Changes in systemic gonadal and adrenal steroids in asymptomatic human immunodeficiency virus-infected men: relationship with the CD4 cell counts

Prevalence of Hypogonadism and Associated Risk Factors among Newly Diagnosed ART Naïve HIV-Infected Males in Mwanza, Tanzania

Background

Hypogonadism is frequent among HIV-infected males and might have significant clinical impact leading to sexual impairment and metabolic derangement. There is limited information about the magnitude of hypogonadism and its associated factors among people living with HIV in Tanzania. We aimed to determine the prevalence of hypogonadism and associated risk factors among newly diagnosed ART naïve HIV-infected men in Mwanza, Tanzania.

Methods

Newly diagnosed ART naïve HIV-infected men were enrolled at Voluntary Counseling and Testing Centres of four selected hospitals in the Mwanza region and subjected to thorough clinical and general physical examination including anthropometric measurements. A prestructured questionnaire was used to collect sociodemographic characteristics and clinical data. Serum total testosterone, follicle-stimulating hormone, luteinizing hormone, and estradiol were estimated. Serum total testosterone <300 ng/dl or testosterone >300 ng/dl with high LH and FSH (compensatory hypogonadism) was taken as markers of hypogonadism. Data were analyzed using STATA version 15.

Results

Of the 388 enrolled participants, hypogonadism was found in 47.9%, with secondary hypogonadism (83.9%, 156/186) being the most frequent form. Logistic regression analysis showed a significant association between hypogonadism and CD4+ count (OR 2.0; 95% CI 1.1-3.6; p=0.022), decreased libido (OR 1.6; 95% CI 1.1-2.4; p=0.024), age of above 46 years (OR 2.3; 95% CI 1.1-4.6; p=0.023), herbal medicine use (OR 2.4; 95% CI 1.5-3.9; p < 0.001), WHO clinical stage 3 (OR 2.7; 95% CI 1.4-5.2; p=0.003), and weight loss (OR 1.8; 95% CI 1.1-3.0; p=0.016).

Conclusion

Hypogonadism was found in nearly half (47.9%) of ART naïve HIV-infected men. The majority (83.9%) had secondary hypogonadism. There was a significant association of hypogonadism with older age, herbal medicine use, weight loss, advanced clinical stage, CD4+ count, and decreased libido.

Hair levels of steroid, endocannabinoid, and the ratio biomarkers predict viral suppression among people living with HIV/AIDS in China

BACKGROUND

Predicting viral suppression early is crucial to improving treatment outcomes among people living with HIV/AIDS (PLWH) in clinics. Viral suppression is affected by stress, making stress indicators a potential predictive factor. Most of previous studies used the self-report questionnaire as stress indicators, but there were great drawbacks due to its subjective. In contrast, end products of neuroendocrine systems such as hypothalamic-pituitaryadrenal (HPA) and hypothalamic-pituitary-gonadal (HPG) axes and endogenous cannabinoid system (ECS) that involved in regulating stress as objective stress indicators are urgently needed to predict viral suppression. Therefore, this study aimed to investigate whether neuroendocrine indictors can strongly predict viral suppression among PLWH in China.

METHODS

This cross-sectional study recruited 1198 PLWH on antiretroviral therapy (ART) in Guangxi, China. The concentrations of steroids (i.e., cortisol, cortisone, dehydroepiandrosterone, testosterone and progesterone) and endocannabinoids (i.e., N-arachidonoyl-ethanolamine and 1-arachidonyl glycerol) in hair were quantitated using the LC-APCI+-MS/MS method. To screen biomarkers that were used to predict viral suppression, association between hair biomarkers and viral suppression was examined by Mann-Whitney U test and partial correlation analyses. Receiver operating characteristic (ROC) curves and binary logistic regression based on the optimal classification threshold determined with ROC curves were used to estimate the prediction effects of the screened biomarkers on viral suppression (HIV-1 RNA < 200 copies/mL).

RESULTS

Hair levels of dehydroepiandrosterone (DHEA), and N-arachidonoyl-ethanolamine (AEA), and the cortisol to DHEA ratio exhibited significant intergroup differences (ps < 0.05) and were correlated with HIV viral load (ps < 0.05). Hair DHEA concentrations strongly predicted viral suppression, showing good classification performance (area under the ROC curve = 0.651, p < 0.01) and strong predictive utility (adjusted odd ratio = 2.324, 95 % confidence interval = 1.211-4.899, p < 0.05) with an optimal threshold of 10.5 pg/mg. A hair AEA concentration of 2.4 pg/mg was the optimal threshold for predicting viral suppression based on good classification performance (area under the ROC curve = 0.598, p < 0.05) and predictive power (adjusted odd ratio = 2.124, 95 % confidence interval = 1.045-4.244, p < 0.05). In hair levels of cortisol to DHEA, viral suppression was observed to be highly predictive, with a threshold of 10.5 pg/mg being optimal for classification (area under the ROC curve = 0.624, p < 0.05) and prediction (adjusted odd ratio = 0.421, 95 % confidence interval = 0.201-0.785, p < 0.05).

CONCLUSION

Hair levels of DHEA, and AEA and the cortisol to DHEA ratio were screened and verified to have significant predictive power with optimal thresholds for predicting viral suppression in a large-scale cohort. The data may provide new insights into predictors of successful virological outcomes and inform public health intervention and clinical practice to assist PLWH in achieving and sustaining viral suppression.

Testosterone, HIV, and cardiovascular disease risk

There has been a recent increase in the use of testosterone supplementation among young adults in the United States, despite the controversy of testosterone replacement therapy (TRT) and cardiovascular safety. The lower testosterone levels and earlier age of TRT use in persons living with HIV (PLHIV) is of particular relevance for this population because cardiovascular disease (CVD) comorbidities are known to be increased among PLHIV. There is very limited data on TRT in PLHIV, as such, in this article, we sought to compile current evidence regarding the diagnosis and management of testosterone deficiency and its link to CVD risk including among PLHIV.

Effects of Testosterone on Serum Concentrations, Fat-free Mass, and Physical Performance by Population: A Meta-analysis

Testosterone (T) administration (TA) increases serum T and fat-free mass (FFM). Although TA-mediated increases in FFM may enhance physical performance, the data are largely equivocal, which may be due to differences in study populations, the magnitude of change in serum T and FFM, or the performance metrics. This meta-analysis explored effects of TA on serum T, FFM, and performance. Associations between increases in serum T and FFM were assessed, and whether changes in serum T or FFM, study population, or the performance metrics affected performance was determined. A systematic review of double-blind randomized trials comparing TA versus placebo on serum T, FFM, and performance was performed. Data were extracted from 20 manuscripts. Effect sizes (ESs) were assessed using Hedge's g and a random effects model. Data are presented as ES (95% confidence interval). No significant correlation between changes in serum T and FFM was observed (P = .167). Greater increases in serum T, but not FFM, resulted in larger effects on performance. Larger increases in testosterone (7.26 [0.76-13.75]) and FFM (0.80 [0.20-1.41]) were observed in young males, but performance only improved in diseased (0.16 [0.05-0.28]) and older males (0.19 [0.10-0.29]). TA increased lower body (0.12 [0.07-0.18]), upper body (0.26 [0.11-0.40]), and handgrip (0.13 [0.04-0.22]) strength, lower body muscular endurance (0.38 [0.09-0.68]), and functional performance (0.20 [0.00-0.41]), but not lower body power or aerobic endurance. TA elicits increases in serum T and FFM in younger, older, and diseased males; however, the performance-enhancing effects of TA across studies were small, observed mostly in muscular strength and endurance, and only in older and diseased males.

