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Background: Genital ulcer diseases (GUDs) are a common syndrome associated with sexually transmitted infections. Genital ulcer diseases increase the risk of HIV transmission, necessitating appropriate diagnosis and treatment. We provide an updated GUD etiology assessment in Malawi to guide diagnostic development and treatment algorithms. Methods: We enrolled patients 18 years or older presenting with GUD at a sexually transmitted infection clinic in Lilongwe, Malawi, between May and October 2021.We purposively sampled by HIV status. Swabs of ulcers were tested for Treponema pallidum, herpes simplex virus (HSV)-1 and HSV-2, Haemophilus ducreyi, and Chlamydia trachomatis using polymerase chain reaction. Blood was collected for syphilis and HSV-2 serologies and acute HIV testing. Participants were treated per Malawi guidelines. Ulcer resolution (size reduced by >50%) was evaluated 14 days later. Results: Fifty participants enrolled (30without HIV, 2with acute HIV infection, 18 with HIV seropositivity; 32men, 18 women). Forty-six (92%) had an etiology identified. Syphilis was more common among those without HIV (22 of 30 [73%]) than participants with HIV (PWH; 8 of 20 [40%]; P = 0.04). Herpes simplex virus was more common among PWH (11 of 20 [55%]) than participants without (2 of 30 [7%]; P = 0.0002). One-fifth (9 of 50 [18%]) had H. ducreyi. Among those who returned for follow-up (n = 45), 9 (20%) had unresolved ulcers; persistent GUD was slightly more common in PWH (6 of 19 [32%]) than participants without (3 of 26 [12%]; P = 0.14). Conclusions: We observed a dramatic increase in syphilis ulcer proportion in a population whose GUDs were previously HSV predominant. Observed differences in etiology and resolution by HIV status could play an important role in the ongoing transmission and treatment evaluation of GUD. [ABSTRACT FROM AUTHOR]

Background: Gentamicin has been used for the treatment of gonorrhea in Malawi since 1993. However, declining clinical cure rates have been suspected. We evaluated current Neisseria gonorrhoeae susceptibility to gentamicin in vitro and clinically.Methods: Men with acute urethritis were recruited at the Bwaila District Hospital STI Clinic in Lilongwe, Malawi, between January 2017 and August 2019. All men provided urethral swabs for etiological testing at enrollment and test of cure (TOC), 1 week later, using Gram-stained microscopy and culture. We used Etest to determine minimum inhibitory concentrations (MICs) of gentamicin, azithromycin, cefixime, ceftriaxone, ciprofloxacin, and spectinomycin; disc diffusion for tetracycline susceptibility; and whole-genome sequencing (WGS) to verify/refute treatment failure.Results: Among 183 N. gonorrhoeae culture-positive men enrolled, 151 (82.5%) had a swab taken for TOC. Of these 151 men, 16 (10.6%) had a positive culture at TOC. One hundred forty-one baseline isolates were tested for gentamicin susceptibility using Etest: 2 (1.4%), MIC = 2 μg/mL; 111 (78.7%), MIC = 4 μg/mL; and 28 (19.9%), MIC = 8 μg/mL. All isolates were susceptible to azithromycin, cefixime, ceftriaxone, and spectinomycin, whereas 63.1% had intermediate susceptibility or resistance to ciprofloxacin. Almost all (96.1%) isolates were resistant to tetracycline. All examined isolates cultured at TOC (n = 13) had gentamicin MICs ≤8 μg/mL. Ten men had pretreatment and posttreatment isolates examined by whole-genome sequencing; 2 (20%) were verified new infections (4119 and 1272 single-nucleotide polymorphisms), whereas 8 (80%) were confirmed treatment failures (0-1 single-nucleotide polymorphism).Conclusions: Gentamicin MICs poorly predict gonorrhea treatment outcome with gentamicin, and treatment failures are verified with gonococcal strains with in vitro susceptibility to gentamicin. The first-line treatment of gonorrhea in Malawi should be reassessed. [ABSTRACT FROM AUTHOR]

