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CME / ABIM MOC / CE

Is HIV a Risk Factor for Type 2 Diabetes?

  • Authors: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 2/11/2022
  • Valid for credit through: 2/11/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for all primary care physicians, infectious disease specialists, endocrinologists, nurses, pharmacists, and other members of the healthcare team who care for people living with HIV (PLWH).

The goal of this activity is to increase clinician knowledge on the prevalence of type 2 diabetes (T2D) among PLWH.

Upon completion of this activity, participants will:

  • Analyze risk factors for T2D among PLWH
  • Distinguish antiretroviral drugs most associated with a higher risk for incident T2D
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


Faculty

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/CE Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.


Accreditation Statements



In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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    For Nurses

  • Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; none of these credits is in the area of pharmacology.

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    For Pharmacists

  • Medscape, LLC designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number JA0007105-0000-22-041-H01-P).

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CME / ABIM MOC / CE

Is HIV a Risk Factor for Type 2 Diabetes?

Authors: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/11/2022

Valid for credit through: 2/11/2023

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Clinical Context

There has been a shift in the general management of people living with HIV (PLWH) to recognize higher rates of chronic illness as patients grow older. One of the most significant of these disease states is type 2 diabetes (T2D). Even though highly active antiretroviral therapy (HAART) has had significant impact on morbidity and mortality in PLWH, it has not been without adverse effects. There has been a shift in the general management of PLWH to recognize higher rates of chronic illness as patients grow older. One of the most significant of these disease states is T2D. Others include dyslipidemia and insulin resistance. A review by Monroe and colleagues, published in the February 1, 2015 issue of Clinical Infectious Diseases,[1] summarizes the interaction between HIV infection and diabetes.

Up to 14% of PLWH have diabetes, although the role of HIV infection as an independent risk factor for diabetes is controversial. Less controversial is the role of antiretroviral (ARV) therapy in the development of diabetes complications. Patients with HIV tend to have increased incidence of hepatitis C infection, HIV-related inflammation, ART-associated lipoatrophy as well as low testosterone, which present as influential factors in the development of diabetes. Use of some medications in this population serves as a contributing factor as well (ie, corticosteroids, atypical antipsychotics, opiates, and some HIV medications). Protease inhibitors can both reduce insulin secretion and increase insulin resistance, and first-generation ARV agents such as stavudine and indinavir were associated with a higher risk for incident T2D; however, the phasing out of these drugs during the decade of the 2000s resulted in a lower incidence rate of T2D.

The current study by Duncan and colleagues evaluates what has happened to the epidemiology of T2D and dysglycemia between 2005 and 2015 among PLWH.

Study Synopsis and Perspective

Modern treatment offers highly effective and well-tolerated means to treat HIV infection, and thus PLWH infection are living longer. This is something to be celebrated as we mark the 40th anniversary of the discovery of HIV infection in the United States; however, increased longevity as well as some adverse effects of treatment for HIV infection have resulted in higher rates of detection of chronic illness among PLWH.

A new study investigates how the prevalence of T2D has progressed among PLWH over the decade between 2005 and 2015. Researchers purposefully sampled a diverse group of PLWH who were receiving care in clinics around London, England that were not specifically focused on the care of HIV. They compared 337 patients during the 2005 period with 338 from the 2014-2015 period. 

The 2014-2015 cohort was significantly older (median age, 49 [interquartile range (IQR), 42-57] years vs 41 (IQR, 35-47) years; P < .001), had higher body mass index (BMI) values (27.4 [IQR, 23.3-29.9] vs 24.9 [IQR, 22.4-28] kg/m2 respectively; P = .019), and higher rates of hypertension (37.9% vs 19.6%, respectively, P < .001) compared with the 2005 cohort. The prevalence rates of T2D in 2014-2015 and 2005 were 15.1% and 6.8%, respectively (P = .003). The relative risk for T2D in the 2015 cohort was estimated at 2.4; however, the prevalence of impaired fasting glucose was similar in the 2 cohorts (2005: 18.1% vs 2015: 17.2%; P = .763). The 2015 cohort showed strong predictors of dysglycemia to be hepatic steatosis and hypertension (odds ratio [OR] = 6.74 [95% CI: 3.48, 13.03] and 2.92 [95% CI: 1.66, 5.16], respectively), and HIV-related factors of weight gain after initiation of ARV and longer duration of infection (OR = 1.07 [95% CI: 1.04, 1.11] and 1.06 [95% CI: 1.02, 1.1] respectively).

