Navigating the GLP-1 Surge and HIV Care: Todd Brown, MD, PhD

The therapeutic landscape for glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has expanded rapidly, moving beyond glycemic control to address systemic metabolic dysfunction. However, for clinicians managing the intersection of HIV and aging, the surge in GLP-1 RA utilization raises critical questions regarding long-term physiological impacts and population-specific safety signals.

To bridge the gap between clinical exuberance and evidence-based practice, Todd Brown, MD, PhD, an endocrinologist and clinical investigator at Johns Hopkins University, sat down at the Conference on Retroviruses and Opportunistic Infections 2026 in Denver, Colorado, to evaluate the nuances of prescribing these agents for people living with HIV.

Brown noted that although current data suggest GLP-1 RAs are as effective in the population living with HIV as in the general public, their implementation requires specific vigilance:

• Titration and GI tolerance: Gastrointestinal adverse effects occur in approximately 50% of patients. Brown advocates for a "low and slow" dose escalation—increasing at monthly intervals—to mitigate treatment-limiting symptoms.
• Perioperative risk: Due to delayed gastric emptying, there is a documented risk of aspiration pneumonia under anesthesia. Patients should discontinue GLP-1 RAs 1 week prior to any surgical procedure to ensure gastric clearance.
• Metabolic complications in aging: A primary concern for this aging cohort is the potential for accelerated loss of bone mineral density and muscle mass. Given the baseline prevalence of sarcopenia and osteoporosis in this population, Brown emphasizes rigorous monitoring for patients in their 60s and 70s.

Regarding drug–drug interactions (DDIs), current peptide-based GLP-1 RAs do not appear to utilize the CYP3A4 pathways common to many antiretroviral regimens. However, Brown cautioned that the imminent arrival of small-molecule, oral GLP-1 RAs will necessitate a re-evaluation of metabolic pathways and potential interactions with protease inhibitors or nonnucleoside reverse transcriptase inhibitors.

Looking forward, Brown envisions a paradigm shift where these agents are categorized not merely as weight-loss tools, but as essential therapies for weight-related comorbidities, including heart failure with preserved ejection fraction and metabolic dysfunction–associated steatohepatitis. For the HIV community, improving access to these therapies could significantly alter the trajectory of chronic disease management.