Your reproductive health and HIV

You should expect the same standards of reproductive, preconception, fertility and antenatal services as your HIV-negative counterparts. Access to reliable and up to date information about reproductive health is a vital part of the overall care provided by your HIV and sexual health clinic teams. Here are some points to consider and discuss with your HIV and sexual health teams:

• Living with HIV shouldn’t be a barrier to having a fulfilling sex life, particularly now that there is very clear evidence that where viral load is undetectable for 6 months or more, HIV cannot be passed on to your sexual partners
• Fear of passing HIV on to sexual partners, despite the knowledge this isn’t possible when your viral load is undetectable remains a concern for many people, regardless of their HIV status. Your clinic team should discuss and explain this with you to allay any concerns you or your partner may have
• There is an important link with HIV, reproductive health and the Human Papilloma Virus (HPV). Infection with certain types (strains) of HPV are strongly associated with the development of abnormal cells within the anus, cervix and penis
• HPV is very common amongst the general population, and many people will be exposed to HPV at some point in their lives. For the majority the immune system keeps it in check and in some cases clear the infection completely over time. The virus can remain dormant for many years, and not cause any symptoms or health problems at all
• People living with HIV are more susceptible to acquiring multiple strains of HPV, which can be more persistent or difficult to treat when compared to their HIV negative peer group. There is also a higher prevalence of HPV related anal & cervical cell abnormalities amongst people living with HIV
• In recent years the number of women attending for regular cervical screening has declined and we advise women, or anyone with a cervix to be screened annually as recommended by the British HIV Association (BHIVA)
• Men who have sex with men can be at increased risk of developing abnormal anal cells and are advised to discuss any changes or sensations in or around the anus for further investigation with their HIV or sexual health clinic team
• People living with HIV should be supported in their decisions to conceive and have children. You and your partner should talk to your clinic teams regarding suitable prevention options such as Treatment as Prevention (TasP), Pre-Exposure Prophylaxis (PrEP) and other options when thinking about having children and conceiving naturally
• Women wishing to conceive should be provided with up to date treatment information to ensure they’re able to make fully informed choices prior to trying to conceive and into pregnancy
• Women wishing to conceive should be given appropriate preconception advice and commenced on a high dose of folic acid (5 mg daily) regardless of the HIV treatment regimen they are taking
• There may be a requirement to change your medication during pregnancy. This is due to a lack of data relating to some new drugs and formulations. It’s important you are provided with up to date information so you can make an informed choice about any change to your HIV medication
• When thinking about contraception methods in the context of HIV it’s important to discuss these with your clinic team to ensure the most suitable method is compatible with your treatment for HIV. There are also considerations relating to barrier methods where either you or your partner have detectable viral load
• Both men and women living with HIV often report problems with sexual dysfunction it’s important your clinic team are sympathetic about any problems you may be having and provide the right level or support and make referrals into specialised services

Treatment as prevention and reproductive health

We now have overwhelming evidence that people who are taking effective treatment and have undetectable viral load, cannot pass HIV onto their sexual partners where condoms aren’t consistently used. Our Plus Undetectable page sets out the science and practical benefits of Treatment as Prevention (TasP). Here are some points to consider and discuss with your HIV and sexual health teams:

• High levels of adherence should be observed where TasP is the main method of HIV prevention. It is important to be aware of the current 6-month window period after your viral load has become undetectable to ensure full protection is provided
• Most of the studies that looked at TasP used a viral load benchmark or cut-off point of 200 copies or less. In the UK most clinics use tests that can detect viral load down to 40 or 20. This provides further reassurances that undetectable really does mean untransmissible in the context of condomless sex
• Treatment options which contain 2 drugs (Dovato, Juluca) rather than 3 are becoming more readily available. These options offer the same protection in the context of TasP, as do boosted protease inhibitors when used as monotherapy
• If you’re currently not taking treatment for your own health, it’s important the decision to start treatment is the right for you. Whilst it’s important to discuss things with your partner, the final decision should be made by you with the support of your clinic team
• Treatment for HIV doesn’t prevent you (or your partner) acquiring other STI’s. You should consider having a sexual health check-up before engaging in condomless sex whilst trying to conceive, or where you decide to discontinue the consistent use of condoms at any other time

Reproductive health for women

Women living with HIV have historically been under-represented in many trials and studies, which means gender specific information isn’t available to underpin guideline development and best practice. All that said, guidelines are always being reviewed and updated as new information comes to light.

