A report on Professor Jenny Hoy's presentation New issues with INSTIs

Professor Jenny Hoy gave an excellent presentation about the emerging evidence in relation to weight gain associated with integrase inhibitors, as well as an assessment of the clinical relevance of these findings.

This topic is particularly important as integrase inhibitors are associated with rapid reduction in viral load, have a high barrier to resistance and generally low side effect profile, thus are recommended in most guidelines as a first line choice. However, as people living with HIV (PLWHIV) are living longer and are developing metabolic and CVS co morbidities, weight gain is a key variable to consider.

Jenny concluded that weight gain is an issue with INSTIs and that there is a hierarchy INSTIs>PIs>NNRTIs. Evidence based on a number of studies in both resource rich and poor settings suggest:

  • Weight gain DTG>ETG>Ral (no data on BTG)
  • Groups with the greatest risk were women, African-American and of older age
  • The weight gain is greater in naïve than switch
  • TAF in combination with DTG appears to augment weight gain
  • The weight gain on INSTIs is both general subcutaneous and central as distinct from lipoatrophy.

Jenny also highlighted the increased risk of diabetes and possibly cardiovascular disease with weight gain and that long-term studies were needed to clarify this. She also highlighted a number of unknowns including any link to inflammation/ immune activation, pathogenesis, and reversibility.

 

Professor Hoy’s presentation highlighted that there is a growing body of evidence indicating weight gain associated with INSTIs. It is crucial for longer term studies to clarify their clinical relevance. With their ability to rapidly suppress viral load, their high barrier to resistance and generally favourable side effect profile, INSTIs are an important first line choice. Comprehensive patient assessment, involvement of the patient in the management, general lifestyle advice and multidisciplinary team approaches are important strategies to optimise patient health outcomes.

 

Nanette Presswell is an experienced general practitioner who has worked in a broad range of culturally diverse, public health oriented, primary health care services. She has worked in HIV primary care over the last 30 years, and for the last 10 years worked at Centre Clinic, a high case load HIV primary care clinic, Thorne Harbour Health.