ICASA 2011 – Addis Ababa 1 Olayemi Matthew, MPH Institute of Human Virology Nigeria (IHVN) High HSV-2 prevalence among pregnant women in Nigeria and its association with HIV infection.

2 Background Pregnancy is an evidence of unprotected sexual intercourse, hence pregnant women are the most appropriate target population for studying and identifying factors regarding sexual behavior and STIs. Sexual behaviors and biological evidence are essential in understanding the epidemiology of STI/HIV interaction. Studies have shown that a great number of new HIV infections are associated with the herpes virus.

3 Background cont. Herpes infection affects the genital mucosa causing increased replication of virus and high transmission rate in an HIV-positive person. The risk of contacting HIV is higher with acute HSV-2 than chronic ones and most people infected are unaware despite the symptoms.

4 Objective Evidence suggests that a substantial proportion of new HIV infections in African countries are associated with HSV-2. Thus the magnitude of HSV-2 infection in a population may suggest the expected course of the HIV epidemic. Objective – We determined the prevalence of genital herpes and associated factors among pregnant women in two communities in Nigeria that have a low but increasing HIV prevalence.

5 Methods Multi-site prospective cohort study 2362 pregnant women attending two different clinics aged between 18 – 49 years and within any gestational age period were enrolled into the study with sera tested for HSV-2. A standard structured questionnaire was administered.

Laboratory Methods 6 Antibodies against HIV were screened using sequential algorithm of rapid HIV tests: – Determine HIV-1/2 test (Abbott Laboratories) – Uni-Gold Recombigen HIV (Trinity Biotech) – Stat-Pak (Chembio Diagnostics) Sera were analyzed using ELISA specific for IgG antibodies to HSV-2 (Kalon Biologicals Ltd, U.K) Sensitivity and Specificity of the Kalon HSV-2 Elisa kits – 92% and 79% among men from Kisumu, Kenya. – 97.5% and 96.2% in an HSV-2 prevalent community in Kampala, Uganda. – 92.3% and 97.7%, large study of sera from Kenya, Zambia, Benin and Cameroon in sub-Saharan Africa (

Data Analysis 7 Analysis was done using SAS software version 9.2 Differences in proportion was measured using Chi-square. Differences in mean was measured using t-test. Of 2362, n=22 (0.9%) with indeterminate HSV- 2 serology were excluded. Odds ratios for HSV-2 adjusted for confounders were determined using logistic regression.

Description of Study Populations Mean maternal age = 29.0 years 19.6% first time pregnancy 38.8% HSV-2 seropositivity 18.2% genital ulcer disease (GUD) 10.4% HIV seropositivity – 100% ARV prophylaxis for PMTCT – 38.4% CD4<350 cells/mL 8

Risk factor for HSV-2 seropositivity - All 9 Risk FactorsTotalNo. of HSV-2 Pos. women HSV-2 Pos %P-value Age (yrs) % 36.0% 46.0% 50.6% <.0001 Gest. Age (wks) % 37.6% 33.1% 0.06 No. of sex partners (past 3 mths.) % 38.2% 100% Douching No Yes % 39.2%0.47 Condom freq. (wkly) % 60.0% 62.9%<.0001

10 Risk FactorsTotalNo. of HSV-2 Pos. women HSV-2 Pos (%)P-value Genital ulcer disease No Yes % 61.9%<0.001 Age of sex partner (yrs) % 20.4% 33.4% 44.9% <.0001 First preg. No Yes % 23.1%<.0001 HIV status Negative Positive % 76.3%<.0001 Risk factor for HSV-2 seropositivity - All

Higher HSV-2 at lower CD4 cells counts among HIV+ women with GUD 11 CD4+ lymphocyte at time of testing (cells/mL)

Multivariate Analysis for Risk Factors Risk FactorsOdds Ratios (95% Confidence Intervals) P Age (per 5 yr increase)1.4 (1.1 – 2.1)0.03 Age of sex partner (per 5 yr increase)1.5 (1.0 – 2.2)0.04 HIV seropositivity6.0 (4.3 – 8.3)<0.001 Not first pregnancy1.9 (1.5 – 2.2)<0.001 Current or prior GUD2.4 (1.9 – 3.4)<0.001 All women

Conclusions HSV-2 is highly prevalent but only 19% had prior or current GUD. Older age increases the risk of HSV seropositive. HSV-2 is higher among HIV+ women. Having an older partner remains associated with HSV-2 seropositivity. 13

Conclusions Among HIV+ women – Clinical evidence of HSV-2 is associated with lower CD4 cell counts. – No effect of HSV-2 serostatus on mother-to-child transmission of HIV. ARV prophylaxis is highly effective. 14

Limitations - Further Analyses Analysis underway to distinguish between active vs. chronic HSV-2 infection Analysis of other reproductive tract infections (bacterial vaginosis, trichomonas, etc.) that may associate with HSV-2 and HIV. 15

Acknowledgement 16 Funding Support NIH Avert – R01AI NIH Fogarty AITRP– D43TW UBTH Samson Onemu Joseph Onakewhor University of Maryland School of Medicine Paul Dakum Alash’le Abimiku Man Charurat PSSH/PLASVIREC Tecla Ndomb Bitrus Matawal Petronilla Ozumba Othniel Luka Sophia Osawe IHVN Esosa Osagie Abiola Odejide Lydia Idehenre Comfort Adesanya Magdalen Laraba

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