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Abstract

Background:

As children living with HIV (CWH) achieve longer life expectancy, they face an emerging ‘double burden’ of infectious and non-communicable diseases, specifically pediatric overweight and obesity (OW/OB). This risk is exacerbated by weight-inducing Integrase Strand Transfer Inhibitors (INSTIs). We systematically reviewed family-based pediatric weight management interventions for CWH aged 6 to 12 globally.

Methods:

Following PRISMA guidelines (PROSPERO: CRD42024554376), we searched Medline, Embase, and Cochrane (2007-2024) for clinic-linked behavioral interventions reporting body composition or behavioral outcomes.

Results:

From 1026 records and 7 full-text reviews, no studies met the inclusion criteria. Excluded studies lacked clinical integration or targeted adult populations.

Conclusion:

This ‘null’ finding represents a critical evidence gap and clinic concern: CWH receive weight-inducing medications without evidence-based behavioral support. Future research must prioritize integrating care models using implementation science frameworks (RE-AIM/CFIR) to bridge the gap between primary HIV care and obesity management in resource-constrained settings.

Keywords

HIV pediatrics weight management obesity global health systematic review

Background

Pediatric overweight and obesity (OW/OB) is a pandemic¹; over the past 3 decades, its prevalence has quadrupled, with 80% of the burden affecting lower- and middle-income-countries (LMICs).² In these regions, HIV remains a concurrent public health priority. As antiretroviral therapy (ART) allows children living with HIV (CWH) to survive into adolescence and beyond they face an emerging dual risk of infectious disease and non-communicable comorbidities, with obesity and malnutrition often co-existing within the same communities. While the World Health Organization (WHO) and emerging research has redefined HIV as chronic disease, the co-occurrence of obesity and HIV are leading causes of early mortality among individuals under 18 years old in regions like South Africa.^3-5

There is a critical need to develop interventions aimed at reducing premature mortality from cardiometabolic diseases in children living with HIV (CWH), particularly the 12 million CWH in sub-Saharan Africa. This need is significantly amplified by the global transition to Integrase Strand Transfer Inhibitor (INSTI)-based regimens, such as Dolutegravir, which is now the preferred first-line ART regimen in nearly all LMICs due to its high genetic barrier to resistance and superior efficacy, which have been independently linked to accelerated weight gain in pediatric cohorts.^6-8 This creates a clinical vacuum: while millions of children are being transitioned to life-sustaining, weight-inducing medications as a matter of global policy, there is an absence of evidence-based behavioral interventions tailored to mitigate these cardiometabolic side effects.

Evidence from adult populations demonstrates that integrated approaches addressing HIV alongside non-communicable diseases (NCDs) can be effective and feasible in managing mental health, hypertension, and diabetes.^9-16 However, a significant research gap remains for pediatric populations, where integrative approaches for HIV and obesity have not yet been explored. Landmark reports and the most recent 2023 clinical practice guidelines¹⁷ highlights that children aged 6 years and older benefit from family-based, multi-component behavioral interventions, especially when informed by theoretical frameworks (eg, Social Cognitive Theory, Chronic Care Model for Childhood Obesity).^17-25 While these guidelines emphasize primary care clinics as the principal site for obesity-related assessment and diagnosis, no guidelines specifically address obesity management for CWH.²⁶ Consequently, while family-based interventions are effective in the general pediatric public, their application for CWH, particularly in LMICs, is unexplored.^17,20-25

Primary care clinics are the essential hub where CWH receive their primary and HIV-specific care (eg, HIV antiretroviral therapy, HIV viral load testing), especially in LMICs.^17,27-29 Implementation science (IS) is an emerging field for optimizing care within sub-Saharan Africa.⁹ IS models such as the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework³⁰ are increasingly used to guide and evaluate interventions to improve the adoption, delivery, and sustainment of evidence-based interventions such as integrated HIV and non-communicable disease evidence-based practices.^31-33 However, no specific recommendations for managing OW/OB in CWH have been made despite an increased focus on managing comorbidities,¹⁷ highlighting an urgent need for targeted, theory-driven interventions.

Methods

Adhering to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines,^34,35 this systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on June 15, 2024 (CRD42024554376). We collaborated with a medical research librarian, who is experienced in systematic literature review, to design a comprehensive search of relevant studies from January 2007 to June 2024 (see Appendix 1).^36,37 For this systematic review, we used Ovid Medline, Embase, and Cochrane Library which are key databases for searching health-related literature, building on the framework established by prior research.³⁸ Searches were completed on June 17, 2024, and the results were uploaded to Covidence for screening. Additionally, we also reviewed the reference lists of the included studies for any other studies that were not identified in the database search for further eligibility assessment.

The inclusion and exclusion criteria were carefully defined a priori, based on the established PICOTS framework (population, intervention, comparison, outcome, timing, and setting),³⁹ and further informed by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework (see Supplement 1).^30,40 These criteria were strategically crafted to ensure the selection of the most relevant studies. The eligibility criteria were determined by the following: (1) interventions were conducted in and/or connected to a primary care setting, (2) family-based approaches, (3) participant outcomes focused on changes in body composition (eg, BMI percentile) and/or behavioral changes in both children and parents (eg, FNPA score) (4) case reports, study protocols, commentaries, editorials, and non-peer-reviewed articles were excluded, and (5) studies must be published in English.

