Diabetes Risk in HIV pts, Screening and Monitoring it in People With HIV

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Many HIV populations have high frequencies of classic diabetes risk factors, but is HIV itself a risk factor?This is a controversial question: different cohorts have different results. Some cohorts like the MACS found a clear increase in the prevalence and incidence of diabetes in HIV-infected people compared with uninfected controls.This has also been seen in the Women's Interagency HIV Study (WIHS) and in several other cohorts. But other cohorts such as the Veterans Aging Cohort Study (VACS) have seen quite the opposite -- that HIV-infected patients in the VA system have a lower incidence of diabetes than veterans without HIV. So I think the impact of HIV on diabetes risk is probably population-dependent.
What we're seeing with HIV and diabetes is similar to what we see for other comorbidities: HIV disease itself may have some impact, antiretroviral therapy may have an impact, and traditional risk factors for the comorbidity are also critically important. We can look at each of those factors in turn.TNF receptor levels 48 weeks after antiretroviral initiation, when people had a suppressed viral load, were associated with incident diabetes.From that perspective, HIV is probably an independent risk factor for diabetes.
The next category is the effect of antiretrovirals. Antiretrovirals have changed quite a bit since the introduction of highly active antiretroviral therapy (HAART): In general the medications have become a lot more metabolically friendly, and this improvement definitely includes effects on glucose metabolism. In the late 1990s, soon after widespread uptake of HAART, research showed that early protease inhibitors (PIs) like Stavudine had a marked effect on glucose metabolism.But modern PIs are not causing bad effect on glucose metabolism.
Probably the biggest drivers of diabetes in HIV populations are traditional risk factors -- mainly increased adiposity and obesity. We're seeing high rates of obesity in HIV populations, just as we are in the general population, and this is the biggest driver of the diabetes epidemic in the United States. The other major factor of course is age. The HIV population is getting older, and age is a major diabetes risk factor.
Other reasons why HIV patients may have an increased risk of diabetes are other infections: Hepatitis C infection is associated with abnormal glucose metabolism, and this may contribute to diabetes in HIV/HCV-coinfected patients. Concomitant medications may also play a role. Steroids have a huge effect on glucose metabolism, and for patients taking medications that interfere with steroid metabolism -- such as ritonavir and cobicistat -- this may be a particular problem. Also, some HIV patients take atypical antipsychotics, which can increase diabetes risk by increasing weight and also through an independent effect on glucose metabolism.