Global eradication of donovanosis: an opportunity for limiting the spread of HIV-1 infection.

Genital ulcer disease (GUD) is well recognised in the developing world as a co-factor for heterosexual HIV transmission. Men with GUD are an important high frequency HIV transmitter core group in the general population but few interventions have targeted such individuals so far. Donovanosis is an uncommon GUD with low infectivity characterised by large ulcers that bleed readily and has been identified as a risk factor for HIV in men in Durban, South Africa. Donovanosis is also endemic in Papua New Guinea, India, Brazil and amongst the Aboriginal community in Australia. This curious geographical distribution is unique to any of the sexually transmitted diseases (STD) and might lend itself to control measures not tried previously. In the 1950-60s a global eradication programme was successfully introduced against yaws but this strategy has not been implemented against any of the STD. Donovanosis is a symptomatic disease usually diagnosed on clinical grounds and could be targeted for eradication. Any programme would need to be community-based and require co-operation with both hospital doctors, private general practitioners, nurses, primary health care workers, pharmacists and traditional healers. Donovanosis is usually treated by readily available antibiotics but treatment failure may occur in advanced HIV disease. Drug compliance is often a problem but may be improved by counselling. Early implementation of an eradication programme targeting men with donovanosis could have a significant impact in limiting the spread of HIV in donovanosis-endemic countries and would pre-empt the possibility of both the emergence of drug resistance and treatment failure in individuals with immune impairment.