse impact on bone health. This trial aims to establish whether supplementation with vitamin D3 and calcium carbonate improves musculoskeletal health among peripubertal children living with HIV.

METHODS/DESIGN

We will conduct an individually randomised, double-blinded, placebo-controlled trial of weekly high-dose vitamin D3 (20,000 IU) plus daily calcium carbonate (500mg) supplementation for 48 weeks. Eight hundred and forty children living with HIV aged 11-19 years taking ART for ≥6 months will be enrolled and followed up for 96 weeks. The primary outcome is total body less-head bone mineral content for lean mass adjusted for height (TBLH-BMCLBM) Z-score at 48 weeks, measured by dual-energy X-ray absorptiometry (DEXA). Secondary outcomes are DEXA-measured lumbar spine bone mineral apparent density Z-score, number of respiratory infections, lean muscle mass and grip strength at 48 and 96 weeks and TBLH-BMCLBM Z-scores at 96 weeks. Sub-studies will investigate the effect of the intervention on vitamin D3 pathway metabolites and markers of bone turnover, intestinal microbiota, and innate and acquired immune function.

DISCUSSION

This is the largest trial to date of vitamin D supplementation in children living with HIV. Intervening to address deficits in bone accrual in childhood is critical for optimising adolescent and early adult bone health and prevention of later adult osteoporotic fractures. Trial results will draw attention to the need to screen for and treat long-term comorbidities in children living with HIV in resource-limited settings.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR20200989766029 . Registered on 3 September 2020.

Vitamin D and Calcium Supplement Attenuate Bone Loss among HIVInfected Patients Receiving Tenofovir Disoproxil Fumarate/Emtricitabine/ Efavirenz: An Open-Label, Randomized Controlled Trial

BACKGROUND

Antiretroviral therapy (ART), especially with tenofovir disoproxil fumarate (TDF), has been associated with accelerated bone turnover and leads to significant bone loss.

OBJECTIVE

We aimed to determine the effect of vitamin D2 and calcium on bone mineral density (BMD) in HIV-infected patients receiving TDF/emtricitabine (FTC)/efavirenz (EFV).

METHODS

A prospective, open-label, randomized controlled study was conducted. Eligible patients were ART naïve HIV individuals who initiated TDF/FTC/EFV. The study group received supplementation with vitamin D2 and calcium carbonate, whereas the control group was administered only ART. The primary outcome was the percentage change in total hip BMD at week 24 compared with baseline.

RESULTS

A total of 18 patients were randomized (9 in each group). The mean (standard deviation; SD) total hip BMD significantly decreased from baseline in both groups, from 0.96 (0.14) g/cm2 to 0.93 (0.13) g/cm2 in the study group (p = 0.006) and from 0.87 (0.11) g/cm2 to 0.84 (0.11) g/cm2 in the control group (p = 0.004). The mean (SD) lumbar spine BMD significantly decreased from baseline in both groups, from 1.00 (0.13) g/cm2 to 0.97 (0.13) g/cm2 (p = 0.004) in the study group and from 0.90 (0.09) g/cm3 to 0.86 (0.08) g/cm2 in the control group (p = 0.006). At week 24, the mean (SD) lumbar spine BMD was significantly greater in the study group than in the control group (p = 0.042). However, there were no significant differences in the percentage change of total hip, lumbar spine, and femoral neck BMD between both groups. No adverse events were reported. In conclusion, as early as 24 weeks after TDF initiation, a significant decline in BMD was detected.

CONCLUSION

Vitamin D2 and calcium supplements should be considered for HIV-infected patients receiving TDF/FTC/EFV in a resource-limited setting where there are limited ART options (Clinicaltrials. gov NCT0287643).

Impact of vitamin D and calcium supplementation on bone mineral density and bone metabolism among Thai adolescents with perinatally acquired HIV infection: A randomized clinical trial

BACKGROUND

To evaluate the impact of vitamin D and calcium supplementation(VitD/Ca) on lumbar spine bone mineral density(LSBMD) and bone metabolism among Thai adolescents with perinatally acquired HIV(PHIVA).

