High risk of human immunodeficiency virus in men who have sex with men with herpes simplex virus type 2 in the EXPLORE study

Cervical Cytology and Herpes Simplex Virus Type-2 Serology Among Human Immune Deficiency Virus Infected Women on Highly Active Antiretroviral Therapy in Enugu, Nigeria

BACKGROUND

The prevalence of Human Immunodeficiency Virus (HIV) and Herpes Simplex Virus type-2 (HSV-2) infections are high and the programme for Cervical Cancer Screening is weak in Nigeria.

OBJECTIVES

Prevalence of Herpes Simplex Virus Type-2 co-infection and cervical cytology among HSV-2 co-infected Human Immunodeficiency Virus Sero-positive (HIV+) women on Highly Active Antiretroviral Therapy (HAART) attending Human Immunodeficiency Virus clinic at University of Nigeria Teaching Hospital (UNTH) Ituku/Ozalla Enugu, Nigeria.

METHODS

A cross-sectional, hospital-based study. Active participants included 105 HIV seropositive women on HAART and104 HIV seronegative (HIV-) women who passed inclusion criteria and signed written informed consent. Each participant was coded with a specific number. A structured questionnaire was used to obtain the socio-demographic and medical history. Serum was obtained for HSV-2 serology test for all participants and HIV screening for HIV-negative participants. Cervical smears were collected for Papanicolaou stains and Immunocytochemistry using anti-P16INKa antibody.

RESULTS

Prevalence of HSV-2+ was 50.5% among HIV+ women on HAART and 16.3% among HIV- women, Odds Ratios [95% CI]; p-value was 5.21 [2.74-9.94]; p < 0.0001. HIV+ women on HAART co-infected with HSV-2 significantly had more Cervical Lesions, 11.4% compared to HIVwomen uninfected with HSV-2, 4.8%, OR [95% CI]; p-value 4.8 (1.58-14.54); p = 0.006.

CONCLUSION

The prevalence of HSV-2 was significantly high among HIV+ women on HAART. HSV-2+ co-infection could be an enhancer of Cervical Lesions among HIV+ women on HAART. Hence, anti-herpetic agent introduction and screening for HSV-2 among HIV+ patients are recommended.

Using data from 'visible' populations to estimate the size and importance of 'hidden' populations in an epidemic: A modelling technique

We used reported behavioural data from cisgender men who have sex with men and transgender women (MSM/TGW) in Bangalore, mainly collected from 'hot-spot' locations that attract MSM/TGW, to illustrate a technique to deal with potential issues with the representativeness of this sample. A deterministic dynamic model of HIV transmission was developed, incorporating three subgroups of MSM/TGW, grouped according to their reported predominant sexual role (insertive, receptive or versatile). Using mathematical modelling and data triangulation for 'balancing' numbers of partners and role preferences, we compared three different approaches to determine if our technique could be useful for inferring characteristics of a more 'hidden' insertive MSM subpopulation, and explored their potential importance for the HIV epidemic. Projections for 2009 across all three approaches suggest that HIV prevalence among insertive MSM was likely to be less than half that recorded in the surveys (4.5-6.5% versus 13.1%), but that the relative size of this subgroup was over four times larger (61-69% of all MSM/TGW versus 15%). We infer that the insertive MSM accounted for 10-20% of all prevalent HIV infections among urban males aged 15-49. Mathematical modelling can be used with data on 'visible' MSM/TGW to provide insights into the characteristics of 'hidden' MSM. A greater understanding of the sexual behaviour of all MSM/TGW is important for effective HIV programming. More broadly, a hidden subgroup with a lower infectious disease prevalence than more visible subgroups, has the potential to contain more infections, if the hidden subgroup is considerably larger in size.

The global and regional burden of genital ulcer disease due to herpes simplex virus: a natural history modelling study

Introduction

Herpes simplex virus (HSV) infection can cause painful, recurrent genital ulcer disease (GUD), which can have a substantial impact on sexual and reproductive health. HSV-related GUD is most often due to HSV type 2 (HSV-2), but may also be due to genital HSV type 1 (HSV-1), which has less frequent recurrent episodes than HSV-2. The global burden of GUD has never been quantified. Here we present the first global and regional estimates of GUD due to HSV-1 and HSV-2 among women and men aged 15-49 years old.

Methods

We developed a natural history model reflecting the clinical course of GUD following HSV-2 and genital HSV-1 infection, informed by a literature search for data on model parameters. We considered both diagnosed and undiagnosed symptomatic infection. This model was then applied to existing infection estimates and population sizes for 2016. A sensitivity analysis was carried out varying the assumptions made.

Results

We estimated that 187 million people aged 15-49 years had at least one episode of HSV-related GUD globally in 2016: 5.0% of the world's population. Of these, 178 million (95% of those with HSV-related GUD) had HSV-2 compared with 9 million (5%) with HSV-1. GUD burden was highest in Africa, and approximately double in women compared with men. Altogether there were an estimated 8 billion person-days spent with HSV-related GUD globally in 2016, with 99% of days due to HSV-2. Taking into account parameter uncertainty, the percentage with at least one episode of HSV-related GUD ranged from 3.2% to 7.9% (120-296 million). However, the estimates were sensitive to the model assumptions.

Conclusion

Our study represents a first attempt to quantify the global burden of HSV-related GUD, which is large. New interventions such as HSV vaccines, antivirals or microbicides have the potential to improve the quality of life of millions of people worldwide.

Viral, bacterial, and fungal infections of the oral mucosa: Types, incidence, predisposing factors, diagnostic algorithms, and management

For millions of years, microbiota residing within us, including those in the oral cavity, coexisted in a harmonious symbiotic fashion that provided a quintessential foundation for human health. It is now clear that disruption of such a healthy relationship leading to microbial dysbiosis causes a wide array of infections, ranging from localized, mild, superficial infections to deep, disseminated life-threatening diseases. With recent advances in research, diagnostics, and improved surveillance we are witnessing an array of emerging and re-emerging oral infections and orofacial manifestations of systemic infections. Orofacial infections may cause significant discomfort to the patients and unnecessary economic burden. Thus, the early recognition of such infections is paramount for holistic patient management, and oral clinicians have a critical role in recognizing, diagnosing, managing, and preventing either new or old orofacial infections. This paper aims to provide an update on current understanding of well-established and emerging viral, bacterial, and fungal infections manifesting in the human oral cavity.

HIV incidence among gay men and other men who have sex with men in 2020: where is the epidemic heading?

The goal to effectively prevent new HIV infections among gay, bisexual, and other men who have sex with men (MSM) is more challenging now than ever before. Despite declines in the late 1990s and early 2000s, HIV incidence among MSM is now increasing in many low- and high-income settings including the US, with young, adolescent, and racial/ethnic minority MSM being among those at highest risk. Potentiating HIV risks across all settings are individual-, network-, and structural-level factors such as stigma and lack of access to pre-exposure prophylaxis (PrEP) and antiretroviral treatment as prevention. To make a sustained impact on the epidemic, a concerted effort must integrate all evidence-based interventions that will most proximally decrease HIV acquisition and transmission risks, together with structural interventions that will support improved coverage and retention in care. Universal HIV treatment, increased access to HIV testing, and daily oral PrEP have emerged as integral to the prevention of HIV transmission, and such efforts should be immediately expanded for MSM and other populations disproportionately affected by HIV. Respect for human rights and efforts to combat stigma and improve access to prevention services are needed to change the trajectory of the HIV pandemic among MSM.

Men Who Have Sex With Men-Identification Criteria and Characteristics From the National Health and Nutrition Examination Survey, 1999 to 2014

OBJECTIVES

This study aimed to provide identification criteria for men who have sex with men (MSM), estimate the prevalence of MSM behavior, and compare sociodemographics and sexually transmitted disease risk behaviors between non-MSM and MSM groups using data from a nationally representative, population-based survey.

METHODS

Using data from men aged 18 to 59 years who took part in the National Health and Nutrition Examination Survey (NHANES), 1999 to 2014, detailed criteria were developed to estimate MSM behavior-at least one lifetime same-sex partner (MSM-ever), at least one same-sex partner in the past 12 months (MSM-current), and at least one lifetime and zero same-sex partners in the past 12 months (MSM-past).

