The impact of exposure to parental intimate partner violence on adolescent precocious transitions to adulthood.

INTRODUCTION: Precocious transitions can create stress by placing excessive demands on adolescents and are associated with adverse outcomes that extend into adulthood. The current study assessed whether exposure to parental intimate partner violence (IPV) is associated with adolescent precocious transitions to adulthood. METHODS: Data come from 33,360 individuals aged 18+ years in the United States who participated in the National Epidemiologic Surveys of Alcohol and Related Conditions. Six precocious transitions (leaving home early, early sex, early marriage, early parenthood, early full-time employment, and dropping out of high school) were examined. Robust Poisson regression was used to calculate relative risks for the association between IPV exposure and each precocious transition, adjusting for confounders. We assessed effect modification by gender and by exposure to childhood abuse or neglect. RESULTS: Participants exposed to IPV in childhood were at higher risk of engaging in early sex; dropping out of high school; entering into early full-time employment; entering into early marriage; and entering into early parenthood relative to participants not exposed to IPV. Significant interactions between gender and exposure to IPV were detected for early sex and early full-time work outcomes, such that the associations were stronger for females compared to males. Participants exposed to more frequent or more severe IPV in childhood were at even higher risk for experiencing precocious transitions. CONCLUSIONS: Individuals exposed to IPV in childhood are more likely to experience precocious transitions to adulthood. Findings highlight the need for interventions to mitigate adverse outcomes in adolescence for children exposed to IPV.

Invasive Obstetric Procedures and Cesarean Sections in Women With Known Herpes Simplex Virus Status During Pregnancy.

BACKGROUND: Neonatal herpes is a potentially devastating infection that results from acquisition of herpes simplex virus (HSV) type 1 or 2 from the maternal genital tract at the time of vaginal delivery. Current guidelines recommend (1) cesarean delivery if maternal genital HSV lesions are present at the time of labor and (2) antiviral suppressive therapy for women with known genital herpes to decrease HSV shedding from the genital tract at the time of vaginal delivery. However, most neonatal infections occur in infants born to women without a history of genital HSV, making current prevention efforts ineffective for this group. Although routine serologic HSV testing of women during pregnancy could identify women at higher risk of intrapartum viral shedding, it is uncertain how this knowledge might impact intrapartum management, and a potential concern is a higher rate of cesarean sections among women known to be HSV-2 seropositive. METHODS: To assess the effects of prenatal HSV-2 antibody testing, history of genital herpes, and use of suppressive antiviral medication on the intrapartum management of women, we investigated the frequency of invasive obstetric procedures and cesarean deliveries. We conducted a retrospective cohort study of pregnant women delivering at the University of Washington Medical center in Seattle, Washington. We defined the exposure of interest as HSV-2 antibody positivity or known history of genital herpes noted in prenatal records. The primary outcome was intrapartum procedures including fetal scalp electrode, artificial rupture of membranes, intrauterine pressure catheter, or operative vaginal delivery (vacuum or forceps). The secondary outcome was incidence of cesarean birth. Univariate and multivariable logistic regressions were performed. RESULTS: From a total of 449 women included in the analysis, 97 (21.6%) were HSV-2 seropositive or had a history of genital herpes (HSV-2/GH). Herpes simplex virus-2/GH women not using suppressive antiviral therapy were less likely to undergo intrapartum procedures than women without HSV-2/GH (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.25-0.95; P = .036), but this relationship was attenuated after adjustment for potential confounders (adjusted OR, 0.69; 95% CI, 0.34-1.41; P = .31). There was no difference in intrapartum procedures for women on suppressive therapy versus women without HSV-2/GH (OR, 1.17; 95% CI, 0.66-2.07; P = .60). Similar proportions of cesarean sections were performed within each group of women: 25% without history of HSV-2/GH, 30% on suppressive treatment, and 28.1% without suppressive treatment (global, P = .73). CONCLUSIONS: In this single-site study, provider awareness of genital herpes infection either by HSV serotesting or history was associated with fewer invasive obstetric procedures shown to be associated with neonatal herpes, but it was not associated with an increased rate of cesarean birth.

