Infertility Among Men Living with HIV in Sub-Sahara Africa; Bridging Evidence and Practice Gaps

Abstract

Introduction

Male infertility is an important component of the global burden of infertility and remains an under-addressed reproductive health concern in sub-Saharan Africa (SSA). The increasing number of men living with Human Immunodeficiency Virus (HIV) following expanded access to antiretroviral therapy (ART) has heightened the need to address their reproductive goals and fertility-related needs. However, the intersection of HIV, male infertility, and access to fertility care remains inadequately characterized in the region. This review examined the biological, clinical, sociocultural, economic, and health-system factors influencing the management of male infertility among men living with HIV (MLWH) in SSA and identified key gaps in evidence and service delivery.

Methods

A structured literature search was conducted in PubMed, Scopus, Web of Science, Google Scholar, and African Journals Online (AJOL) for studies published between 2000 and 2026. English-language studies addressing male infertility in the context of HIV, including biological, clinical, sociocultural, economic, or health-system factors, were considered. Studies were screened by title and abstract followed by full-text assessment. Findings were thematically synthesized across biological and ART-related reproductive effects, diagnostic and treatment limitations, sociocultural barriers, economic constraints, and health-system challenges. Due to substantial heterogeneity in study designs, populations, outcomes, and settings, findings were synthesized narratively.

Results

The review identified interacting biological, social, economic, and health-system factors that complicate infertility management among MLWH in SSA. HIV infection has been associated with alterations in semen quality and reproductive function, although findings are heterogeneous and do not establish that HIV or ART uniformly causes male infertility. Evidence regarding ART remains inconsistent and may vary according to regimen, treatment duration, and study population, with limited evidence from contemporary regimens and few longitudinal male-focused studies from SSA. Major barriers to care include HIV- and infertility-related stigma, gendered perceptions of infertility, limited male engagement in reproductive healthcare, fragmented HIV and fertility services, inadequate diagnostic and laboratory capacity, shortages of trained healthcare professionals, limited availability and affordability of assisted reproductive technologies, and substantial out-of-pocket costs. Inadequate policy integration further limits access to comprehensive fertility care.

Conclusion

Male infertility among MLWH in SSA reflects interacting biological and structural challenges. Current evidence does not support the assumption that ART generally impairs male fertility, while regimen-specific evidence remains limited. Strengthening integrated HIV and reproductive health services, improving diagnostic and workforce capacity, reducing financial and stigma-related barriers, and generating longitudinal male-focused evidence from SSA are essential for improving reproductive care and supporting the reproductive rights of MLWH.

Introduction

Infertility is a significant global public health concern, affecting an estimated 15% of couples of reproductive age worldwide, with male factors contributing to nearly half of all cases.1,2 Clinically, infertility is defined as the inability to achieve pregnancy after 12 months or more of regular unprotected sexual intercourse.3 Beyond its biomedical implications, infertility carries profound psychological, social, and economic consequences, particularly in low- and middle-income regions where childbearing is strongly tied to identity, social status, and family continuity.4 In sub-Saharan Africa (SSA), the burden of infertility is disproportionately high compared to other regions of the world. A recent study from 10 SSA countries estimated the overall prevalence of infertility at 16.98%, although most included studies focused on women or mixed populations and therefore should not be interpreted as a direct estimate of male infertility.5 In Ghana, for example, male infertility has been estimated at approximately 15–16%, although estimate vary according to population.6 In Uganda, national survey data have reported overall infertility prevalence of approximately 6.4%, while recent fertility-clinic research demonstrates a considerable burden of male reproductive abnormalities.7 This elevated prevalence is largely driven by preventable and untreated conditions such as sexually transmitted infections (STIs), reproductive tract infections, and other communicable diseases that adversely affect reproductive function.8 In men, these infections can lead to complications such as obstruction of the reproductive tract, impaired spermatogenesis, and chronic inflammation.9 Furthermore, weak health systems characterized by inadequate diagnostic facilities, limited access to specialized care, and under-resourced laboratories significantly hinder timely evaluation and management of male infertility.10 In many SSA settings, fertility services are either unavailable or concentrated in urban centers, leaving a large proportion of the population underserved.11 Sociocultural norms within SSA further amplify the impact of infertility.12 Procreation is often considered a fundamental expectation of marriage, and fatherhood is closely associated with masculinity, lineage preservation, and social recognition.13 Consequently, infertility especially when attributed to male factors can result in stigma, marital instability, and psychological distress.14 Despite the significant contribution of male factors to infertility, cultural perceptions frequently place the burden on women, leading to underdiagnosis and neglect of male reproductive health issues.15 These circumstances underscore the importance of examining factors that may compromise male reproductive health, including chronic infectious diseases such as human immunodeficiency virus (HIV). SSA continues to bear a substantial proportion of the global HIV burden. However, the distribution of HIV varies considerably across countries and subregions. UNAIDS estimates for 2025 indicate that approximately 18.8 million men aged 15 years and older were living with HIV globally, demonstrating the substantial number of men whose long-term health and reproductive aspirations may be affected by the infection.16 HIV prevalence among reproductive-age men should be interpreted using age-specific and region-specific estimates rather than a single global figure, particularly because the burden differs across eastern, western, central, and southern Africa. These epidemiological patterns are relevant to male reproductive health because many men living with HIV (MLWH) are in their reproductive years and may wish to conceive biological children. The expansion of antiretroviral therapy (ART) has improved survival and enabled many people living with HIV to pursue long-term personal and family goals.17 Consequently, fertility intentions, reproductive counselling, and access to appropriate conception services have become increasingly important components of comprehensive HIV care.

The relationship between HIV and male infertility is nevertheless complex and should not be interpreted as a direct or uniform consequence of HIV infection. Potential mechanisms include alterations in the hypothalamic–pituitary–gonadal axis, testicular dysfunction, chronic immune activation, and oxidative stress, which may affect spermatogenesis, sperm motility, morphology, and reproductive hormone profiles.18 However, the extent to which these changes are attributable to HIV itself remains difficult to establish because reproductive outcomes may also be influenced by disease severity, duration of infection, viral suppression, and the presence of other health conditions. In particular, advanced HIV disease may be accompanied by opportunistic infections, systemic inflammation, nutritional deficiencies, weight loss, and other complications that can independently or jointly impair reproductive function. Genital tract infections and other sexually transmitted infections may additionally contribute to inflammation, obstruction, or changes in semen quality. Accordingly, reproductive abnormalities observed in men with advanced disease should not automatically be attributed to the direct effects of HIV infection. Other factors may further modify the relationship between HIV and male reproductive function. These include age, smoking, alcohol consumption, recreational drug use, nutritional status, metabolic disorders, and other comorbidities. ART also requires careful consideration. Although effective treatment improves general health and survival, the effects of individual antiretroviral agents on semen quality, reproductive hormones, and spermatogenesis remain an area of investigation, with findings varying across studies and treatment regimens.19 It is therefore important to distinguish the potential effects of HIV infection from those associated with advanced disease, concurrent infections, comorbidities, lifestyle-related exposures, and ART. This distinction is essential for interpreting the available evidence and avoiding the assumption that all reproductive abnormalities in MLWH are caused by the virus or its treatment. In addition to biological factors, MLWH may experience substantial barriers to accessing fertility-related care. HIV services and reproductive health services are not always adequately integrated, and fertility counselling may not routinely address the reproductive intentions of men living with HIV. Limited availability and affordability of assisted reproductive technologies, inadequate provider training, and concerns about HIV transmission during conception may further complicate access to care.20,21 These challenges are compounded by HIV-related stigma, infertility-related stigma, financial constraints, and limited awareness of available reproductive options. The coexistence of these barriers may discourage men from seeking fertility assessment or disclosing their reproductive concerns to healthcare providers.22

Consequently, the reproductive needs of MLWH may remain insufficiently addressed even when HIV infection is clinically well controlled. Although previous reviews have examined HIV in relation to semen quality, reproductive hormones, sexual health, and broader reproductive outcomes, these topics do not necessarily provide a comprehensive account of the factors contributing to male infertility within the specific sociocultural and healthcare context of SSA. Evidence on biological mechanisms, clinical manifestations, fertility intentions, access to infertility services, and structural barriers may also be distributed across studies addressing different populations and outcomes. The resulting challenge is not simply a lack of information about HIV and semen quality, but the need to bring together evidence on reproductive impairment and the wider clinical, social, and health-system factors that shape infertility among MLWH in SSA. This review therefore adopts a regional and multidimensional perspective, considering the available evidence on biological and clinical factors alongside fertility-related experiences, barriers to care, and emerging management strategies. It also distinguishes, where the available evidence permits, the potential effects of HIV infection from those associated with advanced disease, concurrent infections, comorbidities, lifestyle factors, and ART. The objective of this review is to systematically synthesize the available evidence on the burden, determinants, clinical manifestations, and management of male infertility among men living with HIV in SSA, with particular attention to biological mechanisms, semen quality and reproductive hormones, fertility intentions, and barriers to accessing reproductive healthcare. Specifically, the review seeks to answer what is known about the prevalence, contributing factors, reproductive consequences, and clinical and health-system challenges associated with male infertility among men living with HIV in SSA, and what strategies are available to support their fertility and reproductive health needs.

Methodology

This study adopted a narrative review design to synthesize the available evidence on the challenges associated with the management of male infertility among men living with HIV in sub-Saharan Africa (SSA). A structured literature search was conducted using PubMed, Scopus, Web of Science, Google Scholar, and African Journals Online (AJOL). The search was supplemented by manual screening of the reference lists of relevant publications to identify additional studies that might not have been retrieved through the electronic databases. The search covered English-language publications published between 1 January 2000 and the final search date in 2026. Search terms included combinations of the following keywords: “male infertility,” “HIV,” “men living with HIV,” “antiretroviral therapy,” “sperm quality,” “reproductive health,” “safer conception,” and “sub-Saharan Africa.” The search strategy was adapted to the requirements of each database. Studies were considered eligible if they addressed male infertility or male reproductive health in the context of HIV and examined relevant biological, clinical, sociocultural, economic, ethical, or health-system factors. Evidence from comparable low-resource settings outside SSA was also considered where it provided relevant contextual or clinical information.

Studies were excluded if they did not address HIV or male reproductive health, focused exclusively on female infertility without relevant findings concerning men living with HIV, were published in languages other than English, or consisted of irrelevant commentaries or opinion pieces. Retrieved records were screened by title and abstract, followed by full-text assessment of potentially relevant publications. Information from eligible studies was extracted and organized thematically according to the principal domains of the review: HIV- and antiretroviral therapy-related reproductive effects, diagnostic and treatment limitations, health-system constraints, sociocultural influences, economic barriers, and ethical and policy challenges. Given the narrative design and the heterogeneity of the included evidence, findings were synthesized qualitatively rather than statistically pooled. The relevance and methodological limitations of the available evidence were considered when interpreting the findings. Figure 1 summarizes the literature identification and selection process. The numbers presented in the figure were derived from the updated database searches, duplicate removal, screening records, and full-text eligibility assessments. The diagram was interpreted as a record of the review’s actual selection process rather than as a substitute for a systematic review methodology.

Figure 1.

PRISMA flow diagram illustrating the process of the comprehensive literature search conducted across major electronic databases, including PubMed, Scopus, Web of Science, and Google Scholar.

Staged Clinical Evaluation of Male Infertility Among Men Living with HIV

The evaluation of male infertility among men living with HIV should follow a staged, clinically directed approach rather than requiring every patient to undergo an extensive panel of investigations. HIV status alone does not establish the presence or cause of infertility. The initial assessment should identify the couple’s reproductive goals, relevant risk factors, and clinical indications for further testing. This approach is particularly important in resource-limited settings, where indiscriminate investigations may increase costs and delay access to appropriate care. Stage 1 include the reproductive and sexual history, and physical examination. The initial assessment should include the duration of unsuccessful attempts to conceive, previous pregnancies with the current or previous partners, sexual function, frequency of intercourse, and any history of erectile or ejaculatory difficulties. Relevant medical history should cover previous sexually transmitted infections (STIs), urogenital infections, testicular trauma or surgery, undescended testes, systemic illness, medication use, substance use, and occupational or environmental exposures. For men living with HIV, clinicians should also review ART use and adherence, the most recent viral load, immune status where available, and relevant HIV-associated illnesses. A focused physical examination should assess secondary sexual characteristics, testicular size and consistency, epididymides, vasa deferentia, and signs of varicocele or other abnormalities, where examination and clinical expertise permit. Stage 2 involves initial semen analysis. At least one semen analysis should be obtained using an appropriately collected sample and a laboratory following recognized quality-control procedures. Patients should receive clear instructions regarding the recommended period of ejaculatory abstinence, complete sample collection, and timely delivery to the laboratory. If the result is abnormal, borderline, or inconsistent with the clinical picture, repeat testing should be considered because semen parameters may vary between samples. The need and timing of repeat testing should reflect the initial findings and clinical circumstances. Stage 3 is targeted hormonal assessment. Hormonal investigations should be guided by semen findings, symptoms, and examination results rather than ordered routinely in every patient. Serum testosterone and follicle-stimulating hormone (FSH) are particularly relevant when sperm concentration is low or absent, testicular abnormalities are present, or symptoms suggest androgen deficiency. Luteinizing hormone (LH) and additional endocrine tests may be indicated when initial findings require further clarification. Results should be interpreted in the context of the patient’s clinical condition, medication use, and other possible causes of endocrine dysfunction. Stage 4 involves investigation for infection. STI screening, urine testing, semen microbiology, or other infection-related investigations should be selected according to symptoms, sexual and medical history, examination findings, exposure risks, and local epidemiology. HIV infection alone should not be taken as evidence of a concurrent genital infection, nor should microbiological testing be treated as a mandatory component of every infertility assessment. Where an infection is identified, management should follow relevant clinical guidance. Stage 5 include selective imaging and genetic assessment. Scrotal or transrectal ultrasonography should be requested when the history, physical examination, or semen findings suggest a specific structural or obstructive problem, or when the examination is inadequate or inconclusive. Imaging should not be treated as a routine test for every man presenting with infertility. Genetic assessment should principally be considered in men with azoospermia or severe oligozoospermia, particularly where impaired sperm production or an underlying genetic cause is suspected. The specific tests should be guided by the clinical presentation and applicable professional guidelines, as not every patient with a low sperm count requires the same genetic investigations. Finally, stage 6 involves integrated interpretation and management. Findings from the history, examination, semen analysis, and any indicated additional investigations should be considered together. Evaluation of the female partner should proceed in parallel, where appropriate, because conception depends on the reproductive health of both partners. Management may include treatment of an identified underlying condition, modification of relevant risk factors, counseling on conception, or referral for specialist fertility care. Decisions about assisted reproduction should be based on the couple’s clinical indications, preferences, and circumstances rather than HIV status alone. In men living with HIV, routine HIV care and ART should continue alongside fertility evaluation, with attention to sustained viral suppression and individualized prevention counseling. Table 1 presents the summary of the staged clinical evaluation for reproductive/sexual history and physical examination. This staged approach can help prioritize essential investigations, reduce unnecessary expenditure, and support a more accessible and patient-centered model of infertility care in sub-Saharan Africa. It should be applied alongside relevant national protocols and professional guidelines, with referral for specialist assessment when indicated.

Table 1.

Summary of the Staged Clinical Evaluation for Reproductive/Sexual History and Physical Examination

Step	Initial Action	When to Proceed to Further Testing
1	Reproductive/sexual history and physical examination	Identify risk factors, symptoms, or examination abnormalities
2	At least one properly collected semen analysis	Repeat if abnormal, borderline, or clinically inconsistent
3	Targeted hormonal tests	Low sperm concentration, azoospermia, testicular abnormalities, or symptoms of androgen deficiency
4	STI or infection testing	According to symptoms, history, exposure risk, and local epidemiology
5	Imaging	Suspected structural or obstructive abnormality, or an inadequate/inconclusive examination
6	Genetic testing	Principally azoospermia or severe oligozoospermia, guided by applicable guidelines
7	Integrated management	Interpret male and female partner findings and agree on an individualized plan

Biological and Clinical Challenges

HIV-Related Effects on Male Fertility

HIV infection exerts both direct and indirect deleterious effects on male reproductive function, contributing significantly to impaired fertility among affected individuals.23 At the testicular level, HIV has been associated with structural and functional alterations, including degeneration of seminiferous tubules, disruption of the blood–testis barrier, and impaired Sertoli and Leydig cell activity.24,25 These pathological changes often culminate in testicular dysfunction and clinical or subclinical hypogonadism, characterized by reduced testosterone levels and impaired endocrine regulation of spermatogenesis.26 HIV infection is also strongly linked to abnormalities in semen parameters.18 Men living with HIV frequently exhibit reduced sperm concentration (oligozoospermia), decreased sperm motility (asthenozoospermia), and abnormal sperm morphology (teratozoospermia).27,28 These alterations may arise from direct viral effects within the male genital tract, as HIV has been detected in seminal fluid and testicular tissue, suggesting localized viral replication and immune-mediated damage.29 Clinical studies illustrate this variability. In a retrospective case-control study involving 770 men with HIV receiving stable highly active antiretroviral therapy (HAART), median semen parameters were lower than World Health Organization reference values, and a proportion of participants had values below the reference limits.30 However, multivariable analyses identified age and viral load, rather than ART type or duration, as factors associated with selected semen abnormalities, including impaired progressive motility and sperm morphology. The study therefore supports the possibility of reproductive impairment among some treated men but does not establish that ART was responsible for the observed differences. Its participants were men seeking reproductive counseling, which also limits the extent to which the findings can be generalized to all men living with HIV. The relationship between HIV disease activity and semen quality is also not straightforward. Higher viral load and poorer immune status have been associated with some reproductive abnormalities, but these relationships have not been consistent across all studies. Potential explanations include chronic inflammation, oxidative stress, coexisting genital tract infections, endocrine disturbances, and other clinical or lifestyle factors.31 Differences in participant selection, semen collection and analysis, ART exposure, and the presence of pre-existing fertility problems may also contribute to inconsistent findings. Consequently, the available evidence supports an association between HIV infection and altered reproductive function in some men, rather than a uniform or inevitable effect on fertility. Additionally, disruption of accessory gland function, including the prostate and seminal vesicles, may further compromise semen quality and ejaculatory function.32 A central mechanism underlying HIV-associated male infertility is increased oxidative stress. HIV infection promotes the excessive generation of reactive oxygen species (ROS), overwhelming endogenous antioxidant defenses and leading to oxidative damage to sperm DNA, lipids, and proteins.31 This oxidative imbalance adversely affects sperm viability, motility, and fertilizing capacity.33 Concurrently, chronic immune activation and systemic inflammation, hallmark features of HIV infection, contribute to the release of pro-inflammatory cytokines that can disrupt the hypothalamic–pituitary–gonadal axis and impair normal spermatogenic processes.25

In addition to the direct effects of the virus, opportunistic infections and co-infections prevalent in sub-Saharan Africa further exacerbate reproductive dysfunction.34 Conditions such as sexually transmitted infections, tuberculosis, and urogenital infections can lead to epididymal obstruction, orchitis, and chronic inflammation of the reproductive tract.35 These infections may result in scarring, fibrosis, and irreversible damage to sperm-producing tissues, thereby compounding the risk of infertility.36 Collectively, the interplay between viral activity, immune dysregulation, oxidative stress, and co-existing infections creates a complex pathophysiological environment that significantly compromises male reproductive health in men living with HIV (Figure 2).

Figure 2.

Biological and Clinical Challenges in male fertility (HIV context). The image was generated using ChatGPT.

Antiretroviral Therapy (ART) Implications

ART has transformed HIV infection into a manageable chronic condition by suppressing viral replication, preserving immune function, reducing HIV-related morbidity and mortality, and preventing sexual transmission when viral suppression is sustained.37 These benefits are particularly important for men living with HIV who wish to have biological children, as effective treatment improves their general health and provides a safer context for conception. Nevertheless, the relationship between ART and male reproductive function remains complex. Although some studies have reported associations between antiretroviral exposure and alterations in semen quality, reproductive hormones, or testicular function, the findings are inconsistent.38 It is therefore important to distinguish potential drug-related effects from reproductive abnormalities associated with HIV infection itself, advanced disease, opportunistic infections, and other comorbidities. Evidence from men receiving ART illustrates why these distinctions matter. In a prospective cohort of 139 men with HIV attending a reproductive counseling clinic in Madrid, most participants had semen parameters within World Health Organization reference limits, although a proportion had reduced progressive sperm motility, total sperm count, or semen volume.1 Efavirenz exposure was associated with sperm dysmotility. However, because the study was observational and recruited men seeking reproductive counseling, it cannot establish that efavirenz caused the abnormality or that the finding applies to all men receiving this drug. In a larger cohort of 770 men on stable HAART, ART type and duration were not independently associated with semen quality after adjustment for other factors. Taken together, these findings suggest that drug-specific effects may warrant investigation, but they do not demonstrate a uniform adverse effect of ART on spermatogenesis.30 Evidence concerning contemporary regimens is particularly limited. A small before-and-after study investigated dolutegravir-based combination ART in men living with HIV. Only 11 participants provided both blood and semen samples before treatment and after three months. Progressive and total sperm motility increased following treatment, while sperm concentration, total sperm count, morphology, and vitality did not change significantly.39 Testosterone increased, whereas luteinizing hormone decreased. These findings are compatible with the possibility that effective treatment and improvements in clinical status may coincide with changes in some reproductive measures. However, the small sample, short follow-up, and absence of a concurrent untreated comparison group prevent firm conclusions about the effects of dolutegravir itself or the long-term reproductive consequences of contemporary ART. Viral suppression and semen quality should therefore be considered related but distinct outcomes. Sustained viral suppression is central to HIV treatment and sexual transmission prevention, but it does not guarantee normal semen parameters or establish that a couple will conceive.40 Conversely, abnormal semen parameters do not demonstrate that ART has caused infertility. Where reproductive concerns arise, assessment should consider the individual’s semen findings, age, medical history, HIV disease status, coexisting infections, endocrine health, and specific ART exposure rather than attributing the problem to HIV or treatment alone.18

One proposed mechanism of antiretroviral-associated reproductive toxicity is mitochondrial dysfunction. Certain nucleoside reverse transcriptase inhibitors (NRTIs), particularly older agents such as zidovudine and stavudine, have been associated with mitochondrial toxicity through effects on mitochondrial DNA maintenance and function.41,42 Because sperm motility depends partly on mitochondrial energy production, substantial mitochondrial dysfunction could contribute to impaired motility, increased oxidative stress, and reduced sperm function. However, these mechanistic concerns should not be generalized to all NRTIs or all contemporary ART regimens. Older antiretroviral agents differ from newer drugs in their pharmacological properties, tolerability, and toxicity profiles. Contemporary first-line regimens commonly include an integrase strand transfer inhibitor, such as dolutegravir or bictegravir, combined with a backbone containing tenofovir and emtricitabine or lamivudine. These regimens have demonstrated favourable overall tolerability and effective viral suppression, although their long-term effects on specific male reproductive outcomes require further investigation.43 Consequently, findings derived from older drugs or experimental models should be interpreted cautiously when discussing the reproductive safety of current treatment.

