Rising Obesity Prevalence and Weight Gain Among Adults Starting Antiretroviral Therapy in the United States and Canada

The influence of HIV on return to work in stroke survivors amongst a population of the eThekwini district, Kwazulu Natal: A qualitative study

BackgroundBiomedical and biopsychosocial factors with an interaction of systems and stakeholders are considered determinants of participation in a return to work (RTW) process. Human Immunodeficiency Virus (HIV) potentiates the risk of stroke development and employees that may be productive are negatively impacted economically from resultant disability. Evidence on the influence of HIV on the RTW of stroke survivors is scarce.ObjectiveTo explore the influence of HIV in stroke survivors who either have or have not RTW.MethodsA qualitative study with a phenomenological approach using semi-structured interviews was conducted. Twelve HIV positive stroke survivors with a history of employment prior to stroke onset, were recruited from an HIV clinic database.ResultsStroke related physical and cognitive impairments impacted activities of daily living and occupational tasks. Health education aided participants to accept their HIV status and antiretroviral therapy (ART) adherence which promoted longevity amidst acute side effects. During the RTW effort, disclosing the HIV status, eliminating societal barriers, and having a family support structure were considered factors that might increase the desire for continuous employment and restore an acceptable quality of life.Workplace support structure, realistic goal setting, engagement with RTW-related professionals and support services, alleviation of negative employer attitudes and avoidance of undesirable workplace accommodation were noted to promote economic productivity.ConclusionDisclosing both HIV status and ART usage encourages adherence to medical care and explains subsequent absence from work. Full disclosure could result in understanding from the employer and resultant positive economic productivity.

The miRNomics of antiretroviral therapy-induced obesity

Human immunodeficiency virus (HIV) is a retrovirus that incorporates its genetic material into the host's chromosome. The resulting diseases and related conditions constitute a global health problem as there are no treatments to eliminate HIV from an infected individual. However, the potent, complex, and active antiretroviral therapy (ART) strategies have been able to successfully inhibit HIV replication in patients. Unfortunately, obesity following ART is frequent among HIV-infected patients. The mechanism underlying ART-induced obesity is characterized based on expression of traditional markers such as genes and proteins. However, little is known about, yet another key component of molecular biology known as microRNAs (miRNAs). Micro-RNAs are ~ 22 base-long non-coding nucleotides capable of regulating more than 60% of all human protein-coding genes. The interest in miRNA molecules is increasing and their roles in HIV and obesity are beginning to be apparent. In this review, we provide an overview of HIV and its associated diseases, ART-induced obesity, and discuss the roles and plausible benefits of miRNAs in regulating obesity genes in HIV-infected patients. Understanding the roles of miRNAs in ART-induced obesity will aid in tracking the disease progression and designing beneficial therapeutic approaches.

Incidence and determinants of excessive weight gain in people living with HIV initiating tenofovir, lamivudine, and dolutegravir-based therapy: a multicenter retrospective study in northwest Ethiopia

Background

The incidence and nature of excessive weight gain associated with antiretroviral treatment using tenofovir, lamivudine, and dolutegravir based regimens among patients living with human immunodeficiency virus has not been properly examined in Ethiopia. Therefore, this study aimed to assess the incidence and factors associated with excessive weight gain among People living with human immunodeficiency virus on tenofovir, lamivudine, and dolutegravir based regimens in a real-world setting.

Method

A multicenter retrospective cross-sectional study was conducted from December 1, 2022, to August 30, 2023, involving 620 human immunodeficiency virus patients initiating a tenofovir, lamivudine, and dolutegravir based regimen. Data on sociodemographic, clinical details, and excessive weight gain were collected from medical records and patient interviews using a semi-structured questionnaire. Continuous variables were reported with mean and standard deviation. Binary logistic regression analysis was performed, and variables with a P-value ≤0.25 were included in multivariate logistic regression. Statistical significance was set at a P-value of ≤0.05.

Results

A total of 620 participants were involved in the analysis, revealing a 31.43% incidence of excessive weight gain 95%CI (27.1-36.0). The mean weight gain was 3.77 kg with a 1.5 SD at 72 months follow-up. Factors such as being female [AOR = 1.75, 95% CI (1.01, 3.04)], age between 38-46 years [AOR = 1.53, 95% CI (1.23, 2.76)], lack of physical activity were [AOR = 4.41, 95% CI (1.46, 11.80)], having 6-12 months and 13-24 months of since starting new regimen follow up duration [AOR = 3.35, 95% CI (2.79, 4.30)] and [AOR = 2.67, 95% CI (2.43, 3.25)] respectively and having detectable viral load at initiation of regimen [AOR = 2.34, 95% CI (1.18, 6.63)] were significantly associated with excessive weight gain.

Conclusion

PLHIV receiving a tenofovir, lamivudine, and dolutegravir based regimen particularly females, aged 38-54 years, those with limited physical activity, follow-up durations of 6-24 months, advanced disease stages, and a detectable viral load at therapy initiation should be closely monitored for weight gain. Proactive surveillance in these patient groups is crucial to optimize therapeutic outcomes and address potential health concerns associated with weight changes.

Weight and mortality in people living with HIV and heart failure: Obesity paradox in the era of glucagon-like peptide 1 (GLP-1) receptor agonists and sodium-glucose cotransporter-2 (SGLT-2) inhibitors

BACKGROUND

Obesity is a recognized risk factor for heart failure (HF) in people living with HIV. However, among patients with HF, being overweight or having mild to moderate obesity has been associated with significantly improved survival rates compared with those at normal weight-a phenomenon known as the obesity paradox. This paradox has not yet been evaluated in patients with both HIV and HF in the era of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT-2is). Our study aimed to assess the mortality risk associated with body mass index (BMI) in patients with both HIV and HF and evaluate the impact of GLP-1 RAs and SGLT-2is on mortality across different weight categories.

METHOD

This study analyzed data from the New York City Health + Hospitals Corporation (NYC HHC) cohort (NYC 4H), which included records from 11 major New York City Health + Hospitals facilities. The dataset combined retrospective baseline data with ongoing prospective follow-up. The cohort consisted of adults with confirmed HIV and HF who had inpatient or clinic visits between July 2017 and June 2022. HIV infection and HF were initially identified using relevant International Classification of Diseases and Related Health Problems, 10th Revision codes and were further confirmed through laboratory results and echocardiograms. Medication data were verified through electronic health records and cross-referenced with pharmacy records. The primary outcome was the hazard ratio (HR) of overall mortality across different BMI categories in patients with both HIV and HF, assessed using proportional hazard regression models adjusted for age, sex, race, comorbidities, smoking status, and functional status. Secondary analyses included re-hospitalization within 6 months of discharge and the association between GLP-1 RAs/SGLT-2is and overall mortality in patients with HIV and HF. Additional analyses were conducted to assess the efficacy of these medications within different BMI categories.

RESULTS

A total of 1044 patients were analyzed, including 657 males (62.9%) and 387 females (37.1%), with an average age of 61.6 years at baseline and an average follow-up of 3.8 years. A low BMI (<18.5) was associated with a 57% increase in mortality (HR 1.57; 95% confidence interval [CI] 1.03-2.39; p = 0.04), whereas class I obesity (BMI 30.0-35.9) was associated with a 35% reduction in mortality (HR 0.65; 95% CI 0.42-0.99; p = 0.04) compared with normal BMI, after adjusting for covariates. Class II obesity was associated with a lower rate of re-hospitalization within 6 months of discharge. No significant differences were observed in cardiovascular mortality across different BMI categories. The use of GLP-1 RAs was associated with a 46% reduction in overall mortality risk (HR 0.54; 95% CI 0.30-0.97; p = 0.04), and SGLT-2is were associated with a 77% reduction in overall mortality risk (HR 0.23; 95% CI 0.11-0.46; p < 0.001) after adjusting for BMI and comorbidities. For both medications, the greatest mortality benefit was observed in patients with the highest BMI categories.

CONCLUSION

Our study found that overall mortality was higher among underweight individuals with both HIV and HF. Among patients with both conditions, GLP-1 RAs and SGLT-2is significantly reduced mortality, with the greatest survival benefit observed in users within the highest BMI categories.

Short and Long-term Body Weight Change Following the Switch to or the Addition of Integrase Inhibitors in Persons With HIV Differs by Sex

BACKGROUND

Sex-specific, long-term, body weight change in persons with human immunodeficiency virus (PWH) following switch to regimens containing integrase strand transfer inhibitors (INSTIs) is unknown.

METHODS

We compared PWH enrolled in the MACS/WIHS Combined Cohort Study (2007-2020) who switched/added an INSTI to their antiretroviral therapy (ART) regimen to those remaining on non-INSTI ART and to people without human immunodeficiency virus (PWOH), by sex. Follow-up time was time since switch visit (or comparable visit in controls). Linear regression mixed-effects models assessed the effects of sex, group, and time upon weight and anthropometric measurements.

RESULTS

Of 3464 participants included, women (411 INSTI, 709 non-INSTI, 818 PWOH) compared to men (223 INSTI, 412 non-INSTI, 891 PWOH) were younger (47.2 vs 54.5 years), were majority non-Hispanic Black (65% vs 23%), and had higher mean body mass index (31.5 vs 26.9 kg/m2), respectively. Women switching to INSTIs experienced greater absolute and percentage weight gain compared to men at 5 years: +3.0 kg (95% confidence interval [CI], 2.1-3.9) versus +1.8 kg (95% CI, .7-2.9) and +4.6% (95% CI, 3.5%-5.7%) versus +2.3% (95% CI, 1.0%-3.6%), respectively ([sex × time × group interaction, P < .01). Compared to men, women switching to INSTIs experienced greater hip and thigh circumference gain at 5 years: +2.6 cm (95% CI, 1.6-3.6) versus +1.2 cm (95% CI, .3-2.1) and +1.5 cm (95% CI, .7-2.2) versus -0.2 cm (95% CI, -.9 to .5), respectively.

CONCLUSIONS

Weight change among PWH over 5 years after switch to INSTI was 2-fold higher in women than men. The cardiometabolic implications of this difference in weight gain remain unknown.

Body weight changes in people with HIV starting dolutegravir versus efavirenz-based regimens in a large cohort in rural Tanzania

OBJECTIVES

To analyze weight changes associated with dolutegravir- versus efavirenz-based antiretroviral therapy (ART) in people with HIV (PWH) in rural Tanzania, where undernutrition is prevalent.

DESIGN

Longitudinal, observational study of the prospective Kilombero and Ulanga Antiretroviral Cohort (KIULARCO).

METHODS

We included adult, ART-naïve, nonpregnant PWH initiating efavirenz-based ART 12/2016-02/2019 or dolutegravir-based ART 03/2019-12/2022. We used multivariable linear mixed-effects models to assess adjusted weight changes during 18 months after ART start and Cox regression models to assess factors associated with incident obesity, weight gain ≥10% and hypertension.

RESULTS

Of 1205 PWH at ART start [median age 40 years (interquartile range (IQR) 32-48); 719 (59.7%) females], 166 (13.8%) individuals were underweight and 317 (26.3%) overweight/obese; 621 (51.5%) initiated efavirenz-based and 584 (48.5%) dolutegravir-based ART. After 18 months, estimated weight gain was 5.1 kg [95% confidence interval (CI) 4.7-5.5] in the dolutegravir versus 4.0 kg (95% CI 3.7-4.4) in the efavirenz group. The weight gain difference between treatment groups was high in men (1.7 kg (95% CI 0.8-2.6; P  < 0.001)), in those aged 30-49 years (1.5 kg (0.8-2.1); P  < 0.001) and those with CD4 + cell count ≥500/ul (2.5 kg (1.4-3.7), P  < 0.001)). Cumulative obesity incidence at 18 months was 10.9% (95% CI 8.3-14.0) in the dolutegravir and 5.1% (95% CI 3.6-7.1) in the efavirenz group. Associated factors were dolutegravir and a pre-ART body mass index (BMI) of 25-29 kg/m 2 . Dolutegravir and age, but not weight gain were associated with incident of hypertension.

CONCLUSIONS

Dolutegravir-based ART was associated with more weight gain, higher obesity and hypertension - especially in those with a higher pre-ART BMI compared to efavirenz-based regimens.

Preswitch Regimens Associated With Weight Gain Among Persons With HIV who Switch to Integrase Inhibitor-Containing Regimens

Background

Weight gain associated with integrase strand transfer inhibitors (INSTIs) is well documented. However, recent reports suggest that the observed weight gain among persons who switch to INSTIs may be associated with their preswitch regimen.

Methods

We conducted retrospective analyses of persons with HIV on antiretroviral therapy who switched to a second-generation INSTI-containing regimen (bictegravir/dolutegravir) at the Duke Adult Infectious Diseases Clinic (Durham, NC, USA) between 2014 and 2021. The outcome was weight change, operationalized as percent weight change, absolute weight change (kg), gaining ≥5% of preswitch weight, and gaining ≥10% of preswitch weight. The primary exposure was preswitch regimen.

Results

Our analysis included 750 persons. Cohort demographics were as follows: mean age (SD) 51 (11) years, 30% female at birth, 58% Black, 4% Hispanic ethnicity. At regimen switch, the mean CD4 count was 701 cells/mm3, and 68% had a viral load ≤20 copies/cc. Persons with preswitch regimens containing efavirenz had higher odds of gaining ≥5% body weight (odds ratio [OR], 1.62, 95% CI, 1.13-2.32) and ≥10% body weight (OR, 1.68; 95% CI, 1.02-2.73) after regimen switch, adjusted for age, sex, race, ethnicity, and preswitch body mass index. Persons with preswitch regimens containing tenofovir disoproxil (TDF) also had higher odds of gaining ≥5% body weight (OR, 1.64; 95% CI, 1.17-2.30).

Conclusions

Preswitch regimens containing efavirenz and TDF were associated with significant weight gain after switching to INSTI-based regimens. Our findings support the hypothesis that the weight gain observed with switching to INSTI-based regimens could be driven by stopping medications with weight-suppressing properties.

Effect of 2 Forms of Tenofovir on Duodenal Enterocytes-A Hypothesis for Different Effect of Tenofovir Disoproxil Fumarate and Tenofovir Alafenamide on Body Weight and Plasma Lipids

BACKGROUND

Tenofovir disoproxil fumarate (TDF), compared to tenofovir alafenamide (TAF), leads to lower body weight and plasma lipids by an unknown mechanism. We hypothesize that TDF, when absorbed, may damage enterocytes of the proximal duodenum, leading to reduced absorption of nutrients.

METHODS

People with human immunodeficiency virus, without significant gastrointestinal symptoms, receiving a regimen containing TDF (n = 12) or TAF (n = 12), underwent esophagogastroduodenoscopies. Plasma/serum concentrations of nutrients absorbed from proximal duodenum and serum intestinal fatty acid-binding protein (I-FABP), a marker of enterocyte damage, were measured. Cytochrome c oxidase/succinate dehydrogenase (COX/SDH) staining and electron microscopy (EM) were conducted to evaluate mitochondria.

RESULTS

Five patients in the TDF group (1 celiac disease [excluded from further analyses], 1 Helicobacter gastritis, and 3 esophagitis) and 2 in the TAF group (2 esophagitis) had a pathological finding in esophagogastroduodenoscopy. Villi were flatter (337 [59] vs 397 [42] μm; P = .016), crypts nonsignificantly deeper (200 [46] vs 176 [27] μm; P = .2), and villus-to-crypt ratio lower (1.5 [0.42] vs 2.5 [0.51]; P = .009) in the TDF versus TAF group (mean [standard deviation]). I-FABP concentration was higher in the TDF versus TAF group (3.0 [1.07] vs 1.8 [0.53] ng/mL; P = .003). The TDF group had numerically but not statistically significantly lower concentrations of folate and vitamins A, B1, D, and E. COX/SDH staining and EM showed similar mitochondrial damage in both groups.

CONCLUSIONS

Duodenal villous alterations may explain TDF-associated decrease in body weight and plasma lipids. Larger studies are needed to evaluate concentrations of nutrients absorbed from duodenum among TDF users..

CLINICAL TRIALS REGISTRATION

NCT05326971; EudraCT 2022-000849.

The Primacy of Adipose Tissue Gene Expression and Plasma Lipidome in Cardiometabolic Disease in Persons With HIV

BACKGROUND

Persons with HIV (PWH) on contemporary antiretroviral therapy (ART) are at elevated risk for developing age-related cardiometabolic diseases. We hypothesized that integrative analysis of cross-tissue, multimodal data from PWH could provide insight into molecular programming that defines cardiometabolic phenotypes in this high-risk group.

METHODS

We enrolled 93 PWH without diabetes who were virologically suppressed on contemporary ART and obtained measures of insulin resistance, glucose intolerance, and adiposity. We performed circulating lipidomics, proteomics, and metabolomics, as well as subcutaneous adipose tissue (SAT) bulk transcriptomics, and used multiomics factor analysis (MOFA) to perform integrative analyses of these datasets.

RESULTS

The median age was 43 years, median body mass index 30.8 kg/m2, 81% were male, and 56% were self-identified non-Hispanic White. We identified a specific MOFA factor associated with visceral adipose tissue volume (ρ = -0.43), homeostasis model assessment 2 insulin resistance score (ρ = -0.52), liver density (ρ = 0.43), and other cardiometabolic risk factors, which explained more variance in the SAT transcriptome and circulating lipidome compared with the circulating proteome and metabolome. Gene set enrichment analysis of this factor showed extracellular matrix and inflammatory pathways that primarily mapped to SAT myeloid cells and adipose progenitor cells using single-cell deconvolution. Lipidomic analysis showed that this factor was significantly enriched for triacylglycerol and diacylglycerol species.

CONCLUSIONS

Our multiomic analysis demonstrated coordinated, multitissue molecular reprogramming in virologically suppressed PWH with elevated cardiometabolic disease risk. Longitudinal studies of PWH with assessments of adipose tissue and lipid handling are necessary to understand mechanisms of cardiometabolic disease in PWH. Clinical Trials Registration. NCT04451980.

Weight gain, obesity, and the impact of lifestyle factors among people living with HIV: A systematic review

HIV remains a significant health concern, but the advent of antiretroviral therapy (ART) has transformed it into a manageable chronic condition. However, weight gain and obesity pose a substantial challenge for people living with HIV (PLWH). Moreover, the role of lifestyle has not yet been comprehensively investigated. This review aims to provide an updated perspective on the role of lifestyle factors in weight gain and obesity among PLWH. A systematic search was conducted on Medline, Web of Science, Scopus, and ClinicalTrials.gov according to PRISMA guidelines. Overall, 378 articles were identified, of which 22 studies met the inclusion criteria. No article comprehensively addressed all lifestyle factors, and only 8 (36.4%) evaluated 3 or more factors. Addictions (72.7%), food (34.4%), and physical activity (31.8%) were the most analyzed aspects. An absence of concordance was identified among the articles concerning the timing of assessments, methodologies employed in surveys, and the operational definitions utilized for "weight gain," "overweight," and "obesity." Weight gain in PLWH represents a complex phenomenon necessitating a holistic approach to promote well-being in this vulnerable population.

Weighing In: Glucagon-Like Peptide-1 Receptor Agonism for Persons With HIV

Weight gain among persons with HIV PWH) on contemporary antiretroviral therapy (ART) can extend beyond an initial return-to-health phenomenon and lead to overweight/obesity in the first 1 to 2 years, resulting in enhanced cardiometabolic risk. Factors that may contribute to increased weight gain include specific ART regimens (those initiating dolutegravir and tenofovir alafenamide or withdrawing tenofovir disoproxil and efavirenz), women with HIV, and certain virologic factors including lower baseline CD4 count and higher HIV viral load. Weight reduction starting at 5% body weight confers metabolic protection, such as improved hypertension and dysglycemia. Even greater metabolic impact has been shown with weight reduction in the approximate range of 15% body weight, as evidenced by decreases in cardiovascular disease mortality. Effective weight management is essential to reducing cardiometabolic risk, may not be achieved with lifestyle changes alone, and requires other therapeutic strategies. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are well recognized to provide potent weight reduction among persons with overweight/obesity; in addition, studies have shown cardiovascular benefit among those with established cardiovascular disease. Recent studies have permitted us to begin to understand the potential role of GLP-1 RAs among PWH and overweight/obesity. This review highlights weight gain specific to PWH and discusses current evidence and key clinical considerations for GLP-1 RA use among PWH.

