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Foreskin inflammation is associated with HIV and herpes simplex virus type-2 infections in Rakai, Uganda
Global Health Sciences Literature Digest
Published February 3, 2010
Journal Article

Johnson KE, Sherman ME, Ssempiija V, et al. Sherman ME, Ssempiija V, et al. Foreskin inflammation is associated with HIV and herpes simplex virus type-2 infections in Rakai, Uganda. AIDS. 2009 Jul 3.

In Context

Trials in sub-Saharan Africa have demonstrated that adult male circumcision reduces acquisition of HIV, symptomatic genital ulcer disease, and herpes simplex virus (HSV)-2. This is consistent with other findings that HIV acquisition is facilitated by HSV-2, possibly through local mucosal inflammation and recruitment of target lymphocytes. This study was performed to obtain pathological and histological findings to expand epidemiological and trial findings.


To assess the presence, type and extent of foreskin inflammation associated with HIV and HSV-2 infection in African men


Rakai District, southwestern Uganda

Study Design

Primarily cross-sectional (foreskin pathology) with longitudinal blood draws as part of two ongoing circumcision trials


Taking part in the study were 97 HIV-infected and 135 HIV-uninfected men, aged 15-49 years, already enrolled in two randomized controlled trials of the effect of circumcision on HIV acquisition and transmission. Men infected with HIV were enrolled if they had >350 CD4 cells/mL and no AIDS-defining illness.


Extent, intensity, and cellular composition of infiltrates in the epithelium and stroma of circumcised foreskin tissues, and their association with HIV infection, HIV/HSV-2 co-infection, and HSV-2 infection alone.


Men in the parent trials were randomized to receive immediate circumcision by the sleeve procedure or to be in a control group. At 24 months, men in the control arms also underwent circumcision. All men were followed regularly with physical examination, questionnaires, and blood draws for HIV and HSV-2, if seronegative at baseline. Paraffin sections of foreskin samples obtained by circumcision were stained with hematoxylin and eosin to assess inflammatory infiltrates; an ordinal scoring system of 0-3 was used to grade extent, intensity and cellular composition of infiltrates. Inflammation was assessed by two pathologists. Immunohistochemistry was performed for qualitative identification of CD4 and CD8 cells via light microscopy. Viral load was evaluated using the Roche Amplicor v1.5 assay, and HSV-2 infection was determined using an immunoglobulin (Ig)G enzyme-linked immunosorbent assay (Kalon Biologicals), with seropositivity defined as a Kalon index value of ≥1.5. Multivariate Poisson regression was used to identify factors independently associated with epithelial and stromal inflammation, using prevalence rate ratios (PRR).


At enrollment, 33% of men were HIV/HSV-2 coinfected, 28% had HSV-2 only, 9% had HIV only, and 31% had neither. By the 24-month follow-up, there were an additional 15 incident HSV-2 infections. Overall, foreskins from 82 (35%) men were found to have any inflammation; focal mononuclear infiltrates predominated, with a mixture of both CD4 and CD8 subsets. The frequency of epithelial and stromal inflammation, respectively, was 4% and 14% in men without infection, 8% and 30% in those with HSV-2 alone, 19% and 33% in those with HIV alone, and 32% and 60% in dually infected men. Foreskins from men with incident HSV-2 showed no significant difference in inflammation compared with HSV-2 seroprevalent men.

The following were independently associated with epithelial inflammation: HIV/HSV-2 coinfection (PRR=6.1, 95% confidence interval [CI]: 1.8-20.1; P=0.003); smegma on examination (PRR=5.9, 95% CI: 1.4-24.4; P=0.01); and self-report of genital ulceration (PRR=2.4, 95% CI: 1.1-5.3; P=0.03). The following were associated with stromal inflammation: HIV/HSV-2 coinfection, PRR=3.6, 95% CI: 2.0-6.9; P<0.001); and smegma (PRR=3.0, 95% CI: 1.2-7.2; P=0.02). Having HIV or HSV-2 alone and self-report of four or more sexual partners were associated with inflammation, but did not reach statistical significance.

HIV-seropositive men were much more likely to have epithelial inflammation (29% vs. 6%) and stromal inflammation (55% vs. 22%), compared to those without HIV (P<0.001). The intensity of stromal inflammation was also higher among those with HIV infection. Among men with higher viral loads, epithelial inflammation was present in 44%, compared with 15% of those with viral loads of <4.5 log10 cells/mL.


HIV and HSV-2 infections are associated with inflammatory changes in the foreskins of men and are most pronounced among those with coinfection and high HIV viral loads. The finding of primarily mononuclear infiltrates suggests local immune activation from chronic viral infection. Results support other findings that subclinical HSV-2 inflammation can persist for many weeks after resolution of visible lesions. The presence of smegma, possibly due to poor hygiene, also may contribute to inflammatory changes.

Quality Rating

This study was of high quality. Some of the methodology could have been described in more detail. Data and skin specimens were from men already enrolled in other trials, but it was not stated what proportion of those men were included in this study. Although two pathologists were used to evaluate and grade specimens, it was not clear if all slides were evaluated by both and how discrepancies were resolved. No mention was made of whether any men in the control groups HIV seroconverted.

Programmatic Implications

These findings primarily lend pathological evidence to support the relation between HIV and HSV-2 infection. Men with HSV-2 infection may be more likely to transmit or to acquire HIV, in part due to the inflammatory changes present in the foreskin. Men with HSV-2 need to know that inflammation, and therefore HIV viral shedding, may be increased even if no visible lesions are present. Genital hygiene in uncircumcised men may help reducing the risk of HIV transmission and acquisition. Condom use continues to be needed.