Challenges in the management of osteoporosis and vitamin D deficiency in HIV infection

Until 2013, the National Osteoporosis Foundation guidelines did not include HIV infection and highly active antiretroviral therapy as osteoporosis risk factors that should trigger dual-energy x-ray absorptiometry (DEXA) screening for low bone mineral density (BMD) in older adults, but numerous data indicate that individuals with HIV infection are at early and increased risk for osteoporosis and fracture. For this reason, experts support the use of DEXA screening for HIV-infected postmenopausal women and men older than 50 years. Factors contributing to increased risk of low BMD in individuals with HIV infection include inflammation, effects of antiretroviral therapy, and numerous patient risk factors, including vitamin D deficiency. Workup for low BMD should include assessment for fracture risk and secondary causes of low BMD, including vitamin D deficiency, hyperparathyroidism, subclinical hyperthyroidism, hypogonadism, and phosphate wasting. Bisphosphonates are the preferred treatment to prevent fracture in low BMD but are not appropriate for treating osteomalacia, which is characterized by vitamin D deficiency and phosphate wasting.