Weight gain in people with HIV in Africa and Asia: a review of causes, consequences, and management implications.

PURPOSE OF REVIEW: To examine weight gain epidemiology in people with HIV (PLWH) across Africa and Asia, focusing on data published in the preceding 18 months, and to identify clinical and programmatic implications, acknowledging that regionally derived evidence remains sparse.

RECENT FINDINGS: New population-level data from East Africa demonstrate that the nutrition transition is accelerating faster than ART-related weight gain. Thus, HIV-negative individuals gained more weight than PLWH on ART over the transition to dolutegravir regimens in rural Kenya and Uganda. In Asian cohorts, men gained more weight than women after ART initiation. This is the reverse of the sex-specific changes in body weight seen in Africa, and this is particularly worrisome because standard BMI thresholds systematically underestimate cardiometabolic risk in this population. Programmatic data from Uganda have shown that dolutegravir exposure doubles the risk of incident hypertension even after adjustment for BMI change. ART switch trials conducted in high-income settings (DEFINE, ACTG A5391) confirm that regimen changes do not reverse established obesity; however, emerging data from a South African randomized trial (Opti-DOR) suggest that regimen at ART initiation influences weight trajectory. GLP-1 therapies demonstrate compelling efficacy for both weight loss and cardiometabolic health improvement in PLWH, including in Africa, but remain economically inaccessible.

SUMMARY: Weight gain in people with HIV in Africa and Asia reflects the convergence of the nutrition transition, ART pharmacology, and immune reconstitution, disproportionately affecting women in African cohorts and men in Asian cohorts. Cardiometabolic consequences, particularly hypertension, are now robustly documented in African programmatic data, but equivalent evidence from Asia remains sparse. Switching ART does not reverse established obesity, although regimen choice at initiation influences weight trajectory. Access to antiobesity medications may be the defining health policy challenge for these populations over the next decade.