COMPARISON OF CLINICALLY DIRECTED, DISEASE-SPECIFIC, AND SYNDROMIC PROTOCOLS FOR THE MANAGEMENT OF GENITAL ULCER DISEASE IN LESOTHO

Objective: To evaluate two protocols for the syndromic management of g enital ulcer disease (GUD) in Lesotho, southern Africa and to compare the performance of these protocols with that of a conventional disease specific approach. Methods: A cross sectional study was conducted amo ng consecutive patients with GUD attending an STD clinic in Maseru, Le sotho. The clinical diagnoses were made by using predefined criteria a t the initial visit before the performance of laboratory tests. Attemp ts were made to detect the specific aetiology of the genital ulcers us ing PCR assays and syphilis serology. The results of PCR assays and sy philis serology were used as the gold standard against which the perfo rmance of the management approaches were applied. Results: Of 100 pati ents initially recruited into the study, Haemophilus ducreyi infection was detected in 56%, herpes simplex virus in 26%, Treponema pallidum in 23%, and lymphogranuloma venereum in 7%. No pathogens were detected in 6% of patients. 17% of patients had mixed infections. Sensitivity, specificity, positive and negative predictive values of the three man agement protocols for GUD were compared after applying each to the stu dy population. Theoretically, the lowest correct treatment rate would have been obtained by using the disease specific protocol (62%) compar ed with more than 90% in both syndromic management protocols. Consider able overtreatment for primary syphilis would occur following applicat ion of both syndromic protocols. This would be the result of the overd iagnosis of chancroid, in particular the misdiagnosis of genital herpe s as chancroid, which would receive treatment for syphilis unnecessari ly. The HIV seroprevalence among these patients was 36%. A significant ly higher rate of HIV seropositivity was detected among the patients w ith herpes simplex virus infection when compared with those patients h aving other causes of genital ulcer disease (58% v 27%; odds ratio 3.7 3; 95% CI 1.26-11.26; p = 0.01). Conclusions: Poor sensitivity, specif icity, and predictive values were recorded when the disease specific p rotocol was applied to the study population. In contrast, the syndromi c management protocols provided adequate treatment for more than 90% o f patients with GUD. Protocol C, which identified a minority of cases of genital herpes, was found to have an advantage when compared with p rotocol B (all patients with genital ulcer disease treated for both sy philis and chancroid) in that 29% of genital herpes cases would receiv e appropriate counselling.