One third of people with HIV and diabetes in a New York City university medical center had poor control of blood sugar, and low proportions met guidelines for blood pressure, cholesterol, and triglycerides.1 In addition, physicians tested few of these people with HIV and diabetes for serious diabetes complications.
One in 10 US adults has diabetes, a disease marked by high sugar levels in the blood. Diabetes rates are especially high in African Americans and Hispanics.2 Diabetes is a serious lifelong disease that can cause high blood pressure, heart disease, kidney disease, and blindness. HIV and two types of antiretrovirals -- nucleosides and protease inhibitors -- may contribute to the risk of diabetes. In a study of US gay men, the diabetes rate was 4 times higher in those with HIV than in those without HIV.3
Earlier studies found poor blood sugar control in people with diabetes and HIV.4,5 Researchers at a New York City university medical center planned this study to see how well blood sugar is controlled in their patients with diabetes and HIV, and to identify factors that may contribute to poor blood sugar control. The study also aimed to determine whether people with diabetes and HIV met American Diabetes Association guidelines6 for blood pressure and lipids (blood fats) and whether they were tested for eye and kidney complications of diabetes.
American Diabetes Association Goals for People With Diabetes6
The research team recorded all the antiretrovirals and other drugs study participants took from October 2007 to December 2008, and they noted other important lifestyle and HIV-related factors that may influence blood sugar and diabetes. The researchers also figured how well people with HIV and diabetes met American Diabetes Association goals for blood pressure, "good" highdensity lipoprotein (HDL) cholesterol, "bad" low-density lipoprotein (LDL) cholesterol, and triglycerides (see box).6 Finally, the researchers checked to see whether people with HIV and diabetes were examined for diabetic retinopathy (damage to the image-reading part of the eye) and microalbuminuria (the first sign of diabetic kidney disease).
People with poor blood sugar control did differ significantly from those with adequate control in five ways:
In the whole study group, two thirds met the American Diabetes Association goal for LDL cholesterol6 (Figure 1). But only 42% met the blood pressure goal, 33% met the HDL cholesterol goal, and 31% met the triglyceride goal (Figure 1). Significantly more people taking a nonnucleoside (such as Intelence, Sustiva, or Viramune) met the HDL cholesterol goal than did people taking a protease inhibitor (such as Kaletra, Prezista, or Reyataz) (40% versus 25%). People taking the older nucleosides Retrovir, Videx, or Zerit were less likely to meet triglyceride goals than people taking newer nucleosides (14% versus 40%). Among the 39 people who did not meet the goal for LDL cholesterol, 25 (64%) never took a statin in 2008. Statins are a type of LDL cholesterol-lowering drug.
Figure 1. Two thirds of people with HIV and diabetes in a New York City clinic met American Diabetes Association goals6 for low-density lipoprotein (LDL) cholesterol. But fewer than half met the blood pressure goal, and only one third met goals for high-density lipoprotein (HDL) cholesterol and triglycerides.
Only 27 of these 142 people (19%) had a test called the urine albumin-to-creatinine ratio in 2008. This ratio can identify people with microalbuminuria, which means the kidney is starting to spill a protein called albumin into the urine. Microalbuminuria is an early signal of diabetic kidney disease. Thirteen of the 27 people tested (48%) did have microalbuminuria.
Only 66 of the 142 study participants (46%) had a record of an eye exam to check for diabetic retinopathy (damage to the retina that may occur with diabetes). Thirteen of 59 people (22%) with test results on record did have evidence of retinopathy.
A few factors assessed suggested which people had a higher risk of poor blood sugar control (see bullet list above). Some of these factors, such as use of diabetes medications and insulin, were probably the result of having higher blood sugars rather than causing poor blood sugar control. Most factors analyzed -- including age, gender, race, CD4 count, and antiretroviral use -- did not differ between people with poor versus adequate blood sugar control. As a result, the researchers suggest that individual characteristics cannot be easily used to predict poor blood sugar control.
The study also found that low proportions of this group with HIV and diabetes met accepted goals for blood pressure, "good" HDL cholesterol, and triglycerides (Figure 1). One third of the study group did not meet the goal for "bad" LDL cholesterol. And two thirds of people who did not meet the LDL cholesterol goal never took a type of drug (a statin) that lowers LDL cholesterol and so lowers the risk of serious heart disease and stroke. The researchers say HIV health care providers should be educated about "the importance of aggressive statin use in patients with diabetes."
Doctors in this HIV clinic were not checking most people with diabetes for a serious diabetic eye complication -- or at least not recording in the chart that they had seen an eye doctor. And few patients had a test to detect diabetesrelated kidney trouble. The researchers note that a standard urine test does not reliably identify diabetes-related kidney problems. The urine albumin-to-creatinine ratio can detect an early signal of kidney damage. Because drugs are available to treat this problem, the researchers say "education of HIV primary care providers on the importance of this screening test is essential."
Together, these findings indicate that some HIV doctors may not be offering adequate care to people with diabetes and HIV. HIV-positive people with diabetes and their physicians should be aware of goals for blood sugar, cholesterol, triglycerides, and blood pressure. American Diabetes Association 2011 guidelines6 are available online at (http://care.diabetesjournals.org/content/34/Supplement_1/S11.full).
All people with HIV should take basic steps to control their blood sugar, including eating a balanced diet and exercising. The American Diabetes Association has a Website devoted to the general public, which includes information on diet and exercise (click on "Food & Fitness" tab at www.diabetes.org/). This site also has advice on preventing diabetes and living with diabetes. The home page of the American Diabetes Association lists a toll-free number to call with questions about diabetes (1-800-DIABETES) as well as an online chat option.