[pronut-hiv] Is diabetes a complication of HIV infection?

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Is diabetes a complication of HIV infection?

Type II diabetes could be a complication of untreated HIV infection,
according to a case report published in the online version of Clinical
Infectious Diseases on 12th April. The report describes an African man
with advanced HIV infection and diabetes, which resolved after viral
replication was suppressed with antiretroviral therapy. 

Resistance to the hormone insulin is responsible for type II diabetes,
a dangerous condition when the body cannot control sugar levels in the
blood. While diabetes is a known side-effect of antiretroviral therapy,
particularly with protease inhibitors, some studies have claimed a link
between the onset of diabetes and HIV infection itself. 

Studies carried out before the introduction of combination
antiretroviral therapy failed to demonstrate a consistent link between
HIV infection and diabetes. However, last month's case report, along
with two similar reports published in 2004, suggests that uncontrolled
HIV replication may cause diabetes in some patients. 

The study's authors, from the University of Colorado, Denver,
describe a 52 year-old African man who they saw at their clinic in early
2004. He had been diagnosed with HIV infection and diabetes in late
2003. Despite four months of treatment with the anti-diabetes drug
metformin, he was still complaining of excessive thirst and urination,
blurred vision and tiredness. 

When he was seen in Denver, the man's CD4 cell count was 84 cells/mm3
and his viral load was 3,940,000 copies/ml, indicating advanced HIV
infection with very high levels of HIV in his blood. 

He also had laboratory signs of diabetes with elevated blood sugar
levels and glycosylated haemoglobin levels: he had a random glucose
level of 409 mg/dl, a fasting glucose level of 249 mg/dl and a
glycosylated haemoglobin level above 14.5%. 

The doctors at the Denver clinic increased the man's dose of
metformin from 1500 to 2000mg per day and added glyburide. Around one
week later, he started co-trimoxazole prophylaxis and an anti-HIV drug
combination of 200mg FTC (emtricitabine, Emtriva), 300mg tenofovir
(Viread) and six capsules of ritonavir-boosted lopinavir (Kaletra) every
day. 

A month after starting his anti-HIV treatment combination, the man's
CD4 cell count had risen to 254 cells/mm3 and his viral load was 3320
copies/ml. His fasting glucose level had fallen to below the threshold
for a diabetes diagnosis to 44 mg/dl, as had his glycosylated
haemoglobin level, which was 7.1%. He stopped taking his anti-diabetes
drugs and continued to show improvement in his blood sugar levels, as
well as regaining some the weight he had lost before treatment. 

The man temporarily required insulin therapy when he suffered multiple
organ failure after a burst appendix. However, he did not need to
continue anti-diabetes therapy once he had recovered. 

"Our case suggests that HIV infection itself may precipitate type II
diabetes mellitus and that effective viral suppression can reverse this
disorder," conclude the doctors. "In two other cases, treatment of
advanced HIV infection was also associated with apparent resolution of
apparent type II diabetes mellitus. Interestingly, the men with these
cases were also of African descent." 

The doctors offer a number of suggestions for how HIV could cause
diabetes. These include opportunistic infections such as
cytomegalovirus, alterations in hormone or cytokine levels and
interactions of HIV's protein Vpr with proteins responsible for
glucose transport within cells. However, larger studies are needed to
establish whether these observations reflect a true relationship between
HIV infection and diabetes, and to investigate the doctor's
suggestions for a mechanism linking HIV to insulin resistance. 

Reference 

Koeppe J et al. Apparent resolution of type 2 diabetes mellitus after
initiation of potent antiretroviral therapy in a man from Africa with
HIV infection. Clin Infect Dis 42: e79-e81, 2006.