By Esther Nakkazi
Bone loss doubled in young women initiating antiretroviral treatment containing tenofovir disoproxil fumarate (TDF) and Depo-Provera an injectable hormonal contraceptive according to a two-year study done in Uganda.
According to Dr. Flavia Matovu Kiweewa, a researcher with the Makerere University-Johns Hopkins University Research Collaboration in Uganda (MU-JHU), use of Depo-Provera was associated with a doubling of bone loss in young women imitating TDF containing ART compared to the use of TDF alone.
The high rates of bone mineral density (BMD) loss demonstrate increased risk of early osteoporosis and bone fragility fractures in HIV-infected young women using the most preferred and widely used contraceptive in sub-Saharan African, Depo-Provera and TDF is the most commonly prescribed ART in resource-limited settings, says Kiweewa-Matovu.
The results of the study were presented at the virtual 23rd International Conference, known as AIDS 2020 on 6-10 July 2020. The BONE CARE study, funded by the NIH is the first study to assess the combined effect of Depo-Provera and TDF globally.
About 15 million women in sub-Saharan Africa use Depo-Provera, its popular because it is a reversible contraceptive, its safe, discreet, highly effective when used consistently (less than 0.2% failure rate), and easy to administer (IM injection) by the health workers.
In this study, which was seeking to determine the levels of BMD loss among young women using both Depo-Provera and TDF, the scientists recruited a total of 334 women aged 18-35 years from general health care facilities and HIV care centers in Kampala and its suburbs.
The women were 26 years on average, those who were HIV positive at the beginning of the study and starting ART had a median CD4 count of 450 cells/mm3 and a viral load of 16,000 copies/ml, and the baseline BMD was not significantly different from that of HIV-uninfected controls.
They recruited into three arms based on a combination of their HIV infection status, contraceptive use, and intention to initiate TDF based ART; one with 69 HIV-negative women, 159 HIV positive women starting ART with TDF and using Depo as a contraceptive, and a third arm with 106 HIV positive women starting ART with TDF but not using contraceptives.
The women were followed over a two year period (between 2015 – October 2017 pre-test and treat era) and the BMD was assessed by means of dual-energy x-ray absorptiometry scans of the lumbar spine, total hip, and femoral neck (below the ball of the hip joint) every six months.
The researchers reported greater rates of BMD loss per year in HIV-infected women with the greatest loss occurring in Depo users compared to HIV-infected non-hormonal users, or uninfected controls at all sites.
Lumbar spine bone density decreased by -2.4% annually compared to -1.0% among HIV-positive women not using hormonal contraception, but it rose by +0.8% among HIV-negative women. Total hip bone density declined by -2.1% and -0.8% in the respective HIV-positive groups, with no loss observed in the HIV-negative group. Bone density at the femoral neck fell by -2.5%, -1.0% and 0.1% per year, respectively.
“We are already conducting follow-on studies among the same cohort of HIV infected women to see if the bone loss can be mitigated by the use of bone sparing regimens,” says Kiweewa-Matovu.
Sylvia Nakasi, the policy and advocacy officer at Uganda Network of AIDS Service Organisations (UNASO) says women need more choices for family planning and sub-Saharan Africa needs superior ART regimens.
“We also need regular check-ups for the people taking these drugs so that they can reduce on the side effects because disability is for life,” says Nakasi.