JAIDS Journal of Acquired Immune Deficiency Syndromes:
Brief Report: Epidemiology and Social Science
Longitudinal Assessment of HIV-1 and HSV-2 Shedding in the Genital Tract of West African Women
Nagot, Nicolas MD, MSc*†; Foulongne, Vincent PhD‡; Becquart, Pierre PhD‡; Mayaud, Philippe MD, MSc†; Konate, Issouf MD*; Ouedraogo, Abdoulaye MD*; Defer, Marie-Christine PhD*; Weiss, Helen PhD†; Van de Perre, Philippe MD, PhD‡; Segondy, Michel PhD‡
From the *Centre Muraz, Bobo Dioulasso, Burkina Faso; †London School of Hygiene and Tropical Medicine, London, UK; and ‡Laboratory of Virology, Montpellier University Hospital and UMR145 (University of Montpellier and Institut de Recherche pour le Développement), Montpellier, France.
Received for publication August 12, 2004; accepted December 6, 2004.
Supported by a grant from the Agence Nationale de Recherche sur le Sida (ANRS), France (grant #ANRS 1285), and by the Knowledge Programme on HIV/AIDS & STI of the London School of Hygiene & Tropical Medicine, funded by the Department for International Development (DFID) of the UK Government.
Reprints: Michel Segondy, Laboratory of Virology, Saint-Eloi Hospital, 34295 Montpellier Cedex 05, France (e-mail: firstname.lastname@example.org).
Forty-two HSV-2-seropositive women, of whom 22 were HIV-1 seropositive, were followed up weekly for 3 weeks for assessment of HIV-1 and HSV-2 genital shedding in Bobo Dioulasso, Burkina Faso. HSV-2 DNA and HIV-1 RNA were quantitated in cervicovaginal lavages enriched with a cervical swabbing (eCVL) using real-time polymerase chain reaction. HIV-1 RNA shedding was detected in eCVL from 19 of 22 (86.4%) of the HIV-1-seropositive women and HSV-2 DNA was detected in eCVL from 12 of 42 (28.6%) of the women. Compared with the HIV-1-seronegative women, the HIV-1-seropositive women showed more persistent HSV-2 genital shedding and higher HSV-2 DNA loads in eCVL. This study showed that eCVL is a reliable sampling method for detecting both viruses. Three measurement points (at weekly intervals in this study) seem to adequately allow detection of most HIV-1 or HSV-2 genital shedders.
There is strong evidence that herpes simplex virus type 2 (HSV-2) enhances HIV-1 sexual transmission.1-5 In countries where both HIV-1 and HSV-2 are frequently cocirculating, HSV-2 suppression by antiviral drugs has been proposed as a potential intervention to reduce HIV-1 transmission.6 Randomized controlled trials to demonstrate the efficacy of such interventions should also include measurements of HIV-1 and HSV-2 genital shedding as trial endpoints. However, there is little current consensus as to how this should best be done. The aim of the present research was to prospectively study HIV-1 and HSV-2 shedding in the genital tract of women in Bobo Dioulasso, Burkina Faso, to assess a new sample collection method, and to estimate the optimal frequency of HIV-1 and HSV-2 shedding measurement to be used in subsequent intervention trials.
POPULATION AND METHODS
Forty-two volunteers from a cohort of female sex workers were selected for this pilot observational study. The study was approved by the Institutional Review Board of Centre Muraz, Bobo-Dioulasso, the Ethical Committee of the Ministry of Health of Burkina Faso, and the Research Ethics Committee of the London School of Hygiene and Tropical Medicine. All participants provided informed signed consent. All women (median age, 34 years; range, 23-45 years) were HSV-2 seropositive and 22 were also seropositive for HIV-1. None of these women were taking any antiretroviral treatment, although 4 (18%) were in World Health Organization AIDS stages III/IV, nor HSV-specific treatment, as these were not available in Burkina Faso at the time of the survey. Few women (4/42, 9.5%) were taking oral or injectable contraceptives. Study participants were seen weekly for 3 weeks, and genital samples were collected for a total of 4 time points. A cervicovaginal lavage (CVL) was performed using 2-mL physiological saline for 60 seconds and collected into a cryotube. A polyester swab was applied to the cervical os and rotated 360°, avoiding any mucosal trauma, then stirred in the CVL cryotube and fluid expressed on the tube walls, thereby creating an “enriched” CVL (eCVL), which was immediately dispensed into 0.5-mL aliquots and frozen at −80°C.
