Seroprevalence of herpes simplex virus infections in a family medicine clinic

Does genital herpes symptom history predict herpes simplex virus type 2 antibody positivity?

BACKGROUND

Sexually transmitted infections (STIs) associated with genital ulcer disease due to herpes simplex virus-2 (HSV-2) are a prominent cause of morbidity and mortality. Serologic screening for HSV-2 is recommended only for individuals with genital herpes symptom history. However, no validated symptom screening tool currently exists.

METHODS

Currently asymptomatic adults presenting for routine care at STI clinics in Lima, Peru completed a survey of prior genital herpes symptoms and received HSV-2 serological testing with the Euroimmun Anti-HSV-2 (gG2) ELISA IgG (Lubeck, Germany). A sub-sample of indeterminate results were sent for Western blot confirmatory testing. We assessed associations between past symptoms and anti-HSV-2 positivity and corrected the HSV-2 prevalence by re-classifying indeterminates per Western Blot results.

RESULTS

We enrolled 131 participants between July and October 2022. HSV-2 antibody test results found 21.4% positive, 41.2% indeterminate, and 37.4% negative. Excluding indeterminate results, 36.4% were positive. Of participants with no prior symptoms 31.2% tested positive, compared to 35.7% with one prior symptom, 50.0% with 2, and 50.0% with 3+ prior symptoms. Among the sub-sample of indeterminates, 92.6% were confirmed positive by Western Blot, bringing the total estimated proportion of participants with HSV-2 antibodies to 59.5%. Either based on the original classification of HSV-2 antibody status or after incorporation of confirmatory testing results, there was no significant association between symptom history and HSV-2 antibody positivity.

CONCLUSIONS

With currently available tests, recommendations to screen individuals based on genital herpes symptom history may not be useful. More discriminatory symptom screening tools or HSV-2 antibody tests with better performance are needed.

Adolescent Primary Genital Herpes Simplex Virus Type 1 Infection with Sepsis Secondary to Streptococcus pyogenes Bacteremia

BACKGROUND

Adolescents and young adults are responsible for most new genital herpes virus infections. Historically, primary genital herpes infections were thought to be caused by herpes simplex virus (HSV) type 2, however, recent studies suggest that up to 50% of incident episodes of genital herpes are caused by HSV type 1.

CASE

In this case report we present an 18-year-old G1P0010 female who presented with a primary genital HSV type 1 outbreak that resulted in sepsis secondary to Streptococcus pyogenes bacteremia.

SUMMARY AND CONCLUSION

Complications that might arise from HSV include encephalitis, Bell's palsy, aseptic meningitis, hepatitis, pneumonitis, sacral radiculitis, viremia, and superimposed bacterial infections. HSV infections are rarely associated with these complications; however, physicians should be aware of sepsis secondary to bacteremia as a possible complication of primary genital HSV infections when treating immunocompetent adolescents.

Herpes simplex laryngitis: Comparison between pediatric and adult patients

OBJECTIVES

Infection with herpes simplex virus (HSV) typically causes limited oral and genital symptoms, however HSV can also affect the larynx and result in severe aerodigestive symptoms. Due to the rarity of HSV laryngitis, the symptoms and clinical course of are not well understood. This study aims to more completely characterize HSV laryngitis in order to aid clinicians in understanding and recognition of HSV laryngitis.

METHODS

Comprehensive literature search of MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews to identify articles relating to HSV laryngitis. Patient demographics, presenting signs and symptoms, treatment and clinical course were extracted from the selected manuscripts.

RESULTS

There were 31 studies on HSV laryngitis that identified 36 patients (17 pediatric, 19 adult). The average age for pediatric patients was 11 months (9 M, 8F) and 52 years for adults (11 M, 8F). In the pediatric population, stridor was more common at presentation in comparison to the adult population (p < .01). Adults more commonly presented with dysphagia (p = .03) and dysphonia (p < .01) Adult patients were significantly more likely to undergo tracheotomy than pediatric patients (p = .047). The mean length of inpatient hospital stay was 21.2 days in pediatric patients and 15.8 days for adult patients.

CONCLUSION

HSV laryngitis has a unique presentation in pediatrics and adults, but is nonspecific in both populations leading to delays in diagnosis and treatment. HSV laryngitis is associated with significant morbidity including multi-week hospital stay and risk for needing tracheostomy in both adults and pediatric population which demonstrates need for clinical awareness of this complication of HSV infection.