METHODS

A multicenter, randomized, active-control, open-labeled trial was conducted. PHIVA(aged10-20years) who were on stable cART were enrolled. Baseline LSBMD status was defined as low(z-score≤-2) and normal(z-score>-2). Eligible PHIVA were randomly assigned to receive standard-dose VitD/Ca (400IU/1,200mg daily), or high-dose VitD/Ca supplementation (400IU/1,200mg daily plus ergocalciferol 20,000IU weekly) for 48 weeks (ratio 1:1,stratified by baseline LSBMD). Study outcomes were the changes in LSBMD, LSBMD z-scores, and bone metabolism-related biomarkers (25-hydoxyvitamin D[25OHD], intact parathyroid hormone[iPTH], C-terminal telopeptide[CTX], procollagen type I amino-terminal propeptide[PINP]) from baseline to week48.

RESULTS

Among 200 enrolled PHIVA, a median age was 16 (IQR:14-18)years; 61% were on NNRTI-based cART. The median 25OHD level was 25.5 (IQR:20.8-33.0)ng/ml. After a 48-week VitD/Ca supplementation, LSBMD significantly increased in both treatment groups (high-dose,median:+0.07g/cm 2,IQR:+0.04 to +0.11g/cm 2,P<0.001; standard-dose,median:+0.09g/cm 2, IQR:+0.03 to +0.13g/cm 2,P<0.001). Notably, the change in LSBMD z-scores was significantly greater in high-dose versus standard-dose groups (median:+0.4,IQR:-0.1 to +0.9 versus median:+0.1,IQR:-0.4 to +0.7;P=0.02). The levels of 25OHD increased, whereas iPTH, CTX, and PINP declined significantly in both groups(P<0.05); but no between-group differences were demonstrated.

CONCLUSIONS

Over the 48-week VitD/Ca supplementation, significant increase in LSBMD, and significant decreases in bone metabolism-related markers were observed among our Thai PHIVA in both treatment groups. The improvement in LSBMD z-score was more enhanced with high-dose VitD/Ca supplementation compared with standard-dose. High-dose VitD/Ca supplementation might be considered to promote bone health in this population.

Effects of vitamin D and calcium supplementation on bone mineral density among Thai youth using daily HIV pre-exposure prophylaxis

INTRODUCTION

Tenofovir disoproxil fumarate with emtricitabine (TDF/FTC) is used for HIV pre-exposure prophylaxis (PrEP). TDF may affect bone mineral density (BMD), particularly in youth who are at a stage of peak bone mass accrual. The objective of this study was to evaluate the effect of vitamin D and calcium supplementation on BMD among Thai youth receiving daily oral PrEP.

METHODS

This open-label randomized trial was conducted in male youth aged between 15 and 24 years. Participants were randomized to Arm A who received once-daily TDF/FTC plus vitamin D3 and calcium supplementation with meals twice daily (400 units of vitamin D3 and 1200 mg of elemental calcium/day) or Arm B who received once-daily TDF/FTC only. PrEP users were defined as taking at least two tablets/week (tenofovir-diphosphate level of >350 fmol/punch). Adherence to vitamin D/calcium supplementation was defined as self-reported adherence of >50%. Lumbar spine (L2-L4) BMD (LSBMD) was evaluated by dual-energy X-ray absorptiometry scan zero and six months after PrEP initiation.

RESULTS

From March 2019 to March 2020, 100 youth were enrolled. Baseline characteristics between the two arms were similar. Median (IQR) age was 18 (17 to 20) years. At entry, median (IQR) LSBMD z-score was -0.8 (-1.5 to -0.3), 17% had low LSBMD (Z-score < -2). The median amount of calcium intake from nutritional three-day recall was 167 (IQR 94 to 272) mg/day, 39% of participants had vitamin D deficiency, defined as 25(OH)D levels <20 IU/mL. At six months, 79 participants were evaluated. Of these, 42 (52%) were PrEP takers and 25 of 38 (66%) of arm A participants had good adherence to vitamin D/calcium supplementation. Significantly higher proportions of youth in arm A compared to arm B had >3% increase in LSBMD at month 6 compared to baseline (67.6% vs. 42.9% respectively; p = 0.03). There were significantly higher increases in LSBMD among youth with vitamin D deficiency who were supplemented; arm A + 0.05 (0 to 0.05) compared to arm B + 0.03 (-0.1 to 0.03), p = 0.04.

CONCLUSIONS

Increases in LSBMD over six months among youth using PrEP who received vitamin D/calcium supplementation was greater than those not supplemented. Long-term follow-up should be considered to explore long-term outcomes.