Prevalence of Herpes Simplex Virus 1 and 2 in a Sexually Transmitted Disease Clinic in Miami

The Prevalence of HSV-1 and HSV-2 among STD clinics in Miami is not known. The objective of this study was to evaluate infection rates of HSV 1 and 2, and to describe the socio-demographic characteristics, sexual orientation and co-infection with HIV and other STIs, in individuals attending a Sexually Transmitted Diseases (STD) clinic in Miami. A cross-sectional study of 663 patients tested for HSV type-specific serology or herpes culture during the year 2007 was performed. An overall infection rate of HSV-1 was 42.1% and 36.7% for HSV-2. Statistically higher infection rates for HSV-1and 2 were seen among Hispanics (56.7%, 54.4%) compared to non-Hispanic black (36.80%, 41.70%) and non-Hispanic white patients (6.1%, 3.5%) respectively. Females showed higher HSV-2 infection rates over males, 41.6% vs. 58.4%; p = 0.03. HSV-1 and 2 infection rates were 60.2% and 57.6% among foreign-born individuals, in contrast to 39.8% and 42.4% found among persons born in the United States. Our data shows high infection rates for HSV-1 and 2 in this community, and especially among the Hispanic population. Efforts to decrease acquisition among the Hispanic population should be a focus of future STI prevention programs. Florida Public Health Review, 2011; 8, 10-14. Background Herpes Simplex Viruses (HSV), members of alpha-herpes viruses, are common human pathogens mainly causing oral mucocutaneous and genital ulcerative disease (Singh et al. 2005). Herpes simplex virus type 2 (HSV-2) is the main cause of genital herpes, although HSV-1 is an emerging cause both in developing and industrialized countries (Peña, Adelson, Mordechai, & Blaho, 2010; Samra, Scherf, & Dan, 2003). Seroprevalence of HSV 1 and HSV 2 has particular public health importance mainly due to the synergistic relationship between HSV, STIs and the HIV epidemic. Most HSV-infected individuals are asymptomatic, are unaware of their infection and have sub-clinical disease. Transmission as a consequence of asymptomatic viral shedding contributes to the spread of disease. Episodic outbreaks of genital ulcers as well as asymptomatic shedding facilitate the acquisition and transmission of HIV and other STIs (Lingappa et al., 2009) For the general U.S. population, an estimate of the prevalence of HSV 1 and HSV 2 can be obtained by the US National Health and Nutrition Examination Surveys (NHANES) database. According to the NHANES study, in 1999-2004, the overall ageadjusted HSV-2 seroprevalence was 17.0% (95% CI, 15.8%-18.3%) and the seroprevalence for HSV-1 was 57.7% (95% CI, 55.9%-59.5%) (Xu et al., 2006). However, the statistics found in the NHANES database are unlikely to be representative of the HSV prevalence in ethnically diverse cities such as Miami and cannot be extrapolated to high risk groups. Purpose The objective of this study is to evaluate infection rates of HSV 1 and HSV 2, and to describe the socio-demographic characteristics, sexual orientation and co-infection with HIV and other STIs, in individuals attending a Sexually Transmitted Diseases (STD) clinic in Miami. Methods A retrospective chart review of patients tested for HSV type-specific serology or herpes culture during the year 2007 was performed. HSV IgG specific serology testing is available at the Miami Dade County STD clinic and is offered to individuals if clinically indicated or if specifically requested. For the purpose of this study we defined HSV infection by having either a positive IgG serology for HSV-1 and/or HSV-2, or a positive culture from a lesion consistent with genital herpes based on clinical finding. SPSS V.17 software was used to analyze the data. Univariate analyses were performed to examine the association between HSV-1 and HSV-2 prevalence rates and socio-demographic data, sexual preference, and other STIs by Pearson’s χ. A pvalue less than 0.05 with a 95% confidence interval was considered