Evidence concerning semen parameters among men receiving ART is similarly mixed. Some studies have reported reduced sperm concentration, motility, or normal morphology among treated men, whereas others have found no significant differences or have reported improvements following treatment. These discrepancies may reflect differences in the antiretroviral agents examined, treatment duration, age, baseline semen quality, HIV disease severity, viral load, immune status, and the prevalence of concurrent infections or metabolic disorders. Moreover, studies comparing men receiving ART with HIV-negative controls may not adequately distinguish the effects of medication from those of the underlying infection. Comparisons involving untreated men with HIV also require caution because untreated participants may differ substantially in viral replication, immune function, and general health. Thus, an association between ART exposure and impaired semen quality does not, by itself, establish that the medication caused the observed abnormality.18 Potential endocrine effects also warrant careful interpretation. HIV infection, chronic inflammation, nutritional deficiencies, and advanced disease can contribute to hypogonadism and disturbances in the hypothalamic–pituitary–gonadal axis. Some studies have additionally reported associations between particular treatment regimens and changes in testosterone or other reproductive hormones. ART-related metabolic changes, including alterations in body-fat distribution, insulin sensitivity, and lipid metabolism, may indirectly influence endocrine function in some individuals.39 Table 2 presents the selected reviews and empirical studies informing the evidence on HIV, male reproductive health, and fertility-care access. However, these outcomes are not necessarily attributable to direct testicular toxicity, and the evidence does not establish that contemporary ART routinely causes clinically significant impairment of spermatogenesis. Assessment of reproductive hormones should therefore consider clinical symptoms, disease history, comorbidities, and the specific regimen rather than assuming that hormonal abnormalities are treatment-induced. Importantly, the potential reproductive risks of ART must be considered alongside its benefits. Effective treatment reduces viral replication and helps restore immune function, thereby limiting the consequences of uncontrolled infection and reducing the likelihood of HIV-related complications.44 Sustained viral suppression is also central to safer conception. Current clinical guidance indicates that people living with HIV who take ART as prescribed and maintain a viral load below 200 copies/mL do not transmit HIV sexually to their partners. For couples planning pregnancy, sustained viral suppression, appropriate preconception counselling, and screening and treatment for genital tract infections are important components of care.45 These benefits should not be overlooked when interpreting reports of possible ART-associated reproductive toxicity.

Table 2.

Selected Reviews and Empirical Studies Informing the Evidence on HIV, Male Reproductive Health, and Fertility-Care Access

Reference and Source Type	Country/Setting and Population	Design and Sample Size	ART Regimen or Exposure	Fertility-Related Findings	Main Limitations to Acknowledge
Teixeira et al28/review	International literature; not a single study population	Narrative review; no original participant sample	Not applicable as a single study; discusses evidence across different exposures	Reviews evidence linking viral infections, including HIV, with changes in semen quality and male reproductive function	No single country, sample size, regimen, or treatment duration. Use as background evidence, not as an original study
Boadi and Dzramad40/primary qualitative study	St. Michael’s Hospital ART clinic, Ashanti Region, Ghana; adults living with HIV, including men and women	Qualitative phenomenological study; 12 participants aged 25–45 years	Participants received ART, but the exact regimens and individual treatment durations are not reported in the abstract; verify the full text for regimen-level data.	Participants reported gaps in fertility counseling, safer-conception information, and awareness of assisted reproductive options. All 12 reported lacking awareness of assisted reproductive technologies and safer-conception services.	Small, single-facility qualitative sample; includes women as well as men and does not directly measure semen quality, infertility diagnoses, pregnancy, or live birth. Highly relevant to counseling and service-delivery barriers, but not a study of male fertility outcomes
Boadi and Dzramad40/primary qualitative study	ART clinic at St. Michael’s Hospital, Pramso, Ashanti Region, Ghana; people living with HIV	Qualitative descriptive study; 12 participants, including 3 men and 9 women	ART-treated participants; exact regimens and duration require confirmation from the full text	Explores participants’ experiences of fertility counseling and perceived gaps in provider support.	The male subgroup is very small, and the study examines counseling experiences rather than clinical infertility or semen outcomes. It is useful for the health-system section, but not as evidence of biological effects.
Akhigbe et al20/review	International literature; includes human and experimental evidence	Narrative review; no single participant sample	Not applicable as a single study	Discusses oxidative stress, inflammation, testicular damage, and sperm abnormalities associated with viral infections.	Covers viral infections broadly, not only HIV or men living with HIV in SSA. Mechanistic evidence does not independently establish clinical infertility in a specific population
De Vincentis et al26/review	International literature on men with HIV	Review; no original participant sample	Reviews evidence across different treatment contexts; no single regimen or duration	Examines sexual dysfunction and associated endocrine, clinical, and psychosocial factors in men with HIV.	Sexual dysfunction is not equivalent to infertility. It should support discussion of sexual health, not be treated as direct evidence of impaired semen quality or reduced pregnancy rates.
Costa et al41/review	International literature on mitochondrial function and male fertility	Review; no original participant sample	Not applicable to a single ART regimen.	Reviews mitochondrial quality control and its role in sperm function and male fertility.	Not an HIV-specific clinical study. It may support general biological mechanisms but should not be used as direct evidence that ART causes male infertility.
He et al18/review	International literature; not a single country or cohort	Review; no original participant sample	Discusses ART broadly; no single regimen or duration	Synthesizes potential links between HIV, semen quality, orchitis, hypogonadism, and ART	Useful for framing the field but cannot supply study-level participant characteristics or regimen-specific effect estimates. Primary studies cited within the review should be traced where possible
Guzha et al24/review	International clinical literature	Review; no original participant sample	No single regimen or duration	Reviews pituitary and endocrine abnormalities associated with HIV	Indirect evidence for male fertility; endocrine abnormalities do not necessarily establish impaired spermatogenesis or infertility
Peters et al44/review	Global HIV and STI prevention and service-delivery evidence	Review/Series article; not a single fertility cohort	Not a regimen-specific fertility study	Discusses HIV/STI prevention, diagnosis, and service-delivery approaches relevant to safer conception and integrated care.	Does not directly quantify male infertility or semen outcomes. Use to support service integration and prevention context, not as a primary fertility study.

The distinction between virological outcomes and fertility outcomes is particularly important. Viral suppression reduces the risk of sexual HIV transmission and improves the clinical management of infection, but it does not necessarily normalize every semen parameter or guarantee conception. Conversely, an abnormal semen analysis in a man receiving ART does not establish that the treatment is responsible. Fertility depends on multiple factors, including sperm production and function, reproductive hormones, genital tract health, the female partner’s reproductive health, and the duration of attempts to conceive. Men with persistent fertility concerns should therefore receive an appropriate reproductive assessment rather than having ART presumed to be the underlying cause. Overall, the available evidence supports a balanced interpretation of ART in relation to male fertility. Although certain older antiretroviral agents and specific treatment exposures have raised concerns about mitochondrial function, oxidative stress, endocrine regulation, and spermatogenesis, the evidence remains insufficient to conclude that contemporary ART regimens generally cause male infertility. Future studies should compare specific regimens, distinguish older agents from current first-line treatments, account for HIV disease severity and relevant confounders, and assess longitudinal changes in semen quality, reproductive hormones, and pregnancy outcomes. In clinical practice, concerns about fertility should prompt individualized assessment and discussion with the treating HIV clinician and, where indicated, a reproductive specialist. ART should not be discontinued or changed solely because of suspected fertility effects without clinical evaluation. The aim should be to maintain effective viral suppression while identifying and managing potentially reversible contributors to impaired reproductive function (Figure 2).

Limited Diagnostic Capacity

The accurate evaluation of male infertility requires a comprehensive and multidisciplinary diagnostic approach that includes semen analysis, hormonal profiling, microbiological assessment, imaging studies such as scrotal ultrasonography, and, where indicated, advanced genetic testing. These investigations are essential for identifying underlying etiologies, including spermatogenic failure, endocrine disorders, obstructive pathologies, and genetic abnormalities. However, in many sub-Saharan African settings, the capacity to perform such standardized assessments remains severely constrained, thereby limiting effective clinical management. A major challenge lies in the inadequate laboratory infrastructure across much of the region. Many healthcare facilities, particularly at the primary and secondary levels, lack the equipment, reagents, and trained personnel required to conduct even basic semen analysis according to internationally accepted standards.46 Where such services are available, issues related to poor quality control, lack of standardization, and limited technical expertise further compromise the reliability and reproducibility of results (Björndahl and Brown, 2022).47 Advanced diagnostic modalities, including hormonal assays for testosterone, luteinizing hormone, and follicle-stimulating hormone, as well as molecular and genetic testing, are often unavailable or inconsistently accessible (Targonskaya and Maslowski, 2023).48 In addition, diagnostic services for male infertility are largely centralized in urban tertiary hospitals and private specialized centers.49 This urban concentration creates significant geographic inequities in access, particularly for men residing in rural and peri-urban areas, where the majority of the population in sub-Saharan Africa resides. The need to travel long distances to access specialized care imposes logistical challenges, including transportation costs, time constraints, and loss of income, all of which discourage timely health-seeking behavior.

Financial barriers further exacerbate limited access to diagnostic services. In many countries within the region, infertility investigations are not covered under public health insurance schemes and are instead financed through out-of-pocket payments.50 The cumulative cost of multiple diagnostic tests including repeated semen analyses, hormonal evaluations, imaging procedures, and specialist consultations can be prohibitive for a large proportion of the population.51 This economic burden often leads to incomplete diagnostic workups, delayed presentation, or complete avoidance of medical evaluation. The combined effect of inadequate infrastructure, geographic disparities, and financial constraints results in delayed, incomplete, or inaccurate diagnosis of male infertility.52 Consequently, many men remain undiagnosed or are misdiagnosed, leading to inappropriate or ineffective treatment interventions. This diagnostic gap not only undermines clinical outcomes but also perpetuates the sociocultural burden of infertility, as the absence of a clear medical explanation often reinforces stigma and misconceptions. Figure 2 presents the biological and clinical challenges in male fertility (HIV context). Addressing these limitations is therefore critical for improving the identification and management of male infertility, particularly among vulnerable populations such as men living with HIV in sub-Saharan Africa.

