Differing Presentations of Excess Visceral Abdominal Fat in People Living With HIV: Two Clinical Cases Highlighting Distinct Therapeutic Pathways With Tesamorelin and Glucagon-Like Peptide-1 Receptor Agonists

BACKGROUND: Excess visceral abdominal fat (EVAF) is a prevalent metabolic complication among people living with HIV-1 (PLWH), occurring even in individuals with normal or mildly elevated body mass index (BMI). This pattern of fat accumulation is associated with metabolic dysfunction, cardiovascular risk, and reduced quality of life. Since EVAF can present without generalized obesity, weight-based assessments may fail to identify it; moreover, addressing EVAF warrants distinct approaches based on a patient's presentation. Two therapeutic classes have been studied in this setting: growth hormone-releasing hormone analog (tesamorelin), which selectively reduces visceral fat, and glucagon-like peptide (GLP-1) receptor agonists, which induces generalized weight loss in a nonspecific way. CASE PRESENTATIONS: Two adults with well-controlled HIV presented with central adiposity. The first patient demonstrated a nonobese visceral adiposity phenotype characterized by increased waist circumference (WC) and a BMI of 27 kg/m². Treatment with tesamorelin led to marked reductions in WC, improved lipid levels, and enhanced functional well-being. The second patient, a woman with higher BMI representative of obesity, received a GLP-1; however, her intermittent access to the medication resulted in fluctuating weight trends and persistent abdominal fat. Incorporation of tesamorelin provided a more targeted approach to reduce visceral adiposity in this context. RESULTS: Both cases demonstrated that EVAF may persist independent of BMI category and may respond differently to therapies targeting generalized obesity versus selective visceral abdominal fat. CONCLUSIONS: These cases highlight the heterogeneity of EVAF in PLWH and support individualized management strategies informed by fat distribution rather than weight alone.