352 Genitourin Med 1993;69:352-356 HIV and other sexually transmitted diseases at a rural hospital in Genitourin Med: first published as 10.1136/sti.69.5.352 on 1 October 1993. Downloaded from Franky Le Bacq, Peter R Mason, Lovemore Gwanzura, Valerie J Robertson, Ahmed S Latif

Abstract serology was found in 64% patients. Objective-To define the epidemiological There was no statistical association with characteristics of STD patients attending current genital ulcers, though there was an outpatient clinic in rural Zimbabwe, an association with previous STD to examine the aetiologic agents causing episodes and particularly with serologi- infection and to determine their relation- cal evidence of syphilis. Apart from ship with HIV infection. yeasts, there was no association between Subjects-319 men and 146 women, mak- positive HIV-1 serology and the presence ing a sample of about 7% all patients ofpathogens in the genital tract. attending an STD clinic during the 3 Conclusions-The high prevalence of month study period. Microbiological HIV-1 antibodies in STD patients in data were collected from 104 men and 72 suggests integration of STD and women selected randomly from these. AIDS control programmes to be a neces- Pregnant women were excluded and sity. Since paid employment was a com- patients who had received antibiotics mon feature of both STD clinic within the previous 14 days were attendance and HIV-1 seropositivity, excluded from the microbiology sub- these programmes may be effectively sample. directed through the work place. Setting-An outpatient STD clinic at a District Hospital on a major truck route (Geniwurin Med 1993;69:352-356) about 300 km north of the capital, . Introduction Methods-All new patients attending the Sexually transmitted diseases are a significant clinic during a 3 month period were public health problem in both urban and enrolled for clinical and epidemiological rural areas of Africa.' They occur commonly, investigations using a standard proce- have a major effect on maternal-child health dure. Specimens for microbiological and may require the allocation of a substan- investigation were taken from every sec- tial proportion of the health budget. In ond patient seen on the first three days of Zimbabwe, annual reports from the two http://sti.bmj.com/ each week. major urban centres, Harare and , Results-The typical patient was male have noted an increasing frequency of (m:f ratio 2.2) aged 20-29 years (68% reported cases of STD over the last decade23 patients), not married (56% men) and in and in 1990 over one million STD infections paid employment (66% men vs. 27% for were treated. Similar data may be obtained in

the district). In men the most common rural communities. In , a on October 1, 2021 by guest. Protected copyright. presenting feature was genital ulceration, mainly agricultural district some 200 km while in women, discharges were more north of Harare, the number of STD cases common. Genital warts were noted fre- rose from just over 13 000 in 1986 to almost quently in both sexes. In the sub-sample 20 000 in 1990. The district has an adult examined microbiologically, H ducreyi population estimated at 140 0004 making a Karoi District Hospital, Karoi was isolated from 46% ulcers clinically reported incidence of about 14 cases per 100 F Le Bacq diagnosed as chancroid, and motile people annually. STDs make up about 11% Department of spirochaetes were detected in 25% pain- of all new cases seen at the District Hospital, Medical Microbiology less ulcers. Neither of these were being the second most common complaint in P R Mason detected in ulcers in women, but L Gwanzura HSV adults attending out-patient clinics. V J Robertson antigen was found as frequently in ulcers The shortage of laboratory facilities and Department of from men (19%'/o) as from women (17%). personnel at rural health centres means that Medicine In patients with genital discharges, gono- most infections are diagnosed clinically. A S Latif coccal infection occurred in 64% men Accurate data on STD aetiology in University of and 17% women, while T vaginalis was Zimbabwe have been reported