Achieving American Diabetes Association goals in HIV-seropositive patients with diabetes mellitus

Treatment outcomes among adults with HIV/non-communicable disease multimorbidity attending integrated care clubs in Cape Town, South Africa

Background

The growing burden of the HIV and non-communicable disease (NCD) syndemic in Sub- Saharan Africa has necessitated introduction of integrated models of care in order to leverage existing HIV care infrastructure for NCDs. However, there is paucity of literature on treatment outcomes for multimorbid patients attending integrated care. We describe 12-month treatment outcomes among multimorbid patients attending integrated antiretroviral treatment (ART) and NCD clubs in Cape Town, South Africa.

Methods

As part of an integrated clubs (IC) model pilot implemented in 2016 by the local government at two primary health care clinics in Cape Town, we identified all multimorbid patients who were enrolled for IC for at least 12 months by August 2017. Mean adherence percentages (using proxy of medication collection and attendance of club visits) and optimal disease control (defined as the proportion of participants achieving optimal blood pressure, glycosylated haemoglobin control and HIV viral load suppression where appropriate) were calculated at 12 months before, at the point of IC enrolment and 12 months after IC enrolment. Predictors of NCD control 12 months post IC enrolment were investigated using multivariable logistic regression.

Results

As of 31 August 2017, 247 HIV-infected patients in total had been enrolled into IC for at least 12 months. Of these, 221 (89.5%) had hypertension, 4 (1.6%) had diabetes mellitus and 22 (8.9%) had both diseases. Adherence was maintained before and after IC enrolment with mean adherence percentages of 92.2% and 94.2% respectively. HIV viral suppression rates were 98.6%, 99.5% and 99.4% at the three time points respectively. Retention in care was high with 6.9% lost to follow up at 12 months post IC enrolment. Across the 3 time-points, optimal blood pressure control was achieved in 43.1%, 58.9% and 49.4% of participants while optimal glycaemic control was achieved in 47.4%, 87.5% and 53.3% of participants with diabetes respectively. Multivariable logistic analyses showed no independent variables significantly associated with NCD control.

Conclusion

Multimorbid adults living with HIV achieved high levels of HIV control in integrated HIV and NCD clubs. However, intensified interventions are needed to maintain NCD control in the long term.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-021-00387-3.

Individual-Level and Clinic-Level Factors Associated With Achieving Glycemic Control in a Large Cohort of People With HIV in Care-Washington, DC

BACKGROUND

Optimal management of noncommunicable diseases, including diabetes mellitus (DM), is crucially important as people with HIV (PWH) live longer with antiretroviral therapy. Our objective was to assess patient-level and clinic-level factors associated with achieving hemoglobin A1c (HbA1c) ≤7.0% among PWH and DM.

SETTING

The DC Cohort, an observational clinical cohort of PWH, followed from 2011 to 2019 at 12 sites in Washington, DC.

METHODS

Among PWH with diagnosed DM and elevated HbA1c (>7.0%), we examined the association between achieving HbA1c ≤7.0% and demographic and clinical factors, including time-updated medication data, and clinic-level factors related to services and structure. A multilevel marginal extended Cox regression model was generated to identify factors associated with time to HbA1c ≤7.0%.

RESULTS

Over half (52.3%) of 419 participants achieved HbA1c ≤7.0%. Individual-level factors associated with HbA1c ≤7.0% included a diagnosis of DM after enrollment and a longer time since HIV diagnosis [hazard ratio (HR) = 2.65 and 1.13, P < 0.05 for both]. Attending a clinic with an endocrinologist was associated with the outcome [adjusted HR (aHR) = 1.41 95% confidence interval (CI): (1.01 to 1.97)]. In addition, comparing clinics that treat everyone, refer everyone or have a mix of treating and referring, showed an association between attending a clinic that treats everyone [aHR = 1.52 95% CI: (1.21 to 1.90)] or a clinic that refers everyone [aHR = 2.24 95% CI: (1.63 to 3.07)] compared with clinics with a mix in achieving glycemic control.

CONCLUSION

Multiple factors are associated with achieving glycemic control in an urban cohort of PWH. Determining if specific services or structures improve DM outcomes may improve health outcomes for PWH and DM.

