By  James Myhre & Dennis Sifris, MD 

In the United States, men account for around 80% of all new HIV infections each year. Although the majority of these are among men who have sex with men (MSM), an estimated 10% occur in men who engage exclusively in heterosexual sex, according to data from the Centers for Disease Control and Prevention (CDC).

In 2018, of the estimated 1.2 million Americans living with HIV, just over 912,000 were men. Of these, six out of every seven knew that they had been infected prior to their diagnosis.

While the signs and symptoms of HIV are largely the same whether you are male or female, there are several specific to men that can occur during early-stage or later-stage infection.

Acute HIV Infection

Acute HIV infection, also known as acute seroconversion or acute retroviral syndrome (ARS), is the initial stage of the disease following exposure to the virus. It is the period during which the body will start producing antibodies to fight the virus, which usually lasts for around seven to 14 days.

Though some people will experience symptoms during the acute phase of infection—typically described as flu-like with swollen lymph nodes and occasionally rash—recent studies have suggested that as many as 43% will not have any symptoms at all.

When they do, the signs and symptoms of ARS do not really vary between men and women. Where they do vary is the rate of seroconversion, wherein heterosexual men are 50% less likely to get infected per sexual act compared to heterosexual women (due to differences in size and porosity of penile mucosal surfaces versus those of the vagina or rectum).

The biological disparities are one of the main reasons why heterosexual men account for 8% of all new infections in the United States, while women account for 18%.

HIV and STD Co-Infection

Another way that acute HIV differs in men is in the types of symptoms that can develop when there is an accompanying sexually transmitted disease (STD).

HIV transmission is often facilitated by a co-occurring STD, the latter of which undermines the integrity of the penile mucosa while increasing the concentration of immune cells the virus can infect. In such cases, an acute HIV infection may be identified by the signs and symptoms of the STD rather than those of HIV itself.

Among some of the symptoms commonly seen in men with an HIV/STD co-infection:

• • Penis sores: Syphilis develops in stages, the first of which involves the appearance of a painless, ulcerative sore (called a chancre) at the site of the exposure. In men, the penis is typically involved but the rectum or mouth can also be affected. The break in the skin allows HIV easier access into the body to establish an infection.
  • Pain and burning with urination: This is a common symptom in men with gonorrhea and chlamydia. STDs increase the porosity of the penile mucosa and trigger acute inflammation, drawing a high concentration of immune cells to the site of the exposure. Among them are CD4 T-cells, the very cells that HIV preferentially targets and infects.
  • Testicular pain and swelling: This is another possible sign of chlamydia and gonorrhea in which the tube that stores and transports sperm from the testicle (the epididymis) becomes inflamed. The inflammation is referred to as epididymitis, and, when accompanied by swelling, epididymo-orchitis.
  • Pain with ejaculation: Also known as dysorgasmia, this is yet another symptom of gonorrhea and chlamydia in men but one that can occur with another STD known as trichomoniasis.

Chronic HIV Infection

After the immune system produces enough antibodies to bring the acute infection under control, HIV will go into a period of latency when there may be few, if any, notable symptoms.

This chronic stage of infection can persist for years, during which HIV will silently and progressively deplete the number of CD4 T-cells that the body relies upon to trigger the immune response.

As these immune cells are depleted, the body will become increasingly susceptible to an ever-widening range of opportunistic infections (OI). These are infections that the body would otherwise be able to control had its immune defenses remained intact.

As the number of CD4 T-cells progressively drop—as measured by the CD4 count—the risk, severity, and range of OIs will increase.

Opportunistic Infections in Men

As opposed to the acute stage of infection, the symptoms of chronic HIV are primarily related to the development of OIs rather than the virus itself.

In men and women, the expression of these OIs remains more or less the same. At CD4 counts of between 250 and 500, common OIs include candidiasis (oral and vaginal thrush), herpes simplex, herpes zoster (shingles), bacterial pneumonia, bacterial and fungal skin infections, tuberculosis, and HIV-associated meningitis.

