The way you feel about sex, and your ability to have sex, are affected by a number of factors. These include psychological issues, such as how you feel about yourself and your sexuality, what you think others might think of you, your desire for children, or general anxiety and depression.

Physical factors can also affect sexual performance, including things such as:

• hormone levels
• disorders affecting the flow of blood to the genitals
• the natural ageing process
• side-effects from drugs taken for medical problems
• drug interactions
• pregnancy
• alcohol and recreational drugs
• physical disability.

If you’re experiencing sexual problems, there may not be a single cause. Rather, a combination of the factors listed above, both physical and psychological, may be involved.

Although sexual problems (often called sexual dysfunction) can be a problem for anyone at different times in their lives, people living with HIV may be particularly affected. The loss of sexual drive or desire (libido) can have a significant impact on your quality of life, feelings of self-worth and relationships with your partners. They may contribute to emotional problems such as anxiety and depression.

Sexual problems commonly arise during stressful life experiences – experiences such as receiving a positive HIV test result. This is likely to be a time of shock, worry, fear and disbelief, so it’s not surprising that sexual desire and performance can be affected. Concerns about possibly infecting sexual partners can also affect a person’s desire for sex and intimacy.

Three types of sexual problems are commonly reported. There are:

• Problems with desire: this usually involves a loss of interest in sex, but sometimes a person’s sexual desires can increase to such an extent that they become problematic for them.
• Problems with arousal: difficulties obtaining or sustaining an erection for men; becoming relaxed and lubricated for women.
• Orgasm problems: not experiencing an orgasm at all or taking a long time to have one, or for men, premature ejaculation.

The way you feel about sex and about yourself can contribute to the development of sexual problems. The stigma attached to HIV infection, or other issues such as homophobia or disapproval of sex outside marriage for some people, often mean that people with HIV feel that their sexual behaviour is in some way abnormal or wrong.

The way you interact with your partner (or partners), and wider issues in your relationship(s), can also affect your sexual performance.

Physical issues may also be important. For example, sexual dysfunction among men can often be a result of decreased testosterone levels (hypogonadism), which can also lead to fatigue and loss of motivation and sexual desire. Lower-than-normal testosterone levels have been found in people with HIV infection – caused by either the direct effects of HIV or of chronic ill health. Many men receive testosterone treatment to alleviate these problems. Men who use testosterone replacement therapy usually gain muscle mass and experience both an emotional 'lift' and an increase in their libido. It is a good idea to discuss this therapy with a member of your healthcare team before starting it. Hormone replacement therapy can increase women’s libido after hormone levels have been affected by the menopause.

HIV, and some HIV treatments, can in some cases damage the nerves (a condition called neuropathy) and this can lead to erectile problems. Some anti-HIV drugs, such as the now rarely used ddI (didanosine, Videx/Videx EC), may cause numbness in the genital area, and this can make it difficult to obtain or sustain an erection. Protease inhibitors have also been reported to cause impotence on occasion. Sexual problems can also be a side-effect of other medicines. Many of the drugs commonly used to treat depression, e.g. fluoxetine (Prozac), can cause erectile problems or difficulty having an orgasm.

General ill health can also lead to the development of sexual problems, either causing a loss of interest in sex, or an inability to perform sexually. 

Excessive intake of alcohol or recreational drugs can also affect both the desire and the ability to have sex. Smoking may also lead to erectile dysfunction.

Megestrol acetate (Megace), an appetite stimulant, has been shown to cause loss of libido.

If you find that your sexual problems are present all the time and in all situations (for example, both with any sexual partners and when trying to masturbate alone) then it’s likely that physical factors, the effects of recreational drugs or alcohol, or treatment side-effects are responsible. If, on the other hand, you find that your problems only emerge in certain circumstances, for example with a particular partner, or when you’re having sex in certain circumstances, then psychological factors are likely to be the cause.

The first step is to recognise and accept that you have a problem. You don’t need to be ashamed or embarrassed if you’re not happy with the way you feel about sex, your sexual behaviour or about your sexual performance.

The next step may be to talk to your partner or a close and trusted friend about what you are feeling or experiencing. Your HIV doctor may be able to help or, if not, can refer you to a specialist, nurse, health adviser or counsellor who can.

It is also possible that your doctor might be able to refer you to a specialist HIV counsellor, so you can talk through with them your concerns and problems. In other cases, a referral to psychosexual therapy (offered at your HIV clinic) or to a specialist mental health service might be appropriate. You may be offered a ‘talking therapy’, such as a course of cognitive behavioural therapy (CBT), to help you recognise and overcome your sexual problems.

If you have a GP, they may also be able to help you with these issues, offer counselling at the surgery or refer you to a local service offering talking therapies. You can find out more about the options available in NAM’s information booklet, HIV, mental health and emotional wellbeing. HIV support agencies are another good place to seek information and help (visit our online e-atlas to find an organisation near where you are).

If you’re having problems with arousal or ejaculation, then it’s important to identify exactly what kind of problems you are experiencing and what their cause or causes are. This may require an examination and some tests (such as simple blood tests to check hormone levels, or to look for other conditions that may be causing problems).

For men with erectile problems, a number of medicines may be able to help. If tests show that you have low levels of testosterone, then you might find that testosterone replacement therapy helps. Your HIV healthcare team should be able to provide you with advice on this.

If you have general erectile problems, both with your sexual partner or partners and by yourself, then the drugs sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra) are likely to provide an effective treatment. They work by increasing blood flow to the penis.

However, these drugs should be taken with caution by people taking protease inhibitors, non-nucleoside reverse transcriptase inhibitors (NNRTIs), the anti-fungal drug ketoconazole (Nizoral), itraconazole (Sporanox) or the antibiotic erythromycin, because of possible drug interactions. People taking full-dose ritonavir (Norvir) should not use Levitra at all, and Viagra only in limited amounts.

It’s important you tell any doctor prescribing one of these drugs about any other medication you are taking.

Poppers (alkyl nitrites, also known as amyl nitrites), a recreational drug, cause a drop in blood pressure, as do the erectile dysfunction drugs Viagra, Cialis and Levitra. Advice is not to take these drugs at the same time as poppers.

Delayed ejaculation or orgasm can be a side-effect of medicines, particularly antidepressants. Tell your doctor if you are experiencing such side-effects, and are concerned about them, as there may be another drug available that is less likely to cause them. Some people feel that a reduction in sexual desire is outweighed by the benefits of effective treatment for depression.

Medical solutions for women with sexual problems are more limited. There are no Viagra, Cialis or Levitra equivalents: research has suggested these might have some benefits for women but the evidence is not yet clear.

If you are experiencing problems, for any reason, it is always a good idea to discuss these issues with someone in your healthcare team. It’s possible that a physical condition (for example, the effects of HIV, diabetes or general ill health) may be contributing to any sexual problem, as can factors such as medication side-effects, damage to the genital area or heavy drug or alcohol use.

For post-menopausal women, hormone replacement therapy may be helpful in increasing your libido and reducing vaginal dryness. Using a lubricant can also help with dryness.

Often, the types of sexual problems reported by women with HIV have underlying psychological or social causes (some of these causes can cause physical problems too). Talking through issues, counselling, CBT or psychotherapy can often help and may be available through your HIV clinic or GP. Ask about what help is available.