HSV DNA was extracted from 200 μL of eCVL fluid using the QIAamp DNA minikit (Qiagen, Courtaboeuf, France), then eluted in 100 μL buffer. HSV subtyping was based on real-time polymerase chain reaction (PCR) using the LightCycler technology (Roche Diagnostics, Meylan, France) with differentiation of HSV-1 and HSV-2 by melting curve analysis as previously described.7 HSV-2 DNA was amplified from 5 μL of eluate by TaqMan (Applied Biosystems, Courtaboeuf, France) real-time PCR using the ABI Prism 7000 Sequence Detection Systems (Applied Biosystems, Courtaboeuf, France). Primers were HSV Pol F and HSV Pol A7 and the probe was (6-FAM)_5′-CCAAGAAAAAGTACATCGGCGTCATCGCGG-3′_(TAMRA). PCR consisted of 45 cycles and HSV-2 DNA was quantitated by reference to a standard curve.
HIV-1 RNA was extracted from 200 μL of eCVL fluid using the QIAamp viral RNA minikit (Qiagen) and a 20-μL aliquot from the 60-μL elution fluid was used for amplification using the same equipment as for HSV-2 DNA. Primers were NEC 152: 5′-GCCTCAATAAAGCTTGCCTTGA-3′ (forward) and NEC 131: 5′-GGCGCCACTGCTAGAGATTTT-3′ (reverse), and the probe was 6-FAM_5′-AAGTAGTGTGTGCCCGTCTGTTRTKTGACT-3′_TAMRA. The target sequence was located within the 5′ long terminal repeat of HIV-1. PCR consisted of 50 cycles and HIV-1 RNA was quantitated using an external standard provided by the Agence Nationale de Recherche sur le SIDA (ANRS). Detection of sperm traces was based on Y-chromosomal Short Tandem Repeat (STR) identification by PCR as described,8 and presence of blood in the eCVL was ascertained visually by a physician and a laboratory technician, independently. A sample was considered to be contaminated by blood on agreement of these 2 persons. Concurrent genital infections were tested: cultures were done on specific media to detect Neisseria gonorrhoeae and Candida albicans, while Trichomonas vaginalis and bacterial vaginosis were diagnosed using immediate wet mount microscopy and Nugent score of a Gram-stained smear,9 respectively. Active or recent syphilis was defined as dual seroreactivity to Rapid Plasma Reagin (Human Gmbh, Wiesbaden, Germany) and Treponema pallidum hemagglutination assay tests (Newmarket Laboratory, Ltd., Kentford, UK). Molecular diagnosis of Chlamydia trachomatis infection was not available at the time of the study but this infection had been shown to be rare (<2%) by PCR in our study population.10 CD4 lymphocyte counts were measured from plasma samples using a standard flow cytometric method.
Binary variables among women were compared using the χ2 test and Fisher exact test where appropriate. For analyses involving all specimens, adjustments for nonindependence of samples within each woman were allowed for, using robust standard errors.
HIV-1 RNA was detected at least once in eCVL from 19 of 22 (86.4%) of the HIV-1-seropositive women. The proportion of HIV-1 RNA shedders at each of the 4 time points was 17/22 (77%), 16/22 (73%), 14/22 (64%), and 12/20 (60%), respectively (P = 0.60 for difference between time points). The average proportion of women shedding at any given time was 68.4%. Cumulative prevalence of HIV-1 shedding was calculated as the average proportion of HIV-1-seropositive women who shed any time over several measurement points, and this was 80.6, 87.1, and 90.0% over any 2, 3, and 4 time points, respectively. Among HIV-1 shedders, 10 of 19 women (53%) shed HIV-1 at each of the 4 time points, but 6 of 19 women (32%) shed at only 1 or 2 time points. The median level of HIV-1 RNA in eCVL among shedders was 3.01 log copies/mL (interquartile range, 2.15-3.89 log copies/mL).
HSV-2 DNA was detected at least once in eCVL from 12 of 42 women (28.6%). The proportion of HSV-2 DNA shedders at each of the 4 time points was 7 of 42 (17%), 5 of 41 (12%), 6 of 42 (14%), and 6 of 37 (16%), respectively (P = 0.93 for difference between time points). The average proportion of women shedding at any given time was 14.8%. The cumulative prevalences of women who shed any time over 2, 3, and 4 time points were 23.2, 27.9, and 32.4%, respectively.