Search results were managed using Covidence software. Two team members independently reviewed each abstract against the established eligibility criteria. Those appropriate for consideration by at least 1 reviewer were selected for full-text screening. Each full-text article was then independently reviewed for eligibility by at least 2 team members, with any disagreements resolved after team discussion and through consensus. To ensure the reliability of the selection process, Kappa statistics were calculated to measure the level of inter-rater reliability or agreement for article inclusion. For studies that met the inclusion criteria, a single investigator meticulously extracted data on PICOTS and RE-AIM characteristics (see Supplement 2) into an Excel spreadsheet, with a second team member conducting a thorough dual review to ensure accuracy and consistency.

Ethical Approval and Informed Consent

Ethics approval was not required for this systematic review.

Results

A total of 1026 studies were imported for screening, and 265 were identified as duplicates by Covidence. Of the 761 titles and abstracts screened, 752 were removed, primarily due to irrelevant study outcomes. Of the 7 full-text studies assessed for eligibility, no articles met the inclusion criteria (see Figure 1). During the first round of review, the inter-rater reliability was 0.98, reflecting a high level of agreement among reviewers. In the second round, the inter-rater reliability increased to 1, indicating perfect agreement. Among the articles reviewed, 1 article⁴¹ highlighted the role of pediatricians advocating for childhood OW/OB. Another study focused on OW/OB in pregnant women.⁴² A third study examined children ages 0 to 5 with OW/OB but did not discuss HIV.⁴³ Additionally, 4 out of the 7 studies (57%) were excluded given their lack of connection to healthcare facilities and instead described the CIrCLE of Life Initiative, a school-based educational intervention aimed at addressing childhood OW/OB and HIV in sixth-grade children.^44-47

Figure 1.

PRISMA 2020 flow diagram for new systematic reviews.

Discussion

The obesity pandemic continues to grow disproportionally, affecting individuals in LMICs who now face the double burden of infection and non-communicable comorbidities. A significant portion of this population consists of CWH, who are now living longer and increasingly affected by OW/OB. Our systematic review identifies a stark and concerning reality: despite the urgent clinical need, there is currently an absence of evidence-based, family-based behavioral interventions tailored specifically for CWH aged 6 to 12.

The absence of eligible interventions in our review is particularly alarming given the global transition to Integrase Strand Transfer Inhibitor (INSTI)-based regimens. Recent cohort data have confirmed that transitioning to Dolutegravir is independently associated with accelerated weight gain and increased BMI z-scores in pediatric populations.^6-8 This ‘INSTI Paradox’—where life-sustaining treatment contributes to long-term cardiometabolic risk—creates a clinical vacuum. Specifically, clinicians are effectively prescribing weight-inducing medications without offering evidence-based and tailored behavioral/lifestyle interventions to mitigate those side effects. Without data-informed strategies, CWH face increasingly preventable health risks, including early-onset hypertension and diabetes.

Barriers and Contextual Realities

Several factors likely contribute to this research gap. First, structural and funding barriers in LMICs prioritize acute HIV management, leaving limited resources for co-morbid interventions. Second, the complex needs and competing priorities of HIV antiretroviral therapy (ART) and obesity management may deter researchers from implementing family-based obesity interventions.

Third, existing care models, such as the Chronic Care Model and implementation science frameworks like the Consolidated Framework for Implementation Research (CFIR) and RE-AIM, have largely been applied in high-income countries, limiting their direct translation to resource-constrained settings.⁹ Contextual and cultural differences necessitate interventions that are locally adapted, yet such tailoring requires significant investment in formative research and community engagement.

Lessons from the Field: Clinic Versus Community

It is essential to consider the context of healthcare interventions across diverse global settings. Models such as the Obesity Chronic Care Model⁴⁸ emphasize clinic-based interventions in promoting OW/OB behavior change. However, our review noted that in the Global South, effective outreach may need to occur outside of the traditional clinical setting.

Innovative examples, such as the CIrCLE of Life Initiative in South Africa, demonstrate the feasibility of community- and school-based interventions targeting OW/OB and HIV in children.^44-47 While these were excluded from our primary analysis because they were not clinic-linked, they offer valuable lessons for integrating obesity prevention into broader pediatric HIV care frameworks and underscore the need for flexible intervention models that account for local realities.

Strengths

First, guided by an implementation science lens,^49,50 this review focused on an understudied and highly vulnerable population. Second, the review was conducted by a transdisciplinary authorship team of clinicians and researchers from the Global South and North, ensuring diverse perspectives in its development and analysis. The review team conducted this review in accordance with evidence-based practices (PRISMA).

Limitations

Several limitations of this review should be acknowledged. First, the requirement that interventions be connected to a healthcare provider or healthcare system may have limited the scope of our review, especially given that a school-based intervention was identified. This criterion aligns with clinic-based care models⁵¹ that were developed in the Global North and may not fully apply to the Global South. Second, while more than 90% of peer-reviewed articles are published in English,⁵² it is possible that relevant studies published in other languages were not included in this review. Third, publication bias could be possible, as research with significant findings is more likely to be published.

Future Directions

Future research could expand on this review by exploring school- and community-based interventions as valid adjuncts to clinical care. Adopting an implementation science lens and drawing from Kenneth Rothman’s the Sufficient-Component Cause Model,⁵³ it will be crucial to reevaluate evidence-based guidelines and models to identify which practices are universally necessary and which components may be more context-specific, particularly in different global populations and settings.

Call to Action and Opportunities

Addressing pediatric obesity among CWH demands urgent, transdisciplinary, coordinated action across research, clinical practice, and policy domains (Table 1):

(1) Research Priorities: Develop and evaluate family-based, multi-component interventions targeting CWHs in LMICs using IS frameworks like CFIR and RE-AIM to guide adaptation and delivery

(2) Clinical and Health Systems Integration: Leverage primary care settings as hubs for integrated HIV and obesity management. This includes training providers to recognize the ‘double burden’ of malnutrition and incorporating behavioral counseling into routine HIV care.

(3) Policy and Funding Strategies: Advocate for dedicated funding streams and encourage supranational health entities (eg, WHO) to include integrated pediatric obesity interventions in official HIV programing guidelines.

Table 1.

Strategic Roadmap for Addressing the Dual Burden of HIV and Pediatric Obesity.

Domain	Key strategies	Priority actions	Expected impact
Research	Evidence generation and adaptations	Develop and pilot family-based, multi-component interventions specifically for CWH.	Validated, culturally tailored intervention protocols that address the specific metabolic needs of CWH.
		Utilize RE-AIM and CFIR frameworks to evaluate feasibility in resource-limited settings.
		Expand research to school- and community-based ‘hybrid’ models.
Clinical practice	Service integration	Designate primary care clinics as integrated hubs for both HIV and NCD management.	Early identification of weight-related complications and reduction in long-term cardiometabolic morbidity.
		Standardize routine BMI screening and metabolic monitoring (glucose/lipids) during ART visits.
		Train providers in culturally sensitive behavioral counseling.
Health system	Capacity building	Train a transdisciplinary workforce (nurses, CHWs, nutritionists) on the ‘double burden’ of malnutrition.	Improved health worker self-efficacy and more holistic, patient-centered pediatric care.
Health system	Capacity building	Incorporate dietary and physical activity guidance into the standard Pediatric HIV Care Package.
Policy and funding	Systemic advocacy	Secure dedicated funding for NCD-HIV integration (eg, via PEPFAR or Global Fund).	Sustainable, institutionalized support and scaled reach of obesity prevention programs.
		Update national and supranational (eg, WHO) guidelines to include obesity management for CWH.
		Foster cross-sector partnerships between Ministries of Health and Education.
Equity	Justice-oriented metrics	Implement equity-focused metrics to monitor outcomes across different socio-economic and geographic strata.	Reduction in health disparities and equitable access to next-generation HIV care.
Equity	Justice-oriented metrics	Ensure interventions are accessible to rural and highly marginalized populations.

Conclusion

CWH in LMICs face a pressing, yet under-recognized, dual burden of malnutrition and obesity. The absence of family-based interventions for this population highlights a critical research and implementation gap. Urgent action is needed to design, evaluate, and scale interventions that address both HIV and pediatric obesity in an equitable, context-sensitive manner to prevent early morbidity and improve long-term health outcomes for some of the world’s most vulnerable children.

Supplemental Material

sj-docx-1-gph-10.1177_30502225261421700 – Supplemental material for The Gap in Integrated Pediatric Care: A Systematic Review of Family-Based Weight Management for Children Living with HIV

Supplemental material, sj-docx-1-gph-10.1177_30502225261421700 for The Gap in Integrated Pediatric Care: A Systematic Review of Family-Based Weight Management for Children Living with HIV by Joshua S. Yudkin, Christopher Owens, James Gilbreath and Charles Martyn-Dickens in Sage Open Pediatrics

Footnotes

Appendix 1 Acknowledgements

We would like to thank Megan Bell who peer-reviewed the search. We would also like to thank Drs. Izat and Nguyen for their editorial assistance.

ORCID iDs

Joshua S. Yudkin

Christopher Owens

James Gilbreath

Charles Martyn-Dickens

Author Contributions

Joshua S. Yudkin: Conceptualization, Methodology, Writing – Original Draft. Dr. Yudkin ideated the study, contributed to the review of articles, and prepared the original draft of the manuscript. Christopher Owens: Writing – review and editing. Dr. Owens provided significant editorial input and writing support throughout the manuscript development process. James Gilbreath: Methodology, resources. As the library scientist, Mr. Gilbreath led the development of the search strategy and ensured access to necessary resources. Charles Martin-Dickens: Investigation, writing – review and editing. Dr. Martin-Dickens served as the second reviewer for articles and contributed to manuscript revisions and edits. All authors have read and approved the final manuscript and agree to be accountable for all aspects of the work.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was partially supported by the Fogarty International Center of the National Institutes of Health (NIH) under Award Number D43TW012274.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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