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McGee DM, Cotter AG. HIV and fracture: Risk, assessment and intervention. HIV Med 2024; 25:511-528. [PMID: 38087902 DOI: 10.1111/hiv.13596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 11/17/2023] [Indexed: 05/09/2024]
Abstract
OBJECTIVES With management of comorbidity in people living with HIV (PLWH) a key component of clinical care, early loss of bone integrity and clinical fracture are recognized as important issues. This review aims to describe the epidemiology of fracture in PLWH, as well as summarizing the relative balance of factors that contribute to fracture. We also aim to describe fracture risk assessment and interventional strategies to modify the risk of fracture in this population. RESULTS Data from recent meta-analyses show that PLWH have significantly more fractures than the general population, with men and injecting drug users at higher risk. Modifiable factors that contribute to fracture risk in this cohort include body mass index (BMI), drug use, concurrent medications, frailty, and hepatitis C virus infection. Relating to antiretroviral therapy, current or ever tenofovir exposure has been identified as predictive of fracture but not cumulative use, and a potentially modest protective effect of efavirenz has been observed. Fracture Risk Assessment Tool scores underestimate fracture risk in PLWH with improved accuracy when HIV is considered a cause of secondary osteoporosis and bone mineral density (BMD) included. CONCLUSION Early consideration of risk, prompting evaluation of modifiable risk factors, frailty and falls risk with bone density imaging and prompt intervention may avert fracture in PLWH. Guidance on screening and lifestyle modification is available in international guidelines. Bisphosphonates are safe and effective in PLWH, with limited data for other agents.
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Affiliation(s)
- D M McGee
- Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
| | - A G Cotter
- Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
- UCD Centre for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Republic of Ireland
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2
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Vélez-Díaz-Pallarés M, Delgado-Silveira E, Fernández-Fradejas J, Montero-Llorente B, Palomar-Fernández C, Montero-Errasquín B, Cruz-Jentoft AJ, Álvarez-Díaz A. Potentially Inappropriate Prescribing in Older People Living With HIV: A Scoping Review. J Acquir Immune Defic Syndr 2023; 94:445-460. [PMID: 37851956 DOI: 10.1097/qai.0000000000003298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/21/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Antiretroviral therapy has transformed HIV from a progressive and often fatal infection to a chronic disease. Currently, people living with HIV (PLHIV) have near-normal life expectancy; however, they face accelerated ageing and a rise in non-AIDS-defining HIV-associated conditions. Comorbidities increase the number of prescribed drugs and, therefore, the risk of polypharmacy and prescribing potentially inappropriate medications (PIMs). Still, there are no specific tools to identify PIMs in older PLHIV, which opens a pathway to investigate the particularities in the prescription of medication in this population. METHODS We conducted a scoping review in 5 electronic databases for studies reporting the use of tools to identify PIMs in older PLHIV. No language or date restrictions were applied. To complete the search, abstracts published in the most relevant HIV Conferences and Events in their editions from 2010 to 2022 were screened. RESULTS Of 50,193 records returned (13,701 of the databases and 36,492 of the Congresses), 39 studies met the inclusion criteria. Most studies were single-centre and conducted in Europe. Twenty-eight studies were cross-sectional, and most researchers used explicit criteria, mainly Beers and STOPP-START criteria, to identify PIMs. CONCLUSIONS Potentially inappropriate prescribing is frequent among older PLHIV. Explicit conventional tools to identify PIMs in older populations may need to be adapted to tackle the needs of PLHIV. Implicit tools may be more valid, although their use is more time-consuming, and standardization is complex.
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Affiliation(s)
| | - Eva Delgado-Silveira
- Servicio de Farmacia, Hospital Universitario Ramón y Cajal, IRYCIS. Madrid, Spain; and
| | | | | | | | | | | | - Ana Álvarez-Díaz
- Servicio de Farmacia, Hospital Universitario Ramón y Cajal, IRYCIS. Madrid, Spain; and
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3
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Hechter RC, Zhou H, Leyden WA, Yuan Q, Pak KJ, Lam JO, Alexeeff S, Lea A, Hu H, Marcus JL, Rivera AS, Adams AL, Horberg MA, Towner WJ, Lo JC, Silverberg MJ. Fracture Risk and Association With TDF Use Among People With HIV in Large Integrated Health Systems. J Acquir Immune Defic Syndr 2023; 94:341-348. [PMID: 37884055 DOI: 10.1097/qai.0000000000003274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/10/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Greater decline in bone health among people with HIV (PWH) has been documented but fracture risk and the impact of specific antiretroviral therapy (ART) regimens remain unclear. SETTING Retrospective analyses of electronic health record data from 3 US integrated health care systems. METHODS Fracture incidence was compared between PWH aged 40 years or older without prior fracture and demographically matched people without HIV (PWoH), stratified by age, sex, and race/ethnicity. Multivariable Cox proportional hazards models were used to estimate fracture risk associated with HIV infection. The association of tenofovir disoproxil fumarate (TDF) use and fracture risk was evaluated in a subset of PWH initiating ART. RESULTS Incidence of fracture was higher in PWH [13.6/1000 person-years, 95% confidence interval (CI): 13.0 to 14.3, n = 24,308] compared with PWoH (9.5, 95% CI: 9.4 to 9.7, n = 247,313). Compared with PWoH, the adjusted hazard ratio (aHR) for fracture among PWH was 1.24 (95% CI: 1.18 to 1.31). The association between HIV infection and fracture risk increased with age, with the lowest aHR (1.17, 95% CI: 1.10 to 1.25) among those aged 40-49 years and the highest aHR (1.89, 95% CI: 1.30 to 2.76) among those aged 70 years or older. Among PWH initiating ART (n = 6504), TDF was not associated with significant increase in fracture risk compared with non-TDF regimens (aHR: 1.18, 95% CI: 0.89 to 1.58). CONCLUSIONS Among people aged 40 years or older, HIV infection is associated with increased risk of fractures. Bone health screening from the age of 40 years may be beneficial for PWH. Large cohort studies with longer follow-up are needed to evaluate TDF effect and the potential benefit of early screening.
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Affiliation(s)
- Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Wendy A Leyden
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Qing Yuan
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Katherine J Pak
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Jennifer O Lam
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Stacey Alexeeff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Alexandra Lea
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Haihong Hu
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Julia L Marcus
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA; and
| | - Adovich S Rivera
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Annette L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Michael A Horberg
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - William J Towner
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Joan C Lo
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA; and
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA
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Vizcarra P, Moreno A, Vivancos MJ, Muriel García A, Ramirez Schacke M, González-Garcia J, Curran A, Palacios R, Sánchez Guirao AJ, Reus Bañuls S, Moreno Guillén S, Casado JL. A Risk Assessment Tool for Predicting Fragility Fractures in People with HIV: Derivation and Internal Validation of the FRESIA Model. J Bone Miner Res 2023; 38:1443-1452. [PMID: 37545089 DOI: 10.1002/jbmr.4894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
People with HIV have a higher risk of fracture than the general population. Because of the low performance of the existing prediction tools, there is controversy surrounding fracture risk estimation in this population. The aim of the study was to develop a model for predicting the long-term risk of fragility fractures in people with HIV. We included 11,899 individuals aged ≥30 years from the Spanish HIV/AIDS research network cohort. We identified incident fragility fractures from medical records, defined as nontraumatic or those occurring after a casual fall, at major osteoporotic sites (hip, clinical spine, forearm, proximal humerus). Our model accounted for the competing risk of death and included 12 candidate predictors to estimate the time to first fragility fracture. We assessed the discrimination and calibration of the model and compared it with the FRAX tool. The incidence rate of fragility fractures was 4.34 (95% CI 3.61 to 5.22) per 1000 person-years. The final prediction model included age, chronic kidney disease, and chronic obstructive pulmonary disease as significant predictors. The model accurately predicted the 5- and 10-year risk of fragility fractures, with an area under the receiving operator characteristic curve of 0.768 (95% CI 0.722 to 0.814) and agreement between the observed and expected probabilities. Furthermore, it demonstrated better discrimination and calibration than the FRAX tool, improving the classification of over 35% of individuals with fragility fractures compared to FRAX. Our prediction model demonstrated accuracy in predicting the long-term risk of fragility fractures. It can assist in making personalized intervention decisions for individuals with HIV and could potentially replace the current tools recommended for fracture risk assessment in this population. © 2023 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)
- Pilar Vizcarra
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Universidad de Alcalá, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Ana Moreno
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - María J Vivancos
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Alfonso Muriel García
- Unit of Biostatistics, Hospital Universitario Ramón y Cajal, Centro de Investigación Biomédica en Red, Epidemiología y Salud Pública (CIBERESP), Universidad de Alcalá, Madrid, Spain
| | - Margarita Ramirez Schacke
- Unit of Infectious Diseases - HIV, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Juan González-Garcia
- Unit of VIH, Department of Internal Medicine II, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Adrián Curran
- Infectious Diseases Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Rosario Palacios
- Unit of Infectious Diseases, Hospital Universitario Virgen de la Victoria, Malaga, Spain
| | | | - Sergio Reus Bañuls
- Unit of Infectious Diseases, ISABIAL, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | - Santiago Moreno Guillén
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Universidad de Alcalá, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - José L Casado
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Hong N, Kim JH, Treece G, Kim HC, Choi JY, Rhee Y. Cortical and Trabecular Bone Deficit in Middle-Aged Men Living with HIV. J Bone Miner Res 2023; 38:1288-1295. [PMID: 37358254 DOI: 10.1002/jbmr.4873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 06/01/2023] [Accepted: 06/16/2023] [Indexed: 06/27/2023]
Abstract
A significant increase in the risk of hip fracture was observed in middle-aged men living with human immunodeficiency virus (MLWH), almost a decade earlier than those without infection. Data regarding cortical and trabecular bone deficit of hip, an important determinant of bone strength, in MLWH are limited. Quantitative CT was performed in consecutive MLWH aged ≥30 years between November 2017 and October 2018 at Severance Hospital, Seoul, Korea. Volumetric bone mineral density (vBMD) and cortical bone mapping parameters of hip (cortical thickness [CTh], cortical bone vBMD [CBMD], cortical mass surface density [CMSD], endocortical trabecular density [ECTD]) were compared to age-matched and body mass index (BMI)-matched controls (1:2) using a community-based healthy adults cohort. Among 83 MLWH and 166 controls (mean age: 47.2 years; BMI: 23.6 kg/m2 ), MLWH had lower total hip vBMD (280 ± 41 versus 296 ± 41 mg/cm3 ), CMSD (155 versus 160 mg/cm2 ), and ECTD (158 versus 175 mg/cm3 ) than controls that remained robust after adjustment for covariates (adjusted β: total hip vBMD, -18.8; CMSD, -7.3; ECTD, -18.0; p < 0.05 for all). Cortical bone mapping revealed localized deficit of CTh, CBMD, and CMSD in the anterolateral trochanteric region and femoral neck in MLWH compared to controls, with a more extensive ECTD deficit. In MLWH, lower CD4 T-cell count (/100 cells/mm3 decrement) and protease inhibitor (PI)-based regimen (versus non-PI regimen) at the time of antiretroviral treatment initiation were associated with lower total hip vBMD (adjusted β -7.5 for lower CD4 count; -28.3 for PI-based regimen) and CMSD (adjusted β -2.6 for lower CD4 count; -12.7 for PI-based regimen; p < 0.05 for all) after adjustment for covariates including age, BMI, smoking, alcohol use, hepatitis C virus co-infection, tenofovir exposure, and CT scanner types. MLWH had lower hip bone density with cortical and trabecular bone deficit compared to community-dwelling controls. © 2023 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Namki Hong
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, South Korea
- Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, South Korea
| | - Jung Ho Kim
- Department of Internal Medicine, Severance Hospital, AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Graham Treece
- Department of Engineering, University of Cambridge, Cambridge, UK
| | - Hyeon Chang Kim
- Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, South Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Yong Choi
- Department of Internal Medicine, Severance Hospital, AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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Womack JA, Murphy TE, Leo-Summers L, Kidwai-Khan F, Skanderson M, Gill TM, Gulanski B, Rodriguez-Barradas MC, Yin MT, Hsieh E. Performance of a modified fracture risk assessment tool for fragility fracture prediction among older veterans living with HIV. AIDS 2023; 37:1399-1407. [PMID: 37070536 PMCID: PMC10329997 DOI: 10.1097/qad.0000000000003566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVE Fragility fractures (fractures) are a critical outcome for persons aging with HIV (PAH). Research suggests that the fracture risk assessment tool (FRAX) only modestly estimates fracture risk among PAH. We provide an updated evaluation of how well a 'modified FRAX' identifies PAH at risk for fractures in a contemporary HIV cohort. DESIGN Cohort study. METHODS We used data from the Veterans Aging Cohort Study to evaluate veterans living with HIV, aged 50+ years, for the occurrence of fractures from 1 January 2010 through 31 December 2019. Data from 2009 were used to evaluate the eight FRAX predictors available to us: age, sex, BMI, history of previous fracture, glucocorticoid use, rheumatoid arthritis, alcohol use, and smoking status. These predictor values were then used to estimate participant risk for each of two types of fractures (major osteoporotic and hip) over the subsequent 10 years in strata defined by race/ethnicity using multivariable logistic regression. RESULTS Discrimination for major osteoporotic fracture was modest [Blacks: area under the curve (AUC) 0.62; 95% confidence interval (CI) 0.62, 0.63; Whites: AUC 0.61; 95% CI 0.60, 0.61; Hispanic: AUC 0.63; 95% CI 0.62, 0.65]. For hip fractures, discrimination was modest to good (Blacks: AUC 0.70; 95% CI 0.69, 0.71; Whites: AUC 0.68; 95% CI 0.67, 0.69]. Calibration was good in all models across all racial/ethnic groups. CONCLUSION Our 'modified FRAX' exhibited modest discrimination for predicting major osteoporotic fracture and slightly better discrimination for hip fracture. Future studies should explore whether augmentation of this subset of FRAX predictors results in enhanced prediction of fractures among PAH.
