Epidemiology of herpes simplex virus type 2 in sub-Saharan Africa: Systematic review, meta-analyses, and meta-regressions

Strong Association Between HIV Incidence and Herpes Simplex Virus Type 2 in Zambia and South Africa: Prospective Data From the HPTN 071 (PopART) Trial

Background

Herpes simplex virus type 2 (HSV2) is an important cofactor for HIV acquisition and transmission. Associations between the infections are reexamined in longitudinal data from an HIV prevention trial.

Methods

The HPTN 071 (PopART) trial evaluated a combination prevention intervention in 21 urban communities in Zambia and South Africa. HIV incidence was measured in a cohort of approximately 2000 adults (age, 18-44 years) selected randomly from each community and followed up for 36 months. Incidence of HSV2 infection was estimated, and the effects of risk factors were examined. The association between HIV incidence and HSV2 infection was examined at individual and community levels.

Results

An overall 10 539 participants were HSV2 negative at baseline and retested after 36 months. Estimated HSV2 incidence was 5.4 per 100 person-years (95% CI, 5.0-5.7) for women and 2.9 per 100 person-years (95% CI, 2.6-3.2) for men. When compared with those remaining HSV2 negative, HIV incidence was higher in those who were HSV2 positive at baseline (women: adjusted rate ratio [aRR], 3.24 [95% CI, 2.50-4.20]; men: aRR, 2.57 [95% CI, 1.60-4.11]) and even higher in those who seroconverted to HSV2 during follow-up (women: aRR, 5.94 [95% CI, 4.42-7.98]; men: aRR, 8.37 [95% CI, 5.18-13.52]). At the community level, strong associations were seen between HIV incidence and HSV2 prevalence (R 2 = 0.48, P < .001) and incidence (R 2 = 0.36, P = .004).

Conclusions

There were strong associations between HIV incidence and HSV2 prevalence and incidence at individual and community levels. HSV2 control could contribute to HIV prevention.

Exploring microRNA-Mediated Immune Responses to Soil-Transmitted Helminth and Herpes Simplex Virus Type 2 Co-Infections

Over the last two decades, the field of microRNA (miRNA) research has grown significantly. MiRNAs are a class of short, single-stranded, non-coding RNAs that regulate gene expression post-transcriptionally. Thereby, miRNAs regulate various essential biological processes including immunity. Dysregulated miRNAs are associated with various infectious and non-infectious diseases. Recently co-infection with soil-transmitted helminths (STHs) and herpes simplex virus type 2 (HSV-2) has become a focus of study. Both pathogens can profoundly influence host immunity, particularly in under-resourced and co-endemic regions. It is well known that STHs induce immunomodulatory responses that have bystander effects on unrelated conditions. Typically, STHs induce T-helper 2 (Th2) and immunomodulatory responses, which may dampen the proinflammatory T-helper 1 (Th1) immune responses triggered by HSV-2. However, the extent to which STH co-infection influences the host immune response to HSV-2 is not well understood. Moreover, little is known about how miRNAs shape the immune response to STH/HSV-2 co-infection. In this article, we explore the potential influence that STH co-infection may have on host immunity to HSV-2. Because STH and HSV-2 infections are widespread and disproportionately affect vulnerable and impoverished countries, it is important to consider how STHs may impact HSV-2 immunity. Specifically, we explore how miRNAs contribute to both helminth and HSV-2 infections and discuss how miRNAs may mediate STH/HSV-2 co-infections. Insight into miRNA-mediated immune responses may further improve our understanding of the potential impact of STH/HSV-2 co-infections.

Potential Interactions Between Soil-Transmitted Helminths and Herpes Simplex Virus Type II: Implications for Sexual and Reproductive Health in Sub-Saharan African

Sub-Saharan Africa (SSA) bears a disproportionate and overlapping burden of soil-transmitted helminths (STHs) and sexually transmitted viral infections. An estimated 232 million pre-school and school-aged children in SSA are vulnerable to STH infections. Together with this, SSA has a high prevalence of herpes simplex virus type II (HSV-2), the primary cause of genital herpes. Studies have examined the immunological interactions between STHs and human immunodeficiency virus and human papillomavirus during co-infections. However, epidemiological and immunological studies on STH-HSV-2 co-infections are lacking, therefore their impact on sexual and reproductive health is not fully understood. STH-driven Th2 immune responses are known to downregulate Th1/Th17 immune responses. Therefore, during STH-HSV-2 co-infections, STH-driven immune responses may alter host immunity to HSV-2 and HSV-2 pathology. Herein, we provide an overview of the burden of STH and HSV-2 infections in SSA, and host immune responses to STH and HSV-2 infections. Further, we emphasize the relevance and urgent need for (i) focused research into the interactions between these important pathogens, and (ii) integrated approaches to improve the clinical detection and management of STH-HSV-2 co-infections in SSA.

Herpes simplex virus type 2 in sub-Saharan Africa and the potential impact of helminth immune modulation

Herpes simplex virus type 2 (HSV-2) and helminth infections are among the most widespread infectious diseases in sub-Saharan Africa (SSA). Helminths are known to modulate host immune responses and consequently impact the severity and outcomes of unrelated diseases, including allergies, autoimmune conditions, and infectious diseases. In this way, helminths may modulate essential immune responses against HSV-2 during co-infection and may alter susceptibility to and pathology of HSV-2. However, the epidemiology of STH/HSV-2 co-infections is understudied, and whether helminths influence the host immune response to HSV-2 is not well understood. In this perspective piece, we briefly examine the current knowledge on helminth immune modulation of important pathogens that are endemic to SSA, arguing that it is important to explore HSV-2 and helminth co-infections to elucidate potential interactions between HSV-2 and helminths. This is particularly relevant in SSA, where both pathogens are highly prevalent.