Importance of trace elements in the immunometabolic health of people living with HIV/AIDS: a literature review

Trace elements (TEs) are essential for human health and for maintaining immune responses against potentially aggressive pathogens, such as the human immunodeficiency virus (HIV). During the infectious process, the body needs greater amounts of TEs in order to coordinate an efficient immune response to combat the invading agent, a condition that reflects in lymphocyte proliferation and activation of the antioxidant defense system of neutrophils and macrophages. Thus, during the progression phase of a viral infection, immunomodulation of TEs such as iron, zinc, chromium, magnesium, selenium, copper, calcium, and manganese occurs, can lead to immunosuppression and increased oxidative stress. Furthermore, the adverse effects caused by the use of antiretroviral therapy (ART) trigger nutritional disorders and metabolic alterations that contribute to deficiencies in TEs, associated with compromised immune function. Therefore, this narrative literature review aims to contribute as a teaching tool on the TEs involved in the pathogenesis of HIV, by reviewing the role of TEs in the immunometabolic health of people living with HIV/AIDS.

Overweight and Obesity Among People Living With HIV on Dolutegravir- and Efavirenz-Based Therapies: A Comparative Cross-Sectional Study

Background: Overweight and obesity have arisen as major public health challenges, affecting not just the general population but also people living with human immunodeficiency virus (HIV) (PLWH). Obesity and being overweight are both risk factors for heart disease and other related complications. However, little is known in our setting. As a result, this study was conducted to evaluate the prevalence of overweight and obesity and its associated factors among PLWH on dolutegravir (DTG)- and efavirenz (EFV)-based therapies. Methods: An institution-based comparative cross-sectional study was carried out from June 30, 2021, to August 30, 2021. We purposively recruited 128 participants who have been on DTG (n = 64)- and EFV (n = 64)-based regimens for ≥ 6 months. Demographic, anthropometric, laboratory, and clinical data were collected using a structured questionnaire. The data were entered into EpiData Version 4.6 and analyzed using SPSS Version 26.0. Multivariable logistic regression was utilized to identify the factors that are associated with being overweight or obese, and the significance level was set at p < 0.05. Result: The prevalence of overweight and obesity was 28.1% in the DTG-prescribed participants and 15.6% in the EFV-prescribed participants. Age ≥ 40 years (adjusted odd ratio (AOR) = 3.86; 95% confidence interval (CI): 1.08-13.73; and p=0.037), cluster of differentiation 4 (CD4) T-cell counts ≥ 500 cells/mm3 (AOR = 2.95; 95% CI: 1.01-8.59; and p=0.029), and insufficient physical activity (AOR = 4.6; 95% CI: 1.53-13.84; and p=0.007) were predictors of overweight and obesity. Conclusion: Overweight and obesity are not uncommon among PLWH on ART. While the difference was statistically insignificant, the prevalence of overweight and obesity was higher in patients treated with DTG compared with those treated with EFV. Older age, higher CD4 cell counts, and insufficient physical activity were associated with overweight and obesity. As a result, healthcare providers must understand the health implications of obesity and consider incorporating targeted weight control programs into standard HIV treatment.

Single-Cell Analysis of Subcutaneous Fat Reveals Profibrotic Cells That Correlate With Visceral Adiposity in HIV

CONTEXT

Cardiometabolic diseases are common in persons with HIV (PWH) on antiretroviral therapy (ART), which has been attributed to preferential lipid storage in visceral adipose tissue (VAT) compared with subcutaneous adipose tissue (SAT). However, the relationship of SAT-specific cellular and molecular programs with VAT volume is poorly understood in PWH.

OBJECTIVE

We characterized SAT cell-type specific composition and transcriptional programs that are associated with greater VAT volume in PWH on contemporary ART.

METHODS

We enrolled PWH on long-term ART with a spectrum of metabolic health. Ninety-two participants underwent SAT biopsy for bulk RNA sequencing and 43 had single-cell RNA sequencing. Computed tomography quantified VAT volume and insulin resistance was calculated using the Homeostasis Model Assessment 2 Insulin Resistance (HOMA2-IR).

RESULTS

VAT volume was associated with HOMA2-IR (P < .001). Higher proportions of SAT intermediate macrophages (IMs), myofibroblasts, and MYOC+ fibroblasts were associated with greater VAT volume using partial Spearman's correlation adjusting for age, sex, and body mass index (r = 0.34-0.49, P < .05 for all). Whole SAT transcriptomics showed PWH with greater VAT volume have increased expression of extracellular matrix (ECM)- and inflammation-associated genes, and reduced expression of lipolysis- and fatty acid metabolism-associated genes.

CONCLUSION

In PWH, greater VAT volume is associated with a higher proportion of SAT IMs and fibroblasts, and a SAT ECM and inflammatory transcriptome, which is similar to findings in HIV-negative persons with obesity. These data identify SAT cell-type specific changes associated with VAT volume in PWH that could underlie the high rates of cardiometabolic diseases in PWH, though additional longitudinal studies are needed to define directionality and mechanisms.

Optimizing cardiometabolic risk in people living with human immunodeficiency virus: A deep dive into an important risk enhancer

Effective antiretroviral therapy (ART) is now nearly ubiquitous. However, the survival benefits conferred with ART contribute to an aging human immunodeficiency virus (HIV) population and increased risk of chronic diseases, like atherosclerotic cardiovascular disease (ASCVD). Furthermore, HIV is a known risk enhancer of ASCVD and acknowledged as such in the current 2018 AHA/ACC Blood Cholesterol guidelines [1]. This makes cardiovascular risk factor identification and modification among people living with HIV (PLWH) of increasing importance to prevent cardiovascular events. In this review, we aim to summarize the epidemiology and pathogenesis of how HIV is linked to atherogenesis and to discuss cardiometabolic risk factor modification specific to PLWH, covering obesity, hypertension, insulin resistance, metabolic dysfunction-associated steatotic liver disease, and dyslipidemia.

Metabolic Complications Associated with Use of Integrase Strand Transfer Inhibitors (InSTI) for the Treatment of HIV-1 Infection: Focus on Weight Changes, Lipids, Glucose and Bone Metabolism

PURPOSE OF REVIEW

This review aims to summarize recently published peer reviewed papers on the influence of treatment with Integrase Strand Transfer Inhibitors (InSTI) in people with HIV (HIV) on metabolic health, including weight gain, lipid parameters, glucose homeostasis, and bone health.

RECENT FINDINGS

InSTI have a mild/moderate effect on weight gain in both antiretroviral (ART) naïve and ART experienced PWH, which is more pronounced in certain groups (i.e. women, people of Black African ethnicity, those with lower socioeconomic status, and older people). The effect on weight is also driven by other components of the ART regimen as well as previous exposure to certain ART. InSTI have a relatively safe profile in terms of lipid parameters and bone health, compared to other ART classes, although some studies suggest a greater risk of insulin resistance and diabetes in PWH using InSTI, especially 2nd generation InSTI. While there is some evidence suggesting a negative impact of InSTI on some aspects of metabolic health (weight gain and glucose homeostasis), they remain the preferred treatment option for most PWH, due to their high efficacy and tolerability. However, an individualised approach to ART choice in PWH should be used in order to avoid negative outcomes in populations at higher risks of metabolic complications.

Impact of switching to a dolutegravir-based regimen on body weight changes: insights from West African adult HIV cohorts

INTRODUCTION

Adverse metabolic effects related to dolutegravir (DTG) are increasingly reported as countries are adopting DTG-based regimens as first-line antiretroviral therapy (ART), but there is limited data from sub-Saharan Africa. We explored changes in body weight pre- and post-switch to a DTG-based regimen and assessed the association between DTG switch and significant weight gain (SWG) defined as a ≥10% increase over a 12-month period in people living with HIV (PLHIV) on ART in West Africa.

METHODS

We first included all PLHIV followed in the IeDEA West Africa cohorts between January 2017 and June 2021, with a documented switch to DTG during 2019-2021 and in care ≥36 months at the day of switch. Weight change was estimated using a two slope piecewise linear mixed model with change point at the switch date. Secondly, we emulated a sequence of target trials (ETT) based on the observational data, performing pooled logistic regression analysis to compare SWG occurrence between PLHIV who switched to DTG and those who did not.

RESULTS

We first included 6705 PLHIV from Burkina Faso, Côte d'Ivoire and Nigeria. Their median age at the time of switch was 48 years (IQR: 42-54) with a median follow-up of 9 years (IQR: 6-12), 63% were female. Most patients switched from efavirenz (EFV)-based ART (56.6%) and nevirapine (NVP)-based ART (30.9%). The overall post-switch annual average weight gain (AAWG) was significantly elevated at 3.07 kg/year [95% CI: 2.33-3.80] compared to the pre-switch AWG which stood at 0.62 kg/year [95% CI: 0.36-0.88]. The post-switch AWG was greater in patients previously on EFV and protease inhibitor (PI)-based ART compared to those on NVP-based ART. The pooled logistic regression analyses of a sequence of 24 ETT, including 9598 person-trials, switching to DTG was significantly associated with an SWG (aOR = 2.54; 95% CI = 2.18-2.97).

CONCLUSIONS

In West Africa, a 12-month DTG exposure was associated with substantial weight gain, especially in PLHIV previously on EFV and PI-based ARTs. Continuous weight monitoring and metabolic profiling is imperative in HIV cohorts to delineate the long-term cardiometabolic impact of DTG as patients with, or at elevated risk for cardiovascular diseases might benefit from alternative ART regimens.

Immunological Efficacy and the Impact on Weight of Dolutegravir-Based Regimen in Antiretroviral Therapy (ART)-Naïve Patients with HIV Infection

Purpose

This study aimed to assess the immunological efficacy and the impact on weight of dolutegravir (DTG)-based antiretroviral therapy (ART) regimen in ART-naive people living with HIV (PLWH).

Methods

A prospective study was conducted on ART-naïve PLWH who treated with DTG-based or efavirenz (EFV)-based regimens in The Second Hospital of Nanjing. Based on previous studies, the sample size was 332 patients calculated by PASS software. Considering a 20% dropout rate, the expected sample size was 416 patients, which were 208 patients in the DTG and EFV groups, respectively.

