A 57-year-old HIV-infected man who attended for routine HIV clinical review described increased fatigue, reduced libido and erectile dysfunction unresponsive to phosphodiesterase-5 inhibitor use. He had stable type 2 diabetes mellitus (controlled by metformin 1 g b.d). He presented 2 years earlier with pulmonary tuberculosis and HIV-1 infection with nadir CD4 count 50 cells/mm3 and viral load >100,000 copies/ml. His HIV infection was well controlled (CD4 540 cells/mm3, viral load <40 copies/ml) by Maraviroc 300 mg b.d. and Kivexa (abacavir 600mg/lamivudine 300 mg o.d.). Physical and genital examination was normal. Investigations included early morning total testosterone 6.2 nmol/l (normal range 9.4–37 nmol/l), calculated free testosterone 142 pmol/l (normal range 174–729 pmol/l), LH 16 IU/ml (normal range 1–9 IU/ml), FSH 24 IU/ml (normal range 1–10 IU/ml) and SHBG 22 nmol/l (normal range 15–40 nmol/l). A diagnosis of primary hypogonadism was made. Topical testosterone treatment (Testogel, one sachet per day) was initiated with resolution of symptoms.
A 49-year-old heterosexual man who was diagnosed with HIV infection 3 years earlier following screening when hospitalised for pneumococcal pneumonia was managed with once daily darunavir 800 mg, ritonavir 100 mg and emtricitabine 200 mg/tenofovir disoproxil 245 mg. His current CD4 level was 370 cells/mm3 and viral load was <40 copies/ml. He trained regularly at the gym and was a keen amateur boxer. He wished to conceive with his wife but complained of lack of energy and reduced libido. Serum total testosterone levels were 5.5 pmol/l, calculated free testosterone 150 pmol/l, SHBG 14 nmol/l, FSH 4 IU/ml, LH 5 IU/ml and prolactin 89 mIU/ml. He admitted to regular use of oxandrolone and stanozolol over several years.