1. Background
Hypogonadism is defined as low serum testosterone levels, together with more than one of the following clinical manifestations: sexual dysfunction, fatigue, depression, anemia, loss of libido, weight loss, or muscle loss (1, 2). Several studies have revealed that hypogonadism is a prevalent and important endocrinology abnormality among patients infected with the human immunodeficiency virus (HIV) (3, 4).
The cause of hypogonadism in HIV-positive patients is not clearly known and a number of cofactors can intensify it, in addition, some studies have proposed that hypogonadism has multi-factorial causes, including: aging (5), anemia (6), diabetes (7), malnutrition (8), common acute and chronic illnesses (9), weight loss (10), invasion of glands by HIV, or other pathogens like hepatitis (11), smoking, using drugs, such as opiates, megestrol acetate, methadone (12), and steroids (13), as well as progression to AIDS stages (14). Occasionally hypogonadism may contribute to primary testicular etiology, termed 'primary hypogonadism'. As a result of abnormalities in the testis, serum levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), secreted from the gonadotrophs of the anterior pituitary, are increased. However, in the majority of patients, hypogonadism is the result of inadequate stimulation from the gonadotrophs, which is called 'hypogonadotropic hypogonadism' or 'secondary hypogonadism'. In this type of hypogonadism, pituitary gland LH and FSH levels are inappropriately normal or low (15). In hypogonadism patients, prolactine levels may be elevated and sometimes they can predict hypogonadism independently (16). Highly active antiretroviral therapy (HAART) may have a protective effect on the development of hypogonadism (17).
According to the Iranian Ministry of Health and Medical Education, in Iran, a total of 27 041 cases had been identified up to September 2013 (18). Today, with regard to harm reduction strategies, many countries including Iran use methadone for addiction therapy. Based on the previous study, despite the fact that the methadone maintenance treatment (MMT) program has developed in Iran as one of the main methods of harm-reduction, it may cause hypogonadism in patients with an HIV infection (12). Nevertheless, hormonal testing is not routinely performed in the national surveillance program for HIV patients, and policy makers have no current plans to make any changes in the HIV surveillance program after implementing MMT in Iran. Although a total testosterone (TT) assay is widely available and inexpensive to perform, in community practice the choice of testosterone parameter to measure the detection of hypogonadism is still being debated (19).
2. Objectives
In this study we planned to determine the prevalence of hypogonadism among a group of HIV infected men in Shiraz, Iran, based on free and total testosterone levels and their association with some related factors, in order to suggest some new approaches in harm reduction strategies.
3. Materials and Methods
All participants had enrolled in either; voluntary counseling and testing (VCT) services or MMT centers, affiliated with the Shiraz University of Medical Sciences in Shiraz, Southern Iran. In total, 278 men with HIV positive infection were selected for the study, based on convenience sampling between May and October 2010.
The study's objectives were explained to all the participants and written informed consent was obtained from each subject prior to commencement of the study. Then, the questionnaires, including socio-demographic and HIV-related variables, were completed by all participants. Next, the patients were asked to give serum samples for morning serum FT and TT levels, LH, FSH, and prolactine.
In this study, the serum TT concentration was measured through a direct method radioimmunoassay (Immunotech, Marseille, France). Inter-assay variation was ≤ 15% and the normal range was 3.0 to 12 ng/mL. In addition, FT was measured with an enzyme-linked immunosorbent assay (ELISA) (DRG Instruments, Marburg, Germany). The inter-assay variation was ≤ 10% and the normal range was 4.5 to 42.0 pg/mL. In addition, prolactine was measured by an immune radiometric assay (Immunotech, Irma Kit, Czech Republic). The inter-assay variation was ≤ 8.0%, and the normal range was 1.0-18.0 ng/mL. Finally, LH was measured by an immune radiometric assay (Immunotech, Irma Kit, Czech Republic). The inter-assay variation was ≤ 3.7% and the normal range was 0.05-10 IV/L.
From a sample of 278 HIV infected males, 28 (10%) patients completed the questionnaires, but they did not refer for serum sampling at the beginning of the study, and six (2.1%) subjects with systemic diseases, including; cirrhosis, chronic renal failure, chronic pulmonary disease, and diabetes mellitus, which may contribute to hypogonadism, were excluded. As hyper-prolactinemia produces hypogonadism by interfering with the secretion of gonadotropin-releasing hormones, five (1.8%) subjects with hyper-prolactinemia (serum prolactine level above 18 ng/mL), were also excluded from the study. In addition, we excluded two (0.71%) patients with hypergonadism (TT above 12 ng/mL). Finally, 237 (85%) participants were enrolled in this study. We defined hypogonadism patients by TT levels of ≤ 348.3 ng/dL (12.1nmol/L), and FT levels of ≤ 70.0 pg/ML (243 pmol/L).
