Sexual & Reproductive Health: Men, Women

Sexual and Reproductive Health of Women and Men Living with HIV

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
Male condom or female condom use
  • Effective in treated and untreated PLWH
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)
Pre-exposure prophylaxis (PrEP)
ART for HIV-positive partner
  • Considered effective from 6 months of fully suppressive ART if no active STIs
  • Consider in e.g. sero-different couples, see initiation of ART

Undetectable = untransmittable U=U [19], [20]. The evidence is now clear that people living with HIV 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

Reproductive Health

Ensuring that women and men living with HIV are asked about their reproductive goals at HIV diagnosis and in follow-up and receive appropriate and ongoing reproductive counselling is crucial. Providing contraception and family planning counselling to women living with HIV is essential if pregnancy is not currently desired

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

Approaches for sero-different couples who want to have children:
Start ART in partner living with HIV if naȉve.
Screening for STIs (and treatment, if required) of both partners is mandatory.

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

No single method is fully protective against transmission of HIV; the following list represents selected measures with increasing safety for sero-different couples without active STIs:

  • Unprotected intercourse during times of maximum fertility (determined by ovulation monitoring), if the partner living with HIV has undetectable HIV-VL
  • 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 necessary 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

Post-Reproductive Sexual Health

Screen for perimenopause symptoms in women ≥ 40 years, at HIV diagnosis and prior to starting ART. Follow up annually as indicated

Sexual Dysfunction

Guidelines for treatment of sexual dysfunction in the general population are available for men but not women. Refer to specialist where appropriate, see Sexual Dysfunction and Treatment of Sexual Dysfunction in Men Living with HIV

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. Diagnosis procedures should follow local or national guidelines. More comprehensive advice can be found at https://www.iusti.org/regions/Europe/euroguidelines.htm

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

  Therapy Comment
Chlamydia infection Consider doxycycline (100 mg bid po 7-10 days, contraindicated in pregnancy) for urethritis and cervicitis(i) For Lymphogranuloma venereum (LGV) doxycycline (100 mg po bid for 21 days)
Alternatives:
erythromycin (500 mg/6 h po(ii)) or levofloxacin (500 mg/ day) for 7 days (or 21 days in case of LGV)
  • May cause therapy-resistant proctitis in HIV-positive MSM
  • Consider co-infections with Neisseria gonorrhoeae
Gonorrhoea Ceftriaxone (500 mg im as a single dose)(i)
  • Can cause proctitis, prostatitis and epididymitis
  • In women often asymptomatic
  • Fluoroquinolone resistance is highly prevalent in all regions

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 HCV infection in HIV-positive MSM across Europe
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)
HSV infection

Primary infection: aciclovir (400-800 mg po tid), famciclovir (250-500 mg 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 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 orally twice daily) 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.)
  • Successful therapy clears clinical symptoms and decreases VDRL test four-fold within 6-12 months

Notes

  1. Refer to local guidelines
  2. Rarely used