Bone loss in people living with HIV

Osteoporosis as an HIV co-morbidity

People living with HIV (PLWH) are at increased risk of osteoporosis due to altered bone metabolism, both during virus activity and at initiation of antiretroviral therapy (ART), which is associated with increased bone resorption.¹

HIV proteins increase the activity of osteoclasts (which break down bone) and promote the death of osteoblasts (which build it), reducing bone formation and lowering bone strength.¹

Why bone quality matters with HIV

Research shows that fracture risk in PLWH is better captured by assessing both BMD (bone mass) and TBS^® (bone microarchitecture). PLWH have been shown to have lower TBS^®, an indicator of diminished bone architecture, which is associated with vertebral fractures.² In a cohort of HIV-infected young adults, TBS^® directly predicted incident vertebral fractures.³

Co-infection adds a further, more specific risk worth distinguishing. In one comparative study, HIV infection alone was not independently associated with lower TBS^®, but hepatitis C virus (HCV) infection was, and HIV/HCV-co-infected patients showed lower TBS^® than either infection alone.⁴ That distinction matters clinically: Bone-microarchitecture assessment may be particularly informative in patients with HIV/HCV co-infection specifically, rather than a blanket expectation of TBS^® deficit across all PLWH.

Monitoring bone health in PLWH

Osteoporosis risk factors are prevalent in PLWH and should be assessed regularly, regardless of age or sex. DXA screening is recommended for all PLWH aged 50 and over.¹

Clinicians should recognise high-risk individuals and address modifiable risk factors — lifestyle modification, changing ART, calcium and vitamin D supplementation — and pharmacological treatment, which can all help prevent future fractures.¹