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Original research
HSV-infection-related herpetic anogenital ulcer disease among PLWH in southeastern US: electronic medical record based analysis
  1. Yuanfan Ye1,
  2. Greer A Burkholder2,
  3. Howard Wiener1,
  4. Stella Aslibekyan1,
  5. Ashraf E Khan3,
  6. Sadeep Shrestha1
  1. 1Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
  2. 2Division of Infectious Diseases, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
  3. 3Disease Control, Jefferson County Department of Health, Birmingham, Alabama, USA
  1. Correspondence to Dr Sadeep Shrestha, Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA; sshresth{at}


The southeastern US is a domestic epicentre for incident HIV with high prevalence of herpes simplex virus (HSV) coinfection. We estimated the incidence rates (IR) of symptomatic herpetic anogenital ulcer disease (HAUD) and assessed its associations with demographic and clinical characteristics, specifically with immunological markers using median, nadir and trajectory CD4 counts.

Methods Electronic medical records (EMR) of over 7000 people living with HIV (PLWH) attending one of the leading HIV clinics in the southeastern US between 2006 and 2018 were reviewed and analysed. IR of HSV-related HAUD were estimated per 10 000 person years. Joinpoint regressions were performed to examine temporal changes in the trends of IR. All IR and trends were stratified by gender and race. Six CD4 trajectory groups were constructed using the group-based trajectory modelling. Multivariable logistic models were conducted to assess the associations of CD4 counts (nadir, median CD4 and newly defined CD4 trajectory), separately with HAUD.

Results Of the 4484 PLWH eligible individuals (3429 men, 1031 women and 24 transgender), we observed 425 patients with HSV-related HAUD. The mean log10viral load was higher in HAUD than HAUD-free groups, whereas the median nadir CD4 count (cells/uL) was higher in the non-cases than the case groups (p<0.05). HAUD were more frequent in women than men. Median CD4 (<200 cell/uL) was associated with HAUD (OR=2.1), but there were no significant associations with nadir CD4. Significant associations with declining and sustained low CD4 counts trajectory patterns were observed with HAUD.

Conclusions There were significant differences between men and women with incident HAUD among PLWH. EMR-based studies can provide innovative trajectory models that can potentially be helpful in guiding screening and clinical care of HAUD among high-risk PLWH.

  • HSV
  • HIV
  • genital ulcers

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  • Handling editor Jonathan Ross

  • Contributors YY, GAB and SS conceived the study. HW participated in statistical approach. YY processed and analysed the data. YY and SS interpreted the data and wrote the manuscript. All authors have reviewed and approved the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the UAB Institutional Review Board for Human Use (IRB-170329001) and performed in accordance with the ethical guidelines of the Declaration of Helsinki. All informed consents were signed by the patients. Animals were not used in the study.

  • Data availability statement Data are available on reasonable request. The data used for the manuscript is available through the Research and Informatics Service Center (RISC) at the University of Alabama at Birmingham (

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