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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 1, 2016; last reviewed: March 1, 2016)

Table 12j. 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 less than or equal to –2.0 (87% treated with cART).
  • 24% to 32% of Thai and Brazilian adolescents had a BMD z score less than or equal to –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

Medroxyprog-esterone use

Limited 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).
  • Consider obtaining serum 25-OH-vitamin D level.a
  • Obtain DXA.b
Ensure sufficient calcium intake and vitamin D sufficiency.

Encourage weight-bearing exercise.

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

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 that population, the prevalence of vitamin D insufficiency is high.

bUntil 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 could 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:  ART = antiretroviral therapy; ARV = antiretroviral; BMD = bone mineral density; BMI = body mass index; DXA = dual-energy x-ray absorptiometry; LPV/r = lopinavir/ritonavir; PI = protease inhibitor; TDF = tenofovir disoproxil fumarate

Osteopenia and Osteoporosis

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