Metabolic Control and Determinants Among HIV-Infected Type 2 Diabetes Mellitus Patients Attending a Tertiary Clinic in Botswana

PURPOSE

We primarily aimed at determining the prevalence of metabolic syndrome and abnormal individual metabolic control variables in HIV-infected participants as compared to HIV-uninfected participants given current concerns. Our secondary objective was to determine the predictors of metabolic syndrome and individual metabolic control variables among the study participants to guide future management.

PATIENTS AND METHODS

A descriptive, case-matched cross-sectional study for four months from 15th June 2019 to 15th October 2019 at Block 6 Diabetes Reference Clinic in Gaborone, Botswana. We compared the proportions of metabolic syndrome and individual metabolic control variables based on gender and HIV status by means of bivariate analysis (Chi-squared test or Fisher's exact test) to determine factors associated with metabolic control. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Overall, 86% of the study participants were found to have metabolic syndrome by International Diabetes Federation (IDF) criteria with 79.8% among HIV-infected and 89.1% among HIV-negative participants (p-value = 0.018). Older age was significantly associated with metabolic syndrome (p-value = 0.008). Female gender was significantly associated with metabolic syndrome as compared to male gender (P-value < 0.001), and with a statistically significant higher proportion of low HDL-C compared to males (P-value < 0.001). Female participants were significantly more likely to be obese as compared to males (P-value < 0.001). High triglycerides were more common in HIV-infected compared to HIV-negative participants (P-value = 0.004). HIV-negative participants were more likely to be obese as compared to HIV-infected participants (P-value = 0.003).

CONCLUSION

Metabolic syndrome is an appreciable problem in this tertiary clinic in Botswana for both HIV-infected and HIV-negative participants. Future prospective studies are warranted in our setting and similar sub-Saharan settings to enhance understanding of the role played by HAART in causing the metabolic syndrome, and the implications for future patient management.

Diabetes mellitus control in a large cohort of people with HIV in care-Washington, D.C

With more effective antiretroviral therapy (ART), people with HIV (PWH) are living longer and have more chronic diseases, including diabetes mellitus (DM). The prevalence of DM has been estimated in PWH previously, however there is less research regarding DM control. Our objectives were to determine the prevalence of DM and DM control and determine factors associated with DM control in a large urban cohort of PWH in care. We examined DC Cohort participants aged ≥18 years old to determine DM prevalence and to assess DM control (HbA1c measurement <7.0%). Demographic, clinical, and HIV-related factors associated with DM control were identified using multivariate logistic regression. The cohort of 5876 participants was predominantly male (71.3%), Non-Hispanic Black (78.1%) and had a median age of 52.0 years. DM prevalence was 17.4% (1023/5876). Among participants with recent HbA1c data available (39.9%) the proportion with DM control was 60.0% (245/408). In multivariate analysis, higher BMI (aOR: 0.47; 95% CI 0.28, 0.79) and use of non-insulin DM medication (aOR 0.43, 95% CI 0.25, 0.73) or insulin (aOR 0.010, 95% CI 0.04,0.24) compared to no medication use. Our findings suggest that individuals on medication for their DM likely need enhanced support to reach their treatment goals.

Glycemic Control Among People Living with Diabetes and Human Immunodeficiency Virus in Ethiopia: Leveraging Clinical Care for the Looming Co-Epidemics

BACKGROUND

Antiretroviral therapy has decreased human immunodeficiency virus related mortality. However, the incidence of diabetes mellitus is increasing among people living with human immunodeficiency virus and adds complexity to the standards of care.

OBJECTIVE

The study was aimed to determine the glycemic control and delivery of clinical care among people living with diabetes and human immunodeficincy virus in Ethiopia.

METHODS

A comparative prospective cohort study was conducted among patients living with diabetes at follow-up clinics of Jimma Medical Center in two study arms. The first arm was people living with diabetes and human immunodeficiency virus. The second arm was human immunodeficiency virus negative patients living with diabetes. The expanded English version of the summary of diabetes self-care activities scale was used to measure self-care behaviors. In order to identify the predictors of glycemic control, multivariable Cox regression analysis was used. Statistical significance at p-value ≤0.05 was considered.

