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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. Expression of concern regarding paper by Park et al, published on 25 June 2015: “Epidemiological investigation of MERS-CoV spread in a single hospital in South Korea, May to June 2015”, Euro Surveill.
It has been brought to our attention that some of the authors may not have been informed about the content of the above paper. Citation style for this article: Hill C, McKinney E, Lowndes CM, Munro H, Murphy G, Parry JV, Gill ON, the GUM Anon Network.
The objective was to investigate herpes simplex virus (HSV) epidemiology amongst HIV-positive and HIV-negative men who have sex with men (MSM) in England and Wales. Samples were drawn from the National Unlinked Anonymous Survey of Genito-Urinary Medicine Clinic Attendees (GUM Anon) [16] serum archive, which includes unlinked anonymous residual blood specimens collected for routine syphilis serology at representative sentinel sexual health clinics across England and Wales.
The study included a randomised age-stratified sample of 3,968 specimens from a total of 8,463 specimens obtained from MSM attending twelve sentinel sexual health clinics (seven in London and five elsewhere across England and Wales) during 2003. The legal and ethical basis for unlinked anonymous HIV testing was established before the programme began and is consistent with the Human Tissue Act 2004 and other guidelines [24].
Sixteen percent (CI: 15%-17%) of the study population were HIV-positive according to unlinked anonymous HIV antibody testing.
The prevalence of HSV-2 in this study is similar or lower than those found amongst HIV-positive and HIV-negative MSM in studies elsewhere in Europe, the Americas and Australia [8]. This study also showed that seven in 10 MSM were HSV-1-positive, a rate similar to that found in other high-risk groups in Europe [8].
We thank the clinical and lab staff who collaborate in the GUM Anon survey (institutions listed below). Disclaimer: The opinions expressed by authors contributing to Eurosurveillance do not necessarily reflect the opinions of the European Centre for Disease Prevention and Control (ECDC) or the editorial team or the institutions with which the authors are affiliated. Genital HSV is the most common sexually transmitted infection (STI) in both men and women, but as many as 90% don’t know they are infected because their symptoms are too mild to notice or mistaken for another condition. Symptomatic genital herpes is characterized by a burning and itching sensation in the genitals, followed by blistering. HSV skin lesions usually appears as small blisters or sores around the mouth, nose, genitals, buttocks, and lower back, though infections can develop almost anywhere on the skin.
This photo shows HSV-1 lesions on the buttock of a five-year-old girl — also called sacral herpes simplex. Herpetic whitlow is an intensely painful infection of the hand involving 1 or more fingers that typically affects the terminal phalanx.
Serologic testing for HSV has limited value in acute clinical diagnosis because of the time delay for seroconversion following initial infection.
Acyclovir, valacyclovir and famciclovir are the most commonly used agents for treating HSV infections. A wide disparity exists between the public and medical community regarding the significance of herpes infections. The majority of recurrent oral herpes cases are caused by herpes simplex virus type 1 (HSV-1) and the majority of genital herpes cases are caused by HSV-2. Differentiating between the two types of infection using either type specific swab testing, preferably PCR, or type specific IgG antibody testing, is very important because HSV-1 genitally recurs less, is shed less, and presents far less risk of transmission to others than HSV-2.
Fifty seven percent of Americans between 14 and 49 have HSV-1, and 16% of the same group has HSV-2 infection. 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. Unlinked anonymous sera from 3,968 MSM attending 12 sexual health clinics in 2003 were tested for HIV, HSV-2 and HSV-1 antibodies.
In the UK as elsewhere in Western Europe, there are high rates of sexually transmitted infections (STI) (other than HSV) amongst MSM, particularly HIV-positive MSM [12,13], and there have been increasing diagnoses of anogenital herpes reported by sexual health clinics [9]. For each serum limited information was available, including prevention group, prior knowledge of HIV status and diagnoses received at the visit. All sera were tested for HSV-2 and HSV-1 antibodies using a pair of enzyme immunoassays that distinguish the type-specific antibody response against HSV-2 and HSV-1 [20]. Approval was received from local ethics committees covering each site where the GUM Anon survey was underway.
This is of concern, given the increasing evidence for the role of HSV-2 in HIV progression, onward transmission and acquisition [1-3]. This is consistent with the global epidemiology: whilst there is considerable variation in HSV-2 prevalence worldwide, in general, HSV-2 prevalence is lower in Europe than in Africa and the Americas [8,11].
The role of anti-HSV therapeutics in the HIV-infected host and in controlling the HIV epidemic. Herpes simplex virus 2 infection increases HIV acquisition in men and women: systematic review and meta-analysis of longitudinal studies. Sexually transmitted infections in Western Europe among HIV-positive men who have sex with men.
Genital herpes serotesting: a study of the epidemiology and patients' knowledge and attitude among STD clinic attenders in Coventry, UK. Antibody to herpes simplex virus type 2 as serological marker of sexual lifestyle in populations.
The public health applications of unlinked anonymous seroprevalence monitoring for HIV in the United Kingdom.
GACPAT HIV 1 + 2: a simple, inexpensive assay to screen for, and discriminate between, anti-HIV 1 and anti-HIV 2. HIV incidence appears constant in men who have sex with men despite widespread use of effective antiretroviral therapy.
