A high prevalence of metabolic bone disease and osteonecrosis among HIV+ patients on highly active antiretroviral therapy (HAART) has been reported in predominantly white cohorts. We examined bone health in an ethnically diverse cohort of 23 African-Americans and 21 non-African-Americans who were mean (standard deviation) age 45 (7) years old, 66% male, and on HAART for 34 (28) months. Non-African-Americans were more likely to have osteopenia or osteoporosis (59%) compared to African-Americans (26%) (p = 0.09). The prevalence of vitamin D insufficiency (<34 ng/ml) and elevated i-PTH (>65 pg/ml) was 79% and 20%, respectively. Higher mean urinary N-telopeptide levels were found in non-African-Americans [58 (34) nmol BCE/mmol] compared to African-Americans [41 (18) nmol BCE/mmol] (p = 0.09). Magnetic resonance imaging identified one African-American subject (3%) with bilateral asymptomatic hip osteonecrosis. Our findings suggest that the burden of metabolic bone disease in HIV+ patients with HAART-associated lipodystro-phy may be greater in whites than in African-Americans. Studies to examine ethnic variations in bone metabolism are necessary to devise optimal interventions. © Mary Ann Liebert, Inc.