Would you recommend switching from an integrase strand transfer inhibitor-based regimen to a different antiretroviral regimen, or would you instead add weight loss medications for a person with HIV experiencing weight gain that has not improved with lifestyle changes?

The data about weight gain attributable to integrase strand inhibitors is actually a bit controversial. Multiple studies have raised the concern for increased weight gain in patients treated with second-generation INSTIs (ADVANCE, NA-ACCORD), while others indicate more of an impact of tenofovir alafenamide (TAF) or other factors. Our study, based in Dallas, of a diverse cohort of people actually showed no independent effect of INSTIs or TAF on weight gain, although patients who were treated with TDF or efavirenz had less weight gain overall (Drechsler et al., PMID 38831733). Many studies have also raised the concern that women are at the highest risk for weight gain.

Even less clear than the impact of ART on weight gain is whether a switch i...