Epidemiology of herpes simplex virus type 1 in the United States: Systematic review, meta-analyses, and meta-regressions

This study aimed to analytically describe the epidemiology of herpes simplex virus type 1 (HSV-1) infection in the United States through a systematic review and meta-analytics. We reviewed 159 publications, identifying 190 seroprevalence measures and 43 proportions of HSV-1 detection in genital herpes. The pooled mean HSV-1 seroprevalence was 38.0% (95% CI: 30.9-45.4) among general-population children and 63.5% (95% CI: 61.3-65.7) among general-population adults. Age explained 43% of the seroprevalence variation, with rates increasing progressively with age. Seroprevalence declined by 0.99-fold (95% CI: 0.99-0.99) per year. The pooled mean proportion of HSV-1 detection in genital herpes was 15.4% (95% CI: 10.8-20.6), increasing by 1.02-fold (95% CI: 1.00-1.04) per year. Recurrent genital herpes had a 0.17-fold (95% CI: 0.09-0.32) lower proportion of HSV-1 detection compared to first-episode cases. The epidemiology of HSV-1 is shifting, marked by a decline in oral acquisition during childhood and an increase in genital acquisition during adulthood.

Epidemiology of Trichomonas vaginalis infection in the Middle East and North Africa: systematic review, meta-analyses, and meta-regressions

BACKGROUND

Trichomoniasis, caused by the parasite Trichomonas vaginalis (TV), remains an underappreciated sexually transmitted infection (STI), primarily due to inadequate understanding of its epidemiology and public health implications. This study aimed to characterize TV epidemiology in the Middle East and North Africa (MENA).

METHODS

Systematic review and analysis of evidence sourced from international, regional, and national databases were conducted. Findings were reported following PRISMA guidelines. Random-effects meta-analyses and meta-regressions were performed to determine pooled mean prevalence, investigate associations with prevalence, and identify sources of between-study heterogeneity.

FINDINGS

The review identified 263 relevant publications, encompassing 462 TV prevalence measures. The pooled mean TV prevalence was estimated as follows: 4.7% (95% CI: 3.9-5.6%) in the general population of women, 17.2% (95% CI: 5.4-33.6%) among intermediate-risk populations, 10.3% (95% CI: 6.2-15.3%) among female sex workers, 13.9% (95% CI: 12.3-15.6%) among symptomatic women, 7.4% (95% CI: 1.9-15.5%) among infertility clinic attendees, 2.3% (95% CI: 0.1-6.3%) among women with miscarriages or ectopic pregnancies, and 1.6% (95% CI: 0.8-2.7%) among STI clinic attendees. Limited data were found for men. Multivariable meta-regressions explained >40% of the prevalence variation, unveiling a hierarchical prevalence pattern by population type, an inverse correlation with national income, and a prevalence decline at a rate of 1% per calendar year.

INTERPRETATION

Despite conservative sexual norms, MENA has a substantial TV prevalence, comparable to the global TV prevalence. The unexpectedly high prevalence of this curable infection may, in part, be attributed to limited access to and underutilization of STI screening and treatment services.

FUNDING

This work was supported by the Qatar Research, Development, and Innovation Council [ARG01-0522-230273] and by the Biomedical Research Program at Weill Cornell Medicine-Qatar.

Vaccine value profile for herpes simplex virus

Herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) are chronic, highly prevalent viral infections that cause significant morbidity around the world. HSV-2 is sexually transmitted and is the leading cause of genital ulcer disease (GUD). It also increases the risk of HIV acquisition, fueling the HIV epidemic. HSV-1 is typically acquired in childhood through nonsexual contact and contributes to oral and ocular disease, but it can also be sexually transmitted to cause GUD. Both HSV-1 and HSV-2 cause neonatal herpes and neurologic disease. Given the ubiquitous nature of HSV-1 and HSV-2 infections and the limited existing prevention and control measures, vaccination would be the most efficient strategy to reduce the global burden of morbidity related to HSV infection. Vaccine strategies include prophylactic vaccination, which would prevent infection among susceptible persons and would likely be given to adolescents, and therapeutic vaccinations, which would be given to people with symptomatic genital HSV-2 infection. This document discusses the vaccine value profile of both types of vaccines. This 'Vaccine Value Profile' (VVP) for HSV is intended to provide a high-level, holistic assessment of the information and data that are currently available to inform the potential public health, economic and societal value of pipeline vaccines and vaccine-like products. This VVP was developed by subject matter experts from academia, non-profit organizations, government agencies and multi-lateral organizations. All contributors have extensive expertise on various elements of the HSV VVP and collectively aimed to identify current research and knowledge gaps. The VVP was developed using only existing and publicly available information.

Disparities in burden of herpes simplex virus type 2 in China: systematic review, meta-analyses, and meta-regressions

Background

The rising prevalence of herpes simplex type 2 (HSV-2) infection poses a growing global public health challenge. A comprehensive understanding of its epidemiology and burden disparities in China is crucial for informing targeted and effective intervention strategies in the future.

Methods

We followed Cochrane and PRISMA guidelines for a systematic review and included publications published in Chinese and English bibliographic systems until March 31st, 2024. We synthesized HSV-2 seroprevalence data across different population types. We used random-effects models for meta-analyses and conducted meta-regression to assess the association between population characteristics and seroprevalence.

Results

Overall, 23,999 articles were identified, and 402 publications (1,203,362 participants) that reported the overall seroprevalence rates (858 stratified measures) were included. Pooled HSV-2 seroprevalence among the general population (lower risk) was 7.7% (95% CI: 6.8-8.7%). Compared to the general population, there is a higher risk of HSV-2 prevalence among intermediate-risk populations (14.8%, 95% CI: 11.0-19.1%), and key populations (31.7%, 95% CI: 27.4-36.1%). Female sexual workers (FSWs) have the highest HSV-2 risk (ARR:1.69, 95% CI: 1.61-1.78). We found northeastern regions had a higher HSV-2 seroprevalence than other regions (17.0%, 95% CI: 4.3-35.6%, ARR: 1.38, 95% CI: 1.26-1.50, Northern China as the reference group). This highlighted the disparity by population risk levels and regions. We also found lower HSV-2 prevalence estimates in publications in Chinese bibliographic databases than those in English databases among key populations (such as MSM and HIV-discordant populations).