Hypogonadotropic hypogonadism in human immunodeficiency virus-infected men: uncommonly low testosterone levels

Hypogonadotropic hypogonadism (HH) is common and occurs prematurely in HIV-infected men. However, HH with very low testosterone has not been described. Three men with normal pubertal development and HIV1 diagnosis at the ages of 22, 34 and 35 years. All complained of decreased libido, anejaculation and erectile dysfunction thirteen years, six months and one year after HIV diagnosis, respectively. Two had depressive syndrome and two were treated with antiretroviral therapy. Laboratory tests revealed isolated HH in all. Sellar and head CT scans were normal and all had normal CD4 count. They started testosterone replacement therapy, with symptoms improvement. Causes of HH in HIV-infected men include undernutrition, severe illness, drugs, pituitary dysfunction and comorbidities. Despite having none of these conditions (except two that were treated with low-dose psychotropics), our patients had HH with uncommonly low testosterone. This suggests that a different mechanism contributes to severe HH in HIV-infected men.

Metabolic Status and Hypogonadism in Human Immunodeficiency Virus-infected Males

AIMS AND OBJECTIVES

The aim of this study is to determine the prevalence of hypogonadism in human immunodeficiency virus (HIV)-infected males and to study its relation to age, CD4 count, body mass index (BMI), duration of highly active antiretroviral therapy (HAART), and metabolic status.

METHODOLOGY

Eighty-one HIV positive cases and 82 healthy controls were included in this case-control study. Each case underwent a complete physical examination and serum fasting plasma glucose, A1c, lipid profile, total testosterone (TT), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) levels were estimated. Serum TT level <300 ng/dl, or TT >300 ng/dl with high LH and FSH (compensatory hypogonadism) were taken as markers for hypogonadism, and it was correlated with age, CD4 count, duration of HAART, and metabolic status of the patient.

RESULTS

Out of 81 cases, 21 (25.9%) were found to have hypogonadism as compared to 4 (4.9%) out of 82 controls. Of these 21, 14 cases had secondary hypogonadism, five had primary, and the remaining two had compensatory hypogonadism. The mean serum TT value among cases (371.7 ± 102.9 ng/dl) was significantly lower than that among controls (419.7 ± 71.5 ng/dl) (P = 0.007). Hypogonadism was found to be significantly associated with the age of the patient (P = 0.007), CD4 count (P = 0.002), and duration of HAART (P = 0.04) and was independent of the BMI (P = 0.9) and the waist circumference (P = 0.8). Dyslipidemia and dysglycemia were significantly more common among cases as compared to controls (P < 0.05) but were not associated with hypogonadism.

CONCLUSION

The prevalence of hypogonadism is higher among HIV-infected males as compared to healthy individuals. Hypogonadism was significantly associated with age, CD4 count, and duration of HAART and was independent of BMI, glycemic status, and dyslipidemia.

Are traditional body fat equations and anthropometry valid to estimate body fat in children and adolescents living with HIV?

The aim of this study was to assess the validity of traditional anthropometric equations and to develop predictive equations of total body and trunk fat for children and adolescents living with HIV based on anthropometric measurements. Forty-eight children and adolescents of both sexes (24 boys) aged 7-17 years, living in Santa Catarina, Brazil, participated in the study. Dual-energy X-ray absorptiometry was used as the reference method to evaluate total body and trunk fat. Height, body weight, circumferences and triceps, subscapular, abdominal and calf skinfolds were measured. The traditional equations of Lohman and Slaughter were used to estimate body fat. Multiple regression models were fitted to predict total body fat (Model 1) and trunk fat (Model 2) using a backward selection procedure. Model 1 had an R²=0.85 and a standard error of the estimate of 1.43. Model 2 had an R²=0.80 and standard error of the estimate=0.49. The traditional equations of Lohman and Slaughter showed poor performance in estimating body fat in children and adolescents living with HIV. The prediction models using anthropometry provided reliable estimates and can be used by clinicians and healthcare professionals to monitor total body and trunk fat in children and adolescents living with HIV.

HIV and hypogonadism: a new challenge for young-aged and middle-aged men on effective antiretroviral therapy

Male hypogonadism is poorly defined in people living with HIV. Using a reliable free-testosterone assay, we examined the prevalence and risk factors of male hypogonadism among people living with HIV on effective antiretroviral therapy. Male hypogonadism was found in 12.4% of patients, twice the rate reported in the general population of the same age. Two risk thresholds, namely 5 years of antiretroviral therapy and 19% total body fat, may help to identify patients at risk.

The effect of relaxation interventions on cortisol levels in HIV-seropositive women

PURPOSE

Activation of the hypothalamic-pituitary-adrenal axis, assessed in terms of cortisol levels, may enhance the ability of HIV to infect lymphocytes and downregulate the immune system, accelerating disease progression. This study sought to determine the effects of relaxation techniques on cortisol levels in HIV-seropositive women.

METHODS

Women (n = 150) were randomized to a group cognitive-behavioral stress management (CBSM) condition or an individual information condition and underwent 3 types of relaxation training (progressive muscle relaxation, imagery, and autogenic training). Cortisol levels were obtained pre- and postrelaxation.

RESULTS

Guided imagery was effective in reducing cortisol in the group condition (t = 3.90, P < .001), and muscle relaxation reduced cortisol in the individual condition (t = 3.1 I, P = .012). Among participants in the group condition attending all sessions, the magnitude of pre- to postsession reduction became greater over time.

CONCLUSIONS

Results suggest that specific relaxation techniques may be partially responsible for cortisol decreases associated with relaxation and CBSM.

Hypogonadism in the HIV-infected man

Androgen deficiency occurs frequently in men with human immunodeficiency virus (HIV) infection. Antiretroviral treatments had reduced the prevalence of male hypogonadism. The pathogenesis of testosterone (T) deficiency in HIV is multifactorial. Several mechanisms have been proposed; among them, drugs, fat redistribution, and a poor health status could explain the mechanism leading to gonadotropins inhibition and hypogonadotropic hypogonadism. The diagnosis of hypogonadism in HIV-infected men should be made based on clinical symptoms and a specific workup including T measurement. The interpretation of the results of biochemical testing is more difficult in men with HIV due to several confounding factors. T treatment should be offered to HIV-infected men with documented clinical hypogonadism and symptoms, especially if they are losing lean mass.

