IF YOU CAN’T GET IT UP...YOU CAN GET HELP
How common are sexual problems among people with HIV, why do they happen and what can be done?
Patrick James reports
Specific solutions are now available for sexual problems in men living with HIV but there is little help for women, a packed NAM forum heard last month.
Dr Pepe Catalan, consultant psychiatrist at the Chelsea and Westminster Hospital, explained how half the sex problems seen by his team each year are HIV-related.
What kind of sexual problems?
Sexual problems in people with HIV occur for a variety of physical and psychological reasons. Often they are more about lack of sexual desire and dissatisfaction with sex than the mechanics of arousal or orgasm.
Men and women can experience low or inhibited sexual desire. Men experience problems with getting or maintaining erections while women often have problems with poor or absent lubrication, Dr Catalan explained.
Men often have premature or retarded ejaculation while women can experience orgasmic dysfunction. And the problems don’t end there. After sex, some men experience post ejaculatory pain and women often get pain in the vagina.
But referrals for women are rare. “We hardly ever see women referred for sexual problems with HIV - only two or three in 20 years. But there is no evidence Viagra works in women.”
How common are they?
Before the era of HAART (highly active antiretroviral therapy) in the mid 1990s, research showed 75 per cent of gay men with HIV and men with haemophilia reported loss of interest in sex; 40 per cent erectile problems and 40 per cent problems with ejaculation. One in five women with HIV said they had lost interest in sex and 60 per cent said they had difficulties becoming aroused.
Since anti-HIV drug combination therapies became available, loss of interest in sex has gone down to 20 per cent. But sexual dysfunction persist in about one in three of the 900 people questioned. Dr Catalan said this showed sexual dysfunction was not a by-product of HAART because it was there before people with HIV started taking antiretrovirals.
Why do they happen?
Sexual response requires biological and psychosocial components to function adequately. Happy sexual function depends on both your mind and your body.
Chemical imbalances or damage to the brain, nervous system, blood or genitals can be culprits. But just as important are thoughts and feelings about sex, self and partners. To people defined by a rampant sexuality in the past, loss of sex drive can seem worse than anything and compound feelings of inadequacy.
One famous historian described his loss of libido as “being untied from the wild horses”. But vast worldwide profits from Viagra suggest people want an active and happy sex life for as long as they can.
Illness, immune system suppression due to the virus, testicular failure, neuropathy, high lipids, diabetes, recreational drug use, excessive alcohol consumption or a natural loss of sexual appetite with age can all cause problems. But Dr Catalan said there was no proof anti-HIV drugs had any effect one way or the other. “You can have sexual problems with all treatments and you can have sexual problems without any treatments.”
Two thirds of people who reported sexual problems said they had some history of psychiatric problems. People on HIV treatments had fewer psychological problems than those recently diagnosed. Factors associated with low sexual desire in people with HIV include: psychotropic medicine; depression; sexuality (gays reported fewer problems); time on HIV treatments; weight loss, particularly lipoatrophy and prominent veins in the arms and legs; pins and needles in the hands or feet; steroid use (which inhibits natural production of the male sex hormone testosterone and can actually shrink the testes) and ageing.
What can be done?
Psychologists or psychiatrists (many clinics now have specialist mental health clinics to which they can refer people with HIV) will assess you and decide which investigations, if any, are needed.
Dr Catalan said some men only had problems getting hard with their regular partners but had no such problems having sex with others. Anxiety is a major issue; with most people problems are both physical and psychological. Treatments include penile pumps, injections into the penis and urethral applications. But these older methods have now been superseded by new drugs called PDE5 inhibitors. These all require sexual desire and stimuli to boost erection but have different time of action, doses and interactions.
Sildenafil (Viagra) available since 1998. Viagra is taken about an hour before required, lasts for six to eight hours but its action can be delayed by food and can have potentially dangerous interactions with other medicines.
Tadalafil (Cialis) can be taken anything between 30 minutes and 12 hours before sex and are effective for up to 36 hours, have no interactions with food or alcohol and fewer interactions with other medicines.
Vardenafil (Levitra) is taken between 25 and 60 minutes before required in small pills, but the onset of its action may be delayed by fatty foods.
Side-effects for PDE5s can include a throbbing head, headaches, flushing of the skin, dizziness, back pain, indigestion, altered vision and nasal congestion, but these aren’t a problem for everyone. Nitrates (poppers) must be avoided because they can dangerously lower blood pressure. Some protease inhibitor drugs (like ritonavir), some antibiotics (like erythromycin), anti-fungals (like fluconazole) and SSRIs (like Prozac) can also react dangerously.
People on medication for high blood pressure, or with low blood pressure or angina and those with liver problems or recent strokes are strongly advised avoid this group of drugs. You should always seek expert medical advice in advance of taking these drugs and not be tempted to buy them over the internet or from dealers.
NHS rationing
The Department of Health (DH) restricts GPs from prescribing these drugs to everyone who wants them. People with diabetes, MS, polio, those who have had recent pelvic surgery or prostate cancer can get free NHS prescriptions, but others may be asked to pay in full on a private prescription.
Specialists, like psychologists attached to HIV clinics, can prescribe the drugs if the patient can show they are “suffering severe distress.” This requires undergoing a mental health assessment first. HIV doctors are barred from giving their patients Viagra on the NHS but can refer patients to psychologists like Dr Catalan.
DH guidelines restrict prescriptions to a maximum of four tablets a month and there are still a lot of hurdles to get through before getting the pills.
One reassuring point made by Dr Catalan was that he has yet to have a patient die on the drugs and his oldest is a man of 82 who is still going strong “in all departments”.
