The Effects of HIV on the Body

What does human immunodeficiency virus (HIV) look like?

Though symptoms can go undetected for some time, eventually the disease takes its toll on the body by damaging a person’s immune system, paving the way for numerous diseases to move in. While many of the diseases and infections that strike people with HIV are common, others are unusual and their presence is what often leads to a diagnosis of acquired immune deficiency syndrome (AIDS) — the final stage of HIV disease.

HIV: Early Symptoms

The earliest symptoms of HIV can resemble the flu and they generally clear up within a month or two. These symptoms may include fever, headache, fatigue, and swelling in the lymph nodes, particularly those in the neck and groin. However, not everyone who acquires HIV will experience these symptoms. Similarly, for several years, perhaps as long as a decade, a person with HIV may not have any symptoms at all. During that time, though, the virus is still multiplying and it's possible to transmit HIV to someone else.

HIV progresses differently for each person affected. The course of the disease is determined by the specific infections or complications a person with HIV develops. HIV complications can affect different parts of the body: Some are localized to the mouth, others in the brain, and others result in total body changes like losing body weight. Skin conditions are also common.

HIV: Skin Effects

Several of the main skin conditions that affect people with HIV are caused by viruses most people already have in their bodies. However, these viruses typically do not cause disease in people whose immune systems are healthy. Some of the more common dermatological, or skin, effects of HIV include:

• Varicella zoster virus (VZV) infection. VZV is a herpes virus that causes both chicken pox (varicella) and shingles (herpes zoster). Most adults have already been exposed to this virus. HIV-infected individuals may develop new skin sores from either of these diseases. HIV patients who didn’t have chicken pox earlier in their life may develop the condition, which in some cases can affect their organs and become life-threatening. Shingles can be localized to one area or it can spread over large areas of the skin. Shingles lesions can become infected and even lead to the development of encephalitis (brain inflammation) in people with HIV.
• Herpes simplex virus (HSV). HSV was one of the first diseases identified in people with advanced HIV disease and is now considered one of the AIDS-defining diseases by the U.S. Centers for Disease Control and Prevention. HSV causes open sores that may look like a cluster of blisters. They pop and crust over before healing completely; this process takes about 7 to 10 days in otherwise healthy individuals, but in people with advanced HIV disease, the sores may enlarge to 2 to 10 centimeters in diameter, becoming crusted and painful.
• Kaposi’s sarcoma (KS). KS is a cancer caused by a herpes virus called Kaposi sarcoma herpes virus. Healthy individuals may be infected with Kaposi sarcoma herpes virus without developing the cancer. However, as HIV-infected people become sicker, KS may develop. KS tumors grow from cells that line blood vessels and lymph nodes. The cells form tumors on the skin that appear as brown, purple, or red splotches, called lesions. In some cases, the lesions look worse than they are, as they may cause no other symptoms. Other people with KS may experience painful swelling, particularly around the eyes, in the legs, or in the groin. Although less common, KS lesions can also form in organs, like the liver, digestive system, or the lungs, which could be deadly.

HIV: Oral Health Problems

HIV infection can also cause oral health problems that are rare in uninfected people, including:

• Candidiasis. Candidiasis is a fungal infection that HIV patients often get as their CD4+ cell count decreases. One of the most common types associated with HIV, thrush (or pseudomembranous candidiasis), appears as white patches in the mouth or pharynx.
• Periodontal disease. HIV-positive individuals very often have periodontal disease caused by bacterial infections even if they do not have any other symptoms of HIV. At first, the periodontal disease is characterized by the sudden and rapid loss of soft tissue and jaw bone. As the disease progresses, the person may also develop gingivitis with ulcers that leave crater-like crevices after healing.
• Herpes simplex virus. HSV can also cause sores in and around the mouth. Typically, HSV-1 causes ulcers in the mouth and HSV-2 causes genital herpes. However, oral infection with HSV-2 and genital infection with HSV-1 can occur — this infection is usually spread during oral sex. The symptoms of both types are identical.

