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Bone Health and HIV/AIDS

July 28, 2015

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How to Know if You Have Bone Problems

Osteoporosis and Osteopenia

Bone mineral density (BMD) tests are the only way to find out if you have osteoporosis or osteopenia. The most widely used BMD test is a DEXA (Dual Energy X-ray Absorptiometry) scan. The DEXA scan is a kind of x-ray, and is an easy and painless test that takes about 15 minutes.


Osteonecrosis can cause pain in the joints, usually in the hip area. At first the pain may only occur when you put weight on the joint. In more severe cases the pain can be constant. An MRI (magnetic resonance imaging) scan can spot early stages. X-rays and other scans can detect advanced osteonecrosis.

Guidelines for Bone Care

The World Health Organization (WHO) recently released new guidelines for the management of bone health among people living with HIV. The guidelines recommend that all pre-menopausal women living with HIV who are 40 years old or older have their risk of fracture measured using the Fracture Risk Assessment Tool (FRAX) without a DEXA scan. This assessment looks at risk factors for fracture (e.g., age, smoking, family history of fracture, etc.) and calculates a probability of future fracture.

The guidelines also suggest that DEXA scans be conducted for all postmenopausal women living with HIV, HIV+ people with a history of fragility fracture, HIV+ people receiving chronic glucocorticoid treatment, and people living with HIV who have a high risk of falls.

Lastly, the guidelines recommend that people living with HIV who are at risk for bone loss and/or fracture have their HIV treatment regimens adjusted so that they do not contain tenofovir or boosted protease inhibitors.

Diet and Healthy Bones

Even though you cannot control all of the things that lead to bone disease, you can control your diet. The mineral calcium makes up a large part of your bones. This means that if you do not get enough calcium in your diet, your bones may get weaker.

Calcium is found naturally in some foods, and it is added to others. Some foods that contain calcium are:

  • Dairy products, including milk, yogurt, and cheese
  • Soy products: tofu, tempeh, soy milk
  • Seeds: sesame seeds, chia seeds, and flax seeds
  • Dark leafy greens: spinach, kale, chard, collard greens, turnip greens
  • Broccoli
  • Beans: black beans, navy beans
  • Dried fruits and nuts: figs, almonds, brazil nuts
  • Oranges and orange juice (especially calcium-fortified orange juice)
  • Salmon or sardines with the bones

Some people living with HIV still need to take calcium pills every day even if their diet includes foods with calcium in them. A registered dietitian or other trained health care provider can help you decide if you should take calcium supplements. If you do take calcium supplements, it may be a good idea to take calcium pills with vitamin D in them, since your body cannot use calcium without vitamin D. According to the Office of Dietary Supplements at the National Institutes of Health in the US, the recommended dietary allowances are:

  • Girls and young women nine to 18 years old need 1,300 mg of calcium and 600 IU of vitamin D daily
  • Women 19 to 50 need 1,000 mg of calcium and 600 IU of vitamin D daily
  • Women 50 to 70 need 1,200 mg of calcium and 600 IU of vitamin D daily
  • Women 71 and over need 1,200 mg of calcium and 800 IU of vitamin D daily
  • Pregnant and breastfeeding teens need 1,300 mg of calcium and 600 IU of vitamin D daily
  • Pregnant and breastfeeding adults need 1,000 mg of calcium and 600 IU of vitamin D daily

Talk to your health care provider before taking any supplements and do not take more than these amounts unless instructed to by your health care provider.

Physical Activity and Healthy Bones

If you do not have joint pain, it is important to be physically active on a regular basis. When you exercise your muscles pull against your bones, which helps keep your bones healthy and strong. The best kind of physical activities to keep your bones strong are activities that use weight or resistance such as:

  • Walking (you can use ankle weights)
  • Working out with weights, weight machines, or brands (also called resistance training)
  • Stair climbing
  • Hiking
  • Aerobics
  • Jogging

If you cannot do high-impact weight-bearing activities, try lower-impact ones. For example, try walking or stair climbing instead of jogging. If you have not exercised regularly for a while, check with your health care provider before beginning a new exercise program.

Once you have your health care provider’s approval, start your exercise routine slowly. Every week or two, make your routine five minutes longer. In the end, it is recommended that you do 150 minutes of moderate-level physical activity each week (e.g., five 30-minute workouts).

Drugs to Treat Osteoporosis

Diet and exercise are best for keeping bone loss from occurring. They can also be helpful if you already have osteopenia or osteoporosis, but in some cases, your health care provider may also recommend treatment with medication.

Make sure to ask your health care provider about how to take the medication, possible side effects, and whether there are any interactions with HIV drugs you take. Some of the osteoporosis medications that are commonly used include:


These drugs are widely used to treat and prevent osteoporosis. They include:

  • Fosamax (alendronate)
  • Boniva (ibandronate)
  • Actonel or Atelvia (risedronate)
  • Zometa, Zomera, Aclasta and Reclast (zoledronic acid)

It is important to get enough calcium and vitamin D when you are taking a bisphosphonate.


  • Estrogen: In women, replacing the hormone estrogen has been shown to decrease the number of fractures. Sometimes estrogen is combined with another hormone called progesterone. However, estrogen replacement therapy can increase the risk of developing other diseases, including certain cancers. Because of this, the US Food and Drug Administration (FDA) recommends using other osteoporosis medications. If estrogen/progesterone are used, the lowest possible doses should be considered.
  • Testosterone: Testosterone therapy may be useful to slow or reverse decreased bone density and strength in men
  • Miacalcin (calcitonin): This naturally occurring hormone slows bone loss and increases bone density in the spine
  • Forteo (teriparatide): Forteo is a parathyroid hormone that has been shown to rebuild bone and increases bone mineral density, especially in the spine

Selective Estrogen Receptor Modulators (SERMs)

Evista (raloxifene) is in a class of osteoporosis drugs called SERMs. Evista was developed to work like estrogen therapy, but with fewer side effects.

Bone-Modifying Agent

Denosumab (Prolia or Xgeva) is given as a shot (injection), and is used to treat postmenopausal women at high risk for fracture. It works by stopping the development of cells that remove bone.

Protect Your Bones

It is important that women living with HIV, especially those who have experienced menopause, pay careful attention to their bone health. Speak to your health care provider and follow these steps to help protect your bones:

  • Ask your health care provider if you need a DEXA scan
  • Follow a diet with plenty of calcium and vitamin D
  • Seek the advice of a registered dietitian if you need help choosing the right foods
  • Take calcium supplements if needed (talk to your health care provider first)
  • Ask your health care provider what physical activity is safe for you, and start doing it
  • Stop smoking and reduce your intake of caffeine and alcohol
  • Tell your health care provider if you are experiencing joint pain, especially in the hip area
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This article was provided by The Well Project. Visit The Well Project's Web site to learn more about their resources and initiatives for women living with HIV. The Well Project shares its content with to ensure all people have access to the highest quality treatment information available. The Well Project receives no advertising revenue from or the advertisers on this site. No advertiser on this site has any editorial input into The Well Project's content.

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