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Female sex workers in Europe have low levels of sexually transmitted infections, attributable to condom use. The aim of this paper is to describe the seroepidemiology of HSV-1 and HSV-2 in female sex workers in London by using a year prospective study of sex workers. We show that a cohort of sex workers with extensive condom use and little known sexually transmitted infection have high levels of HSV-1 and HSV-2 infection, suggesting that condoms may not be universally protective. Rates of prostitutes in budhwar peth rockville workers are candidates for HSV vaccine efficacy or intervention studies.
The incidence of diagnosed genital herpes in the United Kingdom has steadily increased over recent decades [ 12 ].
Genital herpes has a wide geographic and behavioural distribution that extends well beyond populations considered to be at high risk for other infections such as gonorrhoea. Recently a ificant variation in the seroprevalence of HSV in the general population across Europe has been shown [ 3 ]. General populations, cohorts of young females and patients attending hospital have been investigated but the seroprevalence of HSV-1 and HSV-2 in sex workers is not known. Historically sex workers are a highly mobile and distinct group in terms of sexual behaviour compared to the general population.
Any successful interventions to control genital herpes, whether through vaccination, therapy or behaviour change, would have to reach a large proportion of the sexually active population. There are a of likely limitations: obstacles to the widespread delivery and acceptance of a vaccine against a sexually transmitted infection Rates of prostitutes in budhwar peth rockville [ 7 ], the identification of appropriate individuals for suppressive therapy to reduce onward transmission, and the relative ineffectiveness of condoms against HSV transmission [ 8 ].
Suppressive therapy has mainly been indicated for prevention of recurrent attacks, but has also been shown to have some impact on transmission within HSV discordant partnerships [ 9 ]. It is unlikely that this would have any impact at a population level unless targeted at groups that contribute disproportionately to transmission.
These include people with serological evidence of infection who remain undiagnosed [ 1011 ]. We, therefore, investigated the epidemiology of HSV infection in a cohort of female sex workers in London and discuss whether they are an appropriate group for screening and intervention. This particular cohort has been well described, and has high rates of partner change, high rates of condom use and relatively low rates of bacterial STI and HIV infection [ 1213 ].
The Praed Street Project is a clinical and health promotion service for female sex workers in West London. From tonew attendees were invited to participate in research into health and risk behaviour. Detailed methods are reported elsewhere [ 1213 ]; briefly, baseline information is collected through interview covering social, sexual and medical history. Time in sex work was calculated from recruitment data and reported date of first sex work. Information on condom use was ascertained through interview with questions on the month for male non-paying partners boyfriends and week or most recent week worked for clients.
After giving informed consent, women being tested for HIV antibodies donated additional serum for storage.
Participants were invited to re-attend the clinic for regular screening or when prompted by symptoms or other concerns. Incidence was calculated for those who were initially seronegative and who had more than one sample over time, using the denominator of total time from first test, censored at the time of first positive or last negative test.
The likelihood ratio test and Wald statistic were used to assess whether to remove or retain variables in the model. Sampling bias was explored by comparing behaviour data including clinical HSV history of those who had serological tests with those who did not provide samples for storage. The study was approved by the local research ethics committee.
We explored the potential of selection bias resulting from the inclusion of less than half of project attendees but found no ificant differences in demographic, medical or risk characteristics between those who had samples and those who did not see Table 1. Exploration of potential selection bias: characteristics of sex workers who had serum stored compared with those who did not.
In total, women had available for both as shown in Table 2. HSV-1 increased with age, was higher in women from developing countries or from countries in transition, and increased slightly over time.
The prevalence was highest in women who were born in a developing country and lowest in those from developed countries other than the United Kingdom. Rates were also increased in women with a history of gonorrhoea, with a boyfriend at first visit, and slightly lower in those who did not use condoms consistently for oral rates of prostitutes in budhwar peth rockville with clients. To adjust for confounding particularly between year of recruitment, country of origin and time in sex work, we developed a logistic regression model. Evidence of seroconversion was seen in three of 28 women who were initially HSV-2 negative and had later samples.
There were too few data to perform further analysis on this group.
A further eight women with a history of genital herpes had antibodies to HSV-1 only. The relatively high prevalence of HSV-1 and the small increase over time is likely to reflect the demographics of the population.
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The strongest association of seropositivity for HSV-1 was with origin in countries of the former Soviet Union and Eastern Europe where the background prevalence is higher [ 3 ]. The association with duration of sex work contrasts with earlier reports from this population where STI risks were associated primarily with non-commercial sexual contacts [ 1213 ].
Using this cross-sectional study de, we were unable to explore the relationship between condom use and HSV-2; our condom use data relate to the very recent past while HSV-2 could have been acquired at any time. However, long-term studies in this population show high levels of sustained condom use at work and so it is perhaps surprising that levels of HSV-2 are so high; particularly as condoms may at least be partially protective against HSV [ 16 ]. Our data suggest that HSV-2 antibodies remain a broad marker for cumulative sexual activity, even where condom use is widespread [ 4 ].
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The changing prevalence of these herpes viruses over time requires further investigation to be fully explained. The changing demography of sex workers [ 12 ] in London may explain the small rise in HSV-1, but does not fully explain the decline in HSV More recently, women attending the project reported shorter time in sex work, yet the temporal decline persists after controlling for this factor. It was not possible, however, to demonstrate this connection in our study as we did not have data on the site of clinical herpes.
There are a of limitations to this study, including the small of participants each year and the potential sampling bias, with only a proportion of sex workers having serum stored and tested. We did not identify any systematic bias, but this does not exclude the possibility.
The other major limitation relates to the de of the study, with most data coming from the baseline. We had too few longitudinal data to analyse risk factors for incidence, in part due to the high prevalence of infection at baseline.
The implications of this study are first that sex workers are at increased risk of acquiring herpes simplex infection despite sustained high levels of condom use. Even systematic use of condoms should be considered safer sex not safe sex. Sex workers need to be advised that condoms are not fully protective.
Finally, should we be advocating screening for HSV-2 infection in this population? Evidence of infection of unknown origin, duration or implications for transmission would be difficult to manage without adding to stigma.
Screening followed by counselling and suppressive therapy for the duration of time in sex work would be time consuming and costly, and the benefits would be difficult to establish [ 8 ]. In contrast, a vaccine that prevents acquisition may be of great benefit both to sex workers and to their sexual partners if given early in a sex worker's career; sex workers should be considered for efficacy or intervention studies for candidate HSV vaccines.
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Thanks to all participants, and to the many collaborators who have contributed to this work over the years including John Clarke of the Jefferiss Laboratories, Anna Pallecaros and other staff of the Praed Street Project and the Jefferiss Wing Clinic, and to Reija Koukakis for assistance with data handling and preliminary analysis. Funding for this study was provided by the Wellcome Trust grant no. National Center for Biotechnology InformationU. Journal List Epidemiol Infect v. Epidemiol Infect.
Published online Mar WARD 4. Author information Article notes Copyright and information Disclaimer. : ku. Accepted Jan This article has been cited by other articles in PMC. Table 1 Exploration of potential selection bias: characteristics of sex workers who had serum stored compared with those who did not. Open in a separate window.
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