Developing Diabetes: Monitor Aging Individuals with HIV Closely
As we celebrate the good news that antiretroviral therapy (ART) has led to significantly longer life expectancies among individuals with HIV, we need to acknowledge the bad news that individuals with HIV are significantly more likely to develop age-related comorbidities at earlier ages.
Diabetes mellitus is a particular concern among people living with HIV, especially as they age. As we celebrate the good news that antiretroviral therapy (ART) has led to significantly longer life expectancies among individuals with HIV, we need to acknowledge the bad news that individuals with HIV are significantly more likely to develop age-related comorbidities at earlier ages. Researchers indicate that use of older antiretrovirals, which were associated with fat atropine, visceral fat accumulation, and metabolic complications, are at least in part contributing factors.
Researchers from a number of facilities located in Vancouver, British Columbia, Canada have published a study in BMJ Open Diabetes Research & Care that documents higher incidences of diabetes in older adults with HIV. They also established a correlation between advanced infection, use of older antiretroviral, and the development of diabetes.
The researchers followed 1065 individuals with HIV for approximately 13 years. The majority of patients (80%) were male and 43% had hepatitis C coinfection. Approximately 38% were injection drug users. Of note, the median body mass index for participants was 24 kg/m2, which was normal to low compared to the general population. All participants were 50 years of age or older.
The incidence of diabetes was 1.6 cases/hundred person-years. The researchers noted that this is 1.3 times higher than the rate in the general population among men in Canada. Participants who had started ART between 1997 and 2004 were more likely to have diabetes than those who started later and had shorter durations of ART.
The researchers noted that exposure to zidovudine, stavudine, and didanosine may have contributed to significant metabolic toxicities and eventually, development of diabetes. These agents have been associated with insulin resistance.
The researchers also documented an association between older protease inhibitors including lopinavir, nelfinavir, and indinivir, and increased risk of diabetes. Here too, increased insulin resistance is probably the root cause.
Several previous studies have suggested that hepatitis C viral coinfection may be a risk factor for development of diabetes, but this study was unable to confirm that hypothesis. Like several other studies, it suggests that hepatitis C infection affects diabetes risk in a very complicated way.
The researchers found no association between obesity (or lack thereof) in the development of diabetes.
The clinical implications include a necessity for health care providers to follow evidence-based guidelines when they treat diabetes and HIV. The researchers recommended checking fasting blood sugar and hemoglobin A1c before and after starting ART, and using ART that is less likely to cause metabolic toxicities. They also recommended early, aggressive initiation of ART, noting that in this study, patients with better immune and virologic control were less likely to have diabetes mellitus.
Samad F, Harris M, Puskas CM, et al. Incidence of diabetes mellitus and factors associated with its development in HIV-positive patients over the age of 50. BMJ Open Diabetes Res Care. 2017;5(1):e000457.