Kaposi’s sarcoma and shingles can also cause ulcers in the mouth. Kaposi’s sarcoma oral lesions are very similar to the skin lesions. Shingles lesions in the oral tissue may merge into large ulcers instead of crusting over as they do on the skin. Shingles oral ulcers often get into the gum tissue, causing tooth pain.

HIV: Neurological Effects

Although HIV does not appear to infect nerve cells, it does somehow affect their ability to function normally. People with HIV can experience:

• AIDS-related dementia
• A decrease in the ability to think properly and process information
• Brain tumors that either begin in the brain or spread to the brain from elsewhere in the body
• Progressive multifocal leukoencephalopathy (PML), which is caused by a virus most people are already infected with, but does not cause disease in people with healthy immune systems. Symptoms include difficulty walking and talking, weakness in the limbs, and seizures.

Other neurological complications such as headaches, fever, nausea, and dizziness may occur as a result of HIV treatments.

HIV: Weight Effects and Wasting Syndrome

A big concern for people who have HIV that has progressed to AIDS is AIDS wasting syndrome, which is defined as any unintentional weight loss of 10 percent or more of your body weight. HIV patients may lose muscle as well as fat, and once lost, the weight is difficult to regain. The person may also have diarrhea and a slight fever. These symptoms are usually accompanied by a complete loss of appetite. AIDS wasting syndrome is extremely dangerous for HIV-infected people but it can largely be prevented by eating a healthy, nutrient-rich diet (including such foods as peanut butter, eggs, cheeses, and legumes) and regular exercise to maintain muscle mass.

While HIV infection can lead to a variety of very serious complications, advances in treatments have significantly improved the outlook for people with HIV infection. In fact, a study found that only about 10 percent of people with HIV die of one of the conditions that defines AIDS. Since HIV-infected individuals are now living longer, they are more likely to die from other causes.

Oxymetholone reduces wasting among HIV patients.

Oxymetholone, an anabolic steroid, appears to be effective in countering wasting among HIV-positive patients taking highly active antiretroviral therapy (HAART).

This finding results from a double-blind, randomised, placebo-controlled trial at the University of Essen, and the University of Bonn, Germany. Eighty-nine HIV-positive women and men participated.

Chronic involuntary weight loss is a serious problem among patients on HAART. The alterations in energy metabolism and endocrine regulation cause loss of lean body mass (LBM) and body cell mass (BCM).

There has been partial restoration of LBM in studies among HIV-positive men undergoing androgen replacement therapy, or treatment with recombinant growth hormone. However, these treatments have largely been ineffective among eugonadal individuals.

In the present study, the men and women with wasting were given Oxymetholone 50 mg twice (BID), or three times daily (TID), or placebo for 16 weeks, followed by open-label treatment. Endpoints were body weight, bioimpedance measurements, and appetite.

The clinicians found that Oxymetholone produced a significant weight gain of 3.0 ± 0.5 kg in the TID group, and 3.5 ± 0.7 kg in the BID group, while patients in the placebo group gained an average of 1.0 ± 0.7 kg. Body cell mass increased 3.8 ± 0.4 kg in the BID group and 2.1 ± 0.6 kg in the TID group. This corresponded to 12.4T and 7.4% of baseline BCM, respectively.

The patients taking Oxymetholone reported significant improvements in their appetite and food consumption, plus a reduction in feeling weak. The most important adverse event was liver-associated toxicity.

Overall, 35% of patients in the TID, 27% of patients in the BID Oxymetholone group, and no patients in the placebo group, had a greater than five times baseline increase for alanine aminotransferase during the double-blind phase of the study.

Clinicians concluded that “the BID (100 mg/day) regimen appeared to be equally effective as the TID (150 mg/day) regimen in terms of weight gain, LBM and BCM and was associated with less, but still significant liver toxicity.”

Human growth hormone and HIV/AIDS

Human growth hormone (HGH) is a natural hormone produced in the pituitary gland, which promotes normal growth and development in the body. It activates protein production in muscle cells and the release of energy from fats. It is typically used to stimulate growth in children with hormone deficiency, or to treat people with severe illnesses, burns or infection where destruction of human tissue and muscle occurs.

