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Fractures Occur at a Younger Age in HIV+ Men in
the Multicenter AIDS Cohort Study
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.....Fracture Incidence Rises at Earlier Age in Men With Than Without HIV.....HIV+ Have More Fractures & Get Them at Earlier Ages
Conference on Retroviruses and Opportunistic Infections (CROI), February 22-25, 2016, Boston
Mark Mascolini
Fracture incidence rose with age in both HIV-positive men and HIV-negative men in the Multicenter AIDS Cohort Study (MACS), as would be expected [1]. But incidence jumped at an earlier age--in the 50s--in men with than without HIV infection.
Lower bone mineral density in people with than without HIV leads to a higher fracture risk with HIV, even in younger HIV-positive men [2]. Recent guidelines recommend DXA screening for osteoporosis in HIV-positive men over 50 [3]. MACS investigators conducted this study to gather more data on relative age-related fracture risk in men with versus without HIV and to pinpoint independent risk factors in men with HIV.
The MACS is an ongoing prospective study of HIV-positive men who have sex with men (MSM) and MSM at risk for HIV infection. This analysis focused on HIV-positive or negative men 40 or older. Between 2001 and 2015, MACS men prospectively reported or recalled fractures at twice-yearly visits. Researchers divided fractures into (1) all fractures (except those of the face, skull, or digits), and (2) fragility fractures (those of the vertebral column, femur, wrist, and humerus).
MACS investigators analyzed data from 1221 men with HIV and 1408 without HIV. The groups were similar in body mass index, estimated glomerular filtration rate (eGFR), and prevalence of hypertension, diabetes, and heavy or binge drinking. The HIV group had higher rates of two fracture risk factors: HCV infection (10% versus 6%) and current smoking (38% versus 31%) (P < 0.001 for both). The HIV contingent included a lower proportion of whites, who run a higher fracture risk than blacks (59% versus 73%, P < 0.001).
Incidence of all fractures was similar in HIV-positive and negative men 40 to 49 years old, Incidence stayed about the same in 50- to 59-year-old HIV-negative men but jumped in HIV-positive men that age. This surge in incidence among 50- to 59-year-old men with HIV (but not negative men) held true for osteoporotic fractures. Among men 60 and older, incidence of all fractures and osteoporotic fractures was slightly (but not significantly) higher in men with than without HIV.
Adjusted analyses comparing older groups to HIV-negative men 40 to 49 years old showed similar patterns. For all fractures, HIV-negative men 60 or older had an 84% higher risk than 40- to 49-year-old negative men, while HIV-positive men 60 or older had an 88% higher risk than the youngest HIV-negative group (adjusted incidence rate ratios [aIRR] 1.84, 95% confidence interval [CI] 1.29 to 2.63; and 1.88, 95% CI 1.17 to 3.01). But HIV-negative 50- to 59-year-olds did not run a higher all-fracture risk than 40- to 49-year-old HIV-negative men, while HIV-positive men in their 50s had a 99% higher (almost doubled) all-fracture risk than 40- to 49-year-old HIV negative men (aIRR 1.99, 95% CI 1.44 to 2.74). The same pattern held true for osteoporotic fractures. In other words risk of all fractures and osteoporotic fractures climbed with age in men with and without HIV, but the climb started at age 50 in men with HIV and at age 60 in men without HIV.
Multivariable analysis focused solely on men with HIV picked out five independent fracture predictors:
1. Men 50 to 59 had a 79% higher incidence of all fractures than men 40 to 49 (aIRR 1.79, 95% CI 1.27 to 2.52)
2. Men 50 to 59 had a doubled risk of osteoporotic fracture compared with men in their 40s (aIRR 2.04, 95% CI 1.15 to 3.63), and men 60 or older ran an even higher risk compared with men in their 40s (aIRR 2.3, 95% CI 1.07 to 4.93).
3. eGFR below 60 (indicating declining kidney function) boosted risk of all fractures 64% (aIRR 1.64, 95% CI 1.01 to 2.64)
4. Body mass index at or above 25 lowered all-fracture risk 30% (aIRR 0.7, 95% CI 0.5 to 0.99).
5. Viral load at or above 50 copies cut all-fracture risk 37% (aIRR 0.63, 95% CI 0.42 to 0.93).
The MACS investigators believe their analysis "highlights the importance of early screening for osteoporosis in HIV-infected men, particularly after the age of 50."
The MACS team is working to understand why a detectable viral load appeared to protect against fracture. Possibilities include some protective effect of untreated HIV or absence of antiretroviral-related bone toxicity.
References
1. Gonciulea AR, Wang R, Althoff KN, et al. Fractures occur at a younger age in HIV+ men in the Multicenter AIDS Cohort Study. Conference on Retroviruses and Opportunistic Infections (CROI), February 22-25, 2016, Boston. Abstract 699.
2. Triant VA, Brown TT, Lee H, Grinspoon SK. Fracture prevalence among human immunodeficiency virus (HIV)-infected versus non-HIV-infected patients in a large U.S. healthcare system. J Clin Endocrinol Metab. 2008;93:3499-3504. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2567857/
3. Brown TT, Hoy J, Borderi M, et al. Recommendations for evaluation and management of bone disease in HIV. Clin Infect Dis. 2015;60:1242-1251. http://www.natap.org/2014/HIV/012315_01.htm
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Reported by Jules Levin
Fractures Occur at a Younger Age in HIV+ Men in the Multicenter AIDS Cohort Study
Anda R. Gonciulea1; Ruibin Wang2; Keri N. Althoff2; Frank J. Palella3; Jordan Lake4; Lawrence Kingsley5; Todd T. Brown6
1Johns Hopkins Univ Sch of Med, Baltimore, MD, USA;2Johns Hopkins Bloomberg Sch of PH, Baltimore, MD, USA;3Northwestern Univ, Chicago, IL, USA;4David Geffen Sch of Med at Univ of California Los Angeles, Los Angeles, CA, USA;5Univ of Pittsburgh, Pittsburgh, PA, USA;6Johns Hopkins Univ, Baltimore, MD, USA
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