ART and HIV itself are risk factors for osteoporosis.109,110 As with other co-occurring conditions among PLWHA, inflammation and immune dysregulation are culprits.111 Experts recommend a DXA scan for all HIV-positive (especially those with a history of fracture), postmenopausal women, and HIV-positive men who are 50 years old or younger, to be repeated every 2 to 5 years. Clinicians can support bone health by recommending adequate calcium and vitamin D intake, weight-bearing exercise, limited alcohol intake, and smoking cessation.112
Frailty, a syndrome which includes increased vulnerability to stressors and greater risk for disability and death, is likely to develop significantly earlier in people with HIV than in the general population.113,114 Among PLWA low CD4 cell count despite use of ART predicts frailty, as does abnormal fat distribution and central obesity—which may be modifiable with exercise and dietary changes.113,114 Patients with frailty are likely to have polypathogy, cognitive impairment, and a prior opportunistic infection, and be on multiple medications.115
Overlapping Issues: Substance Use Disorders, Depression, and Cognitive Impairment
“Ryan White has allowed us to have committed staff who do both in-reach and outreach; they work with patients who are hard to engage in care due to their issues with substance use and mental health,” says Telzak. As he explains,
In the Bronx, we have medical case management and outreach for our 250 most challenging patients, those who are least likely to be linked to care, stay in care and take medications. We often meet patients while they are hospitalized—sometimes with opportunistic infections that were exceedingly common prior to highly active antiretroviral therapy and now are quite unusual—and keep them in ambulatory care, help them take their antiretroviral and psychiatric medications, and get them into treatment for substance use disorders. The outcomes that increasingly matter to Ryan White are not just process indicators or the number of patients you referred; they want to see the number of people engaged in care with undetectable HIV viral loads. Ryan White has linked social service outcomes to medical outcomes, which is very important.