Prevalence of low bone mineral density among HIV patients on long‐term suppressive antiretroviral therapy in resource limited setting of western India

Abstract

IntroductionBone mineral density (BMD) assessment in HIV patients is sparsely done in resource limited settings.Materials and MethodsWe conducted a cross-sectional study of BMD amongst HIV patients following up in our clinic from 1 June to 1 December 2013 by performing dual-energy X-ray absorptiometry scan (Lunar Prodigy Advanced DXA System, GE Healthcare) of lumbar spine and hip. Patients on long term (≥12 months), virologically suppressive antiretroviral therapy (ART) were included. Patients who were ART naïve were included as control population. Virologic failures were excluded. Low BMD was defined by WHO T-score criteria (normal: T score ≥−1;osteopenia: T score between −1 and −2.5 SD; osteoporosis: T score ≤−2.5 SD). Baseline risk factors associated with low BMD like age, low BMI, lipoatrophy, diabetes mellitus, current smoking, current alcohol intake, steroid exposure and menopause were recorded. ART-related factors associated with low BMD like ART duration, exposure to tenofovir and exposure to protease inhibitors (PI) were studied.ResultsA total of 536 patients (66% males, 496 ART experienced and 40 ART naïve) were included in this analysis. Median age was 42 years, mean BMI 23.35 kg/m2 and median CD4 count 146 cells/mm3. All ART experienced patients had plasma viral load<400 copies/ml.Prevalence of low BMD amongst ART naive and ART experienced patients was 67% (osteopenia: 70.4%, osteoporosis: 29.6%) and 80.4% (osteopenia: 63.4%, osteoporosis: 36.6%), respectively (p=0.05). Mean T scores at lumbar spine and hip for ART naive and ART experienced patients were −1.37 and −0.9 versus −1.56 and −1.48 (p=0.05), respectively. Age, low BMI, current smoking, menopause, baseline CD4 count and exposure to ART were factors significantly associated with low overall BMD on univariate regression analysis. On multivariable logistic regression analysis age (p<0.001), low BMI (p<0.001), current smoking (0.05) and menopause (0.03) were associated with low BMD. BMI decrease of 1 kg/m2 and baseline CD4 decline of 50 cells/mm3 lead to 14% and 4% increased probability of low BMD, respectively. Choice of antiretroviral use (tenofovir vs non-tenofovir, PI vs No PI) did not influence loss of BMD.ConclusionsExtremely high prevalence of accelerated BMD loss amongst ART naïve and ART experienced patients in our cohort is a matter of deep concern due to its association with pathological fractures. Bone mineral loss was seen irrespective of ART used. Association of low BMD with low baseline CD4 count strengthens the case for early ART.

Reduced bone mineral density among HIV infected patients on anti-retroviral therapy in Blantyre, Malawi: Prevalence and associated factors

“…A comparable prevalence in reduced BMD (23%) was found by Cardeal et al (2017) among 108 individuals living with HIV in Brazil [23]. However, some studies have reported higher prevalence rates of reduced BMD ranging from 37% to 80% among PLWHIV [18][19][20]35]. A slightly lower prevalence in reduced BMD revealed in this study could be due to the age group of participants.…”

“…Higher prevalence rates of up to 85% of low BMD among PLWHIV in low and middle income countries have been reported by a number of studies [18][19][20][21][22]. Apart from ART, factors such as lack of physical activity (PA), lower body mass index (BMI), female sex, older age, nutritional deficiencies of calcium and vitamin D, depression, contraception use, smoking and alcohol use are believed to contribute to high prevalence of low BMD among PLWHIV [22][23][24][25].…”

Low skeletal mass is an important predictor of osteoporosis in HIV infected men in India

“…In an abstract presented at the 2014 annual conference of the International AIDS Society (the only previous report from India), Dravid et al reported 29.6% and 36.6%, respectively, HAART naïve (n = 40) and on HAART patients (n = 496) to have osteoporosis [23]. However, details from that study are not available.…”

Analysis of antiretroviral therapy modification in routine clinical practice in the management of HIV infection

“…Brown et al 23 and Dravid et al 24 demonstrated how tenofovir-based regimens contributed to reduction in bone mineral density, together with HIV-related factors, such as low CD4+ count.…”