The data were analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows, Version 18.0. We carried out a simple descriptive analysis and logistic regression. The study protocol was approved by the Research Ethics Committee of Shiraz University of Medical Sciences.
4. Results
4.1. Characteristics of the Study Participants
Among the 237 participants who were enrolled in the study, the mean age of the participants was 37.4 ± 7.4 years (range 22-63 years), and the largest age subgroup was 30-39 years (54.1%). All of the subjects were male and 84.2% were unemployed. Slightly fewer than half of the participants 106 (44.7%) were single, and 88 (37.1%) were married. Moreover, 54 (22.7%) of the patients had developed AIDS, while 180 (75.9%) subjects and 23 (9.7%) subjects, were HCV-positive and HBS-positive, respectively. According to the weight status categories associated with body mass index (BMI) ranges for adults; 15.1% of the subjects had a BMI below 18.5 (underweight), 51.1% were between 18.5 and 24.9 (normal), 7.6% were between 25 and 29 (overweight), and approximately 0.4% had a BMI above 30 (obese). Almost 194 (82%) subjects smoked cigarettes and 97 (41%) were active clients in the MMT program. There were 32 (13.5%) participants who were injection heroin users, 33 (13.9%) used opium, 8 (3.4%) used marijuana and other drug users, and 11 (4.6%) subjects belonged to others or missing data.
4.2. Hypogonadal vs. Eugonadal
According to the TT levels, 35.4% of the patients had a serum level below three or were hypogonadal, whereas 59.6% had a serum TT level between 3 and 12 ng/mL and were eugonadal. On the other hand, 62.8% and 30.8% of the patients were hypogonadal (FT level below 4.5 pg/mL) and eugonadal (FT between 4.5 to 42 pg/mL). Among the hypogonadal patients defined by total testosterone serum levels, 23.8% had primary hypogonadism, and 76.2% had secondary hypogonadism. Considering free testosterone serum levels, 30.8% and 69.1% of the patients had primary and secondary hypogonadism, respectively. Comparison of hypogonadal and eugonadal patients (Tables 1 and 2).
| - | Hypogonadal (n=84) | Eugonadal (n=133) | P-value | OR (95%CI) |
|---|---|---|---|---|
| Age, y | 37.6 ± 6.6 | 37.7 ± 7.1 | 0.88 | 0.99 (0.95-1.03) |
| 20-29 | 6 (7.1) | 10 (7.5) | - | - |
| 30-39 | 44 (52.4) | 71 (53.4) | - | - |
| 40-49 | 23 (27.4) | 34 (25.6) | - | - |
| 50-60 | 6 (7.1) | 9 (6.8) | - | - |
| BMI, kg/m2 | 20.38 ± 2.7 | 21.7 ± 4.03 | 0.02 | 0.88 (0.79-0.98) |
| <18.5 | 16 (19) | 12 (9) | - | - |
| 18.5-24.9 | 47 (56) | 67 (50.4) | - | - |
| 25.0–29.9 | 4 (4.8) | 15 (11.3) | - | - |
| 30> | 67 (79.8) | 1 (0.8) | - | - |
| FSH, IU/L | 4.3 ± 2.8 | 4.9 ± 3.1 | 0.152 | 0.93 (0.84-1.02) |
| LH, IU/L | 6.8 ± 5.9 | 10.7 ± 7.8 | < 0.0001 | 0.91 (0.87-0.95) |
| PRL, ng/mL | 8.3 ± 4.2 | 6.2 ± 2.9 | < 0.0001 | 1.18 (1.09-1.28) |
| HGB | 12.9 ± 2.3 | 14.1 ± 2.1 | < 0.0001 | 0.788 (0.69-0.89) |
| Smoking | - | - | 0.64 | 0.86 (0.47-1.58) |
| Yes | 71 | 103 | - | - |
| No | 9 | 28 | - | - |
| Unknown | 4 | 2 | - | - |
| Methadone | - | - | 0.67 | 1.12 (0.64-1.96) |
| Yes | 46 | 55 | - | - |
| No | 37 | 77 | - | - |
| Unknown | 1 | 1 | - | - |
| Hepatitis | - | - | 0.14 | 2.3 (CI:0.73-7.5) |
| Negative | 1 | 10 | - | - |
| Positive | 66 | 90 | - | - |
| Unknown | 17 | 33 | - | - |
| AIDS | - | - | 0.912 | 1.03 (0.54-1.98) |
| Yes | 23 | 34 | - | - |
| No | 45 | 69 | - | - |
| Unknown | 16 | 30 | - | - |
| HAART | - | - | 0.50 | 1.23 (0.64-2.44) |
| Yes | 22 | 26 | - | - |
| No | 52 | 77 | - | - |
| Unknown | 10 | 30 | - | - |
| Variables | Hypogonadal (n=149) | Eugonadal (n=73) | P-value | OR (95%CI) |
|---|---|---|---|---|
| Age, y | 38.3 ± 6.9 | 35.9 ± 6.5 | 0.016 | 1.05 (1.010-1.107) |
