Testosterone replacement treatment options for HIV-infected men

Hypogonadism among HIV-infected men in Thailand

This study assessed prevalence and associated factors of hypogonadism among 491 HIV-infected Thai men who visited the HIV outpatient clinic. All participants were interviewed and data were collected from medical records, including demographic and HIV-related illness characteristics. They also completed questionnaires relevant to hypogonadal symptoms, sexual function and depression. All participants’ blood samples were obtained to check for total testosterone, sex hormone-binding globulin (SHBG) and albumin levels, and free testosterone (cFT) was calculated. Hypogonadism was diagnosed if a cFT level of <0.225 nmol/L was detected. The median age of the participants was 37 years old (ranging from 34 to 44 years old). HIV infection was diagnosed for a median of 77 (47-99) months. Eight of 491 participants (2%) had hypertension and 1 % had diabetes mellitus (DM). Fourteen (3%) used methadone and 23% had SHBG level over 70 nmol/L. Of the 491 participants, 123 (25%) men were diagnosed with hypogonadism. The univariate analyses indicated that DM, hypertension, methadone use, SHBG level >70 nmol/L group and lack of antiretroviral therapy were associated with hypogonadism. In multivariate analysis, a SHBG level >70 nmol/L was the only factor that was significantly associated with hypogonadism (odds ratio [OR] = 1.922, P = 0.007).

Reduced bone mineral density among HIV-infected patients in Taiwan: prevalence and associated factors

BACKGROUND

Reduced bone mineral density (BMD) is an emerging threat to the successful long-term management of human immunodeficiency virus (HIV) infection among patients with access to combination antiretroviral therapy (cART). Data on the prevalence and associated factors of reduced BMD in Asian populations remain scarce.

METHODS

From March 2002 to April 2006, a cross-sectional survey was conducted among HIV-infected patients aged ≥ 20 years at the National Taiwan University Hospital. BMD of the lumbar spine was measured with the use of dual-energy X-ray absorptiometry. Osteopenia was defined as a BMD T-score between -1.0 and -2.5, and osteoporosis was defined as a BMD T-score ≤ -2.5. Linear and ordinal logistic regression analyses were performed.

RESULTS

Among 320 patients with a median age of 37.3 years, body mass index (BMI) of 21.4kg/m(2) and 94.4% on cART, osteopenia and osteoporosis were diagnosed in 35.6% and 3.8%, respectively. On multivariate linear analysis, factors associated with reduced BMD were increasing age (p=0.006), longer duration on antiretroviral therapy (p=0.007), and a decreasing BMI (p=0.002). Using ordinal logistic regression, being underweight with a body mass index (BMI)<18.5kg/m(2) was independently associated with reduced BMD (proportional odds ratio, 4.12; 95% confidence interval, 1.93-8.82).

CONCLUSION

Reduced BMD was prevalent among HIV-infected Taiwanese adults on cART. Increased age, lower BMI, and exposure to antiretroviral therapy were significantly associated with decrease of BMD.

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.

Human immunodeficiency virus/acquired immunodeficiency syndrome and infertility: emerging problems in the era of highly active antiretrovirals

OBJECTIVE

To review the effects of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in terms of its associated comorbid conditions and the side effects of antiretroviral treatment on fertility.

DESIGN

PubMed computer search to identify relevant articles.

SETTING

Research institution.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

Biological alterations in reproductive physiology may account for subfertility in patients infected with HIV. Psychosocial factors in patients with HIV infection may affect their reproductive desires and outcomes. Antiretroviral medications may have direct toxicity on gametes and embryos. Available evidence indicates that fertility treatments can be a safe option for couples with HIV-discordant infection status, although the potential risk of viral transmission cannot be completely eliminated.

CONCLUSION(S)

Because their potential reproductive desires are increasingly becoming a concern in the health care of young HIV-infected patients, additional data are needed to address the effect of HIV and its treatments on their fertility and reproductive outcomes.