Conclusion

There is a gradient increase in HSV-2 prevalence risk stratification. We also identified region, population, and age disparities and heterogeneities by publication language in the HSV-2 burden. This study provides guidance for future HSV-2 prevention to eliminate disparities of HSV-2 infection and reduce overall HSV-2 burden.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=408108, identifier CRD42023408108.

Aetiology of vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa: A systematic review and meta-regression

BACKGROUND

Syndromic management is widely used to treat symptomatic sexually transmitted infections in settings without aetiologic diagnostics. However, underlying aetiologies and consequent treatment suitability are uncertain without regular assessment. This systematic review estimated the distribution, trends, and determinants of aetiologies for vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa (SSA).

METHODS AND FINDINGS

We searched Embase, MEDLINE, Global Health, Web of Science, and grey literature from inception until December 20, 2023, for observational studies reporting aetiologic diagnoses among symptomatic populations in SSA. We adjusted observations for diagnostic test performance, used generalised linear mixed-effects meta-regressions to generate estimates, and critically appraised studies using an adapted Joanna Briggs Institute checklist. Of 4,418 identified records, 206 reports were included from 190 studies in 32 countries conducted between 1969 and 2022. In 2015, estimated primary aetiologies for vaginal discharge were candidiasis (69.4% [95% confidence interval (CI): 44.3% to 86.6%], n = 50), bacterial vaginosis (50.0% [95% CI: 32.3% to 67.8%], n = 39), chlamydia (16.2% [95% CI: 8.6% to 28.5%], n = 50), and trichomoniasis (12.9% [95% CI: 7.7% to 20.7%], n = 80); for urethral discharge were gonorrhoea (77.1% [95% CI: 68.1% to 84.1%], n = 68) and chlamydia (21.9% [95% CI: 15.4% to 30.3%], n = 48); and for genital ulcer were herpes simplex virus type 2 (HSV-2) (48.3% [95% CI: 32.9% to 64.1%], n = 47) and syphilis (9.3% [95% CI: 6.4% to 13.4%], n = 117). Temporal variation was substantial, particularly for genital ulcer where HSV-2 replaced chancroid as the primary cause. Aetiologic distributions for each symptom were largely the same across regions and population strata, despite HIV status and age being significantly associated with several infection diagnoses. Limitations of the review include the absence of studies in 16 of 48 SSA countries, substantial heterogeneity in study observations, and impeded assessment of this variability due to incomplete or inconsistent reporting across studies.

CONCLUSIONS

In our study, syndrome aetiologies in SSA aligned with World Health Organization guidelines without strong evidence of geographic or demographic variation, supporting broad guideline applicability. Temporal changes underscore the importance of regular aetiologic re-assessment for effective syndromic management.

PROSPERO NUMBER

CRD42022348045.

Characteristics of reproductive tract infections caused by common pathogens among the outpatients of reproductive medicine center in Putian: retrospective study

BACKGROUND

This study aims to explore the infection and age distribution of Ureaplasma urealyticum (UU), Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Herpes simplex virus type II (HSV II) among the outpatients of Reproductive Medicine Center in Putian, Fujian Province to provide a clinical basis for the early diagnosis and treatment of various reproductive tract diseases and infertility in this region.

METHODS

A total of 1736 samples of secretions and exfoliated cervical cells were collected from the outpatients of the Reproductive Medicine Center of the Affiliated Hospital of Putian University from December 2021 to April 2023. The infections of UU, CT, NG and HSVII were detected by real-time fluorescence polymerase chain reaction (PCR), and the infection statuses of the patients with different genders, ages and diagnoses were analysed.

RESULTS

Among the 1736 patients, 611 were male and 1125 were female. The male patients had higher UU infection rate but lower HSV II infection rate than the female patients. No significant difference in CT and NG infection rates was observed between the genders. The CT infection rate gradually decreased with the increase in the age. The difference in UU, NG and HSV II infection rates among the different age groups was not statistically significant. For UU infection, the male infertile patients had the highest rate of 37.72% (172/456). Meanwhile, the differences in CT, NG and HSV II infection rates among the different diagnosis groups were not statistically significant. Among the male and female infertile patients, the CT infection rate was the highest in the 21-25 years of age group at 11.11% (2/18) and 9.47% (9/95), respectively. No statistically significant difference in UU, CT, NG and HSV II infection rates was observed among the different age groups of patients diagnosed in relation to the family planning guidance and between the male and female patients with other diagnoses results.

CONCLUSIONS

This study showed that UU was the most frequently identified pathogen in infertile men in Putian, Fujian Province. The CT infection rate was the highest in people under 20 years old, and the infection showed a tendency toward young individuals. Therefore, the publicity of sexual health knowledge must be strengthened, and the prevention and treatment of venereal diseases among young and middle-aged people must be improved. Moreover, the pathogen infection is related to infertility to a certain extent, which is conducive to clinical diagnosis and treatment.

Burden and Trends of Symptomatic Sexually Transmitted Infections in Malawi From 2000 to 2021: Comparative Analysis of Survey and Case Report Data

BACKGROUND

In settings without etiologic testing for sexually transmitted infections (STIs), programs rely on STI symptom data to inform priorities. To evaluate whether self-reported STI symptoms in household surveys consistently represent the STI burden, we compared symptomatic infection rates between survey self-reporting and health facility case reporting in Malawi.

METHODS

We analyzed self-reported symptoms and treatment seeking in the past year among sexually active adults from 4 Malawi Demographic and Health Surveys between 2000 and 2015. Bayesian mixed-effects models were used to estimate temporal trends, spatial variation, and sociodemographic determinants. Survey reporting was compared with health facility syndromic diagnoses between 2014 and 2021.

