Dear Dr. D,
I am at wit’s end. I have been HIV positive for three years and have been taking Triomune®. I have been completely adherent but in the last year my stomach has been getting bigger and it now looks like I have a middle age spread. I am only 32! I know it’s from my ARVs (antiretrovirals) and I don’t want to change, but maybe there is some exercise or diet I can do to reduce this. I have always had a trim physique as I do aerobics regularly so it’s not because I have a poor diet that this is happening.
I have also heard that anaebolic steroids could help since they help bulk up muscle. Any advice for this? Help!
Sincerely,
Michael P., Johannesburg

Dear Michael,
Firstly, while I applaud you for remaining adherent and understanding that ARVs can’t be chopped-and-changed like socks, I would consider changing the medications you’re currently on. Triomune® is simply the brand name for three-in-one tablet combining a number of older-generation ARVs, several of which are being phased out because of their high side effect profile. The drug stavudine (also known as Zerit® or d4T) is the primary component of concern, and most guidelines these days have moved it well to the bottom of the barrel. You shouldn’t be on it in my opinion.
Lipodystrophy, or the sometime disfiguring redistribution of body fat, is one of the side effects associated with stavudine. When it occurs, subcutaneous fat (or the fat beneath the outer skin layer) begins in increase in the belly and on the back of the neck, as well as in the breasts with women and some men. At the same time, fat is often lost from the extremities, face, and buttocks. And since these effects are not generally reversible, you can see why you may want to change now before the condition worsens.
It’s important to note, however, that Stavudine is not the only drug associated with lipodystrophy. It’s, therefore, a good idea to change both your diet and exercise routine to address not only the cosmetic concerns related to lipodystrohy, but the long-term health issues, as well. Primary to this is the increase of so-called visceral fat, or the fat in and around the internal organs, which can increase the risk of coronary disease over time.
So I would definitely suggest a change in diet to a largely non-fat regimen, including replacing butter and saturated fats with cold pressed, extra virgin olive oil. (Cold pressed, extra virgin is vital since studies have shown a correlative reduction in “bad” cholesterol and an increase in “good” cholesterol when using it.) Try also to avoid pasta, white bread, alcohol, and sweets (with the exception of fruit) and include much more lean chicken, beans, whole grain breads, and vegetables. .
In terms of exercise, you will need to focus on resistance training rather than just aerobics. You need to increase lean muscle mass, ideally through controlled weight training, and you really need to work out until you SWEAT. Studies again have shown that this level of training, ideally 3-4 times per week, will generally reduce the fat mass in those on ARVs, thereby reducing the impact of lipodystrophy.
In terms of anaebolic steroids, if you haven’t used them before, don’t start now and particularly not for this. I know that, whatever I say, guys will ignore me when I tell them this, so let me lay down the simple facts:
Whether you are HIV positive or not, unsupervised use of steroids can occasionally result in prostratic inflammation, increased blood pressure, increased liver enzymes, acne, breast enlargement, testicular atrophy, enlargement of red blood cells, and good, old-school “‘roid rage.”

Sure, you might beef up, but so might your breast tissue. Your fat distribution won’t change, but your demeanor likely will. And once you stop the steroids, the gains you may have achieved will generally be short-lived.
And as for those with HIV, recent studies show that the use of the anaebolic steroids nandrolone and oxondrolone not only reduce one’s CD4 cell counts, but increase viral loads. It’s a lose-lose situation.
So that means skim milk and sit-ups are your only hope, right? Not necessarily. The U.S. Food and Drug Administration (FDA) is soon to approve a new drug called tesamorelin (brand name Egrifta®) that may help those with abdominal fat increases associated with ARVs. Egrifta® prompts the pituitary gland to release more growth hormone, which has been shown to promote fat loss in people with lipodystrophy. Two Phase III clinical trials have documented a decrease of up to 18 percent in abdominal fat after treatment, with a favorable side effect profile. Approval of the new drug could happen as early as July.
Clearly the FDA approval won’t affect us immediately (particularly with the hopeless South African Medicines Control Council literally years behind on approvals), but for those with overseas access, there is what looks to be promising treatment soon available.
So thank you for the insightful question. I wish you well, and may all your changes be for the better.
Kind regards,
Dr. D