Genital ulcer disease in men in Durban, South Africa.

OBJECTIVE--To study the microbial aetiology of genital ulcer disease (GUD) in men. DESIGN--Microbiological and clinical assessment of genital ulcers in men. SETTING--City Health sexually transmitted diseases clinic, King Edward VIII Hospital, Durban, South Africa. PARTICIPANTS--100 Zulu men with genital ulcers who had not received antibiotics in the previous four weeks. RESULTS--Syphilis was diagnosed in 42%, chancroid in 22%, donovanosis (granuloma inguinale) in 11%, genital herpes in 10% and lymphogranuloma venereum (LGV) in 6%. No pathogens were identified in 24%. Mixed infections were detected in 14 men, in whom 13 had syphilis. Five men had HIV-1 antibodies. Neisseria gonorrhoeae was isolated from the ulcers and urethra in seven men and from the urethra alone in five. Scabies was diagnosed clinically in eight. CONCLUSIONS--All the major causes of GUD are prevalent in Zulu men in Durban. Primary syphilis was the commonest and was invariably present in mixed infections. Donovanosis was under-reported and was associated with a long delay before presentation. In this population, genital ulcers other than superficial lesions should be treated with anti-syphilitic therapy and oral antibiotics effective against chancroid and donovanosis.     

Genital ulcer disease: accuracy of clinical diagnosis and strategies to improve control in Durban, South Africa.

OBJECTIVE--To investigate the accuracy of clinical diagnosis in genital ulcer disease (GUD); to devise management strategies for improving the control of GUD and thereby limit the spread of HIV-1 infection. DESIGN--Clinical and microbiological assessment of GUD in men and women. The index of suspicion, diagnostic accuracy, diagnostic efficiency and positive and negative predictive values of a clinical diagnosis were investigated. SETTING--City Health Sexually Transmitted Diseases Clinic, King Edward VIII Hospital, Durban, South Africa. PARTICIPANTS--100 men and 100 women with genital ulcers. RESULTS--The accuracy of a clinical diagnosis was, in men: lymphogranuloma venereum (LGV) 66%, donovanosis 63%, chancroid 42%, genital herpes 39%, primary syphilis 32%, mixed infections 8%, and in women; secondary syphilis 94%, donovanosis 83%, genital herpes 60%, primary syphilis 58%, chancroid 57%, LGV 40%, mixed infections 14%. Overall, diagnostic efficiency was greater in women than in men. When compared with other causes of GUD, donovanosis ulcers bled to the touch and were larger and not usually associated with inguinal lymphadenopathy. In women, extensive vulval condylomata lata were readily differentiated from all other causes of GUD. CONCLUSION--A clinical diagnosis in genital ulceration was less accurate in men than in women. The diagnostic accuracies for donovanosis and secondary syphilis were relatively high but for most other conditions were low. Differences between clinical and laboratory diagnostic accuracies may reflect similarities between the clinical appearances of the various causes of GUD, the presence of mixed infections, atypical ulceration due to longstanding disease, and insensitive laboratory tests. In this community all large ulcers should be treated empirically for syphilis and donovanosis. Uncircumcised men with GUD are an important HIV core or "superspreader" group locally, and prevention strategies should include counselling and health education in the light of the inaccuracy of clinical diagnosis found in this study. The development of rapid accurate tests for GUD is urgently required.     

Clinico-epidemiological study of donovanosis in Durban, South Africa.

OBJECTIVE: To describe the epidemiological and clinical features of donovanosis and their relevance to the possible coincident risk of HIV-1 transmission in patients attending an STD clinic. DESIGN: Assessment of patients with donovanosis diagnosed by the detection of Donovan bodies on tissue smears stained by the RapiDiff technique. SETTING: City Health STD Clinic, King Edward VIII Hospital, Durban, South Africa. PARTICIPANTS: One hundred and seventy one patients with donovanosis. RESULTS: Donovan bodies were detected in 171 (130 men, 41 women). Ulcers were present for longer than 28 days in 72 (55.4%) men and 19 (46.3%) women. Ninety five (55.6%) came from rural areas. Lesions were ulcero-granulomatous in 162, hypertrophic in eight and necrotic in one. Anal lesions were detected in one woman. Only one of 21 regular sexual partners examined was infected with donovanosis. Complete healing was observed in 41 (24%) who attended for follow up. Extensive lesions were sometimes observed in pregnant women. Serological tests for syphilis were positive in 40 (23.4%). HIV-1 antibodies were detected in 4/48 men and 0/15 women who underwent HIV testing. Donovanosis ulcers in three HIV-1 seropositive men were cured by standard antibiotic therapy. CONCLUSIONS: Delay in presentation, extensive areas of genital ulceration and lack of co-existent infection with donovanosis among sexual partners were notable features. Primary health care facilities in rural areas do not appear to be providing an adequate service for patients with donovanosis. HIV control programmes should consider specific measures aimed at eradicating donovanosis in areas where the condition is prevalent.     

