Epidemiological characteristics of human herpesvirus-8 infection in a large population of antenatal women in Zambia

Lifestyle factors associated with sex differences in Kaposi sarcoma incidence among adult black South Africans: A case-control study

Kaposi Sarcoma (KS) is endemic in several countries in Southern and Eastern Africa, relatively rare worldwide but a leading cancer among people living with HIV. KS has always been more common in adult males than females. We assessed the prevalence of known cancer modifying factors (parity, hormonal contraceptive use in females, sex-partners, smoking and alcohol consumption in both sexes), and their relationship to KS, and whether any of these could account for the unequal KS sex ratios. We calculated logistic regression case-control adjusted odds ratios (OR_adj), and 95% confidence intervals (95%CI), between KS and each of the modifying factors, using appropriate comparison controls. Controls were cancer types that had no known relationship to exposures of interest (infection or alcohol or smoking or contraceptive use). The majority of the 1275 KS cases were HIV positive (97%), vs. 15.7% in 10,309 controls. The risk of KS among those with HIV was high in males (OR_adj=116.70;95%CI=71.35-190.88) and females (OR_adj=93.91;95%CI=54.22-162.40). Among controls, the prevalence of smoking and alcohol consumption was five and three times higher in males vs. females. We found a positive association between KS and heavy vs. non-drinking (OR_adj=1.31;95%CI=1.03-1.67), and in current heavy vs. never smokers (OR_adj=1.82;95%CI=1.07-3.10). These associations remained positive for alcohol consumption (but with wider CIs) after stratification by sex, and restriction to HIV positive participants. We found no evidence of interactions of smoking and alcohol by sex. Smoking and alcohol consumption may provide a possible explanation for the KS sex differences, given both exposures are more common in men, but confounding and bias cannot be fully ruled out. The role smoking and alcohol play in relation to viral loads of HIV/KSHV, differences in immunological responses or other genetic differences between males and females warrant further studies.

Seroprevalence of human herpesvirus 8 in Ireland among blood donors, men who have sex with men, and heterosexual genitourinary medicine and infectious diseases clinic attendees

Human herpesvirus 8 (HHV-8) seroprevalence varies geographically and between subpopulations. High seroprevalence rates have been ascribed to men who have sex with men (MSM), African migrants, and HIV-infected individuals. The objective of this study was to determine the seroprevalence of HHV-8 in an Irish population, including specific risk groups. A cross-sectional study of 200 blood donors and 200 genitourinary medicine (GUM) and infectious diseases (ID) clinic patients was performed, with testing for Immunoglobulin G (IgG) antibodies to HHV-8 lytic antigens using a commercial indirect fluorescence assay (Scimedx Corp.). Verification was performed at the Centers for Disease Control and Prevention (CDC). All 200 blood donor samples were negative for HHV-8 IgG antibodies. 21% of GUM and ID patients were positive for HHV-8 IgG antibodies. One hundred of these patients were MSM, 35% of whom were HHV-8 seropositive (46% of HIV-positive MSM and 24% of HIV-negative MSM). Of 100 heterosexual patients, only 7% were HHV-8 seropositive. The absence of seropositivity in 200 Irish blood donors may suggest that Ireland has a low overall population HHV-8 seroprevalence. The proportion of HHV-8 seropositivity in the MSM population was significantly higher than in the heterosexual population and most marked in HIV-positive MSM.

Eyelid and Orbital Involvement in HIV Infection - An African Perspective

Both infective and neoplastic eyelid and orbital conditions in human immunodeficiency virus (HIV) infected patients are often the result of opportunistic or co-infections (OI). In most cases, these clinical findings in younger patients alert the physician to suspected underlying HIV infection. When the eyelids and periorbital skin are primarily involved in OI with varicella-zoster virus it is called Herpes Zoster Ophthalmicus. Co-infection with a Pox virus manifests as molluscum contagiosum eruptions. Orbital cellulitis is secondary to various organisms (Mycobacterium tuberculosis, Candida albicans, Aspergillus). Neoplastic disorders are also often associated with OI such as human herpes virus 8 in Kaposi Sarcoma, Epstein-Barr virus in Hodgkin Lymphoma and human papillomavirus 16 and 18 in squamous cell carcinoma. In this review we share our personal clinical experience with HIV disease in Sub-Saharan Africa over more than two decades and provide photographs of cases to illustrate pertinent aspects of the conditions discussed.

Kaposi sarcoma

Kaposi sarcoma (KS) gained public attention as an AIDS-defining malignancy; its appearance on the skin was a highly stigmatizing sign of HIV infection during the height of the AIDS epidemic. The widespread introduction of effective antiretrovirals to control HIV by restoring immunocompetence reduced the prevalence of AIDS-related KS, although KS does occur in individuals with well-controlled HIV infection. KS also presents in individuals without HIV infection in older men (classic KS), in sub-Saharan Africa (endemic KS) and in transplant recipients (iatrogenic KS). The aetiologic agent of KS is KS herpesvirus (KSHV; also known as human herpesvirus-8), and viral proteins can induce KS-associated cellular changes that enable the virus to evade the host immune system and allow the infected cell to survive and proliferate despite viral infection. Currently, most cases of KS occur in sub-Saharan Africa, where KSHV infection is prevalent owing to transmission by saliva in childhood compounded by the ongoing AIDS epidemic. Treatment for early AIDS-related KS in previously untreated patients should start with the control of HIV with antiretrovirals, which frequently results in KS regression. In advanced-stage KS, chemotherapy with pegylated liposomal doxorubicin or paclitaxel is the most common treatment, although it is seldom curative. In sub-Saharan Africa, KS continues to have a poor prognosis. Newer treatments for KS based on the mechanisms of its pathogenesis are being explored.

Excellent clinical outcomes and retention in care for adults with HIV-associated Kaposi sarcoma treated with systemic chemotherapy and integrated antiretroviral therapy in rural Malawi

INTRODUCTION

HIV-associated Kaposi sarcoma (HIV-KS) is the most common cancer in Malawi. In 2008, the non-governmental organization, Partners In Health, and the Ministry of Health established the Neno Kaposi Sarcoma Clinic (NKSC) to treat HIV-KS in rural Neno district. We aimed to evaluate 12-month clinical outcomes and retention in care for HIV-KS patients in the NKSC, and to describe our implementation model, which featured protocol-guided chemotherapy, integrated antiretroviral therapy (ART) and psychosocial support delivered by community health workers.

METHODS

We conducted a retrospective cohort study using routine clinical data from 114 adult HIV-KS patients who received ART and ≥1 chemotherapy cycle in the NKSC between March 2008 and February 2012.

RESULTS

At enrolment 97% of patients (n/N=103/106) had advanced HIV-KS (stage T1). Most patients were male (n/N=85/114, 75%) with median age 36 years (interquartile range, IQR: 29-42). Patients started ART a median of 77 days prior to chemotherapy (IQR: 36-252), with 97% (n/N=105/108) receiving nevirapine/lamivudine/stavudine. Following standardized protocols, we treated 20 patients (18%) with first-line paclitaxel and 94 patients (82%) with bleomycin plus vincristine (BV). Of the 94 BV patients, 24 (26%) failed to respond to BV requiring change to second-line paclitaxel. A Division of AIDS grade 3/4 adverse event occurred in 29% of patients (n/N=30/102). Neutropenia was the most common grade 3/4 event (n/N=17/102, 17%). Twelve months after chemotherapy initiation, 83% of patients (95% CI: 74-89%) were alive, including 88 (77%) retained in care. Overall survival (OS) at 12 months did not differ by initial chemotherapy regimen (p=0.6). Among patients with T1 disease, low body mass index (BMI) (adjusted hazard ratio, aHR=4.10, 95% CI: 1.06-15.89) and 1 g/dL decrease in baseline haemoglobin (aHR=1.52, 95% CI: 1.03-2.25) were associated with increased death or loss to follow-up at 12 months.

CONCLUSIONS

The NKSC model resulted in infrequent adverse events, low loss to follow-up and excellent OS. Our results suggest it is safe, effective and feasible to provide standard-of-care chemotherapy regimens from the developed world, integrated with ART, to treat HIV-KS in rural Malawi. Baseline BMI and haemoglobin may represent important patient characteristics associated with HIV-KS survival in rural sub-Saharan Africa.

Seroprevalence and determinants of Kaposi sarcoma-associated human herpesvirus 8 in Indian HIV-infected males

In India Kaposi's sarcoma is rarely seen in AIDS patients. Hence the current belief is that the incidence of human herpesvirus-8 (HHV-8) is very low in this subcontinent, most probably due to the heterosexual route of HIV transmission. However, there is a scarcity of data on the prevalence of HHV-8 in India. In India the primary mode of HIV transmission is the heterosexual route. Therefore we aimed to determine the prevalence of antibodies against HHV-8 in North Indian HIV-infected men naive of antiretroviral therapy (ART). In a prospective study, 165 Indian adult males were recruited from an ART clinic. Blood samples were collected before administering any antiretroviral drug. The sera were tested for antibodies against HHV-8 using a commercial enzyme-linked immunosorbent assay (ELISA) kit, which detects IgG antibodies to lytic antigens of HHV-8. All positive samples were confirmed for the presence of anti-HHV-8 antibodies using an indirect immunofluorescence assay (IFA). The IFA kit is intended to detect primary, latent, persistent, or reactivated infection of HHV-8. Of the 165 males, 43 (26.06%) were positive by ELISA while 26 (15.8%) were also positive by IFA. Seroprevalence decreased with increasing age (p<0.05). Factors independently associated with HHV-8 infection were younger age group and alcohol consumption. These findings suggest that even in a heterosexual population, HHV-8 can be transmitted frequently.

HHV-8 seroprevalence: a global view

BACKGROUND

Human herpes virus 8 (HHV-8) is the underlying infectious cause of Kaposi sarcoma (KS) and other proliferative diseases; that is, primary effusion lymphoma and multicentric Castleman disease. In regions with high HHV-8 seroprevalence in the general population, KS accounts for a major burden of disease. Outside these endemic regions, HHV-8 prevalence is high in men who have sex with men (MSM) and in migrants from endemic regions. We aim to conduct a systematic literature review and meta-analysis in order 1) to define the global distribution of HHV-8 seroprevalence (primary objective) and 2) to identify risk factors for HHV-8 infection, with a focus on HIV status (secondary objective).

METHODS/DESIGN

We will include observational studies reporting data on seroprevalence of HHV-8 in children and/or adults from any region in the world. Case reports and case series as well as any studies with fewer than 50 participants will be excluded. We will search MEDLINE, EMBASE, and relevant conference proceedings without language restriction. Two reviewers will independently screen the identified studies and extract data on study characteristics and quality, study population, risk factors, and reported outcomes, using a standardized form. For the primary objective we will pool the data using a fully bayesian approach for meta-analysis, with random effects at the study level. For the secondary objective (association of HIV and HHV-8) we aim to pool odds ratios for the association of HIV and HHV-8 using a fully bayesian approach for meta-analysis, with random effects at the study level. Sub-group analyses and meta-regression analyses will be used to explore sources of heterogeneity, including factors such as geographical region, calendar years of recruitment, age, gender, ethnicity, socioeconomic status, different risk groups for sexually and parenterally transmitted infections (MSM, sex workers, hemophiliacs, intravenous drug users), comorbidities such as organ transplantation and malaria, test(s) used to measure HHV-8 infection, study design, and study quality.

DISCUSSION

Using the proposed systematic review and meta-analysis, we aim to better define the global seroprevalence of HHV-8 and its associated risk factors. This will improve the current understanding of HHV-8 epidemiology, and could suggest measures to prevent HHV-8 infection and to reduce its associated cancer burden.

Seroprevalence of human herpesvirus-8 in HIV-1 infected and uninfected individuals in Cameroon

We evaluated the prevalence of HHV-8 antibodies in 516 plasma samples collected from HIV positive and negative patients from blood banks and urban areas of Cameroon. Among HIV-1 positive samples, HHV-8 seropositivity rate was 61% based on combined reactivity using both ELISA and IFA techniques. HIV negative samples showed 62% seropositivity rate for HHV-8 antibodies. Our results indicate a high HHV-8 prevalence rate in both HIV infected and uninfected individuals in Cameroon.

Kaposi sarcoma-associated herpes virus and response to antiretroviral therapy: a prospective study of HIV-infected adults

BACKGROUND

The possible impact of coinfection with the Kaposi sarcoma-associated herpes virus (KSHV) on the response to antiretroviral therapy (ART) is unknown. Prospective studies are rare, particularly in Africa.

METHODS

We enrolled a prospective cohort of HIV-infected adults initiating ART in Johannesburg, South Africa. The subjects were defined as seropositive to KSHV if they were reactive to either KSHV lytic K8.1 or latent Orf73 antigen or to both. The subjects were followed from ART initiation until 18 months of treatment. HIV viral load and CD4 counts were tested 6 monthly. Linear generalized estimating and log-binomial regression models were used to estimate the effect of KSHV infection on immunologic recovery and response and HIV viral load suppression within 18 months after ART initiation.

RESULTS

Three hundred eighty-five subjects initiating ART from November 2008 to March 2009 were considered to be eligible including 184 (48%) KSHV+. The KSHV+ group was similar to the KSHV- in terms of age, gender, initiating CD4 count, body mass index, tuberculosis, and hemoglobin levels. The KSHV+ group gained a similar number of cells at 6 [difference of 10 cells per cubic millimeter, 95% confidence interval (CI): -11 to 31], 12 (3 cells per cubic millimeter, 95% CI: -19 to 25), and 18 months (24 cells per cubic millimeter, 95% CI: -13 to 61) compared with that gained by the KSHV- group. Adjusted relative risk of failure to suppress viral load to <400 copies per milliliter (1.03; 95% CI: 0.90 to 1.17) were similar for KSHV+ and KSHV- by 6 months on treatment.

CONCLUSIONS

In a population with a high KSHV prevalence, HIV-positive adults coinfected with KSHV achieved similar immunologic and virologic responses to ART early after treatment initiation compared with those with KSHV-.

Prevalence, incidence and risk factors for anogenital warts in Sub Saharan Africa: a systematic review and meta analysis

Introduction

The quadrivalent HPV vaccine is highly effective in primary prevention of anogenital warts (AGWs). However, there is lack of systematic review in the literature of the epidemiology of AGWs in Sub Saharan Africa (SSA).

Objective

To review the prevalence, incidence and risk factors for AGWs in SSA prior to the introduction of HPV vaccination programs.

Methods

PubMed/MEDLINE, Africa Index Medicus and HINARI websites were searched for peer reviewed English language published medical literature on AGWs from January 1, 1984 to June 30, 2012. Relevant additional references cited in published papers were also evaluated for inclusion. For inclusion, the article had to meet the following criteria (1) original studies with estimated prevalence and/or incidence rates among men and/or women (2) detailed description of the study population (3) clinical or self-reported diagnosis of AGWs (4) HPV genotyping of histologically confirmed AGWs. The final analysis included 40 studies. Data across different studies were synthesized using descriptive statistics for various subgroups of females and males by geographical area. A meta - analysis of relative risk was conducted for studies that had data reported by HIV status.

Results

The prevalence rates of clinical AGWs among sex workers and women with sexually transmitted diseases (STDs) or at high risk of sexually transmitted infection (STIs) range from 3.3% - 10.7% in East, 2.4% - 14.0% in Central and South, and 3.5% - 10.5% in West African regions. Among pregnant women, the prevalence rates range from 0.4% - 3.0% in East, 0.2% - 7.3% in Central and South and 2.9% in West African regions. Among men, the prevalence rates range from 3.5% - 4.5% in East, 4.8% - 6.0% in Central and South and 4.1% to 7.0% in West African regions. In all regions, the prevalence rates were significantly higher among HIV+ than HIV- women with an overall summary relative risk of 1.62 (95% CI: 143–1.82).

The incidence rates range from 1.1 – 2.7 per 100 person-years among women and 1.4 per 100 person years among men. Incidence rate was higher among HIV+ (3.0 per 100 person years) and uncircumcised men (1.7 per 100 person-years) than circumcised men (1.3 per 100 person-years).

HIV positivity was a risk factor for AGWs among both men and women. Other risk factors in women include presence of abnormal cervical cytology, co-infection with HPV 52, concurrent bacteria vaginoses and genital ulceration. Among men, other risk factors include cigarette smoking and lack of circumcision.

Conclusions

AGWs are common among selected populations particularly HIV infected men and women. However, there is need for population-based studies that will guide policies on effective prevention, treatment and control of AGWs.

The role of co-infections in mother-to-child transmission of HIV

In HIV-infected women, co-infections that target the placenta, fetal membranes, genital tract, and breast tissue, as well as systemic maternal and infant infections, have been shown to increase the risk for mother-to-child transmission of HIV (MTCT). Active co-infection stimulates the release of cytokines and inflammatory agents that enhance HIV replication locally or systemically and increase tissue permeability, which weakens natural defenses to MTCT. Many maternal or infant co-infections can affect MTCT of HIV, and particular ones, such as genital tract infection with herpes simplex virus, or systemic infections such as hepatitis B, can have substantial epidemiologic impact on MTCT. Screening and treatment for co-infections that can make infants susceptible to MTCT in utero, peripartum, or postpartum can help reduce the incidence of HIV infection among infants and improve the health of mothers and infants worldwide.

Prevalence and predictors of kaposi sarcoma herpes virus seropositivity: a cross-sectional analysis of HIV-infected adults initiating ART in Johannesburg, South Africa

Background

Kaposi sarcoma (KS) is the most common AIDS-defining tumour in HIV-infected individuals in Africa. Kaposi sarcoma herpes virus (KSHV) infection precedes development of KS. KSHV co-infection may be associated with worse outcomes in HIV disease and elevated KSHV viral load may be an early marker for advanced HIV disease among untreated patients. We examined the prevalence of KSHV among adults initiating antiretroviral therapy (ART) and compared immunological, demographic and clinical factors between patients seropositive and seronegative for KSHV.

Results

We analyzed cross-sectional data collected from 404 HIV-infected treatment-naïve adults initiating ART at the Themba Lethu Clinic, Johannesburg, South Africa between November 2008 and March 2009. Subjects were screened at ART initiation for antibodies to KSHV lytic K8.1 and latent Orf73 antigens. Seropositivity to KSHV was defined as positive to either lytic KSHV K8.1 or latent KSHV Orf73 antibodies. KSHV viremia was determined by quantitative PCR and CD3, 4 and 8 lymphocyte counts were determined with flow cytometry. Of the 404 participants, 193 (48%) tested positive for KSHV at ART initiation; with 76 (39%) reactive to lytic K8.1, 35 (18%) to latent Orf73 and 82 (42%) to both. One individual presented with clinical KS at ART initiation. The KSHV infected group was similar to those without KSHV in terms of age, race, gender, ethnicity, smoking and alcohol use. KSHV infected individuals presented with slightly higher median CD3 (817 vs. 726 cells/mm³) and CD4 (90 vs. 80 cells/mm³) counts than KSHV negative subjects. We found no associations between KSHV seropositivity and body mass index, tuberculosis status, WHO stage, HIV RNA levels, full blood count or liver function tests at initiation. Those with detectable KSHV viremia (n = 19), however, appeared to present with signs of more advanced HIV disease including anemia and WHO stage 3 or 4 defining conditions compared to those in whom the virus was undetectable.

Conclusions

We demonstrate a high prevalence of KSHV among HIV-infected adults initiating ART in a large urban public-sector HIV clinic. KSHV viremia but not KSHV seropositivity may be associated with markers of advanced HIV disease.

Parasite infection is associated with Kaposi's sarcoma associated herpesvirus (KSHV) in Ugandan women

Background

Immune modulation by parasites may influence susceptibility to bacteria and viruses. We examined the association between current parasite infections, HIV and syphilis (measured in blood or stool samples using standard methods) and antibodies against Kaposi's sarcoma herpesvirus (KSHV), measured by ELISA, in 1915 stored plasma samples from pregnant women in Entebbe, Uganda.

Results

Seroprevalence of KSHV was higher in women with malaria parasitaemia (73% vs 60% p = 0.01), hookworm (67% vs 56% p = 0.001) and Mansonella perstans (69% vs 59% p = 0.05); seroprevalence increased with increasing intensity of hookworm infection (p < 0.001[trend]). No associations were found for HIV, five other parasites or active syphilis. These effects were not explained by socioeconomic status or education.

Conclusions

Specific parasite infections are associated with presence of antibodies against KSHV, perhaps mediated via their effect on immune function.

Update on KSHV epidemiology, Kaposi Sarcoma pathogenesis, and treatment of Kaposi Sarcoma

Much has been learned since the discovery of KSHV in 1994 about its epidemiology and pathology but much of what has been learned has yet to be translated into clinical practice. In this review, we survey the current state of knowledge on KSHV epidemiology and KS pathogenesis and highlight therapeutic opportunities in both the developed and developing world.

Kaposi sarcoma in South African children

BACKGROUND

The incidence of Kaposi's sarcoma (KS) in sub-Saharan Africa, increased tens of times since the onset of the AIDS epidemic. There is, however, very little literature concerning the clinical features of this disease, its management and outcome in HIV-positive children in Africa. This study describes retrospectively the clinical presentation of the malignancy, its management and outcome, in a series of HIV-positive children.

PATIENTS AND METHODS

Seventy children with KS and HIV infection were admitted consecutively from January 1998 to December 2009 in South African hospitals. Clinical data were extracted from tumor registries and patient records and analyzed.

RESULTS

The average age in this series was 73 months. The males/females ratio was 1.59:1. Skin lesions were present in 36 out of 63 cases (57.14%), followed by lymph node lesions (28 cases, 44.44%). The mean CD4+ lymphocyte count was 440 (SD = 385). The average CD4+ percentage was 12.20% (SD = 9.13). Only 14 patients (20%) were taking combined antiretrovirals at the time of diagnosis; a further 35 were given HIV treatment after diagnosis. Thirty-two patients (45.71%) survived only 4 months on average; 10 were lost to follow-up; and 28 (40%) were alive, with an average follow-up of 16 months. Antiretrovirals improved survival (P = 0.001).

CONCLUSIONS

The often present skin lesions facilitated the diagnosis; lymphadenopathy was less frequently seen than skin lesions. Antiretroviral drugs were associated with higher survival rate. The mortality remains high in spite of antiretrovirals and cytostatics.

Human herpesvirus 8 infection in children and adults in a population-based study in rural Uganda

BACKGROUND

Human herpesvirus 8 (HHV-8) infection is endemic in sub-Saharan Africa. We examined sociodemographic, behavioral, and biological factors associated with HHV-8 infection in children and adults to determine HHV-8 seroprevalence and potential routes of transmission.

METHODS

Participants were 1383 children and 1477 adults from a population-based sample in a rural community in Uganda. Serum samples were tested for HHV-8 antibodies with use of an enzyme immunoassay against K8.1.

RESULTS

HHV-8 seroprevalence increased from 16% among children aged 1.5-2 years to 32% among children aged 10-13 years (P <.001) and from 37% among participants aged 14-19 years to 49% among adults aged ≥ 50 years (P <.05). HHV-8 seropositivity in children was independently associated with residing with a seropositive parent (P < .001) and residing with ≥ 1 other seropositive child aged <14 years (P < .001). History of sharing food and/or sauce plates was marginally associated with HHV-8 infection in children (P = .05). Among 1404 participants aged ≥ 15 years , there was no association between correlates of sexual behavior (eg, number of lifetime sex partners and HIV infection) and HHV-8 seropositivity (P > .10).

CONCLUSIONS

Our data suggest that HHV-8 is acquired primarily through horizontal transmission in childhood from intrafamilial contacts and that transmission continues into adulthood potentially through nonsexual routes.

Substantial regional differences in human herpesvirus 8 seroprevalence in sub-Saharan Africa: insights on the origin of the "Kaposi's sarcoma belt"

Equatorial Africa has among the highest incidences of Kaposi's sarcoma (KS) in the world, thus earning the name "KS Belt." This was the case even before the HIV epidemic. To date, there is no clear evidence that HHV-8 seroprevalence is higher in this region but interpretation of the available literature is tempered by differences in serologic assays used across studies. We examined representatively sampled ambulatory adults in Uganda, which is in the "KS Belt," and in Zimbabwe and South Africa which are outside the Belt, for HHV-8 antibodies. All serologic assays were uniformly performed in the same reference laboratory by the same personnel. In the base-case serologic algorithm, seropositivity was defined by reactivity in an immunofluorescence assay or in 2 enzyme immunoassays. A total of 2,375 participants were examined. In Uganda, HHV-8 seroprevalence was high early in adulthood (35.5% by age 21) without significant change thereafter. In contrast, HHV-8 seroprevalence early in adulthood was lower in Zimbabwe and South Africa (13.7 and 10.8%, respectively) but increased with age. After age adjustment, Ugandans had 3.24-fold greater odds of being HHV-8 infected than South Africans (p < 0.001) and 2.22-fold greater odds than Zimbabweans (p < 0.001). Inferences were unchanged using all other serologic algorithms evaluated. In conclusion, HHV-8 infection is substantially more common in Uganda than in Zimbabwe and South Africa. These findings help to explain the high KS incidence in the "KS Belt" and underscore the importance of a uniform approach to HHV-8 antibody testing.

Seroprevalence of human herpesvirus 8 infection in individuals from health care centers in Mozambique: potential for endemic and epidemic Kaposi's sarcoma

Human herpesvirus 8 (HHV-8) infection is common in sub-Saharan Africa, but its prevalence in Mozambique is unknown. The seroprevalence of HHV-8 in a cohort of individuals seen at public health centers in Northern (n = 208), Central (n = 226), or Southern (n = 318) Mozambique was examined. All individuals were interviewed to obtain socioeconomic, demographic and clinical data and were tested for serum anti-HHV-8 antibodies using an immunofluorescence assay. The overall frequency of HHV-8 antibodies was 21.4% and, in spite of the diversity of epidemiological characteristics of the tested individuals, did not differ significantly among regions: 18.7%, 24.3% and 21.4% in the North, Center, and South, respectively (chi(2), 2.37; P = 0.305). The variables that were associated significantly with the presence of HHV-8 antibodies were gender, age, level of education, number of siblings and HIV serostatus, but these differed across the regions. In the North, although tested individuals lived under poor socioeconomic conditions, no association between HHV-8 infection and household variables was detected, with the exception of the number of siblings (P = 0.042). In the Central region, HHV-8 infection was associated with gender (P = 0.010), the number of household members (P = 0.031), and the place of attendance (P = 0.021). In the South, HHV-8 infection was associated with the number of siblings (P = 0.023) and HIV status (P = 0.002). The overall prevalence of HHV-8 seropositivity increased with age. These results demonstrate that Mozambique is another country in Africa with endemic HHV-8 infection, and, because of the AIDS epidemic, continued access to antiretroviral treatment is necessary to avert an outbreak of AIDS-Kaposi's sarcoma.

Kaposi's Sarcoma Associated-Herpes Virus (KSHV) Seroprevalence in Pregnant Women in South Africa

Background

Factors previously associated with Kaposi's sarcoma-associated herpesvirus (KSHV) transmission in Africa include sexual, familial, and proximity to river water. We measured the seroprevalence of KSHV in relation to HIV, syphilis, and demographic factors among pregnant women attending public antenatal clinics in the Gauteng province of South Africa.

Methods

We tested for antibodies to KSHV lytic K8.1 and latent Orf73 antigens in 1740 pregnant women attending antenatal clinics who contributed blood to the "National HIV and Syphilis Sero-Prevalence Survey - South Africa, 2001". Information on HIV and syphilis serology, age, education, residential area, gravidity, and parity was anonymously linked to evaluate risk factors for KSHV seropositivity. Clinics were grouped by municipality regions and their proximity to the two main river catchments defined.

Results

KSHV seropositivity (reactive to either lytic K8.1 and latent Orf73) was nearly twice that of HIV (44.6% vs. 23.1%). HIV and syphilis seropositivity was 12.7% and 14.9% in women without KSHV, and 36.1% and 19.9% respectively in those with KSHV. Women who are KSHV seropositive were 4 times more likely to be HIV positive than those who were KSHV seronegative (AOR 4.1 95%CI: 3.4 - 5.7). Although, women with HIV infection were more likely to be syphilis seropositive (AOR 1.8 95%CI: 1.3 - 2.4), no association between KSHV and syphilis seropositivity was observed. Those with higher levels of education had lower levels of KSHV seropositivity compared to those with lower education levels. KSHV seropositivity showed a heterogeneous pattern of prevalence in some localities.

Conclusions

The association between KSHV and HIV seropositivity and a lack of common association with syphilis, suggests that KSHV transmission may involve geographical and cultural factors other than sexual transmission.

Lack of evidence for frequent heterosexual transmission of human herpesvirus 8 in Zimbabwe

BACKGROUND

There is conflicting evidence about the contribution of heterosexual transmission to the spread of human herpesvirus 8 (HHV-8) in southern Africa. This study evaluated the hypothesis that HHV-8 infection is associated with risk factors for human immunodeficiency virus type 1 (HIV-1) and other sexually transmitted infections among Zimbabwean men.

METHODS

HHV-8 seroprevalence was determined for 2750 participants in the Zimbabwe AIDS Prevention Project cohort of male factory workers in Harare, Zimbabwe. Potential associations of HHV-8 antibody detection with risk factors for HIV-1 infection were examined by univariate analysis. Variables with P < .1 in the univariate analysis were included in a multivariate logistic regression model. HHV-8 seroprevalence was also determined among 297 heterosexual couples.

RESULTS

Prevalence of HHV-8, HIV-1, and HHV-8 and HIV-1 coinfection was 28.5% (95% confidence interval [CI], 26.8%-30.2%), 19.5% (95% CI, 18.0%-20.9%), and 6.5% (95% CI, 5.6%-7.5%), respectively. Detection of HHV-8 antibodies was independently associated with older age and HIV-1 infection but not with number of recent sex partners, marital status, education, condom use, prior sexually transmitted infections, payment for sex, chronic hepatitis B infection, or incident HIV-1 infection. HHV-8 seroprevalence was 31.7% (95% CI, 26.3-37.0) among wives in the couples tested, but HHV-8 infection of wives was not associated with HHV-8 infection of husbands (odds ratio, 1.08; 95% CI, 0.62-1.88; P = .8).

CONCLUSIONS

HHV-8 and HIV-1 infection did not have common sexual risk factors among urban Zimbabwean men. Sexual transmission does not explain the high prevalence of HHV-8 in this population.

No evidence of sexual transmission of Kaposi's sarcoma herpes virus in a heterosexual South African population

BACKGROUND

The transmission of Kaposi's sarcoma herpes virus (KSHV) in men who have sex with men is clearly associated with sexual risk factors, but evidence of heterosexual transmission of KSHV is conflicting.

METHODS

Sera were obtained from 2103 South African individuals (862 miners, 95 sex workers, 731 female and 415 male township residents; mean age 33.2 years; +/- 10.1). All sera were tested for antibodies to KSHV lytic K8.1 and latent Orf73, HIV, gonococcus, herpes simplex virus type 2 (HSV-2), syphilis and chlamydia. Information on social, demographic and high-risk sexual behavior was linked to laboratory data, to evaluate risk factors, expressed as odds ratios (95% confidence interval) for KSHV.

RESULTS

Overall KSHV and HIV prevalences were 47.5 and 40%, respectively (P = 0.43). The risk of HIV infection was highest in sex workers then female residents and miners, compared with male residents (P < 0.001). HSV-2 infection was highly prevalent (66%) and lower, but still substantial, prevalences (6-8%) were observed for other sexually transmitted infections (STI). No significant difference in KSHV infection was observed among the residential groups (P > 0.05). KSHV was not associated with any of the STI or any measures of sexual behavior (P > 0.05).

CONCLUSION

The pattern of HIV and STI in sex workers suggests high rates of high-risk sexual behavior in this population. The lack of association with high-risk sexual behavior, particularly in sex workers, and with any markers of STI strongly suggest that the sexual mode does not play a significant role in KSHV transmission in this South African population.

Diverse genotypes of Kaposi's sarcoma associated herpesvirus (KSHV) identified in infant blood infections in African childhood-KS and HIV/AIDS endemic region

Kaposi's sarcoma-associated herpesvirus (KSHV or HHV-8) has been associated with several neoplasias, including childhood endemic Kaposi's sarcoma (KS). It is possible that strain genotypes could contribute to the differences in regional presentation (mainly sub-Saharan Africa), childhood infection, lack of male sex bias, distinct disseminated forms and rapid fatality observed for childhood endemic KS. Early studies, at the advent of the HIV/AIDS epidemic, identified only the K1-A5 genotype in childhood KS biopsies as well as blood of a few HIV positive and negative febrile infants in Zambia, a highly endemic region. This current enlarged study analyses blood infections of 200 hospitalized infants (6-34 months age) with symptoms of fever as well as upper respiratory tract infection, diarrhoea, rash or rhinitis. KSHV and HIV viraemia and were prevalent in this group, 22% and 39%, respectively. Multiple markers at both variable ends of the genome (K1, K12, and K14.1/K15) were examined, showing diverse previously adult-linked genotypes (K1 A2, A5, B, C3, D, with K12 B1 and B2 plus K14.1/K15 P or M) detected in both HIV positive and negative infants, demonstrating little restriction on KSHV genotypes for infant/childhood transmission in a childhood endemic KS endemic region. This supports the interpretation that the acquisition of childhood KSHV infections and subsequent development of KS are due to additional co-factors.

Traditional practices and exposure to bodily fluids in Lusaka, Zambia

OBJECTIVES

To ascertain if there are specific sociocultural and behavioural practices associated with the exposure to saliva, semen and vaginal fluids, particularly through child-rearing practices and the use of traditional medicine in Lusaka, Zambia.

METHODS

We conducted 11 focus group discussions with men and women from diverse ethnic and socioeconomic backgrounds (n = 105) in Lusaka, Zambia in March 2004. We also conducted a brief sociodemographic survey of all focus group participants.

RESULTS

Discussions indicated that saliva was used while engaging in home health care practices associated with childcare and the use of traditional medicine. Additionally, semen and vaginal fluids may be used in rituals associated with childcare and health care for children. Our survey indicated that the use of traditional medicine is associated with lower socioeconomic status.

CONCLUSIONS

Population-based studies are needed to evaluate the relationship between traditional behavioural and sociocultural practices, which involve exchange of saliva and other bodily fluids and risk of infectious disease.

Gender Differences in AIDS-Associated Kaposi Sarcoma in Harare, Zimbabwe

Reasons for gender-related differences in the risk of AIDS-related Kaposi sarcoma (AIDS-KS) are unknown. Four hundred thirty-eight male and 166 female AIDS-KS patients were evaluated in Harare, Zimbabwe. Female patients were younger than male patients in this study (median of 33 vs. 38 years; P < 0.001), mirroring the epidemiology of AIDS in Zimbabwe. In a multivariate model adjusted for CD4 T-cell count, age, prior radiation treatment, and chemotherapy, women were more likely to report fever, diaphoresis, or weight loss (odds ratio = 1.7, 95% confidence interval: 1.1 to 2.7; P = 0.009). These findings suggest an increased severity of KS or other unidentified infections among women with AIDS-KS in Zimbabwe.

Human herpesvirus 8: serovprevalence and correlates in tumor patients from Xinjiang, China

Human herpesvirus 8 (HHV-8), also known as Kaposi's sarcoma-associated herpesvirus, is etiologically associated with Kaposi's sarcoma and other lymphoproliferative diseases. Although HHV-8 prevalence exhibits considerable variation in different geographic regions and populations, the incidence of Kaposi's sarcoma appear to increase in areas with a high prevalence rate. In this study, an enzyme-linked immunosorbent assay based on mixed antigens of HHV-8 ORF(73), ORF(65), and K8.1 in the antigenic region was established and used to determine viral prevalence estimates and risk factors associated with HHV-8 infection. Of 482 tumor patients studied, the overall seropositivity of HHV-8 was 25.5%. Notably, Han people, who were immigrants or descendents of immigrants from inland of China, exhibited 26.4% seropositivity. This is similar to that observed in Uygur people, a local ethnic group with a high prevalence of HHV-8 infection and incidence of Kaposi's sarcoma. While there was no significant difference in patients with different tumors, HHV-8 seroprevalence was higher in individuals with malignant diseases. Logistic regression analysis suggests that the age is a risk factor associated with HHV-8 infection, with prevalence increasing from 12.5% under 20-27.5% above 50. These results suggest that unlike other parts of mainland of China, Xinjiang is an area with a high prevalence of HHV-8 infection.

Chapter 4: Burden and management of non-cancerous HPV-related conditions: HPV-6/11 disease

Human Papillomavirus (HPV)-6 and -11 are the causative agents of ano-genital warts (GWs) and recurrent respiratory papillomatosis (RRP). They are low-risk HPV types that are uncommonly found in malignant lesions. GWs are an extremely prevalent sexually transmitted disease, whereas RRP is a rare disease that can be life threatening and requires multiple surgical procedures. GWs and RRP cause substantial healthcare costs. A quadrivalent HPV-6/11/16/18 vaccine (Merck/SPMSD) has shown essentially 100% protection against GWs in women in early studies. Cost-effectiveness analyses are needed to assess the benefits of the HPV-6/11 virus-like particle (VLP) components of the quadrivalent vaccine in population-based vaccination programmes.

Seroprevalence of six different viruses among pregnant women and blood donors in rural and urban Burkina Faso: A comparative analysis

A seroprevalence study was carried out of six different human pathogenic viruses, namely human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), human T-cell leukemia virus (HTLV), human herpesvirus type 8 (HHV-8), and dengue virus among pregnant women and blood donors from rural (Nouna) and urban (Ouagadougou) Burkina Faso, West Africa. A total of 683 samples from blood donors (n = 191) and pregnant women (n = 492) were collected from both sites and screened for the different virus infection markers resulting in the following prevalence values for Nouna or Ouagadougou, respectively: HIV 3.6/4.6, anti-HBV core (anti-HBc) 69.6/76.4, HBV surface antigen (HBsAg)14.3/17.3, HCV 2.2/1.5, HTLV 1.4/0.5, HHV-8 11.5/13.5, dengue virus 26.3/36.5. Individuals aged > or =25 years were more likely to be infected with HIV than those below 24 years (P < 0.05). Infection with HIV increased the likelihood of co-infection with other viruses, such as HHV-8, HBV and HTLV. Co-infection studies involving five viruses (HBV-HBsAg, HHV-8, HIV, HCV, and HTLV) showed that 4.8% (33/683) of the studied population were dually infected, with HBsAg+ HHV-8 (13/33), HBsAg+HIV (8/33) and HIV+HHV-8 (8/33) being the most common co-infections. Of the population studied 0.6% (4/683) was triply infected, the most common infection being with HBV+HIV+HHV-8 (3/4). There was no difference in the prevalence of HIV, anti-HBc, HBsAg, HCV, HTLV, and HHV-8 either among blood donors or pregnant women in urban or rural setting, while dengue virus prevalence was relatively lower in rural (26.3%) than in urban (36.5%) Burkina Faso.