Improved fracture prediction using different fracture risk assessment tool adjustments in HIV-infected women

AIDS. 2018 Jul 31;32(12):1699-1706. doi: 10.1097/QAD.0000000000001864.


Objectives: A fracture risk assessment tool (FRAX) using clinical risk factors (CRFs) alone underestimates fracture risk in HIV-infected men. Our objective was to determine whether accuracy of FRAX would be improved by considering HIV as a cause of secondary osteoporosis, and further improved with addition of dual-energy X-ray absorptiometry parameters in HIV-infected women.

Design: Subgroup analysis of Women's Interagency HIV Study.

Methods: We included 1148 women (900 HIV-infected and 248 uninfected) over age 40 with data to approximate FRAX CRFs and 10-year observational data for incident fragility fractures; 181 (20%) HIV-infected women had dual-energy X-ray absorptiometry data. Accuracy of FRAX was evaluated by the observed/estimated ratios of fracture in four models: CRFs alone; CRFs with HIV included as a cause of secondary osteoporosis; CRFs and femoral neck bone mineral density (FN BMD); and CRFs, FN BMD and trabecular bone score.

Results: FRAX using CRFs were less accurate in HIV-infected than uninfected women for major osteoporotic (observed/estimated ratio: 5.05 vs. 3.26, P < 0.001) and hip fractures (observed/estimated ratio: 19.78 vs. 7.94, P < 0.001), but improved when HIV was included as a cause of secondary osteoporosis. Among HIV-infected women, FRAX accuracy improved further with addition of FN BMD (observed/estimated ratio: 4.00) for hip fractures, but no further with trabecular bone score.

Conclusion: FRAX using CRFs alone underestimated fracture risk more in older HIV-infected women than otherwise similar uninfected women. Accuracy is improved when including HIV as a cause of secondary osteoporosis for both major osteoporotic and hip fractures, whereas addition of FN BMD only improved accuracy for hip fracture.

Publication types

  • Evaluation Study
  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Absorptiometry, Photon
  • Adult
  • Decision Support Techniques*
  • Female
  • Fractures, Bone / epidemiology*
  • HIV Infections / complications*
  • Humans
  • Middle Aged
  • Osteoporosis / complications*
  • Osteoporosis / epidemiology*
  • Prospective Studies
  • Risk Assessment