LETTER TO EDITOR
Impact of the association of genital infections in HIV-infected women

Impacto da associação de infecções genitais em mulheres infectadas pelo vírus HIV

Newton Sergio de Carvalho 1, Somaia Reda 2, Melissa Mazepa 3, Fernanda Aguiar Gonçalves 4

2013
Vol. 25 - Nº.04
Pag.206 – 207

Curitiba, November 7, 2014.

Dear Editor-in-chief,

The incidence of human immunodeficiency virus (HIV)-infected women is vertiginously raising. The virus mainly affects women at the reproductive phase, and the presence of genital co-infections is very common1,2. These infections may increase HIV susceptibility due to decrease in the amount of lactobacilli in the vaginal flora and consequent loss of H2O2 protection, break of continuity of the epithelial barrier, recruitment, and stimulation of cells that are susceptible to infection by the virus or for stimulating HIV replication1,3. Among the main co-infections, we have genital herpes, syphilis, bacterial vaginosis, trichomoniasis, chlamydia, gonorrhea, and candidiasis. Genital herpes together with human papilloma virus (HPV) infection is considered the most prevalent agent and, consequently, the one that can most be associated with HIV infection. This is a worsening that, when associated with HIV, has higher rates of recurrence, besides the fact that it increases the replication rate of HIV in the mucus membrane4. HIV changes the course of herpes virus infection and may happen in different formats of the usual clinical course1,5. Ulcers that persist for longer than a month suggest immunodeficiency, and HIV infection must be investigated. Its treatment should be performed in a diversified manner6. Genital ulcers in HIV-positive women will be more present in syphilis, however the treatment is the same as in HIV-negative women6.

Bacterial vaginosis, depending on the microorganism involved, may increase in up to 100 times the level of genital HIV7. The appropriate retroviral treatment is important in these patients, since it improves CD4 cells counting and decreases occurrence of persistent infections. Trichomoniasis does not have its track modified by the HIV, but the proper treatment of this disease reduces the viral load in the vaginal secretion6. Chlamydia and gonorrhea are generally asymptomatic infections; however, they may evolve to pelvic inflammatory disease, especially more frequently in HIV-positive women. Furthermore, when such association is present, a clinical presentation with more severe symptoms and higher chances of evolution to ovarian abscess may happen6.

Finally, vulvovaginal candidiasis is a high-prevalence entity in the female population. In seropositive patients, there is an increase in the frequency and severity of the symptoms1,8. CD4 cells counting lower than 200 cells/mm3 and viral load higher than 10 thousand copies/mL increase the risk of worsening. Persistent forms of vulvovaginal candidiasis and those with weak response to therapy are suspicions for HIV virus co-infection9. It is important to emphasize that HIV presence may change the clinical presentation, course and therapeutic response of some infections, mainly in HIV-infected patients with a significant immunologic deficiency and especially in those with AIDS and high viral load.

Therefore, just as it is very important the universal tracking of HIV infection, in these patients tracking of possible genital infections should also be implemented. Thus, we will be increasing protection of HIV-infected women so that infections cannot follow other forms, which can not only deteriorate the HIV course, but also can worsen the evolution of genital co-infection, when associated. Also, by doing this we will be collaborating for decreasing transmission risk of HIV infection and similarly of the genital infections that may be associated.

The authors acknowledge it all.

Affiliation

1 Full Professor of Gynecology in the Department of Tocogynecology at Universidade Federal do Paraná (UFPR). Coordinator of the Sector of Infections in Gynecology and Obstetrics of Hospital de Clínicas at UFPR - Curitiba (PR), Brazil.
2 Intern Physician of the Sector of Infections in Gynecology and Obstetrics of Hospital de Clínicas at UFPR. Professor in the Medicine Course at Universidade Positivo . Physician of Hospital do Trabalhador at the Health Secretariat in the State of Paraná - Curitiba (PR), Brazil.
3 Student of Medicine at UFPR - Curitiba (PR), Brazil.
4 Student of Medicine at Universidade Positivo - Curitiba (PR), Brazil.

REFERENCES

1. Sebitloane MH. HIV and gynaecological infections. Best Pract Res Clin Obstet Gynaecol. 2005;19(2):231-41.
2. ACOG Practice Bulletin No. 117: Gynecologic care for women with human immunodeficiency virus. Obstet Gynecol. 2010;116(6):1492-509.
3. Cohen MS. HIV and sexually transmitted diseases: lethal synergy. Top HIV Med. 2004;12(4): 104-7.
4. Shah R, Bradbeer C. Women and HIV - revisited ten years on. Int J STD AIDS. 2000;11(5):277-83.
5. Sobel JD. Gynecologic infections in human immunodeficiency virus-infected women. Clin Infect Dis. 2000;31(5):1225-33.
6. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):23-4.
7. Mirmonsef P, Krass L, Landay A, Spear GT. The role of bacterial vaginosis and trichomonas in HIV transmission across the female genital tract. Curr HIV Res. 2012;10(3):202-10.
8. Merenstein D, Hu H, Wang C, Hamilton P, Blackmon M, Chen H, et al. Colonization by Candida Species of the oral and vaginal mucosa in HIV-infected and noninfected women. AIDS Res Hum Retroviruses. 2013;29(1):30-4.
9. Cu-Uvin S, Ko H, Jamieson DJ, Hogan JW, Schuman P, Anderson J, et al. Prevalence, incidence, and persistence or recurrence of trichomoniasis among human immunodeficiency virus (HIV)-positive women and among HIV-negative women at high risk for HIV infection. Clin Infect Dis. 2002;34(10):1406-11.

Address for correspondence:


Mail address: . Rua General Carneiro, 181, Setor de Ginecologia e Obstetrícia HC - Alto Glória. Curitiba (PR), Brazil. CEP: 80060-900. Tel: +55 (41) 9973-3186. E-mail: newtonsdc@gmail.com

History

Received: 11/11/2013

Accepted: 02/02/2014

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