Are We Meeting the American Diabetes Association Goals for HIV-Infected Patients with Diabetes Mellitus?

Abstract

We determined rates of achieving the American Diabetes Association goals among human immunodeficiency virus (HIV)-infected diabetic patients. American Diabetes Association goals (for hemoglobin A1c, blood pressure, and lipid levels) were defined by 2008 American Diabetes Association guidelines. HIV-infected diabetic patients achieved American Diabetes Association goals at rates similar to those in general medicine clinic patients. A multidisciplinary approach is needed to improve diabetes management in HIV clinics.

Diabetes mellitus is a leading cause of morbidity in the United States, affecting 8% of the US adult population [1]. Insulin resistance is reported in 25%-30% of human immunodeficiency virus (HIV)-infected patients, and the incidence of diabetes mellitus among this population is estimated to be 2%-8% [2-4]. In the Data Collection on Adverse Events of Anti-HIV Drugs Study, the baseline prevalence of diabetes mellitus was 2.85%, with an incidence rate of 5.72 cases per 1000 person-years [5]. Cohort studies report that patients infected with HIV are up to 4 times more likely to develop diabetes mellitus than is the general population [4, 5].

Caring for patients with diabetes mellitus is complex and often requires a multidisciplinary approach. HIV practitioners at our center provide comprehensive primary care for their patients. Although data exist on the association between insulin resistance, diabetes, and highly active antiretroviral therapy (HAART), we found only 1 report on the management of diabetes mellitus in 40 HIV-infected patients [6]. The objective of this study was to determine rates of achieving the American Diabetes Association (ADA) goals among HIV-infected diabetic patients receiving primary care in a large, urban HIV clinic.

Methods. This was a retrospective study conducted from January through April 2008 at the Ruth M. Rothstein CORE Center (Chicago, Illinois). The Institutional Review Board of the Cook County Bureau of Health Services approved the study. The CORE Center provides care to >4500 HIV-infected patients, the majority of whom are uninsured. Patients with diabetes mellitus were identified from the clinic database if they had 1 of the following criterion: an International Classification of Diseases, Ninth Revision diagnosis of diabetes mellitus, an elevated random glucose level (⩾200 mg/dL) or fasting glucose level (>126 mg/dL), a measurement of hemoglobin A1c (HbA1c), or prescriptions for diabetic medications or testing supplies through CORE pharmacy records within the past year. Data were retrieved through electronic and written records. Primary care provider status was classified as either physician or mid-level provider (physician assistant or nurse practitioner).

ADA guidelines from 2008 [7] were used to define goals. ADA goals for diabetic patients were as follows: HbA1c <7%, blood pressure <130/80 mm Hg, total cholesterol level <200 mg/dL, low-density lipoprotein (LDL) cholesterol level <100 mg/dL, triglyceride level <150 mg/dL, and high-density lipoprotein (HDL) cholesterol level >40 mg/dL in men and >50 mg/dL in women. Body mass index was calculated as weight in kilograms divided by the square of height in meters. The glomerular filtration rate was estimated using the modified dosing for renal disease formula. Nephropathy was defined by a glomerular filtration rate <60 mL/min.

Categorical variables were compared using Fisher's exact test, and continuous variables were compared using Student's t test or the Mann-Whitney U test. For all analyses, P<.05 was considered to be statistically significant for 2-tailed tests. All calculations were performed using SPSS, version 11 (SPSS).

Results. A total of 238 HIV-infected diabetic patients who had ⩾2 clinic visits in the past 12 months were identified. There were 216 patients included in the study; 22 patients were excluded because they had <1 visit or had no laboratory test results. Patient demographic and clinical characteristics are shown in Table 1. Patients had well-controlled HIV infection. Diabetes mellitus was diagnosed a mean of 3 years after diagnosis of HIV infection. Women were younger than men (mean age, 47 vs. 52 years; P=.001) and had higher body mass index (30.9 vs. 27.3; P<.001). Lipid levels were checked in the past 12 months in 207 (96%) of the patients; 151 (70%) had a full lipid profile. The mean HbA1c was 7.3% (standard deviation, 1.9%), and HbA1c measurements did not differ significantly by sex or ethnicity. Of the patients, 116 (54%) had HbA1c <7%, and 155 (72%) had HbA1c <8%. More than one-half of our patients were treated with oral hypoglycemic agents only. Patients who had a diagnosis of diabetes mellitus before the diagnosis of HIV infection were more likely to receive insulin than were those who received the diabetes diagnosis after the HIV diagnosis (54% vs. 28%; P=.003). In the past 12 months, a urinalysis was ordered for 62% of patients; of these, 49% had proteinuria.

Table 1

Characteristics of the 216 Human Immunodeficiency Virus (HIV)-Infected Patients with Diabetes Mellitus

Rates of achieving the ADA goals are shown in Figure 1. Women were less likely to meet goals for lipid levels. There were no differences in attaining goals according to ethnicity or primary provider type. Patients with undetectable HIV RNA levels were more likely to meet the HDL cholesterol level goal (58% vs. 27%; P<.001) but were less likely to meet goals for total cholesterol level (67% vs. 85%; P=.01) and LDL cholesterol (50% vs. 71%; P=.02), compared with patients with detectable HIV RNA. There were no differences in achieving lipid level goals when patients were stratified by use of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor (statin). Current use of protease inhibitors was associated with significantly higher triglyceride levels (313 vs. 215 mg/dL; P=.04). Blood pressure goals were met by 56% of the patients; however, patients receiving medications were less likely to meet the blood pressure goal (47% vs. 79%; P<.001).

