The benefits of tenofovir discontinuation with or without bisphosphonate therapy in osteoporotic people living with HIV

OBJECTIVES Treatment with bisphosphonates and discontinuation of tenofovir disoproxil fumarate (TDF) are recommended strategies for managing osteoporosis in people living with HIV (PLHIV). This study aimed to compare the effects on bone mineral density (BMD) of TDF discontinuation with and without bisphosphonate therapy in osteoporotic PLHIV. METHODS The present study is a retrospective cohort analysis of dual-energy X-ray absorptiometry scan results of PLHIV attending Chelsea and Westminster Hospital HIV clinic between 2009 and 2020. Osteoporotic (T-score < -2.5) patients with ≥ 6 months' TDF exposure were included. Changes in BMD and T-scores at the lumbar spine (LS) and femoral neck (FN) were assessed. RESULTS A total of 84 participants were included, of whom 43 discontinued TDF only (TS) and 41 switched from TDF and received bisphosphonates (TS+): 86.9% were male; 77.4% were white; median (interquartile range, IQR) age was 54.8 (51.0-58.5) years; and median (IQR) TDF exposure was 6.5 (3.5-10.4) years. At a median follow-up of 2 years after TDF-discontinuation, mean spine BMD increased significantly in both groups, but bisphosphonate recipients had greater improvements (4.83% vs. 7.79%; P < 0.019); LS T-scores improved significantly but changes were comparable between groups (TS, 0.5 vs. TS+, 0.6; P = 0.270). At the FN, no significant increases in BMD were observed (TS, 3.05% vs. TS+, 2.71%; P = 0.205); T-scores significantly improved in bisphosphonate recipients only (+0.2; P = 0.003). A greater proportion recovered from osteoporosis in the TS+ group (34.9% vs. 43.9%), although differences between groups were not significant (P = 0.503). CONCLUSIONS Our real-world data indicate that although TDF discontinuation significantly improved bone health in osteoporotic PLHIV, combining bisphosphonates with TDF discontinuation resulted in greater improvements in BMD.