Women have always been more vulnerable than men to HIV infection and its sequelae. A woman is up to a hundred times more likely to be infected by a seropositive partner during vaginal or anal intercourse than a man is during these same sexual activities with an HIV-infected woman -- because the vagina and anus are particularly hospitable environments for the virus, and the intact skin of the penis is not. This explains why the rate of new infections is rising more rapidly among women whose only risk factor is having sex with a seropositive partner than among any other group. It also explains the staggeringly high seroprevalence rates among women of childbearing age in sub-Saharan Africa, where virtually all new infections are due to heterosexual intercourse and where, in the worst-hit regions, one woman in four is HIV-positive.

Once infected, women are more likely than men to experience rapid disease progression and early death. This grim prognosis may reflect an inherent difference in the way a woman's physiognomy responds to HIV, but the more likely explanation is that the differences in morbidity and mortality that we are seeing in our female patients are attributable to differences in quality of care.

In this respect HIV infection is like many other serious medical problems, notably cardiovascular disease and cancer. Like women with heart disease, women with HIV tend to be diagnosed later, to be treated less aggressively, and to have less access to clinical studies, investigational drugs, and cutting-edge therapies. It comes as no surprise, then, that seropositive females generally fare less well than their male counterparts.

This is true at all stages of HIV infection, but it is particularly true during the later stages of infection, when profound immune suppression leaves patients susceptible to a host of AIDS-related opportunistic infections. Women with advanced HIV disease do develop PCP, CMV retinitis, MAC, and all of the other OIs that are commonly seen in AIDS patients, but they also present with a number of infections that are common only to women with HIV. To assist care providers in recognizing, diagnosing, and treating these manifestations of HIV infection, the editors of HIV Newsline have prepared the table that appears below. It is adapted from materials that Dawn Averitt, a member of the editorial advisory board of AIDS Care, developed for Project Inform.