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Affiliation(s)
- Julie A. Womack
- VA Connecticut Healthcare System
- Yale School of Nursing, West Haven, Connecticut
| | - Terrence E. Murphy
- Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | | | - Farah Kidwai-Khan
- VA Connecticut Healthcare System
- Yale School of Medicine, New Haven, Connecticut
| | - Melissa Skanderson
- VA Connecticut Healthcare System
- Yale School of Medicine, New Haven, Connecticut
| | | | - Barbara Gulanski
- Yale School of Medicine, New Haven, Connecticut
- Infectious Diseases Section, Michael E DeBakey VA Medical Center, and Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Michael T. Yin
- Columbia University Medical Center, New York, New York, USA
| | - Evelyn Hsieh
- VA Connecticut Healthcare System
- Yale School of Medicine, New Haven, Connecticut
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Rukuni R, Simms V, Rehman AM, Mukwasi-Kahari C, Mujuru H, Ferrand RA, Gregson CL. Fracture prevalence and its association with bone density among children living with HIV in Zimbabwe. AIDS 2023; 37:759-767. [PMID: 36728418 PMCID: PMC9994799 DOI: 10.1097/qad.0000000000003477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/26/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES HIV infection impairs bone density in children living with HIV (CLWH). We aimed to determine the prevalence of self-reported fracture (past or current), associated risk factors and disability, by HIV status in Zimbabwean children. DESIGN Cross-sectional study. METHODS We recruited CLWH aged 8-16 years taking antiretroviral therapy (ART) for ≥2 years from HIV clinics, and HIV-uninfected children from schools in Harare. Interviewer-administered questionnaires collected data on fracture site and management, sociodemographics, dietary calcium and vitamin D, physical activity and HIV history. Dual-energy X-ray absorptiometry (DXA) measured size-adjusted bone density. RESULTS We recruited 303 CLWH [mean (SD) age 12.5 (2.5) years; 50% female] and 306 children without HIV [12.5 (2.5) years; 51% female]. Median age at HIV diagnosis in CLWH was 3.0 years [interquartile range (IQR) 1.2, 5.9], and median ART duration 8.1 years [IQR 6.2, 9.5]. 53.8% CLWH had self-reported disability and/or functional impairment, vs. 29.4% children without HIV. Fracture prevalence was 5.9% with no difference by HIV status [21/306 (6.9%) vs. 14/303 (4.6%), P = 0.24]. Male sex was associated with fractures. Low size-adjusted bone density ( Z -score < -2) was associated with prevalent fractures in CLWH {risk ratio [RR] 1.14 (95% confidence interval (CI) -0.02, 2.29]}, but not in children without HIV [RR -0.04 (-2.00, 1.91)], P -interaction = 0.27. All sought medical attention for their fracture(s), but CLWH were less often admitted to hospital [2/14 (14.3%) vs. 7/21 (33.3%)]. CONCLUSION Prevalent fractures may be associated with low lumbar spine bone density in CLWH. Fracture surveillance and strategies to reduce future fracture risk are warranted as CLWH enter adulthood.
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Affiliation(s)
- Ruramayi Rukuni
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Victoria Simms
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- MRC International Statistics and Epidemiology Group, Faculty of Epidemiology and Population Health
| | - Andrea M. Rehman
- MRC International Statistics and Epidemiology Group, Faculty of Epidemiology and Population Health
| | - Cynthia Mukwasi-Kahari
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Hilda Mujuru
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Rashida A. Ferrand
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Celia L. Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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8
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Ahmed M, Mital D, Abubaker NE, Panourgia M, Owles H, Papadaki I, Ahmed MH. Bone Health in People Living with HIV/AIDS: An Update of Where We Are and Potential Future Strategies. Microorganisms 2023; 11:microorganisms11030789. [PMID: 36985362 PMCID: PMC10052733 DOI: 10.3390/microorganisms11030789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
The developments in Human Immunodeficiency Virus (HIV) treatment and in the care of people living with HIV (PLWHIV) and Acquired Immunodeficiency Syndrome (AIDS) over the last three decades has led to a significant increase in life expectancy, on par with HIV-negative individuals. Aside from the fact that bone fractures tend to occur 10 years earlier than in HIV-negative individuals, HIV is, per se, an independent risk factor for bone fractures. A few available antiretroviral therapies (ARVs) are also linked with osteoporosis, particularly those involving tenofovir disoproxil fumarate (TDF). HIV and hepatitis C (HCV) coinfection is associated with a greater risk of osteoporosis and fracture than HIV monoinfection. Both the Fracture Risk Assessment Tool (FRAX) and measurement of bone mineral density (BMD) via a DEXA scan are routinely used in the assessment of fracture risk in individuals living with HIV, as bone loss is thought to start between the ages of 40 and 50 years old. The main treatment for established osteoporosis involves bisphosphonates. Supplementation with calcium and vitamin D is part of clinical practice of most HIV centers globally. Further research is needed to assess (i) the cut-off age for assessment of osteoporosis, (ii) the utility of anti-osteoporotic agents in PLWHIV and (iii) how concomitant viral infections and COVID-19 in PLWHIV can increase risk of osteoporosis.
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Affiliation(s)
- Musaab Ahmed
- College of Medicine, Ajman University, Ajman P.O. Box 346, United Arab Emirates
- Center of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman P.O. Box 346, United Arab Emirates
| | - Dushyant Mital
- Department of HIV and Blood Borne Virus, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Nuha Eljaili Abubaker
- Clinical Chemistry Department, College of Medical Laboratory Science, Sudan University of Science and Technology, Khartoum P.O. Box 407, Sudan
| | - Maria Panourgia
- Department of Geriatric Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Henry Owles
- Department of Geriatric Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Ioanna Papadaki
- Department of Rheumatology, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Mohamed H. Ahmed
- Department of Geriatric Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
- Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
- Correspondence:
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9
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Tang MJ, Alexander A, Hoy JF. Gender and sex considerations in HIV and bone health. Curr Opin HIV AIDS 2023; 18:75-80. [PMID: 36722195 DOI: 10.1097/coh.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW People with HIV (PWHIV) are at increased risk for osteoporosis and fractures, because of the effects of HIV and inflammation and antiretroviral therapy (ART) initiation as well as traditional risk factors. This review from recent literature focuses on sex differences in rates of bone disease, risk of fractures, and effects of ART. RECENT FINDINGS Women with HIV in resource-constrained settings experience bone loss because of the additive effect of initiating TDF-containing ART during pregnancy, lactation, and menopause. Children and adolescents experience lower bone accrual during the pubertal growth years. There has been less focus on bone health in recent trials of ART containing tenofovir alafenamide and/or integrase inhibitors. Very few clinical trials or studies compare sex-specific changes in inflammation, immune activation, response to ART and bone turnover or change in BMD resulting in significant knowledge gaps. SUMMARY More data is needed to determine changes in prevalence of osteopenia, osteoporosis, and fractures in the era of immediate initiation of ART at high CD4 cell counts and the use of more bone-friendly ART. The long-term effects of ART and low bone mass on fractures in the ageing population of PWHIV is yet to be realized.
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Affiliation(s)
- Mei J Tang
- Department of Infectious Diseases, Alfred Hospital
| | | | - Jennifer F Hoy
- Department of Infectious Diseases, Alfred Hospital
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Australia
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Abstract
Life expectancy of people living with HIV (PLWH) is now close to that of the HIV-uninfected population. As a result, age-related comorbidities, including osteoporosis, are increasing in PLWH. This narrative review describes the epidemiology of bone fragility in PLWH, changes of bone features over the course of HIV infection and their determinants, as well as the available evidence regarding the management of osteoporosis in PLWH. The risk of fracture is higher and increases about 10 years earlier compared to the general population. The classical risk factors of bone fragility are very widespread and are major determinants of bone health in this population. The majority of bone loss occurs during virus replication and during immune reconstitution at antiretroviral therapies (ART) initiation, which both increase osteoclast activity. Abnormalities in bone formation and mineralization have also been shown in histomorphometric studies in untreated PLWH. Measurement of bone mineral density (BMD) is the first line tool for assessing fracture risk in postmenopausal women, men above 50 years, and other HIV-infected patients with clinical risk factors for osteoporosis. FRAX underestimates fracture probability in PLWH. In case of indication for anti-osteoporotic drug, bisphosphonates remain the reference option. Calcium and vitamin D supplementation should be considered as ART initiation, since it may attenuate bone loss at this stage. Bone-protective ART regimens improve BMD compared to other regimens, but to a lesser extent than bisphosphonate, and without available data on their influence on the incidence of fracture.
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Affiliation(s)
- Emmanuel Biver
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4 Rue Gabrielle Perret-Gentil, 1205, Geneva, Switzerland.