Results

Among 416 enrolled participants, the median age was 30.0 years (25.0-43.0), 388 (93.3%) males. At baseline, patients in the DTG group had worse pre-treatment immune level, but with no significant difference in weight compared to the EFV group. After 12 months of follow-up, the CD4+ T-cell counts increased greater in the DTG group (P=0.036), while the CD4+/CD8+ T-cell ratio increased greater in the EFV group (P=0.014). There was no significant difference in the normalization of various immune indicators between the two groups. The weight gain of patients in the DTG group at different follow-up points was all significantly higher than that in the EFV group (P<0.05). Multivariate logistic regression analysis showed that DTG-based regimens (OR=4.524, 95% CI: 2.371-8.634, P<0.001), baseline VL ≥10^5 copies/mL (OR=2.563, 95% CI: 1.411-4.657, P=0.002), and baseline CD4+ T-cell counts <200 cells/μL (OR=2.595, 95% CI: 1.430-4.709, P=0.002) were risk factors for weight gain ≥5 kg during the 12-month follow-up period.

Conclusion

After 12 months of follow-up, the increase in CD4+ T-cell counts was higher in the DTG group than in the EFV group, but the overall immunological efficacy was similar in both groups. However, attention should be paid to patients' weight, especially in patients with high baseline viral load and low CD4+ T-cell counts who were treated with the DTG-based regimen.

Diabetes Risk Factors in People With HIV Receiving Pitavastatin Versus Placebo for Cardiovascular Disease Prevention : A Randomized Trial

BACKGROUND

REPRIEVE (Randomized Trial to Prevent Vascular Events in HIV) led to new guidelines for statin use among people with HIV (PWH) with low to moderate risk for atherosclerotic cardiovascular disease (ASCVD). Little is known about the natural history of diabetes mellitus (DM) or mechanisms contributing to statin effects on DM among this population.

OBJECTIVE

To determine the contribution of known DM risk factors to excess risk for DM with pitavastatin in REPRIEVE.

DESIGN

Phase 3, primary ASCVD prevention trial over a median of 5.6 years of follow-up. (ClinicalTrials.gov: NCT02344290).

SETTING

Global, multicenter trial.

PARTICIPANTS

7731 PWH aged 40 to 75 years with low to moderate ASCVD risk (by the pooled cohort equations from the American College of Cardiology and American Heart Association) without DM at study entry.

INTERVENTION

Random 1:1 assignment to pitavastatin, 4 mg daily, or placebo.

MEASUREMENTS

New-onset DM was determined at each visit by clinical diagnosis requiring initiation of medication treatment for DM. The incidence of new-onset DM was assessed in relation to predefined demographic and metabolic risk factors, stratified by treatment group. Treatment effects of pitavastatin on progression to new DM in key subgroups were determined.

RESULTS

Participants with at least 3 DM risk factors (vs. no risk factors) had increased risk for DM in each treatment group (incidence rate, 3.24 per 100 person-years [PY] vs. 0.34 per 100 PY [pitavastatin] and 2.66 per 100 PY vs. 0.27 per 100 PY [placebo]). The incidence of DM was highest in South Asia. In adjusted analyses, high body mass index, prediabetes, and metabolic syndrome components were strongly associated with new-onset DM (all P < 0.005).

LIMITATION

Pitavastatin was the only statin assessed; DM was assessed clinically.

CONCLUSION

Metabolic risk factors, including prediabetes and obesity, contributed to new-onset DM in statin- and placebo-treated participants. A clinically significant effect of pitavastatin on DM was seen primarily among those with multiple risk factors for DM at entry. Strategies targeting key metabolic risk factors, like obesity and prediabetes, may help protect against DM among PWH.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute of the National Institutes of Health.

Nucleoside/nucleotide reverse transcriptase inhibitor-associated weight gain in people living with HIV: data from the Copenhagen Comorbidity in HIV Infection (COCOMO) study

Weight gain effects of Nucleoside/Nucleotide Reverse Transcriptase Inhibitors in people with HIV (PWH) have been sparsely studied.Participants were enrolled in the Copenhagen Comorbidity in HIV Infection (COCOMO) study. PWH receiving a backbone of emtricitabine, or lamivudine combined with abacavir, tenofovir disoproxil, or tenofovir alafenamide were analysed. Weight gain according to ART backbone and to the third drug was analysed using a multiple linear regression model. Non-ART risk factors were also determined using multiple linear regression.A total of 591 participants were included in the analysis. The majority were middle-aged, virally suppressed males with a mean BMI just above the normal range. Both tenofovir disoproxil/emtricitabine or lamivudine and abacavir /emtricitabine or lamivudine, but not tenofovir alafenamide /emtricitabine or lamivudine were associated with weight gain over two years (0.6 kg, p = 0.025; 1.0 kg, p = 0.005). The third drugs associated with weight increase were non-nucleoside reverse transcriptase inhibitors (NNRTI) (p = 0.035), dolutegravir (p = 0.008) and atazanavir (p = 0.040). Non-ART risk factors for gaining weight were low or normal BMI, age <40 years, underweight, inactivity or highly active at baseline.Tenofovir disoproxil and abacavir-based ART regimens were associated with a small weight gain. Third drug NNRTI, dolutegravir and atazanavir were associated with an increase in weight.

Bictegravir alters glucose tolerance in vivo and causes hepatic mitochondrial dysfunction

Growing evidence associates antiretroviral therapies containing integrase strand transfer inhibitors or tenofovir alafenamide (TAF) with increased weight gain and metabolic diseases, but the underlying mechanisms remain unclear. This study evaluated the impact of lamivudine, dolutegravir (DTG), bictegravir (BIC), tenofovir disoproxil fumarate, and TAF on metabolic alterations, and explored glucose homeostasis and mitochondrial stress as potential mechanisms. These pathways were analyzed both in vivo (C57BL/6J mice treated with the abovementioned drugs or vehicle for 16 weeks) and in vitro (in Hep3B cells). Mice treated with BIC exhibited higher glucose levels and a slower decrease during a glucose tolerance test. Functional enrichment analyses of livers from antiretroviral-treated mice revealed that only BIC altered the cellular response to insulin and induced a gluconeogenic-favoring profile, with Fgf21 playing a significant role. In vitro, BIC significantly reduced hepatocyte glucose uptake in a concentration-dependent manner, both under basal conditions and post-insulin stimulation, while the other drugs produced no significant changes. Hep3B cells treated with clinically relevant concentrations of BIC exhibited significant alterations in the mRNA expression of enzymes related to glucose metabolism. Both DTG and BIC reduced mitochondrial dehydrogenase activity, but only BIC increased reactive oxygen species, mitochondrial membrane potential, and cellular granularity, thereby indicating mitochondrial stress. BIC promoted mitochondrial dysfunction, modified carbohydrate metabolism and glucose consumption in hepatocytes, and altered glucose tolerance and gluconeogenesis regulation in mice. These findings suggest that BIC contributes to insulin resistance and diabetes in people living with HIV, warranting clinical studies to clarify its association with carbohydrate metabolism disorders.

Risk factors for progression from prediabetes to diabetes among older people with HIV

OBJECTIVE

Risk factors for progression from prediabetes mellitus (pre-DM) to diabetes mellitus (DM) among people with HIV (PWH) receiving modern antiretroviral therapy (ART) require better characterization.

DESIGN

AIDS Clinical Trials Group (ACTG) A5322 (HAILO) was an observational cohort study of PWH ≥40 years old. Participants initiated ART through ACTG randomized clinical trials.

METHODS

We used Cox proportional hazards regression models to identify risk factors for development of DM among HAILO participants with pre-DM.

RESULTS

Among 1035 HAILO participants, 74 (7%) had pre-DM at entry and another 679 (66%) developed pre-DM during follow-up. Of 753 PWH with pre-DM, 167 (22%) developed DM. In multivariable models, the risk of developing DM was greater with higher BMI, lower CD4 count (≤200 cells/mm 3 ), hypertriglyceridemia, or higher waist circumference at pre-DM diagnosis ( P  < 0.01).

CONCLUSION

Rates of pre-DM and progression to DM remain high among virally suppressed PWH receiving modern ART regimens. Traditional risks for DM, such as higher BMI or waist circumference, are associated with increased risk of incident DM among PWH with pre-DM. The association between lower CD4 + and progression to DM suggests a role for advanced immunodeficiency and inflammation. Further investigation of interventions aimed at preventing DM among PWH with pre-DM is needed. Optimizing prevention and treatment for DM may be an intervenable opportunity to improve long-term outcomes for PWH.

Changes in bodyweight after initiating antiretroviral therapy close to HIV-1 seroconversion: an international cohort collaboration

BACKGROUND

Understanding the reasons for and consequences of bodyweight change in people living with HIV initiating antiretroviral therapy (ART) is crucial to optimising long-term health and wellbeing. We aimed to examine bodyweight trends and associated factors among individuals with well estimated dates of HIV-1 seroconversion.

METHODS

In this cohort study, we pooled retrospective data from clinical records of participants in CASCADE aged 16 years and older recruited from clinics in France, Greece, the Netherlands, Spain, Sweden, the UK, and Canada. All participants had well estimated dates of HIV-1 seroconversion, seroconverted between Jan 1, 2007, and Dec 31, 2022 (HIV-1 positive antibody test within 12 months of an HIV-1 negative antibody test, or other laboratory evidence of seroconversion), initiated ART within 1 year of seroconversion, and were previously ART-naive. Participants were followed up to the time of data pooling (May 31, 2023). We modelled bodyweight changes after ART initiation by ART class, BMI categories, and other demographic characteristics using linear mixed models.

FINDINGS

Of 15 755 potentially eligible participants, 5698 met inclusion criteria. Of those, 5148 (90·3%) were assigned male at birth, 517 (9·1%) were assigned female at birth, and 33 (0·6%) had sex not known. 2778 (48·8%) participants initiated integrase strand transfer inhibitor (INSTI)-based ART regimens, 1809 (31·7%) initiated protease inhibitor-based regimens, and 1111 (19·5%) initiated non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. The majority of participants were men who have sex with men (MSM; 4519 [79·3%]). Median age at seroconversion was 33·7 years (IQR 26·9-43·2). Bodyweight changes differed significantly by ART class within all baseline BMI categories (BMI <18·5 kg/m2 p=0·026, BMI 18·5-24·9 kg/m2 p<0·0001, BMI 25·0-29·9 kg/m2 p=0·0021, and BMI ≥30·0 kg/m2 p=0·0033; ART class and BMI interaction p=0·011). Participants with BMI less than 30 kg/m2 on regimens including both INSTI and tenofovir alafenamide gained 4·76 kg (95% CI 4·05-5·46) or more at 3 years. Of those with baseline BMI 18·5-24·9 kg/m2, 31·3% (95% CI 29·5-33·1) on INSTI-based regimens, 25·3% (23·0-27·7) on protease inhibitor-based regimens, 20·4% (18·8-22·9) on NNRTI-based regimens, 37·4% (33·9-40·9) on tenofovir alafenamide-based regimens, and 38·4% (34·6-42·1) on tenofovir alafenamide and INSTI-based regimens had gained more than 10% of their baseline bodyweight at 3 years. The greatest 3-year bodyweight gains by individuals on INSTI-based regimens and with BMI 18·5-24·9 kg/m2 were in women (5·63 kg [95% CI 4·92-6·35]), and people originating from sub-Saharan African (5·76 kg [5·06-6·46]), compared with MSM (3·82 kg [3·50-4·13]).

