Prediabetes among HIV-infected individuals receiving antiretroviral therapy: prevalence, diagnostic tests, and associated factors

Association of prior tuberculosis with altered cardiometabolic profiles of people with HIV: A comparative cross-sectional study in Uganda

Background

Cardiovascular disease (CVD) is the leading cause of mortality among people with HIV (PWH), but the influence of co-infections like tuberculosis (TB) on CVD risk remains underexplored. We aimed to compare cardiometabolic profiles of PWH with and without prior TB to determine if prior TB is associated with distinct cardiometabolic profiles.

Methods

We conducted a comparative, cross-sectional study at a tertiary hospital in Kampala, Uganda. Participants were randomly sampled PWH aged ≥ 18 years on antiretroviral therapy. Specifically, we enrolled PWH with and without prior active TB (ratio of 1:1). Anthropometric measurements, blood pressure, fasting blood glucose (FBG), lipid profile, and glycated hemoglobin were assessed.

Results

A total of 396 participants were enrolled (196 TB survivors and 200 controls). TB survivors had higher median FBG (5.5 vs. 5.1 mmol/l, p < 0.001) and a higher prevalence of DM (17.9 % vs. 9.5 %, p = 0.015). However, they had lower body mass index (23.0 vs. 25.1 kg/m2, p < 0.001) and waist circumference (81.0 vs. 84.0 cm, p = 0.026). TB survivors had higher HDL-c levels (1.0 vs. 0.8 mmol/l, p < 0.001), lower LDL-c levels (2.7 vs. 3.1 mmol/l, p < 0.001) and lower prevalence of dyslipidemia (81.7 % vs. 96.5 %, p < 0.001). Prior TB was independently associated with higher prevalence of elevated FBG (adjusted prevalence ratio (aPR) 1.79, 95 % CI 1.10-2.92) and DM (aPR 2.34, 95 % CI 1.11-4.94), but decreased risk of obesity (aPR 0.42, 95 % CI 0.20-0.88).

Conclusion

TB survivors with HIV exhibit a higher risk of DM but lower risk of obesity compared to those without a history of TB, indicating a need for blood glucose monitoring among TB survivors.

Association of prior tuberculosis with altered cardiometabolic profiles of people with HIV: A comparative cross-sectional study in Uganda

Background

Cardiovascular disease (CVD) is the leading cause of mortality among people with HIV (PWH), but the influence of co-infections like tuberculosis (TB) on CVD risk remains underexplored. We aimed to compare cardiometabolic profiles of PWH with and without prior TB to determine if prior TB is associated with distinct cardiometabolic profiles.

Methods

We conducted a comparative, cross-sectional study at a tertiary hospital in Kampala, Uganda. Participants were randomly sampled PWH aged ≥18 years on antiretroviral therapy. Specifically, we enrolled PWH with and without prior active TB (ratio of 1:1). Anthropometric measurements, blood pressure, fasting blood glucose (FBG), lipid profile, and glycated hemoglobin were assessed.

Results

A total of 396 participants were enrolled (196 TB survivors and 200 controls). TB survivors had higher median FBG (5.5 vs. 5.1 mmol/l, p<0.001) and a higher prevalence of DM (17.9% vs. 9.5%, p=0.015). However, they had lower body mass index (23.0 vs. 25.1 kg/m², p<0.001) and waist circumference (81.0 vs. 84.0 cm, p=0.026). TB survivors had higher HDL-c levels (1.0 vs. 0.8 mmol/l, p<0.001), lower LDL-c levels (2.7 vs. 3.1 mmol/l, p<0.001) and lower prevalence of dyslipidemia (81.7% vs. 96.5%, p<0.001). Prior TB was independently associated with higher prevalence of elevated FBG (adjusted prevalence ratio (aPR) 1.79, 95% CI 1.10-2.92) and DM (aPR 2.34, 95% CI 1.11-4.94), but decreased risk of obesity (aPR 0.42, 95% CI 0.20-0.88).

Conclusion

TB survivors with HIV exhibit a higher risk of DM but lower risk of obesity compared to those without a history of TB, indicating a need for blood glucose monitoring among TB survivors.

