Bones play many important roles in your body. They support you and help you to move. They protect your brain, heart, and other organs from injury. Bones also store minerals such as calcium and phosphorous.

Bones are living tissue and change during your life. Every day, your body removes old bone and adds new bone in its place. In young people, more bone is added than removed. After age 30, more bone is removed than added. This makes the bones lighter and more fragile, putting them at greater risk for injury.

Many people have weak bones and don't know it. That is because bone loss often happens over a long period of time and doesn't hurt. For many people, a broken bone is the first sign that they have a bone disorder.

Being HIV+ puts you at higher risk for bone disease. Experts don’t know why this happens. It could be due to HIV itself, HIV drugs, or HIV+ people getting older. HIV+ people have unusually high rates of three kinds of bone diseases:

Osteoporosis
Osteoporosis happens when too much bone gets broken down and not enough put back. This causes lower bone density, also called bone mineral density (BMD), which means there are lower-than-normal levels of minerals in the bones. Bones become weak and are more likely to break. People with osteoporosis most often break bones in the wrist, spine, and hip.

Osteopenia
Like osteoporosis, osteopenia is caused by a loss of bone minerals that leads to lower-than-normal bone density. It is a less serious condition; however, people with osteopenia are at higher risk of developing osteoporosis over a five- to ten-year period.

Osteonecrosis (avascular necrosis)
Osteonecrosis means bone death. It is caused by a loss of blood supply to the bone. It usually affects the head of the femur, the part of the thigh bone that connects it to the hip.

In addition to HIV and HIV drugs, there are other things can put you at risk for bone disease:

Risk factors you can control

• Diet: Getting too little calcium and vitamin D
• Exercise: Not exercising and not being active
• Low body weight: Being too thin
• Tobacco use: Smoking cigarettes
• Alcohol and coffee intake: Drinking a lot of alcohol and/or caffeine
• Testosterone levels: Low testosterone levels in men
• Use of certain medicines: Long-term use of medicines including glucocorticosteroids (drugs such as prednisone and cortisone), thyroid hormones, anticonvulsants (anti-seizure medications), heparin, pentamidine, and ketoconazole
  

Risk factors you cannot control

• Age: Your chances of getting osteoporosis increase as you get older
• Gender: Women have a greater chance of getting osteoporosis because they have smaller bones
• Menopause: Women lose bone due to hormone changes that happen after menopause
• Ethnicity: White and Asian women are at higher risk; Hispanic and African-American women are also at risk, but less so

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. A DEXA scan is an easy and painless test.

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

Even though you cannot control some 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:

• Milk
• Yogurt
• Cheese
• Calcium-fortified orange juice
• Tofu
• Salmon with the bones

Most HIV+ people still need to take calcium pills every day even if they eat dairy products like milk, cheese, and yogurt. A registered dietitian or other trained health care provider can help you decide if you should take calcium supplements. If so, 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 National Osteoporosis Foundation (NOF):

• Adults under age 50 need 1,000 mg of calcium and 400-800 IU of vitamin D daily
• Adults 50 and over need 1,200 mg of calcium and 800-1,000 IU of vitamin D daily

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

If you don’t have joint pain, it is also important to exercise on a regular basis. When you exercise your muscles pull against your bones, which helps keep them healthy and strong. The best kind of exercise to keep your bones strong is exercise that uses weight such as:

• Walking (you can use ankle weights)
• Working out with weights or weight machines
• Stair climbing
• Hiking
• Aerobics
• Jogging

If you can’t do high-impact weight-bearing activities, try lower-impact ones. For example, try walking or stair climbing instead of jogging. If you haven’t exercised regularly for a while, check with your healthcare provider before beginning a new exercise program.

Once you have your healthcare provider’s approval, start your exercise routine slowly. Every two weeks make your routine five minutes longer. In the end, you should be working out three to seven times a week, about 20-60 minutes each time.

Diet and exercise are best at keeping bone disease 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:

Drugs like Fosamax (alendronate), Boniva (ibandronate), and Actonel (risedronate) are widely used to treat and prevent osteoporosis. It is important to get enough calcium and vitamin D when you are taking a bisphosphonate.

• Estrogen: In women, replacing the hormone estrogen has shown to significantly decrease the number of fractures. Sometimes estrogen is combined with another hormone called progesterone. However, there is an increased risk of developing other diseases including certain cancers. Because of this, the US Food and Drug Administration (FDA) recommends using other osteoporosis medications and, 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.

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

HIV+ women, especially those who have gone through menopause, need to be particularly careful about 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 exercises are safe for you, and start doing them
• 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