Medical Update from the 1999 Conference on Women and HIV/AIDS
The 1999 Conference on Women and HIV/AIDS brought 2000 participants, including 800 HIV-positive women, to Los Angeles to discuss clinical, prevention, and policy issues related to infected and affected women. The conference provided attendees with comprehensive information about HIV infection in women, a crucial tool for self-advocacy in HIV care.
Dr. Jean Anderson of the Women's Health Center in Baltimore, MD, presented a State of the Science lecture describing two common gynecologic conditions, vaginitis and HPV infection. Both of these conditions negatively impact quality of life for women living with HIV, and have implications for overall health and quality of life.
VaginitisSymptoms of vaginitis, the inflammation of the mucous membranes of the vagina, include pain, itching, and foul-smelling vaginal discharge. Infection with yeast or candida, a yeast-like fungus, trichomonas (protozoa), or gardnerella vaginalis (bacteria), can cause vaginitis.
Bacterial VaginosisIt is estimated that 24-37% of all women seen at STD clinics have bacterial vaginosis, (vaginitis of a bacterial origin.) The condition is exhibited in 31-42% of HIV-infected women, with no significant difference in occurrence associated for different CD4 cell counts. Bacterial vaginosis occurs when the normal bacteria in the vagina, the lactobactillus dominant, are displaced by mixed strains of bacteria, including gardnerella vaginalis. There is increased risk of bacterial vaginosis associated with douching, sex with multiple partners, and inconsistent condom use. Complications associated with vaginosis include preterm delivery, low birthweight, postpartum endrometritis (inflammation of the lining of the uterus), pelvic inflammatory disease and postabortal infection.
Several studies have shown an increased rate of sexual transmission of HIV related to bacterial vaginosis or the presence of organisms related to bacterial vaginosis, as the organisms can increase rates of HIV replication. There are also implications for perinatal transmission of HIV: in 343 women from Malawi, perinatal HIV transmission doubled from 14% in women with normal vaginal bacteria to 28% in women with bacterial vaginosis.
Bacterial vaginosis can be treated, using metronidazole in an oral formulation or applied to the vagina in gel form. Clindamycin, another effective treatment, is available in oral or vaginal cream formulations. Treatment recommendations are the same for HIV-positive and HIV-negative women.
Yeast InfectionsAbout 75% of all women experience a yeast infection at some point in their life, and 5% experience chronic recurrences. Symptoms of yeast infections include itching, pain or difficulty urinating, and thick, white vaginal discharge. The prevalence of yeast infections is not significantly different in HIV-positive women, except in women who are severely immunocompromised, but HIV-positive women are more likely to have oral and rectal yeast colonization than HIV-negative women.
Of concern to providers is the increasing number of yeast infections caused by non-albicans strains of candida. Infections caused by non-albicans strains are harder to treat, as they are resistant to most commonly available treatments. The higher incidence of resistant strains can be attributed to the over-use of single-dose treatments for yeast infections and over-the-counter treatments. In HIV-positive women, the incidence of non-albicans strains is about 25%, and there is controversy as to whether this is the same as or higher than the incidence in HIV-negative women, as studies have shown conflicting results.
Several considerations should be made when treating HIV-positive women for yeast infections:
An interesting study by Cassone and colleagues showed that the combination of ritonavir (Norvir) and indinavir (Crixivan) inhibited an enzyme called secretory aspartyl proteinase (SAP), which is produced by candida and contributes to its virulence. The ritonavir/indinavir combination had therapeutic effects in candidiasis similar to fluconazole (Diflucan), a common treatment agent.
TrichomoniasisTrichomoniasis ("trich") affects 2-3 million American women annually, with an incidence rate in HIV-infected women of 10-17%. Trich is usually transmitted sexually, and its symptoms include vaginal itching, yellowish-green vaginal discharge, redness of the vulva and/or vagina, painful intercourse, abdominal pain, and painful urination. Half of infected women may also experience no symptoms (but left untreated, the infection can progress to pelvic inflammatory disease). A single dose of metronidazole (Noritate) is effective for curing the disease, and cure rates are up to 90% if a woman's sex partner is treated simultaneously. Treatment recommendations for HIV-positive and HIV-negative women are identical.
There is an interesting relationship between HIV transmission and trichomoniasis. Secretory leukocyte protease inhibitor (SPLI), a substance that is believed to protect the cells of the mucous membrane of the vagina from HIV infection by inhibiting HIV protease activity, is degraded by trichomoniasis, increasing HIV transmission risk.
