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This study aimed to identify patients with high-probability of ocular involvement of Behçet's disease (BD).The Japanese Ministry of Health, Labour and Welfare provided dataset of ongoing nationwide BD registration project. A patient who had confirmed BD and who was suspected to have BD was registered. We mainly analyzed newly registered patients who had the data for all demographic and diagnostic parameters regardless of fulfilment of any diagnostic criteria.Among 3213 patients with confirmed or possible BD, 1382 (43.0%) were men and 1831 (57.0%) were women with a median age of 38 years (interquartile range (IQR) 30-49 years). The median duration between onset and registration was 0 year (IQR 0-3). A binomial multivariable logistic regression analysis revealed that being female (odds ratio (OR) 0.63, 95% confidence interval (CI) 0.53-0.75, p .001), duration since onset (OR 1.33 per 10 years, 95% CI 1.18-1.51, p .001), genital ulceration (OR 0.28, 95% CI 0.23-0.34, p .001), and gastrointestinal symptoms (OR 0.36, 95% CI 0.30-0.44, p .001) were related to the ocular lesion. Analyses based on data of 2800 patients who satisfied International criteria of BD, age-, sex-, duration-based subgroup analyses, analyses targeting iridocyclitis and retino-uveitis, and analysis including patients with missing data confirmed that the four factors were associated with the probability of eye involvement.The ocular involvement did not accompany with genital ulcer or gastrointestinal symptoms at the early stage of BD.

Objective This report aimed to scrutinize the prevalence of Behcet's disease (BD)-related clinical manifestations based on age- and sex-specific subgroups using a Japanese nationwide registration database. Methods The database of newly registered BD was obtained from the Japanese Ministry of Health, Labour and Welfare. Patients who met the International Criteria for Behcet's Disease were selected and analysed. Results Among 6627 International Criteria for Behcet's Disease cases, 2651 (40.0%) were men and 3976 (60.0%) were women with a median age of 39 years (interquartile range: 31-50 years). Ocular lesion was more common in male [odds ratio (male: female) 2.64 (95% CI: 2.35, 2.95, P < 0.001)] and genital ulceration was more common in female (odds ratio = 0.29, 95% CI: 0.25, 0.32, P < 0.001). Ocular lesion (P < 0.001), arthritis (P < 0.001) and vascular lesions (P < 0.001) were more frequently observed in elderly registered patients. Contrarily, genital ulceration (P < 0.001), epididymitis of males (P = 0.023) and oral ulceration (P = 0.003) were more common in younger patients. Simultaneous assessment of sex and age revealed that male predominance of ocular involvement was found in the young adult generation, but not in patients over 70 year of age. A female predominance of genital ulcer was prominently observed in patients 20-59 year of age; however, the sex difference was not found in patients over 60 years of age. Sensitivity analysis using International Study Group criteria replicated the results. Conclusion We showed that clinical phenotype in early phase of BD was different depending on onset age and sex.

