The Hard Facts

1. The Hard Facts Erectile Dysfunction & HIV Adrian Betts, Executive Director, ACDR

2. So, we’re gonnatalk about dick…

3. Get to know the one-eyed trouser snake….. What to expect today. • What is Erectile Dysfunction? • What is it not? • Myths. • Causes. • The relationship between ED & HIV • Treatment • Group Discussion

4. Make friends with our tool, knob, John Thomas, man’s best friend….. What else to expect today. • Confidentiality • I statements • Respect for others – no judgements • No cross talk • Right to share and the right to pass • We are the experts in our own lives

5. Cock talk • Erections occur when blood pressure builds up in the two sponge-like tubes (the corpus cavernosum) on either side of the penis. • The process is often initiated as a result of sexual arousal, signals are transmitted from the brain to nerves in the penis. • Erections can also be caused manually.

6. What is Erectile Dysfunction? • Erectile dysfunction, or impotence, is the persistent inability to reach or maintain an erection strong enough to allow for satisfying sexual activity. • The word "impotence" affects us on many levels, implying a loss of power over your body and sexuality, as well as your penis. It's a problem that can badly affect sexuality, making you incapable of pleasuring yourself through masturbation, and incapable of erotic exchanges with a partner.

7. Myths • If you have trouble getting an erection, it’s because you’re not attracted to your partner. • If I have erectile dysfunction, I’ll have to take pills for the rest of my life. • ED is just a normal part of growing older and men just have to learn to live with it. • Erectile dysfunction doesn’t hit younger men. It’s only a problem for older guys. • ED makes me less of a man.

8. Traditional Causes of ED. • Drugs - particularly anti-depressants • Neurogenic disorders • Cavernosaldisorders • Surgery • Aging – ED is four times higher in men in their 60s than in men in their 40s. • Kidney failure • Diseases such as diabetes and multiple sclerosis (MS) as they cause issues with both the blood flow and nervous systems. • Lifestyle: smoking is a key cause of erectile dysfunction because it promotes arterial narrowing • Psychological causes: performance anxiety, stress, mental disorders, depression, psychological problems, negative feelings.

9. ED and HIV • Information pulled from three studies. Spain, Italy & California • Articles from the New England Journal of Medicine & Relay Magazine & CATIE. • 53% of poz men have some form of ED versus 27% of negative men of the same age. • Men with AIDS or a past history of AIDS are at greatest risk of erectile dysfunction. • Men with HIV and AIDS reported higher rates of illicit drug use, depression, and severe lower urinary tract symptoms, compared to HIV-negative men.

10. Potential causes of ED in poz men • Premature aging • Decreased testosterone due to meds • Increased cholesterol due to meds • Increased use of anti-depressants, smoking and alcohol • Decreased absorption of vitamins and nutrients particularly vitamin B,C & E • However, in most cases, erectile dysfunction arises from psychological rather than physical causes.

11. Potential causes of ED in poz men • Anxiety • Infecting your partner • Disclosure/rejection • Criminalization of HIV • Performance anxiety - condom use • Stress • Depression and treatment for depression. • Multiple partners. (men with a steady sexual partner had lower odds of reporting erectile dysfunction). • “Anxiety is anathema to an erection for physiological reasons. Anxiety has an effect on the sympathetic nervous system, causing blood vessels in the periphery, including the penis, to contract in order to better supply the central torso area with blood”. Doctor Walt Odetts Clinical Psychologisy

12. ED and HIV • Erectile dysfunction isn't the only type of sexual problem experienced by people living with HIV. According to an article in the March 2007 issue of the Journal du sida, between 20% and 75% of people living with HIV experience some form of sexual dysfunction, including decreased libido (sex drive) or trouble with erection, ejaculation and orgasm.

13. Treatment options • Exercise • Diet • Quitting smoking • Reduce your alcohol intake • Vitamins & minerals • Changing your drug use patterns - both prescription and recreational.

14. Treatment options • Testosterone injections • One of the most common causes of erectile dysfunction is that penile arteries don't open up enough to allow an adequate supply of blood to flow into these chambers. PDE-5 inhibitors work by opening the penile arteries and increasing blood flow. • Pumps – vacuum pressure • Surgery - Rods

15. A word of caution • Priapism, when the penis doesn't return to its flaccid state after orgasm, occasionally occurs and can be painful. Ice can help, but if the erection persists for longer than a few hours, medical help should be sought. • The side effects associated, albeit rarely, with these PDE-5’s , such as headache, vision changes and heart problems, result from greater opening of arteries in the brain, retina (in the eye) and heart. Your doctor should assess your heart health before prescribing a PDE-5 inhibitor. The combination of these drugs and nitroglycerin (to relieve angina or chest pain) or nitrate inhalants (poppers) is very dangerous. • Mixing Viagra and poppers is extremely dangerous because they both cause a person’s blood pressure to drop. The combination can result in fainting, stroke, heart attack, and/or death.

16. Treatment options • Vitamins and minerals appear to play a role in improving sexual function. • The mineral zinc enhances the synthesis of testosterone for both men and women. However, no more than 50 mg should be taken each day and zinc must be taken on an empty stomach. • Selenium is an antioxidant, and deficiency can lead to erectile dysfunction. • Manganese also contributes to the production of sex hormones, and vitamin B enhances orgasm. • The E vitamins reduce the risk of atheroma, which are abnormal fatty deposits in the arteries. • Vitamin C energizes and promotes hormone production. • Ginseng enhances the different sexual phases and Muirapuama, a plant originating in the Amazon, has vasodilating, anti-stress and aphrodisiac properties.

17. …options We must always remember, as sexual beings we are more than our dicks; we have our whole bodies to play with. Explore and enjoy.

18. So what about you? “My conversations with patients about their sexual relationships are important. HIV plays a significant role in every single intimate relationship where it is present, and its impact on a relationship changes over time. As people sort through their beliefs and assumptions about their sexuality, it’s great to see their eyes light up when a myth is debunked or a solution they come up with is affirmed. Through talking to me or their partners, people do discover ways to make their sexual lives satisfying. PHAs can have great sex. You don’t need to go through your life denying this part of yourself. But it can take a lot of work and it’s important to talk with others — health care professionals, counselors and other PHAs who have been there. Your comfort zone will be different from that of other people, and that’s all right. You need to find the sex life that’s right for you.” Doctor Dale Guenter

19. Thank you.