TREATMENT ISSUES: Special Edition - Volume 6, Number 7, Summer/Fall 1992; The Gay Men's Health Crisis Newsletter of Experimental AIDS Therapies
Sharon Lerner

HERPES

Herpes Simplex virus (HSV) can cause sores on the mouth and in or around the genital area, including the inside and outside of the vagina, the rectum, and anus. It may also cause flu-like symptoms shortly before an outbreak, vaginal discharge, painful urination, and general genital irritation. Repeat outbreaks of HSV are thought to develop due to a wide range of factors, including physical or emotional trauma, hormonal changes due to pregnancy and menstruation, ultraviolet light, sexual stimulation, and HIV progression. Outbreaks are increasingly persistent as immune suppression progresses.[4] In people with normal immune systems, herpes outbreaks on the lips triggered by ultraviolet light can be prevented by sunscreen. Without proper treatment, herpes can sometimes spread to other sites. When an outbreak is present in a delivering woman, surgical removal (Caesarian section) of the infant is recommended to avoid transmission.

While there is no way to rid the body of HSV once infection occurs, treatment with acyclovir (Zovirax) can speed up the healing process if it is used within six days of an episode. The drug may also help prevent recurrences, limit the time during which herpes can be passed to another person (viral shedding) through sexual contact, and, in some cases, decrease pain. Acyclovir has been taken safely for more than two years as an effective suppressive treatment. Made by Burroughs Wellcome, the drug is very expensive. For an increasing number of women and men with AIDS in whom acyclovir-resistant strains of HSV have been discovered, a possible alternate therapy is foscarnet. Wearing loose clothing and cotton underwear, taking warm sitz baths, and keeping sores dry with a hair-dryer or towel drying are recommended to alleviate discomfort.

Experimental therapies include BW256U87 (BW256 for short), a drug made by Burroughs Wellcome, that is turned into acyclovir once inside the body. Taken in pill form, this drug can achieve the same blood levels of acyclovir that normally require IV treatment. Cheap, safe, natural treatments for herpes include dysine (4000 mg for treatment/500 mg for prophylaxis); Vitamin C--pills or a paste applied to lesions; Mono-laurin; iodine applied to lesions; zinc, aloe, and vitamin E.[5]

CHLAMYDIA

Little information is available that examines the relationship between HIV and Chlamydia trachomatis infection. Chlamydia was discovered only 15 years ago, though it is currently thought to be the most common STD in the United States. Chlamydia infection is caused by a group of bacteria which have an incubation period of five to ten days. The initial infection is typically asymptomatic. When present, signs and symptoms include yellow vaginal or cervical discharge, painful urination, bleeding or pain with sex, irregular menstrual periods, and spotting between periods. Rectal chlamydial infections can cause rectal pain and discharge. Left untreated, chlamydia can lead to tubo-ovarian abscesses, infertility, cystitis, inflammation following sexual intercourse, and pelvic inflammatory disease. Based on anecdotal evidence, chlamydial infections are more severe in HIV-positive women.[6]

Because chlamydial infection is often asymptomatic and cultures for Chlamydia trachomatis are not easily available to all clinicians, many women go undiagnosed. Diagnosis is often made by ruling out other infections. Women whose sexual partners are infected with Chlamydia have a greater chance of developing chlamydia, as do women who have gonococcal cervicitis, other STDs, and symptoms of urinary tract infections but negative urine cultures. Diagnosis and treatment of partners are also extremely important, since reinfection rates are high. Chlamydia is treated with 500 mg tetracycline taken four times per day for at least a week, or 100 mg doxycycline (Vibramycin), taken by mouth twice each day for at least one week. For women who are pregnant and others who are allergic to tetracycline, 500 mg erythromycin (E-Mycin, Robimycin) taken four times daily for seven days by mouth or a slightly lower dose for a longer period is recommended.

Recent studies with azithromycin show that a single dose treatment of 1 gram of the drug equals the safety and efficacy equivalent of a one-week regimen of doxycycline. Azithromycin has excellent tissue penetration, and uptake of the drug is higher in cells where inflammation is present, conveniently targeting the drug to the area most in need of treatment. Azithromycin (1000 mg single dose) has shown microbiological cure rates of 96% -100%.[7] Azithromycin is also useful against mycoplasma, Ureaplasma urealyticum and against gonorrhea at this dose, allowing for broad-spectrum anti-STD treatment before culture results are available. Azithromycin remains in the body for as long as four days,s and the most common side effects are gastrointestinal. It should be taken on an empty stomach (one hour before or two hours after eating). Azithromycin, while approved for use in the U.S., may be difficult to obtain, and still can be purchased through the underground. In New York City, contact the PWA Health Group at (212) 255-0520.

