Vitamin D deficiency is common in HIV-infected southern Australian adults

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

Background

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

Methods

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

Results

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

Conclusion

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

Vitamin D and Probability of Developmental Disorders among Perinatally HIV-Affected and Unaffected Ugandan Children

We tested the hypothesis that vitamin D deficiency (VDD) is associated with higher developmental disorder probability in 604 children with perinatal HIV infection (CPHIV, n = 199), HIV exposed and uninfected (CHEU, n = 196), and HIV unexposed uninfected (CHUU, n = 201). Children at 6-18 years old and their adult caregivers were assessed at enrollment, 6, and 12-month follow-ups. Serum 25-hydroxyvitamin-D (25OHD) levels in children quantified per the NHANES protocol were used to define VD categories as VDD (25OHD < 20 ng/mL), VD insufficient (VDI, 20 ≤ 25OHD ≤ 25 ng/mL), and VD sufficient (VDS = reference group if 25OHD > 25 ng/mL). Perinatal HIV status per DNA polymerase chain reaction/HIV rapid diagnostic tests included: CPHIV, CHEU, and CHUU. Developmental stage was defined as pre-adolescent (age < 11) vs. adolescent (age ≥ 11) years. Caregiver responses to standardized questions from Behavioral Assessment System for Children, Third Edition (BASC-3), were used to calculate probability scores for four disorders, namely: autism (ASD), attention deficit & hyperactivity (ADHD), emotional behavioral disorder (EBD), functional impairment (FI), and resiliency at 0, 6 and 12 months. Multivariable longitudinal models estimated VD-associated standardized mean difference (SMD) and corresponding 95% confidence intervals (95% CI) in respective probability scores in Statistical Analysis Software (v.9.4). Baseline VDD vs. VDS predicted higher probability scores of moderate clinical importance for ASD, ADHD, EBD, and higher FI among pre-adolescents (SMD = 0.32 to 0.40, 95% CI: 0.00 to 0.74). VDD was not associated with resiliency or any developmental disorders among adolescents. VDD predicted higher developmental disorder and FI scores over 12 months in a developmental stage-dependent manner. This relationship requires further understanding to appropriately target future interventions.

Prevalence and Predictors of Hypovitaminosis D in Ethiopian HIV-Infected Adults

Background

Hypovitaminosis D is associated with bone fracture and cardiovascular disease in patients receiving antiretroviral therapy. Currently, there are few data on the magnitude of hypovitaminosis D in people living with HIV in Sub-Saharan country. Therefore, the present study determines the magnitude of hypovitaminosis D in people living with HIV and its associated factors in Ethiopia.

Methods

A cross-sectional study was conducted among 171 adult people living with HIV at Debre Berhan Specialized Hospital. Serum vitamin D was measured. Multivariate logistic regression analysis and p-value <0.05 was used to identify the associated factors of hypovitaminosis D.

Results

In the present study, the prevalence of hypovitaminosis D was 129/171 (75.4%), with 11/171 (6.4%) having vitamin D deficiency and 118/171 (69%) having vitamin D insufficiency. Female sex was significantly associated with hypovitaminosis D (AOR: 3.01, 95% CI = 1.381–6.561, P = 0.006).

Conclusion

Our study found a high burden of hypovitaminosis D among adult people living with HIV on antiretroviral therapy. Female sex was associated with hypovitaminosis D.

How far is vitamin D implicated in cutaneous infections

Vitamin D is an important cornerstone in the immunologic cascade of many skin infections, systemic infections with cutaneous presentations, and other infectious dermatologic diseases where infections could be a culprit. Vitamin D supplementation is proposed as a protective measure against their occurrence and exacerbation, especially with the emergence of several viral pandemics in recent years. Vitamin D plays a key role in the maintenance of a balanced immunologic profile which could be reflected by a lowered incidence and morbidity of infections. Vitamin D screening and supplementation in patients with deficiencies or insufficiencies should be a part of the dermatologic approach to patients with these diseases.

Vitamin D as Modulator of Drug Concentrations: A Study on Two Italian Cohorts of People Living with HIV Administered with Efavirenz

To date, vitamin D seems to have a significant role in affecting the prevention and immunomodulation in COVID-19 disease. Nevertheless, it is important to highlight that this pro-hormone has other several activities, such as affecting drug concentrations, since it regulates the expression of cytochrome P450 (CYP) genes. Efavirenz (EFV) pharmacokinetics is influenced by CYPs, but no data are available in the literature concerning the association among vitamin D levels, seasonality (which affects vitamin D concentrations) and EFV plasma levels. For this reason, the aim of this study was to evaluate the effect of 25-hydroxy vitamin D (25(OH)D3) levels on EFV plasma concentrations in different seasons. We quantified 25(OH)D3 by using chemiluminescence immunoassay, whereas EFV plasma concentrations were quantified with the HPLC–PDA method. A total of 316 patients were enrolled in Turin and Rome. Overall, 25(OH)D3levels resulted in being inversely correlated with EFV concentrations. Some patients with EFV levels higher than 4000 ng/mL showed a deficient 25(OH)D3 concentration in Turin and Rome cohorts and together. EFV concentrations were different in patients without vitamin D supplementation, whereas, for vitamin D-administered individuals, no difference in EFV exposure was present. Concerning seasonality, EFV concentrations were associated with 25(OH)D3 deficiency only in winter and in spring, whereas a significant influence was highlighted for 25(OH)D3 stratification for deficient, insufficient and sufficient values in winter, spring and summer. A strong and inverse association between 25(OH)D3and EFV plasma concentrations was suggested. These data suggest that vitamin D is able to affect drug exposure in different seasons; thus, the achievement of the clinical outcome could be improved by also considering this pro-hormone.

Increased Risk of Vitamin D Deficiency Among HIV-Infected Individuals: A Systematic Review and Meta-Analysis

Background: Human immunodeficiency virus (HIV) infection is a heavy burden worldwide. Observational studies have reported a high prevalence of vitamin D deficiency (VDD) among people living with HIV (PLWH). However, its deficiency is also a global health problem. Therefore, we conducted a meta-analysis and systemic review to compare differences between HIV-infected subjects and non-HIV-infected subjects.

Methods: We searched PubMed, Web of Science, Embase, and Cochrane library. We extracted data, including demographic information, study type, vitamin D-related values, and HIV-related values, ultimately including 15 studies after removing duplicates and screening titles, abstracts, and full texts and finally performing a meta-analysis in terms of vitamin D level and vitamin D deficiency prevalence.

Results: Regarding VDD prevalence, the HIV vs. the non-HIV group had an odds ratio of 1.502 (95% CI, 1.023–2.205; P = 0.038). In the subgroup analysis, the odds ratios were 1.647 (95% CI, 1.020–2.659; P = 0.041; I² = 94.568) from 7 studies (age over 40), 2.120 (95% CI, 1.122–4.008; P = 0.021; I² = 0.000) from 2 studies (BMI less than or equal to 25), 1.805 (95% CI, 1.373–2.372; P = 0.042; I² = 74.576) from 7 studies (latitude <40), 2.120 (95% CI, 1.122–4.088; P = 0.021; I² = 0.000) from 2 studies (only included male participants), and 2.296 (95% CI, 1.287–4.097; P = 0.005; I² = 19.927) from 3 studies (only included ART-experienced participants). Thirteen studies were deemed to have moderate quality, while two had high quality.

Conclusions: HIV infected subjects are prone to have VDD compared with general population. ART, older age, lower BMI, lower latitude and male sex may present risk factors for VDD in PLWH.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=228096.

