Your reproductive health and HIV

Trans people living with HIV should expect the same standards of reproductive health as others living with HIV and their HIV negative counterparts. Access to reliable and up to date information about your reproductive health is a vital part of the holistic care provided by your HIV and sexual health clinic teams.

Trans people are significantly under-represented in much of the study data which is used to develop guidelines for their cis counterparts and therefore much more research is required. Here are some points to consider and discuss with your HIV, sexual health and your wider healthcare teams:

• As a trans person living with HIV you should be fully supported by your HIV clinic and wider healthcare teams so you can enjoy active, fulfilling sexual relationships, and have the same choices in respect of your reproductive health as other groups living with HIV
• HIV and sexual health clinic teams, together with your wider healthcare providers should be sensitive to the difficulties and barriers often faced by vulnerable groups such as the trans community. It is vital that suitable services and referral pathways are provided to support your physical, emotional and psychological health
• There is an important link with HIV and the Human Papilloma Virus (HPV). Infection with certain types (strains) of HPV are strongly associated with the development of abnormal cells within anus, cervix and penis
• 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. The HPV vaccination can help prevent the development of genital warts and other HPV associated cancers
• There is very little data to understand the interplay of HPV and HIV where trans people have had gender affirming lower surgery (vaginoplasty, phalloplasty or metoidioplasty). It is possible there is a similar risk of developing abnormal cells as seen in other groups living with HIV
• If you have anal sex with men, you may be at similar risk of developing abnormal cells in the anal mucous membranes as cis men who have sex with men. It is important to discuss any changes or sensations in or around the anus for further investigation to your HIV or sexual health clinic teams in the first instance
• Trans people who haven’t had gender affirming lower surgery can remain fertile, despite taking hormone therapy. Whilst fertility may be somewhat reduced, we suggest you talk to your HIV and sexual health teams about contraception to ensure the most suitable method is compatible with both your hormone therapy and treatment for HIV
• If you’re thinking about having children, you should be supported in your decisions and provided with good quality information so you can make informed choices. You (and your partner) should discuss suitable HIV prevention methods where your partner is HIV negative before trying to conceive
• Trans men wishing to conceive should be provided with up to date information to ensure they’re able to make fully informed choices in relation to the HIV treatment prior to trying to conceive and into pregnancy
• You should also 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
• Like many other people living with HIV trans people may have difficulties with sexual dysfunction and your clinic team should be sympathetic and provide the right level of support and referrals into specialised services

Hormone therapy and HIV treatment

Whether you’re established on hormone therapy or plan to start in the future, it’s important to discuss this with your clinic team prior to starting treatment for HIV. Here are some points to consider and discuss with your clinic team:

• Some medications for HIV can interact with hormone therapy. It’s important you and your clinic team carefully consider your HIV treatment options, with the input from other appropriate specialists
• Ensuring your HIV treatment fits into your lifestyle is also an important consideration. You should discuss your preferences in terms of single pill regimens, food and timing requirements with your HIV clinic team. You can find out more about treatment on our Plus Treatment page
• Where you’re already established on hormone therapy it is preferable that treatment for HIV reflects this and is optimised accordingly. Your Dr. is likely to discuss your case as part of a multi-disciplinary team to arrive at the most suitable treatment combination for you
• In some cases, it may be necessary to adjust your hormone therapy to ensure your treatment for HIV is fully effective. This may because of pre-existing health conditions or acquired drug resistance. It’s important you’re provided with good quality information so you can make informed choices in these situations
• As with all other prescription (and non-prescription) medications you should keep your clinic team up to date about any changes to your hormone therapy at your regular check-ups and discuss any plans you have to start hormone therapy in the near future

Treatment as Prevention (TasP) and reproductive health

We have overwhelming evidence that a person who is taking effective HIV treatment and has undetectable viral load cannot pass HIV onto their sexual partners, even where condoms aren’t consistently used. As with many other studies trans people living with HIV are under-represented in the various study data

Our Plus Undetectable page sets out the science and practical implications of TasP. Here are some points to consider and discuss with your clinic team:

• High levels of adherence should be observed where TasP is used as the main method of HIV prevention. It is important to be aware of the 6-month window period once your viral load has become undetectable to ensure full protection
• The majority of TasP studies defined undetectable viral load as being below 200. In the UK, clinics use viral load tests which detect down to 40 or 20. This provides further reassurances that undetectable really does mean untransmissible in the context of condomless sex
• Treatment options that 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
• Treatment for HIV doesn’t prevent you or your current partner(s) acquiring other STI’s. We therefore suggest you and your current partner(s) consider having a sexual health check-up before having condomless sex

Reproductive health for trans women

As a trans women living with HIV you should expect the same standard of reproductive health care as your HIV negative peer group. It’s important you feel supported, treated with dignity, given suitable choices and information about all aspects of your reproductive health. Living with HIV shouldn’t prevent you from forming and enjoying fulfilling sexual relationships.

