Diabetes and HIV

When we eat, our body digests food into glucose (blood sugar) which is carried in the bloodstream and enters cells throughout the body where it is used as energy. If you have type 2 diabetes, this process doesn’t work well. Glucose cannot enter the cells that need it and instead builds up in your bloodstream.

Produced by your pancreas, a hormone called insulin helps glucose to enter cells and keeps glucose at the right level in your blood. People with type 2 diabetes have insulin resistance, which means that the insulin cannot work properly, the pancreas does not produce enough insulin, or both, and as a consequence, levels of glucose increase in the blood.

High levels of glucose (hyperglycaemia) make your blood thick and sticky and can result in damage to the blood vessels in different parts of the body. If your cells don’t get enough glucose, they cannot function properly. Over time, this can lead to serious health problems including heart disease, kidney failure, blindness, dementia, infections and digestive issues. Consistent high levels of glucose can also result in damage to the blood supply to nerves in the hands and the feet. This can cause serious complications in the feet.

The management of type 2 diabetes is not simple. It requires regular and frequent monitoring of your blood glucose levels, at least until your diabetes is stabilised with treatment. You may need to make significant changes to the food you eat (less fat and sugar) and to your physical activity. You may also need to take medications.

This page describes type 2 diabetes, which increasingly affects people living with HIV as they get older.

You may also hear about type 1 diabetes (which usually develops during childhood) and gestational diabetes (which can affect pregnant women). Each condition is managed differently.

You might be told that your levels of blood glucose are higher than normal but not high enough for a diagnosis of diabetes. This is sometimes called pre-diabetes, impaired glucose tolerance or moderate fasting hyperglycaemia. It means that you are at increased risk of developing type 2 diabetes, especially if you don’t make changes to your lifestyle.

Your lifestyle and diabetes

Changes to your lifestyle can reduce your risk of diabetes. If you are living with type 2 diabetes, the same lifestyle changes will help keep your blood glucose levels under control.

Lose weight. This is particularly important if you have excess weight around your belly as larger waist sizes are associated with an increased risk of diabetes. You should aim to keep your weight within the ideal range for your height, age and sex. Your doctor, nurse or dietitian can tell you what this range is. Even losing a little weight can make a big difference.

Exercise regularly. You should aim to do at least 150 minutes of exercise every week (for example, 30 minutes on five days a week). Moderate activity will raise your heart rate and make you breathe faster and feel warmer. It includes activities like walking fast, dancing, gardening, cycling and even cleaning your home for one or two hours. It is also recommended that you do some muscle-strengthening exercises (lifting weights or doing exercises that use your own body weight like yoga or Pilates).

You could also make sure you walk at least 10,000 steps every day. You can monitor how many steps you walk using an app on your smartphone or buy a cheap pedometer. Ideas to help achieve 10,000 steps every day include parking your car further away from the shops or getting off the bus two stops early. In bad weather, you could walk inside shopping centres or museums.

Eat a healthy, balanced diet. A Mediterranean-style diet is recommended, with a lot of vegetables, beans and whole grains. Replace red meat with moderate amounts of chicken and fish. (Red meat contains saturated fat and heme iron, known to reduce insulin sensitivity and increase insulin resistance, respectively.) Limit foods and drinks that are high in refined or added sugar (they are rapidly broken down by the body, causing insulin and blood sugar levels to skyrocket).

Eating a healthy diet may be easier if you plan your meal around vegetables rather than meat, rice or pasta.

If you have been diagnosed with type 2 diabetes, you should mostly eat foods with a low glycaemic index, in other words, ones which only raise blood glucose levels slowly. Also, you’ll need to keep track of portion sizes of starchy foods (carbohydrates) and fatty foods in order to keep your blood glucose levels in the right range. However, low-carb diets are not recommended without the advice of a dietitian.

Your GP and HIV clinic can help you access support to make these changes. This can include referring you to a dietitian who can help you find a diet that will suit the way you live and the foods you like to eat.

Who is at risk?

People over the age of 40, including people living with HIV, are more likely to develop diabetes.

In general, men develop diabetes at a younger age and lower body mass index (BMI is a measure of body size combining a person’s weight with their height, therefore giving an idea of whether a person has the correct weight for their height). However, women with diabetes tend to have more problems like high blood pressure and excess weight than men.

Genetic factors play a role in type 2 diabetes. If a close family member (parent or sibling) has had diabetes or a related medical problem (like high blood pressure), then the risk of developing diabetes is higher. Also, probably due to genetic factors, people of south Asian, African or Afro-Caribbean descent are at much higher risk of developing type 2 diabetes.

Age and genetic factors combine with lifestyle factors. People who are overweight (especially with excess weight around the belly) and people who are physically inactive are more likely to develop diabetes.

Hepatitis B, hepatitis C, high blood pressure, high cholesterol and high triglyceride levels are all associated with an increased risk of diabetes.

Some medications can increase glucose levels and may raise the risk of diabetes. These include corticosteroids like prednisolone and hydrocortisone, and some antipsychotics (drugs prescribed to treat mental disorders, including depression).

Diabetes in people living with HIV

Rates of diabetes are higher in people living with HIV than in the general population. One important reason is that many people living with HIV have some of the risk factors for diabetes mentioned above.

Chronic inflammation (ongoing activation of the immune system) in response to HIV infection may also raise the risk of diabetes. This dysfunctional response of the immune system can harm organs and body systems. HIV treatment and a healthy lifestyle help reduce inflammation but can’t completely eliminate it.

Some anti-HIV medications may contribute to diabetes risk – even several years after you took them. They include older nucleoside reverse transcriptase inhibitors (zidovudine, stavudine and didanosine) and older protease inhibitors (indinavir and lopinavir). These drugs are not generally used today but you may have taken them in the past.

