Antiretroviral therapy, adiposity, and cardiometabolic risk in people with HIV

Return to health accounts for only part of the weight gain observed with modern antiretroviral therapy (ART). A fuller account requires integrating recovery from HIV-related catabolism, HIV-associated adipose tissue remodelling, withdrawal of weight-suppressive antiretrovirals, possible direct or permissive effects of newer agents, individual susceptibility, and obesogenic environments. Evidence from ART initiation and switch studies, PrEP trials, and mechanistic research in adipose tissue suggests that ART-associated weight gain is heterogeneous rather than a uniform restorative process. Once adiposity is established, ART switching has a limited ability to reverse weight gain, consistent with the biological persistence of acquired adiposity. Future care should move beyond ART manipulation alone and incorporate early monitoring, body-composition assessment, cardiometabolic prevention, lifestyle intervention, and appropriate antiobesity pharmacotherapy.