Reduced bone mineral density in human immunodeficiency virus-infected patients and its association with increased central adiposity and postload hyperglycemia

Alcohol and falls among people with HIV infection: A view from Russia and the United States

BACKGROUND

Both human immunodeficiency virus (HIV) infection and alcohol use predispose to autonomic/sensory neuropathy, imbalance symptoms, and cognitive impairment-conditions associated with a greater risk of falls-yet it is unclear how to identify people with HIV (PWH) whose drinking is associated with falls. Research on alcohol and falls using the same instruments in different countries could help to specify the level of alcohol use associated with fall risk. We examined whether a consumption-based measure (the Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]) and/or a symptom-based measure (DSM-5 criteria for alcohol use disorder [AUD]) are associated with sustaining a fall among PWH in St Petersburg, Russia and Boston, Massachusetts in the United States.

METHODS

Separate multivariate logistic regressions were used for each cohort to examine cross-sectional associations for each alcohol measure predicting fall. Potential confounders included physical functioning, depressive symptoms, and other substance use (measured with the Addiction Severity Index).

RESULTS

A fall was reported by 35% (87/251) of the sample in Boston and 12% (46/400) in St Petersburg. Each additional AUD criterion-but not higher AUDIT-C score-was significantly associated with a fall in both Boston (odds ratio [OR] = 1.10; 95% confidence interval [CI] 1.02, 1.18) and St Petersburg (adjusted OR AOR = 1.10; 95% CI 1.02, 1.18). Heavy alcohol use (>6 drinks/occasion, any vs. none) was associated with more than twice the odds of a fall (AOR = 2.24; 95% CI 1.21, 4.13) in Boston.

CONCLUSIONS

These findings suggest that while fall risk may vary by setting and population, heavy alcohol use and AUD symptom severity are potential targets for interventions to prevent falls. Studies in diverse global settings advance our understanding of the relationship between alcohol and falls in PWH.

The combined effects of age and HIV on the anatomic distribution of cortical and cancellous bone in the femoral neck among men and women

OBJECTIVE

To investigate HIV-related and age-related differences in hip bone structure in men and women.

DESIGN

Cross sectional study of bone structure and HIV serostatus.

METHODS

We used Quantitative Computed Tomography (QCT) data from the Multicenter AIDS Cohort Study (MACS) and Women's Interagency HIV Study (WIHS) to examine cortical thickness (CT) and cortical (CBMD), trabecular (TBMD), and integral (IBMD) bone mineral density across anatomic quadrants of the femoral neck in older adult MSM and women with (PWH) and without (PWOH) HIV infection. The percentage difference (%diff) in the means for CT and BMD overall and by quadrant between PWH and PWOH were estimated.

RESULTS

Among 322 MSM (median age 60 years) with bone measures, distributions were similar between HIV serostatus groups with %diff in the quadrant means ranging from -7 to -1% for CT and from -1 to 4% for BMD, and overall lower hip cortical thickness than expected. In contrast, in 113 women (median age 51 years), PWH had lower CT, IBMD and TBMD consistently across all quadrants, with differences ranging from -10 to -20% for CT, -6 to -11% for IBMD and -3 to -6% for TBMD. Estimates reached statistical significance in superoanterior quadrant for CT and IBMD and inferoposterior for CT.

CONCLUSION

Among women, PWH appear to have a thinner cortex and less dense integral bone compared with PWOH, particularly in the superior quadrants whereas MSM overall had a thinner than expected hip cortex.

Factors Associated with Bone Mineral Density and Bone Resorption Markers in Postmenopausal HIV-Infected Women on Antiretroviral Therapy: A Prospective Cohort Study

The study aimed to determine factors associated with changes in bone mineral density (BMD) and bone resorption markers over two years in black postmenopausal women living with human immunodeficiency virus (HIV) on antiretroviral therapy (ART). Women (n = 120) aged > 45 years were recruited from Potchefstroom, South Africa. Total lumbar spine and left femoral neck (LFN) BMD were measured with dual energy X-ray absorptiometry. Fasting serum C-Telopeptide of Type I collagen (CTx), vitamin D and parathyroid hormone were measured. Vitamin D insufficiency levels increased from 23% at baseline to 39% at follow up. In mixed linear models serum CTx showed no change from baseline to end (p = 0.363, effect size = 0.09). Total and LFN BMD increased significantly over two years, but effect sizes were small. No significant change in spine BMD over time was detected (p = 0.19, effect size = 0.02). Age was significantly positively associated with CTx over time, and negatively with total and LFN BMD. Physical activity (PA) was positively associated with LFN BMD (p = 0.008). Despite a decrease in serum vitamin D, BMD and CTx showed small or no changes over 2 years. Future studies should investigate PA interventions to maintain BMD in women living with HIV.

Change in Circulating Undercarboxylated Osteocalcin (ucOCN) Is Associated With Fat Accumulation in HIV-Seropositive Women

BACKGROUND

Bone mineral density loss and fat accumulation are common in people living with HIV. The bone-derived hormone, undercarboxylated osteocalcin (ucOCN) regulates fat metabolism. We investigated the relationship between ucOCN change and body fat change among perimenopausal/postmenopausal HIV-seronegative and HIV-seropositive women on long-term antiretrovirals.

METHODS

Perimenopausal and postmenopausal women enrolled in the Women's Interagency HIV Study MSK substudy underwent trunk and total fat assessment by dual energy x-ray absorptiometry (DXA) at study enrollment (index visit) and again 2 years later. Circulating ucOCN and cOCN were also measured at the index and 2-year visits. The correlation between the 2-year change in ucOCN and cOCN and change in trunk and total fat was assessed as a function of HIV serostatus using linear regression modeling. Multivariate linear regression assessed the association between ucOCN and cOCN change and total and trunk fat change after adjusting for sociodemographic variables. Linear regression models restricted to HIV-seropositive women were performed to examine the contributions of HIV-specific factors (index CD4 count, viral load, and combined antiretroviral therapy use) on the associations.

RESULTS

Increased ucOCN over the 2-year follow-up was associated with less trunk and total fat accumulation in models adjusting for HIV serostatus and participants sociodemographics, whereas there was no association with cOCN and the fat parameters. None of the HIV-specific factors evaluated influenced the association between ucOCN and fat parameters.

CONCLUSION

The current study suggests that increases in ucOCN are associated with decreased fat accumulation in HIV-seronegative and HIV-seropositive postmenopausal women on long-term antiretroviral therapy.

People with HIV infection had lower bone mineral density and increased fracture risk: a meta-analysis

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.

Factors associated with bone microstructural alterations assessed by HR-pQCT in long-term HIV-infected individuals

PURPOSE

In adults with long-term HIV infection, low bone density and increased fracture risk have emerged as significant comorbidities. Our aim was to assess the association of exercise, nutrition, and medications with bone quality in adults with long-term HIV infection.

METHODS

Forty-three adults with HIV infection were enrolled (median BMI 25.7, range 18.2-35.6 kg/m²; median age 57, range 50-69 years). Participants underwent ultradistal radius and tibia high-resolution peripheral quantitative CT (HR-pQCT). Questionnaires included the revised Community Healthy Activities Model Program for Seniors (CHAMPS), the Mini Nutritional Assessment (MNA) as well as medication assessments. Multivariable linear regression models were used to evaluate the association of exercise, nutritional status, tenofovir disoproxil fumarate (TDF) and protease inhibitor (PI) use with bone density and microstructure, adjusting for demographic risk factors.

