“Adults with HIV have a greater risk for developing type 2 diabetes (T2D) compared with someone never diagnosed with HIV,” Amanda Willig, PhD, notes. “However, medications used to treat diabetes don’t always control blood sugar as well for someone with HIV. Identifying factors associated with diabetes risk that are similar to the general population, as well as those that are unique to HIV, can help clinicians provide the best preventive care for patients.

For a study published in AIDS, Dr. Willig and colleagues sought to examine the incidence of T2D among people with HIV and related risk factors. They conducted a retrospective cohort study at an academic HIV clinic in the Southeastern United States, obtaining EMR data on demographics and clinical characteristics.

“We studied over 4,000 eligible patients with available EMR data who received care at our HIV treatment clinic,” she explains. “To understand the role that various risk factors play in the current treatment era, we limited our investigation to a 10-year period from 2008-2018.”

The researchers defined diabetes using three categories: A1C values equal to or greater than 6.5% and/or two glucose results greater than 200 mg/dL at least 30 days apart; a diabetes diagnosis in the EMR; or exposure to diabetes medication.

Patient Characteristics & HIV-Associated Factors Influence Diabetes Risk

“We were surprised to see such a rapid increase in diabetes incidence and prevalence in just 10 years (Figure),” Dr. Willig says. “The continued increasing trajectory of diabetes burden in people with HIV highlights the critical need for access to diabetes prevention care in this population.”

The researchers identified 252 incident cases of diabetes among 4,113 people with HIV. Diabetes incidence increased from 1.04 per 1,000 person-years in 2008 to 1.55 per 1,000 person-years in 2018. Factors related to incident diabetes included BMI (HR, 10.5), liver disease (HR, 1.9), steroid exposure (HR, 1.5), and use of integrase inhibitors (HR, 1.5). Other related factors included lower CD4+ cell counts, duration of HIV infection, exposure to non-statin lipid-lowering therapy, and dyslipidemia.

“The strong association of both low and high body weights with diabetes risk indicate that weight management programs for people with HIV can play a crucial role in diabetes prevention,” she says. “Integrase inhibitors may also impact body weight, and the potential association of this medication class with diabetes incidence highlights the need for preventive lifestyle counseling to minimize the potential impact of these medications, along with consideration of appropriate ART regimens in populations at highest risk for diabetes. Caution in prescribing and utilizing steroids in people with HIV is warranted, with close monitoring for potential side effects.”

Modifiable Risk Factors, Social Determinants of Health, & COVID-19

As patients with HIV live longer, clinicians and researchers “need to focus care not just on improving longevity but on maintaining good QOL,” Dr. Willig notes.

“Modifiable risk factors, such as body weight, certainly play a role in diabetes risk, and greater emphasis on lifestyle modification for diabetes prevention is needed to slow the trajectory of increasing diabetes prevalence,” she says. “However, the impact of HIV infection and certain ART regimens on diabetes risk indicates that these programs should be tailored to address the unique risk factors of those with HIV, including identifying food-insecure patients who may need assistance in meeting nutritional needs and providing medical nutrition therapy.

Dr. Willig pointed to multiple areas for future research highlighted by the current study.

“Other research teams have shown that pharmaceutical treatment for diabetes control may take longer to have equivalent impact for someone with HIV,” she notes. “However, we do not know if lifestyle interventions such as  nutrition and exercise also need to be provided for longer intervals or precisely how nutrition and exercise should be tailored for this population. A greater understanding of social determinants of health that are associated with the risk factors identified here is key to effectively tailoring diabetes prevention efforts.”

Additionally, investigators “need to determine which medical and behavioral treatments are most effective to offer in tandem with integrase inhibitor use to minimize undesirable metabolic effects,” Dr. Willig continues.

A separate but related issue is the COVID-19 pandemic. “We need to explore whether COVID-19 infection or the associated stressors of life during a pandemic have impacted diabetes incidence, and, if that is shown to be the case, whether that changes medical management for diabetes in people with HIV,” she says.