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Special considerations in the management of erectile dysfunction in the HIV-positive patient

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Abstract

Restoration of sexual function to HIV-positive men with erectile dysfunction (ED) is a challenging problem with many faces. Interactions between the novel phosphodiesterase inhibitors for treatment of ED and the highly active antiretroviral therapy (HAART) that currently forms the foundation of medical therapy for HIV infection require appropriate dose adjustment and familiarity with common medical conditions affecting the HIV-positive man. Urologists and general practitioners caring for this group of patients will also have to consider legal precedents governing delivery of care to HIV-positive patients in a new scenario in which the traditional physicianpatient encounter is affected by a third party—the patient’s current and future partner(s) and his or her respective rights.

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... The physician managing the patient with HIV should also have some expertise in sexual medicine and not be reluctant or embarrassed when interviewing the patient about his sexuality. 76,77,88 Sexual dysfunction should, therefore, be approached in the same way as other HIV-related comorbidities (such as cardiovascular or metabolic disorders) and a special ist in sexual medicine should be part of the multi disciplinary management. The physician should provide efforts to ensure a satisfactory sex life, which is a basic human right. ...
... 89 Usually, men with HIV receive information on safer sex at the time of diagnosis and all such information should be reoffered when starting a treatment for ED. Several authors have warned about the prescription of drugs enhancing erectile function to men with HIV; 71,74,77,78,88 however, a better erection avoids risky sexual behaviour such as condom slippage or voluntary removal during sex. 63 ...
Article
Sexual dysfunction in men with HIV is often overlooked by clinicians owing to many factors, including the taboo of sexuality. The improved life expectancy of patients with HIV requires physicians to consider their general wellbeing and sexual health with a renewed interest. However, data on sexual dysfunction in those with HIV are scarce. Erectile dysfunction (ED) is the most common sexual dysfunction in men, with a prevalence of ∼30-50% and is frequent even in men <40 years of age. HIV infection itself is the strongest predictor of ED, and many factors related to the infection-fear of virus transmission, changes in body image, HIV-related comorbidities, infection stigma, obligatory condom use-all impair erectile function. The diagnosis and treatment of sexual dysfunction is based on a multidisciplinary approach, which involves specialists in both infectious diseases and sexual medicine. Particular attention should be paid to the promotion of safer sex in these patients. This Review, describes the issues surrounding sexual dysfunction in men with HIV and aims to provide clinical advice for the physician treating these patients.
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Article
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Urologists and health care professionals treating erectile dysfunction face a significant challenge in caring for the HIV-positive patient who seeks restoration of normal sexual function. The encounter between the health care provider and the patient in this setting requires knowledge of HIV disease and potential drug interactions specific to this population, as well as thorough counseling on strategies aimed at reducing the infectiousness of HIV-1. The interaction extends beyond the immediate boundaries of the doctor-patient relationship and their respective rights, to include careful consideration of the rights of the partner/s and the society as a whole. This paper is a summary and analysis of presentations and discussions by medical, legal, nursing and bioethics specialists in an interactive seminar on this topic.
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Although there is an emerging body of literature on quality of life in persons with human immunodeficiency virus (HIV) disease (Barker et al., 1990; Wu et al., 1990; Wachtel et al., 1992), there is a paucity of published data on the prevalence of sexual dysfunction in HIV-infected persons or on the impact of such dysfunction on quality of life. One previous study has reported that 67% of homosexual men with acquired immunodeficiency syndrome (AIDS) reported a decreased libido and 33% reported impotency (Dobbs et al., 1993). We here describe the findings from an investigation of sexual dysfunction in a large group of homosexual men with severe HIV disease.
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We investigated the impact of the first year of highly active antiretroviral therapy (HAART) on health-related quality of life (HRQL). Medical data for patients in the French APROCO cohort were collected at enrollment (M0) and month 12 (M12). A self-administered questionnaire gathered information about HRQL (Medical Outcome Study 36-Item Short Form Health Survey) and toxicity-related symptoms. Using the twenty-fifth percentile of HRQL scales in the French population as a threshold, patients with normal values in at least three mental and three physical scales were considered to have a "normal HRQL." RESULTS. Of the 1053 patients followed through M12, HRQL data at M0 and M12 were available for 654. Among the 233 patients with a normal baseline HRQL, 63 (27.0%) experienced a deterioration of HRQL at M12. Among the 421 patients with a low baseline HRQL, 121 achieved a normal HRQL at M12. Logistic regression showed that factors independently associated with a normal HRQL at M12 were normal baseline HRQL, baseline CD4 count <500 cells/mm, time since HIV diagnosis <8 years, undetectable HIV-RNA at M12, and lower number of self-reported symptoms at M12. An assessment of HRQL should be integrated to efficacy outcomes to evaluate and compare long-term strategies properly and to optimize the durability of response to antiretroviral therapy.
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The management of HIV infection has dramatically altered the natural history of the disease. Prevention of opportunistic infections and the development of HAART regimens altered the manifestations and conditions that urologists are being asked to evaluate and manage in this patient population.