As outlined in our Your Sexual Health page, it’s important to pay particular attention to some sexually transmitted infections (STI’s), as these can have implications for maintaining good reproductive health. One of the important things to monitor in relation to reproductive health is the Human Papilloma Virus (HPV) and specifically the development of pre-cancerous cells which can affect trans women living with HIV.

Human Papilloma Virus (HPV)

Infection with certain types (strains) of Human Papilloma Virus (HPV) are associated with the development of abnormal cells within the anal and genital mucous membranes. HPV is very common amongst the general population and many people are likely to be exposed to HPV at some point in their lifetime. 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 and difficult to treat when compared to their HIV negative peer group. Strains 16 and 18 of HPV are strongly linked with the development abnormal cells, which can be treated successfully once diagnosed at an early stage.

Here are some points to consider and maybe discuss with your HIV or sexual health teams:

• HPV vaccination history for trans women should be discussed upon initial HIV diagnosis, bearing in mind the HPV vaccination hasn’t historically been offered to those previously assigned male gender at birth
• Although trans women aren’t at risk of developing cervical cancer, they may be at risk of developing anal, and genital cell abnormalities. The benefit of the HPV vaccine should be discussed with your clinic team based on your sexual preferences and activity
• Unvaccinated trans women living with HIV can be offered the HPV vaccine up to the age of 26 regardless of CD4 cell count, treatment for HIV, viral load or hormone treatment. Trans women may also be offered the HPV vaccination as part of the national vaccination program up to the age of 45 where it is felt they may benefit, which is determined on a case by case basis
• Routine screening for HPV isn’t currently indicated for trans women. Investigation and monitoring for HPV is therefore guided by individual circumstances and the development of symptoms or noticeable changes. Where gender affirming lower surgery has been completed, any unexplained post-operative vaginal pain or bleeding should be investigated, and HPV involvement considered, due to the increased risk of HPV related cancers seen in other groups living with HIV

Thinking about having children?

Trans women may have the same desires as their cis counterparts to have children and enjoy family life. You (and your partner) should be afforded the same level of understanding, dignity and care as provided to cis people who are also living with HIV when thinking about having a family.

Assisted conception may be available where semen samples have been stored prior to the use of oestrogen therapy, although additional funding requests may be required in these circumstances. There is very little study data relating to a return to fertility in trans women living with HIV who wish to have children. There is some evidence that suggests long-term exposure to oestrogen may cause testicular damage, which may reduce fertility levels. Referral to a specialist fertility clinic would be beneficial to discuss suitable options to become a parent.

HIV itself is unlikely to have a major impact on your ability to have children where fertility has been restored. In some cases, fertility may be reduced as a result of low CD4 cell count or by HIV associated illness or treatment. Sexual dysfunction can also be a factor for some trans people living with HIV, which may impact on the ability to conceive naturally.

Here are some points you may wish to discuss with your HIV clinic and wider healthcare teams:

• It’s important your HIV, sexual health and wider healthcare teams work together to ensure you (and your partner) are fully supported and the options available to become parents are fully explored and explained
• Self-insemination may be a suitable option for trans women to consider where viral load is at undetectable levels for 6 months or longer. Semen can be captured in a sterile container and then given to your surrogate or partner to place within their vagina to allow conception to occur. This method isn’t suitable if you have dual infection with hepatitis B or C. Sperm washing recommended is in this situation
• Pre-Exposure Prophylaxis (PrEP) for your HIV negative surrogate or partner may be considered where you have deferred treatment for HIV. In this situation all parties should receive suitable information and counselling so they can make informed decisions. You can find out more about PrEP by visiting IWantPrEPNow or Cliniq websites
• PrEP for HIV negative partners isn’t indicated where your viral load is undetectable and has been for 6 months or longer. PrEP may be considered where there are concerns about HIV transmission by either party
• Sperm washing is an option where you wish to defer starting treatment for HIV, although this isn’t available in all areas in the UK and may require an additional funding request. Sperm washing isn’t recommended where your viral load is undetectable
• If you’re having difficulties with sexual dysfunction it’s beneficial to discuss this with your clinic and wider healthcare team. Some larger regional HIV and sexual health centres provide specific services for sexual dysfunction including psycho-sexual support for trans women and their partners
• Some medications used to treat sexual dysfunction have interactions with HIV medications, particularly those that contain a boosting agent (cobicistat or ritonavir) or those containing efavirenz, rilpivirine, etravirine and nevirapine. It’s important to check for any interactions with your pharmacist or clinic team
• We suggest you and your partner obtain expert help and support when thinking about having children, which involves a multi-disciplinary team approach, which includes HIV, fertility and assisted conception specialists

