A survey about preferences for bone therapy

Researchers have found that when people initiate potent combination anti-HIV therapy (commonly called ART or HAART) their bones can lose some of their density. Usually the loss is between 2% and 6%. However, by the second year of therapy this loss generally stabilizes.

Some researchers think that this period of initial bone thinning needs to be addressed rather than wait for bone density to fall to critical levels. Perhaps bone drugs could be used for a relatively short period of time after the initiation of ART to help stabilize bone density so that osteopenia and/or osteoporosis do not develop.

Toronto-based infectious disease specialist Darrell Tan, MD, and colleagues surveyed HIV-positive patients about their knowledge of bone issues and their willingness to take therapy to maintain or increase their bone density.

About half of the patients surveyed expressed a willingness to take short-term medicines to prevent bone thinning. The researchers also uncovered misperceptions about bone health that underscore the need for patient education about this topic.

Study details

Researchers developed a survey and recruited participants who attended a primary care clinic and a hospital-based clinic, both in downtown Toronto.

Participants were asked to complete a questionnaire concerning the following three themes:

• preferences regarding therapy to prevent and/or treat thinning bones
• knowledge about bone health
• knowledge about fracture risk

Participants were surveyed in the summer of 2013. A total of 112 participants completed the survey. Their average profile was as follows:

• 80% men, 20% women
• age – 43 yeas
• 25% had never taken ART
• 23% initiated ART in the past 12 months
• 52% had begun taking ART more than a year earlier
• major ethno-racial groups were distributed among participants as follows: white (42%), black (30%), Asian (12%)
• major HIV risk factors were as follows: 55% had condomless sex with another man; 35% had condomless sex with a heterosexual partner; 4% had received contaminated blood; 2% had shared needles
• fracture history – 21% had a previous fracture
• taking supplemental vitamin D₃ – 25%

No participant was taking therapy to stabilize or increase bone density.

Results

Just over half (52%) of participants said that they would be interested in taking medicines to maintain bone density or prevent its loss. This result was the same regardless of whether or not participants were taking ART or had not yet started.

Participants presently taking a large number of pills were more willing to take medicines for bones should they need to in the future compared to participants taking relatively few pills.

Among participants who were willing to take bone medicines, most (80%) were willing to take them for “as long as needed.”

When offered a choice, a clear majority of participants preferred taking bone medicines once weekly (71%) to daily (13%).

Modest knowledge

Based on responses to the survey, researchers described participants’ knowledge of bone health as “modest.” Between 33% and 50% of participants were not aware that there were several important factors—such as HIV infection, some anti-HIV drugs, smoking and excessive use of alcohol—that could have an unfavourable impact on bone density and increase their risk for fractures. Furthermore, 83% of participants believed that osteoporosis was “something that only mattered for the elderly.”

Most participants (65%) stated that they had no risk factors for osteoporosis. In analysing the data collected, researchers were able determine the following about the participants’ risk factors:

• 24% had one risk factor for fractures
• 8% had two risk factors for fractures
• 4% had three risk factors for fractures

The researchers found the following risk factors present in participants:

• smoking
• past or present use of corticosteroids for prolonged periods (more than three months)
• parents who had a hip fracture
• excessive intake of alcohol
• rheumatoid arthritis
• liver disease
• premature menopause

Good for bones

A total of 55% of participants reported doing an activity that helps to strengthen bones—resistance exercises (weight lifting) once or more each week.

The survey shows that slightly more than half of the participants were willing to take therapy for low bone density. Furthermore, a clear preference for once-weekly therapy was expressed. The research team noted that this would make the once-weekly formulation of the drug alendronate (Fosavance) an “attractive option” for many patients.

Alendronate has been studied in large numbers of HIV-negative people at high risk for reduced bone density, including the following populations:

• postmenopausal women
• corticosteroid users
• men with prostate cancer who have taken prescribed therapy to reduce their production of testosterone

Alendronate has also been tested in small studies in HIV-positive people where it has significantly increased their bone density.

The researchers noted that other drugs, including zoledronate, could also be selected for future clinical trials in HIV-positive people.

The present Toronto study is a good and important step for assessing patient preferences for the prevention of low bone density among HIV-positive participants. A future study should assess a larger number of HIV-positive women about their preferences for bone therapy.

The Canadian HIV Trials Network is sponsoring a pilot study by Dr. Tan and colleagues. In this study, called CTNPT 021 or BATARI, researchers will test different interventions, including the following:

• immediate initiation of once-weekly alendronate (Fosavance) 70 mg with vitamin D₃
• delayed initiation of once-weekly alendronate 70 mg with vitamin D₃
• no alendronate or vitamin D₃

—Sean R. Hosein

REFERENCE:

Taras J, Arbess G, Owen J, et al. Acceptability of bone antiresorptive therapy among HIV-infected adults at different stages of antiretroviral therapy. Patient Preference and Adherence. 2014 Sep 24;8:1311-6.