Hypogonadism in human immunodeficiency virus-positive men

In recent years, the life expectancy for those living with human immunodeficiency virus (HIV) with access to combined antiretroviral therapy (cART) has increased. As men live longer, the role testosterone plays in sexual function as well as in general well-being is becoming increasingly important. Here we discuss the available literature concerning androgens and HIV disease. A review was undertaken by using a PubMed search with the umbrella terms HIV or AIDS and testosterone or androgens spanning 1985 to 2011. Significant articles found in references in the primary search were also included. The reported prevalence of androgen deficiency appears to be greater in HIV-infected males than in the general population. Androgen deficiency is usually associated with low luteinizing hormone and follicle-stimulating hormone and is sensitive to the type of measurement of testosterone used. Rates of hypogonadism may be falling since the advent of cART. Causes of low testosterone levels have been attributed to chronic illness, HIV replication, cART, opportunistic infections, comorbidities and coinfections, wasting, and normal age-related declines. Studies of testosterone treatment in HIV-positive men are lacking in standardization and outcome measures.

Altered plasma concentrations of sex hormones in cats infected by feline immunodeficiency virus or feline leukemia virus

Gender differences may affect human immunodeficiency virus (HIV) infection in humans and may be related to fluctuations in sex hormone concentration. The different percentage of male and female cats observed to be infected by feline leukemia virus (FeLV) or feline immunodeficiency virus (FIV) has been traditionally explained through the transmission mechanisms of both viruses. However, sexual hormones may also play a role in this different distribution. To study this possibility, 17β-estradiol, progesterone, testosterone, and dehydroepiandrosterone (DHEA) concentrations were analyzed using a competitive enzyme immunoassay in the plasma of 258 cats naturally infected by FIV (FIV(+)), FeLV (FeLV(+)), or FeLV and FIV (F(-)F(+)) or negative for both viruses, including both sick and clinically healthy animals. Results indicated that the concentrations of 17β-estradiol and testosterone were significantly higher in animals infected with FIV or FeLV (P < 0.05) than in negative cats. Plasma concentrations of DHEA in cats infected by either retrovirus were lower than in negative animals (P < 0.05), and F(-)F(+) cats had significantly lower plasma values than monoinfected cats (P < 0.05). No significant differences were detected in the plasma concentration of progesterone of the four groups. No relevant differences were detected in the hormone concentrations between animal genders, except that FIV(+) females had higher DHEA concentrations than the corresponding males (P < 0.05). In addition, no differences were observed in the hormone concentrations between retrovirus-infected and noninfected animals with and without clinical signs. These results suggest that FIV and FeLV infections are associated with an important deregulation of steroids, possibly from early in the infection process, which might have decisive consequences for disease progression.

HIV-1 accessory protein Vpr: relevance in the pathogenesis of HIV and potential for therapeutic intervention

The HIV protein, Vpr, is a multifunctional accessory protein critical for efficient viral infection of target CD4⁺ T cells and macrophages. Vpr is incorporated into virions and functions to transport the preintegration complex into the nucleus where the process of viral integration into the host genome is completed. This action is particularly important in macrophages, which as a result of their terminal differentiation and non-proliferative status, would be otherwise more refractory to HIV infection. Vpr has several other critical functions including activation of HIV-1 LTR transcription, cell-cycle arrest due to DCAF-1 binding, and both direct and indirect contributions to T-cell dysfunction. The interactions of Vpr with molecular pathways in the context of macrophages, on the other hand, support accumulation of a persistent reservoir of HIV infection in cells of the myeloid lineage. The role of Vpr in the virus life cycle, as well as its effects on immune cells, appears to play an important role in the immune pathogenesis of AIDS and the development of HIV induced end-organ disease. In view of the pivotal functions of Vpr in virus infection, replication, and persistence of infection, this protein represents an attractive target for therapeutic intervention.

Effect of HIV-1 infection and increasing immunosuppression on menstrual function

AIM

The aim of this study was to determine the prevalence, pattern and determinants of menstrual abnormalities in HIV-positive Nigerian women.

METHODS

A cross-sectional study was carried out involving 3473 (2549 HIV-seropositive and 924 seronegative) consecutive and consenting women seen at the HIV treatment centers at the Nigerian Institute of Medical Research, Lagos and the Federal Medical Centre, Markurdi.

RESULTS

The sociodemographic characteristics of the two groups were comparable, except for body mass index (BMI): the HIV-negative women (28.1 ± 8.1) had statistically significantly (P < 0.005) higher BMI compared to the HIV-positive women (21.9 ± 7.5). Menstrual abnormalities were significantly more common in women living with HIV/AIDS (29.1%) compared to the HIV-negative (18.9%) women (P < 0.001). The proportions of women in the two groups with intermenstrual bleeding, menorrhagia, hypermenorrhea, and postcoital bleeding were similar (P > 0.005), however amenorrhea, oligomenorrhea, irregular periods and secondary dysmenorrhea were more common in the HIV-positive women (P < 0.02). Primary dysmenorrhea was less common in HIV-positive women (P < 0.03). Among the HIV-positive women, menstrual dysfunction was more common in women living with HIV/AIDS with opportunistic infections, CD4 count < 200, not undertaking therapy, symptomatic disease and BMI < 20. However, after controlling for cofounders, only CD4 < 200 (odds ratio [OR], 3.65; 95% confidence interval [CI], 1.2-9.7), BMI < 20 (OR, 2.4; 95%CI, 1.3-3.5) and not taking antiretroviral drugs (OR, 2.05; CI, 1.7-6.5) were associated with amenorrhea, oligomenorrhea, irregular periods and secondary dysmenorrhea.

CONCLUSION

HIV-positive women in this study experienced more menstrual abnormalities of amenorrhea, oligomenorrhea, and irregular periods compared to the HIV-negative controls. HIV-positive women with CD4 count < 200, BMI < 20 and who do not take antiretroviral drugs are at the greatest risk.

[Gonadotrophic axis dysfunction in men with HIV-infection/aids]

Gonadotrophic axis dysfunction is commonly observed in HIV-infected patients. The pathogenesis is multifactorial and related to duration of HIV infection, direct cytopathic effects of viruses, use of drugs, opportunistic infections, malignancies, and malnutrition, among other factors. In men, reduced levels of testosterone is associated with loss of muscle mass and strength, decreased bone mineral density, lipodystrophy, depression, asthenia, fatigue and sexual dysfunction. In HIV-infected patients with hypogonadism, numerous studies have shown the beneficial effects of testosterone replacement on the metabolic profile and distribution of body fat, with increased body mass weight, and promote better quality of life, reduce the bone mass loss and the rates of depression. Thus, this review aimed to present a brief update of epidemiologic data, pathophysiology aspects and treatment strategies for the major abnormalities of male gonadotrophic axis associated with HIV infection and its treatment.