Background Genital ulcers (GUs) remain a common reason that both men and women seek treatment at US sexual health clinics. Presumptive diagnosis based solely on the macroscopic lesion characteristics is insensitive for differentiating between the common etiologies of GUs, which include HSV1/2, VZV, and syphilis. Given the ongoing and rapidly-expanding Syphilis epidemic, more accurate and timely identification of GU etiology would facilitate accurate therapeutic decision making, promote antibiotic stewardship, and have positive impacts on public health. The current study describes diagnostic workflows that allow for sequential/reflex or parallel GU testing, relying on a combination of IVD and published NAAT-based solutions, performed on the cobas® 4800 and/or cobas® 6800 Systems, to detect HSV1/2, VZV, and T. pallidum from a single specimen. Methods Commercially available control material for HSV1, HSV2, VZV, and T. pallidum were spiked into MSwab™ and cobasâ PCR medium at varying concentrations. The spiked medium was either aliquoted directly to cobas® PCR Media Secondary Tubes (for testing on the cobasâ 6800 System) or MSwabs were dipped directly into the spiked specimen vials and transferred to their respective collection tubes (cobasâ 4800 System). GU testing on the cobas® 4800 System was sequential: performing the cobas® HSV1 and 2 Test first, followed by VZV and T. pallidum detection using residual DNA eluates and the User Defined Workflow (UDF) software. Testing on the cobas® 6800 System allowed for parallel processing and simultaneous detection of the 4 targets utilizing the cobas omni Utility Channel, which supports a complete, automated Lab Developed Test workflow. Results Qualitative detection of HSV1, HSV2, VZV and T. pallidum was demonstrated on both systems. Conclusion Novel solutions that aim to reduce empiric therapy, or shorten the interval to treatment success, are critical for both diagnostic and antibiotic stewardship. Through parallel or sequential testing algorithms, panel testing schematics on either the cobas® 4800 and 6800 Systems allow for more accurate discrimination between GU etiologies that may help address the re-emergence of Syphilis in the USA. Disclosures All authors: No reported disclosures.

Herpes simplex virus type 2 (HSV-2) is the most common cause of genital ulcer disease in the world, and sub-Saharan Africa bears a heavy burden of infections [1, 2]. Manifestations of HSV-2 infection range from asymptomatic or nonulcerative symptoms to periodic outbreaks of painful ulcers [3, 4]. There is a strong synergistic relationship between HSV-2 and human immunodeficiency virus type 1 (HIV-1), resulting in greater shedding and elevated infectiousness of both viruses [5–10]. HSV-2 can be managed with episodic antiviral medication (eg, acyclovir, valacyclovir, or famciclovir) to abort or reduce the duration of outbreaks or with daily suppressive treatment to prevent outbreaks and reduce asymptomatic viral shedding [11]. Although suppressive HSV-2 treatment reduces plasma HIV-1 viral load, a recent randomized trial failed to show a benefit of suppressive acyclovir therapy in reducing HIV-1 transmission [12]. However, daily suppressive therapy with valacyclovir decreases herpes transmission to sexual partners [13]. Prevention of new HSV-2 infections may be an effective HIV-1 prevention strategy, particularly among HIV-1-discordant couples in which either member of the couple is HSV-2 seronegative. While estimates vary due to population characteristics, 10%–25% of new HIV-1 infections in sub-Saharan Africa occur in HIV-1-discordant couples [14–17]. In this region, HSV-2 prevalence in one or both members of HIV-1-discordant couples is as high as 80% [18]. Yet there is limited knowledge about the timing and risk factors for HSV-2 acquisition in this high-risk population. Given the importance of HSV-2 in mediating HIV-1 transmission, we sought to better understand HSV-2 transmission in HIV-1-discordant couples by investigating its prevalence and incidence among stable HIV-1-discordant heterosexual couples in Nairobi, Kenya.

Background. The association between initiation of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection and possible herpes simplex virus type 2 (HSV-2) shedding and genital ulcer disease (GUD) has not been evaluated. Methods. GUD and vaginal HSV-2 shedding were evaluated among women coinfected with HIV and HSV-2 (n = 440 for GUD and n = 96 for HSV-2 shedding) who began ART while enrolled in a placebo-controlled trial of HSV-2 suppression with acyclovir in Rakai, Uganda. Monthly vaginal swabs were tested for HSV-2 shedding, using a real-time quantitative polymerase chain reaction assay. Prevalence risk ratios (PRRs) of GUD were estimated using log binomial regression. Random effects logistic regression was used to estimate odds ratios (ORs) of HSV-2 shedding. Results. Compared with pre-ART values, GUD prevalence increased significantly within the first 3 months after ART initiation (adjusted PRR, 1.94; 95% confidence interval [CI], 1.04–3.62) and returned to baseline after 6 months of ART (adjusted PRR, 0.80; 95% CI, .35–1.80). Detection of HSV-2 shedding was highest in the first 3 months after ART initiation (adjusted OR, 2.58; 95% CI, 1.48–4.49). HSV-2 shedding was significantly less common among women receiving acyclovir (adjusted OR, 0.13; 95% CI, .04–.41). Conclusions. The prevalence of HSV-2 shedding and GUD increased significantly after ART initiation, possibly because of immune reconstitution inflammatory syndrome. Acyclovir significantly reduced both GUD and HSV-2 shedding and should be considered to mitigate these effects following ART initiation.

