Erectile dysfunction (ED) is the result of a complex interaction between psychological and organic factors and has a prevalence in the general population of 7% in Romanian men with ages between 25 and 45 years and of 22% in men with ages between 45 and 55 years.¹ Sexual dysfunction has also been recognized as a health problem for many HIV-positive men, most of them reporting erectile dysfunction (ED). It has a major impact on the quality of life, leading to negative behavior including low adherence to antiretroviral therapy, with consequences on the virological and immune control of HIV infection.^2-4

Studies have revealed that erectile dysfunction affects between 30% and 65% of HIV-infected men,^5-9 without precisely concluding which are the associated factors. These unclear results may be in part due to the use of different assessment methods, or different patient populations in terms of age, therapy regimen, and comorbidities. Erectile dysfunction can be associated with older age, lower levels of testosterone, depression, lipodystrophy, fear of virus transmission, HIV-related comorbidities, condom use and infection stigma.⁹Although data presented in field literature suggest a positive correlation between sexual dysfunction and factors related to HIV infection, the exact mechanisms involved are poorly understood. Certain authors have reported a correlation between sexual dysfunction and antiretroviral therapy, especially for protease inhibitors (PIs),¹⁰ but other studies contradicted these findings.^11-13

The aim of our study was to assess the prevalence of erectile dysfunction in a cohort of HIV-positive men under medical surveillance, to ascertain aspects of sexual function and to determine the role of specific risk factors such as smoking, drug use, or administration of PIs in developing erectile dysfunction.

This was a cross-sectional study that took place in Bucharest between May 2014 and August 2014. We evaluated a cohort of HIV-infected men monitored in the National Institute for Infectious Diseases "Prof. Dr. Matei Balș” Bucharest, Romania.

To evaluate the erectile function we used the International Index of Erectile Function (IIEF) with 15 questions, all having answers from 1 to 5. This is a self-administered questionnaire, a standardized method to evaluate 5 domains of sexual function, such as erectile dysfunction, sexual desire, intercourse satisfaction, overall satisfaction and orgasmic function. The erectile function is investigated by questions 1, 2, 3, 4, 5, 15 with a maximum score of 30. Using a cutoff score ≤ 25, the results were translated into positive ED from 6 to 25 and no ED from 26 to 30. The severity of ED was classified as no ED (score 26-30), mild ED (score 22-25), mild to moderate ED (score 17-21), moderate ED (score 11-16), severe ED (score 6-10).¹⁴

The patients were asked to complete the IIEF questionnaire and they offered data about their medical history, therapy regimens, tobacco smoking and drug use. Data obtained were statistically analyzed with IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, NY, USA). The correlation between risk factors (PI therapy, smoking, drugs consumption, age) and ED was tested using a set of statistical parametric and non-parametric multivariable functions, based on variable distribution.

During the study timeline a number of 80 patients were invited to participate in this study; 17 of them refused to complete the questionnaire and a final number of 63 patients were included in the study. Their mean age and standard deviation were 36.6 ± 9.4 years with values ranging from 20 to 56 years. The age distribution is presented in Figure 1.

From the study group 62 (98%) patients were on antiretroviral therapy at the time of evaluation, and 41 (66%) were receiving therapy with a protease inhibitor. A number of 44 (69.8%) patients had undetectable levels of HIV-RNA, 17 (26.9%) patients had detectable viral load, and 2 patients did not perform the test during the study timeline. Most of the patients (49, 78%) self-reported that they were smokers (more than five cigarettes per day) and 10 (15%) of them reported using drugs (defined as any kind of drugs, at least once in the last month before completing the IIEF questionnaire).

Figure 1. Age distribution of the study population

A number of 33 (52.4%) patients had no ED while 30 (47.6%) had some degree of ED, as follows: 18 (60%) patients had mild erectile dysfunction, 7 (23.3%) had mild to moderate erectile dysfunction, 4 (13.3%) patients had moderate erectile dysfunction and 1 (3.3%) patient had severe erectile dysfunction (Table 1). The mean age and standard deviation for patients with ED were 39.1±10.4.

 Table 1. Distribution of erectile dysfunction (ED) in the study group

The statistical analysis revealed no correlation between the presence of ED and risk factors such as HIV-RNA level, smoking and drug consumption. Therapy with PIs appeared to display a weak statistical association with ED, but because of the relatively small number of patients included in the study group, the data failed to reach statistical significance (p=0.064). Unsurprisingly, the presence of ED was positively associated with age, p=0.040 (Table 2).

Table 2. Correlations between erectile dysfunction and risk factors

The introduction of highly active antiretroviral therapy has led to increased life expectancy for HIV-infected patients, transforming this infection into a chronic and mostly manageable condition.^5,9,15In this context, ensuring an increased quality of life for these patients has become of utmost importance.

In this study we evaluated the sexual aspects of HIV infection in a cohort of men, patients under medical observation at a national reference center for infectious diseases in Bucharest, Romania. In field literature there is a lack of clear information on this topic, most studies performed so far presenting contradicting information. For example, some studies revealed a positive correlation between ED and PI therapy whereas others found no such correlation.^10-12,16,17

Using the erectile function domain of the IIEF questionnaire based on self-reported information we found that 47.6% of the men included in this study had some degree of ED, more than 80% of them having mild and mild to moderate ED at a mean age of 36.6 years. This prevalence of ED was a lot higher compared to the reported 7% in the general population at the same age category,¹ but the results are in accordance with conclusions presented by other researchers worldwide, which reported the rate of ED among HIV-positive men to be between 30% and 65%.^5-9,13

As mentioned above, some studies found that therapy with PIs had a negative impact on sexual function, documented through low scores on the ED domain in the IIEF questionnaire;^10,16,17 our study revealed a weak correlation between PI therapy and ED, similar to data reported by other authors¹² but failing to reach statistical significance, possibly because of the relatively low number of participants who agreed to fill out the questionnaire.

Taking into account the severe health issues that can develop during HIV infection,¹⁸ the sexual problems tend to go unnoticed or underdiagnosed by medical care providers. As our study revealed, many men from this HIV cohort presented a degree of ED, affecting their quality of life. Importantly, none of them had reported this issue to their physicians; this points to the fact that there is an unmet need to actively screen patients to recognize sexual dysfunctions in order to ensure timely intervention.

Moreover, as age (the only risk factor that we identified as being statistically correlated with ED) in an unmodifiable factor, it becomes important to investigate larger cohorts of HIV-positive patients in a better powered study, in order to be able to identify specific modifiable risk factors, needed for developing targeted interventions for minimizing the risk of erectile dysfunction in this particular patient population.

ED appears to be a health problem with high prevalence among Romanian HIV-positive men with a mean age of 36.6 years, about 48% of them reporting some degree of erectile dysfunction. Risk factors such as PI therapy, HIV-RNA level, tobacco smoking and drug use do not appear to have an important effect on sexual function in this cohort where the only factor associated with ED was, unsurprisingly, the age of the participants.

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