Screening for HSV-2 infection in STD clinics and beyond: a few answers but more questions

Epidemiology of herpes simplex virus type 2 in Europe: systematic review, meta-analyses, and meta-regressions

Background

Herpes simplex virus type 2 (HSV-2) infection is a globally prevalent, life-long, sexually transmitted infection. This study characterized HSV-2 seroprevalence in Europe for various at-risk populations and proportions of HSV-2 detection in genital ulcer disease (GUD) and in genital herpes. Data on neonatal herpes and HSV-2's contribution to HIV transmission were also reviewed.

Methods

Cochrane and PRISMA guidelines were followed to systematically review, synthesize, and report HSV-2 related findings. The search was conducted in PubMed and Embase databases up to February 20, 2022. Any publication reporting data on the outcome measures was included. Meta-analyses and meta-regressions were conducted.

Findings

211 relevant reports were identified, including 12 overall incidence measures, 294 overall (813 stratified by factors such as age and sex) seroprevalence measures, 13 overall (15 stratified by sex) proportions of HSV-2 detection in clinically diagnosed GUD, and 70 overall (183 stratified by factors such as age and sex) proportions of HSV-2 detection in laboratory-confirmed genital herpes. Pooled mean seroprevalence was 12.4% (95% CI: 11.5-13.3%) among general populations, 27.8% (95% CI: 17.5-39.4%) among men who have sex with men, 46.0% (95% CI: 40.1-51.8%) among people living with HIV and people in HIV discordant couples, and 63.2% (95% CI: 55.5-70.6%) among female sex workers. Most measures showed heterogeneity in HSV-2 seroprevalence. The pooled mean seroprevalence among general populations increased with age and was 0.65-fold (95% CI: 0.58-0.74) lower in men than women. Seroprevalence decreased by 1% per calendar year. Pooled mean proportions of HSV-2 detection in GUD and in genital herpes were 22.0% (95% CI: 15.3-29.6%) and 66.0% (95% CI: 62.9-69.1%), respectively. HSV-2 detection in genital herpes cases was 1.21-fold (95% CI: 1.10-1.32) higher in men compared to women and decreased by 1% per calendar year. Incidence of neonatal herpes indicated an increasing trend.

Interpretation

Although seroprevalence is declining, a significant proportion of Europe's population is infected with HSV-2. HSV-2 accounts for approximately one-fifth of GUD cases and two-thirds of genital herpes cases. Findings support the need to invest in HSV-2 vaccine development, and sexual and reproductive health services.

Funding

Qatar National Research Fund [NPRP 9-040-3-008] and pilot funding from the Biomedical Research Program at Weill Cornell Medicine in Qatar supported this study.

Epidemiology of herpes simplex virus type 2 in Latin America and the Caribbean: systematic review, meta-analyses and metaregressions

Objective

To characterise epidemiology of herpes simplex virus type 2 (HSV-2) in Latin America and the Caribbean.

Methods

HSV-2 reports were systematically reviewed and synthesised, and findings were reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analyses and metaregressions were conducted.

Finding

102 relevant reports were identified including 13 overall incidence measures, 163 overall (and 402 stratified) seroprevalence measures, and 7 and 10 proportions of virus detection in genital ulcer disease and in genital herpes, respectively. Pooled mean seroprevalence was 20.6% (95% CI 18.7% to 22.5%) in general populations, 33.3% (95% CI 26.0% to 41.0%) in intermediate-risk populations, 74.8% (95% CI 70.6% to 78.8%) in female sex workers, and 54.6% (95% CI 47.4% to 61.7%) in male sex workers, men who have sex with men and transgender people. In general populations, seroprevalence increased from 9.6% (95% CI 7.1% to 12.4%) in those aged <20 years to 17.9% (95% CI 13.6% to 22.5%) in those aged 20–30, 27.6% (95% CI 21.4% to 34.2%) in those aged 30–40 and 38.4% (95% CI 32.8% to 44.2%) in those aged >40. Compared with women, men had lower seroprevalence with an adjusted risk ratio (ARR) of 0.68 (95% CI 0.60 to 0.76). Seroprevalence declined by 2% per year over the last three decades (ARR of 0.98, 95% CI 0.97 to 0.99). Pooled mean proportions of HSV-2 detection in GUD and genital herpes were 41.4% (95% CI 18.9% to 67.0%) and 91.1% (95% CI 82.7% to 97.2%), respectively.

Conclusions

One in five adults is HSV-2 infected, a higher level than other world regions, but seroprevalence is declining. Despite this decline, HSV-2 persists as the aetiological cause of nearly half of GUD cases and almost all of genital herpes cases.

