by Carolyn Chu, MD, MSc, AAHIVS, AAHIVM Chief Medical Officer

December 5, 2023

Featured Literature:

Zino L, Wit F, Rokx C, et al.  Outcomes of bariatric surgery in people with Human Immunodeficiency Virus: a retrospective analysis from the ATHENA Cohort.  Clin Infect Dis.  2023 Nov 30; 77(11):1561-8.  doi: 10.1093/cid/ciad404.  PMID: 37392435

This study examined 51 patients who underwent bariatric surgery between 2004 and 2022 in the Netherlands.  Median age at surgery was 46 years and 55% were women; 76% underwent gastric bypass and 24% had sleeve gastrectomy.  Median weight and BMI pre-procedure were 121kg and 39.8kg/m2.  43/51 (84%) had VL < 40 at baseline.  49% were on a INSTI + 2 NRTI combination, with 29% using DTG as their anchor.  Of these 43 people, only one person (who was receiving a three-class regimen) developed virologic failure eight months post-surgery; this was attributed to non-adherence.  Three people with undetectable VL at baseline developed blips after 6-7 months.  The three people on dual therapy remained suppressed over the 18-month follow-up period.  89% achieved >20% loss of baseline weight, and lipid profiles improved significantly.  There were 24 ART modifications among 21 patients, mostly for routine reasons (e.g., desire for treatment simplification, pregnancy, other).  One person modified therapy due to persistent low-level viremia.  Twelve people stopped all their non-HIV medications and approximately half stopped their antihypertensive or antihyperlipidemic medications; 75% stopped their antidiabetic medications.  Plasma concentration testing found adequate/therapeutic exposure for elvitegravir, dolutegravir, emtricitabine, and tenofovir (TDF and TAF); darunavir/ritonavir results were mixed.  There was no significant difference in weight reduction among people who continuously took INSTI without TAF, or INSTI plus TAF vs. non-INSTI/non-TAF regimens.

Author’s Commentary:

This retrospective analysis provides reassuring medium-term clinical outcome data across HIV and metabolic-related parameters.  Although gastric bypass and other weight-loss surgeries will be considered for only a subset of patients, obesity is likely to remain a priority health concern for HIV providers in the years ahead.  As highlighted in a 2018 review, it is critical to understand how these procedures will impact medication absorption, other pharmacologic considerations, and ART efficacy.  Additionally, with widespread use of second-generation INSTIs and TAF, more data on post-operative weight changes and hyperlipidemia/other metabolic-related outcomes among people on these specific ARVs are needed.  Finally – the medication profile changes highlighted in this study are notable and highly relevant given increasing polypharmacy concerns for aging PWH.       

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