Weight change after HIV treatment carries layered meanings of health, stigma and identity, review finds

For people living with HIV, a shift on the bathroom scale is rarely just a number. A qualitative systematic review and meta-synthesis published on 27 October 2026 in Frontiers in Public Health has brought together the scattered qualitative literature on how people receiving antiretroviral therapy (ART) experience and interpret changes in their weight, and it paints a picture in which body size functions simultaneously as a medical signal, a social marker and a deeply personal measure of wellbeing. The review, conducted by researchers at Henan University of Chinese Medicine and its affiliated hospital, synthesized seven qualitative studies into three overarching findings and concluded that weight change in the treatment era carries intertwined medical, psychological and sociocultural meanings that clinicians cannot afford to overlook.

The scale of the underlying issue is considerable. In 2025, an estimated 40.9 million people were living with HIV worldwide, of whom approximately 32.1 million were receiving ART. As survival has improved and HIV has become a manageable chronic condition requiring lifelong care, the clinical meaning of weight has shifted: before effective therapy was widely available, weight loss and wasting often signaled disease progression, whereas today weight recovery after treatment initiation, excessive gain and obesity have become increasingly important concerns. Approximately 13 percent of people initiating ART gain more than 10 percent of their baseline body weight within the first year, and excessive post-treatment weight gain has been associated with diabetes, metabolic syndrome and cardiometabolic events. Weight and appearance changes have also been associated with depression, anxiety, social withdrawal and other forms of psychological distress.

To synthesize the experiential evidence, the team searched eleven databases, including PubMed, Embase, Web of Science, Scopus, CINAHL, ProQuest, PsycINFO and several Chinese-language databases, from inception through June 2026. After screening 2,300 records plus two identified through reference lists, and removing 1,156 duplicates, the reviewers assessed 67 full-text reports and included seven studies. Methodological quality was appraised with the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research; one study was rated grade A and the remaining six grade B, and only studies meeting grade A or B criteria entered the synthesis. Findings were aggregated using the JBI meta-aggregation approach, and confidence in each synthesized finding was evaluated with the CERQual framework. The review was registered prospectively in PROSPERO under registration number CRD420261425511.

The included evidence was geographically concentrated: five studies were conducted in sub-Saharan Africa and two in the United States, with none from Asia, Europe or Latin America. Several studies also recruited selected clinical subgroups, including women receiving dolutegravir-based regimens, participants with obesity, and participants with obesity and/or type 2 diabetes, which may have increased the representation of people with pre-existing or clinically salient weight concerns. From the seven studies, the reviewers extracted 57 unequivocal findings, grouped them into 12 categories, and synthesized three overarching findings. Confidence was rated high for the first finding, the multiple meanings of weight change, and moderate for the other two, the attributions and impacts of weight change and the barriers to and support for weight management, mainly because of methodological limitations in the contributing studies and uneven, less extensive data across components.

The first synthesized finding shows how heavily symbolic body size remains in the context of HIV. Participants often interpreted weight loss as a sign of untreated or worsening HIV, a poor treatment response, or comorbid disease such as tuberculosis, and previous experiences of illness-related wasting intensified these fears. In several sociocultural settings, thinness was perceived as a visible marker of HIV infection, raising concerns about unintended disclosure, gossip, derogatory labeling and social exclusion; as one participant in a South African study put it, “When you are thin, you are not on treatment,” while another, from a Kenyan study, observed, “Always when you are growing slim… person thinks of HIV.” Conversely, weight gain was frequently assigned positive meanings, linked to good health, recovery, successful treatment, attractiveness, strength and socioeconomic wellbeing. “You see as I am fat, I can feel that all is well with me,” one participant said.

Importantly, participants generally did not express an unconditional preference for larger body size. Many preferred a moderate or slightly above-average weight that avoided illness-associated thinness while preserving mobility, a preference one participant described as liking the “medium size” rather than being too thin or too heavy. Some participants who had experienced severe wasting viewed additional body weight as a nutritional reserve against future illness. The review’s authors stress that the umbrella term “weight change” encompassed clinically distinct phenomena, including illness-associated or unintentional weight loss, weight restoration after ART initiation that may reflect a return-to-health process, persistent or unwanted gain, obesity or body-size concerns, and attempts to manage weight, and that these should not be interpreted as clinically equivalent even though their experiential meanings overlapped.

