Does HIV cause erectile dysfunction? Whilst HIV infection does not directly cause erectile dysfunction through a single mechanism, men living with HIV experience higher rates of ED than the general population. The relationship is complex and multifactorial, involving biological effects of the virus—including potential nervous system changes, vascular dysfunction, and hormonal imbalances—alongside psychological factors, medication effects, and cardiovascular risk factors. Modern antiretroviral therapy has transformed HIV into a manageable chronic condition, and many men with well-controlled HIV maintain normal sexual function. However, understanding the connections between HIV and erectile dysfunction remains essential for comprehensive care and effective management.

Does HIV Cause Erectile Dysfunction?

The relationship between HIV and erectile dysfunction (ED) is complex and multifactorial. HIV infection itself does not directly cause erectile dysfunction through a single, straightforward mechanism. However, men living with HIV appear to experience erectile dysfunction at higher rates than the general population, with studies suggesting varying prevalence rates depending on the population studied and whether they are receiving modern antiretroviral therapy (ART).

Several biological pathways may contribute to this association. HIV can affect the nervous system through HIV-associated neurocognitive disorders, potentially impacting the neurological pathways essential for achieving and maintaining an erection. The virus may also contribute to endothelial dysfunction—damage to the inner lining of blood vessels—which impairs the vascular mechanisms necessary for erectile function. Chronic inflammation associated with HIV infection, even in individuals with well-controlled viral loads, may further compromise vascular health.

Hypogonadism (low testosterone levels) appears more common in men with HIV, particularly in those with advanced disease or not on effective treatment. Testosterone plays a crucial role in sexual desire and erectile function, and its deficiency can significantly contribute to ED. The mechanisms behind HIV-related hypogonadism are not fully understood but may involve effects on testicular function, hypothalamic-pituitary axis disruption, or the impact of chronic illness.

It is important to recognise that whilst there is no simple causal link, the presence of HIV creates a biological environment that may increase vulnerability to erectile dysfunction through multiple interconnected pathways. Modern antiretroviral therapy has transformed HIV into a manageable chronic condition, and many men with well-controlled HIV maintain normal sexual function. However, sexual health concerns, including ED, remain an important aspect of comprehensive HIV care.

Other Factors Contributing to Erectile Dysfunction in HIV

Beyond the direct effects of HIV, numerous additional factors contribute to erectile dysfunction in this population. Understanding these multifactorial influences is essential for effective management.

Antiretroviral medications, whilst life-saving and essential for viral suppression, may contribute to ED through various mechanisms. Some older protease inhibitors have been associated with metabolic complications including dyslipidaemia (abnormal cholesterol levels) and insulin resistance, both of which can impair vascular function. Certain ART regimens may also affect testosterone levels or contribute to body composition changes that impact self-image and sexual confidence. However, it is crucial to note that the benefits of ART far outweigh these potential side effects, and never stopping or modifying treatment without medical supervision is paramount.

Other medications commonly prescribed to people with HIV may contribute to ED, including certain antidepressants (SSRIs, SNRIs), antipsychotics, opioid painkillers, and some treatments for high blood pressure (particularly thiazide diuretics, beta-blockers and alpha-blockers).

Psychological factors play a substantial role in erectile dysfunction among men living with HIV. The diagnosis itself can trigger anxiety, depression, and concerns about transmission to partners, all of which significantly impact sexual function. Studies indicate that depression affects 20-30% of people living with HIV, considerably higher than the general population. Performance anxiety, reduced self-esteem, and relationship difficulties further compound these challenges.

Cardiovascular risk factors are more prevalent in people living with HIV, partly due to chronic inflammation and partly due to metabolic effects of some medications. Conditions such as hypertension, diabetes, and atherosclerosis—all recognised causes of ED in the general population—occur at higher rates and often at younger ages in HIV-positive individuals.

Lifestyle factors including smoking, excessive alcohol consumption, and recreational drug use are more common in some HIV-affected populations and independently contribute to erectile dysfunction. It is particularly important to note that 'poppers' (amyl nitrite) should never be used with ED medications due to potentially dangerous interactions. Additionally, co-infections such as hepatitis C and the presence of other chronic conditions can further complicate the clinical picture. A holistic assessment considering all these factors is essential for understanding and addressing ED in men living with HIV.

Treatment Options for Erectile Dysfunction with HIV

Effective treatments for erectile dysfunction are available for men living with HIV, and management should follow a comprehensive, individualised approach. The first step involves addressing any modifiable contributing factors and optimising overall health.

Phosphodiesterase type 5 (PDE5) inhibitors—including sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Spedra)—represent the first-line pharmacological treatment for ED, as recommended by NICE Clinical Knowledge Summaries. These medications work by enhancing the natural erectile response to sexual stimulation by increasing blood flow to the penis. They are generally effective in men with HIV, with success rates similar to the general population. However, important safety considerations must be addressed:

• Absolute contraindications: PDE5 inhibitors must never be used with nitrate medications (including prescribed nitrates for angina and recreational 'poppers') due to the risk of potentially fatal blood pressure drops. They are also contraindicated with the pulmonary hypertension medication riociguat.