Endocrine complications of human immunodeficiency virus infection: hypogonadism, bone disease and tenofovir-related toxicity

Treatment with highly active antiretroviral therapy (HAART) has revolutionized care of patients with HIV infection. The cost of increased survival has been antiretroviral toxicity and increasing age-related co-morbidities that include significant metabolic issues. Hypogonadism was first described in the setting of advanced AIDS and can be primary or secondary. Data regarding treatment largely concern patients with wasting. Varied syndromes involving bone have been described in patients with HIV including osteonecrosis, low bone mineral density (BMD) and osteoporosis, and rarely osteomalacia. Low BMD leading to osteoporosis is the most common bone pathology and may be as a result of HIV infection, drug toxicity or co-morbidities. However, increasingly fragility fractures are reported in HIV-infected patients, suggesting bone demineralization in this population is of clinical relevance. Further research is required to understand its pathogenesis and determine effective management; however, initiation of antiretroviral therapy seems to accelerate (in the short-term) bone demineralization. One particular antiretroviral agent, tenofovir is widely used and is potentially implicated as having a greater role in long-term bone and renal dysfunction. As this population ages, screening for low BMD will become increasingly more important.

Effects of HIV infection and antiretroviral therapy with ritonavir on induction of osteoclast-like cells in postmenopausal women

SUMMARY

Ritonavir (RTV) is a commonly used antiretroviral associated with bone loss. We show that peripheral blood mononuclear cells (PBMCs) from human immunodeficiency virus (HIV)-positive women on RTV are more likely to differentiate into osteoclast-like cells when cultured with their own sera than PBMCs and sera from HIV- women or HIV+ on other antiretrovirals.

INTRODUCTION

RTV increases differentiation of human adherent PBMCs to functional osteoclasts in vitro, and antiretroviral regimens containing RTV have been associated with low bone mineral density (BMD) and bone loss.

METHODS

BMD, proresorptive cytokines, bone turnover markers (BTMs), and induction of osteoclast-like cells from adherent PBMCs incubated either with macrophage colony-stimulating factor (MCSF) and receptor activator of nuclear factor κB ligand (RANKL) or with autologous serum were compared in 51 HIV- and 68 HIV+ postmenopausal women.

RESULTS

BMD was lower, and serum proresorptive cytokines and BTMs were higher in HIV+ versus HIV- women. Differentiation of osteoclast-like cells from adherent PBMCs exposed to either MCSF/RANKL or autologous serum was greater in HIV+ women. Induction of osteoclast-like cells was greater from PBMCs exposed to autologous sera from HIV+ women on RTV-containing versus other regimens (172 ± 14% versus 110 ± 10%, p < 0.001). Serum-based induction of osteoclast-like cells from adherent PBMCs correlated with certain BTMs but not BMD.

CONCLUSIONS

HIV infection and antiretroviral therapy are associated with higher BTMs and increased differentiation of osteoclast-like cells from adherent PBMCs, especially in women on regimens containing RTV. HIV+ postmenopausal women receiving RTV may be at greater risk for bone loss.

Testosterone Levels and Quality of Life in Diverse Male Patients With Cancers Unrelated to Androgens

Purpose

Symptoms secondary to hormonal changes significantly impact quality of life (QoL) in patients with cancer. This cross-sectional study examines prevalence of hypogonadism and its correlation with QoL and sexual dysfunction.

Patients and Methods

We collected blood and medical histories from 428 male patients with non–testosterone-related cancer at three cancer centers. Serum was analyzed for total testosterone (TT), free testosterone (FT), bioavailable testosterone (BAT), and sex hormone binding globulin (SHBG). The Functional Assessment of Cancer Therapy-Prostate (FACT-P) QoL questionnaire measured physical, social, emotional, and functional domains as well as sexual function. Exclusion criteria were prostate, testicular, or male breast cancer; known hypogonadism; and HIV.

Results

Mean and median TTs were 337.46 and 310 ng/dL, respectively. The mean age of patients was 62.05 years. The crude prevalence of hypogonadism (ie, TT < 300 ng/dL) was 48%, and mean TT in hypogonadal patients was 176 ng/dL. The prevalences that were based on FT (ie, hypogonadal < 52 pg/dL) and BAT (ie, hypogonadal < 95 ng/dL) were 78% and 66%, respectively. The mean FT and BAT values in hypogonadal patients were 25 pg/dL and 45 ng/dL, respectively. Hypogonadal patients had decreased total QoL scores on FACT-P (P = .01) and decreased three-item sexual function subset (P = .003).

Conclusion

The prevalence of hypogonadism was unexpectedly high. Measurement of FT or BAT detected a higher prevalence than TT alone, which confirmed previous studies. Correlation of T with FACT-P showed significant reduction of both overall QoL and sexual function for hypogonadal men. BAT and FT levels showed a stronger correlation than TT with overall FACT-P and subscales. The prevalence of symptomatic hypogonadism in male patients with cancer exceeds that found in comparable studies in noncancer populations.

