These were the findings in the paper titled “Weight gain in people living with HIV” published as part of The Lancet HIV Series on 8 November.
This Series highlights how HIV and weight stigma can intersect, and how community-led, integrated services can help address both.
By adapting HIV’s activist-built tool, i.e., community leadership, stigma measurement, legal protection and integrated treatment access, weight-stigma reduction can move beyond blame and toward care that treats obesity as a health issue, not a moral failing.
“Obesity and HIV are shaped by stigma that extends beyond public prejudice. In HIV, moral judgements about sex, loss of autonomy, and enduring associations with death based on widespread images of HIV as a wasting disease, have delayed care-seeking and sustained discrimination,” says Dr Simiso Sokhela of Ezintsha at Wits University, South Africa, and a Series author.
“Effective treatment has reduced some enacted stigma, but anticipated and internalised stigma often persist, even among people with an undetectable viral load.”
Weight stigma shares important features with HIV stigma: Body size is immediately visible, allowing judgement before any clinical or workplace interaction. It is also commonly framed as a failure of personal willpower, despite the roles of genetics, metabolic differences, medications, food environments, and structural poverty.
These attitudes have consequences. Evidence shows that weight stigma is associated with poorer mental health, avoidance or delay of care, and discrimination. Whether weight stigma affects adherence to antiretroviral therapy remains poorly understood and requires research.
A collision of epidemics
There is an increasingly complex overlap between HIV and obesity. HIV was associated with wasting and visible thinness, embedding weight loss itself in stigma. In some settings, cultural ideals that valued larger bodies as signs of health, prosperity, or beauty were reinforced when a larger body appeared to signal presumed HIV-negative status.
Modern antiretroviral regimens have changed this landscape. Newer integrase inhibitor-based therapies, particularly when combined with tenofovir alafenamide, are consistently associated with greater weight gain than older regimens.
The largest increases have been observed among black people, especially women, likely reflecting a combination of biological factors and possible unmeasured socioeconomic or structural confounders, rather than race itself. This weight gain is associated with rising burdens of hypertension, diabetes, and other cardiometabolic conditions.
“For people living with HIV who also carry higher body weight, these are not two stigmas experienced side by side. They are a single, intersecting experience, shaped by HIV-related prejudice, weight bias, and wider inequities,” says Professor Francois Venter, Wits Ezintsha Executive Director and lead author of the Series.
“Research on women living with HIV similarly finds that stigma related to body size intersects with HIV status, gender, race, age, and other forms of discrimination.”
For communities once marked by visible wasting, the result can be a disorienting new stigma: criticism for gaining weight after surviving a disease once defined by losing it.
Different systems, intersecting lives
Clinical infrastructure also reveals divergence. In many countries, HIV care has evolved from standalone clinics toward integration into primary care through differentiated service delivery, nurse-initiated management, and multi-month dispensing, although some high-income countries retain limited dedicated sites. Conversely, obesity has no established clinical home: care is fragmented across primary care, endocrinology, gastroenterology, bariatric surgery, nutrition services, and other specialties.
Lessons for policy and care
Concerns about repeating an early mistake of the HIV response have arisen; that of withholding effective treatment while waiting for prevention to catch up. Arguments that pit obesity prevention against drug treatment threaten to revive that error, which costs lives.
“Progress depends less on new science than on redistribution of power and access,” says Sokhela, who urges communities to lead their own advocacy.
Other urgent steps, she says, include clinician awareness of stigmatising language and clinical management biases, weight integration into clinics that already serve people with HIV, and affordability of effective medicines where the need is greatest.
