Chancroid Ulcers as HIV Entry Points
All genital ulcers caused by chancroid—the painful, necrotizing ulcerations characteristic of Haemophilus ducreyi infection—serve as entry points for HIV transmission. 1
Understanding the HIV-Chancroid Connection
The CDC explicitly states that chancroid has been "well established as a co-factor for HIV transmission" with high rates of HIV infection reported among chancroid patients in both the United States and internationally. 1 This relationship is bidirectional:
- Any disruption of the genital epithelium created by chancroid ulcers facilitates HIV entry by breaching the protective mucosal barrier. 1
- The ulcers themselves—whether single or multiple, regardless of size—all represent potential portals for viral transmission. 1
- Both the primary painful ulcers and associated suppurative inguinal lymphadenopathy (buboes) contribute to increased HIV susceptibility. 1
Clinical Implications for HIV Risk
The typical presentation of chancroid includes:
- One or more painful genital ulcers with ragged, undermined edges and purulent bases—all of which compromise mucosal integrity. 1
- Tender inguinal adenopathy occurring in one-third of patients, which when suppurative is almost pathognomonic for chancroid. 1
- The combination of genital ulceration with regional lymphadenopathy creates multiple sites of potential HIV exposure. 1
Critical Management Priorities
HIV testing must be performed at the time of chancroid diagnosis because of this established transmission risk. 1 The CDC recommends:
- Immediate HIV testing at initial presentation with chancroid. 1
- Repeat HIV testing at 3 months if the initial test is negative, given the window period for seroconversion. 1, 2
- Recognition that genital ulcers may be markers of high-risk sexual behavior beyond the direct biological facilitation of HIV transmission. 3
Treatment Urgency
Early treatment reduces both HIV transmission risk and onward spread of chancroid itself. 4 Single-dose regimens (azithromycin 1 g orally or ceftriaxone 250 mg IM) are preferred because they:
- Ensure compliance at first presentation. 1, 5, 6
- Rapidly initiate ulcer healing, reducing the duration of HIV vulnerability. 1, 5
- Minimize the window for HIV transmission to sexual partners. 4
Special Considerations
HIV-positive patients with chancroid face bidirectional complications:
- Chancroid ulcers heal more slowly in HIV-infected individuals. 1, 2
- Treatment failure rates are higher among HIV-positive patients. 1, 2
- These patients may require prolonged therapy courses beyond standard regimens. 1, 2
- The CDC recommends the 7-day erythromycin regimen (500 mg orally four times daily) for HIV-infected patients with close follow-up. 1, 5
Partner Management
All sexual contacts within 10 days before symptom onset must be treated empirically, regardless of symptoms, to prevent reinfection and limit onward transmission of both chancroid and HIV. 1, 5, 7