Herpes Simplex Virus type 1 among people living with HIV in Mbeya, Tanzania

doi:10.21203/rs.2.18477/v1

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Herpes Simplex Virus type 1 among people living with HIV in Mbeya, Tanzania

https://doi.org/10.21203/rs.2.18477/v1

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Background Clinical manifestations of HSV-1 infection is quite common in patients with HIV/AIDS. In Tanzania, nearly five percent of individuals aged 15 to 49 years are living with HIV, with the highest prevalence observed in the southern highland region. Studies are now reporting a growing HIV epidemic due to genital HSV-1. Despite such evidence, the prevalence of HSV-1 infection in HIV positive and negative individuals in the general Tanzanian population is mostly unknown. The objective of this study was to describe the prevalence of Herpes Simplex Virus type 1 infections among HIV positive and negative individuals in the Mbeya region, the third most affected region with HIV in Tanzania.

Methods We conducted a study in the Mbeya region in the archived blood sera of participants from the recently completed EU funded EMINI project. A specially designed questionnaire was used to isolate the social and demographic characteristics of the study participants in the database. We tested archived participants’ sera for Herpes Simplex Virus type 1 using Virotech HSV-1 (gG1) ELISA (Enzygnost, Behring, Germany). Univariate and multivariate Poisson regression models were used to identify factors associated with HSV-1.

Results A total of 640 adults were randomly recruited after stratification by HIV status, age, and sex. The overall seroprevalence of HSV-1 in the study population was 92.1%. The extrapolated prevalence estimate of Herpes Simplex Virus type 1 in the general population was 95.0% (96.0% in males versus 94.0% in females). Men and females were equally affected by HSV-1. HSV-1 was less prevalent in HIV positive individuals and was more common in individuals with elevated blood pressure.

Conclusion People living with HIV were less likely to be HSV-1 positive. Further studies can evaluate whether the Herpes Simplex Virus type-1 can reduce the incidence of HIV infection.

Infectious Diseases

Epidemiology

Seroprevalence

HSV-1

HIV

Mwakyula

Mbeya

Tanzania

In Tanzania mainland, the prevalence of HIV infection among adults aged 15–49 years is 4.7 %, while females affected twice as men (6.2% vs. 3.1%). The prevalence in the Southern highland regions is higher than the national average. (1)

Herpes simplex virus (HSV) infection causes ulcerative mucocutaneous disease. HSV–1 predominantly causes orolabial ulcers and is acquired during childhood, while HSV–2 causes genital herpes that is commonly associated with sexual activities. Sufficient evidence has demonstrated the increased trend of genital HSV–1 such as one study that demonstrated an increase in the prevalence of HSV–1 anogenital isolates from 3% in the early 1980s to around 41% in 2003.(2)

Few works of literature have reported that individuals with both HIV and HSV–1 have a higher risk of transmitting HIV to a partner who does not have HIV during sexual contact. (3) Despite all this knowledge, the prevalence of HSV infection among HIV positive and negative individuals in the general Tanzanian population is unknown. Few studies have documented the prevalence of HSV–1 in the sub-Saharan general population, and it is estimated to be over 90%. (4,5)

This study aimed to establish the burden of Herpes Simplex Virus type 1 among individuals in the general population based on their HIV status.

The current study was population-based cross-sectional research that analyzed data and blood of a subset of participants who were recruited into the finished EMINI (Establishment of the Infrastructure to Evaluate and Monitor the Impact of New Interventions) cohort.

EMINI was a closed population-based cohort study that was conducted in Mbeya region between May 2005 and completed in 2009 and established a cohort of 20,000 people, enrolled from 10% of all households in nine randomly selected communities (urban, semi-urban and rural). The overall objective of the EMINI project was to contribute to the general improvement of health by controlling communicable diseases in the Mbeya region.

During each of the annual study visits; a research team visited every participant to conduct a general physical examination, perform interviews, particularly on sexual risk behaviors, and collect several specimens that included blood.

The blood specimens collected from the participants were then tested for HIV–1 in the NIMR-MMRC central laboratory at the Mbeya Zonal Referral Hospital according to the existing national HIV testing algorithm. Plasma from every participant during each survey was stored at –80^oC for future use.

The Virotech IgGIgM HSV–1 ELISA kit (Enzygnost, Behring, Marburg, Germany) was used to examine samples for HSV–1. Standard operating procedures and data worksheets for this kit were made and followed according to manufacturer’s recommendations.

