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Transcript of The Body's Live Chat on Lipoatrophy (Fat Loss) With Dr. Joel Gallant

Sponsored by Gilead Sciences

November 1, 2005

Joel E. Gallant, M.D., M.P.H.
Following is the transcript of The Body's live chat on lipoatrophy (fat loss), which took place on Nov. 1, 2005, at 9 p.m. Eastern Standard Time. The chat was sponsored by Gilead Sciences, moderated by The Body's editorial staff and hosted by Dr. Joel Gallant, a leading HIV specialist in the United States. This transcript has been edited for grammar and clarity. In rare occurrences, additional follow-up information was obtained from the host after the chat's conclusion.

This is the fourth chat that The Body has moderated; to see transcripts of previous chats, click here.

Chat Room: Thank you for joining this live, interactive chat at TheBody.com! During tonight's chat, Dr. Joel Gallant will answer your questions about lipoatrophy, the loss of fat in certain parts of the body. This chat is sponsored by Gilead Sciences, which produces several HIV medications.

Room is moderated. You can now talk.

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Moderator 1: Thank you all for coming to The Body's live, interactive chat on lipoatrophy (fat loss), a difficult health issue experienced by many people who take HIV medications.

Our speaker for tonight's chat on lipoatrophy is Dr. Joel Gallant, one of the United States' most knowledgeable HIV specialists.

Moderator 1: Dr. Gallant, we're honored to have you as our chat speaker tonight. Is there anything you'd like to tell everyone about yourself before we let the questions fly?

Dr. Joel Gallant: I'm an assistant professor of medicine and epidemiology at the Johns Hopkins University School of Medicine, and associate director of the Johns Hopkins AIDS Service [in Baltimore, Md.]. I also run the Garey Lambert Research Center, which conducts clinical trials of new antiretroviral agents. I run a question and answer forum for people with HIV infection on the Johns Hopkins AIDS Service Web site (www.hopkins-aids.edu/ask.html). And of course, I also take care of lots of patients!

Moderator 1: Thanks, Dr. Gallant! With that, I think we're ready to start tackling everybody's questions. Fire away! (Remember: Since this is a moderated chat, you won't see your question in the chat room until Dr. Gallant answers it.)

Original message from Edward: Can you give us a definitive answer on the difference between lipodystrophy and lipoatrophy? It's very confusing to me! Thank you.

Reply from Dr. Joel Gallant: I agree -- it IS confusing, which is why I try never to use the word "lipodystrophy." We used that term, along with "fat redistribution," back when we thought that fat was being "redistributed" from the face, arms, legs, and buttocks to other areas, such as the abdomen, breast, and the upper back ("buffalo hump"). Now we know that those can be separate processes. So it's better to use more precise terms: "lipoatrophy" to describe loss of subcutaneous fat, and "fat accumulation" to describe ... well, to describe fat accumulation. It's also easy to confuse lipoatrophy with wasting, because they can look the same. Wasting is loss of both fat and muscle, usually caused by uncontrolled HIV infection. It can also be caused by low testosterone levels, poor nutritional intake, malabsorption, or other endocrine problems. By the way, although this is supposed to be a chat about lipoatrophy, we can talk about fat accumulation, too.

Moderator 1: Please keep in mind that there may be a delay of a minute or two between answers, as Dr. Gallant writes his next response to one of your questions. Thank you for your patience!

Original message from sfguy: I was on HIV meds for a long time -- about eight years. I'm on a cocktail holiday now. I've not taken meds for seven months now. I'm wondering if I still can get lipoatrophy. My arms have gotten smaller, and my legs.

Reply from Dr. Joel Gallant: You can't get lipoatrophy if you're not on medications. However, you CAN lose weight. Remember "wasting"? That's what happened to people in the bad old days before we had effective therapy. If you're losing weight after taking a drug holiday, maybe your body is trying to tell you something!

Moderator 1: Our live chat on lipoatrophy (fat loss) has begun! Please continue to submit any questions you may have for Dr. Joel Gallant, one of the United States' most knowledgeable HIV specialists.

Dr. Gallant is the associate director of the Johns Hopkins AIDS Service, one of the foremost HIV medical centers in the United States; the editor of "The Hopkins HIV Report," a bimonthly HIV care newsletter; and the co-author of the seminal HIV treatment guide "Medical Management of HIV Infection."

