Content written by Hossein Sadeghi-Nejad

It is estimated that up to 17 million women over the age of 15 are infected with HIV worldwide. Globally this represents 50% of people with HIV. However in sub-Saharan Africa young women may be three times more likely to be infected than young men. There are up to a million people in the USA currently who have immigrated into the USA from sub Saharan African countries.

Women in high income countries seem to find it particularly difficult to come forward in general to discuss their sexual problems, so that as few as 3% of women with sexual dysfunction have discussed these issues with a health care professional. Reasons given by women for non consultation include a “perceived lack of perception or lack of bothersomeness of their problem”, not perceiving it as medical problem and embarrassment. It may be surprising that as few as 4% of HIV health carers in the UK ever ask their HIV positive female patients about sexual functioning. This neglect of clinical care is likely underpinned by physician and nurse ignorance, lack of time and embarrassment.

Sexual functioning issues in women with HIV in developing countries worldwide are more likely to be associated with male coercive sex and domestic violence. Gender power differentials and poverty can force women to engage in unsafe forced sex in order to secure food and economic security for themselves and their children.

The best predictor of female sexual dysfunction (FSD) in general is lack of general emotional well. This is often found in women with depression, anxiety and relationship difficulties. The evidence to date suggests this generalisation also holds for women with HIV. Studies in women with HIV in the USA and UK suggest that fear of HIV disclosure, fear of rejection and decreased self esteem can impact on the emotional well being of women with HIV.

In general the new highly active antiretroviral therapy (HAART) combination drug treatments for HIV have prolonged the length and increased the quality of life of women with HIV. Therefore on the whole HAART does not seem to cause sexual problems. However, some studies show that non adherence to HAART is associated with FSD. This might be because of medication side effects (particularly the protease inhibitors) or because of advancing severity of HIV. There are suggestions but no proof that loss of sensation and other problems with nerves going to the genital area (usually with the older HAART medications), as well as narrowing of blood vessels in the genital area are associated with some HAART medications. This may result in lack of genital swelling and lubrication at sex

HIV related lipodystrophy, results in severe fat loss and/or accumulation in women. Lipodystrophy problems are putting on excess weight in the abdomen and breasts and loss of fat in the buttocks, face and legs. Lipodystrophy is not common nowadays in the USA. It appears to be caused by a combination of HAART and HIV itself . The protease inhibitors have been incriminated in fat accumulation and the nucleoside analogue reverse transcriptase inhibitors with fat loss . Women with these problems may be easily labelled as having HIV in some communities and have self image and psychosocial problems that disrupt sex or prevent them making new relationships. Exercise training and safe injection of facial fillers can result in a marked improvement in self image and self esteem

Advanced HIV disease can lower testosterone levels and contribute to fatigue and low mood. Where necessary this hormone can be safely replaced. Estrogen containing contraceptives may interact with some HAART medications. Barrier contraception is vital where a partner does not have HIV. If condoms do break post exposure prophylaxis for HIV (PEP) may be safely and effectively given up to 72 hours after the event.

As there are now more than 25 HAART medications it is now usually possible to find a combination with minimal side effects.

Treatments for FSD associated with sexual dysfunction therefore use a combination of medication therapy and sex therapy.