A genetically engineered or ‘recombinant’ version of HGH has been produced (rHGH). Test tube experiments have shown that it can stimulate immune cells such as natural killer (NK) cells, which are related to tumour control and T-cells. rHGH is also known as somatrem or somatotropin. One form of HGH is made by Serono under the brand name Serostim, although other forms are made by other manufacturers. It is given as an injection under the skin.

rHGH is a licensed treatment that can be prescribed on the National Health Service for children with short stature as a result of growth hormone deficiency. However, it is not licensed for prescribing to people with HIV in Europe. rHGH is also very expensive to produce, casting doubt on the feasibility of its introduction into routine HIV care.

There has been some concern that the use of human growth hormone in people with HIV would stimulate viral replication and lead to increased viral load. However, recent evidence suggests that individuals who add growth hormone to their anti-HIV combination are likely to experience a small drop in viral load.

In HIV disease, HGH is best known as a treatment for HIV-related wasting, although it is not an approved treatment for this condition in Europe. High doses of HGH have been found to increase weight and lean body mass in people with AIDS wasting.  An increase in lean body mass is thought to be important in HIV disease because the loss of lean body mass is the form of wasting most closely related to an increased risk of death.

In August 1996, HGH was granted accelerated approval in the United States for the treatment of AIDS wasting. Studies of up to twelve weeks in duration have found that the drug may stabilise weight or reverse weight loss in people with HIV, although no improvements in survival were seen. The long-term safety and tolerability of HGH are unknown. In the European Union, HGH has been granted orphan drug status for the treatment of AIDS wasting, which means that Serono will have exclusive rights to market the product for this purpose in Europe, even though other companies also have their own versions of the treatment.

In a recent meta-analysis of treatments for wasting, rHGH was found to have similar efficacy to the other two major treatments, testosterone and anabolic steroids, with all three showing a significant benefit over placebo. However, rHGH may have advantages in terms of increasing muscle function and quality of life.

Clinical studies, including two randomised trials, have confirmed that HGH can reduce abdominal fat and increase muscle mass in people taking anti-HIV treatment. These improvements in body composition are paralleled by increases oxygen uptake, the ability to carry out moderate physical exercise, and the capacity for high-intensity exercise.

Reductions in ‘buffalo hump’ and breast size have also been reported, although breast development in men has been noted as a side-effect of rHGH. Improvements may reverse on stopping rHGH and may be more likely among individuals with mild body fat abnormalities.

The benefits of rHGH seem to be limited to boosting muscle and decreasing fat accumulation. It has no effect on fat loss in the face and limbs.

In addition to its possible beneficial effects on wasting and fat redistribution, recent studies have suggested that rHGH may improve CD4 cell counts in patients on antiretroviral therapy. In one randomised study addition of 1.5mg rHGH daily to antiretroviral therapy for 48 weeks increased CD4 cell counts by a median of 55 cells/mm3, while a shorter course of 3mg daily for 24 weeks improved CD4 cell counts by the same amount. Around half of this increase was in naive CD4 T-cells and it was coupled with an increase in the size and function of the thymus gland, the organ under the breastbone that produces new naive T-cells.

Further research is needed to establish whether these effects are paralleled by an improved ability to fight infection.

Side-effects of HGH can include headache, muscle pain, joint pain, salt and water retention and rare instances of carpal tunnel syndrome (pain or tingling in the first three or four fingers of the hand). Children treated with the drug over the long term develop antibodies to it, but these do not seem to have any harmful effects.

A large-scale study of rHGH in people with AIDS wasting identified several serious side-effects which were thought to be associated with rHGH. These included skin cancers, gastrointestinal bleeding, inflammation of the arteries, and breast development in men. Elevated triglycerides and the development of diabetes have also been reported among individuals taking rHGH with antiretroviral therapy-related body fat changes. In a randomised study of several HGH doses to treat AIDS wasting, glucose levels rose modestly in 28% of patients receiving a daily dose and 18% of patients receiving doses on alternate days. There was one case of new onset diabetes and two cases of hyperglycaemia amongst the 646 patients who received HGH for up to 24 weeks.

