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This Month in HIV: A Podcast of Critical News in HIV
  

Bone Disease and HIV/AIDS: More Common Than You Think -- This Month in HIV

An Interview With Todd Brown, M.D., Ph.D., and Ben Young, M.D., Ph.D.

January 2010

This podcast is a part of the series This Month in HIV. To subscribe to this series, click here.

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Dr. Todd Brown
Dr. Ben Young

Introduction

Hello and welcome to This Month in HIV. My name is Bonnie Goldman.

With the remarkable success of HIV treatment comes a renewed focus on other health issues that plague people with HIV. You've probably heard a lot about heart disease and HIV and certainly lipodystrophy and HIV, but bone disease may affect up to 50 percent of HIV-positive people and it is little talked about.

With me to explore this issue is Todd Brown, M.D., Ph.D. Dr. Brown is an endocrinologist and an assistant professor of medicine at Johns Hopkins School of Medicine. He's also one of the top researchers when it comes to bone disease in HIV-positive peoples and has been researching this issue since 2004.

Also with me is one of TheBody.com's online experts, Ben Young, M.D., Ph.D. Dr. Young is an assistant clinical professor of medicine at the University of Colorado. He is also a consultant physician at Denver Infectious Disease Consultants, and as such he'll be able to speak to what he's seeing in what is one of Denver's largest private practices.

"I think the biggest issues now are how to best screen, diagnose and optimally manage people who may have bone disease and HIV."

-- Ben Young, M.D., Ph.D.

Bonnie Goldman: Welcome, Dr. Young and Dr. Brown to This Month in HIV. I want to start with you, Dr. Young. What is the biggest issue you're seeing in your practice today?

Ben Young: Our patients are living much longer, and are much healthier than they were in the earlier pre-HAART [highly active antiretroviral therapy] and early HAART eras. This means that they are now beginning to worry about long-term survival and issues related to aging -- all of which are good things.

In the midst of all of this, though, about four or five years ago, we started seeing one or two patients a year with unexplained fractures. Compression fractures of the vertebrae were the sentinel symptoms of this problem.

At first, we thought that they were just outliers, unusual people with unusual problems, and not part of a larger trend. It was Dr. Brown's analysis in 20061 that brought the magnitude and the frequency of this problem to a head.

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The biggest issues now are how to best screen, diagnose and optimally manage people who may have bone disease and HIV. I think this is going to be a very important topic, particularly as our patients age into the next decade of their lives, and so on.

Bonnie Goldman: What percentage of patients in your practice have bone disease?

Ben Young: We'll probably touch on this later, but it was really because of Dr. Brown's meta-analysis that we became concerned about silent bone disease in our practice. That is to say, thinning of the bones and brittle bones -- osteopenia and osteoporosis, respectively. What we detect in patients are fractures.

Obviously, from a preventive medicine standpoint, we like to identify patients who are at risk of having very serious fractures, or fracture risk, before they fracture. So we embarked on a program to try to do just this, namely doing dual energy X-ray absorptiometry, or DXA scanning.

"I've screened about 80 percent of the patients in our practice. ... Over 50 percent of our patients have one form or another of abnormally thin bones. This is a really striking number, much greater than many, many of the other complications that we worry about."

-- Ben Young, M.D., Ph.D.

I've screened about 80 percent of the patients in our practice. What we find is entirely sanguine with Dr. Brown's earlier analysis, which is: Over 50 percent of our patients have one form or another of abnormally thin bones. This is a really striking number, much greater than many, many of the other complications that we worry about.

Bonnie Goldman: When you say "silent," what do you mean? Do you mean no one is experiencing any symptoms?

Ben Young: This is similar to hardening of the arteries, which doesn't cause symptoms until something bad happens. A patient who has osteopenia, for example, should have no symptoms whatsoever. A patient who has osteoporosis frequently doesn't have fractures, right up until the point that he or she fractures a hip or a vertebral body. The real problem is recognizing risk and trying to improve bone health before this fracture.


Figuring Out Bone Disease Prevalence in the HIV-Positive Population

Bonnie Goldman: Dr. Brown, what made you initiate your investigations into bone disease in the HIV-positive population?

