People with HIV infection can be expected to experience the usual age-related milestones in decline of sexual function but can also face additional challenges with regard to sexual function and sexuality. In terms of sexual function, sex hormone levels responsible for libido and secondary sexual characteristics, decline with age: testosterone drops from peak levels at age 30 by about 1% per annum; and, oestrogen falls more precipitously in the peri-menopausal period. [101] These changes may vary greatly between individuals, and within individuals and can impact sexual function, sexual identity and relationships. Males can expect a decline in erectile function, with early manifestations represented by less nocturnal tumescence. This can affect turgidity and duration of erections, delay arousal and orgasms, potentially creating psychological tensions, which exacerbate the physiological functions. Erectile dysfunction may be amenable to specific therapy, but other medications can jeopardise performance, enjoyment or have limited impact on underlying problems. Females may experience vaginal dryness, delays in arousal and dyspareunia in the extreme. Libido is primarily driven via testosterone, which will decline with advancing age. [102]
These concerns may be associated with a diminution in quality of life and may not be addressed in the clinical consultation. Questions about sexual and reproductive health and sexual function should be routinely asked at HIV consultation. This includes characterising the sexual problem, including at what phase in the sexual cycle the problems occur. Easy to use, online clinical questionnaires for men and women exist. [42] The next stage of assessment is to screen for an endocrine cause, i.e. related to hypogonadism. If there are signs or symptoms of hypogonadism in men, hormonal assessment via blood tests are suggested. These include serum levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), total testosterone and sex hormone-binding globulin to calculate free testosterone. If hypogonadism is present, referral to an endocrinologist is suggested. In women, signs of hypogonadism are those related to oestradiol insufficiency/menopause, and if present, can be confirmed with testing for LH, FSH and oestradiol levels. If symptoms of menopause are present, referral to an endocrinologist or gynaecologist should be considered. [42]
The third part of the clinical assessment for sexual dysfunction is to screen for other causes; including psychosocial problems, urogenital infections, medications, drugs and lifestyle factors. [42] Common medication classes associated with sexual dysfunction include psychotropics, lipid-lowering and antihypertensive drugs in men. [42] The contribution of ART is controversial and a change in regimen is not recommended. Treatment of erectile dysfunction in men is primarily with oral PDE5 inhibitors (sildenafil, tadalafil, vardenafil). [42] Dosage should be lowered if the patient is receiving a boosted PI as part of their ART regimen. Of importance, ‘poppers’ can have a synergistic effect with PDE-5 inhibitors and lead to profound hypotension – concurrent use is not recommended. Treatment of premature ejaculation includes behavioural interventions, psychosexual counselling, SSRIs, tricyclic antidepressants, clomipramine and topical anaesthetics. [42] Drug-drug interactions may necessitate dosage adjustment. [42]
There is now clear evidence that people with HIV infection do not transmit HIV in the context of at least 6 months of effective, fully suppressive ART and no concomitant STIs. This concept, of Undetectable = Untransmittable (U=U), has been reported in both HIV serodiscordant MSM and heterosexual couples. [42, 103-105] With the knowledge of U=U, people with HIV infection should be empowered by their HIV clinician, and fears allayed of transmitting the infection to their partner, in order to help restore intimacy and sexual fulfilment.
Ongoing sexual activity should be reviewed in the context of infection risk, transmission potential (HIV, HCV, HBV, other sexually-transmitted infections [STIs]), new STIs, the presence of other chronic health conditions [106-108] and perceptions of wellbeing. Notably, psychological wellbeing appears associated with protected sex behaviour. [109] Screening for STIs should continue at recommended intervals suggested by guidelines; and people counselled in relation to risk. [28] Older people with HIV infection may have a higher risk of transmission if not virally suppressed, in the context of a change in risk-related behaviours (i.e. no condom use due to less concern about pregnancy and high-risk sexual activity with increased use of medication for erectile dysfunction). [28] Reduced mucosal and immunological defences (e.g. post-menopausal atrophic vaginitis) may also lead to an increased risk of acquisition of HIV. [28] Screening practices for HIV infection in older adults may also be low. [28] In those whom may be at risk of acquiring HIV, prevention strategies should be emphasised, as well as PrEP – age alone is not a reason for exclusion. [28]
Key recommendations
- Assessment of sexual function should be performed in all people with HIV infection.
- The assessment of sexual dysfunction includes three main aspects for men and women: characterising the sexual dysfunction, screening for hypogonadism, with appropriate hormonal tests and endocrinology or gynaecology referral if required, and screening for other causes (i.e. psychosocial, urogenital infection, medication-related).
- ART does not appear to contribute to sexual dysfunction and switching of ART regimen is currently not recommended.
- Treatment of erectile dysfunction and/or premature ejaculation can be considered, potential for drug-drug interaction with current ART regimen, however, should be checked for with dosage adjustment if necessary.
- There is now clear evidence that people with HIV infection who have suppressed HIV viral load (<200 copies/mL) while receiving 6 months of effective, fully suppressive, ART will not transmit HIV to a serodiscordant partner. The concept of U=U may be important for the HIV physician to emphasise in those who have a fear of transmitting the virus, which may be impacting on current sexual function.
- In those ageing people with HIV infection who are sexually active (requires direct questioning), assess the risk of STIs and screen on a regular basis as per routine practice.