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11
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Reconstruction and repair, using mini-plate and bone graft for persons living with HIV with giant cell tumor of long bone: retrospective analysis of a single-center experience. AIDS Res Ther 2021; 18:82. [PMID: 34727929 PMCID: PMC8565052 DOI: 10.1186/s12981-021-00406-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 10/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background To evaluate the effect of reconstruction and repair, using a mini-plate and bone graft for HIV -positive patients with giant cell tumor of long bone. Methods We conducted a retrospective analysis of 12 HIV positive patients with giant cell tumor of long bone. A non-HIV-positive cohort of patients, matched for age, sex, and disease type, was selected as the control group. From June 2012 to August 2020, curettage by ultrasonic scalpel was performed in all patients, combined with min- plate and bone graft treatment. All patients were followed- up for 18 to 60 months. Limb function was evaluated, using the MSTS93 scoring system, and any examples of postoperative recurrence, distant metastasis, complications, MSTS93 score, and fracture prognosis were recorded. Results The mean age of HIV group was 43.5 years. The ratio of men to women was 11: 1. In all cases the histopathological diagnosis was clear, except the patients with primary malignant giant cell tumor of bone, including five, three, two, and two cases in the proximal tibia, distal femur, distal tibia, and talus, respectively. Following their surgery, all patients were followed up with an average of 31.24 ± 11.84 months. No local recurrence or pulmonary metastases were observed. Post-surgery, all the 12 patients showed good bone morphologic repair and reconstruction, good bone healing, good joint function, and no pathological fractures around their lesion. In the HIV group, one case of giant cell tumor in the proximal tibia showed mild articular surface collapse and mild valgus deformity of the knee joint but retained good joint function. The MSTS scores of excellent or good in the two groups comprised 83.3%, thus, there was no significant difference between them (P > 0.05). Compared with preoperatively, the MSTS scores in the HIV group were significantly improved, ranging from 7 to 11 points preoperatively to 24 to 27 points postoperatively; this difference was statistically significant (P < 0.05). Conclusion Reconstruction and repair, using a mini-plate and bone graft for HIV -positive patients with giant cell tumor of long bone can achieve satisfactory results. The mini- plate requires little space and is flexible during reconstruction and fixation, significantly reducing complications such as surgical site infection, as well as preserving joint function and avoiding amputation; therefore, it is a safe and effective treatment method.
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12
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Atencio P, Cabello A, Conesa-Buendía FM, Pérez-Tanoira R, Prieto-Pérez L, Carrillo I, Álvarez B, Arboiro-Pinel R, Díaz-Curiel M, Herrero-Beaumont G, Mediero A, Górgolas M. Increased risk factors associated with lower BMD in antiretroviral-therapy-naïve HIV-infected adult male. BMC Infect Dis 2021; 21:542. [PMID: 34107907 PMCID: PMC8188666 DOI: 10.1186/s12879-021-06263-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 05/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low BMD (bone mineral density) has been described as a non-AIDS (Acquired Immune Deficiency Syndrome)-related event in HIV (human immunodeficiency virus)-patients but it is poorly studied in young HIV-infected men who have received no previous antiretroviral therapy. METHODS A cross-sectional study of 245 naïve-HIV-infected men over 21 and under 50 years old who voluntary attended the Infectious Disease Division appointment in Hospital Fundación Jimenez Díaz in Madrid, from January 1st, 2014 to September 30th, 2017. All subjects underwent a baseline DXA scan (dual energy x-ray absorptiometry) performed prior to start antiretroviral treatment. Further, all patients who started treatment between May 1st and September 30th, 2017 were invited to participate in a substudy on bone mineral metabolism. All the information was collected through clinical history and complementary questionnaire. RESULTS The mean age was 36.4 years, been 68% Caucasian, 29.3% Latin American and 2.7% African race. At the time of diagnosis, 91% of patients had stage-A (median CD4+ T-cell 481cells/μL, IQR, 320-659). 10% had a count below 200 CD4 cells/μL, and 40% had a CD4/CD8 cell-count-ratio below 0.4. Regarding lifestyle and risk factors, 14.1% presented underweight, 36.1% were not engage in any regular exercise, 51.9% were active smokers and 35.3% reported drug use. Low levels of vitamin D were seen in 87.6% of the study participants. Low BMD (Z-score <- 2.0) was found in 22.8% of the patients. It was only observed a significant association of Z-score in lumbar spine (LS) with CD8 and the CD4/CD8 ratio, and with alcohol for femoral neck (FN) measurement. CONCLUSIONS We find prevalence of increased bone involvement among naïve HIV-infected men under 50 years old. Further studies are necessary to evaluate if changes in actual guidelines are needed to assess BMD measurements in HIV-infected adult male patients under 50.
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Affiliation(s)
- Patricia Atencio
- Infectious Diseases Division, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, 28040, Madrid, Spain
| | - Alfonso Cabello
- Infectious Diseases Division, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, 28040, Madrid, Spain.
| | - Francisco M Conesa-Buendía
- Bone and Joint Research Unit, IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, 28040, Madrid, Spain
| | - Ramón Pérez-Tanoira
- Infectious Diseases Division, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, 28040, Madrid, Spain
| | - Laura Prieto-Pérez
- Infectious Diseases Division, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, 28040, Madrid, Spain
| | - Irene Carrillo
- Infectious Diseases Division, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, 28040, Madrid, Spain
| | - Beatriz Álvarez
- Infectious Diseases Division, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, 28040, Madrid, Spain
| | - Rosa Arboiro-Pinel
- Internal Medicine, Metabolic Bone Diseases Unit, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, 28040, Madrid, Spain
| | - Manuel Díaz-Curiel
- Internal Medicine, Metabolic Bone Diseases Unit, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, 28040, Madrid, Spain
| | - Gabriel Herrero-Beaumont
- Bone and Joint Research Unit, IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, 28040, Madrid, Spain
| | - Aránzazu Mediero
- Bone and Joint Research Unit, IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, 28040, Madrid, Spain
| | - Miguel Górgolas
- Infectious Diseases Division, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, 28040, Madrid, Spain
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13
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Chiu ML, Liang WM, Li JP, Cheng CF, Chiou JS, Ho MW, Wu YC, Lin TH, Liao CC, Huang SM, Tsai FJ, Lin YJ. Timing, Dosage, and Adherence of Antiretroviral Therapy and Risk of Osteoporosis in Patients With Human Immunodeficiency Virus Infection in Taiwan: A Nested Case-Control Study. Front Pharmacol 2021; 12:631480. [PMID: 33995032 PMCID: PMC8121495 DOI: 10.3389/fphar.2021.631480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 04/21/2021] [Indexed: 11/27/2022] Open
Abstract
The progression of acquired immunodeficiency syndrome is delayed in patients with human immunodeficiency virus (HIV) infection receiving antiretroviral therapy (ART). However, long-term ART is associated with adverse effects. Osteoporosis is one of the adverse effects and is a multifactorial systemic skeletal disease associated with bone fragility and an increased risk of fracture. We performed a longitudinal, comprehensive, nested case-control study to explore the effect of ART on the risk of osteoporosis in 104 osteoporotic and 416 non-osteoporotic patients with HIV infection at their average age about 29 years old in Taiwan. Patients with history of ART, current exposure to ART, higher cumulative defined daily doses (DDDs), or higher ART adherence were at a higher risk of osteoporosis (p < 0.05). Patients receiving nucleoside/nucleotide reverse transcriptase inhibitor (NRTI)-containing regimen (zidovudine-lamivudine combination, lamivudine-abacavir combination, and abacavir alone) and protease inhibitor (PI)-containing regimen (lopinavir-ritonavir combination, ritonavir, and atazanavir) had a higher risk of osteoporosis (p < 0.05). Especially, patients receiving high doses of the PIs lopinavir-ritonavir combination had an increased risk of osteoporosis (p < 0.05). In conclusion, history of ART, current exposure to ART, higher cumulative DDDs, and higher ART adherence were associated with an increased risk of osteoporosis. Furthermore, NRTI- and PI-containing regimens and high doses of PIs lopinavir-ritonavir combination may be associated with an increased risk of osteoporosis in patients with HIV infection in Taiwan.
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Affiliation(s)
- Mu-Lin Chiu
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.,School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Miin Liang
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Ju-Pi Li
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chi-Fung Cheng
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.,Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Jian-Shiun Chiou
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Mao-Wang Ho
- Section of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yang-Chang Wu
- Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine and Chinese Medicine Research and Development Center, China Medical University and Hospital, Taichung, Taiwan
| | - Ting-Hsu Lin
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chiu-Chu Liao
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Shao-Mei Huang
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Fuu-Jen Tsai
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.,School of Chinese Medicine, China Medical University, Taichung, Taiwan.,Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan
| | - Ying-Ju Lin
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.,School of Chinese Medicine, China Medical University, Taichung, Taiwan
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14
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Ofotokun I, Collins LF, Titanji K, Foster A, Moran CA, Sheth AN, Lahiri CD, Lennox JL, Ward L, Easley KA, Weitzmann MN. Antiretroviral Therapy-Induced Bone Loss Is Durably Suppressed by a Single Dose of Zoledronic Acid in Treatment-Naive Persons with Human Immunodeficiency Virus Infection: A Phase IIB Trial. Clin Infect Dis 2021; 71:1655-1663. [PMID: 31621838 DOI: 10.1093/cid/ciz1027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/14/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) infection and antiretroviral therapy (ART) are associated with bone loss leading to increased fracture rate among persons with HIV (PWH). We previously showed long-acting antiresorptive zoledronic acid (ZOL) prevented ART-induced bone loss through 48 weeks of therapy and here investigate whether protection persisted. METHODS We randomized 63 nonosteoporotic, treatment-naive adult PWH initiating ART to ZOL (5 mg) versus placebo in a double-blinded, placebo-controlled, phase IIb trial. Here we analyzed the long-term outcome data (144 weeks). Plasma bone turnover markers and bone mineral density (BMD) were quantified at weeks 0, 12, 24, 48, 96, and 144. Primary outcome was change in bone resorption marker C-terminal telopeptide of collagen (CTx). Repeated-measures analyses using mixed linear models were used to estimate and compare study endpoints. RESULTS At 96 weeks, mean CTx was 62% lower with ZOL relative to placebo (n = 46; CTx = 0.123 vs 0.324 ng/mL; P < .001); at 144 weeks a 25% difference between arms was not statistically significant. At 48 weeks, lumbar spine BMD with ZOL was 11% higher than placebo (n = 60; P < .001) and remained 9-11% higher at 96 (n = 46) and 144 (n = 41; P < .001) weeks. 144 weeks after ZOL infusion, BMD did not change at the lumbar spine (P = .22) but declined at the hip (P = .04) and femoral neck (P = .02). CONCLUSIONS A single dose of ZOL administered at ART initiation blunts bone resorption and BMD loss at key fracture-prone anatomical sites in treatment-naive PWH for 3 years. A multicenter randomized phase III clinical trial validating these results in a larger population is needed. CLINICAL TRIALS REGISTRATION NCT01228318.
