This study employed a cross-sectional design that included HIV-positive women aged 18 years and above who received regular HIV care at the Mbarara City Health Centre IV and consented to participate in the study.

Ethical consideration

Ethical approval was granted by the Research Ethics Committee of Mbarara University of Science and Technology (MUST-2023-1284), and administrative clearance was obtained from the Mbarara City Health Officer. Prior to enrollment, written informed consent was obtained from all participants. Confidentiality and privacy were strictly maintained in accordance with standard clinical protocols. Participants retained the right to withdraw at any time without compromising their medical care. Study supervisors ensured compliance with ethical guidelines, safeguarding patient rights and dignity throughout all procedures.

Sample size

According to Mbarara City Council HCIV’s Open Medical Records System (OpenMRS), which was used to determine the sample size of participants, 10 HIV-positive women on average report VVC signs and symptoms each week (MCC Weekly Reports, 2023). Therefore, the sample size to a finite population using the formula n 1 = N × n/ (n + N-1) where N is the finite population and n 1 is the corrected sampled size. We adjusted for a 10% attrition rate (131/0.1). Therefore, we enrolled 144 participants in this study.

Data collection

Quantitative data were collected through structured questionnaires and medical record reviews. A systematic questionnaire conducted by an interviewer was utilized to obtain data about the participants’ socio-demographics of participants and the variables associated with vulvovaginal candidiasis.

Sample collection, culture and identification

Following a clinical examination by the midwife, vulvovaginal samples were collected with the patient in lithotomy position. The vulva was swabbed front-to-back using sterile saline-soaked gauze swabs. A sterile cotton swab was then inserted 20–30 mm into the vaginal canal and rotated gently for sample collection. Two vaginal swabs were taken; one for gram staining and the other for culture and sensitivity testing.

The labelled samples were transported to the Microbiology laboratory of Mbarara university of science and technology immediately after collection. In the laboratory, the swabs were inoculated on Sabouraud Dextrose Agar (SDA) at 37 °C for 48 h10. A wet mount preparation using saline and gram staining was performed to examine microscopically for budding yeast cells. Species identification was achieved through germ tube test, using Candida API strips, and subculturing on CHROMagar10,11.

Antifungal susceptibility testing was performed using the disc diffusion method on Mueller Hinton Agar supplemented with 2% glucose and methylene blue12. The antifungal agents tested included Fluconazole (25 µg), Voriconazole (1 µg), Nystatin (100 IU), Clotrimazole (50 µg), Miconazole (10 µg), and Amphotericin B (2.5 µg/mL). Plates were incubated at 37 °C for 24–48 h, allowing detection of slower-growing species like Candida glabrata and Candida krusei10. C. albicans ATCC 90,028, C. parapsilosis ATCC 22,019 and, C. krusei ATCC 6258 were used as control strains.

Every tenth sample was evaluated at the Epi-Centre laboratory Mbarara), a level three authorized laboratory in Mbarara, for external quality control.

Data analysis

Questionnaires were checked for completeness on the same day of the data collection. Data was entered in Excel, cleaned, coded, and backed up. Data were exported to STATA V17 for analysis.

The baseline characteristics of participants were summarized using mean with SD, median with IQR, or proportions as deemed appropriate. Descriptive statistics were used to summarize the demographic, behavioral, and clinical characteristics of the study population. The prevalence of VVC was estimated with confidence intervals. Logistic regression analysis was performed to identify factors associated with VVC adjusting for potential confounders.