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Kamkwalala AR, Garg A, Roy U, Matthews A, Castillo-Mancilla J, Lake JE, Sebastiani G, Yin M, Brown TT, Kamer AR, Jabs DA, Ellis RJ, Boffito M, Greene M, Schmalzle S, Siegler E, Erlandson KM, Moore DJ. Current Considerations for Clinical Management and Care of People with HIV: Findings from the 11th Annual International HIV and Aging Workshop. AIDS Res Hum Retroviruses 2021; 37:807-820. [PMID: 34405689 PMCID: PMC8817696 DOI: 10.1089/aid.2021.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The number of people with HIV (PWH) aged 50 years or older continues to steadily increase. The convergence of age- and HIV-related complications in these individuals presents a challenge for both patients and clinicians alike. New findings continue to emerge, as numerous researchers evaluate the combined impact of these two factors on quality of life, physiological systems, and mental health in PWH. Since its first occurrence in 2009, the International Workshop on HIV and Aging has served as a multidisciplinary meeting to share basic biomedical data, clinical trial results, treatment strategies, and epidemiological recommendations, toward better understanding and outcomes among like-minded scientific professionals. In this article, we share a selection of key findings presented in plenary talks at the 11th Annual International Workshop on HIV and Aging, held virtually from September 30, 2020 to October 2, 2020. We will also address the future directions of HIV and aging research, to further assess how the aging process intersects with chronic HIV.
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Affiliation(s)
| | - Ankita Garg
- Department of Infectious Diseases, University of Georgia, Athens, Georgia, USA
| | - Upal Roy
- Department of Health and Biomedical Sciences, The University of Texas Rio Grande Valley, Brownsville, Texas, USA
| | - Avery Matthews
- Department of Psychiatry, South Texas Veteran Health Care System, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jose Castillo-Mancilla
- Department of Medicine, Division of Infectious Disease, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jordan E. Lake
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Giada Sebastiani
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Michael Yin
- Department of Infectious Disease, Columbia University, New York, New York, USA
| | - Todd T. Brown
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Angela R. Kamer
- Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, New York, USA
| | - Douglas A. Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Ophthalmology, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ronald J. Ellis
- Department of Neurosciences, University of California San Diego, La Jolla, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Marta Boffito
- Department of HIV Services, Chelsea and Westminster Hospital, London, United Kingdom
| | - Meredith Greene
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Sarah Schmalzle
- Department of Infectious Disease, University of Maryland, Baltimore, Maryland, USA
| | - Eugenia Siegler
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Kristine M. Erlandson
- Department of Medicine, Division of Infectious Disease, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - David J. Moore
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
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Vizcarra P, Gallego J, Vivancos MJ, Sifuentes WA, Llop M, Casado JL. Evaluation of the fracture risk assessment tool for determining bone disease and the impact of secondary causes of osteoporosis in people living with HIV. HIV Res Clin Pract 2020; 21:63-71. [PMID: 32698706 DOI: 10.1080/25787489.2020.1794438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Among HIV-infected individuals, screening for bone disease is encouraged to assess reversible risk factors and plan therapeutic interventions. OBJECTIVE We assessed the usefulness of Fracture Risk Assessment (FRAX) tool to identify candidates for dual X-ray absorptiometry (DXA) scan, or individuals with bone loss progression. We further explored how secondary causes of osteoporosis are reflected on FRAX. METHODS Longitudinal study of 217 consecutive individuals (mean, 45.8 years, 24% females) included after DXA scan. FRAX was calculated without/with femoral neck bone mineral density (BMD), checking the box of "secondary osteoporosis" for all the individuals. RESULTS Low BMD was observed in 133/217 (61%) individuals, of whom 98.5% had not been selected as candidates for DXA by current FRAX thresholds. Specifically, 23% of individuals aged <50 had low BMD but none was candidate for DXA. Adding BMD data, FRAX results increased by 50-100%, with 2/217 individuals (1%) above the thresholds. Classical and HIV-related secondary causes of osteoporosis (observed in 98% overall) correlated with low BMD, modifying significantly FRAX results (HCV coinfection, +124%; longer time of HIV infection, +93%; longer time on antiretroviral therapy, +147%; tenofovir exposure +36%). Individuals with lower BMD and higher FRAX results at inclusion had less bone decline in a follow-up DXA after a median of 3.5 years. CONCLUSIONS Currently recommended FRAX thresholds are not useful to select candidates for DXA scan, which could delay its performance in a population with a high prevalence of secondary factors for low BMD. Classical and HIV-related factors alter BMD and fracture risk estimation.
