Diabetes risk in HIV infection and antiretroviral therapy: A systematic review and meta‐analysis of prospective cohort evidence

OBJECTIVES: To quantify the incidence rate (IR) of diabetes in people living with HIV (PLWH), assess disparities relative to HIV-negative individuals and clarify the associations of antiretroviral therapy (ART) exposure and treatment duration with diabetes incidence. METHODS: We searched PubMed up to July 20, 2025, for prospective cohort studies including PLWH aged ≥18 with ≥6 months of follow-up and reported diabetes incidence. Two reviewers independently assessed study quality using the Newcastle-Ottawa Scale and extracted data. A random-effects model estimated pooled incidence rates and subgroup differences. Meta-regression was performed to evaluate study-level associations between ART duration and diabetes incidence. RESULTS: Thirty-one studies contributed 1 230 314 person-years (PY) of follow-up. The IR in PLWH was 12.98 cases per 1000 PY (95% CI: 10.97-14.98). No significant difference was observed between PLWH (12.97 cases per 1000 PY) and HIV-negative individuals (12.67 cases per 1000 PY; p = 0.9597), although this comparison was based on a limited number of studies. However, incidence among PLWH on ART (14.05 cases per 1000 PY) was significantly higher than in those not on ART (7.42 cases per 1000 PY; p = 0.0179). Each year of ART exposure was associated with an increase of 0.354 cases per 1000 PY in univariable meta-regression (p = 0.008). In multivariable meta-regression, the association between ART duration and diabetes incidence remained significant after adjustment for mean age (p = 0.038), while age was also independently associated with higher incidence (p < 0.001). CONCLUSIONS: Diabetes incidence in PLWH is substantial and varies across regions and diagnostic definitions. Evidence comparing PLWH with HIV-negative individuals remains limited. ART exposure and longer ART duration are associated with higher diabetes incidence, highlighting the importance of routine metabolic screening in long-term HIV care.