Fracture risk assessment in patients prescribed pre-exposure prophylaxis for HIV: An audit and comparative evaluation of screening tools

Background Tenofovir disoproxil, a component of most pre-exposure prophylaxis for HIV (PrEP), is associated with reduced bone mineral density. UK guidelines recommend assessing fracture risk for PrEP users aged over 50 years, and in 2025 QFracture joined FRAX as a suggested screening tool. Awareness of fracture risk supports decision making including the need for bone mineral density measurement or use of tenofovir alafenamide-based PrEP. We audited staff adherence to assessment and characterised the clinical impact, including any effect of screening tool choice. Methods This study reviewed the patient records of PrEP users at nine sexual health services in northwest England during January-April 2025 who met UK guideline criteria for osteoporosis risk assessment. FRAX and QFracture were calculated for each patient and used to determine clinical outcome. Results Fracture risk assessment had been completed for 156/220 (71%) eligible patients. 6/15 (40%) indicated dual-energy X-ray absorptiometry (DEXA) scans had been requested. 129/220 (59%) patients had sufficient available data for inclusion in the comparison of FRAX and QFracture outcomes. 10-year major osteoporotic fracture risk was significantly lower using QFracture (1.4%) compared to FRAX (3.5%; p < .001), as was the indication for DEXA scan (QFracture 0.8%, FRAX 11.6%; p < .001). Based on FRAX assessment, three patients were switched to PrEP containing tenofovir alafenamide and two started a bisphosphonate for osteoporosis. Use of QFracture would have missed both patients. Conclusions Choice of screening tool impacts both estimated fracture risk and clinical outcome. FRAX may be preferable to QFracture due to increased sensitivity and may be more feasible by incorporating fewer variables. Fracture risk assessment in line with national guidelines supports best practice for patient case, and services should therefore audit practice and optimise processes to maximise staff adherence.