Academy Exchange

Hello and thank you for all the helpful information on this message board! 

I am still learning my way around HIV care, and this group had been very helpful. My question today is regarding a patient who has had weight gain on Biktarvy. She has gained almost 50 pounds since last July. Her only medications right now are Biktarvy, and Bactrim DS 1 tab daily for OI prophylaxis. Last CD4 was 155 on 10/22/24, viral load <30. She had a period of time off ART from 2022 to 2024. She was hospitalized in October 2024 for acute hypoxic respiratory failure due to asthma and rhinovirus infection. Also has eczema. 

She reports HO T2DM, and she was on Victoza previously, but not now, as she does not have a PCP at this time. She will be establishing with PCP in May. I ordered TSH and hemoglobin A1c today. She is not the best about coming to appointments though her ART adherence has been better lately.

We discussed diet and exercise, but it will take more than that for the weight loss she hopes for. I hope her new PCP can get her on to something like Ozempic. She wants to change from Biktarvy to another ART combo with less weight gain associated. I have tried researching this, but have not found a clear recommendation on an ART combo that might be as effective for HIV and as safe as Biktarvy regarding other potential adverse effects. 

I would greatly appreciate any recommendations on ART med options. Thank you. 

Barbara Hart APRN

There's no evidence that Biktarvy causes weight gain, aside from the weight gain associated with improved health resulting from viral suppression (reversal of the catabolic effect of untreated HIV infection). Earlier suggestions that TAF, integrase inhibitors, or both could cause weight gain are now explained by the fact that they were based on comparisons with regimens containing EFV or TDF, both of which cause weight suppression.  Multiple switch studies have failed to show weight loss with switches off Biktarvy or other TAF/INSTI-based regimens.  The only exception is a switch back to weight-suppressive TDF, which does result in modest weight loss. (Presumably, a switch back to EFV would do the same.) However, few of us are excited about switching from TAF to TDF or from INSTIs to EFV, especially when weight suppression is mostly likely a drug toxicity.

The best approach is to treat this as you would any other unwanted weight gain: with diet, exercise, and GLP-1 agonists, if indicated.  That being said, this can be a hard conversation to have with patients, since it's very easy for them to do their own "Google research" and find sources saying that Biktarvy causes weight gain. Good luck!

Hello and thank you for all the helpful information on this message board! 

I am still learning my way around HIV care, and this group had been very helpful. My question today is regarding a patient who has had weight gain on Biktarvy. She has gained almost 50 pounds since last July. Her only medications right now are Biktarvy, and Bactrim DS 1 tab daily for OI prophylaxis. Last CD4 was 155 on 10/22/24, viral load <30. She had a period of time off ART from 2022 to 2024. She was hospitalized in October 2024 for acute hypoxic respiratory failure due to asthma and rhinovirus infection. Also has eczema. 

She reports HO T2DM, and she was on Victoza previously, but not now, as she does not have a PCP at this time. She will be establishing with PCP in May. I ordered TSH and hemoglobin A1c today. She is not the best about coming to appointments though her ART adherence has been better lately.

We discussed diet and exercise, but it will take more than that for the weight loss she hopes for. I hope her new PCP can get her on to something like Ozempic. She wants to change from Biktarvy to another ART combo with less weight gain associated. I have tried researching this, but have not found a clear recommendation on an ART combo that might be as effective for HIV and as safe as Biktarvy regarding other potential adverse effects. 

I would greatly appreciate any recommendations on ART med options. Thank you. 

Barbara Hart APRN

In our clinic, when we encounter this scenario, we often consider switching to a two-drug regimen-typically discontinuing the TAF component, which is thought to contribute to weight gain. Check out the PASO DOBLE study by Viiv  to get some more insight on the supporting literature for this but in summary: -

 Compared Biktarvy to Dovato, found no difference in virally suppressed patient switching (largest head to head study, I believe) but those on the Dovato had (clinically) significant less weight gain ( >5% change in body weight). That said, it's important to set realistic expectations with patients. While weight stabilization or modest loss may occur, it's unlikely to result in dramatic reductions (e.g., 10–20 lbs). Most studies report a difference of approximately 2–3 kg between regimens.

