In South Africa approximately 5,51 million
people are HIV positive, of which nearly 40% are
currently receiving Highly Active Antiretroviral
Treatment (HAART).
Since the introduction of HAART, the landscape
of HIV in South Africa has changed
considerably, as the drugs (colloquially referred
to as “miracle drugs”) have brought about a
profound improvement in the quality of life and
and increased life expectancy in HIV positive
patients.
However, as with all medicines, HAART does
have side effects and should be investigated
and attended to in all people taking them.
The side effects of HAART are usually very mild
with a slight upset tummy, occasional nausea
and vomiting or a rash being the most
commonly reported negative effects.
Some side effects may only present after a
period of time. A common side effect of HAART,
lipodystrophy, where losing or gaining of body
fat over a period of time can cause significant
disfiguring and even stigmatisation, is not
immediately apparent .
Some effects are not even noticed by the
patient, as is the case with lipid abnormalities
and metabolic bone disease (MBD) which is
now a well-recognised and studied side effect
of HAART.
What is metabolic bone disease?
MBD refers to spectrum of bone disorders
caused by abnormalities in the metabolism of
calcium, phosphorus , magnesium and vitamin
D which is important in healthy bone
development and maintenance.
Most well known are osteopenia and
osteoporosis .
Osteopenia describes the “thinning” of bone
that is not yet as severe as is in the case of
osteoporosis where the bone density
deteriorates enough to change the micro-
architecture of bone and subsequently makes
the patient very prone to fractures.
The measurement of bone mineral density
(BMD) is an accurate indication of the
development and progression of bone
conditions like osteoporosis.
HAART increases the development of MBD
Research show an increase in the development
of metabolic bone disorders with the use of
HAART. A meta-analysis done by researchers
at Johns Hopkins University (USA) showed
very interesting numbers:
67% of a group of 884 HIV positive patients
from various studies, had reduced BMD, with
15% having established osteoporosis.
Compared with the HIV negative control group,
HIV positive patients had a:
- 6.4 fold increase in odds of having a reduced
BMD
- 3.7-fold increase in odds of osteoporosis.
The analysis showed a two times greater
occurrence of MBD in patients receiving
HAART.
The exact causes are unclear
The exact causes of these phenomena are not
yet clear. Some research, although still highly
controversial, suggest increased bone
resorption. Others believe that the HIV virus has
a direct effect on the activity of osteoclasts
(cells found in bone responsible for the
breakdown of old bone).
A study published in the HIV/Aids Journal in
2010 states that a 2% to 6% decrease in BMD
is expected over the course of two years once
HAART is initiated. The study concluded that a
complex interaction between the HIV infection
itself, traditional osteoporosis risk factors and
HAART-related factors.
Several emerging studies showed a significant
increase in fracture rates in HIV positive
patients with some studies suggesting an
increase of 30% to 70% in risk.
HAART benefits outweigh risks
The introduction of HAART changed the
management of HIV globally. The most obvious
question is whether the risk of MBD is of such a
nature that HAART should be stopped.
The significant enhancement of quality of life for
patients on HAART seem to outweigh the
benefits of not taking the medication.
Although MBD may have detrimental effects on
the life of a patient suffering, for example, a
fracture, the overall effect HAART has on
patient well being should not be ignored.
Screening for possible MBD in HIV positive
patients is important. Detailed history, physical
examination and appropriate special
investigations are integral in early detection
and effective management of these disorders.
Researchers recommend a Bone Density Scan
for all HIV positive post-menopausal women
and men aged 50 and over. Such
investigations in younger patients are probably
not indicated as the risk of fractures secondary
to MBD are fairly low. Patient who have a
history of fragility fractures should be
investigated regardless of age.
Keeping bones healthy
Adequate nutrition is vital in maintaining
healthy bones. Research suggest that HIV
positive people should supplement their diets
with additional calcium and vitamin D.
Regular exercise will strengthen muscles to
prevent falls and subsequent fractures. Weight-
bearing exercises in post-menopausal women
are especially indicated.
Co-morbid conditions must be managed
effectively with specific treatment, i.e. if a
patient suffers from hypothyroidism, it should
also be attended to.
Cessation of smoking, moderate alcohol intake
should be pursued.
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