INTERPRETATION

Our findings suggest a direct effect of INSTIs and tenofovir alafenamide on bodyweight gain, rather than a return to health effect. Given the known risk for cardiometabolic disease, bodyweight management needs to be part of the overall care of individuals prescribed these drugs.

FUNDING

ViiV Healthcare UK, Janssen Pharmaceutica, and Merck Sharp & Dohme.

Weight Gain and Antiretroviral Therapy

Antiretroviral therapy (ART) agents as a determinant of body weight in ART-naïve and ART-experienced persons with human immunodeficiency virus (HIV) (PWH) has become a major focus area in research and clinical settings. Recent studies demonstrating weight-suppressing properties of efavirenz and tenofovir disoproxil fumarate led to re-evaluation of weight gain studies, and a reassessment of whether other agents are weight promoting versus weight neutral. In this review, the authors synthesize recent literature on factors related to obesity, clinical measurements of adiposity, weight gain in ART-naïve and ART-experienced PWH, metabolic consequences of ART and weight gain, and the clinical management of weight gain in PWH.

Efficacy, Safety, and Pharmacokinetics by Body Mass Index Category in Phase 3/3b Long-Acting Cabotegravir Plus Rilpivirine Trials

BACKGROUND

Cabotegravir plus rilpivirine (CAB + RPV) is a guideline-recommended long-acting (LA) injectable regimen for the maintenance of human immunodeficiency virus-1 (HIV-1) virologic suppression. This post hoc analysis summarizes CAB + RPV LA results by baseline body mass index (BMI) category among phase 3/3b trial participants.

METHODS

Data from CAB + RPV-naive participants receiving every 4 or 8 week dosing in FLAIR, ATLAS, and ATLAS-2M were pooled through week 48. Data beyond week 48 were summarized by study (FLAIR through week 96 and ATLAS-2M through week 152). HIV-1 RNA <50 and ≥50 copies/mL, confirmed virologic failure (CVF; 2 consecutive HIV-1 RNA ≥200 copies/mL), safety and tolerability, and plasma CAB and RPV trough concentrations were evaluated by baseline BMI (<30 kg/m2, lower; ≥30 kg/m2, higher).

RESULTS

Among 1245 CAB + RPV LA participants, 213 (17%) had a baseline BMI ≥30 kg/m2. At week 48, 92% versus 93% of participants with lower versus higher BMI had HIV-1 RNA <50 copies/mL, respectively. Including data beyond week 48, 18 participants had CVF; those in the higher BMI group (n = 8) all had at least 1 other baseline factor associated with CVF (archived RPV resistance-associated mutations or HIV-1 subtype A6/A1). Safety and pharmacokinetic profiles were comparable between BMI categories.

CONCLUSIONS

CAB + RPV LA was efficacious and well tolerated, regardless of baseline BMI category.

CLINICAL TRIALS REGISTRATION

NCT02938520, NCT02951052, and NCT03299049.

Identification of hepatic steatosis among persons with and without HIV using natural language processing

BACKGROUND

Steatotic liver disease (SLD) is a growing phenomenon, and our understanding of its determinants has been limited by our ability to identify it clinically. Natural language processing (NLP) can potentially identify hepatic steatosis systematically within large clinical repositories of imaging reports. We validated the performance of an NLP algorithm for the identification of SLD in clinical imaging reports and applied this tool to a large population of people with and without HIV.

METHODS

Patients were included in the analysis if they enrolled in the Veterans Aging Cohort Study between 2001 and 2017, had an imaging report inclusive of the liver, and had ≥2 years of observation before the imaging study. SLD was considered present when reports contained the terms "fatty," "steatosis," "steatotic," or "steatohepatitis." The performance of the SLD NLP algorithm was compared to a clinical review of 800 reports. We then applied the NLP algorithm to the first eligible imaging study and compared patient characteristics by SLD and HIV status.

RESULTS

NLP achieved 100% sensitivity and 88.5% positive predictive value for the identification of SLD. When applied to 26,706 eligible Veterans Aging Cohort Study patient imaging reports, SLD was identified in 72.2% and did not significantly differ by HIV status. SLD was associated with a higher prevalence of metabolic comorbidities, alcohol use disorder, and hepatitis B and C, but not HIV infection.

CONCLUSIONS

While limited to those undergoing radiologic study, the NLP algorithm accurately identified SLD in people with and without HIV and offers a valuable tool to evaluate the determinants and consequences of hepatic steatosis.

Cardiometabolic health in people with HIV: expert consensus review

OBJECTIVES

To develop consensus data statements and clinical recommendations to provide guidance for improving cardiometabolic health outcomes in people with HIV based on the knowledge and experience of an international panel of experts.

METHODS

A targeted literature review including 281 conference presentations, peer-reviewed articles, and background references on cardiometabolic health in adults with HIV published between January 2016 and April 2022 was conducted and used to develop draft consensus data statements. Using a modified Delphi method, an international panel of 16 experts convened in workshops and completed surveys to refine consensus data statements and generate clinical recommendations.

RESULTS

Overall, 10 data statements, five data gaps and 14 clinical recommendations achieved consensus. In the data statements, the panel describes increased risk of cardiometabolic health concerns in people with HIV compared with the general population, known risk factors, and the potential impact of antiretroviral therapy. The panel also identified data gaps to inform future research in people with HIV. Finally, in the clinical recommendations, the panel emphasizes the need for a holistic approach to comprehensive care that includes regular assessment of cardiometabolic health, access to cardiometabolic health services, counselling on potential changes in weight after initiating or switching antiretroviral therapy and encouraging a healthy lifestyle to lower cardiometabolic health risk.

CONCLUSIONS

On the basis of available data and expert consensus, an international panel developed clinical recommendations to address the increased risk of cardiometabolic disorders in people with HIV to ensure appropriate cardiometabolic health management for this population.

Contemporary Treatment Approaches for Human Immunodeficiency Virus Infection: Association of Antiretrovirals with Weight Gain and Potential Solutions

Integrase inhibitors and tenofovir alafenamide have become a mainstay in modern antiretroviral therapy; more recently, they have been implicated as causing increased weight gain beyond what may be expected with the "return to health" phenomenon. Some patients, namely those assigned female at birth, of the black race, or with lower baseline CD4 counts, may be more likely to experience weight gain. This review outlines existing evidence linking the agents to excessive weight as well as ongoing efforts to combat these effects.

12-week Dolutegravir treatment marginally reduces energy expenditure but does not increase body weight or alter vascular function in a murine model of Human Immunodeficiency Virus infection

Combination antiretroviral therapy (cART) has markedly increased life expectancy in people with HIV (PWH) but has also resulted in an increased prevalence of cardiometabolic disorders, whose etiopathology remains ill-defined. Notably, the respective contribution of cART and HIV-derived proteins to obesity and vascular alterations remain poorly understood. Therefore, we investigated the individual and combined effects of HIV-proteins and of the integrase strand transfer inhibitor Dolutegravir (DTG) on body composition and vascular reactivity. Male wildtype (WT) and HIV transgenic (Tg26) mice, received DTG or vehicle for 12 weeks. Viral proteins expression in Tg26 mice lowered fat mass, increased heat production, and induced a 2-fold increase in brown adipose tissue (BAT) uncoupling protein 1 (UCP1) expression. DTG increased the expression of markers of adipogenesis in adipocytes in culture, but also reduced heat production and BAT UCP1 and UCP3 expression in Tg26 mice. DTG increased food intake, fat percentage and protected from lean mass reduction in Tg26 mice only. However, DTG did not increase body weight in either WT or Tg26 mice. Viral protein expression reduced acetylcholine (endothelium)-mediated relaxation by 14% in mesenteric arteries preconstricted with phenylephrine. However, DTG did not impair nor improve endothelium-dependent relaxation. Together, these data indicate that DTG's effects on food intake, adipogenesis and energy expenditure are insufficient to increase body weight, even in the presence of HIV-proteins, suggesting that body weight gain in PWH involves additional factors likely including other cART components and pre-existing comorbidities. Moreover, these data rule out DTG as a source of vascular disorders in PWH.

Trends in body mass index in the pre-dolutegravir period in South Africa

Background

Antiretroviral therapy (ART) is associated with weight gain, but this has been shown to be more marked with dolutegravir and other integrase strand transfer inhibitors.

Objectives

We studied weight gain in people living with HIV (PLWH) on ART compared to the general population in the period before dolutegravir was introduced in a rural South African cohort.

Method

Longitudinal analysis of the Ndlovu Cohort Study including 36-48 months' follow-up data. From 2014 to 2019, data were collected annually in Limpopo, rural South Africa. Linear mixed models using HIV status, demographics, ART use and cardiovascular risk factors were used to estimate trends in body mass index (BMI) over time.

Results

In total, 1518 adult, non-pregnant participants were included, of whom 518 were PLWH on ART (79.8%), 135 PLWH not yet on ART (20.2%) and 865 HIV-negative. HIV-negative participants had significantly higher BMIs than PLWH on ART at all study visits. There was a significant increase in BMI in all subgroups after 36 months (PLWH on ART, BMI +1.2 kg/m2, P < 0.001; PLWH not on ART, BMI +1.8 kg/m2, P < 0.001 and HIV-negative, BMI +1.3 kg/m2, P < 0.001).

Conclusion

The increase in BMI in PLWH and HIV-negative participants is a serious warning signal as obesity results in morbidity and mortality.

