Diabetes and HIV: current understanding and future perspectives

Associations of HIV and prevalent type 2 diabetes mellitus in the context of obesity in South Africa

It is unclear how rising obesity among people with HIV (PWH) in sub-Saharan Africa (SSA) impacts their risk of type 2 diabetes mellitus (diabetes). Using a South African national cross-sectional sample of adult PWH and their peers without HIV (PWOH), we examined the associations between HIV and prevalent diabetes across the spectrum of body mass index (BMI), waist circumference (WC) and waist-to-height ratio (WtHR). Analyses were sex stratified, and adjusted for age, sociodemographic and behavioral factors. The prevalence of diabetes among males was similar between PWH and PWOH, overall and at all levels of adiposity. In contrast, overall diabetes prevalence was higher among female PWOH than female PWH. However, there were differences according to adiposity such that, compared to female PWOH, relative diabetes prevalence in female PWH was reduced with obesity but accentuated with leanness. These differences in the relationship between adiposity and diabetes by HIV serostatus call for better mechanistic understanding of sex-specific adipose tissue biology in HIV in South Africa, and possibly in other HIV endemic settings in SSA.

Low-density granulocytes display immature cells with enhanced NET formation in people living with HIV

While the protective role of neutrophil extracellular traps (NETs) in limiting human immunodeficiency virus (HIV) spread to susceptible cells has been documented, there is comparatively little insight into whether NET formation is harmful in people living with HIV (PLWH). To gain insight into neutrophil dysregulation and the pathological role of NETs in HIV, we examined expressions of NET-associated markers [cell-free DNA (cfDNA) and citrullinated histone H3 (CitH3)] in the plasmas from a cohort of the Hawaii Aging with HIV-cardiovascular and HIV-seronegative (HIV-) individuals. In a subset of participants, circulating low-density granulocyte (LDG) levels and their maturation and activation status were analyzed via flow cytometry. We demonstrated higher plasma levels of CitH3 in PLWH compared to HIV- individuals. LDGs from PLWH had heightened CD66b, but reduced CD16 expression. The percentages and counts of CD10+ LDGs were significantly decreased in PLWH. In addition, the CD16Lo LDG subsets were enriched in PLWH, compared to HIV- group, indicating that immature LDGs are increased in PLWH. Moreover, LDGs from PLWH exhibited significantly higher NET forming capacity. In summary, our study presents evidence that LDGs from PLWH on ART display an immature and altered phenotype with increased NET formation. Among PLWH, plasma NET levels as well as LDG parameters correlated with blood markers for inflammation and coagulation, suggesting that neutrophil activation and NETs may exert proinflammatory and coagulation effects. Our data provide insights into the pathologic role of LDGs at least in part mediated through NET formation in PLWH.

Neutrophil (dys)function due to altered immuno-metabolic axis in type 2 diabetes: implications in combating infections

Metabolic and inflammatory pathways are highly interdependent, and both systems are dysregulated in Type 2 diabetes (T2D). T2D is associated with pre-activated inflammatory signaling networks, aberrant cytokine production and increased acute phase reactants which leads to a pro-inflammatory 'feed forward loop'. Nutrient 'excess' conditions in T2D with hyperglycemia, elevated lipids and branched-chain amino acids significantly alter the functions of immune cells including neutrophils. Neutrophils are metabolically active cells and utilizes energy from glycolysis, stored glycogen and β-oxidation while depending on the pentose phosphate pathway for NADPH for performing effector functions such as chemotaxis, phagocytosis and forming extracellular traps. Metabolic changes in T2D result in constitutive activation and impeded acquisition of effector or regulatory activities of neutrophils and render T2D subjects for recurrent infections. Increased flux through the polyol and hexosamine pathways, elevated production of advanced glycation end products (AGEs), and activation of protein kinase C isoforms lead to (a) an enhancement in superoxide generation; (b) the stimulation of inflammatory pathways and subsequently to (c) abnormal host responses. Neutrophil dysfunction diminishes the effectiveness of wound healing, successful tissue regeneration and immune surveillance against offending pathogens. Hence, Metabolic reprogramming in neutrophils determines frequency, severity and duration of infections in T2D. The present review discusses the influence of the altered immuno-metabolic axis on neutrophil dysfunction along with challenges and therapeutic opportunities for clinical management of T2D-associated infections.

Development of Hypertension and Diabetes Mellitus, and Associated Factors, Among Adult HIV Patients in Ethiopia

Background

Medical improvements and increased access to treatment have turned HIV from a highly fatal disease into a treatable and controllable disease. With the improvement in lifespan, HIV patients face increasing morbidity and mortality from chronic comorbidities (hypertension and diabetes mellitus). There is, nevertheless, a paucity of information on the scale of HIV noncommunicable disease comorbidity and its associated factors. This study aimed to investigate the incidence and predictors of chronic comorbidity in HIV patients in a resource-limited setting.

Methods

A prospective cohort study was conducted from 2019 to 2021. We included 520 HIV patients at baseline. Patients without hypertension or diabetes were followed for two years to determine the incidence of developing comorbidities. Nine trained nurses used a pre-tested structured questionnaire to collect data during routine care consultations in three hospitals in southern Ethiopia. To find predictors of these chronic comorbidities, a multivariable logistic regression analysis was used.

Results

After two years, 54 out of 377 participants, or 14%, had chronic comorbidity, which is defined as having diabetes and/or hypertension. Hypertension (12%) and diabetes (4%), respectively, were observed. When compared to those who were not overweight, the risk of developing chronic comorbidity was three times higher in overweight people [AOR = 3.45, 95% CI: (1.04, 11.45), P = 0.045]. Older participants were about 6 times more likely than younger participants to have chronic comorbidity [AOR = 4.93, 95% CI: (1.56, 15.57), P = 0.007]. Those who did not engage in regular physical activity were twice as likely to develop chronic comorbidity [AOR = 2.16, 95% CI: (1.09, 4.29), P = 0.027].

Conclusion

The incidence of chronic comorbidity was high in the study population. Targeted screening for early signs of chronic comorbidity, nutritional counseling, and awareness creation in regular physical activity programs should be integrated into HIV care to prevent and control chronic comorbidity in resource-limited settings.

Drug-induced mitochondrial toxicity: Risks of developing glucose handling impairments

Mitochondrial impairment has been associated with the development of insulin resistance, the hallmark of type 2 diabetes mellitus (T2DM). However, the relationship between mitochondrial impairment and insulin resistance is not fully elucidated due to insufficient evidence to support the hypothesis. Insulin resistance and insulin deficiency are both characterised by excessive production of reactive oxygen species and mitochondrial coupling. Compelling evidence states that improving the function of the mitochondria may provide a positive therapeutic tool for improving insulin sensitivity. There has been a rapid increase in reports of the toxic effects of drugs and pollutants on the mitochondria in recent decades, interestingly correlating with an increase in insulin resistance prevalence. A variety of drug classes have been reported to potentially induce toxicity in the mitochondria leading to skeletal muscle, liver, central nervous system, and kidney injury. With the increase in diabetes prevalence and mitochondrial toxicity, it is therefore imperative to understand how mitochondrial toxicological agents can potentially compromise insulin sensitivity. This review article aims to explore and summarise the correlation between potential mitochondrial dysfunction caused by selected pharmacological agents and its effect on insulin signalling and glucose handling. Additionally, this review highlights the necessity for further studies aimed to understand drug-induced mitochondrial toxicity and the development of insulin resistance.

Association of Cumulative Viral Load With the Incidence of Hypertension and Diabetes in People With HIV

BACKGROUND

HIV induces several metabolic derangements that contribute to cardiovascular disease, but it is unclear if HIV increases diabetes or hypertension risk. Refining longitudinal relationships between HIV-specific factors and cardiovascular disease risk factors across different care settings may help inform cardiovascular disease prevention among people with HIV (PWH).

METHODS

We tested the hypothesis that long-term higher cumulative viral load (viremia-copy-year) is associated with higher risk of diabetes and hypertension by analyzing electronic records of PWH from 2 distinct health systems in Chicago (Northwestern Medicine and Howard Brown Health Care) receiving care in 2004 to 2019. We used joint longitudinal-survival models to assess multivariable-adjusted associations. Subgroup analyses per site were also conducted.

