What HIV taught us about dealing with obesity
- Ñî¹óåú´«Ã½ University
Veteran HIV clinician-scientist Professor Francois Venter takes on the obesity epidemic.
As a young doctor amid the unrelenting chaos that characterised the height of the HIV epidemic in South Africa in the late 1990s, Professor recalls writing between 10 and 20 death certificates a day at the then Johannesburg General Hospital.
A senior, curmudgeonly doctor inspired much of what underpins Venter’s work and human sensibilities. He recalls sitting in front of this doctor, who paged nonchalantly through a You magazine while consulting with his younger staff during ward rounds.
But the older doctor’s seeming insouciance was, in fact, far from it. The senior doctor knew in minute detail everything about each patient, and his assertion was that HIV patients must be given equal clinical rigour and dignity (fear, stigma and denial were particularly devastating and inherent across the system, including government).
Sustaining standards of care
Venter still shudders when he thinks about the early days of HIV. “There was no plan. The bureaucracy was crazy, unwieldy … And the worst were the senior officials who didn’t seem to care.”
He remembers that when critically ill patients lay on the floors because wards had exceeded their capacity, he urgently asked provincial administrators to redirect ambulances to other nearby facilities. The dying patients from other provinces, he was instructed, must be sent back to those provinces instead.
“But this insistence on maintaining standards of care I learnt as a young doctor (by the curmudgeon), no matter what the patient was afflicted with or where they were from, was formative, despite the overwhelming conditions,” says Venter.
Ezintsha Innovation
Venter is now the Director of the Ñî¹óåú´«Ã½ Research Centre, which has completed 34 research projects since 2018, including technically difficult yet necessary clinical trials.
In academic parlance, Venter is a clinician-researcher who believes that being a medical doctor isn’t enough and that research contributions are imperative in improving people's health and lives.
Venter learnt the ropes of clinical trials as a junior doctor, working on various pharmaceutical company trials as a minor cog in the wheel. Years later, he was approached to do what he calls an “unpopular” trial, which involved trying to bring down the cost of a toxic antiretroviral medication.
“There weren’t many people who had the expertise and were willing to take the risk on. We designed the study, set up the infrastructure and published journal articles a few years later. It was an amazing experience, because it was such a difficult endeavour and taught us so much.”
But it was the ADVANCE trial that Venter and his team are perhaps most famous for.
This helped drive the shift to safer, dolutegravir-based HIV treatment, now the basis for treatment for most people with HIV in the world. The study showed that newer regimens could suppress the virus as effectively as older ones, but with far less toxicity.
The HIV and obesity epidemics
ADVANCE revealed something else, however: patients, particularly women, were gaining weight. “At the time, we thought it was a side effect of the drugs. But overweight and obesity are part of a much bigger picture, and we know it is a complex interplay between the virus and modern food, as well as maybe the drugs. As HIV care has improved, a new set of health challenges has emerged, and so we need to link the chronic treatment of HIV to the treatment of obesity.”
Ezintsha now works at the intersection of HIV and non-communicable diseases like diabetes, hypertension and obesity.
About two-thirds of women and almost a third of men in South Africa are overweight or obese. Excess weight is linked to long-lasting health problems, including type 2 diabetes, high blood pressure, certain cancers, liver and kidney disease, mental illness and sleep disorders.
What links the HIV and obesity epidemics, in Venter’s mind, is not just the scale but also the misunderstanding. Both diseases are complex and were initially framed too narrowly, delaying the kinds of responses needed to manage them effectively.
“A nuanced and rapidly growing health challenge is being reduced to individual behaviour. Worryingly, many health workers still misunderstand obesity and will simply tell patients to eat less and exercise more, when the research shows that while those are really important habits, there is a lot more that makes a person overweight and obese, and these factors have little to do with their behaviours.”
The 'ARVs' for obesity
Obesity research is evolving more quickly than policy and care models. Just as with HIV, it took time and evidence to see how structural factors shape risk. Poverty, education, geography and access to care all determine health.
There are new drugs, “the ARVs of metabolic health,” that Venter deems miraculous, set to provide the missing piece in obesity management. Semaglutide, in particular (better known by the brand names Ozempic and Mounjaro), targets GLP-1 receptors, which reduce hunger and improve metabolic control. But the drugs are eye-wateringly expensive. A one-month supply costs between R2800 and R6000.
Once again, the people who cannot access obesity drugs are disproportionately black, poor and “under-engaged in health systems.” Venter notes that the medications are not just good for obesity, but for liver, gut, cardiovascular health, pain, addiction and maybe even immunity.
Many people are concerned about the long-term side effects of semaglutides, but Venter says that over 20 years of research suggests that they are very safe.
“We need to build a system that can deliver GLP-1 care to 27% of the population,” says Venter. And it seems possible: one of his colleagues, Dr Andrew Hill, has shown that injectable semaglutide could be produced for as little as $3 a month.
“We know what needs to happen now, and we know what happens if we don’t respond in time. History shows us that. Can we apply the lessons we learnt in the HIV crisis and apply it to our emerging health challenges?”