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Antiretroviral Therapy and Periarticular Osteonecrosis Development in Patients With HIV
Tyler J Bahoravitch1, Amil Agarwal, Anna M Ifarraguerri
1From the Department of Orthopaedic Surgery, George Washington School of Medicine and Health Science, Washington, DC (Bahoravitch, Agarwal, Ifarraguerri, and Howard) and the Department of Orthopaedic Surgery, Johns Hopkins Medicine, Howard County General Hospital, Columbia, MD (Srikumaran, and Thakkar).
Insights
Antiretroviral therapy (ART) for HIV is linked to an increased risk of periarticular osteonecrosis (ON). Clinicians should monitor patients on ART for ON, especially in the hip and knee, and manage modifiable risk factors.
Area of Science:
- Orthopedics
- Infectious Diseases
- Pharmacology
Background:
- HIV is now a chronic condition due to effective antiretroviral therapy (ART).
- Previous research has not conclusively determined the risk of periarticular osteonecrosis (ON) associated with ART in HIV-positive individuals.
- Understanding this risk is crucial for managing long-term HIV care.
Purpose of the Study:
- To investigate the association between ART use and the incidence of periarticular osteonecrosis (ON) in patients with HIV.
- To compare the risk of ON in HIV patients on ART versus those not on ART.
- To identify specific joints affected by ON in these patient cohorts.
Main Methods:
- A retrospective case-control study utilizing the PearlDiver database from 2010 to 2019.
- International Classification of Diseases codes were used to identify patients with periarticular ON and HIV, categorized by ART status (HIV+/ART+ and HIV+/ART-).
- Multivariable analysis controlled for age, sex, comorbidities, and other ON risk factors, comparing incidence rates between groups.
Main Results:
- Patients on ART (HIV+/ART+) showed a higher incidence of ON in any joint (+1.7%), hip (+1.31%), knee (+0.08%), and shoulder (+0.08%) compared to those not on ART (HIV+/ART-).
- Multivariate analysis revealed significantly higher odds of developing periarticular ON in the HIV+/ART+ cohort for any joint (OR=1.40), hip (OR=1.41), knee (OR=2.56), and shoulder (OR=1.05) compared to the HIV+/ART- cohort.
- The knee joint exhibited the highest increased odds of ON in patients on ART.
Conclusions:
- While ART offers significant benefits for HIV management, it is associated with an elevated risk of periarticular osteonecrosis.
- Clinicians must maintain heightened vigilance for ON in patients receiving ART, particularly in the hip and knee.
- Focusing on modifiable risk factors and timely surgical intervention is recommended for patients on ART at risk for ON.
Introduction:
With modern antiretroviral therapy (ART), HIV has become a chronic condition. Previous studies have not definitively assessed the risk of periarticular osteonecrosis (ON) that ART poses to the HIV population.
Methods:
A retrospective case-control study using the PearlDiver database was done using International Classification of Diseases codes. Patients were selected from 2010 to 2019 with a diagnosis of periarticular ON and HIV taking ART (HIV+/ART+) and not taking ART (HIV+/ART-). The control was patients HIV- and not on ART. Subcategorization, by International Classification of Diseases codes, was used for which joint was affected-hip, knee, or shoulder-excluding patients with ON of the jaw. Chi-squared univariate analysis was used to compare incidence rates and control for age, sex, Elixhauser comorbidities, and other known risk factors for developing ON in multivariable analysis.
Results:
In total, 219,853 patients had HIV between 2010 and 2019. Of those patients, 123,710 (56.27%) had a history of ART (HIV+/ART+), while 96,143 (43.74%) did not (HIV+/ART-). Difference in incidence rates for HIV+/ART+ was higher in any joint (+1.7%), as well as the hip (+1.31%), knee (+0.08%), and shoulder (+0.08%). All risk factors met inclusion criteria in the multivariate analysis except coagulopathy. Multivariate analysis found that patients in the HIV+/ART+ cohort had higher odds of developing periarticular ON when compared with the HIV+/ART- cohort in any joint (odds ratios = 1.40; 95% CI, 1.38 to 1.42), hip (OR:1.41; 95% CI, 1.38-1.43), knee (OR:2.56; 95% CI, 2.39 to 2.74), and shoulder (OR:1.05; 95% CI, 1.01-1.10).
Conclusion:
Patients with HIV taking ART have well-established morbidity and mortality benefits. However, this study found that ART is associated with a higher risk of developing periarticular ON when compared with those not taking ART. Therefore, clinicians should be hypervigilant of patients on ART and their risk of ON, especially asymptomatic patients, and focus on modifiable risk factors and early surgical correction.
Level Of Evidence:
III.
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