Good sexual health is important to overall quality of life.
Sexual dysfunction, whether due to HIV, side effects of HIV treatments, or other factors, can dramatically reduce quality of life.
Sexual dysfunction includes reduced sex drive (a loss of interest in sex) and physical difficulties (such as loss of erection or difficulty reaching orgasm).
Although several reports linked this to protease inhibitors, sexual dysfunction is not generally reported as a side effect of HIV drugs.
It is likely that sexual problems affect a lot of HIV positive people, not least because of the complex social factors. It takes many people a long time after they are diagnosed before they develop or regain sexual confidence.
Although most research into sexual dysfunction associated with HIV has been carried out in men, when women have been included in these studies, a similar level of concern has been reported.
For example, a study by anonymous questionnaire in over 900 HIV positive people using combination therapy (80% men, 20% women) found that around one-third reported less interest in sex.
With new partners, the decision to discuss HIV, perhaps before you know very much about a person, can be difficult. Not disclosing your HIV status, even when your partner is not at risk because you use condoms, can be a difficult barrier to overcome later in any relationship.
In long-term relationships, fear and concerns about risk might never be discussed or resolved in detail. With an HIV negative partner, either or both partners might become preoccupied with a risk of transmission during sex, however small the risk and however safe the sex.
This is a pity given that having an undetectable viral load on ART makes it difficult to transmit HIV. The risk becomes so low PEP (using HIV treatment after a potential exposure) is no longer recommended in these circumstances.
If both people are HIV positive, they might worry about resistance or reinfection even though this risk is close to zero if both partners have undetectable viral load on ART.
Many people find it difficult to talk to their doctor about this aspect of their lives and it is something that doctors rarely ask patients about directly.
Together with many of the medical issues listed below, it might be complicated to identify one single cause.
Now that treatment has given us the possibility of living a natural life-span, it is important to try and resolve sexual problems. This is something that your clinic can help with, but it is something you might need to directly ask about.
Sexual dysfunction can be caused by a wide range of medical and psychological issues.
- HIV positive men and women have reduced testosterone levels compared to HIV negative people.
- Depression can affect sexual health.
- Many treatments for depression including fluoxetine (Prozac), citalopram (Cipramil), paroxetine (Seroxat) and sertraline (Lustral) can decrease libido and lead to erection difficulties in men. Mirtazapine (Zispin) might be considered as it has little or no effect on sex drive and fewer interactions with HIV drugs.
- Sedatives, tranquillisers and other medications can cause sexual dysfunction, as can smoking, alcohol and recreational/illegal drug use.
- Long-term use of steroids or male hormones.
- Stress, related to relationship or work.
- Some side effects are associated with higher rates of sexual dysfunction. This can include neuropathy (for physical reasons) and lipodystrophy (for psychosocial reasons).
- Sexual dysfunction is more common in HIV positive people who are not using HIV drugs compared to HIV negative people.
- Age (older than 40 years), diabetes, pelvic surgery, fear of failure, hypertension can all cause changes in sexual function.
If you have a reduced sex drive then ask to have your testosterone levels checked with a simple blood test.
For men, the range for normal levels is 10-30 nmol/L but this does not allow for changes in age. If your levels are lower than this, testosterone replacement treatment can be given by patch, gel, implant or injection.
If you have other symptoms (low sex drive, fatigue, etc) then testosterone treatment is one option you can try, even if you are within ‘normal’ levels.
If your testosterone levels are low, have your bone density monitored as HIV positive people are at higher risk of osteoporosis.
If effective, increased testosterone levels should reduce depression and fatigue and increase sex drive.
Testosterone (at much lower doses) is being studied as a treatment for sexual dysfunction in women. Hair growth, deeper voice and clitoral enlargement are side effects that require caution in women.
How you feel about yourself and your body and how you feel about HIV can affect your sexual health. HIV-negative people and society in general can react in irrational ways to HIV, which can contribute to how you feel as an HIV positive person.
Dealing with an HIV diagnosis, whether or not you are on treatment, takes a lot of courage and perseverance. If treatments work well, you can be faced with new choices in life. But it can be difficult to make choices if meds are not working well and you are dealing with illness or side effects. You would expect these things to impact on your sex life.
Talk to your doctor. Referral to a sexual health clinic or counselling support is often appropriate. Many clinics have psychologists who are trained and experienced in sexual dysfunction.
Treatments for sexual dysfunction
Different approaches are used depending on the most likely cause. Approaches to treating erectile dysfunction for men include counselling, vacuum devices, cockrings and treatments like Muse (an implant) and alprostadil injections (Caverject).
Oral medications include sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis).
Oral medications can sometimes help reduce psychologically difficult situations. For HIV-positive people they should be available on the NHS (after a consultation) or by asking your doctor for a private prescription.
Some HIV medications interact with Viagra. Lower doses – usually one 25 mg in any 48-hour period – are used for people using a PI or NNRTI based combination.
Viagra should never be used with poppers (amyl nitrate).
There are much fewer options for women. Viagra is not currently licensed for women although small studies reported benefits.
In 2015, flibanserin (Addyi) was approved in the US as a treatment to increase sexual desire for premenopausal women. Depsite a lot of publicity it has not been widely used.
Partly this is because it is a daily medicine – not just something to take when you want sex. To use flibanserin women need to stop drinking alcohol. Efficacy was also not great, with only one additional sexually satisfying experience reported each month compared to women taking a placebo. It is also expensive ($800 a month).
1 August 2016