In patients infected with human immunodeficiency virus (HIV), genital herpes can result in severe and atypical clinical presentations, and can become resistant to aciclovir treatment. Rarely, these manifestations may represent concurrent herpes simplex virus (HSV) with other agents. We report a 41-year-old black woman with HIV who presented with extensive and painful ulceration of the genitalia. Histological examination of a biopsy sample was suggestive of herpetic infection, and intravenous aciclovir was started, but produced only partial improvement. PCR was performed on the biopsy sample, and both HSV and cytomegalovirus (CMV) DNA was detected. Oral valganciclovir was started with therapeutic success. CMV infection is common in patients infected with HIV, but its presence in mucocutaneous lesions is rarely reported. This case exemplifies the difficulties of diagnosis of genital ulcers in patients infected with HIV. The presence of exuberant and persistent HSV genital ulcers in patients with HIV should also raise suspicions of the presence of co-infection with other organisms such as CMV.

Acyclovir suppressive therapy (400 mg twice daily) reduces herpes simplex virus (HSV) type 2-associated genital ulcer disease and lesional HSV shedding. In an international trial of acyclovir for suppression of HSV type 2 to prevent human immunodeficiency virus (HIV) acquisition (HIV Prevention Trials Network 039), acyclovir had a smaller effect on the frequency of genital ulcer disease as well as a smaller effect on the frequency and quantity of lesional HSV DNA in African women and Peruvian men, compared with its effects in men in the United States. The observed regional variation in the clinical and virologic efficacy of acyclovir for HSV suppression warrants further evaluation of determinants of responses to acyclovir. (ClinicalTrials.gov identifier: NCT00076232.).

Background. Genital ulcer disease (GUD) is commonly caused by pathogens for which suitable therapies exist, but clinical and laboratory diagnoses may be problematic. This collaborative project was undertaken to address the need for a rapid, economical, and sensitive approach to the detection and diagnosis of GUD using noninvasive techniques to sample genital ulcers. Methods. The genital ulcer disease multiplex polymerase chain reaction (GUMP) was developed as an inhouse nucleic acid amplification technique targeting serious causes of GUD, namely, herpes simplex viruses (HSVs), Haemophilus ducreyi, Treponema pallidum, and Klebsiella species. In addition, the GUMP assay included an endogenous internal control. Amplification products from GUMP were detected by enzyme linked amplicon hybridization assay (ELAHA). Results. GUMP-ELAHA was sensitive and specific in detecting a target microbe in 34.3% of specimens, including 1 detection of HSV-1, three detections of HSV-2, and 18 detections of T. pallidum .N oH. ducreyi has been detected in Australia since 1998, and none was detected here. No Calymmatobacterium (Klebsiella) granulomatis was detected in the study, but there were 3 detections during ongoing diagnostic use of GUMP-ELAHA in 2004 and 2005. The presence of C. granulomatis was confirmed by restriction enzyme digestion and nucleotide sequencing of the 16S rRNA gene for phylogenetic analysis. Conclusions. GUMP-ELAHA permitted comprehensive detection of common and rare causes of GUD and incorporated noninvasive sampling techniques. Data obtained by using GUMP-ELAHA will aid specific treatment of GUD and better define the prevalence of each microbe among at-risk populations with a view to the eradication of chancroid and donovanosis in Australia. Genital ulcer disease (GUD) is commonly caused by pathogens against which suitable therapies exist but for which clinical and laboratory diagnoses may be problematic. The 3 most common etiological agents of genital lesions are the herpes simplex viruses (HSVs), Treponema pallidum subspecies pallidum (a gram-negative