We linked the results to responses of data obtained from a demographic characteristics and sexual risk behavior questionnaire. Data regarding age, gender, socio-demographic status, appropriate behaviors of participants, and physical examination were all collected during interviews in the participants’ households using PDAs for data capture. They were downloaded into Microsoft Access databases and imported into Stata 16 software where data checking and management were performed.

Overall, 7,287 participants of the EMINI cohort were in the age group of 15–49 years. Randomization of EMINI participants meeting the inclusion criteria was done using Stata 16 after stratification by Age, Sex, and HIV status. Stratification was necessary because otherwise, the number of HIV positive participants would have been too low for meaningful comparisons.

Each participant was assigned a random number, and 23 participants were initially selected per stratum (overall = 23 participants x 28 strata = 644 participants). Strata with less than 23 participants were filled from higher age strata with the same Sex and HIV combination. For each stratum, 10 participants were also selected for replacement in case the selected initial samples could not be found (Total replacements were 280). Responses from EMINI interviews were used to assess the socio-demographic characteristics of participants.

We did all analyses in Stata 16.0 (Stata Corp., College Station, TX). Univariate and multivariate associations of different factors with HSV–1 infection were analyzed using Poisson regression with robust variance estimates.

We randomly selected a total of 640 subjects from nine wards of the Mbeya region with equal distribution of sex and HIV status. The majority of the study population had completed primary level of education (58.4%), were peasants (70.0%), involved in seasonal activities (50.5%), married with one spouse (55.0%) and Christians (77.5%). Some of the socio-demographic characteristics of these participants are shown in table 1.

Six hundred and twenty-nine sera were tested for HSV–1, among which 18 sera were indeterminate, and in 11 participants’ the amount of volume of sera was insufficient to run the test. None of the sera with indeterminate results were retested. From 611 participants sera tested for Herpes Simplex Virus type 1, 51.2% were males, and 52.4% of sera came from HIV negative individuals.

The overall prevalence of HSV–1 infection was 92.1%, with males and females having a prevalence of 94.2% and 89.9% respectively. HIV negative females were 95.7% reactive to herpes simplex type 1 virus as compared to 83.2% of HIV positive females. These proportions were slightly lower as compared to the prevalence of 96.9% and 91.6% of HIV negative and positive males, respectively.

We stratified the study participants by HIV status, sex, and age in order to have enough participants in each stratum. About 50% of study subjects were HIV infected, contrary to 9.3% of the prevalence of HIV infection in the general population of Mbeya. The unadjusted seroprevalence did not interfere with the analysis of the seroprevalence of HSV infections in HIV infected and uninfected individuals; however, they did not represent the overall prevalence in the general population. After extrapolation of the current results to the age, sex and HIV status distribution of the EMINI study population, the prevalence estimate of Herpes Simplex Virus type 1 in the general population was 95.0% (96.0% in males versus 94.0% in females).

A chi-square test of independence was performed to examine the relationship between gender and HSV–1 seropositivity. The relation between these variables was significant, X2 (1, N = 611) = 3.929, p =.047461. Men were more likely than women to be HSV–1 positive (Table 2).

The correlation between HSV–1 and HIV status was tested using chi-square and Z Score tests. A chi-square test of independence showed that there was a significant association between HSV–1 seropositivity and HIV status, X2 (1, N = 611) = 15.6482, p =.000076 and agreed with a Z score that was –3.9558 with a p-value of.00004. The result suggests that either disease, HIV, or HSV–1, would be protective to the other.

Poisson regression test with robust variance estimates analysis was used to predict the trend of prevalence of Herpes Simplex Virus type 1 over age by HIV status. Table 3 shows that there was no significant change in the trend of prevalence by age.

To assess the univariate association of various factors such as gender, HIV status, blood transfusion, and circumcision with HSV–1 infection, Poisson regression with robust variance estimates for stratification variables was used (Table 4). There was no significant difference between HSV infections in females and males. People with HIV were less likely to have HSV–1 infections. Factors that were associated with HSV–1 included the history of blood transfusion and circumcision in males.

When we included different variables (Table 5) into the same model, a multivariate association of HSV–1 unmasked a 7% decrease and an 8% increase (p-value<0.05) in the prevalence of HSV–1 in HIV positive and hypertensive individuals, respectively.