Health System and Structural Challenges

Fragmentation of HIV and Reproductive Health Services

The delivery of healthcare services in many SSA settings is characterized by structural fragmentation, particularly between HIV care and reproductive health services.53 Historically, HIV programs have been developed as vertical interventions with a primary focus on diagnosis, antiretroviral therapy provision, and prevention of transmission, while reproductive health services including fertility evaluation and management have evolved within separate clinical frameworks.54,55 This lack of integration has resulted in parallel systems of care that inadequately address the interconnected needs of men living with HIV who desire to achieve parenthood. One of the major consequences of this fragmentation is the loss of opportunities for comprehensive, patient-centered care. Men receiving routine HIV care often have frequent contact with healthcare providers through antiretroviral therapy clinics, yet these encounters rarely incorporate assessment of reproductive intentions or fertility status.56 As a result, critical opportunities to provide early counseling on fertility, safe conception practices, and potential reproductive risks are frequently missed. This gap is particularly significant given that timely intervention can mitigate both infertility and the risk of horizontal or vertical HIV transmission. In addition, referral systems between HIV clinics and specialized fertility services are often weak, poorly coordinated, or entirely absent.53 Healthcare providers in HIV care settings may lack clear clinical pathways or established networks for referring patients to andrology or reproductive specialists. Even when referrals are made, they are frequently hindered by logistical challenges, including long waiting times, limited availability of specialists, and inadequate communication between facilities. This discontinuity of care can lead to patient attrition, delayed diagnosis, and suboptimal treatment outcomes.

The absence of structured fertility counseling within HIV care programs further compounds the problem. Many HIV clinics do not routinely incorporate discussions on reproductive goals, fertility preservation, or assisted reproductive options into standard care protocols.56 This is often due to a combination of factors, including limited provider training, time constraints, and persistent misconceptions that individuals living with HIV should avoid childbearing.

Reproductive counseling should be individualized according to the couple’s fertility goals, HIV treatment status, viral suppression, and any identified fertility problems. For men living with HIV who are taking antiretroviral therapy (ART) and have achieved and maintained viral suppression, timed intercourse may help couples coordinate attempts at conception with the woman’s fertile window, but it is not required to prevent sexual HIV transmission when sustained viral suppression is established. Pre-exposure prophylaxis (PrEP) may be discussed as an additional prevention option for the HIV-negative partner, particularly when viral suppression is uncertain, cannot be confirmed, or the partner prefers an additional method of protection. However, PrEP should not be presented as mandatory for every couple in which one partner is living with HIV. Assisted reproductive techniques, including intrauterine insemination and in vitro fertilization, should be considered according to the couple’s infertility diagnosis, reproductive circumstances, preferences, and access to services not solely because one partner has HIV. Where infertility is identified, treatment should address the underlying cause while supporting the couple’s reproductive goals. Counseling should also explain the benefits of sustained viral suppression, the importance of continued ART adherence, and the need to evaluate both partners rather than attributing difficulty conceiving to HIV status alone. These discussions should be non-directive and should respect the reproductive autonomy of men living with HIV and their partners.

Moreover, the lack of integration reflects broader systemic and policy-level deficiencies, including insufficient guidelines that explicitly address the reproductive health needs of men living with HIV. While significant progress has been made in integrating HIV services with maternal and child health programs, similar efforts targeting male reproductive health remain limited. This oversight reinforces gender disparities in reproductive healthcare and perpetuates the marginalization of men within fertility services. Overall, the fragmentation of HIV and reproductive health services represents a critical barrier to effective management of male infertility among men living with HIV. Addressing this challenge requires the development of integrated service delivery models that promote coordinated care, strengthen referral systems, and embed fertility counseling within routine HIV care. Figure 3 presents the health system and structural challenges of infertility with men living with HIV. Such approaches are essential for ensuring that the reproductive rights and aspirations of men living with HIV are adequately supported within the healthcare system.

Figure 3.

Health System and Structural Challenges. The image was generated using ChatGPT.

Limited Availability of Assisted Reproductive Technologies (ARTs)

The availability and accessibility of ARTs in sub-Saharan Africa remain markedly limited, constituting a significant barrier to the effective management of male infertility, particularly among men living with HIV. Advanced fertility interventions such as sperm washing, intrauterine insemination (IUI), and in vitro fertilization (IVF) play a critical role in enabling conception while minimizing the risk of HIV transmission, especially in serodiscordant couples where one partner is HIV-positive and the other is HIV-negative.57 Assisted reproductive technologies (ARTs), including sperm processing, intrauterine insemination (IUI), and in vitro fertilization (IVF), may be useful for selected couples experiencing infertility or requiring specific reproductive interventions.58 However, these procedures should not be regarded as routinely necessary for all couples affected by HIV. For couples in whom the partner living with HIV is receiving ART and has achieved and maintained viral suppression, sexual HIV transmission is prevented, and assisted reproduction is not required solely to prevent transmission.59 The choice of conception method should instead reflect the couple’s fertility status, the reproductive health of both partners, their preferences, and the availability and affordability of appropriate services. Assisted reproduction remains important when indicated by male-factor infertility, female-factor infertility, combined fertility problems, or other clinical circumstances affecting conception. Where viral suppression is uncertain or other transmission-related concerns exist, clinicians should provide individualized counseling on available prevention options, including PrEP where appropriate, and refer couples for specialist advice when necessary. This approach avoids medicalizing HIV status alone while ensuring that couples who need fertility treatment or additional support can access appropriate care. However, the provision of these services across the region is constrained by multiple structural, economic, and systemic challenges. One of the most prominent limitations is the overall scarcity of ART facilities in sub-Saharan Africa (Buzwani et al, 2026).60 Compared to high-income regions, where assisted reproduction is widely available and increasingly integrated into mainstream healthcare, many countries within SSA have only a few functional fertility centers, and some lack such services entirely. Where available, these technologies are often limited in scope, with advanced procedures such as sperm processing for HIV-seropositive men being inconsistently offered due to technical complexity and biosafety concerns. This scarcity significantly restricts the range of safe and effective reproductive options for affected individuals (Karaga et al, 2023).61 Furthermore, existing ART services are predominantly concentrated in urban tertiary hospitals and private fertility clinics, creating substantial geographic disparities in access.54 Rural and peri-urban populations, which constitute a large proportion of the region’s demographic profile, are often excluded from these services due to distance, limited transportation infrastructure, and inadequate referral systems. This urban concentration reinforces inequities in reproductive healthcare access and disproportionately affects individuals from lower socioeconomic backgrounds.

Financial inaccessibility represents an additional and critical barrier. Assisted reproductive procedures are typically expensive and are rarely subsidized or covered by public health insurance schemes in most sub-Saharan African countries.62 The costs associated with IVF, sperm washing, and related interventions including consultation fees, laboratory procedures, medications, and repeated treatment cycles are often prohibitive for the majority of patients.63 As a result, access to ART is largely restricted to affluent individuals, leaving a significant unmet need among economically disadvantaged populations. The limited availability of ART services also reflects broader systemic challenges, including shortages of trained reproductive specialists, embryologists, and laboratory personnel, as well as inadequate infrastructure to support sophisticated laboratory procedures.64 Regulatory and policy frameworks governing assisted reproduction are often underdeveloped or absent, further hindering the expansion and standardization of services.65 In addition, concerns regarding infection control and the handling of HIV-positive biological samples may discourage some facilities from offering ART to men living with HIV.66 Collectively, these constraints severely limit the feasibility of safe conception strategies for serodiscordant couples and men living with HIV who wish to father biological children. In the absence of accessible ART options, many couples may resort to unprotected intercourse without appropriate medical guidance, thereby increasing the risk of horizontal HIV transmission. Addressing these gaps requires substantial investment in infrastructure, workforce development, policy formulation, and the subsidization of fertility services to ensure equitable access to safe and effective reproductive technologies across the region.

Workforce Constraints

Human resource limitations represent a critical barrier to the effective management of male infertility among men living with HIV in sub-Saharan Africa. The provision of comprehensive fertility care requires a multidisciplinary team comprising andrologists, reproductive endocrinologists, urologists, embryologists, laboratory scientists, and healthcare providers trained in both HIV management and reproductive health.45 However, across much of the region, there is a pronounced shortage of such specialized personnel, which significantly undermines the quality, accessibility, and continuity of care. A major challenge is the limited number of clinicians with expertise in male reproductive health, including andrologists and reproductive specialists (Shah et al, 2025).67 In many sub-Saharan African countries, medical training programs place relatively little emphasis on andrology as a subspecialty, resulting in a workforce that is inadequately prepared to diagnose and manage male infertility.62 Consequently, male reproductive health issues are often managed by general practitioners or gynecologists, who may have limited training in the evaluation of male factor infertility.68 This gap contributes to underdiagnosis, misdiagnosis, and inappropriate management of conditions affecting male fertility. In addition to clinical expertise, there is a shortage of trained laboratory personnel capable of conducting specialized fertility investigations.69 Accurate semen analysis, hormonal assays, and advanced procedures such as sperm processing and cryopreservation require skilled technicians and strict adherence to standardized protocols.70 However, many laboratories in the region are understaffed and lack personnel with adequate training in reproductive laboratory techniques. This deficiency not only limits the availability of diagnostic services but also affects the quality and reliability of test results, thereby compromising clinical decision-making.

Another important dimension of workforce constraints is the limited capacity of HIV care providers to address fertility-related concerns. Although HIV clinicians play a central role in the long-term care of men living with HIV, many lack formal training in reproductive health counseling, particularly in relation to male infertility and safe conception strategies.27 As a result, discussions on fertility intentions, reproductive risks, and available treatment options are often absent or insufficient within routine HIV care. This gap further contributes to missed opportunities for early intervention and integrated care. Workforce shortages are further exacerbated by systemic issues such as brain drain, inadequate remuneration, limited opportunities for professional development, and uneven distribution of healthcare workers between urban and rural areas. Skilled professionals are often concentrated in major cities or migrate to higher-income countries in search of better working conditions, leaving rural and underserved areas with minimal access to specialized care.71 Collectively, these workforce constraints contribute to suboptimal care delivery, characterized by delayed diagnosis, limited treatment options, and inadequate patient counseling. Addressing these challenges requires strategic investment in education and training, including the development of specialized curricula in andrology and reproductive medicine, capacity building for laboratory personnel, and integration of fertility counseling into HIV care training programs. Strengthening the healthcare workforce is essential for improving the quality and accessibility of infertility services and for meeting the reproductive health needs of men living with HIV in sub-Saharan Africa.

