Vaginal infections in human immunodeficiency virus-infected women

Vaginal microbiota and susceptibility to HIV

: Bacterial vaginosis, characterized by the replacement of the Lactobacillus-dominant microbiota with anaerobic bacteria and facultative Gram-negative rods, has been associated with adverse reproductive health outcomes including HIV acquisition. With the advent of newer molecular techniques, the vaginal microbiota can be investigated in more detail and the association with HIV examined more thoroughly. This review examines recent evidence suggesting that vaginal dysbiosis with increased microbial diversity, specific vaginal bacterial communities, and the presence and concentrations of some individual bacterial species, may increase HIV susceptibility. Potential mechanisms through which vaginal microbiota could impact HIV susceptibility are discussed. On the basis of the available data, this review finds that there is a modest, but growing, body of evidence linking vaginal microbiota to HIV susceptibility in women. The evidence could be strengthened through two main pathways. First, laboratory studies such as ex-vivo or animal experiments are needed to move from plausible mechanisms towards proven mechanisms that explain an effect of the vaginal microbiota on HIV susceptibility. Second, experimental evidence could directly test the hypothesis that sustaining optimal microbiota reduces HIV risk, though there are important obstacles to conducting such studies. Finally, this review examines strong evidence from a recent publication suggesting that deviations from an optimal vaginal microbiome, and particularly the presence of some bacterial communities with high relative abundance of Gardnerella vaginalis, reduces the efficacy of vaginal tenofovir-based microbicides.

Mucosal immunity in the female genital tract, HIV/AIDS

Mucosal immunity consists of innate and adaptive immune responses which can be influenced by systemic immunity. Despite having been the subject of intensive studies, it is not fully elucidated what exactly occurs after HIV contact with the female genital tract mucosa. The sexual route is the main route of HIV transmission, with an increased risk of infection in women compared to men. Several characteristics of the female genital tract make it suitable for inoculation, establishment of infection, and systemic spread of the virus, which causes local changes that may favor the development of infections by other pathogens, often called sexually transmitted diseases (STDs). The relationship of these STDs with HIV infection has been widely studied. Here we review the characteristics of mucosal immunity of the female genital tract, its alterations due to HIV/AIDS, and the characteristics of coinfections between HIV/AIDS and the most prevalent STDs.

Interventions for prevention and treatment of vulvovaginal candidiasis in women with HIV infection

BACKGROUND

Vulvovaginal candidiasis (VVC) is one of the most common fungal infections that recur frequently in HIV infected women. Symptoms of VVC are pruritis, discomfort, dyspareunia, and dysuria. Vulval infection presents as a morbiliform rash that may extend to the thighs. Vaginal infection is associated with white discharge, and plaques are seen on erythematous vaginal walls.Even though rarely or never resulting in systemic fungal infection or mortality, left untreated these lesions contribute considerably to the morbidity associated with HIV infection. Prevention and treatment of this condition is an essential part of maintaining the quality of life for these individuals.

OBJECTIVES

-To compare the efficacy of various antifungals given vaginally or orally for the treatment and prophylaxis of VVC in HIV-infected women and to evaluate the risks of the same.

SEARCH STRATEGY

The search strategy was comprehensive, iterative and based on that of the HIV/AIDS Cochrane Review Group. The aim was to locate all relevant trials, irrespective of publication status or language. Electronic databases :CENTRAL,Medline, EMBASE, LILACS and CINAHL were searched for randomised controlled trials for the years 1980 to 1st October 2010. WHO ICTRP site and other relevant web sites were also searched for conference abstracts.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of palliative, preventative or curative therapy were considered. Participants were HIV positive women receiving one or more of the following:treatment / prophylaxis for VVC or HAART(Highly Active Antiretroviral Therapy).

DATA COLLECTION AND ANALYSIS

Three authors independently assessed the methodological quality of the trials and extracted data. The quality of the evidence generated was graded using the GRADE PRO approach.

