Sentinel surveillance of sexually transmitted infections in South Africa: a review

OBJECTIVES: To review studies of sexually transmitted infection (STI) prevalence in South Africa between 1985 and 2003 in selected sentinel populations. To examine how STI prevalence varies between populations and to identify the limitations of the existing data. METHODS: Studies of the prevalence of syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum, gonorrhoea, chlamydia, trichomoniasis, bacterial vaginosis, candidiasis, and herpes simplex virus type 2 (HSV-2) were considered. Results were included if they related to women attending antenatal clinics or family planning clinics, commercial sex workers, individuals in the general population (household surveys), patients with STIs, patients with genital ulcer disease (GUD), or men with urethritis. RESULTS: High STI prevalence rates have been measured, particularly in the case of HSV-2, trichomoniasis, bacterial vaginosis and candidiasis. The aetiological profile of GUD appears to be changing, with more GUD caused by HSV-2 and less caused by chancroid. The prevalence of gonorrhoea and syphilis is highest in "high risk" groups such as sex workers and attenders of STI clinics, but chlamydia and trichomoniasis prevalence levels are not significantly higher in these groups than in women attending antenatal clinics. CONCLUSIONS: The prevalence of STIs in South Africa is high, although there is extensive variability between regions. There is a need for STI prevalence data that are more nationally representative and that can be used to monitor prevalence trends more reliably.     

Can behavior change explain increases in the proportion of genital ulcers attributable to herpes in sub-Saharan Africa? A simulation modeling study

BACKGROUND: The proportion of cases of genital ulcer disease attributable to herpes simplex virus type 2 (HSV-2) appears to be increasing in sub-Saharan Africa. GOAL: To assess the contributions of HIV disease and behavioral response to the HIV epidemic to the increasing proportion of genital ulcer disease (GUD) attributable to HSV-2 in sub-Saharan Africa. STUDY DESIGN: Simulations of the transmission dynamics of ulcerative sexually transmitted diseases (STDs) and HIV with use of the model STDSIM. RESULTS: In simulations, 28% of GUD was caused by HSV-2 before a severe HIV epidemic. If HIV disease was assumed to double the duration and frequency of HSV-2 recurrences, this proportion rose to 35% by year 2000. If stronger effects of HIV were assumed, this proportion rose further, but because of increased HSV-2 transmission this would shift the peak in HSV-2 seroprevalence to an unrealistically young age. A simulated 25% reduction in partner-change rates increased the proportion of GUD caused by HSV-2 to 56%, following relatively large decreases in chancroid and syphilis. CONCLUSION: Behavioral change may make an important contribution to relative increases in genital herpes.     

Sexually transmitted infections among married women in Dhaka, Bangladesh: unexpected high prevalence of herpes simplex type 2 infection

OBJECTIVES: To document the prevalence of reproductive tract infections (RTI) and sexually transmitted infections (STI) among women attending a basic healthcare clinic in Dhaka, Bangladesh, to identify risk factors associated with the diseases and to estimate the incidence of syphilis, hepatitis C (HCV), hepatitis B (HBV), and herpes simplex type 2 (HSV-2) infection. METHODS: A cross sectional sample of 2335 consecutive women was examined during 1996-8. Women were interviewed about risk factors for RTI/STI and tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Treponema pallidum, HIV, HCV, HBV, HSV-1 and HSV-2 infection as well as vaginal candidosis and bacterial vaginosis. Women with antibodies to T pallidum were retested at regular intervals. One year after ending the study seroconversion for syphilis, HBV, HCV, and HSV-2 infection was detected among women initially negative for the respective diseases. RESULTS: The overall prevalence rate of N gonorrhoeae, C trachomatis, T vaginalis, and T pallidum infection was 0.5%, 1.9%, 2.0%, and 2.9% respectively. Overall, 35% of the women had antibodies to hepatitis B core antigen, 0.9% had HCV, and 12% HSV-2 infection. Risk factors for gonorrhoea/C trachomatis infection were a husband not living at home or suspected of being unfaithful. HSV-2 infection was associated with the same risk factors and with a polygamous marriage. The prevalence of HSV-2 infection among women "at risk" was 23%. HIV infection was not diagnosed. Repeated serological examination indicated that only 32% of women with serological evidence of syphilis had active disease. The seroincidences of HBV, HCV, and HSV-2 were 0.03, 0.007, and 0.009 per person year. Seroconversion for syphilis was not observed.     

