Determinants of sexual function in men living with HIV younger than 50 years old: Focus on organic, relational, and psychological issues

Sexual function and dysfunction in the LGBTQIA+ community-including before and after gender-affirming surgery: recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024)

INTRODUCTION

Evidence-based clinical practice guidelines focused on sexual (dys)function for the LGBTQIA+ (ie, lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual) community, including before and after gender-affirming surgery, are still scarce.

OBJECTIVES

To provide an overview and recommendations for sexual (dys)function among individuals with diverse sexual orientations, transgender and gender-diverse individuals, and intersex individuals/individuals with differences of sexual development (DSD).

METHODS

A committee of experts conducted a comprehensive review of the literature, focusing on scientific publications since the last consultation, for the fifth International Consultation on Sexual Medicine.

RESULTS

Researches that considered populations with diverse sexual orientations were reviewed and largely focused on sexual satisfaction/pleasure, sexual functioning, and sexual difficulties. Additional topics included relationship and psychological dimensions, sexual functioning during receptive anal sex, chemsex, minority stress, asexuality, and sexuality in older adulthood. The main challenges are related to small sample sizes and mostly cross-sectional study designs that limit the generalization of findings. Research focused on sexual (dys)function among transgender and gender-diverse individuals tends to focus on a medical perspective of sexual function and is often based on cisgender models or methodology. Research has also focused attention on the relationship between medical interventions for gender-affirming care (eg, hormone therapy, surgery) and has often included cross-sectional designs or short-term follow-up. Current research also highlights the unique facets of sexual (dys)function that appear important to gender-diverse individuals, such as relational and body image factors. Fewer articles focused on individuals with intersex traits/DSD, and these included a diverse approach to the samples studied and methodology used. Much of this research focused on the impact of medical interventions (eg, hormone therapy, surgery) on sexual satisfaction and function. Across populations, there were limited validated measures of sexual (dys)function.

CONCLUSION

Overall, the main challenges in the field are related to methodological gaps, as acknowledged in this review, and a summary of the literature is provided. Diversity, equity, and inclusion, as well as ethical considerations, are addressed, and clinical recommendations for supporting the sexual well-being of individuals with diverse sexual orientations, transgender and gender-diverse individuals, and intersex individuals/individuals with DSD are presented.

Penile vascular status in young men living with HIV experiencing erectile dysfunction: A comparative cross-sectional pilot study

BACKGROUND

Erectile dysfunction in people living with HIV is a multifactorial disease, but the role of penile vascular status assessed by dynamic penile color Doppler echography is underexplored.

OBJECTIVES

This study assessed penile vascular status in young males living with HIV experiencing erectile dysfunction, comparing them to HIV-negative controls stratified into young (<50 years) and middle-aged (51-60 years).

MATERIALS AND METHODS

This monocentric, comparative cross-sectional study included young males living with HIV (18-50 years) on antiretroviral therapy for >12 months and HIV-negative individuals presenting with erectile dysfunction. We used dynamic penile color Doppler echography to evaluate penile vascular parameters such as peak systolic velocity, intima-media thickness, and end-diastolic velocity. Statistical analyses, including k-means clustering and stepwise multivariate logistic regression, assessed associations between clinical variables and vascular parameters.

RESULTS

Of 310 young males living with HIV screened, 50 (16.1%) reported erectile dysfunction and were enrolled, with 97 HIV-negative individuals included as controls. Pathological intima-media thickness was significantly higher (p = 0.004) in young males living with HIV (76%) than in young controls (49%) but comparable to middle-aged controls (76.1%). Stepwise multivariate logistic regression identified belonging to the young control group, compared to young males living with HIV, as a protective factor against pathological intima-media thickness (OR 0.353, 95% CI 0.138-0.902, p = 0.0295), while increasing age was a significant risk factor (OR 1.09, 95% CI 1.01-1.18, p = 0.0247). Relative inhomogeneity of clusters was tested demonstrating that membership in either the people living with HIV or HIV-negative group was a significant predictor of cluster assignment based on dynamic penile color Doppler echography parameters, independent of age (p = 0.0025).

DISCUSSION AND CONCLUSIONS

This study is the first to utilize dynamic penile color Doppler echography to evaluate erectile dysfunction in young males living with HIV, highlighting the association between HIV and early vascular alterations. Clinicians should incorporate routine sexual health evaluations into routinary out-patients visits, using erectile dysfunction as a potential indicator for further vascular screening and early intervention.

Sexual difficulties in men who have sex with men living with HIV: their mental health and health-related quality of life

Background

Health-related quality of life (HRQoL) is gaining significance for people living with human immunodeficiency virus (HIV), with sexual difficulties being a crucial yet frequently neglected component of HRQoL, especially in HIV-positive men who have sex with men (MSM).

Aim

The study sought to assess the levels of sexual difficulties and explore the associations between sexual difficulties, mental health, and HRQoL in HIV-positive MSM.

Methods

A cohort of 475 HIV-positive MSM was studied from January 2017 to December 2021. Sociodemographic, clinical, and lifestyle data were collected. Participants were divided based on Arizona Sexual Experience Scale (ASEX) scores into 2 groups: those with sexual difficulties and a control group without difficulties.

Outcomes

Psychological symptoms were evaluated by the Symptom Checklist-90 (SCL-90), HRQoL was accessed via 36-item Short Form Health Survey, and sexual function was assessed using the ASEX. We also employed path analysis to unveil latent mechanisms, alongside multivariate analysis to identify independent factors, and aimed to elucidate the interplay among sexual function, HRQoL, and mental health in HIV-positive MSM.

