Dr. Gordon Arbess is a staff physician with the Department of Family and Community Medicine and St. Michael’s Academic Family Health Team in Toronto. He specializes in HIV Primary Care.
As a physician in the treatment and care of HIV, I see people living and thriving with HIV. Today, with early diagnosis and effective treatments, a 20-year old HIV-positive person can expect to live into his/her early 70s. In fact, the majority of people with HIV are now over the age of 50, and within the next 10 to 15 years, we expect the average age of a person living with HIV to be over 55 years. We have made incredible advances in the management of HIV since the virus was first identified almost 35 years ago, and the first treatment was approved only 30 years ago.
However, as people age with HIV we now face other health risks that often mirror aging in uninfected people. For example, today as many patients achieve viral load suppression, I am seeing an increase in cases of co-morbid health conditions, including osteoporosis, kidney disease and heart disease – predominantly as a result of the evolution of the disease itself and the patient’s history of HIV treatment (antiretroviral therapy).
The recent Osteoporosis Awareness Month reminds us that it is a good time to strengthen our knowledge of this condition and its impact on bone health in the context of HIV, and build a better bone health action plan with your doctor.
Osteoporosis, or fragile bone disease, is a disorder characterized by low bone mineral density (BMD) and a deterioration of bone tissue that is associated with increased bone fragility and fractures. Like a house that has a solid foundation and load-bearing walls to support its structural integrity, the human body has 206 bones that continue to grow and strengthen to provide a structural frame for a human skeleton. However, in both cases, a lack of care, or inattention to the weakened or damaged infrastructure, can see both the house and the body crumble right underneath us.
Regardless of HIV status, as both men and women age, it is normal that bones become gradually less dense, weaker and more fragile. Osteoporosis causes more than 80% of all fractures in people over the age of 50. Bone loss may lead to fragility and fracture, and in turn, increase the risk of hospitalization, subsequent fractures, decreased quality of life, and even death. Data show that 1 in 4 individuals with a hip fracture will die within 5 years.
Specifically, in those living with HIV, there is a 2 to 4-fold increase in the prevalence of fractures compared to HIV-uninfected people, and HIV-positive people are five times more likely to suffer a hip fracture. In fact, a recent study published in the journal AIDS, showed the incidence of fractures started to rise one full decade earlier in HIV-positive men compared to HIV-negative men, with a significant increase in fracture incidence among HIV-positive men between the ages of 50 to 59 years.
Frailty, a common feature of aging, is also associated with bone loss, which can lead to fracture. Frailty is defined as any three of: unintentional weight loss, reduced grip strength, reduced walking speed, exhaustion, or a low level of physical activity. One study estimated that 1 in 12 people with HIV in middle age were already frail, and at least one-third showed signs of early frailty compared to the general population. Frailty is significantly higher in patients who have suffered a major osteoporotic fracture, and often increases the risk of another major fracture, falls and death.
It is unfortunate, but a fact that many people living with HIV are not aware that they are at an increased risk of bone loss, due to the disease itself and medications. In HIV, the balance of bone resorption and bone rebuilding is disrupted leading to bone loss. In a review of studies on the prevalence of osteoporosis in HIV-infected people compared to those uninfected, HIV patients showed a 6.4-fold increase in a decrease of BMD and a 3.7-fold increase in osteoporosis. People with HIV showed a 15% increase in the risk of osteoporosis, as well as a 52% increase in the risk of osteopenia (low BMD, without being as severe as osteoporosis).
You may now be thinking, what’s my first step to address my bone health and risk of osteoporosis?
To determine your bone health risk(s) that may make osteoporosis more likely, your physician may conduct an assessment to identify current or future risks, such as checking: traditional risk factors (i.e., smoking, low body weight, low testosterone and estrogen levels, and alcohol intake); HIV specific and other disorder risk factors (i.e., duration of infection, level of virus, co-infection with HCV); and medication risk factors as some HIV antiretroviral treatments and some other mediations are associated with a more accelerated bone loss.
Why not start with some prevention measures: stop smoking; limit alcohol, sodium and caffeine consumption; maintain a healthy body weight (not underweight or overweight); and start weight bearing exercises (walking and resistance training).
Review your current medication and past treatment with your physician to determine the most effective treatment plan moving forward. Research has shown that the initiation of antiretroviral therapy is associated with a 2 to 6% reduction in BMD in the first 1 to 2 years of treatment. Today, new medications may have less of an impact on BMD.
Talk about osteoporosis, fracture risks and screening with your physician. This may be especially important for HIV-positive people over the age of 50. Discuss other strategies that may help preserve your bone density including increasing your dietary sources or supplementation with Vitamin D and Calcium.
Just as you plan to fix the roof of the house before a leak damages the inside of your home, plan to keep your bones healthy before osteoporosis leads to a fracture. As you continue to age with HIV, take action to strengthen, build and fortify your bones to protect yourself from bone loss, fragility and fracture that can, unfortunately, lead to a poor quality of life, or death. Here’s to healthy aging with HIV!