HIV, genital ulceration, and granuloma inguinale

Global eradication of donovanosis: an opportunity for limiting the spread of HIV-1 infection

Genital ulcer disease (GUD) is well recognised in the developing world as a co-factor for heterosexual HIV transmission. Men with GUD are an important high frequency HIV transmitter core group in the general population but few interventions have targeted such individuals so far. Donovanosis is an uncommon GUD with low infectivity characterised by large ulcers that bleed readily and has been identified as a risk factor for HIV in men in Durban, South Africa. Donovanosis is also endemic in Papua New Guinea, India, Brazil and amongst the Aboriginal community in Australia. This curious geographical distribution is unique to any of the sexually transmitted diseases (STD) and might lend itself to control measures not tried previously. In the 1950-60s a global eradication programme was successfully introduced against yaws but this strategy has not been implemented against any of the STD. Donovanosis is a symptomatic disease usually diagnosed on clinical grounds and could be targeted for eradication. Any programme would need to be community-based and require co-operation with both hospital doctors, private general practitioners, nurses, primary health care workers, pharmacists and traditional healers. Donovanosis is usually treated by readily available antibiotics but treatment failure may occur in advanced HIV disease. Drug compliance is often a problem but may be improved by counselling. Early implementation of an eradication programme targeting men with donovanosis could have a significant impact in limiting the spread of HIV in donovanosis-endemic countries and would pre-empt the possibility of both the emergence of drug resistance and treatment failure in individuals with immune impairment.

Ceftriaxone in the treatment of chronic donovanosis in central Australia

OBJECTIVES

To determine the effectiveness of intramuscular (IM) ceftriaxone sodium in the treatment of chronic donovanosis, and the acceptability to patients and staff of supervised outpatient treatment in rural clinics.

METHODS

We collected demographic and sexual health data from participants using a standard questionnaire, and recorded their donovanosis lesions at baseline using genital diagrams. Treatment consisted of a single daily IM injection of 1 g ceftriaxone diluted in 2 ml of 1% lignocaine. Clinic staff followed patients for between three and 12 months, enabling the detection of late recurrences.

SETTING

Rural Aboriginal communities in central Australia.

PARTICIPANTS

The study describes eight women and four men with chronic donovanosis in detail, and summarises the outcome in 12 additional cases. All cases presented with advanced lesions which had failed to heal on the standard oral antibiotic regimens used in the region.

RESULTS

The mean duration of infection was 3.0 years (SD 1.9 years), and between four and ten courses of antibiotics had been prescribed for six of the 12 patients. Patients received between 7-26g of ceftriaxone sodium. Clinical improvement was dramatic in most lesions, and four patients healed completely without recurrence after a total 7-10g of ceftriaxone. Mild recurrences responded to further ceftriaxone or short courses of oral antibiotics. Treatment was well tolerated, and both patient and staff compliance high.

CONCLUSION

Donovanosis is an important cause of chronic genital ulceration in central Australia, and is potentially an important risk factor for HIV transmission in Aboriginal communities. The pharmacokinetics and safety profile of ceftriaxone make it a useful and cost-effective agent in the ambulatory management of donovanosis, especially in remote communities. Supervised multidrug regimens of two or more long-acting agents may provide the best answer in donovanosis, administered through the existing health care infrastructure.