Frequency and Factors Associated with Erectile Dysfunction in People Living with HIV Managed in the Department of Internal Medicine at the Departmental Hospital University of Borgou (DHU-B) in 2017 ()
1. Introduction
Antiretrovirals have dramatically reduced mortality and morbidity, extended the duration and improved the quality of life for many people living with HIV (PLHIV). PLHIV are nevertheless faced with many chronic conditions such as high blood pressure, diabetes, and metabolic disorders but also sexual disorders such as erectile dysfunction (ED) in men. The prevalence of ED is higher in patients living with HIV than in the general population and can reach 50% [1] [2]. The pathogenesis of ED in these subjects is still not well defined and is multifactorial [3] [4]. Apart from the traditional factors associated with ED, HIV infection itself and its treatment contribute to it [5]. The impact of ED could be devastating because sexual function is an important index of quality of life [6] [7] and has a negative emotional, social, sexual and intellectual impact. ED is also increasingly recognized as a cardiovascular risk factor [8] [9]. It is therefore important to take an interest in this taboo health problem that is ED. In Benin, studies on ED in the general population and particularly in diabetics and hemodialysis patients exist. But no study has been done in the ED in PLHIV. The present study was therefore initiated to fill the gap. The results of this study will allow to assessing its extent and the associated factors with the aim of effective and comprehensive management of HIV-positive patients.
2. Study Framework and Methods
Study setting: the study took place in the Internal Medicine Service of the Departmental Hospital University of Borgou (DHU-B).
Type and period of study: this was a cross-sectional, descriptive and analytical study covering the period from March 1, 2017 to June 31, 2017.
Study population: this consists of all people living with HIV followed in the Internal Medicine department of DUH-B in 2017. All male patients, 18 years old and above, on antiretrovirals and who gave their consent were included in the study. Patients with trauma or pathology of the pelvis or spine and unable to answer the questions were not included in the study.
Sampling: an exhaustive census of people living with HIV positive patient on antiretrovirals was received for consultation in the Internal Medicine Department of DUH-B during the data collection period.
Variables: the dependent variable studied was ED. It had been evaluated on the basis of the IIEF5 score (International Index of Erectile Function) composed of 5 questions which evaluate erectile function. ED is defined according to the score below 21. ED is severe if the score is between 5 and 10 inclusive, moderate between 11 and 15 inclusive and mild if between 16 and 20 inclusive [10]. The independent variables concerned sociodemographic data, psychological status, lifestyle, clinic, biology, treatment and evolution. BECK’s questionnaire enabled the diagnosis of depression to be made. The Hamilton Anxiety Rating Scale was used.
Technique and data collection tool: data collection was done by counting the consultation register, face-to-face interview, clinical and anthropometric examination. A data collection sheet and other appropriate tools were used.
Data processing and analysis: The data collected had been recorded and processed with the EPI INFO software (Version 7.2). Microsoft Word 2010 software was used for entering the data and Excel 2010 for organizing the data in the form of tables and graphs. Quantitative variables were expressed as a mean plus or minus standard deviation and qualitative variables were expressed as a simple count and as a percentage. The means were compared with the Student test. The comparison of percentages and proportions was carried out with the Chi 2 test (or Fisher’s exact test as the case may be). For these comparisons, a probability p < 0.05 was considered statistically significant. The analysis was bivariate then multivariate.
Ethical aspects: Data confidentiality was respected during the survey. After explaining to the patients the purpose of the study and their contribution, they were free to participate or not to participate in the survey and that once accepted, they were enrolled. The anonymity and privacy of the patients had been respected because the survey sheets were not nominal. Before carrying out our study, the common agreement of the administrative authorities and the head of the Internal Medicine department of DUH-B was obtained.
3. Results
A total of 280 patients were included in the study. The average age of patients was 42 ± 10.04 years with extremes of 23 and 67 years. The most represented age group was that of 40 - 49 years (37.14%). Diabetes was present in 32 (11.43%) patients; 56 (20%) patients had arterial hypertension; 58 (20.71%) presented lipodystrophy with respectively 56 (18.57%) presenting lipoatrophy and 6 (2.14%) lipohypertrophy. Peripheral neuropathies were present in 104 (40.71%) patients and 38 (13.57%) were malnourished. As for the way of life, the consumption of tobacco, alcohol and drugs were found respectively in 64 (22.86%), 104 (37.14%) and 4 (1.43%) patients; multiple sexual partners were found in 26.43% of patients and 56.43% were sedentary. The lipid profile was characterized by 10.71% of PLHIV having HDL hypocholesterolemia, 17.14% hypertriglyceridemia, 38.57% LDL hypercholesterolemia and 23.57% total hypercholesterolemia. Dyslipidemia was found in more than half of the patients (52.86%). Regarding ARV treatment, 17.14% of patients had a protease inhibitor in their treatment and 23.37% were non-compliant with ARVs. The average duration of ARV treatment was 4.26 ± 1.47 years. On the psychoaffective level, 23.57% had anxiety and 47.86% depression. ED was found in 146, a frequency of 52.14%. Of the 146 patients with erectile dysfunction, 41% had severe ED. ED appeared suddenly in 28% of patients; 46.67% of patients reported that ED had occurred before testing for HIV infection and 52.05% of patients reported having nocturnal erections (Table 1).
Factors associated with ED in people living with HIV in bivariate analysis were older, low CD4 count, long duration of antiretroviral treatment, high Hamilton scale and low Beck score for quantitative variables (Table 2) and arterial
![]()
Table 1. General characteristics of PLHIV followed in the internal medicine department of DUH-B in 2017 (n = 280).