Health indicators among low income women who report a history of sex work: the population based Northern California Young Women's Survey

OBJECTIVES: We examined differences in demographic characteristics, HIV related risk behaviour, prevalence of sexually transmitted infections (STI), and HIV and other health concerns among women with and without a history of sex work. METHODS: A secondary analysis of a population based, cross sectional survey of young, low income women in northern California. RESULTS: Of the 2543 women interviewed, 8.9% reported a history of sex work. These women reported more lifetime male sexual partners, were more likely to use drugs before sex, and were more likely to have a history of having sex with partners at high risk for HIV (that is, men who have sex with men, inject drugs, or were known to be HIV positive). They were significantly more likely to have positive serology for syphilis, herpes simplex virus type 2 (HSV-2), and hepatitis C regardless of their personal injecting drug use history; however, they were no more likely to have HIV, chlamydia, gonorrhoea, hepatitis A or hepatitis B infection compared to women without a history of sex work. Women with a history of sex work were significantly more likely to have a history of sexual coercion and tobacco use. CONCLUSIONS: These data measure the population prevalence of sex work among low income women and associated STI. Women with a history of sex work have health concerns beyond STI and HIV treatment and prevention.     

Baseline survey of sexually transmitted infections in a cohort of female bar workers in Mbeya Region, Tanzania

OBJECTIVES: To determine baseline prevalence of sexually transmitted infections (STI) and other reproductive tract infections (RTI) and their association with HIV as well as sociodemographic and behavioural characteristics in a newly recruited cohort of female bar workers in Mbeya Region, Tanzania. METHODS: 600 female bar workers were recruited from 17 different communities during September to November 2000 and underwent gynaecological examination, laboratory testing for HIV/STI, and interviews using structured questionnaires. RESULTS: HIV-1 seroprevalence was 68%. Prevalences of STI/RTI were high titre syphilis (TPPA/RPR >/=1/8), 9%; herpes simplex virus 2 antibodies, 87%; chlamydia, 12%; gonorrhoea, 22%; trichomoniasis, 24%; and bacterial vaginosis, 40%. HIV infection was associated with TPPA and HSV-2 seropositivity, bacterial vaginosis and clinically diagnosed genital ulcers, blisters, and warts. Reported high risk sexual behaviour during the past year (having multiple casual partners) was associated with prevalent STI. CONCLUSION: Female bar workers in Mbeya are at high risk of STI and HIV infection. Targeted STI/HIV prevention interventions for these women and their sexual partners need to be reinforced. Methods should be sought to improve healthcare seeking and to provide easily accessible and affordable STI care services.     

Prevalence of sexually transmitted infections and high-risk sexual behaviors in heterosexual couples attending sexually transmitted disease clinics in Peru

OBJECTIVES: The objectives of this study were to determine the prevalence of sexually transmitted infection (STIs) in heterosexual couples and the sexual behaviors associated with their acquisition. GOAL: The goal of this study was to better direct educational efforts to decrease STI among heterosexual couples in Lima, Peru. STUDY DESIGN: We conducted a case-control study in 195 heterosexual couples without HIV infection who attended 2 sexually transmitted disease clinics in Lima, Peru. A case was defined as an individual with one or more newly diagnosed STIs such as gonorrhea, chlamydia, trichomoniasis, herpes simplex, syphilis, mycoplasma, or ureaplasma. RESULTS: Thirty-three percent of individuals (41 men and 89 women) had at least one STI and 26 couples (13%) had the same STI detected. Men who have sex with men (MSM) accounted for 13% of all men, had higher rate of STIs and higher risk behaviors than non-MSM. Ureaplasma infection was the most prevalent STI found in both men and women and was associated with oral sexual contact. In heterosexual pairs, condom use during anal sex occurred less than 10% of the time. CONCLUSIONS: The heterosexual couples in sexually transmitted disease clinics have high-risk behaviors and STIs are frequent. The educational effort concerning prevention of STIs requires higher effort.     