Living with HIV should never be a barrier for women to access good quality services for their reproductive health. Where possible you are encouraged to share your HIV diagnosis with their GP in order that you receive the very best care when thinking about cervical screening, contraception and when planning to have children.

You and your partner should be supported in the choices you make when it comes to family planning, pregnancy and beyond. We outline below some of the more important aspects of your reproductive health for you to consider and discuss with your HIV, sexual health and wider healthcare teams:

Human Papilloma Virus (HPV) vaccinations and cervical screening

Infection with certain types (strains) of Human Papilloma Virus (HPV) are associated with the development of abnormal cells within the cervix. HPV is very common amongst the general population and most people will be exposed to HPV at some point in their lives. For the majority, the immune system will keep HPV in check and may clear the virus without any treatment. HPV can remain dormant for many years, and not cause any symptoms or health problems at all.

People living with HIV have an increased risk of acquiring multiple strains of HPV, which can be more persistent and difficult to treat when compared to their HIV negative peer group. There is a higher prevalence of HPV related cervical cell abnormalities amongst women living with HIV, which is why screening is so important.

Cervical screening (smear test) is important to check the health of the cervix. The test doesn’t check for cancer, but it can help prevent cancer, by identifying abnormal cells before they have the opportunity become cancerous in nature. Here are some points to consider, and discuss with your HIV or sexual health teams:

• Strains 16 and 18 of HPV are associated with the development of abnormal cervical cells, which if left undiagnosed and treated can result in cervical cancer
• Your HIV clinic team should ask about your HPV vaccination history when you’re first diagnosed. Where you’ve previously received the HPV vaccination your Dr. or nurse should ask about the type of vaccine and number of doses you were given
• If you’ve not previously had the HPV vaccination BHIVA recommend you're offered the vaccine up to the age of 26 regardless of your CD4 cell count, treatment for HIV or viral load
• BHIVA also suggest it may be beneficial for unvaccinated women living with HIV up to the age of 40 be offered the vaccination. This may not be readily available within the national program, but it’s worth asking about
• Previously unvaccinated women who have a CD4 cell count below 200, who are not on treatment may defer the HPV vaccine until they are established on treatment for HIV
• Annual cervical screening is recommended for all women living with HIV between the ages of 25 and 65, which can be performed by your GP or other suitable service. It’s important the clinical reason for annual cervical screening is documented on the sample request form. Without this, your sample may be rejected. It’s worth checking this information has been correctly added to the sample form
• Colposcopy examination is also recommended upon diagnosis of HIV, although this may not always be offered due to resource limitations. It’s certainly worth asking your HIV, sexual health teams or GP if this is available
• BHIVA guidelines for women diagnosed with HIV after the age of 25 recommend colposcopy examination for those with previous cervical abnormalities or a long interval since last screening
• Your GP should ensure you receive a cervical screening invitation letter each year. It’s good practice for your clinic team to also discuss cervical screening and the results as part of your regular HIV clinic check-ups
• Where any lower grade cell abnormalities are found, these may not require treatment, as they tend not to progress and often resolve over time. Close monitoring is therefore important to ensure any changes are identified and treatment provided where appropriate
• After the age of 65 you should not have cervical screening unless you fulfil the national screening criteria for ongoing monitoring due to the development of abnormal cells or other concerns

Thinking about having children?

The landscape has changed considerably for people living with HIV who wish to start a family or have more children. Modern treatment has opened up so many possibilities for planning a family and bringing up children who do not have HIV.

