1304 • CID 2005:41 (1 November) • HIV/AIDS
H I V / A I D SM A J O R A R T I C L E
Changes in the Etiology of Sexually Transmitted
Diseases in Botswana between 1993 and 2002:
Implications for the Clinical Management
of Genital Ulcer Disease
Gabriela Paz-Bailey,1Mafiz Rahman,3Cheng Chen,1Ronald Ballard,1Howard J. Moffat,4Tom Kenyon,1
Peter H. Kilmarx,1,5Patricia A. Totten,2Sabina Astete,2Marie Claude Boily,6and Caroline Ryan1
1National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia;
Division of Infectious Diseases, University of Washington, Seattle;
Project, Gaborone, Botswana; and
2Department of Medicine,
4Princess Marina Hospital, and
3AIDS/STD Unit, Ministry of Health,
6Department of Infectious Diseases Epidemiology, Imperial College, London, United Kingdom
(See the editorial commentary by Schmid et al. on pages 1313–5)
In recent years, increasing evidence has accumulated that suggests the majority of cases of genital
ulcer disease in sub-Saharan Africa are due to viral and not bacterial infections. Although many cross-sectional
studies support such a trend, few serial cross-sectional data are available to show the evolution of genital ulcer
disease over time.
We surveyed the prevalence of sexually transmitted diseases (STDs) among patients with STD
symptoms and women recruited from family planning clinics in 3 cities in Botswana in 2002 and compared our
findings with those from a survey of a similar population conducted in 1993.
The observed proportion of cases of genital ulcer disease due to chancroid decreased from 25% in
1993 to 1% in 2002, whereas the proportion of ulcers due to herpes simplex virus increased from 23% in 1993
to 58% in 2002. Although the proportion of ulcers due to syphilis was similar for both surveys, the rate of positive
serologic test results for syphilis among patients with genital ulcer disease decreased from 52% in 1993 to 5% in
2002. During this period, decreases in the prevalence of gonorrhea, syphilis-reactive serologic findings, chlamydial
infection, and trichomoniasis were also detected among patients with STDs and women from family planning
clinics. These changes remained significant after estimates were adjusted for the sensitivity and specificity of
Our findings suggest a decrease in the prevalence of bacterial STDs and trichomoniasis, a
reduction in the proportion of ulcers due to bacterial causes, and an increase in the proportion of ulcers due to
herpes simplex virus during the period 1993–2002. These changes should be taken into considerationwhendefining
new guidelines for the syndromic management of genital ulcer disease.
Botswana has one of the highest prevalences of HIV
infection worldwide. In 1992, the prevalence of HIV
infection in antenatal clinics was 18% and reached37%
in 2003 . Severalstudieshaveinvestigatedriskfactors
for HIV infection among adults in sub-Saharan coun-
tries; the most important factors include risky sexual
Received 14 January 2005; accepted 30 May 2005; electronically published 4
Reprints or correspondence: Dr. Gabriela Paz-Bailey, Global AIDS Program,
NCHSTP, CDC, Unit 3321, APO AA, Miami, Florida, 34024 (email@example.com).
Clinical Infectious Diseases2005;41:1304–12
? 2005 by the Infectious Diseases Society of America. All rights reserved.
behavior, the presence of sexually transmitted diseases
(STDs), and noncircumcision in males [2, 3].
Treatment of STDs has been advocated as an im-
portant component of preventionofHIVinfection,and
many countries have adopted a syndromic approach to
the treatment of STDs, using guidelines developed and
advocated by the World Health Organization (WHO).
However, the success of these programs will depend on
whether the treatment is appropriate for the syndrome
being observed and treated. There is evidence that the
HIV infection epidemic has changed STD epidemiol-
ogy, with the proportion of cases of genitalulcerdisease
(GUD) attributable to herpes simplex virus (HSV) type
2 increasing in countries with severe HIV infec-
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HIV/AIDS • CID 2005:41 (1 November) • 1305
tion epidemics . In South Africa, there was an increase in
the proportion of GUD due to HSV-2 from 17% in 1993 to
36% in 1998 . Similar findings have been observed in Dur-
ban, where the proportion of ulcers due to HSV-2 increased
from 11% in 1991  to 36% in 1994 , and to 48%  in
A study was conducted in 2002 to evaluate the national
algorithms for the management of STDs in Botswana. In this
article, we present the prevalences of STDs among male and
female patients with STDs and women from family planning
clinics and compare them to findings from a 1993 survey of a
This study comprises 2 surveys. The first one was conducted
in 1993 by the AIDS/STD Unit of the Ministry of Health (Bot-
swana, Gaborone) and the STD Research Unit, South African
Institute for Medical Research (Johannesburg, South Africa).
