SEARCHCROSS-SECTIONALendocrinology, rheumatology

cross-sectional·endocrinology, rheumatology, infectious_disease, geriatrics, public_health, orthopedics·PMC10071443

Osteoporosis, Rather Than Sarcopenia, Is the Predominant Musculoskeletal Disease in a Rural South African Community Where Human Immunodeficiency Virus Prevalence Is High: A Cross-Sectional Study

Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research · 10 authors, 8 centres

AI SUMMARY

FIDELITY 100%

POPULATION805 black South African adults aged 20–80 years living in a rural community in Bushbuckridge, Mpumalanga province (547 women, 258 men)

INTERVENTIONHIV infection status (34 men and 129 women living with HIV; 88% on antiretroviral therapy)

COMPARISONParticipants without HIV infection

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TL;DR

In a rural South African community with high HIV prevalence, osteoporosis was common (19.4% of women and 8.4% of men aged ≥50 years), while sarcopenia was rare. HIV infection was strongly associated with lower bone mineral density, particularly at the femoral neck, with 37% of older women with HIV having femoral neck osteoporosis. The findings suggest that HIV clinics in South Africa should consider routine bone health assessment, especially in aging women, to address future fracture risk.

Full summary

3,858 CHARS

**Background:** Life expectancy is rising in sub-Saharan Africa, yet the burden of age-related musculoskeletal diseases like osteoporosis and sarcopenia in this region is poorly understood. HIV infection, which is highly prevalent in Southern Africa, may exacerbate bone and muscle loss through chronic inflammation, ART effects, and nutritional deficiencies. This study aimed to determine the prevalence of osteoporosis and sarcopenia in a rural South African community with high HIV prevalence and to investigate associations between HIV, BMD, muscle strength, lean mass, and gait speed.

**Methods:** This cross-sectional study was nested within a wider multimorbidity study in the Agincourt Health and Socio-Demographic Surveillance System site in Bushbuckridge, Mpumalanga province, South Africa. Participants aged 20–80 years were recruited through household sampling (phase 1–2) and word-of-mouth (phase 3) between November 2017 and November 2018. Data collection included questionnaires, anthropometry, HIV testing, grip strength (hand dynamometry), maximal gait speed over 6 meters, and DXA (Hologic Discovery A) for BMD and body composition. Sarcopenia was defined per EWGSOP2 guidelines: probable sarcopenia (low grip strength: <16 kg women, <27 kg men), confirmed (plus low ALM/height²: <5.5 kg/m² women, <7.0 kg/m² men), severe (plus gait speed ≤0.8 m/s). Osteoporosis was defined as BMD T-score ≤ -2.5 at any site for those aged ≥50 years, using NHANES III white reference data. Linear and logistic regression were used to assess associations, with multivariable models adjusting for age, sex, grip strength, ALM/height², gait speed, fat mass, and HIV status.

**Key Results:** Among 805 participants (mean age 44.6 ± 14.8 years; 68.2% female; all black South African), HIV prevalence was 13.2% in men and 23.6% in women, with 88% on ART. Osteoporosis prevalence in those aged ≥50 years was: femoral neck 19.4% in women (95% CI 14.2–25.6) and 4.2% in men (95% CI 1.2–10.4); lumbar spine 18.4% in women (95% CI 13.3–24.5) and 8.4% in men (95% CI 3.7–15.9); total hip 5.0% in women (95% CI 2.4–9.0) and 3.2% in men (95% CI 0.7–9.0). Femoral neck osteoporosis was significantly more common in women with HIV than without (37.1% vs 15.7%; p=0.003). HIV infection was associated with approximately 0.5 SD lower femoral neck BMD in both sexes. No participant had confirmed or severe sarcopenia; probable sarcopenia affected 11.6% of men and 4.4% of women (p=0.001), with no association with HIV. In multivariable analysis, older age, female sex, lower ALM/height², slower gait speed, and HIV infection were independently associated with lower femoral neck BMD. An age-by-HIV interaction was found for total body less head BMD in women (interaction p=0.027), suggesting greater postmenopausal bone loss in those with HIV.

