Guidelines for Assessing, Preventing and Treating Low Bone Density in HIV

June/July 2015

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HIV-positive people are at increased risk for thinning bones or reduced bone density. Thinner bones are weaker and have difficulty supporting a person's weight, therefore, they are prone to break or fracture.

The reasons for the elevated risk for bone issues in people with HIV may be related to at least the following factors:

  • excess inflammation, a consequence of long-term viral infection
  • poor nutrition
  • being underweight
  • tobacco use
  • excess use of alcohol
  • lower-than-ideal levels of vitamin D

Readers should note that other researchers have found thinner-than-normal bones in some young men at high risk for HIV before they acquired this infection.


Role of ART

Potent combination anti-HIV therapy (commonly called ART or HAART) has made a dramatic difference to the survival prospects of HIV-positive people. Research suggests the possibility that some young people who are diagnosed with HIV today and who initiate ART shortly thereafter will live into their 70s and 80s.

Despite this beneficial role of ART, some researchers, doctors and patients have raised questions about the impact that ART might have on bone health. Well-designed studies have found that once ART is initiated, bone density can diminish by an average of 2% to 6% for a year or two and then stabilize. Why this should occur during the first few years of using ART is not clear. One drug in particular, the nuke tenofovir (Viread and found in Truvada, Atripla, Complera and Stribild), has been associated with bone loss in some patients in some studies but not others. The reasons for this are not clear.

Developing Recommendations

Faced with the bone-related issues mentioned here, a team of doctors and researchers from Australia, Europe, East Asia, Latin America and the U.S. collaborated to develop bone-focused guidelines to assist doctors and nurses caring for HIV-positive people. The team reviewed data from relevant studies that dealt with key common biomedical issues relating to bone health and arrived at agreement and recommendations. Before getting into the recommendations, we first discuss a term used.

A Note on Terms

Doctors sometimes use the term "fragility fractures." This term refers to bones that have broken because of simple, everyday activities, such as falling from standing height. Fragility fractures can be a concern for people with less-than-ideal bone density.

Major risk factors for fragility fractures include the following:

  • a history of fragility fractures
  • taking corticosteroids at doses of 5 mg/day or greater for more than three months
  • a high risk for falling (perhaps because of difficulty with balance or vision)


The team made the following recommendations:

  • all HIV-positive adults should be assessed for fragility fractures and low bone mineral density (BMD)
  • patients who have fragility risk factors should undergo a bone density scan. Such scans are called DEXA (dual-energy X-ray absorptiometry) and use low-dose X-rays.


The team stated that certain patients might not need DEXA scans, as follows:

  • patients without major risk factors for fragility fractures
  • men aged 40 to 49 years
  • women who have not entered menopause and who are at least 40 years old

In such cases, the team recommended that doctors use the Fracture Risk Assessment Tool (FRAX). This is an online calculator that can provide predictions about the risk of a person developing a major fracture over the next 10 years of his/her life. Specifically, FRAX estimates the risk of a fracture occurring in the backbone (spine), forearm, shoulders and hips.

FRAX calculators have been developed by the World Health Organization (WHO) and optimized for many countries, including Canada.

The team recommends that FRAX be repeated "every two to three years or when a new clinical risk factor develops."

FRAX takes into account at least the following risk factors:

  • age
  • race
  • country
  • gender
  • height and weight
  • parental history of fracture

A FRAX calculator is available online.


The team stated that it is "reasonable" to assess bone density with DEXA scans in the following groups of HIV-positive people whose likelihood of developing a major fracture in the next decade of their life (as predicted by FRAX) is at least 10%:

  • men aged 40 to 49 years
  • women aged 40 to 49 years who have not begun the transition to menopause

The team also recommended the use of DEXA scans in the following populations:

  • all post-menopausal women
  • all men 50 years of age and older
  • adults "with a major fragility risk factor regardless of age"

The team stated that "routine DEXA screening of all HIV-[positive] patients on ART is not recommended."

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication TreatmentUpdate. Visit CATIE's Web site to find out more about their activities, publications and services.

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