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Objective: To describe the prevalence of Herpes Simplex Virus-2 (HSV-2) infection among males in six major cities of Pakistan.
Methods: A cross sectional behavioural and biological survey of urban male population aged 16-45 years was conducted in Rawalpindi, Lahore, Karachi, Faisalabad, Peshawar and Quetta to measure the prevalence of five sexually transmitted infections and assess sexual behaviours. Conclusion: Empirical evidence from this study suggests that there is city wise variation in the prevalence of HSV-2 infection across the major cities in Pakistan.
Globally Herpes Simplex Virus Type-2 (HSV-2) is amongst the most common sexually transmitted infections.1 HSV-2 seroprevalence studies show variation in infection by geographic location. Till recently, we did not have either national or city wise prevalence estimates for HSV infection in Pakistan. The main component of the study was a cross-sectional behavioural and biological survey of 2400 men carried out in six major cities of Pakistan from June to August 2007. City selection was based on inclusion of the four provincial capitals of the country, Lahore, Peshawar, Quetta and Karachi as well as two other larger cities, Rawalpindi and Faisalabad. The structured survey questionnaire was developed taking into consideration existing questionnaires developed on this topic by previous studies such as Behavioural Surveillance Survey.8 Separate informed consent was obtained from the participants for conducting both the behavioural questionnaire and obtaining biological specimens. The entire study was approved by the Ethical Review Boards of the Population Council in New York, the London School of Hygiene and Tropical Medicine and HOPE (Health Oriented Preventive Education), a Pakistani research NGO which has its own ethical clearance board.
Of a total of 83 respondents, 12 were positive for HSV-2 infection and were also diagnosed with syphilis. In Table, the multivariate analysis shows that HSV-2 infection was significantly associated with age greater than 27 years (27 years was selected as the cut off since it was the median age of the respondents in the overall sample). According to Corey et al,14 more than 30 epidemiologic studies have demonstrated that prevalent HSV-2 is associated with a two to four fold increased risk of HIV-1 acquisition. The clear linkage between HSV-2 infection and HIV acquisition points to the need for the prompt diagnosis and early management of HSV-2 infections as an important strategy for combating the spread of the HIV infection.
An important aspect of HSV infection that raises a major public health challenge is the high proportion of infections that are unrecognized by both patients and clinicians. Many cases of genital herpes are transmitted by persons who are unaware that they are infected.
Based on the growing international evidence policy makers and programme managers should consider the prevalence of HSV-2 infection as a "canary in the mine" in predicting the emergence of a future HIV epidemic and the need to invest in HSV-2 surveillance programmes.
Future prevention intervention must therefore keep in mind targeting this specific group of older men, through focused IEC (Information, Education and Communication) and behaviour change strategies that reduce individual vulnerability by modifying sexual behaviours. To further enhance the effectiveness of prevention programmes, primary care providers should be trained to recognize, counsel and adequately manage STIs.
Currently, due to paucity of specific STI clinics in the public sector facilities, most men resort to traditional or private practitioners to manage their sexual health problems. The study of Sexually Transmitted Infections among urban male population in Pakistan: Identifying the Bridging Population was commissioned by the National AIDS Control Program, Government of Pakistan, with funding from the Department for International Development (DFID), United Kingdom.
9.Enzyme-linked immunosorbent assay (ELISA) for the qualitative detection of human IgG class antibodies to HSV-2.
This journal is a member of and subscribes to the principles of the Committee on Publication Ethics. Zovirax and Vectavir are two antiviral creams which can be bought over the counter in pharmacies to treat cold sores.
Abreva is an over the counter cream approved by the Food and Drug Administration for treating cold sores. Some people find applying Bach Rescue Remedy cream to cold sores helps prevent them from worsening. 3.A number of studies show you can reduce the frequency of cold sore attacks by taking vitamin C and the amino acid lysine on a daily basis. Please Note: Information provided on this site is no substitute for professional medical help. I agree to Shutterstock's Website Terms, Privacy Policy, Licensing Terms and to receive emails that I can opt out of at any time. All plans come as a Standard license, and can be upgraded to an Enhanced license at any time.
