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Bone and calcium disorders in HIV-infected patients

Melissa Weinberg, MD
Morris Schambelan, MD
Section Editor
John G Bartlett, MD
Deputy Editor
Howard Libman, MD, FACP


As the HIV-infected population continues to live longer due to effective antiretroviral therapy (ART), osteopenia and osteoporosis are becoming more common [1]. Certain lifestyle and hormonal factors, which increase the risk of disordered bone metabolism, are prevalent in HIV-infected patients. These include physical inactivity, suboptimal intake of calcium and vitamin D, cigarette smoking, alcohol and opiate use, depression, and low testosterone levels. ART itself may be associated with decreased bone mineral density.

This topic will discuss pathogenesis, prevalence, risk factors, screening, and interventions for patients with bone loss. Topics of HIV and aging are discussed elsewhere. Issues of screening and management of osteoporosis in the general population are discussed separately. (See "HIV infection in older adults" and "Overview of the management of osteoporosis in postmenopausal women".)


Osteoporosis is a skeletal disorder characterized by compromised bone strength, which predisposes to an increased risk of fracture. The World Health Organization defines osteoporosis as a bone mineral density (BMD) measurement by dual X-ray absorptiometry (DXA) at the spine, hip, or forearm that is more than 2.5 standard deviations below that of a "young normal" adult (T-score <-2.5) or a history of one or more fragility fractures. Osteopenia is characterized by low BMD (T-score between -1.0 and -2.5) and can be a precursor to osteoporosis. (See "Screening for osteoporosis".)


Several studies suggest that fracture rates are higher in HIV-infected patient populations than among matched uninfected patients [2-8]. A retrospective analysis comparing 8525 patients with HIV and 2,208,792 patients without HIV found an increased fracture prevalence based on the International Classification of Diseases, Ninth Revision (ICD-9) coding (2.9 versus 1.9 per 100 persons, p<0.0001) [2]. In the HIV Outpatient Study (HOPS), a prospective cohort study of 5826 HIV-infected patients in treatment at 10 HIV clinics throughout the United States, age-adjusted fracture rates were 1.98 to 3.69 times higher than rates in the general population [6]. Another cross-sectional study of 222 HIV-infected outpatients and an equal number of age-matched uninfected controls reported more fractures in the HIV group (45 versus 16 fractures) [9].

As in the general population, osteoporosis is a strong risk factor for fracture among HIV-infected individuals. Among 1006 participants in two HIV cohort studies, for example, the presence of osteoporosis was associated with a fourfold increased risk of incident fracture (predominantly of the rib or sternum, hand, foot, and wrist) [10]. As the HIV-infected population ages, prevention of osteoporotic fractures is likely to become a significant therapeutic goal. (See "HIV infection in older adults" and "Overview of the management of osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".)

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Literature review current through: Nov 2017. | This topic last updated: Jun 12, 2017.
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