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Affiliation(s)
- Ighovwerha Ofotokun
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Grady Health System, Atlanta, Georgia, USA
| | - Lauren F Collins
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Grady Health System, Atlanta, Georgia, USA
| | - Kehmia Titanji
- Division of Endocrinology and Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Antonina Foster
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Caitlin A Moran
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Grady Health System, Atlanta, Georgia, USA
| | - Anandi N Sheth
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Grady Health System, Atlanta, Georgia, USA
| | - Cecile D Lahiri
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Grady Health System, Atlanta, Georgia, USA
| | - Jeffrey L Lennox
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Grady Health System, Atlanta, Georgia, USA
| | - Laura Ward
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kirk A Easley
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - M Neale Weitzmann
- Division of Endocrinology and Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Atlanta Department of Veterans Affairs Medical Center, Decatur, Georgia, USA
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15
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Yavropoulou MP, Kolynou A, Makras P, Pikilidou M, Nanoudis S, Skoura L, Tsachouridou O, Ntritsos G, Tzallas A, Tsalikakis DG, Tsave O, Metallidis S, Chatzidimitriou D. Circulating microRNAs Related to Bone Metabolism in HIV-Associated Bone Loss. Biomedicines 2021; 9:biomedicines9040443. [PMID: 33924204 PMCID: PMC8074601 DOI: 10.3390/biomedicines9040443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 11/16/2022] Open
Abstract
The pathophysiology of human immunodeficiency virus (HIV)-associated bone loss is complex and to date largely unknown. In this study, we investigated serum expression of microRNAS (miRNAs) linked to bone metabolism in HIV-associated bone loss. This was a case-control study. Thirty male individuals with HIV infection (HIV+) and osteoporosis/osteopenia (HIV+/OP+) (cases) and 30 age-matched male HIV+ individuals with normal bone mass (HIV+/OP-) (controls) were included in the analysis. Thirty male individuals matched for age without HIV infection (HIV-), were also included as second controls. The selected panel of miRNAs was as follows: hsa-miRNA-21-5p; hsa-miRNA-23a-3p; hsa-miRNA-24-2-5p; hsa-miRNA-26a-5p; hsa-miRNA-29a-3p; hsa-miRNA-124-3p; hsa-miRNA-33a-5p; and hsa-miRNA-133a-3p. Within the cohort of HIV+ individuals, relative serum expression of miRNA-21-5p and miRNA-23a-3p was significantly lower (p < 0.001) while the expression of miRNA-24-2-5p was significantly higher (p = 0.030) in HIV+/OP+ compared to HIV+/OP-. Expression of miRNA-21-5p demonstrated a sensitivity of 84.6% and a specificity of 66.7 in distinguishing HIV+/OP+ individuals. Expression of circulating miRNAs related to bone metabolism; miRNA-23a-3p, miRNA-24-2-5p, and miRNA-21-5p is significantly altered in HIV+OP+ individuals, in line with data on other causes of osteoporosis, suggesting a common pattern of circulating miRNAs independent of the underlying cause.
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Affiliation(s)
- Maria P. Yavropoulou
- Endocrinology Unit, The First Department of Propaedeutic and Internal Medicine, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Laboratory of Medical Research, 251 Hellenic Air Force & VA General Hospital, 11525 Athens, Greece; (P.M.); (O.T.)
- Correspondence: (M.P.Y.); (A.K.)
| | - Artemis Kolynou
- Department of Microbiology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
- Correspondence: (M.P.Y.); (A.K.)
| | - Polyzois Makras
- Laboratory of Medical Research, 251 Hellenic Air Force & VA General Hospital, 11525 Athens, Greece; (P.M.); (O.T.)
| | - Maria Pikilidou
- First Department of Internal Medicine, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (M.P.); (S.N.); (O.T.); (S.M.)
| | - Sideris Nanoudis
- First Department of Internal Medicine, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (M.P.); (S.N.); (O.T.); (S.M.)
| | - Lemonia Skoura
- Department of Microbiology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Olga Tsachouridou
- First Department of Internal Medicine, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (M.P.); (S.N.); (O.T.); (S.M.)
| | - Georgios Ntritsos
- Department of Informatics & Telecommunications, School of Informatics & Telecommunications, University of Ioannina, 47100 Arta, Greece; (G.N.); (A.T.)
| | - Alexandros Tzallas
- Department of Informatics & Telecommunications, School of Informatics & Telecommunications, University of Ioannina, 47100 Arta, Greece; (G.N.); (A.T.)
| | - Dimitrios G. Tsalikakis
- Department of Engineering Informatics and Telecommunications, University of Western Macedonia, 50100 Kozani, Greece;
| | - Olga Tsave
- Laboratory of Medical Research, 251 Hellenic Air Force & VA General Hospital, 11525 Athens, Greece; (P.M.); (O.T.)
| | - Simeon Metallidis
- First Department of Internal Medicine, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (M.P.); (S.N.); (O.T.); (S.M.)
| | - Dimitrios Chatzidimitriou
- National AIDS Reference Centre of Northern Greece, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
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16
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Jespersen NA, Axelsen F, Dollerup J, Nørgaard M, Larsen CS. The burden of non-communicable diseases and mortality in people living with HIV (PLHIV) in the pre-, early- and late-HAART era. HIV Med 2021; 22:478-490. [PMID: 33645000 PMCID: PMC8247855 DOI: 10.1111/hiv.13077] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 12/24/2022]
Abstract
Objectives To estimate the burden of non‐communicable diseases (NCDs) and mortality among PLHIV in the pre‐, early‐ and late‐HAART (highly active antiretroviral therapy) era. Methods We conducted a cohort study using population‐based Danish medical registries including all adult HIV‐infected residents of the Central Denmark Region during 1985–2017. For each HIV patient, we selected 10 comparisons from the background population matched by age, sex and municipality of residence. Based on hospital‐related diagnoses we estimated the prevalence and incidence of specific NCD at diagnosis and at 5 and 10 years. Results We identified 1043 PLHIV and 10 430 matched comparisons. PLHIV had lower socioeconomic status and more were born outside western Europe. At HIV diagnosis, 21.9% of PHLIV vs. 18.2% of non‐HIV individuals had at least one NCD, increasing to 42.2% vs. 25.9% after 10 years. PLHIV had higher prevalence and cumulative incidence of alcohol abuse, chronic obstructive pulmonary disease (COPD), ischaemic heart disease, mental disorders, renal and liver disease, but no increased risk of diabetes mellitus. Only PLHIV in the age groups 41–50 and > 51 years had an increased incidence of osteoporosis. From the pre‐ to the late‐HAART era, 10‐year mortality among PLHIV decreased from 45.5% to 9.4% but continued at more than twice that of uninfected comparisons. However, in the late‐HAART era, the mortality of PLHIV who were alive 2 years after HIV diagnosis was approaching that of comparisons. Conclusions Even in the late‐HAART era, PLHIV have an excess mortality, which may be attributable to several NCDs being more prevalent among PLHIV. The prevalence rates of ischaemic heart disease, diabetes, osteoporosis and renal disease tend to increase over calendar time. Therefore, improvement of survival and quality of life of PLHIV neets strategies to reduce the risk of developing NCDs, including avoiding toxic antiretroviral therapy and lifestyle changes.
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Affiliation(s)
- N A Jespersen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark
| | - F Axelsen
- Gilead Sciences Denmark, Copenhagen S, Denmark
| | - J Dollerup
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - M Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - C S Larsen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark
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17
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Chang CJ, Chan YL, Pramukti I, Ko NY, Tai TW. People with HIV infection had lower bone mineral density and increased fracture risk: a meta-analysis. Arch Osteoporos 2021; 16:47. [PMID: 33638754 DOI: 10.1007/s11657-021-00903-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/01/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED A meta-analysis to investigate the difference in fracture risk between individuals with and without HIV infection was performed. People living with HIV had lower bone mineral density (BMD) and greater risks of overall fractures and fragility fractures. Reducing fragility and maintaining skeletal strength for PLWH are urgently needed for this population. PURPOSE The introduction of effective antiretroviral therapy increased the life expectancy of people living with HIV (PLWH). This population now faces problems related to aging such as decreased bone mineral density (BMD) and increased fracture risk. Some antiretroviral therapies may also negatively impact bone health. We performed a meta-analysis to investigate the difference in the fracture risk between individuals with and without HIV infection. METHODS We compared BMD, risk of fragility fracture, and risk of all fracture between the two groups. This study included 35 articles with 106,994 PLWH and 228,794,335 controls. RESULTS PLWH had lower lumbar spine and hip BMD than controls. PLWH had a higher prevalence of all fracture events (4.08% versus 0.44%) and fragility fractures (2.66% versus 2.19%). The relative risks of all and fragility fractures of PLWH were 1.91 (95% confidence interval (CI), 1.46-2.49; p < 0.001) and 1.68 (95% CI: 1.40-2.01; p < 0.001). PLWH also had more vertebral fractures (1.26% versus 0.37%; RR, 1.97; 95% CI: 1.22-3.2; p < 0.05), hip fractures (1.38% versus 0.81%; RR, 1.88; 95% CI: 0.99-3.57; p = 0.05), and wrist fractures (1.38% versus 1.29%; RR, 1.67; 95% CI: 1.13-2.45; p < 0.05) than healthy controls. The pooled incidence of fractures was 1.72 per 100 person-years in PLWH and 1.29 in healthy controls. CONCLUSION PLWH had lower BMD and greater risks of all fractures and fragility fractures. Reducing fragility and maintaining skeletal strength for PLWH are urgently needed for this population.
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Affiliation(s)
- Chao-Jui Chang
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan, 70428, Taiwan
| | - Yi-Lin Chan
- Department of Life Science, Chinese Culture University, Taipei, Taiwan
| | - Iqbal Pramukti
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Faculty of Nursing, Universitas Padjadjaran, , West Java, Bandung, Indonesia
| | - Nai-Ying Ko
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ta-Wei Tai
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan, 70428, Taiwan.
- Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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18
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Guo F, Song X, Li Y, Guan W, Pan W, Yu W, Li T, Hsieh E. Longitudinal change in bone mineral density among Chinese individuals with HIV after initiation of antiretroviral therapy. Osteoporos Int 2021; 32:321-332. [PMID: 32803316 PMCID: PMC9509525 DOI: 10.1007/s00198-020-05584-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 08/03/2020] [Indexed: 01/05/2023]
Abstract
UNLABELLED This is the first study to report changes in BMD and related risk factors among Chinese patients with HIV after initiation of tenofovir disoproxil fumarate (TDF)-containing antiretroviral therapy. Greater bone mineral density (BMD) loss was observed in patients treated with TDF, compared to those on non-TDF-containing regimens. Our findings provide important knowledge regarding the risk factors in the long-term clinical management of patients with HIV in China. INTRODUCTION Persons living with HIV (PLWH) are at increased risk for osteoporosis and fracture. Tenofovir disoproxil fumarate (TDF) has been associated with higher rates of bone mineral density (BMD) loss, osteoporosis, and fracture. Few studies have studied the impact among PLWH in Asia. METHODS We analyzed retrospectively patients from the outpatient HIV clinic of a large tertiary hospital in Beijing, China, from March 2007 to May 2016. Patients who had dual-energy X-ray absorptiometry testing prior to antiretroviral initiation and at 48 and/or 96 weeks after initiation were included in this analysis. RESULTS A total of 136 patients were included (mean age 36.0 ± 10.6 years) and over 90% participants were male and Han Chinese ethnicity. We observed greater declines in BMD at the spine from baseline to week 48 (-2.94% vs. -0.74%) and at the hip from baseline to week 96 (-4.37% vs. -2.34%) in the TDF group compared with the non-TDF group. With regard to HIV-specific parameters, longer duration since HIV diagnosis and undetectable viral load over time were associated with lower BMD at the hip [relative risk (RR) 0.97, 95% confidence index (CI) (0.95, 0.99) per 1 year increase and RR 0.96, 95%CI (0.94, 0.99), respectively] and femoral neck [RR 0.97, 95%CI (0.95, 0.99) per 1 year increase and RR 0.97, 95%CI (0.95, 0.998), respectively] over 96 weeks. CONCLUSIONS This is the first study to report changes in BMD among PLWH after initiation of TDF-based antiretroviral therapy in China. Our findings provide important knowledge for the long-term clinical management of PLWH from this region.
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Affiliation(s)
- F Guo
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - X Song
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Y Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - W Guan
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - W Pan
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - W Yu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - T Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China.
- Center for AIDS Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - E Hsieh
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China.
