HIV Infection, Combined Antiretroviral Therapy, and Female Infertility in Sub-Saharan Africa: Implications for Assisted Reproductive Technology Access

Abstract

Background: Human immunodeficiency virus (HIV) infection disproportionately affects women in Sub-Saharan Africa (SSA) and is associated with reduced fertility through complex biological, endocrine and behavioural mechanisms. Despite the widespread rollout of combined antiretroviral therapy (cART), HIV-positive women continue to experience significantly higher rates of infertility compared to HIV-negative counterparts. Assisted reproductive technology (ART) represents the definitive treatment for tubal-factor infertility, the most prevalent cause of infertility in this population; however, access remains critically limited across the SSA region.Objective: To systematically review the published literature examining the relationship between HIV infection, cART use, and infertility in SSA women of reproductive age, and to assess the availability, accessibility, and outcomes of assisted reproductive technology in the region.Methods: A comprehensive search of published and grey literature from 2012 to 2022 was conducted across six databases including MEDLINE, PubMed Central, Cochrane Library, Google Scholar, Meta-Register of Controlled Trials, and the Networked Digital Library of Theses and Dissertations. After screening 2,569 records, 47 studies meeting pre-specified inclusion criteria were included for thematic analysis.Results: Six major themes emerged: (1) a persistently high burden of HIV infection among SSA women; (2) substantial cART coverage with incomplete fertility restoration; (3) regionally high rates of infertility with significant psychosocial consequences; (4) tuboperitoneal pathology as the predominant mechanism of HIV-associated infertility; (5) critical under-availability and unaffordability of ART services; and (6) major deficits in regional data reporting, which impede evidence-based policy formulation.Conclusion: HIV-positive women in SSA face a dual burden of infection and infertility compounded by limited access to reproductive care. Despite effective cART programmes, fertility does not fully normalise. Urgent policy action is needed to integrate fertility care into HIV management, establish public-sector ART services, and strengthen regional data surveillance systems.