Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.
Bone Health in HIV
I really enjoyed the sessions today on co-morbidities and as a S100 general practitioner found this very useful. The discussion re bone health was especially interesting to me given a number of my patients have low BMD.
Professor Jennifer Hoy outlined practical management and screening of bone disease in HIV. Osteoporosis is a silent disease until fracture occurs and people living with HIV have a higher risk of low BMD and fragility fractures than the general population. This is likely due to lifestyle risk factors, low vitamin D levels, HIV induced inflammation and the effect of ART. The question is who should be screened? Which tool should be used? When should we start screening and how often should we be screening our patients?
Who should be screened? All HIV positive individuals over the age of 40years, those with a history of fragility fractures, those taking corticosteroids for more than 3 months at doses of greater than 5mg per day and prior to ART initiation.
Which tool do we use ?Using the FRAX calculator ( https://www.shef.ac.uk/FRAX/tool.aspx?country=31) calculates the ten year probability of fracture with BMD. However the FRAX calculator while useful has not been validated in the HIV population. High risk patients should have a DEXA scan. However DEXA scan can only be accessed if there is a history of previous low BMD or previous fragility fracture/fracture with minimal trauma, if there is a history of chronic liver or renal disease, proven malabsorptive disorder, history of rheumatoid arthritis, thyroid excess states and in patients over 70 years of age. It does make it difficult if your patient does not fall into this category and alternatives to DEXA include the 'Measure Up Mobile Dexa Bone Health'unit, quantitative CT scan and heel ultrasound.
DEXA screening intervals are based on the baseline screening result. For normal-mild osteopenia this would be every 5 years and for more advanced osteopenia every 1-2 years. Professor Hoy mentioned that there was insufficient evidence for more frequent screening for those on certain ART regimens i.e. tenofovir.
In terms of treatment for those with fragility fracture or low BMD this includes:
- adequate dietary calcium
- ensure they are vitamin D replete
- lifestyle modifications ie smoking cessation/alcohol reduction
- exclude secondary cause of low BMD
- discontinue or change ART regimen if appropriate
- initiate bisphosphonates under the same criteria as general population
This was a very informative session and information that will be very useful in my position as a GP