Medical Advice

July 13 2021

Caring for Your Heart

Media Team Medical Advice arthrosclerosis, blood pressure, cardiovascular disease, chest pain, chest pains, cholesterol, diabetes, diet, heart disease, heart disease risk factors, heart problems, high blood pressure, hormone replacement therapy, hypertension, lipodystrophy, overweight, PIs, rheumatic fever, rheumatic heart disease, smoking, stress, stroke, Women and AIDS, Women and HIV 0

Heart Disease Basics

Many people think of heart disease as a problem for men, yet it is a leading cause of death for women worldwide. According to the World Health Organization (WHO), heart disease and stroke were the top two causes of death among women overall in 2012, though the leading cause of death in girls and women ages 15-44 years was HIV/AIDS.

In the US, heart disease was also the number one cause of death for women in 2017, accounting for about one in five of all female deaths. By comparison, breast cancer caused only one in 38 deaths among women in the US. Almost two-thirds of women who died suddenly of coronary heart disease had no symptoms of heart trouble before they died. This is why it is important to get regular check-ups and understand your risk for heart disease (see Risk Factors of Heart Disease below).

Heart disease is a type of cardiovascular disease (CVD). This means that it affects your heart and blood vessels. There are several types of heart disease. The most common in the US is coronary artery disease (CAD), or coronary heart disease (CHD). It affects the blood vessels that supply the heart muscle and is most commonly associated with heart attacks. Another type is cerebrovascular disease, which affects the blood vessels that supply the brain. This type is most commonly associated with strokes.

CAD or CHD occur when hard patches, called plaques, build up in the blood vessels that supply blood to the heart. Plaque is made up of cholesterol, a fat-like substance found in the blood. Plaque buildup causes the arteries (blood vessels leading to the heart) to get narrower and become less flexible. This process is called atherosclerosis.

A heart attack occurs when a plaque breaks free from a blood vessel’s wall and forms a clot that blocks an artery which is supplying blood to your heart. Because of this blockage, the oxygen-rich blood that the heart needs for pumping cannot reach it. As a result, part of the heart muscle may become injured or die.

Recent studies have shown that statins, a type of cholesterol-lowering drug, may reduce the amount of plaque in the blood vessels of people living with HIV. Thus, statins may help to reduce the risk of heart disease in people living with HIV. For more information, see the section ‘Reducing the Risk for Heart Disease’ below.

Symptoms of a Heart Attack

For some people, the first sign of heart disease is a heart attack. Symptoms of a heart attack include:

Pain, pressure, or discomfort in the chest: this may feel like heaviness, aching, burning, fullness, squeezing, or stabbing
Shortness of breath
Indigestion or heartburn
Nausea or vomiting
Pain in the arms, left shoulder, neck, throat, jaw, or back
Heart palpitations (irregular beats)
Increased heart rate (‘racing’ heart)
Weakness
Dizziness
Sweating

As with men, women’s most common heart attack symptom is chest pain or discomfort. However, one study reported that four in ten women experienced no chest pain during a heart attack. In 2016, the American Heart Association confirmed that women are more likely than men to have some of the other common symptoms, particularly shortness of breath, nausea or vomiting, and back or jaw pain. Many women who have suffered a heart attack report that they simply felt like they had indigestion. If you feel heart attack symptoms, seek medical attention immediately.

Risk Factors for Heart Disease

Two out of every three women who die suddenly of coronary heart disease do not have any symptoms beforehand. You therefore should know your risk factors for heart disease and maintain good heart health. One of the most important factors is family history. If someone in your family has had heart disease, you are at greater risk for problems with your heart.

Age and gender also affect heart health. Generally, men are at greater risk than women and at an earlier age. For men, risk begins to go up at age 45 and continues to grow each year. For women, the risk generally does not start to go up until after menopause, when women lose the protective effect of estrogen. By age 65, the heart disease risk in women rises substantially.

