By Michael Gwarisa
A groundbreaking Zimbabwean study has revealed that older people living with HIV have significantly poorer bone health than their HIV-negative peers, with women facing an even greater risk of developing osteoporosis and suffering debilitating fractures as they age.
Published in the Journal of Bone and Mineral Research, the study found that HIV is associated with substantial deterioration of the internal architecture of bones, even among people receiving long-term antiretroviral therapy (ART). The findings suggest that bone health should become a routine component of HIV care as the population of people living with HIV continues to age.
The research, led by Dr MÃcheál Ó Breasail of Monash University and the University of Bristol together with Prof. Celia L. Gregson, Dr Kate A. Ward, Dr Rashida A. Ferrand, Tadios Manyanga, Dr Cynthia Kahari, Tafadzwa Madanhire, Peter R. Ebeling and colleagues, examined 1,101 adults aged 40 years and above in Harare, including 223 people living with HIV. Researchers used advanced peripheral quantitative computed tomography (pQCT) scans to assess bone density, bone structure and estimated bone strength in both the forearm and lower leg.
The study found that both men and women living with HIV had approximately 10% lower trabecular bone mineral density—the spongy inner part of the bone that is particularly vulnerable to osteoporosis—than HIV-negative participants. However, women living with HIV experienced additional damage to the outer cortical layer of bone, including thinner cortices and reduced bone density, changes that make bones more fragile and susceptible to fractures.
The researchers warned that these differences remained significant even after accounting for age, body size and socioeconomic factors, suggesting HIV itself contributes to accelerated bone deterioration.
“Older Zimbabwean people living with HIV have markedly lower trabecular bone density compared to HIV-negative peers, while additional cortical compartment impairments were evident in women. These data add to the growing evidence that women with HIV in particular may be at increased risk of age-associated osteoporotic fragility fracture relatively early in their life-course,” the authors wrote.
One of the study’s most striking findings was the relationship between the duration of HIV infection and worsening bone health among women. Every additional year since HIV diagnosis was associated with progressive reductions in bone density and bone strength, independent of age and the length of time on antiretroviral therapy. In contrast, among men, longer HIV duration was mainly associated with a reduction in bone size, while current use of tenofovir disoproxil fumarate (TDF), a widely used antiretroviral medicine, was linked to lower cortical bone density.
Although antiretroviral therapy has transformed HIV into a manageable chronic condition, allowing millions to live into older age, researchers say the success has brought new health challenges. HIV and some HIV medicines are known to interfere with the normal process of bone formation and breakdown, increasing the risk of osteoporosis and fractures.
According to the researchers, most evidence on HIV-related bone disease has previously come from Europe and North America. Data from sub-Saharan Africa—home to the world’s largest population of people living with HIV—have been limited, making the Zimbabwe study particularly important.
The researchers noted that the findings build on earlier work showing HIV-associated bone loss among middle-aged women in Zimbabwe and South Africa, but this study is among the first to comprehensively assess both older men and women using sophisticated imaging capable of distinguishing between different compartments of bone.
Importantly, participants who had already experienced major osteoporotic fractures consistently had poorer bone density and weaker bones than those without previous fractures, reinforcing the clinical significance of the observed bone deficits.
The authors argue that as Zimbabwe’s HIV-positive population continues to age, health systems should begin integrating bone health assessments into routine HIV care, particularly for women after menopause.
In their conclusion, the researchers state that “older Zimbabweans living with HIV have substantially poorer trabecular bone mineral density, whether male or female, while HIV-related cortical impairments were only evident in women. This study adds to the growing literature from Southern Africa highlighting the urgent need to prioritize bone health across the lifecourse for people living with HIV.”
They caution that while the study clearly demonstrates significant differences in bone architecture, it was cross-sectional and therefore cannot prove cause and effect. They recommend long-term follow-up studies to determine how these bone changes translate into future fracture risk and to better understand the influence of different HIV treatment regimens on bone health.