RESULTS

In surveys, 11.0% (95% confidence interval, 10.7%-11.4%) of adults reported STI or STI-related symptoms in the last year, of whom 54.2% (52.8%-55.7%) sought treatment. In facilities, the mean annual symptomatic case diagnosis rate was 3.3%. Survey-reported treatment in the last year was 3.8% (95% credible interval, 2.3%-6.1%) for genital ulcer, 3.8% (2.0%-6.7%) for vaginal discharge, and 2.6% (1.2%-4.7%) for urethral discharge. Mean annual diagnosis rates at facilities were 0.5% for genital ulcer, 2.2% for vaginal discharge, and 2.0% for urethral discharge. Both data sources indicated a higher burden of symptoms among women, individuals older than 25 years, and those in Southern Malawi.

CONCLUSIONS

Survey and facility case reports indicated similar spatial and demographic patterns of STI symptom burden and care seeking, but implied large differences in the magnitude and relative burden of symptoms, particularly genital ulcer, which could affect program priorities. Targeted etiologic surveillance would improve interpretation of these data to enable more comprehensive STI surveillance.

Epidemiology of gonorrhoea: systematic review, meta-analyses, and meta-regressions, World Health Organization European Region, 1949 to 2021

BackgroundEpidemiology of Neisseria gonorrhoeae (NG) infection remains inadequately understood.AimWe aimed to characterise NG epidemiology in Europe.MethodsWe used Cochrane and PRISMA guidelines to systematically review, report, synthesise and analyse NG prevalence data from 1949 to 30 September 2021. Random-effects meta-analyses estimated pooled prevalence. Meta-regression analyses investigated associations and sources of heterogeneity.ResultsThe 844 included publications yielded 1,573 prevalence measures. Pooled prevalence of current urogenital infection was 1.0% (95% CI: 0.7-1.2%) among general populations, 3.2% (95% CI: 1.8-4.8%) among female sex workers, 4.9% (95% CI: 4.2-5.6%) among sexually transmitted infection clinic attendees and 12.1% (95% CI: 8.8-15.8%) among symptomatic men. Among men who have sex with men, pooled prevalence was 0.9% (95% CI: 0.5-1.4%), 5.6% (95% CI: 3.6-8.1%), and 3.8% (95% CI: 2.5-5.4%), respectively, for current urogenital, anorectal or oropharyngeal infection. Current urogenital, anorectal or oropharyngeal infection was 1.45-fold (95% CI: 1.19-1.77%), 2.75-fold (95% CI: 1.89-4.02%) and 2.64-fold (95% CI: 1.77-3.93%) higher among men than women. Current urogenital infection declined 0.97-fold (95% CI: 0.96-0.98%) yearly, but anorectal and oropharyngeal infection increased (1.02-fold; 95% CI: 1.01-1.04% and 1.02-fold; 95% CI: 1.00-1.04%), respectively.ConclusionsNeisseria gonorrhoeae epidemiology in Europe has distinct and contrasting epidemiologies for vaginal sex transmission in heterosexual sex networks vs anal and oral sex transmission in MSM sexual networks. Increased transmission may facilitate drug-resistant strain emergence. Europe is far from achieving the World Health Organization target of 90% incidence reduction by 2030.

Age Patterns of HSV-2 Incidence and Prevalence in Two Ugandan Communities: A Catalytic Incidence Model Applied to Population-Based Seroprevalence Data

BACKGROUND

Herpes simplex virus type 2 (HSV-2) is an incurable sexually transmitted infection associated with increased risk of acquiring and transmitting human immunodeficiency virus (HIV). HSV-2 is highly prevalent in sub-Saharan Africa, but population-level estimates of incidence are sparse.

METHODS

We measured HSV-2 prevalence from cross-sectional serological data among adults aged 18-49 years in 2 south-central Uganda communities (fishing, inland). We identified risk factors for seropositivity, then inferred age patterns of HSV-2 with a Bayesian catalytic model.

RESULTS

HSV-2 prevalence was 53.6% (n = 975/1819; 95% confidence interval, 51.3%-55.9%). Prevalence increased with age, was higher in the fishing community, and among women, reaching 93.6% (95% credible interval, 90.2%-96.6%) by age 49 years. Factors associated with HSV-2 seropositivity included more lifetime sexual partners, HIV positive status, and lower education. HSV-2 incidence peakied at age 18 years for women and 19-20 years for men. HIV prevalence was up to 10-fold higher in HSV-2-positive individuals.

CONCLUSIONS

HSV-2 prevalence and incidence were extremely high, with most infections occurring in late adolescence. Interventions against HSV-2, such as future vaccines or therapeutics, must target young populations. Remarkably higher HIV prevalence among HSV-2-positive individuals underscores this population as a priority for HIV prevention.

Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls in western Kenya: a cluster randomised controlled trial

Background

High rates of sexual and reproductive health (SRH) harms and interrupted schooling are global challenges for adolescent girls, requiring effective interventions. We assessed the impact of menstrual cups (MCs) or cash transfers conditioned on school attendance (CCTs), or both, on SRH and schooling outcomes in western Kenya.

Methods

In this cluster-randomised Cups or Cash for Girls (CCG) trial, adolescent girls in Forms two and three at 96 secondary schools in Siaya County (western Kenya) were randomised to receive either CCT, MC, combined CCT and MC, or control (1:1:1:1) for an average of 30 months. The CCT intervention comprised 1500KES (US$15 in 2016) via a cash card each school trimester. All four treatment groups received puberty and hygiene training. Assenting girls with parent or guardian consent who were post-menarche, not pregnant, area residents, not boarding, and had no disabilities precluding participation were eligible. Socio-behavioural risk factors and incidence of HIV and herpes simplex virus type 2 (HSV-2) were measured annually. School retainment and adverse events were monitored throughout. The primary outcome comprised a composite of incident HIV, HSV-2 and/or all-cause school dropout by school exit examination. The primary analysis was by intention-to-treat (ITT) using generalised linear mixed models, controlling for a priori selected baseline covariates. The trial is registered with ClinicalTrials.gov, NCT03051789.

Findings

Between February 28, 2017 and June 30, 2021, 4137 girls (median age 17.1 [interquartile range (IQR): 16.3-18.0]) were enrolled and followed annually until completion of secondary school (median 2.5 years [IQR: 2.4-2.7]); 4106 (99.3%) contributed to the ITT analysis. No differences in the primary composite outcome between intervention and control groups were seen (MC: 18.2%, CCT: 22.1%, combined: 22.1%, control: 19.6%; adjusted risk ratio [aRR]: 0.97, 95% confidence interval 0.76-1.24; 1.14, 0.90-1.45; and 1.13, 0.90-1.43, respectively). Incident HSV-2 occurred in 8.6%, 13.3%, 14.8%, and 12% of the MC, CCT, combined and control groups, respectively (MC: RR: 0.67, 0.47-0.95, p = 0.027; aRR: 0.71, 0.50-1.01, p = 0.057; CCT: aRR: 1.02, 0.73-1.41, p = 0.92; combined aRR: 1.16, 0.85-2.58, p = 0.36). Incident HIV was low (MC: 1.2%, CCT: 1.5%, combined: 1.0%, and control: 1.4%; aRR: 0.88, 0.38-2.05, p = 0.77, aRR: 1.16, 0.51-2.62, p = 0.72, aRR: 0.80, 0.33-1.94, p = 0.62, respectively). No intervention decreased school dropout (MC: 11.2%, CCT: 12.4%, combined: 10.9%, control: 10.5%; aRR: 1.16, 0.86-1.57; 1.23, 0.91-1.65; and 1.06, 0.78-1.44, respectively). No related serious adverse events were seen.

Interpretation

MCs, CCTs, or both, did not protect schoolgirls against a composite of deleterious harms. MCs appear protective against HSV-2. Studies of longer follow-up duration with objective measures of health impact are needed in this population.

Funding

Department of Health and Social Care, the Foreign, Commonwealth & Development Office, the Medical Research Council and Wellcome.

Seroprevalence of herpes simplex virus type 1 and type 2 among the migrant workers in Qatar

BACKGROUND

Limited data exists on herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) infections in migrant populations. This study investigated HSV-1 and HSV-2 seroprevalences and associations among craft and manual workers (CMWs) in Qatar who constitute 60% of Qatar's population.

METHODS

A national population-based cross-sectional seroprevalence survey was conducted on the CMW population, all men, between July 26 and September 9, 2020. 2,612 sera were tested for anti-HSV-1 IgG antibodies using HerpeSelect 1 ELISA IgG kits and for anti-HSV-2 IgG antibodies using HerpeSelect 2 ELISA IgG kits (Focus Diagnostics, USA). Univariable and multivariable logistic regression analyses were conducted to identify associations with HSV-1 and HSV-2 infections.

RESULTS

Serological testing identified 2,171 sera as positive, 403 as negative, and 38 as equivocal for HSV-1 antibodies, and 300 sera as positive, 2,250 as negative, and 62 as equivocal for HSV-2 antibodies. HSV-1 and HSV-2 seroprevalences among CMWs were estimated at 84.2% (95% CI 82.8-85.6%) and 11.4% (95% CI 10.1-12.6%), respectively. HSV-1 infection was associated with nationality, educational attainment, and occupation. HSV-2 infection was associated with age, nationality, and educational attainment.

CONCLUSIONS

Over 80% of CMWs are infected with HSV-1 and over 10% are infected with HSV-2. The findings highlight the need for sexual health programs to tackle sexually transmitted infections among the CMW population.

Tenofovir vaginal film as a potential MPT product against HIV-1 and HSV-2 acquisition: formulation development and preclinical assessment in non-human primates

Tenofovir (TFV) is an adenosine nucleotide analog with activity against HIV and HSV-2. Secondary analyses of clinical trials evaluating TFV gel as pre-exposure prophylaxis (PrEP) for HIV have shown that gel formulations of TFV provide significant protection against both HIV and HSV-2 acquisition in women who had evidence of use. An alternate quick-dissolving polymeric thin film, to deliver TFV (20 and 40 mg) has been developed as a potential multipurpose technology (MPT) platform. Film formulation was developed based on excipient compatibility, stability, and ability to incorporate TFV doses. Placebo, low dose (20 mg), and high dose (40 mg) films were utilized in these studies. The developed film platform efficiently incorporated the high dose of TFV (40 mg/film), released more than 50% of drug in 15 min with no in vitro toxicity. Pharmacological activity was confirmed in an ex vivo HIV-1 challenge study, which showed a reduction in HIV-1 infection with TFV films. Films were stable at both doses for at least 2 years. These films were found to be safe in macaques with repeated exposure for 2 weeks as evidenced by minimal perturbation to tissues, microbiome, neutrophil influx, and pH. Macaque sized TFV film (11.2 mg) evaluated in a pigtail macaque model showed higher vaginal tissue concentrations of TFV and active TFV diphosphate compared to a 15 mg TFV loaded gel. These studies confirm that TFV films are stable, safe and efficiently deliver the drug in cervicovaginal compartments supporting their further clinical development.

Epidemiology of herpes simplex virus type 1 in Canada: systematic review, meta-analyses, and meta-regressions

Background

The objective of this study was to characterize herpes simplex virus type 1 (HSV-1) epidemiology in Canada.

Methods

HSV-1 publications as recent as December 6, 2021 were systematically reviewed, synthesized, and reported following PRISMA guidelines. Meta-analyses and meta-regressions were conducted.

