1. Effects of Physiologic Testosterone Supplementation on Fat Mass and Distribution in HIV-Infected Men with Abdominal Obesity CM Shikuma, RA Parker, F Sattler, B Alston, R Haubrich, T Umbleja, S Bhasin, for the AIDS Clinical Trials Group Protocol A5079 Study Team CM Shikuma 1, RA Parker 2, F Sattler 3, B Alston 4, R Haubrich 5, T Umbleja 2, S Bhasin 6, for the AIDS Clinical Trials Group Protocol A5079 Study Team 1 University of Hawaii, Honolulu, HI; 2 Harvard School of Public Health, Boston, MA; 3 University of Southern California, Los Angeles, CA 4 Division of AIDS, NIAID, Bethesda MD; 5 University of California, San Diego, San Diego, CA; 6 Boston University, Boston MA

2. Background Abdominal obesity is commonly seen in HIV+ men following use of potent antiretroviral therapy Abdominal obesity is commonly seen in HIV+ men following use of potent antiretroviral therapy In the general population, increases in visceral adipose tissue [VAT] have been linked to increased risk of cardiovascular disease and type 2 diabetes 1 In the general population, increases in visceral adipose tissue [VAT] have been linked to increased risk of cardiovascular disease and type 2 diabetes 1 1 Sowers JR, Am J of Med 115 (8A):37s-41s

3. Background Testosterone replacement in hypogonadal HIV- middle-age men decrease visceral fat, increase insulin sensitivity and lower triglyceride and cholesterol levels 1,2,3 Testosterone replacement in hypogonadal HIV- middle-age men decrease visceral fat, increase insulin sensitivity and lower triglyceride and cholesterol levels 1,2,3 Few studies have addressed the effects of testosterone therapy on body fat distribution in HIV+ men Few studies have addressed the effects of testosterone therapy on body fat distribution in HIV+ men –Specifically, the effect of therapy on visceral fat in HIV+ men with abdominal obesity is unknown. 1 Marin P et al 1992, Int J Obes Relat Metab Disord 16:991-997; 2 Marin P et al Obes Res 1993, 1:245-251; 3 Rebuffe-Scrive M Int J Obes 1991, 15:791-5

4. A5079 Phase III, prospective, multicenter, randomized, placebo-controlled, double- blind study Phase III, prospective, multicenter, randomized, placebo-controlled, double- blind study Objective Objective –to evaluate whether change in visceral fat cross-sectional area by CT is greater with testosterone replacement than with placebo in HIV+ men with abdominal obesity and mildly to moderately reduced serum testosterone levels

5. Methods Study Population: HIV+ male subjects: Study Population: HIV+ male subjects: –Abdominal obesity waist-to-hip ratio >0.95 or mid-waist circumference > 100 cm waist-to-hip ratio >0.95 or mid-waist circumference > 100 cm –Mildly to moderately reduced testosterone (T) levels serum total T 125-400 ng/dL, or serum total T 125-400 ng/dL, or if serum total T > 400 ng/dL then bioavailable T 400 ng/dL then bioavailable T < 115 ng/dL by ammonium sulfate precipitation method or free T < 50 pg/mL by equilibrium dialysis –Stable potent antiretroviral regimen for at least 3 months prior to entry, and plasma HIV RNA <10,000 copies/mL

6. A5079 Schema Double-Blind phase Open-Label phase 24 wk 10 gm testosterone gel daily vs placebo 10 gm testosterone gel daily Wk 0Wk 12Wk 24 Wk 48 CT DEXA Body Cir CT DEXA Body Cir CT DEXA Body Cir CT DEXA Body Cir Wk 36 Body Cir

7. Statistical Methods Intent-to-treat approach with last- value-carried-forward Intent-to-treat approach with last- value-carried-forward Significance of changes over time within a treatment group was tested using a Wilcoxon Signed Rank test Significance of changes over time within a treatment group was tested using a Wilcoxon Signed Rank test Comparison between groups was tested using a Wilcoxon Rank Sum test Comparison between groups was tested using a Wilcoxon Rank Sum test

8. RESULTS: Baseline Demographic and HIV Related Variables Treatment TreatmentP-value Active (n=44) Placebo (n=44) Age (median) [yrs] 4843 0.37 a Ethnicity [%] White White Black Black Hispanic Hispanic Other Other61%7%23%9%82%7%7%5% 0.13 b IVDU [% ever used] 9%14% 0.74 c HIV RNA (% undetectable) 50%50% 1.00 b CD4 count (median) [cells/mm 3 ] [cells/mm 3 ]544586 0.52 a a Kruskal-Wallis; b Exact Test for RxC Tables; c Fisher’s Exact Test

