Bone problems

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.

Smoking and heart attacks

Another concern as people with HIV get older is cardiovascular disease – this includes heart attacks, strokes and high blood pressure. It is the cause of around one-in-ten deaths of people living with HIV.

There’s scientific debate about why these rates are so high in people who have HIV. But a new study from Denmark suggests that the principal cause is smoking.

In this large study, just under half the people with HIV smoked, compared to less than one in five in people of the same age and gender in the general population. During the study, 3% of people with HIV had a heart attack, compared to 1% in the general population.

People living with HIV who smoke had an almost three-fold greater risk of heart attack than HIV-negative smokers.

So not only is smoking more common among people with HIV than the general population, but it may also be more damaging to their health than in people who do not have HIV.

The research shows the importance for people with HIV of avoiding smoking. One month ago in HIV update, we reported on a different study showing that across Europe and North America, smoking doubles the risk of death for people with HIV. As well as heart attacks and strokes, these deaths are caused by lung cancer, other cancers, and liver disease. And as we’ve already mentioned in this issue, smoking increases the risk of having bone problems.

You can get more information and advice on quitting smoking in our resource Living with HIV.

HIV treatment soon after infection

Generally, people only find out that they have HIV some months or years after getting infected. But occasionally people do seek medical care and get tested during the first few weeks of having HIV. Some studies suggest that starting HIV treatment as soon as possible during this period can have long-term benefits in terms of preserving the immune system, the body’s natural ability to fight HIV.

But a new study has shown that – contrary to some researchers’ expectations – starting treatment immediately after infection and then interrupting it was no better than delaying treatment until CD4 counts fell below 350. Only those who started treatment early and stayed on it had a significant advantage in terms of immune recovery.

The study compared people diagnosed during the first few weeks who either:

  • started HIV treatment immediately and stayed on it,
  • started HIV treatment immediately, had a break from treatment, and then went back on treatment, or
  • did not take treatment until two or three years after diagnosis.

The researchers looked at two different measures of the strength of the immune system, the CD4 count and the CD4:CD8 ratio. People in the first group had more than 100 more CD4 cells/mm3 than people in either of the other two groups. Many of them also had a CD4:CD8 ratio that was comparable to that of people who don’t have HIV, whereas this wasn’t the case for people in the other two groups.

So the study confirms the benefit of starting HIV treatment very soon after acquiring HIV – but only for people who stay on treatment.

For more information, see our illustrated leaflet on Very recent infection or our factsheet on Primary infection.