RESULTS

The estimated prevalence of MSM-ever was 5.5%-of these, 52.4% were MSM-current and 47.1% were MSM-past. Furthermore, MSM-ever are a nonhomogenous subpopulation, for example, 70.4% of MSM-current identified as homosexual and 71.2% of MSM-past identified as heterosexual (P < 0.001).

CONCLUSIONS

The prevalence of MSM behavior identified here is similar to other published estimates. This is also the first article, to our knowledge, to use National Health and Nutrition Examination Survey data to compare MSM by 2 recall periods (recent vs. lifetime) of last same-sex sexual behavior.

The clinical effectiveness of individual behaviour change interventions to reduce risky sexual behaviour after a negative human immunodeficiency virus test in men who have sex with men: systematic and realist reviews and intervention development

BACKGROUND

Men who have sex with men (MSM) experience significant inequalities in health and well-being. They are the group in the UK at the highest risk of acquiring a human immunodeficiency virus (HIV) infection. Guidance relating to both HIV infection prevention, in general, and individual-level behaviour change interventions, in particular, is very limited.

OBJECTIVES

To conduct an evidence synthesis of the clinical effectiveness of behaviour change interventions to reduce risky sexual behaviour among MSM after a negative HIV infection test. To identify effective components within interventions in reducing HIV risk-related behaviours and develop a candidate intervention. To host expert events addressing the implementation and optimisation of a candidate intervention.

DATA SOURCES

All major electronic databases (British Education Index, BioMed Central, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Educational Resource Index and Abstracts, Health and Medical Complete, MEDLINE, PsycARTICLES, PsycINFO, PubMed and Social Science Citation Index) were searched between January 2000 and December 2014.

REVIEW METHODS

A systematic review of the clinical effectiveness of individual behaviour change interventions was conducted. Interventions were examined using the behaviour change technique (BCT) taxonomy, theory coding assessment, mode of delivery and proximity to HIV infection testing. Data were summarised in narrative review and, when appropriate, meta-analysis was carried out. Supplemental analyses for the development of the candidate intervention focused on post hoc realist review method, the assessment of the sequential delivery and content of intervention components, and the social and historical context of primary studies. Expert panels reviewed the candidate intervention for issues of implementation and optimisation.

RESULTS

Overall, trials included in this review (n = 10) demonstrated that individual-level behaviour change interventions are effective in reducing key HIV infection risk-related behaviours. However, there was considerable clinical and methodological heterogeneity among the trials. Exploratory meta-analysis showed a statistically significant reduction in behaviours associated with high risk of HIV transmission (risk ratio 0.75, 95% confidence interval 0.62 to 0.91). Additional stratified analyses suggested that effectiveness may be enhanced through face-to-face contact immediately after testing, and that theory-based content and BCTs drawn from 'goals and planning' and 'identity' groups are important. All evidence collated in the review was synthesised to develop a candidate intervention. Experts highlighted overall acceptability of the intervention and outlined key ways that the candidate intervention could be optimised to enhance UK implementation.

LIMITATIONS

There was a limited number of primary studies. All were from outside the UK and were subject to considerable clinical, methodological and statistical heterogeneity. The findings of the meta-analysis must therefore be treated with caution. The lack of detailed intervention manuals limited the assessment of intervention content, delivery and fidelity.

CONCLUSIONS

Evidence regarding the effectiveness of behaviour change interventions suggests that they are effective in changing behaviour associated with HIV transmission. Exploratory stratified meta-analyses suggested that interventions should be delivered face to face and immediately after testing. There are uncertainties around the generalisability of these findings to the UK setting. However, UK experts found the intervention acceptable and provided ways of optimising the candidate intervention.

FUTURE WORK

There is a need for well-designed, UK-based trials of individual behaviour change interventions that clearly articulate intervention content and demonstrate intervention fidelity.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42014009500.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Brief Report: Rethinking Data Collection for HIV Prevention Trials

There is a strong push to conduct large-scale randomized controlled study designs in HIV prevention studies. In these randomized controlled studies, the primary research objective is typically to determine the treatment effect based on some biological outcome (eg, HIV infection). But many unused self-reported outcomes are also being collected. We illustrate the extent of this problem using the EXPLORE data as an example.

Effect of HSV-2 infection on subsequent HIV acquisition: an updated systematic review and meta-analysis

Background

HIV and herpes simplex virus type 2 (HSV-2) infections cause a substantial global disease burden and are epidemiologically correlated. Two previous systematic reviews of the association between HSV-2 and HIV found evidence that HSV-2 infection increases the risk of HIV acquisition, but these reviews are now more than a decade old.

Methods

For this systematic review and meta-analysis, we searched PubMed, MEDLINE, and Embase (from Jan 1, 2003, to May 25, 2017) to identify studies investigating the risk of HIV acquisition after exposure to HSV-2 infection, either at baseline (prevalent HSV-2 infection) or during follow-up (incident HSV-2 infection). Studies were included if they were a cohort study, controlled trial, or case-control study (including case-control studies nested within a cohort study or clinical trial); if they assessed the effect of pre-existing HSV-2 infection on HIV acquisition; and if they determined the HSV-2 infection status of study participants with a type-specific assay. We calculated pooled random-effect estimates of the association between prevalent or incident HSV-2 infection and HIV seroconversion. We also extended previous investigations through detailed meta-regression and subgroup analyses. In particular, we investigated the effect of sex and risk group (general population vs higher-risk populations) on the relative risk (RR) of HIV acquisition after prevalent or incident HSV-2 infection. Higher-risk populations included female sex workers and their clients, men who have sex with men, serodiscordant couples, and attendees of sexually transmitted infection clinics.

Findings

We identified 57 longitudinal studies exploring the association between HSV-2 and HIV. HIV acquisition was almost tripled in the presence of prevalent HSV-2 infection among general populations (adjusted RR 2·7, 95% CI 2·2–3·4; number of estimates [N_e]=22) and was roughly doubled among higher-risk populations (1·7, 1·4–2·1; N_e=25). Incident HSV-2 infection in general populations was associated with the highest risk of acquisition of HIV (4·7, 2·2–10·1; N_e=6). Adjustment for confounders at the study level was often incomplete but did not significantly affect the results. We found moderate heterogeneity across study estimates, which was explained by risk group, world region, and HSV-2 exposure type (prevalent vs incident).

Interpretation

We found evidence that HSV-2 infection increases the risk of HIV acquisition. This finding has important implications for management of individuals diagnosed with HSV-2 infection, particularly for those who are newly infected. Interventions targeting HSV-2, such as new HSV vaccines, have the potential for additional benefit against HIV, which could be particularly powerful in regions with a high incidence of co-infection.

Funding

World Health Organization.

Incidence of and temporal relationships between HIV, herpes simplex II virus, and syphilis among men who have sex with men in Bangkok, Thailand: an observational cohort

Background

High HIV incidence has been detected among men who have sex with men (MSM) in Thailand, but the relationship and timing of HIV, herpes simplex virus 2 (HSV-2), and syphilis is unknown. This analysis measures incidence, temporal relationships, and risk factors for HIV, HSV-2, and syphilis among at-risk MSM in the Bangkok MSM Cohort Study.

Methods

Between April 2006 and December 2010, 960 men negative for HIV, HSV-2, and syphilis at entry enrolled and contributed 12–60 months of follow-up data. Behavioral questionnaires were administered at each visit; testing for HIV antibody was performed at each visit, while testing for syphilis and HSV-2 were performed at 12 month intervals. We calculated HIV, HSV-2, and syphilis incidence, assessed risk factors with complementary log-log regression, and among co-infected men, measured temporal relationships between infections with Kaplan-Meier survival analysis and paired t-test.

Results

The total number of infections and incidence density for HIV, HSV-2, and syphilis were 159 infections and 4.7 cases/100 PY (95 % Confidence Interval (CI): 4.0–5.4), 128 infections and 4.5/100 PY (95 % CI: 3.9–5.5), and 65 infections and 1.9/100 PY (95 % CI: 1.5–2.5), respectively. Among men acquiring >1 infection during the cohort period, mean time to HIV and HSV-2 infection was similar (2.5 vs. 2.9 years; p = 0.24), while syphilis occurred significantly later following HIV (4.0 vs. 2.8 years, p < 0.01) or HSV-2 (3.8 vs. 2.8 years, p = 0.04) infection. The strongest independent predictor of any single infection in adjusted analysis was acquisition of another infection; risk of syphilis (Adjusted Hazards Ratio (AHR) = 3.49, 95 % CI: 1.89–6.42) or HIV (AHR = 2.26, 95 % CI: 1.47–3.48) acquisition during the cohort was significantly higher among men with incident HSV-2 infection. No single independent behavioral factor was common to HIV, HSV-2, and syphilis acquisition.