High Rate of ß-Globin DNA Detection Validates Self-Sampling in Herpes Simplex Virus Shedding Studies.

BACKGROUND: Self-sampling is a convenient, feasible, and acceptable way of collecting genital specimens, but the veracity of reported self-collection is difficult to verify. We investigated whether a host gene, ß-globin, can be used to confirm adequacy of self-collected mucosal and skin genital specimens in studies of genital herpes simplex virus type 2 (HSV-2) infection. METHODS: Herpes simplex virus type 2-seropositive adults self-collected daily anogenital and oral swabs. Mucosal samples were tested for HSV DNA using a real-time quantitative polymerase chain reaction assay. A real-time Taqman polymerase chain reaction detecting the ß-globin gene was used to quantify host cells. RESULTS: One hundred twelve participants collected 5559 genital and 2002 oral swabs. Sixty (54%) were women, 65% were HSV-2 seropositive, and 35% were HSV-1 and HSV-2 seropositive by Western blot. ß-globin DNA was detected in 99% and 93% of swabs obtained from women and men, respectively. The quantity of ß-globin DNA detected was significantly higher when HSV was present in genital swabs in women (0.1 log10 copies/mL; P = 0.001) and in men (0.6 log10 copies/mL; P < 0.001), but not in oral swabs in women (0.2 log10 copies/mL; P = 0.08) or men (0.0 log10 copies/mL; P = 0.70). CONCLUSIONS: Human ß-globin DNA detection rate was high, and the quantity obtained significantly increased with genital, but not oral HSV shedding. The high rate of ß-globin DNA detection is consistent with high adherence to study procedures in longitudinal studies of genital herpes shedding.

Plasma and cerebrospinal fluid herpes simplex virus levels at diagnosis and outcome of neonatal infection.

OBJECTIVE: To evaluate the utility of quantitative herpes simplex virus (HSV) polymerase chain reaction (PCR) levels for prognosis and management of neonatal HSV disease. STUDY DESIGN: Clinical and virologic data were abstracted by medical record review from neonatal HSV cases treated at Seattle Children's Hospital between 1993 and 2012. HSV PCR results from plasma (n = 47), cerebrospinal fluid (n = 56), or both (n = 40) at the time of diagnosis were available from 63 infants; 26 with skin-eye-mouth (SEM), 18 with central nervous system (CNS), and 19 with disseminated (DIS) disease. RESULTS: Plasma HSV PCR was positive in 78% of the infants with SEM, 64% with CNS and 100% with DIS disease. Mean plasma viral level was 2.8 log10 copies/mL in SEM, 2.2 log10 copies/mL in CNS, and 7.2 log10 copies/mL in DIS infants. The HSV levels were higher among infants who died compared with surviving infants, 8.1 log10 copies/mL (range 7.7-8.6) vs 3.8 log10 copies/mL (range 0.0-8.6), P = .001, however, level of HSV DNA in the cerebrospinal fluid or in plasma did not correlate with neurologic outcome. Dynamics of HSV clearance from plasma during high-dose acyclovir treatment showed single-phase exponential decay with a median viral half-life of 1.26 days (range: 0.8-1.51). CONCLUSIONS: Plasma HSV levels correlate with clinical presentation of neonatal HSV disease and mortality, but not neurologic outcome.

A prospective cohort study of partner testing for herpes simplex virus and sexual behavior during pregnancy.

