Virologic characteristics of subclinical and symptomatic genital herpes infections

Neuropsychiatric symptoms and immune activation in patients with genital herpes

OBJECTIVE

Neuropsychiatric disturbances are common among patients with genital herpes simplex virus (HSV) infection. To date, no studies have examined the possible role of immune activation in the aetiology of these disturbances. The aim of this study was to examine the relationship between markers of immune activation and measures of emotional and somatic dysfunction among patients with symptomatic genital herpes.

METHODS

Twenty-two patients with documented genital herpes were assessed when herpetic lesions were present and when they were not. Each assessment included a clinical examination, self-reported symptom measures as well as a blood and urine collection. Markers of immune activation [neopterin and interleukin (IL)-6] in serum and urine were quantified by enzyme-linked immunoassay. These measures were also obtained from a group of healthy control subjects.

RESULTS

Urine, but not serum, levels of neopterin and IL-6 correlated significantly with measures of reported psychological distress and fatigue. These associations were not confined to periods of overt clinical lesions.

CONCLUSIONS

HSV-related neuropsychiatric morbidity correlates selectively with regional, but not systemic, measures of immune activation. We hypothesise that communication between the local inflammatory site in the pelvis and the brain occurs through autonomic afferent pathways.

Does frequency of genital herpes recurrences predict risk of transmission? Further analysis of the valacyclovir transmission study

BACKGROUND

The benefit of suppressive antiviral therapy for reducing the risk of herpes simplex virus (HSV)-2 transmission to sex partners may be enhanced if persons at high risk for transmission can be identified.

OBJECTIVE

To determine whether frequency of genital herpes recurrences is associated with increased risk of HSV-2 transmission.

METHODS

Analysis of recurrence frequency and shedding frequency (subset) among participants in a randomized controlled trial of valacyclovir 500 mg qd versus placebo for reducing the risk of HSV-2 transmission.

RESULTS

Overall, 1484 monogamous HSV-2-serodiscordant couples participated and 41 HSV-2 transmissions occurred during the 8-month trial; 40 were able to provide a history of recurrence frequency. The rate of recurrences per year before study entry did not differ between source partners who transmitted and those who did not, 4.8 versus 5.1, respectively. Similarly, the mean frequency of recurrences observed during the study also did not differ among those who transmitted versus those who did not for placebo recipients (4.4 vs. 4.8) or valacyclovir recipients (1.4 vs. 1.3). Among the 40 source partners who transmitted HSV-2, 8 of 27 placebo recipients and 7 of 13 valacyclovir recipients had no recurrences during the study.

CONCLUSION

Clinical assessment of HSV-2 disease severity as defined by the frequency of genital herpes recurrences does not predict the risk of transmission to sexual partners. Though patients with frequent recurrences are most likely to benefit clinically from suppressive therapy, frequency of recurrences is not helpful in identifying persons who are most likely to transmit HSV-2.

Accuracy of herpes simplex virus detection in liquid-based (SurePath) Papanicolaou tests: a comparison with polymerase chain reaction

A review of our institution's Papanicolaou test records over an 11-yr period showed that liquid-based Papanicolaou tests (LBPTs) had a significantly higher frequency of diagnoses of Herpes simplex virus (HSV)-related cellular changes compared to conventional Papanicolaou smears (77/302,841, 0.026% vs. 56/376,173, 0.015%, P = 0.002). To investigate the accuracy of the diagnosis of HSV by LBPT, we performed conventional polymerase chain reaction (PCR) on the residual samples from 258 prospectively collected LBPT and real-time PCR using a different primer set on a subset of 40 LBPT. Conventional PCR was positive in 22 of 22 cases diagnosed of HSV, 1 of 2 cases diagnosed as suspicious for HSV, and none of 234 LBPT without a cytologic HSV diagnosis. Real-time PCR was positive in 8 of 8 cases diagnosed as HSV and none of the 32 controls. We conclude that LBPT allows an increased detection of HSV that is highly accurate.

Inhibitory effect of essential oils against herpes simplex virus type 2

Essential oils from anise, hyssop, thyme, ginger, camomile and sandalwood were screened for their inhibitory effect against herpes simplex virus type 2 (HSV-2) in vitro on RC-37 cells using a plaque reduction assay. Genital herpes is a chronic, persistent infection spreading efficiently and silently as sexually transmitted disease through the population. Antiviral agents currently applied for the treatment of herpesvirus infections include acyclovir and its derivatives. The inhibitory concentrations (IC50) were determined at 0.016%, 0.0075%, 0.007%, 0.004%, 0.003% and 0.0015% for anise oil, hyssop oil, thyme oil, ginger oil, camomile oil and sandalwood oil, respectively. A clearly dose-dependent virucidal activity against HSV-2 could be demonstrated for all essential oils tested. In order to determine the mode of the inhibitory effect, essential oils were added at different stages during the viral infection cycle. At maximum noncytotoxic concentrations of the essential oils, plaque formation was significantly reduced by more than 90% when HSV-2 was preincubated with hyssop oil, thyme oil or ginger oil. However, no inhibitory effect could be observed when the essential oils were added to the cells prior to infection with HSV-2 or after the adsorption period. These results indicate that essential oils affected HSV-2 mainly before adsorption probably by interacting with the viral envelope. Camomile oil exhibited a high selectivity index and seems to be a promising candidate for topical therapeutic application as virucidal agents for treatment of herpes genitalis.

Genital herpes

Genital herpes is the main cause of genital ulcers worldwide; the prevalence of herpes simplex virus (HSV) type 2 infections in the general population ranges from 10% to 60%. Most genital herpes is caused by HSV-2, although HSV-1 accounts for about half of new cases in developed countries. The risk of HIV acquisition is three times higher in people with HSV-2. Neonatal herpes is an uncommon but serious complication of genital herpes. Most genital HSV-2 infections are unrecognised and undiagnosed; infected individuals, even with mild symptoms, shed HSV, and can infect sexual partners. Since clinical diagnosis is neither sensitive nor specific, virological and type-specific serological tests should be used routinely. Oral antiviral drugs for HSV infections are safe and effective and can be used both to treat episodes and to prevent recurrences. Antiviral treatment of the infected partners and condom use reduce the risk of sexual transmission of HSV-2.

Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management

Eight of the more than 80 known herpesviruses are human pathogens. Human herpes simplex virus (HSV) is a contagious infection with a large reservoir in the general population. It has a potential for significant complications in the immunocompromised host. In addition, psychological distress caused by the negative stigma associated with genital herpes and visible facial lesions in those experiencing frequent outbreaks renders it a challenging clinical dilemma. This article reviews the epidemiology, pathogenesis, and diagnostic features of HSV infections, providing the clinician with an up-to-date understanding of the available management strategies for mucocutaneous HSV-induced disease.

Famciclovir Reduces Viral Mucosal Shedding in HSV-Seropositive Persons

OBJECTIVE

Many cases of herpes simplex virus (HSV) infection occur through asymptomatic shedding from persons without evidence of clinical disease. This study explores whether famciclovir reduces HSV shedding in HSV-2 seropositive persons with or without a history of symptomatic genital herpes.

STUDY DESIGN

One hundred twenty-seven HSV-2 seropositive participants were randomly assigned to 42 days of famciclovir, followed by 14 days of washout and 42 days of placebo, or vice versa. All subjects swabbed the genital/perianal area; those with HSV-1 infection also swabbed the oral area daily for HSV DNA PCR.

RESULTS

Famciclovir reduced genital and oral HSV shedding from 11.4% of days during the placebo period to 4.7% of days during famciclovir therapy. The reduction was greater in participants with a history of genital herpes (74%) than in those without such a history (30%). In multivariate analyses, famciclovir protected against total (clinical and subclinical) genital shedding among persons with a clinical history of genital herpes (RR, 0.23; 95% CI, 0.15-0.35; P < 0.001). Among HSV-2 seropositive participants without a history of genital herpes, 60% had HSV detected in the genital area at least once during the study. Famciclovir therapy did not result in a statistically significant reduction in total HSV shedding in participants without a history of genital herpes.

CONCLUSION

Famciclovir therapy decreases genital HSV shedding in HSV-seropositive persons, especially those with a history of genital herpes. Overall, antiviral drugs may have varying effects on symptomatic and asymptomatic viral shedding, depending on the clinical history of the disease.

Relaxed repression of herpes simplex virus type 1 genomes in Murine trigeminal neurons

The expression of herpes simplex virus (HSV) genomes in the absence of viral regulatory proteins in sensory neurons is poorly understood. Previously, our group reported an HSV immediate early (IE) mutant (d109) unable to express any of the five IE genes and encoding a model human cytomegalovirus immediate early promoter-green fluorescent protein (GFP) transgene. In cultured cells, GFP expressed from this mutant was observed in only a subset of infected cells. The subset exhibited cell type dependence, as the fractions of GFP-expressing cells varied widely among the cell types examined. Herein, we characterize this mutant in murine embryonic trigeminal ganglion (TG) cultures. We found that d109 was nontoxic to neural cultures and persisted in the cultures throughout their life spans. Unlike with some of the cultured cell lines and strains, expression of the GFP transgene was observed in a surprisingly large subset of neurons. However, very few nonneuronal cells expressed GFP. The abilities of ICP0 and an inhibitor of histone deacetylase, trichostatin A (TSA), to activate GFP expression from nonexpressing cells were also compared. The provision of ICP0 by infection with d105 reactivated quiescent genomes in nearly every cell, whereas reactivation by TSA was much more limited and restricted to the previously nonexpressing neurons. Moreover, we found that d109, which does not express ICP0, consistently reactivated HSV type 1 (KOS) in latently infected adult TG cultures. These results suggest that the state of persisting HSV genomes in some TG neurons may be more dynamic and more easily activated than has been observed with nonneuronal cells.

Asymptomatic shedding of herpes simplex virus (HSV) in the oral cavity

OBJECTIVE

The aim of this study was to investigate the rate of herpes simplex virus (HSV) shedding from the oral cavity, because recent studies suggest that shedding is more frequent than originally reported. Factors that could influence the rate and duration of shedding from the oral cavity were examined.

METHODS

Existing epidemiologic data from 22 reports of HSV shedding from more than 3,500 individuals were analyzed with regard to demographics, frequency of sampling, and methodologic assays.

RESULTS

HSV-1 was more likely to be detected than HSV-2 in the oral cavity of asymptomatic persons (7.5 odds ratio, 95% confidence interval 4.4-12.8; P < .0001). The rate of shedding was highly variable among individuals, ranging from none to 92% of days tested, and occurred in seropositive and seronegative individuals. In cell culture studies, the rate of detection on a single day was 6.3%. Polymerase chain reaction studies provided a different picture. HSV-1 DNA was present in 97 of 180 patients (53.9%) at multiple visits, with a rate of daily detection of 33.3%. The mean duration of shedding was between 1 and 3 days, but more than 3 days in about 10% of patients.

CONCLUSIONS

At least 70% of the population shed HSV-1 asymptomatically at least once a month, and many individuals appear to shed HSV-1 more than 6 times per month. Shedding of HSV-1 is present at many intraoral sites, for brief periods, at copy numbers sufficient to be transmitted, and even in seronegative individuals. The dental implications of these findings are discussed.

Diversity of the CD8+ T-cell response to herpes simplex virus type 2 proteins among persons with genital herpes

Cytolytic T cells play a major role in controlling herpes simplex virus type 2 (HSV-2) infections in humans. In an effort to more thoroughly evaluate the response to HSV-2 directly, ex vivo, we developed an enzyme-linked immunospot (ELISPOT) assay that utilized pools of overlapping synthetic peptides presented by autologous dendritic cells to purified CD8(+) T cells. Donor response rates to individual open reading frames (ORFs) ranged from fewer than 5% responding to as many as 70% responding, with the greatest frequency of responses (by ORF) being directed against UL39, UL25, UL27, ICP0, UL46, and UL47 in descending order of frequency. HSV-2-seropositive subjects responded to as few as 3 or as many as 46 of the 48 ORFs tested, with a median of 11 ORFs recognized. HLA-B*07 expression correlated with stronger responses overall that were directed primarily against UL49 and UL46. Cumulative precursor frequencies in the blood ranged from 500 to almost 6,000 HSV-2 spot-forming units/10(6) CD8(+) T cells. The magnitude and breadth of the response in the infected population were greater than previously appreciated. Whether this variability in the CD8(+) T-cell response within individuals is associated with the frequency of viral reactivation warrants further study.

Suppressive Therapy With Valacyclovir in Early Genital Herpes: A Pilot Study of Clinical Efficacy and Herpes-Related Quality of Life

BACKGROUND

Suppressive therapy has not been studied during the first year after acquisition of genital herpes, the time of maximum frequency of reactivation, potential for transmission, and impact on quality of life.

OBJECTIVE

The objective of this study was to evaluate the effectiveness of suppressive therapy with valacyclovir initiated within 3 months of infection.

STUDY DESIGN

The authors conducted a double-blind, randomized, controlled trial of 1.0 g valacyclovir daily versus placebo for 6 months in 119 patients.

RESULTS

Herpes simplex virus (HSV) type 2 and HSV-1 were documented in 75 and 22 patients, respectively. In intention-to-treat analysis, annualized rates of symptomatic recurrences for valacyclovir and placebo, respectively, were 1.7 +/- 2.7 (mean +/- standard deviation) and 3.4 +/- 4.0 outbreaks per year (P = 0.012). Time to first recurrence was 80 +/- 47 days for valacyclovir and 54 +/- 49 days for placebo (P = 0.001). The differences in favor of valacyclovir were greatest in patients with confirmed HSV-2 infection. The Recurrent Genital Herpes Quality of Life score in HSV-2 infected patients rose 11.9 +/- 11.1 points for valacyclovir and 5.9 +/- 9.1 points for placebo (P = 0.040).