RESULTS

In regression models, higher nutrition scores were associated with higher tibia cortical thickness (R² = 0.23; β = 0.03; p = 0.044) and higher radius cortical BMD (R² = 0.43; β = 8.4; p = 0.026). Higher weekly frequency of all physical activities was significantly associated with higher radius trabecular BMD (R² = 0.38; β = 0.96; p = 0.050), higher radius trabecular number (R² = 0.31; β = 0.01; p = 0.026), lower tibia and radius trabecular separation (tibia: R² = 0.30; β = -0.003; p = 0.038; radius: R² = 0.35; β = -0.003; p = 0.021), and higher radius bone stiffness (R² = 0.45; β = 0.38; p = 0.047). Higher frequency of bone loading physical activities was significantly associated with higher tibia trabecular density (R² = 0.44; β = 4.06; p = 0.036), higher tibia bone stiffness (R² = 0.46; β = 3.06; p = 0.050), and higher tibia estimated failure load (R² = 0.46; β = 0.17; p = 0.049). TDF used in combination with a PI was associated with lower radius trabecular BMD (R² = 0.39; β = -41.2; p = 0.042), lower radius trabecular number (R² = 0.34; β = -0.44; p = 0.009) and greater radius trabecular separation (R² = 0.42; β = 0.16; p = 0.002), while TDF use without a PI was not associated with reduced bone quality.

CONCLUSIONS

In adults with HIV infection, malnutrition is associated with poor cortical bone quality, while reduced frequency of physical activities and specifically reduced frequency of mechanical loading activities are associated with deficient trabecular bone structure and reduced estimates of bone strength. TDF use in combination with a PI is associated with deleterious effects on trabecular bone structure.

Occurrence & predictors of osteoporosis & impact of body composition alterations on bone mineral health in asymptomatic pre-menopausal women with HIV infection

Background & objectives:

Data on bone mineral density (BMD) and sarcopenia are scant from young females with HIV. This study was conducted to determine occurrence, predictors and impact of body composition alterations on osteoporosis in pre-menopausal women with HIV.

Methods:

A total of 214 females with serologically documented HIV infection were screened, of whom 103 pre-menopausal women, 25-45 yr age, clinically stable, having at least one year follow up data, underwent hormonal and dual-energy X-ray absorptiometry analysis for BMD and body composition. Seventy five matched controls were also evaluated.

Results:

Females with HIV had significantly lower BMD and Z-score at lumbar spine (LS), total femur, neck of femur (NOF), and radius ultra-distal (UD) compared to controls. Osteoporosis at least at one site was observed in 34.95 per cent patients, compared to eight per cent in controls (P <0.001). Most common site of osteoporosis in females with HIV was radius UD (24.27%), followed by radius 33 per cent (17.48%), radius total (15.53%) and greater trochanter, NOF and LS (6.80% each). HIV patients had significantly lower bone mineral content, lean mass (LM), fat per cent, android (A) fat, gynoid (G) fat, and A/G ratio. LM and fat mass (FM) were −15.65 and −11.54 per cent lower in HIV patients, respectively. Osteoporosis patients had significantly higher use of antiretroviral therapy and lower LM, FM and fat per cent. On logistic regression, LM followed by A/G ratio and BMI were the best predictors of osteoporosis. Sarcopenia was observed in 17.5 per cent patients.

Interpretation & conclusions:

Our results showed that osteoporosis and sarcopenia were significant problems in young women with HIV. HIV was associated with greater LM loss, which was critical for bone health. Sarcopenia may predict low BMD in HIV.

Reduced bone mineral density in human immunodeficiency virus-infected individuals: a meta-analysis of its prevalence and risk factors

A meta-analysis was conducted to evaluate the prevalence of osteopenia/osteoporosis in human immunodeficiency virus (HIV)-infected individuals. The prevalence of osteopenia/osteoporosis in HIV-infected and antiretroviral therapy (ART)-treated individuals was significantly higher than respective controls. Evidence regarding bone loss within first year of HIV infection or ART initiation was preliminary.

PURPOSE

The aim of the study is to systematically review published literature on the prevalence of osteopenia/osteoporosis and its associated risk factors in HIV-infected individuals.

METHODS

A literature search was conducted from 1989 to 2015 in six databases. Full text, English articles on HIV-infected individuals ≥ 18 years, which used dual X-ray absorptiometry to measure BMD, were included. Studies were excluded if the prevalence of osteopenia/osteoporosis was without a comparison group, and the BMD/T-score were not reported.

RESULTS

Twenty-one cross sectional and eight longitudinal studies were included. The prevalence of osteopenia/osteoporosis was significantly higher in both HIV-infected [odds ratio (OR) = 2.4 (95%Cl: 2.0, 2.8) at lumbar spine, 2.6 (95%Cl: 2.2, 3.0) at hip] and ART-treated individuals [OR = 2.8 (95%Cl: 2.0, 3.8) at lumbar spine, 3.4 (95%Cl: 2.5, 4.7) at hip] when compared to controls. PI-treated individuals had an OR of 1.3 (95%Cl: 1.0, 1.7) of developing osteopenia/osteoporosis compared to controls. A higher proportion of tenofovir-treated individuals (52.6%) had lower BMD compared to controls (42.7%), but did not reach statistical significance (p = 0.248). No significant difference was found in the percent change of BMD at the lumbar spine, femoral neck, or total hip from baseline to follow-up between HIV-infected, PI-treated, tenofovir-treated, and controls. Older age, history of bone fracture, low BMI, low body weight, being Hispanic or Caucasian, low testosterone level, smoking, low CD4 cell count, lipodystrophy, low fat mass, and low lean body mass were associated with low BMD.

CONCLUSIONS

The prevalence of osteopenia/osteoporosis in HIV-infected and antiretroviral therapy (ART)-treated individuals was two times more compared to controls. However, evidence concerning bone loss within the first year of HIV infection and ART initiation was preliminary.

Vitamin D Status and the Relationship with Bone Fragility Fractures in HIV-Infected Patients: A Case Control Study

HIV-infected patients show high risk of fracture. The aims of our study were to determine the prevalence of vertebral fractures (VFs) and their associations with vitamin D in HIV patients. 100 patients with HIV infection and 100 healthy age- and sex-matched controls were studied. Bone mineral density was measured by quantitative ultrasound at the non-dominant heel. Serum osteocalcin and C-terminal telopeptide of collagen type 1 served as bone turnover markers. Bone ultrasound measurements were significantly lower in patients compared with controls (Stiffness Index (SI): 80.58 ± 19.95% vs. 93.80 ± 7.10%, respectively, p < 0.001). VFs were found in 16 patients and in 2 controls. HIV patients with vertebral fractures showed lower stiffness index (SI) (70.75 ± 10.63 vs. 83.36 ± 16.19, respectively, p = 0.045) and lower vitamin D levels (16.20 ± 5.62 vs. 28.14 ± 11.94, respectively, p < 0.02). The majority of VFs (87.5%) were observed in HIV-infected patients with vitamin D insufficiency, and regression analysis showed that vitamin D insufficiency was significantly associated with vertebral fractures (OR 9.15; 95% CI 0.18–0.52, p < 0.04). VFs and are a frequent occurrence in HIV-infected patients and may be associated with vitamin D insufficiency.

