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Senior Consultant, Infectious Diseases
Hospital Juan Fernández
Director, Fundación Huesped
Professor of Infectious Diseases
Buenos Aires University Medical School
Buenos Aires, Argentina
Pedro Cahn, MD, PhD, has disclosed that he has received funds for research support and consulting fees from Merck and ViiV and fees for non-CME/CE services from Gilead Sciences, Merck, and ViiV.
During the past 3 decades, the global incidence of obesity has increased to 27.5% in adults and 47.1% in children. During the early days of the HIV epidemic, however, weight loss—rather than weight gain—was the main concern for patients and healthcare professionals. The most relevant body composition–related issues in HIV treatment were “slim disease” in the era before highly active antiretroviral therapy (ART) and peripheral lipoatrophy with fat gain in the abdomen with early combination ART.
Based on their efficacy, safety, simplicity, and tolerability, integrase strand transfer inhibitors such as dolutegravir and bictegravir are the first-line options recommended by international antiretroviral guidelines (eg, the DHHS, International AIDS Society, and WHO). Regarding the nucleos(t)ide reverse transcriptase inhibitors backbone, tenofovir disoproxil fumarate and, more recently, tenofovir alafenamide (TAF) are recommended instead of abacavir or zidovudine.
Weight gain, however, is associated with integrase strand transfer inhibitors and TAF. In particular, the ADVANCE trial showed that the combination of dolutegravir with TAF was associated with weight gain in Africa, particularly in females who were overweight at entry. Different studies have shown that weight gain is more common in women, Black people, and those who were in poorer health before starting treatment. We are aware that obesity may be caused by disease or pharmacologic therapies and may be associated with an increased risk of diabetes and cardiovascular disease.
Having said that, Kumar and colleagues have postulated that there might be a “return to health” weight gain with reversal of the catabolic effects of HIV infection after ART initiation. Therefore, healthcare professionals and patients have to differentiate obesity—which is defined as having a body mass index of 30 kg/m2 or higher—from a modest increase in weight after antiretroviral initiation.
Results from a study presented by Coelho and colleagues at CROI 2021 highlight the impact of weight gain after initiating ART in people with HIV in Latin America, where 1 of 4 people qualifies as obese, and in Haitians and Latin Americans with HIV in the United States and Canada.
Data were extracted from the NA-ACCORD and CCASANet cohort studies in the Americas from 2000-2016 (N = 60,831). Weight (kg) and body mass index (kg/m2) trajectories at 1 and 3 years post-ART initiation were the study endpoints. Covariates analyzed included sex, age, year of ART initiation, ART regimen and weight, CD4+ cell count, and HIV-1 RNA at ART initiation.
At 3 years post ART, average weight gain among men was 3.2 kg in non-Latinx people in the United States and Canada, 3.9 kg in Latinx people in the United States and Canada, 6.2 kg in Latinx people in Latin America, and 4.1 kg in Haitians. Average weight gain among women was 4.5 kg in non-Latinx people in the United States and Canada, 3.2 kg in Latinx people in the United States and Canada, 6.2 kg in Latinx people in Latin America, and 3.7 kg in Haitians. Weight gain was greatest during the first year post-ART initiation.
In addition, the use of protease inhibitor–based regimens, higher CD4+ cell counts, and lower HIV-1 RNA at baseline were associated with lower post-ART weight gain. The authors concluded that in the Americas, people with HIV substantially gain weight after ART initiation, with Latinx people in Latin America and Haitian men having the steepest observed post-ART weight gain trajectories. The authors suggest that the initial prevalence of obesity coupled with post-ART weight gain may reflect a healthy catch-up phenomenon among Latinx people with HIV in Latin America relative to the United States/Canada that is influenced by nutrition and healthy migrant effects—that is, the common observation that new immigrants are generally healthier than residents who share similar racial or ethnic backgrounds.
What does this study add to our knowledge? First, it shows that people of Latinx ethnicity have patterns of weight gain similar to other ethnic groups. Second, patient geographic location may play a major role in weight gain trajectories. Finally, advanced disease also was associated with higher average weight gain after initiating ART.
What are your thoughts about the findings from these this study? I encourage you to answer the polling question and post your thoughts and questions in the discussion box below.