VI. The following text will give you some information about genital

Infections in hiv-infected women. Now look at these statements

and try to made a short summary of it.

1. HIV infection is becoming increasingly common in women.

2. Prominent role of heterosexual transmission.

3. The most common gynecologic disorders in HIV-infected women.

HIV INFECTION IN WOMEN Presentations and Protocol

In the 11th year of the AIDS epidemic in the United States, it is clear that more and more women are becoming infected with HIV. Genital infections by other pathogens may be the first clue to the diagnosis. With progressive immunodeficiency, such infections may follow a protracted course or become recurrent, often requiring maintenance therapy.

HIV-infection is becoming increasingly common in women throughout the United States. Yet there is generally little awareness of the problem in the medical community, and hardly any data on the primary gyneco­logic care of infected patients. Genital infections that resist standard therapy may be the first indication of immunodeficiency and are impor­tant to diagnose. In addition, because of the more aggressive and pro­tracted course such conditions often take, HIV-infected women require heightened gynecologic surveillance, including more frequent Pap smears and liberal use of colposcopy.

HIV-Related Gynecologic Conditions

Candida vaginitis, genital herpes, syphilis, pelvic inflammatory dis­ease, and human papillomavirus disease (condyloma acuminatum, cervical dysplasia, and cervical carcinoma) are of particular concern in the man­agement of HIV-infected women. All occur with greater frequency and severity in this population, and all may demonstrate atypical manifesta­tions, including lack of response to standard therapies. Nonsyphilitic gen­ital ulcers - chancroid and lymphogranuloma venereum - are also more common in women who are HIV infected than in women in general.

Candida vaginitis. Although still widely neglected, this is the most common gynecologic disorder in HIV-infected women. In those who are severely immunocompromised, it may present as painful coalescing ulcer­ations requiring aggressive local treatment, followed by maintenance therapy with topical agents or an oral imidazote such as ketoconazole or fluconazole. In women who are not otherwise symptomatic - including those in whom HIV-infection has not yet been diagnosed - the presence of persistent or frequently recurrent vaginal candidiasis may be an early clue of immune suppression (sometimes earlier than oral thrush). Cases refractory to topical treatment frequently herald severe immune suppres­sion and a rapid progression to AIDS.

Herpes simplex virus, either type I or II, may similarly manifest as frequent, persistent, or severely ulcerating disease. If extensive areas of the perineum are involved or the lesions are atypical, definitive laborato­ry diagnosis will ensure effective treatment. Severe manifestations of herpes may require maintenance therapy with oral acyclovir for adequate suppression. Coexistent herpes simplex and Candida infections are rela­tively common, and bacterial superinfection may also be present.

Apart from their morbidity, genital ulcer diseases such as herpes, syphilis, and chancroid have been repeatedly correlated with enhanced transmission of HIV. In either sex, gross or microscopic bleeding and skin or mucosal injury increases the possibility of direct viral exposure. In addition, the body responds to genital ulcer disease with mobilization of activated lymphocytes and macrophages to the site of infection. These activated cells are highly vulnerable to HIV. Thus, a genital ulcer in an HIV-infected patient can serve as a source of infection for the patient's partner, and in an uninfected person, as a portal of entry for the virus.

J Both primary and secondary syphilis have increased dramatically in the United States in recent years, and coinfection with HIV is common. In a survey of patients attending STD clinics in Baltimore, serologic evi­dence of prior syphilis was far more common in HIV-positive patients than in uninfected patients, even when analysis was limited to hetero­sexual men and women. As might be anticipated, the rising incidence of syphilis infections in sexually active adults has been accompanied by an equally rapid and alarming rise in the rate of congenital syphilis.

Pelvic inflammatory disease is more likely to be refractory to antibi­otic therapy and to require hospitalization in women who are HIV-infect­ed than in those who are not. Studies from a number of cities hit hard by the AIDS epidemic indicate that PID and AIDS frequently|coexist. The onset of PID in HIV-infected women may be very subtle.

The patient may experience a subacute infection with only nonspecif­ic abdominal pain or no pain at all. Cervical motion tenderness or other signs considered classic for PID may be entirely absent.

Human papillomavirus is the oncogenic agent thought to be responsi­ble for most cervical carcinomas and is therefore the most potentially dan­gerous of the genital diseases common in HIV-infected women. Reports of frequently abnormal Pap smears in this group - often 5 to 10 times the expected rate - deserve particular attention. Increased cervical dysplasia and unusually aggressive HPV disease have been observed in other immunosuppressed populations, such as renal transplant recipients and cancer patients on chemotherapy.