Beyond Antibodies: B Cells and the OPG/RANK-RANKL Pathway in Health, Non-HIV Disease and HIV-Induced Bone Loss

HIV infection leads to severe B cell dysfunction, which manifests as impaired humoral immune response to infection and vaccinations and is not completely reversed by otherwise effective antiretroviral therapy (ART). Despite its inability to correct HIV-induced B cell dysfunction, ART has led to significantly increased lifespans in people living with HIV/AIDS. This has in turn led to escalating prevalence of non-AIDS complications in aging HIV-infected individuals, including malignancies, cardiovascular disease, bone disease, and other end-organ damage. These complications, typically associated with aging, are a significant cause of morbidity and mortality and occur significantly earlier in HIV-infected individuals. Understanding the pathophysiology of these comorbidities and delineating clinical management strategies and potential cures is gaining in importance. Bone loss and osteoporosis, which lead to increase in fragility fracture prevalence, have in recent years emerged as important non-AIDS comorbidities in patients with chronic HIV infection. Interestingly, ART exacerbates bone loss, particularly within the first couple of years following initiation. The mechanisms underlying HIV-induced bone loss are multifactorial and complicated by the fact that HIV infection is linked to multiple risk factors for osteoporosis and fracture, but a very interesting role for B cells in HIV-induced bone loss has recently emerged. Although best known for their important antibody-producing capabilities, B cells also produce two cytokines critical for bone metabolism: the key osteoclastogenic cytokine receptor activator of NF-κB ligand (RANKL) and its physiological inhibitor osteoprotegerin (OPG). Dysregulated B cell production of OPG and RANKL was shown to be a major contributor to increased bone loss and fracture risk in animal models and HIV-infected humans. This review will summarize our current knowledge of the role of the OPG/RANK–RANKL pathway in B cells in health and disease, and the contribution of B cells to HIV-induced bone loss. Data from mouse studies indicate that RANKL and OPG may also play a role in B cell function and the implications of these findings for human B cell biology, as well as therapeutic strategies targeting the OPG/RANK–RANKL pathway, will be discussed.

A Direct Comparison of the Effects of the Antiretroviral Drugs Stavudine, Tenofovir and the Combination Lopinavir/Ritonavir on Bone Metabolism in a Rat Model

Antiretroviral (ARV) treatment may induce metabolic complications in HIV patients on long-term therapy that can affect bone health. In this study, the effects of the ARVs Stavudine (d4T), Tenofovir (TDF) and Lopinavir/ritonavir (LPV/r) on bone metabolism and lipodystrophy were directly compared in rats to negate the consequences of HIV-associated confounding factors. Healthy 12-14-week-old male Wistar rats (n = 40) were divided into four treatment groups and received an oral animal equivalent dose of either Stavudine (6.2 mg/kg/day), TDF (26.6 mg/kg/day), LPV/r (70.8 mg/kg/day) or water (Control 1.5 mL water/day) for a period of 9 weeks. Whole-body DXA measurements, a biomechanical three-point breaking test and histomorphometric analysis were performed on the femurs and tibias at the end of the treatment period. Stavudine monotherapy was found to be associated with decreased femoral bone mineral density that translated into reduced bone strength, whereas histomorphometric analysis demonstrated that Stavudine induces an imbalance in bone metabolism at tissue level, evident in higher resorption (eroded surfaces, osteoclast surfaces and osteoclast number) and lower formation parameters (osteoblast surfaces and osteoid surfaces). This was less clear in the rats treated with either TDF or LPV/r. Furthermore, both Stavudine and TDF treatment resulted in significant bone marrow adiposity, although no significant redistribution of body fat was noted in the treated rats compared to controls. The data from this study suggest that in the absence of HIV-associated factors, LPV/r is less detrimental to bone metabolism compared to Stavudine and TDF.

Brief Report: HIV Infection Is Associated With Worse Bone Material Properties, Independently of Bone Mineral Density

Low bone mineral density (BMD) in HIV-infected individuals has been documented in an increasing number of studies. However, it is not clear whether it is the infection itself or the treatment that causes bone impairment. Microindentation measures bone material strength (Bone Material Strength index) directly. We recruited 85 patients, 50 infected with HIV and 35 controls. Median Bone Material Strength index was 84.5 (interquartile range 83-87) in HIV-infected patients and 90 (88.5-93) in controls (P < 0.001). No significant differences in BMD between cases and controls at any of the sites examined (total hip, femoral neck, and lumbar spine). HIV infection is associated with bone damage, independently of BMD.

Predictors of longitudinal change in bone mineral density in a cohort of HIV-positive and negative patients

OBJECTIVE

Although low bone mineral density (BMD) is prevalent in HIV, changes in BMD over time remain unclear. We aimed to compare rates of, and factors associated with, BMD change between HIV-positive and HIV-negative patients.

METHODS

In a prospective, 3-year cohort, HIV-positive and HIV-negative patients provided annual demographic and clinical data, fasting bloods, and dual x-ray absorptiometry. Using longitudinal mixed models we compared and determined predictors of rate of change in BMD.

RESULTS

Of 384 study participants (45.8% HIV positive), 120 contributed two and 264 contributed three BMD measurements. Those with HIV were younger [median interquartile range 39 (34-46) vs. 43 (35-50) years; P = 0.04], more often men (61 vs. 46%; P = 0.003), and less likely Caucasian (61 vs. 82%; P < 0.001). Although BMD was lower in those with HIV, BMD declined in both groups, with nonsignificant between-group difference in rate of BMD change over time. Within the HIV group, starting antiretroviral therapy (ART) within 3 months of enrolment was associated with greater BMD decline at all anatomical sites (all P < 0.001). Age more than 30 years, Caucasian ethnicity, and not being on ART during follow-up were associated with greater decline and higher parathyroid hormone associated with a smaller decline in BMD at the femoral neck. We found no association between BMD change and exposure to tenofovir disoproxil fumarate or protease inhibitors.

CONCLUSION

We observed no difference in rate of BMD decline regardless of HIV status and in HIV-positive patient, having started ART within the previous 3 months was the only factor associated with greater BMD decline at all three sites.

More than osteoporosis: age-specific issues in bone health

PURPOSE OF REVIEW

The interaction between fall and fracture risk factors is an area of increasing clinical relevance, but little information is known about the age-specific issues in bone health unique to HIV-infected adults. The present review will focus on what is known about falls and fall risk factors among HIV-infected adults, and then review the association between decreased muscle, increased adiposity, and frailty with both low bone mineral density (BMD) and falls.

RECENT FINDINGS

The rate of falls among middle-aged HIV-infected adults is similar to that of HIV-uninfected adults 65 years and older. Many of the clinical factors that contribute to low BMD overlap with risk factors for falls, resulting in a high risk of a serious fall among older adults with the greatest risk for a fracture. Low muscle mass, increased adiposity and metabolic syndrome, physical function impairment and frailty, common among older HIV-infected adults, contribute to an increased risk for low BMD and falls, and subsequently, may increase the risk of fracture among HIV-infected older adults.

SUMMARY

Interventions with dual benefit on reducing fall risk and improving BMD are likely to have the greatest impact on fracture prevention in the older, HIV-infected adult.

Learning from the experiences of people with HIV using general practitioner services in London: a qualitative study

Aim To explore the experiences of people with HIV (PWHIV) using general practitioner (GP) services in order to identify barriers to use.

BACKGROUND

Traditionally, GPs have little involvement in the care of PWHIV. However, as HIV becomes a chronic condition and the population of PWHIV ages, there is a need to increase this involvement. Despite high levels of GP registration, the majority of PWHIV in London report that their GP is not involved in their HIV care.

