About three in 10 men and women taking part in a prospective longitudinal study in rural Uganda reported having had genital ulcers, according to data from more than 500 participants.¹ Those infected with HIV were substantially more likely than other individuals to have had genital ulcers; in the subgroup with HIV infection, men were significantly more likely than women to report the condition. Among participants with genital ulcers, nearly four out of 10 said that they had engaged in sexual activity while symptomatic, but few said that they had told their partner about their condition.

Genital ulceration has been shown to promote HIV transmission. Because of the high levels of genital ulcer disease seen in some parts of Sub-Saharan Africa (mainly genital herpes, chancroid and syphilis), such infections are thought to play an important role in sustaining the HIV epidemic there. Although the syndromic treatment of sexually transmitted infections (STIs) may help limit the transmission of many infections in settings where laboratory testing is unavailable, guidelines for syndromic management (when they call only for treatment with antibiotics) may not be effective in reducing the spread of genital ulcer disease in a community if a viral infection like herpes causes a particularly important share of the cases.

To examine the levels of genital ulceration, the role of herpes, and the relationships between genital ulcers, HIV infection and sexual activity, researchers conducted a follow-up cohort study in a subsample of participants from a long-term, population-based study of HIV prevalence in rural Uganda. Individuals identified in the original study as HIV-positive and a similar number of HIV-negative controls were invited to join the cohort. Once they were enrolled, participants were asked about their medical and sexual history and received a physical examination at the study clinic.

Each participant was visited at home every three months to set up a follow-up appointment at the clinic; more than 90% of participants who were still in the study area adhered to the quarterly schedule. Every time study participants visited, the clinician asked if they had noticed a genital ulcer or genital herpes in the previous three months. Those who said that they had were asked for more information about their symptoms, any treatment they had sought and how many sexual partners they had had.

The analyses were based on data from the period 1991-1999. Over that time, the 257 HIV-positive individuals and 268 participants not infected with HIV at admission to the study had made a total of 7,856 routine visits, and at nearly all of these visits (7,834) the clinician had obtained information on experience with genital ulceration over the previous three months.

Thirty percent of the 525 study participants reported genital ulceration at some time during the entire follow-up period--41% of those infected with HIV and 20% of those not infected. Likewise, the rate of genital ulceration differed substantially according to HIV status: Participants infected with HIV reported 26 episodes of genital ulcers per 100 person-years, compared with seven per 100 among those not infected. Men also had a greater tendency to report symptoms than did women, but this was significant only among participants infected with HIV (34 vs. 19 per 100 person-years).

A multivariate analysis showed that the risk of having genital ulcers at a particular clinic visit was significantly elevated among participants who were HIV-positive (odds ratio, 3.5), who had AIDS (2.2), who were male (1.5) or who had reported a genital ulcer at the previous three-month visit (2.0). Neither age nor having had more than one sexual partner was associated with a higher risk of experiencing genital ulceration.

It was not until 1992 that study participants who reported genital ulcers in the previous three months were asked routinely about whether they had had sex while having STI symptoms; thus, the researchers had such data for 312 of the 340 visits at which participants reported genital ulceration. In all, 38% of these participants (43% of men and 30% of women) said that they had had sexual intercourse while symptomatic during the preceding three months. Of the 111 individuals with genital ulcers who said they had had sex while symptomatic in the preceding three months and reported on whether they had informed their sexual partner about their status, only 16% reported having done so (15% of men and 19% of women). The investigators noted that this proportion did not change over the eight-year study period.

Only 12% of participants who reported genital ulceration sought treatment, even though visits were free and a clinician was available. Logistic regression indicated that neither age, gender, HIV status, clinical stage, number of partners nor previous report of genital ulceration predicted whether a person sought treatment.

The authors of the study suggest that the "disappointing" level of treatment reported by the participants could be related to the possibility that "those with recurrent genital herpes may have attended with the problem previously, only to be disappointed with the results of the treatment." They comment that "ways of encouraging more individuals with genital ulcer disease to attend for treatment must be devised, and treatment guidelines should be revised to take into account the high prevalence of genital ulceration caused by herpes."

Overall, the researchers conclude that "the implications of these findings for HIV control are of great concern." They note that the study population "had been exposed constantly to repeated health education messages about the prevention of HIV," and that they had easy access to free services at the clinic. "If this population is representative of other rural areas in Africa," they conclude, "investing in STI treatment programs and [developing] suitable treatment algorithms, although desirable for reducing STIs, will have a disappointing impact on the transmission of HIV."--M. Klitsch

REFERENCE

1. Morgan D et al., Genital ulceration in rural Uganda: sexual activity, treatment-seeking behavior, and the implications for HIV control, Sexually Transmitted Diseases, 2001, 28(8):431-436.