August 18, 2017
A cohort study comparing HIV-positive and HIV-negative men who have sex with men (MSM) over the age of 45 in the Netherlands has shown that HIV infection is independently associated with decreased erectile function, Maartje Dijkstra of the Amsterdam Public Health Service told the 9th International AIDS Society Conference on HIV Science in Paris, France, on July 26. Moreover, current use of lopinavir/ritonavir (Kaletra) appears to be an independent risk factor for decreased erectile function.
Previous studies have shown a high prevalence of sexual dysfunction in people with HIV, but have not included control groups. Data on the contribution of protease inhibitors to erectile dysfunction has been inconsistent.
These new data come from AGEhIV, a cohort of middle-aged and older people living with HIV, as well as HIV-negative control subjects, living in the Netherlands. Controls were recruited from sexual health clinics and existing HIV cohort studies. The study is investigating associations between HIV status and age-related co-morbidities.
All data for this analysis were collected at baseline. Questionnaires and analyses of medical records yielded data on co-morbidities, medication use, depression, frailty and other possible risk factors for sexual dysfunction.
To assess sexual function, three questions from the International Index of Erectile Function were used.
The first question was: "Have you felt unsatisfied with your own sex life?" Participants who responded "always" or "often" were considered to have decreased sexual satisfaction. This was the case for 17.8% of HIV-positive men and 11.8% of HIV-negative men (P = .02).
In response to the question, "Have you worried about minimal sexual desire?" which offered the same range of responses, 7% of HIV-positive men and 3.6% of HIV-negative men were considered to have decreased desire (P = .03).
The third question was, "How often could you develop an erection while being sexually active?" Participants who responded "never" or "a few times" were considered to have decreased erectile function. This was the case for 13% of HIV-positive and 3.4% of HIV-negative men (P < .001).
The associations between the first two aspects of decreased function and HIV status were statistically significant in an unadjusted analysis, but lost significance when adjusted for age, ethnicity, waist-to-hip ratio, number of age-related comorbidities, depression, frailty, use of antidepressants and use of antihypertensive medication.
In contrast, the association between erectile dysfunction and HIV status was significant in both an unadjusted analysis (odds ratio 4.2) and an adjusted model (adjusted odds ratio [AOR] 2.5).
In terms of risk factors for decreased erectile function in the HIV-positive participants, a multivariable analysis showed no associations between most of the examined risk factors associated with HIV and antiretrovirals, such as an AIDS diagnosis and years on antiretroviral treatment. However, time spent with a CD4 cell count below 200 cells/mm3 had a borderline-significant association with decreased erectile function (AOR per year 1.2, 95% confidence interval 0.9-1.4).
Use of certain protease inhibitors was also associated with erectile dysfunction. Dijkstra noted that some, but not all, previous studies have shown that protease inhibitors have been associated with lower sexual functioning. In the Dutch cohort, neither prior use of protease inhibitors nor current use of atazanavir (Reyataz) or darunavir (Prezista) was associated with erectile dysfunction. In contrast, associations were shown with current use of ritonavir (Norvir; AOR 2.8) and current use of lopinavir/ritonavir (AOR 5.6) after adjustment for frailty and number of age-related comorbidities. The associations persisted after adjustment for the amount of time that had passed since HIV diagnosis and time spent with a CD4 cell count below 200 cells/mm3.
To disentangle whether it was the lopinavir or the ritonavir booster causing the bulk of the problems, the researchers constructed a further multivariable model that included both current exposure to lopinavir/ritonavir and only ritonavir. In this model, use of ritonavir was no longer significantly associated with decreased erectile function, whereas current use of lopinavir/ritonavir remained significantly associated (AOR 4.3).
The higher prevalence of decreased sexual satisfaction and decreased sexual desire among MSM living with HIV compared to HIV-negative MSM appears to be explained by the higher prevalence of depression, frailty and age-related comorbidities in men living with HIV, Dijkstra concluded.
However, HIV infection is independently associated with decreased erectile function in MSM. Furthermore, current use of lopinavir appears to be an independent risk factor for decreased erectile function.
Dijkstra also noted during her presentation that the researchers and clinicians in the audience had heard a lot about sex, but almost always in relation to prevention and risk. Sexual pleasure was less discussed. "So, I think the take-home message is not only to feel the pulse of your patients, but also to talk about sex," she advised attendees.
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