Emilia H. Koumans, Fujie Xu, Maya Sternberg, Lauri E. Markowitz National STD Prevention Conference March 11, 2008 Prevalence of HSV-2 in relation to bacterial vaginosis status among sexually active women in the U.S., 2001-2004 Good morning. I will be presenting data on the prevalence of HSV2 in relation to BV status among sexually active women in the U.S. I’d like to thank my co-authors, … Emilia H. Koumans, Fujie Xu, Maya Sternberg, Lauri E. Markowitz

Background – Bacterial vaginosis BV is a common genital tract infection in the U.S. BV is characterized by changes in vaginal flora Normally predominant lactobacilli are reduced or absent Normally infrequent anaerobes and genital mycoplasmas overgrow and predominate BV is associated with increased risk of STI acquisition, including HSV-2 among sex workers and clinic-based populations BV

Background – Herpes Simplex Virus 2 HSV-2 is also a common genital tract infection HSV-2 may be characterized by an initial acute infection of painful blisters, chronic recurrences, or by no recognized symptoms HSV is associated with increased risk of HIV acquisition HSV

Objective To describe the prevalence of HSV-2 in relation to BV status among sexually active women aged 20-49 years in the U.S. Our objective was to describe the prevalence of HSV in relation to BV status

Methods survey design and data analysis National Health and Nutrition Examination Survey (NHANES) 2001-2004 for sexually active women aged 20-49 years Cluster survey methodology to represent civilian, non-institutionalized population of the U.S. Mexican Americans were oversampled Prevalence estimates generated using SUDAAN for complex survey design incorporating NCHS-generated weights Estimates for non-Hispanic blacks, non-Hispanic whites, and Mexican Americans We used data from the National Health and Nutrition Examination Survey from the years 2001-2004 for women ages 20-49. There were 1696 women who participated Cluster survey methodology was used to represent the civilian, non-institutionalized population of the U.S. Mexican Americans were oversampled Variables were used in accordance with National Center for Health Statistics (NCHS) recommendations Prevalence estimates were generated using SUDAAN for complex survey design incorporating NCHS-generated weights I will present estimates for non-Hispanic blacks, non-Hispanic whites, and Mexican Americans. Each of these groups had a sufficient sample size to generate stable estimates.

Methods BV specimen collection and interpretation Self-collected vaginal swabs used for pH determination and slide preparation Slides air-dried, Gram stained, and read using Nugent’s criteria Slides scored on the basis of lactobacilli and gram-negative and anaerobic bacteria quantity Score of 0-3 defined as negative, 4-6 as intermediate, and 7-10 as positive Score of 7-10 defined as BV Self-collected vaginal swabs were used for pH determination and slide preparation After private self collection, slides were air-dried, shipped in batches to the laboratory, Gram stained, then read using Nugent’s criteria Slides were scored on the basis of lactobacilli and gram-negative and anaerobic bacteria quantity. Quality control showed that 3% of slides were given the same determination after a second independent reading A Score of 0-3 was defined as negative, 4-6 as intermediate, and 7-10 as positive We defined a score of 7-10 as BV

Methods HSV-2 serology Serum samples collected for all persons 14-49 years of age Type-specific immunodot assay Glycoproteins of gG1 and gG2 as antigens The same assays and the same laboratory have been used since NHANES II (1976-1980) HSV-2 positivity was determined using serum collected during the NHANES visit for all persons 14-49. A type-specific immunodot assay was used, it targets the glycoproteins of gG1 and gG2 The same assay and laboratory have been used since NHANES II

Prevalence of bacterial vaginosis and HSV-2 among U.S. women by age Overall prevalence of BV = 30% Overall prevalence of HSV-2 = 27%

HSV-2 prevalence by BV status Prevalence of HSV-2 (%) (95% confidence interval) Without BV 22.6 (20.3-25.0) With BV 37.2 (33.6-41.2) Prevalence Ratio: 1.6, p<0.05

Prevalence of HSV-2 by age and by BV status HSV-2 prevalence (%) (95% confidence interval) Prevalence Ratio Age (yrs) Without BV With BV 20-29 14.4 (10.9-19.0) 25.6 (19.5-33.6) 1.8* 30-39 22.4 (18.4-27.3) 41.4 (35.8-47.8) 40-49 28.9 (24.8-33.6) 43.6 (35.7-53.2) 1.5* * p<0.01

Prevalence of HSV-2 by race/ethnicity and by BV status HSV-2 prevalence (%) (95% confidence interval) Prevalence Ratio Race/ethnicity Without BV With BV N-H white 18.7 (16.2-21.6) 29.1 (23.3-36.3) 1.6* N-H black 52.9 (46.8-59.9) 65.6 (58.2-74.0) 1.2* Mexican American 17.8 (13.3-23.9) 19.5 (12.3-30.8) 1.1 * p<0.01

Prevalence of HSV-2 by number of lifetime partners and by BV status HSV-2 prevalence (%) (95% confidence interval) Prevalence Ratio Lifetime sex partners Without BV With BV 1-4 13.2 (10.3-16.8) 20.1 (14.4-28.0) 1.5 5-9 24.9 (20.2-30.8) 40.5 (32.9-49.8) 1.6* 10+ 39.1 (33.5-45.6) 58.4 (48.5-70.3) 1.5* * p<0.01

Risk factors for HSV-2 prevalence Race/ethnicity, age, and lifetime numbers of sex partners are known risk factors for HSV BV was associated with an increased prevalence (Odds ratio=1.57, 95% CI 1.1-2.3) of HSV-2 seroprevalence, after adjusting for these known risk factors Race/ethnicity, age, and lifetime partners are known risk factors for HSV-2. After adjusting for these factors, BV remained associated with HSV-2 status with an odds ratio of 1.57.

Prevalence of HSV-2 by Nugent score for BV HSV-2 prevalence (%) (95% confidence interval) Normal flora (Nugent score 0-3) Intermediate (Nugent score 4-6) BV (Nugent score 7-10) 23.5 (19.0-29.1) 22.0 (18.6-26.0) 37.2 (33.6-41.2) Relationship was unchanged when stratified by race/ethnicity or age

Symptoms Among women with BV, the proportion with vaginal symptoms was not associated with HSV-2 positivity

Conclusions BV and HSV-2 commonly co-exist among sexually active women HSV-2 seroprevalence was higher among women with BV than women without BV We are unable to describe temporal relationships because NHANES is a cross-sectional study BV was associated with an increased risk of HSV-2, after adjustment for race/ethnicity, age, and lifetime sex partners

Discussion BV has been found to increase the risk of acquiring HSV-2 among sex workers in Kenya and clinic patients in Pittsburgh HSV-2 has been found to be associated with BV acquisition in one study BV may play a role in the disparities in HSV-2 prevalence The causes for the relationship between the prevalence of BV prevalence of HSV-2 needs further study

Acknowledgements NHANES participants and staff The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention