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. Physical factors can also affect sexual performance, including things like hormone levels, disorders affecting the flow of blood to the genitals, the natural ageing process, treatment side-effects and drug interactions. If you’re experiencing sexual problems, it’s unlikely that there is a single cause. Rather, a combination of the factors listed above will probably be involved.

Although sexual problems (often called sexual dysfunction) can be a problem for anyone, people living with HIV may be particularly affected. The loss of sexual drive or desire (libido) can have a significant impact on a person’s quality of life and feelings of self-worth, and 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.
• Problems with arousal: Difficulties obtaining or sustaining an erection for men, or becoming lubricated for women.
• Orgasm problems: Not experiencing an orgasm at all, or for men, premature ejaculation.

What causes sexual problems?

The way you feel about sex and yourself can contribute to the development of sexual problems. The stigma attached to HIV infection, and for gay men, homophobia, often mean that people with HIV feel that their sexual behaviour is in someway transgressive.

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. Lower-than-normal testosterone levels have been found in people with advanced HIV infection – caused by either the direct effects of HIV or just by 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.

HIV can damage the nerves (a condition called neuropathy) and this can lead to erectile problems. 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 diminish both the desire and the ability to have sex.

Sexual problems can also be a side-effect of medicines. Many of the drugs commonly used to treat depression, e.g. fluoxetine (Prozac) or paroxetine (Seroxat), can cause erectile problems or difficultly having an orgasm. Additionally, megestrol acetate (Megace), an appetite stimulant, has been shown to cause loss of libido.

Some anti-HIV drugs, such as ddI (didanosine, Videx/Videx EC) and d4T (stavudine, Zerit), 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, with some evidence suggesting that those containing ritonavir are particularly likely to cause problems.

If you find that your sexual problems are present all the time and in all situations (for example, both with all your sexual partners, or when trying to masturbate alone) then it’s likely that physical factors 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 the probable cause.

Dealing with sexual problems

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

The next step is to try talking to your partner or a close and trusted friend about what you are feeling or experiencing. Your HIV doctor will be able to help or, if not, refer you to a specialist, nurse, health adviser or counsellor who can. It’s important to identify exactly what kind of problems you are experiencing and what their cause or causes are. This may require some tests (such as simple blood tests to check hormone levels).

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 specialist HIV mental health services might be appropriate. Here you may be offered a course of cognitive behavioural therapy (CBT) to help you recognise and overcome your sexual problems.

For men with sexual 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. 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, making it more sensitive to touch. However, these drugs should be taken with caution by people taking protease inhibitors, non-nucleoside analogues (NNRTIs), the anti-fungal drug ketoconazole (Nizoral), itraconazole (Sporanox) or the antibiotic erythromycin.

People taking full-dose ritonavir (Norvir) should not use Viagra at all, given the potential health risks. Similarly, the recreational drug poppers (alkyl nitrites) must not be used with Viagra, Cialis, or Levitra under any circumstances, as this can cause a dangerous drop in blood pressure.

Delayed ejaculation/orgasm can be a side-effect of medicines, particularly antidepressants. Tell your doctor if you are experiencing such side-effects as there may be another drug available that is less likely to have these side-effects.

The range of medical solutions for women with sexual problems is limited. There are no Viagra equivalents. For post-menopausal women hormone replacement therapy may be helpful. Often, however, the types of sexual problems reported by women with HIV have underlying psychological or social causes. Counselling, CBT, or psychotherapy can often help and is often available through your HIV clinic. Ask what help is available.