High rates of osteopenia and osteoporosis: importance of DEXA monitoring
Simon Collins, HIV i-Base
Bone disease was addressed in many of the posters, with the first of these reports coming from Guys and St Thomas and the remaining three from the Chelsea and Westminster Hospital.
Perry and colleagues from reported results of a cross-sectional study of 175 randomly selected HIV-positive patients who completed lifestyle and general health questionnaires that were compiled with biochemical analyses and DEXA lumber spine and hip. 
Baseline characteristics included median age 38 years (IQR 30-43); 64% male, 41% black, 85% ARV-experienced, 31% current smokers.
DEXA results showed 49% patients had reduced BMD, 13% with osteoporosis and 36% with osteopenia. Age increased the association (p=0.007) occurring at a median age of 44.50 years (IQR 3851 years) but not gender, with osteoporosis diagnosed in approximately 10% of patients aged 40-49 and 20% in those aged >50 years. (See Table 1).
Table 1: BDM results by gender and age
In multivariate analysis, other risk factors were low BMI (OR 0.87; 95%CI 0.790.95; p= 0.003) and ever having been on HAART (OR 4.43; 95%CI 1.5712.50; p= 0.005). Gender, ethnicity, HIV viral load, CD4 cell count, CD4 cell count nadir and vitamin D were not statistically associated with abnormal BMD.
In their conclusion the authors highlighted the high proportion of patients with HIV from young age groups, and a signi?cant correlation with HAART and that this may provide a rationale for routine screening for risk factors that predict fracture in HIV, including low BMD.
Stuart-Buttle and colleagues reported results from a retrospective audit of 106 patients who had DEXA scans from 20072009. 
12% had osteoporosis, 30% had osteopaenia and 58% had normal DEXA scans. Of the 44 patients over 50 (mean age 58.1 +7.02), 36% had a diagnosis of osteoporosis and 41% had osteopaenia, compared to 28% and 5%, respectively, in the group under 50 years.
While this was a retrospective study, presumably in patients selected for DEXA bone concerns, the researchers concluded that HIV should be considered a risk factor and that including HIV-positive people >50 years need to be included in screening studies. No signi?cant correlation between bone mineral density and CD4 count, calcium or vitamin D levels.
Hughes and colleagues presented results from a new over 50s clinic that was set up in January 2009. Of 54/70 patients with DEXA results (4 patients were excluded due to with diagnosed bone disease), osteopaenia was diagnosed in 24% (13/54) and osteoporosis in 11% (6/54). Of these, 77% (10/13) with osteopaenia and 100% (6/6) with osteoporosis were male. 
The mean age was 60 years, 93% (50/54) were male and 85% (46/54) of white ethnicity. All patients were taking ART (100% VL <50, mean CD4 551 cells/mm3).
Low vitamin D levels occurred in 66% (4/6) with osteoporosis, 38% (5/13) with osteopaenia and 49% (17/35) with normal DEXA result. With over one third of this cohort with osteopaenia or osteoporosis, the authors concluded that this supported routine screening in individuals aged over 50.
Finally, Rashid and colleagues, prospectively measured Vitamin D levels (25(OH) vitamin D) in 312 patients in July 2009. 
Mean age was 48 years (range 25-83), 88% male, mean duration of HIV infection 12 years (range 0-26). Median vitamin D level was 66nmol/L (range <10-221) with 35% levels low (40-70nmol/L) and 21% de?cient (<40nmol/L). Low Vitamin D correlated with non-caucasian ethnicity (p<0.001) and female sex (p<0.001), but not antiretroviral class or speci?c agent, including efavirenz.
Of note, in 102 patients (33%) who had DEXA scans for unrelated reasons, median vitamin D levels were 71, 71 and 58 nmol/L for those with normal, osteopaenic and osteoporotic results respectively.
The lack of association of low vitamin D levels with DEXA results, and also with alkaline phosphatase levels, suggest the importance of larger definitive studies to inform patient management in this area.
All references are to the Abstracts of the 2nd Joint conference of the BHIVA and BASHH, 2023 April 2010, Manchester.
Abstracts from the conference are published as a supplement to the May 2010 edition of HIV Medicine; Volume 11, Supplement 1.
1. Perry M et al. The relationship of HIV and bone density: implications for screening. Poster abstract P44.
2. Stuart-Buttle C et al. Screening for bone disease in HIV patients. Poster abstract P46.
3. Hughes A et al. Over 50? Its time for a dual energy x-ray absorptiometry (DEXA) scan. Poster abstract P39.
4. Rashid T et al. No association of vitamin D levels with individual antiretroviral agents, duration of HIV infection, alkaline phosphatase levels or bone mineral density ?ndings. Poster abstract P45.