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

We examined the association between host factors present near the time of human immunodeficiency virus type 1 (HIV-1) acquisition and subsequent virus loads in a prospective cohort study of women in Mombasa Kenya. Women were prospectively followed monthly before HIV-1 infection. One hundred sixty-one commercial sex workers who became infected with HIV-1 were followed for a median of 34 months and 991 plasma samples collected =4 months after infection were tested for HIV-1 RNA. The median virus set point at 4 months after infection was 4.46 log/10 copies/mL and the average virus load increase during subsequent follow-up was 0.0094 log/10 copies/mL/month. In a multivariate analysis that controlled for sexual behavior the use of the injectable contraceptive depot medroxyprogesterone acetate (DMPA) at the time of HIV-1 infection was associated with a higher virus set point and the presence of genital ulcer disease (GUD) during the early phase of HIV-1 infection was associated with greater change in virus load during follow-up. These findings suggest that in women the use of DMPA and the presence of GUD during the early phase of HIV- 1 infection may influence the natural course of infection. (authors)

To assess the timing of symptomatic genital ulcer disease (GUD) relative to human immunodeficiency virus (HIV) seroconversion, we studied 248 case subjects who underwent HIV seroconversion and 496 HIV-negative control subjects, at 3 interview visits conducted at 10-month intervals: visit 1, before HIV acquisition; visit 2, after seroconversion; and visit 3, 10 months after detection of seroconversion. Odds ratios (ORs) and 95% confidence intervals (CIs), for HIV acquisition, were estimated by logistic regression. HIV load was measured by RNA-polymerase chain reaction, and herpes simplex virus type 2 (HSV-2) serologic testing used HerpeSelect EIA with Western blot confirmation. The OR of HSV-2 seropositivity associated with HIV acquisition was 1.7 (95% CI, 1.2-2.4). Prevalence of GUD was increased among case subjects, at visits 2 (OR, 3.2; 95% CI, 1.9-5.3) and 3 (OR, 2.1; 95% CI, 1.1-3.9). HIV load was increased in HSV-2-seropositive case subjects, compared with that in HSV-2-seronegative subjects, at 5 (P=.04) and 15 (P=.02) months after seroconversion. HIV acquisition is associated with HSV-2 seropositivity, and GUD is increased after seroconversion. HIV load is increased in HSV-2-positive subjects who seroconverted, suggesting a role for treatment of HSV-2 infection in HSV-2-seropositive, dually infected individuals.

The private sector plays a major role in the delivery of health care in South Africa. Over the past two decades, the quality and equity of such provision has been questioned internationally. A study was conducted in Gauteng Province to explore these issues, using care for sexually transmitted disease (STD) as a case study. Private general practitioners (GPs) were interviewed by telephone. Each was presented with a set of STD syndromes and requested to describe how s/he would manage the patient, first if the patient was insured, then secondly if the patient was paying cash (uninsured). Reported prescriptions were costed and assessed for effectiveness against main causative pathogens using local standard clinical guidelines. Knowledge of recent developments in STD syndromic management and effectiveness of prescribed drugs was poor, especially for genital ulcer and pelvic inflammatory disease, and less than half the prescriptions overall were judged as effective. Although the effectiveness of prescriptions for insured and uninsured patients were similar, for most syndromes uninsured patients were offered significantly cheaper and less convenient antibiotic regimens. Effective regimens were also significantly more expensive than ineffective regimens. The results suggest that GPs' perceptions of patients' willingness or ability to pay for drugs have a bearing on quality of care. The paper concludes that STD patients who present to GPs are often offered poor quality of care, and the choice of inconvenient antibiotics impacts disproportionately on the poor. Improvements in the quality and equity of GP care will require interventions that address the factors that determine their behaviour.