The Most Common Opportunistic Infections in Women With HIV

Infection	Symptoms	Diagnosis	Treatments	Alternative Treatments	Cautions	Other Information
Bacterial Vaginosis (BV or gardnerella) Bacterial infection	Odorous, frothy vaginal discharge	Checking the vaginal pH Mixing with potassium hydroxide solution and noting a characteristic odor Looking at a sample of the discharge under the microscope	Metronidazole (Flagyl, MetroGel, and others) 500 mg by mouth, twice a day for seven days	Metronidazole (MetroGel) cream (insert twice a day for five days) Clindamycin (Cleocin) cream (insert once a day for seven days) Herbal treatment with goldenseal (1Tbsp goldenseal in warm bath)	No metronidazole with alcohol Herbal treatments should not be used by pregnant women, because they may not be effective (this may also apply to women with a history of PID)	Treat female sexual partners with the same regimen. There is no evidence that BV increases risk for acquiring HIV infection.
Trichomonas (Trich) Protozoal infection	Heavy, itchy vaginal discharge (sometimes a greenish-yellow color), usually with a fishy odor; can cause pain and soreness in and around the vagina; can cause extreme itching	Checking the vaginal pH Microscopic examination Note: Trich may be noted on a Pap smear, but it is not diagnosed by a Pap smear.	Metronidazole 2 gm, taken by mouth in a single dose, cures 95% of cases as long as sex partners are treated at the same time	Metronidazole 375 mg, taken twice a day by mouth for seven days Garlic suppositories (insert a clove of garlic secured in gauze overnight for 10-14 days)	No metronidazole with alcohol	Treat all sexual partners Note: Women with HIV may require the 7-day regimen for effective treatment.
Vaginal Candidiasis (Yeast infection) Fungal infection	Itchy, lumpy white or yellow discharge accompanied by rash and irritation	Checking the vaginal pH Clinical signs during the speculum exam Adding potassium hydroxide to the discharge and looking for the organism under the microscope Note: Yeast may be noted on a Pap smear, but it is not diagnosed by a Pap smear.	Fluconazole (Diflucan) 150 mg, taken by mouth in a single dose There are a number of 7-day or 3-day creams and suppositories available by prescription or OTC	Single-dose creams are available by prescription Douching with betadine or vinegar Note: Douching is not recommended for women who are pregnant or have any history of PID.	Yeast infections may be accompanied by a skin rash (much like a diaper rash). Treat it with creams such as clotrimazole, Desitin, vaseline, zinc oxide, or A&D ointment, all of which are available OTC. For more difficult rashes use prescriptions of clotrimazole (Lotrisone).	Patients may be able to prevent recurrences by: Decreasing sugar in the diet (including sweets and high-sugar-containing products like alcohol) Eating lactobacillus-containing yogurt or taking acidophillus capsules daily Taking fluconazole 100 mg by mouth once a week
Herpes Simplex Virus (HSV) Viral infection	Painful blister-like sores in and around the vagina, rectum, and/or anus; painful urination; genital irritation, swollen lymph nodes in the groin, fever, headaches, muscle aches, fatigue	Can sometimes be diagnosed by visual exam. Fluid from sores can be cultured to confirm infection. Note: Blood tests can confirm that a person is infected, but not if the infection is currently active.	Acyclovir (Zovirax) 200 mg, 5 times a day by mouth for 10 days during outbreak	Famciclovir (Famvir) 125 mg, taken by mouth twice a day for 5 days Sores can be covered with facial clay or zinc oxide for comfort; valacyclovir (Valtrex) 500 mg, taken twice a day by mouth for five days for acyclovir-resistant HSV. Note: HSV can cause moderate to severe pain. Lidocaine (Xylocaine or Neosporin Plus) gel applied directly to the sores can help. Other pain relievers may be necessary.	The earlier the treatment is started, the more quickly symptoms will resolve. Recurrences may occur as rarely as every few years or as often as every few weeks. Low immune function usually means more outbreaks. In addition, outbreaks can lead to secondary bacterial skin infections	Transmission is most likely during outbreaks, but it is also possible at other times.
Human Papilloma Virus (HPV, genital warts) Viral infection	Often asymptomatic; sometimes there are multiple tiny white spots (warts) on the vagina or around the anus; other symptoms include some vaginal discharge or, rarely, pain during intercourse	Can often be diagnosed visually, but since warts may be associated with cancer or precancer anywhere in the genital tract, diagnosis should be made by biopsy whenever there is any question. Diagnosis is also made by Pap smear, but should be followed up with colposcopy.	Multiple options including: Trichloroacedic acid Electrocautery Cryotherapy	More treatment options: surgical excision, laser excision, and various chemicals that destroy warts.	Recurrence of warts is very common, especially in immune-compromised persons.	Prevention tips for patients: Stop smoking (tobacco is associated with both warts and cancerous growths) Practice safer sex (may help prevent passing HPV between partners)
Pelvic Inflammatory Disease (PID) Mixed microbial infection	Lower abdominal pain and abnormal vaginal discharge; can also cause fever, pain in the upper-right abdomen, painful intercourse, and irregular menstrual bleeding as well as bleeding with insertive sexual activity.	No clear-cut standards for diagnosis. Usually diagnosed by symptoms and pain on the pelvic exam. Sonogram may be performed; surgical diagnosis is occasionally required.	Treatment is usually at least two antibiotics that are effective against a wide range of infections since PID is probably the result of multiple pathogens; plus bed rest for 14 days.	Women with HIV and PID should be hospitalized for treatment with IV antibiotics.	PID is usually caused by infection with gonorrhea or chlamydia, which spreads to the uterus, tubes and ovaries, carrying other pathogens and causing a mixed bacterial infection. In women with HIV, PID can occur without reinfection with an STD.	Chronic pain is common after several episodes. PID can lead to tubal infertility.
Molluscum Viral infection	Tiny growths, most commonly found on the face, in the groin, or on genitals; may cause itching	Usually diagnosed by visual exam. HPV should be ruled out.	No proven treatment Some clinicians apply podophyllum to the lesions	Other caustic treatments may be used; consult a dermatologist.	The infection is easily spread from person to person and it may disappear spontaneously. Immune compromise is associated with increased number of lesions and less likelihood of remission.	Not associated with cancer or any other complications Some reports claim that molluscum disappear in patients who respond well to HAART