Sexual health and HIV

We know that for people living with HIV some sexually transmitted infections (STIs) can be more difficult to treat and may require closer monitoring and follow-up. Viral hepatitis and Human Papilloma Virus (HPV) can play a role in more serious conditions which can have an impact on your reproductive health and potentially wider general health.

• Viral hepatitis, particularly Hep B and Hep C can result in liver damage if left undiagnosed and untreated. Liver disease can progress more rapidly in people living with HIV, even when viral load is consistently undetectable. Liver cancer is seen more frequently in people living with HIV which is why regular monitoring includes checks for viral hepatitis
• People living with HIV have an increased risk of acquiring multiple strains of HPV, when compared to HIV negative people, which can be more persistent and more difficult to treat in some cases. There is also a higher prevalence of HPV related conditions that are associated with the development of cancer amongst people living with HIV
• Herpes simplex virus (HSV) is very widespread amongst the general population, many of whom never have any symptoms or outbreaks as the virus is kept in check by the immune system. Herpes Simplex Virus 2 (HSV2) which causes genital herpes can become more active in people living with HIV and some people may experience frequent outbreaks
• Syphilis infection can be more difficult to treat for people living with HIV which may require repeat treatment if not fully cleared after initial treatment. People living with HIV also have an increased risk of developing neurosyphilis than HIV negative individuals, so close monitoring is important

Regular sexual health screening

Your HIV clinic visits may not always include a full STI check-up as part of the regular HIV monitoring you receive. If you have overlapping, multiple sexual relationships, frequent changes in sexual partners, or at increased exposure risk, it’s a good idea to increase the frequency of STI check-ups based on your personal circumstances, and those of your partner.

What can I expect during a sexual health check-up?

Sexual health check-ups have changed for the better in recent years, which makes the experience less embarrassing and daunting. There are a growing number of stand-alone clinics which offer a variety of sexual and reproductive health services, some of which offer self-sampling and rapid test analysis where results are provided within hours rather than days.

Your sexual health check-up will vary depending on the location and size of the clinic. Here are some of the things you can expect:

• Complete a basic form upon arrival at the clinic reception to help assess the reason for your visit to the clinic. The information required is usually kept to a minimum to safeguard your privacy
• If you don’t have any symptoms and just want a regular check-up, you’ll probably be seen by a nurse or a sexual health advisor. If you have symptoms you can expect to be seen by a Dr. who can prescribe any treatment required
• During your appointment you’ll be asked about your most recent sexual activity, which may include some quite personal questions. It may feel embarrassing to share information, but you can be assured clinic staff are non-judgemental and are very rarely shocked
• Your sexual history is used to help assess the most suitable range of tests required, and if a physical examination is required. Any examination will be guided by the symptoms you’re experiencing or where ulcers and other lumps and bumps have appeared which you’re concerned about

Your check-up may include tests for the most common STIs and also others we’ve not listed here, depending on your personal circumstances:

• Chlamydia – urine sample or intimate and/or throat swab
• Gonorrhoea – urine sample or intimate and/or throat swab
• Syphilis – blood test or intimate swab
• Hepatitis B – blood test.
• Hepatitis C – blood test
• Genital warts – physical examination
• Individuals from particular communities may be offered other tests where there is a greater possibility of acquiring specific infections. Once all the necessary samples have been collected you should ask how your results will be communicated to you
• Where you have no symptoms, test results are likely to be provided at a later date by text message or you may need to call your clinic to obtain the results. In the event of any positive test results your clinic will usually call you so you can return for follow-up treatment
• In some cases, not all symptoms are related to an STI (bacterial vaginosis, thrush, balanitis), so it can be reassuring to get checked out and where required further investigations completed so that effective treatment can be provided

Further detailed information about the most common STIs can be found by visiting Terrence Higgins Trust sexual health pages.

Home sampling test kits for Sexually Transmitted Infections (STI’s)

Sexual health clinics are increasingly using home sampling kits for regular STI checks. These provide a convenient way to get checked out but are only suitable if you don’t have any symptoms. Here are some points to consider about using home sampling kits:

• You’ll need to register online and complete a brief questionnaire to order your home sampling kit. The questionnaire will ask for information about your sexual orientation, type of sex you engage in etc. This is to ensure home sampling is the best option for you and also which samples are most appropriate
• Whilst the postal kit packaging is discreet, if you share your home with others this is something to consider in terms of your privacy. The kits provide full instructions on how to collect the samples which usually include a urine, intimate and/or throat swabs and possibly a small blood sample
• Some people worry about collecting a blood sample. Our top tip here is to read the instructions through a couple of times, familiarise yourself with the lancets and collection vial before attempting to collect your blood sample. Make sure your hands/fingers are warm as this will help when taking your blood sample
• Once you’ve taken all the samples place them back into the original packaging as directed by the instructions and complete any form that needs to accompany your samples. Seal the box and simply pop it in the post – job done
• You’ll be able to track the progress of your kit either by signing into your online account or by electing to receive text messages or emails. Test results are usually communicated by text message, or you may receive a phone call to discuss any positive results and then signposted to the most appropriate sexual health clinic

