The study also found that greater weight gain in people with advanced HIV was associated with taking the integrase inhibitors dolutegravir or raltegravir, while Tenofovir alafenamide was associated with greater weight gain than tenofovir disoproxil or abacavir. The researchers suggested that the choice of treatment for people with advanced HIV should consider the risk of weight gain as well as the impact of treatment on viral load and CD4 count.

Integrase inhibitors have been shown to reduce high viral load and improve CD4 counts more effectively than other agents, making them a recommended first-line treatment for people with HIV in Europe and North America. However, integrase inhibitors have also been associated with substantial weight gain, which may increase the long-term risk of heart disease, diabetes, and some cancers.

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Studies of risk factors for weight gain after starting HIV treatment have consistently shown that a low CD4 count or a high viral load raises the risk of weight gain. Weight gain after starting treatment could be a ‘return to health’ effect in people with advanced HIV, as weight loss can be a consequence of living with untreated HIV. If HIV is suppressed, body weight tends to increase to a level that is normal for the age, gender, and social setting of the person with HIV.

The French Hospital Database on HIV followed 12,773 people with HIV receiving care at more than 180 hospitals in France. The researchers compared weight changes after starting treatment in two groups: ‘early presenters’ and ‘advanced HIV’. Early presenters were those who began treatment with a CD4 count above 350 and a viral load below 100,000, or during the first few months of infection. Advanced HIV participants were those who began treatment with a CD4 count below 200 or an AIDS diagnosis.

The groups of early presenters and people with advanced HIV differed in several ways. Early presenters were more often gay and bisexual men while people with advanced HIV were more often heterosexual and born in sub-Saharan Africa. Early presenters were less likely to start treatment with a protease inhibitor-based regimen and more likely to start treatment with a rilpivirine-based regimen or an integrase inhibitor.

The study found that almost two-thirds (63%) of those with advanced HIV experienced weight gain of at least 10% compared to 20% of early presenters. In people with advanced HIV, the risk of gaining at least 10% of body weight was almost twice as high in people taking raltegravir, dolutegravir, or darunavir compared to people taking rilpivirine, and in people with viral load above 500,000 compared to those with viral load below 30,000. Having had an AIDS-defining illness also doubled the risk of 10% weight gain. Taking tenofovir alafenamide (TAF) raised the risk of at least 10% weight gain by approximately 50% compared to taking TDF.

An increase in body mass index of at least 5kg/m2 is associated with an increased risk of several common cancers and an increased risk of death in people who are already overweight. Almost one in four (24%) people with advanced HIV gained at least 5kg/m2 in body weight, and the risk of gaining this amount of weight was the same for people who were underweight or in the obese weight category