British HIV Association, BASHH and FSRH Guidelines for the Management of the Sexual and Reproductive Health of People Living With HIV Infection 2008

A. Fakoya; H. Lamba; N. Mackie; R. Nandwani; A. Brown; E.J. Bernard; C. Gilling-Smith; C. Lacey; L. Sherr; P. Claydon; S. Wallage; B. Gazzard

Disclosures

HIV Medicine. 2008;9(9):681-720. 

In This Article

1.0 Summary of Key Points and Recommendations

Levels of evidence:

  • I = high-quality meta-analyses, systematic reviews of randomized control trials (RCTs);

  • II = other good-quality trials such as case-control or cohort studies;

  • III = non-analytic studies such as observational studies, case reports or case series;

  • IV = consensus or expert.

1.1 Sexual and Reproductive Health of Women and Men Living with HIV

1.1.1 Sexual Health Support. All HIV-positive individuals under regular follow-up should have:

  • a sexual health assessment, including a sexual history documented at first presentation and at 6-monthly intervals thereafter (II);

  • access to staff trained in taking a sexual history and who can make an appropriate sexual health assessment (III);

  • access to ongoing high-quality counselling and support to ensure good sexual health and to maintain protective behaviours (IV);

  • an annual offer of a full sexual health screen (regardless of reported history) and the outcome documented in the HIV case notes, including whether declined (II);

  • documented local care pathways for diagnosis, treatment and partner work for sexually transmitted infections (STIs) in people with HIV, which can be actively communicated to all clinic staff and to HIV-positive patients (II).

1.1.2 Management of Sexually Transmitted Infections in HIV-positive Men and Women.

  • The majority of STIs in people with HIV, including gonorrhoea and chlamydial infection, can be managed as in people without HIV (II).

  • STIs should be considered in the differential diagnosis of presentations such as skin rash or proctitis in HIV-positive patients (I).

  • Syphilis serology should be documented at baseline and at 3-monthly intervals and taken as part of the routine HIV blood set (unless indicated otherwise) to detect asymptomatic syphilis (II).

  • There are British Association for Sexual Health and HIV (BASHH) guidelines for the management of syphilis, genital herpes and warts in people with HIV. These should be referenced if managing individuals with these conditions (I).

1.1.3 Management of Hepatitis and Blood-borne Viruses. All HIV-positive individuals under regular follow-up should have:

  • hepatitis A, B and C screening at baseline; if not already immune to hepatitis B (HBV), they should be vaccinated against it regardless of sexual orientation (III);

  • screening for hepatitis B and C, which should be offered annually in those who have exposure risks (IV).

1.1.4 Post-exposure Prophylaxis.

  • All units should have explicit policies and procedures on post-exposure prophylaxis (PEP) following sexual exposure (IV).

  • All HIV-positive individuals should be made aware of the units' procedures to access PEP (IV).

1.1.5 Pre-conceptual Counselling, Natural Conception and Assisted Reproduction.

  • HIV-positive men and women and their partners planning to have children should receive pre-conceptual counselling on all their conception options, including HIV transmission risks associated with each case, so that they can make an informed choice (IV).

  • Detailed comprehensive pre-conceptual counselling should be available for couples considering conceiving. This should review the available options and the possible risks of each method. All discussions should be documented clearly in clinical notes (IV).

  • Clinics advising serodiscordant couples on risk-reduction strategies for natural conception should obtain signed consent that both parties understand and accept the small risks of HIV transmission (IV).

1.2 Cervical and Anal Pre-cancers and Cancers

1.2.1 Cervical Cancer.

  • All newly diagnosed HIV-positive women should have a sexual and gynaecological history as part of their initial medical assessment, including cervical cytology and a sexual health screen if appropriate (III).

  • Advanced HIV disease is the strongest independent risk factor for developing cervical abnormalities. All abnormal smears (mild dyskaryosis) should be referred to specialist colposcopy services (II).

  • Annual cervical smears are currently recommended (IV).

  • The management of cervical intraepithelial neoplasia (CIN) in HIV-positive women should not differ from that in the general population (III).

  • There is limited and controversial data on the effect of highly active antiretroviral therapy (HAART) on the natural history of disease; therefore, management of women should be the same whether they are receiving therapy or not (II).

