Bariatric surgery outcomes in HIV-infected subjects: a case series

Virologic outcomes of antiretroviral therapy in patients with HIV-1 following bariatric surgery: A case series and review of the literature

BACKGROUND

Selection of an antiretroviral regimen for people living with HIV (PLWH) involves various clinical considerations, such as comorbidities, archived drug resistance mutations, concomitant medications, and potential drug interactions and side effects. Alterations in the surface area and pH of the gastrointestinal tract following bariatric surgery may alter absorption, antiretroviral pharmacokinetics and viral suppression. Data on the efficacy of antiretroviral (ARV) therapy in PLWH who have undergone bariatric surgery are limited or lacking for new antiretrovirals, such as dolutegravir and bictegravir.

METHODS

This case series reports virologic outcomes and side effects in eight cases of PLWH receiving ARV therapy who underwent bariatric surgery. A systematic literature review was performed to review the available literature on the efficacy and safety of antiretroviral regimens in PLWH who have undergone bariatric surgery.

RESULTS

Virologic suppression was not impacted for obese PLWH who underwent bariatric surgery following failure of life-style modifications and pharmacological therapy.

CONCLUSIONS

There were no deleterious effects on HIV progression for PLWH that underwent bariatric surgery. More prospective research is required to validate the effects of bariatric surgery on immunologic and virologic function outcomes. Close involvement of HIV and surgical specialists is recommended to manage ARV therapy in patients undergoing bariatric surgery.

Antiretroviral Drug Exposure and Response in Obese and Morbidly Obese People With Human Immunodeficiency Virus (HIV): A Study Combining Modelling and Swiss HIV Cohort Data

BACKGROUND

Obesity is increasingly prevalent among people with HIV (PWH) and can possibly result in suboptimal antiretroviral drug (ARV) exposure and response. However, this has not been thoroughly evaluated given that obese PWH are underrepresented in clinical trials. We performed virtual trials using physiologically based pharmacokinetic (PBPK) modelling combined with observed clinical data to provide ARV dosing guidance in obese individuals.

METHODS

Each trial included a cohort of virtual adults with a body mass index (BMI) between 18.5 and 60 kg/m2. Therapeutic drug-monitoring data from the Swiss HIV Cohort Study (SHCS) were used to verify the predictive performance of the model. Subsequently, the model was applied to predict the pharmacokinetics of ARVs for different obesity classes. The association between ARV plasma concentrations and virological response was investigated in obese and nonobese individuals.

RESULTS

The PBPK model predicted an average reduction in ARV exposure of ∼20% and trough concentrations of ∼6% in obese (BMI ≥30 kg/m2) compared with nonobese (BMI: 18.5-25 kg/m2) individuals, consistent with observed clinical data. Etravirine and rilpivirine were the most impacted, especially in individuals with BMI >40 kg/m2 whose trough concentrations were below the clinical target threshold. Obese PWH in the SHCS did not have a higher rate of unsuppressed viral load than nonobese PWH.

CONCLUSIONS

The concentrations of ARVs are modestly reduced in obese individuals, with no negative impact on the virological response. Our data provide reassurance that standard doses of ARVs are suitable in obese PWH, including those who gained substantial weight with some of the first-line ARVs.

Antiretroviral Therapy Efficacy Post-Bariatric Weight Loss Surgery: A Case Series of Persons Living with Human Immunodeficiency Virus

Purpose

Human immunodeficiency virus (HIV)–related mortality has decreased secondary to advances in antiretroviral therapy (ART), and the incidence of obesity in this population is increasing. Bariatric surgery is an effective method of weight loss, though changes in the gastrointestinal tract may affect ART absorption and virologic suppression. Existing data are limited to case reports studying outdated therapeutic regimens; studies evaluating modern ART regimens are needed. The objective of this study was to determine if undergoing bariatric surgery impacts HIV virologic failure rate at 12 months post-surgery and to characterize the failure population.