Analytic Characterization of the Herpes Simplex Virus Type 2 Epidemic in the United States, 1950-2050

Background

We analytically characterized the past, present, and future levels and trends of the national herpes simplex virus type 2 (HSV-2) epidemic in the United States.

Methods

A population-level mathematical model was constructed to describe HSV-2 transmission dynamics and was fitted to the data series of the National Health and Nutrition Examination Survey.

Results

Over 1950–2050, antibody prevalence (seroprevalence) increased rapidly from 1960, peaking at 19.9% in 1983 in those aged 15–49 years, before reversing course to decline to 13.2% by 2020 and 8.5% by 2050. Incidence rate peaked in 1971 at 11.9 per 1000 person-years, before declining by 59% by 2020 and 70% by 2050. Annual number of new infections peaked at 1 033 000 in 1978, before declining to 667 000 by 2020 and 600 000 by 2050. Women were disproportionately affected, averaging 75% higher seroprevalence, 95% higher incidence rate, and 71% higher annual number of infections. In 2020, 78% of infections were acquired by those 15–34 years of age.

Conclusions

The epidemic has undergone a major transition over a century, with the greatest impact in those 15–34 years of age. In addition to 47 million prevalent infections in 2020, high incidence will persist over the next 3 decades, adding >600 000 new infections every year.

Epidemiological Impact of Novel Preventive and Therapeutic HSV-2 Vaccination in the United States: Mathematical Modeling Analyses

This study aims to inform herpes simplex virus type 2 (HSV-2) vaccine development, licensure, and implementation by delineating the population-level impact of vaccination. Mathematical models were constructed to describe the transmission dynamics in presence of prophylactic or therapeutic vaccines assuming 50% efficacy, with application to the United States. Catch-up prophylactic vaccination will reduce, by 2050, annual number of new infections by 58%, incidence rate by 60%, seroprevalence by 21%, and avert yearly as much as 350,000 infections. Number of vaccinations needed to avert one infection was only 50 by 2050, 34 by prioritizing those aged 15-19 years, 4 by prioritizing the highest sexual risk group, 43 by prioritizing women, and 47 by prioritizing men. Therapeutic vaccination of infected adults with symptomatic disease will reduce, by 2050, annual number of new infections by 12%, incidence rate by 13%, seroprevalence by 4%, and avert yearly as much as 76,000 infections. Number of vaccinations needed to avert one infection was eight by 2050, two by prioritizing those aged 15-19 years, three by prioritizing the highest sexual risk group, seven by prioritizing men, and ten by prioritizing women. HSV-2 vaccination offers an impactful and cost-effective intervention to prevent genital herpes medical and psychosexual disease burden.

No Role of Herpes Simplex Virus Type 2 (HSV-2) Infection on HIV Progression in Naïve HIV Patients

Background:

Herpes simplex virus type 2 (HSV-2) is a common infection in human immunodeficiency virus (HIV) patients and may accelerate HIV progression by rising HIV viral load and decreasing CD4 count. However, the available data regarding the influence of HSV-2 seropositivity on HIV progression in HIV individuals are inconclusive. Therefore, we aimed to determine HSV-2 seroprevalence in naïve HIV patients and normal controls and also investigate the relation of HIV viral load and CD4 count with HSV-2 seropositivity. Subsequently, we investigated the association of HSV-2 serostatus with changing in CD4 count and HIV viral load in our subjects, after one year follow-up.

Methods:

In this study, 116 naïve HIV patients and 85 healthy controls from Tehran, Iran were enrolled. HSV-2 IgG antibody was detected by ELISA. CD4 count was determined by flowcytometry, and serum HIV RNA copy numbers were determined using real-time PCR.

Results:

The prevalence of HSV-2 IgG was 18.1% in naïve HIV patients and 0% in the control group (P = 0.000). HSV-2 seroconversion was observed in 2.43% of HIV patients after one year. There was no significant difference regarding HSV-2 serostatus with CD4 count and HIV RNA viral load in our study cohort at baseline and after one year.

Conclusion:

Our results revealed that the prevalence and incidence of HSV-2 infection are low in our HIV cases, and it is negligible in the control group. However, it seems that HIV/HSV2 co-infection has no role on HIV infection acceleration.

Evaluation of Health Disparity in Bacterial Vaginosis and the Implications for HIV-1 Acquisition in African American Women

There is a health disparity for both bacterial vaginosis (BV) and human immunodeficiency virus type 1 (HIV-1) infection in African American women that may be linked. The evidence that BV predisposes women to higher risk for HIV infection is well documented. The underlying mechanisms to support the epidemiological connections will require further investigations. This review explores the risk factors for BV disease with implications for HIV-1 acquisition in the context of race as a potential driver of the 20-fold increase in HIV-1 acquisition for African American women compared to white women. Specifically, it explores (i) disparities for BV in African American women, (ii) racial disparity for HIV-1 acquisition in African American women, (iii) common factors associated with BV and HIV acquisition in African American women, and (iv) potential mechanisms of the enhancement of HIV-1 transmission by BV.