RESULTS

We observed 230 (3.0%) incident diabetes cases in 7628 PWH without baseline diabetes and 496 (6.7%) hypertension cases in 7450 PWH without baseline hypertension. Pooled analysis showed a direct association of viremia-copy-year with incident hypertension (hazards ratio, 1.20 [95% CI, 1.14-1.26]) but not with diabetes (hazards ratio, 1.03 [95% CI, 0.96-1.10]). However, site-specific differences existed whereby the Northwestern-only analysis demonstrated a significant association of viremia-copy-year with hypertension (hazards ratio, 1.29 [95% CI, 1.08-1.32]). Additionally, higher social deprivation index (both sites) and diagnosis of mental health disorder (Howard Brown Health only) was associated with higher diabetes and hypertension risk.

CONCLUSIONS

Cumulative viral load may be associated with incident hypertension among PWH. Associations of HIV control with cardiovascular disease risk factors among PWH may differ by health care system context.

The association of physical activity and cardiorespiratory fitness with β-cell dysfunction, insulin resistance, and diabetes among adults in north-western Tanzania: A cross-sectional study

Introduction

Research on the associations of physical activity and cardiorespiratory fitness with β-cell dysfunction and insulin resistance among adults in Sub-Saharan Africa (SSA) is limited. We assessed the association of physical activity and cardiorespiratory fitness with β-cell function, insulin resistance and diabetes among people living with HIV (PLWH) ART-naïve and HIV-uninfected Tanzanian adults.

Method

In a cross-sectional study, we collected data on socio-demography, anthropometry, fat mass and fat free mass and C-reactive protein. Data on glucose and insulin collected during an oral glucose tolerance test were used to assess β-cell dysfunction (defined as insulinogenic index <0.71 (mU/L)/(mmol/L), HOMA-β index <38.3 (mU/L)/(mmol/L), and overall insulin release index <33.3 (mU/L)/(mmol/L)), oral disposition index <0.16 (mU/L)/(mg/dL)(mU/L)-1, insulin resistance (HOMA-IR index >1.9 (mU/L)/(mmol/L) and Matsuda index <7.2 (mU/L)/(mmol/L), prediabetes and diabetes which were the dependent variables. Physical activity energy expenditure (PAEE), sleeping heart rate (SHR), and maximum uptake of oxygen during exercise (VO2 max) were the independent variables and were assessed using a combined heart rate and accelerometer monitor. Logistic regressions were used to assess the associations.

Results

Of 391 participants, 272 were PLWH and 119 HIV-uninfected. The mean age was 39 ( ± 10.5) years and 60% (n=235) were females. Compared to lower tertile, middle tertile of PAEE was associated with lower odds of abnormal insulinogenic index (OR=0.48, 95%CI: 0.27, 0.82). A 5 kj/kg/day increment of PAEE was associated with lower odds of abnormal HOMA-IR (OR=0.91, 95%CI: 0.84, 0.98), and reduced risk of pre-diabetes (RRR=0.98, 95%CI: 0.96, 0.99) and diabetes (RRR=0.92, 95%CI: 0.88, 0.96). An increment of 5 beats per min of SHR was associated with higher risk of diabetes (RRR=1.06, 95%CI: 1.01, 1.11). An increase of 5 mLO2/kg/min of VO2 max was associated with lower risk of pre-diabetes (RRR=0.91, 95%CI: 0.86, 0.97), but not diabetes. HIV status did not modify any of these associations (interaction, p>0.05).

Conclusion

Among Tanzanian adults PLWH and HIV-uninfected individuals, low physical activity was associated with β-cell dysfunction, insulin resistance and diabetes. Research is needed to assess if physical activity interventions can improve β-cell function and insulin sensitivity to reduce risk of diabetes and delay progression of diabetes in SSA.

Incidence of diabetes mellitus among people living with and without HIV in British Columbia, Canada between 2001 and 2013: a longitudinal population-based cohort study

INTRODUCTION

People living with HIV (PLHIV) are increasingly at risk of age-related comorbidities such as diabetes mellitus (DM). While DM is associated with elevated mortality and morbidity, understanding of DM among PLHIV is limited. We assessed the incidence of DM among people living with and without HIV in British Columbia (BC), Canada, during 2001-2013.

METHODS

We used longitudinal data from a population-based cohort study linking clinical data and administrative health data. We included PLHIV who were antiretroviral therapy (ART) naïve at baseline, and 1:5 age-sex-matched persons without HIV. All participants had ≥5 years of historic data pre-baseline and ≥1 year(s) of follow-up. DM was identified using the BC Ministry of Health's definitions applied to hospitalisation, physician billing and drug dispensation datasets. Incident DM was identified using a 5-year run-in period. In addition to unadjusted incidence rates (IRs), we estimated adjusted incidence rate ratios (IRR) using Poisson regression and assessed annual trends in DM IRs per 1000 person years (PYs) between 2001 and 2013.

RESULTS

A total of 129 PLHIV and 636 individuals without HIV developed DM over 17 529 PYs and 88,672 PYs, respectively. The unadjusted IRs of DM per 1000 PYs were 7.4 (95% CI 6.2 to 8.8) among PLHIV and 7.2 (95% CI 6.6 to 7.8) for individuals without HIV. After adjustment for confounding, HIV serostatus was not associated with DM incidence (adjusted IRR: 1.03, 95% CI 0.83 to 1.27). DM incidence did not increase over time among PLHIV (Kendall trend test: p=0.9369), but it increased among persons without HIV between 2001 and 2013 (p=0.0136).

CONCLUSIONS

After adjustment, HIV serostatus was not associated with incidence of DM, between 2001 and 2013. Future studies should investigate the impact of ART on mitigating the potential risk of DM among PLHIV.

Susceptibility for Some Infectious Diseases in Patients With Diabetes: The Key Role of Glycemia

Uncontrolled diabetes results in several metabolic alterations including hyperglycemia. Indeed, several preclinical and clinical studies have suggested that this condition may induce susceptibility and the development of more aggressive infectious diseases, especially those caused by some bacteria (including Chlamydophila pneumoniae, Haemophilus influenzae, and Streptococcus pneumoniae, among others) and viruses [such as coronavirus 2 (CoV2), Influenza A virus, Hepatitis B, etc.]. Although the precise mechanisms that link glycemia to the exacerbated infections remain elusive, hyperglycemia is known to induce a wide array of changes in the immune system activity, including alterations in: (i) the microenvironment of immune cells (e.g., pH, blood viscosity and other biochemical parameters); (ii) the supply of energy to infectious bacteria; (iii) the inflammatory response; and (iv) oxidative stress as a result of bacterial proliferative metabolism. Consistent with this evidence, some bacterial infections are typical (and/or have a worse prognosis) in patients with hypercaloric diets and a stressful lifestyle (conditions that promote hyperglycemic episodes). On this basis, the present review is particularly focused on: (i) the role of diabetes in the development of some bacterial and viral infections by analyzing preclinical and clinical findings; (ii) discussing the possible mechanisms by which hyperglycemia may increase the susceptibility for developing infections; and (iii) further understanding the impact of hyperglycemia on the immune system.

Pancreatogenic Diabetes: Triggering Effects of Alcohol and HIV

Multiorgan failure may not be completely resolved among people living with HIV despite HAART use. Although the chances of organ dysfunction may be relatively low, alcohol may potentiate HIV-induced toxic effects in the organs of alcohol-abusing, HIV-infected individuals. The pancreas is one of the most implicated organs, which is manifested as diabetes mellitus or pancreatic cancer. Both alcohol and HIV may trigger pancreatitis, but the combined effects have not been explored. The aim of this review is to explore the literature for understanding the mechanisms of HIV and alcohol-induced pancreatotoxicity. We found that while premature alcohol-inducing zymogen activation is a known trigger of alcoholic pancreatitis, HIV entry through C-C chemokine receptor type 5(CCR5)into pancreatic acinar cells may also contribute to pancreatitis in people living with HIV (PLWH). HIV proteins induce oxidative and ER stresses, causing necrosis. Furthermore, infiltrative immune cells induce necrosis on HIV-containing acinar cells. When necrotic products interact with pancreatic stellate cells, they become activated, leading to the release of both inflammatory and profibrotic cytokines and resulting in pancreatitis. Effective therapeutic strategies should block CCR5 and ameliorate alcohol's effects on acinar cells.

