Insulin resistance, HIV infection, and anti-HIV therapies

Insulin resistance, a risk factor for cardiovascular disease, is increasingly seen in persons infected with HIV. In those affected, it is unclear whether insulin resistance is a direct result of HIV infection alone; however, the development of insulin resistance has been established as a complication of antiretroviral therapies. Some protease inhibitors (PIs) are culpable, and there are significant differences in the impact of different PIs on glucose metabolism, with current evidence suggesting that atazanavir does not cause insulin resistance. The paucity of standardized laboratory tests makes early diagnosis of insulin resistance relatively elusive. Still, there are some clinically useful methods for assessing its presence. For prevention and/or treatment, exercise and optimal diet are useful, and metformin and rosiglitazone have been shown to improve insulin resistance. Changing an effective antiretroviral regimen to counter insulin resistance must be approached thoughtfully in carefully selected patients.