"It's only fatness, it doesn't kill": a qualitative study on perceptions of weight gain from use of dolutegravir-based regimens in women living with HIV in Uganda

Body image among people living with HIV: A systematic review and narrative synthesis

OBJECTIVES

The aim of this systematic review was to analyse, synthesise and review existing research on body image among people living with HIV (PLWH). Specifically, the review investigated the relationship of body image with sociodemographic and clinical variables and psychological correlates among PLWH.

METHOD

A comprehensive literature search was conducted using Web of Science, PsycARTICLES, MedLine, ProQuest and Scopus databases and yielded a total of 699 abstracts. The inclusion criteria encompassed quantitative and peer-reviewed articles published in English devoted to HIV/AIDS adult patients, with validated measurements of body image operationalized explicitly as an outcome variable.

RESULTS

A total of 17 articles were accepted for systematic review and analysis. The quality of the studies was evaluated using STROBE guidelines for observational studies. The findings revealed that body image disturbances are common among PLWH and are influenced by factors such as lipodystrophy, depression, anxiety, self-efficacy in health behaviours, social support, stigma and quality of life. Higher body image disturbance was also linked to poorer adherence to antiretroviral therapy (ART) and increased HIV sexual transmission risk behaviours.

CONCLUSIONS

Body image is a crucial aspect of the psychosocial functioning of PLWH. Despite medical advancements, PLWH continue to face significant body image disturbances that impact their quality of life. Future research should focus on longitudinal studies, diverse geographical contexts and interventions aimed at improving body image among this population. Addressing body image concerns through psychosocial support and therapeutic interventions can potentially enhance the overall well-being and health outcomes of PLWH.

Effect of dolutegravir on weight changes and lipid profile compared with efavirenz in people living with HIV: A retrospective cohort study

BACKGROUND

There are limited data on DTG-associated weight gain among treatment-naïve Asian people living with HIV (PLHIV).

METHODS

Eighty-one and 100 PLHIV initiating DTG-based and efavirenz (EFV)-based antiretroviral therapy (ART), respectively, were retrospectively investigated for weight changes and lipid profiles at 6 and 12 months after ART initiation.

RESULTS

At baseline, the DTG group had a lower mean body weight (BW) (60.7 kg vs. 64.3 kg, p = 0.071) and lower mean cholesterol level (172 mg/dL vs. 185 mg/dL, p = 0.029) than the EFV group. Mean BW remained lower in the DTG group than in the EFV group at 6 [58.2 kg vs. 66.0 kg, mean difference (MD) -7.8, p = 0.005] and 12 (59.6 kg vs. 67.0 kg, MD -7.3, p = 0.008) months. BW did not significantly change between baseline and 12 months in the DTG group (60.7 kg vs. 59.6 kg, p = 0.495), whereas it significantly increased between baseline and 12 months in the EFV group (64.3 kg vs. 66.9 kg, p = 0.019). Cholesterol levels did not significantly increase between baseline and 12 months in either group. After adjustment, DTG use [MD -5.85, 95 % confidence interval (CI) -10.45, -1.24, p = 0.013] and baseline BW (MD 0.97, 95 % CI 0.79, 1.15, p < 0.001) were significantly associated with BW changes over time.

CONCLUSIONS

DTG-based ART was not significantly associated with increased BW and cholesterol levels compared with EFV-based ART in treatment-naïve Thai PLHIV.