Conclusion

HIV and HSV-2 incidence was high among this Thai MSM cohort. However, acquisition of HIV and co-infection with either HSV-2 or syphilis was low during the time frame men were in the cohort. Evaluation of behavioral risk factors for these infections suggests different risks and possible different networks.

High HIV Burden in Men Who Have Sex with Men across Colombia's Largest Cities: Findings from an Integrated Biological and Behavioral Surveillance Study

BACKGROUND

Among Latin America's concentrated HIV epidemics, little is known about men who have sex with men (MSM) in Colombia, the region's third largest country. To date, surveillance studies have been limited to Bogota, while 80% of HIV cases and deaths originate from Colombia's other cities and departments. The extent to which interventions should prioritize MSM outside of Bogota is unknown.

METHODS

We recruited 2603 MSM using respondent-driven sampling from seven of Colombia's largest cities. HIV prevalence was estimated by site from dried blood spot samples. Behavioral data were collected through face-to-face interviews and risk factors for HIV infection analyzed using weighted, multi-level logistical regression models accounting for recruitment patterns.

RESULTS

Across cities, HIV prevalence averaged 15%, varied from 6% to 24% and was highest in Cali, Bogota, and Barranquilla. In the past 12 months, 65% of MSM had ≥ 5 casual male partners and 23% had a female partner. Across partnerships (i.e., casual, stable, and commercial), the proportion of MSM engaging in unprotected sex was ≥ 52% with male partners and ≥ 66% with female partners. Self-reported history of STI (24%) and past-year illicit drug use (38%) were also common. In multivariate analysis, age ≥ 35 (adjusted odds ratio [AOR], 19.2) and 25-39 (AOR, 5.6) relative to ≤ 18-24 years, identifying as homosexual relative to heterosexual (AOR 0.1), meeting casual partners on the Internet (adjusted odds ratio [AOR], 3.1) and age of sexual debut of ≤ 13 years (AOR, 3.1) predicted HIV infection. HIV testing and prevention messaging reached just 24% of MSM in the past year.

CONCLUSIONS

Findings support consistently elevated HIV burden among MSM throughout Colombia's largest cities and a need for enhanced behavioral prevention and HIV testing, emphasizing men who use the Internet as well as physical venues to meet sex partners.

Recent anxiety symptoms and drug use associated with sexually transmitted infection diagnosis among an online US sample of men who have sex with men

The extent to which mental health problems, including current anxiety and depressive symptoms, may co-occur, or are associated, with the acquisition of sexually transmitted infections other than HIV remains largely unexplored among men who have sex with men. In a cross-sectional survey of 8,381 US men who have sex with men recruited from a sexual networking website, 15 percent reported a past 60-day sexually transmitted infection diagnosis. Among HIV-negative men, increased odds of reporting a sexually transmitted infection were associated with current anxiety symptoms and past 60-day drug use. Findings underscore the need to better understand causal pathways among anxiety, drug use, and sexually transmitted infection acquisition and transmission among men who have sex with men.

Risk behaviours and prevalence of sexually transmitted infections and HIV in a group of Dominican gay men, other men who have sex with men and transgender women

OBJECTIVES

The objectives of this study were to estimate the point prevalence of sexually transmitted infection (STI) and to investigate the sexual practices and behaviours associated with STIs in a group of gay men, other men who have sex with men and transgender women (GMT) in the province of La Romana, Dominican Republic.

DESIGN

A cross-sectional study of a convenience sample of GMT persons.

SETTING

The study was conducted in the province of La Romana, Dominican Republic, in June-July 2013.

PARTICIPANTS

Out of 117 GMT persons screened, a total of 100 completed the study. Participants had to be at least 18 years of age, reside in La Romana and have had sex with another man in the preceding 12 months. All participants were interviewed and tested for STI.

PRIMARY OUTCOME MEASURE

The main outcome of interest was the detection of any STI (HIV, herpes simplex virus type 2 (HSV-2), syphilis, hepatitis B or C) by serology.

RESULTS

Among 100 participants, the median age was 22 years (range 18-65). One-third had consumed illicit drugs the preceding year and only 43% consistently used condoms. Prevalence was 38% for HSV-2, 5% for HIV and 13% for syphilis. There were no cases of hepatitis B or C. Factors associated with the odds of a STI were age >22 years (OR=11.1, 95% CI 3.6 to 34.5), receptive anal intercourse (OR=4.2, 95% CI 1.3 to 13.6) and having ≥2 male sexual partners during the preceding month (OR=4, 95% CI 1.3 to 12.5).

CONCLUSIONS

In this group of GMT persons, seroprevalence of STI was high, and a number of risk behaviours were associated with STI. These preliminary data will help inform policy and programmes to prevent HIV/STI in GMT persons in the region.

Disparities in herpes simplex virus type 2 infection between black and white men who have sex with men in Atlanta, GA

HIV disproportionately affects black men who have sex with men, and herpes simplex virus type 2 is known to increase acquisition of HIV. However, data on racial disparities in herpes simplex virus type 2 prevalence and risk factors are limited among men who have sex with men in the United States. InvolveMENt was a cohort study of black and white HIV-negative men who have sex with men in Atlanta, GA. Univariate and multivariate cross-sectional associations with herpes simplex virus type 2 seroprevalence were assessed among 455 HIV-negative men who have sex with men for demographic, behavioural and social determinant risk factors using logistic regression. Seroprevalence of herpes simplex virus type 2 was 23% (48/211) for black and 16% (38/244) for white men who have sex with men (p = 0.05). Education, poverty, drug/alcohol use, incarceration, circumcision, unprotected anal intercourse, and condom use were not associated with herpes simplex virus type 2. In multivariate analyses, black race for those ≤25 years, but not >25 years, and number of sexual partners were significantly associated. Young black men who have sex with men are disproportionately affected by herpes simplex virus type 2, which may contribute to disparities in HIV acquisition. An extensive assessment of risk factors did not explain this disparity in herpes simplex virus type 2 infection suggesting differences in susceptibility or partner characteristics.

Setting the bar high or setting up to fail? Interpretations and implications of the EXPLORE Study (HPTN 015)

Controlled studies show that HIV risk reduction counseling significantly increases condom use, reduces unprotected sex and prevents sexually transmitted infections. Nevertheless, without evidence of reducing HIV incidence, these interventions are generally discarded. One trial, the EXPLORE study, was designed to test whether ten sessions of risk reduction counseling could impact HIV incidence among men who have sex with men in six US cities. Based on epidemiologic models to define effective HIV vaccines, a 35 % reduction in HIV incidence was set a priori as the benchmark of success in this behavioral intervention trial. Results demonstrated a significant effect of the intervention, with more than a 35 % reduction in HIV incidence observed during the initial 12-18 months following counseling. Over an unprecedented 48-month follow-up, however, the effect of counseling on HIV incidence declined to 18 %. The current review examined how the scientific literature has thus far judged the outcomes of the EXPLORE study as well as the policy implications of these judgments. We identified 127 articles that cited the EXPLORE study since its publication. Among articles that discuss the HIV incidence outcomes, 20 % judged the intervention effective and 80 % judged the intervention ineffective. The overwhelmingly negative interpretation of the EXPLORE study outcomes is reflected in public policies and prevention planning. We conclude that using a vaccine standard to define success led to a broad discrediting of the benefits of behavioral counseling and, ultimately, adversely impacted policies critical to the field of HIV prevention.

Stability of glycoprotein gene sequences of herpes simplex virus type 2 from primary to recurrent human infection, and diversity of the sequences among patients attending an STD clinic

Background

Herpes simplex virus type 2 (HSV-2) is sexually transmitted, leading to blisters and ulcers in the genito-anal region. After primary infection the virus is present in a latent state in neurons in sensory ganglia. Reactivation and production of new viral particles can cause asymptomatic viral shedding or new lesions. Establishment of latency, maintenance and reactivation involve silencing of genes, continuous suppression of gene activities and finally gene activation and synthesis of viral DNA. The purpose of the present work was to study the genetic stability of the virus during these events.

