As the population of people living with HIV gets older, bone problems are becoming an increasing concern. Low bone mineral density and fragility fractures occur more frequently in people living with HIV than in other people of a similar age. Bone mineral density usually declines by 2-6% in the first two years after starting antiretroviral treatment. Studies have shown that the rate of fractures of the spine, hip and wrist is approximately 60% higher than in the general population.
The reasons for this are unclear. HIV may be one cause, but people living with HIV often have risk factors for osteoporosis including smoking, high alcohol consumption, low body weight and poor nutrition.
International guidelines for how bone problems should be managed in people with HIV have just been published. An important part of the guidelines cover screening and risk assessment.
The guidelines recommend that screening should be a routine part of medical care for all people living with HIV aged 40 or over. For men in their forties and for women who have not yet been through the menopause, doctors should use a scoring system based on the person’s lifestyle and medical history.
As people get older the screening should be based on DEXA scans (a type of X-ray). This is recommended for men in their fifties and older, women past the age of menopause, people who have already had a fragility fracture, and other people considered to be at risk of fractures.
When screening shows that a person has low bone mineral density or osteoporosis, their choice of antiretroviral drugs should be examined. If they are currently taking tenofovir or a boosted protease inhibitor, an alternative drug may be considered.
Dietary changes are also important. Foods rich in calcium are valuable (milk and other dairy products, leafy green vegetables such as kale and broccoli, beans such as soy and baked beans, nuts, sesame seeds, some fish including salmon and sardines). Vitamin D is also important – it is found in oily fish and eggs, as well as in foods that are specially fortified, such as breakfast cereals and margarines. But some people may want to consider taking supplement tablets as well.
Lifestyle advice for those with low bone mineral density include getting the right kind of exercise, stopping smoking and not drinking too much alcohol. The guidelines also recommend some medications which may help.
For an in depth review on bone problems, see this article from HIV Treatment Update published in 2010.