Simon Collins, HIV i-Base
A small randomised placebo-controlled study (ANRS 120) showed that alendronate therapy (70mg once-weekly) significantly increased bone mineral density (BMD) at the osteoporotic site after 96 weeks. All patients also received calcium carbonate 500mg and vitamin D 400 units daily. 
Rozenberg and colleagues randomised 44 patients (n=20 alendronate; n=24 placebo)) with T-scores less than 2.5 at lumbar spine and/or total hip assessed by DXA. Mean age at baseline was 45 years, CD4 count was 422 cells/mm3 and 84% had viral load <400 copies/mL. Only two women were in this study.
At week 96, BMD increased at the osteoporosis site by 7.1% vs 1.0% in the alendronate and placebo groups respectively [mean difference 6.1% 95%CI 2.8 to 9.3%; p=0.003]. BDM increased by >2.5% in 86% vs 40% in each group respectively. A greater number of adverse events were reported in the placebo group (13 vs 6).
The authors concluded that alendronate improved BMD in HIV positive people using antiretroviral treatment who were diagnosed with osteoporosis.
While this study confirmed results from an earlier 48-week randomised trial , and suggested additional benefits from longer treatment, the earlier study should have been sufficient not to require a placebo for any patients with diagnosed osteoporosis. Aledronate is already included in HIV guidelines that discuss the management of osteoporosis.
However, until DXA screening is included in routine management, the majority of HIV-positive patients with low bone mineral density are unlikely to have their osteoporosis diagnosed unless it becomes symptomatic (ie post-fracture).
The recent EACS monitoring guidelines (November 2009) included the recommendation to use the FRAX online calculator to screen HIV-positive
- Rozenberg S et al. Effect of alendronate on HIV-related osteoporosis: a randomised, double-blind, placebo-controlled trial (ANRS 120). 12th EACS, 11-14 November 2009, Cologne. Abstract PS5/4.
- McComsey G et al. Alendronate with calcium and vitamin D supplementation is superior to calcium and vitamin D alone in the management of decreased bone mineral density in HIV-infected patients: Results of ACTG 5163. 14th CROI, 2007. Oral abstract 42.