MAIN RESULTS

Our search did not yield any trial investigating treatment of VVC in HIV positive women.Two trials dealing with prophylaxis were eligible for inclusion.One trial (n= 323) favoured the use of weekly Fluconazole as compared to placebo (RR 0.68; 95% CI 0.47 to 0.97).The second trial with three arms of comparison;Clotrimazole,Lactobacillus and Placebo gave no definitive results in preventing an episode of VVC. Clotrimazole against placebo (RR 0.49; 95% CI 0.22 to 1.09), Clotrimazole against lactobacillus (RR 1.11; 95% CI 0.45 to 2.76) and lactobacillus against placebo (RR 0.54 ;95% CI 0.26 to 1.13).

AUTHORS' CONCLUSIONS

Implications for practiceNo trials were found addressing treatment of VVC in HIV positive women.In comparison to placebo,Fluconazole was found to be an effective preventative intervention. However, the potential for resistant Candida organisms to develop might impact the feasibility of implementation.Direction of findings suggests that Clotrimazole and Lactobacillus improved the prophylactic outcomes when compared to placebo.Implications for research There is a need to evaluate drugs and drug regimens for VVC treatment and prophylaxis in HIV positive women through randomised clinical trials. Development of resistance to azoles remains under-studied and more work must be done in this area, so as to determine whether routine prophylaxis for VVC is at all needed or whether adequate ART would be sufficient to prevent recurrent VVC. The viral load in vaginal secretions with or without treatment or prophylaxis has not been studied, this is very relevant to the spread of HIV.

Bacterial vaginosis and HIV acquisition: a meta-analysis of published studies

OBJECTIVES

To assess and summarize the published literature on the extent to which bacterial vaginosis may increase the risk of HIV acquisition.

DESIGN

Meta-analysis of published studies.

METHODS

Medline and other electronic databases were systematically searched for eligible publications. The association between bacterial vaginosis and incident HIV was separately analyzed from that between bacterial vaginosis and prevalent HIV. The latter was further analyzed, stratified by bacterial vaginosis diagnostic method, HIV risk profile of the study population, and whether or not adjusted estimates were presented.

RESULTS

Twenty-three eligible publications were identified, including a total of 30,739 women. Bacterial vaginosis was associated with an increased risk of HIV acquisition in HIV-incidence studies (relative risk = 1.6, 95% confidence interval: 1.2, 2.1). All but one of 21 HIV-prevalence studies reported estimates above the null. The latter results were heterogeneous and showed some evidence of funnel plot asymmetry, precluding the estimation of a single summary measure. The association between bacterial vaginosis and HIV in prevalence studies appeared stronger for women without high-risk sexual behavior.

CONCLUSION

Bacterial vaginosis was consistently associated with an increased risk of HIV infection. High bacterial vaginosis prevalence may result in a high number of HIV infections being attributable to bacterial vaginosis. More prospective studies are needed to accurately evaluate the role of bacterial vaginosis in HIV acquisition in low-risk versus high-risk women. Furthermore, randomized clinical trials may be worth considering to determine the effect of bacterial vaginosis control measures on HIV acquisition.

Rapid testing for vaginal yeast detection: a prospective study

OBJECTIVE

The purpose of this study was to determine the accuracy of rapid vaginal yeast detection assay compared with yeast cultures for the diagnosis of vulvovaginal candidiasis.

STUDY DESIGN

This was a prospective study that involved 104 subjects, 34 asymptomatic women and 70 symptomatic women with vaginitis. Vaginal swabs were obtained from all subjects for wet mount, yeast culture, and the rapid yeast detection test. Overall, the prevalence rate was 39.4%, based on positive yeast cultures. The rapid yeast test performed by the physician was positive in 30 of 41 subjects with positive cultures and 13 of 63 subjects with negative cultures.