Adrenal function in HIV infection

PURPOSE OF REVIEW

Adrenal dysfunction can increase morbidity and mortality among patients with HIV infection. Disorders and medications affecting cortisol, aldosterone or adrenal androgens in patients with HIV infection are reviewed.

RECENT FINDINGS

Iatrogenic Cushing's syndrome and hypothalamic-pituitary-adrenal suppression from concomitant use of ritonavir with nonsystemic corticosteroids such as intra-articular triamcinolone in addition to the previously reported interactions with inhaled fluticasone are increasingly recognized in HIV patients. Integrated measure of aldosterone throughout the day is higher in patients with HIV-associated visceral adipose tissue accumulation.

SUMMARY

Abnormalities in adrenal function are more common in HIV patients than in the general population. HIV care providers should pursue workup for adrenal dysfunction in HIV patients when symptoms or signs are present, especially in patients with advanced AIDS or receiving medications that can affect adrenal function. The clinical implications of aldosterone elevation in HIV patients with visceral adiposity will need to be examined in future research studies.

Growth and puberty in children with HIV infection

Children with perinatal HIV infection may present with clinical features of endocrine dysfunction such as growth failure and pubertal delay. Pediatric care providers and pediatric endocrinologists should implement appropriate preventive, screening, and therapeutic strategies to maximize survival and quality of life in these children. Growth and pubertal delay can be exacerbated by a variety of treatable infectious, endocrine, nutritional, and immunological disorders. Timely diagnosis and appropriate treatment of these conditions may lead to improvement or even normalization of growth and puberty. HIV-infected children with advanced disease should undergo periodic growth evaluation, including GH levels, IGF-I, IGF binding protein 3 and androgens, in order to identify subclinical endocrine dysfunction. However, little is known about the association between HIV infection and endocrine dysfunction in children. Highly active antiretroviral therapy may also be associated with endocrine dysfunction with consequences on growth and puberty. Growth retardation and pubertal delay are always seen in children with advanced HIV infection and are often related to the proinflammatory milieu found in advanced AIDS. Growth and pubertal impairment are markers of advanced disease and require proper evaluation. A dysregulation of the hypothalamic-pituitary axis, toxic or allergic drug reactions may play a role in growth and pubertal delay of HIV-infected children. These dysfunctions require careful monitoring, in order to assess metabolic alterations that may be important in regulation of growth among HIV infected children. Better understanding of the mechanisms leading to impairment of growth and puberty in children with perinatal HIV-1 infection might lead to appropriate treatment when required.

Effects of potent antiretroviral therapy on free testosterone levels and fat-free mass in men in a prospective, randomized trial: A5005s, a substudy of AIDS Clinical Trials Group Study 384

BACKGROUND

Low testosterone levels are commonly reported in patients with advanced human immunodeficiency virus disease. The effects of initiation of different antiretroviral regimens on testosterone levels and changes in fat-free mass have not been reported.

METHODS

Antiretroviral-naive men (n=213) were randomized to receive nelfinavir, efavirenz, or both plus either zidovudine and lamivudine or stavudine and didanosine. Patients underwent measurements of metabolic parameters, including determination of free testosterone level by equilibrium dialysis and bioelectrical impedance analysis, over a 64-week period.

RESULTS

At baseline, the median free testosterone level was 92 pg/mL; the level was subnormal (i.e., <50 pg/mL) in 6%. Lower CD4 cell count at the time of study entry, higher weight, and greater age were independently associated with lower baseline free testosterone level. At week 64, the median free testosterone level increased more in zidovudine-lamivudine recipients (48 of whom had paired values available; change, +31 pg/mL) than in stavudine-didanosine recipients (57 of whom had paired values; change, +3 pg/mL; P=.001, by Wilcoxon rank sum test), and it increased more in efavirenz recipients (37 of whom had paired values; change, +30 pg/mL) than in nelfinavir recipients (28 of whom had paired values; change, -3 pg/mL; P=.05). The median fat-free mass for the entire group increased by 1.2 kg at week 64 (change, +2.0%; P<.001); the increase was greater in the zidovudine-lamivudine group (n=70; change, +1.8 kg) than in the stavudine-didanosine group (n=79; change, +0.5 kg; P=.04), and the increase was also greater for efavirenz recipients (n=53; change, +2.1 kg) than among nelfinavir recipients (n=47; change, +0.4 kg; P=.003). White race, lower CD4 cell count at study entry, assignment to the efavirenz treatment arm, and assignment to the zidovudine-lamivudine treatment arm independently predicted greater absolute change in fat-free mass at week 64.

CONCLUSIONS

Subnormal free testosterone levels occurred infrequently among these antiretroviral-naive men. Free testosterone and fat-free mass levels increased after initiation of antiretroviral therapy, with greater increases at 64 weeks among zidovudine-lamivudine recipients than among stavudine-didanosine recipients and among efavirenz recipients than among nelfinavir recipients.

Associations among body composition, androgen levels, and human immunodeficiency virus status in adolescents

PURPOSE

To investigate whether factors influencing body composition may be unique for male and female adolescents with horizontal transmission of human immunodeficiency virus (HIV).

METHODS

HIV infected and uninfected youth (aged 13-18 years) participating in the multi-center project REACH (Reaching for Excellence on Adolescent Health Care) had at baseline anthropomorphic measurements including height, weight, bicep, tricep, subscapular and suprailiac skinfold measurements and midarm circumference. Body mass index, muscle mass, fat free body mass, and fat mass were calculated and predictors of these measures were assessed using multiple variable linear regression. Predictors included contraception, HIV status and related variables (CD4 counts, treatment status, and viral load), substance use, androgen levels as well as appetite changes, and bone age.

RESULTS

In multiple variable linear regression analysis, female adolescents' body composition was associated with HIV status, CD4 + T cell counts, and free testosterone levels. HIV status was found associated with higher fat and lean body mass, however lower CD4+T cell counts were associated with lower fat and lean body mass. Higher testosterone levels were associated with higher lean and fat mass. For adolescent males, higher total testosterone levels but not free testosterone levels were associated with lower lean and fat mass.

CONCLUSIONS

HIV status was not associated with a lower muscle or fat mass. Different factors influenced body composition for females than males. Higher testosterone levels may be protective against loss in lean and fat mass in females.

The effects of illicit drug use and HIV infection on sex hormone levels in women

Drug use and HIV infection may affect sex hormone levels in women. One hundred and ninety-six women with and without a history of illicit drug use (50 HIV-negative and 148 HIV-infected), with regular menses, who never used antiretrovirals, were evaluated. Luteinizing hormone levels were significantly higher in women with a CD4 cell count <200/microl (p < 0.002). Current methadone use was associated with lower levels of total testosterone (p = 0.03) and higher levels of prolactin (p = 0.002); mean estradiol levels were 43% lower in women who used intravenous drugs (p < 0.001). Alcohol and crack cocaine use was not associated with sex hormone levels. Age, race, body mass index and degree of HIV immunosuppression were also associated with differences in sex hormone levels.

