Short Communication: From Wasting to Obesity: Initial Antiretroviral Therapy and Weight Gain in HIV-Infected Persons

Abstract

Data on weight gain and the progression to overweight/obesity in HIV-infected persons during initial combination antiretroviral therapy (cART) are limited, and comparisons to the general population are inconclusive. Weight and body mass index (BMI) changes were studied in HIV-infected adults who remained on initial cART for 12 consecutive months and in an HIV-uninfected cohort receiving care at Duke University Medical Center between 1998 and 2008. Overweight/obesity was defined as BMI ‡ 25 kg/m 2 . Variables were analyzed by Chisquare and Student's t-tests. Ninety-two HIV-infected persons (median age 38.2 years) met inclusion criteria. Weight and BMI increased during 12 months of cART (80.0 to 84.4 kg, p < 0.0001; 26.4 to 27.9 kg/m 2 , p < 0.0001; respectively). Weight gain was greater in HIV-infected females compared to males (8.6 vs. 3.6 kg, p = 0.04), in persons treated with protease inhibitor (PI)-based cART compared to non-PI-based cART (9.0 vs. 2.7 kg, p = 0.001), and in persons with a pretreatment CD4 count < 200 cells/mm 3 compared to ‡ 200 cells/mm 3 (8.9 vs. 0.3 kg, p < 0.0001). Overweight/obesity prevalence increased from 52% to 66% during 12 months of initial cART, a 27% relative increase ( p = 0.002). HIV-infected persons had a lower prevalence of pretreatment overweight/ obesity compared to 94 age-matched control subjects (52% vs. 91%, p < 0.001); however, there was no change in weight (92.7 vs. 93.0 kg, p = 0.5) or overweight/obesity prevalence (91% to 92%, p > 0.9) during 12 months in the control cohort. Management should anticipate excess weight gain during the first year of cART in persons who are female, have a pretreatment CD4 < 200 cells/mm 3 , or will initiate PI-based cART.

The Fat of the Matter: Obesity and Visceral Adiposity in Treated HIV Infection

“…In an AIDS Clinical Trial Group (ACTG) study of ART initiation in resource-diverse settings (A5175), more than 25% of participants were classified as overweight or obese at entry, and approximately 40% of participants were overweight or obese by week 144[8]. Some weight gain following ART initiation may be attributable to a “return to health” phenomenon; however, excessive weight gain can occur, with persons with the highest pre-ART HIV-1 RNA or lowest CD4 + T lymphocyte counts at risk for greater weight gain[10, 11]. Further exemplifying the fact that weight gain can represent differential effects depending on the host, weight gain among underweight persons has been associated with a decline in circulating high-sensitivity C-reactive protein levels[12] and improved survival[13], whereas weight gain among overweight or obese individuals has been associated with significant increases in circulating levels of the monocyte activation marker soluble CD14[12], no mortality benefit[13] and a ≥67% prevalence of multi-morbidity[14].…”

Circulating Interleukin-6, Soluble CD14, and Other Inflammation Biomarker Levels Differ Between Obese and Nonobese HIV-Infected Adults on Antiretroviral Therapy

“…[1][2][3] Obesity and chronic, treated HIV infection are associated with a higher risk of developing a similar constellation of metabolic and cardiovascular diseases, and obese HIV-infected adults are more likely to have multiple concomitant comorbidities compared to normal-weight HIVinfected persons. [4][5][6] While the etiology of the increased morbidity in HIV-infected obese individuals is likely multifactorial, persistent systemic inflammation is a hallmark of both excess adiposity and HIV infection, and a predictor of cardiovascular events, diabetes mellitus, and all cause mortality among persons on ART.…”

Cardiovascular disease risk in an aging HIV population

“…(59) Clinical management should also anticipate excess weight gain in certain subgroups initiating ART. (60) Newer or non-protease inhibitor based ART regimens have improved metabolic side effect profiles(61, 62) though some debate about PI-regimens remains. (63) Lastly, ART clinical trials rarely include older patients – who often have significant co-morbidity and reduced immune response (64) – who nonetheless currently receive these drugs.…”