Key considerations for people living with HIV

Introduction to diabetes

Diabetes is primarily defined by hyperglycemia that substantially increases the risk of microvascular damage (retinopathy, nephropathy and neuropathy).1 Diabetes may arise as a result of decreased insulin production by the pancreas, increased resistance to the action of insulin in peripheral tissues (insulin resistance), or both.2 There are varying degrees of abnormal glucose metabolism, including impaired glucose tolerance, impaired fasting glucose and frank diabetes. Diabetes is associated with significant morbidity due to microvascular complications, increased risk of cardiovascular disease (ischemic heart disease, stroke and peripheral vascular disease) and diminished quality of life.1

Consequences of diabetes and cardiovascular risk in the general population

Diabetes is associated with significant morbidity due to microvascular complications, increased risk of cardiovascular disease (ischemic heart disease, stroke and peripheral vascular disease) and diminished quality of life1


  • When assessing cardiovascular risk in diabetes, the International Diabetes Federation (IDF) recommend that risk equations developed for non-diabetic populations are not used and instead recommend the UKPDS risk engine for assessment and communication of risk3

Diabetes and impaired glucose homeostasis in people living with HIV (PLWHIV)

  • Insulin resistance is an under-recognized consequence of HIV treatment4 and could predispose to the development of diabetes. Insulin resistance and diabetes may be associated with dyslipidemia. For example in one study diabetes occurred in 7% of patients with dyslipidemia, which was 14 times more frequent than in healthy, matched controls4  

  • Although most patients receiving antiretroviral therapy have normal fasting glucose levels, impaired glucose tolerance has been reported in 16–40% of patients receiving PI-based regimens5,6 
  • Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) indicate a four- to six-fold increased risk for the future development of diabetes;7 diabetes is associated with cardiovascular morbidity and mortality3,8,9  

  • HIV-infected patients with IFG and/or IGT should be targeted for lifestyle intervention6 (see treatment section) and their cardiovascular risk factors checked and treated7 (refer to section on cardiovascular disease)

Diabetes treatment/prevention

  • Treatment for diabetes in PLWHIV is generally similar to that for non-HIV-infected people4,5,10 
  • The use of certain antiretrovirals may be associated with the development, or worsening, of insulin resistance
  • Refer to the treatment section for strategies that may help to prevent or delay the onset of diabetes, and for information on diabetes treatment in people living with HIV

Diabetes and pregnancy

References

  1. Report of a WHO/IDF Consultation. Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycemia. Accessed 20 February 2011.
  2. US National Library of Medicine. Diabetes. Accessed 9 May 2011.
  3. International Diabetes Federation. Global Guideline for Type 2 Diabetes, 2005. Accessed 20 February 2011.
  4. Gazzard BG on behalf of the BHIVA Treatment Guidelines Writing Group. British HIV Association guidelines for the treatment of HIV-1-infected adults with antiretroviral therapy 2008. HIV Medicine. 2008;9:563–608.
  5. Schambelan M, Benson C, Carr A, et al. Management of metabolic complications associated with antiretroviral therapy for HIV-1 infection: Recommendations of an International AIDS Society USA Panel. J Acquir Immune Defic Syndr. 2002;31:257–275.
  6. Carr A, Samaras K, Thorisdottir A, et al. Diagnosis, prediction and natural course of HIV protease inhibitor-associated lipodystrophy, hyperlipidaemia and diabetes mellitus: a cohort study. Lancet. 1999;353:2093–2099.
  7. European AIDS Clinical Society (EACS). Guidelines. Version 6.0. Accessed 3 July 2012.
  8. American Diabetes Association. Standards of medical care in diabetes 2011. Diabetes Care. 2011;34; Suppl 1:S11–S61.
  9. Rodbard HW, Blonde L, Braithwaite SS, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13(Suppl 1):1–68
  10. Mullen MP and Caplivski D. HIV and Comorbidities: A Case Based Approach to Diagnosis and Management. Oxford American Infectious Disease Library. Oxford University Press. 2008.