Results

A total of 391 HIV-positive MSM were enrolled in the control group and 84 in the sexual difficulties group. The control group had significantly higher physical HRQoL (P = .004) and mental HRQoL (P = .045). In addition, SCL-90 scores were higher in the sexual difficulties group (P = .001). Multivariate analyses that indicated regular exercise (odds ratio, 0.553; P = .024) and alcohol consumption (odds ratio, 1.780; P = .033) were independent factors associated with sexual difficulties. The proportion of alcohol consumption in the sexual difficulties group was significantly higher (P = .003). ASEX scores increased gradually with increasing frequency of alcohol consumption (P = .031). Results from structural equation model showed a negative association between HRQoL and ASEX scores (β = -0.13, P < .001) and SCL-90 scores (β = -0.40, P < .001).

Clinical Implications

HIV-positive MSM experiencing sexual difficulties exhibited lower HRQoL and worse mental health, with independent associations identified for regular exercise and alcohol consumption in relation to sexual difficulties.

Strengths and Limitations

Our research has pioneered in demonstrating that HRQoL mediates the relationship between sexual difficulties and psychological symptoms among HIV-positive MSM undergoing highly active antiretroviral therapy. We found the protective factor associated with sexual difficulties was regular exercise while the risk factor was alcohol consumption. However, the data were collected only from China, and it is still unclear how HRQoL changes after intervention.

Conclusion

Routine follow-up for people living with HIV should encompass an investigation into sexual function, emphasizing the need for timely assessment and intervention, particularly in HIV-positive MSM with identified risk factors.

The chronic alcohol consumption influences the gonadal axis in men: Results from a meta-analysis

BACKGROUND

Low testosterone concentrations affect 2-13% of adult males, with a direct association between reduction in testosterone (T) concentrations and cardiovascular events. Lifestyle habits have been linked to visceral fat accumulation and endocrine disorders like secondary hypogonadism. Alcohol intake has also been a topic of debate, with studies showing a detrimental effect on sperm production and underlying mechanisms. This meta-analysis aims to comprehensively evaluate the effect of alcohol consumption on T serum concentrations in adult men.

METHODS

The literature search included only controlled clinical trials comparing men who drink alcohol to men who do not, or who assumed placebo or nonalcoholic beverages. The primary outcome was the comparison of total testosterone serum concentrations between the study and control groups. The publications were examined for publication bias using Egger's test.

RESULTS

Twenty-one studies were included in the analysis for a total of 30 trials that examined the effects of alcohol consumption on testosterone level in 10,199 subjects. The meta-analysis showed that alcohol consumption overall is related to significant reduction in circulating concentrations of total testosterone (mean difference [MD] = -4.02; 95% CI -6.30, -1.73), free T (MD = -0.17; 95% CI -0.23, -0.12), sex hormone binding globulin (SHBG) (MD = -1.94; 95% CI -3.37, -0.48), an increase in estradiol (E2) (MD = 7.65; 95% CI 1.06, 14.23) and neutral effect on luteinizing hormone (LH) (MD = -0.15; 95% CI -0.36, 0.06), independently by age, body mass index (BMI), E2, and LH serum concentrations and alcohol intake. However, these results are evident only in healthy men exposed to chronic alcohol consumption and not in those with a recognized diagnosis of alcohol use disorder or after acute alcohol intake.

CONCLUSION

This study suggests how chronic alcohol consumption may inhibit the gonadal axis in healthy men, although the exact pathophysiological mechanisms connecting alcohol exposure and steroidogenesis are still not completely clarified.

Update on acquired hypogonadism in men living with HIV: pathogenesis, clinic, and treatment

Hypogonadism is a frequent finding among men living with HIV (MLWH) and it seems to occur earlier in comparison with the general male population. Although the prevalence of hypogonadism in MLWH has significantly lowered thanks to advancements in medical management, it remains high if compared with age-matched HIV-uninfected men, ranging from 13% to 40% in the age group of 20-60 years. Signs and symptoms of low serum testosterone (T) in MLWH are cause of concern since they are non-specific, of mild-to-moderate degree, and often overlapping with those of infection per se. For these reasons, hypogonadism can be underestimated in the absence of targeted laboratory blood examinations. With regard to the etiological factors involved in the T decrease, emerging evidence has suggested the functional nature of hypogonadism in MLWH, pointing out the mutual relationship between sex steroids, health status, comorbidities, and HIV-related factors. In agreement with this hypothesis, a therapeutic approach aiming at improving or reversing concomitant diseases through lifestyle changes (e.g. physical activity) rather than pharmacological T treatment should be theoretically considered. However, considering both patient's barriers to lifestyle changes to be maintained overtime and the lack of evidence-based data on the efficacy of lifestyle changes in normalizing serum T in MLWH, T therapy remains an option when other non-pharmacological interventions are ineffective as well as for all other functional forms of hypogonadism. From this perspective, the traditional therapeutic management of male hypogonadism in MLWH, especially the role of T supplementation, should be revised in the light of the probable functional nature of hypogonadism by considering a good balance between benefits and harmful. This narrative review presents an overview of current knowledge on hypogonadism in MLWH, deepening the factors driving and taking part in T decrease, providing advice for the clinical approach, and underlining the importance of individualized treatment aiming at optimizing non-gonadal comorbidities and thus avoiding over-, or even unnecessary, treatment with T.