The Effects of Oxandralone on Body Weight and Composition in Patients with HIV-Associated Weight Loss

A variety of anabolic steroids are in use to help counteract the severe loss of body weight that effects many patients with advanced HIV disease. Studies have previously shown that HIV-related wasting causes the destruction of body cell mass (or BCM: active muscle and tissue) while leaving fat stores relatively untouched, so treatments that preserve or help regain healthy, active body tissue are obviously important.

This open-label observational study enrolled 572 patients (527 men and 45 women) with a mean age of 40 years and a mean baseline weight of 68.1 kilograms. Patients were on stable antiretroviral regimens, had documented weight loss, and had no active opportunistic infections or cancers. All patients were treated daily with 20 mg of oxandrolone, an anabolic steroid in pill form. Study visits were scheduled after 1, 2, 4, 8 and 12 months. At each visit, patients were weighed, asked to assess their appetite, sense of well-being, and energy levels, and underwent bioelectric impedance assay (BIA) analysis. BIA measures body cell mass, amount of water in the body, and fat vs. muscle ratio.

Only 26 of the 572 patients had completed the full year-long study before Geneva, but their results, and the interim results from other the patients, were promising. Among the first 26, mean increases in total body weight (and body cell mass, listed in parentheses) were as follows:

• Month 1 2.4 kg total (1.4 kg of which was BCM)
• Month 2 2.8 kg (1.5 kg)
• Month 4 4.4 kg (2.1 kg)
• Month 8 5.4 kg (3.1 kg)
• Month 12 6.1 kg (3.5 kg) 

Patients' self-assessment also improved, with increased appetite and sense of well-being, and oxandralone was generally well-tolerated, with fewer than one percent of patients experiencing liver function test abnormalities, a side effect associated with anabolic steroids. Most side effects were managed with dose reductions. 

Anabolic steroids help AIDS patients

My hope is by sharing my story (which I’ve told to only a few friends) you also might be encouraged to document and share your own story about AIDS. It is our stories that are the heart and soul of the history of AIDS.  None should be forgotten. Ever.

It was in 1988 that a friend of mine introduced me to Dr. Walter Jekot, an HIV doctor practicing in Los Angeles. Dr. Jekot knew I was semi-retired at 24 and asked if I’d consult with him to help market his sports medicine practice in West Hollywood. The bulk of his patients were gay men, mostly bodybuilders and a few athletes. Why not, I thought. Partying every night was starting to get kind of boring anyway.

One Saturday afternoon, a couple of months into working with Dr. Jekot, two men wearing suits came into his office and closed the door. They stayed for more than three hours. After they left, I went in to ask Dr. Jekot what was going on. As I asked my first question, he just looked up and stared at me. He was ghost white. “What’s wrong,” I asked. “Sit down, Dave,” he replied. “There is something I have to tell you.”

He said the men were his attorneys. “I am being prosecuted by the federal government for what they say is the illegal distribution of anabolic steroids and growth hormone,” he explained. Then he told me his story.

After the 1988 Olympics in Los Angeles, scandal hit the sports world. Ben Johnson, a Canadian sprinter and gold medal winner that year, was to appear at a court hearing that would be broadcast live around the world. The government wanted to find out if Johnson could be prosecuted for cheating because he allegedly took anabolic steroids during the 1988 Olympic Games. During the trial, Johnson’s doctor said that Dr. Jekot had dispensed anabolic steroids to the U.S. Olympic athletes during the same Olympic Games.

Within 15 minutes every news agency in the world was beating down Dr. Jekot’s door, trying to get a comment, demanding an interview. A week later, the assistant attorney general of the United States announced on live television that the Department of Justice was going after Dr. Jekot with every legal resource available to the federal government.

I sat there stunned. I felt betrayed. I got up and started to leave, but he blocked the door. “Wait,” he asked.  “There is something else.”

First, he apologized for not telling me sooner. He said he was scared and didn’t know whom he could trust, including his own attorneys. “Did you do it,” I asked. When he said no, I sat down again.