only for Zimbabwe Medical isolated from 390/o women and 8% School, Harare, only patients attending a referral centre in the cap- Zimbabwe men. Over 60% gonococcal isolates were ital,5 and as part of a programme on STD in Address for correspondence: PPNG, and 18% showed in vitro resis- rural centres, we investigated new cases pre- Prof P R Mason, Dept of tance to tetracycline. Yeasts, mainly C senting at Karoi District Hospital Medical Microbiology, during a University of Zimbabwe albicans were isolated from 42% women three month period. The data we present Medical School, P 0 Box with a discharge and 25% women with here cover clinical and A178 Avondale, Harare, epidemiological char- Zimbabwe. ulcers. In men the presence ofyeasts was acteristics of all patients, and the results of Accepted for publication associated with superficial ulceration microbiological investigations on a represen- 28 June 1993 and itchiness of the glans. Positive HIV-1 tative sample of these. HIV and other sexually transmitted diseases at a rural hospital in Zimbabwe 353

Materials and methods and the serum separated and stored at Patient selection -20°C. Sera were subsequently tested for All new patients presenting to the outpatient antibody to HIV-1 by a single ELISA (Abbott department of Karoi District Hospital with Labs, USA), and by RPR, TPHA and FTA-

suspected STD during March to May 1991 Abs for syphilis serology. Genitourin Med: first published as 10.1136/sti.69.5.352 on 1 October 1993. Downloaded from were enrolled in the study. Patients were given a thorough clinical examination and a Microbial identification standard questionnaire was taken for details All cultures were incubated under appropri- of past history, with particular regard to pre- ate atmospheric and temperature conditions. vious STD and treatments. Women who were Neisseria gonorrhoeae was identified on the suspected to be pregnant were referred to the basis of colony morphology, Gram stain, oxi- ante-natal rather than the STD clinic, and so dase activity and utilisation of glucose but not were excluded. maltose. All isolates were tested for fl-lacta- Because of limited finance and facilities, mase (Intralactam, Mast Labs, UK) and for microbiological data were collected on a sub- disc sensitivity to penicillin G (2 units) and sample selected as every second patient seen tetracycline (25 ug). Diamond's cultures were at the clinic during the first three days of each examined daily for 3 days, and T vaginalis week. Patients who had documentary evi- was identified by microscopy. H ducreyi was dence of antibiotic treatment within the past identified on the basis of colony morphology, two weeks were excluded, despite having including a "push test", Gram stain and neg- symptoms, because of the effect this may ative porphyrin test. Gram negative, metro- have had on the microbial flora. No speci- nidazole sensitive organisms growing on mens were taken from asymptomatic patients selective medium and able to hydrolyse starch because of ethical and financial constraints. and raffinose were identified as G vaginalis. Yeasts were tested for germ tube production, Specimen collection and negative isolates were identified using Cotton tipped swabs were used to collect commercial tests (API Systems, France). specimens of urethral, vaginal and/or cervical discharge from men and women. These were Statistics inoculated immediately on to Thayer-Martin The data were recorded on database for agar for gonococci, and then into Diamond's analysis by either chi square or Fisher's exact medium for maintenance of Trichomonas test. Probabilities are recorded as <0 01, vaginalis and yeasts. For the latter, a drop of <005 or not significant (NS). the medium was subsequently inoculated on to Sabourauds dextrose agar (SDA) with 50 mg/l chloramphenicol. A second swab was Results taken into transport medium for detection of Patients chlamydial antigen (Chlamydiazyme, Abbott In all 465 patients were enrolled, making were Labs, USA). Genital ulcers irrigated about 7% of all outpatients at Karoi District http://sti.bmj.com/ with about 2 ml sterile saline and the washing Hospital during the study period. There were was injected into a sterile bottle. A drop of 319 men and 146 women, giving a this fluid was examined by dark ground male:female ratio of 2.2. The age and gender microscopy within 10 mins. Further samples distribution is shown in table 1. Eighty nine were inoculated onto two media (Mueller- (61%) women claimed to be married, com- Hinton agar with 3 mg/l vancomycin, horse pared with 139 (44%) men (p < 0.01). The blood and isovitalex, and Brain-Heart mean age of married men was 31 years com- on October 1, 2021 by guest. Protected copyright. Infusion containing 10% foetal bovine serum pared with 24 years for unmarried men (p < plus 3 mg/l vancomycin) for isolation of 00 1), but there was no significant difference Haemophilus ducreyi.6 7 A second drop was in the mean ages of married (26 years) and inoculated onto SDA with chloramphenicol unmarried (25 years) women. The majority for yeasts. Smears were prepared on glass of women (121, 83%) were not in paid slides, fixed in acetone and stored at-20°C employment, while the majority of men (210, for detection of herpes simplex virus types 66%) were employed either in town or on I and II (HSV) using fluorescein labelled surrounding commercial farms. monoclonal antibody (provided by California There was a previous STD history in 86 State Dept Health Services, Berkeley, USA). (59%) women and 235 (74%) men, though For women with a discharge, the vaginal data on the exact nature of the STD were not vault was irrigated with about 2 ml sterile saline, and the saline-discharge mixture was injected into a sterile bottle. This was used to Table 1 Age and gender distribution ofnew STD inoculate SDA for yeasts and Diamond's patients at Karoi District Hospital, March-May 1991 medium for rchomonas as above, and to No. (%) M:F ratio inoculate selective agar for Gardnerella vagi- Age (years) Women Men (District*) nalis (Mast Labs. UK). A drop of the saline- was 10-19 15 (10%) 19(25%) 1-3 (1-0) discharge examined microscopically for 20-29 100 (69%) 214 (67%) 2-1 (0.8) "clue cells". Initial cultures were set up at 30-39 21 (14%) 58 (18%) 2-8 (0.9) within two 40+ 4 (3%) 24 (8%) 6-0 (1.2) Karoi, hours of specimen collec- NRt 6 (4%) 4 (1%) tion, and were transported to Harare each Total 146 319 2-2 (1.0) week for final identification. *M:F ratio for the district (see ref. 4). Clotted blood was taken from each patient, tNR = not recorded. 354 Bacq, Mason, Gwanzura, Robertson, Latif

Table 2 Clinicalfindings in STD patients Table 3 Isolation ofpathogensfrom STD patients No. (%/S) No. (%) patients with discharge Clinicalfindingsl diagnosis Men Women p Men (n = 36) Women (n 65)

Genital ulcer 202 (63%) 35 (24%) <0 01 Ngonorrhoeae 23 (64%) 11 (17%) Genitourin Med: first published as 10.1136/sti.69.5.352 on 1 October 1993. Downloaded from painful Tvaginalis 3 (8%) 25 (39%) with bubo 137 (43%) 28 (19%) <0 01 Chlamydia antigen 3 (8%) 10 (15%) without bubo 41 (13%) 4 (3%) <0 01 G painless 65 (20%) 7 (5%) <0 01 vaginalis - 10 (15%) Genital discharge 88 (28%) 114 (79%) <0 01 Yeasts - 27 (42%) vaginal 89 (61%) No. (%) patients with GUD cervical 41 (28%) Generalised 207 (65%) 60 (41%) <0 01 Men (n = 78) Women = lymphadenopathy (n 12) Lymphogranuloma 11 (3%) 4 (3%) NS Spirochaetes 10 (13%) 0 venereum H ducreyi 22 (28%) 0 Genital warts 39 (12%) 19 (13%) NS Yeasts 8 (10%) 3 (25%) Acute orchitis 13 (4%) HSV antigen 15 (19%) 2 (17%) *Comparing male and female. always available and so these were omitted with antibiotics at a rural health centre. from data analysis. A history of previous STD Cotrimoxazole had been given to 67 (28%) was found in 76% wage earners, 75% com- GUD patients and 34 (17%) patients with mercial farm workers and 62% unemployed discharge. Other antibiotics frequently given people (p < 0 05). Employed patients came to GUD patients were penicillin (55 patients) for treatment sooner than unemployed and tetracycline (20 patients), while for patients (median 7 vs 14 days resp. p < 0.01). patients with a discharge, 29 had received penicillin, 20 had received kanamycin and 20 Clinicalfindings had received metronidazole. Genital ulcer disease (GUD) was by far the most common presentation in men, while dis- Microbiology charge was more common in women (table Specimens were collected from 104 men and 2). In men and women with GUD the num- 72 women, that is, 38% of all STD patients ber of ulcers was similar (range 1-17 for during the study period. Of the men, 68 women, 1-30 for men, mean 4 in both) and (65%) presented with GUD, 26 (25%) with more than two thirds of the patients discharge and 10 (10%) with both. Of the described the ulcers as painful. Ulcers were women 60 (83%) had a discharge, 7 (10%) indurated in 47% cases in men, compared had ulcers and 5 (7%) had both. with 23% cases in women (p < 0.01). In men Gonococci were isolated from 34/101 the ulcers were most commonly on the sulcus (34%) patients with a discharge, and signifi- (46%), foreskin (37%) and frenulum (21%), cantly more frequently from men (table 3). /B- and less frequently on the glans, shaft or lactamase activity was shown by 21 (62%) urethra. In women, most ulcers were located isolates, and 6 (18%) showed resistance to on the labia (80%) and/or fourchette (54%) tetracycline. Amongst women with a dis- http://sti.bmj.com/ but rarely on the perineum, vagina or clitoris. charge, yeasts and T vaginalis were the most At least one inguinal bubo was found in frequently detected pathogens. The great 20% men and 6% women, being unilateral in majority of yeasts were Candida albicans, but the great majority of these. Longitudinal C kreusi and Torulopsis glabrata were occasion- superficial ulceration of the foreskin, ally found. Chlamydial antigen was detected were "rhagades", noted in 18 (6%) men. in 13/101 patients with a discharge, and G on October 1, 2021 by guest. Protected copyright. Itchiness of the glans was reported by 33 vaginalis was isolated from 10 women. (10%), and secondary phimosis was found in H ducreyi was isolated only from men, 42 (13%) men. Enlarged lymph nodes in at being recovered from 28% of all ulcers, but least two extrainguinal sites were recorded for from 46% ulcers that were described as two thirds of the men, but less than half the painful. Spirochaetes also were only identified women. Oral candidiasis was found in only in specimens from men, with 8/32 (25%) two (male) patients. painless ulcers being positive by dark ground Multiple clinical diagnoses were made for microscopy compared with 2/47 (4%) painful 34 (23%) women and 42 (13%) men (p < ulcers (p < 0.05). Yeasts were commonly 0.01). None of the women, and only two of isolated from ulcer fluids from both men and the men had been circumcised. women, and in men they were associated with "rhagades" and itchiness of the glans. HSV Treatment history antigen was detected in 17/90 men and Before coming to the hospital many men women with genital ulcers, while spirochaetes (42%) and women (40%) had been treated were found only in ulcer fluids from men (table 3). Table 4 Results ofsyphilis serology No. ofsera Syphilis serology RPR + ve* -v* There was generally good agreement between 66 110 the results of the two specific Treponema TPHA +ve -ve +ve -ve 29 37 29 81 pallidum tests, with discrepant results in only FTA + ve -ve + ve -ve + ve -ye + ve -ve 27 (15%) cases. There was less agreement 24 5 6 31 20 9 7 74 between RPR and either TPHA (66 dis- * + ve = positive test, -ve = negative test. crepant results) or FTA-Abs (63 discrepant HIV and other sexually transmitted diseases at a rural hospital in Zimbabwe 355

Table S Co-infections in HIV-1 positive and negative patients Discussion No. (%) with positive culture/test This study shows the high prevalence of STDs Organism/test HIV-1 +ve HIV-1 -ye p in a small rural town in Zimbabwe. During Ngonorrhoeae* 19 (31%) 15 (39%) NS the three months of study, STDs were the Tvaginalis* 17 (27%) 11 (28%) NS most common outpatient condition seen in Genitourin Med: first published as 10.1136/sti.69.5.352 on 1 October 1993. Downloaded from Yeasts* 23 (37%) 4 (10%) <0 05 Chlamydia antigen* 4 (7%) 9 (23%) <0-05 adults, with the 20-29 year age group being Gvaginalist 7 (17%) 3 (13%) NS seen in numbers disproportionate to their Hducre"4 17 (28%) 5 (17%) NS HSV antigenr 13 (22%) 4 (13%) NS numbers in the community. The male:female Spirochaetest 6 (10%) 4 (13%) NS patient ratio was 2-2, while in the district it is Yeastst 8 (13%) 3 (10%) NS varies from 0.8 to 1-2 in different age groups.4 *Discharge (n = 62 HIV +ve, 39 HIV -ve) Although mainly a commercial and subsis- tDischarge in women (n = 42 HIV +ve, 23 HIV -ve) *Ulcer (n = 60 HIV +ve, 30 HIV -ve) tence farming area, Karoi is also on the main truck route to Zambia, Malawi and other results). Seven of the 10 sera from patients countries to the north, and a high prevalence with spirochaete-positive ulcers were positive of STDs has been reported in long distance by FTA-Abs, compared with four positive by truck drivers in East Africa.8 While none of TPHA and five positive by RPR. The syphilis these patients was a driver, these transient serology results are summarised in table 4. men may have contributed to the STD bur- den of the community by infecting local HIVserology women. It is clear from other studies in Antibodies to HIV-1 were found in 47 (69%) Africa910 that prostitutes are a significant women and 63 (61%) men. Amongst HIV-1 source of STD. There were insufficient positive men, 49 (78%) had a previous STD resources for gathering of detailed behavioural history compared with 20 (49%) HIV-1 data, but full time prostitution is rare in Karoi, negative men (p < 0.01). Generalised lym- while paid casual sex occurs frequently. The phadenopathy was noted for 47 (75%) men finding that amongst men the most significant subsequently found HIV-1 positive, com- risk factor for any STD was employment, with pared with 20 (49%) HIV-1 negative men 66% male STD patients being employed com- (p < 0.01). Lymphadenopathy was however pared with 27% for the district,4 suggests that found in a smaller proportion of HIV-1 posi- paid sex is a significant factor in transmission. tive women (19/47, 40%), and not statisti- Clinically, the most common findings were cally different from that in HIV-1 negative of GUD in men and genital discharge in women (6/25, 24%). HIV-1 positive serology women, as is frequent in Africa."1-13 The was found with 22 (88%) unmarried women prevalence of genital warts was similar to that compared with 25 (53%) married women seen in STD patients and pregnant women in (p < 0.01). Harare,5s " but warts were recorded in less Apart from these there were no epidemio- than 1% STD patients in Malawi12 and were logical or clinical associations with positive not found in any of 193 pregnant women in a was no HIV-1 serology. In particular there rural clinic in S. Africa.'3 The reason for this http://sti.bmj.com/ association with current GUD, with 60 apparently high prevalence in Zimbabwe is (67%) GUD patients being HIV-1 positive not known. compared with 50 (58%) patients without Of particular note in these STD patients ulcers. was the high prevalence of HIV-1 seroposi- tivity. There are few published studies on the HIV and other STDs prevalence of HIV in the general population Except for yeast infections there was no of Zimbabwe, though data from pregnant on October 1, 2021 by guest. Protected copyright. detectable association between HIV-1 serol- women presenting at various clinics in Harare ogy and STDs detected in genital tract speci- indicate a seroprevalence of 15-20% in this mens (table 5). Despite numbers being small, selected group.14 In men who have been a positive Chlamydia test occurred more fre- deferred as blood donors because of risk quently in HIV-1 negative than positive behaviour, an HIV seroprevalence of 36% has patients. been recorded in our laboratory (unpublished There was good correlation between HIV- data). Our data demonstrate a much higher 1 positive serology and serological evidence of seroprevalence in STD patients attending a current or past syphilis, with 48/57 (84%) rural hospital, indicating the need for integra- FTA-Abs positive sera having antibodies to tion of STD and AIDS preventive pro- HIV-1, compared with 62/119 (52%) FTA- grammes. Abs negative sera (p < 0-01). There was less We found generalised lymphadenopathy to strong correlation with TPHA positive sera, be a sensitive (though not specific) indicator 45/58 (76%) being HIV-1 positive compared of HIV-1 infection only in men. Since clinical with 65/118 (56%) TPHA negative sera diagnosis of HIV infection is normal in many (p < 0.05) and there was no significant corre- developing countries because of the high cost lation with RPR, with 46/66 (70%) RPR pos- of laboratory tests, more detailed investiga- itive sera being HIV-1 positive compared with tions to determine differences in presentation 64/110 (58%) RPR negative sera. Thirty nine in men and women are needed. Oral candidi- (35%) of the HIV-1 positive sera showed asis was uncommon, despite the high preva- evidence of active syphilis (positive RPR plus lence of HIV-1 seropositivity, though this at least one of the two specific tests), may be because these patients were still in compared with 8/66 (12%) HIV-1 negative early stages of infection, with adequate sera (p < 0..01). immunity. 356 Bacq, Mason, Gwanzura, Robertson, Latif

GUD is known, from a number of African In summary our findings were that in studies, to be a significant risk factor in HIV Karoi District STDs are an important health transmission,'5-'7 though in many of these problem, with chancroid, trichomoniasis, studies the prevalence of HIV infection was gonorrhoea and syphilis being prevalent. The

much lower than in Karoi. The relationship high prevalence of HIV-1 infection in STD Genitourin Med: first published as 10.1136/sti.69.5.352 on 1 October 1993. Downloaded from between GUD and HIV transmission is com- patients is indicative of the relationship plex and dynamic, and it has been noted that between HIV and STDs, and supports argu- cross sectional studies may be inadequate to ments for the integration of both AIDS and clearly demonstrate this relationship.9 STD prevention programmes if control is to Previous episodes of STD were frequently be achieved. It is clear that STDs are at least reported by the patients in Karoi, and thus as common in rural as in urban communities, there may have been exposure to HIV during and control measures would therefore need to prior GUD episodes. In men, chancroid was be established countrywide. Targeting the the most common cause of GUD, with employed through the work-place would H ducreyi being isolated from 46% ulcers appear to be an effective means of delivery of diagnosed clinically as chancroid. This was such programmes. substantially lower than found in GUD in The technical and administrative assistance of Mr N Kondo is men in an urban clinic in S. Africa,'8 but con- greatly appreciated. This study received the support of the Mashonaland West Principal Medical Director, Dr Katito, ditions for the isolation and growth of H and of the Medical Research Council of Zimbabwe. Finance ducreyi were less than optimal with the limited was provided by the University of Zimbabwe Research Board facilities at Karoi. Microscopic examinations and Medicus Mundi. of the ulcer fluid often showed typical organ- isms, but these failed to grow. Improvements in diagnostic technique are needed in order to 1 Latif AS. Sexually transmitted diseases in Africa. more clearly define the epidemiology of chan- Genitourin Med 1990;66:235-7. croid in rural areas. 2 Annual Report of the Medical Officer of Health. City of In women with Harare. 1990. a discharge, trichomoniasis 3 Annual Report of the Medical Officer of Health. City of was one of the most frequent diagnoses, and Bulawayo. 1990. 4 District Population Data. Central Statistical Office. this is in keeping with other studies in Government of Zimbabwe. Harare. 1989. Zimbabwe.5 '9 Gonococcal infection was 5 Mason PR, Gwanzura L, Latif AS, Marowa E. Genital infections in women attending a genitourinary clinic in demonstrated in nearly two thirds of dis- Harare, Zimbabwe. Genitourin Med 1990;66:178-81. charges in men, and in about 17% of dis- 6 Sottnek FO, Biddle JW, Kraus SJ, et al. Isolation and cul- tivation of Haemophilus ducreyi in a clinical study. Jf Clin charges in women. The high frequency of Microbiol 1980;12:170-4. penicillin resistance is in keeping with reports 7 Dylewski J, Nsanze H, Maitha G, Ronald AR. Laboratory from but diagnosis of Haemophilus ducreyi: sensitivity of culture Harare, evidence of the emergence media. DiagMicrobiol InfDis 1986;4:241-5. of tetracycline resistance is disquieting, as this 8 Bwayo JJ, Omooi AM, Mutere AW, et al. Long distance has not previously been experienced.20 There truck drivers: 1. Prevalence of sexually transmitted dis- eases (STDs). EAfrMedJ7 1991;68:425-9. was a relative absence of G vaginalis in 9 Nzila N, Laga M, Thiam MA, et al. HIV and other sexu- women with discharge, whether diagnosed on ally transmitted diseases among female prostitutes in

Kinshasa. AIDS 1991;5:715-21. http://sti.bmj.com/ the basis of culture or by the presence of clue 10 Simonsen JN, Plummer FA, Ngugi EN, et al. HIV infec- and in tion among lower socioeconomic strata prostitutes in cells, this is contrast with findings in Nairobi. AIDS 1990;4:139-44. Harare.5 In this study, women who had been 11 Latif AS, Bvumbe S, Muongerwa J, et al. Sexually trans- treated with antibiotics were mitted diseases in pregnant women in Harare, excluded, Zimbabwe. AfrJ Sex Trans Dis 1984;1:21-3. whereas at the referral centre in Harare many 12 Kristensen JK. The prevalence of symptomatic sexually of the women had received treatment transmitted diseases and human immunodeficiency before virus infection in Lilongwe, Malawi. Genitourin Med

referral, and the two groups are therefore not 1990;66:244-6. on October 1, 2021 by guest. Protected copyright. strictly comparable. 13 O'Farrell N, Hoosen AA, Kharsany ABM, Van Den Ende J. Sexually transmitted pathogens in pregnant women in In this study we found evidence of chla- a rural South African community. Genitourin Med mydial infection to be negatively 1989;65:276-80. associated 14 Mahommed K, Kasule J, Makuyana D, et al. Sero- with evidence of HIV-1 infection. This is in prevalence of HIV infection amongst antenatal women marked contrast in greater Harare, Zimbabwe. Centr Afr J7 Med 1991; to other cross sectional stud- 37:322-5. ies which demonstrate no association9'0 or 15 Nsubuga P, Mugerwa R, Nsibami J, et al. The association longitudinal studies in which chlamydial of genital ulcer diseases with HIV infection at a derma- tology-STD clinic in Uganda. JAIDS 1990;3:1002-5. infection was shown to be a risk factor in 16 Plummer FA, Simonsen JN, Cameron DW, et al. HIV-1 acquisition.'7 Cofactors in male-female sexual transmission of human immunodeficiency virus type 1. Jf Inf Dis 1991;163: There was evidence of primary syphilis, 233-9. with spirochaetes in ulcer fluid, in 13% men 17 Latif AS, Katzenstein DA, Bassett MT, et al. Genital ulcers and transmission of HIV among couples in with GUD, and 27% sera tested showed evi- Zimbabwe. AIDS 1989;3:519-23. dence of active syphilis. Studies elsewhere in 18 Dangor Y, Fehler G, Exposto FD, Koormhof HJ. Causes and treatment of sexually acquired genital ulceration in Africa have shown the prevalence of active southern Africa. SAfrMedJ 1989;76:339-41. syphilis to vary from 47% in prostitutes in 19 Mason PR, Patterson BA, Latif AS. Epidemiology and clinical diagnosis of Trichomonas vaginalis infection in Somalia to less than 1% of pregnant women Zimbabwe. CentrAfr_Med 1983;29:53-6. in Nigeria.2'22 Syphilis is regarded as an 20 Mason PR, Gwanzura L, Latif AS, Marowa E. Antimicrobial susceptibility of Neisseria gonorrhoeae in important cofactor in HIV transmission,17 Harare, Zimbabwe: relationship to serogroup. Sex Trans and our finding of a correlation between Dis 1990;17:63-6. 21 Ahmed HJ, Omar K, Adan SY, et al. Syphilis and human syphilis and HIV-1 seropositivity was not immunodeficiency virus seroconversion during a 6- unexpected. We found only 17 patients with month follow up of female prostitutes in Mogadishu, Somalia. IntrJ STD AIDS 1991;2: 119-23. ulcer fluid containing HSV antigen, and these 22 Gini PC, Chukuddebelu WO, Njoku-Obi AN. Antenatal numbers were too small to detect an associa- screening for syphilis at the University of Nigeria Teaching Hospital, Enugu, Nigeria-a six year survey. tion with other STDs. IntrJ Gynaecol Obstet 1989;29:321-4.