![]()
Table 2. Bivariate analysis of factors associated with erectile dysfunction in people living with HIV followed in the internal medicine department, DUH-B in 2017 (quantitative variables).
A: Average SD: Standard Deviation.
hypertension, lipodystrophy, multiple sexual partners and the use of protease inhibitors for the qualitative variables (Table 3). In multivariate analysis, age over 40, anxiety, depression, hypertension, lipodystrophy, multiple sexual partners and use of protease inhibitors are associated with erectile dysfunction (Table 4).
![]()
Table 3. Bivariate analysis of factors associated with erectile dysfunction in people living with HIV followed in the internal medicine department, DUH-B in 2017 (qualitative variables).
![]()
Table 4. Multivariate analysis of factors associated with erectile dysfunction in people living with HIV followed in the internal medicine department, DUH-B in 2017.
4. Discussion
This study focused on a taboo subject often hidden by patients. The diagnosis of ED was made by a method respecting international recommendations. At the end of this study, the following results were obtained. The prevalence of ED was 52.14%. Ouédraogo et al. [11] in Burkina Faso in 2015 reported a similar prevalence (55.8%). In the study by Bernal et al. [9] in Spain, 61.2% of HIV-infected subjects in their cohort had erectile dysfunction.
The study found that PLHIV over the age of 40 were at greater risk of having ED. Fumaz et al. [12] in Spain in 2016 found the same association. In Camara’s study [3] in Guinea on sexual disorders in PLHIV, age over 35 was associated with ED. Age was known to be the main risk factor for ED. This association is thought to be due to the improved life expectancy of people living with HIV linked to antiretrovirals, which exposes them to age-related diseases such as cardiovascular disease and ED. It should also be noted that the decline in testosterone with age explains ED in the elderly.
Multiple sexual partnerships were associated with ED. Dong et al. in China had reported the same association [13]. Multiple sexual partnerships could be considered as a means of satisfying sexual desire despite conflicts with spouses.
Lipodystrophy was associated with ED as reported by De Vincentis et al. [14]. Indeed, lipodystrophy promotes the elevation of fibroblasts and macrophages with the consequence of a conversion of testosterone into estrogen. This phenomenon would be favored by the high level of interleukin 6 and hydroxycorticosteroids related to lipodystrophy [15] [16].
Psychological disorders such as anxiety and depression were respectively observed in 23.57% and 47.86% of the subjects surveyed. These proportions were similar to those reported by Shumye et al. [17] with respectively a prevalence of 29% for anxiety and 43% for depression. Anxiety was significantly associated with ED. Fumaz et al. [12] and Schönesson et al. [6] in their respective works had found similar results. In the same order, depression was associated with ED. Similar results were reported by Ouedraogo et al. [11]. Moshfeghy [7] reported that the predictive factors of erectile dysfunction in PLHIV were stress, depression and anxiety. This could be explained by the fact that HIV infection, in addition to its physical effects, constitutes a heavy psychological burden for patients. In addition to feeling different from others, some infected people avoid blending in with the crowd for fear that their disease will be discovered with the risk of being stigmatized. Marital conflicts, professional difficulties, can be the cause of emotional instability. Erection being a psychoneurochemical phenomenon, psychic disorders thus prevent infected people from having an erection sufficient for a fulfilling sex life. Also in our study, more than half of our patients said that erectile disorders were sudden onset but also had nocturnal erections. From these different results, it appears that ED also has a significant psychogenic component in people living with HIV. It is therefore important to promote psychological care in order to improve the quality of life of people infected with HIV. Among the factors favoring depression are poverty and unemployment [4] frequently found among PLHIV.
Protease inhibitor use was associated with ED. Dijkstra et al. [18] and Jansen et al. [19] found similar results. This could be explained by the fact that protease inhibitors cause peripheral neuropathies but also a metabolic syndrome that could lead to ED. The role of protease inhibitors in the occurrence of ED continues to be controversial. It is therefore essential to carry out in-depth prospective studies in order to refine the link between protease inhibitors and ED, but also to inventory possible ARV drugs, in particular protease inhibitors which could be origin of an ED.
This study has limits to the extent that it has been limited to the study of erectile function. It is necessary to assess sexual function in general to better understand the question. Also, testosterone is not measured in these patients in order to assess cases of hypogonadism known to be an important risk factor for ED.
5. Conclusion
The present study had made it possible to lift the taboo in order to know the extent of ED in people living with HIV. It shows that more than half of the people living with HIV followed in the Internal Medicine department of DUH-B suffered from ED. The risk factors for ED in these patients were both organic and psychogenic. The sexual health of people infected with HIV should be considered a public health issue. It is therefore essential to take care of them globally, both clinically and psychologically, in order to improve the quality of life of people living with HIV.
Appendix: Questionnaire
1) Age (years)
2) Comorbidities
Hypertension: Yes No
Diabetics Yes No
Lipodystrophy Yes No
Peripheral neuropathy Yes No
3) Nutritional status
Weight (kgs)
Size (m)
Mass index (kg/m2)
4) Way of life
Alcohol consumption Yes No
Tobacco consumption Yes No
Use of other drugs Yes No
Multiple sexual partners Yes No
Physical activity Active Inactive
5) Antiretroviral therapy
Use of protease inhibitor Yes No
Adherence to antiretrovirals Yes No
Current CD4 count
Duration of ARV treatment
6) Psychological status
Anxiety Yes No
Depression Yes No
7) Erectile dysfunction Yes No
8) Lipid profile
Total cholesterol level Low Normal High
HDL cholesterol level Low Normal
LDL cholesterol level Normal High
Triglyceride level Low Normal High