According to a French study published in PLOS ONE, the missed diabetes diagnosis rate can be significant in people living with HIV who are on HIV treatment. The study also found that the rate of under-treated diabetes in this population was surprisingly high. In addition, participants with diabetes had an increased risk of cardiovascular disease.
background
Diabetes mellitus is a global health problem whose already high prevalence of 8.5% is expected to increase over the next few decades. Diabetes also does not spare people living with HIV, where the prevalence is up to 15%, which adds to an increased risk of complications such as cardiovascular disease.
Risk factors for diabetes – age, male gender, high body mass index (BMI), family history of diabetes, black ancestry, dyslipidemia, and high blood pressure – are similar in the general population and in people with HIV. However, people living with HIV are exposed to additional risks specifically targeted to HIV and its treatment: the number of years on antiretroviral drugs, the use of protease inhibitors and first-generation nucleoside analogs, lipodystrophy, the duration of HIV positivity lower CD4 low and persistent HIV inflammation.
The effectiveness of today’s antiretroviral therapies has increased the life expectancy of people living with HIV. As a result, their exposure to these risks is more significant, as a study shows that people on antiretroviral therapy are four times more likely to have diabetes than those who are HIV-negative.
glossary
diabetes
A group of diseases characterized by high blood sugar (glucose) levels. Type 1 diabetes occurs when the body doesn’t make insulin, a hormone that regulates blood sugar. Type 2 diabetes occurs when the body either does not make enough insulin or does not use insulin normally (insulin resistance). Common symptoms of diabetes include frequent urination, unusual thirst, and extreme hunger. Some antiretroviral drugs can increase your risk of type 2 diabetes.
glucose
A simple form of sugar found in the bloodstream. All sugars and starches are converted to glucose before they are absorbed. Cells use glucose as a source of energy. People with consistently high levels of glucose can have a condition called diabetes.
Body mass index (BMI)
The body mass index or BMI is a measure of body size. It combines a person’s weight with their height. The BMI tells you whether a person is the right weight for their height. Under 18.5 is considered underweight; between 18.5 and 25 is normal; between 25 and 30 is overweight; and over 30 is obese. You can find many BMI calculators on the Internet.
Comorbidity
The presence of one or more additional health conditions at the same time as a primary disease (e.g. HIV).
Managing diabetes in people with HIV is therefore critical to improving their quality of life and avoiding complications. Although the guidelines for this goal are similar to those for the general population, there is some evidence that people living with HIV should be addressed differently. For example, studies have shown that their response to blood sugar lowering therapy may be worse than that of the general population.
These considerations led Professor Laurence Slama and colleagues from the Hôtel-Dieu University Hospital in Paris to investigate risk factors, the circumstances surrounding the diagnosis and treatment of diabetes in a cohort of people with HIV. This single-center cohort, named OVIHD, evaluates the efficacy and safety of antiretroviral therapy and the incidence of comorbidities in 1,494 people enrolled for routine HIV follow-up since 2010.
For the present study, the researchers analyzed data collected in 2010-2018 from OVIHD participants with diabetes. The criteria for diabetes were:
- have a fasting glucose (FG) of ≥ 126 mg / dL twice or Having
- HbA1c of ≥ 6.5% or
- A history of diabetes or
- Receiving anti-diabetic treatment.
In terms of glycated hemoglobin, HbA1c is a monitoring measure of how well your blood sugar has been controlled over a period of about three months. Most international guidelines also recommend it for diagnosing diabetes, but France does not.
Results
Of the 1,494 OVHID participants, 156 were diabetic and 1,338 were not (10.4% and 89.6% of the total OVHID cohort, respectively). The median follow-up was 5.6 years for the former and 4.5 years for the latter (p <0.001). The median duration of antiretroviral therapy (approximately twelve years) was similar in both groups.
Similar to the overall OVHID cohort, the participants with diabetes were predominantly male (75%). However, they were more often born in sub-Saharan Africa (32% and 22%, p = 0.027) and significantly older (median age: 54.6). [IQR: 48.9-62.1] versus 49.9 [IQR: 44.6-55.8]and p = 0.001) compared to their non-diabetic counterparts.
Unsurprisingly, diabetics were more likely to be overweight or obese: BMI> 25 in 46% of them vs 35% in those without diabetes (p = 0.020). There was a difference (p = 0.009) between diabetics (47% heterosexuals; 31% men who have sex with men) and nondiabetics (34.5% heterosexuals; 45% men who have sex with men) with regard to the transmission of HIV. Men).
Control of HIV infection was worse in participants with diabetes than in non-diabetics (HIV RNA <50 copies found in 80.1% and 89.5%, respectively, p <0.001).
Of the 156 study participants, 97 (60%) had already been diagnosed with diabetes at the start of the study and 40/156 (26%) were receiving hypoglycemic treatment (in this study the baseline was the first visit where diabetes was mentioned). Among the treated persons, 61% (25/40) had an HbA1c value below 7%, defined as correctly controlled diabetes.
However, 59 (38%) of the above 156 participants were undiagnosed at baseline with diabetes, even though all had previously had test results suggestive of the condition. In 29 participants (18.6%) the diabetes diagnosis was missed despite two previous 8-hour fasting glucose measurements of over 126 mg / dl; and for 30 of their colleagues (19.2%) despite their previous HbA1c value of more than 6.5%.
A total of 116 participants, for whom the diagnosis should already (n = 57) or should (n = 59) be made at the baseline visit, were untreated.
The researchers also looked at baseline cardiovascular risk factors and comorbidities. Compared to non-diabetic participants, they found that those with diabetes:
- Current smokers were less frequent (22% vs 25%, p = 0.001).
- More often received antihypertensive drugs (22% vs. 14%, p = 0.010) and / or lipid-lowering drugs (38% vs. 25%, p <0.001).
- More often reported a history of cardiovascular events (5% vs. 2%, p = 0.017) and had renal impairment (12% and 7%, p = 0.030).
- Had significantly lower hypertension control (61% vs. 88% or p <0.001).
- Controlled dyslipidemia better: 94% achieved the goal of an LDL cholesterol below 70 mg / dl (vs. 84%); with a target of 55 mg / dL, these rates were 87% versus 55% for non-diabetic participants (p <0.001 in both cases).
“38% went undiagnosed with diabetes despite having previously had test results that suggest the condition.”
The results of this study are worrying, although they are only from a cohort of a central Paris hospital and may not be generalized. In fact, they show that the treatment of diabetes in people living with HIV is nowhere near optimal.
How could this be improved? In their conclusion, Slama and colleagues make some suggestions. They underline the need to raise awareness among HIV carers about metabolic problems. Such a step is said to help avoid a nearly 20% missed diagnosis rate of diabetes. Awareness should also lead to a review of therapeutic approaches in diabetes: in the study, treatment consisted mainly of a single blood sugar lowering drug, while in many cases a combination of drugs might be more appropriate.
The researchers also recommend closer monitoring of diabetes-related risk factors to reduce cardiovascular disease in people with HIV.
They point out the importance of the HbAc1 test for the diagnosis of diabetes in combination with the fasting glucose test and the oral glucose tolerance test. Finally, based on their data, the researchers believe that diabetes screening should be done earlier – possibly a decade in advance – in HIV-positive people than in HIV-negative people.
More studies looking at the management of diabetes in people living with HIV in a “real world” setting are also needed.