- Section of Rheumatology, Allergy, and Clinical Immunology, Yale School of Medicine, 300 Cedar Street, TAC S-525, PO Box 208031, New Haven, CT, 06517, USA.
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Kumar RN, Masters MC, Williams J, Morrison LR, Galvin S, Krueger KM. Evaluation of Adherence to Dual-Energy X-Ray Absorptiometry Scan Ordering for Persons Living with HIV at a Tertiary Medical Center. AIDS Patient Care STDS 2021; 35:31-32. [PMID: 33571045 DOI: 10.1089/apc.2020.0250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Rebecca N. Kumar
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mary C. Masters
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Janna Williams
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Infection Prevention, Shirley Ryan Ability Lab, Chicago, Illinois, USA
| | - Lindsay R. Morrison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shannon Galvin
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Karen M. Krueger
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Jacobson DL, Yu W, Hazra R, Brummel S, Geffner ME, Patel K, Borkowsky W, Wang J, Chen JS, Mirza A, DiMeglio LA. Fractures in children and adolescents living with perinatally acquired HIV. Bone 2020; 139:115515. [PMID: 32619695 PMCID: PMC7484335 DOI: 10.1016/j.bone.2020.115515] [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] [Received: 01/01/2020] [Revised: 06/28/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Across numerous settings, bone mineral density for age and sex is lower in children/adolescents living with perinatally-acquired HIV (PHIV) compared to uninfected peers. We assessed incidences of any fracture/any long bone fracture, and osteoporosis prevalence in PHIV and HIV-exposed uninfected (PHEU) participants in the Pediatric HIV/AIDS Cohort Study (PHACS). METHODOLOGY Lifetime history of fracture events from birth up to age 20 years was obtained by chart review and/or interview, including age at fracture, mechanism, and bone(s) fractured. Poisson regression models were fit comparing fracture incidence by HIV status adjusted for age, sex, and race, with effect modification by age (<6, ≥6 yr). RESULTS PHIV (N = 412) were older (median 17.5 vs 16.7 yr) and more frequently reported black race (72% vs 61%) than PHEU children/adolescents (N = 206). 17% of PHIV and 12% of PHEU ever reported a fracture. Among children <6 yr, the adjusted incidence rate ratio of ≥1 fracture was higher (7.23; 95% CI 0.98, 53.51) in PHIV than PHEU, but similar among children/adolescents ≥6 years (1.20; 95% CI: 0.77, 1.87). Results were similar for long bone fracture. The most common fracture mechanisms were falling to the ground from a standing height (23.6% PHIV vs 8.8% PHEU) and sports injuries (21.3% vs 32.4%), and the most commonly fractured sites were the forearm and small bones of the wrist/hands. None of the children had osteoporosis. CONCLUSIONS Among children/adolescents ≥6 yr of age, fractures were similar by perinatal HIV status. Prospective, targeted collection of fracture history will be necessary to determine rates of fracture as PHIV and PHEU age into adulthood. SUMMARY Lifetime fracture history was collected in children/adolescents living with perinatally-acquired HIV (PHIV) and HIV-exposed uninfected (PHEU) children from birth up to age 20 years. Fracture incidence was higher in PHIV compared to PHEU among children <6 years old, but not among older children/adolescents.
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Affiliation(s)
- Denise L Jacobson
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, USA.
| | - Wendy Yu
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Rohan Hazra
- Maternal and Pediatric Infectious Diseases Branch, Division of Extramural Research, Eunice Kennedy Shriver National Institute of Child Health and Development, National Institutes of Health, Department of Health and Human Services, Bethesda, USA
| | - Sean Brummel
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Mitchell E Geffner
- The Saban Research Institute, Children's Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, USA
| | - Kunjal Patel
- Department of Epidemiology and Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, USA
| | | | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Janet S Chen
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, USA
| | - Ayesha Mirza
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, USA
| | - Linda A DiMeglio
- Department of Pediatrics, Division of Pediatric Endocrinology/Diabetology and Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, USA.
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Abstract
PLHIV have an increased risk of osteoporosis and fractures when compared with people of the same age and sex. In this review, we address the epidemiology and the pathophysiology of bone disease and fractures in PLHIV. The assessment of fracture risk and fracture prevention in these subjects is also discussed. The spectrum of HIV-associated disease has changed dramatically since the introduction of potent antiretroviral drugs. Today, the survival of people living with HIV (PLHIV) is close to that of the general population. However, the longer life-span in PLHIV is accompanied by an increased prevalence of chronic diseases. Detrimental effects on bone health are well recognised, with an increased risk of osteoporosis and fractures, including vertebral fractures, compared to the general population. The causes of bone disease in PLHIV are not fully understood, but include HIV-specific risk factors such as use of antiretrovirals and the presence of chronic inflammation, as well as traditional risk factors for fracture. Current guidelines recommend the use of FRAX to assess fracture probability in PLHIV age ≥ 40 years and measurement of bone mineral density in those at increased fracture risk. Vitamin D deficiency, if present, should be treated. Bisphosphonates have been shown to increase bone density in PLHIV although fracture outcomes are not available.
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Affiliation(s)
- M O Premaor
- Department of Clinical Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.
| | - J E Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
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Vizcarra P, Gallego J, Vivancos MJ, Sifuentes WA, Llop M, Casado JL. Evaluation of the fracture risk assessment tool for determining bone disease and the impact of secondary causes of osteoporosis in people living with HIV. HIV Res Clin Pract 2020; 21:63-71. [PMID: 32698706 DOI: 10.1080/25787489.2020.1794438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Among HIV-infected individuals, screening for bone disease is encouraged to assess reversible risk factors and plan therapeutic interventions. OBJECTIVE We assessed the usefulness of Fracture Risk Assessment (FRAX) tool to identify candidates for dual X-ray absorptiometry (DXA) scan, or individuals with bone loss progression. We further explored how secondary causes of osteoporosis are reflected on FRAX. METHODS Longitudinal study of 217 consecutive individuals (mean, 45.8 years, 24% females) included after DXA scan. FRAX was calculated without/with femoral neck bone mineral density (BMD), checking the box of "secondary osteoporosis" for all the individuals. RESULTS Low BMD was observed in 133/217 (61%) individuals, of whom 98.5% had not been selected as candidates for DXA by current FRAX thresholds. Specifically, 23% of individuals aged <50 had low BMD but none was candidate for DXA. Adding BMD data, FRAX results increased by 50-100%, with 2/217 individuals (1%) above the thresholds. Classical and HIV-related secondary causes of osteoporosis (observed in 98% overall) correlated with low BMD, modifying significantly FRAX results (HCV coinfection, +124%; longer time of HIV infection, +93%; longer time on antiretroviral therapy, +147%; tenofovir exposure +36%). Individuals with lower BMD and higher FRAX results at inclusion had less bone decline in a follow-up DXA after a median of 3.5 years. CONCLUSIONS Currently recommended FRAX thresholds are not useful to select candidates for DXA scan, which could delay its performance in a population with a high prevalence of secondary factors for low BMD. Classical and HIV-related factors alter BMD and fracture risk estimation.
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Affiliation(s)
- Pilar Vizcarra
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Juan Gallego
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - María J Vivancos
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Walter A Sifuentes
- Department of Rheumatology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - María Llop
- Department of Rheumatology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - José L Casado
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
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Anthropometric cutoff points to identify lipodystrophy characteristics in people living with HIV/AIDS: an observational study. NUTR HOSP 2020; 36:1315-1323. [PMID: 31657611 DOI: 10.20960/nh.02715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Introduction: currently, there is no consensus regarding accurate and low-cost methods for diagnosing lipodystrophy in people living with HIV/AIDS (PLWHA). The aim of this study was to propose anthropometric cutoff points for the diagnosis of lipodystrophy among PLWHA. Methods: we included 106 PLWHA (men = 65, women = 41) who are under antiretroviral therapy and have been clinically classified into either a "lipodystrophy" or "non-lipodystrophy" group. Anthropometric measurements included 19 regions of body perimeters and 6 skinfold thickness measures. The Youden index was used to establish anthropometric cutoff points for the diagnosis of lipodystrophy, using the mean values of the anthropometric data (referred to as "original") along with the "Z index" (ZI) values, which were adjusted by the "Phantom Strategy." The cutoff points were proposed when "original" anthropometric measurements and ZI values had a statistical significance of p < 0.01 and an area under the curve (AUC) higher than 70%. The size effect was assessed to verify the influence of lipodystrophy on each anthropometric measure. Results: our data analysis proposes sex-specific cutoff points for the diagnosis of lipodystrophy in PLWHA - 17 points using the "original" anthropometric measurements, and 20 using the ZI values (average effect size between 1.0 and 1.1, and AUC = 76.7% and 78%). Conclusions: our study proposes accurate cutoff points for the diagnosis of lipodystrophy using "original" anthropometric measurements and ZI values adjusted by the "Phantom Strategy." Our findings support the use of anthropometric measurements as a simplified method for diagnosing lipodystrophy and monitoring body composition alterations in people living with HIV/AIDS.
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Management of Osteoporosis in Patients Living With HIV-A Systematic Review and Meta-analysis. J Acquir Immune Defic Syndr 2020; 83:1-8. [PMID: 31809356 DOI: 10.1097/qai.0000000000002207] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Osteoporosis is reported as a common comorbidity in patients living with HIV (PLHIV). The aim of this systematic review and meta-analysis is to assess the evidence on fracture risk in PLHIV, bone mineral density (BMD) in PLHIV compared with controls, longitudinal changes in BMD in PLHIV, and effect of antiosteoporosis treatment in PLHIV. METHODS A systematic literature search was conducted using the databases Medline at PubMed and EMBASE using the search terms: "HIV" and "fracture" or "bone turnover," or "bone mineral density." Eligibility criteria followed the aim of the study and include randomized controlled trials and observational studies. Two reviewers extracted the data independently. Meta-analysis was performed using random-effects model assessing fracture risk, BMD compared with controls, and changes in BMD. RESULTS One hundred forty-two of 2397 papers identified were included in the systematic review, and subsequently, 84 were included in the meta-analysis. The risks of a fragility fracture [1.51, 95% confidence interval (CI): 1.41 to 1.63] and hip fracture (4.05, 95% CI: 2.99 to 5.49) were increased. PLHIV have lower BMD at the hip (z-score -0.31, 95% CI: -0.46 to -0.27) and lumbar spine (z-score -0.36, 95% CI: -0.39 to -0.15) compared with controls. The reduced BMD did not fully explain the increased fracture risk in PLHIV. CONCLUSIONS Current management of osteoporosis in PLHIV follows general osteoporosis guidelines; however, the increased fracture risk is not fully explained by lower BMD, and thus, antiosteoporosis intervention may be beneficial at a higher BMD in PLHIV.
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Prevalence of and Risk Factors for Low Bone Mineral Density Assessed by Quantitative Computed Tomography in People Living With HIV and Uninfected Controls. J Acquir Immune Defic Syndr 2020; 83:165-172. [PMID: 31929404 DOI: 10.1097/qai.0000000000002245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Low bone mineral density (BMD) has been described in people living with HIV (PLWH). We examined the prevalence of low BMD measured by quantitative computed tomography (QCT), a method that allows 3-dimensional volumetric density measures at the thoracic spine, in well-treated PLWH and uninfected controls and assessed risk factors for reduced BMD. METHODS Cross-sectional study including 718 PLWH from the Copenhagen Co-Morbidity in HIV infection (COCOMO) study and 718 uninfected controls matched on age and sex from the Copenhagen General Population Study (CGPS). Trabecular BMD was determined by QCT. RESULTS Median BMD was 144.2 mg/cm in PLWH vs. 146.6 mg/cm in controls (P = 0.580). HIV status was not associated with BMD in univariable or multivariable linear analyses. However, a higher prevalence of very low BMD (T-score ≤ -2.5) was found in PLWH (17.2% vs. 11.0% in controls, P = 0.003). In unadjusted analysis, HIV was associated with very low BMD (odds ratio 1.68 [95% confidence interval: 1.24-2.27], P = 0.001), but this association was not significant after adjusting for age, sex, smoking, alcohol, body mass index, physical activity, and ethnicity. Previous AIDS-defining disease was associated with lower BMD, but no other associations with HIV-specific variables were identified. CONCLUSION Using QCT, we found a higher prevalence of very low BMD in PLWH than in controls. However, HIV status was not independently associated with BMD indicating that traditional risk factors contribute to the difference in prevalence of very low BMD. Focus on improvement of lifestyle factors, especially in PLWH with previous AIDS-defining disease, may prevent very low BMD in PLWH.