Original message from Brick: Fat loss may be due to insulin insensitivity, from what I can gather. Would [the] insulin meds used by diabetics be one way to combat fat loss?

Reply from Dr. Joel Gallant: Insulin wouldn't work well, because your body would be resistant to it. But, if you have insulin resistance, then some of the insulin sensitizers, like metformin [brand names: Glucophage, Fortamet] or the "glitazones" [like the brand name drug Avandia], might help decrease your blood sugar, and they MAY help to decrease fat accumulation.

Original message from hoffer: What do you think of Sculptra for facial lipoatrophy?

[Editor's Note: Sculptra, also known as New-Fill, is an injectable product made of poly-L-lactic acid. It has been approved by the U.S. Food and Drug Administration to correct facial fat loss in people with HIV.]

Reply from Dr. Joel Gallant: All I can say is that some of my patients are so happy with it that they burst into tears after each treatment, and I certainly notice the difference, too. The real question relates to durability of the effect. I'm sure that occasional touch-ups will be required, but if you're able to get off the drugs that are causing the lipoatrophy, then Sculptra may help to improve your appearance while you wait for fat to slowly return.

Original message from Michael H: Besides aesthetics, does lipoatrophy of the face pose any other health problems?

Reply from Dr. Joel Gallant: No, there are no known health problems associated with facial lipoatrophy. However, I have seen people with lipoatrophy of the legs or buttocks develop "compression neuropathies" (tingling or numbness) because their nerves are no longer padded by fat and can be compressed by sitting on a wallet, crossing your legs, etc.

Original message from megan_rn: What is the best combination of meds for someone who is going to start therapy [and who] wants to minimize body changes? Thank you.

Reply from Dr. Joel Gallant: If you have no drug resistance and can take anything you want, then combinations that are unlikely to cause body shape changes would be either Truvada [generic name: tenofovir/FTC] or Epzicom [generic name: abacavir/3TC; also known by the brand name Kivexa] PLUS either Sustiva [generic name: efavirenz; also known by the brand name Stocrin], Viramune [generic name: nevirapine], or Reyataz [generic name: atazanavir] (preferably Reyataz boosted with Norvir [generic name: ritonavir]). However, you're unlikely to get lipoatrophy with any protease inhibitor, as long as you're using Truvada or Epzicom, and the association between fat accumulation and protease inhibitors is not as direct as the association between lipoatrophy and thymidine analogs (like AZT [brand name: Retrovir; also known as zidovudine] and d4T [brand name: Zerit; also known as stavudine]).

Original message from thomasb1230: I have lipoatrophy. I went from 155 pounds to 135 in two years. CD4 is 350 and viral load is <2,000. I feel great. Why should I be concerned about lipoatrophy? Isn't it just a loss of body fat?

Reply from Dr. Joel Gallant: The main reason to be concerned is just because it changes your appearance, making you look older or sicker than you are. If that doesn't bother you, then you're unusual, but that's OK. Still there MAY be a link between lipoatrophy and fat accumulation or increased lipids. If the fat you eat can't go to the usual places, it has to go somewhere else.

Original message from AlexP: I am an African-American male age 43 and in the past year [I] have [had] tremendous facial loss. I stopped taking Zerit last year and switched drugs, but after nine months the facial muscle has not come back. What can I do besides cosmetic surgery to increase facial muscle? Also, [I have visible] veins in [the] lower limbs of [my] legs and loss of buttocks on both sides.

Reply from Dr. Joel Gallant: It's probably not facial muscle that you've lost, but facial fat. The same is true for your legs and buttocks. If you've switched from Zerit to either Viread [generic name: tenofovir] or Ziagen [generic name: abacavir] (rather than to AZT), then your fat should start coming back, but it can take a long time, and there's no guarantee that it will be completely restored. If you've got the money, Sculptra injections seem to be the most effective way to deal with facial fat loss.

Original message from ladyluck: Have there been any studies on [the] prevalence of lipoatrophy among one race or sex [as compared to] another?

Reply from Dr. Joel Gallant: In some studies, there has been a tendency for men to develop lipoatrophy sooner, while women are more likely to develop fat accumulation. This may just be due to the fact (like it or not!) that women tend to have more body fat to start with, so it takes them longer to lose fat, and fat gain will be more apparent. I haven't seen too much on racial differences.

Original message from travelover: I have experienced weight loss in my face, legs, and buttocks, and at the same time gained weight in the stomach. Does the fat loss transfer to the stomach area?

