It is clear that most women with HIV will experience some gynecological disorders as a result of HIV. As HIV progresses, gyn complications can become more severe and harder to treat.
The major focus of research and health care for HIV infected women has been on HIV infection during pregnancy. Researchers have focused on the health and well being of the fetus and newborn, with little regard for the health of women. Research is just beginning to note the medical needs of HIV+ women who are not pregnant.
The incidence of AIDS in the United States increased 50% more rapidly in women than in men from 1992 to 1993. Heterosexual transmission currently accounts for the majority of AIDS in women.
After a 3 year long campaign launched by lesbian AIDS activists, the Centers for Disease Control (CDC) finally expanded the case definition for AIDS in 1993. The broadened definition helped the medical community to recognize the importance of dealing with HIV in nonpregnant adult women.
The new classification system includes several gynecological diseases. In the HIV symptomatic category are:
- persistent, frequent, or poorly responsive vaginal candidiasis, (yeast infections);
- moderate or severe cervical intraepithelial neoplasis (CIN/ which can lead to Cervical Cancer); and
- pelvic inflammatory disease (PID).
Added to the AIDS-defining diseases are: chronic herpes simplex virus ulcers, and invasive cervical cancer.
In this article, we will address pelvic inflammatory disease (PID), a gynecological condition now included in the HIV classification system.
What Is PID-
PID: Pelvic Inflammatory disease: is a spectrum of disorders in the female genital tract. When any infections of the vagina and/or cervix go up into the tubes, uterus, or ovary areas, it causes severe abdominal inflammation inside the pelvic area. PID can cause extreme damage to the ovarian ducts, ovaries, and surrounding tissues, also causing infertility. PID can be life threatening and, if left untreated, it can be fatal.
Chlamydia and gonorrhea are a common source of PID, but they are not the only source. It may result from a sexually transmitted disease, tuberculosis, or post-partal infection.
HIV+ women definitely should never use IUD's (intrauterine devices) for contraception! The IUD provides a direct channel for bacteria and other infections to go right up the cord and gain internal access to the ovaries, etc..
Symptoms & Treatment
The symptoms are fever, recurrent discharge from the vagina and lower abdominal pain. However, in women with HIV, PID can be almost silent. There may not be any symptoms at all, no fever, no discharge, and no pain, and it can still progress rapidly to abscesses. In addition, pelvic pain is often misdiagnosed. It's important that gynecologists do cultures on women with HIV every 6 months. Treatment is high dosages of strong antibiotics (usually Septra). Treatment & prevention for PID must be tailored to the individual.
HIV infection can increase the frequency and/or severity of pelvic inflammatory disease. Results of recent studies have suggested that pelvic inflammatory disease (PID) in HIV infected women is associated with a lowered white blood cell count and is more likely to require surgery. Surgery is often required, even if there are no abscesses. HIV infected women with acute PID should be hospitalized for intravenous therapy according to CDC recommendations.
HIV And PID
HIV can cause deterioration of the vaginal tissue, leaving positive women more susceptible to gynecologic infections. Immune system dysfunction caused by HIV can cause existing lower genital tract infections to travel more rapidly to the upper genital tract. Once upper-tract disease is present, an HIV+ woman may not respond to standard treatment for the disease, especially with lowered CD4+ (T- cell) counts.
It is important for doctors who take care of HIV infected women to conduct precise and accurate screening for gynecologic diseases and be alert and watchful for conditions that do not respond to standard treatment.
What We Know
Scientists compared white blood cells of tissue from the lining of the uterus in 12 HIV+ and 12 HIV- women. Tissue from HIV+ women had fewer CD4+ cells than HIV negative tissue. They suggest that lowered local immunity in the vaginal tissue could make HIV+ women more susceptible to PID.
Others found a higher rate of germ colonies (anaerobes) in HIV+ compared with HIV- women. This could account for the high rate of symptomatic PID in HIV+ women involved in this study.
Both HIV and the germs (organisms) associated with PID can be sexually transmitted. In the United States, among women with PID from 7% to 22% of them are also HIV positive. Counseling and testing for HIV infection should be offered to women with a diagnosis of PID.
While data from large studies is being collected and analyzed, a number of small reports suggest that PID may have a different initial presentation and response to treatment in some HIV+ women. Researchers reported lower white blood cell counts and a trend toward more surgical intervention in HIV positive women as compared with HIV negative women admitted to the hospital with PID.
In a recent report on the course of PID in HIV+ compared with HIV- women admitted to San Francisco General, HIV+ women with PID had significantly lower white blood cell counts.
Finally, HIV+ women with PID required more surgical intervention even though their incidence of tubo-ovarian abscess was similar to the HIV- controls. Of the five women with AIDS or AIDS-related complex in this study, three required surgical intervention. Women with asymptomatic HIV infection required surgical treatment of PID as often as HIV- women.
Preliminary results of other studies have been reported in abstracts. In the largest of them, researchers compared the clinical presentation and course of PID in 16 HIV+ and 64 HIV- women. The positive women were more likely to have genital ulcers, positive VDRL (syphilis test), urinary tract infections, and were more likely to be admitted to the hospital. Once hospitalized, their clinical courses were identical. In another study researchers compared 13 HIV+ and 138 HIV- women with PID and found lower white blood counts in the HIV+ group.
The available data suggest that the clinical course of PID may be altered by symptomatic HIV infection and that such patients have reduced local immune defenses resulting in a slower or inadequate response to medical therapy. PID in HIV+ women is frequently due to the ascent of infections originating in the lower genital tract from disease producing agents that are no longer controlled by local immunity. We must always go beyond the minimal recommendations when treating HIV and PID. We must be more vigilant and alert for treatment failure in these women.
Korn AP, Landers DV, "Gynecologic Disease in Women Infected with Human Immunodeficiency Virus type 1", J Acquir Immune Defic Syndr Hum Retrovirol 1995 Aug 1;9(4):361-70 and Women Being Alive Newsletter, Summer, 1993