Drug interactions between psychoactive substances and antiretroviral therapy in individuals infected with human immunodeficiency and hepatitis viruses

The liver disease characteristic of alcohol dependence encompasses three main related entities: steatosis, alcoholic hepatitis, and cirrhosis. Alcoholic cirrhosis is a leading cause of global morbidity and mortality. Alcohol intake among injecting drug users is a major contributor to transmission of viral infections, such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C viruses (HCV). HIV and HCV coinfected patients develop liver diseases earlier and more severely than the monoinfected individuals, including hepatocellular carcinoma. Interactions exist between the therapeutic drugs used to minimize and control the drug and alcohol dependence. Furthermore, drug-drug interactions occur between the highly active antiretroviral therapy (HAART) and alcohol, different HAART components and methadone, or each one of the therapies with the other, thus contributing to a higher toxicity level. With the evolution of effective antiretroviral therapy, survival of persons with HIV, and the syndrome it causes, acquired immunodeficiency syndrome (AIDS) has increased dramatically. Drug-drug interactions may appear between alcohol and anti-HBV or anti-HCV, therapy in the presence or absence of anti-HIV therapy. Several other medical-, social-, and drug-related factors of this population have to be considered when providing HAART. Because many coinfected patients also have problems with substance use, dealing with their drug dependence is an important first step in an attempt to improve adherence to and tolerance of antiviral therapy. It is necessary to minimize the risk of liver disease acceleration and/or reinfection with hepatitis viruses. Knowledge of potential drug interactions between methadone, antiretroviral therapy, psychoactive drugs, and antipsychotics and the role of coinfection with HBV or HCV and the drugs used in eradicating viral hepatitis permits suitable antiretroviral combinations.

A review of hypogonadism and erectile dysfunction among HIV-infected men during the pre- and post-HAART eras: diagnosis, pathogenesis, and management

Hypogonadism and erectile dysfunction (ED) appear to be more common among men infected with HIV compared to age-matched men within the general U.S. population. HIV providers should consider these conditions and utilize standardized evaluation and diagnostic criteria. Treatment of both hypogonadism and ED increases sexual function and quality of life; testosterone supplementation in the setting of hypogonadism may also improve lean body mass, mental status, and anemia. We review the epidemiology, diagnosis, pathogenesis, and treatment options of both hypogonadism and ED among HIV-infected men.

Immune modulation of the hypothalamic-pituitary-adrenal (HPA) axis during viral infection

Compelling data has been amassed indicating that soluble factors, or cytokines, emanating from the immune system can have profound effects on the neuroendocrine system, in particular the hypothalamic- pituitary-adrenal (HPA) axis. HPA activation by cytokines (via the release of glucocorticoids), in turn, has been found to play a critical role in restraining and shaping immune responses. Thus, cytokine-HPA interactions represent a fundamental consideration regarding the maintenance of homeostasis and the development of disease during viral infection. Although reviews exist that focus on the bi-directional communication between the immune system and the HPA axis during viral infection (188,235), others have focused on the immunomodulatory effects of glucocorticoids during viral infection (14,225). This review, however, concentrates on the other side of the bi-directional loop of neuroendocrine-immune interactions, namely, the characterization of HPA axis activity during viral infection and the mechanisms employed by cytokines to stimulate glucocorticoid release.

Psychogenic erectile dysfunction

OBJECTIVE

To educate healthcare professionals on the historical aspects, clinical diagnosis, and current treatment methods of psychogenic erectile dysfunction.

METHOD

A topic review of current literature was performed. Chief sources included primarily mainstream journals in the fields of urology, psychiatry/psychology, impotence/erectile dysfunction, epidemiology, and internal medicine. MEDLINE and PsycINFO databases were utilized.

DATA EXTRACTION

Data from clinical studies, trials, and review articles concerned primarily with psychological aspects of the arousal (erectile function) phase of the male sexual response cycle were collected, analyzed, and summarized in this review article.

RESULTS

There has been a shift in how erectile dysfunction has been perceived and treated over the past 30 years. With the current focus now on the very prevalent organic causes of ED, psychological factors are increasingly overlooked, though they remain important to the treatment of the patient as a whole. This article provides a complete, concise review of the interplay between psychological components and erectile function, reviews the work-up and diagnosis of psychogenic ED, and discusses treatment methods.

CONCLUSIONS

Erectile dysfunction is a prevalent problem that can affect, and can be affected by, psychosocial aspects of a man's life. Medical or pharmacological interventions are often appropriate to treat ED, but the psychosocial aspects should not be ignored. It has become easier for practitioners to put aside patients' psychosocial and interpersonal concerns regarding sexual health. Clinicians provide the best possible treatment if they recognize that erectile dysfunction is a complex, multifactorial disorder, and treat accordingly.

Role of testosterone in maintaining lean body mass and bone density in HIV-infected patients

Low testosterone levels are common in both men and women with human immunodeficiency virus (HIV) infection and may contribute to loss of lean body mass and AIDS wasting. Causes of low testosterone levels are complex and may include chronic illness, HIV infection and its complications, medications used to treat HIV and opportunistic diseases, and normal aging-related declines. In the majority of studies addressing the use of testosterone treatment in HIV-infected patients, testosterone has been found to help prevent loss of lean body and muscle mass. Whether the combination of exercise and testosterone is more effective in preventing loss of lean body mass than either therapy alone is not yet clear and warrants further study. In addition to its effects on body composition, testosterone treatment results in improved mood and libido in HIV-infected women and increased bone mineral density in HIV-infected men. Testosterone may thus make a valuable contribution to the treatment of HIV-infected individuals. International Journal of Impotence Research (2003) 15, Suppl 4, S21-S25. doi:10.1038/sj.ijir.3901032

Intracerebral HIV-1 glycoprotein 120 produces sickness behavior and pituitary-adrenal activation in rats: role of prostaglandins

HIV infection is associated with profound neurobehavioral and neuroendocrine impairments. Previous studies demonstrated that HIV causes neuropathological alterations indirectly, via shedding of glycoprotein 120 (gp120) within the brain. To extend these findings, we examined the neurobehavioral and neuroendocrine effects of central administration of gp120, as well as the role of brain prostaglandins in mediating these effects. Intracerebroventricular (i.c.v.) injection of gp120 in rats produced a marked sickness behavior syndrome, consisting of reduced exploratory behavior, suppressed consumption of food and saccharin solution, and reduced body weight. Gp120 also induced a significant febrile response and increased serum levels of ACTH and corticosterone. Following i.c.v. gp120 administration, the ex vivo production of PGE2 by the hypothalamus, frontal cortex, and hippocampus was significantly elevated, and indomethacin, a prostaglandin synthesis inhibitor, attenuated this elevation. Pre-treatment with indomethacin reduced the fever and adrenocortical activation induced by gp120 administration, but not its behavioral effects. These findings indicate that gp120 may be responsible for some of the behavioral and endocrine abnormalities seen in HIV-infected patients. Prostaglandins are important mediators of the physiological, but not the behavioral effects of brain gp120.

