Looking at him now, one would never guess that Dan Bueling has HIV, that he takes more than 30 pills a day to manage the infection, or that he once packed little wads of tissue inside his jowls to fill in areas left hollow by the resulting facial wasting.

For Bueling, the subtle changes in his face began appearing just when he was happy, healthy and looking forward to a long life thanks to medical advances in HIV treatment.

Lipoatrophy -- a wasting of facial fat common to people with human immunodeficiency virus that causes the most seriously afflicted to look like walking death -- probably is caused by the ravages of the HIV infection and the medications patients must take to stay alive. The trade-off is one Bueling couldn't take -- and now he doesn't have to.

The Kaiser patient has started using a product called Sculptra, an injectable form of poly-L-lactic acid, a synthetic polymer that has been widely used in dissolvable stitches, bone screws and facial implants.

It comes as a powder that gets reconstituted in sterile water and injected under the deepest layer of skin. The product gets broken down in the body, but in the process, the skin thickens and the face appears fuller.

The improvement to folds and sunken areas of the face means that Bueling, and others like him, can move through life without the visual stigma of an illness.

The U.S. Food and Drug Administration in August 2004 approved the injectable filler to correct facial fat loss in people with HIV infection. It has been sold for years in Europe under the name New-Fill.

Sculptra was the first such treatment approved for lipoatrophy. It does not correct the underlying cause of facial fat loss, but creates a healthier look.

``The nice thing about Sculptra is it removes that telltale sign,'' said Ed Lortz, 62, of San Francisco. He learned about Sculptra after joining a Yahoo message group for people dealing with HIV-related problems.

But it's expensive. One Sculptra treatment costs well over $1,000, and patients need between three and six courses to achieve lasting results. Touch-up work is necessary about every two years.

DuLong and other Kaiser doctors pressed the health maintenance organization to offer Sculptra as a covered benefit, so Kaiser patients pay just $5 per treatment.

Blue Cross of California, Pacificare and Medi-Cal, the state's health insurance for the poor, will cover Sculptra on a case-by-case basis if it's deemed medically necessary.

``On a technical level, facial wasting is a byproduct of the HIV disease process as well as the treatment, so it ought to be dealt with as reconstructive surgery,'' said Dana Van Gorder, a lobbyist with the San Francisco AIDS Foundation who is pushing the state to cover Sculptra and other treatments, such as silicone, for lipoatrophy. Van Gorder's concern is that patients will delay or suspend taking life-saving anti-retroviral drugs for fear of this crippling side effect.

Bueling went off his medications for a full year while he researched options for lipoatrophy, but he doesn't recommend that, and neither do physicians.

Lortz, a retiree, applied for a patient subsidy with the manufacturer, Dermik Laboratories of Berwyn, Pa. He is more or less pleased with the results.

``I feel a very small bump under the skin,'' Lortz said of a side effect of the Sculptra treatment. Patients are advised to massage their face for five minutes, five times a day, for five days to smooth away lumps that might form.

On a recent Friday afternoon, DuLong programmed the XM Satellite Radio in the exam room to the ``Awesome '80s'' station. As Stevie Nicks set the mood, DuLong snapped on a pair of rubber gloves, grabbed a sterile marking pen and began mapping out problem areas on a patient's face.

``Do you agree with the treatment area?'' DuLong asked, handing the patient a mirror so he could see what would be accomplished on this fourth visit. The man nodded and reclined in an exam chair.

Little specks of blood appeared on his face as DuLong first numbed each side with a local anesthetic and then injected Sculptra into multiple areas. The doctor followed each needle pass with a gentle massage to keep the thick solution from clumping up under the skin.

Much of this fast effect is due to swelling and the presence of the liquid under the skin. But when the Sculptra resorbs, the natural collagen that formed around it will remain, providing a gradual and significant increase in skin thickness.

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