------------------------------------------------ Sexually transmitted diseases, yeast infections, cancers, and other conditions occur differently, commonly, and more severely in HIV-positive women than HIV-negative women. -------------------------------------------------

GONORRHEA

In numerous studies, no association has been found between a history of gonorrhea and HIV infection.[9] Gonorrhea, an extremely common bacterial infection, is transmitted almost exclusively through sexual contact and is thought to increase with lowered immunity in women.[10] The infection must be diagnosed properly and treated when suspected. Women are thought to have a 30% chance of contracting gonorrhea after one sexual contact with an infected partner. The percentage increases to almost 100 percent for women who are on birth control pills.[11] Very little data are available about the course of gonorrheal infection in HIV-positive women. If untreated, the infection can spread beyond the cervix through and into the uterus and tubes, causing infertility and chronic pelvic pain.[12] Like chlamydia, gonorrhea is often asymptomatic, and up to 80% of infected women do not experience symptoms. When present, initial symptoms will appear from three to eleven days after infection and include an increase in vaginal discharge, uncomfortable and more frequent urination, conjunctivitis, menstrual irregularities, swelling of the vulva, and spotting after sexual intercourse.

Gonorrhea can be diagnosed by taking a culture from the cervix, anus, mouth or oropharynx; cultures are not very reliable and can test falsely negative if women douche or take antibiotics, or if the infection is further in than the cervix or anus.[13] Because of its prevalence and because it can lead to serious complications, the presence of gonorrhea should be considered in all women with other STDs. Treatment is with Rocephin (250 mg intramuscular injection) and doxycycline (100 mg twice daily) for seven days.

TRICHOMONAS VAGINALIS

This infection is caused by a protozoan called Trichomonas vaginalis and remains asymptomatic in about 50% of infected women.[14] Symptoms, when present, include itching, irritation, presence of a thin yellow-green odorous discharge, and painful intercourse. Topical clindamycin has been studied for use during pregnancy and appears to be effective in women with HIV. Small, moving organisms may be visible on a wet mount lab test. Recommended treatment is with 250 mg of Metronidazole (Flagyl) three times a day for seven days. Flagyl must be taken with food to avoid nausea, and should never be taken with alcohol. Drinking alcohol while on Flagyl leads to a reaction involving dizziness, nausea, sweating, and bloodshot eyes.

VAGINAL CANDIDIASIS (YEAST INFECTION, THRUSH, OR VAGINITIS)

Vaginal candidiasis is usually caused by Candida albicans. It is said to be the most common initial clinical manifestation of HIV infection in women and occurs in women with relatively high T4 cell counts.[15] In one study of 29 women at Walter Reed Army Hospital, chronic vaginal candidiasis preceded the development of oral thrush and was the earliest indication of immune suppression in 25% of the women.[16] This fungal infection can occur before any significant lowering in T4 cell counts and before candida infections develop in other parts of the body, such as the mouth, esophagus, and gastrointestinal tract.[17] Though favorable response to treatment has been noted, recurrence rates are high.[18] The possibility of HIV infection should be considered in all women experiencing recurrent, persistent vaginal candidiasis.

Symptoms of vaginal candidiasis include thick, odorless, white or yellow discharge. Additional symptoms include vaginal and vulvar itching or burning, pain during urination, and raised white and gray patches on the vaginal skin. While vaginal thrush is common in all women, HIV-positive women experience more frequently recurring hard-to-treat infections.

Yeast infections can be diagnosed by looking at a smear under a microscope. Some clinics do not check for yeast under a microscope and may prescribe medications based on symptoms. It is important to advocate other tests, since many yeasts are asymptomatic and can be obscured by the symptoms of HIV infection. Many women have had experience with yeast infections and self-medicate with over-the-counter treatments (Gynelotrimin, Monostat-7, Yeast-guard). If self-treatments do not succeed, a physician should be consulted and an additional infection investigated. If the infection is in fact yeast, and local treatment has not worked or has failed to prevent recurrences, a stronger local antifungal or systemic therapy (fluconazole and ketoconazole) can be tried. If these fail to relieve symptoms, an additional diagnosis should again be considered. Yeast infections developing in women on prophylactic fluconazole are either drug-resistant or unusual organisms (such as Torulopsis glabrata or Candida krusei) that fluconazole does not affect. Resistant yeast is treated with topical or intravenous (IV) amphotericin B, sometimes in combination with Flucytosine. Many drugs used to treat HIV- related diseases will change the vaginal environment and encourage yeast to flourish.

Treatment with a variety of antifungals includes the following:

* Cream or suppositories include miconazole nitrate (Monostat), terconazole (Terazol-7), clotrimazole (Mycelex), butoconazole (Femstat), nystatin (Mycostatin), or tioconazole (Vagistat).

* Boric acid powder, which is not recommended for pregnant women, is also sometimes used. Boric acid is inexpensive and found in any drug store. Poured into a number two gelatin capsule at 600 mg twice daily (available at many health food stores) and inserted into the vagina at bedtime every day for two weeks, it may help re-acidify the vagina and kill yeast.

