1. Supporting HIV-affected Women and Men to Safely Meet Reproductive Goals: Insights into Contraception, Safer Conception, and Infertility Prevalence, consequences and key issues in the management of infertility and subfertility among men and women living with HIV
Dr. Jolly Beyeza-Kashesya
Mulago National Referral Hospital
Kampala, Uganda

2. Having a desire and intention to conceive does not translate into conception and childbearing
Fertility decisions (Mental fertility regulation)
Fecundity (biologically fertile)

3. Prevalence of infertility among the population compare to the HIV Affected couples.
Global rates of infertility remain unchanged over past 2 decades
50 million couples worldwide are unable to have a child after five years of trying
10% of the population
Sub-Saharan Africa
Fertility is 25– 40% lower in HIV-1 infected women than uninfected controls.

4. Consequences of infertility in populations with high fertility
“I didn’t even tell my close friends. I didn’t even tell my mother, we were very close, or my sister. My sister’s a year younger than me. I didn’t even tell her.” “I hid it for so long … keeping it as a shameful secret.
Importance of reproduction among African populations
Stigma of infertility
Psychological
96% of women report feeling isolated and lonely during their efforts to get pregnant

5. Your ARVs isn’t a form of birth control
(we’re pretty sure)
Implications of Infertility among HIV-positive patients
Stigma of childbearing among HIV affected couples
Stigma of HIV
Stigma of infertility
Double edged sword
Infertility’s Global Stigma
Black women struggle with infertility in silence

6. Does HIV cause infertility?
Role of HIV itself in infertility have had mixed results.
? Anovulatory cycles
Insufficient testosterone.
60 percent experience erectile or ejaculatory dysfunction.
19% of HIV-positive women experienced pregnancy loss compared to 12% of uninfected women.

7. HIV treatment causes infertility?
Antiretroviral Therapy May Affect Fertility
Zidovudine (Retrovir) and other older nucleoside reverse transcriptase inhibitors (NRTIs)
older NRTIs may cause damage to mitochondria
HIV-positive men on HAART
Damaged sperm, decreased sperm count, and decreased sperm motility.

8. Diagnosis of infertility
Population: 1 year of trying to conceive
Usually no consultations
Among the HIV couples: ?
We expect them to consult first before they try
To be guided how to make babies
TUI, MSI, Use of ART and Pre-EP
Clients are instructed how to time ovulation
How many cycles are allowed? (12 or 6)

9. Treatment of infertility
Client work-up
Couple
Investigations
Hormonal assays
Tubal patency
Pelvic organs assessment
Sperm factor
? HIV
(For discussion)

10. Infertility and HIV Infertility Management of Couples With HIV
Discordant couples

11. Fertility Treatment Options For People With HIV
Accessing reproductive health care
Intrauterine insemination
In vitro fertilization
Intracytoplasmic sperm injection
Few centres provide assisted reproductive services to HIV-positive patients
3% in the U.S (2011)
No justification for denying treatment to parents who are HIV positive

12. Treatment of infertility in LICs
Tertiary fertility treatment
Laparoscopy
Endometriosis
Myomas
Tubal surgery

13. Challenges of infertility treatment1
Africa and High fertility
Lack of help from medical professionals
Public Hospitals
Cost of available services
???€€££$$

14. Challenges of infertility treatment2
Alternative therapies
Traditional healers
Spiritual healers
Variable success
“Whenever you cross a border, the game will be the same but rules will be different.”
(Baker & McKenzie)

15. Conclusions Importance of reproduction among African populations
High infertility among HIV affected
Repeated tryouts among discordant couples
Limited access to infertility treatment
Even for general populations
Stigma of HIV
Stigma of infertility
Failing to program for PLHIV who want to have children will only continue to fuel the HIV epidemic

16. Acknowledgement The Rand Corporation Mulago National Referral Hospital
MUCHS, School of Public Health

17. ANNOUNCEMENT
The workshop is titled: HIV and Infertility: A Pragmatic Approach for the Evaluation and Management in Low-Resource Environments Friday, July 22 at 11 am in Session room 10 INTERESTED?: PLEASE ATTEND