Beyond DXA: Trabecular Bone Score, Quantitative Ultrasound and Bone Turnover Markers for Morphometric Vertebral Fracture Assessment in People Living with HIV

<b>Background and Objectives</b>: People living with HIV (PLWH) have excess osteoporosis and fractures not fully captured by dual-energy X-ray absorptiometry (DXA). We evaluated whether trabecular bone score (TBS), calcaneal quantitative ultrasound (QUS) and bone turnover markers improve vertebral fracture risk assessment beyond areal bone mineral density (BMD) in PLWH. <b>Methods</b>: In this cross-sectional study, 87 antiretroviral-treated adults undergoing DXA had lumbar spine TBS and calcaneal QUS. Morphometric vertebral fractures were identified, correlates of degraded TBS were analyzed using multivariable regression, and sequential logistic models quantified the incremental contribution of TBS and CTX to discriminate for prevalent morphometric vertebral fractures. <b>Results</b>: Low BMD (osteopenia/osteoporosis) was present in 62% of participants, degraded TBS in 37% and morphometric vertebral fractures in 17%. Degraded versus normal TBS was associated with older age (49.1 vs. 39.7 years), longer HIV duration and lower nadir CD4+ count, as well as more frequent tenofovir disoproxil fumarate exposure (66% vs. 52%; all <i>p</i> ≤ 0.04). In multivariable analysis, age (per 10-year increase; adjusted odds ratio [aOR] 1.78; 95% CI 1.13-2.83) and nadir CD4+ < 200 cells/mm³ (aOR 2.29; 95% CI 1.06-4.97) independently predicted degraded TBS. In sequential cross-sectional models for prevalent morphometric vertebral fractures, the area under the curve increased from 0.71 (clinical variables) to 0.79 after adding lumbar spine T-score and to 0.85 after adding TBS; adding CTX yielded 0.87 without a statistically significant incremental gain. <b>Conclusions</b>: In PLWH, TBS captures bone quality deficits and improves vertebral fracture risk discrimination beyond BMD, supporting its integration alongside DXA in routine HIV care.