Contraception for trans women

The need for contraception will be determined by several factors, including gender affirming lower surgery, your sexual preferences and those of your partner(s). It’s important that trans women living with HIV have the opportunity to discuss contraception methods with their clinic team and wider healthcare providers. This can help you make informed choices about contraception and overcome any difficulties you may be experiencing.

Some points to consider or discuss with your HIV clinic or sexual health team include:

• Worries about HIV transmission and the use of oestrogen therapy can lead to sexual dysfunction which can make consistent and correct condom use difficult. Therefore, condoms may not be a suitable method of contraception for some trans women
• There is a higher incidence of sexual dysfunction amongst people living with HIV than their negative counterparts. This may be linked to psycho-sexual difficulties or physical health problems as a result of HIV and/or in the context of changes to gender identity
• Some larger regional HIV clinics have specialised services for trans women who experience sexual dysfunction and psychosexual difficulties. Smaller local clinics should offer appropriate levels of support and have an appropriate referral pathway in place. It’s important that your HIV, sexual health and wider healthcare team work together to provide the very best outcomes
• Physical conditions including obesity and high cholesterol are also associated with sexual 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 sexual dysfunction which can result in a loss of confidence when using condoms. Moving towards a healthier lifestyle can significantly improve sexual 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 HIV drugs may cause sexual dysfunction, which can impact on correct and consistent condom use

Reproductive health for trans men

As a trans men living with HIV you should expect the same standard of care for your reproductive health as your HIV negative peer group. It’s important you (and your partner) feel supported, treated with dignity, given suitable choices and information about all aspects of your reproductive health. Living with HIV shouldn’t prevent you forming and enjoying fulfilling sexual relationships.

The ability to have children can be an important aspect for trans men who haven’t had lower gender affirming surgery. Trans men living with HIV (and their partners) who have plans to have children should be fully supported in their decisions and provided with high quality information.

As outlined in our Your Sexual Health page, it’s important to pay particular attention to some sexually transmitted infections (STI’s), as these can have implications for maintaining good reproductive health. One of the important things to monitor in relation to reproductive health is the Human Papilloma Virus (HPV) and specifically the development of pre-cancerous cells which can affect trans men living with HIV.

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 and anus. HPV is very common amongst the general population and many people are likely to be exposed to HPV at some point in their lifetime. 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 difficult to treat when compared to their HIV negative peer group. Strains 16 and 18 of HPV are strongly linked with the development abnormal cells, which can be treated successfully once diagnosed at an early stage.

Here are some points to consider and discuss with your HIV or sexual health teams:

• HPV vaccination history should be discussed upon initial HIV diagnosis with the type and number of vaccination doses previously received as part of the national vaccination program. If you’ve not been previously vaccinated, you should be offered the HPV vaccination up to the age of 26 regardless of CD4 cell count, treatment status or viral load
• Where you have sex with other men the HPV vaccination may be offered up to and including the age of 45. The age cut off may be extended where an individual may benefit from the HPV vaccination outside the national vaccination program, which is determined on a case by case basis
• If the cervix has been removed the benefit of the HPV vaccine should be discussed based on sexual preference and those of your partner. The HPV vaccine can help prevent anal, throat and neck cancer
• The British HIV Association (BHIVA) endorse the view that annual cervical screening is important for anyone who has a cervix between the ages of 25 and 65. There is good evidence that a higher proportion of people living with HIV have HPV which is linked to the development of pre-cancerous abnormal cervical cells
• Where your cervix is still present it’s important to attend for annual cervical screening which can be performed by you GP, sexual health or your wider healthcare team. The clinical reason for annual cervical screening should be documented on the sample request form, without this the sample may be rejected. It’s worth checking this information has been completed
• Colposcopy examination is also recommended upon HIV diagnosis where your cervix is still present. 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. Colposcopy examination can also be offered for trans men diagnosed with HIV after the age of 25 and for those with previous cervical abnormalities or a long interval since last screening
• If any low-grade cell abnormalities are found, these may not require any treatment, as they often don’t progress and may resolve over time. Close monitoring is therefore an important to ensure any changes are identified
• Where your gender has been assigned male on your medical records, you won’t automatically receive an invite for cervical screening. Your GP or other healthcare provider should ensure you receive an 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 check-ups
• After the age of 65 there is no requirement to attend for cervical screening, unless you fulfil the criteria for ongoing monitoring due to the development of abnormal cells