Methods

HSV-2 was collected from 5 patients with true primary and recurrent infections, and the genes encoding glycoproteins B,G,E and I were sequenced.

Results

No nucleotide substitution was observed in any patient, indicating genetic stability. However, since the total number of nucleotides in these genes is only a small part of the total genome, we cannot rule out variation in other regions.

Conclusions

Although infections of cell cultures and animal models are useful for studies of herpes simplex virus, it is important to know how the virus behaves in the natural host. We observed that several glycoprotein gene sequences are stable from primary to recurrent infection. However, the virus isolates from the different patients were genetically different.

Factors associated with herpes simplex virus type 2 incidence in a cohort of human immunodeficiency virus type 1-seronegative Kenyan men and women reporting high-risk sexual behavior

BACKGROUND

Herpes simplex virus type 2 (HSV-2) is an important cause of genital ulcers and can increase the risk for human immunodeficiency virus type 1 (HIV-1) transmission. Our objective was to determine the incidence and correlates of HSV-2 infection in HIV-1-seronegative Kenyan men reporting high-risk sexual behavior, compared with high-risk HIV-1-seronegative women in the same community.

METHODS

Cohort participants were screened for prevalent HIV-1 infection. HIV-1-uninfected participants had regularly scheduled follow-up visits, with HIV counseling and testing and collection of demographic and behavioral data. Archived blood samples were tested for HSV-2.

RESULTS

HSV-2 prevalence was 22.0% in men and 50.8% in women (P < 0.001). HSV-2 incidence in men was 9.0 per 100 person-years, and was associated with incident HIV-1 infection (adjusted incidence rate ratio [aIRR], 3.9; 95% confidence interval [CI], 1.3-12.4). Use of soap for genital washing was protective (aIRR, 0.3; 95% CI, 0.1-0.8). Receptive anal intercourse had a borderline association with HSV-2 acquisition in men (aIRR, 2.0; 95% CI, 1.0-4.1; P = 0.057), and weakened the association with incident HIV-1. Among women, HSV-2 incidence was 22.1 per 100 person-years (P < 0.001 compared with incidence in men), and was associated with incident HIV-1 infection (aIRR, 8.9; 95% CI, 3.6-21.8) and vaginal washing with soap (aIRR, 1.9; 95% CI, 1.0-3.4).

CONCLUSIONS

HSV-2 incidence in these men and women is among the highest reported, and is associated with HIV-1 acquisition. Although vaginal washing with soap may increase HSV-2 risk in women, genital hygiene may be protective in men.

Herpes simplex virus and HIV: genital infection synergy and novel approaches to dual prevention

Sexual transmission of HIV-1, in the absence of co-factors, is poorly efficient. Data support that herpes simplex virus type-2 (HSV-2) may increase a woman's susceptibility to HIV-1. Potential mechanisms by which HSV-2 serves as an HIV-1 enhancing co-factor include (1) initiation of a clinical or subclinical mucosal inflammatory response, (2) alteration of innate mucosal immunity and (3) weakening or breaching the protective genital epithelia. No clinical trial has examined prevention of primary HSV-2 infection to eliminate the major morbidities of this recurrent disease and as a strategy to reduce HIV-1 transmission. Topical administration of potent antivirals can achieve local concentrations that are orders of magnitude higher than those obtained with oral administration. This paper reviews major advances in oral and topical pre-exposure prophylaxis of HIV-1 and HSV-2 and, based on these data, hypothesizes that simultaneous prevention of sexual acquisition of HSV-2 and HIV-1 via topical antiretroviral agents will have a synergistic impact on both epidemics.

High HIV-1 incidence, correlates of HIV-1 acquisition, and high viral loads following seroconversion among MSM

BACKGROUND

HIV-1 incidence estimates and correlates of HIV-1 acquisition in African MSM are largely unknown.

METHODS

Since 2005, HIV-1-uninfected men who reported sex with men and women (MSMW) or sex with men exclusively (MSME) were followed at scheduled visits for collection of behavioural and clinical examination data and plasma for HIV-1 testing. Urethral or rectal secretions were collected from symptomatic men to screen for gonorrhoea. Poisson regression methods were used to estimate adjusted incidence rate ratios to explore associations between risk factors and incident HIV-1 infection. Plasma viral loads (PVLs) were assessed over 2 years following seroconversion.

RESULTS

Overall HIV-1 incidence in 449 men was 8.6 [95% confidence interval (CI) 6.7-11.0] per 100 person-years. Incidence was 5.8 (95% CI 4.2-7.9) per 100 person-years among MSMW, and 35.2 (95% CI 23.8-52.1) per 100 person-years among MSME. Unprotected sex, receptive anal intercourse, exclusive sex with men, group sex, and gonorrhoea in the past 6 months were strongly associated with HIV-1 acquisition, adjusted for confounders. PVL in seroconverters was more than 4 log10 copies/ml at 230 (73.4%) of 313 visits in MSMW and 153 (75.0%) of 204 visits in MSME.

CONCLUSION

HIV-1 incidence is very high among MSM in coastal Kenya, and many seroconverters maintain high PVL for up to 2 years after infection. Effective HIV-1 prevention interventions, including treatment as prevention, are urgently needed in this population.

Successes and challenges of HIV prevention in men who have sex with men

Men who have sex with men (MSM) have been substantially affected by HIV epidemics worldwide. Epidemics in MSM are re-emerging in many high-income countries and gaining greater recognition in many low-income and middle-income countries. Better HIV prevention strategies are urgently needed. Our review of HIV prevention strategies for MSM identified several important themes. At the beginning of the epidemic, stand-alone behavioural interventions mostly aimed to reduce unprotected anal intercourse, which, although somewhat efficacious, did not reduce HIV transmission. Biomedical prevention strategies reduce the incidence of HIV infection. Delivery of barrier and biomedical interventions with coordinated behavioural and structural strategies could optimise the effectiveness of prevention. Modelling suggests that, with sufficient coverage, available interventions are sufficient to avert at least a quarter of new HIV infections in MSM in diverse countries. Scale-up of HIV prevention programmes for MSM is difficult because of homophobia and bias, suboptimum access to HIV testing and care, and financial constraints.

A prospective cohort study of partner testing for herpes simplex virus and sexual behavior during pregnancy

BACKGROUND

We investigated whether serotesting sexual partners of pregnant women for herpes simplex virus (HSV) improves adherence to safer-sex practices.

METHODS

A total of 287 HSV-2-seronegative pregnant women were recruited, and their partners were invited for HSV serologic testing. On the basis of test results, women were placed into 4 groups: those at risk for HSV-2 infection, those at risk for HSV-1 infection, those whose partner was not tested, and those not at risk for HSV infection. Women received safer-sex counseling and completed diaries of sexual activity.

RESULTS

Women in HSV-2-serodiscordant couples (ie, those in relationships in which they were at risk for HSV-2 acquisition) reported a smaller percentage of days with unprotected genital sex acts as compared to women who were not at risk (2% vs 8%; relative risk [RR], 0.3 [95% confidence interval {CI}, .1-.8]; P = .002) and to women whose partners' HSV status was unknown (2% vs 11%; RR, 0.2 [95% CI, .1-.8]; P = .02). Women in HSV-1-serodiscordant couples showed no difference in the frequency of genital sex acts, unprotected genital sex acts, or oral sex acts as compared to those not at risk and to those whose partners' status was unknown.

CONCLUSIONS

Pregnant women at known risk of HSV-2 acquisition by partner serotesting were less likely to engage in unprotected genital sex acts than HSV-2-seronegative women with partners who were negative or not tested.

Equal HIV-1 decay kinetics in HSV-2-infected and HSV-2-uninfected clinical trial participants treated with antiretroviral therapy

Herpes simplex virus-2 increases HIV-1 viral load and may augment HIV-1 transmission probability. To test the hypothesis that lower HIV-1 clearance rates in HSV-2-infected persons may account for this higher HIV-1 viral load, we studied 149 participants from 3 ACTG viral dynamic studies (A315, A5160s, and A5166s). Though HIV-1 viral load was 0.19 logs higher in HSV-2-positive versus HSV-2-negative persons, first and second phase clearance rates during antiretroviral therapy were equal between participants in these 2 groups.

Prevalence and risk factors associated with herpes simplex virus-2 infection in a contemporary cohort of HIV-infected persons in the United States

BACKGROUND

We compared the herpes simplex virus type 2 (HSV-2) seroprevalence in a contemporary HIV cohort with the general US population and determined risk factors for HSV-2 infection among HIV-infected persons.

METHODS

The Study to Understand the Natural History of HIV and AIDS in the Era of Effective Therapy (SUN) Study is a prospective observational cohort of 700 HIV-infected adults enrolled in 4 U.S. cities between 2004 and 2006. At baseline, participants completed a behavioral risk questionnaire and provided specimens for HSV-2 serology. We calculated HSV-2 seroprevalence, standardized by age, gender, and race among HIV-infected persons compared with the general US adult population, using data from the National Health and Nutrition Examination Survey from 2003 to 2006. We examined risk factors associated with HSV-2 infection among HIV-infected persons using multivariate logistic regression.

RESULTS

Among 660 (94%) SUN participants with adequate specimens for HSV-2 serologic testing, 548 (83%) were 20 to 49 years old (median age, 39 years; 77% male; 59% non-Hispanic white; median CD4 count, 470 cells/mm; 74% with HIV RNA viral loads <400 copies/mL). HSV-2 seroprevalence was significantly higher among HIV-infected adults (59.7%, 95% confidence interval: 55.8-63.6) compared with the general US population (19.2%, 95% confidence interval: 17.5-21.1). In multivariate analysis, we found that older age, female gender, black non-Hispanic race/ethnicity, being currently unemployed, high-risk anal HPV infection, and longer duration since HIV diagnosis were associated with significantly higher odds of HSV-2 infection.

CONCLUSION

HSV-2 seroprevalence is 3 times as high among HIV-infected adults as in the general U.S. population. Clinicians should be aware that increased risk for HSV-2 infection was distributed broadly among HIV-infected persons and not limited to those with high-risk sexual behaviors.

High-dose valacyclovir HSV-2 suppression results in greater reduction in plasma HIV-1 levels compared with standard dose acyclovir among HIV-1/HSV-2 coinfected persons: a randomized, crossover trial

BACKGROUND

Standard-dose HSV-2 suppressive therapy (acyclovir 400 mg twice daily) reduces plasma HIV-1 levels by 0.25-0.50 log(10) copies/mL. It is not known if higher doses might further suppress HIV-1 levels.

METHODS

We enrolled 32 HIV-1/HSV-2 dually infected Kenyan individuals who were not on antiretroviral therapy (ART) into a randomized, crossover trial of 2 dosing regimens of HSV-2 suppression: valacyclovir 1.5 g vs acyclovir 400 mg, both twice daily for 12 weeks, then a 2-week washout, and then the alternative for 12 weeks. Weekly plasma HIV-1 RNA quantity was measured (ClinicalTrials.gov number NCT01026454).

RESULTS

Mean plasma HIV-1 levels were significantly lower on valacyclovir compared with acyclovir: 2.94 vs 3.56 log(10) copies/mL, an average difference of 0.62 log(10) copies/mL (95% confidence interval [CI]: -0.68, -0.55; P < .001), a 76% decrease. Valacyclovir resulted in a 1.23 log(10) copies/mL decrease compared with baseline HIV-1 levels without HSV-2 suppression. Adherence was similar (99.4% of dispensed study tablets taken), and high-dose valacyclovir was well tolerated.

CONCLUSIONS

High-dose valacyclovir reduced plasma HIV-1 viral levels by 0.62 log(10) copies/mL compared with standard-dose acyclovir. The potential for higher-dose HSV-2 suppressive therapy to slow HIV-1 disease progression and reduce HIV-1 infectiousness among HIV-1/HSV-2 coinfected persons not yet eligible for ART warrants further evaluation.

Impact of herpes simplex virus type 2 on HIV-1 acquisition and progression in an HIV vaccine trial (the Step study)

INTRODUCTION

Extensive observational data suggest that herpes simplex virus type 2 (HSV-2) infection may facilitate HIV acquisition, increase HIV viral load, and accelerate HIV progression and onward transmission. To explore these relationships, we examined the impact of preexisting HSV-2 infection in an international HIV vaccine trial.

METHODS

We analyzed the associations between prevalent HSV-2 infection and HIV-1 acquisition and progression among 1836 men who have sex with men. We used Cox proportional hazards regression models to estimate the association between HSV-2 infection and both HIV acquisition and antiretroviral therapy (ART) initiation, and linear regression to explore the effect of HSV-2 on pre-ART viral load.

RESULTS

HSV-2 infection increased risk of HIV-1 acquisition among all volunteers [adjusted hazard ratio 2.2; 95% confidence interval (CI): 1.4 to 3.5]. Adjusting for demographic variables, circumcision, Ad5 titer, and significant risk behaviors, the risk of HIV acquisition among HSV-2-infected placebo recipients was 3-fold higher than HSV-2 seronegatives (adjusted hazard ratio 3.3; 95% CI: 1.6 to 6.9). Past HSV-2 infection was associated with a 0.2 log10 copies per milliliter higher adjusted mean set point viral load (95% CI: 0.3 lower to 0.6 higher). HSV-2 infection was not associated with time to ART initiation.

CONCLUSIONS

Among men who have sex with men in an HIV-1 vaccine trial, preexisting HSV-2 infection was a major risk factor for HIV acquisition. Past HSV-2 did not significantly increase HIV viral load or early disease progression. HSV-2-seropositive persons will likely prove more difficult than HSV-2-seronegative persons to protect against HIV infection using vaccines or other prevention strategies.

Male circumcision and risk of HIV acquisition among MSM

OBJECTIVES

To assess the association between male circumcision, insertive anal sex practices, and HIV acquisition in a cohort of MSM.

METHODS

Data were from 1824 HSV-2-seropositive, HIV-seronegative MSM, 1362 (75%) from Peru and 462 (25%) from the US, who participated in a randomized placebo-controlled trial of HSV-2 suppression for HIV prevention (HPTN 039). Circumcision status was determined by examination at enrollment. HIV testing was done every 3 months for up to 18 months. Partner-specific sexual behavior for up to the last three partners during the previous 3 months was analyzed.

RESULTS

There was no significant association between male circumcision and HIV acquisition in univariate analysis [relative risk (RR) = 0.84, 95% confidence interval (CI) 0.50-1.42]. In a prespecified multivariate analysis that assumed a linear relationship between the proportion of insertive acts and effect of circumcision on HIV acquisition, the interaction between circumcision and proportion of insertive acts was not significant (P = 0.11). In an exploratory analysis that categorized behavior with recent partners by proportion of insertive acts (<60 or ≥60% insertive acts), circumcision was associated with a nonstatistically significant 69% reduction in the risk of HIV acquisition (RR = 0.31, 95% CI 0.06-1.51) among men who reported at least 60% of insertive acts with recent male partners.

CONCLUSION

Circumcision does not have a significant protective effect against HIV acquisition among MSM from Peru and US, although there may be reduced risk for men who are primarily insertive with their male partners. This association needs to be investigated across diverse cohorts of MSM.

Interactions of HIV, other sexually transmitted diseases, and genital tract inflammation facilitating local pathogen transmission and acquisition

Despite several decades of clinical trials assessing the impact of etiological treatment of sexually transmitted diseases (STDs) to decrease HIV acquisition and transmission, almost all of these trials have not proven to be efficacious. Increasing evidence suggests that specific STD treatment alone may not be sufficient to alter the genital tract inflammatory milieu that is created by STDs. This paper examines the associations between STDs and HIV susceptibility and infectiousness, and considers the role of chronic and refractory inflammation to create an environment that potentiates HIV and STD transmission and acquisition by reviewing biological, observational, and clinical trial data.