He wanted to tell me something, he said, about a discovery he made, but I had to promise not to tell anyone else. I declined.  He told me anyway:  “I have discovered that anabolic steroids and growth hormones can help AIDS patients by reversing the wasting process.”

Wasting is the involuntary loss of body weight the entire gay community had seen time and again.

Having a sports management background, I had spent years warning our athletes about the ills of steroids. I was skeptical. In fact, I didn’t believe him. Why should I?  But some strange force kept me in that chair listening. I wanted to know more about the discovery that might help AIDS patients.

A month later I asked for and received written permission to have access to the medical records of 13 AIDS patients who were being treated with anabolic steroids or growth hormones for AIDS-related wasting. I also asked to be permitted to interview each patient. All agreed.

It was 1989. After sitting down with each of the 13 patients, I became convinced anabolic steroid treatments worked. I had no idea why or how, but something was keeping these patients alive. They had energy and looked healthy and fit.

Thus began my quest to have the most unpopular and denounced drug in the world become accepted as the therapy to reverse wasting syndrome and bring people back to life. I believe this was, in fact, the first Lazarus Effect treatment. Within three years, anabolic steroids became standard treatment to reverse AIDS-related wasting.

For some, steroid use builds hope

A few years after his HIV diagnosis, Nelson Vergel began wasting away. No matter how much he ate, no matter how many protein shakes he added to his diet, no matter how much iron he pumped, the chemical engineer could not regain 25 pounds the virus had stripped from his 5-foot-7 frame. He watched as dozens of HIV-infected friends progressively lost body fat and muscle, and, ultimately, their lives. "Either I have to do something," Vergel thought, "or I'll be the next one." Then he found anabolic steroids.

For more than a decade, Vergel has been among the chronically ill patients who take anabolic steroids - legally - for the same fundamental reason some athletes use them on the sly: to build up their bodies. A storm of attention has been paid of late to illicit use of steroids among athletes, who forever want to run faster and hit balls farther. But at the same time, a quiet movement is under way to discover what legitimate role the drugs can play in mainstream medicine.

For years, doctors have prescribed anabolic steroids for those with HIV or AIDS, kidney disease, cancer and other illnesses that cause malnutrition or muscle wasting that can leave patients dangerously thin. And, although the long-term side effects of anabolics aren't fully known, even at low doses, some physicians see definite therapeutic benefits.

"Not only do they help rebuild muscle, they make you feel better," said Dr. Bruce Rashbaum, a Washington internist who has prescribed anabolic steroids to HIV and AIDS patients for 15 years. "It's not as if these patients are going to become Hercules, because they aren't going to be."

Not all doctors think the benefits of prescribing anabolic steroids for chronic conditions outweigh the potential risks, however. What's more, they say, simply adding muscle to a frail body isn't necessarily going to help someone who is dying from a disease anyway. But given the difficulty physicians have had in helping severely malnourished people gain lean muscle tissue -- as opposed to fat - scientists are continuing to study whether steroids might be among the answers.

Said Rashbaum: "Everyone has this notion that these drugs are taboo, and they don't even entertain the idea of learning about it. I really think in the short and long run the benefit certainly outweighs the risk for those patients that really need them."

In 1999, Dr. Kirsten L. Johansen, director of dialysis at the San Francisco VA Medical Center, led a study of 29 patients with kidney failure. Over six months, they were either injected with an anabolic steroid or given a dummy pill. Those in the drug group gained an average of nearly six pounds more in lean body mass - and reported less fatigue - than those taking the placebo. Johansen has been following up on that research to determine whether the patients' boost in weight was attributable to muscle and whether it translated into better physical function and quality of life.

"We know that people who lose muscle mass tend to die sooner," she said. "But what we really don't know is: If we build muscle mass, are we helping them? These patients are really debilitated. For some of them, that's just such an issue that they really might benefit from this."

