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Abstract

The role of sexual function and its impact on HIV management have been inadequately evaluated. A cross-sectional study in 2009 of 202 patients with HIV were recruited to examine sexual function and psychosocial/HIV management factors. Analyses assessed the relationship between sexual function, sociodemographic factors, biomedical markers, and depressive symptomology. The M-Estimator compared differences in the means of the HIV, cancer survivors, and the normative cohorts. More than 75% were on combination antiretroviral therapy, of which 70% had suppressed HIV viral loads. Patients with unsuppressed HIV viral loads reported lower rates of arousal. Better overall health was associated with higher rates of overall sexual function, arousal, and interest. Compared to the normative and cancer survivor cohorts, mean sexual function was significantly lower in the HIV-infected cohort in all subscales, except for masturbation. These findings suggest lower sexual function impacts individuals with HIV in ways related to negative biomedical and psychosocial factors.

Keywords

sexual function HIV/AIDS depression HIV management

Introduction

HIV infection has become a manageable chronic disease among individuals who have access and adhere to medical care and medication.¹ Studies have identified that individuals reduce unprotected sexual behavior once they are diagnosed with HIV.² HIV transmission risk is minimal among those who are virally suppressed; thus, promotion of safer sexual behaviors now focuses on medication adherence, not necessarily condom use. Identifying factors that interrupt HIV medical care and medication adherence is key in improving health outcomes across the continuum of care.³ Addressing sexual health needs is an integral component of comprehensive HIV care and may serve as a barrier to adherence to care as is considered a basic need among populations who are infected.^4,5 Sexual function is likely to be minimally addressed in HIV care and is a fundamental component of physical and mental health. A common method of addressing sexual function within HIV clinic settings has been prescribing medications for erectile dysfunction.⁶

Sexual function among individuals with HIV is challenging to evaluate and address, as it is situated within the context of individual guilt and fear of transmission, which is compounded with discomfort with discussions of sexuality.⁷ Psychologically, patterns of poorer sexual function have been related to higher rates of depression, guilt, anger, dissatisfaction with body image, and higher body mass index among individuals with HIV.^8,9 Premature ejaculation, erectile dysfunction, and hypogonadism have been identified most often in relation to sexual dysfunction in comparison to uninfected populations.^10,11 Sexual dysfunction among men who have sex with men with HIV has ranged from 10% to 30% of clinic populations.¹¹ Specifically, studies of women with HIV have been documented, with 30% to 41% of hypoactive sexual function, such as less sexual interest and reduced satisfaction when compared to uninfected women.^9,12,13 Finally, older age has been associated with declines in sexual function in populations with HIV infection as well, making this a relevant barrier, as individuals diagnosed with HIV are living longer and with less morbidity.¹⁴ Sexual function has been routinely measured and differentially treated by gender outside the context of HIV infection.

Due to these findings, recommendations for the treatment of sexual dysfunction both among populations with HIV and among individuals with other chronic illnesses have been developed, yet they are not consistently promoted in health-care settings.^15,16 HIV care providers need an enhanced understanding of related health issues among their clinic populations. The purpose of this study was to assess sexual function among individuals with HIV, identify relationships between sexual function and HIV parameters, and compare sexual function rates to already established literature through normative and cancer survivor cohorts.¹⁷

Methods

Patients were recruited from the outpatient Washington University HIV Clinic (St Louis, Missouri). Patients with HIV and 18 years or older were eligible to participate in an interview as part of a cross-sectional study of psychological distress, sociodemographic characteristics, sexual function, and HIV management measures. Patients were remunerated for participation in the study. Trained personnel at the Washington University HIV Clinic conducted interviews in a private, confidential space. The Human Protection Office of the academic institution approved all study protocols.

Symptoms of depression were assessed using the Patient Health Questionnaire 9 (PHQ-9) and quality of life as measured by the Short Form 12 (SF-12).^18
-20 Data were abstracted from participants’ medical records to document the most recent CD4 counts and HIV viral loads. Patients were considered to be on combination antiretroviral therapy (ART) if they were receiving ≥3 antiretroviral drugs from 2 or more classes. Viral load suppression was considered <400 copies/mL as the test sensitivity was such at the time of data collection.