Human immunodeficiency virus and assisted reproduction: reconsidering evidence, reframing ethics

OBJECTIVE

To review the advances in the treatment of human immunodeficiency virus (HIV) infection and revisit the medical, ethical, and legal issues surrounding infertility management in HIV-infected couples.

DESIGN

Analytic review.

RESULTS(S)

HIV infection continues to be a serious public health and reproductive issue. However, present policies which allow for the categorical exclusion of HIV-infected individuals from infertility services should be reconsidered in light of improvements in the prognosis of infected individuals and a dramatic decrease in the risk of vertical transmission. An analysis of the ethical cogency of the arguments against the provision of services does not substantiate the exclusion of HIV-infected individuals; rather, the principle of justice requires that HIV-infected women be treated the same way as a woman who might have an increased risk of conceiving a child with a disability or a may have a decreased life expectancy due to a chronic illness such as diabetes. Ethical disagreement notwithstanding, with the precedents recently established by the Americans with Disabilities Act (ADA), discrimination based on HIV status would also likely be unlawful under most circumstances.

CONCLUSIONS(S)

With advances in the treatment of HIV infection, contextualized counseling and a respect for patients' decisions regarding infertility treatment should be adopted as public policy. It is neither ethically nor legally justifiable to categorically exclude individuals from infertility services on the basis of HIV infection.

Glucocorticoids suppress human immunodeficiency virus type-1 long terminal repeat activity in a cell type-specific, glucocorticoid receptor-mediated fashion: direct protective effects at variance with clinical phenomenology

Glucocorticoid administration and/or excess secretion have been associated with increased Human Immunodeficiency Virus Type-1 (HIV-1) replication and AIDS progression. The HIV-1 long terminal repeat (LTR) promoter contains glucocorticoid-responsive element (GRE)-like sequences that could mediate a positive effect of glucocorticoids on HIV-1. In addition, we recently demonstrated that the HIV-1 accessory protein Vpr is a potent coactivator of the glucocorticoid receptor, which, like the host coactivator p300, potentiates the effect of glucocorticoids on GRE-containing, glucocorticoid-responsive genes. Such an effect may increase the sensitivity of several host target tissues to glucocorticoids by several fold, and may, thus, contribute to a positive effect of glucocorticoids on the HIV-1-LTR in infected host cells. In this study, we determined the direct effect of glucocorticoids on HIV-1-LTR by examining the ability of dexamethasone to modulate the activity of this promoter coupled to the luciferase reporter gene in human cell lines. Dexamethasone markedly inhibited Tat-stimulated, p300- or Vpr-enhanced luciferase activities in a cell-type specific, dose-dependent, and glucocorticoid receptor-mediated fashion. This effect of dexamethasone was not potentiated by Vpr, was antagonized by the glucocorticoid receptor antagonist RU 486 and required the DNA-binding domain of the receptor. These data suggest that the inhibitory effect of glucocorticoids on the HIV-1-LTR may be exerted via non-GRE-dependent inhibition of the strongly positive host transcription factor NF-kappaB, which interacts with the DNA- and ligand-binding domains of the receptor. Alternatively, it is also possible that dexamethasone-activated glucocorticoid receptor competes with other transcription factors for their binding sites on the promoter region or squelches transcription factors shared by HIV-1-LTR and glucocorticoid-responsive promoters. We conclude that glucocorticoids suppress, rather than stimulate, the HIV-1 promoter, thus acting, protectively for the host. Their apparent negative clinical association with AIDS is most likely due to immunosuppression of the host.

Prevalence of hypogonadism among men with weight loss related to human immunodeficiency virus infection who were receiving highly active antiretroviral therapy

Previous studies have indicated that there is a significant prevalence (50%) of hypogonadism among men with acquired immunodeficiency syndrome (AIDS)-associated wasting, and for these patients testosterone administration has been shown to increase lean body mass and improve quality of life. However, the prevalence of hypogonadism is not known among men with weight loss related to human immunodeficiency virus (HIV) infection who are receiving highly active antiretroviral therapy (HAART). From 1997 through 1999, we investigated total and free testosterone levels in 90 men who were <90% of ideal body weight or had weight loss of >10% from preillness weight; 71% of these subjects were receiving HAART. Twenty-one percent of the subjects receiving HAART had low free testosterone levels. No correlation was seen between weight, CD4 cell count, medication status, and other clinical factors. These data suggest that hypogonadism remains relatively common in men with AIDS wasting, despite treatment with HAART. HIV-infected men with wasting syndrome should be screened for hypogonadism and receive physiological androgen replacement therapy if they are hypogonadal.

Acute and long-term effects of AIDS and injection drug use on gonadal function

Hypogonadism has been observed in both the HIV-infected population and injection drug users (IDUs). Considering these populations in conjunction is essential because IDUs and HIV often occur in the same individual. Additionally, although the etiology of hypogonadism may be different in each population, its treatment with respect to the underlying condition is similar. The philosophy of both AIDS and IDU treatment has changed drastically in recent years, due to several factors. Survival rates of HIV patients have been steadily increasing, forcing a closer examination of the long-term effects of AIDS-related symptoms, and the quality of life issues associated therewith. In comparison, IDU is now viewed as a chronic addiction like that for alcoholism, which must be treated, rather than an untreatable personal problem. Therefore, it is logical that the endocrine and metabolic changes associated with both HIV and IDU should be examined to help alleviate these symptoms in a continuing effort to treat the underlying condition.

High versus low basal cortisol secretion in asymptomatic, medication-free HIV-infected men: differential effects of severe life stress on parameters of immune status

The authors hypothesized that HIV-infected men with high basal cortisol secretion would exhibit greater stress-related reductions in the ratio of Th1/Th2 cell-derived cytokines and numbers of CD8+ T and NK lymphocytes than low basal cortisol secretors. A semistructured interview was used to assess life stress during the preceding 6 months of 94 HIV-infected men classified as high and low cortisol secretors (n = 47/group). Increased levels of severe life stress were highly correlated with lower numbers of CD8+ T cells, CD16+ and CD56+ NK cells, CD57+ cells, and higher DHEA-S concentrations in the high cortisol group. Conversely, no significant correlations were found in the low cortisol group. No correlations were found between stress and CD4+ T helper/inducer cell counts, cytokine production, or testosterone levels in either participating group. These data suggest that severe stress in combination with high glucocorticoid activity may modify select parameters of immune status in HIV-infected men.

