Other sexually transmitted diseases (STDs) and opportunistic
infections of the genital area are common in both men and women with AIDS, and
may recur on numerous occasions. Considerable evidence suggests that STDs that
cause ulcerative lesions promote the transmission of HIV through sex. Effective
diagnosis, care and education about genital problems are, therefore, crucial to
both the prevention of HIV transmission and to the care of people with HIV
In women, the genital area consists of the external and internal
labia of the vagina, the surrounding skin surface, the opening of the vagina
(which is called the vulva) and the vagina itself. The genital area in the male
consists of the penis, which may be circumcised or not, the scrotum containing
the testicles and the surrounding skin. If uncircumcised, the end of the penis
will be covered with loose skin which can be pulled back. This is called the
The rectal area and the inguinal areas of the groin in men and
women may also be involved in genital problems such as infections, rashes, warts
Problems and possible causes
Opportunistic infections of the genital area, including certain
sexually transmitted diseases (STDs), are common in both men and women with
AIDS. They often cause pain and discomfort.
There are six common ways that such genital problems appear in
men and women:
· an unusual
discharge (a mucus or pus-like substance) from the vagina
· an unusual discharge from the urethral opening of the
· open sores or ulcers in the genital,
groin or rectal areas, which sometimes start as blisters
· a rash in or around the genital area
· warts in the genital area or around the
· swollen glands in the
If a person feels they may have a sexually transmitted
disease (STD), their first action should be to seek treatment from a health care
worker where available, BEFORE attempting any form of home treatment.
What to do at home
Firstly and very importantly, always advise people to use a
condom each and every time they have any sexual contact. It is dangerous for
someone who is already infected with HIV' to be exposed to other sexually
transmitted diseases. The use of condoms offers protection from all STDs, and
also provides protection to the partners of those with such conditions. (See
Chapter Two for further information on safer sex.)
All women normally have a small amount of vaginal discharge
which is clear, milky-white or slightly yellow and varies in amount and
appearance over the course of the monthly menstrual cycle. Any change in this
normal discharge, particularly if it is accompanied by an unpleasant smell,
itching, soreness and sometimes fever, is probably caused by a sexually
transmitted infection such as gonorrhoea, chlamydia or trichomonas.
Vaginal infections are important because:
· They may be passed
on to others through sexual intercourse.
· Sexually transmitted
infections (e.g. gonorrhoea, chlamydia) are particularly likely to spread from
the genital area to the upper reproductive tract causing pelvic inflammatory
disease. This may even lead to abscesses with severe cramps and pains in the
abdomen, with the result that such infections become difficult to treat, even
with strong medicine, and can be life-threatening.
· They increase the risk of
acquiring, or passing on, HIV infection during sex.
· They may be transmitted to an
unborn child during pregnancy.
People should be given the following advice on ways to avoid
· Always use condoms
when having any sexual contact (see Chapter Two).
· Keep the vulva and anal area
clean by washing with water (but avoid soaps that damage this delicate skin).
· After going to the latrine,
wipe the anus in a direction away from the vagina so that faeces doesn't
get into the vulva, vaginal region.
· Avoid washing out the vagina
or putting anything (e.g. leaves, herbs) inside unless advised by a health care
Anyone with vaginal discharge should be examined by a health
Urethral discharge in men
Pus or mucus discharge from the opening of the urethra, often
accompanied by burning when passing urine, is usually a sign of an STD. Anyone
with these symptoms should be examined by a health care worker.
Open sores or lesions on the genitals may be caused by an STD.
As with any open wound (see the section on skin problems in this chapter) an
additional infection may occur. People with open sores should be advised to:
· always use condoms
when having any sexual contact (see Chapter Two)
· keep the affected area dean
with soap and water
· between washings keep the
· watch for signs of infection,
and seek help if redness, pus or swelling are seen, or if the sores become
Genital warts are very common, are infectious, and can be caught
by sexual contact then passed on to other people in the same way. They are often
larger, spread more quickly and are more difficult to treat in people with AIDS.
In women, they appear as skin-coloured lumps or swellings on the outside and
inside of the vagina, and the area around the anus, while in men they appear
particularly under the foreskin and around the anus. If they get rubbed by
clothing or damaged they may become sore (inflamed), infected and may even
Encourage people to seek early treatment from a health care
worker for this condition. Local treatment of the warts provided by a health
care worker can be effective if it is applied before the warts are too big. If
someone waits too long and the warts become quite big it may be necessary to
have them cut out, a surgical procedure which has risks associated with it.