The relevance of vitamin D in the oral health of HIV infected patients

HIV infection affects 36.9 million people globally, and vitamin D deficiency is a global public health concern for HIV patients. Approximately 70 %-80 % of HIV-infected patients have vitamin D deficiency. The deficiency is associated with many pathologies such as immune disorders, infectious diseases, chronic inflammation, oral diseases, as well as the fast progression of HIV. The causes of vitamin D deficiency in HIV infections include HIV itself, traditional factors such as less sun exposure, mal-absorption, hypercholesterolemia, seasonal variation, poor nutrition as well as some HAART drugs like efavirenz. Vitamin D has an immunomodulatory, anti-inflammatory, and anti-proliferative function. In the oral cavity, it plays a significant role in preventing oral infections such as periodontal and gum diseases, dental caries, and oral candidiasis. The consequences of vitamin D deficiency are bone resorption, increased productions of pro-inflammatory cytokines, T-lymphocytes, increased T-helper-1 functions, and decreased T-helper-2 functions. Consequently, this leads to increased infections, chronic inflammation, and the occurrence of oral diseases such as oral candidiasis, periodontal and gum diseases, and dental caries. The majority of these oral diseases are encountered in HIV patients. Vitamin D deficiency is significantly found in HIV patients. There is a lack of studies that directly link vitamin D to most oral diseases in HIV patients; however, the role of vitamin D in immunoregulation, prevention of oral diseases, and HIV infection is substantiated.

Increased risk factors associated with lower BMD in antiretroviral-therapy-naïve HIV-infected adult male

BACKGROUND

Low BMD (bone mineral density) has been described as a non-AIDS (Acquired Immune Deficiency Syndrome)-related event in HIV (human immunodeficiency virus)-patients but it is poorly studied in young HIV-infected men who have received no previous antiretroviral therapy.

METHODS

A cross-sectional study of 245 naïve-HIV-infected men over 21 and under 50 years old who voluntary attended the Infectious Disease Division appointment in Hospital Fundación Jimenez Díaz in Madrid, from January 1st, 2014 to September 30th, 2017. All subjects underwent a baseline DXA scan (dual energy x-ray absorptiometry) performed prior to start antiretroviral treatment. Further, all patients who started treatment between May 1st and September 30th, 2017 were invited to participate in a substudy on bone mineral metabolism. All the information was collected through clinical history and complementary questionnaire.

RESULTS

The mean age was 36.4 years, been 68% Caucasian, 29.3% Latin American and 2.7% African race. At the time of diagnosis, 91% of patients had stage-A (median CD4+ T-cell 481cells/μL, IQR, 320-659). 10% had a count below 200 CD4 cells/μL, and 40% had a CD4/CD8 cell-count-ratio below 0.4. Regarding lifestyle and risk factors, 14.1% presented underweight, 36.1% were not engage in any regular exercise, 51.9% were active smokers and 35.3% reported drug use. Low levels of vitamin D were seen in 87.6% of the study participants. Low BMD (Z-score <- 2.0) was found in 22.8% of the patients. It was only observed a significant association of Z-score in lumbar spine (LS) with CD8 and the CD4/CD8 ratio, and with alcohol for femoral neck (FN) measurement.

CONCLUSIONS

We find prevalence of increased bone involvement among naïve HIV-infected men under 50 years old. Further studies are necessary to evaluate if changes in actual guidelines are needed to assess BMD measurements in HIV-infected adult male patients under 50.

Serum Vitamin D is Differentially Associated with Socioemotional Adjustment in Early School-Aged Ugandan Children According to Perinatal HIV Status and In Utero/Peripartum Antiretroviral Exposure History