Materials and Methods

This retrospective case series included adults with virologically suppressed HIV on ART who underwent roux-en-y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery between 2000 and 2019 (n=20) at one of three medical centers within one academic medical system. The primary outcome was proportion of patients with ART failure at 12 months post-surgery. Select additional data collected included CD4+ count, metabolic parameters, postoperative complications, and medication non-adherence.

Results

A total of 18 patients were included in this analysis. Seventeen of 18 patients (94%) maintained virologic suppression within 12 months post-surgery. There were no significant changes in CD4+ counts before and after surgery. The one failure was an African American woman who underwent sleeve gastrectomy surgery. This patient’s baseline viral load was undetectable and CD4+ count was 263 cells/mm³.

Conclusion

Undergoing bariatric surgery did not increase virologic failure rate in a small cohort of persons living with HIV, and ART non-adherence was associated with virologic failure.

Graphical abstract

Weight Gain and Metabolic Syndrome in Human Immunodeficiency Virus Patients

While human immunodeficiency virus (HIV)-associated wasting has declined with significant advances in antiretroviral therapy (ART), weight gain and metabolic syndrome (MetS) are now becoming a problem for people living with HIV (PLWH) worldwide. The development of a new and more effective ART regimen has increased viral suppression and improved immunologic function recovery, leading to the extension of the lifespan of PLWH. It has recently been reported as one of the significant factors associated with weight gain, obesity, and long-term metabolic consequences in PLWH. This article reviewed the epidemiology of overweight and MetS among PLWH and the known risk factors for weight gain and its major comorbidities, such as dyslipidemia, diabetes mellitus, cardiovascular diseases, neurocognitive disorders, and liver diseases, in PLWH. In addition, reports on the pharmacological and surgical management of overweight and obesity in PLWH has been briefly summarized.

Safety of Bariatric Surgery in Morbidly Obese Patients with Human Immunodeficiency Virus: A Nationwide Inpatient Sample Analysis, 2004-2014

Background: Despite rising rates of obesity among human immunodeficiency virus (HIV)-positive individuals, the safety and tolerability of surgery in this population have not been established. The primary aim of this study was to examine the safety of bariatric surgery and rate of in-hospital postoperative complications in morbidly obese patients with HIV. Materials and Methods: The U.S. Nationwide Inpatient Sample database was queried between 2004 and 2014 for discharges with codiagnoses of morbid obesity and bariatric surgery. The primary outcome was in-hospital mortality. Secondary outcomes included length of stay, hospitalization costs, and multiple categories of complications, including systemic complications, surgical complications, and nutritional and behavioral complications. Results: Among 267,082 patients with discharge diagnoses of morbid obesity and bariatric surgery, 346 (0.13%) were diagnosed with HIV. On multivariable analysis, HIV did not influence in-hospital mortality (p = 0.530). HIV was not associated with increased risk of renal failure (p = 0.274), thromboembolism (p = 0.713), myocardial infarction (p = 0.635), sepsis (p = 0.757), hemorrhage (p = 0.303), or wound infection (p = 0.229). Other measured surgical complications were not significantly different (p > 0.05). Notably, HIV-positive patients had an increased risk for postoperative pneumonia (p = 0.002), pancreatitis (p = 0.049), and thiamine deficiency (p = 0.016). Conclusion: Bariatric surgery among HIV-positive patients appears to be acceptably safe with the risk of postoperative complications comparable with non-HIV patients.

Obesity and Weight Gain in Persons with HIV

PURPOSE OF REVIEW

The proportion of overweight and obese persons with HIV (PWH) has increased since the introduction of antiretroviral therapy (ART). We aim to summarize recent literature on risks of weight gain, discuss adipose tissue changes in HIV and obesity, and synthesize current understanding of how excess adiposity and HIV contribute to metabolic complications.