Todd Brown: There had been scattered reports of low bone density among HIV-positive patients. There's some question regarding whether or not it was related to HIV itself, or antiretroviral therapy.

When I was in training at Georgetown University, we had conducted a study2 but it wasn't large enough to be able to draw firm conclusions about the most severe losses in bone mineral density.

"We did find about a 15 percent prevalence of osteoporosis -- the average age was probably the low 40s -- across the various studies that we looked at. Compared to the respective HIV-negative control population, this was about three and a half times the prevalence that was seen in those populations."

-- Todd Brown, M.D., Ph.D.

That's why the meta-analysis was an effective way to do this. We could look at osteoporosis, rather than a combined category of osteopenia, which is a lower than normal bone mineral density, and osteoporosis.

We did find about a 15 percent prevalence of osteoporosis -- the average age was probably the low 40s -- across the various studies that we looked at.

Compared to the respective HIV-negative control population, this was about three and a half times the prevalence that was seen in that population.


Defining Low Bone Mineral Density

Bonnie Goldman: Could you explain what osteopenia and osteoporosis are?

Todd Brown: Bone density is probably the best way, or the most available way, of measuring and evaluating fracture risk using DXA, or dual X-ray energy absorptiometry. Osteoporosis and osteopenia are really designations, or classifications, based on [the bone density of] postmenopausal women. A lot of this research has been done in postmenopausal women just for the simple fact that this is where the burden of fractures lies.

When you look at bone density tests, DXA scans, the measure that most people use is something called the "T-score." This is the number of standard deviations that a person's bone mineral density is away from that of a gender-matched, young, normal population.

If your T-score is more than two-and-a-half standard deviations lower than that of a young, normal population, then you have osteoporosis. You have osteopenia if your T-score is between one standard deviation and 2.5 standard deviations less than that of the young, normal population.

Bonnie Goldman: When you say bone mineral density, are you simply referring to the thickness of someone's bones?

Todd Brown: That's right: the amount of mineral that's in your bones. This designation, as I mentioned, has mostly been validated in postmenopausal women, but has been applied to other populations, as well.

Bonnie Goldman: Postmenopausal women are the most likely to lose bone because of the hormonal changes that occur after they stop menstruating, is that right?

Todd Brown: That's right.

Bonnie Goldman: So, it's really not common in the general population.

Todd Brown: There's not a lot of good, standard data to understand what the bone mineral density is in the average person.

Bonnie Goldman: Dr. Young, is it a challenge to explain bone disease to patients?

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Ben Young: Actually, I think that people get it. Osteoporosis is common enough in the general population that people have heard about it.

My mother, for example, had osteoporosis. That's a precise term: a brittle bone. Often we'll use the terminology of abnormal, but not diseased, bones -- much analogous to HIV without AIDS, for example. It's not particularly complicated for people to understand.

Sometimes the T-score/Z-score standard deviation language can confuse people. But it just indicates how far away from the expected bone density you are. Once you're two-and-a-half standard deviations below that, then we define that as having osteoporosis.

What people should realize is that these scores, the standard deviations, are a continuous variable, in a way, so that the risk of fractures is continuous. It's a function of both the strength of the bones, if you will, and the likelihood that one is going to fall -- a larger component that also influences the risk of having a fracture.

In general, people do understand this. Explaining to them why I'm concerned about assessing them for bone health is not as complicated as some of the other things that we do in HIV medicine.

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Copyright © 2010 Body Health Resources Corporation. All rights reserved. Podcast disclaimer.

This podcast is a part of the series This Month in HIV. To subscribe to this series, click here.


  

This article was provided by TheBody.com. It is a part of the publication This Month in HIV.
 