Reply from Dr. Joel Gallant: Not exactly, though it's true that if you have no subcutaneous fat stores in the usual places and you gain fat, it has to go somewhere, so it might go to the abdomen or other areas. It's like people who get their love handles removed by liposuction: If they don't exercise regularly and watch their diet, they can get fat build-up inside their abdomens. The love handles may not come back, but they may still look fat.

Original message from Arbelboy: Do the nerves that lose their fat ever come back at all or will I feel the tingling on my face forever?

Reply from Dr. Joel Gallant: You don't lose nerves when you get lipoatrophy. If you have tingling in the face, that's probably caused by something else.

Original message from radcliffe: My nutritionist did a body fat analysis on me using electrodes. My fat was pretty high. He was concerned because I don't necessarily look like I am carrying that much fat, but it was significant enough to concern him. We suspect that I have hidden fat that developed in crevices between my organs. Have you heard of this? Do you have any suggestions on losing this fat? Thanks.

Reply from Dr. Joel Gallant: I'm not a big fan of BIAs, which is probably what you had, because they don't tell you anything about where the fat is located. In other words, it's not going to distinguish between subcutaneous fat and visceral (intra-abdominal fat). If you look and feel OK, you're probably OK. But it never hurts to improve your diet and exercise more. You can use the BIA results for motivation.

Moderator 1: BIA is short for "bioelectric impedance analysis."

Original message from dj_joe: I am a 59-year-old male and have always had a very flat nice trim stomach. All of a sudden I have a very, very large round abdomen. I have been HIV positive for 20 years and this has started in the last six months. What is going on?

Reply from Dr. Joel Gallant: I don't know, because I don't know what meds you're taking or what other conditions you have. It's important to distinguish treatment-related fat accumulation from the obesity that often afflicts us as we grow older. If you can grab a handful of belly fat and pinch it between your fingers, then you have to blame the french fries and the TV remote control, not the drugs. On the other hand, if your fat is all INSIDE your belly, then it may be related to treatment, in which case I'd want to know more about the drugs you're on, your lipid profile, and whether you have insulin resistance. However, regardless of the cause, aerobic exercise and a low-fat diet can help.

Original message from knuck: Can weight lifting reverse the effects of wasting?

Reply from Dr. Joel Gallant: You can't bring fat back through weight lifting, but you can build muscle that can help to compensate for the fat loss. Squats and stair-climbing machines can build up your buttocks, for example, even though it may not look like the same butt you had before you lost the fat. Of course, it's also important to avoid the drugs that cause fat loss.

Moderator 1: Dr. Gallant, the person who asked a question earlier about tingling in the face has asked if you could talk about what the tingling might be caused by. Could you add any thoughts?

Dr. Joel Gallant: I can't make a diagnosis from here; all I can say is that I see a lot of people with lipoatrophy and they don't have facial tingling. You should really discuss this with your doctor or with a neurologist to find out the cause.

Original message from wunderbar: I have been dealing with facial wasting for years. What is the best way to fix the problem? Fortunately, I live in a small town and most don't recognize the facial wasting as an HIV problem. I go to an infectious disease doctor locally and he is not willing to help me convince my insurance company to cover such things as Sculptra. I went to a plastic surgeon and he said the facial wasting is cosmetic. I don't have a social life because I feel like I look so disfigured. Who would want to be seen with me? I can barely stand to look at myself in the mirror to shave or brush my teeth. Please let me know what I can do. Thanks.

Reply from Dr. Joel Gallant: It's true that facial wasting is a "cosmetic problem," but that doesn't mean it's not important. And since it's a complication of medical therapy, it's a shame that we can't convince insurance companies to pay for it, but so far, I haven't heard of this happening. There is a patient assistance program provided by the manufacturers of Sculptra that can help to offset the cost of the material, but you'd still have to pay the plastic surgeon his fee. You should also check around, as dermatologists do this as well, and some might have lower fees. And of course you need to make sure you're not still on drugs that can make this worse.

Original message from theoc: What are the drugs that have been identified to cause lipoatrophy? Is lipoatrophy reversible? My regimen is Viramune and Combivir [generic name: AZT/3TC] and my lipoatrophy is continuing. What are your suggestions for a switch in treatment drugs?