RECENT FINDINGS

Recent studies have implicated contemporary ART regimens, including use of integrase strand transfer inhibitors and tenofovir alafenamide, as a contributor to weight gain, though the mechanisms are unclear. Metabolic dysregulation is linked to ectopic fat and alterations in adipose immune cell populations that accompany HIV and obesity. These factors contribute to an increasing burden of metabolic diseases in the aging HIV population. Obesity compounds an increasing burden of metabolic disease among PWH, and understanding the role of fat partitioning and HIV- and ART-related adipose tissue dysfunction may guide prevention and treatment strategies.

Sleeve Gastrectomy in Morbidly Obese HIV Patients: Focus on Anti-retroviral Treatment Absorption After Surgery

CONTEXT

Anti-retroviral therapy (ART) dramatically reduced AIDS development, thus enabling patients to live as long as the general population. New challenges have emerged particularly cardiometabolic diseases and weight gain, with some HIV patients seeking bariatric surgery (BS). However, BS outcomes during HIV remain poorly described, with scarce data on ART pharmacokinetic post-BS.

OBJECTIVE

Describing sleeve gastrectomy (SG) results in HIV patients in terms of ART pharmacokinetic, HIV control, weight loss, and metabolic outcomes.

DESIGN, SETTING, AND PATIENTS

Prospective study of HIV patients undergoing SG in a referral academic center, with at least 6 months follow-up.

MAIN OUTCOME MEASURE

Clinical and biological parameters, HIV medical history, and ART pharmacokinetics were gathered before and post-SG.

RESULTS

Seventeen patients (mean BMI = 44.2 ± 5.7 kg m^-2) and major obesity-related diseases (47% type-2 diabetes, 64% obstructive sleep apnea, 70% hypertension) underwent SG during a mean 2 years of follow-up. They displayed an average of 20% reduction of initial BMI and improved body composition, similarly to obese non-HIV patients. SG improved metabolic status. All patients had undetectable viral load before BS. Upon HIV follow-up, 12 patients had undetectable viral load with correct ART kinetic parameters (3 and 6 months); 4 displayed detectable viral load along with significant decrease in raltegravir and atazanavir treatment exposure, leading to ART change with subsequent undetectable viral load; and 1 had persistent detectable viral load despite ART change.

CONCLUSIONS

SG seems effective and safe in obese HIV patients. However, ART treatment should be monitored post-SG to control HIV infection. We suggest that some ART should be adapted before SG conjoints with infectious disease specialists.

The Effect of Bariatric Surgery on Patients with HIV Infection: a Literature Review

Obesity among human immunodeficiency virus (HIV)-infected individuals is on the rise. Bariatric procedures such as Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) alter the GI tract. Whether this alteration has any impact on the absorption of highly active antiretroviral therapy (HAART), thus affecting HIV disease markers such as CD4 cell count or viral load (VL), is not yet known. We conducted this review to look into the outcomes of bariatric surgery procedures, RYGB, SG and adjustable gastric band (AGB) and its effects on the CD4 cell counts and VL and HAART therapy. A literature search was conducted between January and April 2017, by two independent reviewers, using Pubmed and Google Scholar. The terms 'bariatric surgery and HIV', 'obesity surgery and HIV', 'gastric bypass surgery and HIV', 'sleeve gastrectomy and HIV' and 'gastric band and HIV' were used to retrieve available research. Of the 49 papers reviewed, only 12 reported the outcomes of patients with HIV undergoing bariatric surgery and were therefore included in this review. Six papers assessed patients undergoing RYGB only (N = 18), 3 papers reported on SG only (N = 18) and 3 papers reported on case mix, including 7 cases of RYGB, 4 cases of SG and 11 cases of AGB. Data is limited; however, based on the available data, bariatric surgery is safe in HIV-infected individuals and does not have any adverse impact on HIV disease progress. Additionally, there was no difference in HIV-related outcomes between SG and RYGB.

Comparative Outcomes of Bariatric Surgery in Patients With and Without Human Immunodeficiency Virus

BACKGROUND

Paradoxically, advances in anti-retroviral therapy that has increased survival for patients with human immunodeficiency virus (HIV) have resulted in greater numbers of HIV+ patients developing other chronic diseases, including obesity. Little comparative literature exists detailing perioperative or metabolic outcomes of bariatric surgery in the HIV+ population compared to HIV negative (HIV-) controls.

