Developments in STD/HIV Interactions: The Intertwining Epidemics of HIV and HSV-2

The female reproductive tract virome: understanding the dynamic role of viruses in gynecological health and disease

The human body is inhabited by a large and complex network of commensal and predatory eukaryotic viruses and bacteriophages collectively termed the virome. Despite being the most abundant and genetically diverse biological entities on the planet, the impact of viruses on human health especially within the female reproductive tract (FRT) remains understudied. To better appreciate current knowledge regarding the dynamic role of viruses in FRT health and disease, in this review we highlight the known constituents of the FRT virome, transkingdom interactions within the FRT and their influence on gynecological disease. A better understanding of the FRT virome may pave the way toward improved outcomes in gynecological, reproductive, and neonatal health.

One Night Stan: Feasibility Study of an HIV Prevention and Sexual Risk Reduction Social Card Game for Young Black Women

OBJECTIVE

To develop and test the feasibility and preliminary impact of the social card game prototype, One Night Stan, a theory-driven and evidence-based human immunodeficiency virus (HIV) prevention intervention for young black women.

MATERIALS AND METHODS

The study included the enrollment of 21 young, heterosexual black women (mean age 19) to test the feasibility and preliminary impact of the card game, using a pre/postdesign. Participant satisfaction and gameplay experience were assessed using quantitative and qualitative measures. Knowledge, self-efficacy, and intentions regarding condom use and HIV/sexually transmitted infection partner testing were assessed using standardized assessments. Effect sizes for the change in these outcome variables were calculated to determine the preliminary efficacy of the game.

RESULTS

One hundred percent of participants reported that that they would play the game again, 95% liked the way the game looked, 100% enjoyed playing the game, and 100% reported that they would tell their friends to play. Effect sizes were large (ranged from 0.21 to 0.51) for all variables except perceived susceptibility (0.07) and suggest that playing the game can lead to increased self-efficacy and intentions to use condoms and insist that their partners get tested for HIV across time.

CONCLUSIONS

One Night Stan is a feasible intervention approach and may be efficacious in helping players develop a pattern of cognitions and motivation that can protect them against the risk of HIV.

Strychnos pseudoquina A. St. Hil.: a Brazilian medicinal plant with promising in vitro antiherpes activity

AIMS

To investigate the anti-HSV and anti-inflammatory effects of a standardized ethyl acetate extract (SEAE) prepared with the stem bark of Strychnos pseudoquina, along with two isolated compounds: quercetin 3-O-methyl ether (3MQ) and strychnobiflavone (SBF).

METHODS AND RESULTS

The mechanisms of action were evaluated by different methodological strategies. SEAE and SBF affected the early stages of viral infection and reduced HSV-1 protein expression. Both flavonoids elicited a concentration-dependent inhibition of monocyte chemoattractant protein-1 (MCP-1), whereas 3MQ reduced the chemokine release more significantly than SBF. Conversely, both compounds stimulated the production of the cytokines TNF-α and IL-1-β in LPS-stimulated cells, especially at the intermediate and the highest tested concentrations.

CONCLUSIONS

SEAE and SBF interfered with various steps of HSV replication cycle, mainly adsorption, postadsorption and penetration, as well as with β and γ viral proteins expression; moreover, a direct inactivation of viral particles was observed. Besides, both flavonoids inhibited MCP-1 selectively, a feature that may be beneficial for the development of new anti-HSV agents.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results indicated that the samples present anti-HSV and anti-inflammatory activities, at different levels, which is an interesting feature since cold and genital sores are accompanied by an inflammation process.

