The effect of HIV-hepatitis C co-infection on bone mineral density and fracture: a meta-analysis

HIV and fracture: Risk, assessment and intervention

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.

HIV and an Ageing Population-What Are the Medical, Psychosocial, and Palliative Care Challenges in Healthcare Provisions

The continuing increase in patient numbers and improvement in healthcare provisions of HIV services in the UK, alongside the effectiveness of combined antiretroviral therapy (cART), has resulted in increasing numbers of the ageing population among people living with HIV (PLWH). It is expected that geriatricians will need to deal with many older people living with HIV (OPLWH) as life expectancy increases. Therefore, geriatric syndromes in OPLWH will be similar to the normal population, such as falls, cognitive decline, frailty, dementia, hypertension, diabetes and polypharmacy. The increase in the long-term use of cART, diabetes, dyslipidaemia and hypertension may lead to high prevalence of cardiovascular disease (CVD). The treatment of such conditions may lead to polypharmacy and may increase the risk of cART drug-drug interactions. In addition, the risk of developing infection and cancer is high. OPLWH may develop an early onset of low bone mineral density (BMD), osteoporosis and fractures. In this review, we have also provided potential psychosocial aspects of an ageing population with HIV, addressing issues such as depression, stigma, isolation and the need for comprehensive medical and psychosocial care through an interdisciplinary team in a hospital or community setting. OPLWH have a relatively high burden of physical, psychological, and spiritual needs and social difficulties, which require palliative care. The holistic type of palliative care that will improve physical, emotional and psychological wellbeing is discussed in this review.

Bone Health in People Living with HIV/AIDS: An Update of Where We Are and Potential Future Strategies

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.

Osteoporosis and HIV Infection

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.

Negative correlation between bone mineral density and subclinical fractures in patients with human immunodeficiency virus

Background

Although low bone mineral density (BMD) is associated with an increased risk of fracture, few studies have assessed fracture rates in patients with human immunodeficiency virus (HIV).

Methods

The occurrence of subclinical fractures in patients with HIV was assessed. Pearson’s chi-square test was used to analyze the relationship between subclinical fractures and related factors.

Results

Fifty patients with HIV were included, among whom 11 were diagnosed with subclinical fractures. These 11 patients had a mean body mass index of 24.127 ± 3.482 kg/m², smoked a mean of 142.091 ± 3.482 cigarettes/month, drank a mean of 61.545 ± 13.026 mL/day of alcohol, had a mean CD4⁺ T cell count of 247.727 ± 181.679 cells/mm³, had a mean duration of acquired immunodeficiency syndrome (AIDS) of 4.27 ± 0.786 years, and had a mean BMD of the third lumbar spine of 0.810 ± 0.063 g/cm³. The AIDS duration and BMD of the third lumbar spine were significantly associated with subclinical fractures. The BMD of the third lumbar spine was negatively correlated with subclinical fractures.

Conclusion

A significant negative correlation was found between the BMD of the third lumbar spine and subclinical fractures.

Veterans Aging Cohort Study Index as a Marker of Bone Disease in HIV-Infected Patients

People living with human immunodeficiency virus (HIV) infection have higher risk of low bone mineral density (BMD) and fragility fracture than general population. The aim of our retrospective study was to explore if HIV-specific Veterans Aging Cohort Study (VACS) Index and its specific components could help identify patients at risk for low BMD. A total of 195 HIV-infected patients with dual-energy X-ray absorptiometry (DXA) scan between 2007 and 2014 were included and DXA scan results were used to classify patients with osteopenia. VACS Index was calculated for all patients using laboratory values closest to the date of DXA scan. Logistic regression was used to assess the association between VACS Index score or individual components of VACS Index with the presence of low BMD after adjusting for confounding variables. A total of 109 (56%) patients were diagnosed with low BMD. VACS Index score was significantly associated with low BMD, with the odds of low BMD increasing 1.21 times for each 10 unit increase in VACS Index score [confidence interval (95% CI) 1.03-1.42; p = .02]. The two groups differed significantly on patient weights, proportion of white patients, and hepatitis C-coinfected patients. After adjusting for white race and weight, hepatitis C coinfection was significantly associated with increased risk of low BMD (odds ratio 24.4; 95% CI 7.45-80.16). VACS Index score, previously demonstrated to be a marker of frailty in HIV-infected patients, is significantly associated with risk of low BMD and could be used to develop a prediction tool to screen for low BMD in resource-limited setting where DXA scans are not easily available.