The second synthesized finding concerned how participants explained weight change and what they believed it did to them. Participants offered multiple causal accounts: some attributed weight gain to ART, increased appetite or medication-related effects, while others linked fluctuations to gastrointestinal symptoms, depression, emotional wellbeing, dietary intake or overeating. The review is explicit that these are participants’ own perceptions and attributions and do not establish that ART, any individual antiretroviral agent or a specific regimen caused the reported changes. Participants perceived higher body weight as raising the risks of cardiovascular disease, diabetes, hypertension, high cholesterol, reduced mobility and functional limitation, though the threshold at which weight became concerning varied. Both weight loss and unwanted substantial gain were associated with psychological distress, body dissatisfaction, diminished self-worth and altered social participation, and some participants described cycles of depression, emotional eating, further weight gain and worsening body image. Perceived medication-related weight change could also influence confidence in treatment and intentions regarding ART, including considering discontinuation or interruption, while stigma attached to visible weight loss could contribute to missed doses.

The third synthesized finding mapped the practical landscape of weight management. Participants frequently framed weight management as a personal responsibility involving diet, self-discipline and physical activity, and successful weight loss strengthened self-efficacy, whereas inability to achieve a desired weight caused frustration; the normalization of obesity within families or communities could also feed fatalistic beliefs about weight-related risk. People used walking, exercise, dietary changes and other lifestyle modifications, and group-based activity could be more acceptable than exercising alone, as one participant indicated by saying, “I cannot [workout] by myself.” Acceptance of pharmacological weight-management options was conditional on side effects and treatment burden, with additional tablets, repeated clinic visits and weekly injections reducing acceptability. Financial pressures, household responsibilities, the high cost of healthier foods, family food norms and ridicule of dietary restraint were important barriers, and long working hours, limited time for meal preparation and the convenience of fast food further constrained sustained dietary change. Participants also expressed a preference for integrated HIV and noncommunicable-disease services that would reduce the burden of multiple visits, with one participant noting that services “need to be under the same roof—HIV, blood pressure and diabetes.”

The review’s authors are careful about the boundaries of what their synthesis can show. Because it captures participants’ perceptions, beliefs and causal attributions, it cannot establish that ART or any specific regimen caused the reported weight changes, and the qualitative findings alone do not define clinical thresholds for intervention. Specific recommendations for serial monitoring of weight, BMI, waist circumference, metabolic indicators and cardiovascular risk are drawn from external clinical guidelines rather than from the seven qualitative studies. The evidence base is also limited by small, purposively selected samples, incomplete reporting of ART regimens, treatment duration and baseline weight status, and restriction to Chinese- and English-language publications, which may have introduced language and publication bias. Reflexivity was incompletely reported in several included studies, and the synthesis is intended to identify transferable patterns of experience rather than to estimate prevalence or support statistical generalization.

Nevertheless, the authors argue, the findings carry a clear message for HIV care: interpretations of weight change are shaped by prior illness experiences, beliefs about antiretroviral therapy and prevailing sociocultural norms, and may in turn affect psychosocial wellbeing, physical health and treatment-related behaviors. They suggest that clinical encounters should explicitly elicit patients’ explanations of weight change, body image concerns, emotional responses and intentions to modify or discontinue treatment, and that follow-up conversations should explore what weight change means to the individual, which body size they consider acceptable, and whether changes in appearance raise concerns about unintended disclosure. Because difficulty with weight management was shaped by family routines, finances, work demands, cultural expectations and access to professional support, the authors caution against reducing it to limited motivation or self-discipline. They conclude that HIV care should integrate routine monitoring of weight and metabolic risk with sustained, individualized support, adapted to patients’ practical circumstances and preferences, while specific monitoring and treatment decisions should be guided by external clinical evidence, relevant guidelines and individualized risk assessment.

Subject of Research: Experiences and perceptions of weight change among people living with HIV receiving antiretroviral therapy

Article Title: Experiences and perceptions of weight change among people living with HIV receiving antiretroviral therapy: a qualitative systematic review and meta-synthesis

Article References: Zhang, S., Gao, J., Liu, Y., & Jiang, X. (2026). Experiences and perceptions of weight change among people living with HIV receiving antiretroviral therapy: a qualitative systematic review and meta-synthesis. Frontiers in Public Health, 14, Article 1947513. https://doi.org/10.3389/fpubh.2026.1947513

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1947513

Keywords: HIV, antiretroviral therapy, weight change, qualitative systematic review, meta-synthesis, body image, HIV stigma, weight management, adherence, metabolic risk, CERQual, integrated care