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Improving Bone Health
How New Data From CROI 2017 May Inform Switch Strategies in HIV-Infected Patients With Poor Bone Health

Released: April 21, 2017

Expiration: April 20, 2018

Charles B. Hicks
Charles B. Hicks, MD
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In this HIV cases series, we highlight common patient case scenarios and the critical decision making that goes into selecting optimal patient management strategies. This case features a postmenopausal woman with HIV infection who is virologically suppressed on an ART regimen that includes tenofovir disoproxil fumarate (TDF) and who has been diagnosed with osteopenia. Data recently presented at CROI 2017 may help with selection of an alternative regimen that may minimize the impact of ART on bone metabolism.

Case Details
A 52-year-old postmenopausal woman with well-controlled HIV infection recently moved to your location from another state and presents to your clinic to establish care. She is virologically suppressed on an initial ART regimen that consists of dolutegravir (DTG) plus emtricitabine (FTC)/TDF with a CD4+ cell count > 500 cells/mm3. She tolerates this regimen well and reports near-perfect adherence. She currently takes a calcium-containing multivitamin and reports no previous fractures or other bone problems but complains of wrist discomfort. An x-ray reveals no fracture or significant abnormalities other than osteopenia. This diagnosis is confirmed with a DXA scan.

Key Considerations 
Starting ART is generally associated with an initial loss of calcium from bones in all patients, but available data suggest that inclusion of TDF in the regimen is associated with increased loss of calcium from bones compared with non-TDF–containing ART. What strategies are available to attenuate bone demineralization in persons being treated with TDF-containing ART?

Three-year extended follow-up data presented at CROI 2017 from the phase III GS-104/111 studies indicate that, compared with TDF-containing treatment, a tenofovir alafenamide (TAF)–based ART regimen was associated with superior long-term virologic efficacy and lesser effects on renal biomarkers and on spine and total hip bone mineral density (BMD).

In virologically suppressed women, the GS-128 open-label extension of the phase IIIb WAVES study showed that switching to elvitegravir/cobicistat/FTC/TAF positively affected bone and renal health compared with continuation of atazanavir/ritonavir plus FTC/TDF. At Week 48, key differences in patients who switched to the TAF-containing regimen included:

  • Significantly improved spine BMD
  • Numerically higher increase in total hip BMD
  • Significantly reduced markers of tubular proteinuria

Making the Switch
Several studies have now shown that replacing TDF with TAF leads to improvements in BMD decline as well as improvements in renal biomarkers. In some studies, using TDF with PIs increased toxicity. Therefore, a potential recommendation for this patient would be to switch to DTG plus FTC/TAF, a combination likely to sustain her virologic suppression while helping with the management of her osteopenia. Patients experiencing osteopenia or osteoporosis also benefit from evaluation by an expert in bone metabolism who may offer additional management strategies for the long term.

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Based on data from the WAVES open-label extension, the number of women for whom I recommend a switch to a TAF-containing regimen will . . .
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