CONCLUSIONS

Early suppressive therapy with valacyclovir reduces symptomatic recurrent outbreaks, especially in patients with HSV-2 infection. Valacyclovir therapy was associated with improved herpes-related quality of life.

Superior efficacy of helicase-primase inhibitor BAY 57-1293 for herpes infection and latency in the guinea pig model of human genital herpes disease

The efficacy of BAY 57-1293, a novel non-nucleosidic inhibitor of herpes simplex virus 1 and 2 (HSV-1 and HSV-2), bovine herpesvirus and pseudorabies virus, was studied in the guinea pig model of genital herpes in comparison with the licensed drug valaciclovir (Valtrex). Early therapy with BAY 57-1293 almost completely suppressed the symptoms of acute HSV-2 infection, and reduced virus shedding and viral load in the sacral dorsal root ganglia by up to three orders of magnitude, resulting in decreased latency and a greatly diminished frequency of subsequent recurrent episodes. In contrast, valaciclovir showed only moderate effects in this set of experiments. When treatment was initiated late during the course of disease after symptoms were apparent, that is, a setting closer to most clinical situations, the efficacy of therapy with BAY 57-1293 was even more pronounced. Compared with valaciclovir, BAY 57-1293 halved the time necessary for complete healing. Moreover, the onset of action was fast, so that only very few animals developed new lesions after treatment commenced. Finally, in a study addressing the treatment of recurrent disease in animals whose primary infection had remained untreated BAY 57-1293 was efficient in suppressing the episodes. In summary, superior potency and efficacy of BAY 57-1293 over standard treatment with valaciclovir was demonstrated in relevant animal models of human genital herpes disease in terms of abrogating an HSV infection, reducing latency and the frequency of subsequent recurrences. Furthermore, BAY 57-1293 shortens the time to healing even if initiation of therapy is delayed.

Atypical cutaneous manifestation of HSV-2 with Candida albicans co-infection in a patient with HIV-1

Herpes simplex virus type 2 (HSV-2) infection was one of the first opportunistic infections identified among patients with AIDS. In the literature there are many data suggesting that the natural history of HSV-2 infection is altered in HIV-HSV-2 co-infected patients. Furthermore, a relationship between HIV seropositivity and HBV infection because of their analogous way of transmission is also described. We report the case of a 37-year-old patient who suffered from multiple painful ulcerative lesions of the perianal region. Laboratory examination showed positivity for HIV and HBV infections. In HIV-positive patients perianal HSV-2 can have atypical manifestations, especially if co-infection by Candida albicans occurs.

Herpes simplex virus genes Us3, Us5, and Us12 differentially regulate cytotoxic T lymphocyte-induced cytotoxicity

Many viruses, including Herpes Simplex Virus (HSV), have developed strategies to avoid detection by cytotoxic T lymphocytes (CTLs). In this article, we evaluated the role of individual HSV-1 genes in preventing cytolysis and apoptosis, and in decreasing viral yield after CTL exposure of HSV-infected fibroblasts, using viruses deleted for the immune evasion gene Us12 or one of the two antiapoptotic genes Us3 and Us5. To evaluate CTL-mediated apoptosis, we used a flow cytometry assay measuring active caspase-3 in target cells. This assay was more sensitive than the chromium release assay used to evaluate cytolysis, and measured a different aspect of CTL cytotoxicity. Although virus with deletion of Us12 was markedly defective in the ability to prevent lysis of target fibroblasts, it retained most of its ability to protect target fibroblasts from CTL-induced apoptosis. Virus with deletion of Us3 was also defective in the ability to prevent lysis of target fibroblasts, yet such virus protected target fibroblasts from CTL-induced apoptosis as well as wild-type viruses. In contrast, Us5-deleted virus showed defects in the ability to protect target fibroblasts from both cytolysis and apoptosis after CTL attack. In addition, the replication of Us12-deleted virus was reduced compared with wild-type virus in fibroblasts subjected to CTL attack 6 h after infection, but showed equivalent replication when CTL attack occurred later. In contrast, Us3- or Us5-deleted virus showed no measurable defect in their ability to replicate in fibroblasts under CTL attack. Our data suggest that cytolysis, apoptosis, and viral yield do not necessarily correlate in infected cells under CTL attack. Furthermore, the Us3, Us5, and Us12 viral genes each have unique inhibitory effects on the different T lymphocyte cytotoxic effects. Taken together, these results suggest that HSV evasion of cellular immunity is multifacterial and complex, and relies on the partially redundant activities of various individual HSV proteins.

Frequent and asymptomatic oropharyngeal shedding of human herpesvirus 8 among immunocompetent men

BACKGROUND

Little is known about the clinical and virologic manifestations of human herpesvirus (HHV)-8 infection in immunocompetent persons in the absence of malignancy.

METHODS

A total of 46 human immunodeficiency virus-negative, HHV-8-seropositive men collected saliva daily, and 25 recorded 15 common symptoms daily (gastrointestinal, constitutional, and oropharyngeal) and absences from work or school. Quantitative polymerase chain reaction measured HHV-8 DNA in saliva.

RESULTS

Some 44 (96%) of 46 men reported having sex with men (MSM). Of the 44 MSM, 27 (61%) had HHV-8 detected in saliva on > or = 1 day; heterosexual men also shed HHV-8. In analyses restricted to MSM, HHV-8 DNA was detected on 636 (22%) of 2897 days. Among MSM with HHV-8 detected in saliva, the median rate was 20% (range, 1%-100%), with 30% shedding on > 50% of days, and the median quantity was 4.5 log10 copies/mL (range, 2.0-7.3 log10 copies/mL). The quantity of HHV-8 shed was lower in nonwhites (P<.001) and younger participants (P=.03). The frequency of HHV-8 detection and quantity were correlated (r=0.62; P<.001). Symptoms were reported on 10 (9%) of 114 days when HHV-8 was present, compared with 78 (9%) of 830 days without (odds ratio, 0.93 [95% confidence interval, 0.30-2.88]; P=.9).

CONCLUSIONS

HHV-8 is detected frequently and intermittently in the saliva of chronically infected immunocompetent MSM, but this infection is asymptomatic.

Famciclovir for the treatment of recurrent genital herpes: a clinical and pharmacological perspective

Herpes simplex virus is one of the most common causes of genital ulcer disease worldwide. Herpes simplex virus-2 is the more common cause of genital herpes, a chronic infection that is characterised by periodic reactivation, with the capacity to produce recurrent symptomatic disease in the host (e.g., vesicular eruption), as well as intermittent asymptomatic shedding. Relapsing episodes may be physically and psychologically distressing. Shedding accounts for the majority of cases of transmission of genital herpes to sexual partners. Pregnant women who are shedding may transmit the virus at the time of delivery, with severe and potentially fatal consequences to the baby. Famciclovir, a synthetic acyclic guanine derivative, is the prodrug of penciclovir, which demonstrates in vitro antiviral activity against various types of herpes virus, including herpes simplex virus-2. Its pharmacokinetics allow for administration in a convenient dosing regimen compared with acyclovir, which may improve compliance. Clinical studies have demonstrated its efficacy in the episodic treatment of relapses, with the most recent report demonstrating its efficacy and tolerance as a single-day treatment. It is also efficacious and well tolerated for the suppression of frequently recurring episodes. These results have been demonstrated in various patient populations, including immunocompetent patients and those infected with HIV. Famciclovir is well tolerated, with an adverse events profile similar to placebo.

Comparative efficacy of famciclovir and valacyclovir for suppression of recurrent genital herpes and viral shedding

BACKGROUND

Daily antiviral therapy with famciclovir and valacyclovir has been shown to be effective in reducing both symptomatic and asymptomatic reactivation of herpes simplex virus type 2 (HSV-2) when compared to placebo. However, few comparative studies between the 2 antivirals have been performed.

OBJECTIVES

To compare the clinical and virologic effects of famciclovir and valacyclovir administered as daily suppressive therapy for persons with genital herpes.

STUDY DESIGN

Two randomized, double-blind, placebo-controlled studies comparing daily famciclovir 250 mg bid with valacyclovir 500 mg qd were performed. Study 1 randomized 320 participants and compared the clinical effect of the drugs given for 16 weeks, and study 2 enrolled 70 HSV-2 seropositive subjects and compared the virologic effect of the drugs given for 10 weeks.

RESULTS

In study 1, the time to first recurrence was similar in famciclovir and valacyclovir recipients, hazard ratio (HR) 1.17 (95% CI, 0.78-1.76), but time to first virologically confirmed recurrence was shorter among famciclovir recipients, HR = 2.15 (95% CI, 1.00-4.60). In study 2, HSV was detected on 3.2% of days among famciclovir recipients and 1.3% of days among valacyclovir recipients, relative risk 2.33 (95% CI, 1.18-4.89).

CONCLUSION

Valacyclovir appear to be somewhat better than famciclovir for suppression of genital herpes and associated shedding. Further comparative trials of antiviral drugs for various indications should be performed as acyclovir and penciclovir appear to have different ability to abrogate HSV reactivation.

Effect of valacyclovir on viral shedding in immunocompetent patients with recurrent herpes simplex virus 2 genital herpes: a US-based randomized, double-blind, placebo-controlled clinical trial

OBJECTIVE

To determine the efficacy of daily suppressive therapy with a 1-g dose of valacyclovir in reducing total (clinical and subclinical) herpes simplex virus 2 (HSV-2) shedding compared with placebo in Immunocompetent patients diagnosed as having recurrent HSV-2 genital herpes.

PATIENTS AND METHODS

From June 18, 2004, to December 17, 2004, patients from 27 US sites with a history of 6 or more genital herpes recurrences per year were randomized in a 3:1 ratio to receive 1 g/d of valacyclovir or placebo. During the double-blind suppressive therapy, patients were provided with the study drug (500-mg valacyclovir caplets or matching placebo) and Instructed to take 2 caplets once daily without regard to meals for 60 days. Daily genital and anal or rectal swabs were self-collected during the 60-day study period for evaluation of HSV-2 viral shedding as determined by quantitative type-specific polymerase chain reaction assay.

RESULTS

One hundred fifty-two patients were randomized into this study, 43 to placebo and 109 to 1 g/d of valacyclovir. A total of 134 completed the study (40 placebo [93%], 94 valacyclovir [86%]), and 18 prematurely withdrew (3 placebo [7%], 15 valacyclovir [14%]). Valacyclovir significantly reduced the percentage of days with total (clinical and subclinical) HSV-2 shedding throughout 60 days compared with placebo. In the intent-to-treat population, a 71% reduction in total shedding (P < .001), a 58% reduction in subclinical shedding (P < .001), and a 64% reduction in clinical shedding (P = .01) were observed. Valacyclovir was not associated with any significant toxic effects compared with placebo.

CONCLUSION

This study demonstrated that 1 g/d of valacyclovir administered for 60 days was generally well tolerated and was an effective suppressive therapy that significantly reduced total (clinical and subclinical) HSV-2 shedding compared with placebo in immunocompetent patients diagnosed as having recurrent HSV-2 genital herpes.

Oral shedding of herpes simplex virus type 1 in immunocompetent persons

BACKGROUND

Reactivation of herpes simplex virus-1 (HSV-1) can result in recurrent herpes labialis lesions (RHL) and in oral shedding of virus. This study utilized polymerase chain reaction (PCR) to document the frequency and quantity of such shedding.

METHODS

Thirty adults with greater than three RHL episodes per year were followed through one recurrence. They collected swabs for PCR every 12 h starting at prodrome and for 10 days thereafter. Shedding was analyzed with regard to frequency, timing and quantity.

RESULTS

HSV-1 was detectable in 87% of participants for a mean of 4 days. Shedding occurred most frequently during the vesicle/ulcer stage (91% of subjects), but was common in both clinical and subclinical stages (50% vs. 23%, average log DNA copy number/ml(2) 2.6 vs. 1.4).

CONCLUSION

The majority of RHL patients shed viral DNA. Shedding occurred before and after the appearance of clinical lesions. Such findings may be useful in designing methods to reduce viral shedding and prevent transmission.

The microenvironment of vulvar skin in women with symptomatic and asymptomatic herpes simplex virus type 2 (HSV-2) infection

BACKGROUND

It is not known why some individuals infected with herpes simplex virus type 2 (HSV-2), experience frequent recurrences, while most of those infected have a completely silent infection.

OBJECTIVE

We wanted to study if local factors in the skin could explain this difference. DESIGn 21 HSV-2 seropositive patients, 10 with history of >8 clinical recurrences a year (symptomatics) and 11 without symptoms of genital herpes (asymptomatics) were included. All had to answer a questionnaire. With standardised methods, the skin temperature, pH, and the skin barrier function, expressed as transepidermal water loss (TEWL) and skin capacitance, were measured on labium majus and perineum. Culture for bacteria was performed from the same regions.

RESULTS AND CONCLUSION

No significant differences in terms of pH and skin barrier function were registered between symptomatic and asymptomatic patients. Asymptomatic patients had a tendency (0.06) to a higher colonisation with lactobacilli on labium majus than symptomatic patients.

Incidence and Prevalence of Herpes Simplex Virus Infections in Adolescent Women

OBJECTIVES

We conducted this study to examine the incidence, prevalence, and risk factors for herpes simplex virus (HSV) 1 and HSV 2 infection in a cohort of young women who were closely followed for acquisition of sexually transmitted infections.

STUDY DESIGN

Women between the ages of 14 and 18 years had blood and genital specimens obtained quarterly to test for incident sexually transmitted infections. Subjects also had 2 12-week periods each year when they kept a detailed behavioral diary and performed weekly vaginal swabs. Serum specimens were tested for HSV 1 and HSV 2 antibody, and genital specimens were tested for HSV DNA by PCR.

RESULTS

A total of 100 subjects enrolled and had at least 2 sera that could be analyzed for seroconversion. The mean age of the subjects was 15.8 years at entry. The HSV 1 and HSV 2 seroprevalence at entry was 59.6% and 13.5%, respectively. During the study, 4 subjects acquired HSV 1 antibody and 7 acquired HSV 2 antibody, but there were no cases of symptomatic HSV infection identified. The annualized incidence among susceptible individuals was 8.9% for HSV 1 and 7.4% for HSV 2. Three of the 7 HSV 2 sero-converters had HSV 2 DNA detected in vaginal swabs. Age, duration of sexual activity, and the presence of other sexually transmitted infections were predictors of HSV 2 antibody positivity.

CONCLUSIONS

Acquisition of HSV 1 and HSV 2 is relatively common in adolescent women, although symptomatic infection is uncommon. HSV 2 is shed in the genital tract despite the lack of symptoms.

Valacyclovir prophylaxis to prevent recurrent herpes at delivery: a randomized clinical trial

OBJECTIVE

To measure the efficacy of valacyclovir suppression in late pregnancy to reduce the incidence of recurrent genital herpes in labor and subsequent cesarean delivery.

METHODS

A total of 350 pregnant women with a history of genital herpes were assigned randomly to oral valacyclovir 500 mg twice a day or an identical placebo from 36 weeks of gestation until delivery. In labor, vulvovaginal herpes simplex virus (HSV) culture and polymerase chain reaction (PCR) specimens were collected. Vaginal delivery was permitted if no clinical recurrence or prodromal symptoms were present. Neonatal HSV cultures and laboratory tests were obtained, and infants were followed up for 1 month after delivery. Data were analyzed using chi2 and Student t tests.

RESULTS

One hundred seventy women treated with valacyclovir and 168 women treated with placebo were evaluated. Eighty-two percent of the women had recurrent genital herpes; 12% had first episode, nonprimary genital herpes; and 6% had first episode, primary genital herpes. At delivery, 28 women (8%) had recurrent genital herpes requiring cesarean delivery: 4% in the valacyclovir group and 13% in the placebo group (P = .009). Herpes simplex virus was detected by culture in 2% of the valacyclovir group and 9% [corrected] of the placebo group (P =.02). No infants were diagnosed with neonatal HSV, and there were no significant differences in neonatal complications. There were no significant differences in maternal or obstetric complications in either group.

CONCLUSION

Valacyclovir suppression after 36 weeks of gestation significantly reduces HSV shedding and recurrent genital herpes requiring cesarean delivery.

LEVEL OF EVIDENCE

I.

The psychosocial impact of serological diagnosis of asymptomatic herpes simplex virus type 2 infection

OBJECTIVES

To evaluate the impact of a positive herpes simplex virus type 2 (HSV-2) serological test on psychosocial functioning among people with no known history of genital herpes.

METHODS

Individuals (age 14-30 years) without a history of genital herpes were recruited from an urban university setting and sexually transmitted diseases (STD), primary care, and adolescent clinics. Participants completed a questionnaire addressing psychological functioning, psychosocial adjustment, and perceived quality of sex and were offered free HSV-2 antibody testing. 33 HSV-2 positive people and 60 HSV-2 negative people demographically matched from the same source of recruitment were re-evaluated at a 3 month follow up visit. HSV-2 positive participants also completed a genital herpes quality of life (GHQOL) measure.

RESULTS

Of the 33 who were HSV-2 seropositive, four did not recall their diagnosis. In comparing those who were HSV-2 positive with those who were negative, repeated measures analysis of variance indicated there were no significant differences over time on any of the measures. None the less, many HSV-2 positive individuals indicated that the diagnosis had a notable impact on their quality of life. Also, among the HSV-2 positive people, lower GHQOL at the 3 month follow up was predicted by higher interpersonal sensitivity (r = -0.44, p<0.05), lower social support (r = 0.40, p<0.05), and quality of sex (r = 0.62, p<0.01) at baseline.

CONCLUSIONS

A diagnosis of asymptomatic HSV-2 infection does not appear to cause significant lasting psychological difficulties. Those for whom the diagnosis had the greatest impact were interpersonally vulnerable before the diagnosis. These results suggest that assessment of interpersonal distress may be important to include as part of pretest and post-test counselling.

Type specific seroprevalence of HSV-1 and HSV-2 in four geographical regions of Poland

OBJECTIVE

To examine the type specific seroprevalence of herpes simplex virus (HSV) types 1 and 2 infections, stratified by age and gender, and associated risk factors for HSV-2 seropositivity in Poland.

METHODS

2257 serum samples of individuals from 15-65 years were randomly selected from serum banks in four different geographical regions of Poland, including the Zachodnio-pomorskie, Warmińsko-mazurskie, Lubelskie, and Mazowieckie districts. Type specific serum antibodies to HSV-1 and HSV-2 were detected using HerpeSelect IgG ELISA tests.

RESULTS

Overall prevalences of type specific HSV-1 and HSV-2 serum antibodies were 90.4% and 9.3%, respectively. Age standardised HSV-2 seroprevalence was higher in women (9.7%) than men (8.8%) (p = 0.06), and increased notably with age from 4% in 15-24 year olds to 12% in those aged 50-65 years. HSV-1 seroprevalence was consistently higher than HSV-2 seroprevalence in each specific age group, ranging from 74.5% in 15-24 year olds to 98.8% in 50-65 year olds. HSV-2 seroprevalence varied significantly by geographical region, with the highest prevalence in the Zachodnio-pomorskie district (12%). Significant multivariate risk factors for HSV-2 seropositivity included older age, female gender, and geographical place of residence.

CONCLUSION

This large survey found a notably high seroprevalence of HSV-1, even among young female adolescents 15-19 years of age (80%). HSV-2 seropositivity was under 12% in all age groups surveyed in Poland, tending to be among the lowest overall HSV-2 seropositivity rates reported thus far in Europe.

