Type 2 diabetes and HIV

Considering World Aids Day, Dr Alessandra Prioreschi examines the connection between Type 2 diabetes and HIV.

Increase of lifestyle diseases in HIV patients

Advances in treatment of HIV have resulted in HIV patients being able to live longer lives, largely due to controlling their disease using combination antiretroviral therapies (cARTs). This has resulted in people with HIV experiencing increases of lifestyle diseases. These include hypertension, cancers, metabolic disease and Type 2 diabetes.

These non-communicable diseases (NCDs) occur due to the normal aging process. However, the presence of HIV and drug therapy used to treat HIV are associated with increased risk of developing NCDs. Thereby, resulting in people with HIV having multiple risk factors for developing an NCD, such as Type 2 diabetes¹.

Increase of Type 2 diabetes in Africa

Type 2 diabetes is becoming increasingly common in Africa. This is due to the rapid transition to a ‘Westernised lifestyle’ that has occurred over the last few years. Although the reasons are not fully clear, recent studies internationally have associated diabetes with HIV infection and with cART^1-3.

Systematic review

The Developmental Pathways for Health Research Unit (University of the Witwatersrand, Faculty of Health Science) therefore conducted a systematic review and meta-analysis of the literature. This is the most rigorous scientific method to review published literature to determine the overall effects found from multiple studies.

The aim was to determine whether HIV infected patients in Africa were more likely to have Type 2 diabetes than non-infected individuals. We also wanted to determine whether cART treated patients were more likely to have Type 2 diabetes than non-treated patients.

After screening for eligibility, 21 articles were found to meet the search criteria and were included in the analysis.

Findings

The results showed no statistically significant association between HIV infection or cART treatment with Type 2 diabetes prevalence. These findings are contrary to international studies in Europe and North America, which showed a higher prevalence of diabetes in HIV infected compared to uninfected participants⁴,particularly when treated with cART^1-3.

Therefore, from the limited data available in Africa, it does not seem as if the risk of Type 2 diabetes is higher in populations infected with HIV than in a normal healthy ageing African population.

However, we did find that the number of new cases of Type 2 diabetes that occur in HIV infected cART treated African patients was higher than what has been shown internationally. Therefore, it does not seem that patients with HIV in Africa are presenting with Type 2 diabetes more frequently than a normal aging population in Africa. However, the number of cases of Type 2 diabetes is higher than rates reported internationally for HIV infected patients.

Possible reasoning

It is possible that this finding is in part due to African populations being more susceptible to diabetes, regardless of HIV status. This could be due to ‘Westernisation’, which is happening rapidly in many African countries, resulting in changes in lifestyle and metabolism. In Africa, there is an added risk for infants born during periods of Westernisation to develop metabolic disorders later in life, due to metabolic changes occurring during pregnancy.

In fact, in this systematic review, a substantial proportion of participants infected with HIV were overweight or obese and thereby predisposed to diabetes. This presents a different picture to the undernourished HIV infected individual previously associated with Africa.

Importance of screening

In this new context, higher diabetes risk may just be an effect of lifestyle rather than due to HIV disease or treatment. Therefore, although this review did not show a higher risk of Type 2 diabetes in HIV infected individuals compared to uninfected individuals, it does support the importance of screening for diabetes in African populations infected with HIV, where diabetes incidence appears to be high in general.

Furthermore, these findings reinforce the importance of managing and screening for metabolic diseases, such as diabetes, as part of routine clinical care of patients infected with HIV to support continuity of care⁵.

Limitations of review

It is important to note that there were some limitations; namely the small number of studies available to analyse and the small number of participants included in these studies.

Over and above that, all the studies available for this analysis were observational. So, we were unable to determine how things may change over time. However, this meta-analysis shows that currently HIV infection and cART do not seem to predispose patients in Africa to Type 2 diabetes. However, high rates of Type 2 diabetes warrant focus on screening and preventative programmes for HIV infected people living in Africa.

References:

1. Samaras K. The burden of diabetes and hyperlipidemia in treated HIV infection and approaches for cardiometabolic care. Curr HIV/AIDS Rep. 2012;9(3):206-17.
2. Hadigan C, Kattakuzhy S. Diabetes mellitus type 2 and abnormal glucose metabolism in the setting of human immunodeficiency virus. Endocrinol Metab Clin North Am. 2014;43(3):685-96.
3. Paik IJ, Kotler DP. The prevalence and pathogenesis of diabetes mellitus in treated HIV-infection. Best Pract Res Clin Endocrinol Metab. 2011;25(3):469-78.
4. Galli L, Salpietro S, Pellicciotta G, Galliani A, Piatti P, Hasson H, et al. Risk of type 2 diabetes among HIV-infected and healthy subjects in Italy. Eur J Epidemiol. 2012;27(8):657-65.
5. Rabkin M, Melaku Z, Bruce K, Reja A, Koler A, Tadesse Y, et al. Strengthening Health Systems for Chronic Care: Leveraging HIV Programs to Support Diabetes Services in Ethiopia and Swaziland. J Trop Med. 2012;2012:137460.