Final Conference Report – San Diego HIV Consortium

Aging, Weight Gain, and Their Combined Negative Effects in People Living with HIV (PLWH)

Executive Summary

This report summarizes key findings from sessions addressing the intersection of aging, weight gain, and health outcomes in people living with HIV (PLWH),highlighting accelerated aging patterns, ARV-related weight gain, and cardiovascular risks in this population.

I. Weight Gain in PLWH

Session Title: “Weight Gain!”
Session Leader: Dr. Nomathemba Chandiwana, South Africa

Key Findings on Life Expectancy and Comorbidities

Dr. Chandiwana reported that most PLWH now experience approximately 16 years of good health before developing comorbidities including:

Heart disease
Non-HIV cancers
Hypertension
Metabolic syndrome
Pre-diabetes and type 2 diabetes
Hepatic disease (fatty liver)
Neurocognitive disorders (including Alzheimer’s disease)
Decreased mobility affecting activities of daily living

All these conditions are related to obesity.

Critical Age Differences

Data from Kaiser Permanente database of 400,000 people across all WHO regions

Comorbidity onset: Age 52 (HIV-negative) vs. Age 36 (PLWH)

Life Expectancy Gap Improvements

II. Metabolic Disease and Global Trends

Metabolic Disease Terminology Update

Important Note:

MASLD (Metabolic dysfunction-associated steatotic liver disease) has replaced NAFLD (nonalcoholic fatty liver disease)
MASH (Metabolic dysfunction-associated steatohepatitis) has replaced NASH (nonalcoholic steatohepatitis)

Global Obesity Trends

Obesity is rising globally in middle- and high-income countries, with rates in women approximately three times higher than in men.

ARV-Related Weight Gain

Characteristics:

Observed across all ARV regimens
Most weight gain occurs within the first 2 weeks of treatment
Modern ARV regimens typically include:
- TAF (tenofoviralafenamide, found in Descovy® and most combination pills)
- INSTI (integrase strand transfer inhibitor)

Higher Risk Groups:

Women living with HIV
Those in urban settings

Assessment Challenges:

Better obesity measures than BMI are needed, but good alternatives are limited
Body roundness index considers body shape: BRI Calculator

“Obesity is a social and political problem. Policy changes take 10-20 years to show effects. Brazil, for example, is relabeling food despite pressure from the food industry.”

III. HIV and Women’s Health

HIV and Menopause

Key Finding: Menopause begins approximately 5 years earlier in women living with HIV compared to HIV-negative women.

Associated Risks:

Heart disease
Fatty liver
Insulin resistance
Mood disorders
Cognitive decline

Pathophysiology of Weight Gain and Health Risks

Historical vs. Current Understanding:

IV. Management Strategies and Research

Current Management Approaches for Obesity

Diet and exercise (remain important)
GLP-1 receptor agonists
Tesamorelin (Egrifta®) for lipodystrophy
Future considerations: Switching ART regimens and novel medical therapies (currently under study)

Note: No regimen has yet been identified that leads to weight loss

Research Studies on Weight Management

Semaglutide Studies:

South African study: Gut biopsies showed weight loss associated with increased gut CD4 cells
Reference: Chandiwana N, et al. IAS 2025 Poster LB11, “Liraglutide for Obesity in HIV”

SLIM Liver Study:

Design: Small study (n=51) using semaglutide
Results: Improved fatty liver in PLWH
Reference: Lake J, et al. CROI 2025 abstract

ART Optimization Studies:

DO-IT Trial Details:

IAS 2025 abstract OAB0206LB A5391 – randomized multicenter3-arm controlled trial for obese individuals on integrase inhibitors andtenofovir alafenamide switching to doravirine, with or without tenofovirdisoproxil fumarate.

