Who misses HIV suppression and gains weight in South Africa?

Unsuppressed viral load during antiretroviral therapy (ART) is linked to worse health and ongoing HIV transmission, while being overweight or obese raises the chance of other chronic diseases. Both the effectiveness of ART and body mass index (BMI) can be shaped by social, psychological and health-related factors, but how these factors interact in people living with HIV in South African primary care was not well understood. To probe these relationships, Babalwa Zani and colleagues carried out a secondary analysis of data from a randomised controlled trial of depression management involving 2,002 adults receiving ART. The team set out to see which sociodemographic characteristics, comorbidities, depression symptoms and other health measures related to two outcomes: viral load non-suppression (defined as viral load ≥1000 copies/ml) and BMI. They measured depression with the Patient Health Questionnaire-9 (PHQ-9), functional disability with WHODAS-2.0, and also recorded AIDS-related stigma and self-reported ART adherence. The study compared these factors at the start of the study (baseline) and tracked changes over 12 months.

The researchers used longitudinal mixed effect logistic and linear regression models to test associations with the two outcomes, selecting and adjusting for potentially confounding variables using least absolute shrinkage and selection operator (LASSO) inference. At baseline, people with viral load non-suppression were more likely to be male, younger and to have lower income. Health-related baseline factors tied to non-suppression included a history of tuberculosis, having been on ART for less than 6 months or for more than 10 years, and self-reported non-adherence to ART. Looking ahead 12 months, a higher disability score and ART duration of under 6 months or over 10 years predicted an increased likelihood of viral load non-suppression. For BMI, higher baseline values were associated with being female, being married, having higher income, and having hypertension; higher BMI at baseline was also linked to not having viral load non-suppression and to no history of tuberculosis. Overall BMI rose from baseline to follow-up, and younger people showed larger BMI increases over 12 months. Importantly, depression symptom scores and stigma scores were not associated with viral load non-suppression or BMI in these analyses.

Taken together, these findings suggest different patterns for viral control and body weight in people on ART in South African primary care. Viral load non-suppression tended to go with lower BMI, which the authors interpret as most likely reflecting the effects of HIV-related illness. Both viral non-suppression and BMI were tied to a range of sociodemographic factors such as age, sex, marital status and income, while non-suppression was additionally linked to functional disability and to ART non-adherence. These consistent associations point to specific subgroups who may benefit most from improved ART access and adherence support: younger men, people with recent ART start or very long ART duration, those with a history of tuberculosis, and people reporting higher disability. The lack of association between either outcome and the measured severity of depression symptoms or self-reported stigma suggests that, in this sample, clinical and sociodemographic factors were stronger drivers of viral control and BMI than the depression or stigma measures used.