Sexual dysfunction

Key points

  • ‘Sexual dysfunction’ includes loss of sexual desire, painful sex, and problems with erection or orgasm.
  • Stress, health problems and heavy drinking can contribute to sexual dysfunction.
  • Help is available from doctors and psychologists.

While sexual dysfunction can be a problem for anyone, people living with HIV may be particularly affected. If sexual problems are serious or prolonged, they can contribute to emotional problems, including anxiety and depression.

Loss of sexual drive or desire (libido), the inability to obtain and sustain an erection or to have an orgasm, or experiencing pain during sex can have a significant impact on quality of life and feelings of self-worth. 

Sexual problems are common during times of stress, such as experiencing work or relationship difficulties. Some people may find that their sexual desire or performance is affected when they are first diagnosed HIV positive. You may be concerned about the impact of the diagnosis on your current relationship(s) or on your chances of creating new ones, especially with someone who is HIV negative. However, many people are reassured by the knowledge that effective HIV treatment reduces the risk of passing on HIV to a sexual partner to very low levels. You can read more about the impact of HIV on sexual function on aidsmap.com.

Excessive intake of alcohol or recreational drugs can diminish both the desire and ability to have sex. Sexual problems can also be a symptom of other physical problems, such as an underactive thyroid, as well as of mental or emotional health issues. But there are many things you can do to address them. So it’s worth talking to your HIV doctor or GP about them, rather than living with them.

Issues for men

Sexual dysfunction affects about one in ten men, becoming more common as men get older. It can be caused by other health conditions such as heart disease and diabetes. It can 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, and can be caused both by the direct effects of HIV or chronic ill health itself. Testosterone treatment can be used to alleviate these problems. Men who use testosterone replacement therapy usually gain muscle mass, experience an emotional ‘lift’, and an increase in their libido.

Untreated HIV can also cause nerve damage that can result in erectile problems.

Some prescription drugs can affect sexual function in men, including drugs for high blood pressure and depression (for example, citalopram [Cipramil] or fluoxetine [Prozac]). If this happens, your GP (family doctor) may be able to prescribe a different drug without this side-effect.

Erectile problems can also be a side-effect of some anti-HIV drugs.  Many of these drugs, such as ddI (Videx) and d4T (stavudine, Zerit), which are only rarely used in the UK nowadays, can cause numbness in the genital area.

It makes good sense to mention erectile or other sexual problems to your HIV doctor or GP so the cause can be investigated. Your doctor may recommend you try making changes to your lifestyle, such as stopping smoking, or reducing your alcohol or drug use. If this isn’t an issue, or doesn’t work, there are drug treatments available. Talking therapies may also help if it seems your sexual problems may be linked to other issues in your life.

Viagra (sildenafil), Cialis (tadalafil) and vardenafil (Levitra) are tablets used to treat erectile dysfunction (or impotence) that work by increasing blood flow to the penis, making it more sensitive to touch. They do not increase sexual desire.

These drugs should be taken with care by men using protease inhibitors, and ketoconazole, itraconazole or erythromycin (drugs used to treat some infections). The standard doses of Viagra should be reduced to 25mg, Cialis to 10mg and Levitra to 2.5mg. However, for people taking full-dose ritonavir (Norvir), it is recommended that Viagra should not be used at all given the potential health risks and that the dose of Levitra should be reduced to no more than 2.5mg in 72 hours.

Similarly, the recreational drug poppers should not be used with Viagra, Cialis or Levitra as this could result in a potentially dangerous drop in blood pressure.

Older treatments for impotence include the injection of alprostadil, a hormone produced by the prostate gland that alters the flow of blood in the penis. This can be done using Caverject or Viridal, a tiny needle used to inject the penis with the hormone. This works very quickly, is often effective for men where oral treatments haven’t worked, and the effects can last for hours. Some men may find the process unappealing. Do not use these alongside oral treatments. Alternatively, alprostadil comes as a pellet which you insert into the urethra using an applicator. This is known as Muse.

"There are many things you can do to address sexual problems. So it’s worth talking to your HIV doctor or GP about them, rather than living with them."

A range of different implants are also available, but these will need replacing as time passes. A semi-solid silicone implant can make the penis firmer, though not hard. Alternatively, a pocket can be created within the penis, into which a silicone rod is inserted to form an erection. Vacuum pumps, including the Rapport pump, are also available tax-free with a doctor’s prescription.

Issues for women

Women with HIV may experience the menopause (the end of your menstrual cycle) earlier than women who are HIV negative. This is as a result of abnormal production of the female hormones progesterone and oestrogen. Oestrogen and testosterone levels fall significantly during and after the menopause, and can cause a reduction in sexual desire.

Women may experience sexual problems caused by physical symptoms such as vaginal dryness or thrush, pain or severe pre-menstrual syndrome (PMS), or as the result of damage caused to the vagina during pregnancy or childbirth.

Talk to your HIV doctor or GP if you are concerned about your lack of sexual desire, discomfort during sex, or any other sexual problem. They can rule out any other underlying condition as the cause, and you can discuss what options there may be for treating problems. Hormone replacement therapy (HRT) can be prescribed to treat the symptoms of the menopause, including vaginal dryness and loss of libido. None of the sexual dysfunction drugs have been fully studied in women.

Psychological help

If you have concerns about any aspect of sexual dysfunction, consider talking it through with your doctor at your next hospital visit or seeing your GP.  He or she may be able to refer you to a specialist service, such as a psychologist or psychotherapist. If the underlying causes of the problem are emotional, any treatment prescribed will provide only partial benefit. A short course of sessions with a psychologist or counsellor may provide additional help. You can see a therapist on the NHS, although there may be a wait, or privately. See aidsmap.com for more information on finding the right therapist.

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