The Patient-Provider Continuum of Care: Narratives of People Living With Comorbid HIV and Diabetes in Northern Thailand

Background:

Among South-East Asia Region countries, Thailand has a high prevalence of HIV with an increasing significant comorbidity of diabetes mellitus (DM).

Objective:

Guided by syndemics, the purpose of this qualitative study is to develop insight into the experience of patients living with comorbid HIV and DM in Northern Thailand for quality improvement.

Methods:

Interviews were conducted in 2 groups for content analysis: (1) people living with comorbid HIV and DM and (2) health-care staff providing care to patients living with the comorbidity.

Results:

Participants’ (N = 12) ages ranged from 42 to 56 (mean = 49). Health staff (N = 12) generated complementary narratives. All participants reported onset of diabetes after discovering they were HIV infected. Content analysis revealed emergent themes regarding (1) knowledge and perceptions and (2) management framed by syndemics and chronicity.

Conclusion:

Findings suggest routine training for patient education and provider integration of care. Macrosocial factors such as limited access and resources and biological factor such as drug interactions are noted as key considerations for future interventions and alterations in the care for patients with comorbid HIV and DM.

Risk Factors of Leishmania Infection among HIV-Infected Patients in Trang Province, Southern Thailand: A Study on Three Prevalent Species

There are two main species of Leishmania reported in Thailand, that is, Leishmania siamensis and Leishmania martiniquensis. Moreover, leishmaniasis cases caused by Leishmania donovani complex were also reported. There is still a lack of information concerning risk factors of Leishmania infection in Thailand. This study aimed to identify the risk factors of Leishmania infection caused by these three species among HIV-infected patients. A cross-sectional study was conducted in HIV clinic at Trang Hospital, Thailand. Nested PCR and sequencing were performed to detect Leishmania DNA in blood and saliva samples and identify Leishmania species. A standardized questionnaire was used to interview individuals. A total of 526 patients were recruited in this study. Sixty-three (12.0%) were positive for L. siamensis, 24 (4.6%) were positive for L. martiniquensis, and 23 (4.4%) were positive for L. donovani complex. Risk factors of L. siamensis infection included using intravenous drug (adjusted odds ratio [AOR] 2.01, 95% CI: 1.01-4.02). Risk factors of L. martiniquensis infection included female gender (AOR 4.23, 95% CI: 1.52-11.75), using recreational drug (AOR 3.43, 95% CI: 1.00-11.74), and having comorbidities (AOR 4.94, 95% CI: 2.00-12.21). Risk factors of L. donovani complex infection included having opportunistic infection (AOR 4.22, 95% CI: 1.00-17.79), CD4 count 200-500 cells/mm³ (AOR 3.64, 95% CI: 1.14-6.86), and not using insect repellent (AOR 3.04, 95% CI: 1.08-8.58). This study identified the risk factors of Leishmania infection caused by three Leishmania species in Thailand. The data could be useful for disease prevention and control. Further studies on trends of Leishmania infection and preventive measures are recommended.

Diabetes Mellitus and Associated Factors Among Adult HIV Patients on Highly Active Anti-Retroviral Treatment

BACKGROUND

Highly active anti-retroviral therapy (HAART) prolongs the life span of people living with HIV (PLWHIV) and intensely reduces HIV-related morbidity and mortality. Globally, HIV-associated non-communicable diseases are becoming major public concerns, and chronic comorbidities have appeared as a substantial reason for morbidity and mortality in HIV patients with prolonged use of HAART.

PURPOSE

A cross-sectional study design was used to assess the magnitude of diabetes mellitus and risk factors among adult HIV patients exposed to HAART at Jimma Zone Public Hospitals from May to July 30, 2018.

PATIENTS AND METHODS

A convenient sampling technique was used to include a total of 271 adult HIV patients on HAART visiting the selected health facilities at the time of data collection. Socio-demographic and clinical data were collected by interviewer-administered questionnaire and by reviewing patients' record data. Bivariate and multivariate logistic regressions were used to identify variables that are independent predictors for diabetes mellitus.

RESULTS

The prevalence of diabetes and pre-diabetes among PLWHIV exposed to HAART was 11.4% and 16.6%, respectively. The prevalence of diabetic dyslipidemia in PLWHIV exposed on HAART was 8.9% (n=24). Government workers (AOR: 0.17, 95% C.I=0.03-0.85, P=0.031), long duration in HAART use (AOR: 11.06, 95% C.I:1.03-18.67, P=0.047), hyper-triglyceridemia (AOR: 2.62,95% C.I:0.82, 8.39, P=0.005), LDL-C <130 mg/dl (AOR: 4.04, 95% C.I=1.33-12.30, P=0.014), and obesity (AOR: 9.62, 95% C.I: 1.01-91.52, P=0.049) were independent risk factors for diabetes mellitus in PLWHIV exposed to HAART.

CONCLUSION

Exposure to HAART increased the prevalence of diabetes mellitus in PLWHIV although it enhances quality of life, improves immune functions and prevents the onset of opportunistic infections. Therefore, regular screening for blood glucose level for PLWHIV on HAART is advisable.

Nutritional status and the associated factors among people living with HIV: an evidence from cross-sectional survey in hospital based antiretroviral therapy site in Kathmandu, Nepal

BACKGROUND

Nutritional status is the key concern among the people living with HIV but this issue has been failed to be prioritized in HIV strategic plan of Nepal. This study aims to assess the nutritional status among people living with HIV and determine their associated factors.

METHODS

A hospital based cross-sectional study was conducted where 350 people living with HIV attending the ART clinic were selected using systematic random sampling technique. Nutritional status among people living with HIV was assessed through anthropometry, body mass index; Underweight (body mass index < 18.5 kg/m2) and overweight/obesity (body mass index > 23 kg/m2). HIV related clinical factors such CD4 count, WHO stage, opportunistic infection, antiretroviral therapy regimen etc. were collected from the medical records. Socio-demographic data were collected using pretested structured questionnaire through interview technique. Multiple linear regression method was employed to determine the association between different independent factors and body mass index score.

RESULTS

The prevalence of underweight was found to be 18.3% (95% CI: 14.3-22.6). Most of the study participants were overweight/obese (39.1%). After subjection to multiple linear regression analysis, it was found that age, being male, being married, being in business occupation, smoking, hemoglobin level and antiretroviral therapy duration were significantly associated with body mass index score. Majority of the participants in our study lacked diversified food (62.3%).

CONCLUSION

Overweight/obesity is an emerging problem among people living with HIV. This group of participants should be screened for the presence of non-communicable disease. This study also highlights the importance of nutritional program being an integral part of HIV/AIDS continuum of care. Therefore, an effort should be made to address the burden of malnutrition by addressing the identified determinants.

Pilot test of an educational intervention to improve self-management of diabetes in persons living with HIV

People living with a diagnosis of HIV (PLWH) and type 2 diabetes (T2DM) can experience a synergistic negative impact on their vascular and immune systems if their conditions are poorly controlled. The purpose of this study was to adapt a community-based diabetes self-management intervention for people living with HIV and test the feasibility of administering the intervention with PLWH+T2DM who are low-income, predominantly minority, vulnerable population. The intervention was 12 weeks long with 6 h of educational instruction followed by 6 weekly support telephone calls to reinforce training and problem solve. The study used a one-group pretest-posttest design. Participants were a convenience sample of 25 adults diagnosed with HIV + T2DM. Diabetes knowledge, HIV knowledge, and self-management skills were measured. Analyses comprised descriptive statistics and correlations. Participants completed an average of 2.7 of 6 h of instruction and an average of 3 of 6 possible telephone calls. There was a 34% increase in diabetes self-management skills from pretest to posttest, but there were no changes in knowledge about HIV or diabetes. Based on this pilot study, next steps will include a multi-modal educational intervention, with in-person, at-home, and teleconference components. Blood sample collection procedure will be coordinated with study visits to decrease participants' burden, and the updated diabetes knowledge instrument with a higher reported internal consistency will be used.