BACKGROUND: We investigated whether serotesting sexual partners of pregnant women for herpes simplex virus (HSV) improves adherence to safer-sex practices. METHODS: A total of 287 HSV-2-seronegative pregnant women were recruited, and their partners were invited for HSV serologic testing. On the basis of test results, women were placed into 4 groups: those at risk for HSV-2 infection, those at risk for HSV-1 infection, those whose partner was not tested, and those not at risk for HSV infection. Women received safer-sex counseling and completed diaries of sexual activity. RESULTS: Women in HSV-2-serodiscordant couples (ie, those in relationships in which they were at risk for HSV-2 acquisition) reported a smaller percentage of days with unprotected genital sex acts as compared to women who were not at risk (2% vs 8%; relative risk [RR], 0.3 [95% confidence interval {CI}, .1-.8]; P = .002) and to women whose partners' HSV status was unknown (2% vs 11%; RR, 0.2 [95% CI, .1-.8]; P = .02). Women in HSV-1-serodiscordant couples showed no difference in the frequency of genital sex acts, unprotected genital sex acts, or oral sex acts as compared to those not at risk and to those whose partners' status was unknown. CONCLUSIONS: Pregnant women at known risk of HSV-2 acquisition by partner serotesting were less likely to engage in unprotected genital sex acts than HSV-2-seronegative women with partners who were negative or not tested.

Hepatitis C virus is infrequently evaluated and treated in an urban HIV clinic population.

This retrospective cohort study of HIV/hepatitis C virus (HCV) coinfected patients evaluated time trends and rates of HCV evaluation for patients seen between January 1, 1997 and October 30, 2004. Survival analysis and Cox proportional hazards modeling were used to describe the time to evaluation and covariates associated with this outcome. Patients were predominantly white and male. Of 248 eligible patients, 108 (44%) were evaluated for HCV treatment. The median time to evaluation was 2.98 years. Of 108 evaluated, 17 (16%) received at least one dose of interferon and/or ribavirin. The median time to treatment after being evaluated was 1.39 years. Of the 17 (35%) treated 6 patients had a sustained virologic response, but only 2.4% of the original number of patients were cured. Approximately one half of patients in an HIV-specialty clinic were evaluated for HCV therapy and 16% received treatment, but the median time to treatment from the time of HCV diagnosis was over 4 years. Further efforts to identify and to overcome barriers to HCV treatment are warranted.

The acceptance of HSV-testing partners of HSV-2 seronegative pregnant women.

OBJECTIVES: To estimate the acceptance of HSV testing partners of HSV seronegative pregnant women and identify associated factors. STUDY DESIGN: Consecutive women identified as HSV-2 seronegative during routine testing in pregnancy were asked to invite their partners for HSV testing to identify serodiscordance. Logistic regression identified factors associated with partner testing. RESULTS: Between 2001 to 2006, 315 women enrolled (28% of those approached) and 242 (77%) partners were tested. Married couples were most likely to be tested [adjusted odds ratio (aOR) 7.72, 95% CI: 2.47-24.15]. Partners of black women (aOR 0.17, 95% CI: 0.04-0.71), and those with at least a college degree (aOR 0.43, 95% CI: 0.19-0.98) were less likely to be tested. CONCLUSIONS: In this population, partner testing among HSV-2 seronegative women was feasible which supports further study to determine if identification of partners who pose a potential risk of HSV infection during pregnancy is an effective approach to reduce HSV acquisition in pregnant women.

Impact of HIV infection and Kaposi sarcoma on human herpesvirus-8 mucosal replication and dissemination in Uganda.