Interferon Upregulation Associates with Insulin Resistance in Humans

In humans, insulin resistance is a physiological response to infections developed to supply sufficient energy to the activated immune system. This metabolic adaptation facilitates the immune response but usually persists after the recovery period of the infection and predisposes the hosts to type 2 diabetes and vascular injury. In patients with diabetes, superimposed insulin resistance worsens metabolic control and promotes diabetic ketoacidosis. Pathogenic mechanisms underlying insulin resistance during microbial invasions remain to be fully defined. However, interferons cause insulin resistance in healthy subjects and other population groups, and their production is increased during infections, suggesting that this group of molecules may contribute to reduced insulin sensitivity. In agreement with this notion, gene expression profiles (transcriptomes) from patients with insulin resistance show a robust overexpression of interferon- stimulated genes (interferon signature). In addition, serum levels of interferon and surrogates for interferon activity are elevated in patients with insulin resistance. Circulating levels of interferon- γ-inducible protein-10, neopterin, and apolipoprotein L1 correlate with insulin resistance manifestations, such as hypertriglyceridemia, reduced HDL-c, visceral fat, and homeostasis model assessment-insulin resistance. Furthermore, interferon downregulation improves insulin resistance. Antimalarials such as hydroxychloroquine reduce interferon production and improve insulin resistance, reducing the risk for type 2 diabetes and cardiovascular disease. In addition, diverse clinical conditions that feature interferon upregulation are associated with insulin resistance, suggesting that interferon may be a common factor promoting this adaptive response. Among these conditions are systemic lupus erythematosus, sarcoidosis, and infections with severe acute respiratory syndrome-coronavirus-2, human immunodeficiency virus, hepatitis C virus, and Mycobacterium tuberculosis.

Diagnosis and Risk Factors of Prediabetes and Diabetes in People Living With Human Immunodeficiency Virus: Evaluation of Clinical and Microbiome Parameters

Diabetes mellitus (DM) is more common among people living with human immunodeficiency virus (PLWH) compared with healthy individuals. In a prospective multicenter study (N = 248), we identified normoglycemic (48.7%), prediabetic (44.4%), and diabetic (6.9%) PLWH. Glycosylated hemoglobin (HbA1c) and fasting blood glucose (FBG) sensitivity in defining dysglycemia was 96.8%, while addition of oral glucose tolerance test led to reclassification of only 4 patients. Inclusion of 93 additional PLWH with known DM enabled identification of multiple independent predictors of dysglycemia or diabetes: older age, higher body mass index, Ethiopian origin, HIV duration, lower integrase inhibitor exposure, and advanced disease at diagnosis. Shotgun metagenomic microbiome analysis revealed 4 species that were significantly expanded with hyperglycemia/hyperinsulinemia, and 2 species that were differentially more prevalent in prediabetic/diabetic PLWH. Collectively, we uncover multiple potential host and microbiome predictors of altered glycemic status in PLWH, while demonstrating that FBG and HbA1c likely suffice for diabetes screening. These potential diabetic predictors merit future prospective validation.

HIV and comorbidities - the importance of gut inflammation and the kynurenine pathway

PURPOSE OF REVIEW

The purpose of this article is to review alterations in microbiota composition, diversity, and functional features in the context of chronic inflammation and comorbidities associated with HIV infection.

RECENT FINDINGS

The gut microbiome is an important mediator of host immunity, and disruption of gut homeostasis can contribute to both systemic inflammation and immune activation. Ageing and HIV share features of intestinal damage, microbial translocation and alterations in bacterial composition that contribute to a proinflammatory state and development of age-related comorbidities. One such inflammatory pathway reviewed is the nicotinamide adenine dinucleotide (NAD+) producing kynurenine pathway (KP). Kynurenine metabolites regulate many biological processes including host-microbiome communication, immunity and oxidative stress and the KP in turn is influenced by the microbiome environment. Age-associated decline in NAD+ is implicated as a driving factor in many age-associated diseases, including those seen in people with HIV (PWH). Recent studies have shown that KP can influence metabolic changes in PWH, including increased abdominal adiposity and cardiovascular disease. Furthermore, KP activity increases with age in the general population, but it is elevated in PWH at all ages compared to age-matched controls. Host or microbiome-mediated targeting of this pathway has merits to increase healthy longevity and has potential therapeutic applications in PWH.