Results

HSV-1 measures were extracted from 22 studies and included 32 overall seroprevalence measures (79 stratified), 2 overall proportions of HSV-1 detection in clinically diagnosed genital ulcer disease (2 stratified), and 8 overall proportions of HSV-1 detection in laboratory-confirmed genital herpes (27 stratified). Pooled mean seroprevalence was 19.1% [95% confidence interval (CI): 12.6-26.4%] among healthy children and 51.4% (95% CI: 47.3-55.5%) among healthy adults. Pooled mean seroprevalence among healthy general populations increased with age, with the lowest being 35.7% (95% CI: 29.1-42.6%) among individuals <20 years of age, and the highest being 70.0% (95% CI: 54.8-83.2) among individuals ≥40 years. Seroprevalence increased by 1.02-fold (95% CI: 1.01-1.04) per year. Pooled mean proportion of HSV-1 detection in genital ulcer disease was 30.8% (95% CI: 12.6-52.8%). Pooled mean proportion of HSV-1 detection in genital herpes was 37.4% (95% CI: 29.5-45.6%) and was highest in women and in young persons. Proportion of HSV-1 detection in genital herpes increased by 1.04-fold (95% CI: 1.00-1.08) per year.

Conclusions

HSV-1 epidemiology in Canada appears to be shifting toward less oral acquisition in childhood and more genital acquisition in adulthood, particularly among youth. Both HSV-1 seroprevalence and proportion of HSV-1 detection in genital herpes are increasing with time.

Epidemiology of herpes simplex virus type 2 in the Middle East and North Africa: Systematic review, meta-analyses, and meta-regressions

BACKGROUND

Herpes simplex virus type 2 (HSV-2) infection is a prevalent, sexually transmitted infection with poorly characterized prevalence in the Middle East and North Africa (MENA) region. This study characterized HSV-2 epidemiology in MENA.

METHODS

The systematic review was guided by the Cochrane Collaboration Handbook and findings were reported following PRISMA guidelines. Random-effects meta-analyses and meta-regressions were performed to estimate pooled mean outcome measures and to assess predictors of HSV-2 antibody prevalence (seroprevalence), trends in seroprevalence, and between-study heterogeneity.

FINDINGS

61 overall (133 stratified) HSV-2 seroprevalence measures and two overall (4 stratified) proportion measures of HSV-2 detection in laboratory-confirmed genital herpes were extracted from 37 relevant publications. Pooled mean seroprevalence was 5.1% (95% CI: 3.6-6.8%) among general populations, 13.3% (95% CI: 8.6-18.7%) among intermediate-risk populations, 20.6% (95% CI: 5.3-42.3%) among female sex workers, and 18.3% (95% CI: 3.9-39.4%) among male sex workers. Compared to Fertile Crescent countries, seroprevalence was 3.39-fold (95% CI: 1.86-6.20) and 3.90-fold (95% CI: 1.78-8.57) higher in Maghreb and Horn of Africa countries, respectively. Compared to studies published before 2010, seroprevalence was 1.73-fold (95% CI: 1.00-2.99) higher in studies published after 2015. Pooled mean proportion of HSV-2 detection in genital herpes was 73.8% (95% CI: 42.2-95.9%).

CONCLUSION

MENA has a lower HSV-2 seroprevalence than other world regions. Yet, 1 in 20 adults is chronically infected, despite conservative prevailing sexual norms. Seroprevalence may also be increasing, unlike other world regions. Findings support the need for expansion of surveillance and monitoring of HSV-2 infection in MENA. This article is protected by copyright. All rights reserved.

Epidemiology of herpes simplex virus type 1 and genital herpes in Australia and New Zealand: systematic review, meta-analyses and meta-regressions

Herpes simplex virus type 1 (HSV-1) infection is a lifelong infection that is acquired primarily orally and during childhood. We aimed to characterise HSV-1 epidemiology in Australia and New Zealand. HSV-1-related data as recent as 6 December 2021 were systematically reviewed, synthesised and reported, following PRISMA guidelines. Pooled mean seroprevalence and proportions of HSV-1 detection in genital ulcer disease (GUD) and in genital herpes were calculated using random-effects meta-analyses. Meta-regressions were also conducted. HSV-1 measures were retrieved from 21 eligible publications. Extracted HSV-1 measures included 13 overall seroprevalence measures (27 stratified) in Australia, four overall proportions of HSV-1 detection in clinically diagnosed GUD (four stratified) in Australia, and ten overall proportions of HSV-1 detection in laboratory-confirmed genital herpes (26 stratified) in Australia and New Zealand. Pooled mean seroprevalence among healthy adults in Australia was 84.8% (95% confidence interval (CI) 74.3-93.1%). Pooled mean seroprevalence was 70.2% (95% CI 47.4-88.7%) among individuals <35 years of age and 86.9% (95% CI 79.3-93.0%) among individuals ≥35 years. Seroprevalence increased by 1.05-fold (95% CI 1.01-1.10) per year. Pooled mean proportion of HSV-1 detection in GUD was 8.2% (95% CI 0.4-22.9%). Pooled mean proportion of HSV-1 detection in genital herpes was 30.5% (95% CI 23.3-38.3%), and was highest in young individuals. Proportion of HSV-1 detection in genital herpes increased by 1.04-fold (95% CI 1.00-1.08) per year. Included studies showed heterogeneity, but 30% of the heterogeneity in seroprevalence and 42% of the heterogeneity in proportion of HSV-1 detection in genital herpes were explained in terms of epidemiological factors. HSV-1 seroprevalence is higher in Australia than in other Western countries. HSV-1 epidemiology in Australia and New Zealand appears to be transitioning towards less oral acquisition in childhood, but more genital acquisition among youth.

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.

Aetiology of genital ulcer disease and associated factors among Mthatha public clinic attendees

Background

Genital ulcer disease (GUD) is a sexually transmitted disease characterised by ulcerating lesions. Despite the introduction of sexually transmitted infections (STIs) syndromic management approach into primary healthcare in South Africa (SA) in 1995, the prevalence of STIs in South Africa remains high.

Objectives

The study investigated the aetiology of GUD and factors influencing it among public community health centre (CHC) attendees in the Eastern Cape, South Africa.

Method

A total of 105 participants were recruited among individuals presenting with GUD from three CHCs located in the Eastern Cape Province, South Africa. Blood and genital ulcer samples were collected from consented participants. Blood samples with suitable sera were tested for human immunodeficiency virus (HIV) and syphilis. Herpes simplex virus types 1/2 (HSV-1/2), Chlamydia trachomatis, Treponema pallidum, Haemophilus ducreyi and Klebsiella granulomatis were detected in nucleic acid extracted from genital ulcer specimens.