| 20-29 | 9 (6) | 8 (11) | - | - |
| 30-39 | 78 (52.3) | 42 (57.5) | - | - |
| 40-49 | 38 (25.5) | 18 (24.7) | - | - |
| 50-60 | 13 (8.7) | 2 (2.7) | - | - |
| BMI, kg/m2 | 20.6 ± 2.8 | 22.2 ± 4.4 | 0.009 | 0.87 (0.79-0.96) |
| < 18.5 | 24 (16.1) | 5 (6.8) | - | - |
| 18.5-24.9 | 74 (49.7) | 42 (57.5) | - | - |
| 25.0-29.9 | 9 (6) | 11 (15.1) | - | - |
| 30 > | - | 1 (1.4) | - | - |
| FSH, IU/L | 4.6 ± 3.1 | 4.8 ± 2.9 | 0.669 | 0.98 (0.89-1.07) |
| LH, IU/L | 8.4 ± 7.1 | 11.7 ± 8.1 | 0.041 | 0.96 (0.93-0.99) |
| PRL, ng/mL | 7.5 ± 3.8 | 6.04 ± 3.04 | O.006 | 1.13 (1. 03 – 1. 23) |
| HGB | 13.2 ± 2.2 | 14.6 ± 1.9 | < 0.0001 | 0.7 (0.6-0.82) |
| Smoking | - | - | 0.20 | 0.68 (0.38-1.2) |
| Yes | 124 | 54 | - | - |
| No | 19 | 19 | - | - |
| Unknown | 6 | 0 | - | - |
| Methadone | - | - | 0.042 | 1.74 (0.97-3.1) |
| Yes | 79 | 24 | - | - |
| No | 69 | 48 | - | - |
| Unknown | 1 | 1 | - | - |
| Hepatitis | - | - | 0.24 | 1.9 (0.63-6.0) |
| Negative | 5 | 5 | - | - |
| Positive | 110 | 51 | - | - |
| Unknown | 34 | 17 | - | - |
| AIDS | - | - | 0.40 | 0.75 (0.38-1.4) |
| Yes | 36 | 21 | ||
| No | 82 | 36 | - | - |
| Unknown | 31 | 16 | ||
| HAART | - | - | 0.39 | 1.34 (0.67-2.67) |
| Yes | 31 | 18 | - | - |
| No | 95 | 41 | - | - |
| Unknown | 23 | 14 | - | - |
Comparison Between Hypogonadal and Eugonadal Subjects Based on Free Testosterone a
According to Tables 1 and 2, BMI, LH, and HGB were related to hypogonadism for both TT and FT. Nevertheless, a significant association was only observed between FT and age, as well as methadone. Furthermore, increasing age and lower body mass index were associated with hypogonadism. By increasing one unit of LH and HGB, a protective effect can be seen, which means that anemia, or lower HGB and lower LH levels, can cause hypogonadism. On the other hand, increasing the PRL serum level could induce hypogonadism. According to levels of free testosterone, the patients who received methadone maintenance therapy might have been affected by hypogonadism. There was no relationship between hypogonadism and HAART, smoking, hepatitis, and AIDS.
5. Discussion
In the present study, the prevalence of hypogonadism among people with an HIV infection was high based on FT and TT. This difference could be due to abnormalities of the testosterone binding to sex hormone binding globulin (SHBG). Assessing the androgen levels in HIV-infected patients is a much more reliable method than measuring levels of (FT), which is not bound to SHBG. In fact, higher SHBG levels in HIV-positive patients may cause an increase in (TT) levels, but not (FT) (3, 4), however, the most widely accepted parameters to establish the presence of hypogonadism is the measurement of serum TT (20). On the other hand, some studies have proposed that FT is the preferred method for the detection of hypogonadism (19). We found BMI, LH, PRL and HGB to be the most important risk factors for inducing hypogonadism based on total testosterone, in addition to these factors, age and methadone can decrease (FT) and cause hypogonadism.
The results showed that as age increased, the total serum testosterone concentration decreased slightly; similarly, the results of one study has showed that serum free testosterone falls more rapidly in older patients and patients who are at risk of HIV infection also had low androgen levels as well. Similar to these studies, our study revealed a relationship between increasing age and hypogonadism based on FT. Although the mean age of the participants was 37.4 + 7.4 years, the risk of hypogonadism increased by 0.05% per year with increasing age, although age was not considered as one of the risk factors for inducing hypogonadism based on a TT assessment.
