NYMC Faculty Publications

Improved Fracture Prediction Using Different Fracture Risk Assessment Tool Adjustments in HIV-Infected Women

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July 2018


Epidemiology and Community Health


OBJECTIVES: A Fracture risk assessment tool (FRAX(R)) 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 DXA 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 DXA data. Accuracy of FRAX was evaluated by the observed/estimated (O/E) ratios of fracture in 4 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 (TBS). RESULTS: FRAX using CRFs were less accurate in HIV-infected than uninfected women for major osteoporotic (O/E ratio: 5.05 vs 3.26, p<0.001) and hip fractures (O/E 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 (O/E ratio: 4.00) for hip fractures, but no further with TBS. CONCLUSIONS: 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, while addition of FN BMD only improved accuracy for hip fracture.