Sexual and Reproductive Health of PLWH

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:

Measure	Comment
ART for HIV-positive partner	Undetectable equals untransmissible (U=U) from 6 months of fully suppressive ART if no active STIs Consider in e.g. sero-different couples(i)
Pre-exposure prophylaxis (PrEP)	Effective in HIV-negative persons with high risk sexual situations, see Pre-exposure prophylaxis (PrEP)
Post-exposure prophylaxis (PEP)	Consider after situations of unprotected anal or vaginal intercourse, if one partner has detectable HIV-VL and the other partner is seronegative Start as soon as possible and within 48/72 hours post sexual exposure, see Post-exposure prophylaxis (PEP)
Male condom or female condom use	Effective in treated and untreated PLWH

U=U should be discussed with all PLWH, at diagnosis and when starting/switching ART. The evidence is now clear that PLWH with an undetectable VL do not transmit HIV sexually. Large studies of sexual HIV transmission among thousands of sero-different couples, one partner of which was living with HIV and the other was not, were undertaken in recent years. In those studies, there was not a single case of linked sexual transmission of HIV from a virally suppressed PLWH to their HIV-negative partner. However, a person can only know whether he or she is virally suppressed by taking a VL test.

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

Reproductive Health

All PLWH should be asked about their reproductive goals at HIV diagnosis and in follow-up and 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

The following list represents selected measures with increasing safety for sero-different couples without active STIs:

• 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 uncertainty about HIV-positive partner’s adherence, 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 PLWH 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 in PLWH, 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

General health risk assessment for women age > 40 years

1. Cancer, see Cancer screening methods
2. Assessment of bone mineral density (BMD), see Bone Disease: Screening and Diagnosis 
   1. Assess risk factors for low BMD. If BMD is normal at initial assessment, consider fracture risk using FRAX® every 3-5 years
   2. Consider DXA in women with 10-year major osteoporotic fracture risk > 20% based on FRAX® regardless of menopausal status
   3. Consider DXA in women with prior history of low impact fracture regardless of menopausal status
   4. Reassess DXA in those with osteoporosis after 2 years if on treatment to ensure response and reassess need for continued treatment after 3-5 years
3. CVD risk assessment yearly, especially in women with vasomotor symptoms, see Prevention of Cardiovascular Disease
4. Mental health - screen for anxiety and depression, consider screening tools such as GAD-2, see also Mental Health in PLWH, Depression: Screening and Diagnosis

Treatment for menopausal women

1. Topical (vaginal) hormone replacement therapy (HRT) should be considered in all woman 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
• 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 in PLWH

 

STI screening and treatment

STI screening should be offered to all sexually active PLWH at the time of HIV diagnosis, annually thereafter or at any time STI symptoms are reported and during pregnancy. More frequent screening at three-month intervals is warranted for PLWH at particularly high risk of STIs, including those with multiple or anonymous partners. Frequent HIV screening is also essential for those on PrEP, see Pre-exposure Prophylaxis (PrEP)

Diagnosis procedures should follow local or national guidelines. More comprehensive advice can be found at https://iusti.org/treatment-guidelines/

The following STIs should be universally considered in PLWH and their sexual partner(s):