Socio-Cultural and Behavioral Challenges

Stigma and Masculinity Norms

Stigma and deeply entrenched constructions of masculinity constitute significant sociocultural barriers to the effective management of male infertility among men living with HIV in sub-Saharan Africa. In many societies within the region, masculinity is strongly associated with virility, sexual potency, and the ability to father children.72 Fatherhood is not only regarded as a personal achievement but also as a social obligation tied to lineage continuity, inheritance, and community status. Within this context, infertility in men represents a profound deviation from socially prescribed gender roles, thereby attracting considerable stigma and social scrutiny. Men living with HIV who experience infertility are often subjected to a dual burden of stigma arising from both conditions.59 Infertility may be perceived as a failure of masculinity, while HIV infection is frequently associated with moral judgment, promiscuity, and social deviance. The convergence of these stigmatized identities amplifies psychological and social vulnerability, creating a complex environment in which affected individuals may struggle to openly acknowledge or address their reproductive health challenges.73 Cultural expectations surrounding male virility often led to denial of infertility among men. Admitting to infertility may be perceived as an admission of weakness or inadequacy, which conflicts with dominant norms of male strength and control. As a result, many men may resist or delay seeking medical evaluation, even in the presence of clear reproductive difficulties.74 This denial is further reinforced by societal tendencies to attribute infertility primarily to women, thereby allowing men to avoid scrutiny while simultaneously perpetuating gender inequities in reproductive health responsibility.75 Reluctance to seek medical care is another critical consequence of stigma and masculinity norms. Health-seeking behavior among men in sub-Saharan Africa is generally lower compared to women, and this disparity is further accentuated in the context of reproductive health. Fear of being diagnosed with infertility or HIV, concerns about confidentiality, and anticipation of social judgment discourage men from accessing healthcare services.76 In addition, reproductive health clinics are often perceived as female-oriented spaces, which may further alienate men and limit their engagement.

The psychological impact of these sociocultural pressures is substantial. Men facing infertility and HIV may experience feelings of shame, inadequacy, anxiety, and depression. The inability to fulfill expected gender roles can lead to diminished self-esteem and strained interpersonal relationships, including marital conflict and social isolation.15 In some cases, these pressures may drive maladaptive coping mechanisms, such as avoidance of medical care or engagement in high-risk behaviors. Male infertility is also frequently misinterpreted as sexual weakness or impotence, despite being a distinct medical condition that may not affect sexual performance.77 This misconception exacerbates stigma by conflating reproductive capacity with sexual function, thereby intensifying the perceived threat to masculine identity. Such misinterpretations contribute to misinformation, hinder open discussion, and further discourage affected men from seeking appropriate evaluation and treatment. In parallel, HIV-related stigma continues to pose a major barrier to healthcare access. Despite advancements in treatment and increased public awareness, HIV remains highly stigmatized in many SSA communities.57 Fear of disclosure, discrimination, and social exclusion discourages men from undergoing HIV testing, adhering to treatment, or engaging in discussions about reproductive intentions within clinical settings.78 This stigma not only limits access to HIV care but also obstructs opportunities for integrated reproductive health services, including fertility counseling and safe conception planning.78 Overall, the interplay between stigma and culturally defined masculinity norms creates a powerful deterrent to the recognition, disclosure, and management of male infertility among men living with HIV. Figure 4 presents socio-cultural and behavioral challenges in infertility among men living with HIV. Addressing these challenges requires culturally sensitive interventions that promote positive masculinity, reduce stigma, and encourage male engagement in reproductive health. Community education, inclusive healthcare environments, and targeted counseling strategies are essential for transforming perceptions and improving health-seeking behaviors in this population.

Figure 4.

Socio-Cultural and Behavioral Challenges. The image was generated using ChatGPT.

Gender Dynamics and Blame

Gender dynamics within many sub-Saharan African societies continue to shape the perception, attribution, and management of infertility in ways that disproportionately disadvantage both women and men, particularly in the context of male factor infertility. Despite growing biomedical evidence demonstrating that male factors contribute substantially to infertility, sociocultural norms and traditional belief systems frequently assign primary responsibility for childlessness to women. This persistent gender bias reflects deeply rooted patriarchal structures in which reproductive outcomes are viewed as a reflection of female biological function, while male fertility is often assumed to be inherently intact.79 The attribution of infertility to women has significant implications for male participation in fertility evaluation.80 Men are often less likely to present for diagnostic assessment, as societal narratives rarely position them as potential contributors to infertility. This perception is reinforced by cultural expectations of male virility and dominance, which discourage acknowledgment of possible reproductive limitations. Consequently, women are more likely to undergo repeated and sometimes invasive diagnostic procedures, while male partners may remain untested or inadequately evaluated.81 This imbalance undermines the principles of comprehensive infertility management, which require simultaneous assessment of both partners.

The limited involvement of men in fertility evaluation contributes directly to delays in the diagnosis of male factor infertility.82 In many cases, clinical investigations are initially focused exclusively on women, and only after unsuccessful interventions is attention redirected to the male partner.83 This sequential and gender-biased approach prolongs the diagnostic process, delays appropriate treatment, and may lead to unnecessary medical interventions for women. Furthermore, the absence of early identification of male-related causes reduces the likelihood of timely and effective management, particularly in settings where advanced diagnostic and treatment options are already limited.84 The consequences of gendered blame extend beyond clinical outcomes to affect interpersonal relationships and social stability. Infertility can place considerable strain on intimate partnerships, particularly when responsibility is unevenly assigned.85 Women may experience blame, discrimination, or even abandonment, while men may avoid accountability or disengage from the reproductive health process.86 In situations where male infertility is eventually identified, the revelation may challenge established gender norms and lead to feelings of shame, denial, or conflict within the relationship.76 This dynamic can result in marital discord, reduced communication, and, in some cases, dissolution of unions.

In addition, the social framing of infertility as a predominantly female issue perpetuates stigma and limits opportunities for open dialogue about male reproductive health.87 It discourages men from seeking information, engaging in preventive behaviors, or accessing healthcare services. This lack of engagement not only affects individual health outcomes but also undermines broader public health efforts aimed at addressing infertility in a holistic and equitable manner.88 Overall, the persistence of gendered attribution and blame in the context of infertility represents a significant barrier to effective diagnosis, treatment, and psychosocial well-being. Addressing these challenges requires a paradigm shift toward more inclusive and evidence-based approaches that recognize infertility as a shared reproductive health issue. Promoting male involvement, challenging harmful gender norms, and fostering couple-centered care are essential steps in improving outcomes for individuals and families affected by infertility, particularly among men living with HIV in sub-Saharan Africa.

Low Health-Seeking Behavior

Low health-seeking behavior among men constitutes a persistent and well-documented barrier to effective healthcare delivery in sub-Saharan Africa, particularly in relation to reproductive health and infertility management. Men are generally less likely than women to utilize healthcare services, engage in preventive care, or present early for medical evaluation.89,90 This pattern is influenced by a complex interplay of sociocultural, psychological, and informational factors that collectively discourage timely and appropriate engagement with health systems.90 A primary driver of low health-seeking behavior is the cultural expectation of male self-reliance and resilience.91 In many sub-Saharan African societies, masculinity is closely associated with strength, endurance, and independence, while illness is often perceived as a sign of vulnerability or weakness.92 As a result, men may delay seeking medical attention in an attempt to conform to socially constructed ideals of masculinity. This reluctance is particularly pronounced in the context of reproductive health issues, where acknowledging potential infertility may be interpreted as a challenge to male identity and social standing.93 Fear of stigma further exacerbates reluctance to access healthcare services. Men may avoid health facilities due to concerns about being labeled infertile, HIV-positive, or sexually weak.94 In settings where infertility and HIV are highly stigmatized conditions, the anticipation of discrimination, gossip, or social exclusion becomes a powerful deterrent to care-seeking behavior. This fear is often compounded by concerns regarding confidentiality and the possibility of unintended disclosure of sensitive health information within clinical environments.95

In addition, poor awareness and limited knowledge of reproductive health significantly contribute to low utilization of fertility-related services.96 Many men have insufficient understanding of male infertility, its causes, and the availability of diagnostic and treatment options.97 Reproductive health education is often directed primarily toward women, resulting in a knowledge gap among men regarding their own reproductive health responsibilities.97 Misconceptions, such as the belief that infertility is predominantly a female issue or that fertility is guaranteed in men regardless of health status, further reduce the perceived need for medical evaluation.98 The cumulative effect of these factors is delayed presentation to healthcare facilities, often at advanced stages of reproductive difficulty or after prolonged periods of unsuccessful conception attempts. Late presentation reduces the likelihood of successful intervention, as some causes of male infertility may become irreversible over time without early diagnosis and management.99 In the context of HIV, delayed engagement with care may also increase the risk of transmission and limit opportunities for integrated reproductive health counseling.100 Ultimately, low health-seeking behavior among men contributes to poor clinical and psychosocial outcomes, including prolonged infertility, untreated underlying medical conditions, psychological distress, and strained interpersonal relationships. Addressing this challenge requires targeted interventions aimed at reshaping harmful gender norms, improving reproductive health literacy among men, reducing stigma, and creating male-friendly healthcare environments that encourage early and sustained engagement with health services.

Economic Barriers

Cost of Fertility Services

The financial burden associated with fertility investigations and treatment represents a major barrier to the effective management of male infertility in sub-Saharan Africa. Across many countries in the region, infertility services are characterized by high direct and indirect costs that are largely borne by patients, making access to care highly inequitable and dependent on socioeconomic status. Fertility investigations and treatment modalities are predominantly financed through out-of-pocket expenditures.101 Patients are often required to pay for a range of diagnostic procedures, including semen analysis, hormonal assays, imaging studies, and specialist consultations, in addition to the costs of repeated follow-up assessments. In cases requiring advanced interventions, such as assisted reproductive technologies, expenses escalate substantially due to the need for laboratory procedures, medications, and multiple treatment cycles.102 The cumulative cost of these services often exceeds the financial capacity of many households, particularly in low-resource settings.103 Compounding this challenge is the limited inclusion of infertility care within national health insurance schemes and public health financing systems. In most sub-Saharan African countries, infertility is not classified as a priority public health condition, and as such, related diagnostic and treatment services are frequently excluded from insurance coverage or government subsidy programs.49 This policy gap effectively places infertility care within the domain of private healthcare, where costs are significantly higher and access is restricted to individuals with sufficient financial means.

The absence of financial protection mechanisms creates a disproportionate impact on low-income populations, who already face multiple barriers to healthcare access.104 For these individuals, the high cost of fertility services often leads to delayed presentation, incomplete diagnostic evaluation, or complete avoidance of medical care. In some cases, couples may resort to unregulated or traditional remedies that lack scientific validation, further delaying appropriate clinical intervention and potentially worsening reproductive outcomes.105 Overall, the high cost of fertility services, combined with limited insurance coverage and weak public financing structures, perpetuates significant inequities in access to reproductive healthcare. Addressing these financial barriers is essential for improving the diagnosis and management of male infertility, particularly among vulnerable populations such as men living with HIV, who are already disproportionately affected by overlapping medical and social challenges.

