Genital ulcers and concomitant complaints in men attending a sexually transmitted infections clinic: implications for sexually transmitted infections management.

BACKGROUND: Although genital herpes has emerged as the most common cause of genital ulcers in Southern Africa, treatment for herpes is not available routinely in the region. This study was performed to determine the etiology of genital ulcers in men in Durban and assess other sexually transmitted infections-related symptoms, presentation, and treatment patterns in this group. METHODS: Polymerase chain reaction (PCR) tests were performed on specimens from consecutive male patients with genital ulcers to detect sexually transmitted pathogens. PCR was also performed for the detection of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis on urethral specimens from consecutive subjects with dysuria or urethral discharge. Antibody tests for syphilis and herpes simplex virus type-2 (HSV-2) and human immunodeficiency virus antibodies were performed. RESULTS: Of 162 patients enrolled with genital ulcers, 77.7% were human immunodeficiency virus-positive and 84.6% had antibodies to HSV-2. PCR results showed the following prevalences: HSV-2 53.7%, lymphogranuloma venereum 13.6%, Treponema pallidum 3.7%, Hemophilus ducreyi 1.2%, mixed infections 6.2%, and no pathogens identified 33.3%. One case of donovanosis was diagnosed clinically. In men with HSV-2 ulcers, delay before attendance recorded for 68 men was 1 to 3 days (24%), 4 to 7 days (47%), 8 to 14 days (12%), 15 to 30 days (12%), and >30 days (6%). History-taking using prompting increased the sensitivity but decreased the specificity and positive predictive value of reported genital ulceration when assessed against ulcers seen on examination. CONCLUSIONS: Men at risk of genital ulcers should be asked about relevant symptoms with and without prompting and examined clinically to maximize the likelihood of correct diagnosis and treatment. The finding of a high prevalence of HSV-2 and associated dysuria cautions against providing empirical treatment for gonorrhoea and chlamydia in ulcer patients with dysuria but without urethral discharge. Innovative strategies to limit the burden of HSV-2 infection in this population are required.

Association between HIV and subpreputial penile wetness in uncircumcised men in South Africa.

OBJECTIVES: To describe the prevalence and characteristics of subpreputial penile wetness and to investigate the association between current levels of penile wetness and HIV infection. METHODS: Male attenders at a sexually transmitted infections clinic in Durban, South Africa were enrolled and treated for their presenting sexually transmitted infection complaint. They were asked to return after 14 days when a structured questionnaire was administered, and the degree of wetness of the glans penis and coronal sulcus was assessed clinically. RESULTS: Six hundred and fifty men were enrolled, and 488 (75%) returned. Three hundred eighty-six uncircumcised men were included for statistical analysis of whom 215 (56%) were HIV positive. One hundred ninety-six (50.8%) had no penile wetness, and 190 (49.2%) had penile wetness. In the adjusted analysis, penile wetness was associated with younger age, low level of attained education, low income, higher lifetime numbers of sexual partners, and not washing after sex. The prevalence of HIV was greater in those with penile wetness 126 of 190 (66.3%) compared with 90 of 196 (45.9%) with no penile wetness, crude prevalence odds ratio 2.32 (95% confidence interval [CI], 1.54-3.50, P=or<0.001), crude prevalence relative risk 1.44 (95% CI, 1.23-1.63, P=or<0.001), and adjusted for predictors of HIV, confounders and herpes type 2 antibodies, odds ratio 2.38 (95% CI, 1.42-3.97, P=or<0.001), and relative risk 1.46 (95% CI, 1.19-1.68, P=or<0.001). CONCLUSIONS: This is the first study to show an association between subpreputial penile wetness and HIV. Consideration should be given to providing advice about improving penile hygiene in uncircumcised men in areas where HIV is a significant problem. Good penile hygiene should also be promoted at the community level to become a desirable social norm.

Molecular diagnosis of lymphogranuloma venereum in patients with genital ulcer disease.

The detection of herpes, chancroid, and syphilis in genital ulcers is done by PCR. This is not so for lymphogranuloma venereum (LGV). We report on the use of a PCR with digestion that differentiates the LGV biovar from the trachoma biovar. Our findings suggest that the clinical description of LGV in current textbooks is incomplete.

Association between HIV-1 infection, the etiology of genital ulcer disease, and response to syndromic management.

BACKGROUND: Reports on the effect of HIV-1 infection on healing rates of ulcers are conflicting. GOAL: The goal was to determine the etiology and response to treatment of genital ulcer disease (GUD) in relation to HIV-1 infection. STUDY DESIGN: This was a cohort study of patients with GUD treated with local syndromic management protocols. RESULTS: Among the 587 recruited, the prevalences of infections due to HSV, Treponema pallidum, Chlamydia trachomatis (lymphogranuloma venereum [LGV]), Haemophilus ducreyi, Calymmatobacterium granulomatis, and HIV-1 were 48%, 14%, 11%, 10%, 1%, and 75%, respectively. The prevalence T. pallidum of was higher among men (P = 0.03), and an association was seen among HIV-1-seronegatives on univariate and multivariate analyses (P < 0.001; = 0.01). The prevalence of C trachomatis (LGV) was higher among females (P = 0.004), and an association was seen among HIV-1-seropositives on univariate analysis (P = 0.04). At follow-up, 40/407 (10%) showed a decreased healing tendency, not associated with ulcer etiology or HIV-1 seropositivity. CONCLUSION: Response to syndromic management of GUD was acceptable and not associated with HIV-1 coinfection.