Bayesian Evaluation of Solana HSV 1+2/VZV Assay Compared to Viral Culture and Commercial PCR Assay for Cutaneous or Mucocutaneous Specimens

Results from the Solana HSV 1+2/VZV assay for the detection of herpes simplex virus 1 (HSV-1), HSV-2, and varicella-zoster virus (VZV) in cutaneous or mucocutaneous specimens were compared with that of viral culture and a commercial PCR assay (RealStar alpha herpesvirus PCR kit). Three hundred two mucocutaneous specimens, for which HSV-1, HSV-2, or VZV viral culture or PCR detection have been requested, were randomly selected and prospectively processed on the Solana assay and viral culture or the RealStar assay. Discordant results between culture and the Solana assay were further analyzed using the RealStar assay. A Bayesian latent class model was developed to estimate the performance of each method. Viral culture detected 123 positive specimens (85 HSV-1, 36 HSV-2, and 2 VZV), while the Solana assay detected 27 additional positive specimens (4 HSV-1, 11 HSV-2, and 12 VZV), in agreement with the RealStar PCR assay. The estimated sensitivity of the Solana assay according to our model was 92.7% to 98.7%, 87.1% to 97.8%, and 94.9% to 98.8% (95% confidence interval [CI]) for HSV-1 HSV-2, and VZV, respectively, while the estimated sensitivity of viral culture was 85.2% to 95.0%, 73.6% to 89.6%, and 30.9% to 45.8% (95% CI), respectively. A nonsignificant tendency toward increased sensitivity was noted for the Solana assay compared with culture for HSV-1 and HSV-2, and the Solana assay was significantly more sensitive than culture for the detection of VZV. The Solana assay performed comparably to the RealStar assay. Processing time was reduced with the Solana assay compared with viral culture.

Alternative therapies for common dermatologic disorders, part 1

The exact pathophysiology and curative treatment of many common dermatologic conditions remain unclear. Often conventional treatments are only partially effective, leading patients to look for alternative treatments. Rosacea may be helped by azelaic acid. Seborrheic dermatitis may be helped by tea tree oil. Chronic urticaria may be helped by a focused dietary history and elimination of food additives and salicylates. Although various alternative treatments have been touted as useful in herpes simplex, few have proved efficacious.

HSV-2 Serologic Testing in an HMO Population: Uptake and Psychosocial Sequelae

OBJECTIVES

To prospectively measure the uptake of Herpes simplex virus Type 2 (HSV-2) testing and psychosocial response to a new serologic diagnosis of HSV-2 in a health maintenance organization (HMO) population.

STUDY DESIGN

Randomly selected urban HMO enrollees were invited to be tested for HSV-2 antibody at a research clinic. Participants had blood drawn and completed demographic and psychosocial questionnaires.

RESULTS

Of 3111 eligible enrollees contacted, 344 (11%) were tested. Eighty-seven (26%) tested HSV-2 seropositive, and 44 (51%) of these did not report a prior genital herpes diagnosis. Distress, measured by the total mood disturbance, was 6.5 points higher on average following a new genital herpes diagnosis relative to baseline (actual range = 109 points, P = 0.003) but not statistically different from HSV-2 negative or previously diagnosed participants.

CONCLUSIONS

HMO enrollees unexpectedly testing HSV-2 positive showed short-term psychosocial distress that resolved during 6-month follow-up. Findings suggest that concerns about psychosocial burden should not deter voluntary serologic HSV-2 testing in primary care settings.

A Phase 1 Clinical Study of Intravenous Administration of PV701, an Oncolytic Virus, Using Two-Step Desensitization

PURPOSE

In a previous phase 1 study, adverse events, especially flu-like symptoms, were observed mainly following the first i.v. bolus dose of PV701, an oncolytic Newcastle disease virus. Desensitization to adverse events of subsequent doses occurred, allowing a 10-fold increase in the maximum tolerated dose for these doses. Although one-step desensitization (a single desensitizing dose with higher subsequent doses) addressed the tolerability of high repeat doses, additional testing was required to further improve tolerability of the initial dose. This study tested the hypothesis that two-step desensitization, using two dose increments before high repeat doses, would be well tolerated.

EXPERIMENTAL DESIGN

Sixteen adults with incurable solid tumors were enrolled. Cycles consisted of six PV701 doses over 2 weeks followed by a 1-week rest. Doses 1 to 2 were 1 and 12 x 10(9) plaque-forming units (pfu)/m(2), respectively, whereas doses 3 to 6 were escalated by cohort from 24 to 120 x 10(9) pfu/m(2).

RESULTS

No dose-limiting toxicities were observed, permitting dose escalation through cohort 4 (1, 12, 120, 120, 120, 120 x 10(9) pfu/m(2)). Mild flu-like symptoms were common following the first infusion, diminished with repeated dosing, and were less pronounced than those seen previously. Tumor regression was observed in a patient with anal carcinoma who enrolled with stable disease following palliative radiotherapy. Four patients with clearly progressing cancer before enrollment had disease stabilization of >/=6 months.

CONCLUSIONS

This novel two-step desensitization improved patient tolerability compared with the previous regimen. Toxicities were predictable and manageable. PV701, the first oncolytic virus to enter phase 1 i.v. testing, continues to show single-agent activity, warranting planned phase 2 trials.

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.

Herpes Simplex Virus Type 2 (HSV-2) Western Blot Confirmatory Testing Among Men Testing Positive for HSV-2 Using the Focus Enzyme-Linked Immunosorbent Assay in a Sexually Transmitted Disease Clinic

OBJECTIVE

The objective of this study was to define the positive predictive value (PPV) of the Focus herpes simplex virus type 2 (HSV-2) enzyme-linked immunosorbent assay (ELISA) in a low HSV-2 prevalence population and to develop a new test interpretation algorithm.

