EMAIL YOUR QUESTIONS TO www.projectinform.org/questions JANUARY 2011 Vaginal candidiasis and HIV disease Vaginal candidiasis is a fungal or yeast infection of the vulva and/or vagina. It causes a smelly, thick, white-yellow discharge that might be accompanied by itching, burning and swelling. It can also can make walking, urinating or sex very painful. Vaginal candidiasis can be an occasional problem for even the healthiest woman. However, it’s more common and severe in women with weakened immune systems. For many, a repeating or worsening vaginal yeast infection is the first symptom of HIV infection. This infection can occur at any CD4 count but is likely to occur more often when your CD4 count falls below 100. content. Other factors that may cause candidiasis include diabetes, pregnancy, using antihistamines and iron, folate, vitamin B12 or zinc deficiency. Cancer chemotherapy, stress and depression can also contribute to the disease. Tight fitting pants and reactions to the chemicals in soaps and detergents can lead to vaginal candidiasis as well. Diagnosis Cause Vaginal candidiasis is caused by the fungus called Candida. Everyone has small amounts of the fungus in the mouth, vagina, digestive tract and skin. In healthy persons, their immune systems prevent it from causing infection. However, a weakened immune system can allow the Candida to grow and cause disease. Certain drugs can alter the natural organisms in the vagina, which can then allow the Candida to grow. These include the extended use of antibiotics, steroids and oral contraceptives (birth control) with a high estrogen © PROJECT INFORM Vaginal candidiasis is usually diagnosed by appearance and symptoms. Because symptoms are similar to many other conditions, like the sexual infection trichomonas, your doctor should confirm a diagnosis by scraping the affected area for examination under a microscope. 1375 MISSION STREET Treatment Topical treatments (applied on the affected area) are the first choices for yeast infections and these generally work for mild-to-moderate cases. These include vaginal creams, suppositories or tablets. Many are available over the counter. Most topical treatments last only a few days. Longer courses (7–14 days) may be more effective in HIV-positive women. Generally, topical treatments do not cause side effects, but in a few women they may lead to vaginal burning, itching or skin rash, or even cramps or headaches. Oil-based vaginal creams may weaken latex condoms and diaphragms. FACING NEW DECISIONS? WONDERING WHAT’S THE NEXT STEP? HIV Health InfoLine: 1-800-822-7422 (toll-free) 10a–4p, Monday–Friday, Pacific Time SAN FRANCISCO, CA 94103-2621 415-558-8669 WWW.PROJECTINFORM.ORG EMAIL YOUR QUESTIONS TO 2 www.projectinform.org/questions Vaginal candidiasis and HIV disease If topical treatment does not work, or if outbreaks recur often, you may need oral drugs. A single oral dose of Diflucan (fluconazole) is increasingly used to treat vaginal candidiasis. Antifungal drugs and pregnancy The Federal Guidelines for the Prevention of Opportunistic Infections recommend not using antifungal drugs during pregnancy due to possible birth defects. They further state that azoles be stopped in women who become pregnant and that women taking these drugs use effective birth control. Topical therapies may be preferable for pregnant women. For systemic treatment the Guidelines suggest using AmB, especially in the first trimester. Although no formal studies have been done, pregnant women have used amphotericin B without apparent harm to their unborn children, though the drug has possible severe side effects including kidney toxicity and anemia. TOLL-FREE HIV HEALTH INFOLINE Prevention Using antifungal drugs to prevent fungal infections is approached with great caution and is generally discouraged, especially using fluconazole this way. This makes treating newer and more aggressive infections more difficult and often unsuccessful. However, this may not be possible in some people with recurrent infections who must remain on long-term therapy to prevent them. Read page 3 for ideas on preventing candidiasis through food and other ways Some final thoughts Candidiasis is among the most common conditions in people with HIV. It’s often the first sign of HIV disease progression, particularly yeast infections that recur or respond less to treatment. Candidiasis outbreaks can be frequent, cause great discomfort and add to the decline in health seen in AIDS. Prevent and treating vaginal candidiasis will improve discomfort and reduce further damage it may cause to your immune system. 