The second survey was conducted in 2002 by the Botswana
AIDS/STD Unit and the Centers for Disease Control and Pre-
vention (CDC; Atlanta, Georgia).
Consecutive patients with STDs and women
from family planning clinics were recruited for the study from
12 primary health care government clinics in the city of Ga-
borone. After consent was obtained, participants underwent
a physical examination and were treated for STDs in accor-
dance with syndromic management guidelines. Bloodsamples
and vaginal, cervical, and ulcer swab specimens and urethral
swab specimens (men only) were collected. Cervical and ure-
thral swab specimens were cultured for Neisseria gonorrhoeae
on modified New York City medium and for Chlamydia tra-
chomatis on cycloheximide-treated McCoy cells. Vaginal swab
specimens were cultured for Candida species on Saboraud
medium. Bacterial vaginosis was diagnosed on the basis of
Gram-stained smear findings . Wet mount and culture on
Diamond medium (examined daily for 7 days) was used to
detect Trichomonas vaginalis. HIV infection was diagnosed
with ELISA (Abbott Laboratories) and confirmed by Western
blotting (Immunoblot; Bio-Rad Laboratories). Syphilis was
diagnosed on the basis of rapid plasma reagin (Omega Di-
agnostics) and confirmed by Treponema pallidum haemagglu-
tination assay (Omega Diagnostics). Genital ulcer specimens
were cultured for Haemophilus ducreyi on both Mueller-Hin-
ton–based and gonococcal-agar–based media at 35?C in a
microaerophilic atmosphere. HSV was detected by culture
with human embryo lung fibroblast cells in roller tubes. After
inoculation, cultures were examined daily for up to 10 days
for cytopathic effect. Monolayers exhibiting cytopathic effect
were fixed, stained, and examined for syncytia formation and
intranuclear inclusion bodies. Ulcer specimenswereexamined
by darkfield microscopy for T. pallidum. Lymphogranuloma
venereum was diagnosed on the basis of C. trachomatis iso-
lation from cultures of ulcer specimens and an elevated titer
(?1:256) of broadly cross-reacting antibody detected by chla-
mydial microimmunofluorescence testing. The protocol was
approved by the ethics committee of the Botswana Ministry
The 2002 survey was conducted in the cities
of Gaborone, Selebi-Phikwe, and Francistown, Botswana, from
November 2001 to February 2002. Three clinics were selected
from each city: a primary health care clinic, a 24-h clinic, and
a private clinic. Consecutive patients with STDs and women
from family planning clinics were recruited. After providing
consent, participants completed a standardized questionnaire
and were examined and treated by a clinician. Urine, blood,
ulcer, and vaginalswabspecimenswerecollected.Patientscould
decline undergoing a test for detection of HIV and still par-
ticipate in the survey.
Serum samples were tested for syphilis by rapid plasma
reagin (Becton Dickinson) and confirmed by T. pallidum hae-
magglutination assay (Omega Diagnostics). HIV infection
status was determined by ELISA (Abbott Laboratories) and
confirmed by a second ELISA (Genelavia; Sanofi Diagnostics
Pasteur). Urine specimens were tested for N. gonorrhoeae and
C. trachomatis by ligase chain reaction (LCx; Abbott Labo-
ratories). As part of the clinical utility evaluation of a newly
developed assay, Mycoplasma genitalium was detected by a
research-use only transcription-mediated amplification assay
specific for M. genitalium rRNA, using the same assay format
used for the CT/NG Aptima Combo 2 assay (Gen-Probe), in
accordance with the manufacturer’s instructions. Bacterialva-
ginosis and yeast infection were diagnosed on the basis of
findings of Gram-stained smears of vaginal swab specimens.
A Nugent score of ?7 was considered to be positive for bac-
terial vaginosis, and the presence of budding yeast was con-
sidered to be indicative of yeast infection. A second vaginal
swab specimen was used for T. vaginalis culture using the In-
Pouch TV medium (Biomed Diagnostics), which was ex-
amined microscopically each day for a week. Blood and urine
samples and vaginal swab specimens were processed at the
National Reference Laboratory in Gaborone.