Human Herpesviruses as Copathogens of HIV Infection, Their Role in HIV Transmission, and Disease Progression

Of eight human herpesviruses (HHVs), often, only herpes simplex virus types 1 (HSV-1) and 2 (HSV-2) find mention in medical literature as both of these viruses are commonly associated with genital lesions and oral ulcers, commonly known as cold sores. However, role of human herpesviruses as copathogens and in aggravation and in the transmission of other human diseases, especially the Acquired immunodeficiency syndrome (HIV/AIDS) has only very recently been recognized. Therefore, screening and treating subclinical HHV infections may offer slowing of HIV infection, disease progression, and its transmission. Beside HSV-1 and HSV-2, HHV-3 a causative agent of herpes zoster remained one of the first manifestations of HIV disease before the era of highly active antiretroviral therapy (HAART). HHV-5 also known as human Cytomegalovirus infection remains a significant risk factor for HIV-associated mortality and morbidity even in HAART era. It is proposed that Cytomegalovirus viremia could be a better predictor of HIV disease progression than CD4+ T-lymphocyte count. The role of HHV-4 or Epstein-Burr virus and HHV-6, HHV-7, and HHV-8 is still being investigated in HIV disease progression. This review provides insight into the current understanding about these 8 HHVs, their co-pathogenesis, and role in HIV/AIDS disease progression. The review also covers recent literature in favor and against administering anti-HHV treatment along with HAART for slower AIDS progression and interrupted sexual transmission.

Correlates of prevalent HIV infection among adults and adolescents in the Kisumu incidence cohort study, Kisumu, Kenya

We estimated HIV prevalence and identified correlates of HIV infection among 1106 men and women aged 16-34 years residing in Kisumu, Kenya. Demographic, sexual, and other behavioural data were collected using audio computer-assisted self-interview in conjunction with a medical examination, real-time parallel rapid HIV testing, and laboratory testing for pregnancy, gonorrhoea, chlamydia, syphilis, and herpes simplex virus type 2. Multivariate logistic regression was used to identify variables associated with prevalent HIV infection by gender. Overall HIV prevalence was 12.1%. HIV prevalence among women (17.1%) was approximately two-and-one-half times the prevalence among men (6.6%). Odds of HIV infection in men increased with age (aOR associated with one-year increase in age = 1.21, CI = 1.07-1.35) and were greater among those who were uncircumcised (aOR = 4.42, CI = 1.41-13.89) and those who had an herpes simplex virus type 2-positive (aOR = 3.13, CI = 1.12-8.73) test result. Odds of prevalent HIV infection among women also increased with age (aOR associated with one-year increase in age = 1.16, CI = 1.04-1.29). Women who tested herpes simplex virus type 2 positive had more than three times the odds (aOR = 3.85, CI = 1.38-10.46) of prevalent HIV infection compared with those who tested herpes simplex virus type 2 negative. Tailored sexual health interventions and programs may help mitigate HIV age and gender disparities.

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.

HIV prevalence and associated risk factors among individuals aged 13-34 years in Rural Western Kenya

OBJECTIVES

To estimate HIV prevalence and characterize risk factors among young adults in Asembo, rural western Kenya.

DESIGN

Community-based cross-sectional survey.

METHODS

From a demographic surveillance system, we selected a random sample of residents aged 13-34 years, who were contacted at home and invited to a nearby mobile study site. Consent procedures for non-emancipated minors required assent and parental consent. From October 2003 - April 2004, consenting participants were interviewed on risk behavior and tested for HIV and HSV-2. HIV voluntary counseling and testing was offered.

RESULTS

Of 2606 eligible residents, 1822 (70%) enrolled. Primary reasons for refusal included not wanting blood taken, not wanting to learn HIV status, and partner/parental objection. Females comprised 53% of 1762 participants providing blood. Adjusted HIV prevalence was 15.4% overall: 20.5% among females and 10.2% among males. HIV prevalence was highest in women aged 25-29 years (36.5%) and men aged 30-34 years (41.1%). HSV-2 prevalence was 40.0% overall: 53% among females, 25.8% among males. In multivariate models stratified by gender and marital status, HIV infection was strongly associated with age, higher number of sex partners, widowhood, and HSV-2 seropositivity.

CONCLUSIONS

Asembo has extremely high HIV and HSV-2 prevalence, and probable high incidence, among young adults. Further research on circumstances around HIV acquisition in young women and novel prevention strategies (vaccines, microbicides, pre-exposure prophylaxis, HSV-2 prevention, etc.) are urgently needed.