Adults with Perinatally Acquired HIV; Emerging Clinical Outcomes and Data Gaps

In resourced settings, adults living with perinatally acquired HIV are approaching the 5th decade of life. Their clinical and psychological outcomes highlight potential future issues for the much larger number of adolescents growing up with HIV in sub-Saharan Africa, and will inform the development of appropriate healthcare services. Lifelong exposure to HIV, and increasingly to antiretroviral therapy throughout growth and development, contrasts with adults acquiring HIV in later life. This review describes the clinical outcomes for adults living with perinatally acquired HIV including post transition mortality, morbidity and retention in care. Rates of viral suppression, drug resistance and immunological function are explored. Co-morbidities focus on metabolic, cardiovascular, respiratory and bone health with quality-of-life data including neurocognitive functioning and mental health. Sexual and reproductive health including vaccine-preventable disease and the prevention of onward transmission to partners and infants are considered. The data gaps and future research questions to optimise outcomes for this emerging adult cohort are highlighted.

Efficacy and effect on lipid profiles of switching to ainuovirine-based regimen versus continuing efavirenz-based regimen in people with HIV-1: 24-week results from a real-world, retrospective, multi-center cohort study

Ainuovirine (ANV), a novel non-nucleoside reverse-transcriptase inhibitor (NNRTI), was approved in China in 2021. In a previous randomized phase 3 trial, ANV demonstrated non-inferior efficacy relative to efavirenz (EFV) and was associated with lower rates of dyslipidemia. In this study, we aimed to explore lipid changes in treatment-experienced people with human immunodeficiency virus (HIV)-1 (PWH) switching to ANV from EFV in real world. At week 24, 96.65% of patients in the ANV group and 93.25% in the EFV group had HIV-1 RNA levels below the limit of quantification (LOQ). Median changes from baseline in CD4 +T cell counts (37.0 vs 36.0 cells/µL, P = 0.886) and CD4+/CD8 +ratio (0.03 vs 0.10, P = 0.360) were similar between the two groups. The ANV group was superior to the EFV group in mean changes in total cholesterol (TC, -0.06 vs 0.26 mmol/L, P = 0.006), triglyceride (TG, -0.6 vs 0.14 mmol/L, P < 0.001), high-density lipoprotein cholesterol (HDL-C, 0.09 vs 0.08 mmol/L, P = 0.006), and low-density lipoprotein cholesterol (LDL-C, -0.18 vs 0.29 mmol/L, P < 0.001) at week 24. We also observed that a higher proportion of patients demonstrated improved TC (13.55% vs 4.45%, P = 0.015) or LDL-C (12.93% vs 6.89%, P = 0.017), and a lower proportion of patients showed worsened LDL-C (5.57% vs 13.52%, P = 0.017) with ANV than with EFV at week 24. In conclusion, we observed good efficacy and favorable changes in lipids in switching to ANV from EFV in treatment-experienced PWH in real world, indicating a promising switching option for PWH who may be more prone to metabolic or cardiovascular diseases.

Metabolic causes of liver disease among adults living with HIV from low- and middle-income countries: a cross-sectional study

INTRODUCTION

Liver disease is a leading cause of morbidity and mortality among persons living with HIV (PLHIV). While chronic viral hepatitis has been extensively studied in low- and middle-income countries (LMICs), there is limited information about the burden of metabolic disorders on liver disease in PLHIV.

METHODS

We conducted a cross-sectional analysis of baseline data collected between October 2020 and July 2022 from the IeDEA-Sentinel Research Network, a prospective cohort enrolling PLHIV ≥40 years on antiretroviral treatment (ART) for ≥6 months from eight clinics in Asia, Americas, and central, East, southern and West Africa. Clinical assessments, laboratory testing on fasting blood samples and liver stiffness measurement (LSM)/controlled attenuation parameter (CAP) by vibration-controlled transient elastography were performed. Multivariable logistic regression models assessed factors associated with liver fibrosis (LSM ≥7.1 kPa) and steatosis (CAP ≥248 dB/m). Population attributable fraction (PAF) of each variable associated with significant liver fibrosis was estimated using Levin's formula.

RESULTS

Overall, 2120 PLHIV (56% female, median age 50 [interquartile range: 45-56] years) were included. The prevalence of obesity was 19%, 12% had type 2 diabetes mellitus (T2DM), 29% had hypertension and 53% had dyslipidaemia. The overall prevalence of liver fibrosis and steatosis was 7.6% (95% confidence interval [CI] 6.1-8.4) and 28.4% (95% CI 26.5-30.7), respectively, with regional variability. Male sex at birth (odds ratio [OR] 1.62, CI 1.10-2.40), overweight/obesity (OR = 2.50, 95% CI 1.69-3.75), T2DM (OR 2.26, 95% CI 1.46-3.47) and prolonged exposure to didanosine (OR 3.13, 95% CI 1.46-6.49) were associated with liver fibrosis. Overweight/obesity and T2DM accounted for 42% and 11% of the PAF for liver fibrosis, while HBsAg and anti-HCV accounted for 3% and 1%, respectively. Factors associated with steatosis included overweight/obesity (OR 4.25, 95% CI 3.29-5.51), T2DM (OR 2.06, 95% CI 1.47-2.88), prolonged exposure to stavudine (OR 1.69, 95% CI 1.27-2.26) and dyslipidaemia (OR 1.68, 95% CI 1.31-2.16).

CONCLUSIONS

Metabolic disorders were significant risk factors for liver disease among PLHIV in LMICs. Early recognition of metabolic disorders risk factors might be helpful to guide clinical and lifestyle interventions. Further prospective studies are needed to determine the causative natures of these findings.

Weight loss associated with semaglutide treatment among people with HIV

OBJECTIVE

There is limited real-world evidence about the effectiveness of semaglutide for weight loss among people with HIV (PWH). We aimed to investigate weight change in a US cohort of PWH who initiated semaglutide treatment.

DESIGN

Observational study using the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort.

METHODS

We identified adult PWH who initiated semaglutide between 2018 and 2022 and with at least two weight measurements. The primary outcome was within-person bodyweight change in kilograms at 1 year. The secondary outcome was within-person Hemoglobin A1c percentage (HbA1c) change. Both outcomes were estimated using multivariable linear mixed model.

RESULTS

In total, 222 new users of semaglutide met inclusion criteria. Mean follow-up was 1.1 years. Approximately 75% of new semaglutide users were men, and at baseline, mean age was 53 years [standard deviation (SD): 10], average weight was 108 kg (SD: 23), mean BMI was 35.5 kg/m 2 , mean HbA1c was 7.7% and 77% had clinically recognized diabetes. At baseline, 97% were on ART and 89% were virally suppressed (viral load < 50 copies/ml). In the adjusted mixed model analysis, treatment with semaglutide was associated with an average weight loss of 6.47 kg at 1 year (95% CI -7.67 to -5.18) and with a reduction in HbA1c of 1.07% at 1 year (95% CI -1.64 to -0.50) among the 157 PWH with a postindex HbA1c value.

CONCLUSION

Semaglutide was associated with significant weight loss and HbA1c reduction among PWH, comparable to results of previous studies from the general population.

Weight Gain After Antiretroviral Therapy Initiation and Subsequent Risk of Metabolic and Cardiovascular Disease

BACKGROUND

Weight gain following initiation of antiretroviral therapy (ART) is common. We assessed the impact of changes in weight in the year following ART initiation with subsequent cardiometabolic disease among AIDS Clinical Trials Group (ACTG) participants.

METHODS

Linear regression models were fit to examine the association between change in weight/waist circumference (WC) in weeks 0-48 and change in metabolic parameters in weeks 0-48 and 48-96. Cox proportional hazard models were fit to examine the association between changes in weight/WC in weeks 0-48 and diabetes mellitus (DM), metabolic syndrome, or cardiometabolic and cardiovascular events after week 48.

RESULTS

Participants (N = 2624) were primarily male (81%) and non-White (60%). Mean weight gain from 0-48 weeks was 3.6 kg (SD 7.3); 130 participants developed DM; 360 metabolic syndrome; 424 any cardiometabolic event; 28 any cardiovascular event, over 480 weeks of follow-up. In adjusted models, total cholesterol increased by 0.63 mg/dL (95% confidence interval [CI] [.38, .089]) and LDL by 0.39 mg/dL (0.19, 0.59) per 1 kg increase in weight from weeks 0 to48. Participants who experienced >10% weight gain (vs -5% to 5%) had an increased risk of DM (hazard ratio [HR] 2.01, 95% CI [1.30, 3.08]), metabolic syndrome (HR 2.24, 95% CI [1.55, 2.62]), and cardiometabolic outcomes (HR 1.54, 95% CI [1.22, 1.95]). Participants who lost more than 5% of their baseline weight had a lower risk of incident metabolic syndrome (HR 0.67, 95% CI [0.42, 1.07]). Trends for WC were similar.

CONCLUSIONS

Weight and body composition changes in the first year following ART initiation are associated with contemporaneous changes in metabolic parameters and subsequent cardiometabolic disease.

The Potential of Clostridium butyricum to Preserve Gut Health, and to Mitigate Non-AIDS Comorbidities in People Living with HIV

A dramatic reduction in mortality among people living with HIV (PLWH) has been achieved during the modern antiretroviral therapy (ART) era. However, ART does not restore gut barrier function even after long-term viral suppression, allowing microbial products to enter the systemic blood circulation and induce chronic immune activation. In PLWH, a chronic state of systemic inflammation exists and persists, which increases the risk of development of inflammation-associated non-AIDS comorbidities such as metabolic disorders, cardiovascular diseases, and cancer. Clostridium butyricum is a human butyrate-producing symbiont present in the gut microbiome. Convergent evidence has demonstrated favorable effects of C. butyricum for gastrointestinal health, including maintenance of the structural and functional integrity of the gut barrier, inhibition of pathogenic bacteria within the intestine, and reduction of microbial translocation. Moreover, C. butyricum supplementation has been observed to have a positive effect on various inflammation-related diseases such as diabetes, ulcerative colitis, and cancer, which are also recognized as non-AIDS comorbidities associated with epithelial gut damage. There is currently scant published research in the literature, focusing on the influence of C. butyricum in the gut of PLWH. In this hypothesis review, we speculate the use of C. butyricum as a probiotic oral supplementation may well emerge as a potential future synergistic adjunctive strategy in PLWH, in tandem with ART, to restore and consolidate intestinal barrier integrity, repair the leaky gut, prevent microbial translocation from the gut, and reduce both gut and systemic inflammation, with the ultimate objective of decreasing the risk for development of non-AIDS comorbidities in PLWH.

