AIDS PATIENT CARE and STDs

Volume 20, Number 10, 2006

© Mary Ann Liebert, Inc.

Body Image in Men with HIV

JEANNIE S. HUANG, M.D., M.P.H.,1,2 DANIEL LEE, M.D..3 KAREN BECERRA, D.D.S.,1
ROSANNE SANTOS, B.S.,1 ED BARBER, M.P.H.,3
and W. CHRISTOPHER MATHEWS, M.D., M.S.P.H.3

ABSTRACT

Objective: To determine body image among HIV-infected men and to determine the rela-
tionship of lipodystrophy on body image. Methodology: Self-report questionnaires on body
image were distributed to HIV-infected men at the university-based HIV clinic. Two previ-
ously validated instruments, the Body Image Quality of Life (BIQLI) scale and the Situational
Inventory of Body Image Dysphoria Short Form (SIBID-S) were used to measure body im-
age effects. The presence of lipodystrophy was determined by both self-report and physician
examination. Demographic characteristics, disease stage, health status, and quality of life were
also ascertained. Analysis of responses was performed via both group comparisons and lin-
ear regression analyses. Results: One hundred ten men responded. Seventy-one percent iden-
tified their sexual orientation as men having sex with men (MSM). Forty-eight reported the
presence of lipodystrophic characteristics; 62 reported no lipodystrophic changes. Agreement
regarding the presence of lipodystrophy between physician and subject was 0.80 as measured
by the kappa coefficient of agreement. Compared to HIV-infected men who denied lipodys-
trophy, HIV-infected men with self-reported lipodystrophy demonstrated poor body image
as measured by BIQLI (p  0.0001) and SIBID-S scales (p  0.0001). Similarly, physician rated
lipodystrophy was significantly associated with both body image subscale scores. Conclu-
sions: We demonstrate that lipodystrophy among HIV-infected men is associated with poor
body image.

INTRODUCTION nificant body habitus changes. In particular,

the HIV lipodystrophy syndrome is a recog-

H IV INFECTION OVER THE PAST decades has

been associated with a variety of changes
in body habitus. Prior to the development of
highly active antiretroviral therapy (HAART),
significant weight loss and AIDS wasting had
a negative impact on patients’ quality of life
and body image.1,2 In the post-HAART era,
HIV infection and treatment with antiretrovi-
ral therapy is associated with different but sig-
nized complication of potent antiretroviral
therapy that is characterized by often dramatic
changes in various body fat stores, both central
and peripheral.3,4 Body habitus changes asso-
ciated with the lipodystrophy syndrome in-
clude increased visceral adiposity, hypertro-
phy of the posterior cervical fat pad (“buffalo
hump”), and subcutaneous fat atrophy at the
extremities and face. While many studies have

1Department of Pediatrics, University of California, San Diego, California.

2Children’s
Hospital, San Diego, California.
3Department of Medicine, University of California, San Diego, California.