METHODS

This is a retrospective case-control study with both HIV+ (case) and HIV- control patients. Individuals undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between January 1, 2006 and December 31, 2015 were included. HIV+ status was defined as any individual with documented history of HIV.

RESULTS

Eleven HIV+ patients underwent RYGB or SG during the study period. After matching (1:5 HIV+: HIV-) both cohorts had similar mean age (42 years), gender distribution (63% female), and preoperative BMI (48 kg/m2), as well as comorbidities. There were no differences in postoperative length of stay, or all cause 30-day morbidity. There were 63.7% HIV+ and 76.4% with 1-year follow-up available. Both percent excess weight loss (56% HIV+ vs. 60% HIV-) and BMI (32 HIV+ vs. 34 kg/m2 HIV-) were similar in both groups. There were minimal changes to CD4 count or HIV viral load in the patients during the follow-up period.

CONCLUSION

Bariatric surgery is safe and feasible in HIV-infected population well controlled on anti-retroviral medication. The short-term surgical and metabolic outcomes are similar to HIV- controls with minimal effect on the CD4 count and viral load in HIV+ cohort for long-term follow-up.

HIV Infection Is Not a Contraindication to Laparoscopic Sleeve Gastrectomy for Morbid Obesity

BACKGROUND

The efficacy of antiretroviral therapy has made HIV a chronic condition. The prevalence of obesity in HIV positive patients has subsequently risen and is present in 6-34% of men and 21-30% of women (Keithley et al. J Assoc Nurses AIDS Care 20(4):260-74, 2009). Sleeve gastrectomy is a safe and effective procedure for weight loss in the general population, but having HIV may bring hesitation to performing bariatric surgery for some practitioners.

OBJECTIVES

The aim of this study is to evaluate the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) in patients with HIV.

METHODS

A retrospective analysis of prospectively collected data of patients with HIV who underwent LSG at a community hospital by a single surgeon was performed. Nine patients with HIV underwent LSG. Primary outcomes include weight loss at 6 and 12 months and postoperative CD4 count and viral load. Secondary outcomes include alteration to antiretroviral therapy (ART).

RESULTS

Our patients had a mean BMI of 46 (range 35-66) and were all well controlled on ART preoperatively. Mean weight loss at 12 months was 40 kg (range 21-55), with mean excess body weight loss 69% (range 42-112). There were no significant changes in CD4 counts, and all patients continued to have undetectable viral loads at 1 year postoperatively. One patient had a change in ART, which was unrelated to bariatric surgery. There were no complications in our patient group.

CONCLUSION

This is the largest series to date evaluating sleeve gastrectomy in HIV-positive patients and further supports the safety and efficacy of sleeve gastrectomy in this patient population.

Impact of bariatric surgery in patients with HIV infection: a nationwide inpatient sample analysis, 2004-2014

OBJECTIVE

Despite rising rates of obesity among patients with HIV, the potential role for weight loss surgery in this population remains less clear. The primary aim of this study was to evaluate the role of bariatric surgery on relevant clinical outcomes among hospitalized obese patients with HIV.

DESIGN

Retrospective analysis using the United States Nationwide Inpatient Sample database from 2004 to 2014. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior-bariatric surgery compared with those without bariatric surgery.

PATIENTS

Patients with discharge co-diagnoses of morbid obesity and HIV.

INTERVENTION

Bariatric surgery.

MAIN OUTCOME MEASURES

Primary outcome was in-hospital mortality. Secondary outcomes included renal failure, urinary tract infection, malnutrition, sepsis, pneumonia, respiratory failure, thromboembolic events, gastrointestinal strictures, micronutrient deficiency, length of stay, and hospitalization costs.