As previously mentioned there is now overwhelming evidence that women and men living with HIV who have undetectable viral load for 6 months or longer, cannot pass HIV onto their sexual partners. This enables more couples to conceive as nature intended and have condomless sex without fear of passing HIV on. Here are some points you may wish to consider and discuss with your clinic team:

• Current guidelines covering conception don’t necessarily reflect the up to date position in relation to treatment as a method of prevention and the recommendation that people living with HIV start treatment as soon as possible following their HIV diagnosis
• If you are of childbearing age, your clinic team should ask about any plans you may have to start or add to your family each time you visit your clinic. You (and your partner) should be supported where you wish to explore the options available to have children
• It’s important you (and your partner) have access to reliable information, advice and counselling when trying to conceive, so you can make informed choices prior to attempted or planned conception
• If you or your partner aren’t already taking treatment for your own health, talk to your clinic team about starting treatment, explaining that you’re wishing to become pregnant. Treatment as a form of prevention is reliable once viral load has been undetectable for 6 months or longer
• If you’re established on treatment it may be necessary to review your treatment during the conception period and into pregnancy. This is to ensure your treatment is the most suitable whilst you’re trying to conceive and remain undetectable as your pregnancy progresses
• Making changes to lifestyle prior to conception and beyond is an important consideration for all women wishing to conceive. Folic acid supplementation is recommended prior to conception or as soon as pregnancy is achieved and continued throughout

Becoming pregnant and HIV

Women living with HIV are able to conceive, have a normal pregnancy and give birth to healthy HIV negative babies. The care of pregnant women living with HIV is now well established, with antenatal and HIV services working together to ensure mothers to be are well supported during their pregnancy. Here are some points to consider and discuss with your clinic and wider healthcare teams:

• For the majority of women HIV doesn’t prevent you becoming pregnant. However, in some circumstances, fertility may be affected by HIV and assisted fertilisation techniques can be offered to help you become pregnant. If you’re having difficulty conceiving your clinic team can refer you to an assisted conception specialist for assessment
• If your CD4 cell count is below 200 and you’re not yet established on treatment, it’s preferable to defer pregnancy until you’re on treatment and have ideally achieved undetectable viral load
• Talk to your clinic team about any help and support they can provide as they may have specialist members of the team who can support you during your pregnancy
• Preferred treatment options for use during pregnancy are based on the best safety data currently available. Where the preferred option is contraindicated there are a variety of alternative options available
• Preferred treatment options:
• emtricitabine/tenofovirDF or lamivudine/abacavir (NRTI backbone)
• combined with ritonavir boosted atazanavir or efavirenz (third agent)
• Alternative backbone NRTI backbone option:
• zidovudine/lamivudine (see note below)*
• Alternative third drug options:
• rilpivirine
• raltegravir 400mg (taken twice daily
• darunavir/ritonavir 800/100mg (taken twice daily)
• dolutegravir** (see note below)
• Treatment options currently not recommended during pregnancy:
• Single tablet regimens which contain cobicistat and/or tenofovirAF
• Once daily raltegravir. (This is because there is insufficient data to ensure viral load remains undetectable throughout pregnancy)

* You may wish to include AZT in your combination during pregnancy, and then switch back to your original combination. Long-term use of AZT is no longer recommended for on-going treatment of HIV in the UK.

** Your clinic team should explain that the prevalence of neural tube defects in the developing embryo is 3 times higher where dolutegravir forms part of a treatment regimen at the time of conception when compared with other treatment options available.

Where you choose to continue taking dolutegravir while planning to conceive you should be fully supported in this decision and advised to commence or continue high dose folic acid (5 mg daily) until neural tube development is complete, which occurs at around the 6th week of pregnancy.

Contraception and HIV

Most of the available methods of contraception are suitable for women living with HIV, with the final choice being based on individual circumstances and preferences. Some medications used to treat HIV can interact with hormonal contraception methods and reduce their effectiveness. Here are some points to consider and discuss with your clinic team:

Hormonal contraception

• Your current or preferred method of contraception, whether the contraceptive pill, patch, vaginal ring, injection or implant should be discussed with your clinic team prior to starting HIV treatment
• Some medications used to treat HIV can reduce the effectiveness of hormonal contraceptives. Where you’re already established on an effective form of hormonal contraception, your HIV treatment options should reflect this where possible
• If you have a pre-existing health condition, acquired drug resistance or a preference for a single pill regimen it may be necessary to make adjustments to your hormonal contraception to ensure your HIV treatment is not affected due to drug interactions
• It’s recommended you have discussions with your clinic team at least on an annual basis, or more frequently where required, about your current method of hormonal contraception. This is particularly important where you’re established on HIV treatment and you would like to change your method of contraception
• Whether you’ve been living with HIV for a number of years or recently diagnosed it’s important that you have the opportunity to discuss contraception options with your clinic team as these are likely to change over time
• Where you know the details of your hormonal contraceptive you can check for any interactions with your HIV medications by using the HIV drug interactions website

