Sexual hormones in HIV-infected patients: the influence of antiretroviral therapy

A 'hidden problem': Nature, prevalence and factors associated with sexual dysfunction in persons living with HIV/AIDS in Uganda

BACKGROUND

We conducted a clinic-based cross-sectional survey among 710 people living with HIV/AIDS in stable 'sexual' relationships in central and southwestern Uganda. Although sexual function is rarely discussed due to the private nature of sexual life. Yet, sexual problems may predispose to negative health and social outcomes including marital conflict. Among individuals living with HIV/AIDS, sexual function and dysfunction have hardly been studied especially in sub-Saharan Africa. In this study, we aimed to determine the nature, prevalence and factors associated with sexual dysfunction (SD) among people living with HIV/AIDS (PLWHA) in Uganda.

METHODS

We conducted a clinic based cross sectional survey among 710 PLWHA in stable 'sexual' relationships in central region and southwestern Uganda. We collected data on socio-demographic characteristics (age, highest educational attainment, religion, food security, employment, income level, marital status and socio-economic status); psychiatric problems (major depressive disorder, suicidality and HIV-related neurocognitive impairment); psychosocial factors (maladaptive coping styles, negative life events, social support, resilience, HIV stigma); and clinical factors (CD4 counts, body weight, height, HIV clinical stage, treatment adherence).

RESULTS

Sexual dysfunction (SD) was more prevalent in women (38.7%) than men (17.6%) and majority (89.3% of men and 66.3% of women) did not seek help for the SD. Among men, being of a religion other than Christianity was significantly associated with SD (OR = 5.30, 95%CI 1.60-17.51, p = 0.006). Among women, older age (> 45 years) (OR = 2.96, 95%CI 1.82-4.79, p<0.01), being widowed (OR = 1.80, 95%CI 1.03-3.12, p = 0.051) or being separated from the spouse (OR = 1.69, 95% CI 1.09-2.59, p = 0.051) were significantly associated with SD. Depressive symptoms were significantly associated with SD in both men (OR = 0.27, 95%CI 0.74-0.99) and women (OR = 1.61, 95%CI 1.04-2.48, p = 0.032). In women, high CD4 count (OR = 1.42, 95% CI 1-2.01, p = 0.05) was associated with SD.

CONCLUSION

Sexual dysfunction has considerable prevalence among PLWHA in Uganda. It is associated with socio-demographic, psychiatric and clinical illness factors. To further improve the quality of life of PLWHA, they should be screened for sexual dysfunction as part of routine assessment.

Contemporary Anti-Retroviral Drugs (ARVDs) Disrupt Follicular Development in Female Wistar Rats

Introduction

There are genuine concerns that long-term use of anti-retroviral drugs may be associated with reproductive complications in females. This study aimed to ascertain the effect of highly active anti-retroviral drugs on the ovarian reserve and reproductive potential of female Wistar rats and by extension to HIV-positive human females.

Methods

A total of 25 female Wistar rats, weighing between 140g and 162g, were randomly allotted into non-intervention and intervention groups, receiving the anti-retroviral drugs, Efavirenz (EFV), Tenofovir Disoproxil Fumarate (TDF), Lamivudine (3TC), and a fixed-dose combination (FDC). The dosage was administered orally at 8 am daily for 4 weeks. Serum concentrations of anti-Mullerian hormone (AMH), follicle-stimulating hormone (FSH), luteinising hormone (LH), and estradiol were measured using standard biochemical techniques (ELISA). Follicular counts were made on fixed ovarian tissue from the sacrificed rats.

Results

The mean AMH level for the control group and the EFV, TDF, 3TC, and FDC groups were 11.20, 6.75, 7.30, 8.27, and 6.60 pmol/L, respectively. The EFV and FDC groups had the lowest AMH, compared to the other groups, but there was no statistically significant difference in AMH across the groups. The mean count of antral follicles was significantly lower in the group that received EFV when compared to the other groups. The corpus luteal count was significantly higher in the control group than in the intervention groups.

Conclusion

The study demonstrated a disruption in the reproductive hormones of female Wistar rats receiving anti-retroviral regimens containing EFV. Clinical studies are required to determine if these changes are seen in women receiving EFV-based treatment, as this may compromise reproductive function and predispose them to early menopause.

