AIDS TREATMENT UPDATE, July 1995
David Campbell-Morrison

Weight loss and wasting in people with HIV and AIDS can sometimes be difficult to treat. However, in the past few years some people have experimented using anabolic steroids to build up their weight.

Anabolic steroids have long been used by bodybuilders to build muscle, and in people with AIDS they have been used to replace lean muscle tissue - the main tissue destroyed by HIV-related wasting.

Anabolic steroid use can also increase lean muscle mass in people who are HIV-positive and healthy, perhaps over and above the average weight for an individual's height (ideal body mass).

WHAT ARE STEROIDS?

Steroids are artificial versions of naturally occurring hormones which influence a wide range of bodily functions, such as blood pressure, glucose levels and the development of sexual characteristics. Anabolic steroids are versions of the sex hormones which influence muscle growth and hair growth in both men and women, such as testosterone and androsterone.

In people suffering from HIV-related wasting, testosterone levels are usually low, making it difficult for protein and carbohydrates in food to be converted into muscle tissue. Taking anabolic steroids to replace testosterone could theoretically help stop wasting.

BODYBUILDING

The use of anabolic steroids in the treatment of HIV-related weight loss is still experimental, but a lot of folk knowledge exists about how to use them to the best effect amongst bodybuilders.

Bodybuilders inject anabolic steroids in courses which last around 10 weeks, followed by a rest period to minimise the side-effects. They start with a low dose and gradually escalate, then reduce it again at the end of the 10 week period. There is a belief that to get the maximum anabolic effect with the minimum of side-effects, two different steroids should be used in combination. Although anabolic steroids are available by prescription for some medical conditions, their use for bodybuilding is frowned on by the medical establishment so the drugs are bought on the black market.

Bodybuilders gain an average of about 14lbs during a course (dependent on diet and time spent exercising) but about half of this is due to water retention in body tissues which is rapidly lost when the anabolic steroid is stopped.

Side-effects noted by bodybuilders on a moderate course may include acne on the shoulders, headaches, mood swings and depression. Depression is more common when the course has stopped, perhaps because hard-won muscles decrease slightly in size. The sense of elation whilst on the drug is also lost when the course ends, and there is a decrease in sexual urges.

USE BY PEOPLE WITH HIV

To date there have not been any properly controlled studies into the effects of anabolic steroids on weight among people with HIV. A pilot study undertaken at the Kobler Centre in London enrolled people with CD4 counts of less than 100 and a weight loss of 10% of body mass, meaning that although not very ill they had appreciable HIV disease. Participants received a low dose of an oral anabolic steroid called stanozolol. Half the participants also undertook a daily weight training regime that was designed for each individual by a gym instructor, while the other half did no additional exercise.

People who exercised whilst on the drug had a weight gain of 4 kg over the six weeks course of treatment, while those who did no exercise only maintained their weight. When the course ended, participants lost an average of 1 kg weight, thought to be due to water retention, leaving those who exercised with an overall gain of 3 kg in six weeks. The main weakness of this study is that there was no control group of people who exercised but did not take the steroid, so it cannot tell whether the weight gain might have been due to the exercise and had nothing to do with the steroid. However, it does suggest that exercise may be a very important part of a plan to tackle weight loss.

TAKING STEROIDS

Researchers who are studying the use of anabolic steroids among people with HIV believe that the drug needs to be accompanied by increased food intake. Weight gain is much less likely without a high protein, high carbohydrate diet which is the best diet for building muscle. One method is to prescribe protein supplements and nutrient-enriched sip drinks to accompany the steroids.

Synthetic forms of testosterone can be given by tablet or injection. The tablets may be ineffective because the drug is destroyed in the liver after it has been absorbed from the gut.

Other steroids used in HIV medicine are the corticosteroids such as hydrocortisone and prednisolone. These are very different from anabolic steroids and have quite different effects.

SIDE-EFFECTS

Anabolic steroids do have a number of potentially serious side-effects, the most extreme of which is liver damage which can be fatal. The incidence of liver damage with anabolic steroid use is very low and linked to the dose and the length of time used. Injected anabolic steroids are not as toxic to the liver as steroids taken in tablet form.

Anabolic steroids also alter mood, energy and appetite levels, often in quite startling ways. Increased levels of male hormones will amplify aggressive tendencies. Some people become very aggressive and quick to get angry, a phenomenon called 'roid rage'. Many steroid users are totally unaware that they can become obnoxious to people around them whilst on steroids. The steroid dosage should be decreased if signs of uncontrollable rage appear.

Anabolic steroids also affect hair growth. They can make the hairline recede faster and encourage hair loss on the head in men already genetically 'programmed' for significant hair loss. They can also encourage hair to sprout on the back, shoulders and arms. Women may grow facial hair as a result of steroid use.

Anabolic steroids boost the sex drive in men; libido will diminish quite dramatically once steroid use stops. There may be some decrease in testicle size which is reversed on stopping the steroid; the return may take a few weeks depending on the dose and the length of the course.

In HIV-positive men with normal testosterone levels and good health, anabolic steroid use will have the effect of knocking out natural testosterone production, which takes several months to return once steroid use ceases.

There are theoretical dangers to boosting testosterone. Professor Tony Pinching points out that a French study found that there may be a link between high levels of testosterone and an increased risk of developing KS.

OTHER MEDICAL TREATMENTS

There are other drugs that are sometimes offered to people with weight loss to increase their appetite. Megestrol acetate (Megace) is a female sex hormone which does increase the appetite but also decreases sex drive in men. Other drugs associated with increased appetite include the tricyclic anti-depressants such as amitriptyline and anti-histamines such as cyproheptadine. These can help increase weight by boosting the amount of fat on the body, but it is only increases in lean muscle mass that are linked to improved survival.

A recent trial found that human growth hormone, an extremely expensive synthetic version of a natural body substance, helped people with AIDS to gain muscle mass. It has the unfortunate side-effects of causing growth of the jaw and fingers. For more details, see the article in AIDS Treatment Update issue 21/22. Other imbalances in hormone and cytokine levels are also thought to play an important role in wasting - for example, high levels of tumour necrosis factor (TNF) break down lean muscle tissue. Effective treatment for wasting may require TNF levels to be reduced. TNF inhibitors that are currently being tested in trials include oxpentifylline and thalidomide. For further discussion of TNF, see page 1 of this issue.

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