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Broken bone risk twice higher in HIV-positive versus negative men in their 50s.

Fractures (broken bones) occurred twice as often in HIV-positive men 50 to 59 years old as in HIV-negative men that age, according to results of a large US comparison. (1) Hypertension * (high blood pressure) raised the fracture risk in men with or without HIV infection.

Low bone density affects people with HIV more than HIV-negative people (2) and leads to higher fracture rates in HIV-positive men and women. (3,4) Fracture risk increases with age, so fractures may become even more common in HIV-positive people as they live longer thanks to antiretroviral therapy. Other risk factors for weak bones also affect high proportions of people with HIV, including smoking and drinking too much alcohol.

US researchers conducted this study to compare fracture rates in 10-year age groups of men with versus without HIV infection.

* How the study worked. This analysis involved gay or bisexual men in the Multicenter AIDS Cohort Study (MACS), which includes HIV-positive men and HIV-negative men at risk of HIV infection. Men in MACS make two study visits every year to get a checkup and answer questions related to their behavior and health. Since 2001 MACS men reported whether they had broken a bone since their last visit.

This study focused on two groups of fractures: (1) all fractures except those of the facial bones, skull, fingers, or toes, and (2) fragility fractures, defined as those of the spine, wrist, femur (long bone in the upper leg), and humerus (long bone in the upper arm) (Figure 1). Fragility fractures are those thought likely to result from low bone density.

The researchers divided men into three age groups: 40 to 49, 50 to 59, and 60 or older. They used a statistical method that determined whether HIV status by itself (being HIV-positive or negative) raised the fracture risk in each of these three age groups, independently of risk factors like white race, smoking, drinking too much alcohol, low weight, and other illnesses.

* What the study found. The study included 1221 gay or bisexual men with HIV and 1408 without HIV. The HIV group had a lower proportion of whites (59% versus 73%) and a higher proportion of blacks or Hispanics (41% versus 27%). About 30% of both groups called themselves moderate to heavy alcohol drinkers, and a somewhat higher proportion of men with HIV smoked (38% versus 31%).

Among men with HIV, 182 of 1221 had a new fracture during the study, compared with 197 of 1408 men without HIV. Those numbers gave a new-fracture rate of 12.8 per 1000 person-years in men with HIV and 10.0 per 1000 person-years in men without HIV (Figure 2). A rate of 12.8 per 1000 person-years means about 13 of every 1000 men broke a bone each year.

In men in their 40s, the new-fracture rate for all fractures was about 10 per 1000 person-years in both HIV-positive and HIV-negative men. Among men in their 50s, the new-fracture rate for all fractures stayed around 10 per 1000 person-years in HIV-negative men but jumped to almost 20 per 1000 person-years in men with HIV. Among men in their 60s, the new-fracture rate was similar in men with and without HIV, both about 15 per 1000 person-years.

The rate of new fragility fractures was also higher in men with than without HIV: 4.6 versus 3.4 per 1000 person-years (Figure 2). Again, the new-fracture rate for fragility fractures was similar with and without HIV among men in their 40s. But HIV-positive men in their 50s had a much higher new-fracture rate for fragility fractures, while the rate stayed the same in HIV-negative men in their 50s. New-fracture rates for fragility fractures were similar in HIV-positive and negative men in their 60s.

The statistical analysis that measures the impact of several fracture risk factors at the same time figured that HIV-positive men in their 50s had a doubled rate of all fractures compared with HIV-negative men the same age. HIV-positive men in their 50s also had a doubled rate of fragility fractures compared with HIV-negative men. These findings mean that among men in their 50s, HIV infection by itself doubles the risk of all fractures and of fragility fractures.

Total use of anti-HIV protease inhibitors (like Prezista or Reyataz) or the antiretroviral tenofovir (a part of combination drugs like Stribild and Atripla) was not linked to rates of all fractures or fragility fractures.

One other fracture risk factor, by itself, raised the risk of all fractures: High blood pressure raised the all-fracture risk by 32%.