Protease inhibitor-based antiretroviral therapy in pregnancy: effects on hormones, placenta, and decidua

The use of antiretroviral therapy (ART) in pregnancy is important for maternal health, and has been successful in reducing vertical transmission rates to almost zero in those taking effective ART regimens with good adherence. However, there are reports of higher rates of low birthweight and preterm births in women with HIV, which can be further exacerbated by ART usage in pregnancy. Protease inhibitors, and ritonavir-boosted lopinavir in particular, might directly contribute to placental and uteroplacental pathology in part by altering plasma concentrations of the essential steroid hormones of pregnancy, progesterone and oestradiol. In this Review, we collate the increasing evidence of dysregulated maternal endocrinology, reproductive physiology, and placental compromise associated with protease inhibitors. Based on findings of placental and decidual effects, we recommend that ritonavir-boosted lopinavir should be avoided in pregnancy, in line with US and European guidelines. Long-term follow-up of children exposed to protease inhibitors in utero is also recommended.

Toxic Metals and Non-Communicable Diseases in HIV Population: A Systematic Review

Background and Objectives: HIV has been a serious global health concern since its discovery, with about 37.9 million people living with HIV worldwide as of 2018. Sub-Saharan Africa (SSA) accounts for 68% of the infection and contributed 74% of the 1.5 million deaths in 2013 despite having only 12% of the total world population residing in the region. This systematic review has attempted to determine the association between heavy metal toxicity and the occurrence of non-communicable diseases in the HIV/AIDS population. Materials and Methods: Three databases were systematically searched: PubMed, Scopus, and Google Scholar for studies written in English and published between 1 April 2000 and 12 April 2020. Studies were excluded if the main outcomes were not measured or did not meet the inclusion criteria. Results: All the six included studies are cross-sectional in design, and therefore were evaluated using the STROBE checklist. The data extraction was done using an extraction table; the ratio of female to male participants included in the study was 1.09:1. Qualitative analysis was used due to the heterogeneity in the heavy metal biomarkers and the outcome measured by the included studies. Two studies compared the concentration of heavy metals in HIV-positive and HIV-negative participants while one compared the levels between HAART-naïve and HAART-treated participants, and three determined the association between heavy metal toxicity and non-communicable diseases (liver fibrosis, anaemia, and reproductive parameters, respectively) in HIV-positive patients. Conclusions: Blood lead, cadmium, and mercury levels were higher in HIV-seropositive than -seronegative subjects, whereas serum zinc level was lower in HIV-seropositive than -seronegative subjects, but the causal association between heavy metals and non-communicable diseases in HIV subjects is largely unknown. Interdisciplinary research between nutrition, toxicology, and human health is envisaged for primary and secondary prevention and treatment.

The prevalence of low serum free testosterone and the short-term effect of anti-retroviral therapy in male Japanese treatment-naïve HIV patients

OBJECTIVES

The prevalence of hypogonadism in HIV patients is still a matter of debate. Today, serum free testosterone (fTST) is thought to be more important than serum testosterone in the diagnosis of hypogonadism in patients with HIV. This study aimed to determine the prevalence of low fTST levels and the effects of anti-retroviral therapy (ART) on fTST levels in treatment-naïve male Japanese patients with HIV.

METHODS

Patients who visited Teikyo University Hospital, Japan between 2010 and 2016 were enrolled. Patients' fTST levels were evaluated twice with a radioimmunoassay in the morning, at the onset of ART and one year later. Clinical factors were also reviewed. The patients were divided into two groups ('hypogonadism' and 'normal') based on Japanese criteria. To determine factors related to low fTST in treatment-naïve patients, the Mann-Whitney U test and a multiple-regression analysis were used. Changes in fTST levels after ART initiation were evaluated with a paired t-test.

RESULTS

Data from 25 patients were collected. Their median age was 36.0 years, and the median fTST level was 8.00 pg/ml in the treatment-naïve state. Thirteen patients (52%) were in the hypogonadism group. Low levels of fibroblast growth factor 23 were significantly related to low fTST levels. After the start of ART, fTST levels increased significantly (median 8.00 interquartile range [6.40-9.70] to 9.60 [7.60-13.10] pg/ml, p = 0.0081).

CONCLUSIONS

Subnormal fTST levels occurred frequently among the present study patients in treatment-naïve settings. Free testosterone levels in patients with HIV were significantly increased one year after the start of ART.

