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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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Screening for Bone Disease

Bonnie Goldman: Let's go back to the basics about bone health. Dr. Young, you said that you're looking at all the patients in your practice. How can someone find out if he or she has healthy bones? You mentioned DXA scans. Are there any symptoms that someone might have? Is there something else that would tell someone that he or she might have bone disease?


Ben Young: The key part here is that for the most part, bones don't cause symptoms until they fracture. Probably, the most important thing to stress to patients is that you largely don't have symptoms, and could have bone disease.

In fact, there's a lot of interest in trying to determine which specific risk factors may place one person or another at greater risk of having bone disease. Obviously, there's a lot of research interest in trying to sort out the specific mechanisms of this.

The large surveys suggest that this is a common enough problem that in a way I don't really care what's the specific matrix of risk factors that puts one individual at risk or not; it's common enough in our practice that we see this with quite a bit of frequency.

Indeed, it was with a collaboration with Dr. Brown in a CDC-sponsored study called SUN that we really first became aware of the specific problems in our patients.3 Namely, in our practice, about 50 percent of our patients have bone disease. About 10 percent have osteoporosis. Virtually all of these patients were living their lives just fine before we did the specific testing to look for it.

What You Can Do to Improve Your Bone Health

  • Ask your health care provider to give you a baseline DXA scan.
  • Next time you get your blood count, ask them to check your vitamin D levels.
  • Try to exercise (particularly with weights) at least three times a week for 20 minutes each time. This will not only keep your heart healthy, but will help build and maintain your bones.
  • Stop smoking and you'll help not only your heart and lungs, but your bones.
  • Avoid drinking an excessive amount of alcohol. Excessive drinking can cause bone loss.
  • Be sure to eat a balanced diet rich in calcium and vitamin D. Browse this for foods that may help.
  • Talk to your health care provider about adding vitamin D and calcium supplements to your daily regimen.

So, to your point: There are methodologies to measure the calcium content and the density of the bones. The best and most quantitative way to do that is with these DXA scans.

In fact, that's what we are now embarking on doing for all the patients in our practice. As we expand the number of patients we have screened, from the initial 100 that were in the clinical study to in the neighborhood of 400 or 500 individuals, the numbers remain just that: About 50 percent of our patients have abnormal bone mineral density. And it's quite a bit of a concern.

The problem is that one really needs to do that test to have the best measure of it. There are probably some alternative strategies that are worth mentioning.

For one, many people do get X-rays, for one reason or another. The information in those X-rays can often reveal abnormally low bone mineral density. But one has to be mindful to ask the radiologist. We have occasionally picked up abnormal bone density on chest X-rays that were done not looking for bone density, but rather for pneumonia.

A fracture that is unexplained from a not-so-traumatic event should not just be written off as just an unfortunate fall, or a weird step off the curb that broke your ankle. One should ask the question: Is that a patient who might actually have abnormal bone density?

Bonnie Goldman: Are DXA scans generally covered by insurance and Medicaid?

Ben Young: To my surprise, they are actually covered by most insurance companies. I should add that patients who have other significant risk factors (for example, patients who have been on long-term corticosteroid therapies, patients who have abnormally low testosterone levels or patients who have had abnormal fractures in the past) have access to DXA scans, both by insurance companies and by Medicaid.

The Medicaid question and HIV is a problematic one, because it's not well covered, if at all. Medicaid is variable. It depends a little bit on state funding and such, but it is usually not covered. There are people trying to improve that. But if one has third party insurance, it's pretty easy to get a DXA scan. The doctor just needs to know what to ask for.

Debate: DXA Scans for Everyone With HIV?

Bonnie Goldman: Would you say that everyone with HIV should get a baseline DXA?

Ben Young: This will be controversial, but in our practice, that's our standard. There are no U.S.-based guidelines for this.

"From a knowledge gained and a preventive medicine perspective, the information I get from doing $100 test to look at bone health, is probably more valuable than doing a fourth or fifth viral load test in a patient who is otherwise doing well."