668
BODY IMAGE IN MEN WITH HIV
demonstrated impaired psychosocial function-
ing with the lipodystrophy syndrome as well
as a negative impact on quality of life and sex-
ual behavior, there has not been a formal study
to evaluate the effects such physical changes
have on body image.5–9
We investigated body image in HIV-infec-
tion among HIV-infected men receiving care at
the UCSD Owen Clinic in San Diego, Califor-
nia. Our a priori hypothesis was that men with
HIV and lipodystrophy would have significant
body image dysphoria and reduced body im-
age-related quality of life.
METHODS
Participants and Setting
The study protocol was approved by the
University of California, San Diego Human
Research Protections Program prior to study
performance. One hundred ten HIV-infected
subjects were recruited from an academic mul-
tidisciplinary adult HIV clinic in San Diego.
Male patients were approached during regular
clinic visits by their primary physician and
asked if they would like to participate in the
study. Informed consent was obtained prior to
any and all study procedures.
Questionnaires
The Body Image Quality of Life Inventory
(BIQLI) is a clinical assessment of how an in-
dividual’s body image impacts his or her life.
The BIQLI uses a 7-point response format rang-
ing from very negative (3) to very positive
(3) effects of body image on 19 life do-
mains.10,11 The 19-item BIQLI is internally con-
sistent and has been demonstrated to converge
significantly with multiple measures of body
image evaluation as well as with body mass.
The BIQLI is valuable for quantifying how per-
sons’ body image experiences affect a broad
range of life domains, including sense of self,
social functioning, sexuality, emotional well-
being, eating, exercise, grooming, etc. The
BIQLI is scored as an average numeric score of
the 19 items where a more negative score re-
flects a more negative body image.
The Situational Inventory of Body-Image
669
Dysphoria (SIBID) is an assessment of the fre-
quency of negative body-image emotions
across specific situational contexts. This inven-
tory asks respondents how often they experi-
ence body-image dysphoria or distress (ac-
cording to a numeric range of 0 [never] to 4
[always]) in each of 48 identified situations in-
cluding both social and nonsocial contexts and
activities related to exercising, grooming, eat-
ing, intimacy, physical self-focus, and appear-
ance alterations. Research has confirmed that
this is an internally consistent, stable, and con-
vergently valid measure of body-image affect
that is responsive to body-image therapy.12–15
Recently, a 20-item short form of the SIBID has
been validated and found to correlate highly
(r  0.95) with the original longer version.16
The short form of the SIBID (SIBID-S) was used
in this study. The SIBID-S is scored as the nu-
meric mean score of its 20 items where a higher
score is associated with increased body image
dysphoria.
The Euroqol Visual Analogue Scale (EQ
VAS) is part of the Euroqol-5D (EQ-5D) devel-
oped to describe and value current health sta-
tus.17 It consists of a 20-cm visual analogue
scale that has end points labeled “best imagin-
able health state” and “worst imaginable health
state” anchored at 100 and 0, respectively. Re-
spondents are asked to indicate how they rate
their own health by drawing a line from an an-
chor box to that point on the EQ-VAS which
best represents their own health on that day.
Additional items of EQ-5D include: mobility,
self-care, usual activities, pain/discomfort, and
anxiety/depression.
In addition to the above questionnaires, sub-
jects were asked to identify the location of their
body changes, and to state whether others no-
ticed their body changes and whether they felt
that their disease status was revealed to
strangers based on their body changes.
Study procedures
After study procedures were reviewed and
informed consent was obtained, subjects were
asked to answer the self-administered ques-
tionnaires during their usual clinic visit. A
physical examination was also performed by
one of two study physicians to determine pres-
670
ence or absence of lipodystrophy. In their de-
termination of the presence of lipodystrophy,
study physicians were asked to assess 6 spe-
cific body areas for changes in fat distribution:
face, neck and shoulder, arms, abdomen, but-
tocks and legs, and breasts using a 0- to 2-point
scale with half-point increments to determine
severity18 and then globally assess for presence
or absence of lipodystrophy. Both study physi-
cians assessed lipodystrophy changes concur-
rently in 11 randomly selected subjects to de-
termine concordance. Subjects were also asked
to categorize themselves as having lipodystro-
phy or not and to identify where fat atrophy or
hypertrophy had occurred. Additional data in-
cluding most recent CD4 count, viral load, and
health-related quality of life measures (EQ-5D)
were also obtained from the medical record.
In a subset of 20 subjects, both the BIQLI and
SIBID-S questionnaires were repeated after a
minimum period of 1 month and prior to a
maximum period of 1 year in order to estimate
test–retest reliability within an HIV-infected
sample. Fifty-five percent of the 20 subjects re-
ported that they had lipodystrophy. Self-re-
ported lipodystrophy status did not change
over time in any subject.
Response coding
Racial response categories included: white,
black, Hispanic, Asian, or other; for the pur-
poses of regression analysis, these groups were
collapsed according to Caucasian or non-Cau-
casian origin. Self-reported lipodystrophy sta-
tus and clinician-determined lipodystrophy
status were coded as present or absent. HIV
disease status was coded as meeting AIDS di-
agnostic criteria or not. Sexual orientation was
coded as men having sex with men (MSM) or
other. For regression analyses, age in years was
represented by decade of life and CD4 count
was coded per 100 cells per microliter. HIV
plasma viral load was log10-transformed prior
to analysis and specimens reported as “unde-
tectable viral load” were coded as 400 copies
per milliliter. The depression and anxiety mea-
sure on the EQ-5D was coded as present or ab-
sent. The EQ VAS was coded according to 10
point increments from 0 to 100. Patient re-
ported body site changes were coded as no
HUANG ET AL.
change, fat hypertrophy, or fat atrophy.
Whether others noticed a given subject’s body
changes and whether the subject believed that
his disease status was revealed to strangers
based on his body changes were coded as yes
or no. BIQLI and SIBID-S scores were not mod-
ified.
Statistical analysis
Patients reporting presence or absence of
lipodystrophy were compared according to se-
lected measures using 2 statistics for categor-
ical variables and the Wilcoxon rank sum test
for continuous variables. Body image scale
scores were also compared between patients
with and without clinical lipodystrophy using
the Wilcoxon rank sum test. Body-site–specific
comparisons of mean SIBID-S and BIQLI scores
according to patient and physician reported
change (no change, fat hypertrophy, and fat at-
rophy) were performed using one-way analy-
sis of variance (ANOVA) and pairwise com-
parisons with the “no change” response as
control group were performed using Dunnett’s
test.19 In order to identify independent variable
associations with BIQLI and SIBID-S scores,
stepwise multiple linear regression models
were fit (p  0.25 to enter, p  0.10 to exit).
Among subjects who repeated body image
scales within 1 year, stability of scale scores
over time was evaluated using paired t test
analysis. Statistical analyses were performed
using JMP 5.0 (SAS Institute, Inc., Cary, NC).
RESULTS
Demographics
One hundred ten HIV-infected men partici-
pated in our survey study. Seventy-six percent
of approached patients agreed to participate.
Recruited subjects did not differ from nonre-
cruited subjects by age (p  0.15), lipodystro-
phy status (p  0.16), or race (Caucasian versus
non-Caucasian, p  0.19). Demographic data
are displayed in Table 1. HIV-infected men re-
porting lipodystrophy were older than those
not reporting lipodystrophy, but there were no
differences in sexual orientation or racial di-
versity between groups. CD4 counts were
BODY IMAGE IN MEN WITH HIV 671

