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HUMAN IMMUNODEFICIENCY VIRUS INFECTION AND ACQUIRED IMMUNODEFICIENCY SYNDROME
Any discussion of vulvovaginal infections must include the topic of HIV and acquired immunodeficiency syndrome (AIDS).
The incidence of HIV infection and AIDS is increasing in women. Females represent the fastest-growing segment of the AIDS epidemic. Most are in the reproductive age group, and more than 70% are African American or Hispanic. More than half are intravenous (or injecting) drug users, whereas the other half have been exposed through sexual contact with HIV-infected partners. Women who exchange sex for drugs are at high risk, as are women who engage in anal intercourse. Heterosexual trans-mission is the leading cause of new HIV infection in women. Women are nine times more likely to get HIV from men than men are from women. Factors that may account for this differ-ence include a higher quantity of HIV in semen as compared with vaginal secretions, a larger inoculum on ejaculation, retention of HIV-infected semen in the vagina, and traumatic microscopic mucosal injury during intercourse. The presence of genital ulcers or a friable cervix increases risk. Intercourse during menses may also increase risk. Additionally, any break in skin integrity in-creases the possibility of infection (eg, a herpetic lesion or syphilitic chancre could provide a portal of entry). Nurses need to informwomen about the dangers of unprotected sex (Hader, Smith, Moore & Holmberg, 2001; Healthy People 2010, 2000).
Syphilis appears to accelerate in HIV-positive patients and pro-ceeds directly from primary to tertiary disease in some patients. Chlamydia is associated with a high risk for HIV (which may be related to inflammatory changes of the cervix, providing entry sites). HIV-positive women have a higher rate of HPV, and this risk increases as their CD4 cell count decreases. Infections with HPV and HIV together increase the risk of malignant transfor-mation and cervical cancer. This risk also increases as the CD4 cell count decreases. Thus, women with HIV infection should have frequent Pap smears. HIV-positive women also have larger and more painful herpes lesions with more recurrences, probably re-lated to immunosuppression from their disease. Treatment with acyclovir or other antiviral agents is appropriate for such patients. Pneumonitis, esophagitis, and disseminated skin involvement are common in this population. Candidiasis also occurs frequently in this population; oral candidiasis may signal rapidly advancing disease. Many HIV-infected women have gynecologic disorders, including candidiasis, PID, anogenital warts, and cervical dyspla-sia (Healthy People 2010, 2000).
Women with HIV and women with partners who have HIV must be counseled about safer sex. Consistent use of condoms with an HIV-infected partner can keep seroconversion rates to about 1%, but inconsistent use results in an annual 7.2% sero-conversion rate. Because there is a 25% to 30% chance of peri-natal transmission, decisions to conceive or to use contraception must be based on teaching and care. (The use of antiretroviral agents by pregnant women has been shown to decrease perinatal transmission of HIV infection significantly. Therefore, the use of these agents during pregnancy must also be discussed.) For those who choose to avoid conception, condoms or condoms with oral contraceptives are possible choices.
Women who are at risk for HIV should be offered testing after informed consent by a trained nurse or counselor. Because pa-tients may be reluctant to discuss risk-taking behavior, routine screening should be offered to all women. Early detection permits early treatment to delay progression of the disease. The nurse plays a crucial role in educating patients about HIV and preven-tion of HIV infection and AIDS.
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