El uso de esta pagina web esta sujeto a nuestras Condiciones de uso y las compras a nuestras Condiciones de venta. This program is funded through Health Resources and Services Administration, US Department of Health and Human Services. Figure 1Figure 1 - Chronic Ulcerated Lesions on EarLateral view showing multiple ulcerated ear lesions.
Figure 2Figure 2 - Chronic Ulcerated Lesions on EarPosterior view showing multiple ulcerated ear lesions.
When performing a fluorescent antibody (FA) and culture for HSV, scraping the base of the lesion will provide a lower yield than obtaining exudative fluid.IncorrectBecause HSV is an intracellular virus, the yield of either fluorescent antibody (FA) or culture is significantly greater if a substantial number of cells are obtained when collecting the specimen. The most appropriate therapy for this lesion would be valganciclovir (Valcyte) 900 mg PO bid x 4 weeks.IncorrectValganciclovir (Valcyte) is an antiviral compound with excellent activity against cytomegalovirus and moderate activity against HSV.
The diagnosis of chronic (longer than 4 weeks) ulcerative herpes simplex is an AIDS-defining condition, regardless of CD4 cell count.CorrectThe Centers for Disease Control's case definition for Stage 3 (AIDS) includes HSV chronic ulcer(s) greater than 1 month's duration, regardless of the patient's CD4 cell count. Oral prednisone is recommended as adjunct therapy in patients with chronic ulcerative herpes simplex virus infection.IncorrectThere are no data that support the use of oral or topical corticosteroids as a component of managment of cutaneous herpes simplex virus infection.
Figure 1Figure 1 - Chronic Ulcerated HSV Lesions on FaceMultiple large ulcerated HSV lesions on face resembling impetigo.
Figure 2Figure 2 - Chronic Ulcerated HSV Lesions on ScrotumMultiple persistent small ulcerated HSV lesions on scrotum.
Although HIV-infected persons infected with HSV can develop an array of manifestations, most patients remain asymptomatic. A definitive diagnosis of HSV can be made by scraping a lesion with a Dacron swab and obtaining an FA and culture on the sample. In 2007 the Ministry of Health and the National Aids Control Program (NACP) commissioned a behavioural and biological study of urban male population that was implemented by the Population Council. Only male population were selected as they constitute the bridging population that is a conduit for the spread of sexually transmitted infections from high to low risk general population. A multistage sampling design was employed to select a total of 400 men aged 16-45 years in each city. Two data collection teams, each comprising a doctor, phlebotomist, lab technician and two social interviewers remained in the field for 45 days in each city.


Proportion of unmarried respondents was 47 percent of which 80 percent were employed and 14 percent were illiterate. Nine respondents who tested positive for HSV-2 reported as never having had sexual intercourse in their life times.
The presence of a concentrated epidemic in the high risk groups suggests the need for more targeted interventions at mitigating high risk behaviours including the acquisition of sexually transmitted infections.
Up to 70 percent of genital HSV infections are unrecognized.3 Asymptomatic infection plays a major role in maintaining viral circulation in society.
Results from this study also show the relationship between educational level and infection prevalence to be city specific.
Counseling will play an important role in preventing transmission to the partner and subsequent neonatal mortality. These practitioners mostly prescribe antibiotics which may cover bacterial infections, but they do not treat viral infections. Appropriate strategies for preventing acquisition and management of Sexually Transmitted Infections should be amongst the priorities for curtailing the future spread of an HIV epidemic in Pakistan.
Age-specific prevalence of infection with herpes simplex virus types 2 and 1: a global review. Human immunodeficiency virus infection and genital ulcer disease in South Africa: the herpetic connection. Trends in HIV-1 and HIV-2 prevalence and risk factors in pregnant women in Harare, Zimbabwe. HIV testing in national population-based surveys: experience from the Demographic and Health Surveys. Etiology of genital ulcers and prevalence of human immunodeficiency virus coinfection in 10 US cities. Sero-epidemiological and sociological patterns of herpes simplex virus infection in the world.
The epidemiology of herpes simplex virus type-2 infection among married women in Mysore, India.
The effects of herpes simplex virus-2 on HIV-1 acquisition and transmission: a review of two overlapping epidemics.