Adjuvant potential of virgin coconut oil extract on antiretroviral therapy-induced testicular toxicity: An ultrastructural study

The effects of Virgin coconut oil as an adjuvant to highly active antiretroviral therapy (HAART) were investigated on the testicular ultrastructure and biochemical markers in rats. Twenty male Sprague-Dawley rats, weighing 153-169 g were divided into four groups and treated as follows: control A (distilled water), B (HAART), C (HAART+Virgin coconut oil 10 ml/kg) and D (Virgin coconut oil [VCO] 10 ml/kg). Testicular segments were evaluated using transmission electron microscopy. Serum was assayed for testosterone, luteinising hormone, follicle stimulating hormone and testicular tissue for malondialdehyde and glutathione. Ultrastructure of basement membrane (Bm), mitochondria and spermatocytes was normal in the control group. HAART-treated group showed significant increase (p < .01) in Bm thickness with significant decrease in Leydig cell nuclear diameter (p < .05) and volume (p < .01) when compared with control group. Mitochondrial cristae appear collapsed, and Sertoli cells showed cytoplasmic vacuolations. HAART+VCO group showed improved ultrastructural details in Bm, and Sertoli cell and Leydig cells show abundant lipid droplets. Virgin coconut oil-treated group showed thinning of Bm with otherwise normal ultrastructural features of organelles. HAART-treated group showed significant increase (p < .01) in testosterone levels. There was no significant effect on malondialdehyde and glutathione levels. Virgin coconut oil improved testicular morphology and reversed HAART-induced ultrastructural alterations. Further studies on putative mechanism are required.

Aging with HIV in the ART era

In the current era of therapy for human immunodeficiency virus (HIV), life expectancy for persons living with HIV (PLWH) approaches that of the general population. This newly prolonged survival among PLWH is associated with an increased prevalence of comorbidities due to the inflammation, immune activation and immune senescence associated with HIV infection. Higher prevalence of tobacco and alcohol use, co-infection with viral hepatitis and traditional cardiovascular risk factors such as hypertension and hyperlipidemia contribute as well. In this review, we hope to describe the current comorbidities occurring among PLWH and bring increased awareness for conditions that may otherwise not be considered given the younger age at time of presentation.

Prevalence and factors associated with erectile dysfunction in a cohort of HIV-infected patients

To determine the prevalence of erectile dysfunction and its associated factors we conducted an observational study on a consecutive cohort of asymptomatic HIV-positive men. All the patients completed a questionnaire to evaluate erectile dysfunction based on the International Index of Erectile Function, a validated survey for the diagnosis of anxiety and depression (self-administered HAD), and a questionnaire about cardiovascular risk factors. Epidemiological, clinical, and analytical data were collected. In all, 158 men, participated: mean age 46.0 years, 96.2% on antiretroviral therapy (91.3% undetectable viral load), and the mean CD4 count was 534 cells/mL. Erectile dysfunction was present in 106 (67.1%) patients, and associated factors were age (OR 4.5 for each 5 years; 95% CI 4.3−4.7; p = 0.0001) and anxiety (OR 8.2, 95% CI 2.2−30.4; p = 0.002). The prevalence of erectile dysfunction is high in men living with HIV, even in those with good immunovirological control. It is related to increasing age and anxiety, both of which are important factors within our HIV cohort.

Elevated Testosterone Levels in HIV-Infected Men

Little is known about HIV-infected patients with serum testosterone levels in high normal to elevated ranges. An HIV-infected patient with hepatitis C and unexplained high serum testosterone levels prompted a retrospective chart review into the association of hepatitis C and serum testosterone levels greater than 1000 ng/mL in our clinic. The charts of 1419 male HIV patients were reviewed. Out of 1419 patients, 159 (11%) met the criteria for data analysis. A total of 8 patients had serum testosterone levels greater than 1000 ng/mL. There was no significant correlation between hepatitis C antibody positivity or presence of hepatitis C viremia as measured by viral load, nor was there any significant correlation with CD4+ cell counts. We found a weak positive association between years since reported diagnosis of HIV and high testosterone levels.

