Osteoporosis and fractures in HIV/hepatitis C virus coinfection: a systematic review and meta-analysis

Abstract

Objective: There is growing evidence that fracture risk is increased in individuals with HIV and/or hepatitis C virus (HCV) infection. We systematically reviewed the literature to determine whether prevalence of osteoporosis and incidence of fracture is increased in HIV/HCV-coinfected individuals.

Design: A systematic review and meta-analysis.

Methods: A search was performed of Medline, Scopus and the Cochrane Library databases, as well as of abstracts from annual retroviral, liver and bone meetings (up to 2013) for studies with bone mineral density (BMD) or bone fracture data for HIV/ HCV-coinfected individuals. Osteoporosis odds ratios (ORs) and fracture incidence rate ratios (IRRs) were estimated from studies with data on HIV-monoinfected or HIV/HCV uninfected comparison groups.

Results: Of 15 included studies, nine reported BMD data and six reported fracture data. For HIV/HCV-coinfected, the estimated osteoporosis prevalence was 22% [95% confidence interval (95% CI) 12–31] and the crude OR for osteoporosis compared with HIV-monoinfected was 1.63 (95% CI 1.27-2.11). The pooled IRR of overall fracture risk for HIV/HCV-coinfected individuals was 1.77 (95% CI 1.44-2.18) compared with HIV-monoinfected and 2.95 (95% CI 2.17-4.01) compared with uninfected individuals. In addition to HIV/HCV-coinfection, older age, lower BMI, smoking, alcohol and substance use were significant predictors of osteoporosis and fractures across studies.

Conclusion: HIV/HCV coinfection is associated with a greater risk of osteoporosis and fracture than HIV monoinfection; fracture risk is even greater than uninfected controls. These data suggest that HIV/HCV-coinfected individuals should be targeted for fracture prevention through risk factor modification at all ages and DXA screening at age 50.

Fig. 1. Flow diagram of literature search and study selection

^aConferences searched included American Association for the Study of Liver Diseases (AASLD; 2000–2013), the scientific meeting of the American Society for Bone and Mineral Research (ASBMR, 2000–2013), Conference on Retroviruses and Opportunistic Infections (CROI, 1997–2013), the Conference on HIV Pathogenesis and Treatment of the International AIDS Society (IAS; 2001–2013), the International AIDS Conference (AIDS; 2002–2012) and International Conference on Viral Hepatitis (ICVH; 2011–2013).

Fig. 2. Pooled ratios of osteoporosis prevalence and fracture incidence

(a) Meta-analysis of crude odds ratios for osteoporosis (BMD T-score ≤−2.5 or Z-score ≤−2.0 at spine and/or hip) in HIV/HCV-coinfected individuals versus HIV-monoinfected individuals. (b) Meta-analysis of crude incidence rate ratios for fractures in HIV/HCV coinfected individuals versus HIV-monoinfected individuals. (c) Meta-analysis of crude incidence rate ratios for fractures in HIV/HCV-coinfected individuals versus HIV-uninfected individuals.

Fig. 2. Pooled ratios of osteoporosis prevalence and fracture incidence

(a) Meta-analysis of crude odds ratios for osteoporosis (BMD T-score ≤−2.5 or Z-score ≤−2.0 at spine and/or hip) in HIV/HCV-coinfected individuals versus HIV-monoinfected individuals. (b) Meta-analysis of crude incidence rate ratios for fractures in HIV/HCV coinfected individuals versus HIV-monoinfected individuals. (c) Meta-analysis of crude incidence rate ratios for fractures in HIV/HCV-coinfected individuals versus HIV-uninfected individuals.

Fig. 2. Pooled ratios of osteoporosis prevalence and fracture incidence

(a) Meta-analysis of crude odds ratios for osteoporosis (BMD T-score ≤−2.5 or Z-score ≤−2.0 at spine and/or hip) in HIV/HCV-coinfected individuals versus HIV-monoinfected individuals. (b) Meta-analysis of crude incidence rate ratios for fractures in HIV/HCV coinfected individuals versus HIV-monoinfected individuals. (c) Meta-analysis of crude incidence rate ratios for fractures in HIV/HCV-coinfected individuals versus HIV-uninfected individuals.