Poverty and Access Inequities

Socioeconomic disparities constitute a fundamental determinant of health-seeking behavior and access to specialized medical services, including infertility care, in sub-Saharan Africa. Poverty significantly restricts individuals’ ability to obtain timely, adequate, and high-quality reproductive health services, thereby exacerbating existing inequalities in the diagnosis and management of male infertility, particularly among men living with HIV. One of the primary consequences of socioeconomic disadvantage is limited access to urban-based healthcare centers where specialized fertility services are typically concentrated. Advanced diagnostic and treatment facilities, including andrology clinics and assisted reproductive technology (ART) centers, are predominantly located in major urban and tertiary healthcare institutions.106 Individuals residing in rural and peri-urban areas face substantial geographic and logistical barriers in reaching these facilities.107 These barriers include long travel distances, inadequate transportation infrastructure, travel-related costs, and loss of income due to time spent seeking care. As a result, many individuals either delay seeking care or do not access specialized services at all.107

In addition to geographic constraints, poverty severely limits the ability of affected individuals to afford advanced infertility investigations and treatment options.104 Procedures such as hormonal profiling, scrotal ultrasonography, sperm function tests, and genetic screening are often costly and require repeated assessments. Furthermore, assisted reproductive technologies, including in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), remain financially inaccessible to the majority of the population due to high procedural costs, medication expenses, and the need for multiple treatment cycles. The absence of financial subsidies or comprehensive insurance coverage further intensifies these economic barriers.101 Economic hardship also intersects with the broader health challenges associated with HIV infection. Men living with HIV who experience infertility are often required to manage the dual financial burden of lifelong antiretroviral therapy and fertility-related healthcare costs. This dual burden places significant strain on already limited household resources, frequently forcing individuals to prioritize basic survival needs over reproductive health services. Consequently, fertility care is often delayed, interrupted, or entirely foregone in favor of more immediate health or socioeconomic priorities.108

Furthermore, poverty contributes to broader structural inequities that influence health outcomes, including lower educational attainment, reduced health literacy, and limited awareness of available reproductive health services.109 These factors collectively reduce the likelihood of early presentation and engagement with specialized care, thereby worsening prognostic outcomes for male infertility. Overall, poverty and associated access inequities create a persistent cycle of disadvantages that undermine equitable access to reproductive healthcare. Addressing these disparities requires comprehensive policy interventions aimed at strengthening health system financing, expanding insurance coverage for infertility services, decentralizing specialized care, and improving socioeconomic support mechanisms. Such measures are essential to ensure that access to fertility care is not determined by socioeconomic status, particularly among vulnerable populations such as men living with HIV in sub-Saharan Africa. The challenges affecting male fertility among men living with HIV in sub-Saharan Africa should not be understood as independent problems. Biological factors, including HIV-associated inflammation, co-existing infections, endocrine disturbances, and possible regimen-specific effects of ART, may contribute to reproductive difficulties. However, the identification and management of these problems depend partly on whether men can access appropriate investigations and follow-up care. HIV-related stigma and the social expectations surrounding fatherhood may discourage men from disclosing reproductive concerns or seeking assessment, while infertility-related stigma can contribute to psychological distress and relationship difficulties. These barriers may be intensified by the cost of semen analysis, specialist consultations, and fertility treatment, particularly where services are concentrated in urban centers and are not covered by public financing. At the health-system level, the separation of HIV services from reproductive healthcare can result in missed opportunities for fertility counseling, delayed referrals, and fragmented management. These factors may reinforce one another: for example, financial constraints and stigma may delay presentation, while limited diagnostic capacity may prolong uncertainty and increase the social and economic burden on couples. Conversely, integrating fertility counseling into routine HIV care, strengthening referral pathways, providing affordable first-line investigations, and offering respectful, confidential counseling may help address several barriers simultaneously. This integrated perspective highlights the importance of combining appropriate clinical assessment with social support, financial accessibility, and coordinated service delivery, rather than treating infertility among men living with HIV as a purely biological problem.

Ethical and Policy Challenges

Reproductive Rights and Counseling Gaps

The realization of reproductive rights among men living with HIV in sub-Saharan Africa remains significantly constrained by persistent gaps in reproductive health counseling and service provision. Reproductive rights encompass the fundamental entitlement of individuals to make informed and autonomous decisions regarding their fertility, including the choice to have children, the timing of reproduction, and access to appropriate healthcare services that support safe and desired reproductive outcomes. However, in many HIV care settings within the region, these rights are not fully operationalized for men, largely due to systemic deficiencies in counseling and service integration. Men living with HIV frequently receive inadequate or inconsistent counseling regarding safe conception practices.40 Discussion on strategies for achieving pregnancy while minimizing the risk of HIV transmission to seronegative partners are often limited or entirely absent during routine clinical encounters.44 Essential information, such as the importance of sustained viral suppression, timed unprotected intercourse during periods of confirmed viral control, pre-exposure prophylaxis (PrEP) for partners, and sperm processing techniques, is not routinely communicated. This knowledge gap exposes couples to unnecessary transmission risks and limits their ability to make informed reproductive choices. In addition, counseling on fertility preservation is rarely incorporated into standard HIV care protocols. Men living with HIV may experience progressive deterioration of semen quality due to the effects of chronic infection, opportunistic illnesses, or long-term antiretroviral therapy. Despite this, healthcare providers often do not discuss options such as sperm cryopreservation or early fertility assessment at the time of diagnosis or during early stages of treatment. The absence of proactive fertility preservation counseling reduces future reproductive options and may result in irreversible loss of fertility potential.58

Furthermore, information on the full spectrum of reproductive options available to men living with HIV is frequently limited.68 Assisted reproductive technologies, donor sperm programs, and emerging biomedical strategies for safer conception are not consistently presented as viable alternatives, particularly in resource-limited settings. This lack of comprehensive counseling restricts patient awareness and limits the ability of individuals and couples to consider all possible pathways to parenthood.110 It also reinforces misconceptions that biological parenthood is unattainable or unsafe for people living with HIV.90 These deficiencies in reproductive health counseling raise important ethical and human rights concerns. The absence of adequate information undermines reproductive autonomy by preventing individuals from making fully informed and voluntary decisions regarding their fertility. Informed decision-making is a core principle of ethical healthcare delivery, yet its realization is compromised when patients are not provided with complete, accurate, and culturally appropriate information about their reproductive health options. Overall, the gaps in reproductive counseling for men living with HIV reflect broader systemic weaknesses in integrating HIV care with reproductive health services. Addressing these shortcomings requires strengthening provider training, standardizing counseling protocols, and ensuring that reproductive health discussions are embedded within routine HIV care. Such measures are essential to uphold reproductive rights, enhance patient autonomy, and improve reproductive health outcomes in this population.

Lack of Policy Integration

The absence of coherent and integrated policy frameworks represents a major systemic barrier to the effective management of male infertility among men living with HIV in sub-Saharan Africa. Health policy in many countries within the region has historically prioritized maternal and child health and, more recently, HIV prevention and treatment programs, often at the expense of comprehensive reproductive health strategies that include male infertility and fertility management. As a result, there is a significant policy gap in addressing the intersecting needs of HIV care and reproductive health services in a coordinated and structured manner. A key limitation is that few countries in sub-Saharan Africa have developed or implemented policies that formally integrate HIV care with fertility and reproductive health services.53 HIV programs are typically designed as vertical, disease-specific interventions focusing on antiretroviral therapy delivery, viral suppression, and prevention of transmission. In contrast, fertility services are often situated within separate gynecology or reproductive health units, with minimal formal linkage to HIV care structures.111 This separation at the policy level perpetuates fragmented service delivery, limiting opportunities for comprehensive care that addresses both viral management and reproductive intentions in men living with HIV.18 Furthermore, male infertility remains insufficiently prioritized within national health agendas. Many reproductive health policies continue to focus predominantly on maternal health, family planning for women, and prevention of mother-to-child transmission of HIV, while male reproductive health issues receive limited explicit attention.112 Consequently, there is often no dedicated policy guidance addressing the diagnosis, evaluation, and management of male infertility.113 This omission contributes to the underdevelopment of clinical services and reinforces the perception that infertility is primarily a female health issue.

Another critical gap is the lack of standardized national or regional guidelines specifically addressing infertility management in men living with HIV (MLWH). In the absence of clear policy direction, healthcare providers are left without evidence-based protocols for assessing fertility, counseling patients on safe conception, or integrating reproductive goals into HIV care plans.45 This lack of guidance results in inconsistent clinical practices, variable quality of care, and missed opportunities for early intervention. It also limits accountability within health systems, as infertility management in this population is not clearly defined as a service delivery priority.45 The absence of integrated policy frameworks further undermines efforts to promote reproductive rights and equitable access to care. Without explicit policy recognition, fertility services for men living with HIV remain underfunded, under-resourced, and largely inaccessible within public health systems.91 This policy gap also restricts the development of training programs, resource allocation, and monitoring and evaluation systems necessary to strengthen service delivery. Overall, the lack of policy integration between HIV care and reproductive health services, combined with the neglect of male infertility and the absence of specific guidelines for men living with HIV, contributes to fragmented and inadequate healthcare delivery. Addressing these challenges requires the development of comprehensive, multisectoral policies that explicitly integrate HIV and reproductive health services, prioritize male infertility within national health strategies, and establish clear clinical guidelines for the management of infertility in men living with HIV. Such reforms are essential for improving health system responsiveness and ensuring equitable access to reproductive healthcare in sub-Saharan Africa.

Psychological and Social Impacts

The co-occurrence of HIV infection and male infertility imposes a profound psychological and social burden on affected individuals, with far-reaching implications for mental health, interpersonal relationships, and community integration. In many sub-Saharan African contexts, where fertility is closely tied to social identity, masculinity, and lineage continuity, the inability to father children in the presence of HIV infection creates a compounded vulnerability that extends beyond biomedical illness to encompass significant psychosocial distress. One of the most frequently reported psychological outcomes is the development of depression and anxiety disorders. Men living with HIV who also experience infertility often face chronic emotional stress arising from uncertainty about their reproductive future, fear of social judgment, and perceived failure to fulfill culturally defined masculine roles.15 The persistent awareness of infertility, coupled with the lifelong management of a stigmatized chronic infection, contributes to sustained psychological strain. This can manifest as depressive symptoms, generalized anxiety, emotional withdrawal, sleep disturbances, and reduced overall quality of life.114 In the absence of adequate psychosocial support services, these conditions may remain unrecognized and untreated, further exacerbating mental health outcomes. Closely related to these psychological challenges is a marked loss of self-esteem and personal identity. In many cultural settings within sub-Saharan Africa, fatherhood is regarded as a central marker of manhood and social maturity. Consequently, infertility may be internalized as a personal inadequacy, leading to feelings of shame, guilt, and diminished self-worth.115 The coexistence of HIV infection intensifies this effect, as both conditions are often stigmatized and socially misunderstood. Men may perceive themselves as less valuable within familial and societal structures, which can negatively affect their motivation to seek care, adhere to treatment, or engage in supportive relationships.

