Prevalence of Hypogonadism and Associated Risk Factors among Newly Diagnosed ART Naïve HIV-Infected Males in Mwanza, Tanzania

Background Hypogonadism is frequent among HIV-infected males and might have significant clinical impact leading to sexual impairment and metabolic derangement. There is limited information about the magnitude of hypogonadism and its associated factors among people living with HIV in Tanzania. We aimed to determine the prevalence of hypogonadism and associated risk factors among newly diagnosed ART naïve HIV-infected men in Mwanza, Tanzania. Methods Newly diagnosed ART naïve HIV-infected men were enrolled at Voluntary Counseling and Testing Centres of four selected hospitals in the Mwanza region and subjected to thorough clinical and general physical examination including anthropometric measurements. A prestructured questionnaire was used to collect sociodemographic characteristics and clinical data. Serum total testosterone, follicle-stimulating hormone, luteinizing hormone, and estradiol were estimated. Serum total testosterone <300 ng/dl or testosterone >300 ng/dl with high LH and FSH (compensatory hypogonadism) was taken as markers of hypogonadism. Data were analyzed using STATA version 15. Results Of the 388 enrolled participants, hypogonadism was found in 47.9%, with secondary hypogonadism (83.9%, 156/186) being the most frequent form. Logistic regression analysis showed a significant association between hypogonadism and CD4+ count (OR 2.0; 95% CI 1.1–3.6; p=0.022), decreased libido (OR 1.6; 95% CI 1.1–2.4; p=0.024), age of above 46 years (OR 2.3; 95% CI 1.1–4.6; p=0.023), herbal medicine use (OR 2.4; 95% CI 1.5–3.9; p < 0.001), WHO clinical stage 3 (OR 2.7; 95% CI 1.4–5.2; p=0.003), and weight loss (OR 1.8; 95% CI 1.1–3.0; p=0.016). Conclusion Hypogonadism was found in nearly half (47.9%) of ART naïve HIV-infected men. The majority (83.9%) had secondary hypogonadism. There was a significant association of hypogonadism with older age, herbal medicine use, weight loss, advanced clinical stage, CD4+ count, and decreased libido.


Background
Various studies, mainly from developed countries, have highlighted several endocrine disorders including hypogonadism as more prevalent in HIV infection in the precombined antiretroviral therapy (cART) era.Tese endocrine disorders were mainly associated with HIV-related opportunistic infections and advanced multiorgan failure [1][2][3].Some of these disorders declined during the post-cART era but hypogonadism and diabetes remain frequent endocrinopathies in these patients [4].Hypogonadism can have a signifcant clinical impact leading to sexual impairment, fatigue, depressed mood, anemia and weight loss, or muscle loss [1,5,6].
Hypogonadism can either be primary (hypergonadotropic) or secondary (hypogonadotropic).Luteinizing hormone and follicle-stimulating hormone measurements in addition to testosterone measurement will be required to diferentiate them.Both primary and secondary hypogonadism are relatively common in people living with HIV/AIDS (PLHA), with secondary hypogonadism being more common [4,7].Te exact cause of hypogonadism in HIV patients is not known, but decreased gonadotropin release from the pituitary is thought to be one of the mechanisms [8].Hypogonadism can be intensifed by various factors, and in addition, studies have proposed it to have multifactorial causes, including aging [5,9], noninfectious comorbidities (obesity, diabetes, hypertension, cancers, and malnutrition among others) [5,[10][11][12][13], anemia [5,11], common acute and chronic illnesses [14], weight loss [15], invasion of glands by HIV, or other pathogens such as hepatitis virus [16], cigarette smoking, using drugs, such as opiates, megestrol acetate, methadone [5,17], and steroids [18], as well as progression to AIDS stages [19].Te use of herbal medicines could be one of the contributing factors to hypogonadism.Some herbal medicines are known to have antifertility properties by various mechanisms including inhibiting 5-alpha reductase, a factor that converts testosterone into dihydrotestosterone, reducing gonadotropins and testosterone secretion, and increasing the testosterone afnity for sexspecifc proteins among others [20].Studies have also reported that traditional herbal therapies and complementary alternative medicine are commonly used for the treatment of naïve HIV patients [21,22] and therefore can be one of the cofactors for hypogonadism.
In Tanzania, despite the number of HIV patients remaining high and the reported occurrence of endocrinopathies in these patients, there is a paucity of information regarding the prevalence and risk factors of hypogonadism in these patients.Furthermore, screening for this condition is not routinely carried out in our setting.Terefore, the aim of this study was to determine the prevalence of hypogonadism and its associated risk factors among newly diagnosed ART naïve HIV-infected men in Mwanza, Tanzania.

Materials and Methods
2.1.Study Design, Setting, and Subjects.Tis was a crosssectional study involving newly diagnosed male subjects before starting ART in Mwanza, Tanzania.Newly diagnosed HIV-positive (diagnosed as per WHO guidelines 2015) males aged 18 years and above attending at Voluntary Counseling and Testing (VCT) centres at Sekou-Toure Regional Referral Hospital (STRRH), Bugando Medical Centre (BMC), Nyamagana District Hospital (NDH), Magu District Hospital (MDH), and Ilemela District Hospital (IDH) were recruited and included in the study.Patients with previous history of gonadal dysfunction, taking drugs known to afect hormone levels (i.e., androgens, sex steroids, dehydroepiandrosterone, antiandrogens, antiandrogens, anabolic agents, GnRH agonists, and psycholeptic agents), and having chronic liver disease, chronic kidney injury, and chronic systemic illnesses such as tuberculosis and diabetes mellitus were excluded from this study.
Te sample size for this study was calculated using Kish Leslie formula (1965).Using this formula, the required minimum sample size was found to be 296.A convenient sampling technique was used to enroll study participants, where subjects were recruited as they were coming at each institution until the sample size for the study was attained.At the completion of data collection, the distribution of participants was STRRH 105 (27.1%),BMC 110 (28.4),NDH 132 (34.0%,IDH 15 (3.8%), and MDH 26 (6.7%) 2.2.Data Collection and Laboratory Procedure.All individuals were assessed clinically by detailed history taking and general physical examination including anthropometric measurements that included waist circumference (WC) and body mass index (BMI).Sociodemographic data including age, employment status, marital status, and herbal medicine use status (whether they used any herbal medicine within the past six months or not) as well as symptoms of hypogonadism (whether experienced the symptoms in the past six months) were collected using a prestructured questionnaire.Height was measured in the upright standing position using a calibrated stadiometer.Body weight was measured with minimal clothing by using a standard calibrated weighing scale, and BMI was then calculated by the formula: weight in kilograms divided by height in meters squared.WC was measured at the approximate midpoint between the lower margin of the last palpable rib and the top of the iliac crest using fexible plastic tape and was calculated as an average of 3 measurements.Anthropometric parameters were measured by the same trained research assistant at each hospital.
Five milliliters (mls) of venous blood sample was collected from each of the study participants between 8.00 AM and 11.00 AM, and serum was harvested.Te serum was used for the estimation of total testosterone (TT) hormone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E) levels.Te serum samples were stored at −20 °C for not more than 30 days until analyzed.
Te hormonal tests were carried out using chemiluminescence immunoassay (CLIA) techniques.Te CLIA kits were obtained from the Snibe Co., Ltd., Shenzhen, China.Te fully auto chemiluminescence immunoassay analyzer model Maglumi 2000 (Snibe Diagnostic, China) was used to estimate serum hormones (TT, FSH, LH, and E) according to the principles of CLIA and protocols given by the kit manufacturers.Te CD4+ count was assessed by fow cytometry (Roche Diagnostics).
Hypogonadism was defned as a serum TT level of <300 ng/dl or a serum TT level of ≥300 ng/dl with high FSH (>12 mlU/L) or LH (>12 mlU/L) level [4].Eugonadism was defned as normal TT and normal FSH and LH levels.Compensatory hypogonadism was defned as normal TT but high FSH or LH levels.Primary hypogonadism was defned as low TT levels with high FSH and LH, while secondary hypogonadism was defned as low TT with low or normal FSH or LH [4,23].

Data Analysis
Data were cleaned and checked for completeness and consistency and then corrected.Te data were coded and entered into Microsoft Excel and then transported to 2 International Journal of Endocrinology STATA software, version 15 (Texas, USA) for analysis.Data were summarized using frequencies, percentages, or median with interquartile range (IQR).We used univariate followed by multivariate logistic regression models to determine factors associated with hypogonadism among newly diagnosed ART naïve HIV-infected males whereby factors with a p value less than 0.2 in the univariate were subjected to multivariate logistic regression analysis.Ten, factors with a p value less than 0.05 were regarded as signifcantly associated with hypogonadism.3).