9. Baseline Body Composition Treatment Treatment P-value * ActivePlacebo Body Mass Index [kg/mm 2 ] 27.726.10.29 Waist Cir [cm] 99.898.30.69 Waist/Hip ratio 1.021.010.31 CT (n) 4141 Visceral Abd Fat [cm 2 ] Visceral Abd Fat [cm 2 ]153.1150.00.34 Subcutaneous Abd Fat [cm 2 ] Subcutaneous Abd Fat [cm 2 ]178.7148.40.96 DEXA (n) 4344 Total Body Fat [kg] Total Body Fat [kg]20.117.90.69 Trunk Fat [kg] Trunk Fat [kg]11.511.60.82 Extremity Fat [kg] Extremity Fat [kg]5.74.80.47 Total Body Lean [kg] Total Body Lean [kg]63.263.80.58 Entries are medians, unless otherwise indicated. * Wilcoxon Rank Sum test

10. Changes in Safety Measures during Blinded Phase ActivePlaceboP-value AUA Score 0.50.00.87 PSA (ng/mL) 0.1* 0.1*0.00.06 Hematocrit (pct) 1.6 + 1.6 +0.90.15 CD4+ count (cells/mm 3 ) 25.536.00.80 Log10 HIV RNA (copies/mL) 0.040.230.17 Table entries are median values of change *Change from baseline p=0.05; +Change from baseline p<0.001

11. Percent Change over 24 weeks in CT Measures (ITT) VAT SAT Total Abd Fat P<0.001 Entries within bars are median values of change; *Change in within arm differences p<0.05 P=0.04 P=0.76 3.1% 0.3% 8.1% -7.2% -1.5% 4.3% * *

12. Percent Change over 24 Weeks in DEXA Measures (ITT) Trunk Extremity Total Lean Fat Fat Fat Tissue p=<0.001 P<0.001 p=<0.001 p=0.02 Entries within bars are median values of change; *Change in within arm differences are p<0.05 -9.9% 4.6% -10.1% 3.8% -7.9% 4.5% 1.3% -0.3% * * * * * *

13. Absolute Change over 24 weeks in DEXA Measures (ITT) TreatmentP-value ActivePlacebo Truncal Fat [kg] -1.170.34<0.001 Extremity Fat [kg] -0.480.15<0.001 Total Fat [kg] -1.640.74<0.001 Lean Tissue [kg] 0.80-0.14 0.021 0.021 Entries are median values

14. Change over 24 weeks in Waist and Waist/Hip Ratio Waist to Hip RatioWaist Circumference (cm) -2.1 -0.2 P=0.03 -0.02 0.00 P=0.04 Entries are median values; *Change in within arm differences are p<0.05 * *

15. Summary and Conclusions Testosterone replacement over 24 weeks in HIV+ men with abdominal obesity and low testosterone levels did not result in any significant change in the primary endpoint of abdominal visceral fat content by CT Testosterone replacement over 24 weeks in HIV+ men with abdominal obesity and low testosterone levels did not result in any significant change in the primary endpoint of abdominal visceral fat content by CT Testosterone replacement was however associated with a decrease in subcutaneous fat and increase in lean body mass Testosterone replacement was however associated with a decrease in subcutaneous fat and increase in lean body mass

16. Summary and Conclusions Ten grams of testosterone gel applied topically once daily was safe and associated with a low frequency of adverse events Analyses of testosterone, other hormonal levels, insulin and lipid values are pending and may provide insight into the results of this study

17. Acknowledgements A5079 Protocol Team A5079 Protocol Team Pharmaceutical Co-sponsor: Solvay Pharmaceuticals, Inc Pharmaceutical Co-sponsor: Solvay Pharmaceuticals, Inc ACTG Participating Sites: Bellevue Hosp Cntr, Drew Med Cntr, UCSD, Pittsburgh, LAC/USC Med Cntr, U Minnesota, U Nebraska Med Cntr, Washington U, U Cincinnati, Indiana U, Wishard Mem Hsp, Northwestern, Rush Presbyterian/ St. Luke’s, U of Maryland, Univ. Hawaii, U Puerto Rico, U Colorado, U Pennsylvania ACTG Participating Sites: Bellevue Hosp Cntr, Drew Med Cntr, UCSD, Pittsburgh, LAC/USC Med Cntr, U Minnesota, U Nebraska Med Cntr, Washington U, U Cincinnati, Indiana U, Wishard Mem Hsp, Northwestern, Rush Presbyterian/ St. Luke’s, U of Maryland, Univ. Hawaii, U Puerto Rico, U Colorado, U Pennsylvania Quest Diagnostics Quest Diagnostics Division of AIDS, NIAID, NIH Division of AIDS, NIAID, NIH

18. Acknowledgements Patient volunteers Patient volunteers Thank you