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Bone Health in People Living with HIV: From Pathophysiology to Practical Management
1Division of Infectious Diseases, Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea. eunjeong.joo@samsung.com.
Insights
People with HIV (PLWH) face increased bone loss due to aging and antiretroviral therapy (ART). Optimizing ART and monitoring bone health are crucial for managing osteoporosis and fractures in this population.
Area of Science:
- Bone metabolism and HIV/AIDS research
- Pharmacology and drug safety
- Geriatric medicine and public health
Background:
- Antiretroviral therapy (ART) has increased life expectancy for people living with HIV (PLWH).
- PLWH experience higher rates of bone loss, reduced bone mineral density (BMD), and fractures compared to the general population.
- Factors contributing to bone loss include chronic immune activation, inflammation, and ART-related toxicities.
Purpose of the Study:
- To review the impact of ART on bone health in aging PLWH.
- To discuss current and emerging ART regimens concerning bone safety.
- To outline essential assessment and management strategies for bone disease in PLWH.
Main Methods:
- Literature review of studies on HIV, ART, and bone health.
- Analysis of data on specific ART drug toxicities (e.g., tenofovir disoproxil fumarate, tenofovir alafenamide).
- Evaluation of evidence for newer regimens and bone health outcomes.
Main Results:
- Certain ART, like tenofovir disoproxil fumarate, are linked to reduced BMD and hypophosphatemia.
- Newer regimens, including integrase inhibitor-based or tenofovir-sparing options, show improved bone safety profiles.
- Bone loss can occur irrespective of ART regimen, highlighting the need for long-term monitoring.
Conclusions:
- Bone health is a critical long-term complication for aging PLWH.
- Dual-energy X-ray absorptiometry and fracture risk assessment tools are vital for early detection.
- Comprehensive care requires integrating bone health management, including lifestyle, supplements, and pharmacotherapy, alongside optimized ART selection.
Abstract:
As the life expectancy of people living with HIV (PLWH) continues to rise with the success of antiretroviral therapy (ART), long-term complications such as reduced bone mineral density (BMD) and osteoporosis have become increasingly prevalent. PLWH exhibit a higher risk of bone loss and fractures compared to the general population, driven by multiple factors including chronic immune activation, systemic inflammation, and ART-related toxicity. Tenofovir disoproxil fumarate is known to induce proximal renal tubular dysfunction and hypophosphatemia, contributing to reduced BMD. Tenofovir alafenamide is associated with improved renal and bone safety profiles. Recent data on integrase inhibitor-based or tenofovir-sparing regimens such as dolutegravir/lamivudine and long-acting cabotegravir plus rilpivirine suggest favorable effects on bon health. However, bone loss may still occur following ART initiation, regardless of regimen, and long-term skeletal outcomes remain under investigation. Given the increasing burden of bone disease in aging PLWH, timely assessment using dual-energy X-ray absorptiometry and fracture risk tools such as FRAX is essential. Management strategies should include lifestyle modification, calcium and vitamin D supplementation, and pharmacologic interventions including bisphosphonates or denosumab. Optimizing ART selection to minimize bone toxicity is also an important consideration. As PLWH age, bone health must be integrated into comprehensive HIV care.
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