* What the findings mean for you. As we get older, our bone density decreases and we run a higher risk of breaking a bone. This is true for people with and without HIV. This new study shows that, for men with HIV, the fracture risk starts to climb when they are in their 50s. In contrast, among men without HIV, the fracture risk does not start climbing until they are in their 60s. In other words, the study shows that HIV infection status by itself is a fracture risk factor for men in their 50s.

Because of this finding, the researchers who conducted this study recommend that HIV clinicians start checking bone density in HIV-positive men when they reach their 50s. Current HIV guidelines already make that recommendation, (5) but the extent to which these guidelines are followed is not clear. Those guidelines also recommend bone density testing for HIV-positive women who have reached the menopause and for people who have already had a fragility fracture.

This study also pinpointed hypertension (high blood pressure) as a fracture risk factor in men with or without HIV. Hypertension is common among people with HIV and can lead to serious heart disease. High blood pressure has no symptoms you can feel, but it's easy to detect with a quick blood pressure cuff test. Hypertension usually responds to drug therapy and to lifestyle changes including diet, limiting alcohol drinking, and quitting smoking.

Other research in people with and without HIV identifies several other risk factors for low bone density. See Table 1 on page 24. Some of these risk factors can be avoided or changed, including (1) lack of weight-bearing exercise, (2) smoking, (3) drinking too much alcohol, (4) consuming too little calcium or vitamin D, and (5) weighing less than normal. Because HIV itself is a fracture risk factor, people with HIV should work with their provider to address these changeable risk factors. Low bone density (osteopenia or osteoporosis) can be treated. People who already have low bone density should take precautions to avoid falling. See the link at Reference 6 below for tips on preventing falls.

References

(1.) Gonciulea A, Wang R, Althoff KN, et al. An increased rate of fracture occurs a decade earlier in HIV+ compared to HIV- men in the Multicenter AIDS Cohort Study (MACS). AIDS. 2017; 31:1435-1443.

(2.) Brown TT, Qaqish RB. Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: a meta-analytic review. AIDS. 2006; 20:2165-2174.

(3.) Arnsten JH, Freeman R, Howard AA, Floris-Moore M, Lo Y, Klein RS. Decreased bone mineral density and increased fracture risk in aging men with or at risk for HIV infection. AIDS. 2007; 21:617-623.

(4.) Triant VA, Brown TT, Lee H, Grinspoon SK. Fracture prevalence among human immunodeficiency virus (HlV)-infected versus non-HIV-infected patients in a large U.S. healthcare system./ Clin Endocrinol Metab. 2008; 93:3499-3504.

(5.) Brown TT, Hoy J, Borderi M, et al. Recommendations for evaluation and management of bone disease in HIV. Clin Infect Dis. 2015; 60:1242-1451. https://academic.oup.eom/cid/article-lookup/doi/10.1093/cid/civ010

(6.) Mayo Clinic. Fall prevention: simple tips to prevent falls. http://www.mayoclinic.org/healthy-lifestyle/healthy-aging/in-depth/fall-prevention/art-20047358?pg=1

* Words in bold are defined in the Technical Word List at the end of this issue of HIV Treatment Alerts.

Caption: Figure 1. Fragility fractures in these four areas--thought to be clue to low bone density--occurred twice as often in HIV-positive men in their 50s as in HIV-negative men that age. (Image from Servier PowerPoint Image Bank http://servier.com/Powerpoint-image-bank.)
Figure 2. Rates of all fractures
and fragility fractures per 1000
person-years (p-y) were higher
in HIV-positive men 40 and older
than in HIV-negative men that
age. (For example, a rate of 10
per 1000 person-years means 10
of every 1000 men broke a bone
each year.)

New-fracture rates in men with and without HIV

                      Rate per 100 p-y

                      HIV-pos   HIV-neg

All fractures         12.8      10.0
Fragility fractures   4.6       3.4

Note: Table made from bar graph.
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Publication:HIV Treatment: ALERTS!
Date:Sep 1, 2017
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