April 10, 2018

Antiretroviral treatment (ART) for HIV-positive patients is associated with a greater loss of bone mineral density -- a major risk factor for bone fractures -- than for those who delay ART, according to a recent international study. The work, cofunded by the NIH’s National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the National Institute of Allergy and Infectious Diseases (NIAID), suggests the need for more research on battling the loss of bone mineral density in people with HIV.

The results are from a substudy, with approximately 400 patients, of the NIH-supported Strategic Timing of Antiretrovial Treatment (START) study and appeared in the Journal of Bone and Mineral Research. Medical experts have known that both HIV infection and ART lead to reduced bone mineral density, but it remained unclear how much of a role was attributable to the untreated HIV infection versus the treatment.

A major result of the main START study, which involved 4,685 participants, led to the recommendation to begin ART as soon as HIV is diagnosed. There had previously been a debate over whether it was better to wait for the immune system to decline to a certain degree before starting ART.

An international team of researchers found that HIV patients who begin ART soon after diagnosis experience accelerated bone mineral density loss in the hip and the spine in the first year. Bone mineral density decreased by 2.5 percent at the hip in patients who started ART immediately versus 1 percent for patients in the delayed treatment group. For the spine, researchers found a 1.9 percent bone mineral density decrease in the immediate-ART patient group versus 0.4 percent for the delayed treatment group.

Decline in bone mineral density appears to be the greatest during the first year of ART. After a year or two, the decline slows to match the rate found in HIV patients not yet receiving ART. In both groups, the decline was faster than what would be found in a healthy individual.

The study authors note that despite the bone mineral density findings, the need for immediate ART treatment remains vital for HIV patients. The treatment is linked to reduced risk of other serious health outcomes but, because HIV/AIDS has no cure, patients will continue ART therapy for the rest of their lives.

“With improvements in HIV treatments that allow patients to live longer, healthier lives, secondary health effects become increasingly important to maintain quality of life,” said Jennifer Hoy, MBBS, lead author of the study and a professor at Monash University in Melbourne, Australia. “Successful treatment of HIV negatively impacts bone mineral density and presents the research community with a challenge to focus on understanding the cause of this issue.”

This research was supported by NIAID and NIAMS through grant U01AI068641 and NIAID grant UM1AI120197. These grants funded the International Network for Strategic Initiatives in Global HIV Trials.

Immediate Initiation of Antiretroviral Therapy for HIV Infection Accelerates Bone Loss Relative to Deferring Therapy: Findings from the START Bone Mineral Density Substudy, a Randomized Trial. Hoy JF, Grund B, Roediger M, Schwartz AV, Shepherd J, Avihingsanon A, Badal-Faesen S, de Wit S, Jacoby S, La Rosa A, Pujari S, Schechter M, White D, Engen NW, Ensrud K, Aagaard PD, Carr A; INSIGHT START Bone Mineral Density Substudy Group. J Bone Miner Res. 2017 Sep;32(9):1945-1955. doi: 10.1002/jbmr.3183. Epub 2017 Jun 26.

NIAID conducts and supports research—at NIH, throughout the United States, and worldwide—to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID website.

Last Reviewed: 04/10/2018