Some studies have shown that taking hormone replacement therapy (HRT) may increase a woman’s risk for heart disease, stroke, pulmonary embolism (blood clot in the lung), and breast cancer. For some women, the benefits of hormone replacement therapy outweigh the risk of heart disease. If you are thinking about hormone replacement therapy, talk to your health care provider so that you can decide what is right for you.

Other risk factors for heart disease include:

High blood pressure
High cholesterol and/or high triglycerides (hyperlipidemia)
Smoking
Lack of exercise/physical inactivity
Stress
Poor diet and nutrition
Being overweight or obese
Diabetes
Alcohol use
Depression
HIV

HIV and Heart Disease

People living with HIV (HIV+) have higher rates of heart disease than the general population. There are several reasons for this:

Some HIV drugs and possibly HIV itself can cause lipodystrophy. Lipodystrophy means abnormal fat changes. It is used to describe a number of unwanted changes in body fat that are experienced by people living with HIV. Lipodystrophy can also include changes in fat and sugar levels in the blood. Some of these changes are risk factors for heart disease, including high blood fats or lipids (cholesterol and triglycerides) and diabetes.

Some HIV drugs and possibly HIV itself can also cause high blood fats (hyperlipidemia) and diabetes, even without lipodystrophy
HIV itself causes inflammation that can lead to damage to the heart and blood vessels, potentially increasing the risk of heart disease
While some HIV drugs can cause side effects that may increase the risk of heart disease, studies have shown that HIV medications may actually protect against heart disease, as well as keeping HIV and other HIV-related conditions under control.

A study from Denmark also suggests that the primary reason for the higher risk of heart disease in people living with HIV is that people living with HIV smoke more than those who are HIV-negative. If there is one thing you can do to improve your heart health – and your health overall – it is to quit smoking. For more information and suggestions on how to quit, see our article on Smoking and Tobacco Use.

Reducing the Risk for Heart Disease

People living with HIV should find out about their risk factors for heart disease and take steps to reduce them. Ask your health care provider about the HIV drugs you take to see if any may be raising your lipid (cholesterol and triglyceride) levels. Some newer classes of drugs may not affect your lipids as much as older drugs. Switching drugs may not be an option for everyone. It is important that you not change your HIV drugs without first talking to your health care provider.

While you may not be able to change some risk factors, you can do many things to reduce your risk for heart problems:

Quit smoking — smoking is the biggest risk factor for heart disease. If quitting is not an option for you right now, try cutting back on how much you smoke.
Watch your blood pressure — high blood pressure increases the workload of the heart. If you have high blood pressure, speak to your health care provider about treatment options. If you have high blood pressure, take your prescribed medications daily.
Ensure your provider checks your lipid levels — if HIV drugs cause your cholesterol or triglyceride levels to rise, you may need to switch drugs or use lipid-lowering drugs such as statins. Proper diet and nutrition can also help you maintain healthy lipid levels.
Get regular exercise — being physically active can help reduce your risk for heart disease. It may also help to reduce your cholesterol and blood pressure.
Watch your weight — if you are overweight, you are more likely to develop heart disease
Make sure your provider checks your blood sugar — if you have diabetes or high blood sugar, your risk for developing heart disease is greater. Keeping sugar levels in check can reduce your risk. If you are taking certain HIV drugs, you may be at a greater risk for diabetes; therefore, it is important that you have your blood sugar levels checked regularly.
Get omega-3 fatty acids — these are found naturally in fish, nuts, seeds, and vegetable oils, but can also be taken as supplements. Recent research among people living with HIV has shown that taking omega-3 fatty acid supplements was associated with lower levels of triglycerides and of a marker for inflammation.
Manage stress. Seek out ways to positively deal with life’s stresses – whether this is talking to a therapist or integrating meditation or a yoga practice. For more information, see our fact sheet on Stress Management.
Statin drugs are used to lower cholesterol and prevent heart disease. Early studies among people living with HIV also found that statins could reduce inflammation. Some scientists believe that inflammation is the key to the process of ‘accelerated aging’ that affects some people living with HIV. A large clinical trial called REPRIEVE is currently underway to examine the ability of a statin drug called pitavastatin to reduce inflammation and heart disease among people living with HIV.