The Sexual Function Questionnaire (SFQ) was administered in this study. This instrument has previously been used in populations recovering from differing types of cancer.¹⁷ The measure consists of 1 overall sexual function measure and multiple subscales: interest, desire, arousal, orgasm, relationship, activity, problems, and medical impact. These scales were constructed to measure sexual function by gender, incorporating physiological differences as well. Further rigorous psychometric testing has found this questionnaire to have valid and reliable constructs.²¹ Each subscale and the overall scale range are measured with a Likert-type scale ranging from 5 to 7 potential response options. A normative cohort was established in the development of this instrument as was the cohort that experienced cancer; therefore, it is noted that these 2 sample sizes were established through prior research.¹⁷

Statistical Analyses

All variables within the study were considered at a categorical and interval level, depending on the type of analysis. Education levels were dichotomized: less than equal to high school graduate/general educational development (GED) or greater than high school degree. Employment status was dichotomized into unemployed (including receiving disability benefits) and employed (part- or full-time). Annual income was dichotomized into ≤ and >$10 000. Depression severity was dichotomized to those who expressed symptoms of major depressive disorder or oppositional defiant disorder (MDD/ODD) within the past 2 weeks and those who did not. HIV viral loads were dichotomized (<400 copies/mL and ≥400 copies/mL) as was the standard test results at the time of data collection. CD4 counts were dichotomized as well (<200 cells/mm³ and ≥200 cells/mm³).

Descriptive analyses were conducted to define the overall sample. The Shapiro-Wilk test was conducted to test for normality of the data. The Mann-Whitney U test was used to assess the relationships of sociodemographic factors and HIV-related measures (CD4 counts and HIV viral load). The M-Estimator is considered a robust estimator, resistant to outliers; therefore, it was used to compare differences in the means of the HIV, cancer survivors, and the normative cohorts.^17,22 All tests were 2-tailed, and P < .05 was considered statistically significant. Data were analyzed using SAS version 9.4 for Windows (SAS Institute Inc).

Results

A total of 202 clinic patients were recruited and administered the SFQ. The majority of the sample was male, African American, with a median age of 43.5 years. More than three-quarters of the sample were currently on ART, among those 70% were virally suppressed. Less than half (n = 83, 41.7%) reported being sexually active in the previous 3 months (Table 1).

Table 1.

Sample Characteristics.^a

	n	%
Gender (n = 200)
Male	139	69.5
Female	61	30.5
Age, years	43.5 (36.0, 50.0)	N/A
Race (N = 201)
African American	146	72.6
Caucasian	55	27.4
Education (N = 201)
≤High school degree/GED	98	48.8
>High school degree	103	51.2
Employment
Unemployed	97	48.0
Employed (part- or full time)	105	52.0
Income (N = 199)
≤$10 000	102	48.7
>$10 000	97	51.3
Sexual orientation (N = 100)
Heterosexual	50	24.8
MSM	50	24.8
Years living with HIV	9.5 (4.3, 14.5)	N/A
Depressive symptomology (N = 166)	44	26.5
Overall Health Status (N = 201)
Excellent to good	144	71.6
Fair to poor	57	28.4
Sexually active past 3 months N = 199)	83	41.7
ART receipt	157	77.7
CD4 count (n = 198)
<200 cells/mm³	44	22.2
≥200 cells/mm³	154	77.8
HIV RNA levels (N = 200)
<400 copies/mL	140	70.0
≥400 copies/mL	60	30.0

Abbreviations: ART, antiretroviral therapy; GED, general education development; MSM, men who have sex with men; N/A, not applicable.

^aData frequency (%), median (p25, p75).

Females who reported depressive symptomology had lower overall sexual function, interest, desire, and arousal compared to females who reported no depressive symptomology (P < .05 for all). Females with an unsuppressed viral load had less arousal and interpersonal relationship connections (P < .05). Additionally, those who considered their overall health status to be fair to poor had lower masturbation tendencies (P < .05; Table 2).

Table 2.

