Hi Alan,
It was nice chatting with you a while ago. If I recall, you said your total testosterone is around 323 dl/ng out of a laboratory reference range of 280-800. This barely puts you in the low side of "normal" which is NOT going to cut it for HIV. This is inspite of the fact that you are on Androgel "replacement" therapy. I pretty much would have assumed that or worse. For me, Androgel at 10 grams per day has been demonstrated time and again to only raise blood total testosterone levels about 50 dl/ng. which is practically nothing. It is about enough to take the "edge" off of a low testosterone headache but not enough to make it go away. So forget about being able to realistically gain or hold on to lean mass on that. It simply is NOT enough to pull you through the long haul.
To be honest, you should strive to keep your testosterone levels above at least 500 ng/dl, even at the NADIR. You have to remember that you are not only trying to replace testosterone to approximately mid-range normal levels which in your case the midpoint of the lab reference range is 550 ng/dl but also you are working against a disease that is catabolic by nature.
Remember, with HIV infection, your body is greatly impaired in its ability to metabolize fat and therefore, if you get "knocked down" with any kind of illness, your immune system goes right for the protein stores (metabolic lean body mass--muscle and organ tissue) which it would do to some degree even in HIV negative folks but additionally, while sick your body will burn your lean mass for fuel as well since it really can't burn fat well enough to use in this situation. What is even worse than this is that once the illness is over and you return to "baseline" HIV infection, your body will sense the loss of lean body mass and treat it like starvation. This means that you will have an added propenstity to convert sugars and starches that you eat to fat and store them as fat which you can't use. Physicians that do not measure and track body compostional changes with time but only weigh you on a scale may not even realize that wasting is going on because your overall body weight may not be changing at all but your percentage of bodyfat is increasing and your lean mass is wasting away. And this can be occurring for a couple of years before it becomes obvious to your health care provider if they are only using a scale.
On top of this, your body is fighting a "permanent" infection which your system is not designed to do so it becomes a problem of chronic depletion. This is why wasting it common in HIV positive patients even if they have undectable viral loads. There are studies that show the immune system of a typical person with HIV clears between 1-2 billion viral particles per day throughout the entire course of the disease. This means there is an abnormally high protein expenditure and the whole process is catabolic. So to help counteract this and return the nitrogen balance to a more favorable condition, you need some anabolic therapy as well as higher than "normal" testosterone levels. You are not dealing with "normal" conditions by any means. You will absolutely need to supplement higher than normal amounts of protein to protect the protein that you have as well as add any as well. However, the combination of HIV meds which are liver toxic and strong protein binding androgens like testosterone in combination with heavy protein supplementation can cause some serious "clearance problems" for the liver as well. Remember, you are not dealing with normal conditions. As a result, even on androgens, I would not exceed 2 grams of protein per pound of bodyweight per day and would probably be inclined to keep it more like 1 gram per pound of total bodyweight in your case since you have already had liver problems. And don't worry about what the competitive bodybuilders that you read about do. Your situation is completely different and there are a lot of additional considerations to take into account.
Further, there tends to be some general hormonal resistance issues with HIV that means that "normal" testosterone levels are not as effective in an HIV positive person as they would be in someone that is HIV negative as I discussed above in previous posts. So considering that, it is not surprising that some doctors have found that total testosterone levels below 700 ng/dl do not work well or at all in many HIV positive patients. It is also common for people with HIV to exhibit clinical symptoms of low testosterone (as I discussed in previous posts above) at levels certainly below 500 ng/dl or even at higher levels which will come as quite a shock to doctors not experienced in dealing with this issue directly. There is an interesting article that makes this case on
www.medibolics.com and one of the doctors involved in the study was Doctor Judith Radkin, I believe out of New York State. Personally, it has been my own observation that levels below this do not work very well either but this is a strictly anecdotal, rather that strictly scientific observation, based on my own lab work and compared with the lab work of quite a few others. However, I have seen and experienced enough to suggest that this is fairly accurate as I have been heavily involved in this issue since about 1995 when I suffered a major "knockdown event" and lost 30 lbs.--I dropped from 227 lbs to 197 lbs and had never used any anabolic substance before in my life. My testosterone levels had fallen off the bottom of the chart also and that was the beginning of a long fight to get replacement therapy when it was not "popular" (not like it is now either but it was considered pretty far out there back then). I finally insisted on doing it "the scientific way" and making a change, letting things stabilize and then testing to see what the result was as a reasonable approach that I was able to get my physician on board with as logical.
As a recap there are three issues to consider, HIV is catabolic by nature, general hormonal resistance issues that seems to get worse with time of infection and treatment, and hormonal replacement. So you need for your doctor to learn to think outside of the box in terms of hormones as this goes beyond strict replacement and is also trying to deal with the other issues as well. You can cycle above, on and off, of the replacement amount but should always maintain your basic testosterone replacement therapy as the cornerstone of your anti-wasting program.
In your case, there is one additional consideration. Since you are probably ill advised to use any oral steroids which are all 17 alkylated and you have had problems with oxandrin already (Anadrol is the only other oral one approved in the US for HIV anti-wasting therapy and is a lot harsher because it is dosed MUCH higher than Oxandrin), I would think it reasonable for your physician to allow you to be dosed a little higher than normal to account for the fact that you can not be taking these for anti wasting therapy. In your case, you should be using testosterone and deca as your primary anti-wasting medications since you really don't have many other legal options (Serostim, although approved for anti-wasting therapy, is NOT very good for gaining much lean body mass and is tremendously expensive so the clinical benefit versus the cost and high side effects makes it a poor choice overall but it does have its specific uses but those are outside of what I am trying to cover here). The cost of testosterone is actually quite reasonable in terms of its benefit versus cost so overall it is a very good choice.
Any dose of testosterone prescribed above what you need for replacement should be used for 8-12 week "cycles" above your replacement dose with an equal time off. However, your doctor can not prescribe in a "cyclical manner" as this is not considered theraputic and could get him cross-wise with the State Medical Licensing Board. So he should consider your "on-cycle" dose as well as your standard dose and write a standing scrip for the total. You then take your standard replacement dose and "save up" the extra until you have gone 8-12 weeks and have enough "extra" to cycle above the standard dose. Believe it or not, there are some physicians that know that this is what their patients are doing and are ok with it as there is a genuine theraputic benefit in increasing lean mass. Also some studies have shown a lessoning of a host of other metabolic related problems like lipodystrophy with increased testosterone levels in HIV positive patients as well.
But first things first as this is a process. You need to first figure out what the proper dose for replacment is by trying a dose, say 100 mg/week and then say come back in one month and if you are due for an injection on Friday evening, get your level tested on Friday afternoon (at the NADIR--lowest anticipated level) before you get your shot. Then, based on the lab results, your physician may be justified in upping the dosage to say 200 mg/week or whatever he feels will put you in the target range. Once you are in the target range, he needs to observe you clinically, which he should be doing all along, and determine if you are still showing signs of low testosterone, like fatigue, depression, headaches, etc. and fine tune adjust accordingly. After the replacment dosage is established, then you can discuss with him the possibility of "a bit more" for the purpose of minor cycles to increase lean body mass so you can establish a buffer as this can be VERY important to have this protein reserve in case you get sick.
So I hope this helps. Once again, this is very long.
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