Similar to another study, the present study also revealed a correlation between BMI and hypogonadism (21); since for each unit increase in BMI, the probability of getting hypogonadism was reduced by 13%, this means that weight loss can cause hypogonadism, therefore appropriate diets for these patients should be take into consideration.
Although the MMT program in HIV-seropositive IDUs is associated with harm reduction and health promotion behaviors, several studies have suggested that methadone can cause hypogonadism (5, 22). Methadone shares the ability to stimulate prolactine release along with phenothiazine and butyrophenone narcoleptics. Although approximately half of the patients were chronic methadone users, only 3.5% of the patients with hyperprolactinemia used it. As a consequence, methadone may contribute to secondary hypogonadism. In this study, the patients who used methadone were 74% more likely to have hypogonadism, rather than hyperprolactinemia. More studies should be conducted in order to determine the unknown effects of methadone on hypogonadism. However, the patients who are assigned to HIV harm reduction programs are less likely to use illicit opiates and more likely to adhere to antiretroviral medications during their treatment. As a consequence, they have lower addiction severity scores and are less likely to engage in high risk behaviors. Therefore, one of the most important reasons for applying hormonal evaluation in surveillance programs for these patients could be the distinctive use of MMT in HIV patients in Iran.
Before the introduction of HAART, patients with HIV were commonly diagnosed with hypogonadism. Today, data continue to reveal an increased prevalence of hypogonadism among patients with HIV, although the rates are not as high since the introduction of HAART (1). A protective effect of HAART was not found in this study.
According to a previous study, about one out of three participants with HIV suffer from chronic hepatitis C (23). In this study, more than two thirds of the HIV-positive men had a HCV infection. This might be due to the fact that HCV-HIV co-infection is high according to some studies that have been carried out in Iran (24, 25). In general, patients with cirrhosis can develop hypogonadism (26); however, the study findings showed no significant relationship between chronic hepatitis B and C, without cirrhosis and hypogonadism. For that reason, according to the results of this study, chronic hepatitis without cirrhosis is not an acceptable reason for routine testing of testosterone.
Tobacco use has been associated with a lower risk of hypogonadism (27). Nevertheless, due to the fact that the patients of the current study used cigarette along with methadone, the protective effects of cigarette could not be detected.
Some studies have revealed that hyperprolactinemia frequently induces hypogonadism in men (28). In our study, 5.9% of HIV-positive patients had hyperprolactinemia. We analyzed prolactine separately and the results suggest that hypogonadism has a significant relationship with hyperprolactinemia; with each unit increase in serum prolactine, the probability of hypogonadism decreased by 13%.
The results of another study suggest that hemoglobin increases significantly in a linear, dose-dependent manner in both younger and older men in response to graded doses of testosterone (29). In this study, with each unit increase in Hb, a 0.3% decrease was observed in the probability of hypogonadism. Regarding the elevation of FSH and LH in hypogonadism patients, the results showed a significant difference in eugonadal and hypogonadal patients based on LH.
In this study, the participants were selected from VCT and MMT, the only two places where HIV/AIDS patients are referred in order to use appropriate services, but obviously the sample cannot be representative of the entire HIV/AIDS patients. Since the highest HIV-seropositive patients are likely to be taking medication, including antidepressants, the possible drug interactions that may arise, such as their effects on sexual function and sexual hormones, should be taken into consideration. Another limitation in this study is the missing data for some variables, like HAART or AIDS status, and patients' methadone use. Consequently, this would have affected some of the study's results, and we suggest that future randomized clinical trials would provide better investigations of these risk factors. In Iran, to the best of our knowledge, hypogonadism and its associated factors in males with an HIV infection has not been previously investigated. This study was the first study to compare two scales for detecting hypogonadism, and we also compared some risk factors in hypogonadal and eugonadal patients using two different methods. Moreover, we proposed that sexual dysfunction should be considered as one of the most important factors of HIV/AIDS and that may be beneficial in enhancing HIV/AIDS clinical care programs. In particular, we hope our study encourages other researchers to determine guidelines for best clinical care programs and to find essential aspects of care for the wellbeing of people with an HIV infection.
In this study, we tried to find the relationships between hypogonadism and related risk factors, and the results showed that they differed based on the type of testosterone measure used. One of the most important findings of this study was the high prevalence of hypogonadism among HIV-positive men. The implementation of harm reduction programs in Iran has set the stage for a large number of HIV positive patients to become prone to hypogonadism. Hence, it is recommended that hypogonadism examination is included in surveillance programs; in addition, testosterone replacement therapy could be performed for HIV-positive men.
