The epidemiology of herpes simplex virus type-2 infection among married women in Mysore, India.

HERPES SIMPLEX VIRUS TYPE-2 (HSV-2) is one of the most common sexually transmitted diseases in the world.1 Although the prevalence of HSV-2 infection varies widely by country and population subgroup,2 generally higher rates are found in developing countries where the prevalence in adults can reach 50%.3 Although data are sparse for India, studies have shown HSV-2 seroprevalences among sexually transmitted diseases clinic attendees4,5 ranging from 43% to 83%, and lower prevalences in population-based cross-sectional studies,6–8 from 7.9% to 14.6%. There is growing evidence that HSV-2 infection, in addition to being a significant source of morbidity, is a risk factor for human immunodeficiency virus (HIV) acquisition and transmission.9 One study showed a 3-fold increased risk for HIV infection among individuals with recent seroconversion to HSV-2.4 This raises the possibility that HSV-2 infection may be a key determinant of HIV incidence rates in populations, and that HSV-2 detection and management of herpes infections may offer a prevention strategy for HIV. Cross-sectional analyses were conducted of baseline findings of a prospective cohort study of young married women that examined the relationship of lower genital tract infection to acquisition of HSV-2 infection. Study participants were recruited between November 2005 and March 2006. Potential participants were approached in 2 ways: in the obstetrics gynecology outpatient clinic at CSI Holdsworth Memorial Hospital (HMH), and through outreach in the community where women were invited to the study site for screening. To be included in the study, participants were between 15 and 30 years of age, sexually active, post defined as having had vaginal intercourse at least once in the 3 months, willing to undergo pelvic examination, and planning to stay in the area for 6 months. The study was approved by the Ethical Review Board at the University of California, Berkeley, and Asha Kirana Hospital. Epidemiologic data were collected in Kannada from all eligible participants who gave written informed consent. After completion of the interview, participants underwent a clinical examination and laboratory evaluation for reproductive tract infections (RTI). Diagnostic testing was completed at HMH and Vikram Hospital, Mysore. A type-specific ELISA test was used to detect HSV-2 antibodies (Focus Technologies, Cypress, CA). Manufacturer’s instructions were followed using an index value of 1.1 as positive HSV-2 specimen. Gram stained vaginal smears were independently assessed for bacterial vaginosis (BV) with Nugent score10 by 2 trained study personnel. Vaginal swabs were cultured for Trichomonas vaginalis (TV) (InPouch, Biomed Diagnostic, OR); and for candida species (BioMed Diagnostics, OR). Endocervical swabs were cultured for Neisseria gonorrhoeae (GC) (BioMed Diagnostics, OR). Validation of HSV testing was performed using a masked panel of serum specimens from the University of California, San Francisco. Results yielded 100% agreement. The first 300 sera were run in duplicate for reproducibility of test results. The GC culture system was validated for growth of GC with 3 ATCC strains (49226, 31426, and 19424). There was independent verification of 10% of tests for T. vaginalis and candida by an independent microbiologist, whose results matched the study findings. The primary study outcome was seropositivity for HSV-2 antibodies, analyzed as a binomial variable. Univariate associations of baseline characteristics with HSV-2 seroprevalence were made using Pearson 2 test or Fisher exact method. Variables with P values 0.1 were considered for inclusion in a multivariable logistic regression model. Stata 9.0 (Stata Corporation, TX) was used for statistical analysis. For their generous assistance on this project, the authors thank the Director of Asha Kirana Hospital, Mothi Sarvode; Director of CSI Holdsworth Memorial Hospital, S.C. Karat; Director of Chitra’s Hospital, Mahesh Kumar. Special thanks to Anne Ericson, VHT Swamy, Renuka BS, Gururaj KS, Muralidhar Singh for assisting on the project; and Srinivas Ghante, and Dr. Parthasarathy from Asha Kirana Hospital, Dr. Srikanth from St. Johns Medical College, Jeanne Moncada from UCSF for providing technical support and helpful suggestions. Biomed Diagnostics and Cipla for their generous donations. The study was supported by the Fogarty AIDS International Training and Research Program (Grant 1-D43-TW00003-16). BioMed Diagnostics (White City, OR) donated Trichomonas vaginalis, Neisseria gonorrhoeae, and yeast growth medium for the study. Cipla (Mumbai, India) donated oral Acyclovir. The Fogarty AIDS International Training and Research Program had no role in the study design, conduct, collection, management, analysis, or interpretation of the data, or preparation, review, or approval of the manuscript. Neither companies (BioMed Diagnostics and Cipla) provided monetary funding for the study or had any role in the conduct, collection, management, analysis, or interpretation of the data, or preparation, review, or approval of the manuscript. Correspondence: Purnima Madhivanan, PhD Candidate, Division of Epidemiology, School of Public Health, University of California, Berkeley, 140 Warren Hall, Berkeley 94720-7360. E-mail: [email protected]. Received for publication April 17, 2007, and accepted April 23, 2007. From the *Division of Epidemiology, School of Public Health, University of California, Berkeley; †Asha Kirana Hospital; ‡CSI Holdsworth Memorial Hospital; §Vikram Hospital, Mysore, India; and Department of Medicine, University of California, San Francisco, California Sexually Transmitted Diseases, November 2007, Vol. 34, No. 11, p.000–000 DOI: 10.1097/OLQ.0b013e3180ca965a Copyright © 2007, American Sexually Transmitted Diseases Association All rights reserved.