Anabolic Steroids and HIV Risk

Injecting drug users (IDUs) have long been considered a group at increased risk for HIV acquisition. This is particularly true in parts of Eastern Europe and Central Asia where injection drugs continue to be the major route of transmission, accounting for nearly 70% of HIV infections.

By and large, we tend to associate injecting drug use with illicit drugs such heroin or the combination of heroin and cocaine ("speedballing"). And while these do continue to be the most commonly injected drugs used by HIV-infected IDUs, there has been a concerning shift in drug use patterns in recent years.

According to a 2013 report by Public Health England (PHE), the use of an injectable, image and performance-enhancing drugs (IPEDs) like anabolic steroids and human growth hormone (HGH) is on the rise, with the risk of HIV equal to that of heroin users who share needles.

In fact, in some parts of the U.K., IPED users represent the single, largest group of individuals accessing needle exchange programs, with nearly one in 10 having been exposed to either HIV, hepatitis B (HBV), or hepatitis C (HCV).  The report has also described an alarming, three-fold increase in the use of injectable amphetamines (including crystal methamphetamine and mephedrone) among IPED users.

The median age of the study cohort was 28 years, with 36% reported having taken anabolic steroids for a period of five years or more. Overall, nearly 18% reported either sharing a needle or syringe, sharing a drug vial, or both when taking an IPED.

Although we often associate anabolic steroids with bodybuilders and performance athletes, they can be used to treat a number of HIV-associated conditions. Anabolic steroid treatment is sometimes indicated for individuals who have experienced either severe wasting as a result of HIV or severe muscle loss as a result of lipodystrophy (the sometimes unsightly redistribution of body fat). Testosterone replacement therapy is also employed in HIV-positive men and women who have had severely depleted levels of testosterone (hypogonadism).

While non-injectable versions of these drugs are available—including oral medications, transdermal patches, and topical creams—injections are commonly prescribed within the context of medical therapy.

It is outside of this context, in the area of image and performance enhancement, that HIV risk is seen to increase. It is today reported that within England and Wales, the region where the PHE study was focused, anywhere from 37,000 to 82,000 people are estimated to have used anabolic steroids within the course of a year.

Among the IPED users in the study, the concomitant use of injectable amphetamines was seen to be especially high among men who have sex with men (MSM). According to the study, one in four participants reported injecting a psychoactive drug, of which 25% shared a needle or syringe.

It has long been established that the use of injectable amphetamines (a practice known as "slamming") can increase the likelihood of HIV transmission—and not only when needles are shared. Sexual risk-taking is known to increase under the influence of the crystal methamphetamine and similar class drugs.

While this may account for some of the HIV infection seen among study participants, overall only 5% reported injecting psychoactive drugs and only 9% of these shared a needle. Therefore, while concomitant amphetamine use may increase transmission risk on an individual basis, it doesn't account for the increased incidence of HIV/HBV/HCV infections seen among IPED users.

One of the most important steps in reducing the risk of HIV in IPED users is to first acknowledge that the use of injectable anabolic steroids, HGH, testosterone, or human chorionic gonadotropin carries the same risks as any other injectable drug. Therefore, the same rules apply when reducing risk behaviors, namely:

• Do not share needles or syringes, and avoid sharing an IPED vial between multiple users.
• Access a needle exchange program to ensure that you have ample needles or syringes.
• If you find yourself in a situation where needles are shared or reused, take the proper precautions to ensure that they are disinfected between use.
• Avoid IPED use while under the influence of alcohol, drugs or any substance that can affect your judgment. Seek appropriate treatment in the event of alcohol or substance abuse.
• If you shared needles and fear you may have been exposed to HIV, go to your nearest clinic or emergency room without delay to access post-exposure prophylaxis (PrEP), known to decrease the likelihood of HIV infection.

And finally, remember that HIV is not the only concern related to IPED use. The prolonged use of anabolic steroids and testosterone can result in severe liver problems, including cirrhosis and cancer. Acne, male pattern baldness, testicular shrinkage, sexual dysfunction, prostate enlargement, breast enlargement, and "roid rage" (extreme aggression and anxiety) are also commonly noted.