Background and summary

The use of highly active antiretroviral therapy (HAART) can cause many side effects, as mentioned in our report on nevirapine. One possible side effect of HAART that is not usually mentioned is sexual dysfunction. There's not much information on this problem, in part because people in clinical trials of HIV/AIDS drugs are not usually questioned about sexual dysfunction. As well, both research subjects and data collectors may not feel comfortable talking about this issue.

To help find out more about sexual dysfunction, researchers in the European Union surveyed over 900 people with HIV/AIDS (PHAs). According to their results, a large proportion of PHAs, particularly those using protease-inhibitors (PIs), reported sexual dysfunction. These results are interesting but there are some important points to consider about this study before assuming that PIs cause sexual dysfunction.

Study details

Researchers distributed surveys between 1998 and 1999 at eight major HIV/AIDS treatment centres and four non-govermental organizations in the European Union. The profile of the 904 subjects whose data was used in the analysis was as follows:

• 20% female, 80% male
• average age – 39 years
• time since diagnosis of HIV – 8 years

The proportion of subjects with the following CD4+ cells counts was:

• more than 500 CD4+ cells – 29%
• between 200 to 500 CD4+ cells – 49%
• fewer than 200 CD4+ cells – 22%

The proportion of subjects with the following range of viral loads was:

• fewer than 500 copies – 43%
• between 500 to 30,000 copies – 43%
• more than 30,000 copies – 14%

The proportion of subjects with symptoms of HIV/AIDS was as follows:

• symptom-free – 55%
• mild symptoms – 30%
• symptoms of AIDS – 15%

The following therapies were used by the following proportion of subjects:

• PI-based regimens – 75%
• nucleoside analogues (nukes) only – 10%
• combinations of nukes and non-nukes – 13%

Results — Sexual dysfunction

The researchers found that about 37% of their subjects (29% female, 38% male) reported decreased interest in sex. Other findings included:

• 31% of males reported decreased "sexual potency"
• decreased sexual interest was more likely to occur among PI-users (40%) compared to subjects not using these drugs (16%)

Among those subjects who used PIs, decreased sexual interest occurred more often among those who had signs/symptoms of lipodystrophy (49%) than in those PI-users who did not have lipodystrophy (25%). As well, those subjects who had another complication — nerve damage to the hands and/or feet (peripheral neuropathy) — were also likely to have reduced sexual interest.

The following factors were linked to decreased sexual potency:

• having symptoms of HIV/AIDS
• use of tranquillizers
• use of antidepressants
• use of indinavir (Crixivan) or ritonavir (Norvir)

In general, the researchers found that as the age of subjects increased, so did the risk of sexual dysfunction.

Points to consider

1. Before rushing to blame PIs for yet another side effect, it is important to remember that sexual dysfunction can be caused by several factors, including depression. Researchers did not enquire about this problem, which makes interpreting the results of their survey difficult.

2. The finding about indinavir and ritonavir — but not nelfinavir — being linked to sexual dysfunction is interesting. This does not mean that nelfinavir cannot be associated with sexual dysfunction. The problem in this study was that the average length of time subjects used nelfinavir was shorter than the length of time they used indinavir and ritonavir. Results might have beeen different if researchers had used subjects who had taken different PIs for the same length of time.

3. Researchers need to design and conduct better studies if they are to be certain about the link between something as complex as sexual interest and the use of certain HIV drugs. They also need to rule out other conditions that can cause sexual dysfunction, such as cardiovascular disease, lower-than-normal concentrations of testosterone/estrogen, depression, and use of substances and other medications such as lipid-lowering agents.

1. Schrooten W, Colebunders R, Youle M, et al. Sexual dysfunction associated with protease-inhibitor-containing highly active antiretrovial treatment. AIDS 2001;15:1019-1023.

2. Goldstein I. The mutually reinforcing triad of depressive symptoms, cardiovascular disease, and erectile dysfunction. American Journal of Cardiology 2000;86(2A):41f-45f. [Medline]

3. Martin-Morales A, Sanchez-Cruz JJ, Saenez de Tejada I, et al. Prevalence and independent risk factors for erectile dysfunction in Spain: results of the epidemiologica de la disfuncion erectil masculina study. Journal of Urology 2001;166(2):569-574. [Medline]

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Copyright © 2001 - TreatmentUpdate. Reproduced with permission. Reproduction of this article (other than one copy for personal reference) must be cleared through the Editor, The Canadian AIDS Treatment Information Exchange, 555 Richmond St. West, Suite 505, Box 1104, Toronto, ON, M5V 3B1 • Phone: 416-203-7122 • Toll Free: 1-800-263-1638 • Fax: 416-203-8284  http://www.catie.ca.

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