This review synthesized recent evidence (focusing on studies published in the 18 months before the review) on weight gain in people living with HIV (PLWH) across Africa and Asia. The aim was to describe epidemiology, identify drivers and consequences, and discuss clinical and programmatic implications. The authors acknowledge that regionally derived evidence remains sparse.
Recent population-level data from East Africa indicate that the broader nutrition transition is accelerating weight gain more rapidly than ART-related factors. In rural Kenya and Uganda, HIV-negative individuals experienced greater weight gain than PLWH on ART during the transition to dolutegravir-containing regimens. In Asian cohort data, the pattern differs by sex: men gained more weight than women after ART initiation. This sex-specific difference contrasts with African cohorts, where women have been disproportionately affected by weight gain.
The review frames weight gain in PLWH as the result of three interacting processes. First, the population-level nutrition transition—changes in diet, urbanization, and lifestyle—has increased background weight gain in many settings. Second, ART pharmacology contributes variably to weight changes; the move to integrase inhibitor–based regimens such as dolutegravir has been implicated in weight increases in some datasets. Third, immune reconstitution after starting ART can lead to gains in weight and body mass as health improves. The combined effect of these factors explains regional and individual variability in weight trajectories.
Regional differences in sex-specific weight change were highlighted. African cohorts show a pattern of greater weight gain among women, whereas Asian cohorts report greater gains among men after ART initiation. The review also warns that common BMI thresholds may systematically underestimate cardiometabolic risk in some Asian populations; this has implications for clinical interpretation of weight and BMI change and for risk stratification.
Programmatic data from Uganda provide strong evidence that ART exposure—specifically to dolutegravir—is associated with cardiometabolic outcomes. These data showed that dolutegravir exposure doubled the risk of incident hypertension, and this association persisted after adjustment for BMI change, indicating potential mechanisms beyond weight alone. The review notes cardiometabolic consequences are now robustly documented in African programmatic datasets, while equivalent evidence from Asia is limited.
The review summarizes trial and programmatic evidence regarding ART regimen effects. ART switch trials conducted in high-income settings (for example, DEFINE and ACTG A5391) confirm that switching regimens does not reliably reverse established obesity. Conversely, randomized data from a South African trial (Opti-DOR) suggest that the regimen used at ART initiation can influence subsequent weight trajectory. Thus, regimen choice at initiation appears to matter for future weight patterns, but switching after obesity is established may not reverse weight gain.
Emerging evidence indicates that GLP-1 receptor agonists have compelling efficacy for weight loss and improvement in cardiometabolic health among PLWH, including evidence from African settings. Despite these clinical benefits, the review emphasizes that such therapies remain largely economically inaccessible in many low- and middle-income contexts. Access to antiobesity medications is framed as a major health policy challenge for the coming decade.
The intersection of the nutrition transition, ART-related effects, and immune reconstitution creates a shifting clinical landscape for HIV programs in Africa and Asia. Programmatic priorities include closer monitoring for cardiometabolic complications (for example, hypertension), considering the influence of regimen selection at ART initiation on weight trajectory, and planning for limited access to effective antiobesity pharmacotherapies. Health systems will need to balance ART effectiveness, metabolic monitoring, and prevention strategies as population-level weight patterns evolve.
The review highlights sparse region-specific data—particularly from Asia—on cardiometabolic outcomes related to weight gain in PLWH. Further research is needed to clarify mechanisms linking specific ART agents (such as dolutegravir) to hypertension and other metabolic complications, to define sex- and region-specific risk profiles, and to test interventions that can be implemented in resource-constrained settings. Economic and implementation research on access to effective antiobesity therapies is also identified as a priority.
Weight gain among PLWH in Africa and Asia results from the combined effects of the nutrition transition, ART pharmacology, and immune reconstitution, with differing sex-specific patterns by region. There is now robust evidence—particularly from African programmatic data—that cardiometabolic consequences, notably hypertension, are associated with ART exposure and weight change. Regimen choice at ART initiation influences weight trajectory, but switching regimens does not reliably reverse established obesity. Although GLP-1 therapies are effective for weight loss and cardiometabolic improvement, limited economic access poses a significant policy challenge. The review calls for more regionally focused research and for programmatic strategies that integrate metabolic risk monitoring into HIV care.