Factors Associated With Sexual Function Scales Among Females.^a

	Overall Sexual Function	Interest	Desire	Arousal	Orgasm	Satisfaction	Activity	Relationship	Masturbation	Problems	Medical Impact
Race
African American	2.45	1.19	1.83	1.13	2.67	2.00	1.00	3.92	0.00	4.67	2.05
Caucasian	2.78	1.75	2.33	2.00	2.00	2.50	1.50	3.83	0.50	5.00	2.30
Income
≤$10 000	2.54	1.19	2.00	1.38	3.00	2.25	1.50	4.08	0.00	4.66	2.05
>$10 000	2.20	1.25	1.00	0.75	1.67	2.00	0.25	3.67	0.33	5.00	2.40
Education
≤High school degree/GED	2.56	1.25	2.00	1.50	2.67	2.00	1.13	3.96	0.00	4.75	2.30
>High school degree	2.25	1.19	1.83	1.00	3.17	2.25	0.13	3.67	1.00	5.00	1.95
CD4 counts
<200 cells/mm³	2.43	1.25	1.33	0.75	2.67	2.50	1.25	3.96	1.00	4.67	2.50
≥200 cells/mm³	2.52	1.19	2.00	1.38	2.29	1.88	1.00	3.75	1.18	4.83	2.05
HIV RNA viral loads
<400 copies/mL	2.79	1.31	2.67	1.89^a	3.16	2.50	1.51	4^a	1.25	4.36	2.00
≥400 copies/mL	2.29	0.75	1.00	1.03^a	2.33	2.00	1.09	3.50^a	0.95	4.31	2.40
Depressive symptomology
No	2.48^a	1.25^a	2.00^a	1.69^a	2.67	2.03	1.37	4.08	1.09	4.83	2.15
Yes	1.38^a	0.84^a	0.67^a	1.45^a	0.17	1.44	0.13	3.50	0.79	5.00	2.60
Overall health status
Excellent to good	2.56	1.25	2.00	1.50	2.67	2.00	1.00	2.83	1.00^a	4.67	2.00
Fair to poor	2.09	0.94	1.00	0.50	2.50	2.63	1.50	3.79	0.33^a	5.00	2.80

Abbreviation: MSM, men who have sex with men.

^a P < .05.

In our sample, African American males had a lower score for orgasms in comparison to their caucasian counterpart (P < .05). Further, those with a high school degree/GED or less had lower levels of interest and participating in masturbation (P < .05). Males with CD4 counts <200 cells/mm³ had lower overall sexual function, interest, desired, and arousal compared to those with CD4 counts ≥200 cells/mm³ (P < .05). Males with unsuppressed viral loads also appeared to have lower sexual function related to interest, desire, and arousal in comparison to those with suppressed viral loads (P < .05). Males with depressive symptomology had lower overall function, desire, orgasms, and satisfaction compared to those males who were not depressed (P < .05). Finally, those who reported their overall health status to be fair to poor had significantly lower overall sexual function, arousal, orgasm, and satisfaction (P < .05; Table 3).

Table 3.

Factors Associated With Sexual Function Scales Among Males.