Seroepidemiological study of herpes simplex virus types 1 and 2 in Brazil, Estonia, India, Morocco, and Sri Lanka. Antibody to herpes simplex virus type 2 as a marker of sexual risk behavior in rural Tanzania. High seroprevalence of HSV-1 and HSV-2 in STD clinic attendees and non-high risk controls: A case control study at a referral hospital in South India.
These products do not kill the HSV virus but they may prevent it from multiplying and causing more blisters. To avoid spreading the virus, wash your hands with soap and water after touching cold sores or after applying creams. Everyone who signs up gets full access to our entire library, including our curated collections. Our Standard license allows you to use images for anything, except large print runs over 500,000+ or for merchandising. Once you have downloaded your image, you have life-long rights to use it under the terms of the license purchased. Direct HSV antigen testing with either FA, EIA, or PCR can provide rapid results (within 24 hours). Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. The presence of a chronic ulcerative HSV lesion does not necessarily indicate resistance to acyclovir.
Severe acquired immunodeficiency in male homosexuals, manifested by chronic perianal ulcerative herpes simplex lesions. 1993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults. Chronic erosive herpes simplex virus infection of the penis, a possible immune reconstitution disease.
Valaciclovir versus aciclovir for herpes simplex virus infection in HIV-infected individuals: two randomized trials. Famciclovir for the suppression of symptomatic and asymptomatic herpes simplex virus reactivation in HIV-infected persons.
Valacyclovir for the suppression of recurrent genital herpes in human immunodeficiency virus-infected subjects.
Roles of clinical and subclinical reactivated herpes simplex virus type 2 infection and human immunodeficiency virus type 1 (HIV-1)-induced immunosuppression on genital and plasma HIV-1 levels. Impact of suppressive herpes therapy on genital HIV-1 RNA among women taking antiretroviral therapy: a randomized controlled trial.
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. In each city 10 blocks demarcated by the Population Census Organization were selected based on probability proportional to socio-economic status. The two main objectives of this DFID-funded study were to estimate the prevalence of five commonly occurring STIs, including HIV, in six major cities of the country and to document sexual behaviours amongst urban male population. In the first stage 10 blocks demarcated by the Population Census Organization (that comprise 200-250 households) were selected in each city based on probability proportionate to socio-economic status using male and female literacy as a proxy indicator for economic status. Data analysis included descriptive statistics measuring frequencies, bi and multivariate analysis based on logistic regression models. In total 106 individual respondents were diagnosed with one of the five STIs, out of which 83 cases were diagnosed with HSV-2 infection.
Association was also observed between presence of HSV-2 infection and respondents having four or more non-marital sexual partners (either male or female) in the last 12 months [adjusted O.R.
Having multiple partners is statistically significantly associated with disease occurrence.
For instance, Rawalpindi with a high male literacy rate (82 percent) had the lowest prevalence of HSV-2.
To ensure adequate treatment, antibody specific tests for HSV-2 detection should be made available on an incremental basis at all tertiary level care facilities, at least at the district headquarter hospitals where functional laboratories are already present.


Mass awareness must be created in the general population to access services from trained providers who have the facilities to provide information, counseling, testing, and appropriate treatment. Rana Muzaffar, Head of Molecular Biology at Sindh Institute of Urology and Transplantation (SIUT), and her team, Dr. Also, while they have little effect on blisters that have already formed, they may stop them from getting worse. If at any time you're unsatisfied with your experience with us, you can cancel your subscription. Once a visible lesion appears, it can evolve through several stages that may include vesicles, ulcers, and crusts.
Because HSV is an intracellular virus, the diagnostic yield increases if the base of the lesion is scraped and an adequate number of cells are obtained.
The 2013 opportunistic infections guidelines does not address the management of moderately severe cutaneous lesions[1]; in this author's opinion, most of the moderately severe cutaneous lesions will respond well, albeit slowly, to oral therapy. This paper discusses results related to the prevalence of HSV-2 infection amongst males in the six major cities of Pakistan.