Some more recent HIV treatments including integrase inhibitors (dolutegravir, bictegravir, raltegravir and elvitegravir) have been associated with weight gain, although the reasons for this remain unclear. It’s generally the case that weight gain increases the risk of developing diabetes, and there is now evidence that weight gain linked with integrase inhibitors may be doing so.

For example, in a US cohort study that looked at the long-term outcomes of HIV treatment in over 2500 previously untreated people, participants who experienced a 1kg increase in weight in their first year on treatment had a significant increase of their fasting glucose (see the 'Diagnosis and monitoring' section below for details of this blood test). During nine years of follow-up, 130 participants developed type 2 diabetes. Men who had gained more than 10% weight in the first year had twice the risk of developing diabetes than those gaining less than 5% of weight or losing weight. But weight gain in women was not linked to developing diabetes.

A large international study looked at the relationship between integrase inhibitors-induced weight gain and the development of diabetes among over 20,000 people with HIV who were followed for a median of just under five years. The study found that 785 participants (4%) were diagnosed with diabetes and that those taking an integrase inhibitor had a 48% higher risk of developing diabetes, compared with other antiretroviral drug classes. Further analyses showed that the risk of diabetes increased as body mass index (BMI) rose during follow-up. In people with a BMI above 30 (that is, in a range defined as obesity) the risk of developing diabetes was five times higher than in people with a BMI below 21 (in the range of healthy weight). Being a woman was a factor associated with a 31% lower risk of diabetes than the risk found among men.

While more research is needed to understand the mechanism that raises diabetes risk in people taking integrase inhibitors, we should keep in mind that, overall, integrase inhibitors are well tolerated with few side effects for most people and they may help you suppress your viral load more quickly than any other HIV medication. You can still reduce your risk of diabetes by making healthy changes to your lifestyle, including diet and exercise. If you do feel you are gaining excessive weight on your HIV medicines you should discuss this with your HIV clinician.

Symptoms

Many people develop type 2 diabetes without noticing it. When symptoms do occur, this is often after diabetes is a little more advanced. Symptoms can include increased thirst, frequent urination, increased hunger, weight loss, tiredness, blurred vision, slow-healing sores, skin itches, frequent infections, and areas of darkened skin.

Diabetes can also contribute to sexual problems including problems getting or maintaining an erection, vaginal dryness and other issues.

In the long term, uncontrolled diabetes raises the risk of heart and vascular disease, stroke, kidney disease, infections and blindness. Complications of diabetes can affect the skin, eyes, and nerves in the legs, feet and hands.

Diagnosis and monitoring

According to the British HIV Association (BHIVA), if you are aged 40 or over, your HIV clinic should run a blood test once a year to check the level of glucose in your blood. This test is called haemoglobin A1c (also known as HbA1c or glycated haemoglobin) and gives an average of your glucose levels over the previous 12 weeks. It will indicate whether your blood glucose level is normal, higher than normal (pre-diabetes), or at a level which shows you have diabetes. Results for haemoglobin A1c may be a little different in people taking HIV treatment than in other people – your doctor should take this into account when interpreting the results.

Another diagnostic test for diabetes is the fasting glucose test. This is a simple blood test and will require you to fast (no food and no drinks other than water) for eight to ten hours beforehand.

If you are diagnosed with diabetes, the situation will be monitored with the haemoglobin A1c test. You will have these checks every three to six months.

If you are taking diabetes treatment, you may need to monitor your glucose levels on a daily basis. This will help you monitor your health and see if your treatment is working. Your doctor may ask you to do daily blood glucose tests at home or provide you with a flash or continuous glucose monitor. Daily blood glucose tests involve pricking your finger and applying a small amount of blood to a hand-held meter. Flash or continuous glucose monitors are small devices that you wear under your skin, usually on your arm or belly.

Your blood pressure, cholesterol and triglycerides should be measured regularly as part of your HIV monitoring. This is also important for monitoring diabetes. You may also need regular eye examinations.

Treatment and management

The first line of treatment is to devise a healthy eating and physical activity plan to help reduce body weight that, if successful, will bring diabetes under control. In some people, losing weight and maintaining a healthy diet can cause their diabetes to go into remission. This means their glucose levels remain at a normal range without the need for diabetes medication.

If this approach does not make enough of a difference, medication may be used as well. You may be given tablets that either encourage the body to produce more insulin or make the existing insulin supply work better. The standard choice is a tablet called metformin, although other medication is available. Your doctor may also recommend that you take medications to help control your cholesterol and/or blood pressure.

There are some new diabetes drugs called GLP-analogues and SGLT-2 inhibitors. They have received a lot of attention in the media for helping people lose weight and to prevent cardiovascular disease. However, they are not usually prescribed as first-line treatments for diabetes.

Some people with type 2 diabetes also need daily injections of insulin, but most people don’t.

Healthcare professionals involved in managing diabetes include GPs, specialist nurses and specialist dietitians. A doctor specialising in diabetes may be a diabetologist or an endocrinologist (a doctor who treats disorders of the glands and hormones, including diabetes).

It’s best for the doctors treating your diabetes and your HIV to liaise about your health care. For this to happen, you need to give your permission for them to share your medical information. You can also ask your doctors and pharmacists to check that there are no drug-drug interactions between your treatments for diabetes and HIV.

Other sources of information

For more information, you may find the website of Diabetes UK helpful: www.diabetes.org.uk. You can also contact their helpline team on 0845 601 02 09.

The NHS Healthier You Diabetes Prevention Programme is aimed at people with pre-diabetes. If you are eligible, you can access this programme via your GP or through self-referral at preventing-diabetes.co.uk