Management of testosterone deficiency in HIV positive people
Two posters at BHIVA 2019 reported on under diagnosis and treatment of testosterone deficiency in HIV positive people.
Although low testosterone levels are more common in HIV positive people than the general population, this is often not included in routine HIV care, even when general symptoms warrant screening (erectile dysfunction, low desire, fatigue, low mood and/or reduced muscle mass).
V Kopanitsa from UCL Medical School and colleagues used a retrospective case note review to audit current practice in order to develop new local guidelines and to then audit practice before and after the guidelines had been implemented. The guidelines were developed by a multidisciplinary team of HIV, sexual dysfunction and endocrinology specialists. 
Key points that were highlighted in the guidelines included:
- Repeat testing of asymptomatic individuals which is not recommended.
- Poor accuracy of timing of the samples (these need to be taken before 10.30 am).
- Failure to calculate free (rather than total) testosterone.
While total testosterone (free plus protein bound) is commonly measured, HIV positive people should be monitored by free testosterone levels, because HIV is associated with increased sex hormone binding globulin (SHBG) which complicates the interpretation of test results.
Free testosterone can be calculated online using albumin, testosterone and SHBG results taken at the same time:
Unfortunately, although the local guidelines clearly identified best practice, they failed to improve local practice, showing that more work is still needed.
Although patient numbers were apparently low and were not included in the review the percentages of people with samples taken before 10.30 am dropped from approximately 46% to 13% and measuring free testosterone dropped from approximately 17% to only 5% of tests.
The poster did note that overall the study was small and that the guidelines would be republicised and the results reaudited.
In the second poster, Celia Simpson and colleagues from the Lawson Unit in Brighton, reviewed the management of patients in Brighton who had been diagnosed with low free testosterone (<160 bmol/L) over the previous five years. 
Of the 69 patients identified, approximately half had abnormal SHBG that were too high indicating the risk of under diagnosis from relying on total testosterone and showing the importance of testing free rather than total testosterone.
Median age in this group was 58 years (range: 31 to 88) with CD4 nadir 375 (range 15 to 1037) copies/mm3. All people had undetectable viral load. Average time on ART was 15 years (range 1 to 32). Eight patients had type 2 diabetes and one person had diabetes mellitus. Although median BMI was 26.5 this ranged from 17.1 to 39.0). 32/69 patients have started testosterone therapy with a further five still awaiting treatment.
- Simpson C et al. A review of hypogonadism in an HIV cohort. 25th Annual BHIVA, 2–5 April 2019, Bournemouth (BHIVA 2019). Poster abstract P137.
- Kopanitsa V et al. Improving testosterone testing in people living with HIV. 25th Annual BHIVA, 2–5 April 2019, Bournemouth (BHIVA 2019). Poster abstract P137.