See Also
Bone Health and HIV Disease
More News and Research on Bone Problems
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Reader Comments:

Comment by: CNA Salary (Germany) Sat., Jun. 12, 2010 at 11:16 pm EDT
Wow this is a great resource.. Iím enjoying it.. good article
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Comment by: anon (Atlanta) Fri., Jun. 11, 2010 at 6:13 am EDT
Awesome podcast! I have listened to its entire content twice. This affects my life tremendously, and fits to a T what has been going on with me(my neck, back and possibly my wrist). I was on Viread and P.I's, have low testosterone, low cholesterol, vitamin D level was in range but on the low side,i have been on corticosteroids(for way to long ). Have been positive for 16+ years.
Xrays only showed forminimal narrowing c4-c7 compession and also T8 amd bone spurs
Reply to this comment


Comment by: skip (Conn) Thu., Mar. 4, 2010 at 5:40 pm EST
what a thorough and excellent interview. I will try to see Dr. Brown.
Reply to this comment


Comment by: rachell skeith (Texas) Mon., Mar. 1, 2010 at 8:40 pm EST
Thanks for sharing this information. The more information you have, the better your chances of preventing a std and staying healthy.
Reply to this comment


Comment by: G. Powell (Largo, Florida) Thu., Feb. 25, 2010 at 3:03 pm EST
Good Topic. Too bad it doesn't give any in depth answers. Bone Disease. Is it the feeling of like lets say my toes or fingers feeling like they are spranged or fractured? give more details...
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Comment by: AIDS / STD Counselling HB (Germany) Wed., Feb. 17, 2010 at 4:55 am EST
What, if the mentioned "drop in bone mineral density in the first two years of antiretroviral therapy" is not caused by the ART, but the end of the bone-loss, which started with HIV-infection? And it takes around two years to stop the bone-loss?
Reply to this comment


Comment by: Abie (NYC) Thu., Feb. 11, 2010 at 8:41 pm EST
Todd brown is so on target. I think this problem really needs some looking at. I have many friends who have experienced all kinds bone issues and no one seems to be paying attention. I take 50,000 mil of vitamin D once a week and 1,200 calcium daily but i had to initiate the discussion with my Doc. I also lift weights 4 x a week. But few Docs are recommending this. Dr. Young is really an exceptional Doc.
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Comment by: Pauline M. Norwood (Springfield, MA) Thu., Feb. 4, 2010 at 10:57 am EST
Some people I have worked with that are or were
HIV positive, had problems with their bones (legs mostly) because they were taking methadone
and also AZT. most medicines are toxic, however,
HIV meds. plus Methadone is very toxic and weaken
the bones. I think.
Reply to this comment


Comment by: Erika (Texas) Thu., Jan. 28, 2010 at 11:53 am EST
Thank you very much! This has helped me tramendously! I am working on a project for class! This just made it that much easier!

Thanks again,
Erika, Texas
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Comment by: rispah (kenya) Thu., Jan. 21, 2010 at 5:47 am EST
i wonder what HIV could do to the bone marrow. Please give me some information on this.
Reply to this comment


Comment by: DAVID H (GREENSBORO, NC) Tue., Jan. 19, 2010 at 6:06 am EST
WHAT ARE THE SYMPTOMS OF BONE DISEASE AND HOW TO CONTROL IT LIVING WITH HIV? I TAKE A LOT OF HERBAL SUPPLEMENTS WHICH REALLY HELP ME.
Reply to this comment


