1. Emilia H. Koumans, Fujie Xu, Maya Sternberg, Lauri E. Markowitz
National STD Prevention Conference March 11, Prevalence of HSV-2 in relation to bacterial vaginosis status among sexually active women in the U.S.,
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

2. 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

3. 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

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

5. Methods survey design and data analysis
National Health and Nutrition Examination Survey (NHANES) for sexually active women aged 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 for women ages 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.

6. 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

7. Methods HSV-2 serology
Serum samples collected for all persons 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 ( )
HSV-2 positivity was determined using serum collected during the NHANES visit for all persons
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

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

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

10. 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 ( )
25.6 ( )
1.8*
30-39
22.4 ( )
41.4 ( )
40-49
28.9 ( )
43.6 ( )
1.5*
* p<0.01

11. 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 ( )
29.1 ( )
1.6*
N-H black
52.9 ( )
65.6 ( )
1.2*
Mexican American
17.8 ( )
19.5 ( )
1.1
* p<0.01

12. 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 ( )
20.1 ( )
1.5
5-9
24.9 ( )
40.5 ( )
1.6*
10+
39.1 ( )
58.4 ( )
1.5*
* p<0.01

13. 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 ) 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.

14. 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 ( )
22.0 ( )
37.2 ( )
Relationship was unchanged when stratified by race/ethnicity or age

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

16. 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

17. 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

18. 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