The Impact of Human Immunodeficiency Virus and Menopause on Bone Mineral Density: A Longitudinal Study of Urban-Dwelling South African Women

Abstract

An estimated 25% of South African women live with human immunodeficiency virus (HIV). Antiretroviral therapy roll-out has improved life expectancy, so many more women now reach menopause. We aimed to quantify changes in bone mineral density (BMD) during the menopausal transition in urban-dwelling South African women with and without HIV and determine whether HIV infection modified the effect of menopause on BMD changes. A 5-year population-based longitudinal study recruited women aged 40-60 years residing in Soweto and collected demographic and clinical data, including HIV status, anthropometry, and BMD, at baseline and at 5-year follow-up. All women were staged as pre-, peri-, or postmenopausal at both time points. Multivariable linear regression assessed relationships and interactions between HIV infection, menopause, and change in BMD. At baseline, 450 women had mean age 49.5 (SD 5.7) years, 65 (14.4%) had HIV, and 140 (31.1%), 119 (26.4%), and 191 (42.4%) were pre-, peri-, and postmenopausal, respectively; 34/205 (13.6%) women ≥50 years had a total hip (TH) or lumbar spine (LS) T-score ≤ -2.5. At follow-up 38 (8.4%), 84 (18.7%), and 328 (72.9%) were pre-, peri-, and postmenopausal. Those with HIV at baseline lost more total body (TB) BMD (mean difference -0.013 [95% confidence interval -0.026, -0.001] g/cm² , p = 0.040) and gained more weight 1.96 [0.32, 3.60] kg; p = 0.019 than HIV-uninfected women. After adjusting for age, baseline weight, weight change, and follow-up time, the transition from pre- to postmenopause was associated with greater TB BMD losses in women with HIV (-0.092 [-0.042, -0.142] g/cm² ; p = 0.001) than without HIV (-0.038 [-0.016, -0.060] g/cm² , p = 0.001; interaction p = 0.034). Similarly, in women who were postmenopausal at both time points, those with HIV lost more TB BMD (-0.070 [-0.031, -0.108], p = 0.001) than women without HIV (-0.036 [-0.015, -0.057], p = 0.001, interaction p = 0.049). Findings were consistent but weaker at the LS and TH. Menopause-related bone loss is greater in women with HIV, suggesting women with HIV may be at greater risk of osteoporotic fractures. HIV services should consider routine bone health assessment in midlife women as part of long-term HIV care delivery. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Keywords: BONE MINERAL DENSITY; DUAL-ENERGY X-RAY ABSORPTIOMETRY; HUMAN IMMUNODEFICIENCY VIRUS; MENOPAUSE; SOUTH AFRICA.

Fig. 1

Participant recruitment flow diagram explaining selection of women in Middle‐Aged Soweto Cohort (MASC) study. The flow chart shows the selection of participants in the MASC study at baseline and follow‐up. In addition, the figure summarizes the distribution of data by BMD site, menopause group, and HIV status.

Fig. 2

Absolute changes in BMD in menopause transition stages among women living with and without HIV (top row: unadjusted) (bottom row: adjusted for age and weight at baseline, change in weight, and follow‐up time). Graphs show univariable and multivariable effects of menopause transition on LS, TH, and TB BMD in top and bottom rows, respectively. Linear regression estimates are shown; β (standard error) representing g/cm² losses/gains in BMD over follow‐up period as distinguished by a reference line (x = 0). Individuals with HIV are indicated by triangles and those without HIV by circles. The prevalence of HIV in this population was 14.4%, and at follow‐up, most women (72.9%) were postmenopausal. Evidence of interaction between pre‐post, post‐post MT groups and HIV status on TB BMD was detected in adjusted analyses.