“Because of modern antiretroviral therapy, persons with HIV can expect a similar life expectancy to that of a person without HIV,” says Morgan Birabaharan, MD. “However, living with the virus long term has consequences. Possibly because of chronic inflammation or direct viral mediated effects, persons with HIV are at higher risk to develop a multitude of comorbidities, including cardiovascular disease, metabolic disorders, malignancy, and psychiatric disorders, often at younger ages. A major question that remains, however, is whether the risk of developing chronic diseases differs between men and women with HIV. There have been sex differences found in almost all tenants of HIV research, including acquisition, disease progression, and treatment response. Thus, there is good reason to suspect that differences exist in the risk for chronic diseases.”

For a paper published in AIDS, Dr. Birabaharan and colleagues analyzed whether type 2 diabetes mellitus (T2DM) occurred more frequently among women with HIV than men with HIV. “Our main question was how much HIV infection increased the risk for diabetes between women and men,” explains Dr. Birabaharan. “We used a large population database of 60 million patients, representing all four United States census regions. We performed a cross-sectional analysis, looking at how many persons with HIV had diabetes, and then used multivariate logistic regression models to understand how strongly HIV increased odds of diabetes among men and women after controlling for many confounding variables that may increase a person’s risk for diabetes independent of HIV infection, such as age, sex, race, obesity, hypertension, hyperlipidemia, and smoking.”

The analysis of 19,182,775 participants included 39,485 people with HIV. There were more men with HIV (N=29,360; 76%) than women with HIV (N=10,125; 24%). Patients with HIV were younger than those without HIV (87% aged <65 vs 70% aged <65, respectively), more likely to be Black (43% vs 12%), and more likely to smoke (55% vs 32%).

Diabetes More Likely Among Women With HIV

“Our results were striking,” says Dr. Birabaharan. “Our analysis demonstrated HIV infection increased the odds for diabetes among women with HIV, but not men with HIV.”

Specifically, the researchers found that rates of obesity were higher among women with HIV than men with HIV (58% vs 35%), as were rates of T2DM (23% vs 16%). A sex-stratified adjusted analysis demonstrated that women with HIV had 1.31 times the odds (95% CI, 1.24-1.38) of having T2DM than women without HIV, and HIV among women was associated with T2DM across all demographic subgroups. However, the researchers saw no relationship between HIV and T2DM among men (OR, 1.01; 95% CI, 0.98-1.05).

“HIV infection was associated with diabetes among women, but not men,” notes Dr. Birabaharan. “Usually, subgroup analysis can help identify subpopulations that may have higher odds for diabetes (ie, persons with HIV and obesity). However, our results demonstrate the odds of diabetes is largely the same for all subgroups (Figure). Therefore, awareness is needed for all women with HIV, including those with and without traditional risk factors.

Directions for Future Research

Dr. Birabaharan hopes the results of their study lead to two outcomes. “First, we hope to raise awareness of the need to perform diabetes screening in women with HIV who have symptoms, such as fatigue, weight loss, or excessive urination or fatigue. Second, we hope our research inspires others to pursue understanding sex differences in HIV aging, and query whether our primary care management of HIV should differ depending on sex (ie, screening).”

He also pointed to specific directions for future research. “There are biological reasons as to why women with HIV may be at higher risk for chronic diseases,” says Dr. Birabaharan. “However, the differences in burden of disease we are observing may also be related to societal factors. Women with HIV face food insecurity, housing insecurity, financial distress, and stigma related to the disease at higher rates than men with HIV. Future research hopefully elicits how much of this excessive burden of disease among women with HIV is related to societal versus biological factors.”