- Erection problems often occur as men get older and are more common in men with HIV.
- There may be physical or psychological causes, or a combination of the two.
- There can be drug-drug interactions between erectile dysfunction drugs and anti-HIV medications.
While many men struggle with erectile dysfunction, it is more common in men living with HIV. There may be physical or psychological causes, or more frequently a combination of the two. Factors such as dealing with a new diagnosis, stigma, and anxiety about passing on HIV may impact upon your ability to get hard or stay hard. Physical causes may include older age, diabetes, heart disease, taking certain types of HIV medication and how long you have taken these medications.
Sexual wellbeing is an important part of your overall health and problems in this area can have an impact on how you feel about yourself. Help is available from healthcare professionals if you are struggling with erectile dysfunction. Having sexual problems may also indicate that there are other areas of your physical and psychological health that need to be attended to.
What is erectile dysfunction?
Erectile dysfunction (or impotence) is when you cannot get or keep an erection that enables you to have sex.
Most men are sometimes unable to have an erection, perhaps caused by drinking too much alcohol, using recreational drugs, anxiety or tiredness. Occasional problems are not necessarily a cause for concern, but ongoing erectile dysfunction should be investigated by a doctor.
It is one form of male sexual dysfunction, which also includes problems ejaculating and reduced sexual desire or satisfaction.
Erectile dysfunction often affects men as they get older. It is also more common in men with HIV than in the general population, although it has been difficult to estimate how many men with HIV are affected. Research suggests that around 40 to 60% of men with HIV may have some degree of erectile dysfunction.
What causes erectile dysfunction?
Erectile dysfunction has various physical and psychological causes. It is often associated with conditions that affect blood flow in the penis, including diabetes, high cholesterol, high blood pressure, cigarette smoking, obesity and heart disease. Other factors commonly linked to erectile dysfunction include older age, low testosterone levels, alcohol or drug use, anxiety and depression.
It is important to consider both the physical and the psychological reasons behind sexual problems. If you have experienced impotence in the past, you may fear not being able to get an erection during sex. Your anxiety around sexual performance may add to an existing physical cause and worsen the problem.
Physical causes of erectile dysfunction in men with HIV
In addition to the factors mentioned above, there are specific factors that are important if you are living with HIV. These include having lived with HIV for a longer time, a lower CD4 cell count when you were first diagnosed and possibly taking certain HIV medications (see below). If you have both HIV and hepatitis C, or suffer from body fat redistribution (lipodystrophy), you may be more likely to have difficulties getting an erection.
Many men with HIV have low testosterone levels (hypogonadism). This can be difficult to diagnose because some symptoms (such as loss of vitality, low sexual desire, low bone mineral density and loss of muscle mass) are less specific and can occur in men with HIV who have normal testosterone levels. It is important for your doctor to investigate whether this could be the cause of your impotence. Chronic illness, HIV replication, antiretroviral medications, lipodystrophy, metabolic syndrome, other co-morbidities and co-infections can contribute to low testosterone levels in people living with HIV.
Usually, having spontaneous erections at night or in the morning is a good indicator of testosterone status. It means you have enough testosterone in your blood to rule out a severe deficiency. It would also help your doctor rule out other physical causes of impotence.
As HIV is associated with increased risk of heart disease, the link between erectile dysfunction and heart disease is of particular importance for men living with HIV. Impotence may be an early marker for undiagnosed heart disease. If you are living with HIV and having difficulty getting an erection, you should have a thorough cardiovascular risk assessment done and any risk factors for heart disease should be addressed.
Your lifestyle and erectile dysfunction
As cholesterol, high blood pressure, diabetes and other health conditions can all contribute to erectile dysfunction, lifestyle changes may help.
- Lose weight if you're overweight.
- Exercise regularly: particularly activities that get the heart rate up, such as walking fast, dancing, gardening and cycling.
- Don’t smoke.
Do antiretrovirals and other medications cause erectile dysfunction?
Some research has linked the use of protease inhibitors boosted with ritonavir (Norvir) to erectile dysfunction, but this hasn’t been found in all studies. Nerve damage that occurred with the use of some older antiretrovirals may also contribute, but erectile dysfunction has not been consistently linked with any particular antiretroviral class. The length of time that you have been on certain types of medication seems to be of particular importance.
Other medications can also contribute to erectile dysfunction. These include some drugs taken to treat depression, other mental health conditions and high blood pressure, as well as opioid painkillers. Many recreational drugs cause it too.
If you’re concerned that your medication could be causing your difficulties getting or staying hard, it is important to discuss this with your doctor.
Psychological causes of erectile dysfunction in men with HIV
Your sexual drive or performance can be affected by depression, stress or anxiety, relationship problems, embarrassment or guilt. Psychological causes may be particularly relevant for men living with HIV as there are specific psychological stressors linked to having HIV, such as the fear of transmitting it to others, the stigma surrounding infection, concerns about discussing your status with others, and body image changes. These can potentially affect your feelings about sex.
Living with HIV can have a negative impact on your quality of life, social wellbeing and sexual function. Sexual difficulties may have a physical cause, but also be aggravated by psychological and emotional factors, especially in the case of a stigmatised disease such as HIV.
Pressure to use condoms could also have an impact upon sexual performance. Some men find that their penis is less sensitive to touch when using condoms, which may contribute to erectile dysfunction. Research has linked sexual dysfunction with less condom use and risky sexual behaviour, possibly for this reason.
"The recreational drug ‘poppers’ should not be used with any erectile dysfunction medications as this could result in a potentially fatal drop in blood pressure."
People living with HIV who have sexual dysfunction often also experience anxiety or depression. It’s possible that these mood problems and the medications used to treat them may both contribute to sexual dysfunction.