Results

Out of the 98 samples with suitable sera, 55.1% and 8.2% were HIV and syphilis seropositive, respectively. Ulcerating STI pathogens were detected in 31.4% of the study participants. Herpes simplex virus type 2 was the most detected pathogen (16.2%) followed by Chlamydia trachomatis (10.5%), HSV-1 (8.6%), Haemophilus ducreyi (8.6%) and Treponema pallidum (6.7%). Multiple pathogens were detected in 13.3% of participants. Detected multiple ulcerating pathogens were common among HIV-positives (p = 0.016).

Conclusion

Molecular methods for diagnosing pathogens have the potential to improve the management of GUD. Data generated from this study would contribute to the limited data on GUD in the Eastern Cape Province. Further research with a larger sample size is recommended.

Contribution

Data generated would contribute to the limited data on GUD in the Eastern Cape province, South Africa.

Estimated economic burden of genital herpes and HIV attributable to herpes simplex virus type 2 infections in 90 low- and middle-income countries: A modeling study

BACKGROUND

Economic losses due to herpes simplex infections in low- and middle-income countries (LMICs) are unknown. We estimated economic and quality-of-life losses due to genital herpes in 2019, in 90 LMICs, and from 2020 to 2030 in 45 countries in the World Health Organization (WHO) Africa. We additionally estimated economic losses due to human immunodeficiency virus (HIV) attributable to herpes simplex virus type 2 (HSV-2) infections.

METHODS AND FINDINGS

We estimated genital herpes-related spending on treatment, wage losses due to absenteeism, and reductions in quality of life, for individuals aged 15 to 49 years, living with genital herpes. Had HSV-2 had contributed to the transmission of HIV, we estimated the share of antiretroviral treatment costs and HIV-related wage losses in 2019 that can be attributed to incident and prevalent HSV-2 infections in 2018. For the former, we used estimates of HSV-2 incidence and prevalence from the global burden of disease (GBD) study. For the latter, we calculated population attributable fractions (PAFs), using the classic (Levin's) epidemiological formula for polytomous exposures, with relative risks (RRs) reported in literature. To extend estimates from 2020 to 2030, we modeled the transmission of HSV-2 in 45 African countries using a deterministic compartmental mathematical model, structured by age, sex, and sexual activity, which was fitted to seroprevalence gathered from a systematic review and meta-regression analysis. In the 90 LMICs, genital herpes contributed to US$813.5 million in treatment and productivity losses in 2019 (range: US$674.4 to US$952.2 million). Given observed care-seeking and absenteeism, losses are in the range of US$29.0 billion (US$25.6 billion to US$34.5 billion). Quality-of-life losses in the amount of 61.7 million quality-adjusted life years (QALYs) are also possible (50.4 million to 74.2 million). The mean annual cost of treatment and wage losses per infection is US$183.00 (95% CI: US$153.60 to US$212.55); the mean annual cost of quality-of-life losses is US$343.27 (95% CI: 272.41 to 414.14). If HSV-2 has fueled the transmission of HIV, then seroprevalent HSV-2 cases in 2018 can account for 33.2% of the incident HIV infections in 2019, with an associated antiretroviral therapy (ART) cost of US$186.3 million (range: US$163.6 to US$209.5 million) and 28.6% of HIV-related wage losses (US$21.9 million; range: US$19.2 to US$27.4 million). In the WHO Africa region, the 3.9 million seroprevalent genital herpes cases from 2020 to 2030 contributed to US$700.2 million in treatment and productivity losses. Additionally, quality-of-life losses in the range of 88 million to 871 million QALYs are also possible. If HSV-2 has contributed to the transmission of HIV, then in 2020, the PAF of HIV due to prevalent HSV-2 will be 32.8% (95% CI: 26.7% to 29.9%) and due to incident infections will be 4.2% (95% CI: 2.6% to 3.4%). The PAF due to prevalent infections will decline to 31.0% by 2030 and incident infections to 3.6%. Though we have accounted for the uncertainty in the epidemiological and economic parameter values via the sensitivity analysis, our estimates still undervalue losses due to limiting to the 15- to 49-year-old population.

CONCLUSIONS

Economic losses due to genital herpes in LMICs can be large, especially when considering the lifelong nature of the disease. Quality-of-life losses outweigh spending on treatment and reductions in productivity. If HSV-2 has contributed to the spread of HIV in LMICs, then nearly one third of antiretroviral costs and HIV-related wage losses can be attributed to HSV-2. Given the magnitude of the combined losses, a vaccine against HSV-2 must be a global priority.

Herpes simplex virus type 2 (HSV-2) and its association with HIV, HCV, HBV, HTLV-1&2 and syphilis among men who have sex with men in Burkina Faso

PURPOSE

This study aimed to estimate herpes simplex virus type 2 (HSV-2) seroprevalence and its association with HIV, HBV, HCV, HTLV-1&2 and syphilis among men who have sex with men (MSM) in Ouagadougou, Burkina Faso, West Africa.

MATERIALS AND METHODS

We screened MSM sera for HSV-2 antibodies. A total of 329 sera were collected from an HIV and syphilis behavioral and biological cross-sectional survey conducted among MSM in Ouagadougou from January to April 2013. Serum samples were tested using Enzyme Linked Immuno-Sorbent Assay (ELISA) for the detection of IgG antibodies to HSV-2. Also, antibodies to HTLV-1&2, HBsAg and anti-HCV antibodies were screened by ELISA. Laboratory assays were performed according to manufacturers' instructions at the Biomedical Research Laboratory at the "Institut de Recherche en Sciences de la Sante" (IRSS) in Burkina Faso.