METHODS

HSV-2 Western blots were performed on sera from male sexually transmitted disease clinic patients testing HSV-2 ELISA-positive and used to define a new class of indeterminate HSV-2 ELISA result. HSV-2 Western blots were then prospectively performed on sequential sera with indeterminate HSV-2 ELISAs.

RESULTS

Ninety-one (84%) of 108 HSV-2 ELISA-positive sera tested HSV-2 Western blot-positive. Western blot positivity was more common in men without herpes simplex virus type 1 (HSV-1) antibody than in those with HSV-1 antibody (93% vs 76%, P = 0.02) and in men with a history or clinical evidence of genital lesions (88% vs 80%, P = 0.30). Selectively raising the ELISA index value defining HSV-2 positivity from >1.1 to >or=3.0 either among HSV-1-positive men or among those without a history or clinical evidence of genital lesions increased the PPV to >or=93%. Prospective evaluation of an algorithm incorporating HSV-1 serostatus found that 11 of 70 persons with indeterminate HSV-2 ELISAs were Western blot-positive.

CONCLUSIONS

Clinicians should consider selectively using a higher index value to define Focus ELISA HSV-2 positivity based on either HSV-1 serostatus or clinical circumstances.

Epidemiology of genital herpes simplex virus infections in a community-based sample in France: results of the HERPIMAX study

OBJECTIVE

The objective of this study was to provide information on the prevalence of herpes simplex infections in the general population in Europe.

GOALS

The goals of this study were to determine the prevalence of clinically probable genital herpes and the relationship between serotype and clinical expression in a French community-based sample.

STUDY

A total of 4410 subjects chosen at random were serotyped for herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). Data on symptoms were obtained by questionnaire allowing retrospective diagnosis of clinically probable genital herpes.

RESULTS

Questionnaire data and serotype were available for 3192 subjects. Seroprevalences of HSV-1 and HSV-2 were 65.6% and 15.5%, respectively. Prevalence of clinically probable genital herpes was 11.8%, identified in 11.1% of HSV-1-positive subjects and 26.8% of HSV-2-positive subjects, with a lower prevalence in those coinfected with both virus types.

CONCLUSIONS

Clinically probable genital herpes was observed in one fourth of subjects with HSV-2 infections and in some subjects with HSV-1 infection. Coinfection with HSV-1 appeared to protect against symptom expression in subjects infected with HSV-2.

Macrophages and cytokines in the early defence against herpes simplex virus

Herpes simplex virus (HSV) type 1 and 2 are old viruses, with a history of evolution shared with humans. Thus, it is generally well-adapted viruses, infecting many of us without doing much harm, and with the capacity to hide in our neurons for life. In rare situations, however, the primary infection becomes generalized or involves the brain. Normally, the primary HSV infection is asymptomatic, and a crucial element in the early restriction of virus replication and thus avoidance of symptoms from the infection is the concerted action of different arms of the innate immune response. An early and light struggle inhibiting some HSV replication will spare the host from the real war against huge amounts of virus later in infection. As far as such a war will jeopardize the life of the host, it will be in both interests, including the virus, to settle the conflict amicably. Some important weapons of the unspecific defence and the early strikes and beginning battle during the first days of a HSV infection are discussed in this review. Generally, macrophages are orchestrating a multitude of anti-herpetic actions during the first hours of the attack. In a first wave of responses, cytokines, primarily type I interferons (IFN) and tumour necrosis factor are produced and exert a direct antiviral effect and activate the macrophages themselves. In the next wave, interleukin (IL)-12 together with the above and other cytokines induce production of IFN-gamma in mainly NK cells. Many positive feed-back mechanisms and synergistic interactions intensify these systems and give rise to heavy antiviral weapons such as reactive oxygen species and nitric oxide. This results in the generation of an alliance against the viral enemy. However, these heavy weapons have to be controlled to avoid too much harm to the host. By IL-4 and others, these reactions are hampered, but they are still allowed in foci of HSV replication, thus focusing the activity to only relevant sites. So, no hero does it alone. Rather, an alliance of cytokines, macrophages and other cells seems to play a central role. Implications of this for future treatment modalities are shortly considered.

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.

Development and use of a type-specific antibody avidity test based on herpes simplex virus type 2 glycoprotein G

OBJECTIVES

It is difficult to discriminate between lesions resulting from recently acquired versus established genital herpes simplex virus type 2 (HSV-2) infection. Methods not based on history or serum IgM status are needed.

GOAL

Our goal was to use type-specific gG-2 antibody avidity determinations based on HerpeSelect HSV-2 enzyme-linked immunosorbent assay (ELISA) to identify new infections.

STUDY

Sera (N = 168) from 71 patients with first-episode genital herpes and 45 sera from 21 patients with recurrent episodes were tested.

RESULTS

Median avidity increased from 30.2 in sera drawn </=6 weeks to 54.9 >6 weeks after infection (P <0.001). Patients with recurrent episodes and established HSV-2 infections (median, 6.1 years' duration) had higher avidity antibodies (median, 92.7; range, 55.1-100) than patients after first episodes (median, 33.7; range, 6.4-73.9; P <0.001).

CONCLUSION

Avidity testing based on HerpeSelect ELISA could be a cost-effective method to identify patients with new HSV-2 infections.

Serological testing for herpes simplex virus (HSV)-1 and HSV-2 infection

Serological tests for herpes simplex virus (HSV) that can accurately distinguish between HSV-1 and HSV-2 are now commercially available. These tests detect antibodies to HSV glycoproteins G-1 and G-2, which evoke a type-specific antibody response. Focus Technologies produces the HerpeSelect-1 and HerpeSelect-2 enzyme-linked immunosorbent assay tests and the HSV-1 and HSV-2 HerpeSelect1/2 Immunoblot. Diagnology has marketed POCkit-HSV-2, a point-of-care test for HSV-2 that allows blood from a finger stick to be tested in a clinic. These tests can be used to confirm a genital herpes diagnosis, establish diagnosis of HSV infection in patients with atypical complaints, identify asymptomatic carriers, and identify persons at risk for acquiring HSV. Potential settings for use of these tests include sexually transmitted disease clinics, prenatal clinics, and clinics that care for patients with human immunodeficiency virus. Patient interest in HSV serological tests appears high.

Age-specific prevalence of infection with herpes simplex virus types 2 and 1: a global review

Information on age- and sex-specific prevalence of herpes simplex virus (HSV) types 2 and 1 infections is essential to optimize genital herpes control strategies, which increase in importance because accumulating data indicate that HSV-2 infection may increase acquisition and transmission of human immunodeficiency virus. This review summarizes data from peer-reviewed publications of type-specific HSV seroepidemiologic surveys. HSV-2 prevalence is, in general, highest in Africa and the Americas, lower in western and southern Europe than in northern Europe and North America, and lowest in Asia. HSV-2 and -1 prevalence, overall and by age, varies markedly by country, region within country, and population subgroup. Age-specific HSV-2 prevalence is usually higher in women than men and in populations with higher risk sexual behavior. HSV-2 prevalence has increased in the United States but national data from other countries are unavailable. HSV-1 infection is acquired during childhood and adolescence and is markedly more widespread than HSV-2 infection. Further studies are needed in many geographic areas.

Genital shedding of herpes simplex virus among men

Epidemiologic studies suggest that most sexual transmission of genital herpes occurs when persons shed virus but lack lesions. This study assessed 79 men (63 with a history of genital herpes simplex virus [HSV] type 2 infection, 5 with a history of genital HSV-1 infection, and 11 with HSV-2 antibodies but no history of genital herpes) and obtained daily swabs for viral culture. HSV was isolated at least once from 60 (81%) HSV-2-seropositive men. The total viral shedding rate in HSV-2-seropositive men was 5%; the subclinical shedding rate was 2.2%. Of 11 HSV-2-seropositive men without a genital herpes history, 7 recognized typical recurrences and HSV was detected in 10. The shedding rate among men with genital HSV-2 was significantly higher than among men with genital HSV-1 infection (odds ratio, 4.4; 95% confidence interval, 1.2-15.3). The frequency of viral shedding in men with genital herpes appears comparable with that in women.

Imiquimod 5-percent cream does not alter the natural history of recurrent herpes genitalis: a phase II, randomized, double-blind, placebo-controlled study

Present strategies for control of herpes genitalis recurrences require multiple daily doses of antiviral medication. Imiquimod, an immune response modifier, induces alpha interferon and interleukin-12; application in the presence of local herpes antigens during a recurrence may augment herpes simplex virus (HSV)-specific cell-mediated immunity. To test this theory, we performed a randomized, double-blind, placebo-controlled study of imiquimod 5% cream to assess safety and efficacy for decreasing recurrences. Patients with six or more recurrences of herpes genitalis per year applied study cream (imiquimod or placebo) to lesions one, two, or three times per week for 3 weeks for each recurrence during a 16-week treatment period. This was followed by a 16-week observation period. Of 124 patients randomized to the study, 103 completed the treatment period and 93 completed the observation period. The median times to first genital herpes recurrence were 53 days for those receiving placebo (n = 30) and 54, 60, and 64 days for those receiving imiquimod one time per week (n = 34), two times per week (n = 32), and three times per week (n = 28), respectively. The median annualized recurrence rates during the treatment period were 3.8, 4.9, 3.2, and 3.1, respectively. There were no statistically significant differences in the time to first recurrence or in the annualized recurrence rate between the imiquimod and placebo groups in either the treatment or the observation period. A trend in increased rates of local adverse events at the application site and a delay in lesion healing with more frequent dosing suggested a pharmacologic effect. Although clinical efficacy has been observed for imiquimod in other conditions in which a TH1-type immune response may be beneficial, including other viral infections such as those caused by human papillomavirus, no apparent effect on the short-term natural history of herpes genitalis recurrences was observed.

Seroprevalence of antibodies to herpes simplex virus types 1 and 2 among two sexually active female populations in Middlesbrough, England

Herpes simplex virus (HSV) infection occurs worldwide but its epidemiology varies between different countries and between groups of individuals. Seroprevalence of HSV-1 and HSV-2 antibodies is a more accurate method of determining epidemiology of this infection. In this cross-sectional study, 467 blood samples were obtained from women attending the genitourinary medicine clinic (GUM) and antenatal clinic (ANC) in Middlesbrough, England. Analysis of their blood samples showed that 69.5% GUM patients had HSV-1 antibodies and the figure was 54.5% in the ANC patients, p < 0.0001, with odds ratio 1.9 (95% CI 1.30 to 2.78) for higher prevalence in the GUM group. Also, for HSV-2 antibodies, the seroprevalence was 21.6% for GUM and 8.1% for ANC patients, p < 0.0001, with an odds ratio of 3.13 (95% CI 1.70 to 6.02) for higher prevalence in the GUM group. The overall prevalence for HSV-1 is 63.2% and for HSV-2 is 15.8%. Many of these patients were asymptomatic and constitute a potential source for spreading the virus. Knowledge of HSV seroprevalence can help in planning sexual health promotion strategies.

Increased prevalence of herpes simplex virus type 2 among adolescent women with alcohol use disorders

PURPOSE

To determine the relationship between alcohol use disorders (AUDs) and herpes simplex virus type 2 (HSV-2), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) infections among a sample of sexually active adolescents.

METHODS

Subjects were 240 sexually active male and female adolescents aged 14 to 21 years (mean 17.5 years) recruited from clinical and community settings in western Pennsylvania between 1991 and 1995; 55% had a lifetime history of AUDs (63 females, 69 males) and 45% did not have a lifetime history of AUDs (57 females, 51 males). Participants provided information about demographic factors and sexual behaviors as well as a serum sample that was assayed for antibodies to HSV-2, HBV, and HIV infections. Multivariate logistic regression was used to determine the independent relationship of AUDs to HSV-2 infections among females.

RESULTS

The seroprevalence of HSV-2 infections was 15% among females and 0% among males; the overall prevalence of HBV (1.2%) and HIV (0.4%) infections was very low. Among adolescent females, the seroprevalence of HSV-2 infections was significantly higher among those with an AUD (19%), compared with those without an AUD (10.5%) (adjusted odds ratio 8.1, 95% confidence interval 1.5-44.8, p =.017).

CONCLUSIONS

Adolescent women with an AUD appear to be at substantially increased risk of HSV-2 infection. These results highlight the need to address sexually transmitted diseases among adolescents with alcohol problems.

Rising incidence and prevalence of herpes simplex type 2 infection in a cohort of 26 year old New Zealanders

OBJECTIVES

To examine changes in the incidence and prevalence of herpes simplex type 2 (HSV-2) infection in a birth cohort of 26 year old New Zealanders in whom seroprevalence had been measured at 3.4% at age 21.

METHODS

Sera from 869 cohort members were tested using an indirect IgG enzyme linked immunoassay specific to the HSV-2 glycoprotein G. Serological results were compared with detailed sexual histories.

RESULTS

In all, 96 participants (11%) were seropositive for HSV-2, including at least 56 who seroconverted after their 21st birthday. Among those known to be seronegative at age 21, the annual seroconversion rate was 13.5 cases per 1000 per year, compared with 8.1 cases per 1000 per sexually active year before age 21. New infections were associated with female sex and an early age of first intercourse. The average rate of partner change was lower in the cohort after age 21, and was only modestly increased among those who acquired new HSV-2 infections between ages 21 and 26.

CONCLUSIONS

HSV-2 seroprevalence has risen sharply in this sexually active cohort, despite a reduction in the overall level of partner change. Increased rates of HSV-2 acquisition after age 21 may be due to a higher prevalence of infection in the pool of potential partners encountered during the third decade of life. Factors related to partner choice may have more influence on the risk of HSV-2 infection than the number of sexual partners alone.

The epidemiology of HSV-2 infection and its association with HIV infection in four urban African populations

OBJECTIVES

To estimate age- and sex-specific herpes simplex virus type-2 (HSV-2) prevalence in urban African adult populations and to identify factors associated with infection.

DESIGN AND METHODS

Cross-sectional, population-based samples of about 2000 adults interviewed in each of the following cities: Cotonou, Benin; Yaoundé, Cameroon; Kisumu, Kenya and Ndola, Zambia. Consenting study participants were tested for HIV, HSV-2 and other sexually transmitted infections.

RESULTS

HSV-2 prevalence was over 50% among women and over 25% among men in Yaoundé, Kisumu and Ndola, with notably high rates of infection among young women in Kisumu and Ndola (39% and 23%, respectively, among women aged 15-19 years). The prevalence in Cotonou was lower (30% in women and 12% in men). Multivariate analysis showed that HSV-2 prevalence was significantly associated with older age, ever being married, and number of lifetime sexual partners, in almost all cities and both sexes. There was also a strong, consistent association with HIV infection. Among women, the adjusted odds ratios for the association between HSV-2 and HIV infections ranged from 4.0 [95% confidence interval (CI) = 2.0-8.0] in Kisumu to 5.5 (95% CI = 1.7-18) in Yaoundé, and those among men ranged from 4.6 (95% CI = 2.7-7.7) in Ndola to 7.9 (95% CI = 4.1-15) in Kisumu.

CONCLUSIONS

HSV-2 infection is highly prevalent in these populations, even at young ages, and is strongly associated with HIV at an individual level. At a population level, HSV-2 prevalence was highest in Kisumu and Ndola, the cities with the highest HIV rates, although rates were also high among women in Yaoundé, where there are high rates of partner change but relatively little HIV infection. The high prevalence of both infections among young people underlines the need for education and counselling among adolescents.

Demographic rather than behavioral risk factors predict herpes simplex virus type 2 infection in sexually active adolescents

BACKGROUND

Despite the high prevalence of herpes simplex virus type 2 (HSV-2) infection in adults and data indicating that many HSV-2 infections are acquired in late adolescence, the demographic and sexual behavior correlates of HSV-2 infection in high risk adolescents have not been extensively studied.

METHODS

Using a cross-sectional design we evaluated serologic evidence of HSV-2 infection in 381 adolescents age 14 to 19 years at an urban sexually transmitted disease clinic and a community clinic. Study enrollment was offered to all patients participating in a project offering free hepatitis B vaccine. Participants were interviewed and blood was drawn for HSV Western blot.

RESULTS

Twelve percent [95% confidence interval (CI), 8.6 to 15.1] of 379 adolescents in this study had antibodies to HSV-2. Only 22% of HSV-2-seropositive youth reported a history of herpes. Seropositivity for HSV-2 was significantly associated with African-American race (odds ratio, 2.3; 95% CI 1.1 to 4.8) and female gender (odds ratio, 6.0; 95% CI 2.3 to 15.9); 25% of the African-American girls were HSV-2-seropositive. Self-reported condom use, number of sexual partners in the prior 2 months and history of a sexually transmitted disease did not predict HSV-2 antibody status.

CONCLUSIONS

HSV-2 infection among adolescents was prevalent, particularly among African-American girls, and correlated with demographic rather than behavioral variables. As in adults most HSV-2 infections were unrecognized. These data suggest that type-specific serologic testing for HSV-2 infection should be considered in sexually active adolescents. Prevention efforts should target children before initiation of sexual activity.

Seroprevalence of herpes simplex virus type 1 and type 2 in selected German populations-relevance for the incidence of genital herpes

This study was carried out to determine the prevalence of antibodies to herpes simplex virus types 1 (HSV-1) and 2 (HSV-2) in selected German populations, such as blood donors, hospital patients, and human immunodeficiency virus (HIV)-seropositive individuals. Serum samples collected between 1996 and 1998 were tested by enzyme immunoassays using monoclonal antibody-selected native gG1 and gG2 as antigens and an immunoblot using type-specific recombinant glycoproteins. Equivocal results were resolved by an "in-house" Western blot assay. The prevalence of HSV-1 antibodies increased steadily with age and reached high levels of >/=88% among subjects 40 years of age or older. In the sample of patients and blood donors, the HSV-2 seroprevalence was 12.8% (95% CI = 11.9-13.8%). About 81% of the HSV-2 seropositive subjects were coinfected with HSV-1. When adjusted for age, there was no difference in the HSV-2 seroprevalence between hospital patients and blood donors. The HSV-2 seroprevalence was significantly higher among women (15%) than among men (10.5%), yielding a female : male odds ratio of 1.5 for hospital patients and of 1.67 for blood donors. Among the HIV-infected population, 91.1% were seropositive for HSV-1 and 47.9% for HSV-2. HIV-infected women have a significantly higher risk of HSV-2 infection than men (odds ratio [OR] = 3.22; 95% confidence ratio [CI] 1.99-5.20). In conclusion, although the rate of infections with HSV-2 is relatively low in the German population, attention should be given to the further development in adolescents, especially in view of a possible decrease of HSV-1 seroprevalence in childhood.

Premarket evaluation of the POCkit HSV-2 type-specific serologic test in culture-documented cases of genital herpes simplex virus type 2 [see comment]

BACKGROUND AND OBJECTIVES

The genital herpes epidemic continues, in part, because patients with subclinical or atypical presentations cannot be identified by most herpes simplex virus (HSV) antibody tests. A new product, POCkit HSV-2, has been developed to rapidly and accurately detect antibodies to HSV type 2 (HSV-2) in capillary blood or serum.

GOAL

Sera from patients with culture-documented genital or oral herpes were tested to determine the sensitivity and specificity of the POCkit HSV-2 rapid point-of-care antibody test (Diagnology, Belfast, Northern Ireland).

STUDY DESIGN

Sera from 50 patients with culture-documented HSV type 1 (9 oral, 41 genital) and from 253 patients with genital HSV-2 were tested by POCkit HSV-2 for HSV-2 antibodies. Each subject had a positive culture for HSV within 6 months of serum collection. Sera were preselected to include only those that were seropositive to the respective virus subtype by University of Washington Western blot.

RESULTS

Compared with viral culture and Western blot analysis, sensitivity of the POCkit HSV-2 test for HSV-2 antibody was 96%; specificity was 98%.

CONCLUSION

This test provides rapid, accurate identification of HSV-2 antibody in subjects with established HSV infections.

Reactivation of genital herpes simplex virus type 2 infection in asymptomatic seropositive persons

BACKGROUND

Most persons who have serologic evidence of infection with herpes simplex virus (HSV) type 2 (HSV-2) are asymptomatic. Historically, it has been assumed that these persons have less frequent viral reactivation than those with symptomatic infection.

METHODS

We conducted a prospective study to investigate genital shedding of HSV among 53 subjects who had antibodies to HSV-2 but who reported having no history of genital herpes, and we compared their patterns of viral shedding with those in a similar cohort of 90 subjects with symptomatic HSV-2 infection. Genital secretions of the subjects in both groups were sampled daily and cultured for HSV for a median of 94 days.

RESULTS

HSV was isolated from the genital mucosa in 38 of the 53 HSV-2-seropositive subjects (72 percent) who reported no history of genital herpes, and HSV DNA was detected by the polymerase-chain-reaction assay in cultures prepared from genital mucosal swabs in 6 additional subjects. The rate of subclinical shedding of HSV in the subjects with no reported history of genital herpes was similar to that in the subjects with such a history (3.0 percent vs. 2.7 percent). Of the 53 subjects who had no reported history of genital herpes, 33 (62 percent) subsequently reported having typical herpetic lesions; the duration of their recurrences in these subjects was shorter (median, three days vs. five days; P<0.001) and the frequency lower (median, 3.0 per year vs. 8.2 per year; P<0.001) than in the 90 subjects with previously diagnosed symptomatic infection. Only 1 of these 53 subjects had no clinical or virologic evidence of HSV infection.

CONCLUSIONS

Seropositivity for HSV-2 is associated with viral shedding in the genital tract, even in subjects with no reported history of genital herpes.

Clinical reactivation of genital herpes simplex virus infection decreases in frequency over time

BACKGROUND

Visits to physicians for genital herpes simplex virus (HSV) infection continue to increase. Most patients with symptomatic infections have recurrences, but no studies of the long-term clinical course of genital herpes are available.

OBJECTIVE

To determine whether the frequency of HSV recurrences decreases over time.

DESIGN

Observational cohort study.

SETTING

University-based research clinic.

PATIENTS

664 persons with genital herpes followed for at least 14 months.

MEASUREMENTS

Patients were classified as having initial or recurrent HSV-1 or HSV-2 infection. Patient-reported recurrences and observed recurrences were recorded in a database; more than 12,000 recurrences were analyzed.

RESULTS

Median recurrence rates in the first year of follow-up were one and five per year in patients with newly acquired HSV-1 and HSV-2 infection, respectively; second-year rates were significantly lower in both groups. Patients presenting with recurrent HSV-2 infection had higher rates of recurrence in the first and second years and no significant decrease; significant decreases were detected with longer follow-up. One third of all patients experienced a decrease of two or more recurrences per year between years 1 and 2. Patients infected with HSV-2 who were followed for more than 4 years had a median decrease of two recurrences between years 1 and 5. However, 25% of these patients had an increase of at least one recurrence in year 5, illustrating the variability among HSV-infected persons. Decreases over time among patients who never received suppressive therapy were similar to decreases during untreated periods in patients who received suppressive therapy.

CONCLUSIONS

Herpes simplex virus type 2 infection continues to be a chronic remitting illness. Over time, however, clinically significant reductions occur in a majority of patients. Physicians may wish to periodically assess the need for continued treatment with daily suppressive antiviral chemotherapy.

The use of peptides from glycoproteins G-2 and D-1 for detecting herpes simplex virus type 2 and type-common antibodies

BACKGROUND

identification and discrimination of latent herpes simplex virus (HSV) infection relies on antibody identification. The inclusion of synthetic peptides with HSV glycoproteins provides means for stable and discriminatory assays for population studies.

OBJECTIVE

to determine whether virus-specific synthetic peptides might identify HSV type 2 (HSV-2) antibodies in the presence of the cross-reactive and more common HSV type 1 (HSV-1) antibodies.

STUDY DESIGN

the capacity of synthetic peptides as HSV antigens was analyzed in enzyme immunoassay (EIA) using well characterized human serum cohorts. The HSV peptide assays were evaluated in comparison with two commercial HSV-2 assays.

RESULTS

a combination of two C-terminal HSV-1 glycoprotein D (gD-1) peptides detected type-common HSV immunoglobulin G (IgG) with high sensitivity (95%) and specificity (93%). Peptides derived from the C-terminus of HSV-2 glycoprotein G (gG-2) had a high HSV-2 type-specificity. Inclusion of both gD-1 and gG-2 peptides gave a sensitivity for human anti-HSV-2 IgG that was similar to that of assays including different amounts of native gG-2. With western blotting as a standard, the sensitivity of the peptide assay ranged between 86% for HSV-2 seropositive persons and 61% for HSV-2 seroconverters. Addition of a small amount of native gG-2 to the peptide assay tended to increase the specificity.

CONCLUSION

HSV gG and gD peptides show promise as type-specific and type-common HSV antigens. These peptides are more stable and reproducibly prepared than native or recombinant glycoproteins and may be considered for inclusion in future HSV serodiagnostic assays.

