The management of obesity in patients with HIV

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This CME piece focuses on the management of obesity in HIV patients

HIV-infected patients now live longer and may develop obesity. This weight gain reflects improved health status due to decreased HIV-related morbidity, with increased life span and better quality of life also mirroring trends in the general population.

The prevalence of overweight/obesity in HIV population is between 9 to 37% in the ..USA and in France. In the general population, several studies have shown a positive association between obesity and increased rate of death, cardiovascular and metabolic diseases and neoplasia, particularly in patients with a body mass index (BMI) above 35 kg/m2. Comorbidities such as diabetes, insulin resistance, coronary artery disease, hypertension and neoplasia have been described in the HIV population without obesity since more than 10 years but very few data on comorbidities are available in obese HIV infected patients.

Bariatric surgery is considered to be the best treatment option for morbid obesity (BMI >40 kg/m2 or >35 kg/m2 with comorbidities) in French and International guidelines for the general population. Three surgical methods are currently used: gastric banding (pure restrictive method), gastro-jejunal bypass (restrictive and malabsorptive method) and sleeve gastrectomy (restrictive and endocrine method). This last kind of surgery is associated with long-term weight loss, decreased overall morbidity and mortality and particularly resolution of diabetes and dyslipidemia. Compared to gastric bypass, sleeve gastrectomy preserves digestive continuity and induces less malabsorption, less vitamin deficiency and fewer complications (diarrhea, dumping syndrome, occlusion and late complications) allowing a better quality of life in short and long-term follow-up.

Despite key benefits of surgery in the general population and an important prevalence of obesity in HIV-infected subjects, few data are available about bariatric procedures in obese HIV-infected patients. No specific recommendations exist for bariatric surgery in HIV-infected individuals. All studies are retrospective and only three between them report the use of sleeve gastrectomy including 1, 3 and 8 individuals. Moreover, the performance of a malabsorptive procedure could impact the absorption of antiretroviral drugs with a potential risk of virological failure. Whatever bariatric method is used, the pharmacokinetics of cART and plasma HIV RNA must be evaluated before and after surgery to adapt dosages and thus avoid virological failure.

For HIV-infected subjects, we need to choose a safe procedure, with no disruption of intestinal continuity, avoiding implanted foreign material that could result in less malabsoption and having long-term weight loss efficacy. Sleeve gastrectomy appears as an emerging procedure for the treatment of obesity that provides rapid and satisfactory weight loss without malabsorption. It could be considered as the best option in HIV-infected patients as showed in a recent meta-analysis. Optimal management of HIV-infected patients with morbid obesity could include classical surgical procedure as in non HIV obese patients, with close drug monitoring and immunovirological follow up but further prospective studies were needed.

This post was originally written for ISHEID 2018 newsletter by Valérie POURCHER, she is with the Pitié Salpétrière Hospital, Tropical and Infectious Diseases Department, Paris, France

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