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Incident bone fracture and mortality in a large HIV cohort outpatient study, 2000–2017, USA

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Abstract

Summary

We evaluated the association of bone fracture with mortality among persons with HIV, controlling for sociodemographic, behavioral, and clinical factors. Incident fracture was associated with 48% greater risk of all-cause mortality, underscoring the need for bone mineral density screening and fracture prevention.

Purpose/Introduction

Low bone mineral density (BMD) and fracture are more common among persons with HIV (PWH) than those without HIV infection. We evaluated the association of bone fracture with mortality among PWH, controlling for sociodemographic, behavioral, and clinical factors.

Methods

We analyzed data from HIV Outpatient Study (HOPS) participants seen at nine US HIV clinics during January 1, 2000, through September 30, 2017. Incident fracture rates and post-fracture mortality were compared across four calendar periods. Cox proportional hazards analyses determined factors associated with all-cause mortality among all participants and those with incident fracture.

Results

Among 6763 HOPS participants, 504 (7.5%) had incident fracture (median age = 47 years) and 719 (10.6%) died. Of fractures, 135 (26.8%) were major osteoporotic (hip/pelvis, wrist, spine, arm/shoulder). During observation, 27 participants with major osteoporotic fractures died (crude mortality 2.97/100 person-years [PY]), and 48 with other site fractures died (crude mortality 2.51/100 PY). Post-fracture, age- and sex-adjusted all-cause mortality rates per 100 PY decreased from 8.5 during 2000–2004 to 1.9 during 2013–2017 (P<0.001 for trend). In multivariable analysis, incident fracture was significantly associated with all-cause mortality (Hazard Ratio 1.48, 95% confidence interval 1.15–1.91). Among 504 participants followed post-fracture, pulmonary, kidney, and cardiovascular disease, hepatitis C virus co-infection, and non-AIDS cancer, remained independently associated with all-cause mortality.

Conclusions

Incident fracture was associated with 48% greater risk of all-cause mortality among US PWH in care, underscoring the need for BMD screening and fracture prevention. Although fracture rates among PWH increased during follow-up, post-fracture death rates decreased, likely reflecting advances in HIV care.

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Acknowledgements

The HIV Outpatient Study (HOPS) Investigators include the following persons and sites:

Kate Buchacz, Marcus D. Durham, Jun Li, Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Atlanta, GA; Cheryl Akridge, Stacey Purinton, Selom Agbobil-Nuwoaty, Kalliope Chagaris, Kimberly Carlson, Qingjiang Hou, Carl Armon, Linda Battalora, Jonathan Mahnken Cerner Corporation, Kansas City, MO; Frank J. Palella, Saira Jahangir, Conor Daniel Flaherty, Feinberg School of Medicine, Northwestern University, Chicago, IL; Kenneth S. Greenberg, Barbara Widick, Rosa Franklin, Rocky Mountain Cares, Denver, CO; Douglas J. Ward, Linda Kirkman, Dupont Circle Physicians Group, Washington, DC; Jack Fuhrer, Linda Ording-Bauer, Rita Kelly, Jane Esteves, State University of New York (SUNY), Stony Brook, NY; Ellen M. Tedaldi, Ramona A. Christian, Faye Ruley, Dania Beadle, Princess Davenport, Lewis Katz School of Medicine at Temple University, Philadelphia, PA; Richard M. Novak, Andrea Wendrow, Stockton Mayer, University of Illinois at Chicago, Chicago, IL; Mia Scott, Billie Thomas, APEX Family Medicine, Denver, CO; Cynthia Mayer, Victoria Franco, Karen Maroney, Carrie Humberger, SJH Comprehensive Research Institute, Tampa, FL.

Funding

Centers for Disease Control and Prevention (contract nos. 200-2001-00133, 200-2006-18797, 200-2011-41872, and 200-2015-63931)

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Authors and Affiliations

  1. Colorado School of Mines, 1301 19th St., Golden, CO, 80401, USA

    Linda Battalora & John R. Spear

  2. Cerner Corporation, Kansas City, MO, USA

    Linda Battalora, Carl Armon & Kimberly Carlson

  3. Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Frank Palella

  4. Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA

    Jun Li & Kate Buchacz

  5. University of Alabama School of Medicine, Birmingham, AL, USA

    Edgar T. Overton

  6. CarePoint Healthcare, Denver, CO, USA

    John Hammer

  7. Stony Brook School of Medicine, Stony Brook, NY, USA

    Jack Fuhrer

  8. University of Illinois College of Medicine, Chicago, IL, USA

    Richard M. Novak

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  1. Linda Battalora
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  2. Carl Armon
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  3. Frank Palella
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  10. John R. Spear
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  11. Kate Buchacz
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for the HIV Outpatient Study (HOPS)

Corresponding author

Correspondence to Linda Battalora.

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Conflicts of interest

Frank Palella has been a consultant and/or on the Speakers’ Bureau for Gilead Sciences, Janssen Pharmaceuticals, Merck and Co., and ViiV. TO is supported by the University of Alabama at Birmingham (UAB) Center For AIDS Research CFAR, an NIH-funded program (P30 AI027767-31). Linda Battalora, Carl Armon, Jun Li, John Hammer, Jack Fuhrer, Richard Novak, Kimberly Carlson, John Spear, and Kate Buchacz declare that they have no conflict of interest.

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Highlights

• People with HIV (PWH) have lower levels of bone mineral density and higher fracture rates than people without HIV.

• We determined factors associated with all-cause mortality among PWH, and a subset of those who had incident fracture.

• Incident fracture was associated with 48% greater all-cause mortality among PWH.

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Battalora, L., Armon, C., Palella, F. et al. Incident bone fracture and mortality in a large HIV cohort outpatient study, 2000–2017, USA. Arch Osteoporos 16, 117 (2021). https://doi.org/10.1007/s11657-021-00949-y

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