Population-level effect of HSV-2 therapy on the incidence of HIV in sub-Saharan Africa
- R G White1,
- E E Freeman1,
- K K Orroth1,
- R Bakker2,
- H A Weiss1,
- N O’Farrell3,
- A Buvé4,
- R J Hayes1,
- J R Glynn1
- 1London School of Hygiene and Tropical Medicine, London, UK
- 2Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- 3Pasteur Suite, Ealing Hospital, London, UK
- 4Institute of Tropical Medicine, Antwerp, Belgium
- Dr R G White, Infectious Disease Epidemiology Unit, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK;
- Accepted 30 April 2008
Background: Herpes simplex virus type 2 (HSV-2) infection increases acquisition and transmission of HIV, but the results of trials measuring the impact of HSV-2 therapy on HIV genital shedding and HIV acquisition are mixed, and the potential impact of HSV-2 therapy on the incidence of HIV at the population level is unknown.
Methods: The effects of episodic and suppressive HSV-2 therapy were simulated using the individual-level model STDSIM fitted to data from Cotonou, Benin (relatively low HIV prevalence) and Kisumu, Kenya (high HIV prevalence). Clinician- and patient-initiated episodic therapy, started when symptomatic, were assumed to reduce ulcer duration. Suppressive therapy, given regardless of symptoms, was also assumed to reduce ulcer frequency and HSV-2 infectiousness.
Results: Clinician-initiated episodic therapy in the general population had almost no effect on the incidence of HIV. The impact of patient-initiated therapy was higher because of earlier treatment initiation, but still low (<5%) unless symptom recognition and treatment-seeking behaviour were very high. Suppressive therapy given to female sex workers (FSW) in Kisumu had little effect on population HIV incidence. In Cotonou, suppressive therapy in FSW with high coverage and long duration reduced population HIV incidence by >20% in the long term. Impact was increased in both cities by also treating a proportion of their clients. Long-term suppressive therapy with high coverage in the general population could reduce HIV incidence by more than 30%.
Conclusions: These results show that HSV-2 therapy could potentially have a population-level impact on the incidence of HIV, especially in more concentrated epidemics. However, a substantial impact requires high coverage and long duration therapy, or very high symptom recognition and treatment-seeking behaviour.
Funding: RGW is funded by the MRC (UK) and the Wellcome Trust, and EEF is funded by the Wellcome Trust (grant 069509/Z/02/Z) and the Marshall Scholarship Commission for their financial support. The funders had no involvement in the design, collection, analysis or interpretation of the data, in writing the report or in the decision to submit.
Competing interests: None.