Treatment of Hypogonadal Patients

Testosterone Replacement Therapy

After the earlier interventions have been implemented in a patient with HIV-associated wasting, specific therapies can be started. If the patient is male and hypogonadal, the Panel recommends replacement therapy with testosterone, which has been shown to increase lean body mass and muscle strength in patients with HIV infection who are hypogonadal.37-40

When used in conjunction with progressive resistance exercise, testosterone produces positive changes in arm and leg muscle mass.41 Therapy does not affect a patient's viral load or CD4 cell counts. Although there are very few controlled trials, testosterone replacement therapy is generally considered safe. Its main adverse effect is the reduction of HDL cholesterol. Other potential side effects in men include acne, hair loss, dyslipidemia, sleep apnea, and prostate changes. A digital rectal exam (DRE) and prostate-specific antigen (PSA) test should be performed prior to initiating therapy. Once treatment has been started, PSA testing is performed every 3 to 6 months. Testosterone may be administered either by the intramuscular or transdermal route. Similar doses are used as for HIV-negative men. Currently, the optimal replacement doses or modes of administration are not known for men with HIV infection and wasting who are hypogonadal.

After testosterone replacement therapy is initiated, the clinician should reassess the patient for increases in body cell mass after four weeks of therapy. Laboratory samples for serum total and free testosterone levels can also be taken at this time.