Thinking about having children?

Trans men often have the same desires as their cis counterparts to have children and for some trans men it may be possible to conceive and bear children. You (and your partner) should be afforded the same level of understanding and care as provided to cis individuals who are also living with HIV when thinking about having a family.

Assisted conception may be available where eggs or ovarian tissue have been cryogenically stored prior to the use of testosterone hormone therapy, although additional funding requests may be required in these circumstances. Testosterone therapy for trans men reduces ovulation and causes changes to the menstrual cycle which can prevent successful conception.

There is very little study data relating to a return to fertility for trans men living with HIV who wish to become pregnant. This may be possible in some cases once testosterone therapy is stopped. Some studies suggest this can take up to 6 months for the menstrual cycle to return. Referral to a specialist fertility clinic may be required to discuss suitable options to become a parent.

HIV is unlikely to have a major impact on your ability to conceive. It is possible that in some cases, fertility may be reduced as a result of low CD4 cell count or by any associated illness or treatment. Sexual dysfunction can be a factor for some trans people living with HIV, which may impact on the ability to conceive naturally.

Here are some points you may wish to discuss with your HIV clinic and wider healthcare teams:

• If you are of childbearing age, your clinic team should talk to you 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
• Where you (and your partner) wish to have children it’s important your HIV, sexual health and wider healthcare teams work together to ensure you (and your partner) are fully supported and the options available to become a parent are fully explored and explained
• Current guidelines covering condomless penetrative sex to enable conception for people living with HIV don’t necessarily reflect up to date position in relation to treatment as a method of prevention. It is now recommended that you start your treatment as soon as possible following your HIV diagnosis
• If you’re not established on HIV treatment for your own health and you wish to conceive by having condomless vaginal sex, you are advised to start treatment to achieve undetectable viral load before trying to conceive. Achieving and maintaining undetectable viral load during pregnancy will ensure your baby can be born HIV negative
• Where you have detectable viral load, Pre-Exposure Prophylaxis (PrEP) may be a suitable option for your HIV negative partner (or donor) where you wish to conceive by having condomless sex. In this situation you and your partner should receive suitable information and counselling so you can make informed decisions
• PrEP isn’t indicated for HIV negative partners where your viral load is undetectable and has been for 6 months or longer. PrEP may be considered where you or your partner have worries about HIV transmission, despite your viral load being undetectable. You can find out more about PrEP by visiting IWantPrEPNow or Cliniq websites
• Assisted conception or self-insemination may be a suitable alternative way to conceive where you have deferred treatment for HIV prior to and during the conception period. It is important to discuss the options available to you (and your partner) with your HIV and wider healthcare team
• If you’re established on HIV treatment it may be necessary to review this prior to conception and into pregnancy. This is to ensure your treatment is the most suitable during the conception period and you can remain undetectable throughout your pregnancy
• Making changes to lifestyle prior to conception and beyond is an important consideration for all women wishing to conceive. High dose folic acid supplementation (5mg) is recommended prior to conception or as soon as pregnancy is achieved and continued throughout pregnancy. Vitamin D supplementation should also be considered as people living with HIV tend to have lower levels of vitamin D than the general population

Becoming pregnant and HIV

As has been previously mentioned it may be possible for trans men living with HIV to conceive, have a normal pregnancy and give birth to healthy HIV negative babies. The specific care of pregnant trans men living with HIV isn’t particularly well understood and much more research is required. It’s important that you (and your partner) are well supported during your pregnancy and beyond. Here are some points to consider and discuss with your clinic and wider healthcare teams:

• Once there has been a return to fertility and you’re taking successful treatment for HIV you should be able to become pregnant and go on to have a normal pregnancy. Regular monitoring by your HIV, obstetric, and wider healthcare teams should be the routine standard of care you receive
• 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 drug)
• 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 here 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 for trans men

Hormone therapy isn’t a completely reliable form of contraception where you haven’t had gender affirming lower surgery. Appropriate contraception should be considered if you have penetrative frontal sex with men and you don’t wish to become pregnant. Pregnancy is contraindicated with testosterone therapy, as this can result in the masculinisation of a female foetus.

