Antiretroviral Therapy and Osteoporosis: What You Should Know

Living with HIV means taking antiretroviral therapy (ART) to keep the virus in check. While ART saves lives, it can also speed up bone loss, especially in people over 40. This doesn’t mean you’re doomed to break a bone, but it does mean you should keep an eye on your skeleton. Below we’ll break down why ART messes with your bones and what you can do to stay strong.

Why ART Can Harm Your Bones

Most modern ART regimens include drugs called tenofovir, protease inhibitors, or efavirenz. These medicines can lower calcium absorption in the gut and increase calcium loss in urine. The result is a slower bone remodeling process and lower bone mineral density (BMD). Studies show that people on tenofovir‑based combos lose up to 2% of hip BMD in the first year.

HIV itself also raises inflammation markers, which further weakens bone tissue. When the immune system is constantly activated, it releases cytokines that stimulate bone‑resorbing cells (osteoclasts) more than bone‑building cells (osteoblasts). Combined with ART’s direct effects, the two forces create a perfect storm for osteoporosis.

Older adults, women, and smokers feel the impact more sharply. If you already have low vitamin D levels, ART can push you into the osteoporosis range within a few years.

How to Protect Your Bone Health

The first step is regular screening. Ask your doctor for a DEXA scan at baseline and then every two years. A simple test tells you if you’re losing bone faster than expected.

Make sure you’re getting enough calcium and vitamin D. Aim for 1,200 mg of calcium and 800–1,000 IU of vitamin D daily, either from food or supplements. If you’re unsure about dosage, a quick chat with your pharmacist can clear things up.

Weight‑bearing exercise is a game‑changer. Activities like brisk walking, stair climbing, or light resistance training stimulate bone growth. Even 30 minutes three times a week can offset the loss caused by ART.

If you’re on tenofovir disoproxil fumarate (TDF), talk to your doctor about switching to the newer tenofovir alafenamide (TAF) version, which has a milder impact on bone density. Some clinicians also rotate protease inhibitors with integrase inhibitors to balance viral control and bone health.

Avoid smoking and limit alcohol to one drink a day. Both habits increase bone turnover and reduce calcium absorption.

Finally, stay on top of other health conditions like diabetes or thyroid disorders. Untreated, they can accelerate bone loss and make ART‑related osteoporosis worse.

Bottom line: ART doesn’t have to ruin your bones. By getting screened, eating right, moving regularly, and talking to your doctor about medication tweaks, you can keep your skeleton strong while staying protected from HIV. Take action today—your future self will thank you.