**Clinical Implications:** Osteoporosis is a substantial and under-recognized problem in rural South Africa, particularly among older women living with HIV, where 37% had femoral neck osteoporosis. Despite high obesity rates (73% of women overweight/obese), no participants reported use of osteoporosis medications. Sarcopenia was rare, possibly due to obesity masking lean mass deficits or inappropriate European cut-points. The strong independent associations between muscle measures and BMD suggest muscle-strengthening interventions could benefit bone health. The findings support integrating routine bone health assessment into HIV care for aging women in South Africa, especially given the availability of the South African FRAX tool. However, osteoporosis treatment remains limited as medications are not on the Essential Drugs List. Limitations include cross-sectional design, lack of ART duration/type data, use of non-African reference data for BMD T-scores, and potential selection bias toward healthier participants.

PICO

PPOPULATION

805 black South African adults aged 20–80 years living in a rural community in Bushbuckridge, Mpumalanga province (547 women, 258 men)

IINTERVENTION

HIV infection status (34 men and 129 women living with HIV; 88% on antiretroviral therapy)

OOUTCOME

Prevalence of osteoporosis (BMD T-score ≤ -2.5 at femoral neck, total hip, lumbar spine) and sarcopenia (EWGSOP2 criteria: grip strength, appendicular lean mass/height², gait speed); associations between HIV and BMD

STUDY TYPE

cross-sectional

SPECIALTY

endocrinology

SUMMARISED BY

AI pipeline

FIDELITY CHECK

100% · A

ORIGINAL PAPER

PMC10071443

Osteoporosis, Rather Than Sarcopenia, Is the Predominant Musculoskeletal Disease in a Rural South African Community Where Human Immunodeficiency Virus Prevalence Is High: A Cross-Sectional Study

Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research

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ABSTRACT

The rollout of antiretroviral therapy globally has increased life expectancy across Southern Africa, where 20.6 million people now live with human immunodeficiency virus (HIV). We aimed to determine the prevalence of age-related osteoporosis and sarcopenia, and investigate the association between HIV, bone mineral density (BMD), muscle strength and lean mass, and gait speed. A cross-sectional community-based study of individuals aged 20–80 years in rural South Africa collected demographic and clinical data, including HIV status, grip strength, gait speed, body composition, and BMD. Sarcopenia was defined by the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) guidelines, and osteoporosis as BMD T -score ≤ −2.5 (if age ≥50 years). The mean ± standard deviation (SD) age of 805 black South African participants was 44.6 ± 14.8 years, 547 (68.2%) were female; 34 (13.2%) were men, and 129 (23.6%) women had HIV, with 88% overall taking anti-retroviral therapy. A femoral neck T -score ≤ −2.5, seen in four of 95 (4.2%) men and 39 of 201 (19.4%) women age ≥50 years, was more common in women with than without HIV (13/35 [37.1%] versus 26/166 [15.7%]; p = 0.003). Although no participant had confirmed sarcopenia, probable sarcopenia affected more men than women (30/258 [11.6%] versus 24/547 [4.4%]; p = .001]. Although appendicular lean mass (ALM)/height 2 index was lower in both men and women with HIV, there were no differences in grip strength, gait speed, or probable sarcopenia by HIV status. Older age, female sex, lower ALM/height 2 index, slower gait speed, and HIV infection were all independently associated with lower femoral neck BMD. In conclusion, osteoporosis rather than sarcopenia is the common musculoskeletal disease of aging in rural South Africa; older women with HIV may experience greater bone losses than women without HIV. Findings raise concerns over future fracture risk in Southern Africa, where HIV clinics should consider routine bone health assessment, particularly in aging women.

CITATION EXPORT

Celia L. Gregson, Tafadzwa Madanhire, Andrea Rehman et al.. Osteoporosis, Rather Than Sarcopenia, Is the Predominant Musculoskeletal Disease in a Rural South African Community Where Human Immunodeficiency Virus Prevalence Is High: A Cross-Sectional Study. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. (2022). https://doi.org/10.1002/jbmr.4464

AUTHORS

10 · 8 CENTRES

Celia L. Gregson, Tafadzwa Madanhire, Andrea Rehman, Rashida A. Ferrand, Anne R. Cappola, Steven Tollman, Tshepiso Mokoena, Lisa K. Micklesfield, Alisha N. Wade, June Fabian

1Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
2SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
3Biomedical Research and Training Institute, Harare, Zimbabwe
4MRC International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
5Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
6Division of Endocrinology, Diabetes, & Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
7MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
8Wits Donald Gordon Medical Centre, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa