Seroprevalence of Herpes Simplex Virus Type 2 and Characteristics Associated With Undiagnosed Infection: New York City, 2004

Asymptomatic neonatal herpes simplex virus infection in mice leads to long-term cognitive impairment

Neonatal herpes simplex virus (nHSV) is a devastating infection impacting approximately 14,000 newborns globally each year. Infection is associated with high neurologic morbidity and mortality, making early intervention and treatment critical. Clinical outcomes of symptomatic nHSV infections are well-studied, but little is known about the frequency of, or outcomes following, sub-clinical or asymptomatic nHSV. Given the ubiquitous nature of HSV infection and frequency of asymptomatic shedding in adults, subclinical infections are underreported, yet could contribute to long-term neurological damage. To assess potential neurological morbidity associated with subclinical nHSV infection, we developed a low-dose (100 PFU) HSV infection protocol in neonatal C57BL/6 mice. At this dose, HSV DNA was detected in the brain by PCR but was not associated with acute clinical symptoms. However, months after initial inoculation with 100 PFU of HSV, we observed impaired mouse performance on a range of cognitive and memory performance tasks. Memory impairment was induced by infection with either HSV-1 or HSV-2 wild-type viruses, but not by a viral mutant lacking the autophagy-modulating Beclin-binding domain of the neurovirulence gene γ34.5. Retroviral expression of wild type γ34.5 gene led to behavioral pathology in mice, suggesting that γ34.5 expression may be sufficient to cause cognitive impairment. Maternal immunization and HSV-specific antibody treatment prevented offspring from developing neurological sequelae following nHSV-1 infection. Altogether, these results support the idea that subclinical neonatal infections may lead to cognitive decline in adulthood, with possible profound implications for research on human neurodegenerative disorders such as Alzheimer's Disease.

Seroprevalence and Vaginal Shedding of Herpes Simplex Virus Type 2 in Pregnant Adolescents and Young Women from Morelos, Mexico

Adolescents and young people are particularly vulnerable to contracting STIs, including HSV-2; furthermore, vaginal shedding of HSV-2 during pregnancy can cause vertical transmission and neonatal herpes. To evaluate the seroprevalence of HSV-2 and vaginal HSV-2 shedding in adolescent and young pregnant women, a cross-sectional study was carried out in 496 pregnant women-adolescents and young women. Venous blood and vaginal exudate samples were taken. The seroprevalence of HSV-2 was determined by ELISA and Western blot. Vaginal HSV-2 shedding was assessed by qPCR of the HSV-2 UL30 gene. The seroprevalence of HSV-2 in the study population was 8.5% (95% CI 6-11), of which 38.1% had vaginal HSV-2 shedding (95% CI 22-53). Young women presented a higher seroprevalence of HSV-2 (12.1%) than adolescents (4.3%), OR = 3.4, 95% CI 1.59-7.23. Frequent alcohol consumption was significantly associated with HSV-2 seroprevalence, OR = 2.9, 95% CI 1.27-6.99. Vaginal HSV-2 shedding is highest in the third trimester of pregnancy, but this difference is not significant. The seroprevalence of HSV-2 in adolescents and young women is similar to that previously reported in other studies. However, the proportion of women with vaginal shedding of HSV-2 is higher during the third trimester of pregnancy, increasing the risk of vertical transmission.

Mimics of Monkeypox: Considerations for the emergency medicine clinician

INTRODUCTION

Mpox, formerly known as monkeypox, is a public health emergency most commonly presenting with a painful rash and several systemic findings. However, there are several conditions that may mimic its presentation.

OBJECTIVE

This narrative review provides a focused overview of mpox mimics for emergency clinicians.

DISCUSSION

Mpox is a global health emergency. The disease is primarily spread through contact, followed by the development of a centrifugally-spread rash that evolves from macules to papules to vesicles to pustules. This is often associated with lymphadenopathy and fever. As the rash is one of the most common presenting signs of the infection, patients mpox may present to the emergency department (ED) for further evaluation. There are a variety of mimics of mpox, including smallpox, varicella, primary and secondary syphilis, acute retroviral syndrome, and genital herpes simplex virus.

CONCLUSION

Knowledge of mpox and its mimics is vital for emergency clinicians to differentiate these conditions and ensure appropriate diagnosis and management.

Disseminated Herpes Simplex Virus-2 (HSV-2) as a Cause of Viral Hepatitis in an Immunocompetent Host

Patient: Male, 57-year-old

Final Diagnosis: Hepatitis • herpes

Symptoms: Fever

Medication: —

Clinical Procedure: —

Specialty: General and Internal Medicine

Management of Genital Herpes in Pregnancy: ACOG Practice Bulletinacog Practice Bulletin, Number 220

Genital herpes simplex virus (HSV) infection during pregnancy poses a risk to the developing fetus and newborn. Genital herpes is common in the United States. Among 14- to 49-year-old females, the prevalence of HSV-2 infection is 15.9%. However, the prevalence of genital herpes infection is higher than that because genital herpes is also caused by HSV-1 (). Because many women of childbearing age are infected or will be infected with HSV, the risk of maternal transmission of this virus to the fetus or newborn is a major health concern. This document has been revised to include that for women with a primary or nonprimary first-episode genital HSV infection during the third trimester of pregnancy, cesarean delivery may be offered due to the possibility of prolonged viral shedding.

Parallel declines in HIV and hepatitis C virus prevalence, but not in herpes simplex virus type 2 infection: A 10-year, serial cross-sectional study in an inner-city emergency department

BACKGROUND

The Johns Hopkins Hospital Emergency Department (JHHED) has served as an observational window on the HIV epidemic in a socioeconomically depressed, urban population. We previously reported that HIV incidence among JHHED patients is decreasing and that prevalence has declined from 11.4% in 2003-5.6% in 2013.

OBJECTIVES

This study sought to observe temporal trends in hepatitis C virus (HCV) and herpes simplex virus type 2 (HSV-2) seroprevalence, which are surrogate markers for parenteral and sexual risk behavior, respectively.

STUDY DESIGN

Identity unlinked-serosurveys were conducted over 6-8 weeks in the adult JHHED in 2003, 2007, and 2013. Excess sera from 10,274 patients, previously tested for HIV, were assayed for HSV-2 and HCV antibodies.

RESULTS

Overall HCV seroprevalence declined steadily from 22.0% in 2003-13.8% in 2013 (Ptrend<0.01), and was significant by all gender and race strata. Overall HSV-2 prevalence declined from 55.3% in 2003-50.0% in 2013 (Ptrend<0.01), but was non-significant after adjustment for demographics. Among HIV+ individuals<45years of age, there was a significant decrease in the proportion of individuals with HCV co-infection [without HSV-2] (Ptrend=0.02) from 2003 to 2013, however, there was an increase in individuals with HSV-2 co-infection [without HCV] (Ptrend < 0.01).

DISCUSSION

Little change in age-specific HSV-2 prevalence suggests the decrease in HIV prevalence was likely not associated with changes in sexual risk behavior. In addition to clinical interventions, strategies to address sexual health disparities and continued parenteral harm-reduction efforts are needed to further drive the decline in HIV.

High Rates of Herpes Simplex Virus Type 2 Infection in Homeless Women: Informing Public Health Strategies

BACKGROUND

Homeless and unstably housed women living in an urban setting are at risk for sexually transmitted diseases, yet the seroprevalence and correlates of herpes simplex virus type 2 (HSV-2) specific to impoverished women are poorly understood.

MATERIALS AND METHODS

Between April and October 2010, we conducted a cross-sectional analysis of sociodemographic, structural, and behavioral factors associated with prevalent HSV-2 infection (recent and historical infections) within a community-recruited cohort of homeless and unstably housed women. Logistic regression modeling was used to identify independent sociobehavioral correlates of HSV-2 infection.

RESULTS

Among 213 women (114 HIV positive and 99 HIV negative), the median age was 49, 48% were African American, and 63% had completed high school. HSV-2 seroprevalence was 88%, and only 17% of infected women were aware of their infection. In adjusted analysis, odds of HSV-2 infection were significantly higher for those reporting at-risk drinking (adjusted odds ratio [AOR] = 7.04; 95% confidence interval [CI] = 1.59, 67.91), heterosexual orientation (AOR = 4.56; 95% CI = 1.81, 11.69), and for those who were HIV positive (AOR = 3.64; 95% CI = 1.43, 10.30). Odds of HSV-2 infection decreased as current income increased (AOR for each $500 monthly increase = 0.90; 95% CI = 0.78, 0.997).

CONCLUSIONS

There is an extremely high seroprevalence of HSV-2 infection among homeless and unstably housed women, and most are unaware of their HSV-2 status. Screening all unstably housed women for HSV-2 infection, with additional counseling for sexual risk and alcohol use, may lead to the identification of more infections and be a first step in reducing additional disease transmission.

Herpes simplex virus downregulation of secretory leukocyte protease inhibitor enhances human papillomavirus type 16 infection

Herpes simplex virus (HSV) was originally implicated in the aetiology of cervical cancer, and although high-risk human papillomavirus (HPV) is now the accepted causative agent, the epidemiological link between HSV and HPV-associated cancers persists. The annexin A2 heterotetramer (A2t) has been shown to mediate infectious HPV type 16 (HPV16) uptake by human keratinocytes, and secretory leukocyte protease inhibitor (SLPI), an endogenous A2t ligand, inhibits HPV16 uptake and infection. Interestingly, HSV infection induces a sustained downregulation of SLPI in epithelial cells, which we hypothesized promotes HPV16 infection through A2t. Here, we show that in vitro infection of human keratinocytes with HSV-1 or HSV-2, but not with an HSV-1 ICP4 deletion mutant that does not downregulate SLPI, leads to a >70% reduction of SLPI mRNA and a >60% decrease in secreted SLPI protein. Consequently, we observed a significant increase in the uptake of HPV16 virus-like particles and gene transduction by HPV16 pseudovirions (two- and 2.5-fold, respectively) in HSV-1- and HSV-2-infected human keratinocyte cell cultures compared with uninfected cells, whereas exogenously added SLPI reversed this effect. Using a SiMPull (single-molecule pulldown) assay, we demonstrated that endogenously secreted SLPI interacts with A2t on epithelial cells in an autocrine/paracrine manner. These results suggested that ongoing HSV infection and resultant downregulation of local levels of SLPI may impart a greater susceptibility for keratinocytes to HPV16 infection through the host cell receptor A2t, providing a mechanism that may, in part, provide an explanation for the aetiological link between HSV and HPV-associated cancers.

Prevalence and factors associated with herpes simplex virus type 2 infection in patients attending a Baltimore City emergency department

OBJECTIVES

Herpes simplex virus type 2 (HSV-2) is a common sexually transmitted disease, but there is limited data on its epidemiology among urban populations. The urban Emergency Department (ED) is a potential venue for surveillance as it predominantly serves an inner city minority population. We evaluate the seroprevalence and factors associated with HSV-2 infection among patients attending the Johns Hopkins Hospital Adult Emergency Department (JHH ED).

METHODS

An identity unlinked-serosurvey was conducted between 6/2007 and 9/2007 in the JHH ED; sera were tested by the Focus HerpeSelect ELISA. Prevalence risk ratios (PRR) were used to determine factors associated with HSV-2 infection.

RESULTS

Of 3,408 serum samples, 1,853 (54.4%) were seropositive for HSV-2. Females (adjPRR  = 1.47, 95% CI 1.38-1.56), non-Hispanic blacks (adjPRR  = 2.03, 95% CI 1.82-2.27), single (adjPRR  = 1.15, 95% CI 1.07-1.25), divorced (adjPRR  = 1.28, 95% CI 1.15-1.41), and unemployed patients (adjPRR  = 1.13, 95% CI 1.05-1.21) had significantly higher rates of HSV-2 infection. Though certain zip codes had significantly higher seroprevalence of HSV-2, this effect was completely attenuated when controlling for age and gender.

CONCLUSIONS

Seroprevalence of HSV-2 in the JHH ED was higher than U.S. national estimates; however, factors associated with HSV-2 infection were similar. The high seroprevalence of HSV-2 in this urban ED highlights the need for targeted testing and treatment. Cross-sectional serosurveys in the urban ED may help to examine the epidemiology of HSV-2.

Sexually transmitted and anorectal infectious diseases

Sexually transmitted diseases (STDs) are common and they can involve the anus and rectum in both men and women. In this article, the main bacterial and viral STDs that affect the anus and rectum are discussed, including their prevalence, presentation, and treatment.

Public health strategies for prevention and control of HSV-2 in persons who use drugs in the United States

BACKGROUND

Herpes simplex virus type 2 (HSV-2) affects HIV acquisition, transmission, and disease progression. Effective medications for genital herpes and for HIV/AIDS exist. Parenteral transmission of HIV among persons who inject drugs is decreasing. Reducing sexual transmission of HIV and HSV-2 among persons who use drugs (PWUD; i.e., heroin, cocaine, "speedball", crack, methamphetamine through injection or non-injection) necessitates relevant services.

METHODS

We reviewed HSV-2 sero-epidemiology and HSV-2/HIV associations in U.S.-based studies with PWUD and the general literature on HSV-2 prevention and treatment published between 1995 and 2012. We used the 6-factor Kass framework to assess relevant HSV-2 public health strategies and services in terms of their goals and effectiveness; identification of, and minimization of burdens and concerns; fair implementation; and fair balancing of benefits, burdens, and concerns.

RESULTS

Eleven studies provided HSV-2 serologic test results. High HSV-2 sero-prevalence (range across studies 38-75%) and higher sero-prevalence in HIV-infected PWUD (97-100% in females; 61-74% in males) were reported. Public health strategies for HSV-2 prevention and control in PWUD can include screening or testing; knowledge of HSV-2 status and partner disclosure; education, counseling, and psychosocial risk-reduction interventions; treatment for genital herpes; and HIV antiretroviral medications for HSV-2/HIV co-infected PWUD.

CONCLUSIONS

HSV-2 sero-prevalence is high among PWUD, necessitating research on development and implementation of science-based public health interventions for HSV-2 infection and HSV-2/HIV co-infections, including research on effectiveness and cost-effectiveness of such interventions, to inform development and implementation of services for PWUD.

Sexual HIV/HSV-2 risk among drug users in New York City: an HIV testing and counseling intervention

Undiagnosed and untreated sexually transmitted infections are highly prevalent among users of heroin, crack, cocaine, and amphetamines. Between 2008 and 2009, 58 heroin, cocaine, and crack users in New York City who reported unprotected vaginal and anal sex with more than one partner in the past 30 days were enrolled in an HIV testing and counseling intervention. Four weeks post intervention, increases were found for condom use and STI knowledge. Reductions were noted for safe-sex risk fatigue, number of same-and opposite-sex partners, and days when drugs were injected. Brief but intense counseling interventions can reduce HIV risk among high-risk populations.

Epidemiological impact of a genital herpes type 2 vaccine for young females

Genital Herpes, which is caused by Herpes Simplex Virus-1 or -2 (HSV-1, -2, predominantly HSV-2) is a sexually transmitted infection (STI) that causes a chronic latent infection with outbreak episodes linked to transmission. Antiviral therapies are effective in reducing viral shedding during these episodes, but are ineffective as a whole since many outbreaks are asymptomatic or have mild symptoms. Thus, the development of a vaccine for genital herpes is needed to control this disease. The question of how to implement such a vaccine program is an important one, and may be similar to the vaccination program for Human Papilloma Virus (HPV) for young females. We have developed a mathematical model to describe the epidemiology of vaccination targeting young females against HSV-2. The model population is delineated with respect to age group, sexual activity and infection status including oral infection of HSV-1, which may affect vaccine efficacy. A threshold parameter R(C), which determines the level of vaccine uptake needed to eradicate HSV-2, is found. Computer simulation shows that an adolescent-only vaccination program may be effective in eliminating HSV-2 disease, however, the success of extinction greatly depends on the level of vaccine uptake, the vaccine efficacy, the age of sexual maturity and safe sex practices. However, the time course of eradication would take many years. We also investigate the prevalence of infection in the total population and in women between 16-30 years of age before and after vaccination has been introduced, and show that the adolescent-only vaccination program can be effective in reducing disease prevalence in these populations depending on the level of vaccine uptake and vaccine efficacy. This will also result in a decrease of maternal-fetal transmission of HSV-2 infection. Another important, if commonsense, conclusion is that vaccination of some females reduces infection in men, which then reduces infection in women.

Population-based surveillance for neonatal herpes in New York City, April 2006-September 2010

BACKGROUND

Population-based data for neonatal herpes simplex virus (HSV) infection are needed to describe disease burden and to develop and evaluate prevention strategies.

METHODS

From April 2006 to September 2010, routine population-based surveillance was conducted using mandated provider and laboratory reports of neonatal HSV diagnoses and test results for New York City resident infants aged ≤60 days. Case investigations, including provider interviews and review of infant and maternal medical charts and vital records, were performed. Hospital discharge data were analyzed and compared with surveillance data findings.

RESULTS

Between April 2006 and September 2010, New York City neonatal HSV surveillance detected 76 cases, for an average incidence of 13.3/100,000 (1/7519) live births. Median annual incidence of neonatal HSV estimated from administrative data for 1997 to 2008 was 11.8/100,000. Among surveillance cases, 90.8% (69/76) were laboratory confirmed. Among these, 40.6% (28/69) were HSV-1; 39.1% (27/69) were HSV-2; and 20.3% (14/69) were untyped. The overall case-fatality rate was 17.1% (13/76). Five cases were detected among infants aged >42 days. In all, 80% (20/25) of the case-infants delivered by cesarean section were known to have obstetric interventions that could have increased risk of neonatal HSV transmission to the infant before delivery. Over half (68%, or 52/76) of all cases lacked timely or ideal diagnostics or treatment.

CONCLUSIONS

Administrative data may be an adequate and relatively inexpensive source for assessing neonatal HSV burden, although they lack the detail and timeliness of surveillance. Prevention strategies should address HSV-1. Incubation periods might be longer than expected for neonatal HSV. Cesarean delivery might not be protective if preceded by invasive procedures. Provider education is needed to raise awareness of neonatal HSV and to assure appropriate testing and treatment.

Men who have sex with men have a 140-fold higher risk for newly diagnosed HIV and syphilis compared with heterosexual men in New York City

OBJECTIVES

To describe the population of men who have sex with men (MSM) in New York City, compare their demographics, risk behaviors, and new HIV and primary and secondary (P&S) syphilis rates with those of men who have sex with women (MSW), and examine trends in infection rates among MSM.

DESIGN

Population denominators and demographic and behavioral data were obtained from population-based surveys during 2005-2008. Numbers of new HIV and P&S syphilis diagnoses were extracted from city-wide disease surveillance registries.

METHODS

We calculated overall, age-specific and race/ethnicity-specific case rates and rate ratios for MSM and MSW and analyzed trends in MSM rates by age and race/ethnicity.

RESULTS

The average prevalence of male same-sex behavior during 2005-2008 (5.0%; 95% CI: 4.5 to 5.6) differed by both age and race/ethnicity (2.3% among non-Hispanic black men; 7.4% among non-Hispanic white men). Compared with MSW, MSM differed significantly on all demographics and reported a higher prevalence of condom use at last sex (62.9% vs. 38.3%) and of past-year HIV testing (53.6% vs. 27.2%) but also more past-year sex partners. MSM HIV and P&S syphilis rates were 2526.9/100,000 and 707.0/100,000, each of which was over 140 times MSW rates. Rates were highest among young and black MSM. Over 4 years, HIV rates more than doubled and P&S syphilis rates increased 6-fold among 18-year-old to 29-year-old MSM.

CONCLUSIONS

The substantial population of MSM in New York City is at high risk for acquisition of sexually transmitted infections given high rates of newly diagnosed infections and ongoing risk behaviors. Intensified and innovative efforts to implement and evaluate prevention programs are required.

Seroprevalence of herpes simplex virus 2 among Hispanics in the USA: National Health and Nutrition Examination Survey, 2007-2008

To examine the seroprevalence of herpes simplex virus type 2 (HSV-2) among Hispanics in the USA, we used the cross-sectional, nationally representative National Health and Nutrition Examination Survey to compare the seroprevalence of HSV-2 between Hispanic persons of Mexican heritage and non-Mexican heritage aged 14-44 years, from survey years 2007-2008. The overall HSV-2 seroprevalence among Hispanics aged 14-44 years was 17.5% (95% confidence interval [CI], 15.2, 20.1) in the USA. HSV-2 seroprevalence was significantly lower among Mexican Americans than among other Hispanics (11.7% vs. 27.8%, P < 0.01). Prevalence of HSV-2 was also significantly associated with gender and age. The significant difference in HSV-2 seroprevalence between Hispanic persons of Mexican heritage and non-Mexican heritage suggested that targeting specific subgroups of Hispanics for preventive interventions may be a strategy to reduce the transmission of HSV-2 and HIV among Hispanics in the USA.

Prevalence and risk factors for herpes simplex infection among patients at high risk for HIV infection in Brazil

BACKGROUND

Herpes simplex infection is responsible for substantial morbidity in patients with HIV infection. Data from less-developed countries analyzing risk factors within this population are largely unavailable.

AIMS

Investigate the incidence and seroprevalence of HSV-1 and HSV-2 infection in populations at high and low risk for HIV infection.

MATERIALS AND METHODS

A prospective cohort study was performed in a population at high risk for STDs composed of 170 HIV seronegative male homosexuals and bisexuals (group A). The population at low risk for STDs was composed of 155 volunteer male blood donors (group B). All blood samples were screened using a type specific ELISA to HSV-1 and HSV-2 glycoprotein G (gG).

RESULTS

The prevalence of HSV-1 and HSV-2 infection among all the 325 patients was 83.5% and 63.4%, respectively. Annual incidence of HSV-1 and 2 among group A were 0.053% and 0.08%, respectively. Among group B, the incidence for HSV-1 was 0.04% and for HSV-2 was 0.02%. Educational parameters (P<0.001), irregular use of condoms (P<0.001), and percentage of previous receptive anal intercourse (P<0,012) were significantly associated with seropositivity to HSV-2. About 8.4% of the HSV-1 seronegative subjects presented recurrence episodes of herpes labialis as well as 7.6% of the HSV-2 seronegative patients had genital herpes in the past.

DISCUSSION

The high seroprevalence detected suggests that routine screening for HSV should be performed in populations at high risk for STDs, especially in HIV-infected patients.

CONCLUSION

Educational campaigns, with particular focus on the transmission of HSV, and the regular use of condoms are important measures to reduce the HSV dissemination among patients with less advanced educations and at high risk for STDs.

Seroprevalence, predictors and estimated incidence of maternal and neonatal Herpes Simplex Virus type 2 infection in semi-urban women in Kilifi, Kenya

Background

Herpes Simplex Virus type 2 (HSV-2) has public health importance as a leading cause of genital ulcers, a co-factor in HIV-1 acquisition and transmission and as a cause of neonatal herpes infections. Little is known of its epidemiology and burden in Coastal Kenya.

Methods

We screened plasma samples for HSV-2 infection from 826 women aged 15-34 years who participated in an HIV-1 survey in Kilifi in 2004. The sample comprised 563 women selected randomly from a demographic surveillance system (DSS) and 263 women who presented for voluntary counseling and testing (VCT). Predictors for HSV-2 seropositivity were determined using multivariate logistic regression. The incidence of HSV-2 infection and risk of neonatal herpes were estimated by a simple catalytic model fitted to age-seroprevalence data.

Results

HSV-2 prevalence was 32% in the DSS recruits vs. 44% in the VCT recruits (P < 0.001), while, HIV-1 prevalence was 8% in the DSS recruits vs. 12% in the VCT recruits (P = 0.12). Independent risk factors for HSV-2 infection in all women were: older age (30-34 years; odds ratio (OR) 10.5, 95% confidence interval (CI): 5.2 - 21.0), recruitment from VCT (OR 1.5, 95% CI: 1.1 - 2.1), history of genital ulcers (OR 1.7, 95% CI: 1.2 - 2.3) and HIV infection (OR 2.7, 95% CI: 1.6-4.6). Education beyond primary (OR 0.7, 95% CI: 0.5 - 0.9) was inversely associated with HSV-2 infection. In the DSS sample, HSV-2 incidence was estimated at 4 cases (95% CI: 3.3 - 4.4) per 100 women per year, 17 cases (95% CI: 16-18) per 1,000 pregnancies per year and 33 neonatal cases (95% CI: 31-36) per 100,000 births per year.

Conclusions

HSV-2 transmission is rapid following the onset of sexual activity and likely to result in a significant burden of genital ulcer disease. Nevertheless, the burden of neonatal HSV-2 can be predicted to be low. Educating young women about HSV-2 infection may help in reducing its burden in this semi-urban population.