RESULTS

The seroprevalence of HSV-2 infection among MSM was 14.3%(95% CI: 10.6-18.1), with disparities according to age and occupation. HSV-2 seroprevalence was high among MSM who were seropositive for HIV (40% versus 13.9%), for syphilis (42.9% versus 13.3%), for HCV (32.5% versus 11.7%) and for HTLV-1&2 (38.5% versus 12.9%) compared to people seronegative for these pathogens. Multivariate analysis showed that HIV-positive (ORa ​= ​5.34, p ​= ​0.027), anti-HCV-positive (ORa ​= ​4.44, p ​= ​0.001), and HTLV-1&2 positive (aOR ​= ​4.11, p ​= ​0.046) were associated with HSV-2 infection among MSM. However, no significant statistical association between HSV-2 and syphilis was found.

CONCLUSION

HSV-2 seroprevalence among MSM in Burkina Faso is relatively high. Positive associations between sexual transmitted infections including HIV with HSV-2 suggest that HSV-2 infection's prevention should be strengthened through HIV transmission control programs.

Development of a high specificity typing method for the detection of herpes simplex virus

Herpes disease is caused by Herpes simplex virus (HSV). It has become one of the global health problems. This paper reports a method for HSV type testing. First specific primers sequence for HSV-1 and HSV-2 were selected, designed, and synthesized. Then, these amplification products were proved by sequencing and analysis. Lastly, we optimized the reaction system and PCR reaction program by orthogonal design and sensitivity testing. Results showed that the lowest concentration in HSV-type testing is about 6.67 × 10⁶ copies/ml. Moreover, the specificity of detection was very high. So, this method has very great potentials for HSV type testing in clinical practice.

Epidemiology of Herpes Simplex Virus Type 2 in Canada, Australia, and New Zealand: Systematic Review, Meta-Analyses, and Meta-Regressions

BACKGROUND

This study characterized the epidemiology of herpes simplex virus type 2 (HSV-2) infection in Canada, Australia, and New Zealand.

METHODS

Cochrane and PRISMA guidelines were followed to systematically review, synthesize, and report HSV-2-related data up to January 21, 2021. Meta-analyses and meta-regressions were performed.

RESULTS

In Canada, pooled mean seroprevalence was 10.0% (95% confidence interval [CI], 7.8-12.4%) among general populations, 44.5% (95% CI, 20.0-70.5%) among sexually transmitted infection clinic attendees and symptomatic populations, and 60.7% (95% CI, 49.8-71.1%) among human immunodeficiency virus (HIV)-positive individuals and individuals in HIV-discordant couples. In Australia and New Zealand, combined, pooled mean seroprevalence was 15.4% (95% CI, 9.6-22.2%) among general populations, 27.8% (95% CI, 12.0-47.2%) among men who have sex with men, and 37.2% (95% CI, 23.7-51.8%) among sexually transmitted infection clinic attendees and symptomatic populations. Men had 0.64-fold (95% CI, 0.47-0.86) lower seroprevalence compared with women. No evidence was found for a decline in seroprevalence over time. Pooled mean proportion of HSV-2 isolation in laboratory-confirmed genital herpes was 62.1% (95% CI, 53.8-70.1%) in Canada and 71.9% (95% CI, 64.2-78.9%) in Australia and New Zealand. Proportion of HSV-2 isolation in genital herpes declined by 0.98-fold (95% CI, 0.97-0.99) per year. Pooled mean proportion of HSV-2 isolation in genital ulcer disease was 17.4% (95% CI, 4.0-37.1%) in these countries.

CONCLUSIONS

Over 10% of adults in these countries are infected, with no evidence for declining seroprevalence, unlike other global regions. Over 60% of genital herpes cases are caused by HSV-2 in these countries, yet HSV-2's role is declining by 2% per year.

Epidemiology of herpes simplex virus type 2 in Asia: A systematic review, meta-analysis, and meta-regression

Background

Herpes simplex virus type 2 (HSV-2) infection is a prevalent sexually transmitted infection worldwide. This systematic review was conducted to characterize HSV-2 epidemiology in Asia, including the World Health Organization regions of Southeast Asia and the Western Pacific.

Methods

Cochrane and PRISMA guidelines were followed to systematically review and report findings. Pooled mean seroprevalence and proportions of HSV-2 isolated in genital ulcer disease (GUD) and in genital herpes were calculated using random-effects meta-analyses. Meta-regressions were also conducted. Quality assessment was performed.

Findings

HSV-2 measures extracted from 173 publications included 15 seroconversion rates, 11 seroincidence rates, 272 overall seroprevalence measures (678 stratified), 14 proportions of HSV-2 isolation in GUD (15 stratified), and 27 proportions of HSV-2 isolation in genital herpes (36 stratified). Pooled mean seroprevalence was 12.1% (95% confidence interval (CI): 11.0-13.2%) among general populations, 23.6% (95% CI: 20.9-26.3%) among men who have sex with men and transgender people, 46.0% (95% CI: 39.2-52.9%) among HIV-positive individuals and individuals in HIV-discordant couples, and 62.2% (95% CI: 58.9-65.6%) among female sex workers. Among general populations, pooled mean seroprevalence increased gradually from 4.7% (95% CI: 3.3-6.3%) in <20-year-old individuals to 26.6% (95% CI: 19.2-34.7%) in >60-year-old individuals. Compared to women and across all populations, men had 0.60-fold (95% CI: 54.0-67.0) lower seroprevalence, that is women had 70% higher seroprevalence. Seroprevalence declined by 0.98-fold (95% CI: 0.97-0.99) per year, that is a 2% decline per year in the last three decades. Pooled mean proportions of HSV-2 isolation in GUD and in genital herpes were 48.2% (95% CI: 34.9-61.6%) and 75.9% (95% CI: 68.3-82.8%), respectively.

Interpretation

Over 1 in 10 individuals is infected with HSV-2, but seroprevalence is declining. HSV-2 accounts for half of GUD cases and three-quarters of genital herpes cases. These findings support the need for an HSV-2 vaccine and universal access to sexual and reproductive health services.

Funding

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