Genital Herpes Simplex Virus Type 2 Shedding Among Adults With and Without HIV Infection in Uganda.

BACKGROUND: Despite the high prevalence of herpes simplex virus type 2 (HSV-2) in sub-Saharan Africa, the natural history of infection among Africans is not well characterized. We evaluated the frequency of genital HSV shedding in HIV-seropositive and HIV-seronegative men and women in Uganda. METHODS: Ninety-three HSV-2-seropositive Ugandan adults collected anogenital swab specimens for HSV DNA quantification by polymerase chain reaction 3 times daily for 6 weeks. RESULTS: HSV-2 was detected from 2484 of 11 283 swab specimens collected (22%), with a median quantity of 4.3 log10 HSV copies/mL (range, 2.2-8.9 log10 HSV copies/mL). Genital lesions were reported on 749 of 3875 days (19%), and subclinical HSV shedding was detected from 1480 of 9113 swab specimens (16%) collected on days without lesions. Men had higher rates of total HSV shedding (relative risk [RR], 2.0 [95% confidence interval {CI}, 1.3-2.9]; P < .001); subclinical shedding (RR, 1.7 [95% CI, 1.1-2.7]; P = .01), and genital lesions (RR, 2.1 [95% CI, 1.2-3.4]; P = .005), compared with women. No differences in shedding rates or lesion frequency were observed based on HIV serostatus. CONCLUSIONS: HSV-2 shedding frequency and quantity are high among HSV-2-seropositive adults in sub-Saharan Africa, including persons with and those without HIV infection. Shedding rates were particularly high among men, which may contribute to the high prevalence of HSV-2 and early acquisition among African women.

Clinical Evaluation of 2 Point-of-Care Lateral Flow Tests for the Diagnosis of Syphilis.

A diagnostic performance study comparing the only Food and Drug Administration-approved, point-of-care (POC) treponemal test (Syphilis Health Check) and the World Health Organization pre-qualified SD Bioline POC treponemal test against a treponemal hemagglutination test (TPHA) and a sequential algorithm of nontreponemal rapid plasma reagin and TPHA found both POC tests had >85% sensitivity compared with the TPHA and >85% sensitivity and >95% specificity compared with the rapid plasma reagin and TPHA standards.

Cutaneous T-cell lymphoma in sub-Saharan Africa.

The incidence and economic burden of cancer in sub-Saharan Africa is increasing, and innovative strategies are needed to improve prevention and care in this population. This article uses a case of cutaneous T-cell lymphoma in Uganda to propose guidelines for the diagnosis and treatment of this disease in resource-limited settings. These guidelines were developed from the consensus opinion of specialists at the Uganda Cancer Institute and Fred Hutchinson Cancer Research Center as part of an established collaboration. Areas for future investigation that can improve the care of patients in this region are identified.

Human herpesvirus 8 load and progression of AIDS-related Kaposi sarcoma lesions.

INTRODUCTION: Human herpesvirus 8 (HHV8) is necessary for Kaposi sarcoma (KS) to develop, but whether peripheral blood viral load is a marker of KS burden (total number of KS lesions), KS progression (the rate of eruption of new KS lesions), or both is unclear. We investigated these relationships in persons with AIDS. METHODS: Newly diagnosed patients with AIDS-related KS attending Mulago Hospital, in Kampala, Uganda, were assessed for KS burden and progression by questionnaire and medical examination. Venous blood samples were taken for HHV8 load measurements by PCR. Associations were examined with odds ratio (OR) and 95% confidence intervals (CI) from logistic regression models and with t-tests. RESULTS: Among 74 patients (59% men), median age was 34.5 years (interquartile range [IQR], 28.5-41). HHV8 DNA was detected in 93% and quantified in 77% patients. Median virus load was 3.8 logs10/10(6) peripheral blood cells (IQR 3.4-5.0) and was higher in men than women (4.4 vs. 3.8 logs; p=0.04), in patients with faster (>20 lesions per year) than slower rate of KS lesion eruption (4.5 vs. 3.6 logs; p<0.001), and higher, but not significantly, among patients with more (>median 20 KS lesions) than fewer KS lesions (4.4 vs. 4.0 logs; p=0.16). HHV8 load was unrelated to CD4 lymphocyte count (p=0.23). CONCLUSIONS: We show significant association of HHV8 load in peripheral blood with rate of eruption of KS lesions, but not with total lesion count. Our results suggest that viral load increases concurrently with development of new KS lesions.