If you have any symptoms, it’s important you get these checked out at you nearest sexual health clinic as this will ensure any STI is diagnosed and promptly treated. Sometimes the symptoms you’re experiencing may not be caused by an STI, which is another good reason to get checked out.

Viral hepatitis

There is good evidence to support the view that dual infection with HIV and viral hepatitis, particularly hepatitis B and C can increase the progression of liver disease. Below is some information relating to viral hepatitis in the context of HIV.

Hepatitis A

• Hepatitis A (HAV) is uncommon in the UK but can affect certain groups including men who have sex with men, people who inject drugs, and individuals who may be exposed to the virus as part of their job
• Screening for HAV should be completed for all individuals at initial HIV diagnosis, with vaccination offered to those with no immunity. HAV infection should be checked annually as part of your routine HIV clinic monitoring
• Evidence is emerging to suggest that HAV in people living with HIV may take longer to clear and immunity can be lost over time. The British HIV Association (BHIVA) recommend a booster vaccination is given every 10 years for those most at risk of acquiring HAV
• In a sexual context, the route of infection is usually via anal/oral contact (rimming, fingering), where tiny particles of faecal matter (poo) may be present. Other routes of infection include sharing sex toys, and anal sex where condoms aren’t consistently used
• Infection with HAV can be quite unpleasant, sometimes causing yellowing of the eyes and skin (jaundice). In the majority of cases it’s self-limiting and doesn’t require specific treatment, with most people making a full recovery

Hepatitis B

• HBV is mainly acquired in adulthood, usually through sexual activity, sharing of needles, other injecting drug equipment or where there is contact with blood and other bodily fluids. Consistent condom use helps prevent HBV infection arising from anal and vaginal sex
• HBV can be acquired (extremely rare if at all in the UK) as a result of poor hygiene standards and contaminated equipment used for body piercing, tattooing, medical and dental treatment can be a route of infection
• Your HIV clinic will check for HBV infection as part of the tests completed at initial HIV diagnosis and then annually, depending on your risk of exposure. Some people will spontaneously clear acute infection (less then 6 months) and not display any symptoms. In most cases this will result in natural immunity against further infection
• HBV Vaccinations should be offered if you have not received this previously or have little or no immunity to HBV. Checks for HBV immunity should be completed annually, and a booster offered where required
• Some people are unable to maintain effective levels of HBV immunity, despite having been vaccinated. In this case your clinic team will offer further advice, based on potential for exposure
• Where symptoms for HBV are present, they include fever, tiredness, general aches and pains, together with loss of appetite, nausea and changes in bowel habit. In some cases, yellowing of the eyes and skin (jaundice) may also develop
• If your CD4 cell count is below 350 it may be more difficult for you to clear acute HBV and this can then develop into long-term (chronic) infection. Treatment is required to prevent liver damage
• Some drugs used to treat HIV are also effective for HBV. Where dual infection occurs or if the response to the HBV vaccination is ineffective, treatment for HIV should include emtricitabine/tenofovir (preferred option), although lamivudine/tenofovir can also be used as an alternative option
• Treatment for HBV in the context of HIV should be managed by a multidisciplinary team, including liver and HIV specialists with support from a pharmacist and psychiatric input where required. Larger HIV centres may have combined HBV/HIV clinics managed by a Consultant with experience of both conditions

Hepatitis C

• Hepatitis C (HCV) is the most widespread cause of viral hepatitis, with approximately 210,000 people in the UK having long-term infection. HCV is spread by blood to blood contact, including very small dried blood particles not visible to the naked eye getting into the blood stream. People who inject drugs bear the highest burden of HCV infection by the sharing of needles and other injecting equipment
• Your HIV clinic will check for HCV infection as part of the tests completed at initial HIV diagnosis and then annually, depending on your risk of exposure. Unlike hepatitis A and B, there is no vaccination available for HCV
• Sexual transmission of HCV rarely occurs between heterosexual couples, however higher levels of HCV are seen amongst HIV positive men who have sex with men
• Acute HCV infection (less than 6 months) may not cause any obvious symptoms, with between 20% to 25% of infections being naturally cleared. It can be more difficult for people living with HIV to clear HCV spontaneously. Previous infection doesn’t provide any immunity and therefore re-infection is possible
• Where symptoms are present, they include extreme tiredness, general aches and pains, itchy skin, nausea, loss of appetite, stomach pain, changes in bowel habit and mental confusion (brain fog) and depression. In some cases, yellowing of the eyes and skin (jaundice) may also develop
• Direct Acting Antivirals (DAA’s) are now available for the treatment of HCV which has increased complete clearance rates of the virus. Treatment typically lasts between 8 and 12 weeks, although this will be dependent on viral strain. Access to treatment for HCV may vary as NHS services in the devolved Nations (England, Scotland, Wales & NI) have different treatment policies in place
• Prior exposure and treatment to HCV does not provide any immunity and therefore reinfection can easily occur