RESULTS

Among 7803 patients with discharge diagnoses of HIV and morbid obesity, 346 patients (4.4%) had bariatric surgery. The proportion of bariatric surgery in obese patients with HIV initially declined by -0.10% per year from 2004 to 2009 (Ptrend < 0.05), then increased at an annual rate of +0.33% from 2012 to 2014 (Ptrend < 0.05). On multivariable analysis, bariatric surgery did not influence mortality (P = 0.98). Bariatric surgery was associated with decreased risk for renal failure, respiratory failure, and sepsis (all P < 0.001). However, bariatric surgery increased the risk for postoperative strictures (IRR 2.5; 95% CI 1.5-4.5; P = 0.001).

CONCLUSION

Though initially underutilized, bariatric surgery in morbidly obese HIV patients is increasing and appears to be well tolerated and effective in significantly reducing life-threatening morbidity.

Antiretroviral considerations in HIV-infected patients undergoing bariatric surgery

WHAT IS KNOWN AND OBJECTIVE

With the advent of antiretroviral therapy and the resultant decrease in mortality among adults living with human immunodeficiency virus (HIV), there is now an increased incidence of obesity and obesity-related comorbidities in these patients. Bariatric surgery is becoming an increasingly common treatment option for patients who are classified as clinically obese. There are limited data regarding the use of antiretroviral therapy in patients who have undergone bariatric surgery. The purpose of this review was to evaluate the available literature regarding antiretroviral therapy and pharmaceutical properties in this special population.

METHODS

Literature review was performed through PubMed, utilizing search terms of bariatric surgery, sleeve gastrectomy, Roux-en-Y, HIV infection, obesity and antiretroviral. Direct medical information requests to antiretroviral pharmaceutical manufacturers were also completed.

RESULTS

Several case series and case reports have been published which demonstrate minimal risk of complications and maintenance of virologic suppression in the vast majority of patients. Bariatric surgery appears to be an effective mechanism for assistance in controlling obesity in patients infected with HIV; however, numerous factors may impact the safe and effective use of antiretroviral therapy.

WHAT IS NEW AND CONCLUSION

Due to the physiologic changes and postoperative management following bariatric surgery, evaluation of the patients' medication regimens must be considered and several factors should be taken into account when choosing the appropriate antiretroviral regimen for these patients. Furthermore, communication between the patients' surgeon, HIV provider and a clinical pharmacist should occur prior to surgery to ensure the patient is optimized to achieve the best outcome including maintaining virologic suppression.

Bariatric surgery in HIV patients: experience of an Obesity Reference Center in France

BACKGROUND

Few data on bariatric surgery are available regarding obese human immunodeficiency virus (HIV)-infected patients.

SETTINGS

Antoine Beclere hospital, Clamart, Paris-sud University, France METHODS: Prospective observational follow-up study recruited HIV-infected patients who underwent bariatric surgery from 2009 to 2015. Baseline demographic characteristics, surgery characteristics, perioperative outcomes, changes in weight loss, HIV markers, antiretroviral drug plasma levels are described.

RESULTS

There were 10 patients followed before and after sleeve gastrectomy: 2 men and 8 women; 50% of African origin; median age, 48.5 years, median time since HIV infection, 7.5 years; median body mass index, 48.5 kg/m². Of patients, 8 had co-morbidities. All except 2 patients received antiretroviral drugs at the time of surgery with a median CD4 cell count at 709/mm³. There was no death or postoperative infectious complications. The median follow-up was 18 months (range, 15-55). The median postoperative weight loss was 43 kg (range, 17-83). Median percentage of excess weight loss was 82.5% (range, 35-119) at the latest visit after surgery. All co-morbidities were resolutive with weight loss. We observed no significant modification of CD4 cell count before and after surgery. Pharmacokinetics of antiretroviral drugs remains adequate and efficacious.

CONCLUSION

Our prospective series is the largest one on sleeve gastrectomy procedures performed on obese-treated HIV-infected patients. The sleeve generates good results in weight loss, with no significant impact on HIV infection, and with improvement of obesity-associated co-morbidities. Optimal management of HIV-infected patients with morbid obesity may include classical surgical procedures.