Changes in Body Mass Index Over Time in People With and Without HIV Infection

Background

Excess weight gain is an important health concern among people with HIV (PWH) on antiretroviral therapy (ART). The extent to which ART contributes to body mass index (BMI) changes is incompletely understood.

Methods

We conducted a retrospective study of PWH initiating ART and demographically matched people without HIV (PWoH). Data on baseline BMI (kg/m2; categorized as underweight/normal, overweight, or obese) and ART class (integrase strand transfer inhibitor [INSTI], non-nucleoside reverse transcriptase inhibitor [NNRTI], protease inhibitor [PI]) were obtained from electronic health records. BMI was evaluated longitudinally using piecewise linear splines in mixed effects models by HIV status, baseline BMI, and ART class. Models were adjusted for sociodemographics, comorbidities, and substance use.

Results

The study included 8256 PWH and 129 966 PWoH (mean baseline age, 40.9 and 42.2 years, respectively; 88% men). In adjusted models, the average annual change in BMI in the first 2 years after ART initiation was 0.53 for PWH and 0.12 for PWoH (P < .001). BMI increases among PWH were observed for all ART classes: 0.69 for INSTIs, 0.69 for PIs, and 0.40 for NNRTIs vs 0.12 among PWoH. For PWH initiating INSTIs, BMI increases were observed regardless of baseline BMI. Overall BMI changes >2 years after ART initiation were similar by HIV status (0.02 average annual increase for PWH and PWoH).

Conclusions

PWH initiating ART gained excess weight in the first 2 years, emphasizing the importance of monitoring weight and cardiometabolic health among ART-treated PWH.

Large lessons learned from small vessels: coronary microvascular dysfunction in HIV

PURPOSE OF REVIEW

Large cohort studies have consistently shown the presence of heart failure is approximately doubled among persons with HIV (PWH). Early studies of cardiovascular disease (CVD) in HIV were primarily focused on atherosclerotic burden, and we now have a greater understanding of large vessel disease in HIV. More recent studies have begun to inform us about small vessel disease, or coronary microvascular dysfunction (CMD), in HIV. CMD is recognized to be an important risk factor for adverse events related to heart failure, associated with cardiovascular mortality, and often presents without overt atherosclerotic disease.

RECENT FINDINGS

In this review, we highlight implications for CMD and relevant clinical studies in HIV. Inflammation and endothelial dysfunction, well known risk factors in HIV, may mediate the pathogenesis of CMD. Initial studies suggest that CMD worsens with ART initiation. Newer studies reveal CMD is present among well treated PWH without known CVD. In addition, myocardial flow reserve (MFR), a marker of CMD, is reduced in HIV similar to diabetes. There also appears to be sex differences, such that CMD is worse among women vs. men with HIV.

SUMMARY

Alterations in the coronary microvasculature may be an important mediator of subclinical myocardial dysfunction that deserves further clinical attention among PWH without known CVD.

Antiretroviral Drug Exposure and Response in Obese and Morbidly Obese People With Human Immunodeficiency Virus (HIV): A Study Combining Modelling and Swiss HIV Cohort Data

BACKGROUND

Obesity is increasingly prevalent among people with HIV (PWH) and can possibly result in suboptimal antiretroviral drug (ARV) exposure and response. However, this has not been thoroughly evaluated given that obese PWH are underrepresented in clinical trials. We performed virtual trials using physiologically based pharmacokinetic (PBPK) modelling combined with observed clinical data to provide ARV dosing guidance in obese individuals.

METHODS

Each trial included a cohort of virtual adults with a body mass index (BMI) between 18.5 and 60 kg/m2. Therapeutic drug-monitoring data from the Swiss HIV Cohort Study (SHCS) were used to verify the predictive performance of the model. Subsequently, the model was applied to predict the pharmacokinetics of ARVs for different obesity classes. The association between ARV plasma concentrations and virological response was investigated in obese and nonobese individuals.

RESULTS

The PBPK model predicted an average reduction in ARV exposure of ∼20% and trough concentrations of ∼6% in obese (BMI ≥30 kg/m2) compared with nonobese (BMI: 18.5-25 kg/m2) individuals, consistent with observed clinical data. Etravirine and rilpivirine were the most impacted, especially in individuals with BMI >40 kg/m2 whose trough concentrations were below the clinical target threshold. Obese PWH in the SHCS did not have a higher rate of unsuppressed viral load than nonobese PWH.

CONCLUSIONS

The concentrations of ARVs are modestly reduced in obese individuals, with no negative impact on the virological response. Our data provide reassurance that standard doses of ARVs are suitable in obese PWH, including those who gained substantial weight with some of the first-line ARVs.

Weight Gain After HIV Therapy Initiation: Pathophysiology and Implications

Rapid advances in the potency, safety, and availability of modern HIV antiretroviral therapy (ART) have yielded a near-normal life expectancy for most people living with HIV (PLWH). Ironically, considering the history of HIV/AIDS (initially called "slim disease" because of associated weight loss), the latest dilemma faced by many people starting HIV therapy is weight gain and obesity, particularly Black people, women, and those who commenced treatment with advanced immunodeficiency. We review the pathophysiology and implications of weight gain among PLWH on ART and discuss why this phenomenon was recognized only recently, despite the availability of effective therapy for nearly 30 years. We comprehensively explore the theories of the causes, from initial speculation that weight gain was simply a return to health for people recovering from wasting to comparative effects of newer regimens vs prior toxic agents, to direct effects of agents on mitochondrial function. We then discuss the implications of weight gain on modern ART, particularly concomitant effects on lipids, glucose metabolism, and inflammatory markers. Finally, we discuss intervention options for PLWH and obesity, from the limitations of switching ART regimens or specific agents within regimens, weight-gain mitigation strategies, and potential hope in access to emerging antiobesity agents, which are yet to be evaluated in this population.

The pathogenesis of obesity in people living with HIV

PURPOSE OF REVIEW

The public health challenge of overweight and obesity increasingly affects people living with HIV (PWH). These effects have also accelerated as the prevalence of antiretroviral therapy (ART) use has increased among PWH. It is therefore also critical that we examine and understand the pathogenesis of obesity among PWH.This review will aim to summarize relevant and recent literature related to the risks of weight gain and obesity associated with HIV disease progression, cardiometabolic disease, and multimorbidity among PWH. Further, we will discuss adipose tissue changes associated with weight gain and obesity and how these changes relate to metabolic complications.

RECENT FINDINGS

Several observational and experimental studies in recent years have evaluated the role of contemporary ART regimens, particularly integrase strand transfer inhibitors (INSTIs) and tenofovir alafenamide (TAF), as contributors to weight gain, obesity, and cardiometabolic disease, though the mechanisms remain unclear. Metabolic dysregulation has also been linked to ectopic fat deposition and alterations in innate and adaptive immune cell populations in adipose tissue that accompany HIV and obesity. These factors continue to contribute to an increasing burden of metabolic diseases in an aging HIV population.

SUMMARY

Obesity accompanies an increasing burden of metabolic disease among PWH, and understanding the role of fat partitioning and HIV and ART-related adipose tissue dysfunction may guide prevention and treatment strategies.

The forecasted prevalence of comorbidities and multimorbidity in people with HIV in the United States through the year 2030: A modeling study

BACKGROUND

Estimating the medical complexity of people aging with HIV can inform clinical programs and policy to meet future healthcare needs. The objective of our study was to forecast the prevalence of comorbidities and multimorbidity among people with HIV (PWH) using antiretroviral therapy (ART) in the United States (US) through 2030.

METHODS AND FINDINGS

Using the PEARL model-an agent-based simulation of PWH who have initiated ART in the US-the prevalence of anxiety, depression, stage ≥3 chronic kidney disease (CKD), dyslipidemia, diabetes, hypertension, cancer, end-stage liver disease (ESLD), myocardial infarction (MI), and multimorbidity (≥2 mental or physical comorbidities, other than HIV) were forecasted through 2030. Simulations were informed by the US CDC HIV surveillance data of new HIV diagnosis and the longitudinal North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) data on risk of comorbidities from 2009 to 2017. The simulated population represented 15 subgroups of PWH including Hispanic, non-Hispanic White (White), and non-Hispanic Black/African American (Black/AA) men who have sex with men (MSM), men and women with history of injection drug use and heterosexual men and women. Simulations were replicated for 200 runs and forecasted outcomes are presented as median values (95% uncertainty ranges are presented in the Supporting information). In 2020, PEARL forecasted a median population of 670,000 individuals receiving ART in the US, of whom 9% men and 4% women with history of injection drug use, 60% MSM, 8% heterosexual men, and 19% heterosexual women. Additionally, 44% were Black/AA, 32% White, and 23% Hispanic. Along with a gradual rise in population size of PWH receiving ART-reaching 908,000 individuals by 2030-PEARL forecasted a surge in prevalence of most comorbidities to 2030. Depression and/or anxiety was high and increased from 60% in 2020 to 64% in 2030. Hypertension decreased while dyslipidemia, diabetes, CKD, and MI increased. There was little change in prevalence of cancer and ESLD. The forecasted multimorbidity among PWH receiving ART increased from 63% in 2020 to 70% in 2030. There was heterogeneity in trends across subgroups. Among Black women with history of injection drug use in 2030 (oldest demographic subgroup with median age of 66 year), dyslipidemia, CKD, hypertension, diabetes, anxiety, and depression were most prevalent, with 92% experiencing multimorbidity. Among Black MSM in 2030 (youngest demographic subgroup with median age of 42 year), depression and CKD were highly prevalent, with 57% experiencing multimorbidity. These results are limited by the assumption that trends in new HIV diagnoses, mortality, and comorbidity risk observed in 2009 to 2017 will persist through 2030; influences occurring outside this period are not accounted for in the forecasts.

CONCLUSIONS

The PEARL forecasts suggest a continued rise in comorbidity and multimorbidity prevalence to 2030, marked by heterogeneities across race/ethnicity, gender, and HIV acquisition risk subgroups. HIV clinicians must stay current on the ever-changing comorbidities-specific guidelines to provide guideline-recommended care. HIV clinical directors should ensure linkages to subspecialty care within the clinic or by referral. HIV policy decision-makers must allocate resources and support extended clinical capacity to meet the healthcare needs of people aging with HIV.

