Bone mineral density and HIV

There has been a large shift in the practice of HIV medicine towards that of chronic disease management and management of co-morbidities. One such co-morbidity is osteoporosis/osteopenia – the incidence of which is increasing, driven in part by the ageing HIV population, as well as ART-related effects such as tenofovir disoproxil fumurate (TDF) use. In the session on ‘Trials, Treatment and Toxicity’, Prof Jenny Hoy from the Alfred Hospital and Monash University discussed her findings on a recently completed randomized trial looking at the bisphosphonate zoledronic acid versus TDF-switching on bone mineral density (BMD). Main points from the talk:

-       TDF has previously been shown to cause lower BMD and increases fracture risk (TAF has been shown to have less of an effect on BMD than TDF)

-       Switching from TDF to another agent shows improvement in BMD

-       Zoledronic acid has also previously been shown to increase BMD vs placebo in HIV-positive individuals

-       The trial was a randomized, open-label 2-year trial testing zoledronic acid (5mg) vs switch of TDF to alternate ARV (in most cases to abacavir or an integrase inhibitor) on BMD at time 12 months and 24 months

-       43 patients were analysed for the zoledronic acid group and 42 for TDF-switching

-       There was significantly higher increase in BMD in the zoledronic acid group compared to the TDF-switching group (6.1% vs 2.9%) at 12 months, which continued to increase in the zoledronic acid group at 24 months (7.4% vs 2.9%)

-       The study was not powered to comment on changes in fracture rates

Overall the study demonstrated significant increases in BMD in patients treated with zoledronic acid compared to TDF-switching, however it remains to be seen whether this translates clinically to reduced rates of fractures. Given the ageing cohort of the HIV population and predicted increase in osteopenia/osteoporosis, coupled with previous data demonstrating increasing frailty – risk of fractures remains an important clinical concern. Clinicians should aim to screen for and manage risk factors for co-morbidities early. This was summed up in Prof Georg Behrens opening plenary talk– to consider a ‘hit hard and early’ approach to HIV co-morbidities.

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