While many men struggle with erectile dysfunction, it is more common in men living with HIV. There can be physical or psychological causes, or more frequently, a combination of both. Factors such as dealing with a new diagnosis, stigma, and anxiety about transmitting HIV can affect their ability to get or stay erect. Physical causes can include older age, diabetes, heart disease, taking certain types of HIV medications, and how long they have been taking these medications.
Sexual well-being is an important part of your overall health, and problems in this area can impact how you feel about yourself. Help is available from healthcare professionals if you are experiencing erectile dysfunction. Having sexual problems can also indicate that there are other areas of your physical and psychological health that need attention.
What is erectile dysfunction?
Erectile dysfunction is when you cannot get or keep an erection that allows you to have sex.
Most men sometimes experience difficulty getting an erection, perhaps due to excessive alcohol consumption, recreational drug use, anxiety, or fatigue. Occasional problems are not necessarily cause for concern, but ongoing erectile dysfunction should be investigated by a doctor.
It is a form of male sexual dysfunction, which also includes ejaculation problems and decreased sexual desire or satisfaction.
Erectile dysfunction often affects men as they age. It is also more common in men with HIV than in the general population, although it has been difficult to estimate how many men with HIV are affected. Research suggests that around 40 to 60% of men with HIV may experience some degree of erectile dysfunction.
What causes erectile dysfunction?
Erectile dysfunction has several physical and psychological causes. It is often associated with conditions that affect blood flow to the penis, including diabetes, high cholesterol, high blood pressure, smoking, obesity, and heart disease. Other factors commonly linked to erectile dysfunction include advanced age, low testosterone levels, alcohol or drug use, anxiety, and depression.
It's important to consider both the physical and psychological reasons behind sexual problems. If you've experienced impotence in the past, you may fear not being able to get an erection during sex. Your anxiety about sexual performance can exacerbate an existing physical cause and worsen the problem.
Physical causes of erectile dysfunction in men with HIV.
In addition to the factors mentioned above, there are specific factors that are important if you are living with HIV. These include having lived with HIV for a longer period, a lower CD4 cell count at your initial diagnosis, and possibly taking certain HIV medications (see below). If you have both HIV and hepatitis C, or suffer from redistribution of body fat (lipodystrophy), you are more likely to have difficulty achieving an erection.
Many men with HIV have low testosterone levels (hypogonadism). This can be difficult to diagnose because some symptoms (such as decreased energy, low sex drive, low bone mineral density, and muscle wasting) are less specific and can occur in men with HIV who have normal testosterone levels. It is important for your doctor to investigate whether this could be the cause of your impotence. Chronic illnesses, HIV replication, antiretroviral medications, lipodystrophy, metabolic syndrome, other comorbidities, and coinfections can all contribute to low testosterone levels in people living with HIV.
Generally, having spontaneous erections at night or in the morning is a good indicator of testosterone levels. It means you have enough testosterone in your blood to rule out a severe deficiency. It would also help your doctor rule out other physical causes of impotence.
Because HIV is associated with an increased risk of heart disease, the link between erectile dysfunction and heart disease is of particular importance for men living with HIV. Impotence can be an early marker of undiagnosed heart disease. If you are living with HIV and experiencing difficulty achieving an erection, you should undergo a thorough cardiovascular risk assessment and address any risk factors for heart disease.
Your lifestyle and erectile dysfunction
Since cholesterol, high blood pressure, diabetes, and other health conditions can contribute to erectile dysfunction, lifestyle changes can help.
• Lose weight if you are overweight.
• Exercise regularly: particularly activities that raise your heart rate, such as brisk walking, dancing, gardening, and cycling.
• Do not smoke
Do antiretroviral drugs and other medications cause erectile dysfunction?
Some research has linked the use of ritonavir-boosted protease inhibitors (Norvir) to erectile dysfunction, but this has not been found in all studies. Nerve damage that occurred with the use of some older antiretrovirals may also contribute, but erectile dysfunction has not been consistently linked to any particular class of antiretrovirals. The length of time that certain types of medication have been taken appears to be particularly important.
Other medications can also contribute to erectile dysfunction. These include some medications taken to treat depression, other mental health conditions, and high blood pressure, as well as opioid painkillers. Many recreational drugs also cause it.
If you are concerned that your medication may be causing difficulties in obtaining or maintaining it, it is important to discuss this with your doctor.
Psychological causes of erectile dysfunction in men with HIV.
Their sex drive or performance can be affected by depression, stress or anxiety, relationship problems, shame, or guilt. Psychological causes can be particularly relevant for men living with HIV, as there are specific psychological stressors related to HIV, such as fear of transmitting it to others, the stigma surrounding the infection, concerns about discussing their status with others, and changes in body image. These can affect their feelings about sex.
Living with HIV can negatively impact your quality of life, social well-being, and sexual function. Sexual difficulties can have a physical cause, but they can also be exacerbated by psychological and emotional factors, especially in the case of a stigmatized illness like HIV.
Pressure to use condoms may also impact sexual performance. Some men find their penis is less sensitive to touch when using condoms, which can contribute to erectile dysfunction. Research has linked sexual dysfunction to less frequent condom use and risky sexual behavior, possibly for this reason.
"Recreational drug 'poppers' should not be used with any medication for erectile dysfunction, as this could cause a life-threatening drop in blood pressure."