Diabetes, mortality and glucose monitoring rates in the TREAT Asia HIV Observational Database Low Intensity Transfer (TAHOD-LITE) study

OBJECTIVES

Diabetes is a growing cause of morbidity and mortality in people living with HIV (PLHIV) receiving antiretroviral therapy (ART). We investigated the association between fasting plasma glucose (FPG) levels and mortality, and factors associated with FPG monitoring rates in Asia.

METHODS

Patients from the Therapeutics Research, Education, and AIDS Training in Asia (TREAT Asia) HIV Observational Database Low Intensity Transfer (TAHOD-LITE) cohort were included in the present study if they had initiated ART. Competing risk and Poisson regression were used to analyse the association between FPG and mortality, and assess risk factors for FPG monitoring rates, respectively. FPG was categorized as diabetes (FPG ≥ 7.0 mmol/L), prediabetes (FPG 5.6-6.9 mmol/L) and normal FPG (FPG < 5.6 mmol/L).

RESULTS

In total, 33 232 patients were included in the analysis. Throughout follow-up, 59% had no FPG test available. The incidence rate for diabetes was 13.7 per 1000 person-years in the 4649 patients with normal FPG at ART initiation. Prediabetes [sub-hazard ratio (sHR) 1.32; 95% confidence interval (CI) 1.07-1.64] and diabetes (sHR 1.90; 95% CI 1.52-2.38) were associated with mortality compared to those with normal FPG. FPG monitoring increased from 0.34 to 0.78 tests per person-year from 2012 to 2016 (P < 0.001). Male sex [incidence rate ratio (IRR) 1.08; 95% CI 1.03-1.12], age > 50 years (IRR 1.14; 95% CI 1.09-1.19) compared to ≤ 40 years, and CD4 count ≥ 500 cells/μL (IRR 1.04; 95% CI 1.00-1.09) compared to < 200 cells/μL were associated with increased FPG monitoring.

CONCLUSIONS

Diabetes and prediabetes were associated with mortality. FPG monitoring increased over time; however, less than half of our cohort had been tested. Greater resources should be allocated to FPG monitoring for early diabetic treatment and intervention and to optimize survival.

Risk of diabetes mellitus in HIV-infected patients receiving highly active antiretroviral therapy: A nationwide population-based study

Previous studies have shown that the incidence of diabetes mellitus (DM) has increased in human immunodeficiency virus (HIV)-infected patients with long-term exposure to highly active antiretroviral therapy (HAART). However, the factors associated with DM among HIV-infected patients in Asia remain unclear in the HAART era.A nationwide cohort studyData from Taiwan's National Health Insurance Research Database (NHIRD) between 2000 and 2010 were used to investigate the incidence of and factors associated with DM among HIV-infected patients. Propensity score matching was conducted to match 4797 patients receiving HAART (HAART cohort) with 4797 patients not receiving HAART (non-HAART cohort). HAART use was treated as a time-dependent variable in a Cox regression model.HAART cohort had a significantly higher 10-year incidence of DM (7.16%; 95% confidence interval [CI], 4.30%-10.03%) than non-HAART cohort (2.24%; 95% CI, 1.28%-3.20%) (P < .001). After adjusting for age, gender, and comorbidities, receiving HAART was associated with an increased incidence of DM, with a subdistribution hazard ratio (sHR) of 2.39 (95% CI, 1.65-3.45). Hypertension (sHR = 5.27; 95% CI, 3.21-8.65), gout (sHR = 2.39; 95% CI, 1.38-4.16), and hepatitis C virus (HCV) infection (sHR = 2.43; 95% CI, 1.28-4.61) were significantly associated with a higher risk of DM. Sensitivity analyses showed exposure to HAART remained significantly associated with an increased risk of DM, particularly in those without pre-existing hypertension, gout, or HCV infection.Exposure to HAART increased the risk of DM in HIV-infected Taiwanese patients, particularly in those without pre-existing hypertension, gout, or HCV infection.

Excess mortality related to circulatory system diseases and diabetes mellitus among Italian AIDS patients vs. non-AIDS population: a population-based cohort study using the multiple causes-of-death approach

Background

Chronic diseases, chiefly cancers and circulatory system diseases (CSDs), have become the leading non-AIDS-related causes of death among HIV-infected people, as in the general population. After our previous report of an excess mortality for several non-AIDS-defining cancers, we now aim to assess whether people with AIDS (PWA) experience also an increased mortality for CSDs and diabetes mellitus (DM), as compared to the non-AIDS general population (non-PWA).

Methods

A nationwide, population-based, retrospective cohort study was conducted including 5285 Italians, aged 15−74 years, who were diagnosed with AIDS between 2006 and 2011. Multiple cause-of-death (MCoD) data, i.e. all conditions reported in death certificates, were retrieved through record-linkage with the National Register of Causes of Death up to 2011. Using MCoD data, sex- and age-standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated by dividing the observed number of PWA reporting a specific disease among MCoD to the expected number, estimated on the basis of mortality rates (based on MCoD) of non-PWA.

Results

Among 1229 deceased PWA, CSDs were mentioned in 201 (16.4%) certificates and DM in 46 (3.7%) certificates among the various causes of death. These values corresponded to a 13-fold higher mortality related to CSDs (95% CI 10.8–14.4) and DM (95% CI: 9.5–17.4) as compared to 952,019 deceased non-PWA. Among CSDs, statistically significant excess mortality emerged for hypertension (23 deaths, SMR = 6.3, 95% CI: 4.0–9.4), ischemic heart diseases (39 deaths, SMR = 6.1, 95% CI: 4.4–8.4), other forms of heart diseases (88 deaths, SMR = 13.4, 95% CI: 10.8–16.5), and cerebrovascular diseases (42 deaths, SMR = 13.4, 95% CI: 9.7–18.2). The SMRs were particularly elevated among PWA aged < 50 years and those infected through drug injection.

Conclusions

The use of MCoD data disclosed the fairly high mortality excess related to several CSDs and DM among Italian PWA as compared to non-PWA. Study findings also indicate to start preventive strategies for such diseases at a younger age among AIDS patients than in the general population and with focus on drug users.

Cardiovascular Disease in the Setting of Human Immunodeficiency Virus Infection

Background:

Since the introduction of Antiretroviral Therapy (ART), the life expectancy and health quality for patients infected with Human Immunodeficiency Virus (HIV) have significant-ly improved. Nevertheless, as a result of not only the deleterious effects of the virus itself and pro-longed ART, but also the effects of aging, cardiovascular diseases have emerged as one of the most common causes of death among these patients.

Objective:

The purpose of this review is to explore the new insights on the spectrum of Cardiovascu-lar Disease (CVD) in HIV infection, with emphasis on the factors that contribute to the atherosclerot-ic process and its role in the development of acute coronary syndrome in the setting of infection.

Methods:

A literature search using PubMed, ScienceDirect and Web of Science was performed. Ar-ticles up to Mar, 2017, were selected for inclusion. The search was conducted using MeSH terms, with the following key terms: [human immunodeficiency virus AND (cardiovascular disease OR coronary heart disease) AND (antiretroviral therapy AND (cardiovascular disease OR coronary heart disease))].

Results:

Clinical cardiovascular disease tends to appear approximately 10 years before in infected in-dividuals, when compared to the general population. The pathogenesis behind the cardiovascular, HIV-associated complications is complex and multifactorial, involving traditional CVD risk factors, as well as factors associated with the virus itself - immune activation and chronic inflammation – and the metabolic disorders related to ART regimens.

Conclusion:

Determining the cardiovascular risk among HIV-infected patients, as well as targeting and treating conditions that predispose to CVD, are now emerging concerns among physicians.