Reply from Dr. Joel Gallant: The drugs that are known to cause lipoatrophy are d4T, AZT (whether it is in the form of Retrovir, Combivir, or Trizivir), and possibly also ddI [brand name: Videx; also known as didanosine]. Drugs that are NOT believed to cause it are 3TC [brand name: Epivir; also known as lamivudine], FTC [brand name: Emtriva; also known as emtricitabine], tenofovir (whether it is in the form of Viread or Truvada), and abacavir (whether it is in the form of Ziagen or Epzicom). Because you're on Combivir, you could still be losing fat due to AZT. If your resistance pattern (or lack of it) will allow you to switch to Truvada or Epzicom, that could help a lot.

Original message from D71: My dermatologist recommended Sculptra over silicon fillers. He said that the effects are more natural. I was happy with the results, but not the cost and ongoing maintenance. What are your thoughts on silicon vs. Sculptra?

Reply from Dr. Joel Gallant: I'm not a dermatologist or a plastic surgeon, but my feeling is that Sculptra may be longer lasting than silicon, and my dermatologist colleagues seem to prefer it. I've also heard of silicon causing more "lumpiness."

Original message from lazlo: How do you know which drugs cause this problem? Could others cause it and we just don't know yet?

Reply from Dr. Joel Gallant: Sure, anything could happen if we wait long enough. But we have head-to-head trials that show a clear difference. For example, after three years, people on d4T got lipoatrophy, while those on tenofovir didn't. And we also know that switching from d4T or AZT to either tenofovir or abacavir allows fat to return, which makes it pretty unlikely that either of those drugs causes lipoatrophy.

Original message from Frank: Hi. I have been diagnosed with HIV for about four years now. I do not take any medication, but at the same time am scared of the side effects of the treatment, especially lipoatrophy. I was wondering if there is anything that I can do before starting my treatment to prevent it? Or at least make it as less [of an] effect as possible? I am not sure for how long my CD4 level [will stay] high to keep me away from medication. Thank you.

Reply from Dr. Joel Gallant: Frank, the best thing you can do is to take medications that don't cause lipoatrophy, which is easy enough to do if you're starting therapy for the first time, without any drug resistance. I have lots of patients with lipoatrophy, but they're all people who've been on therapy since back in the 20th century. I'm not seeing NEW development of lipoatrophy anymore, because we now have better treatment options. Don't let the fear of lipoatrophy dissuade you from taking antiretroviral therapy if you need it!

Original message from Brick: It's now known that nucleoside analogs are causing the fat loss [seen with] HIV meds. But, isn't acyclovir [brand name: Zovirax] also a nucleoside analog and would it also contribute to the fat loss?

Reply from Dr. Joel Gallant: Not all nucleoside analogs cause lipoatrophy. It's primarily the thymidine analogs (d4T and AZT). There's no risk to taking acyclovir.

Dr. Joel Gallant: We're having some problems with communication with the moderator, so I'll do my best to provide both the questions and answers, since he can't post the questions.

Original message: What treatment options are available for facial lipoatrophy other than Sculptra and fat injections? What protein and micronutrients package should I be adding to my diet and exercise routine to counteract the lipodystrophy? Do you have a list of recommended packages?

Reply from Dr. Joel Gallant: The best treatment for facial lipoatrophy is not to take the drugs that cause it. I'm not aware of any nutritional interventions that have been shown to work. Aerobic exercise is great for fat accumulation and for overall health, but it can sometimes make lipoatrophy worse. (After all, if you've ever looked at the legs of a serious runner, you won't see much subcutaneous fat!)

Original message from Paul: Are there any studies with Sculptra open for enrollment? How can I connect with an experienced doctor? I've been on HIV medication for three years now (efavirenz, didanosine, and lamivudine) and have lost about 10 percent of my body weight (from around 60 kgs to 53 kgs -- I never was at all fat). My skin is sallow from the weight loss; no fat deposits thankfully though on my stomach or elsewhere. My viral load has been undetectable all along and my T-cell count has gained slowly, but steadily to around the 350 mark. What can I do to reverse the fat loss?

Reply from Dr. Joel Gallant: Paul, if there's a way for you to switch from didanosine/lamivudine to either Truvada or Epzicom, that might help, since we believe that didanosine might contribute to lipoatrophy. I couldn't comment on Sculptra studies, because it depends on where you live, but the company does have a pretty generous patient assistance program. That can help offset the cost of the material itself, but not of the doctor's procedure fee. The point is to find a dermatologist or cosmetic surgeon who is doing it in your area.

