Date of Award

January 2026

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Evelyn Hsieh

Second Advisor

David A. Paltiel

Abstract

AbstractBackground: People living with HIV (PWH) are at increased risk of osteoporosis and sarcopenia, yet access to gold-standard diagnostic tools remains limited in many settings. Low-cost screening tools such as OST, SCORE, and SARC-F offer practical alternatives, but optimal cutpoints and their implications for clinical decision-making in PWH are not well defined.

Methods: We conducted a secondary analysis of cross-sectional data from 229 PWH aged ≥45 years receiving care in Lima, Peru. Osteoporosis was defined using DXA among postmenopausal women and men ≥50 years, and sarcopenia using AWGS-2019 and EWGSOP2 criteria. We evaluated the diagnostic performance of OST, SCORE, their combination, and SARC-F across candidate cutpoints. Risk categories were defined based on category-specific likelihood ratios. Optimal cutpoints were identified using a decision-analytic framework comparing expected costs of test-positive versus test-negative classification, incorporating probabilities of disease and downstream costs.

Results: OST and SCORE demonstrated consistent risk stratification patterns, with lower OST (≤1) and higher SCORE (≥12) categories associated with increased probability of osteoporosis and favorable rule-in performance. Expected cost analysis supported referral (test-positive classification) for intermediate and high-risk categories and conservative management for lower-risk groups. These findings were corroborated by likelihood ratio thresholds. Combined OST and SCORE use improved rule-in performance in concordant high-risk strata (LR >20).SARC-F demonstrated limited diagnostic utility in younger individuals (≥45 years), with likelihood ratios near 1 and no clear clinical benefit across cutpoints. Performance improved with age, with a threshold of ≥4 showing increasing rule-in value and achieving clinical utility among older participants (≥60–65 years). A modified osteoporosis risk score incorporating HIV-related factors (OSTPWH) improved alignment between diagnostic performance and expected cost-based decision thresholds.

Conclusions: Interpreting screening tools within a decision-oriented framework substantially improves their clinical utility in PWH. A risk-stratified approach, prioritizing DXA referral for individuals with OST ≤1 or SCORE ≥12 and applying SARC-F (≥4) preferentially in older populations, offers a pragmatic strategy to optimize resource use and improve case detection in resource-constrained settings.

Comments

This is an Open Access Thesis.

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