The Utility of a Syndemic Framework in Understanding Chronic Disease Management Among HIV-Infected and Type 2 Diabetic Men Who Have Sex with Men

Syndemic theory posits that epidemics of multiple physical and psychosocial problems co-occur among disadvantaged groups due to adverse social conditions. Although sexual minority populations are often stigmatized and vulnerable to multiple health problems, the syndemic perspective has been underutilized in understanding chronic disease. To assess the potential utility of this perspective in understanding the management of co-occurring HIV and Type 2 diabetes, we used linear regression to examine glycemic control (A1c) among men who have sex with men (MSM) with both HIV and Type 2 diabetes (n = 88). Bivariable linear regression explored potential syndemic correlates of inadequate glycemic control. Compared to those with adequate glycemic control (A1c ≤ 7.5 %), more men with inadequate glycemic control (A1c > 7.5 %) had hypertension (70 vs. 46 %, p = 0.034), high triglycerides (93 vs. 61 %, p = 0.002), depression (67 vs. 39 %, p = 0.018), current substance abuse (15 vs. 2 %, p = 0.014), and detectable levels of HIV (i.e., viral load ≥75 copies per ml blood; 30 vs. 10 %, p = 0.019). In multivariable regression controlling for age, the factors that were independently associated with higher A1c were high triglycerides, substance use, and detectable HIV viral load, suggesting that chronic disease management among MSM is complex and challenging for patients and providers. Findings also suggest that syndemic theory can be a clarifying lens for understanding chronic disease management among sexual minority stigmatized populations. Interventions targeting single conditions may be inadequate when multiple conditions co-occur; thus, research using a syndemic framework may be helpful in identifying intervention strategies that target multiple co-occurring conditions.

The Impact of Weight Gain During HIV Treatment on Risk of Pre-diabetes, Diabetes Mellitus, Cardiovascular Disease, and Mortality

Since the introduction of combined antiretroviral therapy (cART) and more effective treatments for AIDS, there has been a dramatic shift from the weight loss and wasting that characterised HIV/AIDS (and still does in countries where cART is not readily available or is initiated late) to healthy weight, or even overweight and obesity at rates mirroring those seen in the general population. These trends are attributable to several factors, including the "return to health" weight gain with reversal of the catabolic effects of HIV-infection following cART-initiation, strategies for earlier cART-initiation in the course of HIV-infection which have prevented many people living with HIV-infection from developing wasting, in addition to exposure to the modern obesogenic environment. Older cART regimens were associated with increased risk of body fat partitioning disorders (lipodystrophy) and cardiometabolic complications including atherothrombotic cardiovascular disease (CVD) and diabetes mellitus. Whilst cART now avoids those medications implicated in causing lipodystrophy, long-term cardiometabolic data on more modern cART regimens are lacking. Longitudinal studies show increased rates of incident CVD and diabetes mellitus with weight gain in treated HIV-infection. Abdominal fat gain, weight gain, and rising body mass index (BMI) in the short-term during HIV treatment was found to increase incident diabetes risk. Rising BMI was associated with increased risk of incident CVD, however the relationship varied depending on pre-cART BMI category. In contrast, a protective association with mortality is evident, predominantly in the underweight and in resource-poor settings, where weight gain reflects access to cART and virological suppression. The question of how to best evaluate, manage (and perhaps constrain) weight gain during HIV treatment is of clinical relevance, especially in the current climate of increasingly widespread cART use, rising overweight, and obesity prevalence and growing metabolic and cardiovascular disease burden in people living with HIV-infection. Large prospective studies to further characterise the relationship between weight gain during HIV treatment and risk of diabetes, CVD and mortality are required.

The Role of Type 2 Diabetes for the Development of Pathogen-Associated Cancers in the Face of the HIV/AIDS Epidemic

The contribution of HIV to the development of pathogen-associated cancers has long been recognized, as has the contribution of type 2 diabetes for the development of several types of cancer. While HIV/AIDS-associated immunosuppression reduces immunosurveillance and indirectly contributes favorably to cancerogenesis, diabetes directly increases cancer development due to chronic low-grade inflammation, dysregulated glucose metabolism, hyperactivation of insulin-responsive pathways, and anti-apoptotic signaling. Pathogen-associated cancers contribute significantly to the cancer burden particularly in low- and middle-income countries. In those countries, the incidence of type 2 diabetes has increased alarmingly over the last decades, in part due to rapid changes in diet, lifestyle, and urbanization. It is likely that the HIV/AIDS epidemic and the steadily increasing rate of type 2 diabetes display synergistic effects on oncogenesis. Although this possible link has not been extensively investigated, it might become more important in the years to come not least due to the stimulating effects of antiretroviral therapy on the development of type 2 diabetes. This review provides an overview of the current understanding of pathogen- and diabetes- associated cancers with focus on geographical regions additionally burdened by the HIV/AIDS epidemic. As both HIV and carcinogenic infections as well as the onset of type 2 diabetes involve environmental factors that can be avoided to a certain extent, this review will support the hypothesis that certain malignancies are potentially preventable. Deploying effective infection control strategies together with educational policies on diet and lifestyle may in the long term reduce the burden of preventable cancers which is of particular relevance in low-resource settings.

The Canadian HIV and aging cohort study - determinants of increased risk of cardio-vascular diseases in HIV-infected individuals: rationale and study protocol

Background

With potent antiretroviral drugs, HIV infection is becoming a chronic disease. Emergence of comorbidities, particularly cardiovascular disease (CVD) has become a leading concern for patients living with the infection. We hypothesized that the chronic and persistent inflammation and immune activation associated with HIV disease leads to accelerated aging, characterized by CVD. This will translate into higher incidence rates of CVD in HIV infected participants, when compared to HIV negative participants, after adjustment for traditional CVD risk factors. When characterized further using cardiovascular imaging, biomarkers, immunological and genetic profiles, CVD associated with HIV will show different characteristics compared to CVD in HIV-negative individuals.

Methods/design

The Canadian HIV and Aging cohort is a prospective, controlled cohort study funded by the Canadian Institutes of Health Research. It will recruit patients living with HIV who are aged 40 years or older or have lived with HIV for 15 years or more. A control population, frequency matched for age, sex, and smoking status, will be recruited from the general population. Patients will attend study visits at baseline, year 1, 2, 5 and 8. At each study visit, data on complete medical and pharmaceutical history will be captured, along with anthropometric measures, a complete physical examination, routine blood tests and electrocardiogram. Consenting participants will also contribute blood samples to a research biobank. The primary outcome is incidence of a composite of: myocardial infarction, coronary revascularization, stroke, hospitalization for angina or congestive heart failure, revascularization or amputation for peripheral artery disease, or cardiovascular death. Preplanned secondary outcomes are all-cause mortality, incidence of the metabolic syndrome, incidence of type 2 diabetes, incidence of renal failure, incidence of abnormal bone mineral density and body fat distribution. Patients participating to the cohort will be eligible to be enrolled in four pre-planned sub-studies of cardiovascular imaging, glucose metabolism, immunological and genetic risk profile.

Discussion

The Canadian HIV and Aging Cohort will provide insights on pathophysiological pathways leading to premature CVD for patients living with HIV.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2692-2) contains supplementary material, which is available to authorized users.

Is there sufficient evidence for a causal association between antiretroviral therapy and diabetes in HIV-infected patients? A meta-analysis

The association of antiretroviral therapy (ART) with diabetes is inconsistent and varies widely across primary epidemiological studies. A comprehensive and more precise estimate of this association is fundamental to establishing a plausible causal link between ART and diabetes. We identified epidemiological studies that compared mean fasting plasma glucose (FPG) concentrations and proportions of diabetes and metabolic syndrome between HIV-infected patients naïve and exposed to ART. Mean difference in FPG concentrations and odds ratios of diabetes and metabolic syndrome were pooled using random-effects meta-analyses. Data on 20 178 participants from 41 observational studies were included in the meta-analyses. Mean FPG concentrations (Pooled mean difference: 4.66 mg/dL; 95% confidence interval [CI], 2.52 to 6.80; 24 studies) and the odds of diabetes (Pooled odds ratios: 3.85; 95% CI, 2.93 to 5.07; 10 studies) and metabolic syndrome (Pooled odds ratios: 1.45; 95% CI, 1.03 to 2.03; 18 studies) were significantly higher among ART-exposed patients, compared to their naïve counterparts. ART was also associated with significant increases in FPG levels in studies with mean ART duration ≥18 months (Pooled mean difference: 4.97 mg/dL; 95% CI, 3.10 to 6.84; 14 studies), but not in studies with mean ART duration <18 months (Pooled mean difference: 4.40 mg/dL, 95% CI, -0.59 to 9.38; 7 studies). ART may potentially be the single most consistent determinant of diabetes in people living with HIV worldwide. However, given the preponderance of cross-sectional studies in the meta-analysis, the association between ART and diabetes cannot be interpreted as cause and effect.