For gay and bisexual men, sexual difficulties have been associated with low self-confidence and poor self-image. There are complex interactions between sexual dysfunction, recreational drug and alcohol use, mood disturbance, sexual risk-taking and HIV infection. In these instances, it is important to seek out help that does not only attend to the physical causes of sexual difficulties, but also considers psychological causes and consequences.
It is important for a health professional to take a full sexual history that includes all of these areas. This may require the expertise of a psychologist.
Treatment and management of erectile dysfunction
If you are experiencing sexual difficulties, a full sexual history, a physical examination and evaluation of cardiovascular risk needs to be done. Tests should include the measurement of testosterone levels, blood fats and sugars, and blood pressure. Your doctor should talk to you about reversible lifestyle risk factors that might affect erection quality (such as cigarette smoking, substance use, obesity or a sedentary lifestyle).
A full history should also include an inventory of all medications taken (such as antidepressants and antihypertensives) and recreational drugs (including anabolic steroids, alcohol and psychoactive substances) as these may be related to erectile dysfunction.
Your doctor might consider a change in your treatment regimen. This might be appropriate if your impotence started soon after starting the drug. This can be discussed with your doctor.
Medications such as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Spedra or Stendra) are used to treat erectile dysfunction. They work by increasing blood flow to the penis, making it more sensitive to touch. They do not primarily increase sexual desire and only work when you are sexually stimulated. These medications are usually the first-line medical treatment for erectile dysfunction and are effective for about 70% of men.
The medications vary in dosage, how quickly they start to work, how long they work for, and their side-effects. Possible side-effects include facial flushing, nasal congestion, headaches and indigestion.
In the UK, you can get Viagra and similar medications at a pharmacy after a short consultation, without a prescription. This offers the opportunity to speak to a pharmacist about drug interactions and contraindications.
These medications are also easy to obtain online, at sex shops or through other informal channels. However, without adequate consultation with a healthcare professional, there is a greater risk of drug interactions or other problems.
There can be drug-drug interactions with other medications you take, including some anti-HIV medications. When taken with ritonavir or cobicistat (boosting agents included in some HIV treatment regimens), the amount of erectile dysfunction medication in your system may be increased. This can increase the side-effects that you experience from the erectile dysfunction medicine and can sometimes be dangerous.
Because of this, if your anti-HIV treatment includes ritonavir or cobicistat you should not take avanafil (Spedra or Stendra). You may still be able to take other erectile dysfunction medication, such as sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra), but you might need to take a lower dose. If you are prescribed these medications by a doctor or pharmacist, you will be closely monitored to make sure you don’t have any dangerous side-effects.
If you’re buying erectile dysfunction medication without speaking to a doctor or pharmacist, it will be more difficult to know how much you can safely take. In general, if you’re taking ritonavir or cobicistat you should not take:
- more than 25mg of Viagra in a 48 hour period
- more than 10mg of Cialis in a 72 hour period
- more than 2.5mg of Levitra in a 72 hour period
When taken with non-nucleoside reverse transcriptase inhibitors (NNRTIs), levels of the erectile dysfunction drug may be lowered.
These drugs should also be taken with care if you are using ketoconazole, itraconazole or erythromycin (drugs used to treat some infections). In these instances, doses of sildenafil and other medications need to be modified or they may need to be avoided altogether.
The recreational drug ‘poppers’ should not be used with any erectile dysfunction medications as this could result in a potentially fatal drop in blood pressure.
Low testosterone (hypogonadism) requires testosterone replacement treatment to restore sexual desire, improve erection quality and enhance the effectiveness of erectile dysfunction medications. Erectile dysfunction medications may be helpful but not as effective if underlying hypogonadism is not treated.
When first-line erectile dysfunction medications do not restore normal erectile function, other medical or surgical treatments should be considered as a second-line therapy, including injections (such as Caverject, Viridal or Invicorp) directly into the penis to help with getting an erection. In circumstances where all other medical therapies have failed, the use of vacuum pumps or surgical implants remain the only choices for improving erections.
Where psychological causes contribute significantly to erectile dysfunction, psychosexual or cognitive behavioural therapy could be helpful. Counselling should also be provided in cases where the primary cause is physical to reduce the associated psychological component. Counselling may also help with HIV-related stigma, reducing anxiety relating to erectile dysfunction and fear of HIV transmission.
Chemsex and erectile dysfunction
Some gay and bisexual men pair recreational drugs (such as crystal methamphetamine) with sex in what is referred to as chemsex or party’n’play. Men may also take erectile dysfunction medications in this situation, often for purposes such as lengthening the time taken to reach orgasm, maintaining erections for prolonged periods or to counteract the loss of erections caused by chemsex drugs. For some men, using these medications can also serve to mask a lack of sexual confidence and self-esteem, or even low desire. It’s also possible to develop unreasonable expectations of your erectile performance.
If you are using Viagra, Cialis or other drugs in this way – especially if you are buying the pills online, at sex shops or in clubs – there are some risks to be aware of:
- Becoming dependent on the medication and losing confidence in your own sexual abilities.
- Buying pills which contain too little of the active ingredient to work properly (some are counterfeit).
- Not getting medical advice on how to use the medications properly, with the result that they do not work.
- Not getting medical advice on using them safely – there may be drug-drug interactions or you may have another medical condition that makes them unsafe to use.
- Taking high doses, which makes interactions with your anti-HIV drugs and other problems more likely.
- Taking them at the same time as cocaine or ecstasy may place additional strain on your heart.
- Using them at the same time as ‘poppers’, which could result in a potentially fatal drop in blood pressure. Poppers and erectile dysfunction medications should not be used at the same time. A dangerous drop in blood pressure could happen at any time when mixing poppers with these medications, even if it has never happened to you in the past.
Thanks to Dr David Goldmeier and Ben Huntingdon for their advice.