Background: Genital ulcer disease (GUD) is a common clinical syndrome in Africa. Periodic surveillance of GUD causes in countries that rely on syndromic management of sexually transmitted infections (STIs) is important for informing treatment guidelines, which recommend presumptive therapy for syphilis, genital herpes, and chancroid. Approximately 20% of all symptomatic clients presenting to STI clinics in Malawi present with GUD. We evaluated the current distribution of etiologies of GUD in Malawi, since the last review10 years ago. Methods: We recruited men and women ≥18 years of age with wet/moist ulcers at Bwaila STI clinic in Lilongwe, between January 2020 and May 2022. Ulcer swabs were collected and underwent polymerase chain reaction (PCR) testing for Haemophilus ducreyi (HD), Chlamydia trachomatis (CT), herpes simplex virus (HSV), and Treponema pallidum subs. pallidum (TP) (polA); genovar-specific PCR to confirm cases of lymphogranuloma venereum (LGV) PCR was not available so CT results were considered presumptive for LGV. We assessed the distribution of GUD etiologies based on demographic characteristics and HIV status. Results: Of the 742 clients with wet/moist genital ulcers, 568 (77%) had ulcer swab specimens with PCR results. The median age was 27 years (IQR: 23, 34), 61% (345/564) were men and 13% (60/464) were HIV seropositive. Two-thirds (368/568, 65%) of participants had TP, 23% (128/568) had HD, 17% (98/568) had HSV, 6% (36/568) had CT and 8% (46/568) had no etiology identified. Most participants (420/568, 74%) had one pathogen, 96 (17%) had two and 6 (1%) had three pathogens identified. TP and HSV were slightly more common among HIV seropositive patients (TP: 73%, HSV: 25%) compared to HIV seronegative patients (TP: 65%, HSV:16%), respectively. Women had slightly more TP (71%) and CT (11%) compared to men (TP: 61%, CT: 3%), respectively. Conclusion: Since the last etiologic review, there has been a rise in the prevalence of syphilis and chancroid, suggesting a shift in the etiologic burden of GUD in Malawi. Routine point-of-care screening, treatment, and active partner notification of syphilis needs to be intensified among patients with GUD, particularly HIV co-infected patients. Further studies investigating HD will be important for informing syndromic treatment guidelines in Malawi. [ABSTRACT FROM AUTHOR]

Abstract: Monitoring the burden of and trends in sexually transmitted infection syndromes is useful in informing syndromic management guidelines. Among sexually transmitted infection clinic patients in Lilongwe, Malawi, between 2006 and 2015, genital discharge, lower abdominal pain, and genital ulcer syndromes were common. Prevalence of most syndromes remained stable during the 10-year period. [ABSTRACT FROM AUTHOR]

Objectives: To examine the time required to suppress HIV in the genital tract with antiretroviral therapy (ART) in men with urethritis., Design: An observational cohort study., Methods: Men with HIV and urethritis not on ART were enrolled at an STI clinic in Malawi and offered to initiate ART. Blood and semen samples were collected pretreatment and at 1, 2, 4, 8, 12 and 24 weeks posturethritis treatment. Median viral loads (VLs) were calculated by ART initiation groups: 'within 1 week', 'between 1 and 4 weeks' and 'no ART before 4 weeks', based on the men's choice about whether or not to initiate ART. The presence of ART at each visit was confirmed by bioanalytical methods., Findings: Between January 2017 and November 2018, 74 men presented with urethritis and HIV and were confirmed ART naive. The median age was 32 years. Forty-one (55% of men) initiated ART within 1 week; 12 (16%) between 1 and 4 weeks; and 21 (28%) did not initiate ART by week 4. Within the 1 week group, median VL was suppressed within 4 weeks in both semen and blood. Among the 1-4 weeks group, VL was suppressed within 4 weeks in semen and 5 weeks in blood. Among the no ART before 4 weeks group, VL in semen declined within the first 4 weeks but remained unsuppressed through week 24, and there was no significant decline in blood HIV., Conclusion: Treatment of urethritis and prompt initiation of ART with counseling for safer sex for at least one month is a critical measure to reduce transmission of HIV., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)