Barrier contraception methods

• Both male and female condoms are a very good option when used consistently and correctly as a method of contraception. They also prevent HIV transmission where you have detectable viral load. Condoms also provide effective protection against other STI’s
• Other barrier methods include caps and diaphragms which cover the cervix and part of the upper vagina. When using these methods, a large part of the vagina isn’t covered by an effective barrier and therefore transmission of HIV can still occur where you have detectable viral load
• If you’re using condoms or other barrier methods as your sole method of contraception, you should be made aware of how to access emergency contraception, should the need arise
• Where you have detectable viral load, you should be made aware of how to access Post Exposure Prophylaxis (PEP) where your partner is HIV negative and there has been a condom failure
• Discussing the most appropriate form of barrier contraception with your clinic team is important to ensure any risks of unintended pregnancy are balanced with any possibility of HIV transmission, where you have detectable viral load

Intrauterine device contraception (Coil)

• Copper bearing coils (CU-IUD’s) and the Mirena coil (Levonorgestrel Intrauterine System LNG-IUS) are safe methods of contraception to use for women living with HIV and have a CD4 cell count above 200
• If your CD4 cell count is below 200 there may be increased risk of infection when the IUD is fitted. If your viral load is undetectable both types of coil may be considered, depending on your individual circumstances. If you already use either of these methods, you can continue to do so where CD4 is below 200
• IUD’s do not provide protection against HIV transmission. Condoms provide a good level of protection (not 100%) where you have detectable viral load

Emergency contraception

• Emergency contraception can be used by all women living with HIV, but there are important differences on the best option based on your HIV medication, CD4 cell count and viral load
• If you’re taking treatment for HIV, have undetectable viral load and your CD4 count is above 200 a copper-bearing coil (Cu-IUD) is considered to be the best method of emergency contraception. The copper coil (Cu-IUD) should be used within 5 days after having condomless sex or where there has been a failure in your usual method of contraception
• If your viral load is detectable or your CD4 cell count is below 200 the morning after pill is often more appropriate form of emergency contraception. This should be decided on a case by case basis as a copper coil (CU-IUD) may be considered where your viral load is undetectable
• Where oral emergency contraceptive (the morning after pill) is used it’s important to let the prescribing healthcare professional (sexual health clinic, pharmacy, some A&E’s walk-in centres) which medications you’re taking for HIV. This will ensure any interactions with your HIV medication can be avoided
• There are 2 different types of morning after pill (Levonelle & Ellaone). Where you are taking treatment for HIV and depending on the drugs in your combination, a double dose of the morning after pill might be needed
• It’s particularly important to discuss your HIV treatment with the prescribing pharmacist where you purchase the morning after pill. It’s advisable to see a Dr who is aware you have HIV as they can then prescribe the most suitable morning after pill for you
• If you experience a failure with male or female condoms where you have detectable viral load, Post Exposure Prophylaxis (PEP) might be appropriate for a partner who is HIV negative. It’s important to get further advice on this as soon as possible, ideally within 24 hours, but no longer than 72 hours (3 days) of the failure occurring

Reproductive health for men

Men living with HIV should expect the same standard of care for their reproductive health as their HIV negative counterparts. Treatment for HIV means where you or your partner (or both) are living with HIV you can have children who are HIV negative and healthy.

As outlined in our sexual health section, it’s important to pay particular attention to some sexually transmitted infections (STI’s), as they can have implications for maintaining good reproductive health. Undiagnosed chlamydia and gonorrhoea in men, when left untreated can cause infertility. The human papilloma virus (HPV) is of particular importance for men living with HIV.

Human Papilloma Virus (HPV)

Infection with certain types (strains) of Human Papilloma Virus (HPV) are associated with the development of abnormal anal and cells on the penis. HPV is very common amongst the general population and most people will be exposed to HPV at some point in their lives. For the majority, the immune system will keep HPV in check and may clear the virus without any treatment. HPV can remain dormant for many years, and not cause any symptoms or health problems at all.