Risk factors for sexual and erectile dysfunction in HIV-infected men: the role of protease inhibitors

OBJECTIVES

To determine the prevalence of erectile dysfunction in a cohort of HIV-infected men in a stable clinical state, the effect of exposure to antiretroviral therapy on sexual dysfunction and to identify the risk factors.

DESIGN

This is a cross-sectional, observational study.

METHODS

HIV-infected men without hepatitis C virus coinfection were included if they were antiretroviral therapy-naive (naive group), on current treatment with an enhanced protease inhibitor (protease inhibitor group) or on current treatment with two to three nucleoside reverse transcriptase inhibitors along with one nonnucleoside reverse transcriptase inhibitor and never having received treatment with protease inhibitor (nonnucleoside reverse transcriptase inhibitor group). Erectile dysfunction was defined as an ejection fraction of 25 or less (International Index of Erectile Function-15).

RESULTS

Ninety patients were included, with an age of 42 +/- 8.2 years and CD4 cell count of 465 cells/microl [P25-75 361-676]: 18.9% in Centers for Disease Control and Prevention class C and 72.2% with undetectable viral load. Seventy-six patients (84.4%) were receiving antiretroviral therapy, 39 (43.3%) in the protease inhibitor group. The prevalence of lipodystrophy was 31.5%. Forty-seven (53.4%) patients had an erectile dysfunction. Multivariate logistic regression analysis confirmed that there was an independent association between the patients' age (per decade; odds ratio 2.2, 95% confidence interval 1.04-4.5, P = 0.04) and greater duration of exposure to protease inhibitor (per year; odds ratio 1.6, 95% confidence interval 1.12-2.4, P = 0.01). Older age, depression and lipodystrophy, combined with the duration of exposure to protease inhibitor, determined a lower score on various sexual dysfunction domains (P < 0.05).

CONCLUSION

There is a high prevalence of erectile dysfunction in HIV-infected men, with age and the duration of exposure to protease inhibitor being the only identifiable risk factors.

Decreased bone mineral density and increased fracture risk in aging men with or at risk for HIV infection

BACKGROUND

Osteopenia has been described in HIV-infected persons, but most studies have not focused on aging men, have not included an HIV-negative comparison group with similar risks to those of the HIV-infected men, or lacked data on fracture rates.

METHODS

We analyzed bone mineral density (BMD) and incident fractures in 559 men who were >or= 49 years old with or at-risk for HIV, including 328 with and 231 without HIV infection.

RESULTS

Median age was 55 years, 56% were black and 89% had used illicit drugs. In unadjusted analysis, BMD was lower in HIV-infected compared with HIV-uninfected men at the femoral neck (0.97 +/- 0.14 versus 1.00 +/- 0.15 g/cm; P < 0.05) and lumbar spine (1.17 +/- 0.20 versus 1.20 +/- 0.21 g/cm; P = 0.06); both differences were significant (P < 0.05) after adjusting for age, weight, race, testosterone level, and prednisone and illicit drug use. Non-black race and body weight were independently associated with BMD at both measurement sites and methadone therapy was independently associated with spine BMD. Among HIV-infected men, 87% had taken antiretrovirals and 74% had taken protease inhibitors, but their use was not associated with BMD. Among men who had at least one subsequent study visit (94%), incident fracture rates per 100 person-years differed among men with normal BMD, osteopenia and osteoporosis (1.4 versus 3.6 versus 6.5; P < 0.01). A 38% increase in fracture rate among HIV-infected men was not statistically significant.

CONCLUSIONS

HIV infection is independently associated with modestly reduced BMD in aging men, and decreased BMD is associated with increased fracture risk.

