Genital Viral Shedding Research Articles

Viral Shedding 1 Year Following First-Episode Genital HSV-1 Infection

Herpes simplex virus type 1 (HSV-1) is the leading cause of first-episode genital herpes in many countries. To inform counseling messages regarding genital HSV-1 transmission, oral and genital viral shedding patterns among persons with first-episode genital HSV-1 infection were assessed. The trajectory of the development of HSV-specific antibody and T-cell responses was also characterized. Prospective cohort followed up for up to 2 years, with 82 participants followed up between 2013 and 2018. Participants were recruited from sexual health and primary care clinics in Seattle, Washington. Persons with laboratory-documented first-episode genital HSV-1 infection, without HIV infection or current pregnancy, were referred for enrollment. First-episode genital HSV-1 infection. Genital and oral HSV-1 shedding and lesion rates at 2 months, 11 months, and up to 2 years after initial genital HSV-1 infection. Participants self-collected oral and genital swabs for HSV polymerase chain reaction testing for 30 days at 2 and 11 months and up to 2 years after diagnosis of genital HSV-1. Blood samples were collected at serial time points to assess immune responses to HSV-1. Primary HSV-1 infection was defined as absent HSV antibody at baseline or evolving antibody profile using the University of Washington HSV Western Blot. HSV-specific T-cell responses were detected using interferon γ enzyme-linked immunospot. Among the 82 participants, the median (range) age was 26 (16-64) years, 54 (65.9%) were women, and 42 (51.2%) had primary HSV-1 infection. At 2 months, HSV-1 was detected from the genital tract in 53 participants (64.6%) and in the mouth in 24 participants (29.3%). Genital HSV-1 shedding was detected on 275 of 2264 days (12.1%) at 2 months and declined significantly to 122 of 1719 days (7.1%) at 11 months (model-predicted rate, 6.2% [95% CI, 4.3%-8.9%] at 2 months vs 3.2% [95% CI, 1.8%-5.7%] at 11 months; relative risk, 0.52 [95% CI, 0.29-0.93]). Genital lesions were rare, reported on 65 of 2497 days (2.6%) at 2 months and 72 of 1872 days (3.8%) at 11 months. Oral HSV-1 shedding was detected on 88 of 2247 days (3.9%) at 2 months. Persons with primary HSV-1 infection had a higher risk of genital shedding compared with those with nonprimary infection (model-predicted rate, 7.9% [95% CI, 5.4%-11.7%] vs 2.9% [95% CI, 1.7%-5.0%]; relative risk, 2.75 [95% CI, 1.40-5.44]). Polyfunctional HSV-specific CD4+ and CD8+ T-cell responses were maintained during the follow-up period. Genital HSV-1 shedding was frequent after first-episode genital HSV-1, particularly among those with primary infection, and declined rapidly during the first year after infection.

Brief Report: Hormonal Contraception Is Not Associated With Reduced ART Effectiveness Among Women Initiating ART: Evidence From Longitudinal Data.

To explore the association between concomitant hormonal contraceptive and antiretroviral therapy (ART) use and (1) plasma viral suppression and (2) genital HIV shedding among HIV-positive women initiating ART. We analyzed plasma viral load and genital viral RNA shedding from 1079 HIV-positive women initiating ART who were followed prospectively in 3 sub-Saharan African HIV prevention studies. Plasma and endocervical swab samples were collected every 6 months. Self-reported contraceptive use was categorized into injectable, implant, oral, or nonhormonal/no contraception. We used multivariate Cox regression to assess time to plasma viral suppression and logistic regression with generalized estimating equations to assess genital viral shedding for each contraceptive method. At the time of ART initiation, there were 211 (20%) injectable, 69 (6%) implant, 50 (5%) oral, and 749 (69%) nonhormonal or no method users. Plasma viral suppression was high (90% by 6 months) and hormonal contraceptives did not diminish time to plasma viral suppression as compared to nonhormonal/no methods [adjusted hazard ratios: injectables 0.89 (95% confidence interval: 0.75 to 1.07), implants 0.91 (0.68 to 1.23), and oral methods 1.33 (1.06 to 1.66)]. Genital viral shedding was uncommon any time after ART initiation (only 9% of samples had detectable viral shedding) and hormonal contraceptives were not associated with an increased detection of genital viral shedding [adjusted odds ratios: injectables 1.07 (0.69 to 1.65), implants 0.67 (0.31 to 1.49), and oral methods 0.56 (0.19 to 1.69)]. The hormonal contraceptives assessed were not associated with reduced ART effectiveness among HIV-positive women initiating ART. HIV-positive women should continue to be offered contraceptive options, including hormonal ones that best meet their needs.