Most of the available methods of contraception are suitable for trans men living with HIV. Combined hormonal contraception which contains oestrogen isn’t suitable for use with testosterone therapy. Some medications used to treat HIV interact with hormonal contraception and this should be discussed with your HIV, sexual health and wider healthcare teams so the most suitable contraceptive options can be provided.

Hormonal contraception

• Where you’re already established on an effective form of hormonal contraception, your HIV treatment options should reflect this where possible, so you can remain on your current hormonal contraception method
• If you have a pre-existing health condition, acquired HIV drug resistance or if you have a preference for a single pill regimen, it may be necessary to make adjustments to your hormonal contraception to ensure your HIV treatment is fully effective
• We suggest you have discussions with your clinic team at least on an annual basis, or more frequently where required, regarding your current method of contraception. This is particularly important where you’re established on HIV treatment and you would like to change your method of contraception
• 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

• Condoms, including internal condoms are a very good option when used consistently and correctly as a method of contraception where you have penetrative frontal sex with other men. Condoms also prevent HIV transmission during frontal and anal sex where you have detectable viral load. They also provide effective protection against other STIs
• Other barrier methods include caps and diaphragms which cover the cervix and part of the upper vagina, where present. This means a large part of the vagina isn’t covered by an effective barrier and therefore transmission of HIV and other STIs can still occur where you have detectable viral load
• Testosterone therapy can cause the lining of the vagina to become thinner and more fragile which can increase the risk of acquiring other STI’s. In addition, vaginal secretions are reduced, which may require the use of additional lubrication to prevent trauma to the vagina during frontal penetrative sex
• If you’re using condoms as your sole method of contraception, you should be made aware of how to access emergency contraception in the event of a condom or device failure. Where you have detectable viral load, your HIV negative partner should consider Post Exposure Prophylaxis (PEP) as soon as possible after the failure occurring, ideally within 24 hours, but no longer than 72 hours (3 days)
• Discussing the most appropriate form of barrier contraception with your clinic and sexual and reproductive health team is important to ensure any risks of unintended pregnancy are also balanced with any possibility of HIV transmission, where you have detectable viral load

Intrauterine device contraception (Coil)

• Copper coils (CU-IUDs) and the Mirena coil (Levonorgestrel Intrauterine System LNG-IUS) provide a convenient and safe method of contraception for trans men who haven’t elected to have gender affirming surgery. There are no interactions with testosterone therapy and HIV treatment
• If your CD4 cell count is below 200 there may be increased risk of infection when a coil is fitted. Where your viral load is undetectable the copper coil (CU-IUDs) may be used, depending on your individual circumstances. If you already have a copper coil in place, you can continue to do so where CD4 is below 200
• Coils do not provide protection against HIV transmission or other STIs, therefore condoms should be used consistently and correctly where either your viral load is detectable

Emergency contraception

• Emergency contraception (coil and hormonal) can be used by trans men living with HIV, although there are important considerations to take into account based on your HIV medication, CD4 cell count and viral load. Testosterone therapy isn’t thought to have any impact on the effectiveness of emergency contraception
• If you’re taking treatment for HIV, have undetectable viral load and your CD4 count is above 200 a copper coil (CU-IUD) is the most effective method of emergency contraception for trans men
• Where your CD4 cell count is below 200 oral emergency contraception (the morning after pill) may be more appropriate, although 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
• There are 2 different morning after pills, Levonelle & Ellaone. It’s important to let the prescribing healthcare professional know which medications you’re taking for HIV. This will ensure any interactions with your HIV medication can be avoided. The morning after pill is available at sexual health clinics, community pharmacies and some A&E’s walk-in centres
• It’s particularly important to discuss your HIV treatment with the prescribing pharmacist if you purchase the morning after pill, rather than obtaining it via prescription. 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
• Where there has been a condom failure for either frontal of anal sex and you have detectable viral load, your HIV negative partner should consider Post Exposure Prophylaxis (PEP) as soon as possible after the failure occurring, ideally within 24 hours, but no longer than 72 hours (3 days)