People living with HIV who experience sexual dysfunction often also experience anxiety or depression. These mood problems and the medications used to treat them may contribute to the sexual dysfunction.
For gay and bisexual men, sexual difficulties have been associated with low self-confidence and a poor self-image. There are complex interactions between sexual dysfunction, recreational drug and alcohol use, mood disorders, risky sexual behavior, and HIV infection. In these cases, it is important to seek help that addresses not only the physical causes of sexual difficulties but also the psychological causes and consequences.
It is important that a healthcare professional take a complete sexual history that includes all these areas. This may require the expertise of a psychologist.
Treatment and management of erectile dysfunction.
If you are experiencing sexual difficulties, you should have a complete sexual history, a physical examination, and a cardiovascular risk assessment. Testing should include measurements of testosterone levels, blood fats and sugars, and blood pressure. Your doctor should discuss reversible lifestyle risk factors that can affect erection quality (such as cigarette smoking, substance use, obesity, or a sedentary lifestyle).
A complete history should also include an inventory of all medications taken (such as antidepressants and antihypertensives) and recreational drugs (including anabolic steroids, alcohol, and psychoactive substances), as these may be related to erectile dysfunction.
Your doctor may consider changing your treatment regimen. This might be appropriate if your impotence began shortly after starting the medication. This can be discussed with your doctor.
Medications such as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Spedra or Stendra) are used to treat erectile dysfunction. They work by increasing blood flow to the penis, making it more sensitive to touch. They do not primarily increase sexual desire and only work when you are sexually stimulated. These medications are usually the first-line medical treatment for erectile dysfunction and are effective for approximately 70% of men.
The medications vary in dosage, how quickly they start working, how long they work, and their side effects. Possible side effects include facial flushing, nasal congestion, headaches, and indigestion.
There may also be drug interactions with other medications you are taking, including HIV medications. When taken with ritonavir or cobicistat (boost agents included in some HIV treatment regimens), the levels of the erectile dysfunction medication may increase, which can increase side effects. On the other hand, when taken with non-nucleoside reverse transcriptase inhibitors (NNRTIs), the levels of the erectile dysfunction medication may decrease.
These medications should also be taken with caution if you are using ketoconazole, itraconazole, or erythromycin (medications used to treat some infections). In these cases, the doses of sildenafil and other medications should be adjusted or avoided altogether.
Recreational drug 'poppers' should not be used with any erectile dysfunction medication, as this could cause a life-threatening drop in blood pressure.
In the UK, you can obtain Viagra and similar medications at a pharmacy after a brief consultation, without a prescription. This provides an opportunity to discuss drug interactions and contraindications with a pharmacist.
These medications are also easy to obtain online, in sex shops, or through other informal channels. However, without proper consultation with a healthcare professional, there is a greater risk of drug interactions or other problems.
Low testosterone (hypogonadism) requires testosterone replacement therapy to restore sex drive, improve erection quality, and enhance the effectiveness of erectile dysfunction medications. Erectile dysfunction medications can be helpful but are not as effective if the underlying hypogonadism is not treated.
When first-line erectile dysfunction medications fail to restore normal erectile function, other medical or surgical treatments should be considered as second-line therapies, including injections (such as Caverject, Viridal, or Invicorp) directly into the penis to help achieve an erection. In circumstances where all other medical therapies have failed, the use of vacuum pumps or surgical implants remains the only option for improving erections.
When psychological factors significantly contribute to erectile dysfunction, psychosexual or cognitive behavioral therapy may be helpful. Counseling should also be provided in cases where the primary cause is physical to reduce the associated psychological component. Counseling can also help with HIV-related stigma, reducing anxiety about erectile dysfunction and fear of HIV transmission.
Chemsex and erectile dysfunction
Some gay and bisexual men combine recreational drugs (such as crystal methamphetamine) with sex in what is known as chemsex or party 'n' play. Men may also take erectile dysfunction medications in this situation, often for purposes such as prolonging the time it takes to reach orgasm, maintaining erections for longer periods, or counteracting the loss of erections caused by the drugs. For some men, the use of these medications can also serve to mask a lack of sexual confidence and self-esteem, or even low libido. It is also possible to develop unrealistic expectations about their erectile performance.
If you are using Viagra, Cialis, or other drugs in this way, especially if you are buying the pills online, in sex shops, or in clubs, there are some risks to be aware of:
• Becoming dependent on medication and losing confidence in their own sexual abilities.
• Buy pills that contain too little of the active ingredient to work properly (some are counterfeit).
• Not obtaining medical advice on how to use medications properly, with the result that they do not work.
• Not getting medical advice on how to use them safely: there may be drug interactions or you may have another medical condition that makes them unsafe to use.
• Taking high doses, which makes interactions with your HIV medications and other problems more likely.
• Taking them at the same time as cocaine or ecstasy can put additional strain on your heart.
• Using them at the same time as poppers could cause a life-threatening drop in blood pressure. Poppers and erectile dysfunction medications should not be used together. A dangerous drop in blood pressure can occur at any time when mixing poppers with these medications, even if it has never happened to you before.
Key points
• Erection problems often occur as men age and are more common in men with HIV.
• There may be physical or psychological causes, or a combination of both.
• There may be drug interactions between erectile dysfunction medications and HIV medications.
Source: aidsmap.com – By: Krishen Samuel