Etiology of genital ulcer disease and association with HIV infection in Malawi

Sex Transm Dis. 2013 Dec;40(12):923-8. doi: 10.1097/OLQ.0000000000000051.

Abstract

Background: The World Health Organization recommends the use of syndromic management for patients presenting with genital ulcer disease (GUD) in developing countries. However, effective treatment guidelines depend on a current country-specific GUD etiological profile, which may change over time.

Methods: From 2004 to 2006, we conducted a cross-sectional analysis of baseline data from patients presenting with GUD at a reference STI clinic in Lilongwe, Malawi. Participants were enrolled in a randomized clinical trial of acyclovir added to syndromic management and followed up for up to 28 days. Serologies for HIV (using parallel rapid tests), herpes simplex virus type 2 (HSV-2; using Focus HerpeSelect IgG2 ELISA [Focus Technologies, Cypress Hill, CA]), and syphilis (rapid plasma reagin confirmed by Treponema pallidum hemagglutination) were determined, with plasma HIV-1 RNA and CD4 count in HIV-positive patients. Genital ulcer disease etiology was determined by real-time multiplex polymerase chain reaction from lesional swabs.

Results: A total of 422 patients with GUD (313 men; 74%) were enrolled. Overall seroprevalence of HIV-1, HSV-2, and syphilis were 61%, 72%, and 5%, respectively. Ulcer etiology was available for 398 patients and showed the following: HSV-2, 67%; Haemophilus ducreyi, 15%; T. pallidum, 6%; lymphogranuloma venereum, 6%; mixed infections, 14%, and no etiology, 20%. Most HSV-2 ulcers were recurrent (75%). Among all patients with HSV-2, HIV prevalence was high (67%) and HIV seroprevalence was higher among patients with recurrent HSV-2 compared with patients with first-episode HSV-2 (78% vs. 39%, P < 0.001).

Conclusions: Herpes simplex virus type 2 ulcers are highly prevalent in this symptomatic population and strongly associated with HIV. Unlike most locations in sub-Saharan Africa, H. ducreyi remains prevalent in this population and requires periodic monitoring and an appropriate treatment regimen.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • AIDS-Related Opportunistic Infections / diagnosis*
  • AIDS-Related Opportunistic Infections / epidemiology*
  • AIDS-Related Opportunistic Infections / immunology
  • AIDS-Related Opportunistic Infections / microbiology
  • Adult
  • Chancroid / diagnosis
  • Chancroid / epidemiology
  • Cross-Sectional Studies
  • Directive Counseling
  • Double-Blind Method
  • Female
  • Genitalia / microbiology*
  • Genitalia / virology*
  • Haemophilus ducreyi / isolation & purification
  • Herpes Genitalis / diagnosis
  • Herpes Genitalis / epidemiology
  • Herpesvirus 2, Human / isolation & purification
  • Humans
  • Malawi / epidemiology
  • Male
  • Prevalence
  • Risk Reduction Behavior
  • Sentinel Surveillance
  • Syphilis / diagnosis
  • Syphilis / epidemiology
  • Ulcer / diagnosis*
  • Ulcer / epidemiology*
  • Ulcer / microbiology
  • Ulcer / virology

Associated data

  • ISRCTN/ISRCTN32121857