1-800-822-7422 LOCAL & INTERNATIONAL 415-558-9051 Other publications that may help Oral Candidiasis www.projectinform.org/publications/ candidao/ Systemic Candidiasis www.projectinform.org/publications/ candidas/ MONDAY–FRIDAY 10–4 PACIFIC TIME EMAIL YOUR QUESTIONS TO 3 www.projectinform.org/questions Vaginal candidiasis and HIV disease Preventing vaginal candidiasis There are many practical ways to try to prevent vaginal candidiasis. For women with recurrent disease, a single dose of fluconazole weekly is sometimes used to prevent the infection. Caution is recommended when considering this approach since its extended use of fluconazole can result in resistant candidiasis. Practical prevention tips • Avoid douching. Douching changes the normal acid level in the vagina and causes inflammation, both of which may increase the risk of infection. • Try not to use scented laundry soap, bleach or fabric softeners. These products can cause yeast infections. Bleach may harm the friendly bacteria that stop Candida from taking over. Also, fabric softeners stop moisture from escaping, keeping the skin damp and more likely for yeast to grow. • Avoid tight clothes which block air flow. • Wear cotton underwear as it lets air in and moisture out. • Avoid washing with deodorant soaps or bubble baths. Non-soap cleansers are less likely to irritate the vaginal area. © PROJECT INFORM 1375 MISSION STREET Food as prevention • Decrease or avoid sugars (corn and maple syrup, glucose, fructose and sucrose). Sugars are food for Candida and help it grow. • Decrease or avoid alcohol. Alcohol converts to sugar and helps Candida grow. • Swallow large amounts of garlic. It’s believed to have some natural antifungal properties. (Fresh is considered best—mince and put into empty gelatin capsules, up to 6 cloves a day.) (NOTE: It is unknown if large amounts of garlic interfere with HIV drugs, but some evidence exists that it may increase the risk of side effects from Norvir [ritonavir].) • Drink milk or eat yogurt with acidophilus bacteria: is “friendly” bacteria that helps keep your body in balance. SAN FRANCISCO, CA 94103-2621 415-558-8669 Treating and preventing fungal infections naturally Nutritional approaches to prevent and treat conditions like candidiasis are complicated and controversial. While there isn’t a magic recipe that prevents or treats yeast infections in everyone, following some basic guidelines may lower the risk of yeast becoming a problem for you. Sugar, yeast, dairy, wheat, caffeine, nicotine and alcohol promote the growth of yeast. Nutritionists recommend ingesting as little as possible of these foods and products to decrease the risk and/or severity of yeast infections. Eating larger amounts of some foods may suppress the growth of yeast, like garlic or milk and yogurt that contain acidophilus. WWW.PROJECTINFORM.ORG EMAIL YOUR QUESTIONS TO 4 www.projectinform.org/questions Vaginal candidiasis and HIV disease TREATING VAGINAL CANDIDIASIS T O P I C A L T H E R A P I E S butoconazole 2% cream 5 grams for 3 days clotrimazole (Lotrimin) 5 grams for 7–14 days 1% cream clotrimazole (Mycelex) One 100mg tablet for 7 days 100mg vaginal tablet or two 100mg tablets for 3 days clotrimazole (Mycelex) Single dose 500mg vaginal tablet miconazole (Monistat) 5 grams for 7 days 2% cream miconazole (Monistat) Once a day for 7 days 100mg suppository miconazole (Monistat) Once a day for 3 days 200mg suppository miconazole (Monistat) Single dose 1,200mg suppository terconazole (Terazol 7) 5 grams for 7 days 0.4% cream terconazole (Terazol 3) 5 grams for 3 days 0.8% cream terconazole (Terazol 3) Once a day for 3 days 80mg suppository tioconazole (Vagistat) A single dose 300mg ointment Over the counter; may weaken latex condoms/diaphragms Over the counter. may weaken latex condoms and diaphragms Over the counter; may weaken latex condoms/diaphragms Over the counter Over the counter May weaken latex condoms/diaphragms May weaken latex condoms/diaphragms Over the counter O R A L T H E R A P I E S fluconazole (Diflucan) One 150mg dose itraconazole (Sporanox) One 100mg dose ketaconazole (Nizoral) One 200–400mg dose Not recommended for pregnant women; sometimes used weekly as a prevention Not recommended for pregnant women; sometimes used weekly as a prevention Not recommended for pregnant women; sometimes used weekly as a prevention O T H E R T H E R A P I E S nystatin vaginal tablet Applied to affected areas (Mycostatin) twice a day for 3 days gentian violet Applied to affected areas once a week for 4 weeks. Over-the-counter. May be useful for recurrent (every 7 days for 1 month); messy; can cause vaginal swelling; refrain from sex Available over-the-counter. Consult doctor for proper application. TOLL-FREE HIV HEALTH INFOLINE 1-800-822-7422 LOCAL & INTERNATIONAL 415-558-9051 MONDAY–FRIDAY 10–4 PACIFIC TIME