This study presents the first report of the prevalence of Herpes Simplex Virus type 1 in the general population of Tanzania based on their HIV status. The unadjusted seroprevalence of Herpes simplex virus type 1 infections in this study population was 92.1%, the prevalence estimate for the general population is 95.0%. This is higher compared to that from the United States of America, where it was estimated at 67% (6), Israel 59.8% (7) and 80% from Switzerland (8). It is, however, comparable to some settings in Syria (9), rural Uganda (91.2%) (4) and in the urban region of Tanzania ( 92%) (5).

Contrary to other studies where seroprevalence of HSV–1 was significantly higher in females(10–12), this study shows that men are more often infected than women, although this association was not significant anymore when adjusted for other factors in the multivariate model (PR 1.04, p-value =.110).

Surprisingly, the present study shows a lower prevalence of herpes simplex type 1 infections among HIV positive individuals compared to HIV negatives (87.6% vs. 96.3%). In a univariate and multivariate analysis being HIV positive was associated with a lower HSV–1 seropositivity, which is contrary to recent literatures that report a growing HIV epidemic due to genital HSV–1 (13), however, the same finding may be supported by few studies that have shown HSV–1 infection is unrelated to sexual transmission in HIV infected individuals (14).

Furthermore, to support this result, one study found HIV superinfection of CEM(HSV) cells would delay HIV–1 production due to cell growth inhibition and apoptosis, resulting from persistent HSV–1 infection and treatment of CEM(HSV) with acyclovir inhibited HSV–1 cytopathic effects and allowed efficient HIV–1 replication (15).

Similarly, some studies have found membrane-bound HSV–1 glycoprotein D is required for the restriction of release of infectious HIV–1 (16) and another study found several HSV–1 proteins like glycoprotein M, US3, and UL24 potently restricted the replication of HIV–1 (17).

In this study it has been shown that patients with hypertension have a high likelihood of being positive for HSV type 1. Association of herpes simplex infections type 1 with cardiovascular diseases has developed interests in a few research. Some studies found significant association of herpes simplex type 1 to be atherogenic (18–20).

The prevalence of HSV–1 in this population was high. People living with HIV were less likely to be HSV–1 positive. Further studies can evaluate whether Herpes Simplex Virus type–1 can reduce the incidence of HIV infection.

HIV - Human Immunodeficiency Viruses

AIDS - Acquired Immune Deficiency Syndrome

HSV–1 - Herpes simplex viruses type 1

EU - European Union

EMINI - Establishment of the Infrastructure to Evaluate and Monitor the Impact of New Interventions

ELISA - Enzyme Linked Immunosorbent Assay

gG1 - glycoprotein G 1

NIMR - National Institute for Medical Research

MMRC - Mbeya Medical Research Center

PDAs - Personal Digital Assistants

TX - Texas

MMReC - Mbeya Medical Research and Ethics Committee

CI - Confidence Interval

CEM - Contagious equine metritis

Ethics approval and consent to participate

We sought ethical clearance from the Muhimbili University of Health and Allied Sciences and Mbeya Medical Research and Ethics Committees (MMReC). We observed Confidentiality, and no unauthorized persons had access to the collected data. Each subject had been assigned a study identification number that was not linked to individual names. The parent study had already received informed consent for adults and parental consent for minors to participate in the study.

Consent for publication

Not applicable

Availability of data and material

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by German Academic Exchange Service and NIMR-MMRC. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors' contributions

IHM and AAN analyzed and interpreted research findings. IHM and AAN performed the serological testing and were major contributors in writing the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

Study limitations:

This study shows that both types of HSV-1 infections are less common in HIV infected individuals. Limited by its cross-sectional design, the analysis of possible risk factors suggests that inferences from its findings should be made cautiously regarding the possible observed association.

Strength of the study:

The strength of this study profits from the use of statistical methods, tailored at the high prevalence of Herpes simplex virus type 1 infection. The use of Poisson regression models with robust variance estimates allows for the direct estimation of prevalence ratios which in high prevalence situations are more interpretable than odds ratios (21).