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Maggiolo F, Rizzardini G, Raffi F, Pulido F, Mateo-Garcia MG, Molina JM, Ong E, Shao Y, Piontkowsky D, Das M, McNicholl I, Haubrich R. Bone mineral density in virologically suppressed people aged 60 years or older with HIV-1 switching from a regimen containing tenofovir disoproxil fumarate to an elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide single-tablet regimen: a multicentre, open-label, phase 3b, randomised trial. Lancet HIV 2020; 6:e655-e666. [PMID: 31578954 DOI: 10.1016/s2352-3018(19)30195-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/29/2019] [Accepted: 06/04/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Tenofovir alafenamide is associated with less renal and bone toxicity than tenofovir disoproxil fumarate and might improve the long-term safety of antiretroviral therapy. We aimed to investigate the effect on bone mineral density of switching from a regimen containing tenofovir disoproxil fumarate to one containing tenofovir alafenamide in participants aged 60 years and older. METHODS We did a prospective, open-label, multicentre, randomised trial in 36 European centres. Participants were virologically suppressed (HIV-1 RNA <50 copies per mL), aged 60 years or older, on a tenofovir disoproxil fumarate-containing regimen and were randomly assigned (2:1) via an interactive web-response system to open-label elvitegravir (150 mg), cobicistat (150 mg), emtricitabine (200 mg), and tenofovir alafenamide (10 mg) daily or continued therapy containing tenofovir disoproxil fumarate (300 mg). Participants were stratified by spine and hip bone mineral density categories. Primary endpoints were change from baseline to week 48 in spine and hip bone mineral density with a null hypothesis of zero between-group difference tested at a significance level of 0·05. This study was registered with ClinicalTrials.gov, NCT02616783. FINDINGS Between Dec 22, 2015, and March 21, 2018, 167 participants were randomly assigned to elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide (n=111 [66%]) or tenofovir disoproxil fumarate (n=56 [34%]). One participant in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group did not receive treatment and was excluded from all analyses. At week 48, the mean percentage change in spine bone mineral density was 2·24% (SD 3·27) in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group and -0·10% (3·39) in the tenofovir disoproxil fumarate group (between-group difference 2·43% [95% CI 1·34-3·52]; p<0·0001), and mean percentage change in hip bone mineral density was 1·33% (2·20) in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group and -0·73% (3·21) in the tenofovir disoproxil fumarate group (difference 2·04% [1·17-2·90]; p<0·0001). The most common adverse events were nasopharyngitis (12 [11%]), back pain (nine [8%]), and diarrhoea (eight [7%]) in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group; and bronchitis (six [11%]), vitamin D deficiency (four [7%]), and arthralgia (four [7%]) in the tenofovir disoproxil fumarate group. 22 (20%) participants in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group and one (2%) participant in the tenofovir disoproxil fumarate group had an adverse event that was considered to be related to treatment. No treatment-related serious adverse events were observed. The proportions of adverse events leading to premature treatment discontinuation were similar between groups (four [4%] in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group; and one (2%) in the tenofovir disoproxil fumarate group). INTERPRETATION The significantly improved bone mineral density, overall safety, and efficacy data show the feasibility of switching from a regimen containing tenofovir disoproxil fumarate to elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in virologically suppressed people living with HIV aged 60 years or older. FUNDING Gilead Sciences.
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Affiliation(s)
- Franco Maggiolo
- Division of Infectious Diseases, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giuliano Rizzardini
- Division of Infectious Diseases, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; School of Clinical Medicine, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - François Raffi
- Department of Infectious and Tropical Diseases and CIC 1413, INSERM, University Hospital, Nantes, France
| | - Federico Pulido
- HIV Unit, University Hospital 12 de Octubre, Imas12, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Jean-Michel Molina
- Department of Infectious Diseases, Saint Louis Hospital, University Paris Diderot, Paris, France
| | - Edmund Ong
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle, UK
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Masters MC, Krueger KM, Williams JL, Morrison L, Cohn SE. Beyond one pill, once daily: current challenges of antiretroviral therapy management in the United States. Expert Rev Clin Pharmacol 2019; 12:1129-1143. [PMID: 31774001 DOI: 10.1080/17512433.2019.1698946] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Modern antiretroviral therapy (ART) has revolutionized HIV treatment. ART regimens are now highly efficacious, well-tolerated, safe, often with one multi-drug pill, once-daily regimens available. However, clinical challenges persist in managing ART in persons with HIV (PWH), such as drug-drug interactions, side effects, pregnancy, co-morbidities, and adherence.Areas Covered: In this review, we discuss the ongoing challenges of ART for adults in the United States. We review the difficulties of initiating ART and maintaining therapy throughout adulthood and discuss new agents and strategies under investigation to address these issues. A PubMed search was utilized to identify relevant publications and guidelines through July 2019.Expert Opinion: Challenges persist in initiation and maintenance of ART. An individual's coexisting medical, social and personal factors must be considered in selecting and continuing ART to ensure safety, tolerability, and efficacy throughout adulthood. Continued development of new therapeutics and novel approaches to ART, such as long acting drugs or dual therapy, are needed to respond to many of these challenges. In addition, future research must address therapeutic disparities for populations historically underrepresented in clinical trials, including women, people aging with HIV, and those with complex comorbidities.
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Affiliation(s)
- Mary Clare Masters
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen M Krueger
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Janna L Williams
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lindsay Morrison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susan E Cohn
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Impact of Antiretroviral Drugs on Fracture Risk in HIV-Infected Individuals: A Case-Control Study Nested Within the French Hospital Database on HIV (FHDH-ANRS CO4). J Acquir Immune Defic Syndr 2019; 80:214-223. [PMID: 30422911 DOI: 10.1097/qai.0000000000001903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND HIV-infected patients have lower bone mineral density and a higher incidence of fractures than the general population of the same age and sex. To assess the impact of antiretroviral (ARV) drugs exposure on the risk of osteoporotic fractures, we conducted a nested case-control study. METHODS Cases were individuals enrolled while ARV-naive, with a first prospectively recorded fracture between 2000 and 2010. Controls were randomly selected after matching for sex, age (±3 years), period of HIV diagnosis (<1997/≥1997), and clinical center. The risk of fracture was analyzed with conditional logistic regression models, using different ways to model ARV exposure. All exposure variables and potential confounders were included in multivariable models. RESULTS Among 861 reviewed cases, 261 fractures were osteoporotic and 254 of cases were matched to at least one control (376 controls). The median year of fracture diagnosis was 2007 (interquartile range 2004-2009): 49% of patients had been exposed to tenofovir disoproxil fumarate (TDF) and 82% to protease inhibitors (PIs). After taking into account the transmission group, AIDS status, geographic origin, body mass index, current smoking status, alcohol consumption, exposure to systemic glucocorticoids, and the period of enrollment, there was no association between the risk of fracture and exposure to TDF [odds ratio for cumulative exposure: 1.04 (0.86-1.27), similar results for ever-exposed subjects], to nucleoside reverse transcriptase inhibitors, or to PIs [odds ratio for cumulative PI exposure: 1.02 (0.92-1.12)]. CONCLUSIONS We found no evidence of an excess risk of fracture after exposure to TDF or PIs. This has important implications for the debate concerning tenofovir alafenamide versus generic TDF.
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McMillan JM, Krentz H, Gill MJ, Hogan DB. Managing HIV infection in patients older than 50 years. CMAJ 2019; 190:E1253-E1258. [PMID: 30348740 DOI: 10.1503/cmaj.171409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jacqueline M McMillan
- Department of Medicine (McMillan, Krentz, Gill, Hogan), University of Calgary; Southern Alberta Clinic (Krentz, Gill), Calgary, Alta.
| | - Hartmut Krentz
- Department of Medicine (McMillan, Krentz, Gill, Hogan), University of Calgary; Southern Alberta Clinic (Krentz, Gill), Calgary, Alta
| | - M John Gill
- Department of Medicine (McMillan, Krentz, Gill, Hogan), University of Calgary; Southern Alberta Clinic (Krentz, Gill), Calgary, Alta
| | - David B Hogan
- Department of Medicine (McMillan, Krentz, Gill, Hogan), University of Calgary; Southern Alberta Clinic (Krentz, Gill), Calgary, Alta
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Negredo E, Langohr K, Bonjoch A, Pérez-Alvárez N, Estany C, Puig J, Rosales J, Echeverría P, Clotet B, Gómez G. High risk and probability of progression to osteoporosis at 10 years in HIV-infected individuals: the role of PIs. J Antimicrob Chemother 2019; 73:2452-2459. [PMID: 29860519 DOI: 10.1093/jac/dky201] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/01/2018] [Indexed: 12/13/2022] Open
Abstract
Background Osteoporotic fractures still remain very infrequent and physicians rarely evaluate bone health. We wanted to assess the magnitude of this problem in the near future by determining the risk and likelihood of progression to osteoporosis. Methods We estimated the risk of progression to osteopenia/osteoporosis among HIV-infected patients with at least 2 DXA scans (3726 scans from 875 patients). Time-non-homogeneous bidirectional multistate models based on three states (normal bone mineral density, osteopenia and osteoporosis) were used to model the progression of bone mineral density as a function of age and to study the association between the risk of bone loss and antiretroviral use. Results The HRs associated with age (>45 versus ≤45 years) were: (i) from normal bone mineral density to osteopenia, 0.71 (95% CI 0.45-1.11) for men and 1.06 (95% CI 0.55-2.05) for women; and (ii) from osteopenia to osteoporosis, 0.83 (95% CI 0.51-1.35) for men and 0.99 (95% CI 0.38-2.56) for women. The transition probabilities from osteopenia to osteoporosis over 10 years among men aged 30 and 50 years were 14.9% (95% CI 10.5%-20.4%) and 19% (95% CI 14.3%-24.3%), respectively; and for women, 6.9% (95% CI 3.1%-14.4%) and 30.1% (95% CI 19.8%-41.8%), respectively. An increased osteoporosis risk was observed for PIs and PIs + tenofovir disoproxil fumarate; darunavir was associated with a higher risk of osteoporosis among men (HR 3.9; 95% CI 2-7.5) and women (HR 4.5; 95% CI 1.4-14.7); and atazanavir was associated with a higher risk of osteoporosis among women (HR 4.2; 95% CI 1.3-14). Conclusions Our results highlight the importance of monitoring bone mineral density given the high probability of progression to osteopenia/osteoporosis, especially in women. In the future, changes in antiretrovirals other than tenofovir, such as PIs, should be recommended to reduce the risk of fracture.
