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Objective To estimate prevalence of low bone mineral density (BMD) in perinatally HIV infected (HIV+) and HIV-exposed but uninfected (HEU) children, and to determine predictors of BMD in HIV+. Design Cross-sectional analysis within a 15-site United States and Puerto Rico cohort study. Methods Total body (TB) and lumbar spine (LS) BMD were measured using dual energy-xray absorptiometry. BMD Z-scores accounted for bone age and sex. Multiple linear regression was used to evaluate differences in Z-scores by HIV status and for predictors of BMD in HIV+. Results 350 HIV+ and 160 HEU were enrolled. Mean age was 12.6 and 10.7 years for HIV+ and HEU, respectively. Most (87%) HIV+ were receiving highly active antiretroviral therapy (HAART). More HIV+ than HEU had TB and LS Z-scores < -2.0 (TB: 7% vs. 1%, p=0.008; LS: 4% vs. 1%, p=0.08). Average differences in Z-scores between HIV+ and HEU were attenuated after height and/or weight adjustment. Among HIV+, TB Z-scores were lower in those with higher CD4% and in those who ever used boosted protease inhibitors or lamivudine. LS Z-scores were lower with higher peak viral load and CD4%, more years on HAART, and ever use of indinavir. Conclusions Rates of low BMD in HIV+ children were greater than expected based on normal population distributions. These differences were partially explained by delays in growth. Since most HIV+ children in this study had not entered their pubertal growth spurt, prepubertal factors associated with BMD, magnified or carried forward, may result in sub-optimal peak BMD in adulthood.

Although BMI and total body fat were significantly lower in the HIV-infected children than in the HEU children, body fat distribution in the HIV-infected children followed a pattern associated with cardiovascular disease risk and possibly related to specific antiretroviral drugs.

Early effective, long-term ART initiated from infancy leads to decay of HIV-1-infected cells to exceedingly low concentrations desired for HIV-1 remission strategies.