Can herpes simplex virus type 2 suppression slow HIV disease progression: a study protocol for the VALacyclovir In Delaying Antiretroviral Treatment Entry (VALIDATE) trial

BACKGROUND

Although highly active antiretroviral therapy (HAART) has dramatically decreased HIV-related morbidity and mortality, the associated costs, toxicities, and resistance risks make the potential delay of HAART initiation an attractive goal. Suppression of herpes simplex virus type 2 (HSV-2) may be a novel strategy for achieving this goal because HSV-2 is associated with clinically significant increases in HIV viral load, the primary driver of HIV disease progression.

METHODS/DESIGN

The VALacyclovir In Delaying Antiretroviral Treatment Entry (VALIDATE) trial is a multicentre, randomized, fully blinded, clinical trial of twice daily valacyclovir 500 mg versus placebo for delaying the need for initiating HAART among HIV-1, HSV-2 co-infected HAART-naïve adults. 480 participants from Canada, Brazil and Argentina will undergo quarterly clinical follow-up until reaching the composite primary endpoint of having a CD4+ T-cell count ≤ 350 cells/mm(3) or initiation of HAART for any reason, whichever occurs first. The primary analysis will use a proportional hazards model, stratified by site, to estimate the relative risk of progression to this endpoint associated with valacyclovir. Secondary analyses will compare the rates of change in CD4 count, median log10 HIV viral load, drug-related adverse events, frequency of HSV reactivations, rate of acyclovir-resistant HSV, and quality of life between study arms.

DISCUSSION

Although HIV treatment guidelines continue to evolve, with some authorities recommending earlier HAART among asymptomatic individuals, the potential delay of HAART remains a clinically relevant goal for many. If shown to be of benefit, implementation of the VALIDATE intervention will require careful consideration of both individual patient-level and public health implications.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66756285. ClinicalTrials.gov NCT00860977.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

New concepts in understanding genital herpes

Herpes simplex virus (HSV)-2 is a lifelong infection that causes recurrent genital ulcers and, rarely, disseminated and visceral disease. HSV-1 infection is an increasingly important cause of genital ulcers. HSV infections are the most common cause of genital ulcers in adults, but acquisition and chronic infection are more commonly asymptomatic than symptomatic. Both the symptomatic and asymptomatic forms of HSV are of clinical consequence for several reasons. HSV-2 infection enhances HIV-1 acquisition and transmission. In addition, sexual and perinatal transmission can occur during asymptomatic viral shedding. Perinatal transmission is of particular concern because neonatal HSV infection results in severe morbidity to the newborn. Antiviral medicines are effective for limiting recurrence duration and decreasing transmission likelihood, although no available intervention completely prevents transmission. This fact highlights the importance of laboratory diagnostics for this lifelong infection, and the need for an HSV vaccine.

Sexual risk behaviors and HIV infection among men who have sex with men who use the internet in Beijing and Urumqi, China

OBJECTIVES

To assess HIV and syphilis infections among men who have sex with men who use the internet (MSMUI) and their risk behaviors.

METHODS

In 2007, 429 MSMUI were recruited via the internet in Beijing and Urumqi, China. A questionnaire was administered, and a blood specimen was collected and tested for HIV and syphilis.

RESULTS

Median age of participants was 25 years. Median number of lifetime sexual partners was 10. 90.7% ever had sex with a cyber friend. Rates of condom use in the last oral, insertive, and receptive anal sex were 9.1%, 66.3%, and 60.4%, respectively. Infection rates of HIV, syphilis, and HIV/syphilis coinfection were 4.8%, 11.4%, and 1.7%, respectively. Factors associated with HIV infection were being < or =24 years [odds ratio (OR) = 2.85, 95% confidence interval (CI): 1.05 to 7.75], syphilis positive (OR = 4.78, 95% CI: 1.68 to 13.58), used non-water-based liquid as lubricant (OR = 8.03, 95% CI: 1.03 to 62.52), and having bleeding gums or oral ulcers during condom-free oral sex (OR = 3.17, 95% CI: 1.13 to 8.88).

CONCLUSIONS

MSMUI engage in high-risk sexual behaviors and have a high prevalence of HIV and syphilis infections. The internet is the predominant venue for the majority of MSMUI to find sexual partners. It is urgent to implement effective intervention programs targeting this group.

Anal sexually transmitted infections and risk of HIV infection in homosexual men

BACKGROUND

We examined a range of common bacterial and viral sexually transmitted infections as risk factors for HIV seroconversion in a community-based cohort of HIV-negative homosexual men in Sydney, Australia.

METHODS

Detailed information about HIV risk behaviors was collected by interview twice yearly. Participants were tested annually for HIV, anal and urethral gonorrhea and chlamydia, herpes simplex virus types 1 and 2, and syphilis. In addition, they reported annual diagnoses of these conditions and of genital and anal warts.

RESULTS

Among 1427 enrolled participants, 53 HIV seroconverters were identified, giving an incidence of 0.78 per 100 person-years. After controlling for number of episodes of insertive and receptive nonseroconcordant unprotected anal intercourse, there were independent associations with anal gonorrhea (adjusted hazard ratio = 7.12, 95% confidence interval: 2.05 to 24.79) and anal warts (hazard ratio = 3.63, 95% confidence interval: 1.62 to 8.14).

CONCLUSIONS

Anal gonorrhea and anal warts were independently associated with HIV acquisition. The added HIV prevention value of more frequent screening of the anus to allow early detection and treatment of anal sexually transmitted infections in homosexual men should be considered.

Human immunodeficiency virus serodiscordant couples on highly active antiretroviral therapies with undetectable viral load: conception by unprotected sexual intercourse or by assisted reproduction techniques?

Until recently, only assisted reproduction was proposed to serodiscordant couples wishing to conceive. Nevertheless, recent publications have proposed unprotected sexual intercourse, targeting fertile days, for couples where antiretroviral treatment has lowered blood viral load to an undetectable level. Available data and the arguments for and against conception by safe sex versus the use of a strategy of unprotected sexual intercourse targeting fertile days are reviewed and analyzed. Although the rate of transmission of human immunodeficiency virus in serodiscordant couples in precise conditions (such as an undetectable viral load on treatment by highly active antiretroviral therapies and sexual intercourse limited to the fertile days) is very low, not zero, here we stress the various factors which can increase the risk of seroconversion in this particular population. In this context, it seems less cautious to abandon the recommendations of safe sex in serodiscordant couples desiring a child. The recourse to medically assisted procreation is advised, as long as evidence from further studies does not show that unprotected sexual intercourse, targeted to fertile days, does not have unexpected harmful consequences.

Prediction of HIV acquisition among men who have sex with men

OBJECTIVE

To develop and validate an easy-to-use prediction model for HIV acquisition among men who have sex with men (MSM).

METHODS

We developed prediction models using medical records data from an STD clinic (2001-2008) and validated these models using data from the control arm of Project Explore, an HIV prevention trial (1999-2003).

RESULTS

Of 1903 MSM who tested for HIV more than once in the development sample, 101 acquired HIV over 6.7 years of follow-up. Annual HIV incidence was 2.57% (95% confidence interval [CI]: 2.09%, 3.12%). During 4 years of follow-up of 2081 Project Explore control arm participants, 144 acquired HIV for an incidence of 2.32% (95% CI: 1.96%, 2.73%). A prediction model that included variables indicating use of methamphetamine or inhaled nitrites in the prior 6 months, unprotected anal intercourse with a partner of positive or unknown HIV status in the prior year, > or =10 male sex partners in the prior year, and current diagnosis or history of bacterial sexually transmitted infection was well calibrated overall (expected-observed ratio = 1.01; 95% CI: 0.97, 1.05) and had modest discriminatory accuracy at 1 year (area under the receiver-operator characteristic curve = 0.67; 95% CI: 0.60, 0.75) and at 4 years (area under the receiver-operator characteristic curve = 0.66; 95% CI: 0.61, 0.71). Over 4 years, cumulative incidence ranged from 3.9% to 14.3% for groups of men defined by the prediction model.

CONCLUSIONS

A new risk score was predictive of HIV acquisition and could assist providers in counseling MSM and in targeting intensified prevention to MSM at greatest risk for HIV infection. Its accuracy requires further evaluation.