Nonviral Liver Disease Burden in People Living With HIV and Elevated Transaminases: A Cross-Sectional Study

INTRODUCTION

Because of improved life expectancy in people living with HIV (PLWH), liver disease is increasingly being recognized. We assessed nonviral chronic liver disease burden in PLWH.

METHODS

The HIV non-virAL liver disease study (2014-2021) prospectively recruited PLWH with elevated serum alanine aminotransferase levels and negative hepatitis serology. Clinically significant hepatic fibrosis (CSHF) was defined as liver stiffness measurement of >7.1 kPa and hazardous alcohol use as Alcohol Use Disorders Identification Test score ≥ 8. Primary outcome was prevalence/predictors of CSHF.

RESULTS

Total recruited were n = 274, 92% male, median age 52 (45-59) years, and 96% having undetectable HIV viral load. Overall, n = 97 (35%) had hazardous alcohol use, n = 72 (26%) had metabolic syndrome, and 17%-27% had exposure to hepatotoxic antiretrovirals. Prevalence of CSHF was 20% (n = 54), prevalence of cirrhosis (liver stiffness measurement > 12.5 kPa) being 7% (19/274). Risk factors for CSHF were hazardous alcohol use in 44% (n = 24), metabolic syndrome in 46% (n = 25), and hepatotoxic antiretrovirals in 56% (n = 30), most having more than one risk factor. Independent predictors of CSHF were serum high-density lipoprotein (odds ratio [OR] 0.220; 95% confidence interval [CI]: 0.061 to 0.790, P = 0.020) (inverse relationship); serum aspartate aminotransferase (OR 1.033, 95% CI: 1.001 to 1.067, P = 0.045), and didanosine use (OR 2.878, 95% CI: 1.228 to 6.774, P = 0.015). Moderate-severe hepatic steatosis was identified in 52% (n = 142). FIB-4 and aspartate aminotransferase-to-platelet ratio index performed poorly in predicting CSHF (positive predictive value 27.3% and 30.6%, respectively) and advanced fibrosis (≥F3) (positive predictive value 17.6% and 5.9%, respectively).

CONCLUSION

In this study, 20% of PLWH had CSHF associated with high prevalence of hazardous alcohol use/metabolic syndrome/potentially hepatotoxic antiretrovirals. These potentially modifiable risk factors need addressing.

Obesity among women with HIV

PURPOSE OF REVIEW

With the introduction of novel and more potent antiretroviral therapies (ART), persons with HIV (PWH) are living longer lives and experiencing higher rates of age- and weight-related comorbidities, including cardiovascular and metabolic diseases. Women with HIV (WWH) experience disproportionate rates of obesity, as evidenced by longitudinal observational cohorts both in the United States and globally.

RECENT FINDINGS

In this article, we aim to review major research findings regarding WWH and obesity over the past few years. Multiple studies have evaluated geographic changes in the obesity epidemic across the globe with focus on developing countries who have seen a drastic change in obesity rates. Other new data assessed the effect of antiretroviral therapy on WWH, the cardiovascular effects of obesity in women on ART including data from the recently published REPRIEVE Trial, and issues unique to women, such as pregnancy and the effect of menopause on WWH.

SUMMARY

Comorbid cardiometabolic conditions are rapidly increasing, in correlation with the obesity epidemic among PWH. WWH may be disproportionately impacted, and experience further effects of obesity, compounded by health disparities in many areas of the world. Further research on the most effective interventions to minimize weight gains and decrease obesity among WWH are urgently needed.

Prevalence of obesity, hypertension and diabetes among people living with HIV in South Africa: a systematic review and meta-analysis

BACKGROUND

HIV has become a manageable chronic condition due to the success and scale-up of antiretroviral therapy (ART). Globally, South Africa has the highest number of people living with HIV (PLHIV) and research evidence indicates that countries with the highest burden of PLHIV have a substantial burden of obesity, hypertension (HPT) and type 2 diabetes (T2D). We sought to summarize the burden of these three common NCDs among PLHIV in South Africa.

METHODS

In this systematic review, multiple databases were searched for articles reporting on the prevalence of obesity, HPT, and T2D among PLHIV in South Africa published since journal inception until March 2022. A meta-analysis was conducted using random-effects models to obtain pooled prevalence estimates of the three NCDs. Heterogeneity was assessed using X2 test on Cochran's Q statistic.

RESULTS

We included 32 studies, with 19, 22 and 18 studies reporting the prevalence of obesity, HPT, and T2D among PLHIV, respectively. The overall prevalence of obesity, HPT, and T2D was 23.2% [95% CI 17.6; 29.9], 25.5% [95% CI 15.6; 38.7], and 6.1% [95% CI 3.8; 9.7] respectively. The prevalence of obesity was significantly higher among women (P = 0.034) compared to men, however the prevalence of HPT and T2D did not differ by sex. The prevalence of each of the three NCDs did not differ significantly between rural, urban, and peri-urban areas. The prevalence of obesity and T2D was higher in studies conducted between 2013 and 2022 compared to studies conducted between 2000 and 2012, while the prevalence of HPT was higher between 2000 and 2012 compared to between 2013 and 2022.

CONCLUSIONS

These findings suggest that South Africa is experiencing a syndemic of NCDs among people PLHIV highlighting the need to increase cost-effective interventions and management strategies that involve integrated HIV and NCD care in the South African setting.

Effective prolonged suppression of HIV-1 viral load using tenofovir alafenamide, emtricitabine and efavirenz in an adult with BMI >59 kg/m2

Limited information is available regarding the efficacy of antiretrovirals in people with HIV-1 and high or very high Body Mass Index (BMI). This is especially the case for the alafenamide salt of tenofovir as clinical trials have only enrolled patients with BMI ≤30 kg/m2. Lower concentrations of some antiretrovirals are expected in patients with BMI >30 kg/m2 due to potential changes in clearance and distribution of medication. This report describes an individual taking tenofovir alafenamide, emtricitabine and efavirenz in whom HIV-1 viral load was consistently undetectable (<50 copies/ml) over a 2.5 year period. During this period the patient's BMI ranged between 59.8 and 68.1 kg/m2. Further data is required to support the efficacy of antiretrovirals in individuals with high and very high BMI.

Longitudinal trajectories of weight changes among people living with HIV on antiretroviral therapy: A group-based study

Weight changes vary among people living with HIV (PLHIV) on different antiretroviral therapy (ART) regimens. Here, we performed multi-trajectory modeling fitting growth mixture models (GMM) to identify longitudinal weight change trajectories of PLHIV. Multiple logistic regression was used to assess correlates of rapid weight gains; 12,683 PLHIV (median age: 34 years [interquartile range 29-42], 91.1% male) who initiated ART at the Third People's Hospital of Shenzhen, China, between January 2003 and September 2022 were included. We identified two trajectories: slow (70.5%) and rapid weight gains (29.5%). PLHIV who initiated ART with dolutegravir- (adjusted odds ratio [aOR] 2.46, 1.92-3.15), raltegravir- (2.74, 1.96-3.82), and lopinavir (1.62, 1.36-1.94)-based regimens were more likely to have rapid weight gains compared with efavirenz-based regimen. The monitoring of nutritional status should be strengthened for PLHIV who initiated these regimens during regular ART follow-ups.

Weight Gain After 12 Months of Switching to Bictegravir/Emtricitabine/Tenofovir Alafenamide in Virologically Suppressed HIV Patients

Recent studies suggest that the introduction of antiretroviral agents such as integrase strand transfer inhibitors (INSTI) may lead to weight gain in people living with HIV (PLHIV). In this retrospective observational study, we report the weight changes observed in virologically suppressed HIV patients after 12 months of switching to bictegravir/emtricitabine/tenofovir alafenamide (BIC/F/TAF) due to a national change in public policy in Mexico. Patients on prior regimens based on TDF/FTC or ABC/3TC plus non-nucleoside retrotranscriptase inhibitor, INSTI, or protease inhibitor were included. In the 399 patients analyzed, a significant weight increase was found, as well as an increase in body mass index (BMI), total cholesterol, low-density lipoprotein cholesterol (LDL-C), glucose, creatinine, and CD4+ cells after 12 months of switching treatment (all p ≤ .001). Mean weight gain was 1.63 kg [confidence interval (95% CI): 1.14-2.11], whereas the average percentage of weight gained was 2.5% (95% CI: 1.83-3.17). After considering the confounding effect of baseline weight status, the change in weight and BMI did not present significant differences between any of the prior treatment schemes. In conclusion, PLHIV switching to BIC/F/TAF therapy experienced weight gain after the first year of switching treatment. Although this weight gain could be due to the switch in treatment regimen, it cannot be excluded that it was caused by other factors since no comparable control group could be used for comparison.

GLP-1 agonists for people living with HIV and obesity, is there a potential?

BACKGROUND AND OBJECTIVES

Obesity trends and metabolic dysregulation are rising in people living with HIV using antiretrovirals (ARVs). Underlying causes and preventive strategies are being investigated. Two glucagon like-peptide 1 (GLP-1) agonists, liraglutide and semaglutide, were formerly approved as glucose-lowering drugs and have been recently approved for long-term weight loss in people with obesity. Due to the lack of therapeutic guidelines or clinical trials in people with HIV, we discuss the potential benefits, safety aspects and pharmacological considerations of prescribing liraglutide and semaglutide in people with HIV.

RESULTS

Clinical experience is limited to two clinical cases of diabetic people with HIV using liraglutide after which a successful weight loss and glycaemic control were observed. None of the adverse events associated with liraglutide and semaglutide usage indicate an additional risk for people with HIV. Extra caution showed be warranted when initiating GLP-1 agonist therapy in people with HIV taking protease inhibitors who have pre-existing risk factors for heart rate variability to reduce the incidence of RP interval prolongation. GLP-1 agonists are metabolized by endopeptidases, and thus do not generate major drug-drug interactions with most drugs, including ARVs. GLP-s agonists are known to inhibit gastric acid secretion, which warrants caution and close monitoring when combined with atazanavir and oral rilpivirine, two ARVs that require low gastric pH for an optimal absorption.

CONCLUSION

Theoretical considerations and a few available clinical observations support semaglutide and liraglutide prescription in people with HIV, with, thus far, no indications of concern regarding efficacy, safety or pharmacological interactions with ARVs.