Changes in the Etiology of Sexually Transmitted Diseases in Botswana between 1993 and 2002: Implications for the Clinical Management of Genital Ulcer Disease

Department of Medicine , University of Washington Seattle, Seattle, Washington, United States
Clinical Infectious Diseases (Impact Factor: 8.89). 12/2005; 41(9):1304-12. DOI: 10.1086/496979
Source: PubMed


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 diagnostic tests.
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 consideration when defining new guidelines for the syndromic management of genital ulcer disease.

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    • "Seroprevalence in women is up to twice as high as men, and increases with age [3] [6]. Although HSV-2 is the leading cause of genital ulcer disease (GUD) worldwide [7] [8], most people are unaware of having the infection [9]. HSV-2 transmission occurs through genital-genital contact during sexual activity. "
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    ABSTRACT: Herpes simplex virus type 2 (HSV-2) infects 530million people, is the leading cause of genital ulcer disease, and increases the risk of HIV-1 acquisition. Although several candidate vaccines have been promising in animal models, prophylactic and therapeutic vaccines have not been effective in clinical trials thus far. Negative results from the most recent prophylactic glycoprotein D2 subunit vaccine trial suggest that we must reevaluate our approach to HSV-2 vaccine development. We discuss HSV-2 pathogenesis, immunity, and vaccine efforts to date, as well as the current pipeline of candidate vaccines and design of trials to evaluate new vaccine constructs.
    Preview · Article · Sep 2013 · Vaccine
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    • "In Botswana, the Ministry of Health (MOH) reviews and updates its national syndromic management protocols based on periodic aetiological studies and other developments in healthcare.9–11 A study performed in 2002 that used highly sensitive diagnostic assays demonstrated a high prevalence of HIV among patients seeking care for STI-related complaints relative to a sentinel HIV prevalence of 38.6% among pregnant women in Botswana in 2001.12 "
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    ABSTRACT: In 2004, the Ministry of Health adopted revised protocols for the syndromic management of sexually transmitted infections (STI) that included routine HIV testing. A training programme for providers was developed on the revised protocols that featured interactive case studies and training videos. An objective of the first phase of the training programme was to test its effect on four measures of clinical practice: (1) routine HIV testing; (2) performance of physical examination; (3) risk-reduction counselling and (4) patient education. Clinical practice in a district where providers were trained was compared with a district without training. The measures of clinical practice were reported by 185 patients of providers who had been trained and compared with reports by 124 patients at comparison clinics. Relative to patients at comparison clinics, a higher percentage of patients of trainees reported that the provider: (1) offered an HIV test (87% versus 29%; p<0.001); (2) conducted a physical examination (98% versus 64%; p<0.001); (3) helped them to make a plan to avoid future STI acquisition (95% versus 76%; p<0.001) and (4) provided patient-specific information about HIV risk (65% versus 32%; p<0.001). Among patients offered HIV testing, the percentage who accepted did not differ between groups (38% of 161 patients of trainees versus 50% of 36 comparison patients; p = 0.260). Overall, 33% of patients of trainees and 14% of comparison patients were tested (p<0.001). A multifaceted training programme was associated with higher rates of HIV testing, physical examination, risk-reduction counselling and better HIV risk education.
    Full-text · Article · Feb 2008 · Sexually transmitted infections
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    • "The low level of serologically active syphilis confirms the low incidence of this previously common pathogen in west and central Africa, and is supported by the absence of detectable lesional T. pallidum in this study. We found a high proportion (45%) of 'unknown' GUD aetiologies, higher than in previous studies (25–35%)2324252627. This cannot be readily ascribed to the detection methods that were very sensitive and undertaken repeatedly. "
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    ABSTRACT: To investigate correlates of herpes simplex virus type 2 (HSV-2) DNA and HIV-1 RNA among women with genital ulcer disease (GUD). Baseline data from a randomized placebo-controlled trial of episodic herpes treatment in Ghana and the Central African Republic. GUD aetiology was determined by polymerase chain reaction (PCR) from a lesional swab. Real-time PCR was used to quantify HIV-1 RNA, and HSV-2 DNA in cervicovaginal lavages (CVL) and HIV-1 RNA in plasma. Genital infection was defined as the presence of virus in the lesion or CVL. Of 441 women enrolled, 79.0% were HSV-2 seropositive, 46.6% were HIV-1 seropositive, and 50.0% had an HSV-2 ulcer. Among 180 HSV-2/HIV-1 co-infected women, cervicovaginal HIV-1 RNA was detected more frequently in women with HSV-2 ulcers (67.9%) or cervicovaginal HSV-2 DNA only (72.3%) compared with women without genital HSV-2 infection (42.4%) (P = 0.004). Women with genital HSV-2 infection had higher median cervicovaginal HIV-1-RNA loads (3.14 log10 copies/mL versus 2.10 log10 copies/mL; P = 0.003), higher plasma HIV-1-RNA loads (median 5.10 versus 4.65 log10 copies/mL; P = 0.07), and lower median CD4 cell counts) (198 versus 409 cells/mm, P = 0.03). Cervicovaginal HIV-1 RNA and HSV-2 DNA were significantly correlated after adjusting for plasma HIV-1 RNA and CD4 cell counts (P < 0.001) and a 10-fold increase in cervicovaginal HSV-2 DNA was associated with a 1.7-fold increase in plasma HIV-1 RNA (P = 0.003). Genital HSV-2 infection is associated with increased cervicovaginal and plasma HIV-1 RNA among co-infected women with genital ulcers, independently of the level of immunodeficiency, highlighting the close interaction between these two viruses and the role of HSV-2 as a co-factor for the sexual transmission of HIV-1.
    Full-text · Article · Aug 2007 · AIDS
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