Within each block 40 individuals were selected from each household through systematic sampling with a random start. All specimens were transported to the laboratory of the Sindh Institute of Urology and Transplantation at Karachi. In this paper the multivariate analysis has looked at the association of the independent factors age, education, marital status, sex in the last three months and number of partners with the presence of HSV-2 infection. The results related to the prevalence of Genital Herpes (HSV-2) in the six major urban centres of the country are presented in Figure. With a concentrated HIV epidemic already manifest in the high risk groups, genital herpes may serve as a conduit for the spread of subsequent HIV infections into the general low risk population of women. On the other hand Karachi which is a metropolitan city with a large migrant population of unskilled workers and a lower male literacy level (72 percent) had the highest prevalence of all six cities. Furthermore health educational campaigns launched through health facilities should educate men about risk factors and the need for periodic testing in order to avoid complications that can occur in case they remain asymptomatic for long. Among HIV-infected persons who do not have severe immune suppression, the clinical presentation of orolabial and genital HSV is usually similar to that seen in persons not infected with HIV. Although most HSV lesions require only 5 to 14 days of therapy, treatment of moderate-to-severe chronic ulcerative HSV lesions usually requires at least 14 days and patients should have close follow-up.
In total 2400 men were administered a behavioural questionnaire and 2396 provided biological specimens for laboratory testing. Informed consent was obtained for both the interview and the sampling of biological specimens. Specimens were airlifted to Karachi taking special precautions during transportation that included maintaining the cold chain and avoidance of spillage and contamination of the specimens. On the other hand, occupation, income and marital status were not found to be significantly associated.
Future prevention programmes must, therefore, be cognizant of and adapt as needed, to city differentials. Encouraging a healthy lifestyle by providing youth with life skills education within schools can be an effective approach in reaching out to young men. A cold sore is caused by a virus (herpes simplex, HSV-1) which is closely related to the virus that causes genital herpes (HSV-2).
Patients with advanced immunosuppression, however, can develop chronic, extensive, deep ulcerated lesions. In general, these patient should receive therapy for HSV until the lesions have completely healed.[10] If the patient has received multiple courses of therapy for recurrent HSV infection, or is taking chronic HSV suppressive therapy when new lesions develop, greater consideration should be given to possible acyclovir-resistant HSV. Special containers were provided by Sind Institute of Urology and Transplantation for this purpose. Without treatment 70 percent of neonates with disseminated infections are unable to survive19 and half of the survivors develop neurological conditions. The empirical evidence from the literature has shown a higher seroprevalence of HSV-2 among females as compared to males.21-23 This argues for the inclusion of women in the overall STI prevention strategy. The information must include messages that conform to our religious and societal norms and emphasize behaviours such as abstinence and marital fidelity along with explanations of the modes of transmission and associated morbidities of sexually transmitted infections.
Antivirals also come in pill form (Valtrex and Famvir) and it is thought that these are more effective. These chronic ulcerative lesions can appear anywhere on the body (Figure 1) and (Figure 2) and (Figure 3). Evaluation and treatment of acyclovir-resistant HSV infection is discussed Case 2 in this Dermatologic Manifestations Module.
The overall refusal rate was 37 percent well within the range of other surveys comprising male population.7,8 The sample size calculations were based on a conservative expected 7 percent prevalence of any tested STI (chlamydia, gonorrhea, or syphilis). Several reports have described patients who developed atypical ulcerative genital HSV lesions after starting highly active antiretroviral therapy, presumably caused by immune reconstitution[2,7]; these lesions may be difficult to treat, despite the absence of acyclovir resistance. Recent studies have shown that HSV PCR of genital lesions has a significantly greater sensitivity than viral culture.[2] The use of a Tzanck preparation to detect cytologic changes consistent with a herpes virus infection provides low sensitivity and specificity and thus is not recommended. Expected compliance for the biological data collection was 70 percent, based on the pretest results. The design effect (which takes into account the increase in standard errors due to clustering) was set at 2.0.
This test qualitatively detects the presence or absence of human lgG class antibodies to HSV-2 in human sera.
The focus diagnostics ELISA uses purified recombinant type specific IgG-2 antigen immobilized on polystyrene microwells.
The proposed sample size was also justified in terms of its power to detect behavioural change with statistical confidence.



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