Sexual & Reproductive Health

Screening questions about sexual and reproductive health and sexual function should be routinely asked at HIV consultation.

Sexual Transmission of HIV

Effective measures to reduce sexual transmission of HIV include:

U=U should be discussed with all persons with HIV, at diagnosis and when starting/switching ART. The evidence is clear that persons with undetectable VL do not transmit HIV sexually. In large studies of sexual HIV transmission among thousands of sero-different couples, (one partner living with HIV and one not), no cases of linked sexual transmission of HIV from a virally suppressed person with HIV on ART to their HIV-negative partner were observed. Within these studies, all HIV transmissions seen were not phylogenetically linked to within-couple transmission.

i  see Recommendations for Initiation of ART in Persons with Chronic Infection without Prior ART Exposure

Reproductive Health

All persons should be asked about their reproductive goals at HIV diagnosis and during follow-up and should receive appropriate and ongoing reproductive counselling. Providing contraception and reproductive counselling to women living with HIV is essential if pregnancy is not currently desired.

Conception:
Reproductive health issues should be preferentially discussed with all partners, particularly in sero-different couples. See Drug-drug Interactions between Contraceptives and ARVs  

Approaches for sero-different couples who want to have children:
Ensuring the partner living with HIV is on fully suppressive ART should be a primary goal for people who wish to conceive. Screening for STIs (and treatment, if required) of both partners is strongly recommended if conception is planned.

For ART in women living with HIV wishing to conceive, see Treatment of Pregnant Women Living With HIV or Women Considering Pregnancy

Intercourse without condom use is recommended as a preferred method of conception. In cases where the partner is living with HIV and is not on effective treatment or treatment adherence remains uncertain, the following should be considered:

• Intercourse without condoms during times of maximum fertility (determined by ovulation monitoring), if the partner living with HIV has undetectable HIV-VL
• PrEP in the absence of HIV viral suppression e.g. during the first 6 months of ART or if there is uncertainty about the partner living with HIV's adherence to ART, see Pre-exposure Prophylaxis (PrEP)
• Vaginal syringe injection of seminal fluid during times of maximum fertility if the male partner is HIV negative. Sperm washing, with or without intra-cytoplasmic sperm injection, is no longer recommended because of effectiveness of ART in avoiding HIV transmission at conception in male persons with HIV with undetectable HIV-VL

Contraception

Women living with HIV of childbearing age should be offered contraception counselling. If hormonal contraceptives are preferred options, EFV should be avoided as it can impair the efficacy of the contraceptive method. Boosted regimens can be used with some contraceptive methods, see Drug-Drug Interactions between Contraceptives and ARVs. Otherwise intra-uterine device should be offered as the preferred option due to its high effectiveness, well established safety and no DDIs. STI and HIV transmission risk should be carefully discussed along with contraception counseling

Menopause

Education
Healthcare providers should present accessible information on menopause to women and encourage the use of self-assessment tools (eg. Menopause Rating Scale (MRS), Greene Climacteric Scale (GCS), see also Mental Health, Depression: Screening and Diagnosis, Anxiety Disorders: Screening and Diagnosis

Screening
We recommend yearly, pro-active assessment of menopausal symptoms in women living with HIV aged > 40 years using a validated menopause symptom questionnaire, such as the MRS or GCS

Treatment for menopausal women

1. Topical (vaginal) hormone replacement therapy (HRT) should be considered in all women given the positive effects on sexual health and urogenital symptoms
2. Systemic HRT should be considered in women experiencing vasomotor, mood or urogenital symptoms.
3. Transdermal estrogen (with progesterone if a woman has a uterus) is the preferred HRT option due to the lower thromboembolic risk. See Drug-Drug interactions between HRT and ARVs
4. Women with premature ovarian insufficiency should be offered HRT until at least the expected age of menopause (eg. aged 50-52 years) to reduce longer term morbidity and mortality risk

Special considerations regarding transgender people

HIV and general medical care, including sexual health services, are often not designed to cover the specific needs of transgender people. Transgender people are often not included in gender-specific health care surveillance programmes.

Using a two-stage question helps both individual care and the development of appropriate services.
(i)   What is your current sex?
(ii)  Is this the same sex you were given at birth?

Sex, gender and sexuality

Although sex is sometimes wrongly decided at birth, it is also independent of sexuality. Specific care for people who are transgender includes medical issues linked to biology (for example cervical screen for some trans men) and social factors (linked to the design of services in a clinic setting, appropriate naming, gender-neutral facilities).

Sexuality cannot be assumed by either sex or gender

In general:

• ART is equally effective for trans and cis gender people
• Access to and management of gender affirming hormones should be sought
• See dosage recommendation for hormone therapy when used at high doses for gender transitioning
• Support for good sexual health and access to reproductive services are equally important for trans people
• There are minimal data about STIs

Sexual Dysfunction

Guidelines for treatment of sexual dysfunction in the general population are available. Refer to specialist where appropriate, see Sexual Dysfunction and Treatment of Sexual Dysfunction