It has long been thought that the heightened risk of diabetes among people living with HIV was mostly due to early-generation antiretroviral drugs that raised glucose levels. But a longitudinal Australian study published in the Feb. 20, 2018, issue of AIDS found that, even in the modern treatment era, HIV-positive men who have sex with men (MSM) developed diabetes at an extremely high rate.
Researchers followed 104 MSM attending a Sydney, Australia, HIV clinic for a mean of 11.8 years starting in 1997. None had diabetes at baseline, but 12.5% developed the disease over the course of follow-up. Another 32.3% developed prediabetes, for a total glucose disorder incidence rate of 45.8%.
All study participants underwent an oral glucose tolerance test at baseline, and 33 had a second test administered during follow-up. That second test found a glucose disorder in 60% of those tested, about twice the rate of diagnoses based on fasting glucose alone. Among the 58 men whose body composition was measured, even modest abdominal fat gains were associated with double or triple the risk of developing incident glucose disorders. None of these participants were obese, and most had a healthy body mass index. "Accurate determination of glucose status in treated HIV infection will identify individuals for early intervention with preventive weight management strategies for cardiometabolic health maintenance and diabetes prevention," study authors concluded.
The World Health Organization reports that 64.5% of Australian adults are overweight, compared with 67.9% of U.S. adults. An analysis of data from the U.S. Veterans Aging Cohort Study found that each pound of weight gained increased participants' diabetes risk compared with people not living with the virus, Amy Justice, M.D., Ph.D., one of its authors, noted when speaking to TheBodyPRO. "If they avoid weight gain, they are unlikely to develop adult onset diabetes," she concluded.
Related: Increased Prevalence of Diabetes in HIV-Positive People
At the start of the epidemic in the 1980s, the adage was that people living with HIV lost weight. But the advent of effective antiretroviral therapy changed that. As people with HIV are living longer, they are also likely to face illnesses that are prevalent in the general population. In addition, some of these antiretroviral medications raise the risk for glucose disorders. In a 2008 editorial, Samuel Dagogo-Jack, M.D., M.B.B.S., FRCP, counseled: "Clearly, physicians who treat patients with HIV-AIDS need to be alert to the adverse metabolic effects of the expanding antiretroviral armamentarium." In the Australian study, the availability of specific HIV medications changed during the long follow-up period. "Medication prescription bias may have existed, as medications with apparently lower diabetes-risk became standard of care during the observation period," study authors acknowledged.
Not only are more Americans than Australians overweight; diabetes is also more common in the U.S. In Australia, about 6% of the general population has diabetes, according to the Australian Institute of Health & Welfare. In the U.S., that rate is 9.4%, according to the Centers for Disease Control and Prevention (CDC). That difference is also reflected among people living with HIV. In a telephone interview with TheBodyPRO, considering only diabetes, Dagogo-Jack calculated an incidence rate of 10.2/1000 person-years of follow up (PFYU) in the Australian study compared with 47/1,000 PYFU in a 2005 U.S. study among people with HIV that included a larger cohort but a shorter follow-up period.
Just as diabetes is more common among people of color in the U.S., it is also more common among Australia's indigenous population. The Australian Institute of Health & Welfare estimates that 13% of the country's indigenous people have diabetes. However, when the longitudinal HIV and diabetes study began, few Indigenous Australians had HIV, Katherine Samaras, M.B.B.S., Ph.D., FRACP, one of the study's authors, told TheBodyPRO via email, and none were included in the cohort. She noted the different demographics of HIV in Australia, with few transmissions from intravenous drug use, crediting needle exchanges and methadone replacement therapy for that fact. "This takes the needle-mode of HIV-infection spread out of the equation. It also helps reduce transmission of hepatitis B and C in that group," she explained.
In the U.S., the CDC has attributed 6% of HIV diagnoses in 2015 to injection drug use, with 38% of these among African Americans. HIV also disproportionately impacts that community, with 44% of new diagnoses in 2016 being among African Americans. Rates of diabetes (12.7%) and being overweight (76.3%) are also higher in this population than in the general U.S. population. Given these statistics, one would expect specific research into diabetes among African Americans living with HIV. However, little such research appears to have been published in the U.S.
As for the Australian study, "The paper can be considered a pilot that begs for a much larger, more diverse follow-up study in the Australian population," Dagogo-Jack said.