A large portion of diabetes cases in sub-Saharan African populations with HIV represent drug-induced diabetes
Abstract
I have read with great interest the review by Goedecke and Mendham and subsequent correspondence from Christensen et al on the causes of type 2 diabetes in sub-Saharan African populations published in Diabetologia. The authors correctly point out that type 2 diabetes is more prevalent among people affected by severe infectious diseases, such as tuberculosis and/or HIV infection.
People with these diseases often have persistent dysglycaemia. Christensen et al noted that dysglycaemia occurs despite treatment.
However, treatment for HIV infection should not be expected to decrease the incidence of new cases of dysglycaemia. The treatment itself is an essential and problematic factor from the point of view of a diabetologist.
Although infectious diseases themselves have the potential to enhance insulin resistance and unmask an underlying beta cell deficiency, some therapies for infectious diseases may contribute to the onset of insulin resistance and dysglycaemia, as previously exemplified. Therefore, we call for more attention to the role of treatment regimens in the onset and progression of type 2 diabetes in sub-Saharan African populations with HIV.
Diabetes that develops in sub-Saharan African populations with HIV is probably a disease with heterogeneous causes. Some patients develop diabetes associated only with HIV infection or with concomitant tuberculosis infection.
In contrast, other patients manifest diabetes only after treatment with various ARTs, thereby being primed by the infectious insult and manifesting the disease after the subsequent drug insult. Drug-induced diabetes and hyperglycaemia have a delay in occurrence, which can be anything from hours to months, or even years after drug initiation.
Ideally, baseline glucose levels should be determined before commencing ART. Routine checks should be performed every 3-4 months during the first year of the therapy and less frequently during follow-up years.
Caution is needed when using HbA1c as a proxy for blood glucose control as patients with HIV may have increased turnover of red blood cells and, therefore, have falsely lower HbA1c levels. Should the role of ART be confirmed in the increased risk of diabetes in those with HIV, a large portion of diabetes cases in sub-Saharan African populations with HIV should be considered to represent drug-induced diabetes.