Washington Blade - March 5, 2004
Christopher Seely

But it doesn't stop with recreational use: Some men with HIV use the drugs, approved only for treating erectile dysfunction, to overcome the side effects of some HIV drugs.

For Keith Folger, living with HIV also means coping with fatigue and the inability to maintain an erection to have sex. "It's a combination of me being 48 and the fatigue that HIV causes," Folger says. "I'm horny as hell but I'm tired because I'm always fatigued from HIV."

Whether the HIV medications cause Folger's impotence or it's the result of fatigue, Folger says he won't sit flaccidly by and miss out on sex.

"I just use Viagra," Folger says.

Health researchers, though, are concerned that mixing erectile dysfunction drugs with HIV medications or using them recreationally can cause complications. Some studies show use of the drugs among gay men can lead to riskier sex and higher rates of HIV and STD infections.

The FDA approved Viagra for erectile dysfunction in 1998. For the last few years, Folger has refilled his prescription each month. But he hasn't tried Cialis or Levitra, competitors to Viagra that gained FDA approval last year.

Crystal meth cocktail

Unlike Folger, some gay men obtain erectile dysfunction drugs without a prescription to combat the impotence that comes with using crystal meth, according to Dr. Charlotte Kent, chief of epidemiology in the STD prevention and control division of the San Francisco Department of Public Health.

Dubbed "crystal dick," the meth-induced impotence "provides motivation for people to take something to compensate for the dysfunction that occurs," Kent says.

Charles, who asked that his last name not be published, suffered from impotence during the months he spent addicted to crystal meth, and he took Viagra to compensate, he says.

The combination turned him into a veritable sex machine.

"That's part of what allowed me to be able to just concentrate on having sex with people," Charles says. "With the crystal I could stay up for three or four days and have sex with 30 to 40 guys easily."

Obtaining the pills was easy, he says.

"I called my own prescription in to pharmacies," Charles says. "Just pretended I was a doctor's office. Some people I know just order from Web sites that provide a medical consultation online."

But gay men who take the crystal meth-Viagra combination contract HIV and STDs at a higher rate than men who take only Viagra, according to a study to be released in March at the 2004 National STD Prevention Conference in Philadelphia.

"Where it is primarily a problem is when people are using meth," Kent says. "That's where we see the biggest risk factor."

Specific results from the study weren't available because it has not yet been published. But gay men who had sex while under the influence of both crystal meth and Viagra were several times more likely to contract syphilis and HIV, Kent says.

A weekend of sex

One of the common places that gay men mix Viagra with crystal meth, in addition to other party drugs, is at circuit parties, according to a three-year-old study by the federal Centers for Disease Control & Prevention.

Gay men use erectile dysfunction drugs to combine with common party drugs such as crystal meth, amyl nitrates (poppers), ketamine, gamma-hydroxybutyrate or gamma-butyrolactone (GHB-GBL), and ecstasy, according to a December 2001 study by the CDC.

The study, published in the Journal of AIDS, examined the sex and drug habits of 295 gay and bisexual men who attend circuit parties.

During one weekend of drug use, 80 percent of study participants used ecstasy, 66 percent used ketamine, 43 percent used crystal meth, 29 percent used GHB/GBL, 14 percent used Viagra and 14 percent used poppers, according to the study.

Poppers and Viagra, when used together, create a potentially lethal combination that could lead to heart failure, says Dr. Lee Golusinski, a gay Atlanta doctor.

More than half of the circuit partiers used four or more drugs during the course of the weekend, according to the study, which concluded that the use of the drugs increased the likelihood of "high-risk behavior," such as unprotected anal sex. The study points a finger at Viagra for the increase.

"It is specifically associated with high-risk sexual behavior," according to the authors of the study.

The study's authors offered two explanations for why Viagra was being taken: HIV-positive men took erectile dysfunction drugs to combat impotence caused by their medications or study participants took Viagra to enable sex while on party drugs.

The combination of party drugs and impotence pills makes sense, Golusinski says.

"We've got one drug that makes you want sex and the other gives you the ability to have it," Golusinski says.

But doctors cannot name Viagra as the problem itself, says Dr. Jason Schneider, who serves on the board of directors of the Gay & Lesbian Medical Association.

"It depends on the individual person and the setting in which it is used," Schneider says. "If you have a same-sex couple who has been together 30 or 40 years, then no, they won't be at higher risk. But contrast that with a single guy at a circuit party using crystal meth. He is at a higher risk. It's not because of Viagra, but of other drugs he's doing and the setting he's in."

Feds 'drag their feet'

Advertisements and consumer information put out by the makers of Cialis, Levitra and Viagra warn prospective users that the pills don't provide protection from sexually transmitted diseases.

Officials with Eli Lilly & Company, which manufactures Cialis, and Bayer Pharmaceuticals and GlaxoSmithKline, which produces Levitra, maintain their literature includes warnings against using the drugs for other than their prescribed purposes. Disclaimers also say the drugs do provide protection against HIV and other STDs.

"It would be very clear to consumers what this product is for and to help avoid any confusion they include HIV/STD information," says Carol Copeland, communication specialist for Levitra.

Pfizer, which manufactures Viagra, did not respond to repeated inquiries. But the company has long warned against the use of the drug for nonapproved purposes, and has educated doctors about the dangers of combining it with both legal and illegal nitrates.

But the FDA should step in and require the companies to do more, according to Dr. Jeff Klausner, director of the STD/HIV prevention unit of the San Francisco Department of Public Health. Warnings on the drugs should also make it clear that it may increase the chance of contracting STDs, he says.

"The FDA has been dragging its feet on this issue," Klausner says. "They have not moved on the issue and it is completely in their authority and responsibility to make physicians and users of their product aware."

In 2002, the San Francisco Department of Public Health asked the FDA to place a more thorough warning on Viagra to make it clear that sexual risks are associated with the drug, Klausner says.

According to a July 2002 study in AIDS, Viagra users reported greater numbers of recent sex partners, higher levels of unprotected anal sex with an HIV-positive partner and higher rates of STDs than non-users.

But the FDA did not follow the recommendation, according to an FDA spokesperson.

With the launch of Levitra and Cialis late last year, the number of new users of erectile dysfunction drugs increased, according to data from NDCHealth, which tracks the numbers of new and refilled prescriptions in pharmacies across the country.

Of the three pills, Cialis remains in a user's system the longest - up to 36 hours - making it the perfect pill for impotent men to take on a Friday afternoon so they can remain sexually active for most of the weekend, Golusinski says.

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