V. Cardiovascular Risk in PLWH

Presenter: Dr. Franck Boccara, Cardiologist, Sorbonne University, France

Risk Factors for Myocardial Infarction

Age
HIV infection
Type 2 diabetes
Hypertension
Obesity
Smoking
Hyperlipidemia
Alcohol use
Methamphetamine use
Low CD4 count
High viral load

Gender Considerations

“Don’t forget women’s hearts.”

Women living with HIV have increased cardiovascular disease risk compared to men.

Risk Assessment Tools

Current tools underestimate risk in PLWH

SCORE2 (Europe): Risk Calculator
10-year ASCVD Risk (US): Risk Calculator

Treatment Recommendations

First-line Hypertension Treatment:

Dual ARB (sartans in the US) plus beta-blocker
Then: Calcium channel blocker and/or diuretic
First-choice diuretic: Spironolactone

Based on European guidelines on arterial hypertension treatment

Hypertension Definitions:

Europe: >130/80 mmHg
US: >140/90 mmHg
Note: African Americans may benefit from different medications

Statin Use:

European AIDS Clinical Society guidance for primary cardiovascular disease prevention(May 2025, Lancet): Reference

VI. Viral Hepatitis Considerations

Organization: Fundação Oswaldo Cruz (Fiocruz)

Hepatitis C

Treatment duration: Shortened to 1-2 months
Reinfection: Remains possible
Recommendation: Continued screening for HCV RNA for patients at ongoing risk

Hepatitis B

Global Statistics:

35 million people live with HIV globally
260 million live with HBV

MANET Trial Results:

Study Design: Monotherapy study in Africa examining RTI-sparing HIV regimens

Key Finding: Surprisingly few HBV reactivations when switching to single HIVdrugs with no HBV activity after discontinuing nucleosides

Clinical Context: Many patients, especially in Africa, have HIV/HBV coinfection. Some medications treat both conditions (tenofovir, lamivudine, Truvada®,Descovy®). This study discontinued dual-active medications while continuing single HIV-active therapy.

VII. Healthy Aging with HIV

Presenter: Dr. Pui Li Wong, Infectious Disease Physician, Universiti Malaya, Malaysia

Global Context

Approximately 39 million people live with HIV globally.

“I apologize that this may seem depressing, but outcomes are improving.”

WHO Model for Healthy Aging

Definition: “Healthy aging is the process that enables individuals to be and to do what they have reason to value throughout their lives.”

Key Components:

Maintaining functional capacity
Intrinsic capacity (sum of physical and mental functions)
Interaction with external environment

ICOPE Framework

Integrated Care for Older People focuses on:

Cognition
Mobility
Vitality
Sensory function (hearing and vision)
Mental health

Reference: WHO integrated care for older people (ICOPE): guidance for person-centered assessment and pathways in primary care, 2nd ed. December 29, 2024

Community Engagement and Support

Global Network:

Dr. Wong has established a global community of 221 members from 22 countries

Contact:agepositively@gmail.com

Additional Resources:

EATG ICOPE HIV Initiative
International Coalition of Older People with HIV (iCOPe HIV)

Innovative Projects in Malaysia

Comprehensive Women’s Health Program:

Menopause management clinic
Ensure Cervical cancer screening and dysplasia treatment
Recognition that women experience more frailty, falls, cognitive impairment, and geriatric syndromes

Cognitive Assessment:

Tablet-based neurocognitive screening using tools developed by Columbia University
Reference: PubMed

Research and Development:

Stakeholder research on “wellness of women with HIV”
Development of aging screening tools and interventions

“Don’t reinvent the wheel. Work with existing local resources.” Jerry Turner is leading an effort to help people age well with HIV.

Scoring system based on WHO guidelines

Mental Health Screening:

10-question survey screening for six mental health conditions with automatic action plan generation, including referrals

Local Advocacy:

Neuro-HIV and aging advocacy group including clinicians, researchers, and community members focused on improving cognition and aging health in HIV

Environmental Factors in Aging

External Environment Impact: