GENITAL ULCER DISEASE - ACCURACY OF CLINICAL-DIAGNOSIS AND STRATEGIESTO IMPROVE CONTROL IN DURBAN, SOUTH-AFRICA

Objective-To investigate the accuracy of clinical diagnosis in genital ulcer disease (GUD); to devise management strategies for improving th e control of GUD and thereby limit the spread of HIV-1 infection. Desi gn-Clinical and microbiological assessment of GUD in men and women. Th e index of suspicion, diagnostic accuracy, diagnostic efficiency and p ositive and negative predictive values of a clinical diagnosis were in vestigated. Setting-City Health Sexually Transmitted Diseases Clinic, King Edward VIII Hospital, Durban, South Africa. Participants-100 men and 100 women with genital ulcers. Results-The accuracy of a clinical diagnosis was, in men: lymphogranuloma venereum (LGV) 66%, donovanosis 63%, chancroid 42%, genital herpes 39%, primary syphilis 32%, mixed i nfections 8%, and in women; secondary syphilis 94%, donovanosis 83%, g enital herpes 60%, primary syphilis 58%, chancroid 57%, LGV 40%, mixed infections 14%. Overall, diagnostic efficiency was greater in women t han in men. When compared with other causes of GUD, donovanosis ulcers bled to the touch and were larger and not usually associated with ing uinal lymphadenopathy. In women, extensive vulval condylomata lata wer e readily differentiated from all other causes of GUD. Conclusion-A cl inical diagnosis in genital ulceration was less accurate in men than i n women. The diagnostic accuracies for donovanosis and secondary syphi lis were relatively high but for most other conditions were low. Diffe rences between clinical and laboratory diagnostic accuracies may refle ct similarities between the clinical appearances of the various causes of GUD, the presence of mixed infections, atypical ulceration due to longstanding disease, and insensitive laboratory tests. In this commun ity all large ulcers should be treated empirically for syphilis and do novanosis. Uncircumcised men with GUD are an important HIV core or ((s uperspreader') group locally, and prevention strategies should include counselling and health education in the light of the inaccuracy of cl inical diagnosis found in this study. The development of rapid accurat e tests for GUD is urgently required.