INTRODUCTION: Kaposi sarcoma (KS) is the leading cause of cancer in Uganda and occurs in people with and without HIV. Human herpesvirus-8 (HHV-8) replication is important both in transmission of HHV-8 and progression to KS. We characterized the sites and frequency of HHV-8 detection in Ugandans with and without HIV and KS. METHODS: Participants were enrolled into one of four groups on the basis of HIV and KS status (HIV negative/KS negative, HIV positive/KS negative, HIV negative/KS positive, and HIV positive/KS positive). Participants collected oral swabs daily and clinicians collected oral swabs, anogenital swabs, and plasma samples weekly over 4 weeks. HHV-8 DNA at each site was quantified by polymerase chain reaction (PCR). RESULTS: 78 participants collected a total of 2063 orals swabs and 358 plasma samples. Of these, 428 (21%) oral swabs and 96 (27%) plasma samples had detectable HHV-8 DNA. HHV-8 was detected more frequently in both the oropharynx of persons with KS (24 (57%) of 42 persons with KS vs. 8 (22%) of 36 persons without, p = 0.002) and the peripheral blood (30 (71%) of 42 persons with KS vs. 8 (22%) of 36 persons without, p<0.001). In a multivariate model, HHV-8 viremia was more frequent among men (IRR = 3.3, 95% CI = 1.7-6.2, p<0.001), persons with KS (IRR = 3.9, 95% CI = 1.7-9.0, p = 0.001) and persons with HIV infection (IRR = 1.7, 95% CI = 1.0-2.7, p = 0.03). Importantly, oral HHV-8 detection predicted the subsequent HHV-8 viremia. HHV-8 viremia was significantly more common when HHV-8 DNA was detected from the oropharynx during the week prior than when oral HHV-8 was not detected (RR = 3.3, 95% CI = 1.8-5.9 p<0.001). Genital HHV-8 detection was rare (9 (3%) of 272 swabs). CONCLUSIONS: HHV-8 detection is frequent in the oropharynx and peripheral blood of Ugandans with endemic and epidemic KS. Replication at these sites is highly correlated, and viremia is increased in men and those with HIV. The high incidence of HHV-8 replication at multiple anatomic sites may be an important factor leading to and sustaining the high prevalence of KS in Uganda.

High-concentration supplemental perioperative oxygen to reduce the incidence of postcesarean surgical site infection: a randomized controlled trial.

OBJECTIVE: Most postcesarean infections are caused by anaerobic bacteria. Oxidative killing, an important defense against surgical infections, depends on the oxygen level in contaminated tissue. Among patients undergoing colorectal surgery, perioperative supplemental oxygen decreased infection rates by 50%. We tested the hypothesis that high-concentration inspired oxygen decreases the incidence of surgical site infection in women undergoing cesarean delivery. METHODS: Using a double blind technique, 143 women undergoing cesarean delivery under regional anesthesia after the onset of labor were randomly assigned to receive low- or high-concentration inspired oxygen via nonrebreathing mask during the operation and for 2 hours after. Surgical site infection was defined clinically as administration of antibiotics for postpartum endometritis or wound infection during the initial hospital stay or within 14 days of surgery. Interim statistical analysis was performed after 25% of the planned sample size (143 of 550) accrued using intention-to-treat principle. The stopping rule P value for futility was P>.11 with two planned interim analyses. RESULTS: Postcesarean infection occurred in 17 (25%, 95% confidence interval [CI] 15-35%) of 69 women assigned to high-concentration oxygen compared with 10 (14%, 95% CI 6-22%) of 74 women assigned to low-concentration inspired oxygen (relative risk 1.8, 95% CI 0.9-3.7, P=.13). The P value exceeded the P value for futility, suggesting these differences were unlikely to reach statistical significance with continued recruitment. CONCLUSION: High-concentration perioperative oxygen delivered through a nonrebreathing mask did not decrease the risk of postcesarean surgical site infection.

Internet and email use among STD clinic patients.

BACKGROUND: Little data exist on Internet and email use among STD clinic patients for research and clinical care communication. METHODS: An anonymous cross-sectional survey of STD clinic patients aged >/=18 years in Seattle, WA, March 13 to 22, 2006. RESULTS: Of 489 study period patients, 251 (51%) completed the questionnaire. Participants had a median age of 30 (range 18-66) years and were 69% male, 56% white, 19% black, 9% Hispanic, and 7% Asian/Pacific Islander. Of all participants, 75% had some postsecondary education but half reported an annual income of

One-day regimen of valacyclovir for treatment of recurrent genital herpes simplex virus 2 infection.