As shown in Table 1, the proportion of women who shed HSV-2 at any time during follow-up was not statistically different between HIV-1-seropositive and seronegative women (32 vs. 25%, P = 0.74). However, there was evidence that HSV-2 genital shedding was more persistent among HIV-1-seropositive women. Indeed, 5 of 22 (23%) of the HIV-1-seropositive women shed on 3 episodes, compared with none of the 20 HIV-1-seronegative women (P = 0.05). The highest HSV-2 DNA loads in eCVL were observed in the HIV-1-seropositive women. Among 21 HIV-1-seropositive women with available CD4 cell measurements (median, 420 cells/μL), 5 had counts <200 cells/μL. HSV-2 shedding at any time point was significantly more common among women with CD4 counts <200 cells/μL (4/5 or 80% vs. 3/16 or 19%; P = 0.03).
Ten women (16 samples) had detectable Y-PCR and 7 women (10 samples) had blood contamination at ≥1 visits (Table 1). HIV-1 or HSV-2 shedding results were similar when data from the 16 Y-PCR-positive or the 10 blood-contaminated samples were excluded (data not shown). No gonococcal infection or syphilis cases were found at baseline and during follow-up. The baseline prevalences of C. albicans, T. vaginalis, and bacterial vaginosis were 23.8, 11.9, and 4.7%, respectively.
This pilot study focused on a limited number of participants. However, to our knowledge, it represents the first study assessing longitudinal shedding of HIV-1 and HSV-2 in the female genital tract in Africa. The point prevalence of HIV-1 and HSV-2 shedding as well as the levels of HIV-1 RNA and HSV-2 DNA were in agreement with previous studies.11-14 The higher frequency and quantity of HSV shedding among HIV-1-seropositive women have been reported elsewhere in Africa,15,16 but, importantly, this study highlighted the need for repeated sampling to identify women with intermittent viral shedding as reported elsewhere.11 Three measurement points (at weekly intervals in this study) seem to adequately allow detection of most HIV-1 or HSV-2 genital shedders.
Sample collection for detecting HIV-1 or HSV-2 genital shedding in women has been based mainly on the use of CVL or cervical swabbing. Both sampling modalities have been directly compared in only a few studies. Good correlation was observed for HIV-1 genital shedding in Central African Republic,13 while discrepant results were observed in a Kenyan study.12 In general, studies have shown that cervical swabbing would be a more adequate sample than CVL for detecting HIV-1 genital shedding, whereas CVL would be more adequate than swabbing for detecting HSV-2 shedding.12,14 The 2 sample collection modalities have therefore been combined in the present study. Shedding rates and frequencies for both viruses were within expected values. This probably indicates that combining CVL and cervical swabbing (eCVL) is suitable for assessing genital shedding of HIV-1 and HSV-2 on a single sample. Our findings might be useful for the design of HSV-2 intervention trials with HIV-1 and HSV-2 genital shedding as trial outcomes.
The authors thank staff at the Service d'Hygiene clinic and at the laboratories of Centre Muraz in Bobo-Dioulasso and the volunteers who participated in this study.
1. Keet IP, Lee FK, van Griensven GJ, et al. Herpes simplex virus type 2 and other genital ulcerative infections as a risk factor for HIV-1 acquisition. Genitourin Med. 1990;66:330-333.
2. Auvert B, Buve A, Ferry B, et al. Ecological and individual level analysis of risk factors for HIV infection in four urban populations in sub-Saharan Africa with different levels of HIV infection. AIDS. 2001;15(Suppl 4):S15-S30.
3. del Mar Pujades Rodriguez M, Obasi A, Mosha F, et al. Herpes simplex virus type 2 infection increases HIV incidence: a prospective study in rural Tanzania. AIDS. 2002;16:451-462.
4. Reynolds SJ, Risbud AR, Shepherd ME, et al. Recent herpes simplex virus type 2 infection and the risk of human immunodeficiency virus type 1 acquisition in India. J Infect Dis. 2003;187:1513-1521.
5. Wald A, Link K. Risk of human immunodeficiency virus infection in herpes simplex virus type-2 seropositive persons: a meta analysis. J Infect Dis. 2002;185:45-52.
6. Wald A, Corey L. How does Herpes simplex virus type 2 influence human immunodeficiency virus infection and pathogenesis? J Infect Dis. 2003;187:1509-1512.
7. Burrows J, Nitsche A, Bayly B, et al. Detection and subtyping of Herpes simplex virus in clinical samples by LightCycler PCR, enzyme immunoassay and cell culture. BMC Microbiol. 2002;2:12. Epub June 9, 2002.