Original message from Per: Hello from Oslo/Norway. Dear Dr., [I had no problems with fat until I started Kaletra (generic name: lopinavir/ritonavir) and began to lose] fat on my legs, thighs, arms, and face and put on fat around my chest and stomach. My question is therefore simple: Is Kaletra worse than other AIDS/HIV medicine? Kind regards Per.

Reply from Dr. Joel Gallant: Per, Kaletra by itself should not cause fat loss. But you must be on more than just Kaletra. It may be the other drugs in your regimen that are causing the problem.

Original message: Hi Dr. Joel. I need to ask you: What good foods should I eat to take better care of myself? Thank you.

Reply from Dr. Joel Gallant: The recommendations are similar to those for everyone else: Eat lots of fresh fruits and vegetables; eat complex, unrefined carbohydrates (e.g., whole grains, brown rice, etc.) rather than simple or refined starches; and minimize sugar and fat intake. If you eat meat, go easy on the red meat and eat more poultry and fish. Avoid fast food or pre-prepared food, which is often high in fat and salt, and avoid fried foods. And make sure that you're eating food you like, or else you'll never be able to keep up with your healthy diet.

Original message: Lipoatrophy affects many HIV-positive people -- some with specific area disfiguring. However, most of us who are long-term HIV-positive persons experience simply a uniform fat loss in particular subcutaneous fat over a long period of time. HIV itself was suspected by many physicians for years as the cause of this. However, recent research is now pointing to nucleoside analogs (i.e., AZT) as the main cause. If this is in fact the case, what would you suspect the results would be by changing to non-nucleoside analogs? In other words, would the lipoatrophy be apt to cease and even reverse? And, if you suspect a reversal, how long after stopping nucleoside analogs do you think a person would begin to show signs of fat replacement? And secondly, what can one do to help promote this reversal in the way of supplements or medications? Would insulin medications prescribed for diabetes be helpful?

Reply from Dr. Joel Gallant: You don't necessarily need to switch to a non-nucleoside analog; you just need to switch to a nucleoside analog that doesn't cause the problem. The biggest culprit is d4T, but AZT does it too, and ddI may also contribute. We now know that this IS a reversible problem, if you can switch from d4T or AZT to tenofovir or abacavir, but the changes don't happen overnight. In the GS903E study, people who switched from d4T to tenofovir regained about as much fat after one year as they had lost in their last year on d4T. It MAY be the case that you regain fat at about the rate that you lost it.

I don't know of any supplements that will help speed this process along. Insulin isn't going to help. There has been some conflicting data on the use of "glitazones" -- insulin sensitizing agents used for diabetes -- but for the most part, the data don't suggest that they're of much benefit for lipoatrophy.

Original message: I have low testosterone and am taking Androgel [generic name: testosterone gel], which helps. I also have facial wasting, Crix-belly, and the start of a buffalo hump. Is there a proven correlation between hypogonadism and lipoatrophy?

Reply from Dr. Joel Gallant: Not between hypogonadism and lipoatrophy, but hypogonadism can cause muscle wasting, which can sometimes look similar.

Original message: I have been on antiretrovirals since 2000. Initially Crixivan [generic name: indinavir] plus Zerit and 3TC. This was changed after three months of nausea and vomiting to Viracept [generic name: nelfinavir] plus Zerit and 3TC. Initially I put on a lot of weight and was forced to start exercising. Then, after three months, diarrhea set in. I had to run to the toilet every time I ate something. Two years of this and after losing 15 kilograms, especially in my legs, [I] had my meds changed to Viread, Combivir, and Viramune. I started feeling better within weeks but for the skinny legs, arms, butt, and face. Managed to put on 5 kilos after about a year, although all this went to my breasts, tummy, and buffalo hump. I am such a sight it's depressing me. Five months ago [I] decided to go to the gym in the hope of gaining a bit of muscle in the right places and losing in the wrong places. So far I have only managed to lose the little I had put on in my legs, and my butt looks like empty bags. I'm depressed to say the least and I am looking for immediate answers.

