Good sexual health is part of good overall health. The impact of living with HIV, a potentially stigmatising sexually transmissible infection, which may have been acquired through sexual or non-sexual routes, should not be underestimated, and is associated with sexual dysfunction and psychosexual morbidity. People living with HIV and their partners require access to appropriate, culturally sensitive and effective information and support about sexual behaviour and minimising transmission risks. Practitioners need knowledge and expertise to be able to sensitively discuss sex and sexuality, safer sexual practices, HIV transmission risk in the context of effective therapy and preventative therapy for contacts, HIV disclosure and fear of criminalisation.
Guidelines produced by BHIVA, BASHH and the FRSH on the sexual and reproductive health of people living with HIV should be followed (www.bhiva.org/SRH-guidelines-consultation). Practitioners should be up to date on key emerging issues affecting sexual risks, such as chemsex, hepatitis outbreaks, and STEI and be able to counsel and support accordingly. STIs are more common in people living with HIV, and they are at a greater risk of complications from STIs such as hepatitis A, B and C, human papilloma virus (HPV), herpes simplex virus (HSV) and syphilis. MSM who are living with HIV have a higher prevalence of bacterial STIs including syphilis and lymphogranuloma venereum (LGV), viral infections including hepatitis C and of emerging STIs such as STEI.
Prompt identification and treatment of all STIs is important as concomitant infection increases the risks of HIV transmission/acquisition. Those who are living with HIV should be provided with information on STI risks and outbreaks at their routine HIV appointments so they can identify whether additional testing is required. In the case of outbreaks, it may occasionally be necessary to advise and recall prior to the next appointment.
Sexual healthcare should be primarily for the benefit of the individual, and the cornerstone of sexual healthcare is open access to a specialist, confidential service with treatment for STIs provided without charge. The clinical care of the individual person should not be compromised by anxieties about any legal issues relating to sexual transmission of HIV.
Partner notification for HIV (and other STIs) is an important public health strategy, facilitating early diagnosis among known sexual partners, where unprotected sex has occurred in the presence of a detectable HIV viral load. Onward HIV transmission can be minimised by ensuring sexual partners are aware of the presence of HIV within the relationship and by the effective use of ART.
Prevention strategies are key and, as discussed in Standard 1b, include risk-reduction counselling and antiretroviral medication, either as prophylaxis for negative partners or as treatment as prevention (TasP), meaning that a person living with HIV who is on ART and has achieved an undetectable viral load in their blood for at least 6 months cannot transmit HIV to their sexual partners.
It is important to note that an undetectable HIV viral load only prevents HIV transmission. Condoms also help prevent HIV transmission as well as other STIs and pregnancy. The choice of HIV prevention method may be different depending upon a person’s sexual practices, circumstances and relationships. For instance, if someone is having sex with multiple partners or in a non-monogamous relationship, they might consider using condoms to prevent acquisition of other STIs.
People living with HIV should be able to access appropriate sexual health support and guidance and may require specific help when telling past and present sexual and/or injecting partners about being HIV positive.