Interleukin-1 receptor antagonist as a treatment of HIV infection

The human immunodeficiency virus (HIV) apparently utilizes human chromosome 2, interleukin-1 (IL-1), glucocorticoid hormones, and viral Tat protein to accelerate its replication and the synthesis of all HIV proteins. HIV Tat protein binds to the long terminal repeat (LTR) ribonucleic acid, including the trans-acting responsive (TAR) sequence and the promoter region to increase HIV replication. Tat-TAR transactivation requires a factor encoded on the long arm of chromosome 2. The interaction of HIV with chromosome 2 may also cause the observed inhibition of interleukin-1 receptor antagonist (IL-1RA), thus increasing the production of IL-1. IL-1, in turn, stimulates the HIV-1 enhancer region of the LTR, thus increasing HIV gene expression and replication. IL-1 also induces glucocorticoid hormone synthesis which stimulates HIV in the virion infectivity factor (Vif) region, thus increasing HIV infectivity. It is, thus, proposed that IL-1RA not only may serve to inhibit HIV-induced IL-1, but may be the unidentified human chorionic gonadotropin-associated factor recently found to have anti-HIV and anti-Kaposi's sarcoma activity.

Characteristics of HIV-infected men with low serum testosterone levels

Low levels of serum testosterone may have negative implications on morbidity in HIV-infected men. The purpose of this study was to determine demographic and clinical characteristics that predict low serum testosterone among men attending our HIV clinic. A cross-sectional study of 587 HIV-positive male patients who presented at the Louisiana State University HIV Outpatient (HOP) Clinic between August 1997 and January 1999 was conducted. Demographic and clinical characteristics were collected and analysed. Of the 587 men studied, 119 (20.3%) had a serum testosterone level below 400 ng/dl. Significantly more men with low serum testosterone levels had a presence of opportunistic infection (especially HIV wasting syndrome, oesophageal candidiasis, or dementia), CD4+ cell counts below 200 cells/mm3, or were taking megestrol acetate. Early detection of low serum testosterone will allow for expedient testosterone supplementation therapy, which could improve morbidity and quality of life for HIV-infected men.

Can androgen therapy replete lean body mass and improve muscle function in wasting associated with human immunodeficiency virus infection?

A significant number of men who are infected with the human immunodeficiency virus (HIV) have low testosterone levels. Androgen deficiency in HIV-infected patients is associated with decreased muscle mass and function, and adverse disease outcome. Administration of replacement doses of testosterone to healthy hypogonadal men augments lean body mass, muscle size, and maximal voluntary strength. Recent studies have shown that physiologic testosterone replacement in HIV-infected men with weight loss who have low testosterone levels can also increase muscle mass and effort-dependent strength. However, further studies are needed to determine whether androgen therapy can improve physical function and health-related outcomes in HIV-infected men.

Dehydroepiandrosterone sulfate (DHEAS) and testosterone: relation to HIV illness stage and progression over one year

This study explored associations between serum dehydroepiandrosterone sulfate (DHEAS), free and total testosterone levels, and HIV illness markers, including viral load, and the behavioral problems of fatigue and depressed mood. Subjects were 169 HIV-positive men evaluated at baseline, 6, and 12 months for levels of DHEAS, total and free testosterone, HIV RNA, CD4, HIV symptoms, opportunistic illnesses, fatigue, and depression. Men with AIDS (N = 105), compared with men with less advanced illness, had lower mean levels of DHEAS. Baseline DHEAS was positively correlated with CD4 count, HIV symptom severity, and was inversely correlated with HIV RNA. Baseline DHEAS below the laboratory reference range (96 microg/dl) was associated with history of opportunistic infections and malignancies (adjusted odds ratio [OR], 4.4; 95% confidence interval [CI], 1.9-10.4) and with incidence of these complications or death over 1 year (adjusted OR, 2.6; 95% CI, 1-7.2). Initiating protease inhibitor combination therapy was associated with an increase in DHEAS over 6 months. Free testosterone was inversely correlated with HIV RNA, but there were no other significant associations between testosterone and HIV illness markers. No hormone was related to fatigue or depression. This study confirms that low serum DHEAS is associated with HIV illness markers, including viral load, and carries negative prognostic value. Further, protease inhibitor therapy may result in increased circulating DHEAS.

The use of a transscrotal testosterone delivery system in the treatment of patients with weight loss related to human immunodeficiency virus infection

PURPOSE

Weight loss is a strong predictor of morbidity and mortality in human immunodeficiency virus (HIV)-infected patients. Men with acquired immunodeficiency syndrome (AIDS) lose body cell mass. Hypogonadism is also common. This study tested the efficacy of a testosterone transscrotal patch (6 mg/day) in improving body cell mass and treating hypogonadism in these patients.

SUBJECTS AND METHODS

This multicenter, randomized, double-blinded, placebo-controlled trial was conducted from August 1995 to October 1996 in 133 men, 18 years of age and older, who had AIDS, 5% to 20% weight loss, and either a low morning serum total testosterone level (<400 ng/dL) or a low free testosterone level (<16 pg/mL). Outcomes included weight, body cell mass as measured using bioelectrical impedance analysis, quality of life, and morning measurements of serum testosterone and dihydrotestosterone levels, lymphocyte subsets, and HIV quantification.

RESULTS

There were no significant differences in baseline weight, CD4 cell counts, or HIV serum viral quantification between treatment arms. Morning total and free testosterone levels increased in those treated with testosterone, but not with placebo. Following 12 weeks of treatment there were no differences (testosterone-placebo) in mean weight change (-0.3 kg [95% confidence interval (CI): -1.4 to 0.8]) or body cell mass (-0.2 kg [95% CI: -1.0 to 0.6]) in the two groups. There were also no changes in quality of life in either group.

CONCLUSION

Hypogonadal men with AIDS and weight loss can achieve adequate morning serum sex hormone levels using a transscrotal testosterone patch. However, this system of replacement does not improve weight, body cell mass, or quality of life.

Cognitive-behavioral stress management buffers decreases in dehydroepiandrosterone sulfate (DHEA-S) and increases in the cortisol/DHEA-S ratio and reduces mood disturbance and perceived stress among HIV-seropositive men

This study examined the effects of a 10-week cognitive-behavioral stress management (CBSM) intervention on dehydroepiandrosterone sulfate (DHEA-S) levels and the ratio of cortisol to DHEA-S (cortisol/DHEA-S), potential surrogate adrenal markers of HIV disease progression, in relation to alterations in mood and distress. HIV-seropositive men were randomized to either a group-based CBSM intervention (n = 43) or to a wait-list control group (n = 24), with both hormonal and distress measures assessed just prior to and immediately following the 10-week period. Results showed that CBSM buffers decreases in DHEA-S and increases in the cortisol/DHEA-S ratio. Further examination also revealed that changes in the cortisol/DHEA-S ratio were significantly and positively related to changes in total mood disturbance and perceived stress over time. These findings demonstrate that a short-term CBSM intervention can buffer against decrements in DHEA-S and increments in the cortisol/DHEA-S ratio among symptomatic, HIV-positive men, and that alterations in the cortisol/DHEA-S ratio move in concert with changes in mood and distress observed during CBSM.