Increasing prevalence of genital herpes in developing countries: implications for heterosexual HIV transmission and STI control programmes

BACKGROUND: The recognition that sexually transmitted infections (STI) facilitate HIV transmission among heterosexuals has led to a rejuvenated focus on improving STI control as a component of HIV prevention programmes in developing countries. While efforts so far have focused mainly on all STI, there is increasing evidence that genital ulcers facilitate a considerable proportion of HIV transmission among heterosexuals and that this effect has been underestimated. This paper focuses on the epidemiology of genital herpes in developing countries past and present. OBJECTIVES: To review the scientific literature about the epidemiology of genital herpes in developing countries and discuss the implications of the findings for STI control and HIV prevention programmes. SEARCH METHODOLOGY: A Medline search for June 1966 to August 1999 using the keywords, genital herpes, STD and developing countries, and genital ulcers in MeSH and free text. Abstract books from recent international AIDS conferences and other international STD conferences were reviewed. The annual reports of the medical officers of heath for Harare 1982-1998 and Durban 1989-1997 were reviewed to detect trends in genital herpes diagnoses. FINDINGS: Genital herpes, formerly regarded as a minor STI in most developing countries, has now emerged as a leading cause of genital ulceration in many countries where syphilis and chancroid were more prevalent previously. This increased recognition of genital herpes reflects both a change in the pattern of STI epidemiology through a decline in syphilis and chancroid as a response to HIV control programmes and improved techniques for diagnosing herpetic infection. Countries with significant heterosexual HIV epidemics also appear to have rapidly increasing numbers of genital herpes cases. CONCLUSIONS: The emergence of this herpes epidemic must be addressed through innovative strategies that will be viable, sustainable, acceptable, and effective in developing countries. In countries where genital herpes is a significant problem, local adaptation of WHO treatment algorithms should be made. STI service providers should be trained about issues around the transmission of herpes and how best to advise clients about dealing with, and recognising, recurrences. The effectiveness of antiviral treatment for genital herpes should be investigated in core groups at high risk of HIV.     

Human immunodeficiency virus infection and genital ulcer disease in South Africa: the herpetic connection

BACKGROUND AND OBJECTIVES: While genital ulcers are a risk factor in HIV infection, the association of specific agents of genital ulcer disease (GUD) with HIV infection may vary. GOAL: To determine the etiology of GUD in HIV-infected and HIV-uninfected men attending sexually transmitted disease (STD) clinics in Durban, Johannesburg, and Cape Town, South Africa, and the association of previous and current sexually transmitted infections with HIV infection in men with ulcerative and nonulcerative STDs. STUDY DESIGN: A cross-sectional study of 558 men with genital ulcers and 602 men with urethritis. RESULTS: Patients with GUD were more likely to be infected with HIV than patients with urethritis (39.4% versus 21.4%, P< or =0.001). Herpes simplex virus 2 (HSV-2) was the most common agent identified in ulcer specimens (35.9%), and was detected in a significantly higher proportion of ulcer specimens from HIV-infected patients than in specimens from HIV-uninfected patients (47.4% versus 28.2%, P< or =0.001). Patients infected with HIV-1 were significantly more likely to have HSV-2 infection, as measured by the presence of the antibody to glycoprotein G-2, than patients not infected with HIV (63.1% versus 38.5%, P< or =0.001). Patients infected with HIV-1 were also significantly more likely to have initial HSV-2 infection than HIV-uninfected patients with GUD (50.0% versus 31.6%, P = 0.007). Haemophilus ducreyi was detected in 31.7% of ulcer specimens; prevalence did not vary by HIV-infection status. Treponema pallidum DNA was detected significantly less frequently in ulcer specimens from patients infected with HIV than in specimens from patients not infected with HIV (10.2% versus 26%, P< or =0.001); no association was found between HIV-infection status and fluorescent treponemal antibody absorption test seroreactivity, even when men with M-PCR-positive syphilis lesions were excluded from the analyses. CONCLUSION: The authors found that HSV-2 is a more common etiology of GUD than has been suggested by previous studies conducted in South Africa; serologic evidence of HSV-2 infection and current cases of genital herpes are strongly associated with HIV infection among men who present to STD clinics with GUD or urethritis.     