Trends in reported cases of donovanosis in Durban, South Africa.

OBJECTIVE--To investigate recent trends in reported cases of donovanosis (granuloma inguinale) in Durban, South Africa. DESIGN--The annual reports of the Medical Officer of Health for Durban 1958-1988 were reviewed to identify cases of donovanosis, genital ulcer disease (GUD) and new patients with sexually transmitted diseases (STD). A rapid staining technique for the detection of Donovan bodies was introduced in 1988. SETTING--City Health STD Clinic, King Edward VIII Hospital, Durban. RESULTS--An initial peak was identified in men 1969-1974. A second peak was recorded in 1988 when reported cases of donovanosis (313) were the highest since records commenced. Both peaks were unrelated to either increases in the numbers of new attenders with STD or patients with GUD. CONCLUSION--The recent increase in donovanosis in Durban may reflect either a new epidemic or under-reporting of a disease previously diagnosed on clinical grounds. Improved control of donovanosis, a condition sometimes causing extensive GUD, and which has been implicated in HIV-1 transmission in local men, should be targeted in HIV control programmes.     

Antimicrobial susceptibility of Neisseria gonorrhoeae isolated in Durban, South Africa.

One hundred and forty clinical isolates of Neisseria gonorrhoeae were screened for production of penicillinase by the intralactam strip method and chromogenic cephalosporin test. Minimum inhibitory concentrations (MICs) of penicillin, ampicillin, tetracycline, cefoxitin, cefuroxime, cefotaxime, sulphamethoxazole-trimethoprim (ratio 19/1), and spectinomycin, were measured for 100 strains by the agar dilution method. Seven (5%) of the 140 isolates were identified as penicillinase producing N gonorrhoeae (PPNG). The MICs of penicillin for the seven PPNG strains ranged from 0 X 25 mg/1 to 2 mg/1. Of the 93 non-PPNG strains, 80 (86%) were fully susceptible to penicillin with MICs ranging from 0 X 0037 mg/1 to 0 X 06 mg/1 and 13 (14%) were of intermediate penicillin resistance with MICs greater than or equal to 0 X 125 mg/1. Of the 100 isolates tested, 86% were fully susceptible to tetracycline with MICs of less than 1 mg/1. No spectinomycin resistant strains were encountered in this study. All gonococcal strains were susceptible to the cephalosporins tested as well as to sulphamethoxazole-trimethoprim.     

Antimicrobial susceptibility of Neisseria gonorrhoeae isolated in Durban, South Africa

One hundred and forty clinical isolates of Neisseria gonorrhoeae were screened for production of penicillinase by the intralactam strip method and chromogenic cephalosporin test. Minimum inhibitory concentrations (MICs) of penicillin, ampicillin, tetracycline, cefoxitin, cefuroxime, cefotaxime, sulphamethoxazole-trimethoprim (ratio 19/1), and spectinomycin, were measured for 100 strains by the agar dilution method. Seven (5%) of the 140 isolates were identified as penicillinase producing N gonorrhoeae (PPNG). The MICs of penicillin for the seven PPNG strains ranged from 0 X 25 mg/1 to 2 mg/1. Of the 93 non-PPNG strains, 80 (86%) were fully susceptible to penicillin with MICs ranging from 0 X 0037 mg/1 to 0 X 06 mg/1 and 13 (14%) were of intermediate penicillin resistance with MICs greater than or equal to 0 X 125 mg/1. Of the 100 isolates tested, 86% were fully susceptible to tetracycline with MICs of less than 1 mg/1. No spectinomycin resistant strains were encountered in this study. All gonococcal strains were susceptible to the cephalosporins tested as well as to sulphamethoxazole-trimethoprim.     

The microbial aetiology of genital ulcers in black men in Durban, South Africa.

The microbial aetiology of genital ulcers was assessed in 100 black men attending a sexually transmitted disease (STD) clinic in Durban, South Africa. Forty patients harboured Haemophilus ducreyi, one hepes simplex virus, and one Neisseria gonorrhoeae. Syphilis was diagnosed in 44 patients on the basis of dark field microscopy or positive syphilis serology test results, or both. Of these 44 patients, eight also harboured N ducreyi, one herpes simplex virus. Lymphogranuloma venereum was diagnosed in one patient. No cause of ulceration could be found in the remaining 16 patients.     