TABLE 1. POPULATION DEMOGRAPHICS

HIV-positive p value between

HIV-positive with without lipodystrophy
Entire cohort lipodystrophya lipodystrophya groups

Number of persons 110 48 62

Age (years)b 44 (38, 50) 45 (39, 51) 42 (38, 47) 0.02c
Race 26% Hispanic, 25% 27% 0.22d
8% black, 2% 13%
59% white, 67% 52%
1% Asian, 0% 2%
6% other 6% 6%
Sexual orientation 78: 32 38: 10 40: 22 0.09d
(MSM: not)
CD4 count 421 (236, 578) 467 (307, 664) 344 (217, 545) 0.04c
(cells/L)b
Log10 HIV viral load 2.6 (2.6, 2.6) 2.6 (2.6, 2.6) 2.6 (2.6, 3.6) 0.17c
(copies/mL)b
AIDS: (yes: no) 72: 38 36: 12 36: 26 0.06d
SIBID-S scoreb 2.1 (1.6, 2.7) 1.3 (0.6, 2.0) 0.0001c
BIQLI scoreb 0.6 (1.2, 0.3) 0.5 (0.3, 1.6)  0.0001c
EQ VAS scoreb 75 (65, 80) 80 (60, 90) 0.51c
Depression and 28% 25% 0.74d
anxiety reported on
EQ 5D (%)
Believe that 55% 11%  0.0001d
appearance reveals
HIV status (%)
aAs reported by the patient.
bExpressed as median (interquartile range).
cp value by Wilcoxon rank sum test.
dp value by 2 statistics.

MSM, men who have sex with men; SIBID-S, Situational Inventory of Body Image Dysphoria-Short Form; BIQLI,
Body Image Quality of Life Inventory; EQ VAS, Euroqol Visual Analogue Scale; EQ 5D, Euroqol-5D.

higher in patients with self-reported lipodys-
trophy, but viral loads were similar between
groups. AIDS status did not differ between
groups.
Lipodystrophy assessment results
Concordance between physician and self-de-
termination of lipodystrophy status was 0.80 as
determined by the  coefficient of agreement.
Between the two study physicians, agreement
regarding absence or presence of lipodystro-
phy was 91% (both assessed 11 randomly se-
lected subjects). In contrast, site-specific as-
sessment of changes in body fat by physician
and patient did not correlate well; a statistic
ranged from 0.22 to 0.4 depending on body site.
Body Image and Lipodystrophy Status
Self-reported lipodystrophy was signifi-
cantly associated with both body image sub-
scales. Forty-eight men reported lipodystro-
phy; 62 denied lipodystrophy. HIV-positive
men with self-reported lipodystrophy had sig-
nificantly lower BIQLI scores as compared to
HIV-infected men who denied lipodystrophy
(mean  standard error of the mean [SEM]:
0.3  0.2 versus 0.6  0.2, HIV-infected with
lipodystrophy versus HIV-infected without
lipodystrophy, respectively, p  0.0001 [Fig.
1]). HIV-positive men with self-reported
lipodystrophy also reported higher SIBID-S
scores compared to HIV-infected men who de-
nied lipodystrophy (2.1  0.1 versus 1.4  0.1,
HIV-infected with lipodystrophy versus HIV-
infected without lipodystrophy, respectively,
p  0.0001 [Fig. 2]). Among subjects who un-
derwent repeated testing within a 1-year pe-
riod, BIQLI (p  0.54) and SIBID-S scores (p 
0.96) remained stable over time.
Specific patient-reported lipodystrophy
changes (i.e. fat atrophy or hypertrophy) were
672 HUANG ET AL.

dystrophy (as defined by physician assessment)

and poor body image quality of life (BIQLI); ad-
ditional associations with poor body image
quality of life were found with Caucasian race
identification and reported anxiety and depres-
sion, as measured by EQ-5D. In a similar anal-
ysis, situational anxiety (SIBID-S) regarding
body image in men with HIV-infection was pre-
dicted by age, presence of depression, and by
subjects’ responding that their HIV-therapy in-
duced body changes (lipodystrophy) were evi-
dent to others. Results are displayed in Table 3.
Stepwise regression analyses were also per-
formed to determine which site-specific pa-
tient-identified fat changes predicted situa-
FIG. 1. Distribution of Body Image Quality of Life
(BIQLI) score by patient self-reported lipodystrophy tional anxiety and affected body image quality
(LPD). of life. Important associations between abdom-
inal hypertrophy (reference  no change,  
0.31, p  0.01), leg atrophy (reference  no
also significantly associated with both body im-
change,   0.57, p  0.002), and buttock atro-
age scales (Table 2). In particular, fat changes at
phy (reference  no change and buttock hy-
the breast, abdomen and buttocks were strongly
pertrophy,   0.33, p  0.01) and BIQLI
associated with BIQLI scores. Similarly, fat
scores were identified (whole model r2  0.23,
changes at the face, neck, arm, and abdomen
p  0.0004). Likewise, significant associations
were strongly associated with SIBID-S scores.
were found between facial change (reference 
Similarly, physician-rated lipodystrophy was
no change,   0.20, p  0.05) and SIBID-S
significantly associated with both body image
scores (whole model r2  0.19, p  0.0002).
subscale scores. Fifty-three men demonstrated
clinical evidence of lipodystrophy; 57 did not.
HIV-positive men with clinical lipodystrophy
DISCUSSION
had significantly lower BIQLI scores compared
to HIV-infected men who did not have clinical We performed an observational study among
lipodystrophy (mean  SEM: 0.3  0.2 ver- HIV-infected men in care to determine whether
sus 0.6  0.2, HIV-infected with lipodystrophy
versus HIV-infected without lipodystrophy re-
spectively, p  0.003). HIV-positive men with
clinical lipodystrophy also reported higher
SIBID-S scores compared to HIV-infected men
without clinical lipodystrophy (2.0  0.1 ver-
sus 1.4  0.1, HIV-infected with lipodystrophy
versus HIV-infected without lipodystrophy re-
spectively, p  0.002).
Fifty-five percent of HIV-infected men with
self-reported lipodystrophy compared to 11% of
HIV-infected men without lipodystrophy be-
lieved that others knew their HIV disease status
based solely on their appearance (p  0.0001).

