This study examined the prevalence and factors associated with T2DM among PLWH in Eastern Uganda.
In our study, 12.5% of participants had T2DM among PLWH in Eastern Uganda. This was slightly lower than a study reported in central Uganda at Mulago National Referral Hospital of 16.0% among PLWH (20). Both studies report higher figures than the prevalence (4.7%) noted in an earlier study (21). However, the latter study used a higher fasting blood sugar cut-off (> 7.8mmol/l) than our study (≥ 7mmo/l), and it was conducted in 2019, with T2DM prevalence on the rise in Uganda since then. Our findings are similar to studies carried out in other parts of Africa for example in Ethiopia, the prevalence was found to be 11.8% -14.9% (14, 22), in Kenya the prevalence of 12,4% (23) while some studies reported a slightly lower prevalence of 8.0%(8, 24). Although the latter studies were carried out before 2020 when the T2DM epidemic was slowly raising. Similar to our findings were also reported in Zimbabwe of 14.0% (3).
We also found out that 50% of the people with T2DM were unaware of their DM status. This is similar to a study carried out in South Africa which reported which reported a prevalence of T2DM among PLWH about 8.1% with 58.0% of patients unaware of their DM status (25).With the current role out of the new HIV guidelines in Uganda that recommend screening for T2DM for all the HIV patients with suspected risk factors for DM every six months (26). This proportion is expected to decrease as health workers become more vigilant in screening for NCDs.
Multivariate logistic regression analysis revealed being age of 50 years and above, more than ten years with known HIV status, high BMI, being on a protease based ART drugs; family history of hypertension and family history of T2DM were independent risk factors for PLWH to develop T2DM.
Our study showed advanced age of more than 50 years is associated with the risk of developing T2DM. This is similar to other studies carried out in other parts of SSA (27, 28). This could be explained by different mechanisms which include, long life expectancy leading to a decrease in insulin secretion (29)and arginine vasopressin (AVP) or its c-terminal fragment, called Copeptin, which lower insulin sensitivity as one gets older(30).
More years on ART was associated with increased risk of developing T2DM similar to findings with other studies (12, 13, 14). This could be explained as PLWH on ART with good adherence are more likely to be virally suppressed as shown by our study and live a near normal life which predisposes them to other modifiable risk factors for DM like Obesity, hypertriglyceridemia and hypertension (31, 32). Patients who were on protease inhibitors based regimen were more likely to be having DM/HIV comorbidity than those on TLE ART regimen. This is similar to some studies which showed that Some PIs, like lopinavir/ritonavir which were among the recommended PIs in Uganda for second line ART treatment, worsen the lipid profiles and increase the risk of developing hyperglycemia and DM (33). However, patients who were on the combination of TLD were less likely to have DM/HIV comorbidity compared to those of Efavirenz based regimen. This could be explained by the fact DTG based ART combination was rolled out across the country in 2022 with clear guidelines about screening for all patients with risk factors for T2DM and if a patient had any of the factors then he/she would not be enrolled on DTG based regimen but instead on initiated on EFV based regimen(26).
Individuals with HIV who had known their HIV status for more than ten years were less likely to have DM/HIV comorbidity. This could be explained by good health seeking behaviour among patients who have been in HIV care for long time and also there has been an epidemiological increase of NCDs including T2DM in the decade.
Regarding family history of T2DM, our analysis revealed that those with self-reported positive family history of T2DM exhibited higher odds of developing T2DM than their counterparts without it. This is because T2DM is mediated by both genetic and shared environmental components amongst family members (34, 35).
Our study showed that hypertension and family history of hypertension are associated with DM/HIV comorbidity. This is similar to other studies which reported hypertension to be associated with T2DM(36).
A current BMI of ≥ 25 was significantly associated with the development of T2DM.This is similar to other studies conducted in Ethiopia (32) and Uganda (37). Obese and overweight are common in PLWH, and an increased risk of incident diabetes has been noted with weight gain after ART initiation in PLWH (38, 39).
Strengths and limitations
This study has some strength that is worth to be noted. We involved two HIV clinics comparing which have patients of different epidemiological profile one clinic being rural and lower health facility while the other Urban located in a referral hospital improving the generalizability of our findings. We were able to carry out fasting Blood sugar on all consenting patients and hence we were able to find out the number of patients who were unaware of their T2DM status which results helped the HIV clinics to operate efficiently and increased T2DM vigilance. Some of the limitations were inclusion of only HIV positive patients limiting the inference of our results from HIV negative patients. Some patients had T2DM already diagnosed and on treatment hence we could not ascertain what came first HIV or T2DM and the duration these patients have had DM/HIV comorbidity. Despite the significant contribution of this study, our results cannot be generalized because we only conducted the study at two facilities.