Erectile dysfunction and hypogonadism among men with HIV

Erectile dysfunction (ED) and hypogonadism are increasingly recognized conditions, however, the prevalence and etiologies of these conditions among HIV-infected men remain unclear. We studied 300 HIV-infected men who completed standardized questionnaires regarding sexual function and hypogonadal symptoms. An early morning testosterone test was performed; patients with a low serum testosterone level (defined by <300 ng/dL), underwent additional blood tests to determine the etiology of the hypogonadism. The participants' mean age was 39 years (range, 19-72); 61% were Caucasian; 24%, African American; 9%, Hispanic; and 5% other. Participants had been HIV-positive for a mean of 9 years (range, 0.5-20) with a mean CD4 count of 522 cells/mm(3) (range, 1-1531). Sixty percent were receiving antiretroviral therapy. ED was reported by 61.4%; of those with ED, 32% did not have a rigid enough erection for penetration, and 46% were unable to sustain an erection for the completion of intercourse. In the multivariate analysis, increasing age (odds ratio [OR] 1.4 for a 5-year increment, p < 0.001) and depression (OR 2.64, p < 0.0001) were associated with ED. A higher current CD4 count was protective (OR 0.80 for each 100 cells/mm(3), p = 0.004). Only 25% of patients with ED had utilized a phosphodiesterase-5-inhibitor for treatment. Seventeen percent of the 300 men were hypogonadal; there was no correlation between hypogonadism and ED. Increasing age and a higher body mass index (BMI) were positively associated with hypogonadism, while smoking was negatively associated (OR 0.44, p = 0.02). All patients with low testosterone had secondary hypogonadism. There was no association between ED or hypogonadism with the current, past, or cumulative use of HIV medications.

HIV infection and bone mineral density in middle-aged women

BACKGROUND

Osteopenia is prevalent in persons with human immunodeficiency virus (HIV) infection and is part of a normal sequence of aging in women. Most studies of bone mineral density (BMD) and HIV infection have focused on men or have lacked a comparison group of individuals without HIV infection with similar behavioral risk factors.

METHODS

We analyzed BMD in 495 middle-aged women (defined as women > or =40 years of age); 263 women had HIV infection, and 232 women were HIV-negative with behavioral risk factors similar to those of the HIV-positive group.

RESULTS

The median age of the women in the study was 44 years, 54% were black, and 92% had used illicit drugs. Femoral neck BMD and lumbar spine BMD were reduced in women with HIV infection, compared with women without HIV infection (femoral neck BMD, 1.01+/-0.13 g/cm2 vs. 1.05+/-0.13 g/cm2; P=.001; lumbar spine BMD, 1.21+/-0.17 g/cm2 vs. 1.24+/-0.17 g/cm2; P=.04). In addition to HIV infection, other factors independently associated with lower BMD in both sites were being older, not being black, and having a low body weight. In race-stratified multivariate analyses, HIV infection was associated with BMD only in non-black women. Among HIV-positive women, 84% had taken antiretrovirals, and 62% had taken protease inhibitors, but their use was not associated with BMD. Methadone treatment was also independently associated with reduced lumbar spine BMD.

CONCLUSION

Middle-aged women with HIV infection have reduced BMD, compared with women at similar risk for HIV infection, independent of antiretroviral use. Among HIV-positive women, those who are not black, who are underweight, and who use opiates may be at particular risk. Although the prevalence of reduced BMD in this cohort was higher among women with HIV infection than among those without (27% vs. 19%), the overall prevalence of reduced BMD was low, compared with national estimates and with previous studies involving HIV-positive women and men.

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.

Improvement in sexual functioning and satisfaction in nonresponders to testosterone gel: Clinical effectiveness in hypogonadal, HIV-positive males

Impairment in gonadal function with reduced testosterone (T) levels is commonly associated with HIV infection and patients often complain of diminished libido and sexual dysfunction. The effectiveness of Testim 1% (Auxilium Pharmaceuticals, Inc., Norristown, Pennsylvania) topical T gel was evaluated in HIV-positive males who failed to experience satisfactory symptom relief following prior treatment with AndroGel 1% (Solvay Pharmaceuticals, Inc., Marietta, Georgia). In this open-label study, consecutive subjects were randomly assigned to experimental treatment with Testim 1% (5 g) or to maintenance therapy (control group) with AndroGel 1% (5 g). Twenty-four experimental subjects and 24 control subjects were followed for 4 weeks to evaluate improvements in sexual functioning and satisfaction. Changes from baseline in the 5 domains of the Brief Male Sexual Function Inventory (BMSFI) were compared between groups. The average percentage improvement favored the experimental treatment in all 5 comparisons of the BMSFI, including sexual drive (53% vs 18%, P < 0.001), erectile function (49% vs 7%, P < 0.004), ejaculatory function (15% vs 8%, P < 0.14), problem assessment (59% vs 12%, P < 0.003), and sexual satisfaction (58% vs 9%, P < 0.006). A greater percentage of subjects also reported satisfaction with the experimental treatment (85% vs 48%, P < 0.03), and these subjects were less likely to require upward dose titration at the final follow-up visit (30% vs 74%, P = 0.01). It is hypothesized that the results of the current study may be explained, in part, by an improved pharmacokinetic profile of the experimental intervention. Consideration of Testim 1% gel in HIV patients who have an inadequate response to prior T therapy is encouraged, although it is difficult to estimate the contribution of nonspecific study effects (eg, placebo) in this trial.