Warts that are damaged may become infected. If this occurs they should be
treated like any open wound in the genital area.
Herpes is a viral infection that many people get around their
mouths or genital area. It tends to remain latent (hidden away), under the
control of the body's defences. It occasionally appears as blisters which break
down to give painful ulcers which heal slowly by themselves. In people with
AIDS, the blisters appear more frequently, spread over a wider area and
sometimes do not heal at all. They can be very difficult to treat.
If herpes is diagnosed, advise the person to bathe the affected
area with salt solution consisting of a teaspoonful of ordinary cooking salt in
half a litre of clean water. They should do this often, every two or three hours
if possible. Between times the affected area should be kept dry. Calamine,
talcum or starch powder may also be applied to the sore.
Candidal infections - caused by several of the fungi belonging
to the genus Candida - are common but they are particularly frequent and
more difficult to cure in people with AIDS. In women, they produce a curdy
discharge and cause redness and soreness of the vulva that is accompanied by
severe itching. The skin may break down and bleed, particularly if scratched.
Candidiasis is also found in men, especially among those who are uncircumcised,
and occurs often and severely in men with AIDS. The foreskin and the area
underneath it become very sore and red. There may be a yellow discharge under
the foreskin. The skin of the penis, scrotum, and around the anus sometimes
becomes red, sore and itchy.
Candidiasis is not sexually transmitted but is often brought on
by the use of antibiotics for the treatment of other conditions, or simply
because the person with AIDS has lowered resistance to the fungi that cause it.
The organisms are always present in the genital area but are not normally a
problem because the body's defences keep them from growing out of control.
If someone is experiencing candidiasis repeatedly, the following
approach may help to alleviate discomfort, to prevent the onset of a new
infection (which can occur, for example, as a result of taking antibiotics given
for another problem) and possibly to decrease the intensity of an existing
· Apply gentian
violet to the vulva and vaginal area or the affected male genital area. To
prepare a gentian violet solution dissolve one or two teaspoonfuls of gentian
violet crystals in one litre of clean water. Apply once daily for three days.
Gentian violet solution should be applied internally or externally to the
affected area using a soaked piece of clean cotton wool, cloth or gauze. This
should be done for at least three days or until the symptoms improve - if this
does not happen then the person must see a health care worker. People should be
advised that gentian violet stains clothing and sheets a purple
A rash on the penis or under the foreskin will often respond to
soaking in a dilute salt and water solution. Dissolve a teaspoonful of salt in a
glass or jam jar of water. Pull back the foreskin, put the penis in the water
and soak for 5 minutes. Repeat 2 or 3 times a day.
If this does not work carry out the same procedure using a
gentian violet solution (1/2 teaspoonfuls gentian violet in 1 litre of clean
water). If the rash does not clear up in 3-4 days the person should ask advice
from a health care worker.
Someone who experiences candidiasis repeatedly should learn to
recognize the signs of an infection and begin the treatment at home while it is
still in the early stages.
Loss of Menstruation
Loss of menstruation and irregular bleeding occur in many
illnesses including AIDS. If a woman loses a lot of weight her periods may stop
altogether or become infrequent. Loss of menstrual bleeding can have many causes
(including pregnancy) and is often seen in women with AIDS. This should be
assessed in order to plan for the future care of the woman (see Chapter Six). If
a woman misses one or two periods, she should be encouraged to go to the health
centre to be examined. If pregnancy is not the cause then the reason for the
loss of menstruation should, where possible, be determined.
Always remember that a woman may feel that loss of menstruation
represents a loss of capacity to bear children or a loss of femininity and may
feel sad or even depressed. You can help a person to fight off this loss of
self-esteem by reassuring her that loss of menstruation is experienced by many
women for a wide variety of reasons. Women should be encouraged to be with
friends, to involve themselves in the people and activities around them, and to
remember that they are still worth while and have a great deal to give.
When sick people and their families
must seek help
· If a STD is
· If difficulty or pain in
passing urine is experienced.
· If genital warts are present.
· If genital ulcers are present.
· If there is an unusual vaginal
discharge that is foul-smelling, itchy, very plentiful, or green, yellow or grey
· If a pain develops in a
woman's lower abdomen, particularly if it is accompanied by a fever.
· If a woman's periods stop or
become irregular or erratic.
· If there is a discharge from
· If there is swelling and/or
pain in the scrotum.
Notes on genital