Delayed HIV treatment initiation and protease inhibitors associated with erectile dysfunction in men living with HIV


Delayed HIV treatment initiation, use of protease inhibitors for more than a year, tobacco use and sleep apnoea increase the odds of erectile dysfunction among cisgender men living with HIV, according to the findings of the US Military HIV Natural History Study (NHS), published in HIV Medicine.

Although HIV is associated with an increased risk of erectile disfunction, the factors related to erectile dysfunction are unclear. Previous studies have shown a clear link between erectile dysfunction and cardiovascular health in the general population. Cardivascular diseases and erectile dysfunction share a lot of common risk factors and the presence of erectile dysfunction may be an early sign of potentially serious cardiovascular events in the future.

Since 1986, the NHS has enrolled 5682 military personnel (serving or retired) who are living with HIV as participants. The data used in the analysis was collected over a longer period of time than most other studies on the topic, which used data collected at a single point in time.



Relating to the heart and blood vessels.


When blood pressure (the force of blood pushing against the arteries) is consistently too high. Raises the risk of heart disease, stroke, kidney failure, cognitive impairment, sight problems and erectile dysfunction.


A mental health problem causing long-lasting low mood that interferes with everyday life.


High levels of lipids (fat) in the blood, such as cholesterol and triglycerides, which raises the risk of cardiovascular disease.

case-control study

An observational study in which a group of people with an infection or condition (called ‘cases’) are compared with a group of people without the infection or condition (called ‘controls’). The past events and behaviour of the two groups are compared. Case-control studies can help us understand the risk factors for having an infection or a condition. However, it is difficult both to accurately collect information about past events and to eliminate bias from case-control studies.

It is important to note that the participants of this study were young with median age at HIV diagnosis of 31, had the relatively healthy lifestyle required for military service and many were enrolled in the study early in the HIV epidemic.

By the end of follow up in 2018, 543 participants (9.6%) were diagnosed with erectile dysfunction. Data from 488 participants, who received their erectile dysfunction diagnosis after their HIV diagnosis, were included in the analysis. Each participant was matched with two controls with similar demographics who have HIV but were not diagnosed with erectile dysfunction.

The case-control study focused on individual risk factors of cardiovascular disease and erectile dysfunction, including hypertension, sleep apnoea, hyperlipidaemia, diabetes, depression and tobacco use. The researchers also examined CD4 count below 200 at HIV diagnosis, delay in HIV treatment initiation (over four years) and use of protease inhibitors (over a year).

In the first analysis, depression, hypertension, hyperlipidaemia, diabetes, CD4 count > 200 , delay in HIV treatment initiation (over four years), sleep apnoea and smoking were associated with erectile dysfunction.

In further analysis, researchers used multivariate logistic regression models in order to adjust for other factors which may influence the development of erectile dysfunction. With this adjustment, hypertension, depression and hyperlipidaemia were not associated with a significant increase in the odds of developing erectile dysfunction.

Current HIV treatment guidelines recommend starting HIV treatment as soon as possible after an HIV diagnosis. Most of the data used in the study was collected prior to these guidelines, and 221 participants with erectile dysfunction started HIV treatment more than four years after their HIV diagnosis. These participants had twice the odds of developing erectile dysfunction than those who started HIV treatment within four years of their HIV diagnosis.

"There are mixed findings from earlier studies on the use of protease inhibitors and development of erectile dysfunction."

Despite the benefits of starting HIV treatment, the study reported an association between the use of protease inhibitors for more than a year and the odds of developing erectile dysfunction. Two hundred and thirty-seven participants with erectile dysfunction used protease inhibitors for more than a year before developing erectile dysfunction, and these participants were 1.81 times more likely to develop erectile dysfunction compared to the controls. However, there are mixed findings from earlier studies on the use of protease inhibitors and development of erectile dysfunction. Some protease inhibitors that were more commonly used in the early years of the epidemic were associated with erectile dysfunction in previous studies. Around 90% of participants using protease inhibitors in the current study received these older protease inhibitors. The reported association may be due to the use of protease inhibitors that are metabolically more active than newer agents. More studies are needed to better understand the effects of newer protease inhibitors such as darunavir and atazanavir on erectile dysfunction.

Tobacco use is a well-established risk factor for cardiovascular diseases and may also increase the chances of developing erectile dysfunction. The study reported not smoking had a protective effect on erectile dysfunction.

Previous studies have found that severe sleep apnoea increases the risk of fatal cardiovascular events. In the NHS study the odds of developing erectile dysfunction was reported to be 2.69 times higher for those with sleep apnoea. Due to associations between erectile dysfunction, sleep apnoea and cardiovascular health, the researchers recommend screening for sleep apnoea following an erectile dysfunction diagnosis.

In this relatively healthy population of men living with HIV, the prevalence of erectile dysfunction was nearly 10%. The researchers recommend a risk evaluation to be considered during sexual health counselling of men living with HIV, especially those with erectile dysfunction risk factors. They also state: “As individuals with HIV continue to live longer, addressing erectile dysfunction risk factors may lead to improved sexual well-being and cardiovascular health.”