	Overall Sexual Function	Interest	Desire	Arousal	Orgasm	Satisfaction	Activity	Relationship	Masturbation	Problems	Medical Impact
Race
African American	2.45	2.13	1.67	1.50	3.33^a	2.00	0.63	2.92	2.33	4.50	2.20
Caucasian	2.81	2.63	2.33	1.75	4.00^a	3.25	0.50	1.60	3.33	4.50	2.35
Income
≤ $10 000	2.48	2.25	1.67	1.50	3.33	2.25	0.50	2.28	2.67	4.25	2.30
>$10 000	2.68	2.38	2.00	1.63	4.00	2.25	0.63	2.00	3.00	4.50	2.10
Education
≤ High school degree/GED	2.37	2.00^a	1.67	1.50	4.00	2.25	0.75	3.00	1.67^a	4.50	2.20
> High school degree	2.71	2.50^a	2.00	1.75	3.67	2.25	0.50	1.75	3.33^a	4.50	2.30
Sexual orientation
Heterosexual	3.36	2.50	2.33	2.63	4.33	4.00	2.00	4.67	3.67	4.50	1.60
MSM	3.23	3.83	2.75	2.755	4.00	4.00	1.75	3.92	2.67	4.75	2.20
CD4 counts
<200 cells/mm³	2.09^a	1.81^a	0.83^a	0.50^a	3.33	1.88	0.88	1.67	2.33	4.25	2.40
≥200 cells/mm³	2.70^a	2.63^a	2.00^a	1.75^a	3.67	2.25	1.19	2.45	2.84	4.50	2.20
HIV RNA viral loads
<400 copies/mL	2.72	2.56^a	2.00^a	1.75^a	3.67	2.52	0.88	2.50	2.67	4.50	2.20
≥400 copies/mL	2.27	2.00^a	1.33^a	1.00^a	3.14	2.42	0.90	1.30	3.00	4.75	2.22
Depressive symptomology
No	2.77^a	2.38	2.17^a	2.00	4.00^a	3.00^a	1.00	2.83	3.33	4.75	2.00
Yes	2.01^a	2.13	1.17^a	1.50	3.33^a	1.88^a	0.50	1.92	2.50	4.25	2.70
Overall health status
Excellent to good	2.72^a	2.50	2.00	1.75^a	4.00^a	2.75^a	0.75	2.45	3.00	4.50	2.00
Fair to poor	2.04^a	2.13	1.33	1.50^a	3.17^a	2.00^a	0.25	1.67	2.00	3.75	2.60

Abbreviation: MSM, men who have sex with men.

^a P < .05

The mean scores for each of the subscales of the SFQ for the HIV cohort were 2.1 (SD = 1.3) for interest, 2.1 (SD = 1.7) for desire, 1.7 (SD = 1.5) for arousal, 2.9 (SD = 1.7) for orgasm, 2.3 (SD = 1.7) for satisfaction, 2.3 (SD = 1.9) for masturbation, 2.7 (SD = 2.2) for relationship, 1.2 (SD = 1.4) for activity, 4.1 (SD = 1.3) for problems, 2.3 (SD = 1.0) for medical impact, and 2.5 (SD = 1.0) for the overall sexual function score. Compared to the HIV-negative cohort, mean sexual function was significantly lower among individuals with HIV among all subscales (overall sexual function, interest, desire, arousal, orgasm, relationship, activity, problems, and medical impact), except masturbation, which was higher functioning among the group with HIV (P < .05). Compared to the cancer survivor cohort, the cohort with HIV had lower sexual function across all the subscales except masturbation (P < .05). Additional details of these relationships are depicted in Table 4.

Table 4.

Comparison of Sexual Function Questionnaire among HIV, Cancer, and Normative Cohorts.

	HIV Cohort (n = 202) Mean (SD)	Cancer Cohort (n = 279) Mean (SD)	Normative Cohort (n = 121) Mean (SD)	M-Estimator of HIV Cohort	95% Confidence Interval of HIV Cohort
Overall SFQ	2.51 (1.03)	3.23 (1.24)	3.93 (0.80)	2.53	2.37-2.65
Interest	2.10 (1.32)	3.62 (1.30)	3.73 (1.33)	2.02	1.90, 2.27
Desire	2.05 (1.72)	3.93 (1.66)	4.67 (1.12)	1.86	1.82-2.31
Arousal	1.73 (1.45)	2.12 (1.24)	2.69 (0.87)	1.58	1.51-1.92
Orgasm	2.91 (1.71)	4.32 (2.27)	5.46 (0.88)	3.30	2.65-3.15
Satisfaction	2.39 (1.74)	3.52 (1.62)	4.2 (1.12)	2.37	2.15-2.63
Masturbation	2.26 (1.92)	1.55 (1.41)	1.96 (1.65)	2.18	2.00-2.53
Relationship	2.74 (2.18)	3.27 (2.06)	4.19 (1.47)	2.68	2.42-3.06
Behavior/activity	1.21 (1.40)	2.49 (1.68)	3.40 (1.35)	0.86	1.02-1.41
Problems	4.05 (1.25)	5.19 (0.95)	5.40 (0.68)	4.45	3.88-4.23
Medical impact	2.28 (0.98)	2.92 (0.96)	N/A	2.19	2.14-2.41

Abbreviations: N/A, not applicable; SD, standard deviation; SFQ, Sexual Function Questionnaire.