Stepwise multiple linear regression analyses

FIG. 2. Distribution of Situational Inventory of Body Im-
Stepwise multiple linear regression analysis age Dysphoria Short Form (SIBID-S) score by patient self-
identified important associations between lipo- reported lipodystrophy (LPD).
BODY IMAGE IN MEN WITH HIV 673

TABLE 2. PATIENT REPORTED SITE-SPECIFIC FAT CHANGES AND BODY IMAGE SCALE SCORES

Body site Fat change SIBID-S p valuea BIQLI p valuea

Face Fat hypertrophy 1.9  0.4 0.003 0.1  0.4 0.06

Fat atrophyb 2.0  0.1 0.2  0.2b
No change 1.4  0.1 0.4  0.2
Neck Fat hypertrophy 2.0  0.3 0.02 0.4  0.3 0.06
Fat atrophyb 2.4  0.3 0.3  0.1
No change 1.6  0.1 0.3  1.3
Arm Fat hypertrophy 1.8  0.8 0.008 0.6  0.7 0.27
Fat atrophyb 2.1  0.2 0.1  0.2
No change 1.5  0.1 0.3  0.2
Breast Fat hypertrophy 3.0  0.4 0.07 0.2  0.3 0.03
Fat atrophy 1.6  0.3 1.2  0.5
No change 1.7  0.1 0.3  0.1
Abdomen Fat hypertrophyb 2.0  0.1 0.008 0.2  0.2b 0.004
No change 1.4  0.1 0.5  0.2
Leg Fat hypertrophy 1.9  0.5 0.10 0.01  0.1 0.93
Fat atrophy 1.9  0.2 0.2  0.2
No change 1.5  0.1 0.2  0.2
Buttock Fat hypertrophy 1.9  0.1 0.16 0.9  0.6b 0.02
Fat atrophy 1.8  0.6 0.3  0.2
No change 1.5  0.1 0.4  0.2

Note: Body Image Scale scores reported as mean  standard error of the mean (SEM).
aBody site-specific p value from one-way analysis of variance (ANOVA) comparison.
bDenotes significant difference between group means as determined by Dunnett’s test comparing fat change group

to “no change” control.

SIBID-S, Situational Inventory of Body Image Dysphoria-Short Form; BIQLI, Body Image Quality of Life Inventory.

self-perceived lipodystrophy status affects have significant heightening of their situational

body image and quality of life. Our findings
suggest that somatic changes interpreted as
lipodystrophy are associated with body image
in HIV-infected men.
Body image encompasses an individual’s
body-related self-perceptions and self-atti-
tudes, and includes thoughts, feelings, beliefs,
and behaviors.20 As such, dramatic alterations
in body appearances, such as is seen in HIV
lipodystrophy, can distort the function and ex-
perience of the human body and such experi-
ences and conditions of embodiment can have
significant effects on psychosocial well-being
and quality of life. Evidence of negative effects
has already been demonstrated in persons af-
fected by AIDS wasting.21 In this study, we
demonstrate evidence of detrimental conse-
quences on body image in men affected by the
HIV lipodystrophy syndrome.
Lipodystrophy status in our study was de-
fined both by subject and physician. Concor-
dance of lipodystrophy status between subject
and study physician was high. Regardless of
the method of definition, HIV-infected men
with lipodystrophic changes were found to
anxiety regarding their body image and re-
duction in their body image related quality of
life as compared to HIV-infected men without
lipodystrophic changes. In addition, clinically
evident or perceived evidence of lipodys-
trophic body changes were important factors
predictive of poor body image measures.
In contrast to assessment of global lipodys-
trophy status (present or absent), site-specific
assessment of lipodystrophy by physician and
patient did not correlate. Such differences in
opinion between physician and patient may re-
flect differences in personal and cultural ideals
regarding certain body parts. Thus, while
study physicians assessed subjects based on
how they differed from the typical male habi-
tus, study participants may have been com-
paring their own body parts to perceived ideals
and thus assessed presence or absence of fat
change according to how they perceived anti-
retroviral therapy may have distorted their
body away from this ideal.
Studies indicate that the typical Western so-
ciety male prefers a muscular body.22,23 In
lipodystrophy, loss of fat in the leg region in-
674 HUANG ET AL.

