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Letters to the Editor

Genital Ulcer Disease Treatment Polices and Herpes

O'Farrell, Nigel MSc, MD, FRCP; Moodley, Prashini MB ChB, PhD

Author Information
Sexually Transmitted Diseases: February 2011 - Volume 38 - Issue 2 - p 150
doi: 10.1097/OLQ.0b013e318205432b
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To the Editor:

We agree with Corbell et al. that drug procurement and access need strengthening for a genital ulcer disease policy in sub-Saharan Africa to be effective.1 Equally as important is having an effective management strategy for genital herpes in place. Corbell et al. used acyclovir as first-line syndromic genital ulcer disease treatment for their assessment, a strategy that is supported by only one study that used acyclovir 400 mg 3 times daily for 5 days in men.2 By contrast, a more recent smaller study from Malawi in men and women with a high prevalence of HIV-1 found that no significant clinical benefit was achieved by adding acyclovir 800 mg twice daily for 5 days to syndromic management algorithms.3 Moreover, a recent review concluded that standard doses of acyclovir 200 mg 5 times a day for 5 days have never been shown to abort lesions early.4 Optimal current treatment for recurrent genital herpes is based either on continual suppression or patient-initiated treatment, the latter being a strategy that perhaps holds great promise for Africa.5

The financial and clinical benefits of using a short course of patient-initiated treatment are now very clear. A recent review of the costs of different regimens of acyclovir using the latest International Drug Price Indicator Guide for 2007, taking the median supplier unit price per tablet, found that the cheapest recommended regimen by far was acyclovir 800 mg tds for 2 days at US $0.31.6,7

If the new sexually transmitted infections guidelines of the World Health Organization support patient-initiated therapy, an effective affordable intervention will at last be available for herpes in Africa. However, for this to work, health care professionals will need to explain to patients about herpes rather than just dispensing syndromic treatment each time they attend with penicillin injections for syphilis and erythromycin for chancroid and acyclovir. Education about prodromal signs and symptoms would enable patients to start treatment as early as possible and could bring about an end to rewarding health-seeking behavior in the wrong way by giving multiple therapies, a practice that only demoralizes health staff providing the treatment.

Nigel O'Farrell, MSc, MD, FRCP

Ealing Hospital

London, England

Prashini Moodley, MB ChB, PhD

Nelson R. Mandela School of Medicine

University of KwaZulu-Natal

Durban, South Africa

REFERENCES

1. Corbell C, Stergachis A, Ndowa F, et al. Genital ulcer disease treatment policies and access to acyclovir in eight Sub-Saharan African countries. Sex Transm Dis 2010; 37:488–493.
2. Paz-Bailey G, Sternberg M, Puren AJ, et al. Improvement in healing and reduction in HIV shedding with episodic acyclovir therapy as part of syndromic management among men: A randomised, controlled trial. J Infect Dis 2009; 200:1039–1049.
3. Phiri S, Hoffman IF, Weiss HA, et al. Impact of acyclovir on ulcer healing, lesional, genital and plasma HIV-1 RNA among patients with genital ulcer disease in Malawi. Sex Trans Infect 2010; 86:345–352.
4. Patel R, Rutland E. Has episodic treatment of recurrent genital herpes come of age? Int J STD AIDS 2007; 18:437–439.
5. O'Farrell N, Moodley P, Sturm AW. Genital herpes in Africa: Time to rethink treatment. Lancet 2007; 370:2164–2166.
6. Wald A, Carrell D, Remington M, et al. Two day regimen of acyclovir for treatment of recurrent genital herpes simplex virus type 2 infection. Clin Infect Dis 2002; 34:944–948.
7. O'Farrell N, Vickerman P. Costs of various drug regimens for episodic treatment of recurrent genital herpes. In: ISSTDR meeting; June 28–July 1, 2009; London, United Kingdom.
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