Integrated PrEP and STI Services for Transgender Women in Uganda: Qualitative Findings from a Randomized Trial

Tenofovir alafenamide fumarate (F/TAF) pre-exposure prophylaxis (PrEP) is understudied in sub-Saharan Africa. The Tandika PrEP study was a randomized trial that evaluated same-day F/TAF initiation, the impact of drug-level feedback on PrEP adherence, and integrated PrEP and sexually transmitted infection (STI) services for HIV-negative transgender women (TGW) in Uganda (NCT04491422). From April 2022-February 2023, a qualitative sub-study of 30 in-depth interviews explored (1) perspectives on same-day initiation of F/TAF PrEP, (2) experiences of urine tenofovir testing and drug-level feedback, and (3) descriptions of self-collection of samples for STI testing. Qualitative data were analyzed using an inductive content analytic approach. Integrated PrEP/STI services were valued by TGW because the convenience of urine testing motivated adherence and allowed for tenofovir and STI detection. (1) Preferred characteristics: F/TAF-based PrEP was easy to take and not readily identifiable as an HIV-related medication, resulting in less stigma than the better-known tenofovir disoproxil fumarate (F/TDF). Weight gain associated with F/TAF use was viewed positively by TGW as a symbol of health and prosperity in African settings. (2) Adherence motivation: PrEP adherence was motivated by a desire not to disappoint healthcare workers; TGW reciprocated adherence support and drug-level feedback by taking PrEP. (3) Facilitating adherence and STI care: Urine testing enhanced STI detection and treatment. Utilization of urine for tenofovir and STI testing motivated the uptake of HIV/STI care, emphasizing the importance of integrated PrEP and STI services. Integrating PrEP/STI services into differentiated delivery models could increase prevention uptake in this vulnerable population.

Cardiometabolic complications in children and adolescents with HIV on antiretroviral therapy

INTRODUCTION

The course of HIV infection has changed radically with the introduction of antiretroviral therapy (ART), which has significantly reduced mortality and improved quality of life. However, antiretroviral drugs can cause adverse effects, including cardiometabolic complications and diseases, which are among the most common. Compared to the adult population, there are fewer studies in the pediatric population on treatment-related complications. The purpose of this review is to provide an update on the literature regarding cardiometabolic complications and diseases in children and adolescents with HIV.

AREAS COVERED

A comprehensive literature review was conducted using PubMed and related bibliographies to provide an overview of the current knowledge of metabolic complications (dyslipidemia, insulin resistance, lipodystrophy, weight gain and liver complications) and diseases (prediabetes/diabetes and cardiovascular diseases) associated with ART in children and adolescents with HIV.

EXPERT OPINION

Metabolic complications are conditions that need to be closely monitored in children and adolescents with HIV, as they increase the risk of early development of non-communicable diseases, such as cardiovascular disease. Key areas for improvement include ensuring access to treatment, reducing side effects and improving diagnostic capabilities. Overcoming existing challenges will require collaborative efforts across disciplines, advances in technology, and targeted interventions to address socioeconomic disparities.

Self-driven solutions and resilience adapted by people with drug-resistant tuberculosis and their caregivers in Bengaluru and Hyderabad, India: a qualitative study

Background

One-fifth of people with drug-resistance tuberculosis (DR-TB) who were initiated on newer shorter treatment regimen (with injection) had unfavourable treatment outcomes in India as on 2020. Evidence on self-driven solutions and resilience adapted by people with DR-TB (PwDR-TB) towards their multi-dimensional disease and treatment challenges are scarce globally, which we aimed to understand.

Methods

In this qualitative study using positive deviance framework, we conducted semi-structured in-depth interviews among consenting adult PwDR-TB (7 women, 13 men) who completed shorter treatment regimen (including injections) with maximum treatment adherence. The study was conducted in the southern districts of Bengaluru and Hyderabad, India between June 2020 and December 2022. Caregivers (14 women, 6 men) and health providers (8 men, 2 women) of PwDR-TB were also interviewed. Interviews were conducted in local language (Kannada, Tamil, Telugu, Urdu and Hindi) and inquired about practices, behaviours, experiences, perceptions and attributes which enabled maximum adherence and resilience of PwDR-TB. Interviews were audio recorded, transcribed, and translated to English and coded for thematic analysis using inductive approach.

Findings

Distinctive themes explanatory of the self-driven solutions and resilience exhibited by PwDR-TB and their caregivers were identified: (i) Self-adaptation towards the biological consequences of drugs, by personalised nutritional and adjuvant practices, which helped to improve drug ingestion and therapeutic effects. Also home remedies and self-plans for ameliorating injection pain. (ii) Perceptual adaptation towards drugs aversion and fatigue, by their mind diversion practices, routinisation and normalisation of drug intake process. and constant reinforcement and re-interpretation of bodily signs of disease recovery (iii) Family caregivers intense and participatory care for PwDR-TB, by aiding their essential life activities and ensuring survival, learning and fulfilling special nutritional needs and goal oriented actions to aid drug intake (iv) Health care providers care, marked by swift and timely risk mitigation of side-effects and crisis response (v) Acquired self-efficacy of PwDR-TB, by their decisive family concerns resulting in attitudinal change. Also being sensitised on the detrimental consequences of disease and being motivated through positive examples.

Interpretation

Synthesised findings on self-driven solutions and resilience towards the multi-dimensional DR-TB challenges provides opportunity for developing and testing new interventions for its effectiveness in DR-TB care settings globally. Designing and testing personalised cognitive interventions for PwDR-TB: to inculcate attitudinal change and self-efficacy towards medication, developing cognitive reinforcements to address the perception burden of treatment, skill building and mainstreaming the role of family caregivers as therapeutic partners of PwDR-TB, curating self-adaptive behaviours and practices of PwDR-TB to normalise their drug consumptions experiences could be the way forward in building resilience towards DR-TB.

Funding

United States Agency for International Development (USAID) through Karnataka Health Promotion Trust (KHPT), Bengaluru, India.

Sociodemographic and Clinical Predictors of Weight Gain During the First Year of Antiretroviral Therapy among Adults Living With HIV in Urban Tanzania

Antiretroviral therapy (ART) has improved the survival of people living with HIV (PLHIV) but this success has been accompanied by an increase in noncommunicable diseases. We conducted a prospective cohort study of 4000 adult PLHIV who were initiating ART in Dar es Salaam, Tanzania, to assess weight gain during the first year of treatment and associated sociodemographic and clinical factors. Anthropometric data were collected at ART initiation and monthly follow-up visits. The mean weight gain during the first year of treatment was 2.6 ± 0.3 kg, and the prevalence of overweight or obesity increased from 26.3% at baseline to 40.7%. Female sex, greater household wealth, lower CD4-T-cell counts, higher WHO HIV disease stage, and pulmonary tuberculosis were associated with a greater increase in body mass index (P < .05). Weight gain following ART initiation was common but was greater among females and PLHIV with advanced HIV or comorbidities.

Impact of weight gain with dolutegravir on antiretroviral adherence and viral suppression in four African countries

OBJECTIVE

We hypothesized that total body weight (TBW) gain after switching antiretroviral therapy (ART) regimen to tenofovir disoproxil fumarate/lamivudine/dolutegravir (TLD) may negatively impact ART adherence and viral load (VL) and therefore sought to examine these associations.

METHODS

The ongoing African Cohort Study (AFRICOS) enrols people with HIV at 12 facilities in Kenya, Nigeria, Tanzania and Uganda supported by The US President's Emergency Plan for AIDS Relief. Among ART-experienced participants who switched to TLD, we used multivariable multinomial logistic regression to examine associations between pre-/post-TLD changes in percentage TBW (≥5% gain, <5% change, ≥5% loss) and changes in self-reported ART adherence (0, 1-2, ≥3 days missed doses in past 30 days) and VL [(<50 copies/mL (undetectable), 50-999 copies/mL (detectable, but suppressed), ≥1000 copies/mL (unsuppressed)].

RESULTS

Among 1508 participants, median time from starting TLD to follow-up was 9 months (interquartile range: 7-11). Overall, 438 (29.1%) participants experienced a TBW gain ≥5%, which was more common among females than among males (32.2% vs 25.2%, p = 0.005) and participants switching from efavirenz [32.0% vs nevirapine (19.9%) and boosted protease inhibitor (20.0%); p < 0.001]. Compared with a TBW change <5% [950 (63.0%) participants], TBW gain ≥5% was not significantly associated with more days with missed ART doses [adjusted odds ratio (aOR) = 0.77, 95% confidence interval (CI): 0.48-1.23] or VL becoming detectable and/or unsuppressed (aOR = 0.69, 95% CI: 0.41-1.16).

CONCLUSIONS

Although a substantial proportion of participants experienced weight gain after switching to TLD, we did not identify a significant impact on adherence or virological outcomes.

Body mass index trends and its impact of under and overweight on outcome among PLHIV on antiretroviral treatment in rural Tanzania: A prospective cohort study

INTRODUCTION

Increased body weight is an important risk factor for cardiovascular disease and is increasingly reported as a health problem in people living with HIV (PLHIV). There is limited data from rural sub-Saharan Africa, where malnutrition usually presents with both over- and undernutrition. We aimed to determine the prevalence and risk factors of underweight and overweight/obesity in PLHIV enrolled in a cohort in rural Tanzania before the introduction of integrase inhibitors.

METHODS

This nested study of the prospective Kilombero and Ulanga Antiretroviral Cohort included adults aged ≥19 years initiated on antiretroviral therapy between 01/2013 and 12/2018 with follow-up through 06/2019. Body Mass Index (BMI) was classified as underweight (<18.5 kg/m2), normal (18.5-24.9 kg/m2), or overweight/obese (≥25.0 kg/m2). Stratified piecewise linear mixed models were used to assess the association between baseline characteristics and follow-up BMI. Cox proportional hazard models were used to assess the association between time-updated BMI and death/loss to follow-up (LTFU).

RESULTS

Among 2,129 patients, 22,027 BMI measurements (median 9 measurements: interquartile range 5-15) were analysed. At baseline, 398 (19%) patients were underweight and 356 (17%) were overweight/obese. The majority of patients were female (n = 1249; 59%), and aged 35-44 years (779; 37%). During the first 9 months, for every three additional months on antiretroviral therapy, BMI increased by 2% (95% confidence interval 1-2%, p<0.0001) among patients underweight at baseline and by 0.7% (0.5-0.6%, p<0.0001) among participants with normal BMI. Over a median of 20 months of follow-up, 107 (5%) patients died and 592 (28%) were LTFU. Being underweight was associated with >2 times the hazard of death/LTFU compared to participants with normal BMI.

CONCLUSION

We found a double burden of malnutrition, with underweight being an independent predictor of mortality. Monitoring and measures to address both states of malnutrition among PLHIV should be integrated into routine HIV care.

Evidence gaps on weight gain in people living with HIV: a scoping review to define a research agenda

BACKGROUND

Combined antiretroviral therapy (cART) dramatically improved survival in people living with HIV (PLWH) but is associated with weight gain (WG), raising concern for a possible obesity epidemic in PLWH. This scoping review aims to identify the gaps in the existing evidence on WG in PLWH and generate a future research agenda.

METHODS

This review was conducted according to the methodology for scoping studies and reported according to the PRISMA Extension for Scoping Review checklist. Articles published in English in the last 10 years indexed in Pubmed, WHO Global Index Medicus, or Embase were searched using specific queries focused on WG in PLWH.

RESULTS

Following the selection process, 175 included articles were reviewed to search for the available evidence on four specific topics: (I) definition of WG in PLWH, (II) pathogenesis of WG in PLWH, (III) impact of ART on WG, (IV) correlation of WG with clinical outcomes. A summary of the data enabled us to identify gaps and clearly define the following research agenda: (I) develop a data-driven definition of WG in PLWH and define noninvasive assessment methods for body weight and fat composition; (II) further investigate the interaction between HIV/cART and immunity, metabolism, and adipose tissue; (III) establish the specific role of individual drugs on WG; (IV) clarify the independent role of WG, cART, HIV, and metabolic factors on clinical events.

CONCLUSIONS

The proposed research agenda may help define future research and fill the knowledge gaps that have emerged from this review.

Effect of a complex lifestyle intervention to optimize metabolic health among females of reproductive age in urban Uganda, a randomized controlled trial

BACKGROUND

The metabolic health of urban Ugandans, mostly females, is increasingly becoming sub-optimal.

OBJECTIVES

We assessed the effect of a complex lifestyle intervention, based on a small change approach, on metabolic health among females of reproductive age in urban Uganda.

METHODS

A cluster randomized controlled two-arm trial with a 1:1 allocation involving church communities in Kampala (Uganda) was undertaken. The intervention arm received infographics and face-to-face group sessions, whereas the comparison arm received infographics only. Eligible participants were aged 18 to 45 years with a waist circumference of ≥80 cm and without cardiometabolic diseases. The study included a 3-month intervention and a 3-month postintervention follow-up. The primary outcome was a reduction in waist circumference. Secondary outcomes included optimization of cardiometabolic health, physical activity, and fruit and vegetable intake. Intention to treat analyses were performed using linear mixed models. This trial was registered at clinicaltrials.gov as NCT04635332.

RESULTS

The study was conducted between 21 November 2020 and 8 May 2021. Six church communities were randomly selected, 3 (n = 66) per study arm. At 3 months and postintervention follow-up, 118 and 100 participants were analyzed, respectively. At 3 months, waist circumference tended to be lower in the intervention arm (-1.48 cm (95% CI: -3.05, 0.10) P = 0.06). The intervention showed an effect on fasting blood glucose concentrations (-6.95 mg/dL (95% CI: -13.37, -0.53) P = 0.034). Participants in the intervention arm consumed more fruits (62.6 g (95% CI: 1.9, 123.3) P = 0.046) and vegetables (66.2 g (95% CI: 25.5, 106.8) P = 0.002), whereas physical activity increased with no notable differences across the study arms. At 6 months, we found an intervention effect on waist circumference (-1.87 cm (95% CI: -3.32, -0.44) P = 0.011), fasting blood glucose concentration (-6.48 mg/dL (95% CI: -12.76, -0.21) P = 0.043), fruit consumption (29.7 g (95% CI: 5.8, 53.7) P = 0.015), and physical activity (2675.1 MET-mins/wk (95% CI: 1045.7, 4304.4) P = 0.001).

CONCLUSIONS

The intervention improved and sustained physical activity and fruit and vegetable intake, but these changes were accompanied by minimal cardiometabolic health improvements. If maintained over time, the attained lifestyle improvements may result in substantial cardiometabolic health improvements.

HIV-1 Integrase Strand Transfer Inhibitors and Neurodevelopment

Children born to mothers, with or at risk, of human immunodeficiency virus type-1 (HIV-1) infection are on the rise due to affordable access of antiretroviral therapy (ART) to pregnant women or those of childbearing age. Each year, up to 1.3 million HIV-1-infected women on ART have given birth with recorded mother-to-child HIV-1 transmission rates of less than 1%. Despite this benefit, the outcomes of children exposed to antiretroviral drugs during pregnancy, especially pre- and post- natal neurodevelopment remain incompletely understood. This is due, in part, to the fact that pregnant women are underrepresented in clinical trials. This is underscored by any potential risks of neural tube defects (NTDs) linked, in measure, to periconceptional usage of dolutegravir (DTG). A potential association between DTG and NTDs was first described in Botswana in 2018. Incidence studies of neurodevelopmental outcomes associated with DTG, and other integrase strand transfer inhibitors (INSTIs) are limited as widespread use of INSTIs has begun only recently in pregnant women. Therefore, any associations between INSTI use during pregnancy, and neurodevelopmental abnormalities remain to be explored. Herein, United States Food and Drug Administration approved ARVs and their use during pregnancy are discussed. We provide updates on INSTI pharmacokinetics and adverse events during pregnancy together with underlying mechanisms which could affect fetal neurodevelopment. Overall, this review seeks to educate both clinical and basic scientists on potential consequences of INSTIs on fetal outcomes as a foundation for future scientific investigations.