Evaluation of Provider Screening Practices for Fracture Risk Assessment among Patients with HIV Disease

People living with HIV are known to have greater risk of low bone mineral density than HIV-negative peers. The reasons for this disparity are multifactorial. To address this increased risk, the Infectious Diseases Society of America (IDSA) released fracture risk screening recommendations in 2015, which differ significantly from recommendations that apply to the general population. A study was conducted at the University of Connecticut to assess for provider awareness and adherence to these recommendations. Electronic surveys were sent to providers, and patients were also surveyed for risk factors and prevalence of low bone mineral density. The results of the provider survey showed low rates of awareness of the IDSA screening recommendations. A substantial proportion of patients surveyed met criteria for low BMD screening but did not have dual-energy X-ray absorptiometry (DXA) ordered by their provider. As an intervention, providers were sent information via e-mail regarding current screening recommendations, as well as notifications if their patient met criteria for DXA screening. A twelve-month follow-up survey showed increased provider knowledge of screening recommendations and improved screening practices. Additionally, the results of a logistic regression analysis of patient factors showed that increasing age and male sex were positively associated with fragility fracture risk. Increased duration of antiretroviral therapy use was associated with a lower likelihood of fragility fracture.

1. Introduction
The risk of low bone mineral density (BMD) and its associated complications including fracture are significantly higher in people living with HIV (PLWH) compared to the uninfected population [1, 2]. The mechanisms leading to this disparity are multifactorial; some are likely related to viral factors, others to antiretroviral therapy (ART) [3, 4]. Secondary osteoporosis risk factors (i.e., malnutrition, coinfection with hepatitis C, substance abuse including tobacco, and alcohol dependence) also have a higher prevalence in the HIV positive population [5, 6]. HIV-infected men frequently develop low serum testosterone levels with aging, further predisposing to bone loss [2, 7]. Furthermore, several studies have found that more than 90 percent of PLWH have 25-hydroxy vitamin D deficiency [8].

To address the increased risk of low BMD in HIV patients, the Infectious Diseases Society of America (IDSA) released fracture risk screening recommendations in 2015 [1]. These significantly differ from screening practices recommended for the general population [9] but are consistent with more recent recommendations from the European AIDS Clinical Society [10]. Specifically, all HIV patients older than 40 years old should be screened for fracture risk using the Fracture Risk Assessment Tool (FRAX) [1]. Dual-energy X-ray absorptiometry (DXA) should also be used in addition to FRAX scores in men aged ≥50 years, postmenopausal women, patients with a history of fragility fracture, patients receiving chronic glucocorticoid treatment, and patients at high risk of falls [1]. Additionally, current guidelines suggest inclusion of HIV infection as a cause of secondary osteoporosis in the FRAX questionnaire [10].

Provider adherence rates to the IDSA screening recommendations are unknown, but there are likely many PLWH who meet criteria for screening and are missed. Primary care providers (PCPs) are less likely to be aware of HIV specific guidelines and may trust instead that this will be addressed by their patient’s Infectious Disease (ID) provider. Simultaneously, ID providers might assume that, as with the general population, screening would be performed by the PCP. ID providers may also be less comfortable testing and treating any underlying bone disease that they may uncover. Bone health screening in patients with HIV, therefore, represents an area of care in danger of falling between the cracks of primary and specialty care for PLWH.

The goal of this study was to evaluate provider knowledge and adherence to recent recommendations from international societies and to evaluate the efficacy of an intervention designed to improve provider knowledge and adherence at an academic medical center. In addition, we evaluated our cohort of patients to independently assess the prevalence of risk factors associated with fragility fracture in PLWH.