Improved fracture prediction using different fracture risk assessment tool adjustments in HIV-infected women

OBJECTIVES

A fracture risk assessment tool (FRAX) using clinical risk factors (CRFs) alone underestimates fracture risk in HIV-infected men. Our objective was to determine whether accuracy of FRAX would be improved by considering HIV as a cause of secondary osteoporosis, and further improved with addition of dual-energy X-ray absorptiometry parameters in HIV-infected women.

DESIGN

Subgroup analysis of Women's Interagency HIV Study.

METHODS

We included 1148 women (900 HIV-infected and 248 uninfected) over age 40 with data to approximate FRAX CRFs and 10-year observational data for incident fragility fractures; 181 (20%) HIV-infected women had dual-energy X-ray absorptiometry data. Accuracy of FRAX was evaluated by the observed/estimated ratios of fracture in four models: CRFs alone; CRFs with HIV included as a cause of secondary osteoporosis; CRFs and femoral neck bone mineral density (FN BMD); and CRFs, FN BMD and trabecular bone score.

RESULTS

FRAX using CRFs were less accurate in HIV-infected than uninfected women for major osteoporotic (observed/estimated ratio: 5.05 vs. 3.26, P < 0.001) and hip fractures (observed/estimated ratio: 19.78 vs. 7.94, P < 0.001), but improved when HIV was included as a cause of secondary osteoporosis. Among HIV-infected women, FRAX accuracy improved further with addition of FN BMD (observed/estimated ratio: 4.00) for hip fractures, but no further with trabecular bone score.

CONCLUSION

FRAX using CRFs alone underestimated fracture risk more in older HIV-infected women than otherwise similar uninfected women. Accuracy is improved when including HIV as a cause of secondary osteoporosis for both major osteoporotic and hip fractures, whereas addition of FN BMD only improved accuracy for hip fracture.

Hepatitis C virus infection and risk of osteoporotic fracture: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Hepatitis C virus (HCV) infection is one of the most common causes of chronic liver disease. Several epidemiologic studies have suggested that patients with HCV infection might have a higher risk of osteoporotic fracture. However, the data are inconclusive. This systematic review and meta-analysis was conducted with the aims to summarize all available evidence.

METHODS

A literature search was performed using MEDLINE and EMBASE database from inception to June 2016. Studies that reported relative risks, odd ratios, or hazard ratios comparing the risk of osteoporotic fracture among HCV-infected patients versus subjects without HCV infection were included. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Three studies with 362,285 participants met our eligibility criteria and were included in analysis. We found a significantly higher risk of osteoporotic fracture among patients with HCV infection with RR of 1.53 (95% CI 1.09 to 2.14).

CONCLUSIONS

Our study demonstrated an increased risk of osteoporotic fracture among HCV-infected patients. Further studies are required to clarify how this risk should be addressed in clinical practice.

Protecting bone in long-term HIV positive patients receiving antiretrovirals

INTRODUCTION

As the population of people living with HIV ages, the increase in non-AIDs morbidities is expected to increase in parallel. Maintaining bone health in those with HIV will be an important area of focus for the HIV clinician to prevent the morbidity and mortality associated with fragility fractures, the principal clinical sequela of low bone mineral density (BMD). Rates of fractures and prevalence of low bone mineral density, a risk factor for future fragility fractures, are already increased in the HIV positive population.