Seroprevalence and factors associated with herpes simplex virus type 2 among HIV-negative high-risk men who have sex with men from Rio de Janeiro, Brazil: a cross-sectional study

BACKGROUND

Herpes simplex virus type 2 (HSV-2) is the leading cause of genital ulcer disease in developing countries, including Brazil, and is especially prevalent among men who have sex with men (MSM). HSV-2 infection represents a risk factor for the acquisition and transmission of other sexually transmitted diseases. The goal of the present cross-sectional study was to estimate HSV-2 seroprevalence and to determine the factors associated with HSV-2 seropositivity in HIV-negative high-risk MSM from Rio de Janeiro, Brazil.

METHODS

Stored sera were tested to estimate HSV-2 seroprevalence, while socio-demographic and sexual behavior data were used to measure associations between risk factors and HSV-2 seropositivity. Using the Poisson regression model with robust variance, prevalence ratios (PR) were used to estimate de degree of association between risk factors and HSV-2 seropositivity in bivariate and multivariate analyses.

RESULTS

Seroprevalence of HSV-2 was of 45.7% (184 out of 403). Factors independently associated with HSV-2 seroprevalence in the multivariate model were: older age (>or= 26 years, PR: 1.41 95% Confidence Interval: 1.11-1.78), non-white race (PR: 1.32 95%CI: 1.06-1.64), positive serology for syphilis (PR: 1.65 95%CI: 1.33-2.05), positive serology for hepatitis B (PR: 1.25 95%CI: 0.99-1.57), stable male partner in the past 6 months (PR: 1.42 95%CI: 1.12-1.79), and unprotected anal sex with a stable female partner (PR: 1.46 95%CI: 1.05-2.04) in the 6 months preceding the cross-sectional assessment.

CONCLUSION

The present study made evident a high prevalence of HSV-2 infection in a sample of HIV-negative high-risk MSM from Rio de Janeiro. This finding indicates the need and urgency for implementing integrated programs for the prevention of HSV-2 and other sexually transmitted diseases, and, in particular, programs targeting high-risk MSM.

Is there a reservoir of sub-clinical lymphogranuloma venereum and non-LGV Chlamydia trachomatis infection in men who have sex with men?

SUMMARY

The aim of this study was to determine if a reservoir of sub-clinical LGV infection exists in men who have sex with men (MSM), as this finding might account for the recent rise in lymphogranuloma venereum (LGV) Chlamydia trachomatis infections among MSM in Canada. MSM without proctitis were enrolled between January and August 2006 in a cross-sectional study. Rectal, urine, serology and pharyngeal specimens were tested for specific C. trachomatis serovars. The median age of the 253 participants was 43 years; 53% were HIV+. We found no active cases of LGV infection; but 20 (8%) participants had positive serology. Thirteen participants (5%) had non-LGV C. trachomatis infections. Unprotected anopenetrative intercourse, rectal enema and drug use were associated with non-LGV C. trachomatis infection. Sub-clinical rectal non-LGV C. trachomatis infection was relatively common but LGV was not identified in our sample. Further studies of screening for non-LGV chlamydia infection in MSM are needed.

Effect of aciclovir on HIV-1 acquisition in herpes simplex virus 2 seropositive women and men who have sex with men: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Across many observational studies, herpes simplex virus type 2 (HSV-2) infection is associated with two-fold to three-fold increased risk for HIV-1 infection. We investigated whether HSV-2 suppression with aciclovir would reduce the risk of HIV-1 acquisition.

METHODS

We undertook a double-blind, randomised, placebo-controlled phase III trial in HIV-negative, HSV-2 seropositive women in Africa and men who have sex with men (MSM) from sites in Peru and the USA. Participants were randomly assigned by block randomisation to twice daily aciclovir 400 mg (n=1637) or matching placebo (n=1640) for 12-18 months, and were seen monthly for dispensation of study drug, adherence counselling and measurement by pill count and self-reporting, and risk reduction counselling, and every 3 months for genital examination and HIV testing. The primary outcome was HIV-1 acquisition and secondary was incidence of genital ulcers. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00076232.

FINDINGS

3172 participants (1358 women, 1814 MSM) were included in the primary dataset (1581 in aciclovir group, 1591 in control group). The incidence of HIV-1 was 3.9 per 100 person-years in the aciclovir group (75 events in 1935 person-years of follow-up) and 3.3 per 100 person-years in the placebo group (64 events in 1969 person-years of follow-up; hazard ratio 1.16 [95% CI 0.83-1.62]). Incidence of genital ulcers on examination was reduced by 47% (relative risk 0.53 [0.46-0.62]) and HSV-2 positive genital ulcers by 63% (0.37 [0.31-0.45]) in the aciclovir group. Adherence to dispensed study drug was 94% in the aciclovir group and 94% in the placebo group, and 85% of expected doses in the aciclovir group and 86% in the placebo group. Retention was 85% at 18 months in both groups (1028 of 1212 in aciclovir group, 1030 of 1208 in placebo group). We recorded no serious events related to the study drug.

INTERPRETATION

Our results show that suppressive therapy with standard doses of aciclovir is not effective in reduction of HIV-1 acquisition in HSV-2 seropositive women and MSM. Novel strategies are needed to interrupt interactions between HSV-2 and HIV-1.

A replication-competent, neuronal spread-defective, live attenuated herpes simplex virus type 1 vaccine

Herpes simplex virus type 1 (HSV-1) produces oral lesions, encephalitis, keratitis, and severe infections in the immunocompromised host. HSV-1 is almost as common as HSV-2 in causing first episodes of genital herpes, a disease that is associated with an increased risk of human immunodeficiency virus acquisition and transmission. No approved vaccines are currently available to protect against HSV-1 or HSV-2 infection. We developed a novel HSV vaccine strategy that uses a replication-competent strain of HSV-1, NS-gEnull, which has a defect in anterograde and retrograde directional spread and cell-to-cell spread. Following scratch inoculation on the mouse flank, NS-gEnull replicated at the site of inoculation without causing disease. Importantly, the vaccine strain was not isolated from dorsal root ganglia (DRG). We used the flank model to challenge vaccinated mice and demonstrated that NS-gEnull was highly protective against wild-type HSV-1. The challenge virus replicated to low titers at the site of inoculation; therefore, the vaccine strain did not provide sterilizing immunity. Nevertheless, challenge by HSV-1 or HSV-2 resulted in less-severe disease at the inoculation site, and vaccinated mice were totally protected against zosteriform disease and death. After HSV-1 challenge, latent virus was recovered by DRG explant cocultures from <10% of vaccinated mice compared with 100% of mock-vaccinated mice. The vaccine provided protection against disease and death after intravaginal challenge and markedly lowered the titers of the challenge virus in the vagina. Therefore, the HSV-1 gEnull strain is an excellent candidate for further vaccine development.

Genital herpes has played a more important role than any other sexually transmitted infection in driving HIV prevalence in Africa

Background

Extensive evidence from observational studies suggests a role for genital herpes in the HIV epidemic. A number of herpes vaccines are under development and several trials of the efficacy of HSV-2 treatment with acyclovir in reducing HIV acquisition, transmission, and disease progression have just reported their results or will report their results in the next year. The potential impact of these interventions requires a quantitative assessment of the magnitude of the synergy between HIV and HSV-2 at the population level.

Methods and Findings

A deterministic compartmental model of HIV and HSV-2 dynamics and interactions was constructed. The nature of the epidemiologic synergy was explored qualitatively and quantitatively and compared to other sexually transmitted infections (STIs). The results suggest a more substantial role for HSV-2 in fueling HIV spread in sub-Saharan Africa than other STIs. We estimate that in settings of high HSV-2 prevalence, such as Kisumu, Kenya, more than a quarter of incident HIV infections may have been attributed directly to HSV-2. HSV-2 has also contributed considerably to the onward transmission of HIV by increasing the pool of HIV positive persons in the population and may explain one-third of the differential HIV prevalence among the cities of the Four City study. Conversely, we estimate that HIV had only a small net impact on HSV-2 prevalence.

Conclusions

HSV-2 role as a biological cofactor in HIV acquisition and transmission may have contributed substantially to HIV particularly by facilitating HIV spread among the low-risk population with stable long-term sexual partnerships. This finding suggests that prevention of HSV-2 infection through a prophylactic vaccine may be an effective intervention both in nascent epidemics with high HIV incidence in the high risk groups, and in established epidemics where a large portion of HIV transmission occurs in stable partnerships.

