Etiology of genital ulcer disease and association with HIV infection in Malawi.
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.
From the *Lighthouse Centre, Lilongwe, Malawi; †University of North Carolina, Chapel Hill, NC; ‡Infectious Disease Epidemiology Unit, London School of Hygiene & Tropical Medicine, London, UK; §University of North Carolina Project, Lilongwe, Malawi; §Centres for Disease Control and Prevention, Atlanta, GA; and ¶Clinical Research Unit, London School of Hygiene & Tropical Medicine, London, UK.
Sam
S
Phiri
Sabrina
S
Zadrozny
Helen A
HA
Weiss
Francis
F
Martinson
Naomi
N
Nyirenda
Cheng-Yen
CY
Chen
William C
WC
Miller
Myron S
MS
Cohen
Philippe
P
Mayaud
Irving F
IF
Hoffman
D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis* / Q000453:epidemiology* / Q000276:immunology / Q000382:microbiology; D000328:Adult; D002602:Chancroid / Q000175:diagnosis / Q000453:epidemiology; D003430:Cross-Sectional Studies; D037001:Directive Counseling; D004311:Double-Blind Method; D005260:Female; D005835:Genitalia / Q000382:microbiology* / Q000821:virology*; D006191:Haemophilus ducreyi / Q000302:isolation & purification; D006558:Herpes Genitalis / Q000175:diagnosis / Q000453:epidemiology; D018258:Herpesvirus 2, Human / Q000302:isolation & purification; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D015995:Prevalence; D040242:Risk Reduction Behavior; D018571:Sentinel Surveillance; D013587:Syphilis / Q000175:diagnosis / Q000453:epidemiology; D014456:Ulcer / Q000175:diagnosis* / Q000453:epidemiology* / Q000382:microbiology / Q000821:virology