	Therapy	Comment
Chlamydia infection	Consider doxycycline (100 mg po bid 7-10 days, contraindicated in pregnancy) for urethritis and cervicitis (i) Preferred if rectal infection Or alternatively: azithromycin 1 g po as a single dose If rectal infection a test of cure (TOC) should be performed For Lymphogranuloma venereum (LGV) doxycycline (100 mg po bid for 21 days) Alternatives: erythromycin (500 mg po qid(ii)) or levofloxacin (500 mg/day po) for 7 days (or erythromycin 500 mg po qid(ii) for 21 days in case of LGV)	May cause therapy-resistant proctitis in HIV-positive MSM Screening recommended at genital, rectal and pharyngeal sites according to exposure Rectal and pharyngeal infections are usually asymptomatic Consider co-infections with Neisseria gonorrhoeae Avoid sexual activity for 7 days post treatment initiation Individuals should only resume having sex after symptoms have resolved and sex partners have been treated The same treatment for LGV is recommended for asymptomatic individuals and contacts of individuals with LGV
Gonorrhoea	Ceftriaxone (1 g im as a single dose)(i)	Can cause proctitis, prostatitis and epididymitis Screening recommended at genital, rectal and pharyngeal sites according to exposure Rectal and pharyngeal infections are usually asymptomatic Often asymptomatic in women Avoid sexual activity for 7 days post treatment initiation Individuals should only resume having sex after symptoms have resolved and sex partners have been treated Fluoroquinolone resistance is highly prevalent in all regions Note ceftriaxone 1 g im as a single dose is based on recent BHIVA recommendations, https://www.bhiva.org/guidelines. IUSTI Guidelines recommend 500 mg im with azithromycin 2 g as a single dose, however these recommendations have not been updated in several years, https://iusti.org/regions/guidelines/
HBV infection HCV infection	See detailed information on HIV/HCV or HIV/HBV co-infections.	Interruption of TDF, 3TC or FTC can lead to HBV reactivation Clusters of acute HAV and HCV infection in HIV-positive MSM across Europe See Vaccination
HPV infection	There are several treatment modalities for the management of genital warts with no evidence to suggest one approach is better than another approach. Consider operative removal by laser surgery, infrared coagulation, cryotherapy, etc. Management of both pre-invasive cervical lesions as well as peri- and intra-anal lesions should follow local or national guidelines	Infection is mostly asymptomatic; relapse of genital warts is frequent Cervical PAP smear test recommended in all HIV-positive women Anal HPV screening and cytology should be considered in all PLWH practicing anal sex Consider high resolution anoscopy in case of suspicious cytological findings (rectal palpation or external inspection is not sufficient) See Vaccination
HSV infection	Primary infection: aciclovir (400-800 mg po tid), famciclovir (250-500 mg po tid) or valaciclovir (1000 mg po bid) for 7-10 days Recurrent episodes: aciclovir (400 mg po tid) or valaciclovir (500 mg po bid) for 5-10 days Suppressive management: Chronic suppressive therapy is usually offered to persons who experience six or more clinical episodes per year or who experience significant anxiety or distress related to their clinical recurrences. Chronic suppression: aciclovir (400-800 mg bid or tid) or famciclovir 500 mg bid or valaciclovir 500 mg po bid	Treatment of HSV2 alone does not prevent HIV-transmission and only modestly prevents HIV disease progression
Syphilis	Penicillin is the gold standard for the treatment of syphilis in both pregnant and non-pregnant individuals. Primary/secondary syphilis: benzathine penicillin G (2.4 million IU im as single dose). In early syphilis adjunctive treatment with prednisolone (20-60 mg po daily for 3 days) prevents optic neuritis, uveitis and Jarisch– Herxheimer reaction Alternative regimen include doxyycline (100 mg po bid for 14 days) Late latent syphilis and syphilis of unknown duration: benzathine penicillin (2.4 million IU im weekly on days 1, 8 and 15); the alternative doxycycline (100 mg po bid for 4 weeks) is considered less effective Neurosyphilis: penicillin G (6 x 3 - 4 million IU iv for at least 2 weeks) There is no evidence to give a general recommendation on prednisolone use in this condition Alternative regimen: ceftriaxone (2 g iv daily for 10 to 14 days) if the person can be safely treated with other beta-lactam drugs. Doxycycline (200 mg po bid) for 21 days is also an alternative approach, but should be reserved for exceptional circumstances. This regimen has very limited supporting data(i)	Expect atypical serology and clinical courses Consider cerebrospinal fluid (CSF) testing in persons with neurological symptoms (evidence for intrathecally-produced specific antibodies, pleocytosis, etc.) or late latent syphilis Successful therapy clears clinical symptoms and decreases VDRL test four-fold within 6-12 months

 

1. Refer to local guidelines
2. Rarely used