Evidence lacking for Viagra-HIV link
November 30, 2006
San Francisco’s STD chief Dr. Jeffrey Klausner caused a heated debate last year when he sounded alarm bells over gay men’s use of Viagra, arguing that illegal use of the erectile dysfunction drug was leading to HIV infections. He went so far as to petition the Food and Drug Administration to classify erectile dysfunction drugs as controlled substances based on studies that linked the use of such drugs to an increase in sexual partners, STDs, and HIV among gay men.
The move caused a public squabble between Klausner and Mayor Gavin Newsom’s HIV policy adviser at the time, Jeff Sheehy, who labeled Klausner’s petition drive “homophobic” and charged that the STD chief wanted “the dicks of people with HIV in his back pocket and he wants us to ask him permission to use it.”
Now, however, a review of published studies has shown no convincing evidence to support Klausner’s claims. A multi-disciplinary panel of researchers and scientists, known as the Bolger conference, found no “convincing evidence � to support the conclusion that PDE-5 inhibitor use is a risk factor for HIV infection,” a summary of the conference stated. Erectile dysfunction medications are known as Phosphodiesterase type 5 inhibitors.
The conference took place September 27-28 at the Bolger Center in Potomac, Maryland and was supported by the National Institutes of Health. The panel published its findings in the November Journal of Sexual Medicine.
“Health care providers should be reminded that individuals infected with HIV frequently have erectile dysfunction from their disease or from pharmacologic agents commonly used in its treatment,” said Journal editor Irwin Goldstein.
For a large majority of men, PDE-5 inhibitor use is conducted in a stable, committed partner relationship, the summary stated. “Under such circumstances, the risk of HIV infection is relatively small. Clinicians and educators did emphasize, however, the importance of safe sex practices for those engaging in risky sexual relations.”
For Sheehy, the news was vindication. It was Sheehy who last year went to the Human Rights Commission after Klausner filed a citizen petition with the FDA.
“Once again, sound science wins out,” Sheehy said Monday, November 27. “It’s speed – crystal meth – that’s the problem.”
Sheehy last year accused Klausner of demonizing HIV-positive gay men. He reiterated that sentiment this week and said the recent Bolger conference findings confirm his own anecdotal suspicions that most gay HIV-positive men using Viagra are using the medication appropriately.
“I think it was much ado about nothing,” Sheehy said of Klausner’s move last year.
For his part, Klausner seemed not to back off his stance.
“Viagra and other drugs for erectile dysfunction in combination with methamphetamines certainly increase the risk for new STDs and HIV infection,” Klausner told the B.A.R. in an e-mail. “When used alone, Viagra and other ED drugs do also increase that risk but it is not as great.”
Klausner said that the Bolger conference “reviewed some, but certainly not all, of the available data at the time, and based on the limited select evidence, the participants concluded that while the use of Viagra and other drugs for ED was concerning for increased risk of STDs and HIV, the data was inconclusive.”
Klausner said he thinks more studies are necessary.
“At this time it is wise for men who use Viagra or other ED drugs to be cautious, get regular and routine STD and HIV screening, and reduce one’s risk of getting infected,” he wrote.
Raymond C. Rosen, Ph.D., lead author of the report, stated, “It’s impressive how responsible most men are who use ED drugs, and the benefits they and their partners achieve with them. I would not like to see Viagra, Cialis, or Levitra being used as performance enhancement drugs – that’s not why these drugs were approved or why physicians approve them.”
Rosen declined to answer additional questions via e-mail.
Goldstein noted that this paper is especially important to the field. “Health care providers should be reminded that individuals infected with HIV frequently have ED from their disease or from pharmacologic agents commonly used in its treatment. Positive clinical benefits have been reported in the HIV population when using PDE-5 inhibitor drugs as indicated.”
One concern men using Viagra should be aware of is a recent finding in an unrelated study that sildenafil, the active ingredient in Viagra, can worsen obstructive sleep apnea. That condition is the temporary blockage of breathing while sleeping. While it is only rarely fatal, it deprives one of a good night’s sleep and contributes to a general sense of malaise and lack of focus during waking hours.
JAMA addresses gay issues
In other health news, the Journal of the American Medical Association included a commentary that specifically discusses gay men. The piece, entitled “Optimizing primary care for men who have sex with men” is in the November 15 issue of JAMA . The focus of that edition is men’s health.
“Primary care for gay men has all too often focused on HIV and sexually transmitted diseases,” but there is also the larger context of delivering health care to gay men, said Ken Mayer in an exclusive interview. He is one of the three co-authors of the commentary and a physician at Fenway Community Health in Boston, which primarily serves the LGBT community.
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Mayer said it is important that one’s health care provider “be sensitive and open to your concerns as a gay man or a man who has sex with men.” The patient needs to be “empowered to interview their doctor” and pick up on signs in the waiting room and in the way the doctor asks questions as to whether or not they are inclusive and capable of meeting a patient’s medical needs.
“If a doctor is uncomfortable talking about sex, that may be an issue. You don’t have to have a gay doctor to get good health care; you need somebody who is knowledgeable,” said Mayer.
The Gay and Lesbian Medical Association offers a listing service of medical professionals who are comfortable working with LGBT patients. People can search for a provider by city, state, telephone area code, and medical specialty.
Mayer said that he and others are working on a textbook for the American College of Physicians called the “Fenway Guide to LGBT Health.”
The JAMA article was directed toward physicians and noted that the last U.S. census identified same-sex households in 99 percent of the counties in the country. Some jurisdictions only have a few such households but in urban areas the figure can go as high as 5 percent to 7 percent.
Another study has found that “2.8 percent of men identified themselves as gay, whereas 9.1 percent described having had same-sex sexual behavior, desire, and identity in the course of a lifetime.”
Behavior can be as important as identity and the “coming out” process can occur at any age. It is important that men understand how disease can be spread through sexual activity and how those risks can be reduced.
Another article in JAMA explored how mental health issues differ between men and women. While women are twice as likely to be diagnosed with depression, men are four times as likely to commit suicide.
Societal pressures contribute to the under treatment of depression and other psychological disorders because men are less willing to even acknowledge that they may have such a problem. There is an expectation that men will be stoic and just suck it up.
However, researchers also are discovering that symptoms of depression often differ in men. Rather than feeling blue, they are more likely to feel irritable, stressed, and not sleep well.
While some patients will benefit from medication, oftentimes a finite program of cognitive behavioral therapy – in which patients come to understand how distorted views of themselves contribute to their problems and how to overcome them – can be just as effective as drugs.
A review of recent research has found physical and functional differences in the brains of men and women. That is reflected in the fact that some 14 percent of actively expressed genes appear to be expressed or function at different levels in the two sexes.
That is starting to help explain how men and women process certain information differently; how they experience pain differently; and how they react differently to certain kinds of drugs. It may eventually be correlated with expressions of sexual orientation and identity.
Other findings
Gay and bisexual men may be more prone to compulsive gambling, according to a small study in the November-December issue of Comprehensive Psychiatry. The study involved 105 men who sought treatment for addictive gambling; 15 were gay and seven bisexual, numbers that are several times higher than what one would expect to see in a cross-section of the population.
The researchers, from Yale and the University of Minnesota, readily acknowledged that the size of the study was small and it only included those who sought help, so it might not be representative of the overall population.
And it leaves unanswered the question of whether the gambling compulsion is tied to a portion of the brain associated with greater risk taking, or whether it is a response to the stress of living in a homophobia society
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