Human immunodeficiency virus and type 2 diabetes

The prevalence of diabetes is higher amongst individuals infected with HIV. The major contributor to hyperglycaemia is thought to be iatrogenic, with protease inhibitors being most commonly associated to insulin resistance. This article is to update general practitioners on the diagnosis and management of diabetes in HIV-infected patients. Specific considerations are highlighted including interactions of particular diabetic drugs with antiretroviral therapy (ART). We articulate why the use of Hemoglobin A1c (HbA1c) testing is not recommended as a diagnostic tool.

Metabolic Disorders in HIV-Infected Adolescents Receiving Protease Inhibitors

Protease inhibitor (PI) may cause abnormal glucose metabolism, abnormal lipid metabolism, and metabolic syndrome in HIV-infected adults but less well studied in Asian adolescents. This cross-sectional study evaluated anthropometric factors, oral glucose tolerance test, and lipid profiles of perinatally HIV-infected Thai adolescents who had received PI-based antiretroviral therapy for at least 6 months. Eighty adolescents were enrolled [median (IQR) age 16.7 (14.6–18.0) years, 42 males]. Metabolic syndrome, prediabetes, and type 2 diabetes mellitus (T2DM) were found in 8 (10%), 17 (22.1%), and 3 (3.8%) adolescents, respectively. Dyslipidemia was found in 56 (70%) adolescents, with hypertriglyceridemia being the most common type. In multivariate analysis, presence of lipohypertrophy (OR: 25.7, 95% CI: 3.2–202.8; p = 0.002) and longer duration of PI use (OR: 1.04, 95% CI: 1.00–1.08; p = 0.023) were associated with metabolic syndrome. Obesity (OR: 7.71, 95% CI: 1.36–43.7; p = 0.021), presence of lipohypertrophy (OR: 62.9, 95% CI: 4.97–795.6; p = 0.001), and exposure to stavudine for ≥6 months (OR: 8.18, 95% CI: 1.37–48.7; p = 0.021) were associated with prediabetes/T2DM, while exposure to tenofovir for ≥6 months reduced the risk (OR: 0.17, 95% CI: 0.04–0.78; p = 0.022). Metabolic disorders were commonly found in adolescents receiving PI. Careful monitoring and early intervention to modify cardiovascular risk should be systematically implemented in this population particularly those with exposure to stavudine.

Clinical Review of Antidiabetic Drugs: Implications for Type 2 Diabetes Mellitus Management

Type 2 diabetes mellitus (T2DM) is a global pandemic, as evident from the global cartographic picture of diabetes by the International Diabetes Federation (http://www.diabetesatlas.org/). Diabetes mellitus is a chronic, progressive, incompletely understood metabolic condition chiefly characterized by hyperglycemia. Impaired insulin secretion, resistance to tissue actions of insulin, or a combination of both are thought to be the commonest reasons contributing to the pathophysiology of T2DM, a spectrum of disease originally arising from tissue insulin resistance and gradually progressing to a state characterized by complete loss of secretory activity of the beta cells of the pancreas. T2DM is a major contributor to the very large rise in the rate of non-communicable diseases affecting developed as well as developing nations. In this mini review, we endeavor to outline the current management principles, including the spectrum of medications that are currently used for pharmacologic management, for lowering the elevated blood glucose in T2DM.

"They just come, pick and go." The Acceptability of Integrated Medication Adherence Clubs for HIV and Non Communicable Disease (NCD) Patients in Kibera, Kenya

Introduction

The number of people on antiretroviral therapy (ART) for the long-term management of HIV in low- and middle-income countries (LMICs) is continuing to increase, along with the prevalence of Non-Communicable Diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments.

Methodology

We conducted a qualitative research study to assess patient and health-care worker perceptions and experiences of MACs in the urban informal settlement of Kibera, Kenya. A total of 106 patients (with HIV and/or other NCDs) and health-care workers were purposively sampled and included in the study. Ten focus groups and 19 in-depth interviews were conducted and 15 sessions of participant observation were carried out at the clinic where the MACs took place. Thematic data analysis was conducted using NVivo software, and coding focussed on people’s experiences of MACs, the challenges they faced and their perceptions about models of care for chronic conditions.

Results

MACs were considered acceptable to patients and health-care workers because they saved time, prevented unnecessary queues in the clinic and provided people with health education and group support whilst they collected their medication. Some patients and health-care workers felt that MACs reduced stigma for HIV positive patients by treating HIV as any other chronic condition. Staff and patients reported challenges recruiting patients into MACs, including patients not fully understanding the eligibility criteria for the clubs. There were also some practical challenges during the implementation of the clubs, but MACs have shown that it is possible to learn from ART provision and enable stable HIV and NCD patients to collect chronic medication together in a group.

Conclusions

Extending models of care previously only offered to HIV-positive cohorts to NCD patients can help to de-stigmatise HIV, allow for the efficient clinical management of co-morbidities and enable patients to benefit from peer support. Through MACs, we have demonstrated that an integrated approach to providing medication for chronic diseases including HIV can be implemented in resource-poor settings and could thus be rolled out in other similar contexts.

Increased risk of dysglycaemia in South Africans with HIV; especially those on protease inhibitors

AIMS

To compare dysglycaemia prevalence (impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or diabetes) in HIV-infected persons, stratified by antiretroviral therapy (ART), with a community-based survey (CBS) in Cape Town, South Africa.

METHODS

Three groups of HIV-infected adults without known diabetes were conveniently sampled from community healthcare centres; ART-naïve, first-line ART (non-nucleoside reverse transcriptase inhibitor (NNRTI) plus dual NRTIs), and second-line ART (lopinavir/ritonavir-boosted protease inhibitor plus dual NRTIs). The CBS recruited a representative cross-sectional sample from urban townships. Participants reporting ART use or known diabetes were excluded. All participants underwent oral glucose tolerance testing. Multiple logistic regression determined independent associations with dysglycaemia.

RESULTS

The samples comprised ART-naïve, first-line ART, second-line ART and CBS participants (n=393, 439, 108 and 880, respectively). Mean age was 34-40years. Dysglycaemia prevalence was as follows: CBS 18.0%, ART-naïve 21.6%, first-line ART 26.0% and second-line ART 37.0%. Diabetes was similar across groups, but IGT was 3-4-fold higher in second-line ART and CBS compared with ART-naïve and first-line ART groups. In contrast, IFG was 14.3-21.2% across HIV groups but only 1.5% in the CBS. Increased risk of dysglycaemia was associated with older age, female gender, and HIV status (ART-naïve: OR 2.31, 95% CI 1.65-3.24; first-line ART: OR 2.47, 95% CI 1.80-3.38; second-line ART: OR 4.10, 95% CI 2.54-6.61). Diabetes family history and central obesity were not related to dysglycaemia.

CONCLUSIONS

In view of the increased risk of dysglycaemia in HIV-infected participants, screening for diabetes should be instituted in ART programmes.

Diabetes mellitus among HIV-infected individuals in follow-up care at University of Gondar Hospital, Northwest Ethiopia

OBJECTIVE

To assess the prevalence of diabetes mellitus (DM) and associated factors among HIV-infected adults in northwest Ethiopia.

DESIGN

Hospital-based cross-sectional study.

SETTING

HIV clinic of the University of Gondar Hospital, Ethiopia.

PARTICIPANTS

All HIV-infected adults who visited the HIV clinic from December 2013 to the end of February 2014 were the source population.

MEASURES

A structured and pretested questionnaire incorporating the WHO STEPwise approach was used. A multivariate logistic regression analysis was applied to assess factors associated with DM.

RESULTS

The overall prevalence of type 2 DM was 8% (95% CI 5.5% to 10.5%). The prevalence of DM was higher (13.2%; 95% CI 8.0% to 18.3%) among subjects receiving pre-antiretroviral treatment (pre-ART) than among those taking ART (5.1%; 95% CI 2.6% to 7.6%). Thirteen (35.1%) of the DM cases were newly identified during the study. Obesity (adjusted OR (AOR) 6.55; 1.20 to 35.8), hypertension (AOR 3.45; 1.50 to 7.90), being in the pre-ART group (AOR 4.47; 1.80 to 11.08), hypertriglyceridaemia (AOR 2.24; 1.02 to 49.5) and tertiary-level education (AOR 11.8; 2.28 to 61.4) were associated with DM.

