Although antiretroviral therapy has led to significantly longer life expectancies among individuals with HIV, this, in turn, has contributed to the likelihood that these individuals will develop age-related comorbidities at earlier ages.
As the population of individuals with HIV is living longer, the development of diabetes mellitus has become a particular concern. Although antiretroviral therapy (ART) has led to significantly longer life expectancies among individuals with HIV, this, in turn, has contributed to the likelihood that these individuals will develop age-related comorbidities at earlier ages. Additionally, research has shown that the use of older antiretrovirals, which were associated with fat atropine, visceral fat accumulation, and metabolic complications, are contributing factors to the development of diabetes in this population.
Recently, investigators from a number of facilities located in Vancouver, British Columbia, Canada 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 antiretrovirals, and the development of diabetes.
For the study, a total of 1065 individuals with HIV were followed 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 considered normal to low compared with the general population. All participants were 50 years of age or older.
The incidence of diabetes in the patient population was 1.6 cases/hundred person-years. The investigators noted that this was 1.3 times higher than the rate in the general population among men in Canada. Interestingly, 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.
Exposure to zidovudine, stavudine, and didanosine may have contributed to significant metabolic toxicities and eventually, development of diabetes in the patients. These agents have been associated with insulin resistance.
The investigators 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 the development of diabetes, but this study was unable to confirm that hypothesis; however, the authors note that it suggests that hepatitis C infection affects diabetes risk in a very complicated way.
The investigators did not find an association between obesity (or lack thereof) in the development of diabetes.
The clinical implications of the study include a necessity for health care providers to follow evidence-based guidelines when they treat diabetes and HIV. The investigators recommended checking fasting blood sugar and hemoglobin A1c before and after starting patients on ART, and using ART that is less likely to cause metabolic toxicities. They also recommended early, aggressive initiation of ART, highlighting that in this study, patients with better immune and virologic control were less likely to have diabetes mellitus.
An earlier version of this article appeared on PharmacyTimes.com.