Presence of CD8+ T Cells in the Ectocervical Mucosa Correlates with Genital Viral Shedding in HIV-Infected Women despite a Low Prevalence of HIV RNA–Expressing Cells in the Tissue

The female genital tract is a portal of entry for sexual HIV transmission and a possible viral reservoir. In this study, the ectocervical CD8+ T cell distribution was explored in situ and was related to expression of CD3 and HLA-DR and presence of HIV RNA. For this purpose, ectocervical tissue samples and genital secretions were collected from HIV-seropositive (HIV+) Kenyan female sex workers (FSWs) (n = 20), HIV-seronegative (HIV-) FSWs (n = 17), and HIV(-) lower-risk women (n = 21). Cell markers were assessed by in situ staining and by quantitative PCR. HIV RNA expression in tissue was analyzed by in situ hybridization, and viral shedding was assessed by quantitative PCR. The HIV+ FSW group had a higher amount of total cells and CD8+, CD3+, and HLA-DR+ cells compared with the HIV(-)FSW group and HIV- lower-risk women. The majority of CD8+ cells were CD3+ T cells, and the numbers of CD8+ cells correlated significantly with plasma and cervical viral load. HIV RNA expression in situ was found in 4 of the 20 HIV+FSW women but did not correlate with cervical or plasma viral load. Thus, the HIV+ women displayed high numbers of CD8+, CD3+, and HLA-DR+ cells, as well as a limited number of HIV RNA+ cells, in their ectocervical mucosa; hence, this localization cannot be neglected as a potential viral reservoir. The elevated levels of CD8+ T cells may play a role in the immunopathogenesis of HIV in the female genital tract.

Genital Shedding of Herpes Simplex Virus Among Symptomatic and Asymptomatic Persons With HSV-2 Infection

Since herpes simplex virus type 2 (HSV-2) antibody tests have become commercially available, an increasing number of persons have learned that they have genital herpes through serologic testing. The course of natural history of HSV-2 in asymptomatic, seropositive persons is uncertain. To evaluate the virologic and clinical course of HSV genital shedding among individuals with symptomatic and asymptomatic HSV-2 infection. Cohort of 498 immunocompetent HSV-2-seropositive persons enrolled in prospective studies of genital HSV shedding at the University of Washington Virology Research Clinic, Seattle, and Westover Heights Clinic, Portland, Oregon, between March 1992 and April 2008. Each participant obtained daily self-collected swabs of genital secretions for at least 30 days. The rate of viral shedding measured by quantitative real-time fluorescence polymerase chain reaction for HSV DNA from genital swabs. Herpes simplex virus type 2 was detected on 4753 of 23,683 days (20.1%; 95% confidence interval [CI], 18.3%-22.0%) in 410 persons with symptomatic genital HSV-2 infection compared with 519 of 5070 days (10.2%; 95% CI, 7.7%-13.6%) in 88 persons with asymptomatic infection (P < .001). Subclinical shedding rates were higher in persons with symptomatic infection compared with asymptomatic infection (2708 of 20,735 days [13.1%; 95% CI, 11.5%-14.6%) vs 434 of 4929 days [8.8%; 95% CI, 6.3%-11.5%]) (P < .001). However, the amount of HSV detected during subclinical shedding episodes was similar (median, 4.3 [interquartile range, 3.1-5.6] log(10) copies in the symptomatic infection group vs 4.2 [interquartile range, 2.9-5.5] in the asymptomatic infection group, P = .27). Days with lesions accounted for 2045 of 4753 days (43.0%; 95% CI, 39.8%-46.5%) with genital viral shedding among persons with symptomatic genital HSV-2 infection compared with 85 of 519 days (16.4%; 95% CI, 11.2%-23.9%) among persons with asymptomatic infection (P < .001). Persons with asymptomatic HSV-2 infection shed virus in the genital tract less frequently than persons with symptomatic infection, but much of the difference is attributable to less frequent genital lesions because lesions are accompanied by frequent viral shedding.

Antiretroviral therapy (ART) with stavudine, lamivudine and nevirapine in women with HIV-1 infection rapidly reduces genital viral shedding,

Antiretroviral therapy (ART) with stavudine, lamivudine and nevirapine in women with HIV-1 infection rapidly reduces genital viral shedding,

Compartmentalization of HIV-1 within the female genital tract: implications for assessing antiretroviral interventions.

