(P356) Etiologies of Genital Ulcer Disease among Sexually Transmitted Infections Clinic Patients in Lilongwe, Malawi

Background: Genital ulcer disease (GUD) is a common clinical syndrome in Africa. Periodic surveillance of GUD causes in countries that rely on syndromic management of sexually transmitted infections (STIs) is important for informing treatment guidelines, which recommend presumptive therapy for syphilis, genital herpes, and chancroid. Approximately 20% of all symptomatic clients presenting to STI clinics in Malawi present with GUD. We evaluated the current distribution of etiologies of GUD in Malawi, since the last review10 years ago.

Methods: We recruited men and women ≥18 years of age with wet/moist ulcers at Bwaila STI clinic in Lilongwe, between January 2020 and May 2022. Ulcer swabs were collected and underwent polymerase chain reaction (PCR) testing for Haemophilus ducreyi (HD), Chlamydia trachomatis (CT), herpes simplex virus (HSV), and Treponema pallidum subs. pallidum (TP) (polA); genovar-specific PCR to confirm cases of lymphogranuloma venereum (LGV) PCR was not available so CT results were considered presumptive for LGV. We assessed the distribution of GUD etiologies based on demographic characteristics and HIV status.

Results: Of the 742 clients with wet/moist genital ulcers, 568 (77%) had ulcer swab specimens with PCR results. The median age was 27 years (IQR: 23, 34), 61% (345/564) were men and 13% (60/464) were HIV seropositive. Two-thirds (368/568, 65%) of participants had TP, 23% (128/568) had HD, 17% (98/568) had HSV, 6% (36/568) had CT and 8% (46/568) had no etiology identified (Figure). Most participants (420/568, 74%) had one pathogen, 96 (17%) had two and 6 (1%) had three pathogens identified. TP and HSV were slightly more common among HIV seropositive patients (TP: 73%, HSV: 25%) compared to HIV seronegative patients (TP: 65%, HSV:16%), respectively. Women had slightly more TP (71%) and CT (11%) compared to men (TP: 61%, CT: 3%), respectively.

Conclusion: Since the last etiologic review, there has been a rise in the prevalence of syphilis and chancroid, suggesting a shift in the etiologic burden of GUD in Malawi. Routine point-of-care screening, treatment, and active partner notification of syphilis needs to be intensified among patients with GUD, particularly HIV co-infected patients. Further studies investigating HD will be important for informing syndromic treatment guidelines in Malawi.