Genital herpes: review of the epidemic and potential use of type-specific serology

Prevention of genital herpes simplex virus (HSV) infections is desirable from both a public health standpoint and the patient's perspective. A key factor in the spread of genital herpes infections is the high proportion of undiagnosed infections. Persons with subclinical or unrecognized infections are best diagnosed by accurate, type-specific antibody tests. Unfortunately, these tests are only now becoming widely available. The use of current, conventional (non-type-specific) serologic tests for diagnosis of herpes infections has resulted in confusion and misdiagnosis of patients. This review provides recent information on the epidemiology of genital herpes infections, describes the importance of subclinical herpes infection and shedding, summarizes the status of HSV type-specific serologic assays being developed, and provides indications for using such assays.

Herpes simplex virus-2 infection. An emerging disease?

Genital herpes infections continue to increase in the world. As outlined previously, several factors play a role in the continued transmission of genital herpes worldwide. Reducing the medical consequences of HSV-2 infection will not be easy. It is also sobering to realize that widespread penetration of HSV-2 into the population had preceded the spread of sexually acquired HIV in most countries. The biological rationale for a connection between HIV and HSV continues to be strengthened. Currently, a specific program to decrease the transmission of genital herpes does not exist. Recent studies with antiviral agents indicate the potential of these compounds to reduce shedding in HIV-negative and in HIV-positive persons and potentially may be useful in preventing some aspects of HSV transmission. Advances in laboratory techniques to assist in the diagnosis of genital herpes infections have added to our knowledge of the natural history and epidemiology of infection. Because of imperfect laboratory tests, negative results do not always indicate lack of infection; this has important public health implications. Large numbers of unrecognized symptomatic cases and frequent asymptomatic shedding are the likely source of continued genital HSV-2 transmission. Solutions for reducing the transmission of genital herpes range from simple, such as counseling patients regarding symptoms and signs of genital herpes and the frequency of subclinical shedding, to complex and expensive, such as screening high risk populations (e.g., STD clinic attendees) for HSV-2 infection. Chronic antiviral therapy may be indicated in HSV-2 seropositive persons without monogamous relationships as they are at risk to transmit HSV to multiple persons. The authors' aim in this review is to provoke discussion of such a control program and to raise the consciousness of the feasibility of instituting control measures for selected populations. We hope to elicit pilot programs designed to reduce the morbidity of this old but re-emerging infectious disease.

Herpes simplex virus seropositivity and reactivation at delivery among pregnant women infected with human immunodeficiency virus-1

OBJECTIVE

Our purpose was to determine whether pregnant women infected with human immunodeficiency virus-1 have an increased risk of herpes simplex virus-2 seropositivity and herpes simplex virus reactivation at delivery.

STUDY DESIGN

Sixty women infected with human immunodeficiency virus and 8408 other patients who were delivered at the University of Washington between 1989 and 1995 had herpes simplex virus serologic determinations at delivery. Genital herpes simplex virus cultures were obtained for 48 (80%) of the human immunodeficiency virus-infected women and 5567 (66%) of the controls. Logistic regression was used to adjust for possible confounding factors.

RESULTS

Forty-five (75%) of human immunodeficiency virus-infected women and 2709 (32%) controls were seropositive for herpes simplex virus-2 (p < 0.0001). Eight percent of human immunodeficiency virus-infected women and 2% of controls had herpes simplex virus reactivation in labor (p < 0.05).

CONCLUSIONS

Infection with herpes simplex virus-2 is common among pregnant women infected with human immunodeficiency virus. Herpes simplex virus reactivation complicates labor in this group more often than in other obstetric patients. The role of herpes simplex virus in perinatal human immunodeficiency virus transmission warrants further study.

Genital herpes in a primary care clinic. Demographic and sexual correlates of herpes simplex type 2 infections

BACKGROUND AND OBJECTIVES

Genital herpes remains one of the most prevalent sexually transmitted diseases (STDs). The sexual behavioral correlates of herpes simplex virus type 2 (HSV-2) infection in the general population have not been well characterized.

GOALS

To assess demographic and sexual behavioral correlates of symptomatic and subclinical HSV-2 infection.

STUDY DESIGN

Cross-sectional survey of 922 randomly chosen patients and 78 of their partners (1,000 total) in a family practice. Sexual behavior information was collected in 492 people.

RESULTS

Two hundred twenty-five (23%) heterosexual people had HSV-2 infection, but only 59 (26%) reported a history of genital herpes. HSV-2 seroprevalence was 63% in African-American women, 27% in white women, 40% in African-American men, and 12% in white men. In multivariate analyses of risk factors for HSV-2 infection among men, 10 or more sexual partners and a prior STD were statistically significantly associated with HSV-2 infection. Among white women, number of sexual partners, a prior STD, marriage or cohabitation, and less than a college education were predictive of HSV-2 infection. A history of oral sex was the only statistically significant predictor of HSV-2 infection in African-American women.

CONCLUSIONS

Risk factors for HSV-2 infection differ by gender and ethnic group. Traditionally recognized behavioral correlates of STD acquisition may not identify people in communities with high prevalence of HSV-2 infection.