NAPWA

When I was first diagnosed I went off sex altogether. I was in a state of shock and was trying to come to grips with what it meant for my future; sex and intimacy took a back seat. I was also a bit unsure if anyone would be interested now and how I should approach sex partners. After about six months I’d gotten over that and realised there were other pos guys out there like me: so I went a bit to the other extreme, having lots of unprotected sex with pos guys and picked up a nasty STI[Sexually Transmissible (or Transmitted) Infection] Infections spread by the transfer of organisms from person to person during sexual contact. Also called venereal disease (VD) (an older public health term) or sexually transmitted diseases (STDs). .

I was lucky that I found another pos guy to settle down with and learned to trust, to develop intimacy and to establish a lasting relationship. Occasionally we have other partners and the issue of disclosure is always there. Sometimes I just think it’s easier to use a condom and forget the sexual negotiation business.

Tony, 45 years

If there is one issue that all HIV-positive people have to deal with, regardless of their level of health or whether they are on treatments or not, it’s sex. It’s an “issue” because, like Tony, we all go through the gamut of emotions, sorting out how we feel about ourselves sexually, how we approach potential partners and learn to deal with the sometimes-fraught business of disclosure.

The Swiss Statement

I sometimes think, that with the medical advances from HAARTHighly Active AntiRetroviral Therapy ??? aggressive treatment of HIV infection using several different drugs together. and a greater understanding of how to treat HIV, issues around sex have become the most difficult things to live with for many positive people. You only have to observe how keenly some pos people have embraced the possibility that the Swiss Statement might mean people with an undetectable viral loadA measurement of the quantity of HIV RNA in the blood. Viral load blood test results are expressed as the number of copies (of HIV) per milliliter of blood plasma. are sexually uninfectious to see what a pressure and a limitation the virusA small infective organism which is incapable of reproducing outside a host cell. has placed on people’s lives — how much we want to throw off those feelings of stigma and fear of rejection, to regain some spontaneity and intimacy in our sexuality.

There is still some debate to be held on the “undetectable equals uninfectious” issue and for many people, while there is any risk they might transmit HIV to a partner they are not prepared to take it.

Other issues impact on positive people’s sexuality too — for people who have had HIV for some time and been on a range of treatments, including various protease inhibitors, there has been lipodystrophy to contend with. The effect the fat accumulation around the abdomen (particularly in men) and breasts (particularly in women) and the loss of limb fat has had on people’s body image and self-esteem has been devastating for some. For others they have lost sexual functioning or their libido for reasons, the scientific researchers seem to be saying, that may be partly psychological but also possibly related to treatments or the virus itself. With the average age of positive people in Australia being currently 37 [1], ageing is a factor as well.

Role of HAART?

A study published in AIDS 2007 [2] by Dr Julio Collazos from the Hospital de Gladacono-Usanasolo in Spain reviewed current research papers on sexual dysfunction in HIV-positive people and found the average prevalence of sexual dysfunction from the studies was 51%, erectile dysfunction 46%, decreased libido 44%, ejaculatory disturbances 39% and orgasmic disorders 27%. (These figures are substantially higher than the general population.)

According to the author, “despite the inconsistent results amongst the studies, the data that support a direct or indirect role of HAART in the generation of these disturbances seem to exceed the data that does not support it.”

Collazos presents evidence of studies that suggest a particular role for some protease inhibitors, especially ritonavir and indinavir, and that sexual dysfunction improved when these were discontinued— and that people treated on other ARVA medication or other substance which is active against retroviruses such as HIV. drug classesA group of anti-HIV drugs with the same target of action. Anti-HIV drug classes include nucleoside analogue reverse transcriptase inhibitors, protease inhibitors and non-nucleoside analogue reverse transcriptase inhibitors, as well as several others. Combining drugs from three or more classes is the basis of Highly Active Antiretroviral Therapy (HAART). did not have as high an incidence (with one study even suggesting an improved function in patients using NNRTIs, including nevirapine). Other studies have suggested that if there is a link with proteases it might be because people fear lipodystrophy and are less adherent or that metabolic disturbances caused by ARVs may help explain some of the problem.

Even so, the author acknowledges that there are a significant number of studies that have found no connection between sexual dysfunction and antiretrovirals [3]. While it might be consoling for men to attribute the cause of their erectile difficulties to treatments, the inconclusive nature of research so far suggests that people shouldn’t rush off to their doctors to demand a change of regimens. ARVs, including proteases have improved the general health of positive people and this has in turn, led to less problems with hypogonadism, energy levels and an increased sense of well-being – and it is unlikely that everyone has treatment-related causes to their problems.

Psychological causes

No one doubts though that psychological issues play a major role in sexual dysfunction in both sexes. Collazos found that psychogenic causes were present in 44% of the studies of HIV-positive men that his group looked at, with a mixture of organic and psychogenic causes responsible for a further 34% of problems. Rates were particularly high in homosexual HIV-positive men.

Richardson [4] and colleagues from St Mary’s Hospital in London found that sexual dysfunction was related to anxiety, and depression (both substantially higher in positive people generally) and the use of antidepressants and recreational drugs, in particular methamphetamines. They also concluded that lipodystrophy and poor body self image affected sexual confidence markedly.