One interesting finding from the study was that common risk factors for T2D such as sedentary behavior were more impactful than HIV-related variables, such as the type of ARV therapy employed.

“The alarmingly high prevalence of [T2D] in HIV requires improved screening, targeted to older patients and those with a longer duration of exposure to [ARVs],” the authors of the study wrote.

The authors concluded that “effective diabetes prevention and management strategies are needed urgently to reduce this risk; such interventions should target both conventional risk factors, such as abdominal obesity, and HIV-specific risk factors such as weight gain following initiation of [ARVs].”

Since the study was published in Plos One,[2] concerns with weight gain in the HIV population have continued to increase, noted first author Alastair Duncan, PhD, principal dietician at Guy’s & St. Thomas’ Hospital and lecturer, King’s College London.

“As in the general population, [PLWH] experienced significant weight gain during COVID-related lockdowns. Added to the higher number of [PLWH] being treated with integrase inhibitors, weight gain remains a challenge,” Duncan told Medscape Medical News.

In addition, “there are not enough studies comparing [PLWH] with the general population,” Duncan added. “We need to conduct studies where participants are matched.”

Overall, the study results suggest that healthcare providers should be screening PLWH for diabetes risk factors, promoting improvement of modifiable risk factors, and routinely testing these patients for T2D.

Study Highlights

  • Researchers recruited PLWH from 3 outpatient clinics in London. They performed the recruitment intentionally to enroll a diverse set of patients.
  • They compared patient data in the health record from 2005 with data from 2014-2015. Data included vital signs and information on chronic illnesses and labs. Patients also provided data from a fasting glucose sample. Normal fasting glucose was defined by a level < 6 mmol/l. Impaired fasting glucose was defined by a value of 6 to 6.9 mmol/l, and T2D was defined by a glucose level of ≥ 7 mmol/l.
  • The main study outcomes were the presence of impaired fasting glucose and T2D in 2005 and 2014-2015. Researchers were also interested in risk factors related to incident T2D.
  • 337 patients had data available for analysis in 2005, and researchers compared them with 338 participants in the 2014-2015 group. Approximately three-quarters of patients were male, and the median age increased from 41 to 49 years in comparing the two study periods.
  • The 2014-2015 cohort also had higher BMI values vs the 2005 cohort; 58% of participants in the 2015 group were overweight or obese.
  • The 2014-2015 cohort also had higher rates of hypertension and duration of HIV infection vs the 2005 group, but they had lower rates of smoking and lipodystrophy.
  • The prevalence rates of T2D in 2014-2015 and 2005 were 15.1% and 6.8%, respectively. The prevalence of impaired fasting glucose was similar in the two cohorts.
  • Variables associated with a higher risk for dysglycemia in both patient cohorts included age, the presence of hypertension, the duration of HIV infection, and the use of ARVs. Variables associated with a higher risk for dysglycemia in 2014-2015 alone included weight gain after initiation of ARV, low levels of physical activity, and weight gain after initiation of ARV.
  • Overall, modifiable risk factors such as physical activity and hypertension were stronger risk factors for dysglycemia compared with HIV-related factors such as duration of infection or ARV treatment.
  • Hepatic steatosis and hypertension stood out as the most significant risk factors for dysglycemia.

Clinical Implications

  • Older ARVs such as stavudine and indinavir are associated with higher risks for T2D among PLWH.
  • In the current study of PLWH by Duncan and colleagues, the prevalence of T2D more than doubled between 2005 and 2015. Hepatic steatosis and hypertension stood out as the most significant risk factors for dysglycemia.
  • Implications for the healthcare team: The healthcare team should encourage PLWH to improve modifiable risk factors for T2D and test for diabetes routinely.

 

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