Herpes simplex virus 2 and syphilis among young drug users in Baltimore, Maryland

OBJECTIVES: To examine the sex specific seroprevalence and correlates of herpes simplex virus 2 (HSV-2) and syphilis among a cohort of young drug users. METHODS: Drug users aged 15-30 years old who used heroin, cocaine, or crack were recruited between October 1999 and August 2002. Baseline interviews gathered information on sociodemographics, drug use and sexual behaviours. Serum was tested at baseline for HSV-2 and syphilis seroreactivity. For each sexually transmitted infection (STI), infected and non-infected participants were stratified by sex and compared using chi2, Mann-Whitney tests, and logistic regression. RESULTS: Of the 543 participants recruited, 42.4% were female and 39.3% were African-American. The seroprevalence of STIs among females and males, respectively, were HSV-2: 58.7% and 22.0%; syphilis: 4.3% and 0.3%. In multivariate models, older age, African-American race, having over 30 lifetime sex partners, current HIV infection and previous incarceration were independently associated with HSV-2 infection among males. For females, older age, African-American race, sex trade, and daily heroin use were independently associated with HSV-2. For females, only a self reported previous syphilis diagnosis was associated with current syphilis seroreactivity in multivariate analyses. CONCLUSIONS: Examination of this cohort revealed a particularly high seroprevalence of HSV-2 and syphilis, especially among female drug users. Few infected participants had been previously diagnosed with these infections.     

Male circumcision and common sexually transmissible diseases in a developed nation setting.

OBJECTIVE--To determine whether the circumcision status of men affected their likelihood of acquiring sexually transmissible diseases (STDs). DESIGN--A cross-sectional study employing an anonymous questionnaire, clinical examination and type specific serology for herpes simplex virus type 2 (HSV-2). SETTING--A public STD clinic in Sydney, Australia. SUBJECTS--300 consecutive heterosexual male patients. MAIN OUTCOME MEASURES--Associations between circumcision status and past or present diagnoses of STDs including HSV-2 serology and clinical pattern of genital herpes. RESULTS--185 (62%) of the men were circumcised and they reported similar ages, education levels and lifetime partner numbers as men who were uncircumcised. There were no significant associations between the presence or absence of the male prepuce and the number diagnosed with genital herpes, genital warts and non-gonococcal urethritis. Men who were uncircumcised were no more likely to be seropositive for HSV-2 and reported symptomatic genital herpes outbreaks of the same frequency and severity as men who were circumcised. Gonorrhoea, syphilis and acute hepatitis B were reported too infrequently to reliably exclude any association with circumcision status. Human immunodeficiency virus infection (rare among heterosexual men in the clinic) was an exclusion criterion. CONCLUSIONS--From the findings of this study, circumcision of men has no significant effect on the incidence of common STDs in this developed nation setting. However, these findings may not necessarily extend to other setting where hygiene is poorer and the spectrum of common STDs is different.     

The epidemiology of herpes simplex virus type 2 infection in low-income urban populations in coastal Peru

OBJECTIVE: The objective of this study was to determine the epidemiology of herpes simplex virus type 2 (HSV-2) in general and socially marginalized populations of low-income, urban, coastal Peru. STUDY: Two low-income populations were administered an epidemiologic survey and serologic tests, determining risk behavior, HSV-2, and HIV prevalence. RESULTS: In the socially marginalized population, HSV-2 prevalence was 72.3% in men who have sex only with men (MSOM), 42.5% in women, and 20.7% in men. In the general population, HSV-2 prevalence was 20.5% in women and 7.1% in men. In all groups except the male general population, HSV-2 prevalence increased with age or number of sexually active years (both P <0.001). HSV-2 infection was associated with HIV infection in MSOM (P <0.023) and other socially marginalized men (P <0.01). CONCLUSION: HSV-2 was common in both low-income populations, and control programs are needed in Peru given high prevalence and association with HIV infection. Prevention of HSV-2 infection should target individuals before they become sexually active.     

