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

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 registration CRD42021231547), 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 2614 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.

Associations of HIV and prevalent type 2 diabetes mellitus in the context of obesity in South Africa

“…However in SSA, PWH who are on ART, including older-generation thymidine analogues and protease inhibitors, appear to have comparable 15, 16 if not better 17, 18, 19 glucose metabolism profiles than the general population. While this may be attributed to insufficient research in SSA, especially the dearth of longitudinal studies with incidence measures 20 , physiological adaptations in PWH in SSA that potentially protect against cardiometabolic disease, including diabetes, have not been considered.…”

“…31, 32 This includes central obesity, with or without lipodystrophy, both significant determinants of prevalent and new-onset diabetes. 31 It is the nexus of these factors, i.e., HIV, ART metabolic side effects, excess weight gain and an obesogenic environment, that is believed to drive excess diabetes risk in persons PWH in HICs 10, 11, 12 whereas its occurrence in SSA 17, 18, 33 , is yet to be mirrored in an excess burden of diabetes in the population of PWH.…”

Evaluating a multifaceted implementation strategy and package of evidence-based interventions based on WHO PEN for people living with HIV and cardiometabolic conditions in Lusaka, Zambia: protocol for the TASKPEN hybrid effectiveness-implementation stepped wedge cluster randomized trial

“…Hypertension afflicts 8.9 million PLHIV globally, and, while prevalence varies by region, it affects nearly 20% of all PLHIV in Eastern and Southern Africa [ 6 , 7 ]. Similarly, cardiometabolic complications related to diabetes are increasing among PLHIV in Zambia and the region [ 8 ], with prevalence estimates exceeding 5% and 15% for diabetes mellitus and prediabetes, respectively [ 9 ]. Diabetes mellitus among PLHIV is associated with 2.4 times the risk of CVD events compared to HIV-uninfected persons [ 10 ].…”

SHBG, Free Testosterone, and Type 2 Diabetes Risk in Middle-aged African Men: A Longitudinal Study

“…Sub-Saharan Africa not only has challenges with an increasing burden of T2D, but it is also the world's epicenter of HIV infections, accounting for more than 70% of the infections, with the numbers of those >50 years living with HIV estimated to triple by 2040 [ 21-23 ]. While earlier studies indicate a higher likelihood of impaired glucose metabolism among people living with HIV compared to those without HIV [ 24-26 ], more recent studies from SSA report inconsistent findings, particularly in the context of newer antiretroviral therapies (ART) [ 27 , 28 ]. Some studies have reported increased risk of diabetes [ 27 , 28 ] and others no association of HIV and ART and prevalent diabetes [ 29-31 ].…”

“…While earlier studies indicate a higher likelihood of impaired glucose metabolism among people living with HIV compared to those without HIV [ 24-26 ], more recent studies from SSA report inconsistent findings, particularly in the context of newer antiretroviral therapies (ART) [ 27 , 28 ]. Some studies have reported increased risk of diabetes [ 27 , 28 ] and others no association of HIV and ART and prevalent diabetes [ 29-31 ]. Notably, studies in the United States have reported that hypogonadism is common among men living with HIV (MLWH) despite effective ART [ 1 , 3 ].…”