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Table 1. Frequency distribution of Socio-demographic characteristics (n=640)

Demography		Frequency	Percent
HIV status
	Negative	322	50.3
	Positive	318	49.7
Sex
	Female	319	49.8
	Male	321	50.2
Age group
	15-19	77	12.0
	20-24	83	13.0
	25-29	106	16.5
	30-34	101	15.8
	35-39	90	14.1
	40-44	90	14.1
	45-49	93	14.5
Level of education
	No formal education	88	26.9
	Completed primary	374	58.4
	After primary	94	14.7
Marital status
	Never Married	154	24.1
	Married-One Spouse	352	55.0
	Others	134	20.9
Religion
	No religion	107	16.7
	Christian	496	77.5
	Others	36	5.8

Table 2. Prevalence of Herpes Simplex Virus Type 1 by sex and HIV status

		Male (Expected Total) [X2]	Female (Expected Total) [X2]	Total
HSV-1
	Positive	295 (288.41) [0.15]	268 (274.59) [0.16]	563
	Negative	18 (24.59) [1.77]	30 (23.41) [1.85]	48
		313	298	611
The chi-square statistic is 3.929. The p-value is .047461. This result is significant at p < .05.

		HIV Positive	HIV Negative
HSV-1
	Positive	255 (268.14) [0.64]	308 (294.86) [0.59]	563
	Negative	36 (22.86) [7.55]	12 (25.14) [6.87]	48
		291	320	611
The chi-square statistic is 15.6482. The p-value is .000076. This result is significant at p < .05.

Table 3. The trend of seroprevalence of Herpes Simplex Virus type 1 infections over age by HIV status and Sex (Results of a Poisson regression test with robust variance estimates.)

	Number of Observations	Prevalence ratios	p-value	95% CI
a) p-values for the trend of HSV-1 over age by HIV infection status and Sex
HIV negative females	161	0.99	0.16	0.97-1.01
HIV negative males	159	1.01	0.34	0.99-1.02
HIVpositive females	137	0.97	0.13	0.94-1.01
HIV positive males	154	0.98	0.25	0.95-1.01
b) p-values for the trend of HSV-1 over age by HIV infection status, regardless of Sex
HIV negative	320	1	0.84	0.99-1.01
HIV positive	291	0.98	0.08	0.96-1.00
c) p-value for the trend of HSV-1 over age regardless of HIV status and Sex
	611	0.99	0.82	0.98-1.00

Table 4. Univariate association of various factors with HSV-1 infection.

Results of Poisson regression with robust variance estimates for stratification variables. Univariate models for Gender, Age, and HIV-status, all other variables adjusted for Gender, Age, and HIV status.

Variable	Stratum	Number in stratum	Prevalence Ratio	95% CI	p-value
Gender
	Female*	298	1	--	--
	Male	313	1.05	(1.00 to 1.10)	0.050
HIV status
	Negative	320	1	--	--
	Positive	291	0.91	(0.87 to 0.96)	<0.001
Had blood transfusion last year
	No*	598	1	--	--
	Yes	10	1.09	(1.05 to 1.14)	<0.001
Circumcised (males only)
	No*	258	1	--	--
	Yes	55	1.08	(1.04 to 1.12)	<0.001

Table 5. Multivariate associations of various factors with HSV-1 infection.

Variable	Stratum	Number in stratum	Prevalence Ratio	95% CI	p-value
Gender
	Female*	298	1	--	--
	Male	313	1.04	(0.99 to 1.10)	0.110
HIV status
	Negative*	320	1	--	--
	Positive	291	0.93	(0.89 to 0.98)	0.004
Hypertensive
	No*	557	1	--	--
	Yes	53	1.08	(1.01 to 1.15)	0.031
Circumcised (Males only)
	No*	556	1	--	--
	Yes	55	1.06	(1.01 to 1.10)	0.011

Download PDF

Journal Publication

published 05 Aug, 2020

Read the published version in BMC Infectious Diseases →

Editorial decision: Major revision
24 Feb, 2020
Review #2 received at journal
23 Feb, 2020
Reviewer #2 agreed at journal
28 Jan, 2020
Review #1 received at journal
11 Jan, 2020
Reviewers invited by journal
19 Dec, 2019
Reviewer #1 agreed at journal
19 Dec, 2019
Submission checks completed at journal
05 Dec, 2019
Editor invited by journal
02 Dec, 2019
Editor assigned by journal
25 Nov, 2019
First submitted to journal
22 Nov, 2019

You are reading this older preprint version

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Herpes Simplex Virus type 1 among people living with HIV in Mbeya, Tanzania

Status:

Journal Publication

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Abstract

Background

Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Status:

Journal Publication

Version 1