Genital ulceration in rural Uganda: sexual activity, treatment-seeking behavior, and the implications for HIV control.

BACKGROUND: Genital ulcer disease (GUD) is documented as a significant risk factor for HIV acquisition. Its prompt recognition and effective treatment are important components of HIV control in sub-Saharan Africa. GOALS: To determine the rate and risk factors for GUD, and to describe sexual and treatment-seeking behavior. STUDY DESIGN: A longitudinal follow-up study of 525 individuals, both those infected with HIV and those uninfected, was conducted in a population-based, clinical cohort over 9 years. RESULTS: The rate of GUD in this population was 16/100 person years, and 30% of the participants reported an episode during the follow-up period. The rates were almost four times higher in participants infected with HIV than in those who were HIV-negative. Half of the participants with a regular sexual partner reported engaging in sex while symptomatic, and only 16% informed their partner. Treatment was sought for only 12% of the genital ulcer disease episodes, despite open access to doctors at a free clinic. A self-diagnosis of genital herpes did not affect treatment-seeking or sexual behavior. CONCLUSIONS: Genital ulcer disease is very common in this rural population, especially among those infected with HIV. Few seek treatment, and many continue sexual activity despite symptoms without informing their partners. The implications of these findings for HIV control are a cause for concern.