Studies in HIV-positive Women [5] showed high rates of decreased sexual pleasure and interest in sex after diagnosis with women reporting real fears about infection of partners, that the spontaneity and abandon that were so much a part of the excitement of sex were no longer possible and that they sometimes perceived sex as “dangerous” now or “just too hard”, particularly when it involved getting men to use condoms. These findings were little different pre and post HAART.

When I spoke with Rebecca Matheson, Executive Officer of Straight Arrows (a support group in Victoria for heterosexuals with HIV), she disagreed with these findings. ‘We used to see people coming to us earlier in the epidemic talking about a lack of libido and interest in sex but that has changed for both sexes after HAART. I’m not saying people don’t have problems once they have a partner about when to tell them about their status but the interest is there and people are dating. Positive women are finding they don’t have such a high rejection rate, even on some of the Internet sites.

‘One thing that is clear to me though is that the HIV-positive women I talk to don’t want to date other positive men. They say it’s hard enough to deal with living with their own HIV rather than have to worry about their partner’s health. They don’t want to limit the field (which is pretty small in Australia, after all) and for some, they have been traumatised by a pos man who infected them in the first place.

This is not the case for the positive heterosexual men though – they want a positive partner to decrease the risk of transmission and to be able to do away with condoms. Some pos men have real difficulties finding partners and make trips to sex workers or to overseas destinations.’

Treating sexual problems

‘Proper use of antidepressant and other psychotropic drugs’ as well as ‘sexual and cognitive therapy’ [6] is recommended in the research studies for psychologically-related sexual problems. Some studies recommend that doctors analyse whether the problems seem to have begun with the introduction of certain ARVs, particularly proteases, and to see if changes can be made here – but there are few clear guidelines or concrete research for doctors to follow yet.

Testosterone replacement has been shown to work in pos men with low levels and there are some trials being done with aramatose inhibitors to treat those men found to have higher levels of oestrogen (with the cause as yet unknown, but possibly related to ARVs) [7]. Then of course, again for men, there is always Viagra, Cialis and other related drugs although these cannot be used with some ARVs and have to be dose-regulated with others.

Bradley, a 55 year-old gay man who has experienced several AIDS-defining illnesses in the past finds that these supposedly magic pills don’t work. ‘I have no doubt that my antiviralsA medication or substance which is active against one or more viruses. May include anti-HIV drugs, but these are more accurately termed antiretrovirals. and HIV have affected my ability to get an erection as has the onset of diabetes[Diabetes mellitus] A disorder in which sugars in the diet cannot be metabolised into energy due to a lack of the enzyme insulin. Late-onset diabetes mellitus may be a long-term side effect of some anti-HIV drugs.,’ he says.

‘Drugs like Viagra don’t work and I have to use penile injections to get anything happening at all. I was lucky to find a clinic that specialises in men’s sexual health where the doctor has worked with me to develop a combination of ingredients to go into the injections that really helped me to have a sexual life again. This is a cheaper arrangement than Caverject, which has now been taken off the PBS[Pharmaceutical Benefits Scheme] The federal government program which subsidises medication costs in Australia. Anti-HIV drugs are part of a special part of the PBS called Section 100 (S100) which is used for expensive, highly specialised drugs.. There are downsides—such as having to learn to inject and the fact that the erection doesn’t go down after ejaculation. HIV has interfered with my ability to have an orgasm too but to be able to perform sexually, there is no doubting what that does for your ego, your confidence and the satisfaction of your partner.’

Rebecca Matheson probably sums up this issue though when she says that doctors don’t spend enough time talking about these things with patients. “I know men are often unwilling to discuss the issues as well. We run workshops to try to get people talking about sex and relationships, including seeking out solutions from their doctors or other health professionals.’ Straight Arrows is producing a booklet Sex Matters: A-Z of Sex based on a Positive Heterosexuals and NSW Health publication to try to address this problem. AFAOAustralian Federation of AIDS Organisations. AFAO is the peak non-government organisation representing Australia's community-based response to HIV/AIDS. AFAO's work includes education, policy, advocacy and international projects. and NAPWA are soon to produce an update of the very popular booklet HIV+ Positive Gay Sex.

The best advice I have ever been given on the subject though came from my GP who said, ‘The best way to solve these things is usually to find a loving, patient partner. Think about where you’re having your sex too. Sometimes places like sex on premises venues actually add to the pressure on sexual performance for gay men. Intimacy in the bedroom can work better.’

You gotta find the person first though, of course.

References

1. Grierson, J., Thorpe, R. and Pitts, M., HIV Futures V, Australian Research Centre in Sex Health in Society, 2006
2. Collazos, J. Sexual dysfunction in the highly active antiretroviral therapy era, AIDS Rev. 2007:9:237-45
3. For example Guaraldi, G et al, Sexual dysfunction in HIV-infected men: role of antiretroviral therapy, hypogonadism and lipodstrophy, Antiviral Therapy 12:7, a study of 357 HIV-positive men in Italy was unable to find a causal link between erectile dysfunction and ARVs.
4. Richardson D. et al, Factors associated with sexual dysfunction in men with HIV infection International Journal of STD and AIDS, 2006 17:764-267
5. Siegel, K, Schrimshaw, E.W., Lekas, H. Diminished Sexual Activity, Interest and Feelings of Attractiveness Among HIV-Infected Women in Two Eras of the Epidemic, Arch Sex Behav, 2006,35:437-449
6. Op. cit. Collazos
7. Op. cit. Richardson et al.