• HIV medication interactions: Some antiretroviral medications, particularly protease inhibitors and cobicistat-containing regimens, can significantly increase PDE5 inhibitor levels in the blood, requiring dose adjustments. Avanafil is contraindicated with strong CYP3A4 inhibitors (including ritonavir and cobicistat), and vardenafil is contraindicated with some protease inhibitors. Your HIV specialist or GP should check for interactions using resources such as the Liverpool HIV Drug Interactions website, and advise on appropriate dosing based on your specific ART regimen.

• Alpha-blocker caution: If you take alpha-blockers for prostate problems or high blood pressure, start with the lowest PDE5 inhibitor dose to minimise the risk of blood pressure drops.

Sildenafil 50mg is available without prescription from UK pharmacies as Viagra Connect, but men taking HIV medications should consult their doctor or pharmacist before purchasing due to potential interactions.

Testosterone replacement therapy may be appropriate for men with confirmed hypogonadism (low testosterone levels documented through at least two morning blood tests). This can improve libido, energy levels, and erectile function. Testosterone is available as gels, injections, or patches, and treatment requires ongoing monitoring of testosterone levels, prostate health (PSA), and blood counts (particularly haematocrit). It may affect fertility and is contraindicated in men with prostate cancer.

Psychological interventions including cognitive behavioural therapy (CBT), psychosexual counselling, or couples therapy can be highly effective, particularly when psychological factors contribute significantly to ED. The NHS provides access to psychological therapies through NHS Talking Therapies for anxiety and depression services.

Lifestyle modifications form an essential component of ED management. These include:

• Smoking cessation

• Reducing alcohol intake

• Regular physical exercise (at least 150 minutes of moderate activity weekly)

• Maintaining a healthy weight

• Managing stress through relaxation techniques or mindfulness

Alternative treatments such as vacuum erection devices, intracavernosal injections (alprostadil injected directly into the penis), or intraurethral suppositories may be considered if oral medications are ineffective or contraindicated. In rare cases where other treatments fail, surgical options including penile prosthesis implantation may be discussed. Optimising HIV treatment itself—ensuring viral suppression and addressing any ART-related side effects—is fundamental to improving overall health and sexual function.

If you experience side effects from any ED treatment, report them through the MHRA Yellow Card scheme.

When to Seek Medical Advice

Erectile dysfunction is a common and treatable condition, and men living with HIV should feel empowered to discuss sexual health concerns with their healthcare providers. Unfortunately, many men delay seeking help due to embarrassment, but addressing ED early can improve both quality of life and overall health outcomes.

You should contact your GP or HIV specialist if:

• You experience persistent or recurrent difficulty achieving or maintaining erections sufficient for satisfactory sexual activity

• Erectile problems are causing distress, anxiety, or relationship difficulties

• You notice a sudden change in erectile function, which may indicate an underlying health issue

• You experience ED alongside other symptoms such as reduced libido, fatigue, mood changes, or loss of morning erections

• You have concerns about how your HIV medications might be affecting your sexual function

Seek urgent medical attention if:

• You develop a painful erection lasting 4 hours or more (priapism)—this is a medical emergency requiring immediate treatment to prevent permanent damage. Call 999 or go to A&E.

• You experience chest pain during sexual activity

• You notice sudden vision or hearing changes after taking ED medication

For urgent but non-emergency concerns, you can contact NHS 111 for advice.

Preparing for your appointment can help ensure a productive consultation. Consider:

• Documenting when ED symptoms began and how often they occur

• Listing all medications you take, including recreational substances

• Noting any other symptoms or health changes

• Preparing questions about treatment options and their compatibility with your ART regimen

Your healthcare provider will typically conduct a thorough assessment including medical history, physical examination, and blood tests. These may include morning testosterone levels (taken between 8-11am and repeated if low), glucose or HbA1c, cholesterol, liver and kidney function tests, and sometimes thyroid function or prolactin levels. They will also check your blood pressure, BMI, and examine for any physical abnormalities such as Peyronie's disease (penile curvature).

You may be referred to a specialist if:

• First-line treatments are unsuccessful

• You have persistent low testosterone levels requiring endocrine assessment

• You have significant penile deformity or physical abnormalities

• You have complex cardiovascular risk factors requiring specialist input

• You would benefit from specialised psychosexual therapy

Remember that discussing sexual health is a routine part of comprehensive HIV care, and healthcare professionals are experienced in addressing these concerns sensitively and confidentially. Many HIV clinics now incorporate sexual health assessments into regular reviews, recognising that sexual wellbeing is an integral component of overall health and quality of life for people living with HIV. Effective treatments are available, and seeking help is an important step towards maintaining both physical health and emotional wellbeing.

Frequently Asked Questions