Table of Contents

• Fat in the Body
• Switching HIV Drugs
• Fat Loss in the Face
• Temporary Facial Fillers
• Permanent Facial Fillers
• Taking Care of Yourself

Fat in the Body

Fat is needed for the body to function. It plays an important role in keeping the skin and hair healthy, protecting body organs, and maintaining body temperature. Fat is also stored energy.

There are different types of fat found in the body. Visceral fat is located deep in the belly under the muscle. Subcutaneous fat is the layer of fat just under the skin. Lipids are fats or fat-like substances in the blood, such as cholesterol and triglycerides.

Lipodystrophy means abnormal fat changes. It is used to describe a number of potentially unhealthy changes including:

• Body shape changes
  • Lipohypertrophy: Fat gain in the breasts or back of the neck (buffalo hump); visceral fat gain in the belly; round lumps that appear under the skin (lipomas)
  • Lipoatrophy: Loss of subcutaneous fat in the arms, legs, butt, or face (sunken cheeks)
• Blood fat and sugar changes (metabolic problems)
  • Increased fats (lipids) in the blood
  • Increased sugar (glucose) in the blood

People living with HIV (HIV+) who have lipodystrophy can have both body shape changes and metabolic problems. Some treatments can help with certain lipodystrophy changes, but no existing treatment gets rid of all of them.

This info sheet looks at treatments for fat loss or lipoatrophy. See also Lipodystrophy Treatments Part I: Treatments for Fat Gain and Lipodystrophy Treatments Part III: Treatments for Metabolic Changes.

Switching HIV Drugs

Some HIV drugs in the non-nucleoside reverse transcriptase (NRTI) class have been linked to subcutaneous fat loss, including Zerit (stavudine, d4T) and Retrovir (zidovudine, AZT).

• For people who have developed lipoatrophy, switching from Zerit or Retrovir to the NRTIs Viread (tenofovir) or Ziagen (abacavir) may keep fat loss from getting worse. Some studies show that people may even get back some fat under the skin after switching. However, this process may take a long time or it may be hard to see for those who have more severe cases of lipoatrophy.
• People who have not developed lipoatrophy should avoid taking Zerit or Retrovir, if possible, to reduce the risk of developing the condition.

Fat Loss in the Face

While lipoatrophy can occur in the arms, legs, and butt, fat loss in the face can be the most difficult for HIV+ people. This can make someone look older and sicker than they are and cause embarrassment and low self-esteem. Many people living with HIV also believe that facial fat loss marks them as HIV+ and increases the stigma they face.

There are a number of treatments available. They all involve having products injected or surgically implanted to fill out hollows in the face. This can restore facial fullness. Temporary and permanent fillers are available. Temporary fillers usually last from three to 12 months and usually require touch-ups. Permanent fillers provide long-lasting results, but generally cannot be removed if the outcome is not good.

Many of these fillers are still being studied and have not been approved by the US Food and Drug Administration (FDA) for HIV-related lipodystrophy. If you are considering a treatment, get as much information as you can about the choices available to you. The long-term effects are unknown and results can be different from person to person.

It is important to consult with a plastic surgeon or dermatologist experienced in treating HIV-related lipodystrophy. If you are planning on using a treatment, and especially if you plan to go outside of the US to get it, check with the product's manufacturer to make sure your provider has been properly trained to perform the procedure.

The treatments are expensive and many insurance companies will not provide coverage. However, some HIV+ people have been able to convince their insurance companies to cover the treatment. If you try to get your insurance company to pay for these treatments, it is important to stress to them that fillers are required to restore facial features lost to HIV drug treatment, not simply for cosmetic purposes.

On a positive note, Medicare pays for facial fillers (Sculptra and Radiesse, below) for HIV+ people on Medicare who experience symptoms of depression due to HIV-related facial lipoatrophy. This decision was made, in part, because studies showed that the fillers can improve self-image, ease symptoms of depression, and help people stick more closely to their HIV drug treatment schedules.

