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Brief Report

Low Sensitivity of the Fracture Risk Assessment Tool in Young HIV-Infected Patients

Time to Revise Our Screening Strategy

van Welzen, Berend J. MD; Yesilay, Sultan BSc; Arends, Joop E. MD, PhD; Hoepelman, Andy I. M. MD, PhD; Mudrikova, Tania MD, PhD

JAIDS Journal of Acquired Immune Deficiency Syndromes: December 15, 2019 - Volume 82 - Issue 5 - p 439–442
doi: 10.1097/QAI.0000000000002177
Clinical Science

Objectives: The burden of reduced bone mineral density (BMD) is high among HIV-infected patients. As a screening strategy, current guidelines recommend calculating a Fracture Risk Assessment Tool (FRAX) score in patients aged 40–49 years. Patients with a 10-year risk of a major osteoporotic fracture ≥10% should undergo dual-energy x-ray absorptiometry (DXA) to assess BMD. The aim of this study was to establish the sensitivity of this threshold to identify patients with risk of osteoporosis in this age category—as a surrogate marker for high fracture risk.

Methods: The study group consisted of patients aged 50–59 years and living with HIV for at least 10 years who recently underwent dual-energy x-ray absorptiometry (DXA). A clinical risk factor–based FRAX score was calculated using patient characteristics from 10 years earlier. In this way, we assessed which patients would have undergone DXA while they were 40–49 year old.

Results: The cohort consisted of 126 patients; 23 patients (18.3%) had osteoporosis. Ten years before the DXA, none of them met the guideline threshold of a 10-year major osteoporotic fracture probability of ≥10%, resulting in a sensitivity of 0% in this cohort. There was no difference between the median FRAX score between patients who developed osteoporosis and those who did not (3.3% vs. 3.4%. P = 0.55).

Conclusions: FRAX lacks sensitivity to determine which HIV-infected patients aged 40–49 years should undergo BMD testing to identify reduced BMD. Its role should be limited to treatment decisions.

Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, the Netherlands.

Correspondence to: Berend J. van Welzen, MD, Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Huispostnummer F.02.126, PO Box 85500, 3508 GA, Utrecht (e-mail:

J.E.A. reports institutional fees from Gilead Sciences, ViiV Healthcare, MSD & Janssen. T.M. reports institutional fees from Gilead Sciences and congress grant from MSD. The remaining authors have no conflicts of interest to disclose.

Received June 28, 2019

Accepted August 19, 2019

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.