Poor Blood Sugar Control and Overall Care in People With Diabetes and HIV

One third of people with HIV and diabetes in a New York City university medical center had poor control of blood sugar, and low proportions met guidelines for blood pressure, cholesterol, and triglycerides.¹ In addition, physicians tested few of these people with HIV and diabetes for serious diabetes complications.

One in 10 US adults has diabetes, a disease marked by high sugar levels in the blood. Diabetes rates are especially high in African Americans and Hispanics.² Diabetes is a serious lifelong disease that can cause high blood pressure, heart disease, kidney disease, and blindness. HIV and two types of antiretrovirals -- nucleosides and protease inhibitors -- may contribute to the risk of diabetes. In a study of US gay men, the diabetes rate was 4 times higher in those with HIV than in those without HIV.³

Earlier studies found poor blood sugar control in people with diabetes and HIV.^4,5 Researchers at a New York City university medical center planned this study to see how well blood sugar is controlled in their patients with diabetes and HIV, and to identify factors that may contribute to poor blood sugar control. The study also aimed to determine whether people with diabetes and HIV met American Diabetes Association guidelines6 for blood pressure and lipids (blood fats) and whether they were tested for eye and kidney complications of diabetes.

• How the study worked. Researchers checked electronic records of the hospital HIV clinic to identify people over 18 years old who had HbA1c checked in at least two different quarters in 2008. HbA1c is a form of hemoglobin (an oxygen-carrying protein in blood) used to identify average blood sugar levels over a prolonged period and thus to help diagnose and monitor diabetes. The file of study participants had to contain a physician's note saying they had diabetes in 2007. People with diabetes diagnosed in 2008 could not be in the study.

  The research team recorded all the antiretrovirals and other drugs study participants took from October 2007 to December 2008, and they noted other important lifestyle and HIV-related factors that may influence blood sugar and diabetes. The researchers also figured how well people with HIV and diabetes met American Diabetes Association goals for blood pressure, "good" highdensity lipoprotein (HDL) cholesterol, "bad" low-density lipoprotein (LDL) cholesterol, and triglycerides (see box).⁶ Finally, the researchers checked to see whether people with HIV and diabetes were examined for diabetic retinopathy (damage to the image-reading part of the eye) and microalbuminuria (the first sign of diabetic kidney disease).

• What the study found. This study focused on 142 adults -- 94 men and 48 women with an average age of 52 years. Forty-seven people (33%) had inadequate blood sugar control, defined as an HbA1c level at or above 7.5% during at least half of the yearly quarters in which it was measured. People with poor blood sugar control did not differ significantly from those with adequate control in age, gender, race (39% African American, 37% Hispanic, and 18% white), use of Medicaid (about three quarters overall), or obesity (about one third overall). The groups with and without poor blood sugar control did not differ in weight, time since diabetes diagnosis, CD4 count, viral load, antiretroviral use, substance abuse, psychiatric disease, medical appointment keeping, number of medical visits, or active hepatitis C virus infection.

  People with poor blood sugar control did differ significantly from those with adequate control in five ways:

  • Average years since HIV diagnosis: 12.7 with poor control versus 15.1 with adequate control
  • Median HbA1c: 8.4% with poor control versus 6.2% with adequate control
  • Use of diabetes medications: 98% with poor control versus 85% with adequate control
  • Use of insulin: 60% with poor control versus 20% with adequate control
  • Median triglyceride level: 238 mg/dL with poor control versus 168 mg/dL with adequate control

  In the whole study group, two thirds met the American Diabetes Association goal for LDL cholesterol⁶ (Figure 1). But only 42% met the blood pressure goal, 33% met the HDL cholesterol goal, and 31% met the triglyceride goal (Figure 1). Significantly more people taking a nonnucleoside (such as Intelence, Sustiva, or Viramune) met the HDL cholesterol goal than did people taking a protease inhibitor (such as Kaletra, Prezista, or Reyataz) (40% versus 25%). People taking the older nucleosides Retrovir, Videx, or Zerit were less likely to meet triglyceride goals than people taking newer nucleosides (14% versus 40%). Among the 39 people who did not meet the goal for LDL cholesterol, 25 (64%) never took a statin in 2008. Statins are a type of LDL cholesterol-lowering drug.

  Figure 1. Two thirds of people with HIV and diabetes in a New York City clinic met American Diabetes Association goals6 for low-density lipoprotein (LDL) cholesterol. But fewer than half met the blood pressure goal, and only one third met goals for high-density lipoprotein (HDL) cholesterol and triglycerides.