Herpes simplex: insights on pathogenesis and possible vaccines

Abstract Herpes simplex viruses are evolutionarily ancient and ubiquitous. In the past 20 years, there has been increasing recognition of a worldwide pandemic of HSV-2 infection. Moreover, HSV-2 prevalence has increased despite fairly widespread use of antiviral drugs for HSV. The success of HSV-1 and HSV-2 stems from latency within long-lived neurons and frequent mucocutaneous shedding. The generally mild medical consequences of HSV infection reflect a functional equilibrium between host and microbe in most immunocompetent persons. However, significant gaps in our knowledge of the correlates of disease severity and HSV immune evasion are limiting rational advances in these areas. Human genetic studies are gradually outlining important innate responses, while recent imaging and biopsy studies have begun to show that the temporal and spatial anatomic interplay between virus reactivation and host immune response may be important in reactivations and disease expression.

HIV-1/HSV-2 co-infected adults in early HIV-1 infection have elevated CD4+ T cell counts

INTRODUCTION

HIV-1 is often acquired in the presence of pre-existing co-infections, such as Herpes Simplex Virus 2 (HSV-2). We examined the impact of HSV-2 status at the time of HIV-1 acquisition for its impact on subsequent clinical course, and total CD4+ T cell phenotypes.

METHODS

We assessed the relationship of HSV-1/HSV-2 co-infection status on CD4+ T cell counts and HIV-1 RNA levels over time prior in a cohort of 186 treatment naïve adults identified during early HIV-1 infection. We assessed the activation and differentiation state of total CD4+ T cells at study entry by HSV-2 status.

RESULTS

Of 186 recently HIV-1 infected persons, 101 (54%) were sero-positive for HSV-2. There was no difference in initial CD8+ T cell count, or differences between the groups for age, gender, or race based on HSV-2 status. Persons with HIV-1/HSV-2 co-infection sustained higher CD4+ T cell counts over time (+69 cells/ul greater (SD = 33.7, p = 0.04) than those with HIV-1 infection alone (Figure 1), after adjustment for HIV-1 RNA levels (-57 cells per 1 log(10) higher HIV-1 RNA, p<0.0001). We did not observe a relationship between HSV-2 infection status with plasma HIV-1 RNA levels over time. HSV-2 acquisition after HIV-1 acquisition had no impact on CD4+ count or viral load. We did not detect differences in CD4+ T cell activation or differentiation state by HSV-2+ status.

DISCUSSION

We observed no effect of HSV-2 status on viral load. However, we did observe that treatment naïve, recently HIV-1 infected adults co-infected with HSV-2+ at the time of HIV-1 acquisition had higher CD4+ T cell counts over time. If verified in other cohorts, this result poses a striking paradox, and its public health implications are not immediately clear.

Analytic insights into the population level impact of imperfect prophylactic HIV vaccines

The population level implications of imperfect HIV vaccines were studied using a mathematical model. A criterion for determining the utility of a vaccine at the population level is introduced, and 2 useful summary measures, namely, vaccine utility (phi) and vaccine infection fitness (psi), are derived and shown to characterize the population-level utility once vaccine efficacies are determined. The utility of the vaccine alone does not guarantee a substantial impact, however, because the effectiveness of partially effective vaccines also depends on the prevailing level of HIV infectious spread. Therefore, a second criterion is introduced through a third summary measure, the hazard index (xi), to describe the effectiveness of a vaccine in substantially reducing HIV incidence. The qualitative features of the impact are delineated by studying 4 distinct scenarios of HIV vaccination. Accordingly, our work delineates the link between vaccine efficacies and the impact of vaccination at the population level and provides the tools for vaccine developers to assess the utility and effectiveness of a given imperfect vaccine straightforwardly and rapidly.

Hormonal contraceptive use, herpes simplex virus infection, and risk of HIV-1 acquisition among Kenyan women

BACKGROUND

Studies of the effect of hormonal contraceptive use on the risk of HIV-1 acquisition have generated conflicting results. A recent study from Uganda and Zimbabwe found that women using hormonal contraception were at increased risk for HIV-1 if they were seronegative for herpes simplex virus type 2 (HSV-2), but not if they were HSV-2 seropositive.

OBJECTIVE

To explore the effect of HSV-2 infection on the relationship between hormonal contraception and HIV-1 in a high-risk population. Hormonal contraception has previously been associated with increased HIV-1 risk in this population.

METHODS

Data were from a prospective cohort study of 1206 HIV-1 seronegative sex workers from Mombasa, Kenya who were followed monthly. Multivariate Cox proportional hazards analyses were used to adjust for demographic and behavioral measures and incident sexually transmitted diseases.

RESULTS

: Two hundred and thirty-three women acquired HIV-1 (8.7/100 person-years). HSV-2 prevalence (81%) and incidence (25.4/100 person-years) were high. In multivariate analysis, including adjustment for HSV-2, HIV-1 acquisition was associated with use of oral contraceptive pills [adjusted hazard ratio (HR), 1.46; 95% confidence interval (CI), 1.00-2.13] and depot medroxyprogesterone acetate (adjusted HR, 1.73; 95% CI, 1.28-2.34). The effect of contraception on HIV-1 susceptibility did not differ significantly between HSV-2 seronegative versus seropositive women. HSV-2 infection was associated with elevated HIV-1 risk (adjusted HR, 3.58; 95% CI, 1.64-7.82).

CONCLUSIONS

In this group of high-risk African women, hormonal contraception and HSV-2 infection were both associated with increased risk for HIV-1 acquisition. HIV-1 risk associated with hormonal contraceptive use was not related to HSV-2 serostatus.

Interactions and management issues in HSV and HIV coinfection

Significant synergistic interactions have been observed between HIV and herpes simplex virus (HSV). HIV-induced immune compromise can cause frequent and persistent HSV disease, while poorly controlled HSV replication may influence HIV pathogenicity and transmission. HSV-2 seroprevalence is high in HIV-infected cohorts worldwide, with rates of over 80% for HSV-1 and ranging from 33% to more than 80% for HSV-2. As seen in HIV-negative individuals, HSV-2 coinfection is associated with female gender, older age and black ethnicity. HSV infection is commonly under-diagnosed in HIV-infected individuals, although the use of PCR for HSV detection in mucocutaneous swabs and HSV type-specific serology can improve the diagnostic yield. In HIV-1-infected patients with frequent clinical episodes of HSV reactivation, suppressive antiviral therapy may prove beneficial in controlling HSV disease while also reducing HSV-mediated promotion of HIV replication. Antiretroviral therapy leads to a gradual recovery of HSV-specific T-cell responses and a reduction in HSV-related morbidity, indicating that successful management of coinfection should target both HIV and HSV replication. The aim of this review is to address the more speculative issues surrounding the management of HSV/HIV coinfection and to summarize the data that inform them.

Clinical and Therapeutic Issues for Herpes Simplex Virus-2 and HIV Co-Infection

A synergy between HIV type-1 (HIV-1) and herpes simplex virus-2 (HSV-2) has been demonstrated in many epidemiological and clinical studies over the last decade. HIV-1 infection exacerbates the clinical impact and frequency of HSV-2 reactivation events; furthermore, HSV-2 infection exacerbates the risk of HIV acquisition and transmission and may accentuate HIV disease progression. In order to maximise the impact of existing and future therapeutic and preventive interventions, this article reviews the epidemiological, clinical and therapeutic considerations associated with episodic treatment and suppression of HSV-2 infection in HIV-infected individuals.Specifically, this article describes the current expanding epidemics of both HIV and HSV-2, and how high rates of asymptomatic herpes virus shedding contribute to the under-diagnosis and continued spread of both HSV-2 and HIV. Furthermore, multiple clinical trials have studied the efficacy and clinical utility of aciclovir and other nucleoside analogues for treating and suppressing HSV-2. We review these studies and summarise the guidelines for these regimens, particularly noting the accumulated experience documenting the utility of herpes treatment and suppression in altering the natural history of symptoms and documenting the low rate of HSV-2 drug resistance to nucleoside analogues observed after more that a decade of use. Finally, there are now also growing data describing the benefits of herpes suppression in the context of individuals co-infected with HIV/HSV-2, with additional clinical trials poised to further elucidate these issues in the near future.