FRAX fracture prediction tool underestimates fracture risk in people with HIV

Theo Smart
Original Article:

The Fracture Risk Assessment Tool (FRAX), an online tool developed by the World Health Organization and used to help guide decisions about who to screen or treat in order to prevent bone fractures, underestimates overall risk of fracture in people living with HIV – even with an adjustment experts have recommended to improve its accuracy for people with HIV – according to an analysis of the Veterans Aging Cohort Study Virtual Cohort (VACS-VC) reported at the recent Conference on Retroviruses and Opportunistic Infections (CROI 2015) in Seattle, USA.

Worse, using the thresholds currently recommended by US guidelines for screening and treatment did not discriminate well between those individuals actually at risk and those not at risk for future fractures, according to Michael Yin from Columbia University, who presented the study findings.

Fractures in people with HIV

The incidence of bone fractures – whether associated with trauma or fragility – is increased in people living with HIV, especially with advancing age. According to a recent meta-analysis of the VACS, the unadjusted risk of fragility fractures was about 38% higher for people living with HIV than for HIV-negative individuals.

This understanding has led to changes in HIV management guidelines. For instance, the most recent HIV Medicine Association guidelines in the US recommend dual energy x-ray absorptiometry (DEXA, or DXA) bone density screening for men and women over age 50. The European AIDS Clinical Society (EACS) also recommends DXA screening for men over 50 and postmenopausal women, but in addition recommends fracture risk assessment using the FRAX tool, without bone mineral density (BMD) assessment, for people with HIV over the age of 40.

As noted, FRAX is a web-based fracture risk calculator that uses easily obtainable clinical risk factors (used with or without BMD) to estimate absolute ten-year risk of having a major osteoporotic (spine, upper arm, wrist or hip) fracture or of having a hip fracture alone. FRAX has been well validated in the general population across many different countries and populations, but there has been a question whether FRAX works equally well at predicting fractures in HIV-positive and HIV-negative individuals.

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