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High Rate of Bone Thinning in People With Long Antiretroviral Treatment

March 2011

Almost three quarters of HIV-positive people in a Spanish clinic had lower-than-normal bone mineral density (osteopenia or osteoporosis), and the rate of bone thinning increased with time.1 This 671-person study found a link between treatment with protease inhibitors (PIs) or Viread (tenofovir) and low bone mineral density. Certain traditional risk factors -- including low weight and older age -- made osteopenia or osteoporosis more likely.


Earlier studies found that people with HIV have about a 3 times higher rate of low bone mineral density than the general population.2-4 Low bone density raises the risk of broken bones (fractures), and other research found a higher fracture rate in HIV-positive people than in the general population.5,6 Some of these studies are relatively small or focus on a single point in time. In contrast, the new study is relatively large and assessed bone density for 5 years or more in many study participants.

Traditional risk factors for osteopenia and osteoporosis -- such as cigarette smoking and low weight -- contribute to the risk in people with HIV. The potential roles of HIV itself and treatment with antiretrovirals in low bone density are not as well understood. Researchers at a large HIV clinic in Barcelona, Spain, planned this study to determine the impact of traditional and HIV-related risk factors on bone density over an extended period.

Table 1. Conditions That May Raise Risk of Osteoporosis or Fracture With HIV

Lifestyle choices or habitsMore than 3 alcohol drinks daily, low dietary calcium, methadone/opiates, physical inactivity, tobacco use
Hypogonadal statesEarly menopause, low testosterone in men, premenopausal infrequent menstruation
Other endocrine disordersAdrenal insufficiency
Blood disordersHemophilia, sickle-cell disease
Lung diseasesEmphysema
MedicationsAntiretrovirals, glitazones, glucocorticoids, proton pump inhibitors, excess thyroxine
MiscellaneousChronic metabolic acidosis, chronic infection, chronic kidney disease, depression, vitamin D deficiency
Source: McComsey et al.7


  1. Bonjoch A, Figueras M, Estany C, et al. High prevalence of and progression to low bone mineral density in HIV-infected patients: a longitudinal cohort study. AIDS. 2010;24:2827-2833.
  2. Knobel H, Guelar A, Vallecillo G, Nogues X, Diez A. Osteopenia in HIV-infected patients: is it the disease or is it the treatment? AIDS. 2001;15:807-808.
  3. Bruera D, Luna N, David DO, Bergoglio LM, Zamudio J. Decreased bone mineral density in HIV-infected patients is independent of antiretroviral therapy. AIDS. 2003;17:1917-1923.
  4. Brown TT, Qaqish RB. Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: a meta-analytic review. AIDS. 2006;20:2165-2174.
  5. Triant VA, Brown TT, Lee H, Grinspoon SK. Fracture prevalence among human immunodeficiency virus (HIV)-infected versus non-HIV-infected patients in a large U.S. healthcare system. J Clin Endocrinol Metab. 2008;93:3499-3504.
  6. Wormack J, Goulet J, Gibert C, et al. HIV infection and fragility fracture risk among male veterans. 17th Conference on Retroviruses and Opportunistic Infections. February 16-19, 2010. San Francisco. Abstract 129.
  7. McComsey GA, Tebas P, Shane E, et al. Bone disease in HIV infection: a practical review and recommendations for HIV care providers. Clin Infect Dis. 2010;51:937-946.

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