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Affiliation(s)
- Eugènia Negredo
- Lluita contra la SIDA Foundation, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain.,Universitat de Vic - Universitat Central de Catalunya, Vic Barcelona, Spain
| | - Klaus Langohr
- Statistics and Operations Research Department, Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Anna Bonjoch
- Lluita contra la SIDA Foundation, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Núria Pérez-Alvárez
- Lluita contra la SIDA Foundation, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain.,Statistics and Operations Research Department, Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Carla Estany
- Lluita contra la SIDA Foundation, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Jordi Puig
- Lluita contra la SIDA Foundation, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | | | - Patricia Echeverría
- Lluita contra la SIDA Foundation, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Bonaventura Clotet
- Lluita contra la SIDA Foundation, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain.,Irsicaixa Foundation, Barcelona, Catalonia, Spain
| | - Guadalupe Gómez
- Statistics and Operations Research Department, Universitat Politècnica de Catalunya, Barcelona, Spain
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Gonciulea A, Wang R, Althoff KN, Estrella MM, Sellmeyer DE, Palella FJ, Lake JE, Kingsley LA, Brown TT. Proteinuria Is Associated With Increased Risk of Fragility Fracture in Men With or at Risk of HIV Infection. J Acquir Immune Defic Syndr 2019; 81:e85-e91. [PMID: 30939529 PMCID: PMC6565496 DOI: 10.1097/qai.0000000000002039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Proteinuria has been associated with bone loss and fractures in general population, but data in HIV-infected population are lacking. SETTING Prospective, multicenter cohort study of men with or at risk of HIV infection. METHODS Between 2006 and 2015, urine protein measurements and bone fracture histories were ascertained semiannually in 947 HIV-infected (HIV+) and 969 HIV-uninfected (HIV-) men aged 40 years or older. Proteinuria was defined as protein-to-creatinine ratio ≥200 mg/g at ≥2 consecutive visits. Outcome measures (1) all fractures (excluding fractures of skull, face, and digits) and (2) fragility fractures (fractures of vertebral column, femur, wrist, and humerus). Multivariable Cox proportional hazards models assessed the association between proteinuria and fracture after adjusting for additional risk factors. RESULTS The overall period prevalence of proteinuria was higher among HIV+ than HIV- (29% vs 6%, P < 0.001). Men with proteinuria had a significantly higher risk of fragility fracture compared with men without proteinuria [adjusted hazard ratio (aHR) = 2.29 (1.12-4.66)] and did not differ by HIV serostatus (p-interaction = 0.83). The risk of all fractures was not statistically different between men with or without proteinuria [aHR = 1.31 (0.84-2.05)]. Among HIV+ men, the association between confirmed proteinuria and fragility fracture was attenuated [aHR = 2.12 (0.95-4.73)] after additional adjustment for CD4 T-cell count/mm, history of AIDS, the presence of detectable plasma HIV-1 RNA, and cumulative exposure to tenofovir disoproxil fumarate. CONCLUSIONS Proteinuria was more common in HIV+ than in HIV- men and was a strong independent risk factor for fragility fracture regardless of HIV serostatus. Proteinuria should prompt consideration of a thorough evaluation for bone disease among HIV+ persons.
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Affiliation(s)
- Anda Gonciulea
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins, University, Baltimore, MD
| | - Ruibin Wang
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD
| | - Michelle M Estrella
- Kidney Health Research Collaborative, San Francisco VA Health Science Center, University of California, San Francisco, San Francisco, CA
| | - Deborah E Sellmeyer
- Division of Endocrinology, Gerontology, and Metabolism, Stanford University, Palo Alto, CA
| | - Frank J Palella
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jordan E Lake
- Division of Infectious Diseases, McGovern Medical School, University of Texas Health Science Center, Houston, TX
| | - Lawrence A Kingsley
- Department of Infectious Diseases and Microbiology, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Todd T Brown
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins, University, Baltimore, MD
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Solimeo SL, McCoy K, Reisinger HS, Adler RA, Vaughan Sarrazin M. Factors Associated With Osteoporosis Care of Men Hospitalized for Hip Fracture: A Retrospective Cohort Study. JBMR Plus 2019; 3:e10198. [PMID: 31667454 PMCID: PMC6808329 DOI: 10.1002/jbm4.10198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/02/2019] [Accepted: 04/14/2019] [Indexed: 01/04/2023] Open
Abstract
Rates of postfracture DXA and pharmacotherapy appear to be declining despite their known benefits in fracture reduction. We sought to identify factors associated with osteoporosis care among male veterans aged 50 years and older after hip fracture and to evaluate trends in rates of care with an observational cohort design using US Department of Veterans Affairs’ (VA) inpatient, pharmacy, and outpatient encounters and Centers for Medicare and Medicaid Services outpatient pharmacy claims (2007 to 2014) from men aged 50 years and older treated for hip fracture (N = 7317). We used the Cox proportional hazards model with random effects for the admitting facility. A sensitivity analysis was performed for a subset of patients aged 65 to 99 dually enrolled in Medicare (
N = 5821). Overall, approximately 13% of patients had evidence of osteoporosis care within one year of fracture. In the adjusted model, rural residence was associated with lower likelihood of care, and several comorbidities were associated with higher likelihood of receiving care. In sensitivity analyses of patients dually enrolled in Medicare, rural residence remained associated with lower likelihood of osteoporosis care. Overall rates of care decreased over time, but rates of DXA in the VA remained stable. These findings highlight the ongoing problem of low rates of postfracture care among a population with the highest risk of future fracture and its associated morbidity and mortality. The rural disparity in care and differences in rates of care across healthcare delivery systems illustrates the importance of healthcare delivery systems in promoting pharmacotherapy and DXA after sentinel events. Because the VA removes a majority of cost barriers to care, this integrated healthcare system may outperform the private sector in access to care. However, declining rates of pharmacotherapy imply knowledge gaps that undermine quality care. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Samantha L Solimeo
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System Iowa City IA USA.,Primary Care Data Analytics Team-Iowa City, Iowa City VA Health Care System Iowa City IA USA.,Department of Internal Medicine Carver College of Medicine, University of Iowa Iowa City IA USA
| | - Kimberly McCoy
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System Iowa City IA USA.,Primary Care Data Analytics Team-Iowa City, Iowa City VA Health Care System Iowa City IA USA
| | - Heather Schacht Reisinger
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System Iowa City IA USA.,Department of Internal Medicine Carver College of Medicine, University of Iowa Iowa City IA USA
| | - Robert A Adler
- Hunter Holmes McGuire VA Medical Center Richmond VA USA.,Department of Internal Medicine Division of Endocrinology, Diabetes & Metabolism, Virginia Commonwealth University Richmond VA USA
| | - Mary Vaughan Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System Iowa City IA USA.,Primary Care Data Analytics Team-Iowa City, Iowa City VA Health Care System Iowa City IA USA.,Department of Internal Medicine Carver College of Medicine, University of Iowa Iowa City IA USA
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Abstract
PURPOSE OF REVIEW Vitamin D (VitD) deficiency is highly prevalent among HIV-infected individuals. Given the overlapping risk for several chronic disease and immunomodulatory outcomes from both long-standing HIV and VitD deficiency, there is great interest in clarifying the clinical role of VitD for this population. RECENT FINDINGS Recent studies have expanded our knowledge regarding the epidemiology and mechanisms of VitD deficiency-associated outcomes in the setting of HIV. Clinical trials focusing on VitD supplementation have demonstrated a positive impact on bone mineral density in subgroups of HIV-infected individuals initiating ART or on suppressive ART regimens; however, significant heterogeneity exists between studies and data are less consistent with other clinical outcomes. Further research is needed to clarify uncertainly in several domains, including identifying patients at greatest risk for poor outcomes from VitD deficiency, standardizing definitions and measurement techniques, and better quantifying the benefits and risks of VitD supplementation across different demographic strata for skeletal and extra-skeletal outcomes.
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Affiliation(s)
- Evelyn Hsieh
- Section of Rheumatology, Yale School of Medicine, 300 Cedar Street, TAC S-525, PO Box 208031, New Haven, CT, 06517, USA.
| | - Michael T Yin
- Division of Infectious Diseases, Columbia University Medical Center, New York, NY, USA
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Navarro-Alcaraz A, Tiraboschi J, Gómez C, Candas-Estébanez B, Saumoy M, Imaz A, Podzamczer D. Lack of benefit with omega-3 fatty acid supplementation in HIV patients: A randomized pilot study. HIV Res Clin Pract 2019; 20:99-105. [DOI: 10.1080/25787489.2019.1656426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Antonio Navarro-Alcaraz
- HIV and STD Unit, Infectious Disease Service, Bellvitge University Hospital, L’Hospitalet del Llobregat, Barcelona, Spain
| | - Juan Tiraboschi
- HIV and STD Unit, Infectious Disease Service, Bellvitge University Hospital, L’Hospitalet del Llobregat, Barcelona, Spain
| | - Carmen Gómez
- Rheumatology Service, Bellvitge University Hospital, L’Hospitalet del Llobregat, Barcelona, Spain
| | - Beatriz Candas-Estébanez
- Clinical Laboratory, Bellvitge University Hospital, L’Hospitalet del Llobregat, Barcelona, Spain
| | - María Saumoy
- HIV and STD Unit, Infectious Disease Service, Bellvitge University Hospital, L’Hospitalet del Llobregat, Barcelona, Spain
| | - Arkaitz Imaz
- HIV and STD Unit, Infectious Disease Service, Bellvitge University Hospital, L’Hospitalet del Llobregat, Barcelona, Spain
| | - Daniel Podzamczer
- HIV and STD Unit, Infectious Disease Service, Bellvitge University Hospital, L’Hospitalet del Llobregat, Barcelona, Spain
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Biver E, Calmy A, Aubry-Rozier B, Birkhäuser M, Bischoff-Ferrari HA, Ferrari S, Frey D, Kressig RW, Lamy O, Lippuner K, Suhm N, Meier C. Diagnosis, prevention, and treatment of bone fragility in people living with HIV: a position statement from the Swiss Association against Osteoporosis. Osteoporos Int 2019; 30:1125-1135. [PMID: 30603840 DOI: 10.1007/s00198-018-4794-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/29/2018] [Indexed: 12/20/2022]
Abstract
Life expectancy of people living with HIV (PLWH) is reaching similar length as in the general population. Accordingly, age-related comorbidities, including osteoporosis, are increasing. Fracture risk is higher and increases approximately 10 years earlier in PLWH. Classical risk factors of bone fragility are highly prevalent in PLWH but factors specific for HIV infection itself and the type of antiretroviral therapy (ART) (triple combination antiretroviral therapy) regimen (especially tenofovir and protease inhibitors) also contribute to bone loss. The majority of bone loss occurs during virus activity and at initiation of ART (immune reconstitution) and is associated with an increase of bone resorption (upregulation RANKL). Recent data indicate that calcium and vitamin D supplements as ART initiation lower BMD loss. The reduction of tenofovir plasma concentrations with tenofovir alafenamide attenuates BMD loss but it remains unknown whether it will contribute to reduce fracture risk. Hence, special considerations for the management of bone fragility in PLWH are warranted. Based on the current state of epidemiology and pathophysiology of osteoporosis in PLWH, we provide the consensus of the Swiss Association against Osteoporosis on best practice for diagnosis, prevention, and management of osteoporosis in this population. Periodic assessment of fracture risk is indicated in all HIV patients and general preventive measures should be implemented. All postmenopausal women, men above 50 years of age, and patients with other clinical risk for fragility fractures qualify for BMD measurement. An algorithm clarifies when treatment with bisphosphonates and review of ART regimen in favour of more bone-friendly options are indicated.
