Correlation of poor bone health with serum testosterone levels in males with acquired immunodeficiency syndrome wasting syndrome

INTRODUCTION

The human immunodeficiency virus (HIV) is the cause of the dangerous and frequently fatal disease known as acquired immunodeficiency syndrome (AIDS). By attacking CD4+ T cells, the virus impairs immunity, increasing susceptibility to infections and several types of cancer. When a person contracts certain opportunistic infections or their CD4 count falls below 200 cells per microliter of blood, they are diagnosed with AIDS.^[1]

Over the past 10 years, India has witnessed hopeful developments, despite the fact that the disease burden is still high. Both prevalence and incidence have decreased as a result of improved diagnostics, increased awareness, and easier access to treatment. HIV prevalence decreased from 0.32% to 0.21% in India and from 0.35% to 0.28% in Punjab between 2010 and 2021. Incidence rates and deaths from AIDS also decreased, with Punjab’s AIDS mortality rate falling from 14.72 to 1.91/100,000 people.^[2]

Wasting syndrome is one of the most difficult of the numerous consequences associated with AIDS. It is characterized by symptoms including fever, weakness, or diarrhea that last longer than a month, as well as involuntary weight loss of more than 10% of body weight, or going below 90% of one’s optimum weight. Although fat loss may account for a portion of the weight reduction, the loss of muscle mass, or “wasting,” is a bigger worry.^[3]

Although the precise origin of wasting syndrome is unknown, a variety of factors that differ from person to person are thought to be involved. Hormonal imbalances, inflammatory processes, poor diet, and issues with nutritional absorption all contribute. A significant hormonal component is a lack of testosterone. Nearly half of males living with AIDS suffer from hypogonadism or low testosterone levels. Loss of lean body mass is intimately linked to this low testosterone, which might worsen as the illness worsens.^[4,5]

Men who have low testosterone frequently suffer from erectile dysfunction, low mood, lethargy, and decreased sex drive. Less obvious signs including muscle loss, thinning body hair, difficulties sleeping, concentration issues, and an increased risk of bone loss may also be present in certain people. Adult men with hypogonadism may not always exhibit visible symptoms such as breast enlargement or decreasing testicles, in contrast to boys with childhood-onset hypogonadism.^[6]

Numerous studies have demonstrated that low bone mineral density (BMD) is more common among HIV-positive individuals, regardless of age. According to a significant review, people with HIV have an almost three-fold higher rate of osteoporosis than people without the virus. Indeed, fractures associated with inadequate bone density are also becoming increasingly common. Although there are numerous potential causes, low testosterone is believed to be a key one. By directly affecting bone tissue, testosterone helps maintain bone strength, and low levels can hasten the disintegration of bone. Consequently, osteopenia and osteoporosis are more common in men with HIV.^[7,8]

MATERIAL AND METHODS

Following approval from the Institutional Research Committee and Ethics Committee for Biomedical and Health Research, Guru Gobind Singh Medical College and Hospital (GGSMCH), Faridkot, this cross-sectional observational study was conducted in the Department of Medicine over a period of 6 months.

A total of 60 male patients were included in the study. The sample size was determined based on the feasibility of recruitment during the study period, considering the prevalence of AIDS Wasting Syndrome in the patient population attending the ART center at GGSMCH. A purposive sampling technique was used, wherein eligible patients presenting during the study duration were enrolled consecutively after applying inclusion and exclusion criteria.

RESULTS

Patients were categorized into three groups based on their BMD T-scores as follows:

• Group A (Normal BMD): T-score between −1 and +1

• Group B (Osteopenia): T-score between −2.5 and −1

• Group C (Osteoporosis): T-score <−2.5.

The comparison of clinical and laboratory parameters across the three groups is presented in Table 1.

Correlation between testosterone levels and BMD

Additional analysis was done on the connection between BMD and blood testosterone levels. Only four (7.3%) of the 55 individuals with reduced testosterone had normal BMD, while 51 (92.7%) had abnormal BMD (osteopenia or osteoporosis). Two (40%) and three (60%) of the five patients with normal testosterone levels had normal BMD and abnormal BMD, respectively. With a P-value of 0.0195, the relationship between blood testosterone levels and BMD was shown to be statistically significant, suggesting that lower testosterone levels were substantially linked to decreased bone density [Table 2 and Figure 1].

Table 2: Correlation between testosterone levels and BMD.

Testosterone level	Normal BMD	Abnormal BMD (Osteopenia+ Osteoporosis)	P-value <0.05
Normal	2	3	0.0195
Decreased	4	51

BMD: Bone mineral density

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Figure 1:

Correlation between testosterone levels and bone mineral density. BMD: Bone mineral density

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DISCUSSION

Low testosterone levels and inadequate BMD in HIV-positive men with AIDS Wasting Syndrome were found to be significantly correlated in this study. Compared to 60% of patients with normal testosterone, the majority of patients with decreased testosterone (92.7%) had abnormal BMD. Hypogonadism and poorer bone health in this population are strongly correlated, according to the statistical significance (P = 0.0195).

These results are consistent with previous Indian research by Aggarwal et al.,^[9] which demonstrated that testosterone levels are positively correlated with CD4 counts and tend to be lower in HIV-infected men. Our findings also showed a correlation between immune suppression and hormonal imbalance, with patients with lower CD4 counts exhibiting both lower testosterone levels and a higher incidence of bone loss.

Low BMD is a well-known issue among those living with HIV worldwide. More than half of HIV-positive people had lower BMD, according to a Chinese study by Meng et al.,^[10] with low body weight, prolonged disease duration, and low testosterone levels being contributory factors. Our patients showed similar risk patterns, with lower weight, lower testosterone, and more severe disease, especially those with osteoporosis.

To keep bones strong, testosterone is essential. It aids in calcium retention, controls bone remodeling, and promotes osteoblast function. Bone thinning and weakness result from increased bone turnover brought on by a decline in testosterone levels. Thomas and Doherty’s^[11] earlier findings that HIV infection is a risk factor for osteoporosis, perhaps because of both direct viral impacts and related endocrine dysfunction, are in line with this.

According to a large study by Monroe et al.,^[12] men with HIV had a considerably greater overall frequency of hypogonadism (24.0%) than men without HIV (7.8%). It is interesting to note that many HIV-positive males had low free testosterone but normal total testosterone, which was not the case for the HIV-negative group. This implies that calculating total testosterone alone may understate hypogonadism in those with HIV.

All things considered, our results lend credence to the notion that testosterone deprivation is a major contributing factor to the bone loss observed in HIV-positive males, particularly those who exhibit wasting. This highlights how crucial it is to test for hypogonadism in these patients, both as a means of identifying individuals at risk for osteoporosis and as part of a general endocrine review. Given the possible hazards and comorbidities involved, rigorous evaluation and individualized decision-making are crucial, even if testosterone replacement therapy may be beneficial for certain people.

CONCLUSION

This study demonstrates a direct correlation between decreased BMD and low serum testosterone levels in male HIV-positive individuals with AIDS Wasting Syndrome. In this population, low testosterone levels seem to be a major cause of poor bone health. Osteoporosis may be prevented or lessened with early detection and treatment of hypogonadism, highlighting the significance of regular hormone testing as a component of comprehensive HIV care.