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A. Danoff, M. Horberg, J. A. Aberg, Reply to Monroe and Brown, Clinical Infectious Diseases, Volume 58, Issue 11, 1 June 2014, Pages 1640–1641, https://doi.org/10.1093/cid/ciu131
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Extract
To theEditor—On behalf of the authors of the HIV Medicine Association of the Infectious Diseases Society of America's primary care guidelines for the management of persons infected with human immunodeficiency virus (HIV), we appreciate the comments by Monroe and Brown [1] emphasizing the impact of binding proteins on testosterone measurements. We welcome their recent report [2] supporting the use of a free testosterone measurement when binding protein abnormalities are suspected, and agree that HIV infection is one such situation. This is especially prudent in the setting of hepatitis C virus coinfection, which, as has been previously reported [3], may be associated with extremely elevated levels of sex hormone binding protein (SHBG). However, we share their concern that most practicing clinicians do not currently have access to the high-quality testosterone and SHBG assays utilized for their investigation. As they also note, the “free testosterone” values in their report were calculated based on the (highly regarded) methods of Vermeulen [4], but that method is dependent upon high-quality total testosterone and SHBG assays, and may not perform identically to free testosterone values obtained by equilibrium dialysis (the gold standard). Therefore, it is worth reemphasizing the importance of mandating that all laboratories utilize a much-needed [5] standardized, cost-effective testosterone assay (optimally unaffected by binding protein differences). Until that time, in the absence of classical clinical findings of hypogonadism supported by unequivocal biochemical abnormalities, the practicing clinician will continue to be faced with uncertainty, and both HIV-infected and -uninfected patients will suffer the adverse consequences of under- and overdiagnosis as well as under- and overtreatment of hypogonadism, the latter of which includes recent concerns [6] suggesting an association between testosterone supplementation and higher rates of cardiovascular disease and death.
