Let’s start with what you should not do to manage weight gain: delay or stop HIV treatment. The newest antiretrovirals are highly effective, and keeping the virus under control is the most important thing you can do to improve your overall health.

“There is never any reason to stop antiretroviral therapy, which is lifesaving and incredibly important,” says Monica Gandhi, MD, MPH, director of Ward 86, the HIV clinic at Zuckerberg San Francisco General Hospital.

However, people who are more prone to putting on pounds may consider avoiding meds that are often linked to weight gain. This is now a big enough concern that it’s become one of the many factors to think about when selecting which drugs to use.

“It has become such an issue at Ward 86 that we have started to put weight as one of our baseline criteria when we decide on a regimen,” Gandhi says.

So far, there hasn’t been much research examining whether switching drugs can reverse generalized weight gain, though changing meds has little effect on visceral fat accumulation in people with lipodystrophy.

“We don’t yet know whether switching off of integrase inhibitors or tenofovir alafenamide to alternative drugs will have an effect on weight gain,” says Marshall Glesby, MD, PhD, of Weill Cornell Medical College in New York City. “Changing antiretroviral combinations does not seem to affect lipohypertrophy.”

Preventing weight gain is easier than losing weight. People starting antiretrovirals or switching regimens should have their weight, body mass index and waist circumference measured at the outset and monitored regularly to catch unusual changes as soon as possible. Monitoring blood sugar (glucose) and lipids such as cholesterol and triglycerides is also useful.

Lifestyle changes can help control weight gain in HIV-positive and HIV-negative people alike.

Experts recommend eating a balanced diet rich in plant-based foods and low in unhealthy fats, sugars and processed foods. For example, Steven Grinspoon, MD, director of the Nutrition Obesity Research Center at Harvard, says a Mediterranean diet is a good option.

Exercise is also key. Aim to move more and sit less throughout the day. Federal guidelines recommend at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous activity per week—ideally spread out over multiple days—as well as muscle-strengthening activities. But any amount of physical activity is better than none.

“Exercise is important in two ways,” Grinspoon says. “One, it helps reduce weight, and two, it’s anti-inflammatory. It will help your blood pressure and help your glucose. Getting some exercise every day is very helpful.”

Unfortunately, it can be difficult to lose weight—and especially to reduce visceral fat buildup—with changes in diet and exercise alone.

In some cases, medications may help. Metformin, a drug used to control blood sugar in people with type 2 diabetes, reduces appetite and can lead to weight loss; it also has anti-inflammatory properties. Studies have shown that metformin led to a decline in body weight, reduced visceral fat and improved the health of the gut microbiome in people living with HIV.

Tesamorelin, which mimics a natural hormone produced in the brain, is approved to reduce excess belly fat in HIV-positive people with lipodystrophy. The growth hormone analogue somatropin is approved to treat HIV-related wasting, but studies suggest it may also help reduce visceral abdominal fat.

Other medications can help manage the metabolic abnormalities that often accompany weight gain. Statins, prescribed to lower cholesterol and reduce the risk for heart attacks and strokes, also have anti-inflammatory properties and may offer a two-for-one benefit for people living with HIV. Grinspoon’s team is currently studying this in a large clinical trial called REPRIEVE.

Tips for Your Overall Health

  • Eat a healthy diet.
  • Get enough exercise.
  • Quit smoking.
  • Limit alcohol and drug use.
  • Get adequate sleep.
  • Find ways to reduce stress.