CONCLUSIONS

Overall DM prevalence was high, particularly among subjects in the pre-ART group. More educated, hypertensive and obese HIV-infected adults were more likely to have DM as a comorbidity. Health policy and the clinical management of HIV-infected individuals should take into account the rising DM.

Predictors of dual control of HIV and diabetes

Diabetes is one of the most frequently diagnosed comorbidities in individuals living with HIV. Dual control of both conditions is essential because both diseases negatively impact the immune and vascular systems. The purpose of this retrospective study was to assess the factors associated with dual control of HIV and diabetes. Patients from a large urban Ryan White-funded HIV clinic with a diagnosis of diabetes were identified; inclusion criteria comprised age over 25 years, use of antiretroviral therapy for at least 6 months, and a diagnosis of diabetes. Optimal control was described as a non-detectable viral load (i.e. log10 HIV1-viral load <1.6) and HbA1c ≤7%. Fewer than half of 186 patients had optimal control of HIV and diabetes. Direct logistic regression using backward stepwise entry identified three variables that significantly fit the model: age, insulin-based therapy, and African-American race. The full model was statistically significant. As patients with HIV now live longer, more effort needs to be given to adherence to improve health outcomes for co-morbidities.

The converging burdens of infectious and non-communicable diseases in rural-to-urban migrant Sub-Saharan African populations: a focus on HIV/AIDS, tuberculosis and cardio-metabolic diseases

Africa has the unenviable challenge of dealing with a double burden of disease: infectious diseases (IDs) such as HIV/AIDS and tuberculosis are high while non-communicable diseases (NCDs) are rapidly rising in the region. Populations with increased susceptibility to both include migrants. This review highlights the susceptibility of rural-to-urban migrants in Sub-Saharan Africa to the IDs of HIV/AIDS and tuberculosis, and to NCDs, particularly cardiovascular diseases. The disruption that occurs with migration is often accompanied by unhealthy exposures and environments. These include partaking in risky sexual practices and a subsequent greater risk for HIV infection in migrants than the general populations which contributes to the spread of the disease. Migrants frequently work and live in conditions that are poorly ventilated and overcrowded with suboptimal sanitation which increases their risk for tuberculosis. Considering that migrants have an increased risk of acquiring both HIV/AIDS and tuberculosis, and in view of the interaction between these diseases, they are likely to be at high risk for co-infection. They are also likely to facilitate the geographical spread of these infections and serve as conduits of disease dissemination to rural areas. Changes in lifestyle behaviours that accompany migration and urbanisation are exemplified primarily by shifts in physical activity and dietary patterns which promote the development of obesity, diabetes, hypertension and cardiovascular diseases. Urban living and employment is generally less physically exerting than rural routines; when migrants relocate from their rural residence they adapt to their new environment by significantly reducing their physical activity levels. Also, nutritional patterns among migrants in urban centres change rapidly with a shift to diets higher in fat, sugar and salt. Consequently, increases in weight, blood pressure and glucose levels have been reported within a year of migration. Interactions between IDs and NCDs are common; considering that migrants have an increased susceptibility to IDs and demonstrate a rapid rise in their risk for NCDs, the concurrent prevalence of both is likely in this population. There is a need for a combined strategy to combat IDs and NCDs with screening and treatment programmes geared towards this high risk group.

Impact of switching from lopinavir/ritonavir to boosted and un-boosted atazanavir on glucose metabolism: the ATAzanavir & GLUcose metabolism (ATAGLU) study

Previous studies have reported that protease inhibitors (PIs) can contribute to glycaemic alterations. However, there are few trials examining the direct effect of a single PI. The objective of the study was to evaluate the modifications of glucose and lipid profiles after a switch from lopinavir/ritonavir (LPV/r) to atazanavir, used as ritonavir-boosted (ATV/r) or un-boosted. We conducted a retrospective observational cohort study on the effect of ATV/(r) on glycaemic metabolism (ATAGLU) in patients with undetectable levels of HIV-RNA who switched from LPV/r. In total, 235 patients treated for 48 weeks with LPV/r plus two nucleoside reverse transcriptase inhibitors (NRTIs) and with undetectable HIV-RNA were included: 134 continued LPV/r after the initial 48 weeks and 101 switched to ATV(/r) (18.3% to ATV; 24.7% to ATV/r). A significant decrease in mean glucose level and insulin resistance was observed in patients who switched to ATV(/r). The mean cholesterol triglyceride levels increased in the LPV/r group and decreased among the patients who switched. A significant increase of CD4 T cells with undetectable levels of HIV-RNA was observed in all groups. The long-term results obtained in this real-life study suggest that patients who have achieved initial suppression on a regimen including LPV/r + two NRTIs can switch to ATV/(r) + two NRTIs with an improvement in lipid and glycaemic metabolism.

HIV with non-communicable diseases in primary care in Kibera, Nairobi, Kenya: characteristics and outcomes 2010-2013

BACKGROUND

Antiretroviral therapy (ART) has increased the life expectancy of people living with HIV (PLHIV); HIV is now considered a chronic disease. Non-communicable diseases (NCDs) and HIV care were integrated into primary care clinics operated within the informal settlement of Kibera, Nairobi, Kenya. We describe early cohort outcomes among PLHIV and HIV-negative patients, both of whom had NCDs.

METHODS

A retrospective analysis was performed of routinely collected clinic data from January 2010 to June 2013. All patients >14 years with hypertension and/or diabetes were included.

RESULTS

Of 2206 patients included in the analysis, 210 (9.5%) were PLHIV. Median age at enrollment in the NCD program was 43 years for PLHIV and 49 years for HIV-negative patients (p<0.0001). The median duration of follow up was 1.4 (IQR 0.7-2.1) and 1.0 (IQR 0.4-1.8) years for PLHIV and HIV-negative patients, respectively (p=0.003). Among patients with hypertension, blood pressure outcomes were similar, and for those with diabetes, outcomes for HbA1c, fasting glucose and cholesterol were not significantly different between the two groups. The frequency of chronic kidney disease (CKD) was 12% overall. Median age for PLHIV and CKD was 50 vs 55 years for those without HIV (p=0.005).

CONCLUSIONS

In this early comparison of PLHIV and HIV-negative patients with NCDs, there were significant differences in age at diagnosis but both groups responded similarly to treatment. This study suggests that integrating NCD care for PLHIV along with HIV-negative patients is feasible and achieves similar results.

Insulin resistance change and antiretroviral therapy exposure in HIV-infected and uninfected Rwandan women: a longitudinal analysis

Background

We longitudinally assessed predictors of insulin resistance (IR) change among HIV-uninfected and HIV-infected (ART-initiators and ART-non-initiators) Rwandan women.

Methodology

HIV-infected (HIV+) and uninfected (HIV-) women provided demographic and clinical measures: age, body mass index (BMI) in Kg/(height in meters)², Fat-Mass (FMI) and Fat-Free-Mass (FFMI) index, fasting serum glucose and insulin. Homeostasis Model Assessment (HOMA) was calculated to estimate IR change over time in log₁₀ transformed HOMA measured at study enrollment or prior to ART initiation in 3 groups: HIV- (n = 194), HIV+ ART-non-initiators (n=95) and HIV+ ART-initiators (n=371). ANCOVA linear regression models of change in log₁₀-HOMA were fit with all models included the first log₁₀ HOMA as a predictor.

Results

Mean±SD log₁₀-HOMA was -0.18±0.39 at the 1^st and -0.21±0.41 at the 2^nd measure, with mean change of 0.03±0.44. In the final model (all women) BMI at 1^st HOMA measure (0.014; 95% CI=0.006-0.021 per kg/m²; p<0.001) and change in BMI from 1^st to 2^nd measure (0.024; 95% CI=0.013-0.035 per kg/m²; p<0.001) predicted HOMA change. When restricted to subjects with FMI measures, FMI at 1^st HOMA measure (0.020; 95% CI=0.010-0.030 per kg/m²; p<0.001) and change in FMI from 1^st to 2^nd measure (0.032; 95% CI=0.020-0.043 per kg/m²; p<0.0001) predicted change in HOMA. While ART use did not predict change in log₁₀-HOMA, untreated HIV+ women had a significant decline in IR over time. Use or duration of AZT, d4T and EFV was not associated with HOMA change in HIV+ women.