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Affiliation(s)
- Pilar Vizcarra
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Juan Gallego
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - María J Vivancos
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Walter A Sifuentes
- Department of Rheumatology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - María Llop
- Department of Rheumatology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - José L Casado
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
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Pramukti I, Liu HY, Chen CC, Chen YC, Yeh CY, Fetzer S, Ibrahim K, Tai TW, Ko WC, Ko NY. HCV co-infection among people living with HIV Is associated with Higher fracture risk. J Infect Public Health 2020; 13:1724-1728. [PMID: 32653478 DOI: 10.1016/j.jiph.2020.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/21/2020] [Accepted: 06/14/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The purpose of this study was to predict the 10-year risk of fracture among people living with HIV (PLWH) using FRAX™, and to determine the risk factors related to a high probability of fractures. METHODOLOGY This study consisted of 288 subjects aged 40 years and above. The ten-year probability of major osteoporotic fractures (MOF) and hip fractures was assessed using the FRAX™ algorithm with bone mineral density (BMD) data. A logistic regression was used to determine risk factors related to a high probability of major osteoporotic fracture and hip fracture. RESULTS The median 10-year probability of fracture was 3.7% (IQR 2.2-6.2) for MOF and 0.8% (IQR 0.3-2.5) for hip fractures. In addition to old age, previous fracture history, and low T-scores, HCV co-infection was associated with a higher risk of hip fractures in PLWH (AOR: 4.3, 95% CI: 1.29-14.33). Old age and low T-scores were also associated with a high probability of MOF. CONCLUSIONS HCV co-infection among PLWH is associated with a higher risk of hip fracture. Sustained efforts in terms of pharmacologic and non-pharmacologic interventions in PLWH are necessary to prevent osteoporotic fractures, especially in those with HCV co-infections.
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Affiliation(s)
- Iqbal Pramukti
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Faculty of Nursing, Universitas Padjadjaran, West Java, Indonesia
| | - Hsiao-Ying Liu
- Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chang-Chun Chen
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yen-Chin Chen
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chun-Yin Yeh
- Department of Computer Science and Information Engineering, National Cheng Kung University, Taiwan
| | - Susan Fetzer
- Southern New Hampshire Medical Center, Nashua, New Hampshire, USA
| | - Kusman Ibrahim
- Faculty of Nursing, Universitas Padjadjaran, West Java, Indonesia
| | - Ta-Wei Tai
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Nai-Ying Ko
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan.
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Chokuda E, Reynolds C, Das S. Association of Low Vitamin D with Complications of HIV and AIDS: A literature Review. Infect Disord Drug Targets 2020; 20:122-142. [PMID: 30574856 DOI: 10.2174/1871526519666181221122731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 06/09/2023]
Abstract
With the advent of combination antiretroviral therapy (cART), the survival of HIV patients has improved dramatically, but the complications of the disease and treatment have become an important issue in the management of HIV patients. Vitamin-D deficiency is common in HIV patients. Low vitamin-D is associated with different comorbidities in the HIV uninfected general population. In this review, we first briefly describe vitamin D synthesis and mechanism of action and we focus on the epidemiological and clinical data dealing with the relationship between vitamin D deficiency in HIV infection with several comorbidities which has been found to be increasingly common in patients living with HIV infection. We searched the PubMed database using the keywords "HIV," "vitamin D" and other common disorders or conditions that are relatively common in HIV infection. The other conditions included in the search were osteoporosis and fracture, cardiovascular disease, diabetes and insulin resistance, active tuberculosis, hepatitis-C co-infection, and HIV disease progression. Articles presenting original data as well as systematic reviews and met analysis related to HIV population were included in our analysis. Vitamin-D deficiency seems to be associated with several adverse outcomes in HIV patients but a definite cause and effect relationship with vitamin-D is yet to be confirmed in most of the cases. However, the literature supporting the efficacy of vitamin-D supplementation is lacking.
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Affiliation(s)
- Evelyn Chokuda
- Department of HIV Medicine, Coventry & Warwickshire Partnership Trust, Coventry, United Kingdom
| | - Chris Reynolds
- Department of HIV Medicine, Coventry & Warwickshire Partnership Trust, Coventry, United Kingdom
| | - Satyajit Das
- Department of HIV Medicine, Coventry & Warwickshire Partnership Trust, Coventry, United Kingdom
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Kelly SG, Wu K, Tassiopoulos K, Erlandson KM, Koletar SL, Palella FJ. Frailty Is an Independent Risk Factor for Mortality, Cardiovascular Disease, Bone Disease, and Diabetes Among Aging Adults With Human Immunodeficiency Virus. Clin Infect Dis 2019; 69:1370-1376. [PMID: 30590451 PMCID: PMC6938206 DOI: 10.1093/cid/ciy1101] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND We characterized associations between frailty and incident cardiovascular disease (CVD), diabetes mellitus (DM), bone disease, and mortality within a cohort of aging persons with human immunodeficiency virus (PWH). METHODS Participants underwent frailty evaluations using the Fried frailty assessment (baseline and annually). Frailty was defined as having ≥3 frailty criteria. Clinical outcomes of mortality, CVD events, DM, and bone disease events were recorded throughout the study period (baseline to most recent study or clinic visit, or date of clinical outcome, whichever came first). Poisson regression models were used to evaluate associations between baseline frailty, change in frailty score over 48 weeks, and each clinical outcome. RESULTS Among 821 men and 195 women (median age 51 years), 62 (6%) were frail at baseline. Frailty scores increased by ≥1 component among 194 participants (19%) from baseline to 48 weeks. Baseline frailty was associated with an increased risk of incident CVD and DM, with a trend toward a significant association with bone events. Among frailty components, slow gait speed was associated with incident DM and borderline associated with incident CVD. An increase in frailty from baseline to week 48 was associated with mortality but not with the other clinical outcomes. CONCLUSIONS Baseline frailty was associated with multiple adverse health outcomes (incident CVD, DM, and bone disease), while increase in frailty score was associated with mortality among PWH engaged in care. Incorporation of frailty assessments into the care of PWH may assist in improvement of functional status and risk stratification for age-related chronic diseases.
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Affiliation(s)
- Sean G Kelly
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kunling Wu
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | | | | | - Susan L Koletar
- Department of Medicine, Ohio State University Wexner Medical Center, Columbus
| | - Frank J Palella
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Erlandson KM, Karris MY. HIV and Aging: Reconsidering the Approach to Management of Comorbidities. Infect Dis Clin North Am 2019; 33:769-786. [PMID: 31395144 PMCID: PMC6690376 DOI: 10.1016/j.idc.2019.04.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Health care for older adults with human immunodeficiency virus can be highly complex, resource intensive, and carry a high administrative burden. Data from aging longitudinal cohorts and feedback from the human immunodeficiency virus community suggest that the current model is not meeting the needs of these older adults. We introduce the 6 Ms approach, which acknowledges the multicomplexity of older adults with human immunodeficiency virus, simplifies geriatric principles for non-geriatrics-trained providers, and minimizes extensive training and specialized screening tests or tools. Implementing novel approaches to care requires support at local/national levels.
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Affiliation(s)
- Kristine M Erlandson
- University of Colorado, Anschutz Medical Campus, 12700 East 19th Avenue, Mail Stop B168, Aurora, CO 80045, USA.
| | - Maile Y Karris
- University of California San Diego, 200 West Arbor Drive #8208, San Diego, CA 92103-8208, USA
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Premaor MO, Compston JE. The Hidden Burden of Fractures in People Living With HIV. JBMR Plus 2018; 2:247-256. [PMID: 30283906 PMCID: PMC6139727 DOI: 10.1002/jbm4.10055] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/02/2018] [Accepted: 04/11/2018] [Indexed: 02/06/2023] Open
Abstract
The survival of people living with human immunodeficiency virus (HIV) has increased markedly since the advent of antiretroviral therapy (ART). However, other morbidities have emerged, including osteoporosis. The estimated incidence of fractures at any site in people living with HIV ranges from 0.1 per 1000 person‐years to 8.4 per 1000 person‐years: at least twice that of people without HIV. This increased risk seems to be related to HIV itself and its treatment. Risk factors for bone disease in HIV‐positive (HIV+) subjects include both classical risk factors for osteoporosis and fracture and factors linked to HIV itself, such as inflammation, reconstitution syndrome, low CD4, ART, and co‐infection with hepatitis B and C viruses. The risk of fractures in these individuals can be at least partially assessed by measurement of BMD and the Fracture Risk Assessment Tool (FRAX™). Only alendronate and zoledronic acid have been studied in HIV+ individuals; both show beneficial effects on BMD, although data on fracture reduction are not available. © 2018 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Melissa O Premaor
- Department of Clinical Medicine Health Sciences Center Federal University of Santa Maria Santa Maria Brazil
| | - Juliet E Compston
- Department of Medicine Cambridge Biomedical Campus Cambridge United Kingdom
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Ethnic Variations in Serum 25(OH)D Levels and Bone Ultrasound Attenuation Measurements in Blacks and Whites. J Racial Ethn Health Disparities 2017. [PMID: 28639252 DOI: 10.1007/s40615-017-0387-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Vitamin D deficiency is more common in Blacks, yet Blacks have lower prevalence of bone fragility fractures or osteoporosis than Whites. Broadband ultrasound attenuation (BUA) has been used to explore the association between serum 25(OH)D levels and bone quality in White and non-white populations. We investigated serum 25(OH)D status with corresponding BUA measurements assessed cross sectionally in a cohort of 232 Blacks and 260 Whites, aged 30-95 years who were part of the calibration study of the large Adventist Health Study-2 (AHS-2). At the calibration clinics, calcaneal BUA was measured and blood drawn for serum 25(OH)D assessment. In multivariable analyses, BUA was negatively associated with age (β-coefficient = -0.38; p < 0.0001) and positively associated with body mass index (BMI) (p (trend) < 0.0001) and positively, but non-significantly, associated with serum 25(OH)D levels. Also, as expected, females had lower BUA (β-coefficient = -5.19; p < 0.05) and Blacks had higher BUA (β-coefficient = 4.26; p < 0.05). Gender and race modified the relationship of serum 25(OH)D on BUA with a positive association in males (p (trend) ≤ 0.05), but no significant association in females after also controlling for menopausal status and hormone therapy. After also controlling for serum 25(OH)D levels, Black males had higher BUA than White men, but such differences were not found among the females. When stratifying on race, a positive association between serum 25(OH)D levels and BUA (p (trend) ≤ 0.05) was found in Blacks, but not among Whites. Further studies are needed to understand how racial/ethnic differences in serum 25(OH)D levels influence bone health.
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Abstract
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.
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Biver E, Calmy A, Rizzoli R. Bone health in HIV and hepatitis B or C infections. Ther Adv Musculoskelet Dis 2017; 9:22-34. [PMID: 28101146 PMCID: PMC5228639 DOI: 10.1177/1759720x16671927] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Chronic infections with human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) add to age-dependent bone loss and may contribute to lower bone strength in the elderly. In this review, we report recent highlights on the epidemiology of bone fragility in chronic viral infections with HIV, HCV and HBV, its physiopathology and discuss the interference of antiviral therapies with bone metabolism. Chronic infections influence bone through the interactions between risk factors for bone fragility and falls (which are highly prevalent in infected patients), virus activity and antiviral drugs. HIV-infected patients are at increased risk of fracture and the risk is higher in cases of co-infection with HIV and untreated chronic viral hepatitis. In HIV patients, the majority of bone loss occurs during virus activity and at initiation of antiretroviral therapy (ART). However, long-term elderly HIV-infected patients on successful ART display bone microstructure alterations only partially captured by dual energy X-ray absorptiometry (DXA). Bone loss is associated with an increase of bone resorption, reflecting the upregulation of the receptor activator of nuclear factor-kappaB ligand (RANKL) and osteoprotegerin (OPG) pathways via a crosstalk between virus activity, inflammation and the immune system. The use of some antiviral drugs, such as tenofovir (controlling both HBV and HIV infections) or protease inhibitors, may be associated with higher bone toxicity. The reduction of tenofovir plasma concentrations with the implementation of tenofovir alafenamide (TAF) attenuates bone mineral density (BMD) loss but it remains unknown whether it will contribute to reducing fracture risk in long-term HIV-treated patients. Moreover, to what extent the new direct-acting agents for treatment of HCV, including nucleotide inhibitors and protease inhibitors, may affect bone health similarly as ART in HIV should be investigated.
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Affiliation(s)
- Emmanuel Biver
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, HIV Unit, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - René Rizzoli
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Abstract
The success of antiretroviral therapy in treating HIV infection has greatly prolonged life expectancy in affected individuals, transforming the disease into a chronic condition. A number of HIV-associated non-AIDS comorbidities have emerged in the ageing HIV-infected population, including osteoporosis and increased risk of fracture. The pathogenesis of fracture is multifactorial with contributions from both traditional and HIV-specific risk factors. Significant bone loss occurs on initiation of antiretroviral therapy but stabilizes on long-term therapy. Fracture risk assessment should be performed in HIV-infected individuals and bone mineral density measured when indicated. Lifestyle measures to optimize bone health should be advised and, in individuals at high risk of fracture, treatment with bisphosphonates considered.
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Affiliation(s)
- J Compston
- Dept of Medicine, Cambridge Biomedical Campus Francis Crick Ave, Cambridge CB2 0SL, UK.
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