A molecular-based subtyping system for Treponema pallidum was used during an investigation of increasing syphilis in Maricopa County, Arizona. Genital ulcer or whole blood specimens from patients with syphilis were assayed by a polymerase chain reaction (PCR) amplification of a T. pallidum DNA polymerase I gene. Positive specimens were typed on the basis of PCR amplification of 2 variable genes. In all, 41 (93%) of 44 of ulcer specimens and 4 (27%) of 15 blood specimens yielded typeable T. pallidum DNA. Twenty-four (53%) of 45 specimens were subtype 14f; other subtypes identified included 4f, 4i, 5f, 12a, 12f, 14a, 14d, 14e, and 14i. Only 2 specimens were from epidemiologically linked patients. This investigation demonstrates that multiple subtypes of T. pallidum can be found in an area with high syphilis morbidity, although 1 subtype (14f) was predominant. Four typeable specimens were from blood, a newly identified specimen source for subtyping.

Stored sera from a cohort of 2397 male factory workers in Harare, Zimbabwe, were screened for herpes simplex virus type 2 (HSV-2)-specific antibodies, to estimate the prevalence and incidence of genital herpes infection and to assess the relation between HSV-2 and human immunodeficiency virus (HIV) acquisition. The prevalence of HSV-2 at enrollment was 39.8%. Correlates of HSV-2 seropositivity were HIV seropositivity, marital status, history of sexually transmitted disease (STD), older age, and higher income. The incidence of HSV-2 seroconversion during follow-up was 6.2/100 person-years. Correlates of HSV-2 seroconversion were enrollment while HIV-positive or seroconversion during follow-up, reported genital ulcer, history of STD, and number of sex partners. No evidence was found that HSV-2 infection was more likely to precede HIV or vice versa. HSV-2 and HIV seropositivity are strong markers for high-risk sexual behavior. Improved interventions targeted to populations in which the incidence of either viral infection is high are needed.

To examine associations between method of contraception, sexually transmitted diseases (STDs), and incident human immunodeficiency virus type 1 (HIV-1) infection, a prospective observational cohort study was done among female sex workers attending a municipal STD clinic in Mombasa, Kenya. Demographic and behavioral factors significantly associated with HIV-1 infection included type of workplace, condom use, and parity. In multivariate models, vulvitis, genital ulcer disease, vaginal discharge, and Candida vaginitis were significantly associated with HIV-1 seroconversion. Women who used depo medroxyprogesterone acetate (DMPA) had an increased incidence of HIV-1 infection (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.4-3.4). In a multivariate model controlling for demographic and exposure variables and biologic covariates, the adjusted HR for HIV-1 infection among DMPA users was 2.0 (CI, 1.3-3.1). There was a trend for an association between use of high-dose oral contraceptive pills and HIV-1 acquisition (HR, 2.6; CI, 0.8-8.5).

A multiplex polymerase chain reaction (M-PCR) assay that simultaneously detects the three major causes of genital ulcer disease (GUD), Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus, was used to evaluate swab specimens for 38 sequential patients with GUD at a Thai sexually transmitted disease clinic. Subjects received clinical diagnoses and syndromic treatment. Swab specimens for H. ducreyi cultures and M-PCR were obtained. No H. ducreyi cultures were positive. Of 38 M-PCR specimens, 31 (81.6%) were positive for HSV, 1 (2.3%) for both HSV and T. pallidum, and none for H. ducreyi or T. pallidum alone; 6 (15.8%) were negative for all 3 pathogens. Clinical diagnoses corresponded poorly to M-PCR findings; none of 5 suspected cases of chancroid were positive by M-PCR and none of 1 for syphilis, but 21 of 24 suspected herpes lesions were confirmed by M-PCR. Human immunodeficiency virus infection status was known for 24 of 38 subjects; 11 (45.8%) were seropositive, and all 11 had HSV by M-PCR. HSV appeared to be the most common pathogen overall.

