HIV Infection Associated With Three-Fold Increase in Fracture Risk

The increased risk was independent of potential confounders such as fracture history, alcohol abuse, or use of drugs such as corticosteroids.

Research demonstrates that bone mineral density is decreased in HIV–infected patients-a finding with important clinical implications, such as increased fracture risk. Until recently, however, data that might allow an accurate assessment of the impact of this phenomenon on the actual fracture risk have been scarce. A recent study published in the Journal of Acquired Immune Deficiency Syndromes,1 drew on registries available from the Danish National Health Services to explore this link.

Investigators identified fracture cases and HIV clinical diagnoses from hospital discharge records. The sample size was very large, identifying more than 124,000 fracture cases in the year 2000 with more than 373,000 controls matched for age and sex. Investigators found an HIV prevalence of 0.04% (n = 50) among patients identified with fractures and 0.01% (n = 52) among controls (P < .01). The overall unadjusted (age- and sex-matched) odds ratio (OR) was 2.89 (confidence interval [CI], 1.99 to 4.18).

Among HIV-infected patients, the authors also found a significant increase in risk for hip fracture (OR = 8.99; 95% CI, 1.39 to 58.0), spine fracture (OR = 9.00; 95% CI, 1.39 to 58.1), and forearm fracture (OR = 3.50; 95% CI, 1.26 to 9.72).

The study shows an almost 3-fold increase in the risk of fractures in HIV-infected patients independent of potential confounders such as fracture history, alcohol abuse, or the use of other medications that could increase fracture risk (eg, corticosteroids). Since the study is epidemiologic, the pathogenesis of this increased risk remains unclear.

Primary care physicians should be aware of the increased risk of fractures in HIV-infected patients, which may have implications for screening. The finding of 9-fold higher odds of hip and spine fractures in this population is a call for vigilance among all clinicians who care for its members. The 2013 updated guidelines from the HIV Medicine Association of the Infectious Diseases Society of America recommend baseline bone densitometry screening for osteoporosis in HIV-infected patients and in postmenopausal women and men aged 50 years and older.2

References:

1. Prieto-Alhambra D, Güerri-Fernández R, De Vries F, et al. HIV infection and its association with an excess risk of clinical fractures: a nation-wide case-control study. J Acquir Immune Defic Syndr. 2014;66:90-95. doi: 10.1097/QAI.0000000000000112.

2. Aberg JA, Gallant JE, Ghanem KG, et al. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2014;58:e1-e34. doi: 10.1093/cid/cit665. Epub 2013 Nov 13.