Urogenital tract infections in pregnancy at King Edward VIII Hospital, Durban, South Africa.

OBJECTIVES--To evaluate the role of detecting asymptomatic bacteriuria and endocervical infections in the black prenatal patients attending King Edward VIII Hospital (KEH), Durban, with the view of justifying a screening programme. Screening for syphilis and human immunodeficiency virus (HIV) infection were also evaluated. SUBJECTS--181 asymptomatic black prenatal patients attending the antenatal clinic for their first antenatal visit volunteered for the study and gave their written consent. DESIGN--Examination of each prenatal patient included obtaining of endocervical swabs to detect endocervical infections (C trachomatis, N gonorrhoeae), serum for syphilitic and HIV testing, and a midstream specimen of urine for microscopy and culture. RESULTS--Asymptomatic bacteriuria was found in 5.6% of patients in this study. Cervical infections were diagnosed microbiologically in 8.2% of women. These were N gonorrhoeae in 4.1% and C trachomatis in 4.7%. Serological tests for sexually transmitted diseases showed the presence of syphilis in 7.6% and antibody to the HIV in 1.9%. Overall, one or more sexually transmitted diseases were found in 16.5% of the women studied. CONCLUSIONS--This study suggests that all women presenting for routine antenatal care in a setting such as Durban should be screened for lower genital tract infections. Ideally this should include a midstream urine specimen for culture, serum for syphilitic and HIV antibody testing and endocervical swabs for sexually transmitted pathogens. In developing communities, however, more reliable and cheaper methods of endocervical screening need to be available before antenatal screening for cervico-vaginal infections can be justified.     

Tinea pedis et unguium in the Muslim community of Durban, South Africa

Background In a pilot study performed in eight mosques in the Durban area, it was found that the prevalence of tinea pedis et unguium in the adult Muslim male population regularly attending mosques was higher than in the nonMuslim male population. The aims of the present study were: (i) to determine the prevalence of tinea pedis et unguium in the adult Muslim male population regularly attending mosques; (ii) to investigate the role of mosque carpets and ablution areas in the spread of infection; and (iii) to develop strategies to combat the infection. Method Seventy-eight regular worshippers comprising adult Muslim males, chosen at random from five mosques in the Durban area, were examined for clinical evidence of tinea pedis et unguium. Skin scrapings and nail clippings were taken from clinically infected individuals and submitted for microscopy and culture for fungal organisms. A control group, comprising 72 nonMuslim adult male office workers from the administration departments of King Edward VIII Hospital, was similarly examined. In addition, scrapings from high traffic areas of the mosque carpets and swabs from the ablution areas were cultured for fungi. Results In the mosque group, it was found that the prevalence of tinea pedis et unguium was 85%, taking either microscopy or culture positivity as indicative of infection. In the control group, the prevalence was 41%. Thus a statistical difference of 44% (P < 0.0001) between the two groups was demonstrated. Dermatophytes and yeasts were isolated from the carpets and/or floors of the ablution areas in all the mosques under investigation. Conclusions The high prevalence of tinea pedis et unguium among regular male worshippers in the Muslim community can be attributed to the spread of fungal organisms in the communal ablution areas and prayer carpets of the mosques. Strategies to combat this spread of infection are being developed. These strategies are expected to find important practical applications in other communal environments, such as gymnasia, health spas, swimming pools, changing rooms of sports clubs, public showers, and even hotels.     

High-risk sexual behaviour in men attending a sexually transmitted infection clinic in Durban, South Africa

Objectives

A study of men with genital ulcer disease (GUD) in Durban, South Africa, at the start of the local HIV epidemic in 1988/1989 found that 36% of men with GUD continued with sexual intercourse despite symptoms. The aim of this study was to determine whether this high‐risk behaviour was still prevalent and to enquire about similar risk behaviours with other sexually transmitted infection (STI)‐related problems.

Methods

650 Men attending the main Durban STI clinic with a new complaint were enrolled. A standard questionnaire was administered. Polymerase chain reaction (PCR) tests were performed to diagnose genital herpes from ulcer specimens and gonorrhoea and chlamydia from those with urethral discharge and/or dysuria. Serology tests were performed for HIV, herpes simplex virus type 2 (HSV‐2) and syphilis.

Results

Sex since the start of symptoms was reported by between 33.3% and 43.9% of men with GUD, herpetic ulcers, gonorrhoea and/or chlamydia or dysuria. The incidence of condom use was very low in all groups having sex despite symptoms. In 87 men with genital ulcers confirmed positive for genital herpes by PCR testing, 30 (34.4%) had had sex since the start of symptoms, 28 (93.3%) of whom had had unprotected sex.

