Lower genital tract infections in HIV-seropositive women in India

OBJECTIVES: The presence of STD facilitates shedding of HIV and increases HIV-1 disease progression, possibly by increasing plasma viremia. Our aim was to study the presence of various associated Sexually transmitted disease/Reproductory tract infections in HIV-seropositive women in India. MATERIALS AND METHODS: The study included 40 HIV-seropositive women attending the antiretroviral therapy (ART) clinic at Lok Nayak Hospital. An informed consent was taken from all subjects. All cases were subjected to detailed gynecological examination and two types of swabs, i.e., a vaginal swab and a cervical swab were taken for STD/RTIs evaluation. The vaginal swabs were used for preparation of wet mount and KOH mount for diagnosis of trichomoniasis and candidiasis; to make a vaginal smear for Gram staining to diagnose bacterial vaginosis (BV) as per Nugent's criteria; for culture of aerobic bacteria and Candida spp. The cervical swab was used for isolation of Neisseria gonorrhoeae by culture and for detection of Chlamydia trachomatis antigen by Chlamydia microplate enzyme immunoassay kit (BIORAD). All data were analyzed using appropriate statistical tests. RESULTS: All 40 cases were evaluated for the presence of STD/RTIs associated with HIV infection. The women belonged to the reproductive age group (15-45 years) and majority (40%) of them were para 2. Most of the women (14, 35%) were in World Health Organization (WHO) stage I and maximum number (28, 70%) had their CD4 cell count more than 200 cells/ml. There was no significant correlation between WHO stage of HIV-seropositive women and their CD4 cell count (P=0.092). Out of 40 cases, 15 (37.5%) were on ART with maximum cases (53.3%) in WHO stage III. The duration of ART was more than 6 months in 9 (60%) cases. The most common presenting complaint was vaginal discharge in women with WHO stage II and III and 27.5% women showed vaginitis on per speculum examination. Laboratory tests showed high prevalence of BV (30%), mixed infection (30%), and candidiasis (10%) among HIV-seropositive women (P<0.001 in both). Women with BV were mostly in WHO stage I (38.4%) and stage II (36.3%), while those with mixed infection were mainly in WHO stage III (36.3%) and stage IV (40%).Women with candidiasis were mainly in WHO stage III. C. trachomatis antigen was found only in one subject (prevalence 2.5%). Both WHO stage and CD4 cell count had no significant correlation with presence of BV (P=0.056 and 0.063, respectively) and candidiasis (P=0.492 and 0.530, respectively). Maximum number of patients on ART had mixed infection (53.3%), while most of the patients (36%) not on ART had BV. There was no significant association between duration of ART and the presence of vaginal infections. CONCLUSIONS: The prevalence of gynecological symptoms and RTIs in HIV-seropositive women is high enough to warrant routine gynecologic evaluation and RTI screening in these patients. However, larger studies and trials are needed to evaluate the effects of ART on these abnormalities as well as to choose the best screening tool in HIV-seropositive women.