Ulcer specimens were tested by multiplex PCR for T. palli-
dum, H. ducreyi, HSV-1, and HSV-2 at the CDC Laboratory
in Atlanta,Georgia. TheconditionsunderwhichmultiplexPCR
amplification was performed were the same as those described
elsewhere , except that 5?-fluorescence labeled primers were
used. Primers were synthesized by the Biotechnology Core Fa-
cility at the CDC (Atlanta, GA). The study protocol was ap-
proved by the CDC Institutional Review Board and the Health
Research Development Committee of the Botswana Ministry
Data entry was performed with EpiInfo
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1312 • CID 2005:41 (1 November) • HIV/AIDS
genital ulcer disease in Lesotho: association with human immunode-
ficiency virus infection. J Infect Dis 1997;175:583–9.
33. Parsons LM, Waring AL, Otido J, Shayegani M. Laboratory diagnosis
of chancroid using species-specific primers from Haemophilus ducreyi
groEL and the polymerase chain reaction. Diagn Microbiol Infect Dis
34. Taylor-Robinson D, Jensen JS, Fehler G, Radebe F, Ballard RC. Ob-
servations on the microbiology of urethritis in black South African
men. Int J STD AIDS 2002;13:323–5.
35. Cohen CR, Manhart LE, Bukusi EA, et al. Association between My-
coplasma genitalium and acute endometritis. Lancet 2002;359:765–6.
36. Government of Botswana Central Statistics Office. 1992–2002 Health
statistics reports. Gaborone: Central Statistics Office, 2003.
37. Creek TL, Thuku H, Kolou B, Rahman M, Kilmarx PH. Declining
syphilis prevalence among pregnant women in northern Botswana: an
encouraging sign for the HIV epidemic? Sex Transm Dis 2005 (in
38. Tsegaye A, Rinke De Wit TF, Mekonnen Y, et al. Decline in prevalence
of HIV-1 infection and syphilis among young women attending an-
tenatal care clinics in Addis Ababa, Ethiopia: results from sentinel
surveillance, 1995–2001. J Acquir Immune Defic Syndr 2002;30:
39. Taha TE, DallabettaGA,HooverDR,etal.TrendsofHIV-1andsexually
transmitted diseases among pregnant and postpartumwomeninurban
Malawi. AIDS 1998;12:197–203.
40. Sombie I, Meda N, Cartoux M, et al. Seroprevalence of syphilis among
women attending urban antenatal clinics in Burkina Faso, 1995–8. Sex
Transm Infect 2000;76:314–6.
41. Temmerman M, Gichangi P, Fonck K, et al. Effect of a syphilis control
programme on pregnancy outcome in Nairobi, Kenya. Sex Transm
42. Nagot N, Meda N, Ouangre A, et al. Review of STI and HIV epide-
miological data from 1990 to 2001 in urban Burkina Faso:implications
for STI and HIV control. Sex Transm Infect 2004;80:124–9.
43. Korenromp EL, Bakker R, De Vlas SJ, Robinson NJ,HayesR,Habbema
JD. Can behaviour change explain increasesintheproportionofgenital
ulcers attributable to herpes in sub-Saharan Africa? A simulationmod-
elling study. Sex Transm Dis 2002;29:228–38.
44. Boily MC, Lowndes CM, Gregson S. Population-level risk factors for
HIV transmission and “the 4 Cities Study”: temporal dynamics and
the significance of sexual mixing patterns. AIDS 2002;16:2101–2.
45. Government of Botswana Central Statistics Office. 1988 Family health
survey. Gaborone: Central Statistics Office, 1989.
46. Government of Botswana Central Statistics Office and Family Health
International. Botswana AIDS Impact Survey (BAIS). Gaborone: Fam-
ily Health International, 2001.
47. Wald A, Link K. Risk of human immunodeficiency virus infection in
herpes simplex virus type 2–seropositive persons: a meta-analysis. J
Infect Dis 2002;185:45–52.
48. Kreiss JK, Coombs R, Plummer F, et al. Isolation of human immu-
nodeficiency virus from genital ulcers in Nairobi prostitutes. J Infect
49. Gadkari DA, Quinn TC, Gangakhedkar RR, etal. HIV-1DNAshedding
in genital ulcers and its associated risk factors in Pune, India. J Acquir
Immune Defic Syndr Hum Retrovirol 1998;18:277–81.
50. Schacker T, Ryncarz AJ, Goddard J, Diem K, Shaughnessy M, Corey
L. Frequent recovery of HIV-1 from genitalherpessimplexviruslesions
in HIV-1-infected men. JAMA 1998;280:61–6.
51. WHO. Guidelines for the management of sexually transmitted infec-
tions; revised version 2003. WHO document WHO/RH/01.10.2003.
Geneva: World Health Organization, 2003.
by guest on December 27, 2015