Many people with HIV choose to have protected sex – that is, sex with condoms – with their sexual partners. This may be for a variety of reasons, apart from the wish to protect others from HIV infection. Condoms offer protection from other sexually transmitted infections, and prevent possible superinfection with HIV which may be drug resistant (which is very rare).

For women, an additional consequence of unprotected sex may be pregnancy. Whilst all women who have sex with men will have a need to consider contraception and pregnancy, there may be special issues for women living with HIV.

The positive impact which HIV therapy has had on the health of many people with HIV, and the availability of effective means of reducing the rate of mother-to-child HIV transmission, may have encouraged some HIV-positive women to reconsider decisions about sex and relationships, and about having children. If you would like support thinking through these issues it may be helpful to see a counsellor, or to talk to other HIV-positive women. One option is Positively UK, a national organisation providing peer support to HIV-positive women and their children (tel 020 7713 0444). Another is Body and Soul, a self-help organisation which supports women, heterosexual men, children and families living with or affected by HIV (tel 020 7923 6880).

In the UK, HIV treatment centres and sexually transmitted diseases (or GUM) clinics offer condoms free of charge. The National Health Service (NHS) provides free access to contraception, that is, you do not need to pay a prescription charge. Contraception is available from GPs, and from family planning clinics. Details of local family planning clinics are available from NHS Direct on 0845 46 47.

For women not on antiretroviral treatment, almost all contraceptive methods can be considered. This means that as well as the condom, female condom, combined pill, progestogen-only pill, skin patch and vaginal ring, there are four types of long-acting reversible contraceptive available: injection, implant, intrauterine device and intrauterine system.

If you are taking HIV treatment, the options change. Some hormonal contraceptives can be affected by antiretroviral drugs (ARVs), making the contraceptive less effective, potentially leading to an unwanted pregnancy.

Contraceptive choices need to be made on an individual basis, with an awareness that condoms alone may provide insufficient protection from pregnancy. Of the alternatives:

• There is no evidence that the coil (IUD) is any less effective as a means of contraception in HIV-positive women, but it may raise the risk of anaemia or pelvic inflammatory disease, which disproportionately affect women with HIV.

• Protease inhibitors may reduce blood levels of the oestrogen component in oral contraceptive pills, so women taking both the Pill and protease inhibitors may need to use back-up methods of contraception.

• Depo provera and Norplant may also be affected by interactions with protease inhibitors.

• A number of other medications, e.g. ampicillin, cotrimoxazole, may interact with oral contraceptives, so getting advice on drug interactions from your HIV doctor or pharmacist is important.

Women whose CD4 count is below 200 may have either very long or very short menstrual cycles, but women with higher CD4 counts are no more likely to have menstrual disorders than HIV-negative women.

Some couples where one partner is HIV-positive and the other HIV-negative choose to have unprotected sex in order to conceive. There is a lot of debate about how infectious a person is when taking effective HIV treatment. The consensus seems to be that taking HIV treatment and having an undetectable viral load significantly reduces the risk of HIV transmission to sexual partners. One major study showed that successful treatment reduced the risk by 96% – approximately the same level as correct and consistent condom use. Many couples make their own assessments of the risk and benefits of unprotected sex.

An HIV-positive woman with an HIV-negative male partner may choose to conceive using a self-insemination method that introduces the semen into her vagina without intercourse.

An HIV-negative woman with an HIV-positive male partner may wish to pursue a technique known as ‘sperm washing’ (there's a NAM factsheet on this subject) whereby rapid spinning of the male partner’s semen in a laboratory allows the separation of the virus.

Involving your doctor and healthcare team in your plans is likely to be very important, particularly if you are taking HIV therapy. Preventing transmission of HIV from mother to baby involves the use of HIV treatment. Planning ahead can help to ensure your treatment decisions support both your own health, and that of your child.