Marital instability is another significant consequence of the psychological and social burden associated with HIV-related infertility (Buzwani et al, 2026).60 The inability to conceive children may generate tension within intimate relationships, particularly in contexts where childbearing is expected soon after marriage. Couples may experience increased conflict, emotional distancing, or breakdown of communication. In some cases, infertility may lead to separation, divorce, or the introduction of polygamous relationships as alternative strategies for achieving parenthood.116 These dynamics are often further complicated when blame is assigned within the relationship, particularly in settings where infertility is culturally attributed to women, even when male factor infertility is present.86 At the community level, men affected by both HIV and infertility may experience social exclusion and diminished social status. In societies where reproductive success is closely linked to respect, inheritance rights, and community leadership roles, the inability to father children can result in reduced social recognition and marginalization (Díaz et al, 2025).117 HIV-related stigma further compounds this exclusion, as individuals may be perceived as morally or socially deviant. Consequently, affected men may withdraw from social interactions, reduce participation in community activities, or conceal their health status, leading to social isolation and reduced support networks.76 Overall, the psychological and social impacts of combined HIV infection and male infertility are complex and interrelated, affecting multiple dimensions of an individual’s life. These challenges underscore the need for integrated care approaches that address not only the biomedical aspects of disease but also the mental health and social well-being of affected individuals. Incorporating psychosocial counseling, stigma reduction strategies, and community-based support systems is essential for mitigating these adverse outcomes and improving quality of life among men living with HIV and infertility in sub-Saharan Africa.

Future Directions and Recommendations

Integration of Services

The integration of HIV care and reproductive health services represents a critical strategy for addressing the complex and overlapping needs of men living with HIV who experience infertility in sub-Saharan Africa. Fragmented service delivery models have historically limited the effectiveness of both HIV management and fertility care; therefore, a more coordinated and patient-centered approach is essential to improve clinical outcomes, enhance service accessibility, and uphold reproductive rights.118 A key component of service integration involves the systematic incorporation of fertility screening and counseling into routine HIV care programs.56 HIV treatment clinics provide a unique and consistent point of contact between healthcare providers and men living with HIV, creating an opportunity to address reproductive health proactively (Shah et al, 2023).119 Embedding fertility-related assessments such as evaluation of reproductive history, early semen analysis where indicated, and screening for risk factors affecting fertility within standard HIV care protocols facilitates early identification of potential infertility issues (Gitau Mburu et al, 2026).120 In addition, structured counseling on reproductive intentions, safe conception practices, and available treatment options ensure that patients are equipped with the knowledge necessary to make informed decisions. Integrating these services into existing HIV programs also reduces missed opportunities for intervention and promotes continuity of care. The development of multidisciplinary reproductive health clinics is another essential strategy for achieving effective integration.56 Such clinics bring together diverse expertise, including HIV specialists, andrologists, urologists, reproductive endocrinologists, laboratory scientists, and mental health professionals, within a single coordinated care framework. This collaborative model enables comprehensive evaluation and management of both HIV infection and infertility, addressing biomedical, psychological, and social dimensions of care simultaneously.118 Multidisciplinary clinics also facilitate efficient referral pathways, reduce delays in diagnosis and treatment, and improve communication among healthcare providers, thereby enhancing the overall quality of care.121 Furthermore, integrated service models promote patient-centered care by reducing the need for multiple clinic visits across different facilities, which is particularly important in resource-limited settings where transportation costs and time constraints are significant barriers.122 By consolidating services, integration improves accessibility and adherence to both HIV treatment and fertility interventions. It also fosters a more inclusive healthcare environment in which reproductive health is recognized as an integral component of HIV care, rather than a separate or secondary concern.123

From a systems perspective, integration supports more efficient use of limited healthcare resources by leveraging existing HIV infrastructure, including trained personnel, laboratory systems, and monitoring frameworks. It also provides a platform for the development of standardized protocols, data collection systems, and quality assurance mechanisms that can be applied across both HIV and reproductive health services.124 Overall, the integration of fertility screening, counseling, and multidisciplinary care within HIV programs is essential for addressing the unmet reproductive health needs of men living with HIV. Such an approach not only improves clinical outcomes but also strengthens health systems, promotes equity in access to care, and advances the realization of reproductive rights in sub-Saharan Africa.

Capacity Building

Capacity building is a fundamental requirement for strengthening the management of male infertility among men living with HIV in sub-Saharan Africa, as it directly addresses critical gaps in human resources, technical expertise, and diagnostic infrastructure. Sustainable improvements in care delivery depend on the development of a well-trained workforce and the establishment of functional, high-quality laboratory systems capable of supporting accurate diagnosis and effective treatment.125 A central component of capacity building involves the training and continuous professional development of healthcare workers in the co-management of male infertility and HIV. Many clinicians in the region have limited exposure to andrology and male reproductive health within their formal training, resulting in inadequate competence in the evaluation and treatment of male infertility.67 Enhancing training curricula at undergraduate, postgraduate, and in-service levels is essential to equip healthcare providers with the necessary knowledge and skills to assess fertility status, interpret diagnostic findings, and provide appropriate clinical interventions. In addition, integrating fertility-related competencies into HIV care training programs ensures that healthcare providers can effectively address reproductive health concerns within routine HIV services.126 Training should also encompass fertility counseling, including communication skills required to discuss sensitive topics such as infertility, sexual health, and reproductive intentions in a culturally appropriate and patient-centered manner.127 This is particularly important in the context of HIV, where counseling must also address safe conception strategies, prevention of transmission, and psychosocial support. Expanding the skill set of healthcare providers to include both clinical and counseling competencies enhances the quality of care and improves patient engagement.128

In parallel, strengthening laboratory infrastructure is essential for supporting accurate and timely diagnosis of male infertility. Functional laboratories equipped to perform standardized semen analysis, hormonal assays, microbiological testing, and, where feasible, advanced reproductive diagnostics are critical components of effective infertility management.43 Investment in modern equipment, reliable supply chains for reagents, and maintenance systems is necessary to ensure consistent service delivery. Equally important is the training of laboratory personnel in quality-controlled procedures, adherence to international standards, and data management practices to enhance the reliability and reproducibility of results.129 Capacity building efforts should also prioritize the establishment of quality assurance systems, including standard operating procedures, external quality assessment programs, and routine supervision to maintain high standards of laboratory performance.130 Strengthening laboratory networks and promoting collaboration between facilities can further improve access to specialized diagnostic services, particularly in resource-limited and rural settings.125 Overall, capacity building through workforce development and laboratory strengthening is essential for addressing the current deficiencies in infertility care among men living with HIV. Such investments not only improve diagnostic accuracy and treatment outcomes but also contribute to the long-term resilience and effectiveness of health systems in sub-Saharan Africa.

Community Engagement and Education

Community engagement and education are essential components of a comprehensive strategy to address the sociocultural barriers that hinder the effective management of male infertility among men living with HIV in sub-Saharan Africa. Given the strong influence of cultural norms, beliefs, and social structures on health behaviors, interventions that extend beyond the clinical setting and actively involve communities are critical for fostering acceptance, improving awareness, and encouraging positive health-seeking practices.131 A key priority within community based interventions is the reduction of stigma associated with both HIV and infertility through culturally sensitive and context-specific approaches.57 Stigma in many sub-Saharan African settings is deeply rooted in misconceptions, moral judgments, and traditional beliefs that link infertility and HIV to personal failure or social deviance.115 Addressing these perceptions requires the development of educational programs that are tailored to local cultural contexts, languages, and belief systems. Community dialogues, public health campaigns, and engagement with influential community leaders including religious leaders, traditional authorities, and local opinion leaders can facilitate the dissemination of accurate information and promote more supportive attitudes toward affected individuals.132 By normalizing discussions around male infertility and HIV, such interventions help to reduce shame, challenge harmful stereotypes, and create an enabling environment for individuals to seek care without fear of discrimination.

In addition to stigma reduction, promoting male involvement in reproductive health is a critical objective of community engagement efforts. Reproductive health services in many settings have traditionally been oriented toward women, resulting in limited participation of men in fertility-related decision-making and healthcare utilization.133 Encouraging male engagement requires deliberate strategies that reposition reproductive health as a shared responsibility between partners. Community education programs should emphasize the role of men in fertility, highlight the importance of joint evaluation of couples, and promote supportive partner dynamics.97 Targeted outreach initiatives, including male-focused health education sessions, workplace programs, and peer support groups, can be effective in increasing awareness and participation among men.134 These interventions should address common misconceptions about male infertility, provide information on available diagnostic and treatment options, and encourage early health-seeking behavior.134 In the context of HIV, community-based programs can also promote understanding of safe conception practices and the possibility of achieving parenthood while minimizing transmission risks.

Furthermore, integrating reproductive health education into existing community health platforms, such as HIV support groups, community health worker programs, and primary healthcare outreach services, enhances the reach and sustainability of interventions. Community health workers, in particular, play a vital role in bridging the gap between health facilities and communities by providing education, facilitating referrals, and supporting individuals throughout the care continuum.135 Overall, community engagement and education serve as powerful tools for transforming social norms, reducing stigma, and improving health behaviors related to male infertility and HIV. By fostering inclusive, informed, and supportive community environments, these interventions contribute to increased utilization of healthcare services, improved reproductive health outcomes, and the promotion of equity in access to care for men living with HIV in sub-Saharan Africa.

Policy Development

Robust policy development is essential for addressing the systemic gaps that hinder the effective management of male infertility among men living with HIV in sub-Saharan Africa. The absence of comprehensive and coordinated policy frameworks has contributed to fragmented service delivery, inequitable access to care, and inconsistent clinical practices.136 Strengthening policy architecture is therefore critical for aligning healthcare systems with the reproductive health needs and rights of this population. A key priority in this regard is the establishment of national guidelines for the management of infertility in men living with HIV. Such guidelines should provide standardized, evidence-based protocols for the evaluation, diagnosis, and treatment of male infertility within the context of HIV care. This includes recommendations on routine fertility assessment, safe conception strategies, integration of reproductive counseling into HIV services, and appropriate use of assisted reproductive technologies where available. The development of these guidelines would enhance clinical consistency, improve quality of care, and support healthcare providers in delivering informed and contextually appropriate interventions. Additionally, clear policy direction would facilitate training, monitoring, and evaluation processes, thereby strengthening accountability within health systems.

Equally important is the expansion of insurance coverage and public financing mechanisms to include fertility-related services. In many sub-Saharan African countries, infertility care is not recognized as an essential component of healthcare and is therefore excluded from national health insurance schemes.5 This exclusion results in high out-of-pocket expenditure and restricts access to diagnostic and treatment services to individuals with sufficient financial resources. Expanding insurance coverage to encompass fertility investigations, counseling, and selected treatment options would significantly reduce financial barriers and promote equitable access to care. Policy initiatives aimed at financial protection should also consider subsidization models, private public partnerships, and inclusion of cost-effective fertility interventions within primary healthcare systems.136 Integrating infertility services into universal health coverage frameworks would ensure that reproductive health is treated as a fundamental aspect of overall well-being, rather than a discretionary or luxury service.

Furthermore, effective policy development requires a multisectoral approach that involves collaboration between government agencies, healthcare institutions, professional bodies, and community stakeholders.136 Engaging these factors in the policy formulation process ensure that guidelines are contextually relevant, culturally sensitive, and responsive to the needs of affected populations. It also promotes ownership and facilitates successful implementation at both national and local levels. Overall, the development and implementation of comprehensive policies that establish clinical guidelines and expand financial access to fertility services are critical steps toward improving the management of male infertility among men living with HIV. Such policy reforms are essential for strengthening health systems, reducing inequities, and advancing reproductive health rights in sub-Saharan Africa.

