Reproductive decision-making is an important, yet complex part of the lives of people living with HIV. The potential for transmission of HIV through either condomless sexual intercourse or vertical transmission, together with concerns about parental health and longevity, complicate the reproductive decisions for people living with HIV. Regulation of fertility services in relation to HIV has made access more difficult for people who are living with HIV than the general population. Providing reproductive health interventions that are grounded in principles of gender equality and human rights can lead to improved health status and quality of life.
People living with HIV may wish to plan pregnancies, to limit their families, or to avoid pregnancy and, therefore, require advice on and access to the full range of contraceptive methods. Hormonal contraception requires care in prescribing to avoid interactions with some antiretroviral drugs. However, the availability of newer antiretrovirals means that people living with HIV can have a greater choice of contraceptive methods that do not interact with their ART.
People living with HIV may request advice around safe conception and should have access to accurate information and support. Couples may be either seroconcordant (both HIV positive) or serodifferent (one partner HIV positive and one partner HIV negative). Conception by condomless sexual intercourse is the recommended option for serodifferent couples, where the partner living with HIV is on stable suppressive ART (fully suppressed for at least 6 months), and the couple should be counselled that HIV cannot be transmitted in this situation. In the era of routine recommendation of early ART for people living with HIV, and treatment as prevention (TasP), where the partner living with HIV is not on ART, or not on fully suppressive treatment, this should be reviewed and ART offered and/or optimised as appropriate.
Pre-exposure prophylaxis (PrEP) for HIV-negative partners of people with detectable viral loads may be considered to reduce the risk of acquisition of HIV by a partner who is HIV negative. Alternative methods of conception such as self-insemination can enable women living with HIV who are not receiving ARVs to become pregnant without risk of acquisition of HIV by a male partner who is HIV negative. However, people living with HIV should be made aware of the range of interventions that has been shown to reduce the risk of onward HIV transmission.
A major success in the management of HIV has been the prevention of vertical transmission. The high uptake of routine antenatal screening for HIV, coupled with appropriate management for women living with HIV prior to conception, during pregnancy and delivery, and effective postnatal care, results in UK vertical-transmission rates of 0.1–1%.
However, pregnant women living with HIV are particularly vulnerable to psychological and emotional distress and are likely to be at considerable risk of postpartum depression; agreed pathways to assess and respond to mental health issues during and post pregnancy should be in place.
Over 10,000 women of potentially menopausal age (between 45 and 56) attended for HIV-related care in the UK in 2016, a five-fold increase over a 10-year period. HIV and its treatment can predispose women living with HIV to a variety of metabolic complications, many of which are also associated with ageing and the menopause. There is limited evidence to suggest that women living with HIV may experience menopause earlier and with more severe symptoms than women without HIV. As earlier menopause is associated with an increased risk of cardiovascular disease and osteoporosis, it is important that modifiable risk factors for these conditions such as smoking cessation, reducing alcohol intake and increasing exercise are identified and addressed. Menopausal symptoms may also impact on people of non-binary gender and should be considered.
It is estimated that 85% of perimenopausal women in the general population experience menopause symptoms including hot flushes, sleep disturbance or mood change. Menopause hormone therapy, MHT, (previously referred to as hormone replacement therapy) has been shown to alleviate these symptoms in HIV-negative women as well as women living with HIV. Use of MHT is underutilised in women living with HIV, and in the absence of evidence on best management strategies for menopausal women living with HIV (including the efficacy and safety of MHT), management should be in accordance with current NICE menopause guidelines. MHT (both systemic and topical) is not contraindicated in women living with HIV for the management of menopausal symptoms. There may be drug interactions with some antiretroviral agents, requiring dose titration of MHT according to symptoms. In addition, topical vaginal oestrogens have very little systemic absorption with no drug interactions, and can greatly alleviate urogenital symptoms of the menopause.