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

June/July 2015

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Spine Fractures

The doctors stated that initially painless fractures in the backbone are "common" among HIV-positive people, with such problems occurring in up to 25% of this population. Furthermore, the team noted that the presence of these fractures is "a strong risk [factor] for future fractures."

The team recommends that the height of patients should be measured every one to two years in adults who are aged 50 years and older. The loss of 2 cm or more in height in such a period is suggestive of osteoporosis and possibly a fracture in the spine.

To screen for these subclinical (initially painless) fractures, the team recommends that X-rays of the spine or a DEXA-based fracture assessment be done, particularly in women aged 70 years and older and men aged 80 years and older. Readers should note that a recent report (appearing later in this issue of TreatmentUpdate) suggests that these subclinical fractures have been found to occur in HIV-positive people who are much younger than these thresholds suggested by the researchers.


Lab Tests

The team stated that blood tests should not be used to "determine fracture risk or low bone density." Although such tests exist, their findings are not always definitive and their use is largely restricted to research settings.


The team stated, "As the benefits of ART far outweigh the potential negative long-term effects on [bone density and bone] metabolism and fracture risk, local or national guidelines for initiation and choice of ART regimen should be followed."

In patients with low bone density or who have osteoporosis, the team recommends that certain anti-HIV medicines be avoided, including the following:

  • tenofovir (Viread and found in Truvada, Atripla, Complera and Stribild)
  • boosted protease inhibitors

Today most protease inhibitors are used with a small dose of the protease inhibitor ritonavir (Norvir). The purpose of a low dose of ritonavir is to raise and maintain, or boost, levels of the other protease inhibitor being used so that once-daily dosing is possible. Over the past five years, commonly prescribed combinations of boosted protease inhibitors have included the following:

  • darunavir (prezista) + ritonavir
  • atazanavir (Reyataz) + ritonavir
  • lopinavir + ritonavir (co-formulated in one pill called Kaletra)

In 2015, the U.S. Department of Health and Human Services (DHHS) recommended that for the initial treatment of HIV infection doctors prescribe combinations of ART containing an integrase inhibitor or the combination of darunavir + ritonavir.

The reasoning behind the recommendation by the team to avoid tenofovir-containing medicines or boosted protease inhibitors other than darunavir + ritonavir is as follows:

"... these regimens have been associated with greater decreases in bone density compared with other [nucleoside analogues] and raltegravir [Isentress]."

The team stated that the combination of dolutegravir (Tivicay) and Kivexa (abacavir + 3TC) is a regimen that they recommend. Dolutgravir is an integrase inhibitor. However, they caution that only limited information on the impact of dolutegravir-containing regimens on bone health is available.

Soft Bones

Osteomalacia (soft bones) generally occurs when bones do not get enough of the minerals calcium and/or phosphorus. This can cause bone pain, weak muscles, low bone density and fragility fractures.

There are some reports of osteomalacia occurring in HIV-positive people who were using tenofovir or efavirenz (in Sustiva, Stocrin and Atripla).

The team advised doctors that osteomalacia should be suspected in patients with low bone density and the following:

  • higher-than-normal levels of phosphorus (or phosphate) in the urine
  • low levels of phosphate in the blood
  • elevated levels of parathyroid hormones in the blood
  • severe vitamin D deficiency -- less than 25 nmol/L (or less than 10 ng/mL) in the blood

In cases of osteomalacia, the team recommended that the use of efavirenz and/or tenofovir should be avoided.

Fragility Fractures and Healthier Habits

The team recommends that all HIV-positive people who are at high risk for fragility fractures be counselled about healthier living strategies. Counselling should include at least the following topics:

  • smoking cessation (where appropriate)
  • avoid excessive intake of alcohol
  • engage in regular weight-bearing and muscle-strengthening exercises
  • take steps to prevent falls


The team encourages doctors to remind their patients to eat foods containing a sufficient amount of calcium every day (referral to a dietician may be necessary).

The team recommends that, ideally, the first approach to attaining daily calcium requirements is to increase the intake of calcium from food. However, the team noted that "calcium supplements may be appropriate if dietary calcium intake is insufficient."

Recommended calcium intakes by the team are as follows:

  • men (50 to 70 years) -- 1,000 mg of calcium daily
  • men (71 and older) -- 1,200 mg of calcium daily
  • women (51 and older) -- 1,200 mg of calcium daily

Vitamin D

Multiple studies have found that HIV-positive people tend to have lower-than-ideal levels of vitamin D in their blood. The team encourages doctors to have laboratories assess the amount of vitamin D in the blood of their patients who have low bone density or who have a history of fractures. In addition, the team noted that doctors should consider testing vitamin D levels in people with the following factors associated with low vitamin D:

  • dark skin
  • avoiding sun exposure
  • malabsorption of nutrients
  • a diet poor in vitamin D
  • obesity
  • chronic kidney disease
  • past or current use of efavirenz

Recommendations about vitamin D dosage

The team recommends that supplementary vitamin D be given to HIV-positive people whose levels in the blood are graded as follows:

  • insufficient -- less than 50 nmol/L (20 ng/mL)
  • deficient -- less than 25 nmol/L (10 ng/mL)

The goal of vitamin D supplementation, the team stated, is to raise levels in the blood to "approximately 75 nmol/L (30 ng/mL)." Once this is achieved, the next goal should be maintenance of this level and that dosing should be driven by blood test results.

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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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