Clinical overview
HIV does not just produce immunodeficiency in the abstract — in the gynaecology clinic it produces patterned, predictable changes in the prevalence, presentation, severity, and natural history of common conditions. A registrar in South Africa needs to know these patterns because they shift screening thresholds, treatment regimens, and follow-up frequency for HIV-positive patients. This chapter complements HIV counselling by focusing on what HIV does to gynaecological organs, the diseases it amplifies, and how clinical management must adapt.
Core knowledge
Cervical disease
HIV-related HPV persistence drives CIN at the cervical transformation zone.
- HPV acquisition and persistence: HIV-positive women acquire HPV more frequently, clear it less, and harbour multiple high-risk types simultaneously. The interaction between HIV and HPV is bidirectional — HIV impairs HPV clearance; HPV (particularly high-risk types) and the associated inflammation may modestly increase HIV shedding.
- CIN incidence and progression: 2–4× higher than HIV-negative; faster progression CIN1 → CIN2/3 → invasive carcinoma.
- Cervical cancer: AIDS-defining illness; in SA accounts for a substantial fraction of cervical cancer presentations. Younger age at diagnosis, more advanced stage at diagnosis.
- Screening adjustment: see Cervical screening SA for SA NDoH 2023 protocol — HIV-positive women screened at diagnosis and every 3 years (more often if abnormal), regardless of age.
- Treatment: LEEP and other excisional treatments are effective; recurrence higher in HIV-positive women, especially with low CD4 and uncontrolled viral load. See CIN management.
Vulval and vaginal disease
- Genital warts (condyloma): more numerous, larger, more refractory to treatment.
- VIN and vulval cancer: increased risk, similar HPV mechanisms. See Vulvar epithelial hyperplasia and Vulval carcinoma.
- Recurrent vulvovaginal candidiasis: more common; long-term suppressive antifungal therapy may be needed. See Candidiasis.
- Herpes simplex: more frequent recurrences, severe and atypical lesions, slower healing, sometimes resistant to standard aciclovir doses → escalate.
- Molluscum contagiosum: larger, more numerous, persistent.
- Bacterial vaginosis: more common; may contribute to PID and vertical-transmission risk.