Conclusions

There is a high level of risk behaviour in this group of men in whom genital herpes is the most common cause of GUD. This risky sexual behaviour could reflect disinhibition, possibly because so many have already been infected with HSV‐2, lack of education or other unknown factors. Syndromic STI management should be strengthened with intensive health education to promote community awareness of both genital ulceration and genital herpes and their role in facilitating HIV transmission. The low level of condom use indicates that condom promotion programmes still have much to achieve.Very high rates of genital ulceration have been reported from countries worst affected by HIV.¹ The reasons for this are uncertain but could reflect low rates of male circumcision or some other behavioural factors not yet identified. At the start of the HIV epidemic in Durban, South Africa, a study of men and women with genital ulcer disease (GUD) in 1988/1989 found that 36% of men and 36% of women with GUD continued with sexual intercourse despite symptoms.² Syphilis and chancroid were the most common causes of GUD then, but subsequent studies have shown that the incidence of both these conditions has declined whereas genital herpes has increased significantly.^3,4 Moreover, in a systematic review and meta‐analysis, prevalent herpes simplex virus type 2 (HSV‐2) infection was associated with a threefold increased risk of HIV acquisition among men and women in the general population, suggesting that in areas of high HIV‐2 prevalence a high proportion of HIV is attributable to HSV‐2.⁵After the onset of the local HIV epidemic in the early 1990s in Durban, sexually transmitted infection (STI) treatment and care was decentralised so that primary care would deal with all but the most complicated or resistant STI cases. Although this strategy was expected to improve delays in treatment, it was uncertain whether staff in primary healthcare settings would be motivated to provide health education for the very high‐risk practices outlined above and to counsel patients diagnosed with genital herpes.The primary objectives of this study were to determine whether there were differences in the sociodemographic profile and sexual behaviour of men with and without genital ulcers and selected aspects of healthcare seeking and sexual behaviour in men with genital ulcers, genital herpes, gonorrhoea and/or chlamydia or dysuria.     

Human immunodeficiency virus infection and genital ulcer disease in South Africa: the herpetic connection

BACKGROUND AND OBJECTIVES: While genital ulcers are a risk factor in HIV infection, the association of specific agents of genital ulcer disease (GUD) with HIV infection may vary. GOAL: To determine the etiology of GUD in HIV-infected and HIV-uninfected men attending sexually transmitted disease (STD) clinics in Durban, Johannesburg, and Cape Town, South Africa, and the association of previous and current sexually transmitted infections with HIV infection in men with ulcerative and nonulcerative STDs. STUDY DESIGN: A cross-sectional study of 558 men with genital ulcers and 602 men with urethritis. RESULTS: Patients with GUD were more likely to be infected with HIV than patients with urethritis (39.4% versus 21.4%, P< or =0.001). Herpes simplex virus 2 (HSV-2) was the most common agent identified in ulcer specimens (35.9%), and was detected in a significantly higher proportion of ulcer specimens from HIV-infected patients than in specimens from HIV-uninfected patients (47.4% versus 28.2%, P< or =0.001). Patients infected with HIV-1 were significantly more likely to have HSV-2 infection, as measured by the presence of the antibody to glycoprotein G-2, than patients not infected with HIV (63.1% versus 38.5%, P< or =0.001). Patients infected with HIV-1 were also significantly more likely to have initial HSV-2 infection than HIV-uninfected patients with GUD (50.0% versus 31.6%, P = 0.007). Haemophilus ducreyi was detected in 31.7% of ulcer specimens; prevalence did not vary by HIV-infection status. Treponema pallidum DNA was detected significantly less frequently in ulcer specimens from patients infected with HIV than in specimens from patients not infected with HIV (10.2% versus 26%, P< or =0.001); no association was found between HIV-infection status and fluorescent treponemal antibody absorption test seroreactivity, even when men with M-PCR-positive syphilis lesions were excluded from the analyses. CONCLUSION: The authors found that HSV-2 is a more common etiology of GUD than has been suggested by previous studies conducted in South Africa; serologic evidence of HSV-2 infection and current cases of genital herpes are strongly associated with HIV infection among men who present to STD clinics with GUD or urethritis.     

