Weight Gain in Patients With HIV

In this podcast, Daniel Lee, MD, answers our questions about dealing with weight gain in patients with HIV, a topic he presented at the ACT HIV 2021 Conference.

Additional Resource: 

• Lee, D. Practical aspects of dealing with weight gain in PLWH. Presented at: American Conference for the Treatment of HIV; May 20-22, 2021. https://www.acthiv.org/

Daniel Lee, MD, is a clinical professor of medicine at the University of California San Diego, and a HIV specialist at UCSD's Owen Clinic. 

TRANSCRIPTION: 

Leigh Precopio:  Hello everyone, and welcome to another installment of Podcasts360, your go‑to resource for medical news and clinical updates. I'm your moderator Leigh Precopio with Consultant360 Specialty Network.

As advances are made to continue the understanding of HIV, the care that health care specialists provide for patients with HIV improves. One important aspect in caring for patients with HIV is weight gain. Weight gain is an important consideration for any patient, but especially so in this at‑risk patient population.

This was one of the topics presented at the 2021 American Conference for the Treatment of HIV. Here with us today is Daniel Lee, MD, to discuss his session "Practical Aspects of Dealing with Weight Gain in People Living with HIV." Dr. Lee is a clinical professor of medicine at the University of California San Diego, and a physician at the Owen Clinic, which is UCSD's HIV clinic.

Thank you for taking the time to speak with me today, Dr. Lee. To begin, could you give us a brief overview of your session? Why is weight gain an important consideration in people living with HIV?

Daniel Lee:  My session is titled Practical Aspects of Dealing with Weight Gain in People Living with HIV. This session is focused mainly on helping medical providers as well as other attendees on several goals.

Number one, to help those to identify risk factors that may contribute to weight gain, to offer non‑pharmacologic options for managing weight gain, such as diet and exercise and more specifics, at least in regards to what that exactly means. Then, lastly, to also discuss which pharmacologic options are appropriate for managing weight gain in people living with HIV. Those are the main topics that I'll be talking about.

As to why weight gain is an important consideration in people living with HIV, first of all, weight gain is important in HIV because it is often a precursor to the development of other comorbidities. These days, I think we are seeing more issues with hypertension, diabetes, dyslipidemias, but even other conditions such as fatty liver as well as sleep apnea can result as a consequence of weight gain.

As you can kind of tell with more weight gain and the development of these comorbidities, then that oftentimes can lead to much more polypharmacy, so more and more medications. Which many of our patients usually do not want to do is to take more and more medications. The problem of polypharmacy oftentimes leads to other problems, such as drug interactions, for instance.

In addition, our patients with HIV are living longer these days. There is a thought that perhaps people with HIV may be aging faster than people without HIV. Part of this has to do with the issues surrounding chronic inflammation. As people naturally age, the metabolism slows down. The thought is that this potential acceleration of the aging process in people with HIV may lead to the emergence of these comorbidities at much younger ages than we might typically expect.

Leigh Precopio:  What is the current standard of care for managing weight in people living with HIV?

Daniel Lee:  The current standard of care for managing weight in people living with HIV is really not that much different than people without HIV. Namely, we always start out with diet and exercise. It seems like the addition of behavioral therapy, maybe talking to a therapist or a counselor, may also be helpful in regards to trying to improve people's adherence to, let's say, diet and/or exercise.

In terms of pharmacologic therapy, the options are very similar to people without HIV as well too, with the slight exception of if there is the presence of HIV‑associated lipodystrophy, which has to do with body composition changes that we may see in people with HIV. If it's determined that the patient has weight gain but also HIV lipodystrophy, then we may want to try using tesamorelin, which is also known as growth hormone‑releasing factor, which is specifically indicated for HIV‑associated lipodystrophy.

What's also different in regards to managing weight in people with HIV is paying attention to some of the HIV‑related medications. Nowadays, there has been some recent research suggesting that integrase inhibitors as well as tenofovir alafenamide might be implicated in possibly causing weight gain. At this time, the mechanisms of why this may occur and who this occurs in is not clear.

But the awareness of these potential risk factors for weight gain in people with HIV may help with improved screening, monitoring, and perhaps may lead to earlier intervention for those who have weight gain.

Leigh Precopio:  Do any specific patient characteristics, such as race or gender, influence how you approach dealing with weight gain in people living with HIV?

Daniel Lee:  I would say yes. The current data regarding weight gain has suggested that there may be more weight gain in Black and Latinx populations more than the White population, in addition to women being at higher risk for weight gain than in men. As to how I might approach these populations differently, I may be a little bit more aggressive with screening and monitoring for weight gain in these specific populations.

Though, to be honest, I do counsel everyone on the potential for weight gain whenever I initiate or even switch antiretroviral therapy these days. Everyone gets counseling across the board, no matter what the race or gender may be.

Of note, I developed a sub‑specialty metabolic clinic about 20 years ago at the UCSD Owen Clinic specifically to manage these types of issues. So some of the other things that I also look for is trying to address risk factors for developing weight gain. I'm fairly aggressive with screening for things like prediabetes or diabetes. I'll also look at checking thyroid function tests to look for thyroid abnormalities as well as checking fasting lipid panels to address dyslipidemia.

Leigh Precopio:  How do you hope health care practitioners implement the key takeaway messages of your session into clinical practice?

Daniel Lee:  I think that the key takeaway messages from my session are easily implementable. I discuss the very practical tips about what to do, at least in regards to taking a history. What to look for on the physical exam, what labs to perform in someone with weight gain, and also made recommendations in regards to terms of pharmacologic management, which ultimately should be individualized to each person.

Leigh Precopio:  What are some knowledge gaps that still need to be addressed?

Daniel Lee:  There are many knowledge gaps, as usual. The ones that come to mind are some of the following. Number one, why does weight gain occur with certain antiretrovirals?

Number two, what are the mechanisms behind weight gain? I suspect that the mechanisms behind integrase inhibitor‑related weight gain as well as TAF‑related weight gain is going to be different. But at this point we still do not know.

Number three, from a treatment standpoint, does non‑pharmacologic interventions, such as diet and exercise, work equally as well in people with HIV as compared to people without HIV? I have seen in my own clinical practice how difficult it has been for some people to lose weight despite doing everything "right." It would be nice to have more clinical studies using non‑pharmacologic interventions, which often are very difficult to find funding for but, in my opinion, are very necessary.

Other knowledge gaps include the switching antiretrovirals for weight gain, is that helpful or not? Then lastly, what's the effectiveness of using various pharmacologic interventions for losing weight in people with HIV?

Obviously, there are always tons of gaps and tons of questions. Hopefully many of these will be answered in the future.

Leigh Precopio:  Thank you for taking the time to speak with me today.

Daniel Lee:  Thank you for having me. I hope this was helpful.