Wasting syndrome was a hallmark of AIDS in the early years of the epidemic, but today, weight gain is a more common problem. One study found that over half of people with HIV struggle with overweight or obesity.

Women with HIV tend to put on more pounds than men, as do Black people compared with white people—meaning Black women are particularly prone to weight gain. Some studies suggest older people and people with a low CD4 T-cell count or a high viral load may be more likely to gain weight.

People with HIV may experience different kinds of weight gain and fat buildup. Visceral fat accumulates deep within the belly surrounding the internal organs. This buildup of internal fat pushes up against the abdominal wall, resulting in a hard belly. Subcutaneous fat—which is soft and pinchable—accumulates beneath the skin, often around the belly, hips and thighs.

In general, weight gain occurs when people consume more calories than they burn. People with HIV may gain weight as they return to health after starting treatment. HIV increases metabolic demands, and stopping viral replication reduces energy expenditure—leading to weight gain if food intake stays the same. Plus, people who feel better tend to eat more.

But that’s not the whole story. Weight gain can occur even among people who start treatment early. Chronic HIV infection can trigger persistent immune activation and inflammation that throws off metabolism and leads to fat buildup.

In recent years, there’s been a growing recognition that some people gain weight when they start antiretroviral therapy or switch regimens. Several studies show that people taking potent integrase inhibitors, such as dolutegravir, are more likely to gain weight. The newer form of tenofovir (tenofovir alafenamide, or TAF) is also more commonly associated with weight gain.

Managing Weight Gain

Excess body weight, especially visceral fat, is linked to a host of health problems. Fat, or adipose tissue, is metabolically active and produces hormones and cytokines that can trigger inflammation. Weight gain often goes hand in hand with metabolic problems, including high blood sugar and abnormal cholesterol and triglyceride levels. People with persistent inflammation and metabolic abnormalities are at greater risk for diabetes, cardiovascular disease, heart attacks and strokes.

Visceral fat can accumulate around the heart and inside the liver and other organs. Over time, fat buildup in the liver can lead to cirrhosis, liver cancer and the need for a liver transplant; excess weight is linked to other types of cancer as well. Obesity can also contribute to cognitive decline and pregnancy complications. What’s more, unwanted weight can have a negative effect on self-esteem, worsen depression and leave people less willing to start or stay on antiretroviral treatment.

For all these reasons, it’s important to maintain a healthy weight—and preventing weight gain is easier than losing it. Lifestyle modification can often help. Experts recommend a balanced diet rich in plant-based foods and low in unhealthy fats, sugars and processed foods.

Aim to move more and sit less. Federal guidelines recommend at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous activity per week along with muscle-strengthening activities—but any amount of physical activity is better than none!

Unfortunately, it can be difficult to lose weight—and especially to reduce visceral fat buildup—with changes in diet and physical activity alone. In some cases, medications may help.

While unwanted weight gain can be distressing, it’s important not to delay or stop HIV treatment due to concerns about gaining weight. If you are putting on more pounds than you want, talk to your doctor about steps you can take to keep your weight under control.