Reply from Dr. Joel Gallant: It sounds like you need to get off the AZT, if you can do so without jeopardizing your virologic response. Everyone knows now that d4T causes lipoatrophy, but we often forget that AZT does it too, but just at a slower rate. Getting off AZT won't make everything all right again, but it could halt further loss of fat, and may allow fat to return ... slowly. You're now on drugs that are less likely to cause fat accumulation, but that doesn't mean that what happened to you on previous regimens will go away. With fat accumulation, the things to do are to (1) eat a low-fat diet; (2) exercise regularly, especially with aerobic exercise; (3) keep your lipids, and especially triglycerides, under control; and (4) treat insulin resistance, if you have it. Insulin resistance is diagnosed by fasting insulin levels and/or glucose tolerance tests.

Original message: Losing fat on my bums and thighs, but the tummies are growing bigger. I can't seem to lose these fats even by exercising. What can I do to shed the fat on my tummies? I am currently on HAART treatment. (1) I have lost tissue in my legs, especially around my knees. Can this tissue come back with changes to regimen? (2) I was able to get Sculptra for free because of my financial situation and although I'm 80 percent pleased with the results, what's happening with insurance companies determining that this should be considered a reconstructive procedure as opposed to cosmetic? I still had to pay for the plastic surgeon's time, which wasn't cheap!

Reply from Dr. Joel Gallant: Just how many "bums" and "tummies" do you have??? One bum and one tummy are enough for most of us!

You didn't give me the details of your HAART regimen, which is important. But I'm sure you'll find answers to your questions during this chat.

Original message from Home: Is eating too much sugar a contributing factor to lipo?

Reply from Dr. Joel Gallant: It could definitely contribute to fat accumulation, but probably not to lipoatrophy. If you have fat accumulation, you need to avoid insulin resistance and hyperglycemia if possible.

Original message from Duane: Hello Dr. Gallant. I've not experienced really extreme lipoatrophy, but [have noted a] general loss of mass in the face. What could I do to lessen the effects? Are there any cosmetic remedies that the VA Hospital would justify as part of ongoing treatment?

Medical history: 1991: AZT. 1994: added ddC [brand name: Hivid; also known as zalcitabine]. 1996: added Crixivan. 1998: changed regimen (not due to resistance to meds) -- new regimen: Sustiva, d4T, and 3TC. 2005: dropped d4T and added Viread. Current regimen: Sustiva, Viread, and Epivir. Thanks in advance.

Reply from Dr. Joel Gallant: Duane, for the first time, you're on a regimen that should not cause lipoatrophy. So the problems you're experiencing are probably due to prior regimens. At this point, some of your fat might be returning, though slowly. I don't know what the VA will cover. It's hard to imagine that they'd cover Sculptra injections, but who knows? It couldn't hurt to ask.

Moderator 1: We'll be wrapping up this chat within the next several minutes. Thank you all for your patience! We can't apologize enough for the technical problems we've experienced; hopefully you've still found this an informative chat.

Original message from stopdisnow: What are the worst antivirals for fat accumulation in the stomach and breast? They want me to take Trizivir [generic name: AZT/3TC/abacavir] and Reyataz. My CD4 is down to 89.

Reply from Dr. Joel Gallant: The link between antiretrovirals and fat accumulation isn't as strong as the link with lipoatrophy, but drugs that cause high triglycerides and insulin resistance may be the ones that cause the problem the most. Protease inhibitors cause those problems, but Reyataz seems to be an exception, so the regimen they're recommending is probably pretty safe from a fat accumulation perspective. You clearly need to be on something now!

Original message from D71: In an earlier answer, you mentioned that ddI may contribute to lipoatrophy. I am on Viramune, Viread, and Videx EC. I have some fat loss in my face and significant loss in my legs. You have mentioned that Viread and Viramune do not cause lipoatrophy, so those should be fine. Should I talk to my doctor about switching to something other than Videx EC? Is there another drug in that class that would be as effective without the fat loss?

Reply from Dr. Joel Gallant: We don't have a lot of information on Videx, because for many years it was usually combined with other drugs that cause lipoatrophy (AZT and d4T). However, there is reason to believe that Videx COULD cause lipoatrophy. In addition, there are several concerns about combining Viread and Videx, including CD4 decline and easy selection of resistance, especially when combined with Viramune or Sustiva. So you have several reasons to discuss this with your doctor.

Moderator 1: If any of you have missed part of tonight's chat, don't worry: A full transcript will be available on TheBody.com within the next week.

Original message from Stephan: How does a guy like Magic Johnson look the way that he looks after announcing years ago that he has HIV. He still looks good, while some of us are wasting away. What has kept him from wasting? Do we know?