OBJECTIVES: To evaluate the efficacy of a 1-day course of valacyclovir in reducing the duration and severity of genital herpes recurrences and to measure the frequency of viral shedding episodes subsequent to antiviral therapy. STUDY DESIGN: In an open-label pilot study, patients with recurrent genital herpes simplex virus 2 (HSV-2) infection were given a 1-day course of valacyclovir (2000 mg given by mouth twice daily) to be taken at the first sign of recurrence or prodrome. Participants maintained diaries of signs and symptoms and collected genital swabs for viral culture while lesions persisted and HSV DNA PCR for 14 days after initiating treatment. RESULTS: Ninety (78%; 41 men, 49 women) of the 115 enrolled persons experienced either a lesional recurrence or prodrome. Seventy-seven (86%) participants developed lesions; 4 (5%) participants experienced a second lesional recurrence during the 14-day study period. The median lesion duration was 5 days, episode duration was 5 days, and pain duration was 3 days. Viral shedding was detected in 60 persons by PCR and 31 persons by culture. Shedding detected by culture lasted for a median of 2 days, and shedding detected by PCR lasted for a median of 3 days. Of 60 participants with viral shedding, 14 (23%) had an additional shedding episode after their initial lesion healed, lasting for a median of 2 days. CONCLUSIONS: A 1-day course of valacyclovir may be a convenient treatment for recurrent genital herpes and comparative trials are warranted.

Prenatal herpes simplex virus serologic screening beliefs and practices among obstetricians.

OBJECTIVE: To describe the beliefs and practices of obstetricians related to prenatal serologic testing for HSV infection. METHODS: A total of 265 (73% of eligible) currently practicing obstetricians in Washington State completed a 36-question mailed survey that assessed beliefs regarding genital herpes in pregnancy, neonatal herpes, serologic testing for herpes in pregnancy, and ease of testing. RESULTS: Ninety-five percent of respondents believed genital herpes was common in reproductive-aged women, 83% believed neonatal herpes was a serious health issue, and 73% believed it warranted systematic prevention efforts; 74% discussed herpes with pregnant patients as part of prenatal care, 31% provided written materials about herpes, and 15% used serologic tests for herpes in 75% or more of their prenatal patients. Factors independently associated with routine herpes serologic testing were academic practice setting (adjusted odds ratio [aOR] 10.4, 95% confidence interval [CI] 2.8-39.1) and metropolitan practice setting (aOR 3.3, 95% CI 1.4-7.9). Beliefs that testing would cause unnecessary distress in pregnancy (aOR 0.3, 95% CI 0.1-0.7), or that testing was not worth the expense (aOR 0.1, 95% CI 0.0-0.6) were associated with not testing. Availability of serologic tests for HSV was reported to be high and was not associated with prenatal HSV testing. CONCLUSION: Most obstetricians believe neonatal herpes prevention is important. LEVEL OF EVIDENCE: II.

HSV-2 serologic testing in an HMO population: uptake and psychosocial sequelae.

OBJECTIVES: To prospectively measure the uptake of Herpes simplex virus Type 2 (HSV-2) testing and psychosocial response to a new serologic diagnosis of HSV-2 in a health maintenance organization (HMO) population. STUDY DESIGN: Randomly selected urban HMO enrollees were invited to be tested for HSV-2 antibody at a research clinic. Participants had blood drawn and completed demographic and psychosocial questionnaires. RESULTS: Of 3111 eligible enrollees contacted, 344 (11%) were tested. Eighty-seven (26%) tested HSV-2 seropositive, and 44 (51%) of these did not report a prior genital herpes diagnosis. Distress, measured by the total mood disturbance, was 6.5 points higher on average following a new genital herpes diagnosis relative to baseline (actual range = 109 points, P = 0.003) but not statistically different from HSV-2 negative or previously diagnosed participants. CONCLUSIONS: HMO enrollees unexpectedly testing HSV-2 positive showed short-term psychosocial distress that resolved during 6-month follow-up. Findings suggest that concerns about psychosocial burden should not deter voluntary serologic HSV-2 testing in primary care settings.