Discussion

The purpose of this study was to examine sexual function among individuals with HIV and identify relationships with psychosocial and HIV management factors. Poor health indicators such as HIV management, overall health status, and depressive symptomology were related to lower overall sexual function. Furthermore, we found that rates of sexual function were lowest in the HIV cohort when compared to the normative and cancer survivor cohorts, excluding the masturbation subscale. This study suggests the need to address sexuality more comprehensively among populations with HIV, in healthcare settings, in order to improve the overall health outcomes.

Being virally unsuppressed and expressing challenges with low sexual function is likely to be associated with medication nonadherence, which would likely increase the risk of HIV transmission.²³ Although there was lower reported overall sexual function among patients who had unsuppressed viral loads, this may suggest there is less risk of HIV transmission, as patients may not be having sex due to their reportedly low sexual function. Additional research is necessary to better understand these relationships. Furthermore, addressing sexuality and sexual function within a clinic setting may help better engage patients in the HIV care continuum and improve health outcomes with more comprehensive care.^3,4 Future studies should further examine the role of sexuality as an operationalized construct to better understand patients with HIV who may experience feelings of guilt and discomfort with their sense of sexual selves, as they manage their HIV disease.²⁴ Our analyses, for both females and males, suggested significant correlation between depressive symptomlogy and overall sexual function and several sexual function subscales. Given these findings, this study suggests managing depressive symptomology may affect sexual function management among populations with HIV. The need to specifically understand how sexuality impacts overall health is a central issue in how individuals can appropriately manage their HIV. For many in the medical field, this disease has transitioned into a chronic disease, yet the stigma, distress, and guilt continues to manifest within infected populations.

Although not studied within this cohort, research has identified the impact of alcohol and substance use behaviors on adherence to HIV medical care. In the literature, individuals with a substance use disorder, including alcohol, are at higher risk for increased HIV transmission sexual behaviors, poor medical, and medication adherence.^25
-27 However, research has not fully elucidated the relationship between substance use disorders and sexual function in the HIV population. The available research has indicated that, in the general population, there is an increased risk of reduced orgasms and arousal phases in those with a substance use disorder.²⁸ Our study provided an understanding of relationships between depression and sexual function, but further research is needed to better understand the role of substance use disorders.

Comparing across chronic diseases of an uninfected cohort, the HIV-infected cohort had lower sexual function across all subscales and overall sexual function, except for masturbation for both the normative and the cancer survivor cohorts. This finding was contrary to what was expected, and populations with HIV had been documented to engage in higher rates of sexual behaviors with more sex partners than individuals without HIV.^29,30 Yet this does support more recent research, which suggests that populations with HIV are not engaging in higher risk behaviors than the uninfected population, although they are more likely to encounter individuals who are HIV infected, thus resulting in HIV transmission.³¹ Further, this finding suggests that populations with HIV may be meeting their sexual needs in a safe manner with masturbation. In relation to the high rates of psychological distress among populations with HIV, interventions that focus on masturbation as a means for sexual and overall health may also provide improvements in health outcomes.

Our study had a relatively small sample, missing values for some variables, recruitment from a single clinic, and the sample included only patients who were engaged in medical care. These factors reduce the generalizability of the findings. Additionally, more than three-quarters of the sample were currently on ART; among those, 70% were virally suppressed. Based on our findings, patients with viral suppression had a tendency to have better sexual function. Thus, this may have skewed the responses to the SFQ²¹ if people perceived stability with their HIV care. Scale developers accounted for female and male gender identity in the development and implementation of the SFQ; therefore, these findings do overlook the importance of gender nonconforming identities, and future studies are needed to further explore this important work.

Conclusion

Sexual function may play an integral component in the management of HIV infection via psychosocial factors. The findings from this study suggest that HIV infection has created challenges to developing and enhancing a sense of positive sexuality among populations who are infected. How individuals are challenged with their sexual function, whether physically or psychologically, may provide understanding in how to better manage their HIV infection due to increased depression, lower quality of life, and other inhibited psychosocial factors.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Examining Sexual Function Among Individuals With HIV in a Midwestern US Urban Outpatient Clinic Setting