Our analysis reveals that the burden of sexual problems is significantly higher among women with HIV-infection compared to uninfected women. Subjective reports of sexual problems are common among women in the United States. Data from the 1992 National Health and Social Life Survey, the most recent nationally-representative study on sexuality among younger adults in the United States, suggest that among sexually active women ages 18–59, over 40% report symptoms indicative of sexual problems over a 12-month period 34
. As would be expected from past research on sexual functioning in women, sexual function scores in the WIHS cohort were associated with age, menopause, symptoms of depression, and relationship status. However, the inclusion of these factors did not mitigate the influence of HIV infection on impaired sexual function scores. In addition, HIV did not influence the relationships between these factors and sexual function scores.
Although we confirmed univariate associations between several previously published correlates of sexual function among HIV-infected women, including BMI, therapeutic regimens for mental health, therapeutic regimens for seizures, blood pressure or heart disease, hormone therapy, and diabetes, these relationships were not sustained in multivariate analysis. In addition, although previous research has described the impact of chronic drug and alcohol use on impaired sexual function 35
, we did not find a relationship between sexual problems and alcohol or drug use. We note, however, that our measures of alcohol and other substance use only estimate whether one or more instances of use were reported since the last study visit; these measures do not account for the role of drug and alcohol abuse and dependence on sexual problems nor the role of drug or alcohol use during sexual activity.
In addition, while CD4 cell count was associated with sexual function in this study, we did not replicate previous findings on factors associated with sexual problems in persons with HIV. We did not, for instance, detect statistically significant associations between sexual problems and being on HIV antiretroviral therapy, being on certain classes of antiretroviral therapy (e.g., a PI containing regimen), or HIV antiretroviral therapy adherence. Given that little investigation in this area has been conducted in populations consisting primarily of women, further research is needed to help clarify these inconsistent findings.
The role of sexual function and HIV/STI transmission risk behaviors has not been clearly established in the literature. In this analysis, we found a positive correlation between reporting fewer sexual problems over the past four weeks and reporting one or more episodes of unprotected anal and/or vaginal sex with male sexual partners since the last study visit. We cannot make causal assumptions given the cross-sectional nature of the analysis and the different time parameters for assessment of sexual behavior and sexual function. However, we believe that this finding warrants further examination. For instance, if additional research demonstrates a causal link between increased sexual function and transmission risk behavior, then HIV/STI prevention approaches may need to be incorporated as part of assessment and treatment of sexual problems. On the other hand, this relationship could simply reflect a measurement artifact, whereby those in sexual relationships tend to score higher on the FSFI than those with no sexual relationships. Those who were not in sexual relationships were scored as having no unprotected anal or vaginal sex, which may account for some of this finding.
Our data did not allow us to examine the relationships between FSFI and sexual risk behavior in different types of relationships, although we did report higher function among those living with a sexual partner or married. The greater level of perceived intimacy that may for instance be present in more established (versus casual) relationships may be linked to increased risk for unprotected sex, given that condom use is less frequent in relationships defined as main or primary, versus those defined by participants as being more casual in nature 36
. Although papers describing patterns of partnerships and transmission risk behaviors with HIV concordant and discordant partners in the WIHS have been published previously 37, 38
, the self-report instrument at the time of the FSFI administration did not include measures of condom use or partner serostatus on a partner specific level. Therefore, we were unable to disentangle these relationships.
We include a note of caution in the interpretation and analysis of scales such as the FSFI in the assessment of sexual function among women living with HIV/AIDS. The FSFI is designed to be utilized for both sexually and non-sexually active women. However, many of the items are scored such that those who report no sexual activity, defined as any sexual activity or sexual intercourse in the past 4 weeks, are assigned a numeric value of “zero,” indicating the lowest level of social, psychological and physical dimensions of sexual functioning. Although sexual activity is defined broadly in the inventory to include activities that occur with or without physical contact with a sexual partner (e.g., masturbation, foreplay), we believe that this measure may over-categorize some women as low functioning. For instance, data from the HIV Cost Services Utilization Study (HCSUS) reveal that approximately 50% of HIV-positive respondents reporting no anal, vaginal or oral sex in the prior 6 months said that their abstinence was deliberate 39
. In an analysis of men and women with HIV who were homeless or had unstable housing, nearly 20% reported intentional abstinence in the past 90 days. In this analysis, common reasons cited for abstinence included unavailability of a sex partner and concern about transmitting HIV 40
. Thus, it could be assumed that at least for some respondents, lack of sexual activity may reflect a temporary unavailability of sexual partners at any given time, or may be based on intentional abstinence for both HIV+ women and women who are at risk for infection. It is unknown whether sexual dysfunction may be less pronounced when intended abstinence explains a lack of sexual activity. Our study did not assess whether a lack of sexual behavior reflected a lack of available partners, a decision to abstain from sex, or some other combination of factors. However, this would be important to examine as a component of furthering this area of study.
We believe that our study contributed to the literature on sexual function in HIV by using a commonly used and widely accepted tool for the assessment of self-reported sexual problems, and by comparing women with HIV to a seronegative cohort. However, we noted some differences in the psychometric properties of the scale in this sample as compared to previous reports. For instance, we note that the FSFI factor structure previously reported by Rosen and colleagues 21
was not reproduced within our sample using the same methods of analysis. In addition, the very high internal consistency suggests that there may be some redundancy that could be addressed in future studies with HIV-infected samples. Thus, some refinements of measurement of the construct of sexual function among HIV-positive women may be useful to help further delineate the extent and nature of these issues.
Although we did not have data available on overall subjective assessments of HIV-related quality of life for the study visit in which we administered the FSFI, we did include some markers of overall health in our analysis. For instance, women with HIV who had CD4+ cell counts of less than 200, which is AIDS defining, had significantly lower FSFI scores than did those with higher cell counts. The causal nature of sexual difficulties on quality of life is unclear, given that these variables can plausibly be argued to be bi-directional in influence. However, there appears to be a strong correlation between impaired sexual function and both emotional and physical satisfaction in relationships, as well as with indices of general life satisfaction and happiness 34
There is continued need for additional investigation into the area of sexual function among HIV-positive women. This would include an increased understanding of sexual function measures in the context of infectious diseases such as HIV/AIDS, particularly in regard to the role of intentional abstinence. While definitive conclusion awaits replication of our findings in other cohorts, our study shows a clear link between HIV infection and sexual problems among women. We propose therefore that there is a role for assessment of sexual problems in the overall care of women with HIV infection, particularly those classified as having AIDS. Additional areas of investigation would include methods for accurate and feasibly implemented assessment of sexual problems in the context of HIV care, as well as an examination of intervention approaches that could be effectively and reasonably implemented in this or similar settings.