Absence of Y-chromosome sequences in tumors from African women with AIDS-related Kaposi sarcoma.

Kaposi sarcoma (KS) occurs with relatively high frequency in immunosuppressed transplant recipients and in patients with AIDS. Recently, Italian investigators reported transplant-related KS tumors bearing donor-derived antigens, suggesting possible parenteral transmission of KS as whole cells, i.e., chimeric tumors. To investigate the hypothesis that KS whole cells may also be transmitted into immunocompromised persons via heterosexual acts, we tested nodular KS lesions and matched normal tissue obtained from female patients with AIDS for the presence of the Y-chromosome specific sex determining sequence (SRY). Among 25 unique tumors tested, none was positive for SRY sequence. While our results do not exclude sexual cellular transmission of whole KS cells, they suggest that if it occurs, it is rare.

Etiology of pruritic papular eruption with HIV infection in Uganda.

CONTEXT: A frequent cause of human immunodeficiency virus (HIV)-related morbidity in sub-Saharan Africa is a commonly occurring, intensely pruritic skin rash. The resulting scars are disfiguring and stigmatizing. Despite the substantial prevalence of pruritic papular eruption (PPE) among HIV-infected Africans, the cause has been elusive. OBJECTIVE: To determine the etiology of PPE occurring in HIV-infected individuals. DESIGN, SETTING, AND PATIENTS: Cross-sectional study of HIV-infected patients with active PPE from clinics in Uganda conducted from May 19 through June 6, 2003. Enrollment occurred in the month preceding May 19. Each participant was clinically examined by 2 dermatologists, had laboratory studies performed, was administered an epidemiologic questionnaire, and had a skin biopsy of a new lesion evaluated by a dermatopathologist. MAIN OUTCOME MEASURES: Histological characteristics of new pruritic lesions. Other assessments included CD4 cell count, eosinophil count, and physician-assessed rash severity. RESULTS: Of 109 patients meeting inclusion criteria, 102 (93.6%) completed the study. The CD4 cell counts in this study population were generally low (median, 46/microL) and inversely related to increasing rash severity (median CD4 cell counts: 122 for mild, 41 for moderate, and 9 for severe; P<.001 for trend). Eighty-six patients (84%; 95% confidence interval, 77%-91%) had biopsy findings characteristic of arthropod bites. Patients with arthropod bites on biopsy had significantly higher peripheral eosinophil counts (median, 330 vs 180/microL; P = .02) and had a trend toward lower CD4 cell counts (median, 40 vs 99/microL; P = .07) than those without histological evidence of arthropod bites. CONCLUSIONS: Pruritic papular eruption occurring in HIV-infected individuals may be a reaction to arthropod bites. We hypothesize that this condition reflects an altered and exaggerated immune response to arthropod antigens in a subset of susceptible HIV-infected patients.

Sero-prevalence of herpes simplex type 2 virus (HSV-2) and HIV infection in Kampala, Uganda.

