Thanks to the power of modern HIV treatment (ART) many HIV-positive people in Canada and other high-income countries who are aware of their status and engaged in their care and treatment and who do not have serious co-infections, unmanaged mental health conditions or addiction, are expected by researchers to have a near-normal life expectancy. ART also has another great effect: By suppressing HIV to levels so low that they are undetectable with routine lab tests, and when people continue to take ART every day so that their viral load stays undetectable, studies have found that HIV-positive people do not pass on the virus to their sexual partners. Given these twin benefits of ART, a healthy sex life contributes to good quality of life and from time to time sexual dysfunction can be a problem for some men living with HIV. In general, there is less research on female sexual dysfunction and far less on such dysfunction in women with HIV.
In this issue of TreatmentUpdate we review key ideas about male sexual dysfunction.
The inability to get and maintain a firm erection is called erectile dysfunction (ED). This is one of the more common problems that all men can experience.
It is difficult to be certain how common ED is among HIV-positive men because many studies that have collected data about ED did not focus on this issue and explore it. Despite this shortcoming, studies suggest that between 50% and 60% of HIV-positive men who were surveyed disclosed that they have experienced ED. As ED can be a difficult subject to talk about, it is possible that more men have ED than have disclosed this problem in surveys.
There are many factors that can underpin ED -- sometimes there may be biological reasons, other times there may be psychological reasons, and still other times there may be a combination of these two areas that underpin ED. Whatever the cause of ED in an individual, diagnosis should usually prompt a discussion between doctor and patient about it. This may lead to an investigation by the doctor and/or referral to a specialist such as a urologist, endocrinologist, psychologist, psychiatrist or others as needed.
ED occurs in HIV-negative men and the same risk factors that operate in that population may also affect HIV-positive men or may be accentuated in them. Below are some possible risk factors for ED.
This is a well-established risk factor for ED.
HIV infection can reduce levels of testosterone and other hormones. A key part of ruling out lower-than-normal levels of testosterone as a cause of ED is a blood test for this hormone.
Note that there are antibodies in the blood that bind to testosterone. Only the testosterone that is unbound is available for use by the body's cells. This unbound testosterone is called "free testosterone." Thus, when getting testosterone measured, specialists often request that free testosterone be assessed by laboratories.
Studies have found that HIV-positive men, whether or not they are using ART, tend to have lower-than-normal levels of testosterone (a condition called hypogonadism). This may be caused by HIV directly as HIV-infected cells produce compounds that may injure the testicles (a major source of testosterone), or it may be caused indirectly through the ongoing inflammation that is associated with HIV disease.
Cholesterol and triglycerides are fatty substances (lipids) in the blood. Abnormal concentrations of these are associated with an increased risk for cardiovascular disease. Prolonged abnormal levels of lipids in association with ED suggests the possibility that problems with blood circulation are developing and possibly affecting the flow of blood to and retention of blood within the penis.
ED is common in males with type 2 diabetes likely because diabetes can affect circulation of blood and is associated with nerve injury.
It is normal to have higher-than-normal blood pressure while exercising or during stressful periods. However, prolonged higher-than-normal blood pressure can injure blood vessels and organs. Elevated blood pressure is a risk factor for ED.
Good flow of blood is necessary to achieve an erection. Not only must blood flow into the penis, it must stay there for the duration of sex. However, in cases where blood vessels are partially blocked due to cardiovascular disease, ED can occur. Injury to the penis from trauma can also affect the circulation of blood in that area.
This is another well-established risk factor for ED.
Emerging research suggests the possibility that some men who have psoriasis may be at increased risk for ED.
Factors affecting mental health can affect sexual health and functioning. For instance, anxiety and depression can also contribute to ED.
Unfortunately, HIV is still a stigmatized condition and some HIV-positive men may worry about inadvertently passing on the virus to their sexual partners. This and other worries can contribute to ED. Also, doctors have generally found that even if ED was ultimately triggered by biological factors, the presence of ED can then incite the development of psychological issues that play a role in prolonging ED.
Some men may also experience feelings of no longer feeling sexually desirable.
In cases where there is a psychological component underpinning ED, referral to a therapist may be useful.
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