-Brenda Simiyu, PharmD, BCIDP, AAHIVP

There's no evidence that Biktarvy causes weight gain, aside from the weight gain associated with improved health resulting from viral suppression (reversal of the catabolic effect of untreated HIV infection). Earlier suggestions that TAF, integrase inhibitors, or both could cause weight gain are now explained by the fact that they were based on comparisons with regimens containing EFV or TDF, both of which cause weight suppression.  Multiple switch studies have failed to show weight loss with switches off Biktarvy or other TAF/INSTI-based regimens.  The only exception is a switch back to weight-suppressive TDF, which does result in modest weight loss. (Presumably, a switch back to EFV would do the same.) However, few of us are excited about switching from TAF to TDF or from INSTIs to EFV, especially when weight suppression is mostly likely a drug toxicity.

The best approach is to treat this as you would any other unwanted weight gain: with diet, exercise, and GLP-1 agonists, if indicated.  That being said, this can be a hard conversation to have with patients, since it's very easy for them to do their own "Google research" and find sources saying that Biktarvy causes weight gain. Good luck!

Hello and thank you for all the helpful information on this message board! 

I am still learning my way around HIV care, and this group had been very helpful. My question today is regarding a patient who has had weight gain on Biktarvy. She has gained almost 50 pounds since last July. Her only medications right now are Biktarvy, and Bactrim DS 1 tab daily for OI prophylaxis. Last CD4 was 155 on 10/22/24, viral load <30. She had a period of time off ART from 2022 to 2024. She was hospitalized in October 2024 for acute hypoxic respiratory failure due to asthma and rhinovirus infection. Also has eczema. 

She reports HO T2DM, and she was on Victoza previously, but not now, as she does not have a PCP at this time. She will be establishing with PCP in May. I ordered TSH and hemoglobin A1c today. She is not the best about coming to appointments though her ART adherence has been better lately.

We discussed diet and exercise, but it will take more than that for the weight loss she hopes for. I hope her new PCP can get her on to something like Ozempic. She wants to change from Biktarvy to another ART combo with less weight gain associated. I have tried researching this, but have not found a clear recommendation on an ART combo that might be as effective for HIV and as safe as Biktarvy regarding other potential adverse effects. 

I would greatly appreciate any recommendations on ART med options. Thank you. 

Barbara Hart APRN

The PASO DOBLE study does not demonstrate that TAF causes weight gain. The majority of people switching from a TDF-based regimen were also on EFV, both of which are known to cause weight suppression. When you switch off those two weight-suppressive drugs, whether to Biktarvy or Dovato, you expect to see weight gain, which we've seen in many switch studies. In contrast, when you switch from a regimen that's not weight-suppressive (e.g. a 3-drug TAF-based regimen or 3TC plus a 3rd agent), you don't tend to see weight gain. In this study, there was an unexplained difference between switching to Dovato vs. Biktarvy, but that result is an outlier that hasn't been seen in other trials or observational data.

No study has ever shown that discontinuing TAF will result in weight loss, with the one exception of the ADVANCE study, in those participants who switched from TAF back to TDF.  Not surprisingly, they lost weight because of TDF-induced weight suppression.  (There's now some evidence that this may be due to toxicity to gastrointestinal microvilli, which could also explain the lipid-lower effects of TDF.)

In the ViiV-sponsored TANGO trial, there was no difference in weight gain between those who switched from a TAF-based regimen to Dovato vs. those who stayed on TAF. (In fact, weight gain was numerically but not significantly higher in those who switched to Dovato.)  PrEP studies also support the weight neutrality of TAF.  In DISCOVER, weight gain on TAF was the same as weight gain on placebo in iPrEx, whereas TDF resulted in about the same amount of weight loss in both trials. Finally, a recent Spanish study randomized people who were suppressed on Dovato to either stay on Dovato or switch to Biktarvy.  At 96 weeks they found that people in both arms gained some weight, with no difference between the arms. 

For an excellent review of this topic, I'd recommend David Wohl's paper: "Antiretrovirals and Weight Change: Weighing the Evidence." Clin Infect Dis 2024 Oct 15;79(4):999-1005.