RESULTS

A total of 297 eligible participants were followed for one year, with a mean age of 44.35±12.55 years. Males accounted for 55.9%. After one year of follow-up, 61.9% of diabetes people living with human immunodeficiency virus, and 49% of human immunodeficiency virus-negative patients with diabetes poorly met blood glucose target (p=0.037). Female gender [AHR: 2.72; 95% CI (1.21-5.72)], age >31 years [AHR: 2.48; 95% CI (1.34-11.01)], increased waist circumference [AHR: 3.64; 95% CI (2.57-16.12)], overweight [AHR: 3.63; 95% CI (1.65-22.42)], chronic disease comorbidity [AHR: 2.02; 95% CI (1.44-2.84)], human immunodeficiency virus infection [AHR: 3.47; 95% CI (2.03-23.75)], living longer with diabetes (>5 years) [AHR: 3.67; 95% CI (3.26-4.14)] showed a higher risk of blood sugar control failure and were independent predictors of uncontrolled glycemia. Tuberculosis infection increased the risk of uncontrolled blood sugar among people living with diabetes and human immunodeficency virus[AHR:3.82;95% CI(2.86-5.84].

CONCLUSION

Significant gaps were observed in achieving the recommended glycemic target and involvement of patients on self-care care behavior in the study area. The co-occurrence of tuberculosis, human immunodeficiency virus, and diabetes is triple trouble needing special attention in their management. It is high time to leverage the clinical care of the looming co-epidemics through chronic comprehensive care clinic.

How the delivery of HIV care in Canada aligns with the Chronic Care Model: A qualitative study

With the advent of continuous antiretroviral therapy, HIV has become a complex chronic, rather than acute, condition. The Chronic Care Model (CCM) provides an integrated approach to the delivery of care for people with chronic conditions that could therefore be applied to the delivery of care for people living with HIV. Our objective was to assess the alignment of HIV care settings with the CCM. We conducted a mixed methods study to explore structures, organization and care processes of Canadian HIV care settings. The quantitative results of phase one are published elsewhere. For phase two, we conducted semi-structured interviews with key informants from 12 HIV care settings across Canada. Irrespective of composition of the care setting or its location, HIV care in Canada is well aligned with several components of the CCM, most prominently in the areas of linkage to community resources and delivery system design with inter-professional team-based care. We propose the need for improvements in the availability of electronic clinical information systems and self-management support services to support better care delivery and health outcomes among people living with HIV in Canada.

Room for Improvement: The HIV-Diabetes Care Continuum Over 15 Years in the Women's Interagency HIV Study

Background

Gains in life expectancy through optimal control of HIV infection with antiretroviral therapy (ART) may be threatened if other comorbidities, such as diabetes, are not optimally managed.

Methods

We analyzed cross-sectional data of the Women's Interagency HIV Study (WIHS) from 2001, 2006, and 2015. We estimated the proportions of HIV-positive and HIV-negative women with diabetes who were engaged in care and achieved treatment goals (hemoglobin A1c [A1c] <7.0%, blood pressure [BP] <140/90 mmHg, low-density lipoprotein [LDL] cholesterol <100 mg/dL, not smoking) and viral suppression. Repeated-measures models were used to estimate the adjusted prevalence of achieving each diabetes treatment goal at each time point, by HIV status.

Results

We included 486 HIV-positive and 258 HIV-negative women with diabetes. In 2001, 91.8% visited a health care provider, 60.7% achieved the A1c target, 70.5% achieved the BP target, 38.5% achieved the LDL cholesterol target, 49.2% were nonsmokers, 23.3% achieved combined ABC targets (A1c, BP, and cholesterol), and 10.9% met combined ABC targets and did not smoke. There were no differences by HIV status, and patterns were similar in 2006 and 2015. Among HIV-positive women, viral suppression increased from 41% in 2001 to 87% in 2015 compared with 8% and 13% achieving the ABC goals and not smoking. Viral suppression was not associated with achievement of diabetes care goals.

Conclusions

Successful management of HIV is outpacing that of diabetes. Future studies are needed to identify factors associated with gaps in the HIV-diabetes care continuum and design interventions to better integrate effective diabetes management into HIV care.

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.

