HIV Infection and Fracture Risk



A large case-control study conducted in a Northern European population showed an elevated fracture risk similar to that previously demonstrated in primarily North American populations.


HIV- and antiretroviral therapy–induced bone loss has long been recognized, but only recently have we begun to appreciate its effect on fracture risk. In a recent case-control study conducted to explore this association, researchers used Danish National Health Service registries data on patients with fractures in 2000 and age- and sex-matched controls without fractures that year (n=124,655 and 373,962, respectively).

After adjustment for traditional osteoporosis risks, HIV infection was associated with a significantly increased fracture risk (odds ratio, 2.00). This association was particularly strong at key fracture-prone sites, including the hip (OR, 6.46), the spine (OR, 4.65), and the forearm (OR, 2.34). The findings were similar between men and women and between younger and middle-aged populations. Risk was related to the duration of infection, rising most rapidly during the first 2 or 3 years following HIV diagnosis and more slowly thereafter.


One limitation of this work was lack of data to evaluate the effects of such confounding factors as CD4-cell counts, antiretroviral regimens, body-mass index, and smoking status. Nevertheless, this study involving a Northern European population confirms the findings of previous investigations of HIV-associated fracture risk (most of which have been conducted in North American populations).

The findings underscore the need for regular bone-disease screening in HIV-infected individuals as they age on antiretroviral therapy. The existing standard for managing bone disease is based on strategies developed for postmenopausal women, for whom therapy is delayed until osteoporosis develops. This approach may be suboptimal in the context of HIV-related bone loss, because the clinical definitions of osteoporosis are based on bone-mineral density (which often does not correlate with fracture risk in individuals aged <55 years — the age of most HIV-infected patients today).

Efforts are needed to understand the mechanism behind this phenomenon, and to develop an effective risk-assessment tool and therapeutic strategies for HIV-induced bone loss, to forestall what many fear to be an impending epidemic of fragility bone fracture in the aging HIV/AIDS population.

Dr. Ofotokun is an associate professor of infectious disease, Emory University School of Medicine, and an investigator for the Atlanta Clinical & Translational Science Institute, Emory University. He reports no conflicts of interest.


  1. Prieto-Alhambra D et al. HIV infection and its association with an excess risk of clinical fractures: A nationwide case–control study. J Acquir Immune Defic Syndr 2014 May 166:90.