An impact of vitamin D in neurocognitive function has been theorized but it remains unknown whether vitamin-D insufficiency (VDI) is associated with worse socio-emotional adjustment (SEA) in vulnerable early school-aged children. This study examines the thesis that deficits in SEA are related to VDI using longitudinal data from 254 children that are perinatally HIV-infected (PHIV), exposed-uninfected (HEU), or unexposed-uninfected (HUU). In utero/peripartum antiretroviral (IPA) exposure was established per medical record documentation of biological mother’s ART regimen in pregnancy. Four caregiver-reported age- and sex-standardized measures of SEA were obtained at months 0, 6, and 12 for dependent children aged 6–10 years: externalizing problems (EPC), internalizing problems (IPC), behavioral symptoms index (BSI), and adaptive skills index (ASI). VDI was highly prevalent (74%, n = 188), and its association with change in SEA measures over 12 months varied by HIV-status (VDI*HIV, all p-values < 0.03). There was further variation in relationship of vitamin-D to SEA by IPA among PHIV (for ASI, BSI, and EPC, vitamin-D*IPA, p-value ≤ 0.01) and HEU (for BSI and EPC, vitamin-D*IPA, p-value ≤ 0.04). Among HUU, BSI (β = −0.32, 95% CI: −0.50, −0.13), IPC (β = −0.28, 95% CI: −0.47, −0.09), and EPC (β = −0.20, 95% CI: −0.37, −0.02) all declined moderately per quartile increment in VD. Among PHIV, on the one hand higher vitamin D predicted ASI gains (moderate vs. low VD, β = 0.52, p = 0.002), but this protective association was absent for BSI, EPC, and IPC (β = 0.36–0.77, p < 0.05). In absence of IPA-exposure, increasing vitamin-D predicted declines in BSI and EPC (moderate vs. low Vitamin D, β = −0.56 to −0.71, p ≤ 0.02) among HEU. However, given IPA exposure among HEU, higher VDI predicted moderate elevation in BSI (β = 0.39, 95% CI: 0.00, 0.78) and IPC (β = 0.48, 95% CI: 0.05, 0.92). Interaction between VD and IPA exposure for SEA outcomes among HEU and PHIV children warrants further investigation. The vitamin-D associated SEA improvement among HUU and HEU without IPA exposure suggests vitamin-D supplementation may remediate behavioral and adaptive deficits in this groups.

Vitamin D deficiency is associated with neurocognitive impairment in HIV-infected subjects

PURPOSE

Low vitamin D levels are associated with higher odds of cognitive dysfunction in the older population, and in subjects with mental disorders or with chronic neurologic diseases. With combination antiretroviral therapy (cART), incidence of HIV-associated dementia has reduced, while the prevalence of milder forms of neurocognitive impairment (NCI) persisted stable over time. Hypovitaminosis D is often found in HIV infection but its association with NCI has not been investigated yet. The aim was to explore this association in a clinic-based HIV-positive population.

METHODS

A retrospective, cross-sectional analysis of an existing monocenter dataset obtained from patients undergoing neuropsychological assessment in routine clinical care between January, 2011 and December, 2016 was carried out. NCI was assessed through a standardized battery of 13 tests on 5 different cognitive domains and HIV-associated neurocognitive deficit (HAND) was classified according to Frascati's criteria. Vitamin D deficiency was defined by 25 hydroxy-vitamin D 25(OH)D levels < 10 ng/mL. Logistic regression was adjusted for main associated covariates and seasonality.

RESULTS

542 patients were included: 96.7% were receiving cART, median CD4 count was 611/mmc (IQR, 421-809), HIV RNA was < 40 cp/mL in 85.8%. Median 25(OH)D was 23.2 ng/mL (IQR, 15.6-29.2), with vitamin D insufficiency 67.7% and deficiency in 9.4%. Overall, NCI was found in 37.1% and HAND in 22.7%. Compared to patients with higher vitamin D levels, subjects with vitamin D deficiency had increased proportions of NCI (52.9% versus 35.4%; p = 0.014) or of HAND (42.9% versus 24.9%; p = 0.012). Median NPZ-8 scores were significantly different based on vitamin D levels (p = 0.021). At multivariable analyses, vitamin D deficiency was the only risk factor of NCI (OR 2.05; 95% CI 1.04-4.05; p = 0.038) or of HAND (OR 2.12; 95% CI 0.99-4.54; p = 0.052).

CONCLUSIONS

In HIV-positive persons, severe hypovitaminosis D was independently associated with a higher risk of neurocognitive impairment in general, and of HIV-associated neurocognitive disorders in particular. Future studies are needed to elucidate causal relationship and whether vitamin D supplementation may reverse this risk.

