Low bone mass in human immunodeficiency virus–infected climacteric women receiving antiretroviral therapy: prevalence and associated factors

Brief Report: Undertreated Midlife Symptoms for Women Living With HIV Linked to Lack of Menopause Discussions With Care Providers

BACKGROUND

Increasingly, women living with HIV are entering menopause (ie, cessation of menses for ≥1 year) and experiencing midlife symptoms. Menopausal hormone therapy (MHT) is first-line therapy for bothersome hot flashes and early menopause (ie, before age 45 years); however, its use in women living with HIV is poorly described. We conducted a cross-sectional assessment of MHT uptake and barriers to use in this group.

SETTING

This study was conducted across 3 Canadian provinces from 2015 to 2017.

METHODS

Perimenopausal and postmenopausal women living with HIV (35 years or older) in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study who answered questions related to MHT use were included. Univariable/multivariable logistic regression evaluated factors associated with MHT use, adjusted for age and contraindications.

RESULTS

Among 464 women, 47.8% (222 of 464) had a first-line indication for MHT; however, only 11.8% (55 of 464) reported ever using MHT and 5.6% (26 of 464) were current users. Only 44.8% had ever discussed menopause with their care provider despite almost all women having regular HIV care (97.8%). African/Caribbean/Black women had lower unadjusted odds of MHT treatment compared with White women [odds ratio (OR) 0.42 (0.18-0.89); P = 0.034]. Those who had discussed menopause with their care provider had higher odds of treatment [OR 3.13 (1.74-5.86); P < 0.001]. In adjusted analyses, only women having had a menopause discussion remained significantly associated with MHT use [OR 2.97 (1.62-5.61); P < 0.001].

CONCLUSION

Women living with HIV are seldom prescribed MHT despite frequent indication. MHT uptake was associated with care provider-led menopause discussions underscoring the need for care provider education on menopause management within HIV care.

Pharmacologic approaches to the prevention and management of low bone mineral density in HIV-infected patients

PURPOSE OF REVIEW

Osteoporosis is a growing concern among people living with HIV (PLWH) because of the recognized risk of fractures, which bring with them morbidity and mortality. New evidence is helping clinicians understand how to prevent and manage osteoporosis in this subpopulation.

RECENT FINDINGS

The benefit of calcium and vitamin D is variable in osteoporosis literature in general, but evidence supports the use of these supplements in PLWH to prevent the loss of bone mineral density when initiating antiretroviral therapy and in enhancing the effectiveness of antiosteoporosis treatments. Of the osteoporosis treatments, alendronate and zoledronate are the only two with substantial evidence of safety and effectiveness in PLWH, but the studies have been small and of limited duration. There are no randomized controlled studies of raloxifene, denosumab or teriparatide in PLWH. Of increasing interest is the possible benefit of statins on bone health through decreased inflammation.

SUMMARY

Osteoporosis is recognized as an issue for PLWH. Although some of the available osteoporosis treatments have proven safe and effective, future studies of the novel treatments, such as statins, along with well-designed studies of established osteoporosis treatments for use in PLWH are needed to further guide the clinical management of osteoporosis in this population.

Perspectives on menopause and women with HIV

Since the implementation of effective combination antiretroviral therapy, HIV infection has been transformed from a life-threatening condition into a chronic disease. As people with HIV are living longer, aging and its associated manifestations have become key priorities as part of HIV care. For women with HIV, menopause is an important part of aging to consider. Women currently represent more than one half of HIV-positive individuals worldwide. Given the vast proportion of women living with HIV who are, and will be, transitioning through age-related life events, the interaction between HIV infection and menopause must be addressed by clinicians and researchers. Menopause is a major clinical event that is universally experienced by women, but affects each individual woman uniquely. This transitional time in women's lives has various clinical implications including physical and psychological symptoms, and accelerated development and progression of other age-related comorbidities, particularly cardiovascular disease, neurocognitive dysfunction, and bone mineral disease; all of which are potentially heightened by HIV or its treatment. Furthermore, within the context of HIV, there are the additional considerations of HIV acquisition and transmission risk, progression of infection, changes in antiretroviral pharmacokinetics, response, and toxicities. These menopausal manifestations and complications must be managed concurrently with HIV, while keeping in mind the potential influence of menopause on the prognosis of HIV infection itself. This results in additional complexity for clinicians caring for women living with HIV, and highlights the shifting paradigm in HIV care that must accompany this aging and evolving population.

Association between HIV infection and bone mineral density in climacteric women

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.

Bone Density and Fractures in HIV-infected Postmenopausal Women: A Systematic Review

With the development of effective antiretroviral therapy, HIV-infected women are living longer and transitioning through menopause. The purpose of our study was to systematically examine the evidence that menopause is an additional risk predictor for osteoporosis and fractures in HIV-infected women. Electronic databases were searched for studies of low bone density or fractures in HIV-infected postmenopausal women. Studies that met the inclusion criteria (n = 10) were appraised using a validated quality assessment tool. The majority of studies were rated as good quality and the remaining were fair. The prevalence of osteoporosis reported in these studies ranged from 7.3% to 84% and 0.7% to 23% in HIV-infected and uninfected postmenopausal women, respectively. In the two qualifying studies, postmenopausal status was not a predictor of fractures in HIV-infected women. Findings suggest that HIV care providers should accurately assess postmenopausal status and modifiable risk factors for osteoporosis in all older HIV-infected women.