Background Antiretroviral therapy in HIV positive patients has resulted in improvements in survival, quality of life and fulfilling sexual relationships. Treatment using phosphodiesterase type 5 inhibitors (PDE5i) for ED has simplified management. However nitrates, including “poppers”, and protease inhibitors (PIs) can interact with PDE5i leading to hypotension and high levels of PDE5i. Ethical issues are a consideration as treatments can lead to HIV transmission if safer sex is not practised. We reviewed our HIV positive men with ED and their outcomes after treatment.

Methods 94 HIV positive patients attending our ED clinics from 2006 to 2012 were identified. Data were collected by review of notes and databases. Patients on PIs were started on half of the lowest dose tablet of PDE5i and titrated upwards if no response. Safer sex was advised.

Results Of 94 patients, 58 were Caucasian, 34 black; 58 were men who have sex with men, 35 heterosexual; 65 had a stable partner, 41 (47.8%) had >30 lifetime partners, 25 (26.5%) were >50 years; 36 (38.2%) used recreational drugs. Two were on therapeutic nitrates. Mean CD4 on presentation was 481 (range 35–1558); 60 (63.8%) had an undetectable VL at baseline. 30 (32%) had ED symptoms for >5 years. Risk factors: smokers 35 (37.2%); peripheral neuropathy 8; diabetic 2; abnormal cholesterol 44 (47%); abnormal hormone profiles 4. Sildenafil was the first agent in 55 (59%) patients and tadalafil in 28 (30%). 18 were on “poppers” and were told to stop before starting PDE5i. Improvement was noted in 51 (54%) after the first agent and 68 (72%) after the final agent. 36 (38%) had PDE5i side effects. 39 (41%) was on PI based Antiretroviral therapy. None reported priapism.

Conclusion It is safe to treat patients on PI with PDE5i by starting with half of the lowest dose tablet. Treatment of ED improves the quality of life in HIV positive patients but care must be taken to avoid serious drug interaction and safer sex practices should be emphasised.