Osteoporosis is called the silent disease for a reason. People rarely show symptoms of bone disease before a break or fracture occurs.
The word “osteoporosis” literally means “porous bone” because it causes the natural holes in your bones to become larger, making your bones thinner and weaker and increasing the likelihood of fracture.
The risk of osteoporosis is particularly high in people with HIV. “HIV infection contributes to bone changes in several ways,” said Anjali Sharma, MD, MS, a professor and researcher focusing on HIV in women at the Albert Einstein College of Medicine.
We asked Sharma to break down the different effects of HIV on bone health and what people living with HIV can do to prevent osteoporosis.
Does the HIV virus itself contribute to changes in bone?
Yes, it does. Bones are constantly renewed, keeping the skeleton strong. When old bone is removed and new bone is replaced in the same location, it is called bone remodeling. This repairs skeletal damage and prevents the formation of old, brittle bones.
In osteoporosis, the balance between bone formation and bone loss shifts, so more and more bone is lost but not replaced. This makes the bone weaker and increases the likelihood of it breaking over time.
HIV can directly infect the cells that remove old bone. HIV can also increase the activity of bone-breaking cells and signal the body to produce more bone-breaking cells, leading to bone loss.
Even with effective treatment, HIV viral proteins remain in the body and can signal the body to make fewer bone-forming cells or impair their ability to form new bone, tipping the scales toward less new bone formation.
HIV also disrupts the body’s immune system, which improves but does not completely disappear with treatment that controls the virus. Low levels of HIV-related chronic inflammation affect cells that remove bone, which also leads to bone loss over time.
How do HIV medications contribute to bone changes and the risk of osteoporosis?
Treating HIV with antiretroviral therapy (ART) has resulted in tremendous health benefits for people living with HIV, but it also has effects on bones.
When a person first starts ART, in addition to reducing circulating levels of HIV in the blood to undetectable levels, the immune system is also quickly rebuilt to restore itself. This process leads to increased inflammation throughout the body. About a year after starting ART therapy, this inflammation leads to bone loss, with more bone being removed than new.
Certain HIV medications cause more bone loss than others. Switching to a newer drug formulation with fewer bone-related side effects has been shown to improve bone density.
Are there other factors that contribute to bone loss in people with HIV?
Certain medical conditions that are more common in people with HIV, such as chronic liver or kidney disease and early menopause (before age 45), increase the risk of osteoporosis.
In addition, certain behaviors such as smoking and drinking alcohol are associated with osteoporosis and may be more common in people with HIV.
Older age is a risk factor for osteoporosis, especially for women. Although it is known that people lose bone as they age and are at increased risk of osteoporosis, this is particularly true for people with HIV, who are not only at higher risk of osteoporosis than people without HIV, but can also 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, and these all apply to people with HIV. Getting the recommended amount of calcium in your diet is important for keeping bones strong. Because the body’s ability to absorb calcium decreases with age, older people require higher amounts of calcium from their diet.
Vitamin D also plays a key role in bone health. It helps the body absorb calcium from food, supports skeletal renewal and mineralization, and helps keep muscles strong to reduce the risk of falls. People with low vitamin D levels may need to take a vitamin D supplement and a calcium supplement to ensure they get enough of both.
To maintain overall health and bone health, it is also important to quit smoking and limit alcohol consumption.
Hormone therapy (HT) with estrogen has been shown to improve bone mineral density after menopause or in transgender women, while less is known about the effects of HT with testosterone on bone in transgender men.
Exercise plays a crucial role in bone health and preventing osteoporosis. Bones and muscles respond and strengthen when stressed by weight-bearing exercise (such as running or dancing). Regular exercise can help build and maintain bone and muscle strength and improve balance to prevent falls. Because osteoporosis is more common in people infected with HIV, the likelihood of a serious injury, such as a fracture, is higher after a fall. If you take safety precautions at home, e.g. You can prevent falls by eliminating tripping hazards, ensuring good lighting, ensuring the correct prescription and fit of your glasses, and wearing comfortable, flat shoes.
Tell your doctor if you feel dizzy or have fallen, and discuss whether your medications may play a role in your risk of falling, especially if you take many different types of medications. Also ask your doctor whether your HIV medications are the most bone-friendly or whether there are other options for you that have fewer side effects on bones.
Read: 6 Ways to Strengthen Your Musculoskeletal System >>
Are there specific bone health screening recommendations for people with HIV?
Because people living with HIV are at higher risk of osteoporosis and fractures compared to people not living with HIV, there are specific recommendations for bone health screening as part of their routine health care.
The most common method of screening for osteoporosis is using a dual-energy X-ray absorptiometry (DEXA) scan, which measures bone mineral density. The results can also be used to predict a person’s risk of a serious fracture.
A DEXA scan is recommended for all postmenopausal women with HIV and all HIV-infected people aged 50 and over.
People with HIV who take certain medications such as steroids, have a history of fractures, or have medical conditions that put them at high risk of osteoporosis and fractures should undergo DEXA testing at an earlier age.
This educational resource was created with support from Merck.
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