Fracture Reduction

Approach to Fracture Reduction in PLWH
Reducing risk of fractures
Subjects at high risk of fractures:
- Frail or sarcopenic subjects
- Low BMD
  • Aim to decrease falls by addressing fall risks(i)
  • Ensure sufficient dietary calcium (1-1.2 g daily) and vitamin D (800-2,000 IU daily) intake and vitamin D (800-2,000 IU daily) intake(ii)
  • Consider screening by DXA scan(iii)
  • Rule out causes of secondary osteoporosis if BMD low
  • Where appropriate, screen for osteoporosis and refer to national/regional guidelines on treatment of osteoporosis
    • If no guidelines available, consider bisphosphonate(iv)
    • Treatment based on FRAX score (see section on Bone Disease Screening and Diagnosis).
    • Ensure adequate calcium and vitamin D intake
    • No significant interactions between bisphosphonates and antiretrovirals
    • If diagnosed with osteoporosis and requiring therapy, optimize vitamin D status and consider using ART that preserves or improves BMD(v)
  • Optimal management of frailty and sarcopenia includes optimising nutrition, exercise (aerobic and resistance training) and hormone replacement in cases of deficiency, see section on frailty
  • In complicated cases (e.g. young men, premenopausal women, recurrent fracture despite bone protective therapy), refer to osteoporosis specialist
  • If on bisphosphonate treatment, repeat DXA after 2 years and reassess need for continued treatment after 3-5 years


  1. see Falls Risk Assessment Tool (FRAT)
  2. see Diagnosis and management of Vitamin D deficiency
  3. See Bone disease screening and diagnosis
  4. Bisphosphonate treatment with either of: alendronate 70 mg once weekly po; risedronate 35 mg once weekly po; ibandronate 150 mg po once a month or 3 mg iv every 3 months; zoledronic acid 5 mg iv once yearly
  5. BMD loss is greatest in the first year after ART initiation, with more BMD loss with ART regimens containing TDF and some PIs. Switch away from TDF can lead to increases in BMD. Consider relative risk/benefit of using these agents in persons with high fracture risk. Vitamin D supplementation can reduce bone loss with ART initiation