SUMMARY

As a growing proportion of PWH age, many face increased risks of developing age-related comorbidities. Chronic inflammation, a pillar of geroscience, the science of ageing and of age-related disease, is influenced by the gut microbiome and its metabolites. Combined, these contribute to a systemic inflammatory signature. Advances in geroscience-based approaches and therapeutics offer a novel paradigm for addressing age-related diseases and chronic inflammation in HIV infection. Whether targeted inhibition of KP activity alleviates pathological conditions or promotes successful ageing in PWH remains to be determined.

Metformin for Preventing Progression From Prediabetes to Diabetes Mellitus in People Living With Human Immunodeficiency Virus

Background Diabetes mellitus (DM) and human immunodeficiency virus (HIV) itself increase the risk for cardiovascular diseases in people living with HIV (PLHIV). Prediabetes, a condition preceding DM, is common in PLHIV receiving antiretroviral therapy (ART). Both metformin and lifestyle interventions have been established to reduce the risk of progression from prediabetes to DM in the general population. This study aimed to evaluate the efficacy of metformin for preventing DM in prediabetic PLHIV. Methods An open-label randomized controlled clinical trial was conducted in HIV-positive persons with prediabetes. The participants were randomized into two groups: the metformin group (received metformin) and the control group (did not receive metformin). All participants were counseled regarding diet control and lifestyle modification and followed for 12 months. The primary endpoint was the development of DM. Fasting plasma glucose (FPG), two-hour plasma glucose (2-h PG) after 75 g oral glucose tolerance test (OGTT), hemoglobin A1c (HbA1c), and computer-based homeostatic model assessment index of beta-cell function (HOMA%B) and insulin resistance (HOMA-IR) were analyzed. Results Seventy-four participants were enrolled, 37 in each group. The mean age was 49.6 years, and 68.9% were males. At baseline, the mean CD4 cell count was 570 cells/mm3, and the mean body mass index (BMI) was 24.6 kg/m2. Baseline characteristics including age, sex, BMI, waist/hip ratio, duration of ART, ART regimen, CD4 cell count, and HIV RNA were similar between the two groups. The mean FPG, 2-h PG, HbA1c, HOMA%B, and HOMA-IR at baseline were also similar between the two groups. At 12 months, one participant in the metformin group and three in the control group developed DM (risk reduction: 5.41%; 95% confidence interval (CI): -6.92%-18.78%). When we compared changes in parameters between the two groups, there were trends toward more changes in HbA1c ([Formula: see text]HbA1c) at both six months (metformin group versus control group: -0.17% ± 0.20% versus 0.02% ± 0.58%; p = 0.074) and 12 months (metformin group versus control group: -0.05% ± 0.23% versus 0.06% ± 0.27%; p = 0.065). When we considered changes in all parameters in each group, the metformin group had significant reductions in body weight (BW) and BMI at both six and 12 months, and significant reductions in HbA1c and HOMA-IR at six months. No participant had adverse effects that led to the discontinuation of metformin. No cardiovascular event was observed during the study period. Conclusions Metformin tends to improve HbA1c and insulin resistance and may prevent progression from prediabetes to DM in HIV-positive persons with prediabetes. A further large study with a longer study period is needed to evaluate the long-term benefit of metformin.

Association between gut microbiota and prediabetes in people living with HIV

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Gut microbiota are known to be associated with various metabolic syndromes.

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Diversity of gut microbiota decreases in PLWH with prediabetes.

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Streptococcus and Anaerostignum are more abundant in the prediabetes group.

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Further study of alteration in gut microbiota on glucose metabolism is warranted.

