LGV - it's here to stay

The sexually transmitted infection lymphogranuloma venereum (LGV) is here to stay, an editorial in the May 2009 edition of Sexually Transmitted Infections concludes.

In 2004 a cluster of LGV infections was reported amongst HIV-positive gay men in the Netherlands. Since then the infection has disseminated across much of the industrialised world with several hundred cases diagnosed in the UK. Of note, many of the HIV-positive men diagnosed with LGV have been co-infected with hepatitis C virus.

Accompanying the editorial are several articles reporting on the ongoing LGV epidemic amongst gay men.

The papers include a description of 13 cases of the infection in London involving genital ulcers and inguinal syndrome.

Also included in the journal is an article examining LGV prevalence amongst gay men in the UK. Over 4800 urethral and 6700 rectal samples were examined. This showed that approximately 1% of gay men had rectal infection with LGV, with only 0.1% of men having urethral infection. Nearly all these cases were symptomatic.

In a separate article, investigators from Italy provide information on 13 cases of the infection diagnosed in the country between 2006 and 2008. All but three of the cases involved rectal infection. The first three patients diagnosed with the infection developed symptoms after unprotected sex abroad, including in northern Europe, the focus of the current epidemic. However, the investigators also report onward transmission of the infection in Italy. Almost two-thirds of the reported LGV cases in Italy have been in HIV-positive gay men.

There are still a number of unanswered questions about the LGV epidemic in HIV-positive gay men. For example, the exact mode of transmission is uncertain, nor has it been firmly established why the majority of the infections have been rectal. One possible reason could be that its transmission is linked to sexual practices such as fisting or the use of sex toys, especially during group sex. The early cases of the infection involved a cluster of men who had attended a fisting party in Rotterdam.

Cases of LGV have disproportionately affected HIV-positive gay men. Two possible explanations for this are advanced by the authors of the investigators: HIV makes individuals more vulnerable to the infection; or the infection has spread in sexual networks of HIV-positive gay men. Epidemiological tracking of the infection to date from a number of countries seems to favour the latter explanation.

The authors emphasise that individuals with symptoms of the infection, or in whom it is suspected, should have the appropriate diagnostic tests. Confirmed and suspected cases should be treated with doxycycline for 21 days.

“In the light of the unanswered clinical and epidemiological questions, it looks likely that LGV is here to stay – at least for now”, conclude the authors.