We found a high level of risk behaviour in men with STI‐related symptoms in Durban, similar to that of 15 years ago despite the emergence of a severe HIV epidemic.2
There were, however, some differences between the two studies in the sociodemographic profile of the men. For example, men in the earlier study were younger (mean age 25.6 versus 29.9 years) and were more likely to be new attenders at the clinic (62% versus 46.3%).9
Although the site of the STI clinic had moved two miles away from the one in the earlier study, these differences probably reflect more cases with recurrent HSV‐2 ulcers attending in 2004.
Since the earlier study, genital herpes has emerged as the most common cause of GUD, but more than a third of men confirmed with genital herpes in the latter study had had sex despite symptoms, and in 28 out of 30 (93%) of these contacts condoms were not used. As HIV‐1 virions can consistently be detected in genital ulcers caused by HSV‐2, sexual intercourse in the presence of lesions must constitute a significant risk of HIV‐1 transmission in men.10
In women, genital HSV‐2 infection is associated with increased cervicovaginal and plasma HIV‐1 RNA among co‐infected women with genital ulcers, highlighting the close interaction between these viruses and the role of HSV‐2 as a co‐factor for the sexual transmission of HIV‐1.11
- More than a third of men attending an STI clinic with STI‐related symptoms had sexual intercourse despite symptoms. Condom use was uncommon in these men.
- Similar results were found in a previous survey in men with genital ulceration attending the same municipal STI clinic 15 years previously.
- Syndromic STI management should be strengthened to include health education about the specific risks of sex in the presence of symptoms and the potential health benefits of abstaining from sex until ulcers have healed completely.
The reasons for the particularly high‐risk sexual behaviour in our study are unclear but could reflect disinhibition or fatalism, possibly because so many are already infected with HSV‐2 and HIV,3
a lack of availability of treatment for both conditions although a self‐diagnosis of genital herpes did not affect treatment‐seeking or sexual behaviour in Uganda,12
health being a low priority or other unknown factors. Another possibility is that couples with both HIV and HSV‐2 and aware of their partners' status might have chosen not to abstain from sex when symptomatic. Qualitative research is required to explore this area further.
The low level of condom use indicates that condom promotion programmes still have much to achieve. Although condom use had increased with casual partners compared with 1988, unprotected sex in those with ulcers and confirmed genital herpes was frequent. This may reflect a lack of understanding about genital herpes or an unwillingness for index cases to admit to partners that they had a problem. In most communities the occurrence of sores in one partner in a stable relationship might be construed as unfaithfulness. For some, the alternative to informing their partners about HSV‐2 infection is to carry on as though nothing abnormal had happened, as reported elsewhere in Uganda.12
Further community‐related research is required to identify how best to limit onward HSV‐2 transmission through changes in behaviour. STI management could be strengthened to include patient‐initiated antiherpes treatment and prophylaxis, and also intensive health education to promote community awareness of genital ulceration and genital herpes in particular, and their role in facilitating HIV transmission. If this trend in very unsafe sex could be reversed, a considerable degree of HIV prevention benefit could be achieved given the fact that genital herpes is likely to be a recurrent problem in many of these HIV‐positive men.
We found evidence of very high rates of sex despite symptoms in all groups selected. Whether previous STI symptoms alter current risk behaviour is unclear.13,14
We therefore believe that all individuals attending the STI clinic should receive intensive health education as an essential component of basic STI care. This message is reinforced by recent preliminary data suggesting that newly circumcised HIV‐positive men who resumed sexual activity before certified wound healing were more likely to transmit HIV than those who waited until complete wound healing.15
Although sex despite bleeding was reported earlier in Durban,2
we did not enquire about this behaviour as the prevalence of the most vascular causes of GUD, donovanosis and chancroid, had decreased recently. Elsewhere in South Africa, however, coital bleeding is still thought to be common.16
Reported contact with sex workers was infrequent. This finding emphasises the difficulties in identifying groups at high risk of STI and HIV. Given the high HIV prevalence in this group, it would seem that all uncircumcised men with poor hygiene continue to be one of the highest risk groups since their initial identification at the start of the HIV epidemic.17
Other public clinics were the most frequent source of treatment for the current STI‐related problem before the current attendance followed by traditional healers, with the relative proportions attending being similar across the four groups. These possible management failures might reflect difficulties in the clinical treatment of herpes in the absence of antiherpes agents or the failure of first‐line treatment for gonorrhoea with ciprofloxacin, which was standard treatment at the time of the study.18
It is interesting to note that traditional healers were still favoured by a significant minority, although they are not permitted to dispense antibiotics or antiviral agents.
Although the first report of HIV in South Africa among indigenous heterosexuals was in this STI clinic population in 1987,19
the anticipated national response to target these high‐risk groups never materialised. Indeed, political acceptance both of HIV as an infectious disease and as a significant cause of mortality in the country has been limited until very recently. Most STI‐related efforts for HIV prevention appear to have focused on the syndromic management of STI, with an emphasis on the provision of treatment for bacterial STI to the neglect of promoting behaviour change. The likelihood of changing high‐risk behaviour in men will require a clear message about the health gains of avoiding HIV infection. Our study suggests that significant changes in the community perception of the importance of STI‐related symptoms among Zulu men must be accomplished if the current high rates of HIV are to be reversed. It is disappointing that HIV prevention efforts appear to have made little impact on this behaviour some 15 years since the initial study.2