A study on hypogonadism in male HIV patients in northeastern part of India.

CONTEXT: After the introduction of highly active antiretroviral therapy (ART), the prevalence of hypogonadism among human immunodeficiency virus (HIV)-infected males is decreasing. AIMS: The aim of this study was (i) to estimate the prevalence of hypogonadism among HIV-infected males and (ii) to determine the risk factors for hypogonadism. SETTINGS AND
DESIGN: This was a cross-sectional study undertaken at ART center of a medical Institute. SUBJECTS AND METHODS: The study recruited HIV-infected males aged 18-65 years receiving ART. Patients with any debilitating chronic illness, diabetes mellitus, chronic smokers or alcoholic, currently on opioids, or methadone were excluded from the study. Androgen Deficiency in Aging Male (ADAM) questionnaire was used to screen patients for the possible presence of hypogonadism. For those screened positive on ADAM questionnaire underwent biochemical evaluation for serum total testosterone, luteinizing hormone (LH), and CD4 count. STATISTICAL ANALYSIS USED: The Chi-square test was used to compare different parameters. Pearson's correlation coefficient was used to assess any relationship between CD4 count, LH, and testosterone. P < 0.05 was considered statistically significant.
RESULTS: In the study, 426 were initially screened and 120 patients who had probable hypogonadism were further evaluated. The mean age of the patients was 41.61 years. The mean body mass index (BMI) of the patients was 22.47 kg/m2. The mean duration of ART was 6.13 years and the mean CD4 count was 442.63 cells/mm3. Hypogonadism was seen in 20 (23.3%) and majority (85.7%) had secondary hypogonadism. There was significant association between hypogonadism and CD4 count, but no association was found with BMI and duration of ART.
CONCLUSIONS: Hypogonadism is seen in 23.3% of HIV-infected males. Majority (85.7%) had secondary hypogonadism. There was significant association of hypogonadism with lower CD4 count.

INTRODUCTION

A wide spectrum of endocrine abnormalities is seen in human immunodeficiency virus (HIV) patients.[123] In older studies, 29%–50% of the men with HIV infection had low total testosterone (TT).[4567] However, after the introduction of highly active antiretroviral therapy (HAART), more recent studies have reported a lower prevalence of around 9%–16%.[891011] Studies from India have reported the prevalence ranging from 13.3% to 33%.[121314] However, with a small sample, Tripathy et al. reported a prevalence of 89.7%.[15] All these prevalence reported are much higher than 6% in the age group of 40–69 years from the Massachusetts Male Aging Study.[16] As men live longer and are generally healthier than they were before the introduction of ART, the role of testosterone plays in sexual function as well as in general well-being is becoming increasingly important.[17] There are no such data from Northeast India on the prevalence of hypogonadism among HIV-infected males. Hence, the present study was planned to estimate the prevalence of hypogonadism in HIV male patients and its determinants.

The study was conducted with the aim as follows:

To estimate the prevalence of hypogonadism among HIV-infected males and

To determine the risk factors for hypogonadism.

SUBJECTS AND METHODS

This cross-sectional study was undertaken in a Centre of Excellence, ART, under the National AIDS Control Organization, Government of India, attached to the Department of General Medicine of a teaching institute. Ethical clearance was obtained from the Institutional Ethics Committee. Informed consent was obtained from all the participants. The study recruited HIV-infected males aged 18–65 years receiving ART. We excluded patients with any debilitating chronic illness, chronic smokers or alcoholic, currently on opioids, or methadone. HIV-infected patients with diabetes mellitus, coinfected with hepatitis B and C were also excluded from the study.

Each enrolled patients underwent through a thorough clinical evaluation. Androgen Deficiency in Aging Male (ADAM) questionnaire was used to screen patients for the possible presence of hypogonadism.[18] For those screened positive on ADAM questionnaire underwent venipuncture in the morning between 8 and 10 am. All blood samples collected in a sterile plain vial and stored at −20°C until analyzed. Serum TT and luteinizing hormone (LH) were assayed using immunochemiluminescence automated analyzer (Vitros Microwell ECIQ assay, Ortho-Clinical Diagnostic, Bridgend, United Kingdom). CD4 cell count was estimated using automated analyzer and fluorescence-activated cell sorter manufactured by BD BioSciences, 2350, Qume Drive, San Jose, CA 95131-1807, USA. The reference range of TT was 132–813 ng/dl, and normal range of LH was 1.4–8.9 ng/dl. Hypogonadism was diagnosed using the Endocrine Society practice guideline cutoff of ≤300 ng/dl.[19] Body mass index (BMI) of the patients was categorized using the WHO Asian classification.[20]

Data collected were checked for completeness and consistency. Data were analyzed using SPSS Statistics 21 for Windows, IBM Corp. 1995, USA 2012. Data were summarized using frequencies, percentage, mean, and standard deviation. Chi-square test was used to compare different parameters among HIV-infected patients with and without hypogonadism. Pearson's correlation coefficient was used to assess any relationship between CD4 count, LH, and testosterone. P < 0.05 was considered statistically significant.