The differences between sexes, if any, mainly involve those of the anal and genital tracts. In men with chronic HIV infection, these symptoms may include:

• • Chronic or recurrent penile ulcers: Chronic genital ulcers (i.e., those lasting for more than one month) are hallmarks of a severely suppressed immune response. In men with HIV, this can manifest with extensive ulcers on the penis, most often caused by herpes simplex virus type 2 (HSV-2).
  • Anal ulcers: HSV-2 is highly prevalent in MSM with HIV, with some studies suggesting a positivity rate of 80%. Anal ulcers, commonly caused by the transmission of HSV-2 during anal sex, is often the first manifestation of HIV in MSM. Although common in MSM, these painful ulcers can also affect anyone who engages in anal sex.
  • Rectal pain: Rectal inflammation, also known as proctitis, is a symptom also commonly linked to HSV-2 in HIV-positive MSM. In addition to causing pain, proctitis can manifest with rectal bleeding, mucus discharge, diarrhea, and tenesmus (a feeling that you need to defecate when your bowel is empty). Anal ulcers sometimes accompany.
  • Erectile dysfunction: The prevalence of erectile dysfunction (ED) is high in men with HIV, even those with good viral control. Some studies have suggested that as many as 67% of men with HIV will experience some degree of ED—a rate that exceeds men in the general population by more than three-fold. Causes include anxiety, HIV-associated hypogonadism (low testosterone level), and HIV-associated lipodystrophy (in which abnormal fat redistribution can impede the ability to achieve an erection).

• Gynecomastia: The abnormal swelling of breast tissue, called gynecomastia, can also occur in men with HIV-associated hypogonadism. Although hypogonadism tends to affect men with CD4 counts below 100, certain OIs can reduce testosterone levels in men with higher CD4 counts. They do so by indirectly impairing the function of the endocrine system, which regulates the production of male hormones. The loss of libido is also common.

AIDS

The final stage of HIV infection is commonly referred to as acquired immune deficiency syndrome (AIDS). This is the point where the immune system is said to be fully compromised, increasing the risk of potentially life-threatening opportunistic infections.

By definition, a person with HIV is considered to have progressed to AIDS when:

• The CD4 count drops below 200 cells/mm³
• A person gets one of 28 AIDS-defining conditions regardless of the CD4 count.

AIDS-defining conditions include OIs that are rarely seen outside of immunocompromised people as well as common OIs that have recurred or have disseminated (spread) beyond the typical site of infection to distant organs.

Symptoms of AIDS in Men

The symptoms of AIDS varies little between men and women. If anything, the symptoms will tend to get more severe. One such example is HSV-2-associated anal ulcers which can become deep and non-healing in MSM with CD4 counts under 100.

Another exception is Kaposi sarcoma (KS), an AIDS-defining cancer that can occur on any part of the body but on rare occasion can manifest with purplish lesions on the penis. Although KS typically occurs when the CD4 count drops below 200, there have been instances when an isolated penile lesion has developed at CD4 counts well over 200.

Non-AIDS-Defining Cancers

In addition to AIDS-defining conditions, people with HIV are at an increased risk of a variety of different cancers. The non-AIDS-defining cancers are thought to be the consequence of chronic inflammation spurred by the infection, which can alter cellular DNA and trigger the development malignant cells.

In men, this can lead to an increased risk of two different types of cancer:

• Penile cancer: Cancer of the penis is extremely rare in the United States, with an annual incidence of around one case per 100,000. HIV infection increases the risk of penile cancer by no less than eight-fold, with 80% of cases directly linked to high-risk strains of the human papillomavirus (HPV).
• Anal cancer: Anal cancer is also rare in the United States, affecting roughly two of every 100,000 men and women every year. Among HIV-positive MSM, the annual incidence skyrockets by 144-fold, again linked to the sexual exposure to high-risk HPV strains.

A Word From Verywell

Although certain symptoms may suggest that you have HIV, the absence of symptoms should not suggest that you are “in the clear.” If you have risk factors for HIV and have not been tested, it may be time to do so.

Currently, the U.S. Preventive Services Task Force recommends once-off HIV testing for all Americans age 15 to 65 as part of a routine medical exam.

If diagnosed and treated appropriately, people with HIV can today live normal to near-normal life expectancy with a lower risk of HIV-associated illnesses. This is especially important in men, who tend to have significantly lower CD4 counts and higher viral loads at the time of diagnosis compared to women.

Early diagnosis and treatment almost invariably lead to better outcomes.

* Dennis Sifris, MD, is an HIV specialist and Medical Director of LifeSense Disease Management. James Myhre is an American journalist and HIV educator.