There is a reason why osteoporosis is known as a silent disease. People rarely show symptoms of bone conditions before they break or fracture.
The word “osteoporosis” literally means porous bones. This is because the natural cavities in the bones become larger, making the bones thinner, weaker, and more likely to break.
The risk of osteoporosis is especially high in people infected with HIV. “There are many ways in which HIV infection affects bone changes,” said Anjali Sharma, M.D., a professor and researcher who focuses on HIV in women at the Albert Einstein College of Medicine.
We asked Sharma to break down the different ways HIV can affect bone health and what people with HIV can do to prevent osteoporosis.
Does the HIV virus itself affect bone changes?
Yes, that’s right. Bones constantly regenerate, keeping the skeleton strong. Removing old bone and replacing it with new bone in the same area is called bone remodeling. This repairs skeletal damage and prevents the formation of old, brittle bones.
With osteoporosis, the balance between bone formation and bone loss is shifted, causing more and more bone to be lost but not replaced. As a result, bones become weaker and more likely to break over time.
HIV can directly infect the cells that remove old bone. HIV can also cause bone loss by increasing the activity of bone-clearing cells and signaling the body to make more bone-clearing cells.
Even with effective treatment, HIV viral proteins can remain in the body, tipping the balance toward less new bone formation by signaling the body to reduce the number of bone-forming cells or interfering with how well it builds new bone.
HIV also disrupts the body’s immune system, which improves with treatment to control the virus, but does not go away completely. Low-level HIV-related chronic inflammation affects bone-removing cells, which leads to bone loss over time.
How do HIV medications affect bone changes and risk of osteoporosis?
Treatment of HIV with antiretroviral therapy (ART) has not only provided tremendous health benefits to people living with HIV, but it also has implications for bones.
When a person first starts ART, it lowers the levels of circulating HIV in the blood to undetectable levels while allowing the immune system to quickly recover and repair itself. The process increases inflammation throughout the body. For about a year after starting ART therapy, this inflammation causes bone loss, with more bone removed than simultaneously formed.
Certain HIV medications cause more bone loss than others. Switching to a new drug formulation with fewer bone-related side effects has been shown to improve bone mineral density.
Are there other factors that contribute to bone loss in people with HIV infection?
Certain medical conditions that are more common in people with HIV, such as chronic liver or kidney disease and early-onset menopause (before age 45), increase the risk of developing osteoporosis.
Additionally, certain behaviors, such as smoking or drinking alcohol, have been linked to osteoporosis and may be more common in people with HIV.
Old age is a risk factor for osteoporosis, especially in women. It is known that bone loss and risk of osteoporosis increase with age, but this is especially true for people with HIV, who not only have a higher risk of osteoporosis than people without HIV, but may develop osteoporosis at a younger age.
How can people with HIV prevent bone loss?
There are many ways people can maintain bone health and prevent bone loss, all of which also apply to people living with HIV. To keep your bones strong, it is important to get the recommended amount of calcium in your diet. Older people need more dietary calcium because the body’s ability to absorb calcium decreases with age.
Vitamin D also plays an important role in bone health. This helps your body absorb calcium from food, helps your skeleton regenerate and mineralize itself, and helps keep your muscles strong, reducing your risk of falls. People with low vitamin D levels may need to take vitamin D supplements and calcium supplements to ensure they are getting enough of both.
To maintain both your overall health and bone health, it is also important to quit smoking and limit your alcohol intake.
Hormone therapy (HT) with estrogen for postmenopausal or transgender women has been shown to improve bone mineral density, but less is known about the bone effects of HT with testosterone for transgender men.
Exercise plays an important role in bone health and preventing osteoporosis. Bones and muscles respond and strengthen when stressed by weight-bearing exercise (e.g. running or dancing). Regular exercise helps build and maintain bone and muscle strength and improves balance, which helps prevent falls. Because osteoporosis is more common in people with HIV, they may be more likely to suffer a serious injury, such as a fracture after a fall. Taking safety precautions at home, such as eliminating fall hazards, ensuring good lighting, making sure your glasses are the right prescription and fit, and wearing comfortable flat shoes are all ways to help prevent falls.
If you feel dizzy or have fallen, tell your health care provider and discuss whether the medications you are taking may affect your risk of falling, especially if you are taking multiple medications. Also ask your health care provider whether your HIV medications are the most bone-friendly or if there are other options that have less side effects on your bones.
Read: 6 ways to strengthen your musculoskeletal system >>
Are there specific bone health screening recommendations for people living with HIV?
Because people infected with HIV have a higher risk of osteoporosis and fractures compared to people without HIV, there are specific bone health screening recommendations for routine health care.
The most common way to test for osteoporosis is with a dual-energy x-ray absorptiometry (DEXA) scan, which measures bone density levels. The results can also be used to predict the risk of serious fractures.
DEXA scans are recommended for all women infected with HIV after menopause and for all people infected with HIV starting at age 50.
People with HIV who take certain medications, such as steroids, have a history of fractures, or have conditions that put them at high risk for osteoporosis and fractures should have a DEXA scan at an earlier age.
This training material was created with support from:m Merck.
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