Prevalence in HIV-positive adults and adolescents

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Osteoporosis has been reported in between 3 and 21% of clinic populations investigated.1 2 3

Osteopenia is more common, affecting about 30% of HIV-positive individuals in many investigations conducted so far. Some prevalence studies have reported higher figures, including a study of Royal Free HIV patients in which  71% showed signs of thinning bones, with increased risk among those who have received antiretroviral therapy,4 and an Italian study which identified loss of bone density in 51% of patients without an existing history of bone problems.5

Osteonecrosis, or avascular necrosis, has also been reported in HIV-positive people. This condition refers to the death of the bone, notably in the hip joint. For more information, see the separate entry Osteonecrosis.

Bone loss in HIV-positive women

Prevalence studies in women have tended to show that bone loss is more common among HIV-positive than HIV-negative women past the age of menopause, but that HIV status has little effect in women below the age of menopause.

One longitudinal study in 168 pre-menopausal women found no significant difference in bone mineral density (BMD) between HIV-positive and HIV-negative women during 2.5 years of follow-up. Another study in post-menopausal women found significantly lower BMD in HIV-positive women, together with faster bone turnover.6 7

A 2004 study found that the prevalence of osteopenia and osteonecrosis was 2.5 times greater in HIV-positive than in HIV-negative women. Risk factors included low body mass index, a history of low body weight, low body fat percentage and infrequent menstruation, but antiretroviral therapy did not alter the risk. The pattern of bone loss in menopausal women was also different in HIV-positive and -negative women.8 

Bone loss in HIV-positive men and boys

An Australian study looking only at men on HAART found that 42% had low BMD, with 4% having osteoporosis. Sixteen percent of the cohort were immediately eligible for biphosphonate treatment for fracture prevention. Low bone density was significantly associated with protease inhibitor use, but high testosterone levels were protective. 9

In the US Cohort of HIV-at Risk Aging Men’s Prospective Study (CHAMPS), a cohort of older men (mean age 56), HIV-positive men had lower BMD at the lumbar spine, femoral neck and overall hip than age-matched HIV-negative men, and over a mean follow-up period of 32 months, HIV-positive men with normal BMD were more likely to develop osteopenia than HIV-negative men (7.2 vs. 2.6 per 100 person-years).10

Another US study also found significantly lower BMD among HIV-positive than HIV-negative pubescent boys. Treatment with lopinavir/ritonavir (Kaletra) was associated with reduced bone mineral content and density. No significant difference was found between HIV-negative and HIV-positive girls.11

How often does bone density loss lead to fractures?

Fewer studies have looked at rates of actual bone fracture among people with HIV. Between the years 2000 and 2008, 4% of HIV-positive patients in the US HIV Outpatient Study experienced bone fractures – a significantly higher rate than that estimated in the general US population. Risk factors included older age (47 years or older), nadir (lowest-ever) CD4 cell counts below 200 cells/mm3, hepatitis C co-infection, diabetes and substance abuse.12

Some analyses focus on fragility fractures – those that occur with minimal impact or trauma, typically at the wrist, vertebrae, or femoral head of the hip. One retrospective analysis compared the risk of fragility fractures between 40,079 HIV-positive and 79,080 HIV-negative men from the US Veterans Aging Cohort Study (VACS) between 1997 and 2009. The analysis excluded 1233 wrist fractures which were common among younger participants with no significant difference according to HIV status. For the remaining 919 fragility fractures (vertebral and hip), HIV was independently associated with a 38% increased risk after adjusting for other risk factors, which included low body weight, cardiovascular disease, alcohol abuse, and older age.13

A retrospective US study did not find an independent risk of bone fracture due to HIV among 2391 women, mostly pre-menopausal and largely black, in the US Women's Interagency Health Study (WIHS). However, the HIV-positive women in this study were more likely to be older and to have other risk factors including lower body mass index and hepatitis C co-infection. This analysis included both fragility and traumatic fractures.14

References

  1. Tebas P et al. Accelerated bone mineral loss in HIV-infected patients receiving potent antiretroviral therapy. AIDS 14:4, F63-F67, 2000
  2. Carr A et al. Osteopenia in HIV-infected men: association with asymptomatic lactic acidemia and lower weight pre-antiretroviral therapy. AIDS 15: 703-709, 2001
  3. Nolan D et al. Stable or increasing bone mineral density in HIV-infected patients treated with nelfinavir or indinavir. AIDS 15(10): 1275-1280, 2001
  4. Moore AL et al. Reduced bone mineral density in HIV-positive individuals. AIDS 15(13): 1731-1733, 2001
  5. Bongiovanni M et al. Osteoporosis in HIV-infected subjects: combined effect of highly active antiretroviral therapy and HIV itself? J Acquir Immune Defic Syndr 40: 503 – 504, 2005
  6. Yin MT et al. Low bone mass and high bone turnover in postmenopausal HIV-infected women. J Clin Endocrinol Metab (advance online publication, January 2010) doi:10.1210/jc.2009-0708., 2010
  7. Yin TM et al. Short-term bone loss in HIV-infected premenopausal women. J Acquir Immune Defic Syndr (published online November 3), 2009
  8. Dolan S et al. Reduced bone density in HIV-infected women. AIDS 18: 475-483, 2004
  9. Calmy A et al. Low bone mineral density, renal dysfunction, and fracture risk in HIV infection: a cross-sectional study. J Infect Dis 200: 1746-54, 2009
  10. Sharma A et al. Prospective study of bone mineral density changes in aging men with or at risk of HIV infection. AIDS, 24: online edition, DOI: 10. 1097/QAD.0b013e32833d7da7, 2010
  11. Jacobson DL et al. Total body and spinal bone mineral density across Tanner stage in perinatally HIV-infected and uninfected children and youth in PACTG 1045. AIDS 24 (advance online publication), 2010
  12. Dao C et al. Higher and increasing rates of fracture among HIV-infected persons in the HIV Outpatient Study compared to the general US population, 1994 to 2008. 17th Conference on Retroviruses and Opportunistic Infections, San Francisco, abstract 128, 2010
  13. Womack J et al. HIV-infection and fragility fracture risk among male veterans. Seventeenth Conference on Retroviruses and Opportunistic Infections, abstract 129, San Francisco, 2010
  14. Yin M et al. Fracture rates are not increased in younger HIV-positive women. Seventeenth Conference on Retroviruses and Opportunistic Infections, abstract 130, San Francisco, 2010
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