TABLE 3. STEPWISE MULTIPLE LINEAR REGRESSION ANALYSES ON BODY

IMAGE MEASURES AND SELECTED PATIENT CHARACTERISTICS

Variable Estimate Standard error p value

Dependent variable: BIQLI, r2  0.29, whole model p  0.001

Presence of clinical lipodystrophy 0.33 0.14 0.02
(no clinical lipodystrophy)
Caucasian (not Caucasian) 0.33 0.12 0.005
Age (by decade) 0.19 0.14 0.18
Depression and anxiety 0.38 0.14 0.007
(no depression or anxiety on EQ-5D)
Others have noticed body changes 0.23 0.44 0.10
(others have not noticed body changes)
EQ VASa 0.01 0.01 0.16

Dependent variable: SIBID-S, r2  0.36, whole model p  0.0001

Self-reported lipodystrophy 0.14 0.11 0.21
(no patient reported lipodystrophy)
Age (by decade) 0.25 0.10 0.01
Others have noticed body changes 0.43 0.11 0.0002
(others have not noticed body changes)
Depression and anxiety 0.19 0.09 0.05
(no depression or anxiety on EQ-5D)
HIV viral load (log10 RNA copies/mL) 0.06 0.09 0.47

Note: The reference group is presented after each variable in parentheses.

aScaled according to 10-point increments from 0 to 100.
BIQLI, Body Image Quality of Life Inventory; EQ-5D, Euroqol 5D; EQ VAS, Euroqol Visual Analogue Scale; SIBID-
S, Situational Inventory of Body Image Dysphoria-Short Form.

