Vaginal Yeast Infections
Vaginal candidiasis is a yeast infection usually caused by Candida albicans. Candida occurs normally in the mouth, digestive tract and vagina of a healthy person, but can overgrow and cause symptomatic infections, a common occurrence in persons with HIV infection. Candidiasis of the vagina occurs in women with or without HIV infection, but is more common in women with HIV infection. This yeast infection can occur in HIV positive women with relatively high T-cell counts, but the prevalence of vaginitis increases as T-cell counts decline, especially below 200. All women with frequent, recurrent, or persistent vaginal candidiasis should be tested for HIV infection.
Symptoms of vaginal candidiasis include a thick, white/yellow vaginal discharge (often described as "cottage cheese" in appearance) associated with mild to severe itching, burning discomfort, and pain with urination. Though many women "self-diagnose" yeast infections, and many providers diagnose the infection by its appearance, diagnosis can be confirmed by looking at a smear of the discharge under the microscope, or sending it to the lab to be grown in culture.
Yeast infections can usually be treated topically, with a cream or suppository that is inserted in the vagina before bed nightly for 3 to 7 nights. Several are available over the counter (without prescription), such as Monostat-7TM or Gyne-lotriminTM. If such treatments fail to relieve symptoms and eradicate signs of infection, women should be checked for the possibility of a different infection. If no other infection exists, and yeast infection is confirmed, then oral azole agents (such as ketoconazole or fluconazole) may be required.
Frequent use of the azole agents for treatment in women with very low T-cell counts, however, can be problematic. Research has shown that these women are at risk for development of infection with resistant strains of Candida. These so called "resistant" infections will fail to respond to treatment with azole drugs, and may require treatment with topical or intravenous amphotericin B, a drug with multiple and sometimes severe side effects. For this reason, it is felt that it is best to use topical treatment for vaginal candidiasis first, and limit the use of azole drugs as much as possible to avoid development of resistant strains.
Use of fluconazole in low weekly doses for prophylaxis of candidiasis showed success in one study, without evidence of development of resistence. In a clinical trial CPCRA 010, which tested 200 mg of fluconazole per week as prophylaxis in 323 HIV positive women showed a 50% reduction in the incidence of thrush and vaginal yeast infections.