Taking Care of Yourself

Your health care provider can determine your risk for heart disease by checking your blood pressure, cholesterol, and blood sugar, and by finding out about your family’s history of heart disease. If you are at high risk or already have symptoms, your provider may suggest tests that can determine if you have heart disease. Medications may also be necessary. They can treat risk factors for heart disease, such as high lipid levels, high blood pressure, diabetes, an irregular heartbeat, and low blood flow.

Heart disease is a growing concern for both men and women living with HIV. One reason is that people are living longer with HIV because effective HIV drugs are used widely. The risk of heart disease increases naturally as you age.

The good news is that there are many things you can do to help prevent and manage heart disease. Healthy lifestyle choices, such as quitting smoking, improving your diet, getting regular medical checkups, and staying physically active, can all help you care for your heart. When lifestyle changes are not enough, several medications and other medical approaches are available.

July 12 2021

Bone Health

Media Team Medical Advice avascular necrosis, bone damage, Bone Disease, calcium, DEXA, fractures, hip, joint pain, osteonecrosis, osteopenia, osteoporosis, phosphates, phosphorus, vitamin D, weak bones 0

The Importance of Healthy Bones

Bones play many important roles in your body. They support you, help you move, and protect some of your organs from injury. Bones also store minerals such as calcium and phosphorus, and make many of the cells that circulate in your blood (e.g., red blood cells, white blood cells, platelets).

Bones are constantly changing throughout 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. As a result, the bones become lighter and weaker, which puts them at greater risk for injury.

Many people have weak bones and do not know it. This is so because bone loss often happens over a long period of time and does not hurt. For many people, a broken bone or a fracture is the first sign of weakened bones. This weakness is often referred to as low bone mass or low bone density. Bone mass or bone density refers to how much internal bone structure is in a given section of bone. For example, more dense bone has more calcium and phosphorus – two key minerals that make up bone – per square inch of bone.

Bone Loss and HIV

Bone loss and weakened bones occur more often in people living with HIV. Experts are not exactly sure why. It could be due to HIV itself, HIV drugs–or the fact that people living with HIV are living longer and experiencing more of the regular effects of getting older. People living with HIV are more likely to experience three bone conditions: osteopenia, osteoporosis, and osteonecrosis.

Osteopenia

Osteopenia is caused by a loss of bone minerals that leads to lower-than-normal bone density. Most often, osteopenia has no symptoms. The only way to know if you have this condition is to have a bone density test (DEXA scan). If you do learn you have osteopenia, there are things you can do to stop it and possibly even reverse it (see the Physical Activity and Diet sections below).

Osteopenia can lead to a more serious condition called osteoporosis (see below). Having osteopenia does not mean you will definitely develop osteoporosis, but it does mean that you are more likely to develop it. Although bone loss with osteopenia is generally less severe than with osteoporosis, it does indicate that bones are weaker and may be more likely to break.

Osteoporosis

Osteoporosis is a more serious condition than osteopenia and refers to a loss of bone density and bone mass. Over time, breaking down more bone than is replaced causes lower bone mineral density, 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. Sometimes bones break without an injury.

Osteonecrosis (avascular necrosis)

Osteonecrosis means bone death. It is caused by a loss of blood supply to the bone. Osteonecrosis may cause pain at the affected joint. It usually affects the head of the femur, the ball-shaped part of the thigh bone that connects it to the hip.

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

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, people living with HIV who have a history of fragility fracture, people living with HIV who are receiving chronic glucocorticoid treatment, and people living with HIV who are at 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 disoproxil fumarate (TDF; see Tenofovir section below).

In the US, guidelines suggest DEXA scans for everyone living with HIV who is older than 50 years and for women who are past their menopause (no longer have their periods).