Discussion
In this study, the prevalence of hypogonadism among ART naïve HIV-infected males was found to be 47.9% (95 CI 43.0%-52.9%).Tis rate of hypogonadism among ART naïve males is comparable with the rate in the previous studies conducted among ART naïve HIV-infected males by Dobs et al. (50%) [24] and Grispoon et al. (49%) [25] and lower than the fnding by Tripathy et al. (89.7%) [26] and higher than the fnding by Raf et al. (29%) [27] but generally higher than the fnding of other studies among HIV males on ART reporting prevalence ranging from 16 to 34 [1,15].A recent meta-analysis study by Santi et al. reported a prevalence of 33.0% when total testosterone alone was considered, but most studies employed were International Journal of Endocrinology carried out among HIV patients on ART and used a diferent cutof of testosterone including a lower value than the current cutof of 300 ng/dl [28].Te heterogeneity of hypogonadism prevalence reported in the ART era is due to diferences among studies in terms of serum TT assays, use of cFT or TT, use of diferent cutofs, and mean age of patients [28,29].During the pre-ART era, studies have shown a high prevalence of hypogonadism, approximately 50% with AIDS, which is associated with increased severity of the disease [27].Te use of cART leading to a lower prevalence of hypogonadism in the post-cART era is expected to be related to the reduction in the number of patients with advanced HIV/AIDS.However, hypogonadism remains a signifcant problem even among patients in the early stages of HIV infection, particularly when the prevalence is still higher than the average rate for the general population [1].Studies showed the prevalence of hypogonadism in the general population ranged from 2.1% to 12.8% in middle aged to older men [30].Te present study showed that the prevalence of hypogonadism in ART naïve HIV-infected males was higher than that of the general population.In this study, the prevalence of hypogonadism was 42% among HIV-infected males below 45 years.In a study by Rochira et al. among HIV-infected men on HAART in Italy, the highest rate of hypogonadism was seen in men aged 40-49 (15.3%, 123/800) and 50-59 (23%, 58/245) years.Notably, 10.6% of patients in the age group 30-39 years also had hypogonadism [4].Among men with hypogonadism, secondary hypogonadism was the predominant form.Tis fnding is similar to observations by several authors.Rochira et al. [4] reported secondary hypogonadism in 86 percent of hypogonadal patients with testosterone <300 ng/dl.Similarly, in the study by Pongener et al. [31] and Dutta et al. [32], hypogonadotropic hypogonadism was found in 86% and 81% of hypogonadal patients, respectively.Tis observation could be due to invasion of the hypothalamic pituitary axis by the virus leading to impairment of its function.
Remarkably, the present study, diferent from most of the previous studies, reported the presence of hypogonadism and/ or reduced testosterone in ART naïve patients (not exposed to ART), therefore indicating that the virus itself or the comorbid condition is able to infuence the hypothalamicpituitary-gonadal axis.Previous studies have shown that poor health status is associated with worse gonadal function in HIV patients [10,33].Secondary hypogonadism might be due to inhibition of gonadotropin secretion through a mechanism such as leptin resistance or adipokine release [34,35] as a result of the efect of the virus itself or comorbid conditions.
Our study found a signifcant association between hypogonadism and older age.Tis fnding corresponds to the previous report which showed increasing prevalence with age [36,37]; however, in HIV, hypogonadism also tends to occur at an earlier age afecting young-aged and middleaged men.About three-quarter of our study participants (72.9%) were between the ages of 18 and 45 years, and 42% of them had hypogonadism.
In our study, we did not observe an association between BMI and hypogonadism.Similar to our fndings, Klein et al. also did not fnd a signifcant association between low androgen levels with BMI [9].Furthermore, some other studies did not fnd any association with weight [15,25].However, diferent from our observation, a study by Crum-Cianfone et al. demonstrated a link between increasing BMI and hypogonadism [7].In studies done by Meena et al. [38] and Jain et al. [19], the incidence of low testosterone was directly associated with BMI.Te lack of association between BMI and hypogonadism in our study could be due to the smaller number of patients with higher BMI.Most of the study participants in the current study had normal BMI, and only a few were obese or overweight.Te higher rate of participants with normal BMI and above recorded in our study could be due to regional variations and the fact that patients with debilitating chronic/systemic diseases were excluded from the study.
A statistically signifcant association was also found between the WHO clinical stage (that determined the clinical progression of the disease) and hypogonadism.HIV infection causes impaired immunity with an associated decrease in CD4+ count leading to comorbid conditions, hence poor health status [10].Tis observation may be explained by the link between poor health status and impaired gonadal function [28].Furthermore, we found that male hypogonadism was associated with weight loss.Tis is 4 International Journal of Endocrinology in support of the fnding by Rietschel et al. [15] which showed hypogonadism to be more common among patients with AIDS-associated wasting.Limitations of our study include the use of TT to diagnose hypogonadism which can underestimate the prevalence of hypogonadism due to the possible rise in serum SHBG in HIV patients.Measurement of SHBG has been highly recommended, in addition to serum LH and TT in these patients [39,40].Another limitation is that testosterone levels were determined using an immune-assay International Journal of Endocrinology technique, whereas mass spectroscopy is often considered "gold standard" but is not commonly used because it is expensive and not widely available.However, the immunochemiluminescence assay used in the determination of gonadal hormone values is internationally certifed and widely used in clinical practice to diagnose and guide treatment in patients with gonadal dysfunction.

Conclusion
Nearly half of ART naïve HIV-infected men were found to have hypogonadism with 42% of patients below 45 years of age.Four in every fve ART naïve HIV-infected men with hypogonadism had a secondary type suggesting the hypothalamic-pituitary axis could be the main element

Table 2 :
Reported symptoms of hypogonadism and clinical characteristics of the 388 study participants.

Table 3 :
Factors associated with hypogonadism among newly diagnosed ART naïve HIV-infected adult males.