Association between HSV1 seropositivity and obesity: data from the National Health and Nutritional Examination Survey, 2007-2008

Background

Herpes simplex virus (HSV) is among the most common sexually transmitted pathogens in the United States and worldwide. HSV has a high incidence of undetected cases. In addition, there is no treatment, and there is a lack of knowledge why disparities among populations exist. Research studies suggest that fat tissue may participate in body's immune responses, and the impact of obesity on susceptibility to HSV1 infection is not clear. The purpose of this study was to examine whether obesity is a risk factor for HSV1 infection using a large sample from the general population.

Methods/Principal Findings

This cross-sectional study used data from the National Health and Examination and Nutritional Examination Survey (NHANES) from 2007–2008. Variables, gender, age, race/ethnicity, marital status, education, poverty level, and diabetes represented potential confounders and were included in analyses. The two-tailed Pearson's chi square, student's t test, and a multiple logistic regression analysis were applied to evaluate associations using a significance value of p≤0.05. Adjusted odds ratios with 95% confidence interval represented the degree of these associations. The prevalence of HSV1 infection in US population between 20 and 49 years old was 60.3% (n = 1,536). In this study, having a BMI classified as the obese group (BMI 30–39.9) was significantly associated with HSV1 infection before [unadjusted OR = 1.74 (95% CI 1.20–2.51), p = 0.006] and after controlling for socio-demographic factors [adjusted OR = 1.50 (95%CI 1.06–2.13)], p = 0.026]. This association was stronger than three already established risk factors of age, female gender, and poverty level.

Conclusions/Significance

This study provides evidence that obesity may play a role in the susceptibility to HSV1 infection. Findings from this study suggest that obesity should be considered when designing preventive measures for HSV1 infection. These results may also explain why some people acquire HSV1 infections and some do not. Further, these findings may justify an increased emphasis on the control and prevention of HSV1 transmission and other pathogens in overweight and obese populations.

Herpes simplex virus type 2 associated with HIV infection among New York heterosexuals living in high-risk areas

Herpes simplex virus type 2 (HSV-2) has been shown to increase the risk of sexual human immunodeficiency virus (HIV) transmission. A matched case-control design was used to examine the association between HSV-2 and HIV infection among heterosexuals in 'high-risk areas' (HRAs) in New York City (NYC). We identified NYC HRAs using HIV surveillance data on heterosexual-related adult HIV diagnoses and USA census data on household poverty. Heterosexuals who were socially or geographically linked to an HRA were recruited using respondent-driven sampling. HIV prevalence was 8.6% and HSV-2 prevalence was 80.1%. Only 6% of HIV-positives knew they were infected. HIV-positive cases were matched to HIV-negative controls on gender, race/ethnicity and age, and tested for antibody to HSV-2. In a multivariate model, HIV infection was associated with HSV-2 infection (adjusted odds ratio [AOR] = 3.5, 95% confidence interval 1.1-11.7) and non-HSV-related sexually transmitted infection diagnosis in the previous year (AOR = 2.6, 1.1-6.2). Effective approaches to HIV risk reduction for individuals with HSV-2 remain uncertain, and these are urgently needed in high-risk communities where multiple social, behavioural and biological factors that facilitate HIV infection coexist.

Racial/ethnic disparities in undiagnosed infection with herpes simplex virus type 2

BACKGROUND

Herpes simplex virus type 2 (HSV-2) is a common sexually transmitted infection (STI) that is the main cause of genital herpes. Studies have found racial/ethnic disparities in HSV-2 prevalence, but there have been few studies of racial/ethnic differences in the proportion of infections that go without a genital herpes diagnosis.

METHODS

Data from 1396 HSV-2-seropositive participants of the National Health and Nutrition Examination Survey 1999-2004 were used to examine racial/ethnic differences in the odds of reporting being diagnosed previously with genital herpes.

RESULTS

The proportion of participants who reported not being diagnosed previously with genital herpes was 85.5%. In adjusted analysis, non-Hispanic blacks had twice the odds of reporting being undiagnosed as non-Hispanic whites (adjusted odds ratio = 2.0, 95% CI = 1.37, 2.87). Being undiagnosed was also significantly associated with less than high school education, no prior STI history or HIV test, no current health insurance, and residence in the Midwest and South.

CONCLUSIONS

The low proportion of genital herpes diagnosis among non-Hispanic blacks with HSV-2 is not accounted for by other sociodemographic factors or health insurance. Combined with the high prevalence of HSV-2, the low proportion of diagnosis in this population is more likely to contribute to ongoing HSV-2 transmission than among non-Hispanic whites or Mexican Americans. More research is needed to assess the role that lack of diagnosis plays in ongoing HSV-2 transmission, and whether targeted HSV-2 screening, counseling and treatment could be part of a more effective prevention strategy for non-Hispanic blacks.

Herpes simplex virus type 2 seropositivity and relationship status among U.S. adults age 20 to 49: a population-based analysis

BACKGROUND

U.S. population studies show herpes simplex virus type 2 (HSV-2) seroprevalence levelling by approximately age 30, suggesting few new infections after that age. It is unclear whether this pattern is driven by greater percentages in stable relationships, and to what extent adults who initiate new relationships may be at risk of incident HSV-2 infection.