Monoclonal antibody blocking tests for the detection of HSV-1- and HSV-2-specific humoral responses: comparison with western blot assay. Performance of Commercially Available Enzyme Immunoassays for Detection of Antibodies against Herpes Simplex Virus Type 2 in African Populations. A monoclonal blocking EIA for herpes simplex virus type 2 antibody: validation for seroepidemiological studies in Africa. Human tissue and biological samples for use in research: Operational and ethical guidelines. Clinical efficacy of high-dose acyclovir in patients with human immunodeficiency virus infection: a meta-analysis of randomized individual patient data.
Neither ECDC nor any person acting on behalf of ECDC is responsible for the use that might be made of the information in this journal. In women who contract the disease, the cervix is infected 80% to 90% of the time during primary infection. This photo shows a close-up of lesions on the upper eyelid in a 20-year-old male patient due to HSV-1.
Of patients who develop seropositivity, 65% do so within six weeks, while approximately 20% do not make antibodies for six months. While all three drugs decrease the duration and severity of illness and viral shedding, they have no effect on nonreplicating viruses, nor do they eliminate the virus from the ganglia. Although treatment options exist, respondents in one survey considered contracting herpes as worse than breaking up with a significant other, getting fired from a job, or failing a course in school. HSV infection is a persistent and chronic infection of the sensory ganglia with a varying, unpredictable degree of skin expression.
Please try searching for the product or category you are seeking or contact us for assistance. 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. For HIV-negative individuals, HSV-2 infection increases the risk of HIV acquisition more than two-fold [1,3,5,6], although trials to date have failed to show an impact of HSV medication on HIV acquisition [1-3].
However, information on the prevalence of HSV amongst HIV-positive and HIV-negative MSM in the UK is not available: the infection is primarily asymptomatic or unrecognised and serological screening is not routinely performed [3,5].
They utilise type-specific murine monoclonal antibodies whose binding to the homologous HSV antigen is blocked when the specimen under test also contains the homologous antibody type.
Among HIV-positive individuals, the association of HSV-2 and HSV-1 serostatus with knowledge of HIV serostatus, recently acquired HIV infection (derived through STARHS) and other characteristics was investigated. The prevalence rates may be an underestimate of current rates amongst MSM attending sexual health clinics, as the annual number of ano-genital herpes diagnoses in sexual health clinics and the prevalence of HIV and other STI have increased since 2003 [9]. In our study, the prevalence of HSV-2 amongst MSM born in sub-Saharan Africa was not different to that amongst UK-born MSM, even after adjusting for age and other factors. Unfortunately, no culture or PCR result was available from the genital ulcers to determine the type causing the presenting ano-genital disease. Primary infections can range from subclinical to severe, with fever, headache, malaise, anorexia, pain, lymphadenopathy and edema. Clinical recurrence occurs on average 3 to 4 times a year, but some patients experience monthly outbreaks.
Cervical infection alone is rarely symptomatic, but because the cervix is not sensitive to pain, infection may pass unnoticed.
Be sure to provide adequate counseling to help patients put their diagnosis in perspective.
This slideshow will highlight variations in presentation and provide more information about diagnosis and treatment. 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. The impact of HSV-1 on HIV is less researched, possibly as it causes genital herpes with less severe symptoms and less frequent recurrences [7] and because it is primarily acquired orally early on in childhood in most countries with a high HIV incidence [7,8]. Specimens that inhibit the binding of the monoclonal antibody by ≥50% are considered to be positive for that HSV type-specific antibody.
Additional information such as ethnicity and sexual behaviour would be needed to understand how MSM born in sub-Saharan Africa attending sexual health clinics in England and Wales differ from the overall population in their region of birth.
Most of those diagnosed with a first attack of ano-genital herpes who were HSV-1 seropositive only may have been infected with HSV-2 as well but had not yet seroconverted.
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.
It is of concern that one in two HIV-positive MSM and one in six HIV-negative MSM may be infected with HSV-2, given increasing evidence of its impact on HIV progression, onward transmission and acquisition. However, 50% of diagnoses of first attacks of ano-genital herpes amongst MSM in the United Kingdom (UK) are now caused by HSV-1 [5,7,9,10].
Sera from individuals with a previously undiagnosed HIV infection were further examined by the Serological Testing Algorithm for Recent HIV Seroconversion (STARHS) using the ‘detuned’ Vironostika HIV-1 microelisa test (bioMerieux). Except where otherwise stated, all manuscripts published after 1 January 2016 will be published under the Creative Commons Attribution (CC BY) licence.
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. To date results have been disappointing from trials aimed at reducing HIV onward transmission and HIV acquisition using HSV antiviral medication.
The mean time since seroconversion for sera testing positive for recently acquired HIV infection by the detuned test is six months [19]. You are free to share and adapt the material, but you must give appropriate credit, provide a link to the licence, and indicate if changes were made.
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).
However, recent research in an African context demonstrates the efficacy of HSV antivirals in delaying HIV progression.
Expected compliance for the biological data collection was 70 percent, based on the pretest results.
The high prevalence of HSV-2 amongst HIV-positive MSM suggests that an increased focus on HSV control in the management of HIV amongst MSM in the United Kingdom (UK) may be warranted. 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.
Given this and existing research on the high prevalence of genitally acquired HSV-1 amongst MSM in the UK, further research is also warranted into the role of HSV-1 in the HIV epidemic in this context. 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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