Integrating cardiovascular diseases, hypertension, and diabetes with HIV services: a systematic review

Non-communicable diseases (NCDs), including cardiovascular diseases (CVD), hypertension and diabetes together with HIV infection are among the major public health concerns worldwide. Health services for HIV and NCDs require health systems that provide for people's chronic care needs, which present an opportunity to coordinate efforts and create synergies between programs to benefit people living with HIV and/or AIDS and NCDs. This review included studies that reported service integration for HIV and/or AIDS with coronary heart diseases, chronic CVD, cerebrovascular diseases (stroke), hypertension or diabetes. We searched multiple databases from inception until October 2015. Articles were screened independently by two reviewers and assessed for risk of bias. 11,057 records were identified with 7,616 after duplicate removal. After screening titles and abstracts, 14 papers addressing 17 distinct interventions met the inclusion criteria. We categorized integration models by diseases (HIV with diabetes, HIV with hypertension and diabetes, HIV with CVD and finally HIV with hypertension and CVD and diabetes). Models also looked at integration from micro (patient focused integration) to macro (system level integrations). Most reported integration of hypertension and diabetes with HIV and AIDS services and described multidisciplinary collaboration, shared protocols, and incorporating screening activities into community campaigns. Integration took place exclusively at the meso-level, with no micro- or macro-level integrations described. Most were descriptive studies, with one cohort study reporting evaluative outcomes. Several innovative initiatives were identified and studies showed that CVD and HIV service integration is feasible. Integration should build on existing protocols and use the community as a locus for advocacy and health services, while promoting multidisciplinary teams, including greater involvement of pharmacists. There is a need for robust and well-designed studies at all levels - particularly macro-level studies, research looking at long-term outcomes of integration, and research in a more diverse range of countries.

Predictors of glycaemic control among HIV-positive veterans with diabetes

Antiretroviral therapy has decreased HIV-related mortality. However, the incidence of diabetes as a co-morbidity is increasing as HIV-positive patients age. The purpose of this study was to assess the correlation between markers of HIV-infection and diabetes and to determine the proportion of patients achieving an haemoglobin A1c (HbA1c) goal <7% according to specific antiretroviral therapy regimens and adherence. In this retrospective study, HIV-positive veterans with diabetes from 2007 to 2012 were identified. Patients were required to be on the same antiretroviral therapy and diabetes regimen for ≥3 months. In 56 patients, it was identified that for each unit increase in log10 viral load, HbA1c increased 0.67 units (p = 0.0085). Only 38% of patients prescribed a protease inhibitor-based regimen vs. 56% of patients not on a protease inhibitor-based regimen achieved an HbA1c goal (p = 0.1864). Additionally, patients on an insulin-based regimen and patients that were less adherent were less likely to be at HbA1c goal (p = 0.018 and p = 0.0378, respectively). Patients with higher viral loads and patients that were less adherent to antiretroviral therapy were more likely to have a higher HbA1c demonstrating that poor adherence to antiretroviral therapy leads to poor control of both disease states.

HIV infection and glycemic response to newly initiated diabetic medical therapy

OBJECTIVES

Type 2 diabetes (DM2) is increasingly common in HIV-infected individuals. Antiretroviral agents and chronic inflammation may adversely affect glycemic control. However, little is known about the effectiveness of diabetic medical therapy in HIV-infected patients. The objective of this study was to compare the effectiveness of initial diabetic medical therapy in patients with and without HIV infection.

DESIGN

A retrospective cohort study was conducted among adults with DM2 initiating diabetic medications within the Centers for AIDS Research Network of Integrated Clinical Systems cohort.

METHODS

Generalized estimating equations were used to compare changes in hemoglobin A1c (HbA1c) through the year after initiation of therapy, controlling for baseline HbA1c and demographic and clinical covariates.

RESULTS

Two hundred and eighty-six HIV-infected patients and 858 age and sex-matched HIV-uninfected patients initiated diabetic medications during the study period. Overall, patients had an adjusted absolute mean reduction in HbA1c of 1.04% [95% confidence interval (CI) -0.87 to -1.22] during the first year of therapy. HIV-infected patients achieved significantly smaller reductions in HbA1c, with an absolute mean difference of -0.17% (95% CI -0.28 to -0.06; P = 0.003). On subanalyses, HIV-infected patients on a protease inhibitor-based regimen had significantly smaller reductions in HbA1c compared to HIV-uninfected patients (adjusted absolute difference -0.21%, 95% CI -0.35 to -0.08; P = 0.002).

