Early in the epidemic, people with HIV often lost a dangerous amount of weight--at times looking gaunt and ghostly. But today, the opposite is often true. Many HIVers are struggling with obesity, which has overtaken wasting syndrome as the top concern. And experts say the waistlines of HIVers are growing right along with the girths of the rest of America as the disease shifts from a death sentence to a chronic condition.
Exact numbers are hard to pin down, but research suggests that nearly two thirds of HIVers could be overweight or obese, mirroring the overall U.S. population. Doctors say there's a growing need to screen people with the virus for obesity, which raises the risk of diabetes, high blood pressure, and cholesterol problems.
"We used to worry that they would lose weight and become wasted," says Nancy Crum-Cianflone, MD, MPH, of TriService AIDS Clinical Consortium in San Diego. "Maybe we should redirect our concerns to making sure they are maintaining a healthy, normal weight."
With the treatment advances made in the past decade-plus, more HIVers are living longer than their counterparts did 20 years ago and may be prone to poor eating habits and lack of exercise.
Some experts offer psychological explanations, though. Since the hallmark of HIV has been weight loss, some patients may be piling on the pounds to avoid looking abnormally thin. "It's very clear now that HIV is no longer a wasting disease in America," says John T. Brooks, MD, an epidemiologist at the Centers for Disease Control and Prevention.
Crum-Cianflone became interested in the problem after noticing her patients were steadily getting fat and decided to study how common obesity was in the HIV population. She and her colleagues pored through medical records of 663 patients with HIV at Navy hospitals in San Diego and Bethesda, Md. The researchers analyzed medication records, duration of HIV infection, and whether patients had a history of diabetes or high blood pressure. Up to 63% in the study were overweight or obese. Only 3% were underweight, and none was considered to have HIV-related wasting. Among those who had an AIDS medical diagnosis, about 30% were overweight or obese. The numbers are particularly striking, the researchers say, because most of the people studied were in the military (some were military spouses) and tend to be in better shape than the rest of the population.
The study's leaders did not find a connection between anti-HIV medications and excess weight. When patients gained weight, they point out, they tended to put on an average of 13 pounds over a decade. Those who became infected younger, those who had the virus for a longer time, or those who had high blood pressure were more likely to get fat.
"These folks are in more ways than not becoming like everyone else. If they're overeating, they're going to get fat," says Michael Saag, MD, director of the Center for AIDS Research at the University of Alabama at Birmingham.
"It would be very sad," the CDC's Brooks adds, "to survive HIV and die of something else that was preventable."
At AIDS Project Los Angeles, pudgy HIV patients outnumber the very thin, according to the agency. "Many of our clients don't even know what wasting is. They never knew that look," says Janelle L'Heureux, a nutritionist at the AIDS service organization.
The problem is most evident in people who are poor because they more often eat junk food and don't have money to join a gym. To help overweight HIVers, APLA offers classes on how to read nutrition labels and cook healthful meals. Jack Gebhardt, a 56-year-old client, says he started packing on the pounds after he quit smoking shortly before he was diagnosed with HIV 12 years ago. After working out three times a week, Gebhardt, who is 5 foot 8, went from 217 to 172 pounds. A diabetic who is on disability, he says he cannot afford a gym membership and has seen his weight creep back up to 182. "I'd still like to lose a lot more weight," he says of his struggle to keep the pounds off.