Prevalence of Obesity and Disturbances in Glucose Homeostasis in HIV-Infected Subjects and General Population

Missed Diagnoses of Diabetes?

A Hanttu; KJ Kauppinen; P Kivelä; J Ollgren; P Jousilahti; K Liitsola; P Koponen; J Sutinen


HIV Medicine. 2021;22(4):244-253. 

In This Article

Abstract and Introduction


Objectives: Comparative data on glucose disorders using fasting blood samples between people living with HIV (PLWH) and the general population are lacking. The objective of this study was to compare the prevalence and risk factors of obesity and disturbances in glucose homeostasis between PLWH treated with modern antiretroviral therapy and the general population.

Methods: Adjusted prevalence of obesity, features of insulin resistance (triglyceride:high-density lipoprotein cholesterol ratio and alanine aminotransferase), impaired fasting glucose (IFG), diabetes mellitus (DM) and combined dysglycaemia (presence of IFG or DM) were determined using fasting blood samples among 1041 PLWH and 7047 subjects representing the general population.

Results: People living with HIV had a lower prevalence of obesity [18.2%, 95% confidence interval (CI): 15.1–21.2 vs. 23.9%, 95% CI: 22.4–25.4], but a higher prevalence of insulin resistance and IFG (20.0%, 95% CI: 16.6–23.4 vs. 9.8%, 95% CI: 8.7–10.8) than the general population. Fasting glucose concentration was higher, but glycated haemoglobin (HbA1c) was lower, among PLWH. Prevalence of dysglycaemia for a given body mass index (BMI) was higher in PLWH than in the general population. The prevalence of DM did not differ between PLWH (13.2%, 95% CI: 10.2–15.9) and the general population (14.5%, 95% CI: 13.6–15.4).

Conclusions: The prevalence of obesity was lower, but the risk of dysglycaemia for a given BMI was significantly higher, among PLWH, highlighting the importance of prevention and treatment of obesity among HIV-infected subjects. Regardless of the increased prevalence of insulin resistance and IFG, DM was surprisingly not more common among PLWH, raising concern about the under-diagnosis of DM, possibly due to low sensitivity of HbA1c in this patient population.


The clinical significance of metabolic comorbidities affecting the aging HIV population is of increasing importance. The pathogenesis of many of these comorbidities including diabetes mellitus (DM) is tightly linked to obesity.[1]

During recent years, concerns have been raised about increasing obesity rates among people living with HIV (PLWH).[2] Although there are some data on obesity from ongoing cohort studies with[3] or without[4] HIV-negative controls, comparative data with the general population are scarce.[5] According to the latest published data from North America, obesity prevalence increased from 9% in 1998 to 18% in 2010 among PLWH and from 22% to 27% in the general population.[6] These data may, however, be outdated due to major changes in treatment guidelines for PLWH during the last 10 years, including the universal treatment recommendation and the preferential use of integrase strand transfer inhibitors (INSTIs) and tenofovir alafenamide (TAF). Of note, both INSTIs and TAF have recently been associated with increased weight gain as compared with the older antiretroviral agents.[7]

Increasing obesity prevalence leads to concerns of rising prevalence of diabetes.[2] However, there are no data comparing the prevalence of diabetes among PLWH and the general population using fasting glucose samples. Some studies with PLWH have used true population controls, but the diagnosis of diabetes has been based on administrative data, with their limitations, or blood samples were not collected in the fasting state.[5,8,9] Fasting glucose samples also allow the detection of an earlier disturbance in glucose homeostasis: impaired fasting glucose (IFG). This has clinical significance, as subjects with IFG have a five-fold higher risk of developing diabetes than subjects with normoglycaemia.[10] Therefore, direct comparison of fasting glucose values can give a more comprehensive view on glucose homeostasis between PLWH and the general population than administrative data.

In the present study, we compare the prevalence rates of obesity, diabetes, IFG and surrogate markers of insulin resistance using fasting blood samples, both in PLWH and in the general population. We also investigate HIV-specific risk factors of these outcomes among PLWH treated with modern antiretroviral therapy (ART), including TAF and INSTI.