Clinical occurrences of HSV reactivation, both symptomatic and asymptomatic, increase in frequency and duration at lower CD4 counts. However, because response to therapy can be delayed, treatment should be continued beyond the standard 10 days if ulcers have not healed or if new lesions continue to appear. While acyclovir resistance has very seldom been a problem in immunocompetent patients, resistance does occur in the context of HIV associated immunosuppression and, resistance testing should be performed in HIV-infected patients who fail to respond to therapy. Foscarnet is the drug of choice to treat resistant virus. Most often, HPV infection causes genital warts, however some types of HPV infection are linked to cancer.
Flat warts are more common within the vagina.
Warts can occur anywhere in the anogenital area and usually are asymptomatic, though some patients complain of rectal discomfort, itching, burning or discharge, symptoms that they frequently attribute to hemorrhoids. HIV patients with CD4 counts below 50 are more likely to have diffuse condylomatosis. No consensus exists regarding a single best approach, therefore decisions regarding care need to factor in patient preference, patient ability to follow application instructions, wart location and accessibility, and cost. Referral to a specialist is indicated if no improvement is seen after 3 treatments, complete clearance has not occurred after 6 treatments, or continued treatment would extend beyond the duration recommended by manufactures of patient applied therapy. Over treatment should be avoided.