The performance of two EIAs (adsorption EIA and lipooligosaccharide [LOS] EIA) that detect antibodies to Haemophilus ducreyi was evaluated with serum specimens obtained from 163 patients (96 with genital ulcer disease [GUD]). Paired serum specimens (initial and follow-up) were obtained from 52 of the GUD patients. By use of initial serum specimens from 82 GUD patients whose etiologic agents for their ulcers had been identified, the adsorption EIA had a sensitivity and specificity for chancroid of 53% and 71%, while the LOS EIA had a sensitivity and specificity of 48% and 89%, respectively. Sensitivity and specificity of the adsorption EIA increased to 78% and 84%, respectively, when the results of follow-up serum specimens were used to calculate optimal performance. The proportion of patients testing positive for H. ducreyi who had anti-H. ducreyi IgG antibodies, as determined by adsorption EIA, increased with the duration of infection, thus limiting the role of EIAs in the diagnosis of chancroid.

The factors responsible for the explosive spread of human immunodeficiency virus type 1 (HIV-1) in sub-Saharan Africa continue to be identified and debated. One of the most controversial factors has been male circumcision. This cross-sectional study was conducted to measure the association between circumcision status and infection with HIV-1 among men with genital ulcer disease. Eight hundred and ten men participated in the study, of whom 190 (23%) were HIV-1-positive. A logistic regression model adjusted for behavioral and historical showed that HIV-1 positivity was independently associated with being uncircumcised (adjusted odds ratio [OR], 4.8; 95% confidence interval [CI], 3.3-7.2) and with a history of urethral discharge (adjusted OR, 2.0; 95% CI, 1.4-2.8). This association could not be explained by measures of sexual exposure to HIV-1 among this population. Male circumcision should be considered as an intervention strategy for AIDS control.

Epidemiologic, clinical, and microbiologic data were collected from 299 men with nonsyphilitic genital ulcer disease. One hundred eighteen (39%) were culture-positive for Haemophilus ducreyi, 57 (19%) were culture-positive for herpes simplex virus, and 124 (41%) were culture-negative. Patients with chancroid were significantly more likely than those with genital herpes to have been frequent users of alcohol (44% vs. 23%, P = .006). They were also more likely recently to have used cocaine (25% vs. 9%, P = .013), had sex with a prostitute (17% vs. 5%, P = .035), traded drugs for sex (16% vs. 2%, P = .005), and had a sex partner who used drugs (38% vs. 13%, P = .001). Culture-negative patients were similar to chancroid patients with respect to most epidemiologic risk factors. Despite the epidemiologic similarities, the clinical features of culture-negative ulcers resembled those of culture-proven herpes ulcers more closely than they did those of culture-proven chancroid ulcers. These data establish a link between chancroid in the United States and the use of crack cocaine.

Men with genital ulcer disease (GUD) attending a clinic in Malawi were evaluated and treated with one of five drug regimens. Hemophilus ducreyi was isolated from 204 (26.2%) of 778 patients. Of 677 men 198 (29.2%) had treponemes detected in ulcer material by direct immunofluorescence or had rapid plasma reagin reactivity of > or = 1:8. Human immunodeficiency virus type 1 (HIV-1) seroprevalence was 58.9% overall and 75.8% among patients reporting a history of GUD (p < 0.001). By logistic regression analysis HIV-1 seropositivity was shown to impair ulcer healing (p = 0.003). Treatment failure rates for culture-proven chancroid were 19% for trimethoprim-sulfamethoxazole 12.9% and 7.4% respectively for low- and high-dose erythromycin regimens and 8.3% and 0 respectively for low- and high-dose ciprofloxacin regimens. Herpes antigen was detected by EIA in 6 (23.1%) of 26 nonhealing ulcers. In Malawi GUD should be managed as a syndrome to assure treatment of both syphilis and chancroid. (authors)

