Conditions that lead to breaks in the vulval and vaginal epithelium, such as syphilis and other ulcerative bacterial conditions including lymphogranuloma venereum and chancroid, have been associated with higher rates of human immunodeficiency virus (HIV) incidence, particularly in the developing world. In a woman with HIV infection, the major risk of developing vulval infection is related to a reduced CD₄ count and consequent immune suppression.

HIV and other infections

The acquisition of HIV infection is more common in women with recurrent vulval herpes simplex virus (HSV) infection. The apparent synergy between HSV‐2 and HIV acquisition prompted the development of randomised clinical trials of HSV‐2 suppressive therapy with the hopes of adding another biomedical HIV prevention strategy; however, multiple studies have failed to demonstrate any effect of suppressive aciclovir on the risk of HIV acquisition despite high levels of adherence [1,2].

Significant immune suppression (CD4 counts < 200 cells/ml) is associated with increased rates of vaginal candidiasis, recurrent HSV, and bacterial vaginosis. Standard treatment for these infections is sufficient in most patients. It is important to exclude resistant HSV in patients with recurrent lesions and a very low CD4 count. After successful treatment of HSV in these cases, antiviral agents should be continued prophylactically.

HIV and human papillomavirus (HPV)‐related disease

Longitudinal case‐controlled studies have demonstrated that HIV‐infected women were at least three times more likely to develop genital warts, although the risk of developing this infection is reduced with higher CD4 counts. Treatment of anogenital warts in immunocompromised individuals can be problematic, although benefits have been reported with immunological therapy [3,4].

It is likely that women who have acquired HIV infection have also been infected with HPV, particularly HPV16, HPV18, and other high‐risk oncogenic subtypes. These are associated with an increased risk of cervical, vulval, and anal premalignant and malignant disease.

There has also been an association of HIV infection with abnormal cervical cytology and a higher risk of more rapid progression to severe dysplasia.

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