Table 7.

2015 Guidelines for management of bone disease in patients with HIV

Source	Year of publication	Patient population	Recommendation for repeat screening	Recommendations for management
Brown et al. Recommendations for evaluation and management of bone disease in HIV. Clin Infect Dis.131	2015	Patients younger than 40 years	No routine screening suggested; assess when develop major risk factor or become >40 years of age	All patients:  Adequate calcium intake  Adequate vitamin levels and supplementation if requiredb  Lifestyle modifications   Smoking and alcohol cessation   Falls prevention   Exercise
		Patients aged 40–50 years with a low 10-year fracture risk based on FRAX (no DEXA required)	Monitor FRAX every 2–3 years
		Patients with moderate 10-year fracture risk:  FRAX ≥10% but <20%  Lowest T-score >−2.5  No history of hip or vertebral fracture	Repeat DEXA in 1–2 years if advanced osteopenia (T-score between −2.00 and −2.49) Repeat DEXA in 5 years if mild osteopenia (T-score between −1.00 and −1.99)
		Patients with clinical osteoporosis:  Patients with high 10-year fracture riska  T-score <2.5 at FN, TH or LS on DEXA scan  Previous hip or vertebral fracture	Repeat DEXA in 2 years	Exclude secondary causes of osteoporosisc Treat osteoporosis as per general population:  Bisphosphonates first-line therapy (alendronate or zoledronic acid preferred)  Review therapy at 3–5 years Consider avoiding TDF or boosted PIs if low BMD or osteoporosis (but benefits of ART outweigh risks)

Notes:

^a≥20% risk of major osteoporotic fracture in 10 years and/or ≥3% risk of hip fracture (with or without incorporation of BMD result); based on validated clinical tool such as the FRAX.

^bCheck vitamin D levels in those with low BMD or previous fracture or risk factors for vitamin D deficiency (dark skin, sun avoidance, malabsorption, obesity, chronic kidney disease, or on treatment with efavirenz); supplemental vitamin D if deficient and target level >30 μg/L.

^cSecondary causes of osteoporosis include: type 1 diabetes mellitus, osteogenesis imperfecta in adults, untreated long-standing hyperthyroidism, hypogonadism, or premature menopause (<45 years), chronic malnutrition, malabsorption, and chronic liver disease. Reproduced from Brown TT, Hoy J, Borderi M, et al. Recommendations for evaluation and management of bone disease in HIV. Clin Infect Dis. 2015;60(8):1242–1251,¹³¹ by permission of Oxford University Press. Copyright ©2015.

Abbreviations: BMD, bone mineral density; ART, antiretroviral therapy; PIs, protease inhibitors; TDF, tenofovir disoproxil fumarate (Viread^®); FN, femoral neck; TH, total hip; LS, lumbar spine; FRAX, Fracture Risk Assessment Tool; DEXA, dual-energy X-ray absorptiometry.