Philadelphia personaltrainer Carla Jones (not her real name) was diagnosed with HIV in 1998. “Some clients look at me,” says Jones, 33, “and ask, ‘How can I get the motivation to work out and be confident in my body like you?’“

If only they knew how hard she has wrestled with her own low self esteem. Three years ago, when her antiretroviral combo gave her lipoatrophy and her rear sagged, she feared she’d lose cred: If she couldn’t get her own bum in shape, why should others pay her to help theirs? “I did lunges and squats,” Jones says. “It helped, but I thought, ‘It’s all about how I carry myself, my attitude.’ I was right. My rear wasn’t perfect, but no one said a thing.”

What about the rest of us mere mortals, with non-trainer butts? For HIV-positive people, mental gymnastics often exaggerate the very real side effects of some meds—or even the possibility of them—to the point of justifying unhealthy behaviors. The condition, body dysmorphia disorder (BDD), is hardly new, but the psychic trauma wrought by the existence (or mere fear of) buffalo humps and rings around the middle (caused by lipohypertrophy) or the loss of subcutaneous fat (caused by lipoatrophy) is finally being studied and charted in all segments of the HIV-positive population.

Long dismissed as a by-product of a disease linked to gay men—stereotyped as narcissists who would exhale their last breath in a sauna—poor or inaccurate body image can lead to eating disorders, steroid and drug abuse, overtraining and sexual compulsion in search of physical approval. In 2005, a multiuniversity study of HIV-positive men and women, straight and gay, found that they perceived their bodies negatively, regardless of whether or not they had visible side effects from HIV or its treatment. In 2004, the International Journal of Men’s Health found that many positive people chase an ever-elusive physical ideal to fight their fear of others looking down on them.

“With many positive clients, I see overcompensation,” Jones says. “They feel [that because of HIV] they don’t own their body anymore.” Jones hands all clients body-image-building guidelines issued by Advocates for Youth (www.advocatesforyouth.org).

Think the effects of BDD aren’t serious? After a brief battle with lipoatrophy, one positive New York City gym rat admitted he “started taking the subway all the way over to New Jersey to work out, thinking no one I knew would see me there.” Ironically, the crowd at the Jersey gym was even more intense and ripped. Rather than paying for two gym memberships and the commute, perhaps he should have paid Jones to help him see right through his bod—to the part that matters most.