  Only 27 of these 142 people (19%) had a test called the urine albumin-to-creatinine ratio in 2008. This ratio can identify people with microalbuminuria, which means the kidney is starting to spill a protein called albumin into the urine. Microalbuminuria is an early signal of diabetic kidney disease. Thirteen of the 27 people tested (48%) did have microalbuminuria.

  Only 66 of the 142 study participants (46%) had a record of an eye exam to check for diabetic retinopathy (damage to the retina that may occur with diabetes). Thirteen of 59 people (22%) with test results on record did have evidence of retinopathy.

• What the results mean for you. This study found that one third of people with HIV and diabetes at a New York City medical center did not have good control of their blood sugar. Diabetes is a disease marked by high blood sugar levels, and controlling blood sugar is the goal of diabetes care. The researchers say their findings are particularly striking because their university-based HIV clinic offers comprehensive care for people with HIV. Poor blood sugar control in diabetics with HIV may be even more frequent in clinics that do not have the resources of this New York City center.

  A few factors assessed suggested which people had a higher risk of poor blood sugar control (see bullet list above). Some of these factors, such as use of diabetes medications and insulin, were probably the result of having higher blood sugars rather than causing poor blood sugar control. Most factors analyzed -- including age, gender, race, CD4 count, and antiretroviral use -- did not differ between people with poor versus adequate blood sugar control. As a result, the researchers suggest that individual characteristics cannot be easily used to predict poor blood sugar control.

  The study also found that low proportions of this group with HIV and diabetes met accepted goals for blood pressure, "good" HDL cholesterol, and triglycerides (Figure 1). One third of the study group did not meet the goal for "bad" LDL cholesterol. And two thirds of people who did not meet the LDL cholesterol goal never took a type of drug (a statin) that lowers LDL cholesterol and so lowers the risk of serious heart disease and stroke. The researchers say HIV health care providers should be educated about "the importance of aggressive statin use in patients with diabetes."

  Doctors in this HIV clinic were not checking most people with diabetes for a serious diabetic eye complication -- or at least not recording in the chart that they had seen an eye doctor. And few patients had a test to detect diabetesrelated kidney trouble. The researchers note that a standard urine test does not reliably identify diabetes-related kidney problems. The urine albumin-to-creatinine ratio can detect an early signal of kidney damage. Because drugs are available to treat this problem, the researchers say "education of HIV primary care providers on the importance of this screening test is essential."

  Together, these findings indicate that some HIV doctors may not be offering adequate care to people with diabetes and HIV. HIV-positive people with diabetes and their physicians should be aware of goals for blood sugar, cholesterol, triglycerides, and blood pressure. American Diabetes Association 2011 guidelines⁶ are available online at (http://care.diabetesjournals.org/content/34/Supplement_1/S11.full).

  All people with HIV should take basic steps to control their blood sugar, including eating a balanced diet and exercising. The American Diabetes Association has a Website devoted to the general public, which includes information on diet and exercise (click on "Food & Fitness" tab at www.diabetes.org/). This site also has advice on preventing diabetes and living with diabetes. The home page of the American Diabetes Association lists a toll-free number to call with questions about diabetes (1-800-DIABETES) as well as an online chat option.

References

1. Satlin MJ, Hoover DR, Glesby MJ. Glycemic control in HIV-infected patients with diabetes mellitus and rates of meeting American Diabetes Association management guidelines. AIDS Patient Care STDs. 2011;25:5-12.
2. Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2007. www.cdc.gov/diabetes/pubs/factsheet11.htm. Accessed February 5, 2011.
3. Brown TT, Cole SR, Li X, et al. Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Arch Intern Med. 2005;165:1179-1184.
4. Adeyemi O, Vibhakar S, Max B. Are we meeting the American Diabetes Association goals for HIV-infected patients with diabetes mellitus? Clin Infect Dis. 2009;49:799-802.
5. Bury JE, Stroup JS, Stephens JR, Baker DL. Achieving American Diabetes Association goals in HIV-seropositive patients with diabetes mellitus. Proc (Bayl Univ Med Cent). 2007;20:118-123.
6. American Diabetes Association. Standards of medical care in diabetes -- 2011. http://care.diabetesjournals.org/content/34/Supplement_1/S11.full. Accessed February 5, 2011.