Sexual Dysfunctions of HIV-Positive Men: Associated Factors, Pathophysiology Issues, and Clinical Management

Sexual dysfunctions in HIV-positive men are associated with an increase in risky sexual behavior and decreased adherence to antiretroviral drug regimens. Because of these important public health issues, we reviewed the literature on the pathophysiology, associated factors and clinical management of sexual dysfunction in HIV-positive men. The goal was to investigate the current research on these issues. Literature searches were performed in June 2011 on PubMed, Web of Science, and PsycInfo databases with the keywords “AIDS” and “sexual dysfunction” and “HIV” and “sexual dysfunction”, resulting in 54 papers. Several researchers have investigated the factors associated with sexual dysfunction in HIV-positive men. The association between sexual dysfunction and antiretroviral drugs, particularly protease inhibitors, has been reported in many studies. The lack of standardized measures in many studies and the varying study designs are the main reasons that explain the controversial results. Despite some important findings, the pathophysiology of sexual dysfunction in the HAART era still not completely understood. Clinical trials of testosterone replacement therapy have shown the treatment to be beneficial to the improvement of sexual dysfunctions related to hypogonadism. However, there are not enough psychological intervention studies to make conclusions regarding the therapeutic effects of psychotherapy.

Has Prolactin a Role in the Hypogonadal Status of HIV-Infected Patients?

Most cases of hypogonadism in human immunodeficiency virus (HIV) infection are of hypophyseal— hypothalamic origin, and hyperprolactinemia, also commonly observed in HIV-infected patients, may cause hypogonadism. We studied 188 HIV-infected men who had simultaneous determinations of gonadal and hypophyseal hormones, and we found that prolactin levels were independently predictive of hypogonadism in multivariate analysis.

HIV treatment adherence and sexual functioning

To our knowledge, no studies have considered the bidirectional relationship between HIV infected patients' social/sexual lives and HAART adherence. To determine it's potential impact the study sample consisted of 135 men starting HAART and being followed for 6 months. Twenty percent of men enrolled in the study self-reported non-adherence. Non-adherent patients reported a greater number and severity of adverse effects such as gastrointestinal and body changes. All participants were aware of these risks, requested support, and were advised by the health care providers. As many as 26% of the HIV infected men, at the second visit, reported sexual dysfunction and none received information regarding the possibility of this side effect. Of importance, patients reporting sexual dysfunction, were more likely to report not being fully adherent to the medication (RR=2.46 95% CI 1.3-4.7; P=0.04). Of most concern, none of the men reported looking for medical advice.

Sexual dysfunction in HIV-infected men: role of antiretroviral therapy, hypogonadism and lipodystrophy

BACKGROUND

Both psychological and organic factors have been recognized to be associated with sexual dysfunction in HIV-infected individuals.

METHODS

In this cross-sectional study we evaluated the prevalence and factors associated with sexual dysfunction in a cohort of HIV-infected adult men. Evaluation tools included: the International Index of Erectile Function (erectile dysfunction [ED], desire, orgasm, intercourse satisfaction, overall satisfaction), the Assessment of Body Change and Distress (body image satisfaction), the Medical Outcomes Study HIV Health Survey (mental and physical health-related quality of life), and plasma free and total testosterone level (hypogonadism).

RESULTS

Three-hundred and fifty-seven men were enrolled. Among 336 patients reporting sexual activities in the 4 weeks before, 94 (29.6%) had mild, 30 (9.4%) moderate and 34 (10.1%) severe dysfunction. The Mental Health Summary score was 2.28 units (95% confidence interval [CI] 1.51, 3.06) lower for each unit higher of body image dissatisfaction and 0.31 units (95% CI 0.27, 0.36) higher for each unit higher of the score for body change interference with habits. At regression analysis, ED was independently related to the body mass index (B = 0.31, 95% CI 0.08, 0.62). Desire, orgasm and overall satisfaction domains were associated with mental health score (B = 0.87, 95% CI 0.47, 1.27; B = 0.75, 95% CI 0.23, 1.26; B = 0.86, 95% CI 0.45, 1.28, respectively). An improved intercourse satisfaction domain was associated with a lower interference of body changes with habits and social life (B = 0.39, 95% CI 0.05, 0.73). Testosterone, metabolic alterations and HAART were not associated with sexual function domains.

CONCLUSIONS

Body image and mental health but not HAART or hypogonadism were associated with sexual function domains.