As part of a comprehensive human immunodeficiency virus (HIV) prevention strategy targeting high-risk groups, sexually transmitted infection (STI) clinics are offered to all prisoners in Thyolo district, southern Malawi. Prison inmates are not, however, allowed access to condoms as it is felt that such an intervention might encourage homosexuality which is illegal in Malawi. A study was conducted between January 2000 and December 2001 in order to determine the prevalence, incidence, and patterns of STIs among male inmates of 2 prisons in this rural district. A total of 4229 inmates were entered into the study during a 2-year period. Of these, 178 (4.2%) were diagnosed with an STI. This included 83 (46%) inmates with urethral discharge, 60 (34%) with genital ulcer disease (GUD), and 35 (20%) inmates with epididymo-orchitis. Fifty (28%) STIs were considered incident cases acquired within the prisons (incidence risk 12 cases/1000 inmates/year). GUD was the most common STI in this group comprising 52% of all STI. This study shows that a considerable proportion of STIs among inmates are acquired within prison. In a setting of same-sex inmates, this suggests inter-prisoner same-sex sexual activity. The findings have implications for HIV transmission and might help in developing more rational policies on STI control and condom access within Malawi prisons.

A cross-sectional study of women attending a sexually transmitted diseases clinic in Nairobi Kenya was undertaken to determine the prevalence of and associated risk factors for HIV-1 infection. HIV-1 antibody was found in 13.8% of 600 women studied most frequently in prostitutes in women reporting histories of genital ulcers and in those with current diagnoses of genital ulcers. The high prevalence of HIV-1 infection was not confined among those identifying themselves as prostitutes. Seropositive women exhibited a significantly greater lifetime duration of oral contraceptive use. Through multivariate analysis the study found an association between genital ulcers and HIV-1 infection. No causal relationship between the 2 may however by deduced from this study. The strongest association for HIV-1 infection independent of sexual behavior was where genital ulcers combined with the use of oral contraceptives. Oral contraceptives may increase womens susceptibility to HIV-1 infection by increasing the area of cervical ectopy indirectly increasing the risk of C. trachomatis and/or by suppressing the immune system. While calculated attributable risks point to the strong role of prostitution and genital ulcer disease in facilitating heterosexual HIV-1 transmission in Nairobi prospective studies would help determine the risk of HIV-1 infection associated with the use of oral contraceptives.

A 16-year-old girl presented to the emergency department of a community hospital with an eight-day history of fever. On the first day of illness, she noted mild upper respiratory tract symptoms that resolved within 24 h. During the following five days, she felt generally well with the exception of nocturnal fevers. Three days before presentation, she developed a painful ulcer on her left labium majus. She had normal bowel movements until the day of presentation when she had one loose, nonbloody bowel movement. She had been taking acetaminophen for two to three days as well as a first-generation cephalosporin for seven days, which the family had purchased in India. The patient denied any recent or remote sexual activity. The family had immigrated from India three weeks before the onset of her illness. Her medical and family history were unremarkable. She denied any sexual activity. Physical examination revealed a well-appearing adolescent with a temperature of 39.5°C as well as a single circular 2 cm × 2 cm white-topped ulcer on her left labium majus. The external genitalia were otherwise normal. The rest of a complete examination was unremarkable. Investigations in the emergency department included a normal complete blood count, negative malarial smear and mild trans-aminitis with an aspartate aminotransferase level of 105 U/L and an alanine aminotransferase level of 117 U/L. Herpes simplex virus and bacterial studies were performed on a swab of the lesion. A rapid plasma reagin test was performed to screen for syphilis, and blood cultures were drawn. She was discharged home with a plan for outpatient follow-up. Further investigation revealed the diagnosis.

review, but most reports are of questionable value because the diagnosis was not confirmed by isolation of the etiologic agent, Haemophilus ducreyi, from the genital ulcer and/or its associated inguinal bubo. Diagnosing chancroid by history and physical examination alone is extremely difficult; even a trained venereologist may be erroneous 40% of the time [1]. Chancroid may be too frequently diagnosed in cases of secondarily infected