Low Sensitivity of the Fracture Risk Assessment Tool in Young HIV-Infected Patients: Time to Revise Our Screening Strategy

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