METHODS

Survey and laboratory data from the 1999-2008 waves of the U.S. National Health and Nutrition Examination Survey (NHANES) were combined for 12,862 adults age 20-49. Weighted population estimates of self-reported genital herpes, HSV-2 seroprevalence, and past-year sexual history were calculated, stratified by age, sex, race, and relationship status. Multivariable logistic regression was used to assess whether relationship status provided additional information in predicting HSV-2 over age, race and sex, and whether any such associations could be accounted for through differences in lifetime number of sex partners.

RESULTS

Those who were unpartnered had higher HSV-2 prevalence than those who were married/cohabitating. Among unpartnered 45-49 year olds, seroprevalence was 55.3% in women and 25.7% in men. Those who were married/cohabitating were more likely to have had a past-year sex partner, and less likely to have had two or more partners. The effect of age in increasing the odds of HSV-2 was modified by race, with higher HSV-2 prevalence among Black Americans established by age 20-24 years, and the effect of race decreasing from age 30 to 49. Relationship status remained an independent predictor of HSV-2 when controlling for age, race, and sex among those age 30 to 49; married/cohabitating status was protective for HSV-2 in this group (OR = 0.69)

CONCLUSIONS

Whereas sexually transmitted infections are often perceived as issues for young adults and specific high-risk groups, the chronic nature of HSV-2 results in accumulation of prevalence with age, especially among those not in married/cohabitating relationships. Increased odds of HSV-2 with age did not correspond with increases in self-reported genital herpes, which remained low. Adults who initiate new relationships should be aware of HSV-2 in order to better recognize its symptoms and prevent transmission.

Loss of the type I interferon pathway increases vulnerability of mice to genital herpes simplex virus 2 infection

The mouse model of genital herpes relies on medoxyprogesterone treatment of female mice to render the vaginal lumen susceptible to inoculation with herpes simplex virus 2 (HSV-2). In the present study, we report that mice deficient in the A1 chain of the type I interferon receptor (CD118(-/-)) are susceptible to HSV-2 in the absence of medroxyprogesterone preconditioning. In the absence of hormone pretreatment, 2,000 PFU of a clinical isolate of HSV-2 was sufficient to establish a productive infection in the vagina of 75% ± 17% and in the spinal cord of 71% ± 14% of CD118(-/-) mice, whereas the same dose of HSV-2 replicated to detectable levels in only 13% ± 13% of vaginal samples and 0% of spinal cord samples from wild-type mice, as determined at day 5 postinfection. The susceptibility to HSV-2 infection in the CD118(-/-) mice was associated with a significant reduction in the infiltration of HSV-specific cytotoxic T lymphocytes into the vaginal tissue, the local production of gamma interferon (IFN-γ), and the expression of T cell-recruiting chemokines CCL5, CXCL9, and CXCL10. Collectively, the results underscore the significant contribution of type I IFNs in resistance to genital HSV-2 infection.

Men who have sex with men in the United States: demographic and behavioral characteristics and prevalence of HIV and HSV-2 infection: results from National Health and Nutrition Examination Survey 2001-2006

OBJECTIVES

To describe demographic and behavioral characteristics and the prevalence of HIV and herpes simplex virus type 2 (HSV-2) infections in men who had sex with men identified through a nationally representative, population-based survey.

METHODS

As part of National Health and Nutrition Examination Surveys in 2001-2006, men 18 to 59 years of age were interviewed about sexual behavior using audio computer assisted self-interview and were tested for antibodies to HIV and HSV-2.

RESULTS

Of the 4319 men interviewed, 5.2% reported having ever had sex with men (MSM). MSM were more likely than non-MSM (those reporting female partners only) to have first sex at <15 years (31.9% vs. 17.3%), have > or =10 lifetime sex partners (73.6% vs. 40.8%), and have ever used cocaine (46.1% vs. 26.6%) (all P < 0.004). Among MSM, the prevalence of HIV and HSV-2 was 9.1% and 18.4%, respectively. Only 44.5% of MSM reported their sexual orientation as homosexual or gay. Comparing with bisexual and heterosexual MSM, homosexual MSM reported the highest number of lifetime male partners and had the highest HIV prevalence (16.5%).

CONCLUSIONS

In this population-based sample of men in the United States, self-reported same-sex behavior and homosexual orientation are strong markers for high risk of HIV infection.

Group sex events amongst non-gay drug users: an understudied risk environment

This article discusses relevant literature on group sex events--defined as events at which some people have sex with more than one partner--as risk environments, with a particular focus on group sex events where people who take drugs by non-injection routes of administration participate and where the event is not primarily LGBT-identified, at a "classic" crack house, nor in a brothel. It also briefly presents some findings from a small ethnography of such events. Group sex participation by people who take drugs by non-injection routes of administration seems to be widespread. It involves both behavioural and network risk for HIV and STI infection, including documented high-risk behaviour and sexual mixing of STI- and HIV-infected people with those who are uninfected. Indeed several HIV and STI outbreaks have been documented as based on such group sex events. Further, group sex events often serve as potential bridge environments that may allow infections to pass from members of one high-risk-behavioural category to another, and to branch out through these people's sexual and/or injection networks to other members of the local community. The ethnographic data presented here suggest a serious possibility of "third party transmission" of infectious agents between people who do not have sex with each other. This can occur even when condoms are consistently used since condoms and sex toys are sometimes used with different people without being removed or cleaned, and since fingers and mouths come into contact with mucosal surfaces of other members of the same or opposite sex. In addition to being risk environments, many of these group sex events are venues where risk-reducing norms, activities and roles are present--which lays the basis for harm reduction interventions. Research in more geographical locations is needed so we can better understand risks associated with group sex events in which drug users participate--and, in particular, how both participants and others can intervene effectively to reduce the risks posed to participants and non-participants by these group sex events. Such interventions are needed and should be developed.

Seroepidemiology of viral hepatitis, HIV and herpes simplex type 2 in the household population aged 21-64 years in Puerto Rico

BACKGROUND

Viral hepatitis and sexually transmitted infections (STIs) are key public health problems that pose an enormous risk for disease transmission in the general population. This study estimated, for the first time, prevalence estimates of serologic markers of HCV, HBV, HAV, HIV and HSV-2 in the adult population of Puerto Rico and assessed variations across sociodemographic and behavioral characteristics.

METHODS

A seroepidemiologic survey was employed using a stratified cluster probability sample of households in Puerto Rico. Participants completed a face-to-face interview, a self-administered questionnaire using an ACASI system, and provided blood specimens for antibody testing. Prevalence estimates of viral hepatitis, HIV and HSV-2 were estimated using a logistic regression model weighting for the probability of participation in each household block and the inverse of the probability of selection according to geographic strata, households' blocks, and sex distribution.

RESULTS

A total of 1,654 adults participated in the study. Seroprevalence estimates for HCV (2.3%, 95% CI: 1.3%-4.2%), HBV (3.1%, 95% CI: 2.0%-4.7%), and HSV-2 (22.3%, 95% CI: 18.5%-26.7%) in Puerto Rico are roughly in agreement with estimates obtained in the US population; however, HAV (41.3%, 95% CI: 36.9%-45.8%) and HIV (1.1%, 95% CI: 0.5%-2.3%) seroprevalence estimates in Puerto Rico were higher. The proportion of individuals that were unaware of their serostatus was as follows: 80% for HCV, 98.3% for HBV, 96.4% for HAV, 36.4% for HIV, and 97.8% for HSV-2. Post-stratification estimates of seroprevalence varied significantly by demographic and risk related characteristics.

CONCLUSION

This data underscore the disproportionate impact of some viral infections across selected population subgroups in Puerto Rico. A concerted island-wide effort is needed to strengthen viral hepatitis and STIs prevention and control strategies, support surveillance to monitor chronic infections, and ensure appropriate counseling, testing, and medical management of infected persons. Integration of HCV, HBV, and HSV-2 counseling into HIV existing prevention services and outreach through social networks might represent a valuable approach to reach high-risk individuals.

One-day famciclovir vs. placebo in patient-initiated episodic treatment of recurrent genital herpes in immunocompetent Black patients

BACKGROUND

There are no known racial differences in genital herpes disease pathogenesis or response to therapy. Despite high herpes simplex virus (HSV) seroprevalence in Black persons, clinical trials investigating the treatment of recurrent genital herpes (RGH) have typically enrolled a small proportion of Black patients.

METHODS

This multicenter, double-blind, placebo-controlled study evaluated the efficacy and safety of patient-initiated, 1-day famciclovir 1000 mg twice-daily in immunocompetent Black adults (USA and South Africa) with RGH. Eligible patients were randomized (2:1) to famciclovir or placebo. The primary endpoint was time to healing of non-aborted genital herpes lesions (i.e., lesions that progressed beyond papule stage). Secondary endpoints included proportion of patients with aborted genital herpes lesions, time to resolution of associated symptoms, and safety.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.gov ; trial identifier NCT00477334.

RESULTS

A total of 299 patients with RGH (66% female, median age = 37 years) received either 1-day famciclovir 1000 mg twice-daily (n = 201) or placebo (n = 98). In the modified intent-to-treat population, the estimated median time to healing of non-aborted genital herpes lesions was 5.38 days for famciclovir and 4.79 days for placebo (median of treatment differences = 0.26 days; 95% CI [-0.40, 0.98]; p = 0.416). Consistent findings were reported in the completer and per-protocol populations. No significant differences were reported for all secondary analyses. Adverse events (AEs) were consistent with the established safety profile of famciclovir: 18 (6%) patients had drug-related AEs (16 [8%] famciclovir; 2 [2%] placebo), none of which were serious or led to discontinuation or dose adjustment/interruption. There are some limitations of this research: many study sites either lacked prior experience in conducting clinical studies in patients with HSV infection or enrolled small numbers of patients, which may have compromised efficacy outcomes. Also, HIV antibody testing was not mandated at enrollment.

CONCLUSION

This study showed similar efficacy and tolerability of 1-day treatment with famciclovir 1000 mg twice-daily compared to placebo in immunocompetent Black adults with RGH. Famciclovir has proven efficacy and safety in the overall RGH population. Further understanding of the efficacy of antiherpes therapy in Black patients with recurrent genital herpes may be warranted.