Valacyclovir for the treatment of genital herpes

Genital herpes is the most prevalent sexually transmitted infection in the USA. While sometimes mild in severity, it can be a distressing and painful chronic condition. Likewise, herpes labialis and herpes zoster can be both physically and psychologically painful. While there is no cure for these conditions, treatment to alleviate symptoms, suppress recurrences and reduce transmission has been drastically improved over the past 20 years with the use of guanine nucleoside antivirals, such as valacyclovir hydrochloride (Valtrex), GlaxoSmithKline) the highly bioavailable prodrug of acyclovir (Zovirax((R)), GlaxoSmithKline), and famciclovir (Famvir, Novartis), a highly bioavailable prodrug of penciclovir (Denavir, Novartis). Clinical trials involving approximately 10,000 patients (including patients from nongenital herpes studies, such as herpes zoster) have assessed the safety and efficacy of valacyclovir in the treatment of initial genital herpes outbreaks, episodic treatment of recurrent episodes and daily suppressive therapy. It was shown that valacyclovir has similar efficacy to acyclovir in the episodic and suppressive treatment of genital herpes. Valacyclovir is the only antiviral drug approved for a once-daily dose of suppressive therapy for genital herpes, as well as the only antiviral drug US FDA approved for a 3-day regimen of episodic treatment of recurrent genital herpes. In addition, valacyclovir is also indicated in the reduction of the sexual transmission of herpes simplex virus infection and for the treatment of herpes labialis. In herpes zoster, valacyclovir is more effective than acyclovir or placebo (and as equally effective as famciclovir) in shortening the length and severity of herpes zoster-associated pain and postherpetic neuralgia. Valacyclovir has an acceptable safety profile in patients with herpes simplex and herpes zoster. The less frequent dosing regimen makes it an attractive option in the treatment of genital herpes and other viral infections, and may contribute to increased patient adherence to therapy.

Sexual behaviour and condom use among individuals with a history of symptomatic genital herpes

OBJECTIVES

This study describes the differences in sexual behaviour in individuals with genital herpes (GH) during "symptomatic" and "asymptomatic" periods of the disease.

METHODS

A cross sectional questionnaire was undertaken by 1193 individuals attending clinics between 1998 and 2001. All participants in this analysis were in heterosexual, monogamous partnerships, self identified with a history of symptomatic GH and with confirmed HSV-2 infection.

RESULTS

Sexual activity reported during asymptomatic v symptomatic periods of GH was 98% v 40% (p<0.001), 76% v 29% (p<0.001), and 25% v 11% (p<0.001) for vaginal, oral, and anal intercourse, respectively, while "always" condom use during asymptomatic and symptomatic periods was 20% v 35% (p<0.001), 2% v 7% (p<0.001), and 10% v 15% (p = 0.131), respectively. The proportion of individuals who either abstained from vaginal intercourse or "always" used condoms was 21% v 74% (p<0.001), for asymptomatic v symptomatic periods. Multivariable analyses indicated that factors associated with engaging in intercourse during symptomatic periods of GH included current intrauterine device use (adjusted odds ratio (aOR) = 2.96, 95% confidence interval (CI) = 1.46 to 6.02); living in Latin America (aOR = 2.16, CI = 1.19 to 3.91) or Europe (aOR = 1.67, CI = 1.21 to 2.28), compared with North America; previous sexually transmitted disease (aOR = 1.42, CI = 1.08 to 1.89); a higher number of sexual acts per month (aOR = 1.09, CI = 1.06 to 1.11); and a higher number of GH recurrences per year (aOR = 1.08, CI = 1.03 to 1.12).

CONCLUSIONS

These data indicate that the majority of people with GH either abstained from intercourse or "always" used condoms during symptomatic periods of GH. However, condom use was relatively low during asymptomatic periods in comparison with symptomatic periods. These results highlight that further education on GH prevention is warranted, particularly for symptomatic periods.

Can population differences explain the contrasting results of the Mwanza, Rakai, and Masaka HIV/sexually transmitted disease intervention trials?: A modeling study

OBJECTIVE

To determine whether population differences can explain the contrasting impacts on HIV observed in the Mwanza trial of sexually transmitted disease (STD) syndromic treatment (ST), the Rakai trial of STD mass treatment (MT), and the Masaka trial of information, education, and communication (IEC) with and without ST as well as to predict the effectiveness of each intervention strategy in each population.

METHODS

Stochastic modeling of the transmission of HIV and 6 STDs was used with parameters fitted to demographic, sexual behavior, and epidemiological data from the trials and general review of STD/HIV biology.

RESULTS

The baseline trial populations could be simulated by assuming higher risk behavior in Uganda compared with Mwanza in the 1980s, followed by reductions in risk behavior in Uganda preceding the trials. In line with trial observations, the projected HIV impacts were larger for the ST intervention in Mwanza than for the MT intervention in Rakai or the IEC and IEC + ST interventions in Masaka. All 4 simulated intervention strategies were more effective in reducing incidence of HIV infection in Mwanza than in either Rakai or Masaka.

CONCLUSIONS

Population differences in sexual behavior, curable STD rates, and HIV epidemic stage can explain most of the contrast in HIV impact observed between the 3 trials. This study supports the hypothesis that STD management is an effective HIV prevention strategy in populations with a high prevalence of curable STDs, particularly in an early HIV epidemic.

Single-Day, Patient-Initiated Famciclovir Therapy for Recurrent Genital Herpes: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Orally administered antiviral therapy for genital herpes improves the time to lesion healing and resolves symptoms during an outbreak. Although traditional therapy for a recurrent episode for healthy adults has consisted of twice-daily dosing for 5 days, recent studies have indicated that shorter courses of antiviral therapy are effective. This study was conducted to assess the efficacy and safety of a patient-initiated, single-day regimen of famciclovir therapy, compared with placebo, in immunocompetent adult patients with recurrent genital herpes.

METHODS

This multicenter, multinational, randomized, double-blind, parallel-group, placebo-controlled study compared single-day, patient-initiated oral famciclovir (1000 mg given twice daily) with placebo for the treatment of recurrent genital herpes. Patients were instructed to initiate therapy within 6 h after onset of prodromal symptoms or genital herpes lesions.

RESULTS

Famciclovir reduced (P < .001) the time to healing of nonaborted lesions (i.e., those that progressed [corrected] beyond the papule stage) (median time, 4.3 vs. 6.1 days) and all nonaborted and aborted lesions (median time, 3.5 vs. 5.0 days), compared with placebo. The proportion of patients with aborted lesions was larger in the famciclovir group than in the placebo group (23.3% vs. 12.7%; P = .003). Adverse events in the famciclovir group were infrequent overall; most were of mild-to-moderate severity and were similar to adverse events in the placebo group.

CONCLUSIONS

A single-day regimen of patient-initiated famciclovir treatment was well tolerated and safe, and the healing of recurrent genital herpes lesions occurred approximately 2 days faster than with placebo. Moreover, single-day famciclovir treatment stopped the development or progression of lesions beyond the papule stage. This convenient single-day regimen has the potential for improving patient compliance and satisfaction with therapy.

