|Adverse Effects||Associated ARVs||Onset/Clinical Manifestations||Estimated Frequency||Risk Factors||Prevention/Monitoring||Management|
|Osteopenia and Osteoporosis||Any ARV regimen
Specific Agents of Concern:
||BMD z-Score Less Than -2.0:
||Longer duration and greater severity of HIV disease
Vitamin D insufficiency/deficiency
Delayed growth or pubertal delay
Prolonged systemic corticosteroid use
Lack of weight-bearing exercise
||Same options as for prevention.
Consider changing the ARV regimen (e.g., switching from TDF to TAF, and/or from LPV/r to EFV or an unboosted INSTI whenever possible).
Treat patient with vitamin D3 to raise serum 25-OH-vitamin D concentrations to >30 ng/mL. There is no clear benefit to administering daily supplemental vitamin D3 doses that are >4,000 IU. If patients are receiving a daily dose of vitamin D3 that is >4,000 IU, consider monitoring levels of 25-OH-vitamin D.
An increase in BMD was seen in one study that evaluated the use of alendronate in youth with HIV. However, the role of bisphosphonates in managing osteopenia and osteoporosis in children with HIV has not been established.
|a Some experts periodically measure 25-OH-vitamin D. This is especially important in children and adolescents with HIV who live in urban areas; the prevalence of vitamin D insufficiency is high in that population.
b Until more data are available on the long-term effects of TDF on bone mineral acquisition in childhood, DXA scanning is not usually recommended for children who are being treated with TDF. DXA scanning could be considered for youth who are receiving TDF along with additional medications which affect bone density and for children with indications that are not uniquely related to HIV infection (such as cerebral palsy).
Key: ART = antiretroviral therapy; ARV = antiretroviral; BMD = bone mineral density; BMI = body mass index; COBI = cobicistat; DXA = dual-energy x-ray absorptiometry; EFV = efavirenz; INSTI = integrase strand transfer inhibitor; IU = international unit; LPV/r = lopinavir/ritonavir; ng = nanogram; PI = protease inhibitor; RTV = ritonavir; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate