HIV Treatment Considerations: ART and Patient Weight


Drs Osama Hamdy and Tavell Kindall react to the association between weight gain and antiretroviral therapies used to treat HIV.

Grace McComsey, MD, FIDSA: Tavell, in your clinic, how much does weight gain concern you? Do antiretroviral therapies [ART] play a role? When you see a patient and you want to choose a regimen for them, is that a big factor?

Tavell Kindall, PhD, DNP, APRN, FNP: It can be, particularly if someone is presenting with weight issues upfront. However, that’s [often] not the case. Where I’m working, many times when [women] come in, they’re newly diagnosed, sometimes they have advanced disease, and they’ll experience a return to healthy weight with viral suppression and CD4 reconstitution. Once they gain the weight, their self-esteem is improved because people aren’t asking questions about why they’re losing all this weight. Now they look healthier, and as a result of that, they feel better and their self-esteem is better. 

In my experience, I haven’t had a lot of issues with weight gain, in terms of patients complaining and telling me they want to come off their medication. A lot of the conversation surrounding the weight gain is: “What does it mean?” “Is this something that’s contributing to someone’s significant loss of control, or increasing their risk for diabetes, or uncontrolled high blood pressure, or other things as it relates to their health?” “Does the weight gain contribute to that or is this just weight gain for the sake of gaining weight because you’re on this medication?” We need more information regarding what the weight gain means. For me—and I’m in New Orleans, [Louisiana]—we have great food down here, and all kinds of other things. There are several reasons why people may have issues with their weight. It’s not necessarily isolated and it’s difficult to tease out if this is truly, directly associated with their ART and not all the other [factors] that can come into play.

Grace McComsey, MD, FIDSA: Osama, initially in HIV [human immunodeficiency virus], is it true what Tavell said? They wanted to gain weight, right? We had a problem with wasting, so we thought weight gain was good. It was a return to health. Now we know that, for some individuals, it’s getting out of control. They’re gaining too much weight. Do you want to comment on weight gain and the relationship to other metabolic complications? Is it good to have a lot of weight? Some people see it as a good thing, right? 

Osama Hamdy, MD, PhD: People are returning from significant weight loss to a healthy weight—this is not a problem. This is a good indication that they’re now recovering. But now we start to see that they’re crossing the age and the weight gain is progressively [increasing]. I see 2 groups of medications: Medication that is used for major psychosis and medication for HIV. HIV is more complex because it’s not just weight gain, it is a lot of mobilization of fat in the body in the form of lipodystrophy and some areas of hypertrophy and lipoatrophy. Based on the gender, ethnicity, and many other genetic factors, the distribution of fat can be different. 

In general, weight gain, per se, is a problem, especially if that weight gain is in the central area of the body, because this is where most of the problem starts. Inflammation occurs in the visceral fat and increased fatty acids [lead to] lipotoxicity. That can lead to hepatic steatosis and beta-cell dysfunction. In general, weight can have some mechanical effect on joints and obstructive sleep apnea, which is common among this population. [Weight gain can also] worsen diabetes. People develop diabetes for many other reasons, such as insulin resistance, beta-cell dysfunction, and so on, but weight gain adds to the problem by making people more insulin resistant.

There’s no reason to stop medication or switch indication if weight gain occurs. If the medication is effective and doing its job in combination, or in a single medication, or double, or triple medication, keep the medication and deal with the weight. We now have more effective medications for weight management than ever. Just a few weeks ago the FDA approved semaglutide, which caused an average weight loss of about 15%, with 35% of the population in the study losing around 20% weight loss, and even 10% almost around 50% weight loss. You can imagine that we have medications that are powerful for weight management. Plus intervention and education to our patients—maybe we can talk about this later in the discussion—can lead to controlling the weight gain to a great extent. But it is not a reason to stop medication for anyone.

Grace McComsey, MD, FIDSA: Thank you for watching this Contagion® Peer Exchange. If you enjoyed the content, please subscribe to the e-newsletter so you can receive upcoming Peer Exchange segments and other great content. Thank you for listening.

Transcript Edited for Clarity

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