In our clinic, when we encounter this scenario, we often consider switching to a two-drug regimen-typically discontinuing the TAF component, which is thought to contribute to weight gain. Check out the PASO DOBLE study by Viiv  to get some more insight on the supporting literature for this but in summary: -

 Compared Biktarvy to Dovato, found no difference in virally suppressed patient switching (largest head to head study, I believe) but those on the Dovato had (clinically) significant less weight gain ( >5% change in body weight). That said, it's important to set realistic expectations with patients. While weight stabilization or modest loss may occur, it's unlikely to result in dramatic reductions (e.g., 10–20 lbs). Most studies report a difference of approximately 2–3 kg between regimens.

-Brenda Simiyu, PharmD, BCIDP, AAHIVP

There's no evidence that Biktarvy causes weight gain, aside from the weight gain associated with improved health resulting from viral suppression (reversal of the catabolic effect of untreated HIV infection). Earlier suggestions that TAF, integrase inhibitors, or both could cause weight gain are now explained by the fact that they were based on comparisons with regimens containing EFV or TDF, both of which cause weight suppression.  Multiple switch studies have failed to show weight loss with switches off Biktarvy or other TAF/INSTI-based regimens.  The only exception is a switch back to weight-suppressive TDF, which does result in modest weight loss. (Presumably, a switch back to EFV would do the same.) However, few of us are excited about switching from TAF to TDF or from INSTIs to EFV, especially when weight suppression is mostly likely a drug toxicity.

The best approach is to treat this as you would any other unwanted weight gain: with diet, exercise, and GLP-1 agonists, if indicated.  That being said, this can be a hard conversation to have with patients, since it's very easy for them to do their own "Google research" and find sources saying that Biktarvy causes weight gain. Good luck!

Hello and thank you for all the helpful information on this message board! 

I am still learning my way around HIV care, and this group had been very helpful. My question today is regarding a patient who has had weight gain on Biktarvy. She has gained almost 50 pounds since last July. Her only medications right now are Biktarvy, and Bactrim DS 1 tab daily for OI prophylaxis. Last CD4 was 155 on 10/22/24, viral load <30. She had a period of time off ART from 2022 to 2024. She was hospitalized in October 2024 for acute hypoxic respiratory failure due to asthma and rhinovirus infection. Also has eczema. 

She reports HO T2DM, and she was on Victoza previously, but not now, as she does not have a PCP at this time. She will be establishing with PCP in May. I ordered TSH and hemoglobin A1c today. She is not the best about coming to appointments though her ART adherence has been better lately.

We discussed diet and exercise, but it will take more than that for the weight loss she hopes for. I hope her new PCP can get her on to something like Ozempic. She wants to change from Biktarvy to another ART combo with less weight gain associated. I have tried researching this, but have not found a clear recommendation on an ART combo that might be as effective for HIV and as safe as Biktarvy regarding other potential adverse effects. 

I would greatly appreciate any recommendations on ART med options. Thank you. 

Barbara Hart APRN

Hello and thank you for all the helpful information on this message board! 

I am still learning my way around HIV care, and this group had been very helpful. My question today is regarding a patient who has had weight gain on Biktarvy. She has gained almost 50 pounds since last July. Her only medications right now are Biktarvy, and Bactrim DS 1 tab daily for OI prophylaxis. Last CD4 was 155 on 10/22/24, viral load <30. She had a period of time off ART from 2022 to 2024. She was hospitalized in October 2024 for acute hypoxic respiratory failure due to asthma and rhinovirus infection. Also has eczema. 

She reports HO T2DM, and she was on Victoza previously, but not now, as she does not have a PCP at this time. She will be establishing with PCP in May. I ordered TSH and hemoglobin A1c today. She is not the best about coming to appointments though her ART adherence has been better lately.

We discussed diet and exercise, but it will take more than that for the weight loss she hopes for. I hope her new PCP can get her on to something like Ozempic. She wants to change from Biktarvy to another ART combo with less weight gain associated. I have tried researching this, but have not found a clear recommendation on an ART combo that might be as effective for HIV and as safe as Biktarvy regarding other potential adverse effects. 

I would greatly appreciate any recommendations on ART med options. Thank you. 

Barbara Hart APRN