Temporary Facial Fillers

• Sculptra: This is the first facial filler approved in the US for HIV-related lipoatrophy. It contains poly-L-lactic acid, a man-made product that has a long history of use in reconstructive surgery. Sculptra stimulates the body's production of collagen, which gives the face a fuller look. The treatment requires three to six sessions and a touch-up every year. It costs approximately $1,500 per office visit. The manufacturer has a patient assistance program (go to https://patientassistanceprogram.sanofi-aventis.us/default.aspx).
• Radiesse: This product is also FDA approved for facial lipoatrophy in HIV+ people. Radiesse contains man-made calcium hydroxylapatite, a substance found in bones and teeth that stimulates the body's production of collagen. It is used for reconstructive surgery and dentistry, and has a good safety record. Radiesse costs approximately $1,500 per office visit. The manufacturer has a patient assistance program (go to www.radiesse-fl.com/What-is-Radiesse/How-much-does-it-cost/).
• Autologous fat transplant: This procedure involves taking fat from one part of the body and injecting it into another part. Fat transplants are considered to be natural looking, however, fat can be difficult to find in HIV+ people with lipoatrophy. Injected fat can also sometimes become too large. Autologous fat transplants do not require FDA approval, but should be performed by a plastic surgeon with experience using this approach. These fat transplants cost approximately $3,000.
• Collagen (Zyderm, Zyblast, CosmoDerm, CosmoPlast): Collagen has been used for more than 25 years for cosmetic purposes, usually as a filler for facial wrinkles. Injected collagen is made from calf skins (bovine collagen) and grown in test tubes using human tissues (human collagen). While not specifically approved for HIV-associated lipoatrophy, collagen is widely available and many plastic surgeons know how to use it. The cost, per session, is about $600.

Permanent Facial Fillers

• PMMA (Artefill, Precise, Metacrill): The FDA approved Artefill for the treatment of facial wrinkles, lines, and furrows, but not for HIV-related facial lipoatrophy. Precise and Metacrill have not been evaluated by the FDA. Most HIV+ people treated with either Precise or Metacrill go to Mexico or Brazil. The cost varies, depending on the brand, the amount of filler needed, and travel expenses for Precise or Metacrill.
• ePTFE Implants (Gore-Tex, Gore S.A.M., SoftForm): These solid implants require minor surgery to insert. Gore-Tex and SoftForm are FDA approved for filling out the face (although not for HIV-related facial lipoatrophy). There is a risk of infection and scarring. The procedure costs approximately $2,000 per cheek.
• Bioalcamid: This product is not approved in the US. It is available in Europe, Mexico, and Canada, where it is used for cosmetic and reconstructive purposes. It is an injectable gel, around which the body then forms collagen. Bioalcamid usually requires one or two sessions. There have been reports of infections and of the Bio-Alcamid moving downward in the face. Total costs are approximately $4,500, including travel.
• Silicone Oil (Silikon 1000, VitreSil 1000): Silicone oil is not approved for lipoatrophy, but is commonly used for this purpose. Its safety and effectiveness are still being investigated for facial filling. The oil is injected in very small quantities which require anywhere from three to six sessions. Once injected, it cannot be removed. The cost depends on the amount of silicone oil needed and the fee associated with the injections.

Taking Care of Yourself

Some body shape changes and metabolic problems have been linked with heart disease and strokes in HIV+ people. To lower your risk of heart disease and/or stroke:

• Get checked and, if needed, treated for high blood pressure
• Have regular lab tests to check your lipid and glucose levels
• Eat a healthy diet; see a dietician or nutritionist if you need help with this
• Get regular exercise
• Stay at a healthy weight
• Stop smoking or cut down on how much you smoke
• For more information, see our info sheet on Caring for Your Heart

It may also be a good idea to get a BIA (Bioelectrical Impedance Analysis). A BIA is an easy and painless test that gives information about fat and lean body mass. Having BIAs done over time can be helpful in monitoring body shape changes.

If you are experiencing lipodystrophy it is especially important to take care of yourself. Keep all of your medical appointments, get regular lab tests, and tell your health care provider about any changes in the way you feel or in your body shape. Do not make any changes to your medication regimen without your health care provider's guidance.