METHODS

This paper presents qualitative findings from a mixed method study of PWHIV's experiences of clinical services. Survey respondents were purposively sampled to recruit 51 PWHIV who took part in eight focus groups. Participants were asked about their experience of using GP services. Findings Three factors emerged which mediated experiences of GP care. Competence: respondents were concerned about the potential for misdiagnosis of symptoms, lack of awareness of the health needs of PWHIV and experiences of prescribing, which could lead to drug interactions. Continuity: not being able to get appointments quickly enough, not being able to see the same doctor twice and not being able to keep the same GP when one changed address were experienced as impediments to use. Communication: lack of communication between GPs and HIV specialists led to what participants called 'patient ping-pong' where they found themselves acting as a go-between for different clinical specialists trying to make sense of their care.

CONCLUSION

Meaningful contact between HIV specialists and GPs is likely to allay concerns about competency as treatment and care decisions can be taken collaboratively between the GP, HIV specialist and patient. A key component of acceptable GP care for PWHIV is likely to be the application of long-term condition management approaches, which includes empowered patient self-management.

Interaction of obesity and infections

There is evidence that certain infections may induce obesity. Obese persons may also have more severe infections and have compromised response to therapies. The objective of this study is to review the available literature identifying infections that potentially contribute to greater body mass index (BMI) and differential responses of overweight and obese persons to infections. A systematic literature review of human studies examining associations between infections and weight gain, differential susceptibility, severity, and response to prevention and treatment of infection according to BMI status (January 1980-July 2014) was conducted. Three hundred and forty-three studies were eligible for inclusion. Evidence indicated that viral infection by human adenovirus Ad36 and antibiotic eradication of Helicobacter pylori were followed by weight gain. People who were overweight or obese had higher susceptibility to developing post-surgical infections, H1N1 influenza and periodontal disease. More severe infections tended to be present in people with a larger BMI. People with a higher BMI had a reduced response to vaccinations and antimicrobial drugs. Higher doses of antibiotics were more effective in obese patients. Infections may influence BMI, and BMI status may influence response to certain infections, as well as to preventive and treatment measures. These observations have potential clinical implications.

HIV-related metabolic comorbidities in the current ART era

Despite effective antiretroviral therapy (ART), HIV-infected individuals have residual chronic immune activation that contributes to the pathogenesis of HIV infection. This immune system dysregulation is a pathogenic state manifested by very low naïve T-cell numbers and increased terminally differentiated effector cells that generate excessive proinflammatory cytokines with limited functionality. Immune exhaustion leaves an individual at risk for accelerated aging-related diseases, including renal dysfunction, atherosclerosis, diabetes mellitus, and osteoporosis. We highlight research that clarifies the role of HIV, ART, and other factors that contribute to the development of these diseases among HIV-infected persons.

Bone alterations associated with HIV

HIV infection and initiation of antiretroviral therapy (ART) have been consistently associated with decreased bone mineral density (BMD), with growing evidence linking HIV to an increased risk of fracture. This is especially concerning with the expanding number of older persons living with HIV. Interestingly, recent data suggest that HIV-infected children and youth fail to achieve peak BMD, possibly increasing their lifetime risk of fracture. Elucidating the causes of the bone changes in HIV-positive persons is challenging because of the multifactorial nature of bone disease in HIV, including contribution of the virus, immunosuppression, ART toxicity, and traditional osteoporosis risk factors, such as age, lower weight, tobacco, and alcohol use. Thus, practitioners must recognize the risk of low BMD and fractures and appropriately screen patients for osteoporosis if risk factors exist. If fractures do occur or elevated fracture risk is detected through screening, treatment with bisphosphonate medications appears safe and effective in the HIV+population.

Skeletal health in adults with HIV infection

Concern has been raised that HIV infection, its treatment, or both adversely affect skeletal health. Cross-sectional studies show that bone mineral density (BMD) is 3-5% lower in patients infected with HIV than in uninfected controls, but patients with HIV infection are, on average, 5 kg lighter than uninfected people. After this weight difference is accounted for, BMD differences are smaller and not clinically relevant. Longitudinal studies show short-term BMD loss of 2-4% over 1-2 years when antiretroviral therapy is started, followed by longer periods of BMD increase or stability. Losses are greatest with treatment regimens that contain tenofovir. Patients infected with HIV have slightly higher fracture rates than controls, but the increased risk of fracture is substantially attenuated by adjustment for traditional risk factors for fracture. These reassuring findings suggest that management of skeletal health in HIV should follow guidelines for the general population. In general, effective antiretroviral treatment and avoidance of undernutrition are the two most important factors for maintenance of skeletal health in patients infected with HIV.

Bone mineral density changes after 2 years of ARV treatment, compared to naive HIV-1-infected patients not on HAART

BACKGROUND

The prevalence of osteopenia and osteoporosis is increased in human immunodeficiency virus (HIV)-infected patients. The pathogenesis of this low bone mineral density (BMD) is multifactorial.

METHODS

We conducted a prospective study over a 2-year period of the BMD in non-treated ARV-naïve HIV-infected-males, in comparison to HIV-infected males commencing a first ARV treatment, and analyzed the evolution of bone turnover markers.

RESULTS

A total of 39 caucasian males (median age 38.6 years) were enrolled, including 10 who started ARV treatment (group 1), and 29 without indications for ARV therapy (group 2). In the latter group, 11 subjects commenced ARV during the study; therefore the remainder of their follow-up was within group 1, which finally consisted of 21 patients. At baseline, 9 patients (19.5%) had osteoporosis at least at 1 site, while 28 (61%) showed osteopenia. Lower BMD was correlated with tobacco use. Lumbar spine and total hip BMD significantly decreased in group 1 patients after 6 months of treatment, then stabilized (2.4% and 4% loss, respectively, at 24 months), while no significant change in BMD was observed in group 2 subjects. At baseline, one patient had an increased CTX (C-terminal cross-linking telopeptide of type 1 collagen) and all BSAP (bone-specific alkaline phosphatase) results were normal. During follow-up, both CTX and BSAP increased in group 1 patients, while they did not change in group 2.

CONCLUSION

Osteoporosis and osteopenia are frequent in HIV-infected males. After ARV initiation, BMD decreased, and bone turnover markers increased, even though the BMD remained stable in non-treated patients. These results underline the impact of HIV treatment on BMD and bone metabolism.

Relative contribution of HIV infection, demographics and body mass index to bone mineral density

INTRODUCTION

Low bone mineral density (BMD) is common in HIV-positive patients, although the role played by HIV infection versus sociodemographic and metabolic factors remains unclear.

METHODS

Understanding the Pathology of Bone Disease in HIV-infected individuals (HIV UPBEAT) is a prospective cohort study, enrolled HIV-positive and HIV-negative participants from similar demographic backgrounds. Dual X-ray absorptiometry at femoral neck, total hip and lumbar spine and blood tests were performed. Associations between BMD and factors of interest were assessed using multivariable linear regression.

RESULTS

A total of 474 participants were recruited. Two hundred and ten were HIV-positive, of whom, 59% were male, 40% African and median (interquartile range) age was 39 (33, 46) years. HIV acquisition risks were heterosexual sex (46.9%), homosexual sex (25.4%) and intravenous drug use (18.7%). Of the HIV-negative participants, 44% were male, 25% were African and median (interquartile range) age was 42 (34-49) years. HIV infection was independently associated with a 0.062 (P < 0.0001), 0.078 (P < 0.0001) and 0.060 g/cm (P =  0.0002) lower BMD at femoral neck, total hip and lumbar spine, respectively, after adjustment for demographic/ lifestyle factors and BMI. After further adjustment for bone biomarkers, HIV remained independently associated with reduced BMD at each site, although effect sizes were reduced. The HIV-positive group had significantly higher bone turnover (all between-group P < 0.0001). Treatment variables and cumulative exposure to antiretroviral therapy were not associated with lower BMD at femoral neck or total hip, but acquisition of HIV infection via intravenous drug use and longer time since HIV diagnosis were independently associated with lower lumbar spine BMD.

