TREATMENT ISSUES--The GMHC Newsletter of Experimental AIDS Therapies - Vol. 5, No. 1 - January 10, 1991
Mary Beth Caschetta

Due to insufficient funding and lack of focus, information about HIV infection in women is sparse, but some generalizations can be made. For instance, Kaposi's sarcoma (KS), which is common in gay and bisexual men who contract HIV infection sexually, rarely occurs in women (9). Also, two-thirds of women who progress to clinical AIDS are found to have pneumocystis carinii pneumonia (PCP) by the time they are first diagnosed with AIDS, which usually occurs late in the course of their illness (10). Female patients may also experience fever, night sweats, cough and weight loss. But the classical early manifestations of AIDS in women are usually gynecological complications, such as chronic vaginal yeast infections, anal or genital warts and ulcers, herpes simplex virus, and pelvic inflammatory disease. Notably, the Centers for Disease Control (CDC) definition of AIDS does not include any of these gynecological symptoms, which are known to occur with frequency and severity in women with AIDS. In July 1990 the CDC published a study stating that 65 percent of HIV-infected women died without fitting the CDC definition for AIDS (11). The ramifications of such underrepresentation are enormous: women are denied disability benefits to which they are entitled; their illness goes misdiagnosed and untreated; and research efforts are skewed, distorting general knowledge of the scope of the AIDS epidemic.

Currently, women are twice as likely as men to have opportunistic infections (OIs) which are missed or misdiagnosed because HIV infection is not suspected (12). When detection does occur, a woman may progress from an AIDS diagnosis to death twice as fast as a man. In fact, according to CDC reports, trends from 1984-1990 show that women are more likely than men to die the same month as they are diagnosed with AIDS (13). Clearly, early detection and management of HIV infection in women is critical to improve survival. It is important to note that the following clinical manifestations of HIV infection in women can and should be considered and appropriately addressed, when treating all female patients. Any woman, regardless of her class, color, ethnic origin, pregnancy status, sexual or drug-using history, and sexual identity, deserves proper medical attention and consideration in this matter.

Vulvovaginal Candidiasis

It is thought that more than one-third of women with HIV infection develop chronic genital yeast infections (14). This condition is caused by an increased growth of yeast that is already established in the vagina by spread of organisms from the anus, or in some cases by sexual transmission. Vulvovaginal candidiasis (yeast infection) may cause severe itching and burning, odor from the vagina, and a "cheesy" discharge. HIV-infected women with candidal vaginitis may experience temporary symptomatic improvement with treatments of antifungal agents, such as intravaginal miconazole or clotrimazole (100 mg once daily for seven days). Clotrimazole will soon be available over-the-counter (Gyne-Lotrimin vaginal inserts, Schering-Plough) for women with vaginal yeast infection (15). This condition may require maintenance therapy in immunosupressed women. Vaginal candidiasis may be the first symptom of HIV infection in women. As T4 cell counts drop, yeast infections may occur with serious consequence in the mouth and throat, and later in the esophagus. Swollen lymph nodes, herpes simplex lesions, and a general lack of energy may also accompany this condition. Fluconazole, a fairly non-toxic but considerably expensive drug, is the recommended treatment for chronic candidiasis in HIV-infected women. Intermittent dosing may be sufficient, but further study is needed.

Human Papillomavirus (HPV) and Cervical Cancer

The human papillomavirus (HPV) is associated with the development of anogenital warts which may cause blockage, abnormal Pap smears, flat or tiny warts on the cervix, and possibly cancer-causing tissue growths (16). Red, spiked warts on the anal or genital regions, especially in moist areas of frequent genital friction, are not difficult to recognize and may be treated with application of acetic acid, cryotherapy (freezing), laser therapy or surgical removal. Frequent recurrences of warts especially after rigorous treatment (topical 5-fluorouracil (5FU); laser therapy; or alpha interferon injections into the warts) are common and may indicate HIV infection.

Inverted warts, dysplasia (abnormal tissue growths) and neoplasia (cancer-causing tissue growths), which can also be caused by HPV, may present more serious problems. Because HPV in HIV-infected women has been found to be strongly associated with genital dysplasia and cancerous growths, detection by frequent Pap smear and colposcopy (a microscopic examination of the vulva, vagina and cervix) is highly recommended for any patient who may be at risk. Recent, alarming reports indicate that Pap smears may not adequately detect abnormal or cancerous cell growth in HIV- infected women, and that cervical biopsy by colposcopic examination may be the preferred means of detection (17). Unfortunately colposcopic exams are costly and not covered by Medicaid.

Treatment of any atypical, pigmented, or persistent warts should be initiated only after a biopsy rules out dysplasia. Also recommended is anoscopy (a microscopic examination of the anus) in order to rule out anal warts and cancers. There is some very strong suggestion that HIV disease in women is related to abnormalities in squamous cells in the cervix and vagina which may cause cancer (18). Follow-up examinations and careful surveillance for cervical cancer with Pap smears (and colposcopic exams when possible) should be given every six months for asymptomatic women without dysplasia.

Pelvic Inflammatory Disease (PID)

Possibly caused by sexually transmitted organisms and thought to be associated with chlamydia (a sexually transmitted bacterial infection), pelvic inflammatory disease (PID) is a painful inflammation of the upper genital tract. Also common to PID are collections of pus in the fallopian tube or the ovary. Abnormal vaginal bleeding, painful and difficult menstruation, infertility and ectopic pregnancy (pregnancy which occurs outside of the uterus) are also possible symptoms of PID. Anecdotal reports suggest that PID is more common and more severe in women with HIV infection, than in women with normally functioning immune systems.

PID diagnosis can be made by examining the abdomen with a surgically inserted instrument called a laparoscope. HIV-infected women may be unable to mount an immune response, causing the inflammation and pain by which professionals are able to make a diagnosis. Because there exists no suitable diagnostic test, detection of PID in HIV-infected women may be extremely difficult (19). Immediate hospitalization is strongly recommended, where severe PID is suspected. Since no single treatment is established for PID, professional medical attention is a must.

Herpes Simplex Virus (HSV)

Chronic herpes lesions may be a symptom of immunodeficiency in women. Genital herpes has also been strongly associated with transmission of HIV infection, possibly due to breaks in the skin allowing entry of the virus into the blood stream. Patients may benefit from oral acyclovir (Zovirax) but maintenance therapy may be necessary. Daily acyclovir is thought to be safe and effective for up to three years (20). Treatment with intravenous acyclovir is reserved for more severe conditions.

Other Sexually Transmitted Diseases

It has been suggested that genital ulcers caused by conditions, such as genital herpes, chancroid, warts and syphilis increase the risk of HIV transmission for women. Other co-factors that may play a role in the severity and prevalence of sexually transmitted diseases (STDs) include: age of first sexual intercourse; the economic necessity of exchanging sex for drugs and money; number of partners; cigarette smoking, and dietary deficiencies (21). Although further study is needed to establish the connection between STDs and HIV, women should be counseled and tested for STDs at every medical screening.

Conclusion

Because of the many psychosocial obstacles barring women access to education, technology, health care, fertility control and financial resources, women do not often seek out primary medical care (22). Beyond contraception, abortion, prenatal care and pediatric visits, a woman may have little or no contact with a doctor or clinic (23). Therefore, it is important to note that any contact between a female patient and a health professional is an invaluable opportunity for culturally sensitive risk-assessment of HIV and other STDs; education about transmission of HIV; information about drug and alcohol treatment; and ongoing counseling, support and medical evaluation.

A future article will focus on reproductive issues and pregnancy for women with HIV infection.

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