Factors Affecting Your Bone Health

There are several things that can affect your bone health and put you at risk for bone loss. Some of these are things you cannot control:

Age: Your chances of getting osteoporosis increase with age
Sex: Women have a greater chance of getting osteoporosis than men
Menopause: Women lose bone due to hormone changes that happen after menopause. While hormone replacement therapy is no longer routinely recommended, it is an effective therapy for bone loss that does not respond to other treatments.
Family history: Having a parent with osteoporosis, especially a mother or father who has had a hip fracture, increases your risk of bone loss
The good news is that there are also several things that you can control – things that you can do to maximize your bone health, regardless of your age, sex, or family history.

Diet and Body Weight

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 (NIH) 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 years old need 1,000 mg of calcium and 600 IU of vitamin D daily
Women over 50 years old need 1,200 mg of calcium and 600 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
It is important that you talk to your health care provider before taking any supplements, and not take more than these amounts unless instructed to by your health care provider. Many first-line HIV regimens that include integrase inhibitors may not be absorbed by the body as well as they should be when they are taken with calcium supplements. It is important that you discuss with your health care provider how to take these medicines together.

Physical Activity

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 activity to keep your bones strong is one that uses weight or resistance such as:

Walking (you can use ankle weights)
Working out with weights, weight machines, or bands (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).

Tobacco, Alcohol, and Caffeine

Using tobacco products, whether it’s smoking or vaping, using snuff, or chewing tobacco, can increase your chances of bone loss. If you use tobacco, it is a good idea to try and quit. Stopping smoking is one of the single best things you can do for your health. Talk with your health care provider about stopping smoking – there are many tools to help you quit. You can also find lots of information and support online (http://www.smokefree.gov).

Drinking a lot of alcohol and/or caffeine can also put you at greater risk of bone loss.

Using Certain Medicines

Long-term use of some medicines can increase the chances of bone loss and lead to weakened bones:

Depo-Provera (an injectable form of birth control)
Glucocorticosteroids (drugs such as prednisone and cortisone)
Thyroid hormones
Anticonvulsants (anti-seizure medications)
Heparin (blood thinner)
Pentamidine (antibiotic)
Ketoconazole (anti-fungal)
Tenofovir disoproxil fumarate (TDF or Viread; see below)
Tenofovir: TDF and TAF
Tenofovir is an HIV drug that comes in two forms: TDF (tenofovir disoproxil fumarate) and TAF (tenofovir alafenamide). TDF is also known by the brand name Viread and found in other combination drugs such as Truvada (tenofovir disoproxil fumarate plus emtricitabine). TAF is not available by itself for the treatment of HIV, but is found in the following approved combination pills:

Biktarvy (bictegravir plus emtricitabine plus tenofovir alafenamide)
Descovy (emtricitabine plus tenofovir alafenamide)
Genvoya (elvitegravir plus cobicistat plus emtricitabine plus tenofovir alafenamide)
Odefsey (emtricitabine plus rilpivirine plus tenofovir alafenamide)
Symtuza (darunavir plus cobicistat plus emtricitabine plus tenofovir alafenamide)

Previous studies have shown that treatment with TDF can lead to lower kidney function and bone loss. Treatment with TAF has been proven to not only produce less bone loss and less reduction in kidney function, but to improve existing kidney and bone problems in those who switched from TDF. TAF can be given at lower doses than TDF while achieving the same level of HIV suppression.

A study of over 12,000 Europeans living with HIV found that treatment with TDF increases not just bone loss, but the risk of actual bone fracture in adults. This is an especially important consideration for women, who often experience bone loss naturally after menopause. The risk of fracture did not increase with increasing time on TDF, which matches our understanding that most of the bone loss associated with taking tenofovir disoproxil fumarate occurs early in treatment.

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:

Bisphosphonates
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.

Hormones
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
Teriparatide (Forteo), abaloparatide (Tymlos) and romosozumab (Evenity): These parathyroid hormones have been shown to rebuild bone and increase bone mineral density, especially in the spine
Selective Estrogen Receptor Modulators (SERMs)
Evista (raloxifene) is in a class of osteoporosis drugs called SERMs. It was developed to work like estrogen therapy, but with fewer side effects.

Bone-Modifying Agent, a Monoclonal Antibody
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