Circulating sex hormones and gene expression of subcutaneous adipose tissue oestrogen and alpha-adrenergic receptors in HIV-lipodystrophy: implications for fat distribution

OBJECTIVE

Circulating oestradiol and testosterone, which have been shown to increase in human immunodeficiency virus (HIV)-infected patients following highly active antiretroviral therapy (HAART), may influence fat distribution and insulin sensitivity. Oestradiol increases subcutaneous adipose tissue in humans possibly through binding to oestrogen-receptor-alpha, which in turn activates anti-lipolytic alpha2A-adrenergic-receptor.

DESIGN AND METHODS

To address these issues circulating pituitary-gonadal-axis hormones and gene expression of receptors in subcutaneous adipose tissue were determined in 31 nondiabetic HIV-infected male patients receiving HAART (16 with lipodystrophy), in whom measures of fat distribution (CT and DEXA-scans) and insulin sensitivity (hyperinsulinaemic euglycaemic clamp) were available.

RESULTS

Total and free oestradiol and testosterone were decreased in lipodystrophic patients compared to nonlipodystrophic patients, whereas luteinizing hormone, follicle-stimulating hormone and prolactin were similar and normal in both study groups. Ratio of subcutaneous to total abdominal fat mass, limb fat, and insulin sensitivity, which were all decreased in lipodystrophic patients, correlated positively with both plasma oestradiol and testosterone (n = 31). Glycerol concentration during clamp (a marker of lipolysis) correlated inversely with expression of alpha2A-adrenergic-receptor, ratio of subcutaneous to total abdominal fat mass, and limb fat, respectively. Expression of alpha2A-adrenergic-receptor correlated positively with expression of oestrogen-receptor-alpha.

CONCLUSIONS

The results fit the hypothesis that sex hormones play a role in altered fat distribution and insulin sensitivity of male patients with HIV-lipodystrophy. The effect of oestradiol on the subcutaneous fat depot and lipolysis may be mediated in part through binding to the oestrogen-receptor-alpha, in turn activating anti-lipolytic alpha2A-adrenergic-receptor.

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.

Hypogonadism in HIV-1-Infected Men is common and does not resolve during antiretroviral therapy

Objectives

To assess the prevalence of abnormal testosterone and gonadotropin values in HIV-infected men before and after 2 years of combination antiretroviral therapy (cART).

Design

Multicentre cohort of HIV-infected adults.

Methods

We identified 139 Caucasian antiretroviral-naive male patients who started zidovudine/ lamivudine-based cART that was virologically successful over a 2 year period. Ninety-seven were randomly chosen and plasma hormone determinations of free testosterone (fT) and luteinizing hormone (LH) at baseline and after 2 years of cART were evaluated.

Results

At baseline 68 patients (70%) had subnormal fT levels. In these, LH levels were low in 44%, normal in 47% and high in 9%. There was a trend for an association between lower CD4+ T-cell counts and hypogonadism. Most participants had normal FSH levels. No significant changes of fT, LH and FSH levels were observed after 2 years of cART.

Conclusions

Low fT levels, mainly with normal or low LH levels and thus indicating secondary hypogonadism, are found in the majority of HIV-infected men and do not resolve during 2 years of successful cART.

Toxic metabolic syndrome associated with HAART

Acquired fat redistribution, that is, peripheral fat loss often accompanied by central fat accumulation in patients with HIV infection is the most common form of lipodystrophy in man. Approximately 30 - 50% of HIV-infected individuals after > or = 12 months on highly active antiretroviral therapy (HAART) may encounter the HIV-associated lipodystrophy syndrome (HALS), which attenuates patient compliance to this treatment. HALS is characterised by impaired glucose and lipid metabolism and other risk factors for cardiovascular disease. This review depicts the metabolic abnormalities associated with HAART by describing the key cell and organ systems that are involved, emphasising the role of insulin resistance. An opinion on the remedies available to treat the metabolic abnormalities and phenotype of HALS is provided.

Impact of street drug use, HIV infection, and highly active antiretroviral therapy on reproductive hormones in middle-aged women

OBJECTIVE

To assess the impact of street drug use and HIV infection on reproductive hormones in 82 women aged 28?56 and 15 HIV-uninfected, regularly cycling premenopausal historical controls.

METHODS

Prospective, pilot cohort study. Baseline blood samples were assayed for follicle stimulating hormone (FSH), human chorionic gonadotropin (hCG), prolactin (PRL), thyroid stimulating hormone (TSH), and estradiol (E(2)). Menopausal status was defined as premenopause: age<40, not amenorrheic; perimenopause: age>40, not amenorrheic; menopause: age>40, with> or =12 months' amenorrhea. Kruskal-Wallis testing was used to compare groups of women sorted by menopausal status and separated by drug use and HIV serostatus. Controls were regularly cycling premenopausal women.

RESULTS

Thirty-eight of the 82 women (46%) reported substance abuse, and 47 of the 82 (57%) were HIV infected. TSH did not differ by HIV serostatus or drug use. PRL was elevated in drug users compared with nonusers and healthy volunteers (10.3, 5.9 vs. 6.2 ng/ml, respectively, p = 0.002), with no effect of HIV serostatus. FSH was reduced in each menstrual category related to drug use and in postmenopausal women associated with positive HIV serostatus. Highly active antiretroviral therapy (HAART) use was not related to PRL or E(2) but was associated with higher FSH. FSH was greater in cohort participants compared with controls.

CONCLUSIONS

Drug use, not HIV, relates to increased PRL. Both drug use and HIV infection are associated with decreased FSH. Women in this socioeconomic stratum at high risk for HIV may be at risk for early menopause. Increased PRL may falsely reduce FSH, necessitating a more careful hormonal characterization of menopausal status in this sample of women.

Recomendaciones de GEAM/SPNS sobre el tratamiento de las alteraciones metabólicas y morfológicas en el paciente con infección por VIH

OBJECTIVE

To provide an update of the metabolic and morphologic alterations in patients infected with HIV with an in-depth analysis of their clinical management and treatment.

METHODS

These recommendations were agreed by consensus by a committee of experts in metabolic alterations and HIV patient care, under the auspices of the Secretariat for the National AIDS Plan. To do this, the latest clinical, epidemiological and physiopathological advances described in studies published in the scientific literature and/or presented in congresses were reviewed.

RESULTS

The most frequent metabolic alterations in HIV patients and in antiretroviral treatment (ART) are dyslipidemia with an atherogenic profile and alterations in carbohydrate metabolism/insulin resistance. A high prevalence of cardiovascular risk factors, especially smoking, has been described. The same criteria for their management as those used in the general population have been employed, with specific nuances. Diet and exercise should be the first therapeutic recommendation. In patients with dyslipidemia who require drug treatment, statins and/or fibrates are indicated. Glitazones have demonstrated efficacy in the treatment of insulin resistance. The approach to anomalous fat distribution continues to be controversial. The main approaches at present are a switch of ART, reparative surgery, psychological support and lifestyle changes. Lactic acidosis is an infrequent but highly serious complication, and the first step is withdrawal of ART. In bone metabolism alterations, prevention and early detection are essential, especially in children and perimenopausal women. Sexual dysfunction is a frequent problem in both men and women; because the causes are highly varied, treatment should be individualized.

CONCLUSIONS

The prevalence of metabolic and morphologic alterations has increased since the introduction of highly active antiretroviral treatment (HAART). Knowledge of the various aspects involved in their diagnosis and treatment is essential for the appropriate care of patients with HIV infection.

Relationship between osteopenia, free testosterone, and vitamin D metabolite levels in HIV-infected patients with and without highly active antiretroviral therapy

The prevalence of osteopenia in HIV-infected patients is high. However, the mechanisms implicated in bone mass loss in HIV infection are unclear. Because of this, we analyzed serum free testosterone and vitamin D3 hydroxylated metabolites in HIV-infected patients, with and without antiretroviral treatment, and the relation between them and osteopenia. Seventy-four HIV-infected patients were selected because they had frozen sera available at a date close to a DEXA evaluation. Free testosterone, 25(OH)D3, and 1,25(OH)2D3 were determined in frozen serum. There were no differences in free testosterone, 25(OH)D3, and 1,25(OH)2D3 levels between patients with and without osteopenia. 25(OH)D3 levels in naive and HAART-treated patients were 26.2 (10.3-32.8) and 33.1 (20.6-46.8) ng/ml, respectively (p = 0.04). 1,25(OH)2D3 levels in naive and HAART treated patients were 60.3 (49.2-80.8) and 85.5 (68-111.6) pmol/liter (p = 0.01). Free testosterone levels in 9 naive men and in 50 HAART-treated men were 42.6 (24.1-67.3) and 69.2 (47.5-112.1) pmol/liter, respectively (p = 0.04). In conclusion, HIV-infected patients with and without osteopenia showed similar levels of vitamin D metabolites and free testosterone. However, antiretroviral drug-naive patients showed lower serum levels of vitamin D metabolites and free testosterone than HAART-treated patients.

