Table 6.

Intervention strategies for perinatally HIV-infected youth with evidence of bone fragility (low BMD, fractures)

Calcium+vitamin D	Provide routine calcium (1300 mg/day) and vitamin D (600 IU/day) supplementation for youth, unless intake history for calcium and measured 25-OH vitamin D levels, respectively, confirm sufficiency. No consensus on target 25-OH vitamin D level, but consider higher threshold (≥30 ng/dL) +/− normal PTH level in youth with bone fragility.
General nutrition	Consider referral to nutritionist for in-depth counselling.
Modify habits	Emphasize importance of not smoking and avoiding alcohol consumption.
Weight-bearing exercise	Prescribe high-intensity impact activities (like running, jumping, gymnastics, basketball) for 10–20 min/day at least three days/ week. Consider referral to physical therapist to improve adherence to exercise regimen.
Reexamine need, or potential substitutes, for non-HIV medications	Avoid or minimize corticosteroids. Consider switching from medroxyprogesterone to alternative contraception. Review list of other agents with potential negative impact on BMD: http://www.nof.org/articles/6.
HIV virologic suppression	Review regimen and optimize adherence to ensure sustained effective ART.
Bone-friendlier ARV regimen	Consider replacing TDF (and/or boosted PI) with other ARV(s), if new regimen anticipated to maintain virologic suppression and be well tolerated.
Anti-resorptives: bisphosphonates	Proven effective (alendronate) in improving BMD in HIV-infected adults and in non-HIV-infected youth with bone fragility. Investigational in youth with HIV infection. Recommend consultation with endocrinologist or other bone specialist.
Other osteoporosis agents	No data for use of other osteoporosis agents (e.g. Denosumab, Teriparatide, Strontium, Raloxifene).

BMD=bone mineral density; ARV=antiretroviral drug; ART=antiretroviral therapy; TDF=tenofovir disoproxil fumarate; PI=protease inhibitor.