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Sexual dysfunction
Whilst sexual dysfunction can be a problem for anyone, people living with HIV may be particularly affected. Loss of sexual drive or desire (libido) can have a significant impact on quality of life and feelings of self-worth, and may even contribute to emotional problems such as anxiety and depression.
Sexual problems are common during times of stress, such as when one receives an HIV-positive diagnosis or experiences work or relationship difficulties. Excessive intake of alcohol or recreational drugs can also diminish both the desire and ability to have sex.
Many of the drugs commonly used to treat depression, e.g. fluoxetine (Prozac) or paroxetine (Seroxat) can also affect sexual function. Additionally, megestrol acetate (Megace), an appetite stimulant, has been shown to cause loss of libido.
Issues for men
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, and can be caused both by the direct effects of HIV or chronic ill health itself. Many males receive testosterone treatment to alleviate these problems. Men who use testosterone replacement therapy usually gain muscle mass, experience an emotional ‘lift’, and an increase in their libido.
Strategies for impotence
Impotence, or the inability to get or maintain an erection, can be caused by HIV damaging the nerves in the penis which control an erection (autonomic neuropathy). Similarly, anti-HIV drugs that cause neuropathy such as ddC, ddI and d4T may cause numbness in the genital area, which can make it difficult to 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 sexual dysfinction.
Viagra (sidenafil) and Cialis (tadalafil) are tablets used to treat impotence which work by increasing blood flow to the penis, making it more sensitive to touch. Viagra and Cialis should be taken with care by people using protease inhibitors, NNRTIs, ketoconazole, itraconazole or erythromycin. The dose of Viagra should be reduced to 25mg and Cialis to 10mg. However, for people taking ritonavir, it is recommended that Viagra should not be used at all given the potential health risks. Similarly, the recreational drug poppers must not be used with Viagra or Cialis under any circumstances.
Older interventions 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, a tiny needle used to inject the penis with the hormone. This works very quickly, and the effects can last for hours, though some men may find the process unappealing. The long-term effects are unknown and there is a limit of three injections a week, otherwise you run the risk of priapism, or persistent painful erection of the penis. Alternatively, alprostadil comes as a pellet which you insert into the urethra using an applicator. This is known as Muse.
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 on the NHS.
Issues for women
It is not uncommon for HIV-positive women to experience early menopause as a result of abnormal production of the female hormones progesterone and oestrogen. Sexual dysfunction among women can also be caused by physical symptoms such as vaginal dryness or thrush, pain or severe pre-menstrual syndrome (PMS). Women can be offered hormone replacement therapy, though this should be carefully monitored for signs of masculinisation. Neither Viagra nor Cialis have been 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. He or she may be able to refer you to a specialist within the hospital, such as a psychologist or psychotherapist. If the underlying causes of the problem are emotional, then you may find that medications provide only partial benefit. A short course of sessions with a psychologist or counsellor may provide additional help.