Sexual health and well-being

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. However, a study from Uganda reported that sex drive changed in some men and women after switching to dolutegravir.

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.

Causes

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.

Testosterone levels

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.

Psychological issues

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 pumps/devices.
• Cock rings.
• PDE5 inhibitors – oral drugs like sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis) and avanafil (Stendra, Spedra).
• Some PDE5 inhibitors are available as gels rather than pills and these can often work more quickly.
• Alprostadil – in various formulations:
  – Stick/pellet (Muse: Medicated Urethral Suppository for Erection).
  – Powder for injections (Viridal).
  – Injections with powder and fluid combined (Caverject, Edex).
  – Cream (Vitaros).
• BOTOX – an Egyptian study reported in 2021 that penile BOTOX injections improved erectile function in 40% of men who were not helped by PDE-5 inhibitors.
• Eroxon gel – a gel approved for erectile dysfunction that doesn’t need a prescription. It works by creating an alternating warming/cooling feeling.

Treatment can help reduce psychologically difficult situations.

For HIV positive people, treatment should be available on the NHS (after a consultation) or by asking your doctor for a private prescription. Most are also sold from online pharmacies, and using an established supplier that provides a wide range of medicine is more likely to be genuine.

Some HIV medications interact with oral medications like sildenafil (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) because of a serious risk of drug interactions that can cause heart failure.

There are fewer options for women. Viagra is not currently licensed for women although small studies reported benefits. See also several references included below.

• In 2015, flibanserin (Addyi) was approved in the US as a treatment to increase sexual desire for premenopausal women. Despite a lot of publicity but 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).

• Bremelanotide (Vyleesi) was approved in the US in 2019. It is an injection you give yourself in the stomach or thigh about 45 minutes before sex. It should only be used once over a day and no more than eight times a month.

Last updated: 1 March 2023.