Discussion and revision of the mathematical modeling tool described in the previously published article "Modeling HIV Transmission risk among Mozambicans prior to their initiating highly active antiretroviral therapy"

Mathematical models are increasingly used in social and behavioral studies of HIV transmission; however, model structures must be chosen carefully to best answer the question at hand and conclusions must be interpreted cautiously. In Pearson et al. (2007), we presented a simple analytically tractable deterministic model to estimate the number of secondary HIV infections stemming from a population of HIV-positive Mozambicans and to evaluate how the estimate would change under different treatment and behavioral scenarios. In a subsequent application of the model with a different data set, we observed that the model produced an unduly conservative estimate of the number of new HIV-1 infections. In this brief report, our first aim is to describe a revision of the model to correct for this underestimation. Specifically, we recommend adjusting the population-level sexually transmitted infection (STI) parameters to be applicable to the individual-level model specification by accounting for the proportion of individuals uninfected with an STI. In applying the revised model to the original data, we noted an estimated 40 infections/1000 HIV-positive persons per year (versus the original 23 infections/1000 HIV-positive persons per year). In addition, the revised model estimated that highly active antiretroviral therapy (HAART) along with syphilis and herpes simplex virus type 2 (HSV-2) treatments combined could reduce HIV-1 transmission by 72% (versus 86% according to the original model). The second aim of this report is to discuss the advantages and disadvantages of mathematical models in the field and the implications of model interpretation. We caution that simple models should be used for heuristic purposes only. Since these models do not account for heterogeneity in the population and significantly simplify HIV transmission dynamics, they should be used to describe general characteristics of the epidemic and demonstrate the importance or sensitivity of parameters in the model.

Exploring the relationship between sexually transmitted diseases and HIV acquisition by using different study designs

BACKGROUND

It is hypothesized that sexually transmitted diseases (STDs) increase the risk of HIV acquisition. Yet difficulties establishing an accurate temporal relation and controlling confounders have obscured this relationship. In an attempt to overcome prior methodologic shortcomings, we explored the use of different study designs to examine the relationship between STDs and HIV acquisition.

METHODS

Acutely HIV-infected patients were included as cases and compared with (1) HIV-uninfected patients (matched case-control), (2) newly diagnosed chronically HIV-infected patients (infected analysis), and (3) themselves at prior clinic visits when they tested HIV negative (case crossover).We used t tests to compare the average number of STDs and logistic regression to determine independent correlates and the odds of acute HIV infection.

RESULTS

Between October 2003 and March 2007, 13,662 male patients who had sex with men were tested for HIV infection at San Francisco's municipal STD clinic and 350 HIV infections (2.56%) were diagnosed. Among the HIV-infected patients, 36 cases (10.3%) were identified as acute. We found consistently higher odds of having had an STD within the 12 months [matched case-control, odds ratio 5.2 (2.2-12.6); infected analysis, odds ratio 1.4 (1.0-2.0); and case crossover, odds ratio 1.3 (0.5-3.1)] and 3 months [matched case- control, odds ratio 34.5 (4.1-291.3); infected analysis, odds ratio 2.3 (1.1-4.8); and case crossover, odds ratio 1.8 (0.6-5.6)] before HIV testing among acutely HIV-infected patients.We found higher odds of acute HIV infection among patients with concurrent rectal gonorrhea [17.0 (2.6-111.4), P < 0.01] or syphilis [5.8 (1.1-32.3), P = 0.04] when compared with those HIV-uninfected patients.

CONCLUSIONS

Acute HIV infection was associated with a recent or concurrent STD, particularly rectal gonorrhea, among men at San Francisco's municipal STD clinic. Given the complex relationship between STDs and HIV infection, no single design will appropriately control for all the possible confounders; studies using complementary designs are required.

An estimate of the global prevalence and incidence of herpes simplex virus type 2 infection

OBJECTIVE

To estimate the global prevalence and incidence of herpes simplex virus type 2 (HSV-2) infection in 2003.

METHODS

A systematic review was undertaken of published seroprevalence surveys describing the prevalence or incidence of HSV-2 by age and gender. For each of 12 regions, pooled prevalence values by age and gender were generated in a random-effect model. HSV-2 incidence was then estimated from these pooled values using a constant-incidence model. Values of the HSV-2 seroprevalence from the model fits were applied to the total population to estimate the numbers of people infected.