HIV and STIs in clients and female sex workers in mining regions of Gejiu City, China

OBJECTIVE: To investigate HIV/sexually transmitted infections (STIs) among female sex workers (FSWs) and clients in a mining region of China. GOAL: To estimate HIV/STI prevalence and to identify HIV risk factors among FSWs and miner clients. STUDY DESIGN: A cross-sectional study of 96 FSWs and 339 miner clients. RESULTS: In FSWs, prevalence of HIV was 8.3%, herpes simplex virus-2 70.8%, syphilis 12.5%, Neisseria gonorrhoeae 36.8%, Chlamydia trachomatis 46.3%, Trichomonas vaginalis 22.1%, and 90.6% were infected with any STI. Illegal drug use was associated with HIV [adjusted odds ratio (OR) = 45.1, 95% confidence interval, 6.4-317.9] in FSWs, and 45.8% reported no condom use with the last client. In miner clients, HIV prevalence was 1.8%, herpes simplex virus-2 14.9%, syphilis 2.4%, N. gonorrhoeae 2.1%, C. trachomatis 6.5%, and 23.2% were infected with any STI. Never using condoms with FSWs and regular partners were reported in 61.2% and 84.1%, respectively. Independent risk factors for HIV in miner clients were illegal drug use (OR 190.2), symptoms of urethral discharge or frequent urination (OR 32.9), early sexual debut (OR 7.1), and visiting 4 or more FSWs in the last 12 months (OR 11.5). CONCLUSIONS: HIV/STI prevalence is high among FSWs and moderate among clients in mining regions of Gejiu City. Drug use is the most important factor placing FSWs and miner clients at risk for HIV in Gejiu City; risky sexual characteristics such as early sexual debut, frequent visits to FSWs, and STI symptoms are also important factors for miner clients. FSWs and miner clients may constitute bridging groups for HIV to low-risk populations.     

High-risk sexual behaviour in men attending a sexually transmitted infection clinic in Durban, South Africa

Objectives

A study of men with genital ulcer disease (GUD) in Durban, South Africa, at the start of the local HIV epidemic in 1988/1989 found that 36% of men with GUD continued with sexual intercourse despite symptoms. The aim of this study was to determine whether this high‐risk behaviour was still prevalent and to enquire about similar risk behaviours with other sexually transmitted infection (STI)‐related problems.

Methods

650 Men attending the main Durban STI clinic with a new complaint were enrolled. A standard questionnaire was administered. Polymerase chain reaction (PCR) tests were performed to diagnose genital herpes from ulcer specimens and gonorrhoea and chlamydia from those with urethral discharge and/or dysuria. Serology tests were performed for HIV, herpes simplex virus type 2 (HSV‐2) and syphilis.

Results

Sex since the start of symptoms was reported by between 33.3% and 43.9% of men with GUD, herpetic ulcers, gonorrhoea and/or chlamydia or dysuria. The incidence of condom use was very low in all groups having sex despite symptoms. In 87 men with genital ulcers confirmed positive for genital herpes by PCR testing, 30 (34.4%) had had sex since the start of symptoms, 28 (93.3%) of whom had had unprotected sex.