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.

Gynecomastia among HIV-Infected Patients Is Associated with Hypogonadism: A Case-Control Study

BACKGROUND

The prevalence, risk factors, and potential hormonal abnormalities associated with gynecomastia in a cohort of HIV-infected men are poorly understood.

METHODS

Breast enlargement was assessed in consecutively evaluated HIV-infected men, and gynecomastia was subsequently confirmed with sonography. For each patient with breast enlargement, a randomly selected control subject without breast enlargement was studied. Clinical data were obtained, including age, body mass index, clinically evident lipodystrophy, prior symptomatic hyperlactatemia, current antiretroviral therapy and duration of exposure to each antiretroviral drug, history of injection drug use, and serological status regarding hepatitis B and hepatitis C. Laboratory parameters, including plasma HIV-1 RNA load, CD4 cell count, free testosterone index, and levels of fasting triglycerides, cholesterol, prolactin, total testosterone, sex hormone-binding globulin, 17-beta-estradiol, follicle-stimulating hormone, luteinizing hormone, and thyroid-stimulating hormone, were measured.

RESULTS

There were 44 of 2275 patients with breast enlargement, of whom 40 (1.8%) had gynecomastia. The mean free testosterone index (+/-SD) was significantly lower among the 40 patients with gynecomastia (42.6%+/-24.0%) than among the 44 control subjects (58.0%+/-25.3%) (P=.006). Although the proportion of patients who were receiving treatment with zidovudine, stavudine, and/or efavirenz at the time of the present study was significantly different between case patients and control subjects, the duration of exposure to each individual antiretroviral drug was not. Lipoatrophy (adjusted odds ratio [OR], 5.6; 95% confidence interval [CI], 1.7-18.6; P=.005), hepatitis C (adjusted OR, 6.1; 95% CI, 1.8-20.6; P=.003), and hypogonadism (adjusted OR, 7.6; 95% CI, 1.8-32.2; P=.003) were independent factors associated with gynecomastia.

CONCLUSIONS

The data suggest that gynecomastia among HIV-infected patients is related to hypogonadism, rather than to an adverse effect of antiretroviral drugs.

Gynaecomastia in HIV-Infected Men on Highly Active Antiretroviral Therapy: Association with Efavirenz and Didanosine Treatment

Background

Gynaecomastia has been described in HIV-infected men undergoing highly active antiretroviral therapy (HAART). However, there are insufficient data on the relationship between gynaecomastia and any specific antiretroviral drug and hormone abnormality.

Objective

To assess the frequency of gynaecomastia in HIV-infected men receiving HAART and its association with antiretroviral drugs and hormone abnormalities.

Methods

We carried out a prospective study of 1304 HIV-infected men undergoing HAART. In addition, we included a case (with gynaecomastia)-control (without gynaecomastia) analysis in the second part of this study. Cases and controls were matched according to age, HIV infection CDC clinical category, HCV infection, the date of study and the physician responsible for the patient. Patients bearing known causes of gynaecomastia were excluded. We analysed epidemiological, clinical, haematological and immunological characteristics and the use and duration of the antiretroviral therapy. In 13 cases and 13 controls a sexual hormone profile was carried out.

Results

A total of 30 (2.3%) HIV-infected men presented with gynaecomastia of unexplained cause. In 22 (73%) of these individuals, gynaecomastia completely resolved after a median time of 9 months (range: 5–22 months). The percentage of individuals who were receiving efavirenz and didanosine at the time of the study was higher among patients with gynaecomastia [57% vs 17% ( P=0.004) and 50% vs 13% ( P=0.003), respectively]. Plasma total testosterone, free testosterone index and bioavailable testosterone levels were lower in patients with gynaecomastia, whereas plasma free testosterone levels were not significantly different in either population.

Conclusions

Gynaecomastia is not uncommon in HIV-infected men undergoing HAART and it is usually transient. Efavirenz and didanosine treatment are associated with the emergence of gynaecomastia. An underlying hypoandrogenism seems to contribute to the emergence of this disorder in these patients.