Compartmentalization of HIV-1 between the blood and genital tract has been suggested for both men and women.1,2 The source of genital virus has been ascribed to infected cells in the genital-associated lymphoid tissue of the vagina and cervix submucosa although there may be a small contribution from the blood compartment.3 Nevertheless, the opportunity for local factors, such as immune activation and hormonal regulation, to affect viral shedding from the genital tract is expected but requires further study. We assessed short-term shedding and natural variability of HIV-1 RNA level from the blood plasma and genital tract of 55 HIV-1-infected women (median CD4 cell count of 209/μL, range 42-624) over 8 weeks.4 Specimens were collected weekly from the endocervical canal using Sno-strip™ wicks and cytobrushes and from the ectocervix with cervicovaginal lavage. The majority of subjects were either Black or Hispanic (85%), and heterosexual contact was a risk factor in 60%. Three-quarters of the women received combination antiretroviral therapy that contained a protease inhibitor. Short-term, serial, quantitative measurements of genital tract HIV-1 showed that the accurate detection of virus depended on the use of multiple sampling methods. For example, repeated sampling of genital fluids increased viral RNA detection from approximately 60%, reported in other studies, to 90% of HIV-1-infected women in our study.3 Moreover, approximately one-half of women shed HIV-1 continuously from the genital tract when sampled weekly for two months. Regression models were developed to predict the blood and genital HIV-1 RNA levels as a function of the menstrual cycle. Significant mean differences in genital tract HIV-1 RNA levels from menses were seen for all genital sampling methods; however, in contrast to some other studies, we found no differences in peripheral blood.5 The general pattern of HIV-1 shedding showed the lowest levels of viral RNA in the follicular phase immediately following menses with a gradual increase throughout the luteal phase until the next menses. Factors associated with HIV-1 genital tract viral shedding depended on the genital subcompartment sampled and include antiretroviral therapy, increased plasma viral RNA and the presence of other genital tract infections. The effect of menses on viral RNA shedding was most pronounced for specimens collected by cervicovaginal lavage but less so from the endocervical canal. For example, cervicovaginal lavage specimens collected during menses were more likely to have detectable viral RNA compared to specimens collected in the week immediately following menses (shedding odds ratio (OR) 0.23; 95% CI, 0.12-0.45; P < 0.001). In contrast, endocervical canal fluid viral RNA levels were influenced less by menses but trended towards having more viral shedding in the week prior to menses (shedding OR 1.94; 95% CI 0.96-3.91). Importantly, endocervical canal fluid viral RNA levels were significantly higher compared to either menses (0.2 log10 RNA copies/mL; P = 0.03) or blood plasma (0.3 log10 RNA copies/mL; P = 0.03). This association between the progesterone responsive luteal phase and increased viral RNA shedding may represent either endocervical canal specific viral production or, possibly, cell-free or cell-associated viral enrichment. These data further support viral compartmentalization between the blood and genital tract. We also found that there was greater natural short-term variation of HIV-1 RNA in the genital tract (13-fold) compared to blood (7-fold), which has important implications for monitoring genital tract-associated HIV-1 level [1]. For women, the variation in genital viral RNA was less than that reported for men for which the variability of seminal plasma viral RNA is approximately 38-fold [1]. This gender-specific viral RNA variation is likely due to differences between the genital microenvironments of men and women. However, in contrast to the male genital tract for which the basis of compartmentalization is largely defined by anatomical, immunological and microbiological barriers, the female genital-tract compartmentalization has a hormonal and microbiological basis. In conclusion, the precise measurement of HIV-1 in the female genital subcompartments (i.e., endocervical canal and ectocervicovaginal fluid) may shed further light on the genital source of HIV-1 and allow for assessment of the local hormonal, immunological and inflammatory effects on HIV-1 shedding. A better understanding of the genital viral shedding patterns is necessary for studying the effects of systemic and topical antiretroviral therapies to prevent both vertical and horizontal transmission of HIV-1.

Human Immunodeficiency Virus in Plasma and Genital Secretions during the Menstrual Cycle

Six human immunodeficiency virus (HIV)-positive women were studied weekly over 8 weeks to detect HIV RNA in plasma and cervical secretions and proviral DNA in cervical, vaginal, and cervicovaginal lavage samples by polymerase chain reaction (PCR) amplification techniques. In cervical swab samples, cell-free HIV RNA was detected more frequently than cell-associated HIV proviral DNA (22/48 vs. 7/48, respectively). Cervical HIV RNA was consistently detected in 2 women with plasma HIV RNA > 100,000 copies/mL but was not detected in 2 women with plasma HIV RNA < 10,000 copies/mL, regardless of menstruation status. HIV-specific IgA was detected in the plasma of 2 women and in at least 1 cervicovaginal lavage sample from all 6 women. Thus, quantitation of cervical HIV RNA can be accomplished by PCR techniques and may be useful in evaluation genital viral shedding.

Acyclovir suppression to prevent cesarean delivery after first-episode genital herpes

To determine if suppressive acyclovir therapy given to term gravidas experiencing a first episode of genital herpes simplex virus (HSV)-infection during pregnancy decreases the need for cesarean delivery for that indication. Forty-six pregnant women with first episodes of genital herpes during pregnancy were randomly assigned to receive oral acyclovir 400 mg or placebo, three times per day, from 36 weeks' gestation until delivery as part of a prospective, double-blind trial. Herpes simplex virus cultures were obtained when patients presented for delivery. Vaginal delivery was permitted if no clinical recurrence was present; otherwise, a cesarean was performed. Neonatal HSV cultures were obtained and infants were followed-up clinically. None of the 21 patients treated with acyclovir and nine of 25 (36%) treated with placebo had clinical evidence of recurrent genital herpes at delivery (odds ratio [OR] 0.04, 95% confidence interval [CI] 0.002-0.745; P = .002). No woman treated with acyclovir had a cesarean for herpes, compared with nine of 25 (36%) of those treated with placebo (OR 0.04, CI 0.002-0.745; P = .002). No patient in either treatment group experienced asymptomatic genital viral shedding at delivery. No neonate had evidence of herpes infection or adverse effects from acyclovir. Suppressive acyclovir therapy reduced the need for cesarean for recurrent herpes in women whose first clinical episode of genital HSV occurred during pregnancy. Suppressive acyclovir treatment did not increase asymptomatic viral shedding and was not harmful to the term fetus.