Conclusions

There is a high level of risk behaviour in this group of men in whom genital herpes is the most common cause of GUD. This risky sexual behaviour could reflect disinhibition, possibly because so many have already been infected with HSV‐2, lack of education or other unknown factors. Syndromic STI management should be strengthened with intensive health education to promote community awareness of both genital ulceration and genital herpes and their role in facilitating HIV transmission. The low level of condom use indicates that condom promotion programmes still have much to achieve.Very high rates of genital ulceration have been reported from countries worst affected by HIV.¹ The reasons for this are uncertain but could reflect low rates of male circumcision or some other behavioural factors not yet identified. At the start of the HIV epidemic in Durban, South Africa, a study of men and women with genital ulcer disease (GUD) in 1988/1989 found that 36% of men and 36% of women with GUD continued with sexual intercourse despite symptoms.² Syphilis and chancroid were the most common causes of GUD then, but subsequent studies have shown that the incidence of both these conditions has declined whereas genital herpes has increased significantly.^3,4 Moreover, in a systematic review and meta‐analysis, prevalent herpes simplex virus type 2 (HSV‐2) infection was associated with a threefold increased risk of HIV acquisition among men and women in the general population, suggesting that in areas of high HIV‐2 prevalence a high proportion of HIV is attributable to HSV‐2.⁵After the onset of the local HIV epidemic in the early 1990s in Durban, sexually transmitted infection (STI) treatment and care was decentralised so that primary care would deal with all but the most complicated or resistant STI cases. Although this strategy was expected to improve delays in treatment, it was uncertain whether staff in primary healthcare settings would be motivated to provide health education for the very high‐risk practices outlined above and to counsel patients diagnosed with genital herpes.The primary objectives of this study were to determine whether there were differences in the sociodemographic profile and sexual behaviour of men with and without genital ulcers and selected aspects of healthcare seeking and sexual behaviour in men with genital ulcers, genital herpes, gonorrhoea and/or chlamydia or dysuria.     

138例男男性接触者性传播感染相关血清学检测

目的 对男男性接触者进行相关血清学检测,以了解该人群的性传播感染情况,为干预提供依据。方法 对男男性接触者进行问卷调查,取血清进行艾滋病病毒、梅毒、单纯疱疹病毒(HSV)2型、乙型肝炎、丙型肝炎和戊型肝炎检测。结果 共调查138例男男性接触者,抗-HIV检测均阴性。梅毒螺旋体明胶凝集试验阳性23例占16.7%,其中快速血浆反应素试验阳性10例占7.2%。抗HSV-2-IgG、HBsAg、抗-HCV、抗-HEV阳性率分别为7.8%、9.7%、0和16.1%。结论 男男性接触者中有一定程度的性传播感染血清阳性率,应重视对该人群的性病艾滋病的防治工作。     

Prevalence and risk factors for herpes simplex virus type 2 antibodies among low- and high-risk populations in Indonesia

OBJECTIVES/GOAL: Data on prevalence of herpes simplex virus type 2 (HSV-2) infections are limited in Asia. This study investigated the seroprevalence of, and risk factors for, antibodies to HSV-2 among low- and high-risk, predominantly asymptomatic populations in Indonesia. STUDY DESIGN: We screened women attending maternal and child health, obstetric, gynecology, and sexually transmitted infection (STI) clinics; men attending STI clinics; and female sex workers (FSWs) for type-specific HSV-2 antibodies using the HerpesSelect 2 enzyme-linked immunosorbent assay IgG and Western blot. RESULTS: HSV-2 antibodies were detected in 153 of 176 FSWs (86.9%; 95% confidence interval [CI], 81.0-91.5); increasing age was the only significant independent risk factor (odds ratio [OR], 1.15; 95% CI, 1.06-1.24; P = 0.001). Among non-sex worker females, HSV-2 antibodies were detected in 78 of 418 (18.7%; 95% CI, 15.0-22.7); significant independent associations were any contraceptive use (OR, 2.24, 95% CI = 1.33-3.85, P = 0.003), symptoms or signs of genital ulcer (OR, 2.69; 95% CI, 1.27-5.70; P = 0.01) and younger age of sexual debut (OR, 0.92; 95% CI, 0.86-0.99; P = 0.03). HSV-2 antibodies were detected in 25 of 116 men (21.6%; 95% CI, 14.5-30.1). CONCLUSIONS: HSV-2 seroprevalence reported here is in the upper range of that reported in nearby regions. Health promotion is needed to encourage affected individuals to recognize symptoms of genital herpes and seek care and advice on reducing transmission. The high seroprevalence among FSWs has potentially serious implications for the HIV epidemic in Indonesia.     

