June 23, 2021
By Lauren Richey, MD, MPH, FIDSA
People with HIV have increased risk of premature bone loss and low bone mineral density. The causes are multifactorial but include the virus itself, medications to treat HIV, poor nutrition, lower body weight, and low vitamin D levels. This low bone density can result in fractures and increased frailty. In 2013, HIVMA released primary care guidelines for people with HIV and included screening for osteoporosis for all people with HIV aged 50 and older. Currently, in the general population, this screening is only for woman aged 65 and older. Little information is available to assess compliance with this recommendation.
The authors of a recent article in Open Forum Infectious Diseases performed a cross-sectional analysis of clinical data from 27 health systems, covering over 70 million patients. People with HIV aged 50 and over were identified using ICD codes. In order to distinguish screening for osteoporosis from management of patients with osteoporosis, patients with a diagnosis of osteoporosis or patients on medications for osteoporosis were excluded. Five years of data, starting in January 2016, were analyzed.
Over 16,000 patients who met the criteria were identified. Most were men (78%) and White (51%). Only 7.4% of all HIV-eligible adults received bone mineral density screening. Screening rates were lower in people aged 50 to 64 (6.9%) and higher in those 65 and older (13.1%). Rates were also higher in women (14.8%) than in men (6.7%). To assess for insurance barriers, stratification by insurance was performed. For patients with Medicaid, 4.5% were screened; private insurance, 6.4%; and Medicare, 8.8%. Fracture prevalence was much higher in people with HIV. In both sexes, among those aged 50 to 64, this prevalence was 2.4 per 100 persons, compared with 1.1 for women and 1.2 for men in the general population in those age groups. For people aged 65 and older, women with HIV had 6.3 fractures per 100 persons and men with HIV had 3.4, compared with 3.7 for women and 2.2 for men in the general population.
The prevalence of osteoporosis and fractures is much higher among people with HIV over 50, yet compliance with screening guidelines remains low. Further research is needed to elucidate the causes and how to improve screening rates.