Conclusions

Baseline BMI and change in BMI, and in particular fat mass and change in fat mass predicted insulin resistance change over ~3 years in HIV-infected and uninfected Rwandan women. Exposure to specific ART (d4T, AZT, EFV) did not predict insulin resistance change in ART-treated HIV-infected Rwandan women.

Epidemiology and management of antiretroviral-associated cardiovascular disease

Risk and manifestations of cardiovascular disease (CVD) in patients infected with human immunodeficiency virus (HIV) will continue to evolve as improved treatments and life expectancy of these patients increases. Although initiation of antiretroviral (ARV) therapy has been shown to reduce this risk, some ARV medications may induce metabolic abnormalities, further compounding the risk of CVD. In this patient population, both pharmacologic and nonpharmacologic strategies should be employed to treat and reduce further risk of CVD. This review summarizes epidemiology data of the risk factors and development of CVD in HIV and provides recommendations to manage CVD in HIV-infected patients.

Lipodystrophic diabetes mellitus: a lesson for other forms of diabetes?

Lipodystrophies are a genetically heterogeneous group of disorders characterized by loss of subcutaneous adipose tissue and metabolic dysfunction, including insulin resistance, increased levels of free fatty acids, abnormal adipocytokine secretion, and ectopic fat deposition, which are also observed in patients with visceral obesity and/or type 2 diabetes mellitus. Pathophysiological, biochemical, and genetic studies suggest that impairment in multiple adipose tissue functions, including adipocyte maturation, lipid storage, formation and/or maintenance of the lipid droplet, membrane composition, DNA repair efficiency, and insulin signaling, results in severe metabolic and endocrine consequences, ultimately leading to specific lipodystrophic phenotypes. In this review, recent evidences on the causes and metabolic processes of lipodystrophies will be presented, proposing a disease model that could be potentially informative for better understanding of common metabolic diseases in humans, including obesity, metabolic syndrome, and type 2 diabetes.

Effect of aging, glucose level, and HIV viral load on response to treatment with pegylated interferon plus ribavirin in HIV/HCV co-infected women

BACKGROUND

This was a post-hoc analysis of the Optimized Pegylated interferons Efficacy and anti-Retroviral Approach (OPERA) study, originally designed to document routine clinical and treatment data in HIV/HCV coinfected patients treated with pegylated interferon/ribavirin (PEG-IFN/RBV). The aim of this study was to define the impact of several variables, such as age, glucose metabolism, and HIV viral load, on PEG-IFN/RBV treatment outcomes, in HIV/HCV coinfected women.

METHODS

Female subjects from the OPERA database were retrospectively evaluated and factors associated with sustained virological response (SVR) were assessed and compared to the male population by logistic regression analysis. At baseline, clinical and demographic data were collected. Patients were then administered with PEG-IFN/RBV therapy for 48 weeks. After a 24-week follow-up period, SVR was evaluated.

RESULTS

A total of 1523 patients were enrolled in 98 centers across Italy, 1284 of whom were IFN therapy naïve and were included in the post-hoc analysis. In the female group, factors associated with SVR were the presence of HCV genotype 2,3 (adjusted odds ratio [AOR]=6.87, p<0.0001), age ≤45 years (AOR=2.61, p=0.014), ≥80% exposure to PEG-IFN (AOR=3.85, p=0.019) and RBV (AOR=3.94, p=0.015) therapy. Also, increased glucose plasma level negatively correlated with SVR (AOR=0.98, p=0.066). In the male population, undetectable HIV-RNA (AOR=1.47, p=0.033) but not glucose level (AOR=1.0, p=0.95) predicted SVR.

CONCLUSIONS

Findings from the present study demonstrate that several factors may be predictive of SVR when pegylated interferon plus ribavirin is used (i.e., age, gender, HIV viral load and HCV genotype) that need to be carefully considered prior to therapeutic intervention, since they may hinder successful therapy. Use of PEG-IFN/RBV with novel direct antiviral agents will likely be still maintained until less expensive and effective interferon-free strategies become available.

Validation of noninvasive methods for detecting hepatic steatosis in patients with human immunodeficiency virus infection

Nonalcoholic fatty liver disease (NAFLD) is common among patients with human immunodeficiency virus (HIV) infection; a reliable noninvasive method of detection is needed. We aimed to validate noninvasive means of identifying steatosis in HIV-positive patients. We performed a single-center retrospective study to validate the abilities of the liver fat score (LFS) and the lipid accumulation product (LAP) to detect hepatic steatosis in HIV-positive patients, compared with HIV-negative individuals (controls); NAFLD was confirmed by histology, and findings were compared with those from ultrasonography. These models then were validated in HIV-positive patients with NAFLD vs patients co-infected with HIV and hepatitis C virus (HCV) infection, without hepatic steatosis. LFS identified hepatic steatosis in HIV-positive subjects, compared with controls, with an area under the receiver operating curve value of 0.971 ± 0.027 (95% confidence interval, 0.91-1.000). At a cut-off value of -0.945, the LFS identified patients with steatosis with 100% sensitivity and 84% specificity. At a cut-off of value of -0.234, the LFS differentiated between HIV-positive subjects with NAFLD and patients co-infected with HIV and HCV with 100% sensitivity and 74% specificity. LAP scores ≥38 identified HIV-positive patients with steatosis with 89% sensitivity and 83% specificity. LAP scores ≥42 differentiated between HIV-positive subjects with steatosis and patients co-infected with HIV and HCV with 89% specificity and 70% sensitivity. We validated the accuracy of LFS and LAP in detecting hepatic steatosis in HIV-positive patients.

Diabetes in the Africa Region: an update

The Africa Region (AFR), where diabetes was once rare, has witnessed a surge in the condition. Estimates for type 1 diabetes suggest that about 39,000 people suffer from the disease in 2013 with 6.4 new cases occurring per year per 100,000 people in children <14 years old. Type 2 diabetes prevalence among 20-79-year-olds is 4.9% with the majority of people with diabetes <60 years old; the highest proportion (43.2%) is in those aged 40-59 years. Figures are projected to increase with the numbers rising from 19.8 million in 2013 to 41.5 million in 2035, representing a 110% absolute increase. There is an apparent increase in diabetes prevalence with economic development in AFR with rates of 4.4% in low-income, 5.0% in lower-middle income and 7.0% in upper-middle income countries. In addition to development and increases in life-expectancy, the likely progression of people at high risk for the development of type 2 diabetes will drive the expected rise of the disease. This includes those with impaired glucose tolerance, the prevalence of which is 7.3% among 20-79-year-olds in 2013. Mortality attributable to diabetes in 2013 in AFR is expected to be over half a million with three-quarter of these deaths occurring in those <60 years old. The prevalence of undiagnosed diabetes remains unacceptably high at 50.7% and is much higher in low income (75.1%) compared to lower- and upper-middle income AFR countries (46.0%). This highlights the inadequate response of local health systems which need to provide accessible, affordable and optimal care for diabetes.

HIV and the heart: the impact of antiretroviral therapy: a global perspective

From a global perspective, cardiovascular disease (CVD) in human immunodeficiency virus (HIV) may result from cardiac involvement upon presentation of opportunistic infections in the presence of advanced immunosuppression, be a consequence of HIV-induced immune activation or derive from antiretroviral therapy-associated dyslipidaemia and insulin resistance. Indeed, in developed countries with unlimited access to antiretroviral therapy CVD has become one of the major causes of death in HIV. Therefore, cardiovascular risk reduction and lifestyle modifications are essential and careful selection of the antiretroviral drugs according to underlying cardiovascular risk factors of great importance. In developing countries with delayed roll-out of antiretroviral therapy pericardial disease (often related to TB), HIV-associated cardiomyopathy, and HIV-associated pulmonary hypertension are the most common cardiac manifestations in HIV. In Africa, the epicentre of the HIV epidemic, dynamic socio-economic and lifestyle factors characteristic of epidemiological transition appear to have positioned the urban African community at the cross-roads between historically prevalent and 'new' forms of CVD, such as coronary artery disease. In this context, cardiovascular risk assessment of HIV-infected patients will become a critical element of care in developing countries similar to the developed world, and access to antiretroviral therapy with little or no impact on lipid and glucose metabolism of importance to reduce CVD in HIV.