FINDINGS

The total number of people aged 15-49 years who were living with HSV-2 infection worldwide in 2003 is estimated to be 536 million, while the total number of people who were newly infected with HSV-2 in 2003 is estimated to be 23.6 million. While the estimates are limited by poor availability of data, general trends are evident. For example, more women than men were infected, and the number infected increased with age. Although prevalence varied substantially by region, predicted prevalence was mostly higher in developing regions than developed regions.

CONCLUSION

The prevalence of HSV-2 is relatively easy to measure since infection is lifelong and has a specific serological test. The burden of disease is less easy to quantify. Despite the often sparse data on which these estimates are based, it is clear that HSV-2 infection is widespread. The dramatic differences in prevalence between regions are worthy of further exploration.

Blocking antibody access to neutralizing domains on glycoproteins involved in entry as a novel mechanism of immune evasion by herpes simplex virus type 1 glycoproteins C and E

Herpes simplex virus type 1 (HSV-1) glycoprotein C (gC) blocks complement activation, and glycoprotein E (gE) interferes with IgG Fc-mediated activities. While evaluating gC- and gE-mediated immune evasion in human immunodeficiency virus (HIV)-HSV-1-coinfected subjects, we noted that antibody alone was more effective at neutralizing a strain with mutations in gC and gE (gC/gE) than a wild-type (WT) virus. This result was unexpected since gC and gE are postulated to interfere with complement-mediated neutralization. We used pooled human immunoglobulin G (IgG) from HIV-negative donors to confirm the results and evaluated mechanisms of the enhanced antibody neutralization. We demonstrated that differences in antibody neutralization cannot be attributed to the concentrations of HSV-1 glycoproteins on the two viruses or to the absence of an IgG Fc receptor on the gC/gE mutant virus or to enhanced neutralization of the mutant virus by antibodies that target only gB, gD, or gH/gL, which are the glycoproteins involved in virus entry. Since sera from HIV-infected subjects and pooled human IgG contain antibodies against multiple glycoproteins, we determined whether differences in neutralization become apparent when antibodies to gB, gD, or gH/gL are used in combination. Neutralization of the gC/gE mutant was greatly increased compared that of WT virus when any two of the antibodies against gB, gD, or gH/gL were used in combination. These results suggest that gC and gE on WT virus provide a shield against neutralizing antibodies that interfere with gB-gD, gB-gH/gL, or gD-gH/gL interactions and that one function of virus neutralization is to prevent interactions between these glycoproteins.

Diagnosis and management of acute HIV infection

HIV infection starts as an acute, systemic infection, followed by a chronic period of clinical latency, usually lasting 3 to 10 years, which precedes the eventual collapse of the immune system. It is increasingly recognized that events occurring during acute HIV infection may determine the natural course of the disease. The very dynamic events of acute HIV infection provide multiple opportunities for biologic interventions, such as anti-retroviral or immune-based therapies. Similarly, the implementation of public health measures during acute HIV infection could help control epidemics or outbreaks. Many of the dramatic possibilities for intervention in acute HIV infection remain unproved, not the least because of traditional difficulty of diagnosing patients during this early period. This article reviews the natural history, pathogenesis and clinical presentation of acute HIV infection, and suggests a diagnostic and therapeutic approach to guide clinicians dealing with patients with suspected or confirmed acute HIV infection.

Modeling HIV transmission risk among Mozambicans prior to their initiating highly active antiretroviral therapy

