This study determined risk factors for decreased sexual satisfaction among men living with HIV (MLHIV). Self-administered questionnaires were distributed consecutively to all MLHIV attending 17 European HIV treatment centres. The sample included 1,017 MLHIV, among whom 79.2% self-identified as homosexual or bisexual. Sexual satisfaction was measured for five domains of sexual functioning and 33.2% reported low satisfaction in at least one domain. Decreased sexual satisfaction was associated with psychosocial factors, i.e. depression (OR 2.77, P < 0.001), anxiety (OR 1.77, P < 0.001), stress (OR 2.27, P < 0.001) and social factors, such as low partner support (OR 2.28, P < 0.001) and experiences of HIV related discrimination (OR 1.69, P < 0.001). Discussing satisfaction with sexuality should be integrated in regular HIV care, considering patients' personal and relationship-related resources next to medical treatment if indicated.