creases definition of muscles and results in an
apparent “toned” appearance. This may ex-
plain the positive effect of fat atrophy in this
region on body image quality of life in our
study population. In contrast, loss of fat in the
gluteal region significantly reduces buttock
size and leads to an atrophic, flattened ap-
pearance, which may explain the negative ef-
fect of fat atrophy compared to fat hypertrophy
or no change in the gluteal region on body im-
age quality of life in our study. Lipodystrophy
is also associated with increased fat in the ab-
dominal region which can result in a “pot
belly” appearance. Persons with increased ab-
dominal girth are often perceived as having
physical activity limitations and diminished
cardiovascular fitness. In our study population,
increased abdominal fat was associated with a
negative effect on body image quality of life. In
contrast to directional effects of fat changes in
other locations, facial fat changes in either di-
rection appeared to have negative effects on sit-
uational anxiety in our study population. Such
findings may reflect societal biases and pre-
judgments regarding certain facial appear-
ances. In particular, facial fat atrophy is often
associated with malnutrition, poor disease sta-
tus and even AIDS. Conversely, facial fat hy-
pertrophy is often associated with obesity and
lack of cardiovascular fitness. While our analy-
ses of specific body fat changes in relation to
body image measures highlight important as-
sociations, these analyses were not sufficiently
powered for in this study. Therefore, reported
nonsignificant associations between specific fat
changes and body image measures require ad-
ditional verification.
Age and race also appeared to have effects
on body image in our study population. In par-
ticular, increasing age appeared to reduce sit-
uational anxiety in situations where attention
was brought to a subject’s body. These results
are validated by the general observation that
increasing age and life experience appear to re-
duce obsessions with body image that can be
prevalent among younger populations. In ad-
dition, reductions in body image related anx-
iety have been previously shown amongst
older women as compared to their junior coun-
terparts.24 Although our study population is
male, these findings among women may nev-
ertheless be relevant to our findings since prior
BODY IMAGE IN MEN WITH HIV
research has indicated that femininity among
gay men may explain the demonstrated higher
levels of body dissatisfaction among gay men
as compared to heterosexual men (71% of our
male study population reported MSM sexual
preference).25–27 Conversely, Caucasian race in
our study population appeared to increase neg-
ative body image effects on quality of life. Iden-
tification with the Western and mainly Cau-
casian concept of body ideals may amplify
body image effects on quality of life. Such dif-
ferences in body image between Westerners
and non-Westerners have been demonstrated
by other researchers.28
Of concern, persons with lipodystrophy
were more likely to feel that their HIV status
was discernible by the body changes induced
by antiretroviral medications compared to
persons without lipodystrophy. Such find-
ings have similarly been reported by another
group.29 Prior studies demonstrate continued
fears of discrimination and social stigmatiza-
tion amongst HIV-infected persons when con-
sidering disclosure of their HIV status.30–32 HIV
disease remains a social stigma in American so-
ciety33–37; and HIV-infected persons who have
disclosed their status often experience discrim-
ination. Although notable efforts are made to
keep HIV status confidential, such protections
may not provide any safeguard against dis-
crimination if overt body changes expose dis-
ease status.
Despite the notable evidence that body im-
age can be an important factor in psychosocial
well being, medical treatment adherence, and
quality of life, patients’ body image concerns
are not usually explicitly addressed by clini-
cians, even in cases of obvious disfigurement
such as HIV lipodystrophy.1,2,5–9,38 Such be-
nign neglect may reflect physicians’ discomfort
with and/or lack of skill at addressing such is-
sues.38 The necessity for clinicians to address
this important issue is underlined by the detri-
mental impact of lipodystrophy on medical
compliance with antiretroviral therapy.39–41 In-
stituting routine body image screening proce-
dures can provide the clinician with a stan-
dardized method to better understand the full
spectrum of body image concerns that patients
experience and result in better communication
between physician and patient. In addition,
675
such methods would allow identification of
persons for whom body image treatment
would be necessary and provide for early in-
tervention and perhaps improved outcome. Fi-
nally, our findings suggest that potential body
image concerns issues should be addressed and
discussed between physician and patient when
selecting initial antiretroviral regimens.
Last, given the notable disfigurement both
physically and psychosocially that occurs in
persons affected by HIV lipodystrophy, plastic
surgery care options have been increasingly
sought by affected patients. Currently, such
procedures are not routinely covered by insur-
ance or medical coverage plans. Nevertheless,
aesthetic procedures in other patient groups
have been demonstrated to result in significant
improvement in self esteem, body image and
quality of life measures.42–44 Given that body
image can have a negative impact on medical
compliance with antiretroviral treatment and
thus affect future health outcomes, cost-benefit
analysis of aesthetic procedures as a means to
improve health quality and reduce anticipated
health morbidities and costs should be per-
formed.
Interpretation of our results is subject to a
number of limitations. First, this was a cross-
sectional evaluation. As a result, we were not
able to compare how lipodystrophy directly af-
fects body image by assessing body image be-
fore and after somatic changes. Nevertheless,
once somatic changes occurred, body image ef-
fects appeared to remain stable over time as
measured in a subset of our population. Sec-
ond, our recruitment method may have pro-
moted selection bias given that physician re-
ferral was required. However, all patients in
any given clinic where recruitment occurred
were approached by attending physicians for
study participation. In addition, demographics
of patients that refused participation did not
significantly differ from the study population.
Third, what is referred to as lipodystrophy syn-
drome is not a homogeneous entity and varies
in severity. By ascertaining its presence in a bi-
nary fashion (presence or absence), the rela-
tionship between degrees of lipodystrophy and
magnitude of body image change could not be
evaluated. Although we were able to further
assess the effects of lipodystrophy on body im-
676
age by performing analyses according to di-
rectional site-specific change, we did not assess
magnitude in these additional analyses.
Fourth, although lipodystrophy in multiple re-
gression analysis was significantly associated
with body image, as assessed by the BIQLI and
SIBID-S questionnaires, there remains a signif-
icant portion of variability not explained by our
current model. Further study is therefore
needed to better assess the relationship be-
tween lipodystrophy and body image and the
contribution of lipodystrophy to the deteriora-
tion of body image in the HIV-infected popu-
lation.
In conclusion, notable body image dyspho-
ria and anxiety is demonstrated in HIV-in-
fected men with lipodystrophy. Universal ef-
forts should be made in the HIV medical
community to recognize body image issues in
this population so that appropriate interven-
tion and support may be provided.
ACKNOWLEDGMENTS
We would like to thank the Owen Clinic and
staff for their generous support and help in per-
forming this study.
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Address reprint requests to:
Jeannie Huang, M.D., M.P.H.
200 West Arbor Drive, MC 8450
San Diego, CA 92103
E-mail: jshuang@ucsd.edu