Anabolic steroids are synthetic versions of the male hormone testosterone, which promote the formation of lean body mass, skeletal muscle and masculine sexual characteristics in the human body. An intake of anabolic steroids has been shown to increase muscle mass and, consequently, anabolic steroids may be used to treat AIDS wasting and weight loss in men and women^[1][2][3]. It can also be used to correct low testosterone levels or ‘hypogonadism’ in both sexes, the commonest hormonal deficiency in HIV-positive patients^[4].

A range of anabolic steroids is available, although none is licensed for use to treat HIV-specific conditions. While testosterone itself is sometimes used, a range of testosterone-derived compounds is available, including testosterone cypionate, testosterone undecanoate (Andriol), testosterone enanthate, testosterone propionate, testosterone undecanoate and Sustanon, a safer formulation of several toxic testosterone varieties. Some experts recommend using testosterone rather than synthetic testosterone analogues for the treatment of wasting and hypogonadism due to the side-effects associated with the synthetic treatments^[5].

Other anabolic steroids include oxandrolone, nandrolone, methandrostenolone, oxymetholone (Anadrol), trenbolone (Parabolan), primabolan, dromastanolone (Permastril) and stanozolol (Winstrol / Stromba). A veterinary steroid called boldenone undecyclenate (Equipoise) is sometimes available on the black market, and is abused by bodybuilders.

Administration

Steroids may be taken orally, injected or absorbed through the skin. Injectable steroids must not be injected into veins, and safe injection techniques are important to avoid bacterial infections and HIV infection. Needle sharing appears to be a common practice amongst anabolic steroid users, but it is dangerous because of the risk of blood-borne infections.

Some studies have tested a skin patch and a gel, which feed testosterone into the bloodstream through the skin of the trunk or the scrotum. The patch and the gel forms produce steady levels of testosterone in the blood, which reduces the likelihood that the body will shut down testosterone production in response to treatment.

Side-effects

Anabolic steroids are widely reported to have a number of serious side-effects, especially if they are used in high doses. However, it is important to distinguish between the many different varieties of anabolic steroids available through both prescription and illicit sources when considering the potential side-effects of these substances.

All steroids can elevate liver enzymes but levels usually return to normal once the cycle is stopped. The injectable, water-based suspension of testosterone, commonly used by bodybuilders, is highly toxic to the liver, and can encourage the development of acne, male pattern baldness, testicular shrinkage and impotence. This steroid tends to be used because large gains in muscle mass are seen in very short periods. Methandrostenolone (Dianabol) shares this side-effect profile in both its oral and injectable forms. Testosterone enanthate and testosterone propionate are also toxic.

Testosterone cypionate causes severe disturbances in the production of the body's own testosterone and high levels of water retention have been reported anecdotally.

Oxymetholone causes water retention, high blood pressure, hair loss, headaches and stomach pains, and is highly toxic to the liver.

Rare side-effects of steroid usage include stomach pain, insomnia, and high blood pressure. In men, side-effects include enlarged prostate gland, causing difficulty with urination and breast development.

Counterfeit steroids are common, and may contain impurities that can in turn result in infections or abscesses. Incorrect selection of an injection site may lead to the disruption of a major nerve, with consequent paralysis or pain in the area served by that nerve.

There has been controversy over the effects of anabolic steroids on the immune system. Some experts have argued that steroids are immunosuppressive, but the only study to look at immune status in HIV-positive men receiving anabolic steroid treatment for wasting showed no detrimental effect on CD4 or CD8 cell counts.

Legal status

The anabolic steroids currently available for prescription in the United Kingdom are licensed for use in osteoporosis in postmenopausal women, Behcet's disease and aplastic anaemia. They are not currently licensed for use in HIV-related wasting or as a preventive measure against weight loss in HIV disease. However, policy about their use varies from one hospital to another.

Anabolic steroids are also available through illicit sources, since they are widely used by bodybuilders to enhance muscle gain during training programmes. In the United Kingdom, anabolic steroids are classified as Class C drugs. It is legal to possess or import steroids as long as they are for personal use, but possession or importing with intent to supply (which includes giving them away) is illegal and could lead to up to 14 years in prison and an unlimited fine.