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Table of Contents

Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection

Management of Medication Toxicity or Intolerance

Osteopenia and Osteoporosis

(Last updated: March 5, 2015; last reviewed: March 5, 2015)

Table 13j. Antiretroviral Therapy-Associated Adverse Effects and Management Recommendations—Osteopenia and Osteoporosis
Adverse Effects Associated ARVs Onset/Clinical Manifestations Estimated Frequency Risk Factors Prevention/ Monitoring Management
Osteopenia and Osteoporosis Any cART regimen

Specific Agents of Possible Concern:
  • TDF
  • PIs, especially LPV/r
  • Any age; more common in months after initiation of cART.
  • Most commonly asymptomatic; fracture (rare).
  • Osteoporosis diagnosis in children requires clinical evidence of bone fragility (e.g., fracture with minimal trauma) and cannot rely solely on measured low BMD.
Low BMD:
  • 7% of a U.S. cohort had a BMD z score of  ≤ –2.0 (87% treated with cART).
  • 24% to 32% of Thai and Brazilian adolescents had a BMD z score of 
    ≤ –2.0 (92% to 100% treated with cART).
Longer duration of HIV infection

Greater severity of HIV disease

Growth delay, pubertal delay



Non-black race


Prolonged systemic corticosteroid use

Medroxy-progesterone use

Minimal weight-bearing exercise
  • Ensure sufficient calcium and vitamin D intake.
  • Encourage weight-bearing exercise.
  • Minimize modifiable risk factors (e.g., smoking, low BMI, steroid use).
  • Assess nutritional intake (calcium, vitamin D, and total calories).
  • Obtain serum 25-OH-vitamin D.a
  • Obtain DXA.b
Ensure sufficient calcium and vitamin D intake.

Encourage weight-bearing exercise.

Reduce modifiable risk factors (e.g., smoking, low BMI, use of steroids, use of medroxyprog-esterone).

Role of bisphosphonates not established in children

Consider change in ARV regimen.

a Some experts would periodically measure 25-OH-vitamin D, especially in HIV-infected urban youth because, in this population, the prevalence of vitamin D insufficiency is high.
b Until more data are available about the long-term effects of TDF on bone mineral acquisition in childhood, some experts would obtain a DXA at baseline and every 6 to 12 months for prepubertal children and children in early puberty who are initiating treatment with TDF. DXA should also be considered in adolescent women on TDF and medroxyprogesterone and in children with indications not uniquely related to HIV infection (such as cerebral palsy).

Key to Acronyms: ARV = antiretroviral; BMD = bone mineral density; BMI = body mass index; cART = combination antiretroviral therapy; DXA = dual-energy x-ray absorptiometry; LPV/r = ritonavir-boosted lopinavir; PI = protease inhibitor; TDF = tenofovir disoproxil fumarate

Osteopenia and Osteoporosis

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