RESULTS

The study included 426 HIV male patients screened for adult-onset hypogonadism using the ADAM questionnaire, out of which 120 patients who had probable hypogonadism were further evaluated. The age of the patients ranged from 22 years to 64 years with the mean of 41.61 ± 9.14 years. The BMI of the patients ranged from 17 to 31 kg/m2 with the mean of 22.47 kg/m2. Most of the patients had normal BMI (n = 59). Duration of ART ranged from 1 to 20 years. The mean duration of ART was 6.13 ± 3.81 years. Maximum (56.6%) patients had been on ART for <5 years. The mean CD4 count was 442.63 ± 276.97 cells/mm3. The mean TT level was 432.73 ± 207.169 ng/dL, and hypogonadism was seen in 20 (23.3%) of those who underwent biochemical screening for TT. The prevalence of hypogonadism according to the age groups is shown in Figure 1. Even patients below the age of 45 years were affected with a prevalence of 25.3%.

Figure 1

Distribution of patients by CD4 count

There was significant association between TT and CD4 count, but no association was found between TT and BMI and duration of ART [Tables 1–3].

Table 1

Association between body mass index and hypogonadism

BMI, kg/m2	Testosterone level, n (%)		P
	≤300 ng/dl	>300 ng/dl
Underweight (<18.5)	1	10	0.550
Normal (18.5–22.9)	16	41
Overweight (23–24.9)	6	23
Obese (>30)	5	18

BMI=Body mass index

Table 3

Association between CD4 count and hypogonadism

CD4 count (cells/mm3)	Testosterone level, n (%)		P
	≤300 ng/dl	>300 ng/dl
≤250z	13 (38.2)	21 (61.8)	0.037
251–50	6 (30)	14 (70)
351–500	4 (17.4)	19 (82.6)
>500	5 (11.6)	38 (88.4)

Test of strength of linear dependence of CD4 count with TT and LH levels was done using the Pearson's correlation coefficient. For all the hormones, the coefficient of correlation (r) was nearer to zero (r = −0.042, −0.145, respectively) and P value for each hormone > 0.05. This indicates that there was negligible or no correlation between CD4 count and serum hormone level.

Among those with low testosterone majority, 85.7% had either low or inappropriately normal LH suggesting secondary hypogonadism as shown in Figure 2.

Figure 2

Gonadal status according to serum total testosterone threshold of 300ng/dL and LH normal range

DISCUSSION

In the present study, 426 HIV male patients were screened for adult-onset hypogonadism using the ADAM questionnaire, out of which 120 patients who had probable hypogonadism were further evaluated. Hypogonadism was seen in 23.3% of the 120 who underwent biochemical evaluation. This finding is comparable with those of other studies in the HAART era reporting the prevalence ranging from 16% to 33%.[9121321222324] Meena et al. reported a prevalence of 33.3% using a testosterone cutoff of 200 ng/dl; hence, their prevalence would be much higher the current cutoff of 300 ng/dl.[12] During the pre-ART era, studies have shown high prevalence of hypogonadism approximately 50% with AIDS which is associated with increased severity of the disease.[5] Recent study published from India showed a prevalence of 13.3% among 45 patients on HAART.[14] Our study is limited to the fact that TT was used to diagnose hypogonadism which can give a falsely lower prevalence. In the Multicenter AIDS Cohort Study, reliance on TT missed 33% of patients with hypogonadism.[11] In another study, Moreno-Pérez et al. reported that TT has a poor sensitivity of 25% to diagnose hypogonadism among HIV-infected patients.[8] This is because sex hormone-binding globulin levels are increased with HIV infection.[2125]

In this study, the prevalence of hypogonadism was 25.3% among patients below 45 years. In a large Italian cohort, highest rate of hypogonadism was seen in men aged 40–49 and 50–59 years. Remarkably, 10.6% of patients in the age group 30–39 years also had hypogonadism.[9]

Among those patients with hypogonadism, secondary hypogonadism was much more frequent than primary hypogonadism. Crum-Cianflone et al. demonstrated that all patients with low testosterone had secondary hypogonadism.[22] In the Swiss HIV cohort, low or inappropriately gonadotropin level was seen in 91% of patients during the initiation of HAART.[26] Similarly, in the study by Arver et al., 81% of hypogonadal patients with HIV infection were hypogonadotropic.[24] Finding similar to our study is reported by several authors.[6912131415]

As secondary hypogonadism is the most common among the patients, a primary impairment of pituitary gonadotropin secretion could be postulated.

