New research eyes herpes screening practices
Results of a recent analysis of a survey of HIV care providers shows that clinicians often don't screen for genital herpes (herpes simplex virus-2 or HSV-2) in HIV-positive patients. Fewer than half knew that most patients with HIV also are infected by herpes.1
Several studies have shown that HSV-2 infection increases the risk for HIV infection by at least twofold.2 In a study designed to monitor trends in HIV seroprevalence in the United States, HIV testing was included in the National Health and Nutrition Examination Survey conducted from 1999 to 2006. Male-to-male sex and the presence of HSV-2 antibody were the strongest predictors of HIV infection.3
Knowledge of possible HSV-2 infection can inform HIV treatment. Studies suggest that patients with co-infection have more frequent genital lesions that might last longer and be more debilitating. Research also indicates that in some patients who have both HSV-2 and HIV infection, HSV-2 reactivation seems to increase plasma HIV ribonucleic acid levels.4
The Centers for Disease Control and Prevention (CDC) does not recommend HSV-2 screening for the general population; however, CDC guidance states such testing might be useful for individuals who are unsure of their status and at high risk for the disease, such as those with multiple sex partners or HIV infection, and men who have sex with men (MSM).5
One advantage of HSV-2 screening in these high-risk groups is there is some indirect data that suggests those diagnosed with HSV might use additional safety precautions to reduce transmission, says Scott Bryan, a CDC spokesperson. However, Bryan notes there are two disadvantages: The tests are costly, and there is a lack of data about whether learning one's HSV-2 infection status leads to changes in sexual behavior and reduction in HSV-2 transmission.
"Additional research is needed to determine the overall benefit, feasibility, and cost effectiveness of serologic testing to prevent HSV-2 transmission," he states.
Look at HSV-2 and HIV
The currently published analysis of HIV care providers' practice was launched in anticipation of results from a large Phase III clinical study designed to examine herpes suppression with acyclovir as a possible means of reducing the risk of HIV transmission, says Hayley Mark, PhD, MPH, RN, assistant professor at the Johns Hopkins University School of Nursing in Baltimore. The acyclovir study, conducted by the HIV Prevention Trials Network, a worldwide collaborative, ultimately found that acyclovir did not reduce the risk of acquiring HIV when given to men and women infected with HSV-2.6
Science continues to look at acyclovir; research has uncovered details of an immune-cell environment conducive to HIV infection that persists at the location of HSV-2 genital skin lesions long after they have been treated with oral doses of acyclovir. This research might explain why HSV-2 infection increases the risk for HIV infection even after successful treatment heals the genital skin sores and breaks that often result from HSV-2.7
The analysis of HIV care providers indicates clinicians are reluctant to test HIV patients for herpes. Twelve percent reported always testing HIV-infected patients for genital herpes, 65% sometimes or usually tested, and 23% rarely or never tested for such infection. Providers were more likely to recommend a herpes test if the patient had symptoms (94%) or had a partner with herpes (83%). They were less likely to recommend testing if patients had no partners (60%) or would rather not know their HSV-2 status(49%).1
Fewer than half of the providers surveyed knew that most people with HIV also are infected by HSV, or that most often, symptoms of HSV-2 are silent. Such findings indicate that efforts need to be made to better educate healthcare providers who, in turn, can educate their patients, says Mark.
"Patients with HIV need to know that if they have HSV-2, too, it can be transmitted to their partners," says Mark. "And if they don't now have HSV-2, they are heightened at risk for acquiring it, unless they practice safe sex."
References
- Gilbert L, Nanda J, Farley J, et al. Providers' knowledge, practices, and barriers related to genital herpes testing for patients with HIV. J Assoc Nurses AIDS Care 2010;21:327-334.
- Centers for Disease Control and Prevention. Seroprevalence of herpes simplex virus type 2 among persons aged 14-49 years United States, 2005-2008. MMWR 2010;59:456-469.
- McQuillan GM, Kruszon-Moran D, Granade T, et al. Seroprevalence of human immunodeficiency virus in the US Household population aged 18-49 years: The National Health and Nutrition Examination Surveys, 1999-2006. J Acquir Immune Defic Syndr 2009;53:117-123.
- Edmunds MW. Why don't providers test HIV-positive patients for genital herpes? Accessed at http://www.medscape.com/viewarticle/726388.
- Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55(RR-11):1-94.
- Celum C, Wald A, Hughes J, et al. 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. Lancet 2008;371:2109-2119.
- Zhu J, Hladik F, Woodward A, et al. Persistence of HIV-1 receptor-positive cells after HSV-2 reactivation is a potential mechanism for increased HIV-1 acquisition. Nat Med 2009; 15:886-892.
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