* Acidophilus bacteria (bacteria attracted to acid) such as lactobacillus, an ingredient found in such brands of plain yogurt as Alta Dena, Maya & Continental, may help keep yeast infections in check. A recent six-month long study found that eating eight ounces of lactobacillus-containing yogurt a day produced a threefold reduction in vaginal candida infections in women with chronic, recurrent vaginal candidiasis.[19] It is possible that lactobacillus acidophilus capsules (available at some health food stores) inserted into the vagina may also reduce the frequency of this infection. The refrigerated kind is preferred.

* Antifungal pills such as fluconazole, and ketoconazole. Systemic antifungals may cause side effects in some women, such as a rash and inflammation of the liver, and are more likely to be used in women with more pronounced immunesuppression in whom it can also prevent oral and esophageal thrush. These drugs are very expensive.

* Garlic capsules may also offer relief.

TRANSMISSION OF STDs

Sexual transmission of organisms that cause the above diseases (except thrush) occurs during direct contact between infectious lesions (warts, ulcers, blisters) and body fluids (semen, vaginal secretions, saliva, and blood). Condom use by male partners and latex dams* by female sex partners can decrease the likelihood of getting STDs. This is true only if barriers are used every time and correctly (no slippage, breaks, or leaks). Chlamydia can also be transmitted during sex between two women if organisms are present in the mouth or on hands, or if the genitals are touched together. The most efficient means of transmitting an infection to a woman, however, is when male ejaculate (cum) is allowed to enter and stay in the female body.

There is no evidence that condoms or latex dams reduce the likelihood of contracting genital warts, HPV, or developing recurrences of cervical cancer. However, barrier contraceptives do reduce the risk of cervical cancer from occurring at all. Condoms do not necessarily protect against transmission of herpes infection, because the site of infection is most commonly the vulva in women and the base of the penis in men, and these sites are left uncovered by condoms. The female condom (Reality brand vaginal pouch) may provide more protection as it covers a larger area.

CONCLUSION

Until researchers and funders put money and efforts into designing a safe, invisible barrier that is 100% controlled by a woman, condoms are the best way to go. In fact, 70% of condom buyers are women. Negotiating use with a male partner can be difficult, but it is vital. HIV can only be complicated by exposure to disease causing organisms which are transmitted through sexual contact. Women must be especially careful during menstruation and when open genital sores are present. In the meantime, unfortunately, few workshops exploring safer sex are disseminating information that consists of the full range of safety issues for heterosexual, bisexual, or lesbian HIV-positive women.

FOOTNOTES ---------

1. Kreiss JK, Coombs R, Plummer F et al. Isolation of HIV from genital ulcers in Nairobi prostitutes. J Infect Dis 160:380-384, 1990.

2. Seigal FP et al. Severe AIDS in male homosexuals manifested by chronic herpes simplex lesions. N Engl J Med 305:1439-1444, 1981.

3. Mosca JD et al. HSV-I can reactivate transcription of latent HIV. Nature 325:67-70, 1987.

4. Moss G.B., Kreiss JK. The relationship between HIV and other STDs. Med Clin N. Amer. 74(6):1647-60, 1990.

5. Personal Communications, Dr. Joan Priestly, May, 1992.

6. Mayer K. Personal Communication February 2, 1992.

7. Lassus, A. Comparative studies of azithromycin in skin and soft tissue infections and sexually transmitted infections by Neisseria and Chlamydia species. J Antimicrob Chemother 25(A):115-121, 1990; and Steingrimsson, O. et al. Azithromycin in the treatment of sexually transmitted disease. J antimicrob chemother 25(A):109-114, 1990

8. Schentag, J.I., et al. Tissue-directed pharmacokinetics. Am J Med. 91(3A):5-11, 1991

9. Moss GB and Kreiss IK. The interrelationship between HIV and other STDs. Med Clin of North Amer. 74 (6):1647-59, 1990.

10. Ibid.

11. Lynda Madaras and Jane Patterson, Womancare (New York: Avon, 1984), P.563.

12. Ibid.

13. Ibid.

14. Sweet, L.R., Pelvic Inflammatory Disease and Infertility in Women. Sexually Transmitted Diseases in Infectious Disease Clinics of North America 1(1):199-215, 1987

15. Imam N et al. Hierarchical pattern of mucosal candida infections in HIV-seropositive women. Amer J Med 89:142-146, 1990.

16. Rhoades JL et al. Chronic vaginal candidiasis in women with HIV infection. JAMA 257(22):3105-3107,1991.

17. Imam et al. Hierarchical pattern of mucosal infections in HIV-seropositive women. Amer J Med 89: 142-146, 1990.

18. Ibid.

19. Hilton, E., et al. Ingestion of Yogurt Containing Lactobacillus Acidophilus as Prophylaxis for Vaginal Candidiasis. Ann Int Med. 116:353-57, 1992; No research has been conducted with dams, three-inch squares of rubber latex, that are laid directly over the vulva during oral sex to create a barrier between a woman's genitals and her partner's mouth. While the author recognizes that the lack of data is problematic in recommending this prevention strategy, she also recognizes this is not the first time a potentially life-saving device for women has not been researched.

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