Prevalence of herpes simplex type 2 and syphilis serology among young adults in a rural Gambian community

OBJECTIVES: To estimate prevalence and risk factors for herpes simplex 2 (HSV2) positivity, syphilis and Chlamydia trachomatis infection among rural people aged 15-34 in the Gambia. METHODS: Questionnaires and serum samples were collected from 1076 men and women aged 15-34 during a cross sectional prevalence survey in a rural area of the Gambia. Sera were screened for antibodies to herpes simplex virus type 2 (HSV2), and for syphilis using Treponema pallidum haemagglutination assay (TPHA) and rapid plasma reagin (RPR) tests. Urine was tested by polymerase chain reaction (PCR) for C trachomatis infection. RESULTS: 28% of women and 5% of men were HSV2 ELISA positive; 10% of women and 2% of men were TPHA positive; and 7% of women and 1% of men were both RPR and TPHA positive. Out of 1030 urine sample tested only six were positive for C trachomatis. 7% of those who reported never having sex were positive for one or other of these tests. Prevalences of all STIs increased with age and were higher in women than men. Women were much less likely than men to seek treatment for STI symptoms at a health centre. Married people were at increased risk of an STI compared with single people. Jola and Fula women had a higher prevalence of HSV2 than women from other ethnic groups, and Fulas also had a higher prevalence of RPR/TPHA positivity. The limited number of sexual behaviour questions were not significantly associated with STIs after adjustment for age, marital status, and ethnic group. CONCLUSIONS: The prevalences of the ulcerative infections HSV2 and syphilis in this population are a cause for concern. In a setting where HIV1 prevalence remains low this indicates an urgent need for STI control and behaviour change programmes to prevent an HIV epidemic. Concerns about the validity of reported sexual behaviour data high light the necessity of biological markers in the evaluation of behaviour change programmes.     

Possible reasons for an increase in the proportion of genital ulcers due to herpes simplex virus from a cohort of female bar workers in Tanzania

OBJECTIVES: To determine trends in the prevalence and aetiological distribution of genital ulcer syndrome (GUS) in a cohort of female bar workers and to assess factors associated with these trends. METHODS: An open cohort of 600 women at high risk of HIV and sexually transmitted infection (STI) was offered screening and treatment for STI at 3-month intervals. The prevalence of GUS and associated aetiological agents (Herpes simplex virus (HSV), Treponema pallidum and Haemophilus ducreyi) were monitored over 27 months through clinical examination, dry lesion swabbing and multiplex polymerase chain reaction. The effects of HIV status and other factors on the prevalence trends of STI were assessed. RESULTS: A total of 753 women were recruited into the cohort over 10 examination rounds. At recruitment, the seroprevalence was 67% for HIV and 89% for HSV type 2 (HSV-2). During follow-up, 57% of ulcers had unknown aetiology, 37% were due to genital herpes and 6% to bacterial aetiologies, which disappeared completely in later rounds. The absolute prevalence of genital herpes remained stable at around 2%. The proportion of GUS caused by HSV increased from 22% to 58%, whereas bacterial causes declined. These trends were observed in both HIV-negative and HIV-positive women. CONCLUSIONS: The changes observed in the frequency and proportional distribution of GUS aetiologies suggest that regular STI screening and treatment over an extended period can effectively reduce bacterial STI and should therefore be sustained. However, in populations with a high prevalence of HSV-2, there remains a considerable burden of genital herpes, which soon becomes the predominant cause of GUS. Given the observed associations between genital herpes and HIV transmission, high priority should be given to the evaluation of potential interventions to control HSV-2 either through a vaccine or through episodic or suppressive antiviral therapy and primary prevention.     

