Genital ulcer disease in India:  etiologies and performance of current syndrome guidelines.
BACKGROUND
In India, genital ulcer disease (GUD) syndrome is clinically classified as herpetic or nonherpetic and managed accordingly; laboratory support is unavailable at most health facilities. We undertook a study to determine the etiology of GUDs in men presenting to sexually transmitted infection (STI) clinics and assess the performance of the national algorithm for syndromic management of herpetic and nonherpetic GUDs in India.


METHODS
A cross-sectional study was conducted among men with complaints of genital ulcers attending 8 STI clinics in 4 states. Ulcer swabs were collected and tested by the multiplex polymerase chain reaction method to determine the etiology of GUD.


RESULTS
Of the 194 men recruited, etiology was confirmed in 121 GUD cases (62%). Herpes simplex virus (48%) was the most common etiological agent identified, followed by Treponema pallidum (23%) and mixed infections (9%). One case of Haemophilus ducreyi was confirmed in this series. The overall sensitivity and specificity of the national syndromic management algorithm for GUD were 68% and 52%, respectively. Using the national algorithm, 52 (42%) cases clinically misclassified as either herpetic (18 cases) or nonherpetic (34 cases) GUD resulting in incorrect treatment.


CONCLUSIONS
Our findings suggest a revision of existing national STI treatment guidelines in India to include treatment of syphilis infections of all GUD patients. Periodic studies are required to monitor changing spectrum of GUD etiologies in India.
India HIV AIDS Alliance, Hyderabad, India. parimiprabhakar@gmail.com
Parimi
P
Prabhakar
Prakash
P
Narayanan
Gururaj Rao
GR
Deshpande
Anjana
A
Das
Graham
G
Neilsen
Sanjay
S
Mehendale
Arun
A
Risbud
D000328:Adult; D000465:Algorithms; D002601:Chancre / Q000188:drug therapy / Q000382:microbiology; D003430:Cross-Sectional Studies; D005260:Female; D005832:Genital Diseases, Male / Q000188:drug therapy / Q000209:etiology*; D019983:Guideline Adherence; D006561:Herpes Simplex / Q000188:drug therapy / Q000209:etiology*; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D018139:Simplexvirus / Q000302:isolation & purification*; D013577:Syndrome; D014210:Treponema pallidum / Q000302:isolation & purification*; D014456:Ulcer / Q000209:etiology* / Q000382:microbiology / Q000821:virology