Susceptibility of penicillinase-producing and non-penicillinase-producing strains of Neisseria gonorrhoeae isolated in Durban, South Africa, to 15 beta-lactam antibiotics

Using two different inoculum sizes (10(4) and 10(7) organisms), we tested 35 penicillinase-producing (PPNG) and 72 non-PPNG strains of Neisseria gonorrhoeae falling into three categories (penicillin-sensitive, intermediately resistant, and resistant) by the agar-dilution method against 15 beta-lactam antibiotics. With the exception of penicillin, ampicillin, amoxicillin, and cephradine, the isolates were uniformly sensitive to all the other antibiotics tested (including spectinomycin, tetracycline, rosoxacin, sulfamethoxazole-trimethoprim [19:1 ratio], and kanamycin). Ceftriaxone and cefotaxime were the two most active compounds tested; all strains were inhibited at concentrations of 0.007 and 0.015 microgram/ml, respectively. Isolates with intrinsic resistance to penicillin were less susceptible to cefoxitin and cefuroxime than were PPNG strains. The effect of inoculum size varied for the different antibiotics; penicillin and cefaclor showed this effect only with PPNG strains, whereas for ampicillin and amoxicillin it was also seen with non-PPNG strains. Cephamandole showed this effect with both penicillin-sensitive and PPNG strains. In view of the increasing resistance to penicillin, we would recommend that alternative drugs be used as first line therapy for gonorrhea in South Africa.     

Coexistence of urethritis with genital ulcer disease in South Africa: influence on provision of syndromic management

OBJECTIVE: To assess whether syndromic management of genital ulcer disease was sound, if based on the premise that men with genital ulcers rarely have a concomitant urethral infection. METHODS: Specimens were taken in 1998 from 186 mine workers in Carletonville, South Africa, who were seen consecutively with genital ulcers. The specimens comprised a swab from the ulcer, a urethral swab for a Gram stained smear, and 10-15 ml of a first catch urine sample. The latter was tested by ligase chain reaction assays for Neisseria gonorrhoeae and Chlamydia trachomatis specific DNA sequences and by a polymerase chain reaction (PCR) assay for Mycoplasma genitalium. Ulcer inducing micro-organisms were detected either by a multiplex PCR assay, or in the case of lymphogranuloma venereum (LGV) serologically, and human immunodeficiency virus (HIV) infection was detected by an enzyme linked immunosorbent assay (ELISA) test. RESULTS: Most (54%) of the ulcers were chancroidal, 18% were herpetic (HSV type 2), 6.5% primary syphilitic, and 3.2% due to LGV. More than one micro-organism was detected in 9.1% of the ulcers and less than 10% were undiagnosed. Microscopic examination of the urethral smears showed that 99 (53%) of the men had urethritis, of whom 45 (45%) were infected with N gonorrhoeae. Of the 54 men (55%) who had non-gonococcal urethritis (NGU), 11 (19.6%) harboured C trachomatis or M genitalium. Almost two thirds (64.5%) of the men had HIV infection, but this did not seem to have influenced the aetiology of the ulcers. Nor was a particular ulcer associated with one type of urethritis more than the other. Neither C trachomatis nor M genitalium was associated significantly with non-gonococcal urethritis (NGU) in either HIV positive or HIV negative men. CONCLUSION: The combination of antibiotics used for the management of genital ulcer disease in men in this South African mining population needs to be widened to encompass frequently occurring concomitant gonococcal urethritis and NGU infections. This means treatment with long acting penicillin, combined with ciprofloxacin and azithromycin or erythromycin. A similar situation may exist in other geographical locations with a need to provide appropriate antimicrobial combinations depending on the patterns of infection detected.     

Sexual behaviour in Zulu men and women with genital ulcer disease.

OBJECTIVE--To investigate patterns of sexual behaviour in men and women with genital ulcer disease (GUD) and their relevance to HIV-1 transmission. METHODS--A sexual behaviour questionnaire was administered by the same interviewer to all participants who were also entered into a study of the microbial aetiology of GUD. SETTING--City Health Sexually Transmitted Diseases Clinic, King Edward VIII Hospital, Durban, South Africa. PARTICIPANTS--100 Zulu men and 100 Zulu women. RESULTS--36 (%) of men and 36 (%) of women had continued with sexual intercourse despite GUD. Patients with donovanosis and secondary syphilis were more likely than those with other causes of GUD to have intercourse despite ulcers. During swab collection bleeding was observed from ulcers in 59 women and 26 men. Prostitutes were not identified and were rarely named as source contacts. Men had more sexual partners (190) than women (122) during the previous three months. Condom use was minimal. Men who migrated between urban and rural areas appeared to have the most sexual partners. Urban women had more partners than women from rural areas. CONCLUSIONS--Men and women with GUD are practising riskful sexual behaviour and could benefit from behaviour modification programmes. In this community men who travel between urban and rural areas and who present late with GUD that bleeds easily are probably the most important high-frequency HIV transmitter core group. A significant potential risk of blood to blood contact during sexual intercourse exists in patients with GUD.