With significant improvements in the treatment of HIV in recent years, life expectancy in patients living with HIV (PLHIV) has increased dramatically and is now near to that of the general population, data indicate. With this increasing longevity, conditions related to aging have begun to emerge in PLHIV, including osteoporosis, which is not reported as a common comorbidity in PLHIV.

A Large Meta-Analysis

For a systematic review and meta-analysis published in the Journal of Acquired Immune Deficiency Syndrome, we sought to assess the evidence on fracture risk in PLHIV, BMD in PLHIV compared with controls, longitudinal changes in BMD in PLHIV, and the effect of anti-osteoporosis treatment in PLHIV.

Our systematic literature review screened nearly 2,400 publications, resulting in 142 papers that were included in the systematic review, and subsequently, 84 papers including more than 60,000 PLHIV in the meta-analysis.

Key Findings

We found an increased risk of fractures in PLHIV (Figure); indeed, PLHIV had a 53% increased risk of any fracture and a 51% increased risk of a fragility fracture when compared with individuals without HIV (controls). Furthermore, the risk of a hip fracture was increased 6-fold in PLHIV when compared with controls.

In contrast, BMD was slightly decreased in PLHIV (z-score at the hip: -0.31, and at the lumbar spine: -0.36) when compared with controls. The slight decrease in BMD could explain the 15% increased risk of any fracture and 50% increased risk of hip fracture that we found. The meta-analysis revealed a decrease in BMD of 2% to 3% within the first year after initiation of antiretroviral treatment, whereas the bone mineral loss was less during following years. We found in our meta-analysis that tenofovir disoproxil fumarate appeared to be associated with a significantly greater reduction in BMD when compared with abacavir and tenofovir alafenamide. Thus, antiretroviral treatment type appears to be of importance in the development of osteoporosis in PLHIV.

In PLHIV, the loss of BMD does not seem to fully explain the level of fracture risk seen in PLHIV. Thus, earlier initiation of anti-osteoporotic treatment may be useful in this patient population. In PLHIV, treatment with alendronate and zoledronate appeared improve BMD, and some studies suggest that zoledronate abolished the bone mineral loss seen after initiation of antiretroviral treatment.

Important Implications

Physicians should be aware of the increased fracture risk in PLHIV, and thus, the importance of screening of osteoporosis and early initiation of anti-osteoporotic treatment as necessary in this patient population. As the reduction in BMD does not appear to fully explain the fracture risk seen in PLHIV, focus is also needed on other potentially contributing factors, such as falls, smoking, vitamin D-insufficiency, and poor nutrition.