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

2.0 Introduction and General Issues

2.1 Addressing the Sexual and Reproductive Health Needs of People Living with HIV/AIDS in the Era of Successful HIV Therapy

The incidence and prevalence of HIV infections continue to rise in the UK.[1,2] Because of the effectiveness of HIV treatment regimens there is now an increasing number of HIV-positive individuals living well on suppressive ART.[3] More attention is thus being given to the wider health needs of people living with HIV/AIDS (PLHA), including a renewed focus on SRH needs.

Men who have sex with men (MSM) (this term is used throughout to refer to homosexual men and other men who have sex with men - see Section 2.4) and culturally diverse heterosexual populations from sub-Saharan Africa account for large proportions of people living with HIV and accessing treatment and care services in the UK. It is recognized that any guidance on SRH must consider the diversity of needs of those living with HIV despite there sometimes being limited access to the specialized services required.

PLHA have the right to protect their own health and to enjoy meaningful sexual relationships and reproductive health. These rights come with responsibilities, however: in particular, to avoid passing infections on to others.

A number of key SRH issues for PLHA have been documented in the literature.

There have been several outbreaks of infectious syphilis and gonorrhoea in HIV-positive MSM[4,5] as well as a more recent outbreak of lymphogranuloma venereum.[6] It is well documented that HIV progression and transmission are increased and facilitated by STIs. Some groups have questioned whether the availability of HAART has resulted in an increase in unsafe sexual behaviour in some MSM.[7]

More HIV-positive women are choosing to have children,[8] and an increasing number of couples are requesting fertility investigations and assisted conception. Couples that are either seroconcordant (both HIV-positive) or serodiscordant clearly require different clinical management strategies.

In recent years there has been a fall in the prevalence of transmitted drug resistance in the UK: from 16% in 2002 to 9% in 2004.[9] Nevertheless, this suggests that transmission occurs from individuals taking HIV drug therapy who would therefore know of their infection. There is a need to develop health prevention messages and sexual health services for HIV-positive people. However, it should be remembered that most HIV transmission occurs in circumstances when individuals do not know their own status.

2.2 Objectives and Development of these Guidelines

The aim of these guidelines is to complement the existing guidance contained in the British HIV Association (BHIVA) guidelines on the management of HIV in pregnancy[10] and the BASHH guidelines on the management of STIs in people living with HIV,[11] syphilis with HIV[12] and PEP.[13] It also draws upon reproductive health guidance from the Clinical Effectiveness Unit of the Faculty of Family Planning (www.ffprhc.org.uk).

This is the first time that expert guidance from the three key UK specialist organizations has been brought together in one place. Central to the development of these guidelines was the involvement of PLHA and community organizations able to both address the specific needs of different PLHA populations and contribute to the knowledge and evidence for planning. These guidelines have been developed with the collaboration of PLHA groups and the voluntary sector, with representation on the writing committee.

2.3 Who are these Guidelines for?

These guidelines have been developed for use by healthcare staff in various disciplines including gynaecologists, staff in primary care, fertility experts and all those involved in the care of HIV-positive individuals. They will also be of use to a wider audience including commissioners, public health specialists and communities or individuals living with or affected by HIV.

2.4 The Use of Terminology

These guidelines cover many of the medical aspects of sexual health and reproduction in the presence of HIV infection. It is important that throughout the document and in practice, practitioners are sensitized to the emotional overlay between sexuality, sexual health and reproduction. At times, clear descriptive medical terminology may not capture the complexity of the emotional or relationship experience. In the HIV field, particular care has been taken to explore the meaning of terminology and avoid judgemental and potentially discriminatory language, even if unintentionally utilized. In this regard the HIV community has been invaluable in providing feedback and guidance on terminology. Clinicians should be aware and sensitive to this. Within the context of these guidelines, three such areas have been pointed out, and this document should be read and applied taking these into account. Adherence refers more accurately to medication taking, whereas compliance reflects a judgemental and unidirectional approach. The former term is preferable. Concordant and discordant couples describe HIV status accurately, but 'discordant' (although often utilized in the literature) may have a negative connotation. Sero-same and sero-different are often easier to describe. Similarly, 'men who have sex with men' may be descriptively accurate but may not acknowledge the divergence and complexity of relationships. In the context of sexual health, these very relationship variations are relevant. Clinicians should be aware of such terms.

2.5 Issues not Addressed Within the 2008 Guidelines

There are a number of evolving issues for which guidance will not be provided at this time but that are important enough to be mentioned:

  • human papilloma virus (HPV) vaccination;

  • the role of circumcision in HIV prevention;

  • the management of the menopause and hypogonadism in chronic HIV infection.

It was felt that there was insufficient evidence to provide definitive guidance at this time, although it is hoped that this will be available in future guidelines.

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