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Low Compliance (10%) with Bone Mineral Density Screening Recommendations for People with HIV Despite High Fracture Rates...."critical to prioritize health screenings"
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Open Forum Infectious Diseases, March 2021
People with HIV have increased risk of premature bone loss and low bone mineral density. The causes are multifactorial but include the virus itself, medications to treat HIV, poor nutrition, lower body weight, and low vitamin D levels. This low bone density can result in fractures and increased frailty. In 2013, HIVMA released primary care guidelines for people with HIV and included screening for osteoporosis for all people with HIV aged 50 and older. Currently, in the general population, this screening is only for woman aged 65 and older. Little information is available to assess compliance with this recommendation.
Despite guideline recommendations, there remains low BMD screening among older PWH and particularly among MWH. Knowledge gaps and insurance coverage may be contributing barriers. Given estimates that predict that 70% of PWH will be 50 years and older in 2030, it is critical to prioritize health screenings that prevent negative health outcomes such as falls and fractures to preserve independent function and enhance well-being [27].
Overall, 1390 (7.4%) of HIV-eligible adults received BMD screening. Screening was lowest in those 50-64 years of age (870; 6.9%), but higher with older age (65+ years: 530; 13.1%). BMD screening was more common among females than males (14.8% vs 6.7%).
In this study, we estimated the frequency of BMD screening among eligible PWH. Over 90% of PWH ≥50 years of age did not undergo osteoporosis screening. Men were less likely to complete screening than females. Frequency of screening did not differ greatly by race, but people with older age (≥65 years) and either Medicare or private health insurance were more likely to undergo BMD testing.
The lower likelihood of men with HIV to perform BMD screening is concerning. Our study demonstrates that among PWH age 50-64 years, fracture rates are similar between men and women with HIV (MWH; WWH). Further, MWH age ≥65 years had similar fracture rates as women age ≥65 in the general population, who are USPSTF recommended to receive BMD screening. Despite the high occurrence of fractures in MWH, WWH were 2-3 times more likely to undergo BMD screening than MWH. Other studies have also demonstrated that fracture rates among MWH are similar and at times higher than WWH [23, 24].
BMD Screening Rates
Overall, 1390 (7.4%) of HIV-eligible adults received BMD screening. Screening was lowest in those 50-64 years of age (870; 6.9%), but higher with older age (65+ years: 530; 13.1%). BMD screening was more common among females than males (14.8% vs 6.7%). Sex differences in BMD screening were observed among both age categories (Figure 1). BMD screening among Black (7.8%), White (9.0%), and other race (8.1%) individuals was similar. In subgroup analysis, age 50-64 years, Medicaid, private insurance, and Medicare had 4.5%, 6.4%, and 8.8% BMD screening rates, respectively. Fracture rates were elevated among all HIV subgroups relative to HIV-seronegative counterparts (Figure 2).
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