While older protease inhibitors (PI) were more frequently associated with central fat accumulation, initiation of currently used ART regimens has been associated with increases in body mass index (BMI), particularly in women and with integrase strand transfer inhibitors (INSTI). The goal of this study was to analyze the differential effect of individual PIs and INSTIs on changes in BMI by sex and race in a large urban HIV clinic.
All patients initiating ART at the Parkland Health and Hospital System in Dallas, TX from 2009 to 2017 were included in the analysis. Exposure to ART was defined as concurrent receipt of at least two nucleoside reverse transcriptase inhibitors (NRTI) and at least one PI, Non-nucleoside reverse transcriptase inhibitor (NNRTI) or INSTI. In regression analysis, we compared yearly change in BMI (kg/m2) between men and women and between Blacks, Hispanics and Non-Hispanic Whites following initiation of PIs (Atazanavir [ATV], Darunavir [DRV] or Lopinavir [LPV]) or INSTI (Raltegravir [RAL], Elvitegravir [EVG] or Dolutegravir [DTG]). We controlled for year of HAART initiation, baseline CD4 count and HIV-1 RNA, and whether patients achieved virologic suppression on HAART.
We included 4,048 patients, 69% male, 53% Black, 28% Hispanic, and 16% non-Hispanic Whites. Mean age was 46.3 years (SD 11.9). Mean baseline BMI was 27.0 kg/m2 (6.4). Median follow-up time on HAART was 6.7 years (IQR 2.8 – 11.2). Cumulative exposure to NNRTI, PI, and INSTI-based HAART were 3546, 6184, and 3090 person-years, respectively. The BMI slope per year on NNRTI, PI and INSTI were 0.22, 0.24 and 0.32, respectively. BMI slopes for individual PI- and INSTI-based regimens by sex, race and ethnicity are presented in Table 1. There was no significant interaction between sex and race/ethnicity on BMI gains. Proportion of overweight /obese (BMI, ≥ 25) increased from 51% at HAART initiation to 65% at year 3 (p<0.001).
We observed a differential effect of individual INSTI and PI-based HAART regimens on BMI changes by sex. All PIs were associated with greater BMI gain in women than in men, but with no difference by race/ethnicity. LPV-based ART was associated with relatively smaller BMI gains. Among INSTIs, while EVG appeared to be associated with greater BMI gains overall, the effect did not vary or by sex or race/ethnicity. DTG and RAL are associated with greater BMI gains in women, and DTG with greater gains in Blacks & Hispanics.