Comment by: Wayne D (Sydney, Australia) Mon., Jan. 18, 2010 at 9:48 pm EST
Having this information several years ago would have been halpful to me in understanding what I was going through as I have been diagnosed with avascular necrosis (AVN) in 6 major joints (both knees, hips and shoulders). I have had to have replaced both hips, right shoulder and right knee and am currently on the waiting list for a replacement for the left shoulder - the other knee will also have to be done at some stage. The cause of the AVN has been put down to a combination of protease inhibitors, corticosteriod use and other lifestyle factors such as alcohol abuse etc over the years. I was first diagnosed with AVN 4 years ago at the age of 46 when I needed my first hip replacement and was told at that stage that it was due to all the prednisone that I was given while in intensive care (with a pulmonary embolism following a deep vein thrombosis) - now they say it is the HIV meds. And while it hasn't been easy to go through all these joint replacements; at least I am still alive. I just wonder how many other people are going to go through the same thing due to the combination of HIV meds and other risk factors and feel it is an issue that more HIV+ people should be aware of - especially those with a history of alcohol abuse as that is another major risk factor for avascular necrosis.
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Comment by: george (Palm Beach, Fla) Mon., Jan. 18, 2010 at 12:49 pm EST
very important interview! thanks so much for this. i will show it to my doctor.
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Comment by: Darren (UK) Sun., Jan. 17, 2010 at 12:49 am EST
For me this article is spot-on, though wish I'd known about this a year ago. I'm 36, HIV+, on Truvada/Viread and Efavirenz, relatively lightweight...and am just recovering from a hip fracture. A DXA scan showed I have osteopenia, and have low levels of vitamin D and calcium. An x-ray showed that I've had a fracture of the vertebrae, which I didn't even know about. Needless to say, if you have HIV and have any of the risk factors listed in this article, get you HIV doc to order a DXA scan! I'm now on calcium and vitamin D supplementation, and will start bispohosphonate treatment soon to strengthen bones and avoid and more breaks. Hopefully no more fractures for me...
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Comment by: Yuri (Queens, NY) Fri., Jan. 15, 2010 at 9:55 am EST
Osteopenia is a "disease" invented by the pharmaceutical industry. Otherwise it is just a regular-occurring condition strongly correlated with age. If we are to believe that we age faster with HIV and the mind-and-body altering meds we take, then we ought to view "bone disease" as a function of the overall aging processs which is perhaps occurring faster in HIV patients than others. With so many ifs and questions, rather than inventing the new meta-wheel for HIV-related bone disease the science-minded doctors should look at advances already made in gerontology and look there for clues to prevent and treat diseases of old age. HIV (and the meds) is a co-factor here not the culprit. Having said that, look at the massive amount of studies done in order to learn the bone decline in older men in general. Keeping your weight in check, exercise, diet rich in calcium and other accompanying minerals, Actonel or similar drugs(if insurance pays for it) every ten days since indeed osteopenia is not a disease. Perhaps then the actually occurring deterioration can be slowed down. Take a look at the affordable and proven calcium-minerals-rich supplements. For 25 years of my diagnosis I constantly checked the medical establishment assumptions about the HIV and human body in general. While we are blessed with the smartest doctors and scientists and very-efficient profit-oriented pharmaceutical industry one always has to keep the admiration in check since the very same smart people are easily beholden to prevalent "paradigm" of the moment . We must avoid blind following of this smart bunch so as not to end being nothing short of guinea pigs for unproven meta theories. I can't tell you how many thresholds for starting HIV treatment we had in the last 3- 5 years alone. Or the near-monthly change in FDA-approved mega dosing of extremely toxic drugs only to find out that they ought to have been cut in half to be both effective and less-toxic. Compliments for excellent medical reporting!
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Comment by: ABINET AMAN (ETHIOPIA) Fri., Jan. 15, 2010 at 8:28 am EST
I think in resource-limited settings it's difficult to know the disease progress.
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Comment by: Dana (Oakland, CA) Thu., Jan. 14, 2010 at 4:21 pm EST
1.14.10

Good read, good docs ... alas, I could have used the alert a few years ago, since MY HIV docs never bestirred themselves and now ... May be I missed The Body's clarion, prob'ly so. My bad!

And, yes, any tenofovir-based med/regimen (and I've been on 'em for several years - I'm 63 and counting) is what did it in my case.

I took my first dose of alendronate 70 mg this week and I'm assiduously popppin' vitamin D and calcium carbonate.

You can't get the word out (and around!) fast enough.

Thanks, guys.

Dana Charles Huffman
Oakland, CA
Reply to this comment


Comment by: Dennis (Ohio) Thu., Jan. 14, 2010 at 3:05 pm EST
I was diagnosed with osteopenia of the spine and osteoporisis of both hips in June. After 20 years of antivirals and reaching 52 this year, nothing was going to shock me about HIV. I must admit this does. My id doctor seemed suprised and said -2.6 in each hip is not bad. Thank you for such a comprehensive article that I will take to my next doctor visits. I have been exercising every day for years, no smoking and no drinking. My weight is slight (130 at 5 feet 8 inches tall) and my age is 52 are the only non hiv factors. Why wait until we all have fractures to do something about the hiden bone density issue? I started on Actonel once per week which is what my insurance covers. Keep up the good medical reporting!
Diagnosed in 1986!
Somewhat healthy in 2010!
Dennis
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