Sexual problems

About sexual problems
Causes
Treatments

About sexual problems

Person with hands crossed across groin Sexual dysfunction, whether due to HIV, side effects of HIV treatments, or other factors, can have a big impact on the quality of your 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 sexual dysfunction is not generally a side effect of HIV drugs, several reports linked this to protease inhibitors.

Under-reporting in studies and at clinics is likely because many people find it difficult to talk to their doctor about this aspect of their lives. It is something that doctors rarely ask patients about directly.

For example, a study by anonymous questionnaire in over 900 HIV-positive people using combination therapy (80% men, 20% women) found that 38% of men and 29% of women reported a decrease in sexual interest. A decrease in sexual potency was reported by 29% of men.

Causes

Sexual dysfunction in HIV-positive people 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) may 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.
Relationship or work-related stress can be a factor.
Lipodystrophy and neuropathy are also associated with higher rates of sexual dysfunction.
Sexual dysfunction is more common in HIV-positive people who are not using anti-HIV drugs compared to HIV-negative people.
Age (>40 years), diabetes, pelvic surgery, fear of failure, hypertension can also cause changes is sexual function.

Treatments

Different approaches are used depending on the most likely cause. Approaches to treat erectile dysfunction include counselling, vacuum devices, cockrings and treatments like Muse (an implant) and caverject (an injection). Oral medications include sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), apomorphine (Uprima) and yohimbine (Yohimbine, Yocon).

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 10-30nmol/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, you should 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 and if they are not working well and you are dealing with illness or side effects, you would expect this to impact on other areas of your life.

Talk to your doctor. Referral to sexual dysfunction clinics or counselling support is often appropriate. Many clinics have psychologists who are trained and experienced in sexual dysfunction.

Sildenafil (Viagra)

Oral medications can sometimes help reduce psychologically difficult situations. For HIV-positive people they should be available on the NHS (after a consltation) or by asking your doctor for a private script.

Some HIV medications interact with Viagra. Lower doses – usually one 25mg 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).

Viagra and apomorphine (Uprima) are not currently licensed for women although studies are underway.