RESULTS

The rapid yeast test had 73.1% sensitivity and 82.0% negative predictive value compared with the wet mount, which had 43.9% sensitivity and 70.9% negative predictive value. In symptomatic patients, the test had 77.4% sensitivity and 81% negative predictive value compared with wet mount, which had 51.6% sensitivity. Patient-performed test results were identical to the tests that were performed by the physicians. The cost of the rapid yeast test kit is estimated to be <$10, compared with a mean of $65 for the yeast culture.

CONCLUSION

Rapid yeast detection assay is accurate and affordable compared with the gold standard yeast culture in the diagnosis of vulvovaginal candidiasis. Relative to the wet mount, it is more sensitive, cheaper, and accurate for the rapid diagnosis of vaginal yeast infection.

The Occurrence of Vaginal Infections Among HIV-Infected and High-Risk HIV-Uninfected Women

OBJECTIVES

To evaluate changes over time in rates of bacterial vaginosis (BV), trichomoniasis (TV), and yeast vaginitis (YV) among HIV-infected and similar HIV-uninfected women.

METHODS

Two thousand fifty-six HIV-infected women and 554 HIV-uninfected women were evaluated semiannually from 1994 until March 2003 in a prospective cohort study. BV was diagnosed by Gram stain, TV by wet mount, and YV by symptoms with microscopically visible hyphae or positive culture. Trends were assessed using Poisson models.

RESULTS

At baseline, BV was present in 42.8% and 47.0% of HIV-infected and uninfected women (P = 0.21), TV in 6.1% and 7.8% (P = 0.17), and YV in 10.0% and 3.8% (P < 0.001). Over time, rates of BV and TV decreased significantly in both groups, whereas rates of YV declined only among HIV-infected women. Risk of BV was not associated with HIV status, whereas HIV-infected women had a lower risk of TV. Highly active antiretroviral therapy (HAART) use was associated with decreased risk of all 3 infections.

CONCLUSIONS

: Declines in BV, TV, and YV represent decreased morbidity for HIV-infected women and, potentially, decreased risk of transmission of HIV, because each has been associated with increased genital detection of HIV.

Intravaginal practices, bacterial vaginosis, and women's susceptibility to HIV infection: epidemiological evidence and biological mechanisms

Intravaginal practices such as "dry sex" and douching have been suggested as a risk factor that may increase women's susceptibility to HIV infection. These behaviours appear common in different populations across sub-Saharan Africa, where practices include the use of antiseptic preparations, traditional medicines, or the insertion of fingers or cloths into the vagina. We systematically review the evidence for the association between women's intravaginal practices and HIV infection. Although a number of cross-sectional studies have shown that prevalent HIV infection is more common among women reporting intravaginal practices, the temporal nature of this association is unclear. Current evidence suggests that bacterial vaginosis, which is a likely risk factor for HIV infection, may be a mediator of the association between intravaginal practices and HIV. Although biologically plausible mechanisms exist, there is currently little epidemiological evidence suggesting that intravaginal practices increase women's susceptibility to HIV infection. Further research into factors that increase women's susceptibility to HIV will help to inform the design of vaginal microbicides and other HIV prevention interventions.

Incidence and risk factors for sexually transmitted infections among women in an Alabama HIV clinic

The objectives of this study were to assess the prevalence and incidence of curable sexually transmitted infections (STI), i.e., gonorrhea, chlamydial infection, or trichomoniasis, in a cohort of HIV-infected women. The study population was derived from women seeking primary care at an outpatient university HIV clinic who were participants in a women's natural history study. Enrollees (n = 225) were predominantly African-American, heterosexually infected, with mean age 35 years. Mean entry CD4+ T cell count was 405 cells/mm3. Over 6% were STI positive at initial screening. Subsequently, the combined curable STI incidence was 4.82/1000 woman-months over a median of 33 months of observation. Of 36 incident STIs, trichomoniasis was most common (n = 32). Predictors for acquisition of a curable STI included absenteeism at scheduled clinic appointments, RR = 1.99 (1.28, 3.08), and a higher CD4+ T cell count, RR = 1.15 (1.0028, 1.3115) for 100 cells. Interventions to prevent curable STI in HIV-infected women are warranted in primary care settings.