to be significant. Florida Public Health Review, 2011; 8:10-14. http://health.usf.edu/publichealth/fphr/index.htm 10 Table 1 Demographic and Epidemiological Characteristics of Individuals with HSV-1 and HSV-2 Infection Total population tested for HSV-1 and HSV-2 = 663 HSV1+ (n=279, 42.1%) HSV2+ (n=243, 36.7%) N Pct Unadjusted OR (95% CI) N Pct Unadjusted OR (95% CI) Gender Male 174 62.4 0.9 (0.6, 1.3) 142 58.4 0.7 (0.5, 1.0) Female 105 37.6 1.0 (0.7, 1.4) 101 41.6 1.3 (0.9, 1.9) Age ≤ 21 20 7.2 0.8 (0.4, 1.5) 10 4.1% 0.3 (0.1, 0.7) 22-34 146 52.3 0.8 (0.6, 1.2) 105 43.2% 0.5 (0.3, 0.6) ≥ 35 113 40.5 1.1 (0.8, 1.6) 128 52.7% 2.6 (1.9, 3.7) Ethnicity Hispanic 148 56.7 1.7 (1.2, 2.3)* 124 54.4% 1.4 (1.0, 1.9)* Non-H black 96 36.8 0.5 (0.4, 0.8) 95 41.7% 0.8 (0.6, 1.1) Non-H white 16 6.1 0.8 (0.4, 1.5) 8 3.5% 0.4 (0.1, 0.8) Birthplace U.S. 111 39.8 0.4 (0.3, 0.6) 103 42.4% 0.5 (0.4, 0.7) Non-U.S. 106 60.2 2.2 (1.6, 3.0)* 140 57.6% 1.7 (1.2, 2.3)* Income ($) < 5000 129 52.4 0.7 (0.5, 1.0) 120 55.0% 0.9 (0.6, 1.2) 5000 – 15000 59 24.0 1.0 (0.6, 1.5) 55 25.2% 1.1 (0.7, 1.6) > 15000 58 23.6 1.5 (1.0, 2.2) 43 19.7% 1.1 (0.7, 1.7) Sexual orientation Same 31 12.4 0.8 (0.5, 1.3) 29 13.1% 0.9 (0.5, 1.5) Opposite 219 87.6 1.0 (0.6, 1.4) 193 86.9% 1.09 (0.7, 1.6) HIV status Positive 5 2.0 1.2 (0.08, 0.5) 14 6.3% 1.1 (0.5, 2.2) Negative 246 98.0 4.5 (1.7, 11.9)* 209 93.7% 0.8 (0.4. 1.7) Prior HSV Yes 32 12.9 1.5 (0.9, 2.7) 37 16.7% 2.6 (1.5, 4.5) No 217 87.1 0.6 (0.3, 1.1) 184 83.3% 0.3 (0.2, 0.6)* Prior STIs Yes 84 33.5 0.618 (0.4, 0.9) 101 45.3% 1.3 (0.9, 1.9) No 167 66.5 1.619 (1.2, 2.3) 122 54.7% 0.7 (0.5, 1.0) Florida Public Health Review, 2011; 8:10-14. http://health.usf.edu/publichealth/fphr/index.htm 11 Figure 1. HSV-1 and HSV-2 Seroprevalence among Hispanics in an STD Clinic in Miami Florida Public Health Review, 2011; 8:10-14. http://health.usf.edu/publichealth/fphr/index.htm 12 Florida Public Health Review, 2011; 8:10-14. http://health.usf.edu/publichealth/fphr/index.htm 13 This study was approved by both, the University of Miami and the State of Florida Institutional Review Boards. Results The total population tested in the study period for HSV1 and 2 was 663, with 418 (63%) males and 245 (37%) females. Overall, the infection rate for HSV-1 was 42.1% and HSV-2 was 36.7%. Table 1 describes the rates of infection with HSV-1 and 2 respectively, by socio-demographics, sexual orientation, co-infection with HIV and history of other STIs. DiscussionWe found infection rates of HSV-1 to be 42.1%,and HSV-2 to be 36.7% in this study. Whencompared to the national statistics for the generalpopulation, the HSV-1 infection rate is similar, butthe HSV-2 rate is markedly high. However, our ratesmay not be comparable due to the biased studypopulation, with a larger percentage of high risk andforeign born persons, ethnical diversity, and lowersocioeconomic status.Statistically higher infection rates for HSV-1andHSV-2 were seen among Hispanics and foreign-bornindividuals. Figure 1 demonstrates HSV-1 and 2infection rates according to age, ethnicity and gender.All Hispanics in the over 35 year age group showed atrend with the highest rates of infection for HSV-1and HSV-2. On the other hand, the NHANESdatabase (1999-2004) reports low overall HSV-2seroprevalence rates (10%) for Mexican-Americans(Xu et al., 2006). This figure contrasts with ourfindings for the Hispanic population in Miami, whichmay speak to the varied infection rates of herpessimplex among Latin-Americans of different origin(Da Rosa-Santos, Goncalves Da Silva, & Pereira,1996; Soto et al., 2007).There were significantly higher rates of HSV-2infection among females and again a trend toward theeldest age group (>35 years), with rates as high as,41.6% (OR 1.38, 95%CI 0.99-1.91) and 52.7% (OR2.67, 95%CI 1.92-3.71) respectively. Higher HSV-2rates among women have been previously describedin the literature and may be as a result of moreefficient transmission from male to female (Gottliebet al., 2002; Singh et al., 2005).There was no significant correlation observedfor HSV-1 or 2 with income or sexual orientation.Among those seropositive for Herpes, the rate of HIVco-infection was unremarkable. This is in contrast tothe high rates of co-infection found when looking atHIV positive groups (Celum et al., 2010).An important limitation of our study was theindividual patient’s compliance to pay for HSVserological testing. Moreover, the retrospectivedesign accounts only for what is recorded in the chartand some cultures may have been negative despitelesions due to HSV.Screening for herpes is generally notrecommended, however, the prevalence of HSV-1and 2 among STD clinics in Miami was not known.87.10% of patients infected with HSV-1 and 83.3%of those with HSV-2 had not known their serologicalstatus, nor were they ever given a clinical diagnosisof genital herpes. Screening high risk persons canprovide a diagnosis for those infected and unaware ofhaving herpes, and could potentially protectunexposed sexual partners. This knowledge andsubsequent education of infected persons, along with,an opportunity to consider suppressive therapy mayreduce transmission of herpes and possibly otherSTIs and HIV. ReferencesCelum, C., Wald, A., Lingappa, J.R., et al.(2010). Acyclovir and transmission of HIV-1 frompersons infected with HIV-1 and HSV-2. NewEngland Journal of Medicine, 362, 427-439.Da Rosa-Santos, O.L., Goncalves Da Silva, A.,& Pereira A.C. Jr. (1996). Herpes simplex virus type2 in Brazil: seroepidemiologic survey. InternationalJournal of Dermatology, 35, 794-796.Gottlieb, S.L., Douglas, J.M. Jr., Schmid, D.S.,Bolan, G., Latesta, M., et al. (2002). Seroprevalenceand correlates of herpes simplex virus type 2infection in five sexually transmitted–disease clinics.Journal of Infectious Diseases, 186, 1381-1389.Lingappa, J.R., Kahle, E., Mugo, N., et al.(2009). Characteristics of HIV-1 discordant couplesenrolled in a trial of HSV-2 suppression to reduceHIV-1 transmission: The partners study. PLoS ONE,4(4), e5272. doi:10.1371/journal.pone.0005272.Peña, K.C., Adelson, M.E., Mordechai, E., &Blaho, J.A. (2010). Genital herpes simplex virus type1 in women: Detection in cervicovaginal specimensfrom gynecological practices in the United States.Journal of Clinical Microbiology, 48, 150–153.Soto, R.J., Ghee, A.E., Nuñez, C.A., et al.(2007). Sentinel surveillance of sexually transmittedinfections/HIV and risk behaviors in vulnerablepopulations in 5 Central American countries. Journalof Acquired Immune Deficiency Syndrome, 46, 101–111.Samra, Z., Scherf, E., & Dan, M. (2003). Herpessimplex virus type 1 is the prevailing cause of genitalherpes in the Tel Aviv area, Israel. SexuallyTransmitted Diseases, 30, 794-796. Singh, A.E., Romanowski, B., Wong, T., et al.(2005). Herpes simplex virus seroprevalence and riskfactors in 2 Canadian sexually transmitted diseaseclinics. Sexually Transmitted Diseases, 32, 95-100.Xu, F., Sternberg, M.R., Kottiri, B.J. et al.(2006). Trends in herpes simplex virus type 1 andtype 2 seroprevalence in the United States. Journal ofthe American Medical Association, 296, 964-973 Maya Morrison-Bryant ([email protected]) iswith the Howard University College of Medicine,Division of Infectious Diseases, Washington, D.C., butwas with Jackson Memorial Hospital and theDepartment of Medicine, University of Miami, at thetime of this project; Maria Alcaide([email protected]) is with the Department ofMedicine, Division of Infectious Diseases, University ofMiami; Khaled Deeb ([email protected]) is withthe University of Miami Miller School of Medicine; andJose G. Castro ([email protected]) is with theUniversity of Miami Miller School of Medicine, all inMiami, Florida. This paper was submitted to the FPHRon January 20, 2011, and accepted for publication onFebruary 21, 2011. Copyright 2011 by the FloridaPublic Health Review. Florida Public Health Review, 2011; 8:10-14.http://health.usf.edu/publichealth/fphr/index.htm14