The prevalence of prediabetes is rapidly increasing in general population and in people living with HIV (PLWH). Gut microbiota play an important role in human health, and dysbiosis is associated with metabolic disorders and HIV infection. Here, we aimed to evaluate the association between gut microbiota and prediabetes in PLWH. A cross-sectional study enrolled 40 PLWH who were receiving antiretroviral therapy and had an undetectable plasma viral load. Twenty participants had prediabetes, and 20 were normoglycemic. Fecal samples were collected from all participants. The gut microbiome profiles were analyzed using 16S rRNA sequencing. Alpha-diversity was significantly lower in PLWH with prediabetes than in those with normoglycemia (p<0.05). A significant difference in beta-diversity was observed between PLWH with prediabetes and PLWH with normoglycemia (p<0.05). Relative abundances of two genera in Firmicutes (Streptococcus and Anaerostignum) were significantly higher in the prediabetes group. In contrast, relative abundances of 13 genera (e.g., Akkermansia spp., Christensenellaceae R7 group) were significantly higher in the normoglycemic group. In conclusion, the diversity of gut microbiota composition decreased in PLWH with prediabetes. The abundances of 15 bacterial taxa in the genus level differed between PLWH with prediabetes and those with normoglycemia. Further studies on the effect of these taxa on glucose metabolism are warranted.

Recent data on adipose tissue, insulin resistance, diabetes and dyslipidaemia in antiretroviral therapy controlled HIV-infected persons

PURPOSE OF REVIEW

Increased total body fat with truncal redistribution is common in antiretroviral therapy (ART)-controlled persons living with HIV(PLWH), leading to insulin resistance, prediabetes/diabetes and dyslipidaemia. We address these topics here.

RECENT FINDINGS

Most antiretrovirals are associated with gain in trunk fat, including visceral adipose tissue (VAT). Protease-inhibitors could inhibit white fat ability to dissipate energy (i.e. beiging) favouring fat gain. Expansion of VAT is associated with a pro-inflammatory profile linked to the tryptophan-kynurenine pathway and CD4+ subtypes. ART-associated increased adipose tissue (AT) quantity leads to decreased AT density, insulin resistance and dyslipidaemia that could be improved by lifestyle modifications.PLWH present high level of insulin resistance, regardless of their treatment, and a higher prevalence of prediabetes, but not diabetes, than noninfected persons. Otherwise, HbA1c values appear inaccurate to diagnose prediabetes/diabetes in PLWH.ART-related-dyslipidaemia is characterized by elevated LDL-C and/or high triglycerides and reduced HDL-C. Whereas treatment with protease inhibitors generally results in worsened lipid values, treatment with integrase-strand-transfer-inhibitors is associated with a better profile. Tenofovir-alafenamide is associated with higher lipid levels than tenofovir-disoproxil-fumarate. Treatment of LDL-C-dyslipidaemia could benefit, in statin-insufficiently controlled patients, from the class of proprotein-convertase-subtilsin-kenin-type-9 (PCSK-9) inhibitors.

SUMMARY

Lifestyle modifications are mandatory to reduce fat and improve dysglycaemia/dyslipidaemia. New drugs can efficiently control diabetes and LDL-C-dyslipidaemia.

Effects of an intensive lifestyle intervention and the role of sleep in people living with HIV and prediabetes: a pilot and feasibility study

Objectives

Prediabetes is prevalent in people living with HIV (PLWH). Insufficient and irregular sleep are linked to abnormal glucose metabolism. This study aimed to investigate the differences in sleep characteristics between PLWH with and without prediabetes, determine the acceptability/feasibility and effects of a pilot six-month intensive lifestyle intervention (ILI) program on glucose metabolism in those with prediabetes, and determine how sleep modulates these effects.

Results

Thirty-nine PLWH (20 normoglycemia and 19 prediabetes) participated. There were no differences in sleep characteristics between individuals with normoglycemia and prediabetes. Next, thirteen individuals with prediabetes completed a six-month ILI program. The ILI program resulted in significant body weight reduction at 6 months (63.5 ± 13.9 to 61.9 ± 14.0 kg, p = 0.012), which was maintained at 12 months (p < 0.001). Waist circumferences were significantly decreased at 12 months (85.4 ± 11.7 to 82.9 ± 12.7 cm, p = 0.014). An increase in sleep variability was significantly associated with an increase in 2-h plasma glucose, independent of changes in BMI (b = 0.603), and physical activity (b = 0.774). This pilot study suggested that ILI in PLWH with prediabetes is feasible and effective in improving metabolic control, with its effects possibly modulated by sleep variability. These findings should be confirmed in a larger study to reduce diabetes risk in this population.

Trail registration: ClinicalTrial.gov, NCT03545217 (date of registration: May 22, 2018)