Abstract
More than 36 million people are living with human immunodeficiency virus (HIV) infection worldwide and 50% of them have access to antiretroviral therapy (ART). While recent advances in HIV therapy have reduced the viral load, restored CD4 T cell counts and decreased opportunistic infections, several bone-related abnormalities such as low bone mineral density (BMD), osteoporosis, osteopenia, osteomalacia and fractures have emerged in HIV-infected individuals. Of all classes of antiretroviral agents, HIV protease inhibitors used in ART combination showed a higher frequency of osteopenia, osteoporosis and low BMD in HIV-infected patients. Although the mechanisms of HIV and/or ART associated bone abnormalities are not known, it is believed that the damage is caused by a complex interaction of T lymphocytes with osteoclasts and osteoblasts, likely influenced by both HIV and ART. In addition, infection of osteoclasts and bone marrow stromal cells by HIV, including HIV Gp120 induced apoptosis of osteoblasts and release of proinflammatory cytokines have been implicated in impairment of bone development and maturation. Several of the newer antiretroviral agents currently used in ART combination, including the widely used tenofovir in different formulations show relative adverse effects on BMD. In this context, switching the HIV-regimen from tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide (TAF) showed improvement in BMD of HIV-infected patients. In addition, inclusion of integrase inhibitor in ART combination is associated with improved BMD in patients. Furthermore, supplementation of vitamin D and calcium with the initiation of ART may mitigate bone loss. Therefore, levels of vitamin D and calcium should be part of the evaluation of HIV-infected patients.
Highlights
There are about 36.7 million people living with human immunodeficiency virus (HIV) infection worldwide [1]
In the United States, the Center for Disease Control and Prevention (CDC) estimates that approximately 1.2 million people are living with HIV, and males accounted for 76% of the HIV-infected population, and more than one-half million people have died with HIV/AIDS
In a comparative analysis of HIV-infected antiretroviral treatment-naïve African American patients, it was found that the antiretroviral therapy (ART) combination of efavirenz, emtricitabine, and tenofovir disoproxil fumarate (TDF) was associated with reduction in bone mineral density (BMD) and maintained the levels of vitamin D compared with the ART combination containing protease inhibitor (PI), raltegravir, darunavir, and ritonavir [60]
Summary
There are about 36.7 million people living with human immunodeficiency virus (HIV) infection worldwide [1]. In the United States, the Center for Disease Control and Prevention (CDC) estimates that approximately 1.2 million people are living with HIV, and males accounted for 76% of the HIV-infected population, and more than one-half million people have died with HIV/AIDS. Long term infection with HIV and use of ART in HIV-infected patients are associated with several bone related abnormalities such as low bone mineral density (BMD), osteomalacia, osteopenia, osteoporosis, osteonecrosis, fracture and other bone disorders [2 - 5]. A better understanding of the etiology and pathogenesis of bone related disorders in HIV-infected people who are living longer because of ART may provide useful information that could be included in the treatment strategies of these aging HIV-infected individuals. This article will review the bone conditions and abnormalities associated with HIV infection and use of ART in HIV-infected patients
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