Intravaginal Practices, HIV and Other Sexually Transmitted Diseases Among South African Women

BACKGROUND AND OBJECTIVES

Intravaginal practices, including wiping, douching, or inserting substances into the vagina, have been hypothesized to increase women's risk of HIV infection. However, data on the prevalence of these practices, and associations with HIV and other sexually transmitted diseases (STD), are limited.

STUDY DESIGN

We interviewed 2,897 women participating in a gynecologic screening study in Cape Town, South Africa, about their intravaginal practices. After clinical examination, cervical and blood samples were collected and tested for HIV and other STD [corrected].

RESULTS

Of the 831 (29%) women reporting some type of intravaginal practice, 48% reported using only water and cloth to clean inside the vagina, whereas 17% reported using antiseptics or detergents. Most women (53%) reported practices as part of regular hygiene. Intravaginal practices were strongly associated with behavioral risk factors, and recent multiple sexual partners [corrected]. Intravaginal practices were associated with prevalent HIV infection (adjusted odds ratio, 1.74; 95% confidence interval, 1.37-2.20), but were not associated with other STDs.

CONCLUSION

Prospective studies that include detailed measurements of correlated sexual risk behaviors are required to discern whether this association is causal in nature; if so, these behaviors could represent an important area for future HIV prevention interventions.

An epidemiological survey of vulvovaginal candidiasis in Italy

Eight Italian hospital or University gynecology clinics participated in a prospective survey of patients with culture-confirmed symptomatic vulvovaginal candidiasis (VVC) (October 1999 to March 2001). Of 1138 patients recruited in the study, 931 were evaluable. A recent history of VVC was documented in 43.5% patients (358/823) with a mean number of 2.9+/-2.7 episodes per patient (N=302). A total of 77 patients (10.0%) had a history of recurrent VVC (four and more episodes in a 12-month period). The most frequent associated factors were related to life style: synthetic fabric underwear, vaginal douching and bike, training bike and motorbike (about 1/3 each). Oral contraception was found in 20.8% patients, recent antibiotic use in 15.9% patients, current pregnancy concerned 10.3% patients while 3.4% patients were taking hormonal replacement therapy. Diabetes, corticosteroids or HIV were rarely encountered. Yeast was documented by direct microscopy in 78.3% patients (448/572). A positive culture was obtained in 98.3% patients (909/925). Candida albicans was the predominant species (77.1%), followed by Candida glabrata (14.6%) and Candida krusei (4.0%). With the exception of one center with a lower proportion of C. albicans, this latter represented between 75 and 85% of the isolates. Overall, this study confirmed the preponderant role played by C. albicans in either sporadic and recurrent VVC.

Gender differences and sex-specific manifestations associated with human immunodeficiency virus infection in women

The rapidly growing rates of human immunodeficiency virus (HIV) infection among women has prompted many challenging issues related to the management and consequences of HIV and its complications in this population. This paper reviews the current evidence with regard to various aspects of HIV infection in women. Special emphasis is placed on gender-differences as well as sex-specific manifestation of this disease, including epidemiology, viral load determination and disease progression, related morbidity, and anti-retroviral therapy. It is concluded that current advances in the understanding of HIV infection among women may lead to further refinement and optimization efforts in the management of HIV-infected women.

Vaginitis: case reports and brief review

Vaginitis is the most frequently gynecologic diagnosis encountered by physicians who provide primary care to women. Accurate diagnosis can be elusive, complicating treatment. Most experts believe that up to 90% of vaginitis cases are secondary to bacterial vaginosis, vulvo-vaginal candidiasis, and trichomoniasis. The diagnosis of vaginitis is based on the patient's symptoms, the physical examination, the findings of microscopic examination of the wetmount and potassium hydroxide (KOH) preparations, and the results of the pH litmus test. Additional cultures and testing may be needed for difficult-to-diagnose cases.