Understanding sexual behavior and assessing transmission risk among people living with HIV-1 is crucial for effective HIV-1 prevention. We describe sexual behavior among HIV-positive persons initiating highly active antiretroviral therapy (HAART) in Beira, Mozambique. We present a Bernoulli process model (tool available online) to estimate the number of sexual partners who would acquire HIV-1 as a consequence of sexual contact with study participants within the prior three months. Baseline data were collected on 350 HAART-naive individuals 18-70 years of age from October 2004 to February 2005. In the three months prior to initiating HAART, 45% (n = 157) of participants had sexual relationships with 191 partners. Unprotected sex occurred in 70% of partnerships, with evidence suggesting unprotected sex was less likely with partners believed to be HIV-negative. Only 26% of the participants disclosed their serostatus to partners with a negative or unknown serostatus. Women were less likely to report concurrent relationships than were men (21 versus 66%; OR 0.13; 95%CI: 0.06, 0.26). Given baseline behaviors, the model estimated 23.2 infections/1,000 HIV-positive persons per year. The model demonstrated HAART along with syphilis and herpes simplex virus type 2 (HSV-2) treatment combined could reduce HIV-1 transmission by 87%; increasing condom use could reduce HIV-1 transmission by 67%.

Nested Case–Control Study of Cervical Mucosal Lesions, Ectopy, and Incident HIV Infection Among Women in Cape Town, South Africa

OBJECTIVE

The objective of this study was to test whether cervical mucosal lesions and ectopy increase women's susceptibility to HIV infection.

STUDY DESIGN

HIV-seronegative women ages 35 to 65 years (n = 5773) enrolled into a cervical cancer screening trial were followed for up to 36 months. All HIV seroconverters (n = 86) in the cohort were compared with randomly selected controls (n = 324) who did not seroconvert. Magnified photographs of the cervix taken during speculum examination at enrollment were evaluated for cervical mucosal lesions and ectopy using standard criteria.

RESULTS

The presence of mucosal lesions (observed among 19% of controls) was associated with increased risk of HIV seroconversion (adjusted odds ratio [AOR] = 1.93; 95% confidence interval [CI] = 1.07-3.48). Ectopy extending over >20% of the cervix was also associated with HIV seroconversion (AOR = 2.18; 95% CI = 1.01-4.69).

CONCLUSIONS

Visible lesions of cervical mucosa and cervical ectopy may be markers of increased susceptibility to HIV infection among women. Protection of the mucosa of the cervix may provide an important approach for new HIV prevention technologies.

Strategies for global HIV prevention

Despite significant advances in the development of therapeutic strategies for HIV over the past 25 years, the AIDS pandemic continues to grow worldwide. Access to life-saving medicines is not universal and there is a critical need for better prevention strategies. This review will highlight current research in the area of HIV prevention strategies, including preventive HIV vaccines, effective microbicides, treatment of sexually transmitted infections and the impact on HIV transmission, in addition to the role of male circumcision and pre-exposure prophylaxis with antiretroviral medications in HIV prevention.

Transmission and Epidemiology of HIV/AIDS: a Global View

Since the first recognition of the condition that is now called AIDS, much has been learned. We now know that AIDS results from infection with HIV types 1 and 2. Advancements in approaches to treatment, in the form of new types of medications, have changed the trajectory of illness by slowing progression and decreasing the incidence of HIV-associated opportunistic infections in the millions of people living with HIV infection, particularly in developed countries. In less developed areas of the world, HIV infection looks different, in part because of the differential availability of medications and health care. This article focuses on epidemiology of HIV infection and AIDS in the United States and worldwide, and on transmission, including susceptibility factors.

Intravaginal practices, bacterial vaginosis, and women's susceptibility to HIV infection: epidemiological evidence and biological mechanisms

Intravaginal practices such as "dry sex" and douching have been suggested as a risk factor that may increase women's susceptibility to HIV infection. These behaviours appear common in different populations across sub-Saharan Africa, where practices include the use of antiseptic preparations, traditional medicines, or the insertion of fingers or cloths into the vagina. We systematically review the evidence for the association between women's intravaginal practices and HIV infection. Although a number of cross-sectional studies have shown that prevalent HIV infection is more common among women reporting intravaginal practices, the temporal nature of this association is unclear. Current evidence suggests that bacterial vaginosis, which is a likely risk factor for HIV infection, may be a mediator of the association between intravaginal practices and HIV. Although biologically plausible mechanisms exist, there is currently little epidemiological evidence suggesting that intravaginal practices increase women's susceptibility to HIV infection. Further research into factors that increase women's susceptibility to HIV will help to inform the design of vaginal microbicides and other HIV prevention interventions.