Reversible azoospermia: anabolic steroids may profoundly affect human immunodeficiency virus-seropositive men undergoing assisted reproduction

BACKGROUND

In vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) has recently been offered to human immunodeficiency virus (HIV)-serodiscordant couples where the man is seropositive and the woman seronegative to achieve pregnancy while minimizing the risk of HIV transmission. Anabolic steroids are commonly prescribed medications for adjunctive treatment of HIV disease to prevent muscle wasting.

CASE

An HIV-serodiscordant couple presented for fertility care and evaluation. The man was found to be azoospermic. Further evaluation attributed his azoospermia to his treatment with testosterone and oxandrolone. After these agents were discontinued, his azoospermia resolved within 3 months. Normal sperm were then cryopreserved for future use, and his medications were resumed. Later the couple conceived by IVF-ICSI using the cryopreserved sperm.

CONCLUSION

The popular use of anabolic steroids in HIV-infected men may predispose them to abnormal sperm production.

Diagnosis and treatment of androgen deficiency in human immunodeficiency virus-infected men and women

Androgen deficiency is a common endocrine abnormality among men and women with human immunodeficiency virus (HIV) infection. Low testosterone concentrations are associated with lower CD4 cell count, advanced stage of illness, medication use, and weight loss. Signs and symptoms may be nonspecific. The most useful laboratory indicator is the serum bioavailable (free) testosterone concentration. A number of different testosterone preparations for treatment of androgen deficiency in HIV-infected men now exist. Administration of im testosterone significantly increases weight and lean body mass, energy, quality of life, and depression scores in HIV-infected men with low testosterone levels. Newer transdermal and gel preparations provide more-consistent steady-state dosing but are not as well tested, and sufficient testosterone concentrations may not be achieved with their use. Androgen deficiency is also common among HIV-infected women. Preliminary studies suggest that use of physiological testosterone administration, to achieve testosterone levels within the normal range, is of benefit in HIV-infected women, but further studies are necessary to define the therapeutic role of androgen therapy in this population.

Double-blind placebo-controlled trial of oral dehydroepiandrosterone in patients with advanced HIV disease

OBJECTIVE

Plasma levels of dehydroepiandrosterone sulphate (DHEA-S) decrease with the progression of HIV disease. Here, we report on the efficacy and safety of the oral administration of DHEA as replacement therapy, in patients with advanced HIV disease, in a trial that was primarily aimed at assessing quality of life.

DESIGN

The trial was randomized and double-blind. Thirty-two patients were allocated to either DHEA 50 mg per day for 4 months (n = 14) or a matching placebo (n = 18). Clinical data, virological and immunological surrogate markers of HIV infection, plasma levels of DHEA-S and the Medical Outcomes Study HIV Health Survey (MOS-HIV) quality of life scale were recorded every month.

RESULTS

The mean age of the patients was 40 +/- 11 years. The mean CD4 cell count at baseline was 32.5 +/- 32.4 x 10(6)/l. The mean DHEA-S plasma level at baseline was 5.23 +/- 0.76 micromol/l. No side-effects related to DHEA occurred during the study. A statistically significant increase in the levels of DHEA-S was observed in the treated group throughout the study (P < 0.01). A significant improvement in the Mental Health and Health Distress dimension of MOS-HIV was observed in the DHEA treated group; P = 0.001 and 0.004, respectively. No change in CD4 cell counts was seen during follow-up.

CONCLUSIONS

The administration of DHEA in patients with advanced HIV infection results in improved mental function scores as assessed by the MOS-HIV quality of life scale.

Gonadal hormone levels in injection drug users

Levels of serum sex hormones, particularly testosterone, luteinizing hormone, and follicle-stimulating hormone, have been shown to change in various disease states. Hypogonadism has been well-documented in patients with HIV infection. As HIV infection and injection drug use are closely linked, we examined whether injection drug users (IDU's) exhibit hormone abnormalities. We evaluated men participating in the ALIVE study (AIDS Linked to Intravenous Experiences), a large cohort study conducted in Baltimore, MD. We found that 20% of 40 IDU subjects (20 HIV+, 20 HIV-) with a mean age 41.5+/-0.9, had low serum total testosterone concentration. We were unable to detect a direct correlation between drug use and hormone levels. Further study is needed on the hormonal milieu of the IDU patient.

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.

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.