Genital herpes vaccines—cause for cautious optimism

The high prevalence of herpes simplex virus infections in many communities, its numerous serious physical and psychological complications and its importance in enhancing the transmission of HIV make this virus an obvious target for prevention by vaccination. Randomised clinical trials of only one genital herpes vaccine has shown efficacy so far. Analysis of clinical results is complicated by the difference between disease and infection, different results for males and females and the interaction between HSV-1 and HSV-2 immunity.

Risk factors for herpes simplex virus transmission to pregnant women: a couples study

OBJECTIVE

This study was undertaken to determine risk factors for herpes simplex virus (HSV) acquisition among at risk pregnant women.

STUDY DESIGN

Women in a prospective study of HSV acquisition in pregnancy invited their sexual partners for HSV type-specific serologic testing. Risk factors for HSV susceptibility, exposure, and acquisition were examined.

RESULTS

A total of 3192 couples enrolled; 22% included women at risk for HSV-1 or HSV-2. Among 582 HSV-1 seronegative women with HSV-1 seropositive partners, 14 (3.5% adjusted for gestation length) acquired HSV-1. Having a partner with a history of oral herpes was associated with HSV-1 acquisition (odds ratio [OR] 8.1, 95% CI: 1.8-36.0) and accounted for 75% of incident infections. Among 125 HSV-2 seronegative women with HSV-2 seropositive partners, 17 (20% adjusted for gestation length) acquired HSV-2. Duration of partnership of 1 year or less was associated with HSV-2 acquisition (OR 7.8, 95% CI: 2.3-25.7) and accounted for 63% of incident infections. No combination of clinical characteristics could identify the majority of susceptible women with serologically discordant partners.

CONCLUSION

HSV acquisition rates in pregnancy are high in discordant couples, especially for HSV-2. Interventions that address risk factors for HSV acquisition should be studied in pregnancy. Clinical profiles cannot replace serologic screening to identify susceptible women with serologically discordant partners.

Differentiation of herpes simplex virus types 1 and 2 in clinical samples by a real-time taqman PCR assay

While the clinical manifestations of HSV-1 and -2 overlap, the site of CNS infection, complications, response to antivirals, frequency of antiviral resistance, and reactivation rate on mucosal surfaces varies between HSV-1 and -2. Detection of HSV DNA by PCR has been shown to be the most sensitive method for detecting HSV in clinical samples. As such, we developed a PCR-based assay to accurately distinguish HSV-1 from HSV-2. Our initial studies indicated the assay using type specific primers was slightly less efficient for detecting HSV-1 and -2 DNA than the high throughput quantitative PCR assay we utilize that employs type common primers to gB. We subsequently evaluated the type specific assay on 3,131 specimens that had HSV DNA detected in the type common PCR assay. The typing results of these specimens were compared with the monoclonal antibody staining results of culture isolates collected from the same patients at the same time, and the HSV serologic status of the patient. The typing assay accurately identified both HSV-1 and -2 with a specificity of >99.5% and was significantly more sensitive than typing by culture and subsequent monoclonal antibody assays. Complete concordance was seen between the typing assay and HSV serologic status of the patient. Dual (HSV-1 and -2) infection in clinical samples was recognized in 2.6% of clinical samples using the new typing assay. This assay, when used in combination with the type common assay, can now accurately type almost all mucosal and visceral HSV isolates by molecular techniques.

Reducing the risk of transmitting genital herpes: advances in understanding and therapy

BACKGROUND

This review considers the epidemiology and impact of genital herpes, discusses how herpes simplex virus-2 (HSV-2) is transmitted, and reviews data on methods of reducing the risk of HSV transmission.

SCOPE

Information for the paper was identified through multiple PubMed searches. Information in the section on interventions was identified through PubMed searches using several pairs of key words (herpes and transmission, herpes and treatment, herpes and antiviral, herpes and valacyclovir, herpes and famciclovir, herpes and acyclovir, herpes and condom, herpes and clinical trial). The searches, conducted in January 2005, did not have date limits. Papers were selected for inclusion based on the author's judgment of their relevance to the topic of the review.

FINDINGS

An estimated 45 million persons in the United States have genital herpes infection, and new infections occur at a rate of approximately one million per year. Approximately 85% to 90% of infections are unrecognized and therefore undiagnosed. Individuals with genital HSV-2 infection shed virus during asymptomatic periods as well as symptomatic periods. In fact, transmission frequently occurs during periods of asymptomatic viral shedding. Asymptomatic viral shedding (1) occurs in the majority of patients with genital HSV-2 infection; (2) accounts for approximately one third of the days of viral shedding; (3) occurs regardless of duration of infection but is most frequent during the first year after infection; (4) occurs more than 7 days before or after a symptomatic recurrence 50% of the time; and (5) does not differ significantly when comparing patients with 1 to 12 annual recurrences to those with no recurrences. A recently published study of discordant couples counseled on safe sex practices found that once daily suppressive therapy with valacyclovir reduced the risk of transmission of HSV-2 in heterosexual immunocompetent adult couples discordant for HSV-2 infection. In an 8-month study, daily valacyclovir compared with placebo reduced the risk of acquisition of symptomatic genital HSV-2 infection by 75% (2.2% placebo vs. 0.5% valacyclovir; hazard ratio = 0.25; p = 0.008). The overall risk of acquisition of HSV-2 infection (defined via laboratory-confirmed symptoms or seroconversion) was reduced by 48% (3.6% placebo vs. 1.9% valacyclovir hazard ratio = 0.52; p = 0.04). The most common adverse events in the study were headache, nasopharyngitis, and upper respiratory infection.

CONCLUSION

Daily suppressive therapy is recommended as a therapeutic option for HSV-2 seropositive individuals at risk of transmitting HSV-2. Because no intervention completely protects against transmission of HSV, infected individuals and their partners should be counseled to use safer sex practices, including the use of condoms.

The effects of herpes simplex virus-2 on HIV-1 acquisition and transmission: a review of two overlapping epidemics

Increasing evidence demonstrates a substantial link between the epidemics of sexually transmitted HIV-1 and herpes simplex virus (HSV)-2 infection. More than 30 epidemiologic studies have demonstrated that prevalent HSV-2 is associated with a 2- to 4-fold increased risk of HIV-1 acquisition. Per-sexual contact transmission rates among couples from Rakai, Uganda indicate that at all levels of plasma HIV-1 RNA in the source partner, HSV-2-seropositive HIV-1-susceptible persons have a 5-fold greater risk of acquiring HIV-1 compared with HSV-2-negative persons. In vitro and in vivo studies suggest that mucosal HIV-1 shedding is more frequent and in greater amounts during mucocutaneous HSV-2 replication, including subclinical mucosal reactivations. Most HIV-1-infected persons are coinfected with HSV-2, and most experience frequent subclinical and clinical reactivations of HSV-2. Subclinical HSV reactivation elevates serum HIV-1 RNA levels, and daily therapy with acyclovir appears to reduce plasma HIV-1 RNA. These data show that greater attention to the diagnosis and treatment of HSV-2 among HIV-1-infected persons is warranted, especially those who continue to be sexually active, those not on antiretroviral therapy, or those whose disease is not well suppressed by antiretrovirals.