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The objective of this study was to investigate if sildenafil influences the pharmacokinetics of nelfinavir. Five HIV-infected patients on steady-state nelfinavir-containing therapy were subject to pharmacokinetic sampling for nelfinavir concentration twice: without sildenafil and with sildenafil 25 mg as a single dose. There were no differences in the AUC, T(max), or C(max) of nelfinavir. In a similar design, two patients on indinavir and two patients on ritonavir combined with saquinavir were studied. In accordance with the literature, neither of these two treatments was affected. It is concluded that nelfinavir pharmacokinetics were unaffected by concomitant intake of a single dose of sildenafil.
Article
Risk factors for erectile dysfunction (ED) (hypertension, diabetes, smoking, lipid abnormality) are also risk factors for coronary artery disease. However, most cardiologists do not routinely ask about ED and patients often are reluctant or embarrassed to discuss it. We determined how common ED was in a group of patients with chronic stable coronary artery disease. We administered the validated Sexual Health Inventory for Men (SHIM) 5-item questionnaire, based on the International Index of Erectile Function questionnaire, to 76 men with chronic stable coronary artery disease during routine outpatient cardiology visits. Most of these men had not previously discussed ED with their cardiologist. The mean patient age was 64 years (range 40 to 82). The questionnaire took about 5 minutes to complete. Of the patients 47% were on beta blockers, 92% statins, 28% diuretics. SHIM score was 21 or less in 53 men (70%), which is indicative of ED. Of the patients 75% had some difficulty achieving erections (question 2) and 67% had some difficulty maintaining an erection after penetration (question 3). The questionnaire reflected successful sildenafil treatment in 4 patients (SHIM scores 23 to 25). If these 4 men are included as having had ED then 57 of 76 (75%) had ED or recent history of ED. ED is extremely common in men with chronic coronary artery disease (affecting approximately 75%) yet most cardiologists do not ask about it. The SHIM is a useful, quick and inexpensive tool for discussion and diagnosis of ED in this population. Although it is well established that cardiovascular risk factors are associated with erectile dysfunction, once it is present there is mixed information on whether treating the risk factors will treat the ED. Problems appear to be that lifestyle modification in midlife may simply be too late to effect a change, and some antihypertensive and lipid lowering drugs may actually exacerbate ED. Oral therapy for ED, namely the PDE5 inhibitors, is effective and safe in most cardiac and hypertensive patients. Organic nitrates such as nitroglycerin remain a contraindication to the concomitant use of these drugs. Guidelines for treatment of ED in the cardiac patient issued by the American College of Cardiology/American Heart Association and Princeton Guidelines may be useful in the approach to the cardiac patient with ED.
Article
This article examines the relationships among depression, ischemic heart disease, and erectile dysfunction. Depression is an independent risk factor for the development of ischemic heart disease, and depression in the post-myocardial infarction patient is associated with increased morbidity and mortality. Ischemic heart disease and erectile dysfunction are also frequently comorbid and share many common risk factors including age, hypertension, diabetes, dyslipidemia, obesity, sedentary lifestyle, and smoking. Depression and erectile dysfunction often occur together; however, the causal relation may be difficult to determine because erectile dysfunction may be a symptom of depression, social distress accompanying erectile dysfunction may precipitate depressive symptoms, or both conditions may result from a common factor such as vascular disease.
Article
The association between different antihypertensive drugs and erectile dysfunction (ED) was examined in a cohort of type II diabetes patients identified in the UK General Practice Research Database (GPRD). The GPRD contains details of diagnoses, prescribing, investigations, risk factors, outcomes, and hospital referrals, together with basic demographic information for approximately six million patients from more than 450 representative general practices throughout the UK. A total of 634 cases and 2526 controls were included for analysis. Unconditional logistic regression analysis was performed to assess the risk of ED after adjusting for age at diabetes diagnosis date, cigarette smoking, depression, glycemic control, use of HMG-CoA reductase inhibitors, use of histamine receptor antagonists, use of digitalis medicines, and use of nitrates. Increased risk of ED was observed among patients taking the following antihypertensives: ACE inhibitors (OR=1.47, 95% CI=1.21, 1.80) and alpha blockers (OR=1.54, 95% CI=1.11, 2.12). However, we identified a nearly 30% reduction in risk among patients on diuretics (OR=0.73, 95% CI=0.54, 0.99). No statistically significant increase in risk was observed among users of beta blockers and calcium channel blockers (OR=1.05, 95% CI=0.85, 1.31) and (OR=1.14, 95% CI=0.91, 1.43), respectively. The results of this study confirm the strong and recognized effect of comorbidities in a diabetic population, but also require additional experimental and observational studies to further understand the potential benefit of diuretics and other ED treatments such as PDE5 inhibitors.
AIDS and the urologist An excellent review of common problems facing urologists in the HIV/AIDS era
  • G Hyun
  • Lowe
Interaction of sildenafil and indinavir when co-administered to HIV-positive patients This is one of the few in-depth publications on the topic of PDE5-protease inhibitor interaction
  • Barry C Merry
  • Mg
  • M Ryan
  • Jf Tjia
  • M Hennessy
  • Eagling
  • Va
Pharmacokinetic interactions between sildenafil and saquinavir/ritonavir This is one of the few in-depth publications on the topic of PDE5-protease inhibitor interaction
  • Gj Muirhead
  • Mb Wulff
  • A Fielding
Disability discrimination in America: HIV/AIDS and other health conditions One of the most important reviews of the legal issues in physician interactions with HIV-positive patients
  • Lo Gostin
  • C Feldblum
  • Webber
AE: The Changing Face of AIDS
  • Oliva Dag
  • DaG Oliva
Ct ed; 1998:2207. The landmark US Supreme Court case categorizing asymptomatic HIV-positive status as a disability worthy of inclusion in the Americans with Disabilities Act
  • Bragdon V Abbott
The landmark US Supreme Court case categorizing asymptomatic HIV-positive status as a disability worthy of inclusion in the Americans with Disabilities Act
  • Abbott Bragdon V
Protease inhibitor combination therapy and decreased condom use among gay men
  • R J Diclemente
  • E Funkhouser
  • G Wingood
  • RJ DiClemente
Male sexual dysfunction associated with antiretroviral therapy
  • A E Colson
  • M J Keller
  • P E Sax
  • AE Colson