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

I summarize it this way: One out of every two patients in my practice probably has abnormal bone density. The cost of doing a scan is roughly $100. It's about half the price of doing a viral load test. From a knowledge gained and a preventive medicine perspective, the information I get from doing a $100 test to look at bone health is probably more valuable than doing a fourth or fifth viral load test in a patient who is otherwise doing well.

Todd Brown: I differ a little bit here. I think that a bone density test is a decent way to assess fracture risk. But the problem that you get into is that people who are younger than 50 really don't fracture all that often. If we were talking about universal screening of HIV-infected patients, I would suggest screening people over the age of 50.

Even if someone has low bone density by DXA and may be at increased risk of having a fracture compared to someone of a similar age who has normal bone density, the chances that he or she is going to have a fracture are just so low, because young people generally don't have fragility fractures.

Ben Young: This is something that is a nice point of debate, Todd. I'll differ with you again a little bit, to make just a couple of points.

Number one is that the largest study regarding this comes from the Massachusetts Study Group, comparing HIV negatives to HIV positives, in which the fracture rate for sub-40-year-olds who are HIV positive approximates that of an HIV-negative 50-year-old. You were an author on this, I believe.4 That analysis suggests that the fracture frequency of HIV positives who are young approximates the fracture frequency for HIV negatives aged greater than 50.

Moreover, to me, the biggest concern is that young people are still in a period where they can improve their bone health with improvements in modifiable risk factors, including calcium supplementation and normalizing vitamin D levels and such.

So there's an opportunity -- if we identify those people earlier. I'd hate to miss the opportunity to improve their bone health before they reach their bone density maximum at age 40 or so.

From a cost benefit analysis, while I think the fracture absolute frequency is, yes, relatively low, there's still an opportunity to intervene with a preventive medicine strategy.

Todd Brown: The counterargument to that is that a lot of the strategies that can be taken to improve bone health should be undertaken in everyone. This means maintaining adequate vitamin D intake and adequate calcium intake, refraining from smoking, refraining from excessive alcohol use; all those things you want to be doing in everyone.

The concern that I have in screening people who are at low fracture risk is that they might be inappropriately put on medications that have long-term side effects for their bones, and they may not actually benefit from them.

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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. 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

Reader Comments:

Comment by: CNA Salary (Germany) Sat., Jun. 12, 2010 at 11:16 pm UTC
Wow this is a great resource.. Iím enjoying it.. good article
Reply to this comment

Comment by: anon (Atlanta) Fri., Jun. 11, 2010 at 6:13 am UTC
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
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Comment by: skip (Conn) Thu., Mar. 4, 2010 at 5:40 pm UTC
what a thorough and excellent interview. I will try to see Dr. Brown.
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Comment by: rachell skeith (Texas) Mon., Mar. 1, 2010 at 8:40 pm UTC
Thanks for sharing this information. The more information you have, the better your chances of preventing a std and staying healthy.
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Comment by: G. Powell (Largo, Florida) Thu., Feb. 25, 2010 at 3:03 pm UTC
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 UTC
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?
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Comment by: Abie (NYC) Thu., Feb. 11, 2010 at 8:41 pm UTC
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 UTC
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.
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Comment by: Erika (Texas) Thu., Jan. 28, 2010 at 11:53 am UTC
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 UTC
i wonder what HIV could do to the bone marrow. Please give me some information on this.
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Comment by: DAVID H (GREENSBORO, NC) Tue., Jan. 19, 2010 at 6:06 am UTC
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Comment by: Wayne D (Sydney, Australia) Mon., Jan. 18, 2010 at 9:48 pm UTC
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 UTC
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 UTC
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 UTC
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 UTC
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 UTC

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
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Comment by: Dennis (Ohio) Thu., Jan. 14, 2010 at 3:05 pm UTC
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!
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