Trends in seroprevalence of herpes simplex virus type 2 among non-Hispanic blacks and non-Hispanic whites aged 14 to 49 years--United States, 1988 to 2010

OBJECTIVES

Genital herpes simplex virus type 2 (HSV-2) is one of the most prevalent sexually transmitted infections in the United States. We sought to assess differences in HSV-2 seroprevalence among non-Hispanic blacks and non-Hispanic whites and describe trends over time from 1988 to 2010.

METHODS

Data from National Health and Nutrition Examination Surveys (NHANES) were used to determine national HSV-2 seroprevalence estimates from National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2002, 2003 to 2006, and 2007 to 2010. Persons aged 14 to 49 years were included in the analyses. Race/Ethnicity was defined by self-report as non-Hispanic white or non-Hispanic black. Purified glycoprotein specific for HSV-2 was used to detect type-specific antibodies using an immunodot assay. The same assay was used in all surveys. History of diagnosed genital herpes was self-reported.

RESULTS

Overall, HSV-2 seroprevalence decreased in the United States between 1988 to 1994 and 2007 to 2010, from 21.2% to 15.5%. Among non-Hispanic white females, HSV-2 seroprevalence decreased from 19.5% (1988-1994) to 15.3% (2007-2010; P < 0.001); HSV-2 seroprevalence remained stable among non-Hispanic black females, 52.5% (1988-1994) to 49.9% (2007-2010; P = 0.1). The female black/white prevalence ratio was 2.7 (95% confidence interval [CI], 2.4-3.0) in 1988 to 1994 increasing to 3.3 (95% CI, 2.9-3.7) in 2007 to 2010 (P = 0.01). Among males, the black/white prevalence ratio was 2.4 (95% CI, 1.9-2.9) in 1988 to 1994 increasing to 4.4 (95% CI, 3.3-5.8) in 2007 to 2010 (P = 0.001). The overall percentage of HSV-2-seropositive survey participants who reported never being told by a doctor or health care professional that they had genital herpes did not change significantly between 1988 to 1994 and 2007 to 2010 and remained high (90.7% and 87.4%, respectively).

CONCLUSIONS

Although HSV-2 seroprevalence decreased overall, the decrease was most marked among non-Hispanic whites, and racial disparities significantly increased over time. These persistent disparities demonstrate the need for innovative prevention strategies among this at-risk population.

Australian sexually transmissible infection and HIV testing guidelines for asymptomatic men who have sex with men 2014: a review of the evidence

Men who have sex with men (MSM) in Australia and overseas are disproportionately affected by sexually transmissible infections (STIs), including HIV. Many STIs are asymptomatic, so regular testing and management of asymptomatic MSM remains an important component of effective control. We reviewed articles from January 2009–May 2013 to inform the 2014 update of the 2010 Australian testing guidelines for asymptomatic MSM. Key changes include: a recommendation for pharyngeal chlamydia (Chlamydia trachomatis) testing, use of nucleic acid amplification tests alone for gonorrhoea (Neisseria gonorrhoeae) testing (without gonococcal culture), more frequent (up to four times a year) gonorrhoea and chlamydia testing in sexually active HIV-positive MSM, time required since last void for chlamydia first-void urine collection specified at 20 min, urethral meatal swab as an alternative to first-void urine for urethral chlamydia testing, and the use of electronic reminders to increase STI and HIV retesting rates among MSM.

Herpes simplex virus type 2 serological testing at a community court: predictors of test acceptance and seropositivity among female defendants

Despite the high prevalence of herpes simplex virus type 2 (HSV-2), testing for asymptomatic infections is uncommon. One population for whom targeted interventions may be prioritized include individuals involved with the correctional system. Here we describe the acceptability of a novel HSV-2 screening program, implemented in a court setting, as a possible intervention for corrections-involved women. Female defendants completed an interviewer administered survey assessing factors associated with uptake/refusal of free point-of-care HSV-2 serologic testing and HSV-2 seropositivity. Participants included 143 women, 18-62 years old (mean 32.85) with diverse ethnicities. The majority (65.7%) accepted testing and 62.4% tested HSV-2 seropositive. Factors independently associated with test acceptance included higher perceived susceptibility to genital herpes infection and not receiving a preventative health screen. Women who were seropositive tended to be older, Black, report having previous STI, and be arrested on a prostitution charge. Findings suggest point-of-care testing in a court setting is acceptable to women and can be implemented to improve case finding of STI.

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.

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.