AREAS COVERED

This review examines the strategies to maintain bone health in those living with HIV from screening through to managing those with established low BMD or fracture, including the role for choice of or modification of antiretroviral therapy to maintain bone health. Expert commentary: The increasing complexity of managing bone health in the age of succesful antiretroviral therapy and an aging patient population as well as future perspectives which may help achieve the long term aim of minimising the impact of low BMD in those with HIV are discussed and explored.

HIV and ageing: improving quantity and quality of life

PURPOSE OF REVIEW

Evidence-based strategies are needed to address the growing complexity of care of those ageing with HIV so that as life expectancy is extended, quality of life is also enhanced.

RECENT FINDINGS

Modifiable contributing factors to the quantity and quality of life in adults ageing with HIV include: burden of harmful health behaviours, injury from HIV infection, HIV treatment toxicity and general burden of age-associated comorbidities. In turn, these factors contribute to geriatric syndromes including multimorbidity and polypharmacy, physiologic frailty, falls and fragility fractures and cognitive dysfunction, which further compromise the quality of life long before they lead to mortality.

SUMMARY

Viral suppression of HIV with combination antiviral therapy has led to increasing longevity but has not enabled a complete return to health among ageing HIV-infected individuals (HIV+). As adults age with HIV, the role of HIV itself and associated inflammation, effects of exposure to antiretroviral agents, the high prevalence of modifiable risk factors for age-associated conditions (e.g. smoking), and the effects of other viral coinfections are all influencing the health trajectory of persons ageing with HIV. We must move from the simplistic notion of HIV becoming a 'chronic controllable illness' to understanding the continually evolving 'treated' history of HIV infection with the burden of age-associated conditions and geriatric syndromes in the context of an altered and ageing immune system.

Bone Loss in HIV Infection

Human immunodeficiency virus (HIV) infection is an established risk factor for low bone mineral density (BMD) and subsequent fracture, and treatment with combination antiretroviral therapy (cART) leads to additional BMD loss, particularly in the first 1-2 years of therapy. The prevalence of low BMD and fragility fracture is expected to increase as the HIV-infected population ages with successful treatment with cART. Mechanisms of bone loss in the setting of HIV infection are likely multifactorial, and include viral, host, and immune effects, as well as direct and indirect effects of cART, particularly tenofovir disoproxil fumarate (TDF) and the protease inhibitors (PIs). Emerging data indicate that BMD loss following cART initiation can be mitigated by prophylaxis with either long-acting bisphosphonates or vitamin D and calcium supplementation. In addition, newer antiretrovirals, particularly the integrase strand transfer inhibitors and tenofovir alafenamide (TAF), are associated with less intense bone loss than PIs and TDF. However, further studies are needed to establish optimal bone sparing cART regimens, appropriate screening intervals, and preventive measures to address the rising prevalence of fragility bone disease in the HIV population.

Hepatitis C virus infection and risk of osteoporosis: A meta-analysis

BACKGROUND/AIMS

Hepatitis C virus (HCV) infection is one of the most common infections worldwide. Several epidemiologic studies have suggested that patients with HCV infection might be at an increased risk of osteoporosis. However, the data on this relationship remains inconclusive. This meta-analysis was conducted with the aim to summarize all available evidence.

MATERIALS AND METHODS

A literature search was performed using MEDLINE and EMBASE databases from inception to June 2016. Studies that reported relative risks, odd ratios (OR), or hazard ratios comparing the risk of osteoporosis among HCV-infected patients versus those without HCV infection were included. Pooled OR and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Four studies met our eligibility criteria and were included in the analysis. We found a higher risk of osteoporosis among patients with chronic HCV with OR of 1.65 (95% CI: 0.98-2.77). Sensitivity analysis including only studies with higher quality yielded a higher OR, and the result was statistically significant (OR: 2.47; 95% CI: 1.03-5.93).

CONCLUSIONS

Our study demonstrated a higher risk of osteoporosis among HCV-infected patients. Further studies are required to clarify how this risk should be addressed in clinical practice.