Continued Interest and Controversy: Vitamin D in HIV

PURPOSE OF REVIEW

Vitamin D (VitD) deficiency is highly prevalent among HIV-infected individuals. Given the overlapping risk for several chronic disease and immunomodulatory outcomes from both long-standing HIV and VitD deficiency, there is great interest in clarifying the clinical role of VitD for this population.

RECENT FINDINGS

Recent studies have expanded our knowledge regarding the epidemiology and mechanisms of VitD deficiency-associated outcomes in the setting of HIV. Clinical trials focusing on VitD supplementation have demonstrated a positive impact on bone mineral density in subgroups of HIV-infected individuals initiating ART or on suppressive ART regimens; however, significant heterogeneity exists between studies and data are less consistent with other clinical outcomes. Further research is needed to clarify uncertainly in several domains, including identifying patients at greatest risk for poor outcomes from VitD deficiency, standardizing definitions and measurement techniques, and better quantifying the benefits and risks of VitD supplementation across different demographic strata for skeletal and extra-skeletal outcomes.

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.

Vitamin D and bone loss in HIV

PURPOSE OF REVIEW

Bone health has become an increasingly important aspect of the care of HIV-infected patients as bone loss with antiretroviral therapy (ART) initiation is significant and osteopenia and osteoporosis are highly prevalent. Vitamin D is tightly linked to calcium balance and bone health, and vitamin D deficiency is common in HIV. This review outlines the epidemiology of vitamin D deficiency in HIV, summarizes our current understanding of the relationship between vitamin D and bone loss in HIV and the impact of vitamin D supplementation in this patient group.

RECENT FINDINGS

Although data are conflicting as to whether vitamin D deficiency is more prevalent among HIV-infected individuals than in the general population, there are several reasons for why this patient group may be at heightened risk. Studies linking vitamin D deficiency to bone loss in HIV are limited; however, data from randomized clinical trials suggest a benefit of vitamin D supplementation for the prevention of bone loss with ART initiation and for the treatment of bone loss with bisphosphonate therapy.

SUMMARY

There are too limited data to recommend universal screening of vitamin D status or supplementation to all HIV-infected individuals. However, testing 25-hydroxyvitamin D levels in those at risk for deficiency and treating patients found to be deficient or initiating ART or bisphosphonate therapy should be considered. Further study on vitamin D supplementation is needed regarding the potential benefit on immune activation and restoration in this patient group.

Bone health and HIV in resource-limited settings: a scoping review

PURPOSE OF REVIEW

Sub-Saharan Africa and other resource-limited settings (RLS) bear the greatest burden of the HIV epidemic globally. Advantageously, the expanding access to antiretroviral therapy (ART) has resulted in increased survival of HIV individuals in the last 2 decades. Data from resource rich settings provide evidence of increased risk of comorbid conditions such as osteoporosis and fragility fractures among HIV-infected populations. We provide the first review of published and presented data synthesizing the current state of knowledge on bone health and HIV in RLS.

RECENT FINDINGS

With few exceptions, we found a high prevalence of low bone mineral density (BMD) and hypovitaminosis D among HIV-infected populations in both RLS and resource rich settings. Although most recognized risk factors for bone loss are similar across settings, in certain RLS there is a high prevalence of both non-HIV-specific risk factors and HIV-specific risk factors, including advanced HIV disease and widespread use of ART, including tenofovir disoproxil fumarate, a non-BMD sparing ART. Of great concern, we neither found published data on the effect of tenofovir disoproxil fumarate initiation on BMD, nor any data on incidence and prevalence of fractures among HIV-infected populations in RLS.

SUMMARY

To date, the prevalence and squeal of metabolic bone diseases in RLS are poorly described. This review highlights important gaps in our knowledge about HIV-associated bone health comorbidities in RLS. This creates an urgent need for targeted research that can inform HIV care and management guidelines in RLS.