Figure 1

Percentage who met American Diabetes Association goals for diabetes care among human immunodeficiency virus-infected patients. The goals were hemoglobin A1c (HbA1c) <7%, total cholesterol (TC) level <200 mg/dL, low-density lipoprotein cholesterol (LDL-c) level <100 mg/dL, high-density lipoprotein cholesterol (HDL-c) level >40 mg/dL in men and >50 mg/dL in women, triglyceride level (TrG) <150 mg/dL, and blood pressure (BP) <130/80 mm Hg.

There was >1 consultation note from the nutritionist in 151 (70%) of the charts. A foot examination within the past year was documented for 38 (18%) of patients. Use of concomitant medications was as follows: aspirin, 95 patients (44%); statins, 98 patients (45%); and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACE-I/ARB), 133 patients (62%). Aspirin was prescribed to 32% of women, compared with 48% of men (P=.03). Patients with proteinuria were more likely to receive an ACE-I/ARB (76% vs. 57%; P=.03), as were patients with nephropathy (82% vs. 59%; P=.01).

Discussion. To our knowledge, this is the largest reported study on the management of diabetes mellitus in HIV-infected patients. Of our patients, 54% met the goal for HbA1c (<7%) and 72% had HbA1c <8%, representing adequate control. In US studies in general medicine clinics, reported rates for HbA1c <7% are 30%-44% [8, 9]. The rate of achievement of all ADA goals for lipid levels, except the goal for triglyceride level, was >50%. Elevated triglyceride levels are a common complication of HAART, and current protease inhibitor use was associated with higher triglyceride levels. Adherent patients (those with undetectable HIV RNA levels) were less likely to meet goals for total cholesterol and LDL cholesterol levels, which supports the notion that certain antiretroviral agents induce hyperlipidemia, which is a substantial problem and remains a challenge to manage. Additionally, the choice of statin prescribed for patients receiving HAART is limited by significant drug-drug interactions [10]. Studies show that most HIV-infected patients treated for hyperlipidemia do not achieve National Cholesterol Education Program goals [10-12]. Differences in rates of achieving ADA goals by primary provider type (ie, physician vs. mid-level provider) were not seen.

In concurrence with most guidelines, diabetes management was with oral hypoglycemic agents for the majority of our patients [7, 13]. Usage of insulin as monotherapy or combined with oral agents was 32%, similar to the 32.5% reported in a previously published study of HIV-infected diabetic patients [6] and the 20%-35% reported in large studies of diabetic individuals in the general population [8, 9]. The majority of our patients had lipid levels checked in the past 12 months, as recommended by HIV treatment guidelines [10]. Our finding that women were less likely to achieve lipid level goals is similar to what has been reported in large studies of diabetes in the general population [14, 15]. This finding has been suggested to be the result of perceived lower cardiovascular risk by women and their primary care providers and may explain why fewer women in our study received aspirin.

Our rates of achieving ADA goals and use of recommended medications were higher than those reported in the previous study of diabetes care for HIV-infected patients by Bury et al [6]. This may be because of differences in study populations and improved awareness over time by HIV care providers about aggressively managing comorbidities. Also, clinical pharmacists at our institution provide patient-focused diabetes education and leave chart notations about treatment and screening recommendations for providers.

It is important to recognize the limitations of the present study. We selected patients who had at least 2 clinic visits in the past 12 months, to ensure that only patients actively receiving care and thus eligible to get all recommended testing were included in the analysis. Thus, we may have overestimated the rate of achieving ADA goals in our clinic. We did not assess the use of fibrates in lipid management. Because of a complex referral system for ophthalmologic examinations in our clinic, we did not evaluate documentation of eye examinations. We also did not assess rates of diabetes-related hospitalizations or other complications, because this was not in the scope of this study.

On the basis of our review, we can make recommendations on how to improve diabetes care in HIV clinics such as ours, where primary providers have competing demands on their time. First, checklists for all diabetic patients, with appropriate flags for the timing of physical examinations and screening procedures, would be beneficial. Second, we could improve patient education by offering group appointments about nutrition, providing foot care and training in home glucose monitoring, and having pharmacists in the clinic educate patients on the appropriate use of concomitant medications and disease management. Last, yearly updates given by endocrinologists to our primary care providers could be beneficial and have been initiated this year.

In conclusion, we found that HIV-infected diabetic patients in our clinic achieved ADA goals at rates similar to those reported for HIV-uninfected diabetic patients in general medicine clinics. Lipid level goals were hard to meet, likely because of the contributing effects of certain antiretroviral medications; however, because these patients are at a high risk for cardiovascular disease, lipid levels should be managed aggressively. A multidisciplinary approach to care is needed to improve disease outcomes for this patient population.

Acknowledgments

We thank Mieoak Bahk and Elisa Trigalo, who assisted in data collection.

Potential conflicts of interest. All authors: no conflicts.