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Affiliation(s)
- E Biver
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - A Calmy
- HIV/Aids Unit, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - B Aubry-Rozier
- Center of Bone Diseases, Lausanne University Hospital, Lausanne, Switzerland
| | - M Birkhäuser
- Gynecological Endocrinology and Reproductive Medicine, University of Berne, Basel, Switzerland
| | - H A Bischoff-Ferrari
- Department of Geriatrics and Aging Research, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - S Ferrari
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - D Frey
- Division of Rheumatology, University Hospital Zürich, Zürich, Switzerland
| | - R W Kressig
- University Center for Medicine of Aging, Basel Mobility Center, University of Basel, Basel, Switzerland
| | - O Lamy
- Center of Bone Diseases, Lausanne University Hospital, Lausanne, Switzerland
| | - K Lippuner
- Department of Osteoporosis, University Hospital, University of Berne, Berne, Switzerland
| | - N Suhm
- Department of Orthopedics and Traumatology, Geriatric Fracture Center, University Hospital Basel, Basel, Switzerland
| | - C Meier
- Division of Endocrinology, Diabetology & Metabolism, University Hospital and University of Basel, Missionsstrasse 24, CH-4055, Basel, Switzerland.
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36
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Milic J, Russwurm M, Cerezales Calvino A, Brañas F, Sánchez-Conde M, Guaraldi G. European cohorts of older HIV adults: POPPY, AGEhIV, GEPPO, COBRA and FUNCFRAIL. Eur Geriatr Med 2019; 10:247-257. [DOI: 10.1007/s41999-019-00170-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 01/24/2019] [Indexed: 12/13/2022]
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Ceballos ME, Carvajal C, Jaramillo J, Dominguez A, González G. Vitamin D and Bone Mineral Density in HIV Newly Diagnosed Therapy-Naive Patients Without Any Secondary Causes of Osteoporosis. Calcif Tissue Int 2019; 104:42-49. [PMID: 30209528 DOI: 10.1007/s00223-018-0474-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/04/2018] [Indexed: 01/08/2023]
Abstract
Bone loss and vitamin D deficiency are common in HIV patients. However, bone health status in newly diagnosed HIV patients has not been thoroughly described. Our aim was to assess the bone mineral density (BMD), bone resorption and vitamin D status in newly diagnosed HIV patients. A prospective observational study in HIV newly diagnosed therapy-naive persons. Patients with secondary causes of osteoporosis were excluded. Bone densitometry (DXA), a bone resorption marker (CTx), 25-hydroxyvitamin D (25OHD), CD4 count and HIV viral load (VL) were done in 70 patients. Vitamin D results were compared with a group of healthy volunteers. All patients were men, mean age 31 years (19-50). Low BMD (Z score ≤ 2.0) was found in 13%, all of them in lumbar spine, and in only one patient also in femoral neck. Bone resorption was high in 16%. One out of four participants had low BMD or high bone resorption. Vitamin D deficiency (25OHD < 20 ng/mL) was found in 66%. Mean 25OHD in patients was significantly lower than in healthy volunteers (p = 0.04). No associations were found between BMD, CTx, 25OHD and VL or CD4 count. We hypothesize that HIV infection negatively affects bone health based on the results we found among newly diagnosed, therapy-naive, HIV-infected patients, without any known secondary causes of osteoporosis. Low BMD or high bone resorption, are significantly prevalent in these patients. HIV-infected patients had a higher prevalence of vitamin D deficiency than controls, which was not correlated with CD4 count or VL.
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Affiliation(s)
- María Elena Ceballos
- Department of Infectious Diseases, Faculty of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Camila Carvajal
- Department of Infectious Diseases, Faculty of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Javier Jaramillo
- Department of Endocrinology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Angelica Dominguez
- Department of Public Health, Faculty of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Gilberto González
- Department of Endocrinology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile.
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38
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Viremia copy-years and mortality among combination antiretroviral therapy-initiating HIV-positive individuals: how much viral load history is enough? AIDS 2018; 32:2547-2556. [PMID: 30379686 PMCID: PMC6535334 DOI: 10.1097/qad.0000000000001986] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Ongoing HIV replication while receiving combination antiretroviral therapy (cART) may reduce survival. Viremia copy-years (VCY) has shown improved mortality risk prediction over single time-point viral load measures. However, the timing of a patient's viral load history most associated with later mortality has not been studied. Here we determined the optimal duration and temporality of viral load history for predicting mortality. DESIGN Survival analysis among HIV-positive men who initiated cART in the Multicenter AIDS Cohort Study (1995-2015). METHODS VCY measures were derived from area-under-the-viral load-curve. The overall VCY based upon the complete post-cART viral load history was compared with 20 VCYs derived from viral loads assessed during different shorter time periods (the most recent 1-10 years and initial 1-10 years following cART initiation) for associations with mortality. RESULTS Each 10-fold increase in VCYs based on the most recent 3-8 years was significantly associated with 23-26% decrease in survival times, a magnitude of effect greater than that of the most recent viral load (16%). These associations were independent of CD4 cell count and single time-point viral loads. In addition, the degree of pre-cART immunodeficiency did not affect the mortality prognostic value of VCY based on viral loads in the most recent 3 years. Conversely, the overall VCY and VCYs based on viral loads immediately following cART initiation were not independent predictors of mortality. CONCLUSION Among cART-treated men, VCY based upon viral loads in the recent 3 years (six viral loads) has a mortality prognostic value greater than that of the overall VCY and single time-point viral loads, making the former a more feasible measure for use.
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40
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Komatsu A, Ikeda A, Kikuchi A, Minami C, Tan M, Matsushita S. Osteoporosis-Related Fractures in HIV-Infected Patients Receiving Long-Term Tenofovir Disoproxil Fumarate: An Observational Cohort Study. Drug Saf 2018; 41:843-848. [PMID: 29623648 PMCID: PMC6061259 DOI: 10.1007/s40264-018-0665-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Introduction Patients with HIV infection may have a higher prevalence of osteoporosis and osteopenia, as well as an increased risk of bone fracture compared with non-HIV-infected individuals. Antiretroviral therapy is thought to be one of factors associated to osteoporosis-related bone fractures. Objective The aim of this study was to assess the effects of long-term exposure to tenofovir disoproxil fumarate (TDF) on the cumulative risk of osteoporosis-related bone fractures in Japanese patients with HIV infection. Design This observational cohort study comprised a joint HIV-related drug survey of patients treated with TDF between April 2004 and March 2013. Methods Thirty-five healthcare facilities in Japan participated in the survey. The incidence of osteoporosis-related fractures was extracted from all adverse events (AEs) using standardized Medical Dictionary for Regulatory Activities queries, and used to calculate the fracture rate per 10,000 patient-years (PY). Kaplan–Meier analysis was used to estimate the cumulative probability of fracture during the study period. Results A total of 3251 patients who received TDF or TDF/emtricitabine between April 2004 and March 2013 were analyzed in this study; 93.5% of patients were male. The fracture rate was 13.5 per 10,000 PY in males and 42.2 per 10,000 PY in females. The mean age for male patients with osteoporosis-related fracture was 43.2 years, whereas it was 65.7 years in female patients. The cumulative probability of osteoporosis-related fracture increased after ≥ 5 years of TDF exposure. The rate of hip fracture (95% confidence interval) was 7.2 (3.1–14.2) per 10,000 PY. Conclusions Among HIV-infected patients in Japan, treatment with TDF for ≥ 5 years increases the risk of bone fractures in younger men, in addition to that seen in older post-menopausal women.
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Affiliation(s)
- Ayami Komatsu
- Pharmaceutical Division, Drug Safety and Risk Management Department, Japan Tobacco Inc., Tokyo, Japan.
| | - Atsushi Ikeda
- Pharmaceutical Division, Drug Safety and Risk Management Department, Japan Tobacco Inc., Tokyo, Japan
| | - Akio Kikuchi
- Pharmaceutical Division, Drug Safety and Risk Management Department, Japan Tobacco Inc., Tokyo, Japan
| | - Chiaki Minami
- Pharmaceutical Division, Drug Safety and Risk Management Department, Japan Tobacco Inc., Tokyo, Japan
| | - Motomu Tan
- Pharmaceutical Division, Drug Safety and Risk Management Department, Japan Tobacco Inc., Tokyo, Japan
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41
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Dos Santos AP, Navarro AM, Schwingel A, Alves TC, Abdalla PP, Venturini ACR, de Santana RC, Machado DRL. Lipodystrophy diagnosis in people living with HIV/AIDS: prediction and validation of sex-specific anthropometric models. BMC Public Health 2018; 18:806. [PMID: 29945584 PMCID: PMC6020387 DOI: 10.1186/s12889-018-5707-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/13/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Body composition alterations, or lipodystrophy, can lead to serious health problems in people living with HIV/AIDS (PLWHA). The objectives of this study are to predict and validate sex-specific anthropometric predictive models for the diagnosis of lipodystrophy in PLWHA. METHODS A cross-sectional design was employed to recruit 106 PLWHA (men = 65 and women = 41) in Brazil during 2013-2014. They were evaluated using dual-energy X-ray absorptiometry, and 19 regions of body perimeters and 6 skinfold thicknesses were taken. Sex-specific predictive models for lipodystrophy diagnosis were developed through stepwise linear regression analysis. Cross-validations using predicted residual error sum of squares was performed to validate each predictive model. RESULTS Results support the use of anthropometry for the diagnosis of lipodystrophy in men and women living with HIV/AIDS. A high power of determination with a small degree of error was observed for lipodystrophy diagnosis for men in model six (r2 = 0.77, SEE = 0.14, r2PRESS = 0.73, SEE PRESS = 0.15), that included ratio of skinfold thickness of subscapular to medial calf, skinfold thickness of thigh, body circumference of waist, formal education years, time of diagnosis to HIV months, and type of combined antiretroviral therapy (cART) (with protease inhibitor "WI/PI = 1" or without protease inhibitor "WO/PI = 0"); and model five for women (r2 = 0.78, SEE = 0.11, r2PRESS = 0.71, SEE PRESS = 0.12), that included skinfold thickness of thigh, skinfold thickness of subscapular, time of exposure to cART months, body circumference of chest, and race (Asian) ("Yes" for Asian race = 1; "No" = 0). CONCLUSIONS The proposed anthropometric models advance the field of public health by facilitating early diagnosis and better management of lipodystrophy, a serious adverse health effect experienced by PLWHA.
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Affiliation(s)
- André P Dos Santos
- Interunit Nursing Doctoral Program, College of Nursing of the University of Sao Paulo, Avenida dos Bandeirantes, Campus Universitario, 3900, Ribeirao Preto, SP, 14040-902, Brazil. .,Kinesiology and Community Health, University of Illinois, Urbana-Champaign, IL, USA.
| | - Anderson M Navarro
- Department of Clinical Medicine, Faculty of Medicine at the University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Andiara Schwingel
- Kinesiology and Community Health, University of Illinois, Urbana-Champaign, IL, USA
| | - Thiago C Alves
- Interunit Nursing Doctoral Program, College of Nursing of the University of Sao Paulo, Avenida dos Bandeirantes, Campus Universitario, 3900, Ribeirao Preto, SP, 14040-902, Brazil
| | - Pedro P Abdalla
- School of Physical Education and Sport of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Ana Claudia R Venturini
- School of Physical Education and Sport of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Rodrigo C de Santana
- Department of Clinical Medicine, Faculty of Medicine at the University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Dalmo R L Machado
- Interunit Nursing Doctoral Program, College of Nursing of the University of Sao Paulo, Avenida dos Bandeirantes, Campus Universitario, 3900, Ribeirao Preto, SP, 14040-902, Brazil.,School of Physical Education and Sport of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
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