Anabolic steroids date to the 1930s, when scientists created a synthetic form of the male hormone Testosterone. They were targeting hypogonadism, a condition in which the testes don't produce enough testosterone for normal growth and sexual function. Soon, researchers discovered that the drug aided the growth of skeletal muscle, too.

But not without a price: Anabolic steroids have been linked to side effects ranging from acne and aggression to cardiovascular disease and liver cancer. This type of steroid, which differs chemically from the corticosteroids commonly used to treat inflammation - is available legally in the United States only by prescription. And athletes typically take doses considerably higher than those prescribed for medical purposes.

Dr. Marc K. Hellerstein, professor of medicine at the University of California, San Francisco, said modest doses of anabolics, combined with weight training -- if patients are well enough to exercise - yield the best result.

He has used that approach for patients with HIV and AIDS. In a 1999 study he led, 22 men lifted weights and received testosterone by injection. Half also took an oral anabolic steroid.
Both groups increased their lean body mass, weight and strength. But those in the steroid group had significantly larger gains. "It was not just cosmetic; this was useful muscle," Hellerstein said. Even at low doses, anabolic steroids can have unpleasant or dangerous side effects, including liver damage and prostate cancer, and doctors who prescribe them have to monitor their patients closely.

In Hellerstein's study, those side effects included a drop in HDL (the "good" cholesterol), as well as irritability and overly aggressive behavior. In general, some patients don't like steroids because the drugs can cause sleep problems or make them more likely to pick fights with their partners. But others thrive on them.

Dr. Adrian S. Dobs, an endocrinologist at the Johns Hopkins School of Medicine, said she believes there's a limited role for anabolics in medicine, including with HIV and AIDS patients. But in other cases, she says, the long-term risks - which are still unknown - might be too great. "I just don't think there's good data to say it's really worth doing, with the exception of a few disease states," she said. "Increasing muscle mass per se is not a benefit. ... Are you doing any good? What's going on with the underlying disease?"

Vergel, who has been taking anabolic steroids since 1994, credits them with helping him through a difficult period before the advent of effective antiviral treatments that helped reduce chronic wasting. During his first four months injecting anabolics, Vergel put on 35 pounds, enough to push him up to 175, more than he weighed when he was healthy. The 46-year-old, who lives in Houston, kept up with the drug regimen and saw his white blood cell count climb. His energy and appetite improved. "I was looking great," he said. "For the first time, I was looking like I was not HIV-positive. I just felt like a superman. I just thought, 'Maybe I'll survive.'"

Vergel, who still takes a regular course of anti-HIV drugs, weighs 190 pounds and looks like a bodybuilder, founded a nonprofit group called PoWeR - Program for Wellness Restoration.

He eventually left his job and wrote a book outlining a health plan for HIV-positive people based on steroids, exercise and nutrition. Anabolics, he says, are only a part of the equation.
A doctor supervises his use of the drugs, regularly checking for changes in liver function and blood pressure and screening for prostate cancer. "When you're sick, the risk-to-benefit ratio changes in your mind,"

Vergel said. "I have no doubt that my quality of life and my life have been extended."

Steroid Can Restore Body Tissue in HIV-Positive People

The oral anabolic steroid Oxandrolone is effective in restoring muscle and fat tissue that many HIV-positive people lose, according to a  new study.  HIV-related wasting is a complication in which people lose a significant percentage of their normal weight, leaving them at risk for secondary infections.

Carl Grunfeld of the University of California-San Francisco and colleagues gave 262 HIV-positive men who had experienced weight loss greater than or equal to 10% to 20% of their body mass index either oxandrolone - in doses of 20 mg, 40 mg or 80 mg - or a placebo daily for 12 weeks. The men who took the steroid in all dose levels had gained weight and muscle tissue, researchers found.

The steroid also produced side effects, including an increase in LDL cholesterol, which is considered unhealthy cholesterol, and a decrease in HDL cholesterol, which is considered healthy cholesterol, the study finds. Some of the men also showed signs of liver toxicity, according to the study. Current therapies for tissue loss, including nutritional supplements and a drug called megestrol acetate, mostly increase body fat, and growth hormone therapies, which also can treat tissue wasting, increase muscle mass but decrease fat stores.