BACKGROUND: Prevalence of herpes simplex type 2 virus (HSV-2) is high worldwide. Previous studies in Uganda were rural or in women. We estimated age and sex-specific sero-prevalence of HSV-2 in Kampala, Uganda. METHODS: Using two-stage random sampling stratified on population density, a survey of persons 15-65 years was conducted. Type-specific serological tests for HSV-2, HSV-1(HerpeSelect2 and 1 ELISA), HIV (Rapid tests and ELISA), syphilis (RPR and TPHA) were done. Additional prevalence analysis included post-stratification weighting on the Uganda 2002 Census gender distribution. RESULTS: Among 1124 persons, HSV-2 prevalence was 58% (95% CI: 55, 60), HSV-1; 98% (95% CI: 97.6, 99.1), HIV; 17.7% (95% CI: 14.8, 19.2) and syphilis; 1.7% (95% CI: 1.4, 1.9). Weighted HSV-2 prevalence was 53.8% (Women; 63.8%, men; 43.2%), similar to unweighted data. Weighted HIV prevalence was 20.7% in women, 8.6% in men. Of 165 HIV infected persons, 85.4% had HSV-2. Risk factors for HSV-2 were being a woman (OR 2.0; 95% CI: 1.42, 2.78), age (OR 3.3; 95% CI: 2.43, 4.53), education (OR 1.70; 95% CI: 1.34, 2.34) and HIV (OR 4.5; 95% CI: 2.70, 7.50). CONCLUSION: Prevalence of HSV-2 and HIV was high especially in women. Syphilis was rare. Awareness of herpes was low. Interventions in young people are needed.

Prevalence of sexually transmitted infections among adolescents in Kampala, Uganda, and theoretical models for improving syndromic management.

PURPOSE: To estimate the prevalence of treatable sexually transmitted infections (STI) in adolescents visiting a youth health clinic. To evaluate the algorithm for management of the abnormal vaginal discharge (AVD) syndrome recommended in Uganda's national guidelines and compare it with other theoretical flowchart models. METHODS: Sexually experienced adolescents who were visiting an urban youth health clinic in Kampala, Uganda were examined and interviewed (with their consent) about their socio-demographic background, sexual risk factors, and genital symptoms. Samples taken for Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG), and Trichomonas vaginalis (TV) were analyzed by polymerase chain reaction (PCR). Rapid plasma reagin (RPR) was used with confirming treponema pallidum hem agglutination (TPHA) for syphilis diagnosis. One hundred ninety-nine females and 107 males were examined. Performance of the national algorithm was compared with different theoretical algorithms. RESULTS: Prevalence of CT, NG, TV and syphilis was 4.5%, 9.0%, 8.0%, and 4.0%, respectively, for girls and 4.7%, 5.7%, 0%, and 2.8%, respectively, for boys. We found that 20.6% of the females and 13.2% of the males had at least one STI. The national AVD flow chart had a sensitivity of 61%, a specificity of 38.5% and a positive predictive value (PPV) of 11.6%. All the models had PPV of less than 20% and sensitivity less than 85%. The best performing algorithm using risk and protective factors, rather than symptoms, implicated a sensitivity/specificity and PPV of 82.6%/47% and 17.3%, respectively (p = .012). CONCLUSIONS: An algorithm for management of STI using behavioral and demographic factors in this population demonstrated enhanced sensitivity, specificity, and PPV.

Sexually transmitted disease management in Uganda's private-for-profit formal and informal sector and compliance with treatment.

OBJECTIVE: The objective of this study was to investigate the management of sexually transmitted diseases (STDs) in the Ugandan private sector clinics and drug shops. STUDY: Men with urethral discharge who had consulted clinics (264) or drug shops (141) for treatment in 5 districts were interviewed using a precoded questionnaire 1 to 3 weeks after initiation of treatment. RESULTS: Seventy-seven percent of patients sought treatment within 1 week of onset of symptoms but only 7% were properly managed (treated according to National Guidelines, told to use a condom or abstain, and to refer their partner). The reported cure rate was 47% and only 9% were treated according to National Guidelines. Eighteen percent of patients used condoms during treatment, 36% persuaded their partner to go for treatment, and 87% completed the recommended treatment course. Of patients not reporting cure, 56% would still recommend the treatment to a friend. CONCLUSION: Quality of STD management by private providers is poor. Improvement should occur concurrently at public and private facilities. Possible strategies include training and social marketing of prepackaged treatment for STDs.