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

6.0 Sexual and Reproductive Health Issues for Men

6.1 Male Condoms and Other Contraceptive Methods

Prevention is still the mainstay of the response to the HIV/AIDS pandemic. The male condom is the single most effective intervention to prevent HIV transmission and the transmission of other STIs from men to women, from women to men and between men.[209,210,211] The use of mineral oil-based lubricants with latex condoms should be discouraged - because of condom damage and increased breakage rates[212] - in favour of water-based lubricants that do not contain N-9. Although latex and polyurethane condoms such as Avanti™ appear equally efficacious at preventing pregnancy,[190,213] no comparative studies looking at HIV transmission have been published. There has been one randomized study that concluded that 'thicker' latex condoms marketed for anal sex were no more effective than condoms of normal thickness.[214]

The use of microbicides such as N-9 can cause a significant increase in genital symptoms, and epithelial disruption[192] may cause rapid rectal epithelial exfoliation;[193] a major study in high-risk women[194] and a meta-analysis[195] do not show any protection against STIs. Given the effects on the genital epithelium the use of N-9 cannot be recommended except in groups at low risk of acquiring STIs and HIV.

6.1.1 Key Points and Recommendations.

  • Use of barrier contraceptives should be encouraged to prevent spread of HIV, superinfection and co-infection with other STIs.

  • Education on proper use appears to be more important than the thickness of the latex condom.

  • There may be legal implications 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. These include medical defence organizations, the Terence Higgins Trust (UK-wide), the National AIDS Trust (UK-wide), George House Trust (north-west England) and HIV Scotland (Scotland).

  • The use of mineral oil-based lubricants with latex condoms, and the use of N-9, should be discouraged.

6.2 Investigation and Management of Sub-fertility in Men

There are few published data on the direct effect that HIV/AIDS has on the fertility and semen quality of infected men. However, two studies have shown little effect of HIV (or HCV) on sperm production[215,216] compared to WHO criteria. One study in the pre-HAART era showed that men with advanced disease, and not on zidovudine monotherapy, had reduced sperm counts and an increased percentage of abnormal sperm forms, but no significant impairment at CD4 cell counts of over 200.[217] However, there is a single case report of reduced semen parameters in an individual whose semen was analysed prior to and after HIV-1 seroconversion.[218]

The effect of specific ARV agents on human sperm production has not been published. One study[219] showed no adverse effect of HAART on sperm production but confirmed that those with CD4 cell counts <200 cells/µL were more likely to have lower sperm counts. Another study looked at men on HAART requesting assisted reproductive technology, and showed some impairment of sperm motility, total sperm counts and ejaculate volume compared to matched seronegative controls. This study also showed a correlation with lower CD4 cell count and increased abnormalities, but the differences observed were probably not marked enough to alter fecundity.

In the absence of good evidence that treated or early HIV disease affects male fertility, it is prudent to follow the NICE guidelines[220] in the investigation and management of male sub-fertility in these men. Patients with low CD4 cell counts or advanced disease with abnormal semen should be advised that optimizing ART, with a rise in CD4 cell count, may improve semen quality,[221] but direct evidence of this is lacking and such men should be assessed and investigated to exclude other causes of sub-fertility according to national guidelines.

6.2.1 Key Points and Recommendations.

  • There is no published evidence that specific ARV agents affect male fertility.

  • There is some evidence that men with advanced disease may have abnormal sperm production; therefore, optimizing HIV treatment should be part of the management of such men.

  • Investigation and management should be in line with NICE guidelines and it is recommended that both partners undergo assessment.

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