1.2.2 Anal Cancer.

  • All major HIV units should develop clinical guidelines for the management of suspected anal cancer and pre-cancer (IV).

  • All major HIV units should develop either local clinical expertise or referral pathways for suspected anal cancer and pre-cancer (IV).

1.3 Psychosocial Issues

  • Psychological considerations are of key importance in several issues including conception and HIV in pregnancy, sexual behaviours to reduce HIV transmission and sexual functioning (II).

  • All units involved in HIV service delivery should consider the funding and provision for mental health and behavioural aspects of sexual and reproductive health (SRH) (IV).

  • An updated understanding of HIV prevention, risk behaviour, reproduction and mother/father perspectives should feed into policy and service provision (IV).

1.4 HIV sexual Transmission and HAART

  • HAART reduces the risk of HIV sexual transmission; for individuals with chronically suppressed viral loads, the transmission risk may be negligible in the absence of STIs (II).

  • In most circumstances, counselling and advice should continue to promote the use of condoms to reduce the transmission risk of HIV and other STIs (III).

  • Detailed individual counselling, including the use of harm reduction, should be available for individuals in sero-different and sero-same long-term relationships who wish to consider unprotected sexual intercourse (IV).

  • The risk of HIV superinfection may diminish with the time from initial infection. Although it appears more likely in the first 3 years following seroconversion, a risk persists after this (II).

  • HIV-positive individuals should be counselled regarding the low but possible risk of superinfection, particularly those who choose to serosort (i.e. have unprotected intercourse with partners who are also HIV-positive) (II).

1.5 HIV and Criminalization

  • Healthcare staff should be aware of the important legal issues regarding HIV transmission and their responsibilities to the duty of care of patients, confidentiality and public health concern (IV).

  • All units should develop local policies and guidelines on partner notification and disclosure (IV).

1.6 Contraception for Women with HIV Infection

  • Consistent condom use should be encouraged in conjunction with the additional contraceptive methods (II).

  • For HIV-positive women not on HAART, all available contraception methods are suitable (II).

  • A full choice of options for contraception should be discussed, with appropriate counselling about potential drug interactions and reduced contraceptive efficacy (III).

  • Because of potential interactions between antiretroviral therapy (ART) and the combined oral contraceptive pill (COC), ORTHO EVRA®, the progestogen-only pill (POP) and implants, these methods may be best avoided for women on HAART or other liver enzyme-inducing drugs (III).

  • There are no known adverse interactions between HAART and depot medroxyprogesterone acetate (DMPA), the levonorgestrel intrauterine system (LNG-IUS) and intrauterine devices (IUDs) (II).

  • For emergency contraception, an emergency IUD is the preferred option for women on ART. If Levonelle® 1500 is used, an additional dose (total 3 mg) is required for women on ART (III).

1.7 Reproductive and Sexual Health in Men

  1. Use of barrier contraceptives should be encouraged to prevent the spread of HIV, superinfection and co-infection with other STIs (I).

  2. Education on proper use appears to be more important than the thickness of the latex condom (II).

  3. There may be legal implication in having unprotected sex, particularly when an individual has not disclosed their HIV status and transmission occurs. This should be raised in the context of safer sex discussions. Further guidance should be sought from relevant sources (IV).

  4. The use of mineral oil-based lubricants with latex condoms, and the use of nonoxinol-9 (N-9), should be discouraged. There is no published evidence that specific antiretroviral (ARV) agents affect male fertility (III).

1.8 Investigation and Management of Sub-fertility in Men

  1. There is some evidence that men with advanced disease may have abnormal sperm production; optimizing HIV treatment should be part of the management of such men (III).

  2. Investigation should be in line with National Institute of Health and Clinical Excellence (NICE) guidelines; it is recommended that both partners undergo assessment (IV).

1.9 Erectile Dysfunction

  1. There is some evidence that men with HIV infection are more likely to experience erectile dysfunction (ED). This may adversely affect effective condom usage, and should be treated (III).

  2. There are some important drug interactions between PDE5 inhibitors and protease inhibitors (PIs), which may necessitate dose modification of the PDE5 inhibitor (II).

  3. Recreational drug use may affect condom use and erectile function, and needs to be assessed. Inhaled nitrates are contra-indicated when using PDE5 inhibitors (III).

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