Tenofovir pharmacokinetic after sleeve-gastrectomy in four severely obese patients living with HIV

There are many unsolved questions about safety of bariatric surgery in the context of severely obese patients living with human immunodeficiency virus (HIV) and notably on antiretroviral therapy (ART) absorption. Here, we provide the first case series of tenofovir disoproxil fumarate (TDF) pharmacokinetic in four HIV-infected patients before and after sleeve-gastrectomy. Our case-series showed a transient and reversible decrease of TDF bioavailability one month after sleeve-gastrectomy without any consequences on CD4 cells and HIV viral load. More studies are needed since the impact of bariatric surgery on drug absorptions in the field of infectious diseases remains poorly investigated.

Long-term virologic outcomes following bariatric surgery in patients with HIV

The management of morbid obesity and its metabolic complications among HIV-infected patients requires a multi-disciplinary approach, with surgical interventions as one option. We sought to assess the long-term durability of ART among HIV-infected patients undergoing bariatric procedures for the management of morbid obesity. During the study period, 7 patients underwent a bariatric surgery procedure for the management of morbid obesity: 3 patients underwent sleeve gastrectomy, 2 patients underwent laparoscopic banding, and 2 patients underwent Roux-en-Y gastric bypass surgery. Overall, the proportion of undetectable HIV viral load levels did not change after the bariatric procedures, although 2 patients did require temporary cessation of medications due to procedure-related complications. Sleeve gastrectomy and Roux-en-Y gastric bypass were safe and effective among morbidly obese HIV-infected patients in our clinic population.

Thirty-day postoperative mortality among individuals with HIV infection receiving antiretroviral therapy and procedure-matched, uninfected comparators

IMPORTANCE

Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized.

OBJECTIVE

To compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, October 1, 1996, to September 30, 2010. Common inpatient surgical procedures were grouped using the Healthcare Cost and Utilization Project Clinical Classification System to match HIV-infected and uninfected patients in a 1:2 ratio. Data on 1641 patients with HIV infection receiving combination ART who were undergoing inpatient surgery were compared with data on 3282 procedure-matched, uninfected comparators. Poisson regression models of 30-day postoperative mortality were adjusted for procedure year, age, Charlson Comorbidity Index score, hemoglobin level, albumin level, HIV infection, CD4 cell count, and HIV-1 RNA level.

MAIN OUTCOMES AND MEASURES

All-cause 30-day postoperative mortality.

RESULTS

The most common procedures in both groups were cholecystectomy (10.5%), hip arthroplasty (10.5%), spine surgery (9.8%), herniorrhaphy (7.4%), and coronary artery bypass grafting (7.0%). In patients with HIV infection, CD4 cell distributions were 80.0% with 200/μL or more, 16.3% with 50/μL to 199/μL, and 3.7% with less than 50/μL; 74.1% of patients with HIV infection had undetectable HIV-1 RNA. Human immunodeficiency virus infection was associated with higher 30-day postoperative mortality compared with the mortality in uninfected patients (3.4% [56 patients]) vs 1.6% [53]); incidence rate ratio [IRR], 2.11; 95% CI, 1.41-3.17; P < .001). CD4 cell count was inversely associated with mortality, but HIV-1 RNA provided no additional information. After adjustment, patients with HIV infection had increased mortality compared with uninfected patients at all CD4 cell count strata (≥500/μL: IRR, 1.92; 95% CI, 1.02-3.60; P = .04; 200-499/μL: IRR, 1.89; 95% CI, 1.20-2.98; P = .01; 50-199/μL: IRR, 2.66; 95% CI, 1.29-5.47; P = .01; and <50/μL: IRR, 6.21; 95% CI, 3.55-10.85; P < .001). Hypoalbuminemia (IRR, 4.35; 95% CI, 2.78-6.81; P < .001) and age in decades (IRR, 1.47; 95% CI, 1.23-1.76; P < .001) were also strongly associated with mortality.