CONCLUSION

Patients with HIV infection who initiate diabetic medical therapy achieve smaller reductions in HbA1c than patients without HIV infection in the course of routine clinical care. This less robust response may in part be related to use of antiretrovirals that exacerbate insulin resistance, specifically protease inhibitors.

HIV quality of care assessment at an academic hospital: outcomes and lessons learned

Rapid changes in HIV treatment guidelines and antiretroviral therapy drug safety data add to the increasing complexity of caring for HIV-infected patients and amplify the need for continuous quality monitoring. The authors created an electronic HIV database of 642 patients who received care in the infectious disease (ID) and general medicine clinics in their academic center to monitor HIV clinical performance indicators. The main outcome measures of the study include process measures, including a description of how the database was constructed, and clinical outcomes, including HIV-specific quality improvement (QI) measures and primary care (PC) measures. Performance on HIV-specific QI measures was very high, but drug toxicity monitoring and PC-specific QI performance were deficient, particularly among ID specialists. Establishment of HIV QI data benchmarks as well as standards for how data will be measured and collected are needed and are the logical counterpart to treatment guidelines.

Control of medical comorbidities in individuals with HIV

BACKGROUND

With improved combination antiretroviral therapy-related survival, diabetes and hypertension increasingly contribute to morbidity and mortality among individuals with HIV. However, there is limited data on diabetes and blood pressure control in this population. We examined whether virologic control is associated with control of diabetes and hypertension.

METHODS

We examined HIV viral load, hemoglobin A1c (HbA1c), and blood pressure measurements from 70 diabetics and 291 hypertensives in the Johns Hopkins HIV Clinical Cohort, an urban, university-based cohort. All patients were treated for HIV and diabetes or hypertension. HbA1c and HIV-1 RNA were captured electronically from laboratory data, and blood pressure was collected electronically from vital signs taken at clinic visits. We used HIV-1 RNA values within 30 days of the HbA1c measurement or blood pressure measurement. The relationships between HIV-1 RNA and HbA1c and HIV-1 RNA and blood pressure were examined using separate random effects generalized least squares linear regression models.

RESULTS

The study sample was predominantly male and black, with a high prevalence of comorbid hepatitis C virus infection and psychiatric illness. In multivariable analysis, each log(10) increase in HIV-1 RNA was associated with higher HbA1c (β = 0.47 units, P < 0.001) among diabetics and higher mean arterial pressure among hypertensive patients (β = 1.95 mmHg, P < 0.001).

CONCLUSIONS

Suboptimal control of HIV, indicated by detectable viral load, correlates with suboptimal control of diabetes and hypertension, indicated by higher HbA1c and mean arterial pressure. Achieving control of multiple medical comorbidities and HIV simultaneously may require expansion of current adherence interventions focused primarily on antiretroviral therapy.

South Asian Consensus Guidelines for the rational management of diabetes in human immunodeficiency virus/acquired immunodeficiency syndrome

As newer methods of management are made available, and accessible, survival rates with human immunodeficiency virus (HIV) are increasing. This means that chronic, metabolic complications of HIV are becoming more frequent in clinical practice, as acute morbidity is controlled. Management of HIV/acquired immunodeficiency syndrome (AIDS) is gradually expanding to include these chronic and metabolic complications of the disease, and the adverse effects associated with its treatments, including diabetes. Unfortunately, no guidelines are available to help the medical practitioners choose appropriate therapy for patients with these conditions. The aim of the South Asian Consensus Guidelines is to provide evidence-based recommendations to assist healthcare providers in the rational management of type 2 diabetes mellitus in patients with HIV. The development of these guidelines used systematic reviews of available evidence to form its key recommendations. These guidelines and associated review of literature represent a compilation of available knowledge regarding rational management of diabetes in HIV. Patients of diabetes with concomitant HIV infection are managed optimally with insulin therapy and judicious use of highly active antiretroviral therapy with suitable alternatives is also recommended. These guidelines should prove helpful to physicians, not only in South Asia, but also across the globe, while managing patients with coexistent HIV and diabetes.