The virus itself and the HAART medications could be implicated in the suppression of the hypothalamic–pituitary–gonadal axis. Secondary hypogonadism might be due to a decrease in gonadotropin secretion during severe illness and involvement of hypothalamic or pituitary tissue by opportunistic infections or malignancies.[27]

Primary gonadal failure may be due to opportunistic infections such as Cytomegalovirus, Mycobacterium avium complex, Cryptococcus neoformans, or infiltration by a neoplasm-like Kaposi's sarcoma.[2829] Cytokines such as interleukin 1 and tumor necrosis factor may decrease Leydig cell steroidogenesis.[30]

Association of hypogonadism with body mass index

BMI was negatively correlated with testosterone, although statistically not significant. Crum-Cianflone et al. demonstrated a higher BMI were positively associated with hypogonadism.[22] In studies done by Meena et al.[12] and Jain et al.,[31] the incidence of low testosterone was directly correlated with the BMI. This may be because of the differences in BMI in the studies. In our study, most of the patients had normal BMI, whereas in theirs, majority of them were underweight patients. The higher BMI recorded in our study could be due to regional variations and also the fact that patients with debilitating chronic diseases/unstable patients were excluded from the study. Klein et al. also did not find any significant association between low androgen level with BMI.[32] Some other studies did not find any correlation with weight.[621]

Association of hypogonadism with CD4 count

There was no significant correlation between CD4 count and testosterone level. Klein et al. did not find any significant association between low androgen level with CD4 count among older males 49–81 years old.[32] Other studies also did not found any correlation between hypogonadism and CD4 count.[61521] However, studies by Meena et al.[12] and Mandal et al.[13] found a negative correlation of TT with CD4 count.

Association of hypogonadism with duration of antiretroviral therapy

Our study did not show any significant relationship between the duration of ART of the patients and gonadal dysfunctions which is consistent with a study by Jain et al.,[31] Rietschel et al.,[21] and Klein et al.,[32] and also did not find any significant association between low androgen level with ART. However, these findings cannot be assured as we did not compare the level of testosterone before the initiation of ART and while on ART. We recommend that a long follow-up to be done. Impotency and low levels of testosterone observed in HIV-infected patients may be related to the progression of the HIV infection or maybe the result of the compound effect of debilitating illnesses and secondary infections along with psychological effects.

Implication of hypogonadism

Wunder et al. reported that there is no or little improvement of hypogonadism before and after ART. However, testosterone replacement among hypogonadal HIV patients increases fat-free mass.[26]

Grinspoon et al. demonstrated an increased depression score in association with hypogonadism in men with AIDS wasting, independent of weight, virologic status, and other disease factors. Administration of testosterone results in a significant improvement in depression inventory score.[33] Sexual function and depression scores improved, and antidepressant medication use decreased with testosterone therapy. Body composition profiles remained stable in men with HIV/AIDS during 12 months of follow-up.[34]

CONCLUSIONS

In this study, almost one-fourth (23.3%) of the patients on ART was found to have hypogonadism, with 25.3% of patients below 45 years affected. Among those patients hypogonadism, around 86% had inappropriately normal or low LH suggestive of secondary hypogonadism. As secondary hypogonadism is the most common among the patients, hypothalamic–pituitary axis should be regarded as the main element involved in the development of hypogonadism in HIV patients. There was negligible or no correlation between serum testosterone with BMI, CD4 count, and duration of ART.

Financial support and sponsorship

This study was financially supported by the Department of Biotechnology, Nodal Cell, Tezpur, Ministry of Science and Technology, Government of India.

Conflicts of interest

There are no conflicts of interest.

Table 2

Association between duration of antiretroviral therapy with hypogonadism

Duration of ART (years)	Testosterone level		P
	≤300 ng/dl	>300 ng/dl
≤5	16	52	0.312
6-10	7	30
11-15	5	7
16-20	0	3

ART=Antiretroviral therapy