DISCUSSION

HIV is independently associated with lower BMD, and its effect is likely mediated, in part, by alterations in bone metabolism.

HIV infection, bone metabolism, and fractures

With the advent of high active antiretroviral therapy there was a significant improvement on HIV subjects survival. Thus, bone changes related to HIV became an important aspect of these individuals. HIV affects bone remodeling causing bone fragility. In addition, antiretroviral therapy may also negatively affect bone metabolism. Several studies describe an increased incidence of fractures in these patients when compared with controls without the disease. The European Society of AIDS (EACS), and other societies, have included guidance on management of osteoporosis in HIV-infected patients emphasizing the identification of patients with low bone mass. Supplementation of calcium and vitamin D and the use of alendronate in these individuals should be recommended on a case base.

HIV protease inhibitors induce senescence and alter osteoblastic potential of human bone marrow mesenchymal stem cells: beneficial effect of pravastatin

HIV-infected patients receiving antiretroviral therapy present an increased prevalence of age-related comorbidities, including osteoporosis. HIV protease inhibitors (PIs) have been suspected to participate to bone loss, but the mechanisms involved are unknown. In endothelial cells, some PIs have been shown to induce the accumulation of farnesylated prelamin-A, a biomarker of cell aging leading to cell senescence. Herein, we hypothesized that these PIs could induce premature aging of osteoblast precursors, human bone marrow mesenchymal stem cells (MSCs), and affect their capacity to differentiate into osteoblasts. Senescence was studied in proliferating human MSCs after a 30-day exposure to atazanavir and lopinavir with or without ritonavir. When compared to untreated cells, PI-treated MSCs had a reduced proliferative capacity that worsened with increasing passages. PI treatment led to increased oxidative stress and expression of senescence markers, including prelamin-A. Pravastatin, which blocks prelamin-A farnesylation, prevented PI-induced senescence and oxidative stress, while treatment with antioxidants partly reversed these effects. Moreover, senescent MSCs presented a decreased osteoblastic potential, which was restored by pravastatin treatment. Because age-related bone loss is associated with increased bone marrow fat, we also evaluated the capacity of PI-treated MSCs to differentiate into adipocyte. We observed an altered adipocyte differentiation in PI-treated MSCs that was reverted by pravastatin. We have shown that some PIs alter osteoblast formation by affecting their differentiation potential in association with altered senescence in MSCs, with a beneficial effect of statin. These data corroborate the clinical observations and allow new insight into pathophysiological mechanisms of PI-induced bone loss in HIV-infected patients.

Bone mass, body composition and vitamin D status of ARV-naïve, urban, black South African women with HIV infection, stratified by CD₄ count

This is the first report examining vitamin D status and bone mass in African women with HIV infection using dual-energy X-ray absorptiometry (DXA) with an appropriate HIV-negative control group. Unlike previous publications, it demonstrates no difference in bone mineral density (BMD) or vitamin D status in HIV-positive patients, at different disease stages, vs. HIV-negative subjects.

INTRODUCTION

Low bone mass and poor vitamin D status have been reported among HIV-positive patients; suggesting HIV or its treatment may increase the risk of osteoporosis, a particular concern for women in countries with high HIV prevalence such as South Africa. We describe bone mass and vitamin D status in urban premenopausal South African women, who were HIV positive but not on antiretroviral therapy (ARV).

METHODS

This study is a cross-sectional measurement of BMD and body composition by DXA and vitamin D status by serum 25-hydroxyvitamin D (25(OH)D) concentration. Subjects were recruited into three groups: HIV negative (n = 98) and HIV positive with preserved CD₄ cell count (non-ARV; n = 74) or low CD₄ cell counts prior to ARV initiation (pre-ARV; n = 75).

RESULTS

The mean (standard deviation (SD)) age of women was 32.1 (7.2) years. Mean CD₄ (SD) counts (×10(6)/l) were 412 (91) and 161 (69) in non-ARV and pre-ARV groups (p < 0.0001). Pre-ARV women were significantly lighter and had lower mean BMI than the other two groups (p < 0.002). The pre-ARV group also had significantly less fat and lean mass compared with non-ARV and HIV-negative subjects (p ≤ 0.05). After full adjustment, there were no significant differences in BMD at any site (p > 0.05) between the groups, nor was vitamin D status significantly different between groups (p > 0.05); the mean (SD) cohort 25(OH)D being 60 (18) nmol/l.

CONCLUSION

Contrary to previous studies, these HIV-positive women did not have lower BMD or 25(OH)D concentrations than HIV-negative controls, despite the pre-ARV group being lighter with lower BMI.

A cross-sectional randomised study of fracture risk in people with HIV infection in the probono 1 study

Objective

To determine comparative fracture risk in HIV patients compared with uninfected controls.

Design

A randomised cross-sectional study assessing bone mineral density (BMD), fracture history and risk factors in the 2 groups.

Setting

Hospital Outpatients.

Subbbjects

222 HIV infected patients and an equal number of age-matched controls. Assessments: Fracture risk factors were assessed and biochemical, endocrine and bone markers measured. BMD was assessed at hip and spine. 10-year fracture probability (FRAX) and remaining lifetime fracture probability (RFLP) were calculated.

Main Outcome Measures

BMD, and history of fractures.

Results

Reported fractures occurred more frequently in HIV than controls, (45 vs. 16; 20.3 vs. 7%; OR=3.27; p=0.0001), and unsurprisingly in this age range, non-fragility fractures in men substantially contributed to this increase. Osteoporosis was more prevalent in patients with HIV (17.6% vs. 3.6%, p<0.0001). BMD was most reduced, and predicted fracture rates most increased, at the spine. Low BMD was associated with antiretroviral therapy (ART), low body mass index and PTH. 10-year FRAX risk was <5% for all groups. RLFP was greater in patients with HIV (OR=1.22; p=0.003) and increased with ART (2.4 vs. 1.50; OR= 1.50; p=0.03).

Conclusions

The increased fracture rate in HIV patients in our relatively youthful population is partly driven by fractures, including non-fragility fractures, in men. Nonetheless, these findings may herald a rise in osteoporotic fractures in HIV patients. An appropriate screening and management response is required to assess these risks and identify associated lifestyle factors that are also associated with other conditions such as cardiovascular disease and diabetes.

Prevalence and risk factors of osteopenia/osteoporosis in Turkish HIV/AIDS patients

BACKGROUND

Recent studies showed a high frequency of low bone mineral density (BMD) in HIV-infected patients and no reports have been issued in Turkey. Our aim was to evaluate BMD and risk factors for osteopenia/osteoporosis in HIV-infected patients that attended an outpatient clinic in Istanbul, Turkey.

METHOD

In order to determine the prevalence of BMD, 126 HIV-infected patients had been studied with dual energy X-ray absorptiometry (DEXA). The association between BMD and age, gender, body mass index (BMI), habits, 25(OH)vitamin D, HIV RNA, CD4 lymphocyte nadir, using and duration of highly active antiretroviral treatment (HAART) were investigated by using multivariate analysis.

