This cohort study was conducted amongst female patients manifesting lipoatrophy while receiving
stavudine-containing first-line antiretroviral treatment regimens at two urban health centres in Rwanda. The objectives were to assess weight evolution after
stavudine substitution and to describe any significant difference in weight evolution when
zidovudine or
tenofovir/
abacavir was used for substitution. All adult patients on
stavudine-containing first-line regimens who developed lipoatrophy (diagnosed using a
lipodystrophy case definition study-based questionnaire) and whose treatment regimen was changed were included (n=114). In the most severe cases
stavudine was replaced with
tenofovir or
abacavir (n=39), and in the remainder with
zidovudine (n=75). For patients changed to
zidovudine a progressive
weight loss was seen, while those on
tenofovir/
abacavir showed a progressive weight increase from six months. The between-group difference in weight evolution was significant from nine months (difference at 12 months: 2.3 kg, P=0.02). These differences were confirmed by follow-up lipoatrophy scores. In multivariate analysis, substitution with
tenofovir/
abacavir remained significantly associated with
weight gain. This is the first study in Africa assessing
weight gain as a proxy for recovery after
stavudine substitution due to lipoatrophy, providing supporting evidence that
tenofovir/
abacavir is superior to
zidovudine. The
weight loss with
zidovudine might justify earlier substitution and access to better alternatives like
tenofovir/
abacavir.