Herpes simplex virus seroprevalence and risk factors in 2 Canadian sexually transmitted disease clinics

OBJECTIVES: The objectives of this study were to determine the seroprevalence and risk factors for herpes simplex virus (HSV) types 1 and 2 in patients attending 2 Canadian sexually transmitted disease (STD) clinics. STUDY: Stored sera were tested for the presence of IgG class antibodies to HSV-1 and HSV-2 and results linked to that obtained from a risk behavior questionnaire. RESULTS: Overall prevalences for HSV-1 and -2 were 56% and 19%, respectively. HSV-1 and -2 seropositivity was associated with increasing age, female gender, nonwhite ethnicity, and a history of STD. HSV-2 seropositivity was also associated with a history of genital herpes, presence of genital sores, and coinfection with either human immunodeficiency virus (HIV) or hepatitis C (HCV). CONCLUSIONS: Herpes simplex infection is common in this high-risk Canadian population. Our finding that HCV seropositivity was a significant predictor for HSV-2 seropositivity emphasizes the overlap between pathogens that are primarily thought to be bloodborne pathogens and sexually transmitted infections and the need to target prevention in these areas concurrently.     

HIV, the clustering of sexually transmitted infections, and sex risk among African American women who use drugs

African American women have high rates of most sexually transmitted infections (STIs), including HIV. STIs have been associated with increased HIV transmission risk. METHODS: Two hundred twenty-eight black women who used drugs completed a structured questionnaire in a central Brooklyn, NY-based research center between March 2003 and August 2005. Women were screened for HIV, herpes simplex virus-2, syphilis, gonorrhea, chlamydia, and trichomoniasis. This analysis determined if STIs cluster within individuals and if clustering and sex practices or partnerships differ by HIV status. RESULTS: Thirty-eight (17%) women tested HIV seropositive and STI prevalence was herpes simplex virus-2 (79%), trichomoniasis (37%), chlamydia (11%), and gonorrhea (2%). Few women knew themselves to be infected with STIs other than HIV. Excluding HIV, the mean number of STIs per woman was 1.3 (SD 0.7). HIV-infected women were significantly more likely than uninfected women to have multiple positive screens (1.6 vs. 1.2, P = 0.002). Women reported having both lower and higher risk sex partners. HIV-infected women were 2 times more likely than uninfected woman to report current sex work (P = 0.05), the only difference in sex risk. In a linear regression model, crack cocaine use was uniquely associated with multiple positive STI screens, excluding HIV (P = 0.002). CONCLUSIONS: Several STIs, including HIV, seem to be endemic among black women who use drugs in this community. In addition to the known geographical clustering of HIV and STIs, STIs were also found to cluster at the individual level. Multiply STI infected individuals may unknowingly, but efficiently, contribute to high STI and HIV rates.     

Prevalence of Kaposi sarcoma-associated herpesvirus compared with selected sexually transmitted diseases in adolescents and young adults in rural Rakai District, Uganda

BACKGROUND: Kaposi sarcoma-associated herpesvirus (KSHV) is transmitted by routes such as homosexual intercourse and is associated with HIV infection in industrialized countries. However, there is little information about its transmission in developing countries where Kaposi sarcoma is an endemic disease. GOAL: To examine KSHV seroprevalence in young adults in a general, rural Ugandan population, and to compare this prevalence with rates of known sexually transmitted infections. STUDY DESIGN: The seroprevalence of KSHV was compared with the epidemiology of sexually transmitted diseases in 523 sexually active subjects aged 15 to 29 years who were randomly selected from a general population cohort in rural Rakai District, Uganda. Participants provided in-home interview data and specimens. Sera were tested for KSHV using immunofluorescence assay and immunoblot for lytically expressed recombinant KSHV ORF65.2. Sera were also tested for HIV type 1, herpes simplex virus type 2, and syphilis. RESULTS: The prevalence of KSHV was significantly higher in participants 15 to 19 years compared with older persons 25 to 29 years (45.0% and 36.1%, respectively; adjusted odds ratio, 0.48; 95% CI, 0.28-0.82). In contrast, herpes simplex virus type 2 and HIV type 1 prevalence increased with age. Kaposi sarcoma-associated herpesvirus serostatus was not associated with HIV type 1, syphilis, herpes simplex virus type 2, or number of sexual partners. Homosexual and anal intercourse were reported by less than 1% of participants. CONCLUSIONS: Kaposi sarcoma-associated herpesvirus does not appear to be a heterosexually transmitted infection in rural Uganda.