Bone Health Management in HIV-Infected Populations

HIV infection and its treatment exert a profound effect on skeletal integrity. The virus itself, persistent immune activation and certain antiretroviral agents converge to accelerate bone turnover, compromise bone mineral density and alter bone microarchitecture. Initiation of therapy often coincides with the greatest bone loss, reflecting immune reconstitution and direct pharmacological effects, particularly with tenofovir disoproxil fumarate. Beyond density, bone tissue quality is influenced by remodelling dynamics and the function of osteoclasts and osteoblasts. Clinically, people living with HIV experience osteoporosis and fractures about a decade earlier than the general population, with heightened prevalence in peri- and postmenopausal women. Management guidelines emphasise early risk stratification through dual-energy X-ray absorptiometry and recognition of HIV as a secondary cause of osteoporosis in fracture-prediction models. Calcium and vitamin D supplementation at therapy initiation may attenuate initial bone loss. Antiresorptive treatments such as bisphosphonates remain first-line for those at highest risk, while switching to bone-sparing regimens—most notably tenofovir alafenamide in place of tenofovir disoproxil fumarate—offers additional protection. Comprehensive care integrates lifestyle modification (nutrition, smoking cessation, exercise) with pharmacotherapy and tailored antiretroviral selection. Emerging approaches, including genomic risk scoring and machine-learning fracture prediction, promise refined individualised management. In resource-limited settings, simplified screening protocols and context-specific calibration of risk tools are critical to address the growing global burden of HIV-associated bone disease.

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Bone Health Management in HIV-Infected Populations publication trend

The graph below shows the total number of articles in bone health management in hiv-infected populations across all publications each year (not limited to Nature Index journals).

Technical terms

Bone mineral density (BMD): A measure of bone strength reflecting mineral content per unit area, commonly assessed by dual-energy X-ray absorptiometry.

Dual-energy X-ray absorptiometry (DXA): Imaging technique used to quantify bone mineral density at axial and appendicular sites.

Fracture Risk Assessment Tool (FRAX): Algorithm that estimates ten-year probability of hip and major osteoporotic fractures by combining clinical risk factors with or without BMD.

Antiretroviral therapy (ART): Pharmacological regimen that suppresses HIV replication, comprising combinations of agents including tenofovir disoproxil fumarate and tenofovir alafenamide.

Tenofovir disoproxil fumarate (TDF) and Tenofovir alafenamide (TAF): Prodrugs of tenofovir with differing pharmacokinetics; TAF achieves lower systemic exposure, thereby reducing bone and renal toxicity.

References

1. Prevalence of HIV-associated osteoporosis and fracture risk in midlife women: a cross-sectional study in Zimbabwe. Journal of Bone and Mineral Research (2024).
2. Effects of Tenofovir Disoproxil Fumarate on Bone Quality beyond Bone Density—A Scoping Review of the Literature. Pharmaceuticals (2024).
3. Changes in bone quality after switching from a TDF to a TAF based ART: A pilot randomized study. Frontiers in Endocrinology (2023).
4. Association of a Polygenic Risk Score With Osteoporosis in People Living With HIV: The Swiss HIV Cohort Study. The Journal of Infectious Diseases (2023).
5. An explainable web application based on machine learning for predicting fragility fracture in people living with HIV: data from Beijing Ditan Hospital, China. Frontiers in Cellular and Infection Microbiology (2025).
6. Osteoporosis and HIV Infection. Calcified Tissue International (2022).