Anabolic steroids like oxandrolone restore both tissue and fat, Grunfeld said, adding that the benefits must be weighed against the side effects. Grunfeld also said that although oxandrolone is not specifically approved for HIV-related wasting, physicians may prescribe it to treat the condition

Anabolic Steroids Help People with HIV Gain Weight

People with HIV who are treated with anabolic steroids to prevent AIDS wasting may realize modest gains in weight and muscle mass, a new review shows.

The review covered 13 studies of adults age 24 to 42 with HIV, 294 of whom received anabolic steroids for at least six weeks and 238 of whom received placebo. The average weight increase in those taking anabolic steroids was nearly three pounds.

“The magnitude of weight gain observed may be considered clinically relevant,” said lead author Karen Johns, a medical assessment officer from the agency Health Canada. “One hopes there would be greater weight gain with the long-term use of anabolic steroids; however, this has not been proven to date in clinical trials.”

AIDS wasting, which leads to significant weight loss in people with HIV, causes severe loss of weight and muscle and can lead to muscle weakness, organ failure and shortened lifespan. Researchers have long sought to reverse this common, destructive effect of HIV with mixed success.

The wasting stems from loss of the body’s ability to grow muscle and from low levels of testosterone.

Anabolic steroids are synthetic substances similar to the male sex hormone testosterone that promote growth of skeletal muscle and the development of male sexual characteristics.

Although most recently in the news for their misuse by professional athletes, anabolic steroids have legitimate medical application for men with low testosterone and people with certain types of anemia. Two anabolic steroids available in the United States, nandrolone decanoate and oxandrolone, have been used to help increase weight and muscle mass in small studies of people with wasting.

Conversely, anabolic steroid use has been associated with increased rates of HIV in those who share needles or use nonsterile needles when they inject steroids.

In the review studies, anabolic steroids were administered to patients either orally or by injection. The main side effects were mild and included abnormal liver function tests; acne; mild increase in body hair; breast tenderness; increased libido, aggressiveness and irritability; and mood swings — all common side effect of anabolic steroid use.

“The risks and side effects of taking anabolic steroids long-term are certainly of concern,” Johns said. “We were unable to assess these risks in our review due to the short duration of treatment in the studies.”

Wayne Dodge, M.D., the HIV/AIDS program director at the Group Health Cooperative in Seattle, suggests that clinicians should obtain blood testosterone levels, “if an HIV-infected individual has had significant weight loss, significant fatigue or muscle wasting, and particularly if associated with a significant decrease in libido and erections. If [testosterone] is in the low or low-normal range then a trial of [steroids] could be tried. The individual and the clinician should decide what result would constitute a successful trial: weight gain of 15 pounds, a 30 percent improvement in sense of well-being [or] a successful erection once a week.”

The reviews authors conclude that further studies are needed to determine if increase in weight leads to improved physical functioning and quality of life, and ultimately increased survival, as well as the potential for serious side effects, especially with prolonged use.

Use of Androgens in Patients Who Have HIV/AIDS

Of the 3 orally active anabolic steroids, oxandrolone has been studied in HIV-infected patients more extensively than has oxymetholone. Stanozolol is used for the treatment of hereditary angioedema and has not been used for its anabolic effect in this patient population to any great extent.

One of the earlier studies of oxandrolone in HIV-infected patients was begun before the introduction of the PIs. Sixty-three HIV-infected men with a loss of body weight greater than 10% were randomized to receive placebo; oxandrolone, 5 mg/d; or oxandrolone, 15 mg/d. The patients who received 15 mg/d of oxandrolone gained weight throughout the 16-week period, whereas those who received 5 mg/d of oxandrolone maintained their weight. In contrast, the patients who received placebo continued to lose weight.

In a follow-up study, which has not yet been published, patients were randomized to placebo or to 1 of 3 dosages of oxandrolone -- 20 mg/d, 40 mg/d, or 80 mg/d (C. Grunfeld, unpublished data, 1998). The patients in the group who received 40 mg/d had the most statistically significant weight gain. However, both the patients in this group and those who received 80 mg/d showed significant increases in serum levels of liver transaminases.