People living with HIV have an increased risk of acquiring HPV which may include multiple strains. These can be more persistent or difficult to treat when compared to their HIV negative peer group. When diagnosed promptly any changes due to HPV can be treated effectively where this is required. Here are some points to consider and discuss with your HIV and sexual health clinic teams:

• Infection with HPV strains 16 and 18 are strongly associated anal and penile cancers and increase the risk of developing other cancer in the throat and neck
• Routine screening for HPV isn’t recommended for men, so it’s important to talk to your clinic if you have any concerns you have about HPV, particularly if you identify as a man who has sex with men (MSM)
• Most adult heterosexual men won’t have received the HPV vaccine. All unvaccinated men living with HIV, regardless of their sexuality, should be offered the vaccine up to the age of 26 regardless of their CD4 cell count, treatment for HIV or viral load
• If you identify as MSM you should be offered the HPV vaccine up to and including the age of 45. Your clinic team should ask about your HPV vaccination history when you were first diagnosed with HIV
• The HPV vaccine can be offered to MSM beyond the age of 45 on a case by case basis, outside the national vaccination programme, where this is thought to be beneficial

Thinking about having children?

Men living with HIV rarely have difficulties with their fertility although in some cases this may be reduced due to low CD4 cell count. Some men find they have symptoms of erectile dysfunction, which may also impact on their ability to conceive with their partner. Here are some points to consider and discuss with your clinic team:

• If you’re not yet established on treatment for your own health and you wish to conceive naturally, you should start treatment to achieve undetectable viral load for 6 months or more prior to trying to conceive with your partner
• Sperm washing is an option where you wish to defer starting HIV treatment, although this isn’t available in all areas and may require an additional funding request. Sperm washing isn’t recommended where viral load is undetectable unless you or your partner also have hepatitis B or C
• If you’re having difficulties with erectile dysfunction it’s beneficial to discuss this with your clinic team and GP. Some larger HIV clinics provide services for erectile dysfunction including psycho-sexual support as well as identifying any physical health conditions that may be related to erectile dysfunction
• Some medications used to treat erectile dysfunction have interactions with HIV medications, particularly those containing a boosting agent (cobicistat or ritonavir) or combinations containing nevirapine, efavirenz or rilpivirine. It’s important to check for any interactions with your pharmacist or clinic team
• Rarely, advanced HIV infection can result in reduced fertility as a result of changes in the hormonal balance which is essential for the production of healthy sperm. In such cases you (and your partner) should be referred to an assisted conception specialist for assessment
• Where you wish to have children, it’s a good idea to make changes to your lifestyle to improve the chances of successful conception. Smoking cessation and alcohol reduction support should be considered prior to trying to conceive as this may be beneficial to aid successful conception. Your clinic team or GP can provide further help and support around this

Male contraception and HIV

Whilst there are many methods available to women, condoms are the mainstay for men. It’s important that men living with HIV have the opportunity to discuss their family planning options with their clinic team together with their partner. This can help couples make informed choices about contraception and overcome any difficulties they may be experiencing.

Here are some points to consider and discuss with your clinic or sexual health team include:

• Worries about HIV transmission can lead to erectile dysfunction regardless of HIV status. This can make consistent and correct condom use difficult, and therefore condoms may not be a suitable method of contraception for some men
• There is a higher incidence of erectile dysfunction amongst men living with HIV than their HIV negative counterparts. This may be linked to psycho-sexual difficulties or physical health problems
• Some larger clinics have specialised services for men who experience erectile dysfunction, although smaller clinics should offer support and have a referral pathway in place
• Physical conditions including obesity and high cholesterol can cause erectile dysfunction. Some drugs used to treat HIV can increase cholesterol levels, so it’s important to discuss this with your clinic team or GP
• Smoking and the use of alcohol are also associated with erectile dysfunction which can result in a loss of confidence at developing or maintaining an erection
• Moving towards a healthier lifestyle can significantly improve erectile dysfunction and therefore improve correct and consistent condom use as a method of contraception
• In very rare circumstances peripheral neuropathy (nerve damage) as a result of long periods of untreated HIV or exposure to the early drugs may reduce the ability to develop or maintain an erection, which as previously stated can have an impact of condom use

Contraception methods are relatively straight forward for men but it can be useful to discuss things with your clinic team so you feel confident that you’re using the best methods to prevent pregnancy.