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Background: Initial declines in BMD following ART initiation in HIV are well described, but data on long-term changes and risk factors for decline, particularly among women, are limited.
Methods: : HIV-infected men and women in the Modena Metabolic Clinic underwent dual-electron X-ray absorptiometry (DXA) scans every 6-12 months for up to 10 years (median 4.6 years). Mixed methods regression models were created for women and men in combined and stratified models to determine factors associated with BMD. Models included variables described below; CD4 nadir, CD4 total and %, smoking, diabetes, and duration of protease inhibitor use were considered in univariate models but were not significant.
Results: 839 women and 1759 men contributed ≥2 DXA scans. The majority (82%) were ≤ 50 years old; 49% had HIV-1 RNA < 50 copies/mL at baseline; 15% of women were post-menopausal and 7% of men had hypogonadism; 30% and 27%, respectively, had hepatitis C virus co-infection. Significant adjusted average annual declines in hip and spine BMD among women and men were observed; women (hip: -0.008, L-spine -0.012 g/cm2/year) and men (hip: -0.004; L-spine: -0.007 g/cm2/year; all p< .0001). In combined mixed effect models, female sex was associated with lower hip but not spine BMD (p< 0.0001). The effects of other variables on BMD are shown (Table). Sex-stratified models yielded similar results with notable exceptions: physical activity (women) and hepatitis C (men) were no longer significant in gender-specific models.

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Conclusions: Bone density at the hip, a significant predictor of fracture risk, declined twice as quickly among women compared to men and sex was independently associated with lower hip BMD in adjusted models. In addition, the results further emphasize the importance of bone health evaluation in HIV-infected adults beginning after age 45, and identify modifiable factors that may limit BMD decline.

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