Bone health, heart health and long-term risks with HIV after menopause

Why bone risk is higher

Studies consistently find lower bone mineral density and more fractures in people living with HIV than in people without HIV of the same age. Contributing factors include HIV-related inflammation, lower body weight, vitamin D deficiency, smoking, alcohol, and some antiretrovirals.

Starting ART causes a modest drop in bone density, larger with tenofovir disoproxil fumarate (TDF) than with tenofovir alafenamide (TAF) or tenofovir-free regimens. Menopause then accelerates bone loss, especially in the first few years after the final period. Earlier menopause means more years without estrogen’s protection.

Bone screening and protection

• Bone density (DXA) scanning: expert recommendations on bone disease in HIV advise DXA for postmenopausal women; the USPSTF recommends screening for all women 65 and older and for younger postmenopausal women at increased risk.
• Fracture risk: tools such as FRAX can be used; some experts recommend entering HIV as a secondary cause of osteoporosis.
• Vitamin D and calcium: checking vitamin D and getting adequate calcium, mainly from food.
• Weight-bearing and strength exercise, and fall prevention.
• Hormone therapy: prevents menopausal bone loss and reduces fractures, particularly valuable with early menopause.
• Osteoporosis medicines such as bisphosphonates when indicated, and discussing a switch from TDF with your HIV clinician if bone loss is significant.

Why heart and vascular risk is higher

Cardiovascular disease is a leading cause of illness in people living with HIV, with risk estimated to be higher than in the general population even when HIV is well controlled. Chronic inflammation, traditional risk factors, and some older antiretrovirals contribute. Women with HIV appear to carry a particularly increased relative risk.

Menopause brings its own changes: LDL cholesterol tends to rise, fat shifts toward the abdomen, and blood pressure may increase. Early menopause is itself associated with higher long-term cardiovascular risk.

Statins and the REPRIEVE trial

REPRIEVE enrolled more than 7,700 people with HIV aged 40 to 75 at low to moderate predicted cardiovascular risk, about a third of them women. Daily pitavastatin reduced major adverse cardiovascular events by about 35% compared with placebo.

Following REPRIEVE, U.S. HIV guidelines recommend statin therapy for many people with HIV aged 40 to 75, including those at low to intermediate risk. Pitavastatin, atorvastatin and rosuvastatin are generally chosen with ART interactions in mind; simvastatin and lovastatin are contraindicated with boosted regimens.

Weight, metabolism and blood sugar

Weight gain is common in midlife and has also been reported with some integrase inhibitors, particularly in women. Insulin resistance, type 2 diabetes and fatty liver disease are more common in people with HIV. Regular checks of weight, waist size, blood sugar (HbA1c) and liver tests help catch changes early.

Other screening that matters in midlife

• Cervical screening: women living with HIV need more frequent cervical cancer screening, continuing beyond 65 for many.
• Breast screening on the usual schedule, and before starting or during hormone therapy.
• Blood pressure, cholesterol and HbA1c at least yearly.
• Kidney function, especially on tenofovir.
• Mood screening: depression and anxiety are more common and very treatable.

Practical steps that help

• Stop smoking: the single most powerful step for bones, heart and overall health. Ask for support and medicines.
• Keep active: aim for regular movement plus strength or resistance training two or more days a week.
• Eat for bones and heart: plenty of vegetables, legumes, whole grains, fish, and calcium-rich foods.
• Limit alcohol.
• Keep taking ART consistently: a suppressed viral load reduces inflammation.
• Bring your bone and heart results to both your HIV and menopause clinicians.

Questions, answered

Common questions