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Viral Load (But Not Antiretrovirals) and HCV Tied to 10-Year Fracture Risk: fracture risk higher in HIV+ vs HIV-neg
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18th Conference on Retroviruses and Opportunistic Infections, February 27-March 2, 2011, Boston
Mark Mascolini
Traditional and HIV-related traits--but not antiretroviral therapy--correlated with a higher fracture risk in a four-country cross-sectional study [1]. Men and women with HIV had bone mineral density similar to values in HIV-negative people a decade or more older.
Clinical researchers in Argentina, Canada, Germany, and Spain used the updated FRAX calculator (http://www.shef.ac.uk/FRAX/) to compare the 10-year risk of hip and major nonhip fractures in HIV-positive men and women with 10-year fracture risk in the general-population NHANES III cohort. They also compared femoral neck bone mineral density derived from DEXA scans of the HIV group with published control values. FRAX calculates absolute 10-year fracture risk in an algorithm that incorporates age, gender, body mass index, family or personal history of fragility fractures, and other standard fracture risk factors.
Study participants were 303 HIV-positive people who had DEXA results available at four comprehensive HIV research centers. Age averaged 50 years (+/- 8), body mass index 24 kg/m(2), and CD4 count 540; 19% of study participants were women, and 80% had a viral load below 50 copies. About one quarter of the study group had low testosterone or a positive HCV test, 40% smoked cigarettes, and 4% had a previous fracture.
DEXA results indicated that 41% of men with HIV had osteopenia and 11% had osteoporosis. Among women with HIV, 41% had osteopenia and 1% osteoporosis. In men from 40 to 49 years old, femoral neck bone mineral density was significantly higher in the general population than in the HIV group. That difference remained significant among 50-to-59-year-old men. In women from 40 to 49 years old, greater femoral neck density in the general population versus the HIV group approached statistical significance (P = 0.07). Femoral neck bone mineral density among 50-to-59-year-old men in the general population was significantly higher than in 40-to-49-year-old men with HIV (P = 0.035). Femoral neck bone density of HIV-positive women in their 40s was similar to that of HIV-negative women in their 50s.
FRAX-determined 10-year hip fracture risks were low in both HIV-positive men and women, but lower still in general-population men:
Hip fracture
40 to 49 years old: HIV+ men 0.4, HIV+ women 0.3, HIV- men 0.1
50 to 59 years old: HIV+ men 1.0, HIV+ women 1.0, HIV- men 0.2
Ten-year risk of any major fracture was equivalent in HIV-positive men, HIV-positive women, and general-population men:
Any major fracture
40 to 49 years old: HIV+ men 2.1, HIV+ women 1.7, HIV- men 2.1
50 to 59 years old: HIV+ men 3.5, HIV+ women 3.0, HIV- men 4.1
Older age, lower body mass index, higher viral load, and HCV positivity all correlated with a higher risk of hip fracture in people with HIV. Age, viral load, and HCV also correlated with a higher risk of any major fracture in people with HIV. Length of exposure to any antiretroviral did not correlate with the risk of hip fracture or any major fracture.
The researchers concluded that overall 10-year risk of hip and all major nonhip fractures was low in this middle-aged international HIV-positive group. However, femoral neck bone mineral density in HIV-positive men in their 40s was similar to that of general-population men in their 60s; and femoral neck density in HIV-positive women in their 40s was similar to that of general-population women in their 50s.
Comparison of 8525 HIV-positive and over 2.2 million HIV-negative patients in a large US healthcare system found a significantly higher overall fracture prevalence in the HIV group (2.87 versus 1.77 patients per 100 persons, P < 0.0001) from late 1996 through early 2008 [2]. The higher prevalence held true in separate analyses of men and women. One quarter of the HIV group was 30 to 39 years old, 34% were 40 to 49, and 20% were 50 to 59. An HIV Outpatient Study analysis found higher age-adjusted first fracture rates in this US HIV cohort than in the National Hospital Ambulatory Medical Care Survey from 2000 through 2006 [3].
References
1. Falutz J, Martinez E, Belloso W, Domingo P, Mauss S, Rosenthall L. Fragility fracture risk in treatment-experienced HIV patients: a descriptive multi-national cohort analysis using the FRAX score. 18th Conference on Retroviruses and Opportunistic Infections. February 27-March 2, 2011. Boston. Abstract 831. Poster online at http://www.retroconference.org/2011/PDFs/831.pdf.
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/?tool=pubmed.
3. Young B, Dao CN, Buchacz K, et al. Increased Rates of bone fracture among HIV-infected persons in the HIV Outpatient Study (HOPS) compared with the US general population, 2000-2006. http://www.natap.org/2011/HIV/031211_02.htm.
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