Clinically Speaking: Questions and Answers About HIV and Bone Health

Does the HIV virus itself contribute to changes in the bone?

Yes, it does. Bone is constantly being renewed, which keeps the skeleton strong. When old bone is removed and new bone is replaced at the same site, it’s called bone remodeling. This repairs skeletal damage and prevents the buildup of old, brittle bone.

With osteoporosis, the balance between bone formation and bone loss is shifted so more and more bone is lost but not replaced. As a result, the bone becomes weak and more likely to break over time.

HIV can directly infect the cells that remove old bone. HIV can also increase the activity of bone-removing cells and signal the body to make more bone-removing cells, which leads 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 disturb how well they make new bone, tipping the balance toward less new bone formation.

HIV also disturbs the body’s immune system, which improves but doesn’t completely go away 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 does HIV medication contribute to bone changes and risk for osteoporosis?

Treatment of HIV with antiretroviral therapy (ART) has led to tremendous health benefits for people with HIV but also has effects on bones.

When a person starts ART for the first time, along with reducing the levels of HIV circulating in the blood to undetectable levels, the immune system quickly builds back to restore itself. That process leads to increased inflammation throughout the body. For about a year after beginning any ART regimen, this inflammation leads to bone loss, with more bone being removed than formed at the same time.

Certain HIV medications cause more bone loss than others. Switching to a newer drug formulation with less bone-related side effects has been shown to improve bone density.

Are there any other factors that contribute to bone loss in people with HIV?

Certain medical conditions that are more common in people with HIV, like chronic liver or kidney disease and early-onset menopause (before age 45), put people at higher risk for osteoporosis.

Additionally, certain behaviors such as smoking and alcohol use have been linked with osteoporosis and may be more common in people with HIV.

Older age is a risk factor for osteoporosis, particularly for women. While it’s known that people lose bone and have an increased risk for osteoporosis as they age, this is especially true for people with HIV who are not only at higher risk for osteoporosis than people without HIV but also may develop osteoporosis at a younger age.

How can people with HIV prevent bone loss?

There are many ways people can maintain their bone health and prevent bone loss, and these all apply to people with HIV as well. Having the recommended calcium in your diet is important to keep bones strong. Because the body’s ability to absorb calcium goes down as they age, older people require higher amounts of dietary calcium.

Vitamin D also plays key roles in bone health. It helps the body absorb calcium from food, helps the skeleton renew itself and mineralize, and helps keep muscles strong to reduce the risk of falling. People with low vitamin D levels may need to take a vitamin D supplement and a calcium supplement to make sure they’re getting enough of both.

Quitting smoking and limiting alcohol intake are also important in order to maintain both overall and bone health.

Hormone therapy (HT) with estrogen after menopause or for transgender women has been shown to improve bone mineral density, while less is known about the bone effects of HT with testosterone for transgender men.

Exercise plays a vital role in bone health and osteoporosis prevention. Bones and muscles respond and strengthen when they are stressed by weight-bearing exercises (such as running or dancing). Regular exercise can help to build and maintain bone and muscle strength and improve balance to help prevent falls. Because osteoporosis is more common in people with HIV, they may be more likely to have a serious injury after a fall, such as a fracture. Taking safety precautions in the home, such as removing trip hazards, ensuring good lighting, making sure your eyeglasses are the right prescription and fit, and wearing comfortable flat shoes, are all ways to help prevent falls.

Let your healthcare provider know if you feel dizzy or have had a fall and discuss whether any of your medications might be playing a role in your risk of falling, especially if you’re taking many different types of medications. Also ask your HCP if your HIV medications are the most bone-friendly or whether there are other options for you that have less side effects on bone.

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 for osteoporosis and fractures compared to people who aren’t living with HIV, there are specific bone health screening recommendations for their routine healthcare.

The most common way to screen for osteoporosis is by using a dual energy X-ray absorptiometry (DEXA) scan, which measures bone mineral density levels. The results can also be used to help predict a person’s risk of having a serious fracture.

A DEXA scan is recommended for all women with HIV after they go through menopause, and for everyone with HIV starting at age 50.

People with HIV who take certain medications like steroids, have a history of fracture or have conditions that put them at high risk for osteoporosis and fracture should have a DEXA scan at an earlier age.