RESULTS

Median age was 40.1 years (range, 20-70); 84% were male; 35.7% patients had AIDS, 63.5% were treated with HAART. Osteopenia and osteoporosis were diagnosed in 53.9% and 23.8%, respectively. Mean plasma HIV RNA was 5.2 (SD 1.0) log10 copies/mL and CD4 lymphocyte nadir was 313.8 (SD 226.2)/mm(3). Factors associated with bone loss were high viral load (p=0.034), using (p=0.033) and duration of HAART (p=0.008). No correlation had been seen between sex and osteopenia/osteoporosis (p=0.794). However, males showed higher rates of osteoporosis than females (p=0.042).

CONCLUSIONS

Our results show a very high prevalence of bone mass reduction in Turkish HIV-infected patients. This study supports the importance of both HIV and antiretroviral therapy in low BMD.

Body composition, soluble markers of inflammation, and bone mineral density in antiretroviral therapy-naive HIV-1-infected individuals

OBJECTIVE

To determine the association among bone mineral density (BMD), inflammatory markers, and alterations in fat and lean mass in untreated HIV-infected individuals.

DESIGN

Cross-sectional analysis of antiretroviral therapy-naive persons enrolled into a randomized clinical trial.

METHODS

Dual-energy x-ray absorptiometry for BMD and lean and fat mass and a laboratory assessment were performed. Soluble biomarkers included adipocytokines (leptin and adiponectin), inflammatory markers (high-sensitivity C-reactive protein and interleukin 6), and markers related to bone metabolism [osteoprotegerin (OPG)], receptor activator of nuclear factor κB ligand. BMD at the lumbar spine, total hip, and femoral neck was expressed as a Z score (number of standard deviations away from age-, race-, and sex-matched reference population).

RESULTS

Three hundred thirty-one subjects had a median (Q1, Q3) age of 36 (28, 45) years, were 89% men, and 44% white. The prevalence of low BMD (Z score ≤ -2 at any of the 3 sites) was 10%. No associations were detected between Z scores and high-sensitivity C-reactive protein, interleukin 6, or receptor activator of nuclear factor κB ligand (P ≥ 0.1). In a linear model adjusting for age, gender, race, and total fat mass, lower lumbar spine Z scores were associated with lower total lean mass, higher serum adiponectin, and lower OPG. Results at the total hip or femoral neck were similar.

CONCLUSIONS

Among antiretroviral therapy-naive HIV-infected individuals, lower BMD was associated with lower lean mass, higher adiponectin, and lower OPG, but not HIV disease variables or any of the inflammatory markers. These findings may have implications for bone metabolism in untreated HIV, in which hypoadiponectinemia and higher OPG may mitigate bone loss.

Bone and vitamin D metabolism in HIV

Human immunodeficiency virus (HIV) infection has progressed to a chronic disease and HIV positive individuals are living longer lives. This has lead to an increase in morbidity and mortality due to secondary issues, one being HIV bone disease. HIV infected pediatric and adult populations have a greater incidence in reduction of BMD as compared to the controls. Osteoporosis has been reported to be present in up to 15 % of HIV positive patients. We are starting to understand the mechanism behind the changes in HIV bone disease. Viral proteins interfere with osteoblastic activity either by direct interaction or by the inflammatory process that they induce. Anti-viral management, including highly active antiretroviral therapy (HAART), protease inhibitors, and nucleoside/nucleotide reverse transcriptase inhibitors (NRTI) also are involved in disrupting proper bone metabolism. Vitamin D levels have strong correlation with bone disease in HIV patients, and are dependent not only to chronic disease state, but interaction of pharmacologic management and inflammatory process as well. Work up of the secondary causes of osteopenia and osteoporosis should be undertaken in all patients. DEXA scan is recommended in all post-menopausal women with HIV, all HIV infected men 50 years of age or older and in those with a history of fragility fractures regardless of age or gender. Preventive measures include adequate nutrition, calcium and Vitamin D intake daily, muscle strengthening and balance exercises to increase BMD and reduce fractures. Bisphosphonates are considered to be the first line for the treatment of HIV associated bone disease. This review will describe how the balanced mechanism of bone metabolism is interrupted by the HIV infection itself, the complications that arise from HIV/AIDS, and its treatment options.

Care of the human immunodeficiency virus-infected menopausal woman

More women than ever before are both human immunodeficiency virus infected and menopausal, because of increased survival and more frequent diagnosis in older women. Such a woman has the combined burden of her infection, its treatment, comorbid conditions, and aging. Thus, she is at risk for a variety of problems, such as disorders of bone mineral density and deficiencies in cognitive functioning. In addition to this, she experiences menopause in a unique fashion, with more symptoms and perhaps at an earlier age. The clinician caring for her must take a proactive approach to this multitude of factors that may affect her health and well-being.

Therapeutic options for low bone mineral density in HIV-infected subjects

With the advent of effective antiretroviral therapy (ART), the recognition and management of long-term complications of HIV infection and ART are increasingly important for HIV physicians. Low bone mineral density (BMD) is more common in those with HIV infection and this review will outline therapeutic options for the management of low bone mineral density relevant to HIV-infected populations.

Vitamin D status in young HIV infected women of various ethnic origins: incidence of vitamin D deficiency and possible impact on bone density

BACKGROUND

Decreased bone mineral density (BMD) was reported in HIV infected patients. Mechanisms leading to this decrease are poorly understood.

AIMS

To assess factors relating to BMD in young HIV infected Israeli women of Ethiopian and Caucasian origin.

PATIENTS AND METHODS

75 young HIV infected women aged 34.5 ± 8.5 followed up at the Institute of Allergy, Clinical Immunology & AIDS filled a questionnaire about sun exposure, daily calcium intake and dress habits. Data about HIV status and treatment regimens were collected from the patients' charts. Serum hydroxyvitamin D [25(OH)D] levels, bone turnover markers and bone densitometry were evaluated.

RESULTS

28 (65%) of Ethiopians and 2 (6.25%) of Caucasians had 25(OH)D serum levels <10 ng/ml (vitamin D deficiency), p = 0.001. 21 (67.7%) Ethiopians and 16 (39%) Caucasians avoided sun exposure, p = 0.019. Mean daily calcium intake was 491 ± 268.6 mg and 279 ± 252.6 mg, respectively, p = 0.001. Z scores < -1 found at Lumbar spine in 26 (89.7%), at Femoral neck in 20 (69%) at Total hip in 17 (58.6%) of vitamin D deficient patients compared to 20 (48.8%), 17 (41.5%), 9 (22%), in patients with 25(OH)D > 10 ng/ml, p < 0.01, <0.03, <0.001, respectively. Significantly more Ethiopian than Caucasian women covered their face (32.3% and 9.5%, p = 0.003) and hands (58.1% and 30.9%, p = 0.03). There was no difference in bone turnover markers levels.

CONCLUSION

Poorer vitamin D status was observed in Ethiopian women might be one of the important factors related to lower BMD in this group.

Hip bone geometry in HIV/HCV-co-infected men and healthy controls

People with both HIV and hepatitis C are more likely than those with HIV alone to have wrist, hip, and spine fractures. We compared hip strength between HIV/HCV-co-infected men and healthy men and found that HIV/HCV-co-infected men had decreased hip strength due to lower lean body mass.

INTRODUCTION

Hepatitis C co-infection is a risk factor for fragility fracture among HIV-infected populations. Whether bone strength is compromised in HIV/HCV-co-infected patients is unknown.

METHODS

We compared dual-energy x-ray absorptiometry (DXA)-derived hip geometry, a measure of bone strength, in 88 HIV/HCV-co-infected men from the Johns Hopkins HIV Clinic to 289 men of similar age and race and without HIV or HCV from the Boston Area Community Health Survey/Bone Survey. Hip geometry was assessed at the narrow neck, intertrochanter, and shaft using hip structural analysis. Lean body mass (LBM), total fat mass (FM), and fat mass ratio (FMR) were measured by whole-body DXA. Linear regression was used to identify body composition parameters that accounted for differences in bone strength between cohorts.

RESULTS

HIV/HCV-co-infected men had lower BMI, LBM, and FM and higher FMR compared to controls (all p < 0.05). At the narrow neck, significant differences were observed between HIV/HCV-co-infected men and controls in bone mineral density, cross-sectional area, section modulus, buckling ratio, and centroid position. After adjustment for race, age, smoking status, height, and weight, only buckling ratio and centroid position remained significantly different between cohorts (all p < 0.05). Substituting LBM, FM, and FMR for weight in the multivariate model revealed that differences in LBM, but not FM or FMR, accounted for differences in all narrow neck parameters between cohorts, except buckling ratio and centroid position.

CONCLUSION

HIV/HCV-co-infected men have compromised hip strength at the narrow neck compared to uninfected controls, which is attributable in large part to lower lean body mass.

High prevalence of radiological vertebral fractures in HIV-infected males

Age-related co-morbidities including osteoporosis are relevant in patients responding to combination antiretroviral therapy (cART). Vertebral fractures are common osteoporotic fractures and their diagnosis is useful for managing at-risk individuals. However, there are few data from HIV-infected patients. Therefore, the aim of this study was to determine the prevalence of and factors associated with vertebral fractures in a population of HIV-infected males. A cross-sectional study of 160 HIV-infected patients with available chest X-rays was conducted from 1998 to 2010. One hundred and sixty-three males with comparable age and with no history of HIV infection were recruited as controls. Semi-quantitative evaluation of vertebral heights in lateral chest X-rays and quantitative morphometry assessment of centrally digitized images using dedicated morphometry software were utilized to detect prevalent vertebral fractures. The result showed that the vertebral fractures were detected in 43/160 (26.9%) HIV-infected patients and in 21/163 (12.9%) controls (P = 0.002). In HIV-infected patients with fractures, 27 had two or more fractures and ten patients had severe fractures. The prevalence of any fractures and multiple fractures in HIV-infected patients receiving cART (29.6 and 20.0%) was slightly higher than in HIV-infected patients not exposed to cART (17.1 and 5.7%), but significantly higher than control subjects (12.9 and 3.7%). At multivariable analyses, body mass index and diabetes mellitus were independently correlated with vertebral fractures in HIV-infected patients. We concluded that a significant proportion of HIV-infected males receiving cART showed vertebral fractures. Furthermore, proactive diagnosis of vertebral fragility fractures is particularly relevant in patients who are overweight or suffer from diabetes.

Tesamorelin: a review of its use in the management of HIV-associated lipodystrophy

Tesamorelin (Egrifta™) is a synthetic analogue of human growth hormone-releasing hormone (also known as growth hormone-releasing factor) that stimulates the synthesis and release of endogenous growth hormone. It is the first and, so far, only treatment indicated for the reduction of excess abdominal fat in patients with HIV-associated lipodystrophy. This article reviews the pharmacological properties, clinical efficacy and tolerability of tesamorelin in patients with HIV-associated central fat accumulation. Subcutaneous tesamorelin was effective in reducing visceral adipose tissue (VAT), but did not affect subcutaneous adipose tissue to a clinically significant extent in two 26-week, well designed, clinical trials in patients with HIV-associated central fat accumulation. This reduction in VAT was maintained in the longer term in patients who continued to receive tesamorelin until week 52 in the extension phases of the two trials. However, discontinuation of therapy during this period resulted in the reaccumulation of VAT. Tesamorelin therapy was also associated with significant improvements in other body composition measures (e.g. trunk fat and waist circumference) and improvements were generally seen in some body image parameters (e.g. belly image distress). Tesamorelin was generally well tolerated, with treatment-emergent serious adverse events occurring in <4% of patients during 26 weeks of therapy. Most of these events were injection-site reactions or events known to be associated with growth hormone therapy (e.g. arthralgia, headache and peripheral oedema). Although long-term clinical experience is needed to further assess the benefits and risks of therapy, current evidence suggests that tesamorelin may be useful for reducing visceral adiposity in patients with HIV-associated lipodystrophy, thereby potentially improving self image.

Menopause-associated metabolic manifestations and symptomatology in HIV infection: a brief review with research implications

Many women living with HIV in the United States have entered or will soon enter menopause. Clinical changes including increased visceral fat, reduced muscle mass, and changes in lipids and bone density are seen across the menopause transition among non-infected women. HIV and antiretroviral therapy use have been associated with similar manifestations, including reduced bone density, and changes in lipid metabolism and body composition. Menopause is also associated with changes in mood, quality of life, and vasomotor symptoms. Similar psychological indices are common among women with HIV, and may worsen during menopause transition. Research investigating the presence and acuity of metabolic, psychological, and vasomotor symptoms among perimenopausal women with HIV is limited. An important, yet unknown consideration for researchers and clinicians is how metabolic and psychological co-morbidities associated with HIV will influence changes associated with menopause in this population. Further research is needed to provide answers to these important questions.

Nucleosides accelerate inflammatory osteolysis, acting as distinct innate immune activators

The innate immune system and its components play an important role in the pathogenesis of inflammatory bone destruction. Blockade of inflammatory cytokines does not completely arrest bone erosion, suggesting that other mediators also may be involved in osteolysis. Previously we showed that nucleosides promote osteoclastogenesis and bone-resorption activity in the presence of receptor activator for nuclear factor κB ligand (RANKL) in vitro. The studies described here further demonstrate that selected nucleosides and nucleoside analogues accelerate bone destruction in mice immunized with collagen II alone (CII) but also further enhance bone erosion in mice immunized by collagen II plus complete Freund's adjuvant (CII + CFA). Abundant osteoclasts are accumulated in destructive joints. These data indicate that nucleosides act as innate immune activators distinct from CFA, synergistically accelerating osteoclast formation and inflammatory osteolysis. The potential roles of the surface triggering receptor expressed on myeloid cells (TREM) and the intracellular inflammasome in nucleoside-enhanced osteoclastogenesis have been studied. These observations provide new insight into the pathogenesis and underlying mechanism of bone destruction in inflammatory autoimmune osteoarthritis.

Bone mineral density in HIV-infected women taking antiretroviral therapy: a systematic review

There is a high prevalence of osteoporosis in HIV-infected patients. Initially described in HIV-positive men, studies have also demonstrated a high prevalence of osteoporosis in HIV-infected women. It would appear that antiretroviral therapy (ART) plays an important role in the pathogenesis of osteoporosis in HIV-infected patients, although little is known about its importance in relation to osteoporosis and fractures in HIV-positive women. The aim of this systematic review was to evaluate the frequency of bone loss, bone mineral density (BMD) and fractures in HIV-positive women taking ART or protease inhibitors (PI). After screening 597 citations from the databases of PubMed, EMBASE and Lilacs, five studies were selected for the review. A difference was demonstrated of over 3% in the BMD at the femoral neck of HIV-positive women taking PI/ART. No difference was registered in the BMD at the lumbar spine between users and non-users of PI/ART. The lack of studies has made it impossible to reach any conclusion regarding the occurrence of fractures.

Bone disease in HIV infection: a practical review and recommendations for HIV care providers

Low bone mineral density (BMD) is prevalent in human immunodeficiency virus (HIV)-infected subjects. Initiation of antiretroviral therapy is associated with a 2%-6% decrease in BMD over the first 2 years, a decrease that is similar in magnitude to that sustained during the first 2 years of menopause. Recent studies have also described increased fracture rates in the HIV-infected population. The causes of low BMD in individuals with HIV infection appear to be multifactorial and likely represent a complex interaction between HIV infection, traditional osteoporosis risk factors, and antiretroviral-related factors. In this review, we make the point that HIV infection should be considered as a risk factor for bone disease. We recommend screening patients with fragility fractures, all HIV-infected post-menopausal women, and all HIV-infected men ⩾50 years of age. We also discuss the importance of considering secondary causes of osteoporosis. Finally, we discuss treatment of the more severe cases of bone disease, while outlining the caveats and gaps in our knowledge.

HIV infection and bone disease: implications for an aging population

Now more than ever, the management of age-related problems, from cardiovascular morbidity to bone pathology, is increasingly relevant for HIV physicians. Low bone mineral density (BMD) and fractures are more common in HIV-infected patients. Although a multifactorial aetiology underlies this condition, increasing evidence suggests a role for antiretroviral therapy in low BMD, especially upon initiation. This review will detail the epidemiology, pathogenesis, diagnosis and management of osteoporosis and low BMD in HIV-infected patients, with particular emphasis on aging.

Hypovitaminosis D and bone mineral density in human immunodeficiency virus-infected men from India, with or without antiretroviral therapy

OBJECTIVE

To study the vitamin D status and bone mineral density (BMD) in men infected with human immunodeficiency virus (HIV) in a tertiary care center from southern India.

METHODS

We conducted a cross-sectional study of 35 HIV-infected men (between 20 and 50 years old) receiving highly active antiretroviral therapy (HAART) (group 1) in comparison with 35 age- and body mass index-matched HIV-positive antiretroviral therapy-naïve men (group 2) and 35 HIV-negative healthy control subjects (group 3).

RESULTS

A significantly greater proportion (P = .002) of patients (74%) in the HAART group had vitamin D deficiency (<20 ng/mL) in comparison with the other 2 groups (37% in each group). The mean intact parathyroid hormone level was higher (P<.001) and the mean duration of exposure to sunlight was lower (P = .001) in the HAART group than in the other 2 groups. By logistic regression analysis, HAART was found to be significantly associated with vitamin D deficiency. The BMD in the femoral neck was significantly lower in men with HIV infection who were receiving HAART in comparison with the other 2 groups (P = .006). On multivariate logistic regression, older age, low body mass index, and high parathyroid hormone levels emerged as factors significantly associated with decreased BMD at the femoral neck.

CONCLUSION

A significant proportion of patients receiving HAART had vitamin D deficiency. The secondary hyperparathyroidism probably due to vitamin D deficiency is an important contributing factor for the observed changes in BMD. Vitamin D deficiency noted in this group is probably multifactorial, and further research is needed to determine whether the effect of HAART on vitamin D metabolism is an additional causative factor and what benefit vitamin D supplementation might confer in these patients.

HIV and bone loss

The use of antiretroviral therapy has significantly reduced the number of deaths due to HIV/AIDS. However, no current therapy can suppress the virus completely, and as the HIV-infected population continues to live longer new complications are emerging from the persistence of the virus and use of antiretroviral therapy. This review summarizes the clinical evidence linking HIV-associated osteoporosis to direct infection and antiretroviral therapy (ART) use. The purported molecular mechanisms involved in bone loss are also reviewed. Additionally, recommendations regarding the pharmacologic management of HIV/ART-related osteoporosis are given.

Anthropometry in the prediction of sleep disordered breathing in HIV-positive and HIV-negative men

BACKGROUND

Body mass index (BMI), waist circumference (WC) and neck circumference (NC) are important screening tools for sleep disordered breathing (SDB); however, the utility of anthropometry for this purpose has not been evaluated among HIV-positive patients.

METHODS

HIV-negative men (n=60), HIV-positive men receiving highly active antiretroviral therapy (HIV-positive/HAART; n=58) and HIV-positive men not receiving HAART (HIV-positive/no HAART; n=41) from the Multicenter AIDS Cohort Study underwent a nocturnal sleep study and anthropomorphic assessment. Moderate-severe SDB was defined as an apnea/hypopnea event rate > or =15 episodes/h. Receiver operating characteristic (ROC) curves were used to compare the ability of different anthropometric measurements to predict SDB within each group.

RESULTS

Moderate-severe SDB was found in 48% of men (HIV-negative [57%], HIV-positive/HAART [41%] and HIV-positive/no HAART [44%]). The performance of BMI, WC and NC to predict SDB was excellent among the HIV-negative men (ROC areas under the curve [AUCs] 0.83, 0.88 and 0.88, respectively) and fair among the HIV-positive/HAART group (AUC 0.71, 0.77 and 0.77, respectively). By contrast, these measurements had no predictive value in the HIV-positive/no HAART group (AUC 0.43, 0.41 and 0.45, respectively). Moreover, in the HIV-positive/no HAART group, moderate-severe SDB was independently associated with serum C-reactive protein > or =3.0 mg/l (odds ratio 6.9; P=0.04) and HIV RNA>10,000 copies/ml (odds ratio 7.1; P=0.05).

CONCLUSIONS

BMI, WC and NC had a better predictive value for moderate-severe SDB in HIV-positive men compared with HIV-positive [corrected] men, and had no value among HIV-positive/no HAART men. Among this latter group, systemic inflammation might contribute to the pathogenesis of SDB.

Prevalence of bone mineral density abnormalities and related risk factors in an ambulatory HIV clinic population

Bone mineral density (BMD) abnormalities are observed frequently among human immunodeficiency virus (HIV)-infected patients. Risk factors for reduced BMD in the setting of HIV have been previously studied, but detailed antiretroviral treatment history is often not available. A cross-sectional observational study was conducted between 2005 and 2007 among unselected HIV-infected adults attending an ambulatory urban HIV clinic. Dual-energy X-ray absorptiometry (DXA) scans of lumbar spine and femoral neck, full laboratory profile, detailed questionnaire, and antiretroviral history were obtained. Univariate and multivariate logistic regression analyses were performed to investigate factors associated with BMD below the expected range for age. Two hundred ninety patients completed the study: 80% Caucasians, 89% males, with median age of 49 yr. Low BMD as assessed by Z-score was present in 19.7% of the patients. By multivariate analysis, only lower body mass index (BMI) was an independent risk factor for low BMD. Cumulative exposure to protease inhibitors, non-nucleosides, and individual nucleoside and nucleotide analogs were not independently associated with low BMD. In conclusion, a 19.7% prevalence of abnormal BMD by DXA scan was identified in an unselected group of HIV-infected adults. Lower BMI was independently associated with low BMD. No correlation was found between abnormal BMD and cumulative exposure to any antiretroviral agents.

Bone changes and fracture risk in individuals infected with HIV

The life expectancy of individuals infected with HIV has improved greatly since the institution of combination antiretroviral therapy. However, many metabolic derangements have been discovered with long-term combination antiretroviral treatment, including lipodystrophy; insulin resistance; and, more recently, abnormal bone metabolism. It is well-documented that bone mineral density (BMD) in HIV-positive patients is lower compared with the expected BMD in non-HIV-positive patients. The underlying cause of lower BMD is unknown but is thought to be a multifactorial process. Conflicting evidence exists regarding the effect of antiretroviral exposure and duration of treatment, antiretroviral type, and cumulative HIV viral exposure on bone health. Here we review the bone changes that occur with HIV infection and treatment.