Fw: NATAP/CROI: Increased Fractures in HIV+

[Guest guest]

from Jules: when I started 2.5 years ago to raise awareness about bone disease in HIV lots of metabolic thought leaders said "well, how do we know this will translate (increased bone loss in HIV) into increased fractures. I knew they were wrong and they are now with several studies showing increased fracture rates which is likely to get worse because patients are just now aging over 60 years old.Higher and Rising Fracture

Rate With HIV Versus General Population

17th Conference on Retroviruses and Opportunistic Infections, February 16-19,

2010, San Francisco

Mark Mascolini

Compared with people in the general population who spent time in the hospital

or saw their doctor with a broken bone, people in the HIV Outpatient Study

(HOPS) had higher fracture rates over the past several years [1]. People with

HIV seemed especially more prone to fragility fractures. And while fracture

rates stayed stable over the years in the comparison groups, they rose in HOPS.

The first large study to verify higher fracture rates in people with versus

without HIV found that fracture prevalence rose with age in HIV-infected men

but not in HIV-negative men HIV [2]. In this large single-center study, the

fracture rate climbed with age in women with or without HIV.

HOPS includes HIV-infected people from 10 clinics in 8 US cities [1].

Dao and colleagues compared fracture trends in HOPS members with data from an

inpatient general-population database (the National Hospital Discharge Survey)

and an outpatient general-population study (the National Hospital Ambulatory

Medical Care Survey). Data from these sources reached through 2006. The HOPS

contingent included people with at least two "clinical encounters"

from 1994 through 2008. In HOPS members with multiple fractures, the

researchers considered only the first one.

The HOPS fracture analysis ran from 2000 to 2008, overlapping with the

general-population databases from 2000 to 2006. The 5826 HOPS participants had

a median age of 40 years (interquartile range [iQR] 34 to 46) at

their first visit, 79% were men, 52% non-Hispanic white, 33% non-Hispanic

black, and 73% with antiretroviral experience. Time since HIV diagnosis stood

at a median of 5.3 years (IQR 1.3 to 9.9), median CD4 count at 372 (IQR 196 to

579), and median viral load at 1305 copies (IQR under 400 to 35,560).

Over the study period, 236 HOPS members (4%) broke a bone. At the time of fracture, median age measured 45

years (IQR 38 to 51). Only 51% of these people had antiretroviral experience.

For people admitted to the hospital with a broken bone, gender-adjusted

fracture rates for 25- to 54-year-olds were substantially higher in HOPS

(always over 100 per 10,000 person-years) than in the general-population

inpatient database (around 25 per 10,000 person-years). While the

general-population fracture rate stayed flat from 2000 to 2006, the rate in

HOPS members rose significantly from 2000 to 2008 (P = 0.01).

For outpatient fractures in 25- to 54-year-olds, the gender-adjusted rate

started above 50 per 10,000 person-years in HOPS and rose significantly from

2000 to 2008 (P = 0.01), while the rate

in general-population outpatients stayed stable at around 25 per 10,000

person-years.

Fractures at fragility sites were more common in HOPS men than

general-population outpatient men at the wrist (9% versus 3%) and vertebrae

(10% versus 1%). Women in HOPS also had more fractures than women in the

outpatient survey at two fragility sites--vertebrae (18% versus 4%) and the

femoral neck (7% versus 1%) (P

</= 0.05 for all comparisons in men and women). People in the general

population had significantly more fractures than HOPS members at nonfragility

sites.

A multivariate model that factored in four demographic variables, six

HIV-related variables, and nine known risk factors for low bone mineral density

isolated five independent predictors of fracture in HOPS members:

·     

Age over 46 versus under 35: adjusted hazard ratio (AHR)

1.6, 95% confidence interval [CI] 1.0 to 2.5, P </= 0.05

·     

Nadir CD4 count under 200 versus over 349: AOR 1.6, 95%

CI 1.1 to 2.3, P </= 0.05

·     

Hepatitis C virus coinfection: AOR 1.6, 95% CI 1.1 to

2.3, P = 0.01

·     

Diabetes: AOR 1.6, 95% CI 1.0 to 2.1, P = 0.05

·     

Substance abuse: AOR 1.5, 95% CI 1.0 to 2.3, P = 0.05

Dao and colleagues cautioned that their analysis is limited

because it compares people from different data collection systems and because

they could not analyze bone mineral density for its contribution to fracture

risk. They also noted that the rising fracture rate in HOPS may reflect a true

increase or improved fracture reporting.

References

1. Dao C, Young B, Buchacz K, et al.

Higher and increasing rates of fracture among HIV-infected persons in the HIV

Outpatient Study compared to the general US population, 1994 to 2008. 17th

Conference on Retroviruses and Opportunistic Infections. February 16-19, 2010.

San Francisco. Abstract 128.

2. Triant VA, Brown TT, Lee H, Grinspoon SK. Fracture prevalence among human

immunodeficiency virus (HIV)-infected versus non-HIV-infected patients in a

large U.S. healthcare system. J Clin Endocrinol Metab. 2008;93:3499-3504. http://jcem.endojournals.org/cgi/content/full/93/9/3499.