A study sought to determine whether a regimen of supraphysiologic doses of androgen (testosterone) plus an anabolic steroid (oxandrolone) would improve the LBM and strength gains achieved with progressive resistance exercise in HIV-infected men who had experienced weight loss.  A second objective of the study was to determine whether antiretroviral therapy with a PI prevented lean body anabolism.

All subjects in the study participated in supervised progressive resistance exercise for 8 weeks. At the same time, they received testosterone, 100 mg/wk, by intramuscular injection. Twenty-four eugonadal men were then randomized to either placebo or oxandrolone, 20 mg/d. Twenty-two patients completed the study. The results indicated that compared with patients who received placebo, those who received oxandrolone experienced improved nitrogen balance ( P = .05); increased LBM ( P = .005); and increased muscle strength, as judged by either maximum weight lifted ( P = .02 to .05) or dynamometry ( P = .01 to .05). The results were similar regardless of whether the patients were taking a PI. However, compared with placebo, oxandrolone was associated with a statistically significant decrease in blood levels of high-den-sity lipoprotein (HDL) cholesterol ( P < .001).

Because all patients in the study participated in progressive resistance training and received testosterone, only an additive effect of Oxandrolone versus placebo was being determined. Therefore, the study appears to be valid even though the number of patients enrolled was small. On the other hand, had the design of the study called for dividing the patients into multiple groups, so that not all patients received testosterone or participated in progressive resistance exercise, the number of patients required to reach statistical significance would have been much higher -- on the order of 350.

The conclusions that can be drawn from the study are that oxandrolone -- 20 mg/d, added to a program consisting of both progressive resistance exercise and physiologic doses of testosterone -- improved the anabolic and functional responses in patients who showed HIV-related weight loss.

Only one study of oxymetholone in HIV-infected patients has been reported. Patients were randomly assigned to receive either oxymetholone (14 patients) or oxymetholone plus ketotifen (16 patients). Ketotifen is an H 1-receptor antagonist (ie, antihista- mine) that has been shown to block tumor necrosis factor a. The patients receiving the medications under study were compared with 30 matched control patients who met the same inclusion criteria, such as advanced HIV infection and chronic cachexia.

At entry into the study, all patients had experienced significant weight loss (greater than 12 kg [26.4 lb]). The average weight gain by the patients who received oxymetholone was 8.2 kg (18 lb), a 14.5% increase over weight at entry ( P < .001). The average weight gain by the patients who received combination therapy was 6.1 kg (13.4 lb), a 10.9% increase over weight at entry ( P < .005). The untreated control patients lost an average of 1.8 kg (4 lb).

Both groups of treated patients showed improvement in the ability to perform activities of daily living (the Karnofsky Index) and in several quality-of-life variables.

Although this study was not a double-blind clinical trial, the investigators believed that the results suggested the need for a randomized, double-blind, placebo-controlled, multicenter trial.

Anabolic steroids for the treatment of weight loss in HIV-infected individuals

Anabolic steroids may be beneficial in the treatment of weight loss in HIV-infected individuals. Anabolic steroids include testosterone and its derivatives. One of the functions of testosterone is to help build muscle. Testosterone has been demonstrated to increase muscle mass and lean body mass in testosterone-deficient but otherwise healthy men. Individuals with HIV infection often lose weight and have low blood levels of testosterone; thus, the use of anabolic steroids in the treatment of weight loss in individuals with HIV infection may be beneficial.

The purpose of this review was to evaluate anabolic steroids as a means of treatment of weight loss in individuals with HIV infection. The review includes 13 randomized clinical trials in the primary analysis. The results suggested that anabolic steroids increased both lean body mass and body weight.

However, the results were not consistent among individual trials and the average increase was small and may not be clinically relevant. Furthermore, the results need to be interpreted with caution as this meta-analysis was limited due to small sample sizes; short duration of treatment and of follow-up; and heterogeneity of the study populations, the anabolic interventions, and concomitant therapies.