title: Proportion of new HIV infections attributable to herpes simplex 2 increases over time: simulations of the changing role of sexually transmitted infections in sub-Saharan African HIV epidemics.
abstract: OBJECTIVE
  To understand the changing impact of herpes simplex 2 (HSV-2) and other sexually transmitted infections (STIs) on HIV incidence over time in four sub-Saharan African cities, using simulation models.
  
  
  METHODS
  An individual-based stochastic model was fitted to demographic, behavioural and epidemiological data from cross-sectional population-based surveys in four African cities (Kisumu, Kenya; Ndola, Zambia; Yaoundé, Cameroon; and Cotonou, Benin) in 1997. To estimate the proportion of new HIV infections attributable to HSV-2 and other STIs over time, HIV incidence in the fitted model was compared with that in model scenarios in which the cofactor effect of the STIs on HIV susceptibility and infectivity were removed 5, 10, 15, 20 and 25 years into the simulated HIV epidemics.
  
  
  RESULTS
  The proportion of incident HIV attributable to HSV-2 infection (the model estimated population attributable fraction (PAF(M))) increased with maturity of the HIV epidemic. In the different cities, the PAF(M) was 8-31% 5 years into the epidemic, but rose to 35-48% 15 years after the introduction of HIV. In contrast, the proportion of incident HIV attributable to chancroid decreased over time with strongest effects five years after HIV introduction, falling to no effect 15 years after. Sensitivity analyses showed that, in the model, recurrent HSV-2 ulcers had more of an impact on HIV incidence than did primary HSV-2 ulcers, and that the effect of HSV-2 on HIV infectivity may be more important for HIV spread than the effect on HIV susceptibility, assuming that HSV-2 has similar cofactor effects on HIV susceptibility and infectivity. The overall impact of other curable STIs on HIV spread (syphilis, gonorrhoea and chlamydia) remained relatively constant over time.
  
  
  CONCLUSIONS
  Although HSV-2 appears to have a limited impact on HIV incidence in the early stages of sub-Saharan African HIV epidemics when the epidemic is concentrated in core groups, it has an increasingly large impact as the epidemic progresses. In generalised HIV epidemics where control programmes for curable STIs are already in place, interventions against HSV-2 may have a key role in HIV prevention.
authors.affiliation: Harvard Medical School, Francis Weld Peabody Society, 260 Longwood Ave, Boston, MA 02115, USA. freeman@hms.harvard.edu
authors.forename: Esther E
authors.initials: EE
authors.lastname: Freeman
authors.forename: Kate K
authors.initials: KK
authors.lastname: Orroth
authors.forename: Richard G
authors.initials: RG
authors.lastname: White
authors.forename: Judith R
authors.initials: JR
authors.lastname: Glynn
authors.forename: Roel
authors.initials: R
authors.lastname: Bakker
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Boily
authors.forename: Dik
authors.initials: D
authors.lastname: Habbema
authors.forename: Anne
authors.initials: A
authors.lastname: Buvé
authors.forename: Richard
authors.initials: R
authors.lastname: Hayes
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa / Q000453:epidemiology; D003430:Cross-Sectional Studies; D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000821:virology; D006558:Herpes Genitalis / Q000150:complications / Q000453:epidemiology*; D018258:Herpesvirus 2, Human; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012307:Risk Factors; D012680:Sensitivity and Specificity; D012725:Sexual Behavior / Q000706:statistics & numerical data; D012749:Sexually Transmitted Diseases / Q000150:complications / Q000453:epidemiology; D013269:Stochastic Processes; D014504:Urban Health / Q000706:statistics & numerical data