In rural KwaZulu-Natal, South Africa, where Human Immunodeficiency Virus (HIV) prevalence remains among the highest in the world, a new qualitative study has shed light on a growing concern for people living with HIV: excessive weight gain following antiretroviral therapy (ART). This phenomenon, often linked to modern ART regimens like tenofovir disoproxil fumarate, lamivudine, and dolutegravir (TLD), poses significant health risks including diabetes, hypertension, and cardiovascular disease. Researchers from local institutions have captured the voices of patients and healthcare workers, revealing nuanced perspectives and practical strategies to mitigate this issue.

The study highlights how initial weight gain is often celebrated as a sign of restored health after years of illness, but as it escalates, it triggers worry about long-term complications. Participants shared stories of transitioning from underweight frailty to overweight challenges, emphasizing the need for tailored interventions in resource-limited rural settings.

🌿 The Dual Burden of HIV and Obesity in Rural KZN

KwaZulu-Natal (KZN) province bears a disproportionate HIV burden, with adult prevalence exceeding 25 percent in some rural districts, far above the national average of 13.9 percent. Over eight million South Africans receive ART, and the shift to dolutegravir-based TLD since 2019 has improved viral suppression but introduced weight gain as a side effect. Women, particularly black women, experience more pronounced increases, averaging 5-10 kilograms within two years of starting treatment.

In rural areas, where clinics serve scattered homesteads amid subsistence farming, obesity rates among women surpass 60 percent. Food insecurity coexists with high-carbohydrate diets reliant on maize meal (pap) and sugary drinks, exacerbating the problem. Physical inactivity is common due to limited infrastructure—no gyms, poor roads for walking—and cultural norms favoring fuller figures as symbols of prosperity.

The study underscores this intersection: HIV recovery boosts appetite and metabolism shifts, but without guidance, it leads to unhealthy gains. Local health data from uMkhanyakude district, a focal rural area, show 40 percent of ART patients becoming overweight within a year.

Study Design: Voices from the Ground

Conducted by a team affiliated with the Africa Health Research Institute (AHRI) and the University of KwaZulu-Natal (UKZN), the research employed in-depth interviews with 30 adults living with HIV (aged 25-60, mostly women) and 15 healthcare workers from primary clinics in rural uMkhanyakude. Thematic analysis identified key patterns in perceptions and coping mechanisms.

Participants were on TLD for at least six months, selected purposively for diverse body mass index (BMI) levels—from normal to obese. Interviews explored views on weight changes post-ART initiation, causes, impacts, and prevention ideas. Ethical approval came from UKZN's Biomedical Research Ethics Committee, ensuring cultural sensitivity in isiZulu discussions.

This approach captured real-life narratives, revealing gaps in routine counseling where weight monitoring is secondary to viral load checks.

Patient Perspectives: Celebration Turns to Concern

Many recounted joy at initial gains: 'When I started treatment, I was skin and bones; now people say I look healthy.' Weight symbolized adherence success and stigma reversal in communities associating thinness with AIDS.

However, excessive gain brought distress: mobility issues, joint pain, breathlessness, and fears of 'sugar diabetes' or heart problems. Women noted clothes no longer fitting, social teasing, and spousal comments. One participant said, 'It's good to be fat at first, but now my knees hurt from walking to the fields.'

Attributions included ART drugs ('this new pill makes you big'), improved appetite, and sedentariness from illness recovery. Few linked it to diet initially, viewing overeating as natural post-malnutrition.

Healthcare Workers' Insights: Frontline Challenges

Nurses and counselors observed rapid BMI rises, especially in women over 35. They attributed it to DTG's metabolic effects, combined with rural diets high in refined carbs and low in protein/vegetables.

Challenges: time constraints in busy clinics (50+ patients/day), lack of scales/nutritionists, patients' resistance ('doctor, weight gain means I'm cured'). Positive views: some proactively advise balanced meals, but resources scarce—no group sessions or referrals.

One nurse noted, 'We tell them to eat morogo (wild greens) and walk, but without follow-up, they forget.'

Practical Strategies Emerging from the Study

Participants proposed actionable steps:

• Dietary shifts: Reduce pap portions, add amaranth greens, beans, and fruits; avoid cold drinks.
• Physical activity: Daily walks to clinics/fetching water, home gardening for movement.
• Clinic support: Routine weigh-ins, nutrition talks during ART clubs, peer groups sharing recipes.
• Monitoring: Self-check waist size, family encouragement.

Healthcare workers advocated integrating dietitians via mobile units and community health workers (CHWs) for home visits. Simple tools like BMI charts and portion models were suggested.

Barriers in Rural Contexts: Poverty and Culture

Rural KZN's realities hinder change: poverty limits vegetable access (R10/kg spinach vs. cheap maize), unemployment reduces motivation, gender roles confine women indoors.

Cultural ideals glorify 'umuntu omkhulu' (big person) as wealthy/fertile. Stigma persists—thinness signals non-adherence. Gender dynamics: men control food purchases, prioritizing starch.

Transport gaps prevent gym access; rainy seasons confine activity. Study calls for context-specific education challenging myths.

University Contributions to HIV Research

UKZN's Discipline of Public Health Medicine and AHRI lead such studies, training postgrads in qualitative methods for community health. Collaborations with global partners fund interventions.

Similar UKZN work on HIV multimorbidity informs policy. AcademicJobs South Africa lists research positions at UKZN for HIV/nutrition experts.

These efforts position South African universities as hubs for low-resource solutions. For details, explore the study abstract.

National Implications and Policy Shifts

South Africa's National Strategic Plan for HIV emphasizes NCD integration. Weight gain affects 30-50 percent of PLHIV on TLD, straining clinics with rising diabetes (prevalence doubled since 2010).

Department of Health pilots nutrition in ART initiation. Study supports scaling counseling, aligning with WHO guidelines on ART metabolic monitoring. Cost-effective: CHW-led groups at R5/person/month.

Future Outlook: Integrated Care Models

Prospects include app-based tracking (pilot at UKZN), fortified foods, farm-to-clinic veggie programs. Trials test metformin adjuncts safely.

Long-term: research on genetic factors in African DTG response. Universities like UKZN drive randomized trials, informing global guidelines.

Optimism prevails: empowered patients reduce risks, enhancing ART success.

Photo by JIBIN SAMUEL on Unsplash

Actionable Advice for Stakeholders

For patients: Track weight monthly, swap soda for water, walk 30 minutes daily, join support groups.

For providers: Use WHO BMI tools, refer nutritionists, partner CHWs.

For policymakers: Fund rural weigh-ins, train staff, subsidize veggies.

For more on HIV research careers in South Africa, check university job listings. Sustainable change demands community buy-in, blending science with culture.