Hepatitis C virus coinfection as a risk factor for osteoporosis and fracture

PURPOSE OF REVIEW

With increased survival of HIV-infected patients, osteoporotic fractures have developed as a major cause of morbidity in these patients, and chronic hepatitis C virus (HCV) coinfection has emerged as a significant contributor to this increased fracture risk. The present article reviews the epidemiologic and clinical evidence for osteoporosis and increased fracture risk among HIV/HCV coinfected patients, and potential mechanisms for these outcomes with HCV coinfection.

RECENT FINDINGS

Epidemiologic studies suggest that HIV/HCV coinfected patients exhibit a three-fold increased fracture incidence compared with uninfected controls, and 1.2-2.4-fold increased fracture risk compared with HIV monoinfected patients. Recent reports suggest that chronic HCV coinfection is independently associated with reduced bone mineral density in HIV, but that it is not associated with significantly increased bone turnover. The deleterious impact of chronic HCV on BMD and fracture risk occurs even in the absence of advanced liver fibrosis or cirrhosis. New tools to assess bone quality, including the trabecular bone score, high-resolution peripheral quantitative computed tomography, and in-vivo microindentation, may help improve understanding of the mechanisms of HCV-associated skeletal fragility. The impact of approved antiosteoporosis medications and direct-acting antivirals for the treatment of chronic HCV infection on patients' bone health remain to be studied.

SUMMARY

Chronic HCV infection is an independent risk factor for osteoporosis and fractures among HIV-infected patients, even before the development of cirrhosis. The underlying mechanisms are being unraveled, but major questions persist regarding the optimal evaluation and management of bone health in HIV/HCV coinfected patients.

Microstructural alterations of trabecular and cortical bone in long-term HIV-infected elderly men on successful antiretroviral therapy

OBJECTIVE

Progress in antiretroviral therapy (ART) has resulted in an almost normal life expectancy for HIV-infected individuals, but an increased risk of fragility fractures has been identified. We investigated the influence of long-term HIV infection on successful ART on bone microstructure in elderly men.

DESIGN

A cross-sectional, case–control study.

METHODS

Dual-energy X-ray absorptiometry (DXA) and high-resolution peripheral quantitative computed tomography (HR-pQCT) were performed in 28 HIV-positive men between 60 and 70 years old on successful ART. Controls were 112 HIV-negative men matched for age 4 years and BMI (4 kg/ m²).

RESULTS

HIV-positive men (median CD4þ cell count, 589 cells/ml; BMI, 24.8 kg/m²) had a median duration of HIV infection of 18.2 years. Compared with HIV-negative men, they had a lower DXA-measured areal bone mineral density at total hip (3.2%, P¼0.050) and ultra-distal radius (8.4%, P¼0.001). At distal radius and tibia, we observed microstructural alterations with a lower total density (16%, P¼ 0.005 and 14.3%, P¼ 0.039), trabecular density (11.6%, P¼ 0.012 and 12.2%, P¼ 0.007) and cortical area (17.5%, P¼ 0.002 and 12.2%, P¼ 0.01). In addition, they had a lower trabecular number (P¼ 0.036), higher trabecular spacing (P¼ 0.027) and lower cortical thickness (19.9%; P¼ 0.008) at distal radius. beta-crosslaps (CTX) and vitamin D levels were higher than in controls. By multivariate analyses, HIV status, higher CTX levels, lower physical activity and estradiol levels were determinants of bone density and microstructure alterations.

CONCLUSION

HIV-infected elderly men on successful ART have trabecular and cortical bone microstructure alterations associated with higher bone resorption, despite adequate vitamin D supplementation.

Human immunodeficiency virus and acquired immunodeficiency syndrome: recent developments and their implications for pediatric surgeons

Advances in medical management have enhanced both the quality and the quantity of life currently enjoyed by HIV-infected infants and children. Advances in surgical treatment have complemented these advances and contributed to the improving prognosis of HIV disease in the pediatric population. The resultant "aging" of the pediatric HIV population means that pediatric surgeons can expect to encounter HIV-infected patients on an ever-increasing basis. This article reviews the new advances in diagnosis and treatment of pediatric HIV disease most relevant to pediatric surgical practice.