Human Papilloma Virus (HPV)

• There are around 100 different types (strains) of Human Papilloma Virus (HPV). Most people will get an HPV infection at some point in their lives, which the immune system will keep in check or clear naturally without treatment
• There are around 40 strains which can affect the genital area, with strains 6 and 11 being associated with the development of genital warts. These strains do not cause the development of anal, cervical, penile or other cancers involving the head and neck
• People living with HIV have an increased risk of acquiring HPV which may include multiple strains. These can be more persistent and difficult to treat when compared to the HIV negative population. There is also a higher prevalence of HPV related conditions amongst people living with HIV
• The HPV vaccine (Gardasil) protects against genital warts which are caused by HPV type 6 and 11. The vaccine also protects against the development of pre-cancerous cells which is associated with HPV type 16 and 18 – see our page on Your Reproductive Health for further information on this
• Genital warts are often visible on or around the genital and anal area. They can also develop internally, within the vagina and anal canal in both men and women. They typically start off as small painless fleshy lumps, which can become larger or more widespread if not treated
• Symptoms of internal genital warts can include itching or bleeding from within the vagina or anus, a change of sensation where you can feel small lumps, or a consistent change in the normal flow when you pee
• Genital warts can be successfully treated but quite frequently return in the same area, which may require several attempts to completely remove them. Treatment can include topical cream or acid used at home, freezing using liquid nitrogen, or removal via minor surgery, which is often required in hard to treat cases

Genital herpes

• The herpes simplex is a viral infection which is very common in the general population and like HPV is kept in check naturally by the immune system. Many people don’t have any symptoms at all or just experience symptoms once. The herpes virus which causes genital herpes cannot be eradicated from the body and stays dormant except during active viral activity, referred to as outbreaks
• Almost all cases of genital herpes are caused by herpes simplex type 2 (HSV2), although it is possible for type 1 (HSV1 usually associated with cold sores) to also cause genital herpes. Dual infection with HIV can sometimes result in more severe or frequent outbreaks which take longer to resolve and completely heal
• Symptoms of genital herpes can include tingling, itching or a burning sensation on or around the genital and anal areas, and the development of tiny blisters which leave red sores when they burst. You may also experience pain when using the toilet. Women may experience unusual vaginal discharge during an active outbreak
• Treatment with antivirals such as acyclovir can help prevent recurrent HSV2 outbreaks. Treatment can be taken daily to prevent outbreaks occurring or taken on demand when the first symptoms are present

Syphilis

• Syphilis is a bacterial infection which can be easily passed on during sexual contact including oral, anal, vaginal sex and the sharing of sex toys. If left untreated syphilis can become a more serious health condition, affecting the heart, brain and nervous system
• It can be more difficult to treat syphilis in people living with HIV and there is a possibility the infection can progress more rapidly. The development of neurosyphilis can be a concern, particularly at lower CD4 cell counts
• Following initial infection, you may notice the development of a small painless ulcers (chancres) usually on or around the genitals and anal area. Ulcers can also occur in other areas including the mouth. These ulcers can be very difficult to spot and can easily go unnoticed
• Symptoms of syphilis include tiredness, fever, headaches, joint pain and swollen glands in the neck, groin and armpit. Blotchy red rash may develop on the palms of the hands and soles of the feet. Small skin growths may also develop around the vulva in women and the anus in both men and women
• Antibiotics are used to treat syphilis with follow-up monitoring required once the treatment has been completed. Treatment may need to be repeated if there is evidence the infection hasn’t cleared
• Antibodies for syphilis can be long lasting, but don’t provide protection against re-infection. It is always helpful to let your HIV/sexual health team know if you’ve previously been treated for syphilis
• Pregnant women are offered routine screening as part of their anti-natal care around 10 to 12 weeks into their pregnancy as syphilis infection can cause complications for the mother and unborn baby