Research Priorities

Advancing the management of male infertility among men living with HIV in sub-Saharan Africa requires a strong and contextually relevant research agenda that addresses existing knowledge gaps and informs evidence-based interventions. Despite growing recognition of the intersection between HIV and male reproductive health, empirical data in this area remain limited, fragmented, and often derived from high-income settings that may not reflect the unique sociocultural and health system realities of the region. Establishing clear research priorities is therefore essential for generating locally applicable evidence and guiding policy and clinical practice. A critical area of investigation is the effect of antiretroviral therapy (ART) on male fertility. While ART has significantly improved survival and quality of life among men living with HIV, its long-term impact on reproductive function remains incompletely understood. Research is needed to elucidate the effects of different antiretroviral drug classes and treatment durations on spermatogenesis, sperm quality, hormonal regulation, and overall reproductive outcomes. Longitudinal studies that distinguish between the effects of HIV infection itself and those of ART are particularly important. Such evidence will inform the optimization of treatment regimens that achieve viral suppression while minimizing potential adverse effects on fertility.

Another key priority is the development and evaluation of low-cost fertility technologies that are suitable for resource-limited settings in sub-Saharan Africa. Conventional assisted reproductive technologies, such as in vitro fertilization and intracytoplasmic sperm injection, are often prohibitively expensive and require advanced infrastructure that is not widely available in the region. Research efforts should focus on adapting existing technologies to reduce cost and complexity, as well as innovating simplified, scalable approaches to infertility management. This includes the exploration of affordable diagnostic tools, simplified sperm processing techniques for safe conception in HIV-affected couples, and decentralized models of care that can be implemented at lower levels of the health system. The development of cost-effective interventions is essential for expanding access and reducing inequities in fertility care. In addition, there is a need for in-depth research on the sociocultural determinants of male health-seeking behavior in the context of infertility and HIV. Understanding how cultural norms, gender roles, stigma, and belief systems influence men’s perceptions of infertility and their engagement with healthcare services is critical for designing effective interventions. Qualitative and mixed-methods studies can provide valuable insights into barriers to care, patterns of health service utilization, and the role of community dynamics in shaping health behaviors. Such research will support the development of culturally sensitive strategies aimed at improving male participation in reproductive health services and reducing stigma associated with both HIV and infertility.

Furthermore, interdisciplinary research that integrates biomedical, social, and health systems perspectives is necessary to capture the complexity of infertility among men living with HIV. Strengthening local research capacity, fostering regional collaborations, and promoting the inclusion of sub-Saharan African populations in global research initiatives are also essential for ensuring that generated evidence is relevant and sustainable. Overall, prioritizing research on the biological effects of ART, the development of affordable fertility technologies, and the sociocultural drivers of health-seeking behavior will provide a robust evidence base for improving clinical care, informing policy decisions, and enhancing reproductive health outcomes among men living with HIV in sub-Saharan Africa.

Limitations of the Review

Several limitations should be considered when interpreting the findings of this review. First, the narrative review design was chosen to provide a broad and integrated discussion of the biological, clinical, sociocultural, economic, and health-system factors influencing the management of male infertility among men living with HIV in sub-Saharan Africa (SSA). Although this approach allows findings from different disciplines to be considered within a common framework, it does not necessarily provide the same level of search reproducibility, comprehensive study identification, or formal risk-of-bias assessment expected of a systematic review. The selection and interpretation of literature may also be influenced by the availability and relevance of published evidence. Consequently, this review should be understood as a thematic synthesis of the available literature rather than an exhaustive account of all research on the subject. The findings are intended to identify important challenges and gaps in current knowledge, rather than to establish definitive estimates of the prevalence or magnitude of infertility or the effects of HIV and antiretroviral therapy (ART) on male reproductive function. A second limitation relates to the heterogeneity of the available evidence. The studies considered in this review differ in design, sample size, participant characteristics, HIV disease status, duration of infection, immune status, and exposure to ART. They also vary in how male infertility and reproductive function are defined and assessed. For example, some studies focus on semen parameters, such as sperm concentration, motility, and morphology, whereas others investigate reproductive hormones, sexual function, or broader clinical outcomes. These measures provide useful but distinct information and should not be treated as interchangeable indicators of fertility. Furthermore, differences in semen collection procedures, laboratory methods, follow-up periods, and the reporting of pregnancy and live-birth outcomes complicate comparisons across studies. Because the evidence is not sufficiently uniform to support direct comparison across all these domains, the review cannot establish a consistent magnitude of reproductive impairment attributable to HIV infection or its treatment. In particular, abnormalities in semen parameters or reproductive hormones do not necessarily translate into an inability to achieve pregnancy. An additional limitation relates to the restriction of the literature search to English-language publications. Although this criterion was applied to maintain consistency during screening and to ensure that the included sources could be assessed by the review team, it may have introduced language-related selection bias. Sub-Saharan Africa is linguistically diverse, and relevant research on HIV, male reproductive health, and fertility-care services may be published in French, Portuguese, and other languages, particularly in countries where these languages are widely used in academic and clinical settings. By excluding non-English publications, the review may have missed locally generated evidence, including findings from Francophone and Lusophone African settings. This could have contributed to an uneven representation of countries and healthcare contexts in the final synthesis, potentially limiting the extent to which the findings reflect the diversity of the region. The direction and magnitude of this potential bias cannot be determined from the included literature alone. Nevertheless, the language restriction should be considered when interpreting the review’s conclusions, particularly those concerning the availability of fertility services, sociocultural barriers, and the applicability of clinical approaches across different national settings. Future reviews should consider multilingual searches, collaboration with researchers proficient in French and Portuguese, and the inclusion of eligible non-English publications where feasible.

A further limitation is the uneven availability of research specifically involving men living with HIV in SSA. Although the region carries a substantial burden of HIV, male reproductive health has received comparatively limited attention in some areas of the literature. As a result, certain biological and clinical findings discussed in this review are drawn from studies conducted outside SSA or from populations that may differ from the intended population of interest. Their applicability to African settings should therefore be considered in light of differences in healthcare infrastructure, access to fertility investigations, prevalence of reproductive tract infections and other co-infections, socioeconomic circumstances, and patterns of ART use. An additional limitation relates to the restriction of the literature search to English-language publications. Although this criterion was applied to maintain consistency during screening and to ensure that the included sources could be assessed by the review team, it may have introduced language-related selection bias. Sub-Saharan Africa is linguistically diverse, and relevant research on HIV, male reproductive health, and fertility-care services may be published in French, Portuguese, and other languages, particularly in countries where these languages are widely used in academic and clinical settings. By excluding non-English publications, the review may have missed locally generated evidence, including findings from Francophone and Lusophone African settings. This could have contributed to an uneven representation of countries and healthcare contexts in the final synthesis, potentially limiting the extent to which the findings reflect the diversity of the region. The direction and magnitude of this potential bias cannot be determined from the included literature alone. Nevertheless, the language restriction should be considered when interpreting the review’s conclusions, particularly those concerning the availability of fertility services, sociocultural barriers, and the applicability of clinical approaches across different national settings. Future reviews should consider multilingual searches, collaboration with researchers proficient in French and Portuguese, and the inclusion of eligible non-English publications where feasible. In addition, the available evidence does not always allow the effects of HIV itself to be separated from those of advanced disease, chronic inflammation, co-existing infections, metabolic disorders, lifestyle factors, or other health conditions. These overlapping influences make it difficult to attribute observed reproductive changes to a single cause and highlight the need for research that reflects the clinical and social circumstances of men living with HIV in the region. The relationship between ART and male reproductive function also requires cautious interpretation. Although some studies have reported associations between ART exposure and changes in semen quality or reproductive hormone levels, other studies have found no significant adverse effects or have identified potential reproductive benefits associated with improved immune function and sustained viral suppression. These differences may reflect variations in drug classes and individual regimens, treatment duration, participants’ health before treatment, HIV disease severity, and study methods. Findings involving older antiretroviral agents should not automatically be generalized to contemporary regimens. Moreover, where evidence is derived from observational studies, it may be difficult to distinguish the effects of medication from those of HIV infection and associated conditions. The findings of this review therefore do not support the conclusion that ART generally causes male infertility. Rather, they indicate that the reproductive effects of particular regimens, especially with long-term exposure, require further investigation using appropriately designed studies. Finally, the practical application of the review’s findings may be affected by substantial differences in the availability, affordability, and organization of fertility services across SSA. Access to semen analysis, hormonal investigations, specialist andrology services, genetic testing, and assisted reproductive technologies varies between countries and between urban and rural settings. Consequently, the clinical pathway and service-delivery approaches discussed in this review should be regarded as a proposed framework for individualized assessment and safer-conception counseling, rather than a uniform protocol that can be implemented in every setting without adaptation. Their feasibility will depend on local resources, referral systems, clinical expertise, and national guidelines. These limitations notwithstanding, the review highlights important areas in which the available evidence remains incomplete. Further systematic reviews, alongside well-designed longitudinal and clinical studies involving men living with HIV in SSA, are needed to clarify the relationship between HIV, specific ART regimens, and reproductive outcomes. Such research should distinguish changes in surrogate markers, such as semen parameters and hormone levels, from clinically meaningful outcomes, including conception and live birth, while also examining how health-system and socioeconomic conditions influence access to fertility care.

Conclusion

This review highlights that the management of male infertility among men living with HIV in sub-Saharan Africa is constrained by interconnected biological, sociocultural, economic, and health-system barriers. Although HIV-related inflammation, endocrine disturbances, and coexisting infections may contribute to impaired reproductive function, the extent to which specific antiretroviral therapy (ART) regimens affect male fertility remains uncertain. Findings on semen quality and reproductive hormones are inconsistent and may vary according to the regimen, duration of treatment, HIV disease status, and other individual factors. Therefore, the potential reproductive effects of ART should be interpreted cautiously rather than regarded as a general consequence of treatment. In contrast, barriers related to stigma, financial constraints, limited diagnostic capacity, fragmented HIV and reproductive health services, and shortages of trained personnel are persistent challenges to accessing appropriate fertility care. These barriers can delay assessment and counseling, limit access to treatment, and undermine the ability of men living with HIV and their partners to make informed reproductive decisions. Integrating fertility care into routine HIV services is therefore important for addressing reproductive needs alongside the established benefits of sustained HIV treatment and viral suppression. A major evidence gap is the limited availability of male-focused research from sub-Saharan Africa, particularly studies examining contemporary ART regimens alongside semen quality, reproductive hormones, and actual outcomes such as conception and live birth. Consequently, conclusions about the region-specific effects of HIV and ART on male fertility remain constrained. Improving the evidence base and ensuring that fertility needs are recognized within HIV care are important for supporting reproductive autonomy, equitable access to services, and the quality of life of men living with HIV and their partners.

Funding Statement

No funding was received for this work.

Declaration of AI Tool Use

Chatgpt (GPT-5.6, OpenAI) was used solely for image generation and editing. The authors reviewed and verified all the images and retained full responsibility for the content.

Data Sharing Statement

The study-level extraction dataset and supporting review materials are available from the corresponding author upon reasonable request.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.