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High prevalence of prediabetes in HIV positive people – SA review

Despite a focus on infectious diseases in Africa, there is increasing acknowledgement of the expanding burden of non-communicable diseases (NCDs) and the double challenge of Africans experiencing both NCDs and infectious diseases, with researchers urging policymakers to integrate cost-effective screening, prevention and treatment of diabetes with HIV care.

While traditional cardiovascular risk factors, exposure to HIV and antiretroviral therapy (ART) are assumed to contribute to cardiometabolic diseases in people living with HIV (PLHIV), there’s still controversy on the relationship of HIV and ART with diabetes, and how these are modified by sociodemographic characteristics, BMI, diagnostic definitions used for diabetes and prediabetes, and HIV-related characteristics including CD4 count, and ART use and duration.

A recent study by researchers from the South African Medical Research Council (SAMRC), in conjunction with international collaborators, determined diabetes and prediabetes prevalence in PLHIV in Africa aiming to delineate these factors, with the results being published in the Journal of the International Aids Society (JIAS).

Significance of findings

The results of this systematic review and meta-analysis highlight that people living with HIV (PLHIV) in Africa have a high and established burden of prediabetes and diabetes, with prevalence rates of 15% for prediabetes and 5% for diabetes, and the latter approximating that observed in the general African population.

“This study is the first from Africa to synthesise the prevalence and influences of diabetes and prediabetes in PLHIV from a large number of studies,” said Professor Nasheeta Peer, chief specialist scientist at the SAMRC’s Non-Communicable Diseases Research Unit.

“Our findings suggest that diabetes prevalence rates in PLHIV in Africa are similar to those of general populations on the continent and influenced by similar risk factors.”

These conclusions were drawn from 61 studies examined. The pooled analyses were conducted among 86 412 and 7 976 participants for diabetes and prediabetes, respectively. The general trends suggested that traditional diabetes risk factors such as older age, greater BMI, which is an indicator of overweight and obesity, and urbanisation possibly contributed to diabetes.

HIV-related factors such as CD4 count, and the use and duration of antiretroviral therapy were not related to diabetes and prediabetes.

Furthermore, a substantial proportion of PLHIV with co-morbid diabetes in Africa were undiagnosed for their diabetes despite being in regular contact with healthcare services for their HIV. This underscores the disparities in management with free treatment provided for HIV but a minimal focus on diabetes in PLHIV on the continent.

There is thus an urgent need to integrate cost-effective and efficient screening, prevention and treatment of diabetes with HIV care to maintain the momentum and secure the advances made in optimising HIV management.

Professor Liesl Zuhlke, vice-president of the SAMRC, said: “In the South African public healthcare sector, there is growing awareness of the increasing burden of non-communicable disease comorbidities in PLHIV. Consequently, novel approaches like hypertension text messaging interventions, are being researched and implemented to treat PLHIV efficiently, cost-effectively and holistically with comorbidities.”

This is important particularly in view of the high prevalence of prediabetes, which is a strong determinant of future diabetes. With about one in six PLHIV in Africa having prediabetes, this foretells a likely increase in future diabetes in PLHIV on the continent.

“These findings have important implications for public health policymakers and in clinical practice, with a change in approach needed for the care of PLHIV with comorbidities,” said Peer.

Study details

Prevalence and influences of diabetes and prediabetes among adults living with HIV in Africa: a systematic review and meta-analysis

Nasheeta Peer, Kim Anh Nguyen, Jillian Hill, Anne E. Sumner, Justin Cirhuza Cikomola, Jean Bisimwa Nachega, Andre-Pascal Kengne.

Published in the Journal of the International Aids Society on 16 March 2023

Abstract

Introduction
In people living with human immunodeficiency virus (PLHIV), traditional cardiovascular risk factors, exposure to HIV per se and antiretroviral therapy (ART) are assumed to contribute to cardiometabolic diseases. Nevertheless, controversy exists on the relationship of HIV and ART with diabetes. To clarify the relationship between HIV and type 2 diabetes, this review determined, in PLHIV in Africa, diabetes and prediabetes prevalence, and the extent to which their relationship was modified by socio-demographic characteristics, body mass index (BMI), diagnostic definitions used for diabetes and prediabetes, and HIV-related characteristics, including CD4 count, and use and duration of ART.

Methods
For this systematic review and meta-analysis (PROSPERO), a comprehensive search of major databases (PubMed-MEDLINE, Scopus, Web of Science, Google Scholar and WHO Global Health Library) was conducted. Original research articles published between 2000 and 2021 in English and French were included, irrespective of study design, data collection techniques and diagnostic definitions used. Observational studies comprising at least 30 PLHIV and reporting on diabetes and/or prediabetes prevalence in Africa were included. Study-specific estimates were pooled using random effects models to generate the overall prevalence for each diagnostic definition. Data analyses used R statistical software and “meta” package.

Results
Of the 2 614 records initially screened, 366 full-text articles were assessed for eligibility and 61 were selected. In the systematic review, all studies were cross-sectional by design and clinic-based, except for five population-based studies. Across studies included in the meta-analysis, the proportion of men was 16–84%. Mean/median age was 30–62 years. Among 86,412 and 7976 participants, diabetes and prediabetes prevalence rates were 5.1% (95% CI: 4.3–5.9) and 15.1% (9.7–21.5). Self-reported diabetes (3.5%) was lower than when combined with biochemical assessments (6.2%; 7.2%).

Discussion
While not statistically significant, diabetes and prediabetes were higher with greater BMI, in older participants, urban residents and more recent publications. Diabetes and prediabetes were not significantly different by HIV-related factors, including CD4 count and ART.

Conclusions
Although HIV-related factors did not modify prevalence, the diabetes burden in African PLHIV was considerable with suboptimal detection, and likely influenced by traditional risk factors. Furthermore, high prediabetes prevalence foreshadows substantial increases in future diabetes in African PLHIV.

 

JIAS article – Prevalence and influences of diabetes and prediabetes among adults living with HIV in Africa: a systematic review and meta-analysis (Creative Commons Licence)

 

SAMRC article – Prevalence and influences of diabetes and prediabetes among adults living with HIV in Africa (Open access)

 

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