Human Papilloma Virus (HPV)It is estimated that more than 50% of sexually active adults are infected with one or more strains of human papilloma virus (HPV). The virus is transmitted by direct contact, and is usually latent after infection. When HPV is expressed, resulting conditions range from genital warts to cancer.
The HIV Epidemiology Research Study (HERS), a surveillance study involving 800 HIV-positive women and 400 matched controls, showed that 66% of HIV-positive women are co-infected with HPV, compared to 34% of HIV-negative women. Another study by Palefsky and colleagues showed that an HIV-positive woman with a CD4 cell count less than 200 is more likely to be infected with HPV than an HIV-positive woman with a CD4 cell count greater than 200. Additionally, the expression of latent HPV is directly related to an individual's degree of immunosuppression. The ratio of latent to active HPV in the general population is 8:1, but is 3:1 in HIV-positive women with CD4 cell counts greater than 500 and 1:1 in HIV-positive women with CD4 cell counts less than 500.
Another striking difference in HPV between HIV-negative and HIV-positive women is in the persistance of the virus in the two groups. Generally, HPV infections are transient, lasting for about 8 months. Persistent high levels of HPV have been linked to CIN -- abnormal cells in the cervix. In a study comparing 220 HIV-positive women and 231 HIV-negative women, 24% of the positive women had persistent HPV, compared with 4% of the negative women.
Regular pap smears are essential for detecting abnormal cells and preventing cervical cancer. A pap smear is a simple procedure in which a physician obtains cells from the surface of the cervix, using a special brush to collect a sample of cells from the area where most cancers begin to develop. The cells are placed on a slide and are examined with a microscope to check for abnormalities. The cervical pap smear is the only cancer screening test in the world that has decreased both the number of cases of a cancer and the number of deaths related to a cancer.
Approximately 25-40% of pap smears performed on HIV-positive women are abnormal, a rate about ten times higher than that of HIV-negative women. There are various abnormal results:
ASCUS -- stands for atypical squamous cells of undetermined significance. Persistent ASCUS results are often further evaluated by a physician through a process called colposcopy. A colposcopy is a magnification of the cells of the cervix in order to pick out cells to biopsy to determine if any cancerous cells are present.
Dysplasia -- occurs when cervical cells undergo a series of changes in their appearance. The cells look abnormal under the microscope, but they do not invade nearby healthy tissue. There are three degrees of dysplasia, classified as mild, moderate, or severe.
HSIL/LSIL -- SIL stands for squamous intraepithelial lesion. HSIL describes high-grade SIL, while LSIL describes low-grade SIL. A squamous intraepithelial lesion is another term that is used to describe abnormal changes in the cells on the surface of the cervix. HSIL indicates a large number of precancerous cells, while LSIL describes early changes in the size, shape, and number of cells.
CIN -- is another term that is sometimes used to describe abnormal cells. The term CIN, along with a number (1 to 3), describes how much of the cervix contains abnormal cells.
Carcinoma in situ -- describes a pre-invasive cancer that involves only the surface cells and has not spread into deeper tissues.
Cervical cancer -- or invasive cervical cancer, occurs when abnormal cells spread deeper into the cervix or to other tissues or organs. Invasive cervical cancer was added to AIDS indicator conditions in 1993.
Common therapeutic options for LSIL include local excision (cell removal); careful observation; cryosurgery (use of liquid nitrogen to freeze tissue to extremely low temperatures, thereby killing the tissue); laser therapy (destruction of abnormal cells with a light beam); LEEP (removal of the top layer of cells on the cervix, followed by an examination to determine if the cells are cancerous); and electrocautery (removal of lesions using electric current to generate heat). For HSIL, therapeutic options also include conization (removal of a cone-shaped piece of the cervix) and hysterectomy (removal of the uterus). Even with these treatments, HIV-positive women are more likely to have recurrences of HSIL/LSIL than their HIV-negative counterparts.
Dr. Anderson concluded her presentation by reviewing recommendations for the management of gynecological concerns for women with HIV. In the first year after HIV diagnosis, two pap smears should be performed, and if both are normal, pap smears should be performed annually. Any HIV-positive woman with a previous abnormal pap smear, a history of HPV infection, treatment as described above for an abnormal pap smear, or with AIDS, should continue more frequent pap smears (every four to six months). Additionally, it is recommended that HIV-positive women who have a pap smear indicating dysplasia or SIL undergo colposcopy. Some practitioners have advocated routine colposcopy as an additional preventative measure.
This article was provided by AIDS Community Research Initiative of America. It is a part of the publication CRIA Update. Visit ACRIA's website to find out more about their activities, publications and services.