Herpes simplex virus in pregnancy: new concepts in prevention and management

Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted diseases in the United States. It is estimated that 45 million adolescents and adults are infected with genital HSV. Most genital herpes infections in the United States are caused by HSV type 2 (HSV-2), and 25% to 30% of women of reproductive age have HSV-2 antibodies. What is more striking is that genital herpes is frequently under-recognized, and that only 5% to 10% of these women have a history of genital herpes. Because such a small percentage of women are aware of being infected with HSV, the risk of maternal transmission of this virus to the fetus or newborn is a significant health issue.

Psychological symptoms associated with genital herpes virus infections: epidemiology and approaches to management

Genital herpes is a common, chronic, recurrent, viral sexually transmitted infection (STI) occurring worldwide. The first episode may be severe and prolonged, but most recurrences are usually short lived and minor. Although most individuals with this infection have no symptoms, STIs, including genital herpes, often cause psychological and psychosexual morbidity. Unfortunately, the existing data on the psychological symptoms associated with genital herpes have many limitations, including anecdotal reporting, evaluation of small and selected populations, use of varied and sometimes unevaluated questionnaires, and lack of controls. Some individuals with recurrent genital herpes display a range of emotional responses, including depression, anguish, distress, anger, diminution of self-esteem and hostility towards the person believed to be the source of infection. However, it is always important to consider the possibility of pre-existing psychopathology. Several retrospective studies have suggested that stress could lead to recurrences of genital herpes infection. However, prospective studies have been unable to demonstrate any relationship between pre-existing stress and recurrences. What these studies were able to demonstrate was that stress and recurrences occurred simultaneously, suggesting that perhaps it was the recurrences that were causing stress, rather than the reverse.

Managing Patients with Genital Herpes and their Sexual Partners

There is increasing recognition of the growing size and significance of the genital herpes epidemic. Recent developments in the wide-scale availability of type-specific herpes simplex virus (HSV) sero-logic assays have meant that many previously undiagnosed mild,atypical, and subclinical infections may now be diagnosed with some degree of confidence without the use of Western blots. The value of such diagnostics is controversial. However, the importance of HSV with its facilitation of HIV transmission and acquisition, the availability of various preventative strategies for limiting vertical HSV transmission, and the growing evidence that condoms, some educational and counseling interventions, and antiviral therapies may limit sexual transmission, have challenged many of the arguments against wider testing of the population.

Counseling the Patient who has Genital Herpes or Genital Human Papillomavirus Infection

Educational counseling has an important role in managing patients who have viral STIs, such as genital herpes and genital HPV infections. Given the lack of a curative therapy for both, patients may require long-term management and may need to be attentive to recurring symptoms. In addition, both diagnoses may raise issues of persisting infectiousness along with a need for patient counseling about the potential risk to partners and risk reduction strategies. Lastly, dozens of published papers over the years describe potential psychosocial sequelae for patients who have genital herpes, and there is a growing psychosocial literature on genital HPV as well. Clinicians can make a significant difference in patient adjustment to the diagnosis of an STI, and addressing these challenging issues will benefit patients greatly.

Developments in STD/HIV Interactions: The Intertwining Epidemics of HIV and HSV-2

Antiviral agents aimed at treating HSV-2 chronically infected individuals have proven to be effective in the prevention of symptomatic genital herpes and the reduction of viral shedding. These agents play a key role in current HIV prevention trials that will assess the role of suppression of HSV-2 infection on the risk for HIV acquisition and transmission. An added clinical benefit of treating HSV-2/HIV-coinfected individuals is the potential survival benefit, as suggested by earlier studies and by the recent findings that HSV-2/HIV dually infected individuals have higher viral loads. The results of the current HSV-2 suppression trials may provide additional tools to fight the global spread of HIV infection. Treatment of HSV-2/HIV dually infected individuals may prove to be a low-cost intervention to improve clinical outcomes and delay the need for antiretroviral therapy.

Demographic, behavioral, and knowledge factors associated with herpes simplex virus type 2 infection among men whose current female partner has genital herpes

OBJECTIVE/GOAL

The objective of this study was to evaluate risk factors for herpes simplex virus type 2 (HSV-2) infection among men whose female partners have genital herpes (GH).

STUDY

Between 1998 and 2001, 717 men in heterosexual monogamous relationships, without a history of GH, completed a cross-sectional questionnaire on demographic, behavioral, and knowledge factors for GH. Their female partners were symptomatic and HSV-2-seropositive. Risk factors for HSV-2 seropositivity were assessed using logistic regression.

RESULTS

On laboratory confirmation, 25% of the men were HSV-2-seropositive. Factors significantly (P<0.01) associated with HSV-2 infection included: never using condoms (adjusted odds ratio [aOR], 1.84; 95% confidence interval [CI], 1.15-2.95), prior sexually transmitted disease (STD) (aOR, 1.80; CI, 1.27-2.58), vaginal intercourse during symptomatic episodes (aOR, 1.77; CI, 1.19-2.62), longer partnership (for each additional year aOR, 1.07; CI, 1.03-1.09), and lower knowledge of GH (aOR, 1.14; CI, 1.05-1.23).

CONCLUSION

Potentially modifiable risk factors for HSV-2 infection included engaging in vaginal sex during symptomatic episodes, never using condoms, and lower knowledge of GH.

Prevalence and determinants of genital shedding of herpes simplex virus among women attending Italian colposcopy clinics

OBJECTIVES

To determine the prevalence of herpes simplex virus (HSV) shedding among women attending Italian colposcopy clinics and describe their lifestyle, demographic characteristics, genital symptoms and signs.

STUDY DESIGN

A cross-sectional study was performed to assess shedding of HSV among 4565 women requiring a gynecological consultation. An amplified enzyme immunoassay that detects an HSV type-common glycoprotein D was used to reveal HSV shedding in cervical specimens. Statistical analysis was performed using Chi-square test and Student's t test.

RESULTS

A prevalence of 7.8% was found among colposcopy clinic patients. No significant differences regarding patients' average age, age at first sexual intercourse, contraceptive method used, and number of sexual partners in the previous year were found between subjects with and without viral shedding (P > 0.05). The detection of a concomitant genital infection with Trichomonas vaginalis as well as the report of previous episodes of genital herpes (GH) were significantly higher in the positive group (P < 0.01). Only 2.8% of the patients shedding HSV presented with vesicles and ulcers, with the majority of them being asymptomatic.

CONCLUSION

This is the first Italian survey on genital herpes conducted among colposcopy clinic patients. Our data show that the prevalence of HSV shedding in this study population is high and confirms that the disease is often asymptomatic. The demographics and behavioural variables of women shedding HSV seem to differ from the ones assessed in high risk patients.