8. Chomont N, Gresenguet G, Hocini H, et al. Polymerase chain reaction for Y chromosome to detect semen in cervicovaginal fluid: a prerequisite to assess HIV-specific vaginal immunity and HIV genital shedding. AIDS. 2001;15:801-802.
9. Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation. J Clin Microbiol. 1991;29:297-301.
10. Nagot N, Ouedraogo A, Ouangre A, et al. Is STI management among sex workers still able to mitigate the spread of HIV infection in West Africa? J Acquir Immune Defic Syndr. In press.
11. Coombs RW, Wright DJ, Reichelderfer PS, et al. Variation of human immunodeficiency virus type 1 viral RNA levels in the female genital tract: implications for applying measurements to individual women. J Infect Dis. 2001;184:1187-1191.
12. John GC, Sheppard H, Mbori-Ngacha D, et al. Comparison of techniques for HIV-1 RNA detection and quantification in cervicovaginal secretions. J Acquir Immune Defic Syndr. 2001;26:170-175.
13. Andréoletti L, Grésenguet G, Chomont N, et al. Comparison of washing and swabbing procedures for collecting genital fluids to assess shedding of human immunodeficiency virus type 1 (HIV-1) RNA in asymptomatic HIV-1-infected women. J Clin Microbiol. 2003;41:449-452.
14. Ndjoyi-Mbiguino A, Ozouaki F, Legoff J, et al. Comparison of washing and swabbing procedures for collecting genital fluids to assess cervicovaginal shedding of herpes simplex virus type 2 DNA. J Clin Microbiol. 2003;41:2662-2664.
15. Mbopi-Keou F-X, Grésenguet G, Mayaud P, et al. Interactions between herpes simplex virus type-2 and HIV-1 infection in African women: opportunities for intervention. J Infect Dis. 2000;182:1090-1096.
16. McClelland RS, Wang CC, Overbaugh J, et al. Association between cervical shedding of herpes simplex virus and HIV-1. AIDS. 2002;16:2425-2430.
This article has been cited 17 time(s).
Plos OneEffect of Genital Herpes on Cervicovaginal HIV Shedding in Women Co-Infected with HIV AND HSV-2 in TanzaniaPlos One
Plos OneHIV-DNA in the Genital Tract of Women on Long-Term Effective Therapy Is Associated to Residual Viremia and Previous AIDS-Defining IllnessesPlos One
New England Journal of Medicine
Reduction of HIV-1 RNA levels with therapy to suppress herpes simplex virus
New England Journal of Medicine, 356(8):
Tropical Medicine & International HealthDesign of epidemiological studies measuring genital and plasma HIV-1 outcomes: lessons from a randomised controlled trialTropical Medicine & International Health
Sexually Transmitted InfectionsUse of the designation "shedder'' in mucosal detection of herpes simplex virus DNA involving repeated samplingSexually Transmitted Infections
Sexually Transmitted InfectionsInterim modelling analysis to validate reported increases in condom use and assess HIV infections averted among female sex workers and clients in southern India following a targeted HIV prevention programmeSexually Transmitted Infections
Impact of suppressive herpes therapy on genital HIV-1 RNA among women taking antiretroviral therapy: a randomized controlled trial
Journal of Infectious DiseasesRoles 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 levelsJournal of Infectious Diseases
Cervicovaginal HIV-1 and herpes simplex virus type 2 shedding during genital ulcer disease episodes
Journal of Infectious DiseasesHerpes simplex virus type 2 infection does not influence viral dynamics during early HIV-1 infectionJournal of Infectious Diseases
Human ReproductionThe levonorgestrel-releasing intrauterine system (LNG-IUS) in HIV-infected women - effects on bleeding patterns, ovarian function and genital shedding of HIVHuman Reproduction
Sexually Transmitted InfectionsLongitudinal effect following initiation of highly active antiretroviral therapy on plasma and cervico-vaginal HIV-1 RNA among women in Burkina FasoSexually Transmitted Infections
Expert Review of Molecular DiagnosticsIn-house HIV-1 RNA real-time RT-PCR assays: principle, available tests and usefulness in developing countriesExpert Review of Molecular Diagnostics
HIV/AIDS epidemiology, pathogenesis, prevention, and treatment
Sexually Transmitted InfectionsEffect of HIV-1 and antiretroviral therapy on herpes simplex virus type 2: a prospective study in African womenSexually Transmitted Infections
HIV-1 RNA; HSV-2 DNA; genital shedding; African women
© 2005 Lippincott Williams & Wilkins, Inc.
Highlight selected keywords in the article text.