Reply from Dr. Joel Gallant: There's nothing "magic" about Magic. Plenty of my patients look great after years of HIV infection. It depends a lot on whether you have resistance or not. If you don't, you can choose medications that don't cause body shape changes. However, if you do have a lot of resistance, you sometimes have to take drugs that cause more problems in order to suppress your viral load. I've met Magic Johnson, and he's not taking anything that isn't available to anyone else.

Original message from chuck: I have lost fat in my ankles and cannot run anymore! My ankles just can't support my athleticism. Anything I can do to reverse this?!

Reply from Dr. Joel Gallant: Who wants fat in the ankles? And why do you need fat ankles to run? You've confused me with this question!

Original message from pos28: Before giving a diagnosis of lipoatrophy, do you first have ways in which you measure each patient's muscle/fat ratios to rule out muscle wasting as the true cause of let's say thinning thighs and flattening buttocks?

Reply from Dr. Joel Gallant: In most cases, it's a diagnosis that can be made just by physical examination. No tests are usually necessary. However, I do usually check the testosterone level, just to be sure that there's no muscle wasting related to hypogonadism as well. If the viral load is undetectable, I'm not worried about HIV-related wasting.

Moderator 1: This chat will conclude in just a few minutes. Thank you all again for joining us tonight!

Original message: What is the best way to get your stomach not to look like you are five months pregnant?

Reply from Dr. Joel Gallant: Use birth control! (Just kidding, but by now I think I've answered this question several times already.)

Original message from Terry: I have had lipoatrophy for four years now. I am currently in a rollover study at the University of Kentucky using TMC125 and Fuzeon [generic name: enfuvirtide; also known as T-20]. I have noticed the large veins in my legs are not as pronounced and I feel as if maybe my face looks a little less gaunt. Could there actually be some type of reversible lipo going on in my body? By the way, I went from [a viral load of] 270,000 to 4,000 and will be tested again in mid November.

Reply from Dr. Joel Gallant: Terry, we know that lipoatrophy is reversible if you stop the drugs that cause it. The reversibility is slow and may not be complete, but that's better than nothing. You didn't mention the drugs you took before and are taking now, so I can't comment on whether that's what happened in your case. Keep in mind that while our focus is now on fat loss, there's still such a thing as HIV wasting: loss of both muscle and fat due to untreated HIV disease. If your viral load has dropped from 270,000 to 4,000, you may be gaining weight, including both fat and muscle, just because you're healthier!

Moderator 1: Our interactive chat on lipoatrophy (fat loss) has now concluded. Thank you, Dr. Gallant, for taking the time to answer everyone's questions!

To all of you who asked questions or took the time to join our chat tonight: Thank you for tuning in, and for making this chat a success!

A full transcript of this chat will be available on TheBody.com within the next week. As soon as it's up, we'll provide a link to the transcript within our weekly e-mail newsletter.

Dr. Joel Gallant: It's been a pleasure. I hope you all found it helpful. Good night.

Moderator 1: To those of you whose questions we were unable to answer tonight: Please try visiting The Body's lipoatrophy information page at www.thebody.com/treat/lipoatrophy.html for more information, or ask our staff of experts at www.thebody.com/experts.html.

Thank you all again! Have a good night!


Post-Chat Questions

These questions were submitted before or during the chat, but because of time limitations, Dr. Joel Gallant did not have the chance to answer them.

Original message: Regarding treatment for facial lipoatrophy: What is considered the longest lasting filler material and is it therefore a logical choice vs. others available?

Reply from Dr. Joel Gallant: The best results I've seen are with polylactic acid (Sculptra), which is now approved. It may be too early to say how long the effects will last without "touch-up" injections, but it seems more longer lasting than collagen or fat injections.

Original message from Kurt: Four years ago, I developed Kaposi's sarcoma. I was treated with interferon. After years of negative screenings, I tested positive in July of this year. My CD4 count was as low as 140 and my viral load over 200,000. I [have now been] on treatment [for six weeks]. After two weeks into the treatment, a screening test was performed. (Viral load under 600 and CD4 [count] of 180.) I am given Truvada (1 a day), Norvir (2), and Telzir (2). I am very concerned about fat loss. (By the way, I am living in Munich, Germany.) Best regards.

Reply from Dr. Joel Gallant: For the rest of you, Telzir is what we Americans call Lexiva [generic name: fosamprenavir; also known as 908]. The combination of Telzir and Truvada should not cause fat loss.


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