CONCLUSIONS AND RELEVANCE

Current postoperative mortality rates among individuals with HIV infection who are receiving ART are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making.

Bariatric surgery: An HIV-positive patient's successful journey

Bariatric surgery is becoming increasingly common in the UK. Little has been done to evaluate its place in HIV-positive patients. Here, we discuss a successful case and the complexities surrounding highly active antiretroviral therapy.

Obesity in HIV-infected patients in France: prevalence and surgical treatment options

Increasing rate of obesity was reported in HIV-infected patients in USA. In France, no data are available to date. Bariatric surgery is the best option for morbid obesity in general population but few data exist in HIV-infected patients. We describe the prevalence of obesity in France in HIV-infected patients. The prevalence of obesity is 15.1% in women and 5.3% in men. Moreover, we described our experience and point of view in the management of HIV infected patients with morbid obesity. Prospective studies are needed for an optimal management of HIV-infected patients with morbid obesity.

Sleeve gastrectomy is a safe and efficient procedure in HIV patients with morbid obesity: a case series with results in weight loss, comorbidity evolution, CD4 count, and viral load

BACKGROUND

The efficacy and safety of bariatric surgery have been poorly studied in patients affected with HIV. Although sleeve gastrectomy (SG) is the most widely used procedure in many countries, most of the published literature reported results with the gastric bypass (GBP) procedure on morbidly obese HIV patients.

METHODS

We have evaluated retrospectively, in eight consecutive patients who underwent a SG, its effect in weight loss and its impact on the treatment and on the markers of HIV infection.

RESULTS

Seven out of eight patients were females. The mean age was 46 years, with a median preoperative BMI of 42 kg/m(2). The mean duration of HIV infection and CD4 cell count were 13.4 years and 457 cells/mm(3), respectively. The mean weight loss was 37 kg in 20 months, the excess BMI loss was 80.8 ± 30.9 %, and the excess weight loss is 81.5 ± 28.9 % with one minor complication. CD4 counts were unchanged. Three patients had therapy modifications that were unrelated to bariatric surgery. Two patients had a therapeutic drug monitoring before and after the intervention. Plasma concentrations remained in therapeutic levels after the SG. Most comorbidities disappeared postoperatively, decreasing the cardiovascular risk.

CONCLUSIONS

The sleeve gastrectomy was safe and effective with no consequences on CD4 counts and viral load in HIV-affected obese patients. It should be considered as a part of the treatment in morbidly obese HIV patients.

Tenofovir, emtricitabine, and darunavir/ritonavir pharmacokinetics in an HIV-infected patient after Roux-en-Y gastric bypass surgery

OBJECTIVE

To determine antiretroviral (ARV) pharmacokinetics in a patient who previously underwent Roux-en-Y gastric bypass (RYGB) surgery.

CASE SUMMARY

We describe a 38-year-old Hispanic man who tested positive for human immunodeficiency virus (HIV) 11 months following RYGB surgery. When the patient presented for care of his HIV, his HIV-1 RNA was 146 138 copies/mL (5.20 log) and his CD4 T cell count was 320 cells/mm(3) (25%). He was initiated on tenofovir disoproxil fumarate (TDF) 300 mg once daily, emtricitabine (FTC) 200 mg once daily, and darunavir/ritonavir (DRV/r) 600/100 mg twice daily. ARV concentrations were similar to historical data. Six months following ARV initiation, HIV-1 RNA was <48 copies/mL and CD4 count had increased to 562 cells/mm(3) (39%).

DISCUSSION

Bariatric surgery has been successfully performed in obese persons infected with the HIV, but data are limited on ARV drug selection and pharmacokinetics in this group. Optimal suppression of HIV replication requires appropriate concentrations of ARV drugs, and in a patient who has undergone RYGB, this can be challenging not only because of a decreased absorptive surface area but also because of an increased intragastric pH.

CONCLUSION

We found that once daily TDF/FTC and twice daily DRV/r produced trough concentrations similar to historic data in a patient who previously underwent RYGB with virologic suppression and immunologic recovery.