Relative influences of sex, race, environment, and HIV infection on body composition in adults

BACKGROUND

The factors that control body composition in disease are uncertain.

OBJECTIVE

We planned to compare the relative influences of HIV infection, sex, race, and environment on body composition.

METHODS

We analyzed results of body composition studies performed by bioelectrical impedance analysis in 1415 adults from 2 cohorts: white and African American men and women from the United States, and African men and women (279 HIV-infected and 1136 control). The effects of sex and HIV infection on weight, body cell mass, and fat-free mass were analyzed by using both unadjusted and age-, weight-, and height-adjusted data.

RESULTS

Control men weighed more and had more body cell mass and fat-free mass than did control women, although control women had more fat. The strongest correlates with body composition were height and weight, followed by sex. HIV infection, age, environment, and race. Control men and women weighed more and had more body cell mass, fat-free mass, and fat than did HIV-infected men. However, differences in body composition between HIV-infected and control groups were strongly influenced by sex. Of the differences in weight between HIV-infected and uninfected subjects, fat-free mass accounted for 51% in men but only 18% in women, in whom the remainder was fat. Sex effects were similar in African and American groups.

CONCLUSIONS

Sex has a marked effect on the changes in body composition during HIV infection, with women losing disproportionately more fat than men. Sex-related differences in body composition were narrower in the HIV-infected groups. Race and environment had smaller effects than sex and HIV infection.

Testosterone therapy for human immunodeficiency virus-positive men with and without hypogonadism

This study was designed to evaluate the safety and effectiveness of testosterone therapy for clinical symptoms of hypogonadism (low libido, low mood, low energy, loss of appetite/weight) in human immunodeficiency virus-positive men with CD4 cell counts less than 400 cells/mm3 and deficient or low normal serum testosterone levels. The trial consisted of 8 weeks of open treatment with 400 mg of intramuscular testosterone cypionate biweekly. Responders were maintained at this dosage for another 4 weeks and then were randomized in a double-blind, placebo-controlled, 6-week discontinuation trial. Of the 112 men who completed at least 8 weeks of treatment, 102 (91%) were rated as responders on a global assessment of sexual desire/function. Of the 34 study completers with major depressive disorder and/or dysthymia, 79% reported significant improvement in mood at week 8. Average weight change was a gain of 3.7 pounds, with 45% gaining more than 5 pounds. Eighty-four men entered and 77 completed the double-blind phase; of these, 78% of completers randomized to testosterone and 13% randomized to placebo maintained their response. No significant medical or immunologic adverse effects were identified. Testosterone therapy was well tolerated and effective in ameliorating symptoms of clinical hypogonadism, and equally so for men with and without testosterone deficiency. For patients with major depression and/or dysthymia, improvement was equal to that achieved with standard antidepressants.

Androgen therapy in AIDS wasting

Hypogonadism in HIV-infected men has been well described, having a prevalence of about 30%. Its aetiology is a combination of non-specific changes from chronic and acute illness, and specific effects due to HIV infection. A depressed serum testosterone level has been associated with viral or infectious invasion of the endocrine organs, and with medications commonly used in treating HIV infection. Recently, many have noted the association between decreased serum testosterone in men and women, and the wasting syndrome of HIV infection, particularly with a reduction in lean body mass. Our understanding of the risks and benefits of testosterone therapy in non-HIV infected men has grown significantly. Treatment in this population can improve sexual function, quality of life parameters and body composition. Based on this information, a few studies have been carried out, and more are being planned to test the hypothesis that therapy with testosterone or its analogues can benefit HIV-infected men and women with wasting and/or low circulating androgen concentrations. To date, the studies have been inconclusive. Not all studies have shown a statistical benefit of androgen therapy on weight, muscle mass or quality of life. Testosterone is now available in several forms for dosing, which has improved compliance and ease of administration. Its potential risk to the prostate or serum lipids should be monitored closely. Although the beneficial effects of androgenic steroids in HIV-infected men have not been demonstrated clearly, short-term studies suggest that testosterone supplementation may improve metabolic outcomes in HIV-infected men with androgen deficiency.

Testosterone replacement treatment options for HIV-infected men

Hypogonadism is well documented in HIV-infected men, particularly as they progress to AIDS and in those with symptoms of wasting. Testosterone deficiency can be diagnosed with simple laboratory tests, and various treatment options exist. The benefits of androgen replacement are well documented from a large body of literature and experience with hypogonadal men without HIV infection. Hypogonadal men who are given testosterone replacement have improved sexual thoughts and functioning, more energy, and improved mood. Generally, quality of life improves with such therapy. Testosterone replacement tends to maintain or improve lean body mass. The benefit, dose, and timing of testosterone replacement treatment for men with HIV infection, however, are less clear and require further study. Appropriate history and a high degree of clinical suspicion, coupled with relatively simple laboratory measurements, can confirm the diagnosis of hypogonadism in men with HIV. Various options for testosterone replacement, including injections of testosterone esters and the use of transcutaneous patches, are discussed, as are the uses of pharmacologic doses of testosterone, primarily for its potential anabolic effect.

A trial of testosterone therapy for HIV-associated weight loss

OBJECTIVE

Weight loss in HIV-infected patients is extremely common and is associated with increased morbidity and mortality. Decreased testosterone concentrations occur commonly in patients with HIV disease and are associated with weight loss. This study assessed the effect of testosterone therapy on HIV associated weight loss in patients with AIDS.

METHODS

Forty HIV-seropositive patients with CD4+ counts of < 2 x 10(5)/l and weight loss greater than 5% of usual body weight were randomized in a double-blind manner to receive 200 mg of testosterone cypionate of placebo intramuscularly every 2 weeks for 3 months. Patients were then crossed to receive the alternate treatment for the next 3 months. Outcome variables included weight, skin fold measurement, a quality-of-life questionnaire, Karnofsky score, T-cell subset analysis, complete blood count, routine blood chemistry measurements and free testosterone concentration.

RESULTS

Thirty-nine patients entered the study. Of these, 35 completed the first 3-month period (18 on placebo, 17 on testosterone) and 23 completed the whole 6 month trial. Analysis of these 23 patients did not show any significant differences between testosterone and placebo treatment. Analysis of the first 3 months only for the 35 patients who completed it did not show any significant difference between the effects of testosterone and placebo treatment on weight gain. Patients treated with testosterone reported improved overall well-being (P = 0.03) and a trend towards increased muscle strength (P = 0.08). There was no difference between the two groups in terms of side-effects or other effects on hematopoetic, liver, renal, or immune function.

CONCLUSIONS

Treatment with testosterone cypionate compared with placebo did not result in significant weight gain. Testosterone supplementation did appear to produce an improved overall sense of well-being and possibly some increases in muscle strength. This randomized, double-blinded study does not confirm the results of other recent studies which show potential benefits of testosterone and its analogs when used as a treatment for weight loss in HIV-positive patients.