The Relationship Between HIV Infection and Cardiovascular Disease

Over 30 million people are currently living with human immunodeficiency virus (HIV) infection, and over 2 million new infections occur per year. HIV has been found to directly affect vascular biology resulting in an increased risk of cardiovascular disease compared to uninfected persons. Although HIV infection can now be treated effectively with combination antiretroviral medications, significant toxicities such as hyperlipidemia, diabetes, and excess cardiovascular co-morbidity; as well as the potential for significant drug-drug interactions between HIV and cardiovascular medications, present new challenges for the management of persons infected with HIV. We first review basic principles of HIV pathogenesis and treatment and then discuss relevant clinical management strategies that will be useful for cardiologists who might be involved in the care of HIV infected patients.

Comorbidity-related treatment outcomes among HIV-infected adults in the Bronx, NY

Aging, HIV infection, and antiretroviral therapy have been associated with increasing rates of chronic comorbidities in patients with HIV. Urban minority populations in particular are affected by both the HIV/AIDS and chronic disease epidemics. Our objectives were to estimate the prevalence of and risk factors for hypertension, dyslipidemia, and diabetes among HIV-infected adults in the Bronx and describe comorbidity-related treatment outcomes. This was a cross-sectional study of 854 HIV-positive adults receiving care at 11 clinics which provide HIV primary care services; clinics were affiliated with a large urban academic medical center. Data on blood pressure (BP), cholesterol, and glycemic control were collected through standardized chart review of outpatient medical records. We found prevalence rates of 26%, 48%, and 13% for hypertension, dyslipidemia, and diabetes, respectively. Older age, obesity, family history, and current protease inhibitor use were consistently associated with comorbidity. Diabetes treatment goals were achieved less often than BP and lipid goals, and concurrent diabetes was a significant predictor for BP and lipid control. In conclusion, major cardiovascular-related comorbidities are prevalent among HIV-positive adults in the Bronx, especially older and obese individuals. Differences exist in comorbidity-related treatment outcomes, especially for patients with concurrent diabetes. Because cardiovascular risk is modifiable, effective treatment of related comorbidities may improve morbidity and mortality in HIV-infected patients.

Glycemic control in HIV-infected patients with diabetes mellitus and rates of meeting American Diabetes Association management guidelines

Limited data exist on the prevalence of inadequate glycemic control and rates of meeting American Diabetic Association (ADA) management guidelines in HIV-infected adults with diabetes mellitus. We conducted a retrospective cross-sectional study of 142 HIV-infected adults with type 2 diabetes at an urban academic HIV clinic during 2008. We estimated the prevalence of and assessed associations with inadequate glycemic control, defined as hemoglobin A(1c) ≥ 7.5% for ≥ 50% of quarters over the year, and determined rates of meeting ADA clinical goals. Ninety-two percent of patients received antiretroviral therapy. The prevalence of inadequate glycemic control was 33% (95% confidence interval [CI] 25%-42%). Compared to patients with adequate control, those with inadequate control had fewer years since HIV diagnosis (12.7 versus 15.1, p = 0.01), increased use of insulin (60% versus 20%, p < 0.001) or any diabetic medication (98% versus 85%, p = 0.02), and higher triglyceride levels (238 versus 168 mg/dL, p = 0.008). Rates of achieving ADA goals were 42% for blood pressure, 66% for low-density lipoprotein cholesterol (LDL-C), 33% for high-density lipoprotein cholesterol, and 31% for triglycerides. Thirty-six percent of patients who did not meet the LDL-C goal received statin therapy. Forty-seven percent of patients were screened for retinopathy and 19% of patients without preexisting renal disease were screened for nephropathy. In conclusion, the prevalence of inadequate glycemic control in HIV-infected patients with diabetes is similar to published data from the general population. Suboptimal rates of meeting ADA blood pressure and lipid goals and adherence to screening guidelines demonstrate need for further clinician and patient education.

Impact of metabolic complications on antiretroviral treatment adherence: clinical and public health implications

Antiretroviral therapy (ART) is an effective strategy for preventing disease progression of HIV infection, particularly when patients adhere closely to the treatment regimen. However, ART medications can cause side effects, including metabolic complications that can impact patients' adherence levels. Selected chronic complications associated with ART include lipodystrophy, hyperlipidemia, insulin resistance and diabetes, peripheral neuropathy, and bone disorders such as osteopenia/osteoporosis. In this article, we review the effects of these metabolic complications on ART adherence and approaches to prevent or reverse them.