High Prevalence Of Alphaherpes Virus 2 (HSV-2) Positivity In Prisons From Midwest Brazil: A Cross-Sectional Study


 Herpes virus 2 (HSV-2) is the main cause of genital herpes, one of the most prevalent sexually transmitted infections (STIs) in the world. STIs are major public health problems in prisons because of the behaviors of prisoners and the presence of other factors that increase the risk of transmission. The present study aimed to estimate the prevalence and risk factors associated with HSV-2 infection at 12 prisons in Mato Grosso do Sul, Brazil. We tested 872 serum samples (732 from males, 140 from females) for anti-HSV-2 IgG, and tested the positive samples (n = 184) for anti-HSV-2 IgM. Anti-HSV-2 IgG positivity (n = 85, 43.1%, 95% CI = 34.6 to 40.4). The prevalence of HSV-2 positivity was much greater than reported in the general population of Brazil and in other prison populations worldwide. There was a greater risk of HSV-2 positivity in prisoners who were older, female, unmarried, HIV positive, positive for other STIs, not previously incarcerated, in the same cell with more than 26 individuals, and in those who reported having had genital discharge in the past month, having had a homosexual relationship in recent months, and not using or occasionally not using condoms during sexual intercourse. Further analysis of prisoners with active HSV-2 infections (anti-HSV-2 IgM positivity) indicated that unmarried status and the presence of 26 or more prisoners in the same cell increased the risk for active HSV-2 infection. This study provides important data on HSV-2 seroprevalence in the prison population of Brazil, and identified risk factors associated with HSV-2 infection. These data provide important information needed to implement procedures that better prevent and control of STIs in prison populations.


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Background 2 Individuals living in precarious environments such as prisons, which are typically 3 characterized by poverty, conflict, discrimination, and apathy, often have poor health [1]. 4 In particular, prisoners have a high risk for infectious diseases. Moreover, the 5 confinement and conditions in prisons make it difficult for these individuals to access 6 integrated and effective health care services [2]. Individuals in prisons throughout the 7 world have increased risk for many health problems. When convicted, prisoners in 8 precarious prisons, police stations, houses of detention/correction, and similar institutions 9 are typically exposed to environments with poor sanitary conditions, and they are 10 confined and in close proximity to others with infectious diseases. A recent study 11 described the prison environment as a site with great concentration and amplification of 12 situations and risk factors that facilitate the spread of infections [3]. Many factors favor 13 the spread of infectious diseases among prisoners, such as their idleness, overcrowding, 14 stress caused by incarceration and disruption of social and family ties, poor sanitary 15 conditions, physical abuse, dependence on licit and illicit toxic substances (alcohol and 16 tobacco), handmade tattoos, sharing of piercing-sharps, gestation without prenatal care, 17 and social marginalization [4] [5]. 18 Brazil has the third-largest overall prison population in the world, according to 19 data of the Ministry of Justice. In 2019, there were 729.949 Brazilians in jail [6]. 20 The Human alphaherpesvirus 2 (HSV-2) is primarily responsible for genital 21 herpes, and is widely distributed worldwide [7]. In addition, this virus is efficiently 22 transmitted, has rapid replication, and can remain latent in the sensory nerves for long 23 periods [8]. There are many symptoms of HSV-2 infections, including oropharyngeal, 24 cutaneous, and genital diseases, and encephalitis [9]. The initial infection usually 25 manifests as an ulcerative lesion in the genitalia, and is more common in adolescents and 26 sexually active adults [10]; [11]; [12]. After an acute primary infection, the virus often 27 remains latent in the sensory ganglia, and may spontaneously re-activate depending on 28 the immune status and genetic predispositions of the patient. Reactivation may lead to 29 recurrent lesions or genital herpes, with manifestations ranging from asymptomatic viral 30 excretions to painful symptomatic blisters [13]; [14]; [15]. 31 The World Health Organization (WHO) estimated that 417 million people aged 32 15 to 49 years have HSV-2 infections [16]. There is no compulsory notification for HSV- 33 2 infections, so data on the prevalence and incidence in Brazil are limited. Researchers 34 believe there is a high rate of HSV infection in Brazil, even though most individuals are 35 asymptomatic. The health ministry estimated that more than 90% of Brazilians have 36 antibodies against HSV-1 and/or HSV-2, even though the majority have never presented 37 with symptoms [17]. Some behaviors may increase the risk of HSV-2 infection, and these 38 are the same factors that increase the risk of sexually transmitted infections (STI) in 39 general populations: unprotected sexual activity, sexual intercourse with many 40 homosexual or heterosexual partners, sexual violence, unprotected sex between inmates, 41 and intimate visits with prisoners [2]. Given the lack of prevention policies regarding   A team of trained health professionals performed the interviews, which were 72 conducted while the prisoners were sunbathing. The interviewers always maintained a 73 safe distance from the interviewees to guarantee the physical integrity of interviewers of 74 the participants. The study subjects were told that participation was voluntary, and they 75 had a right to refuse without any threat of reprisal.

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A simple random probability sampling form was used, so that participants were 77 likely to be representative of the overall population, thus ensuring the internal validity of 78 the study. The collected serum samples were sent to the Oswaldo Cruz Foundation, Rio

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de Janeiro, to be tested for HSV-2.

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The number of subjects (N) was determined as: N = z 2 × p × (1p)/e 2 . Where z 81 is the confidence level based on a standard normal distribution (1.96 for 95%), p is the 82 expected prevalence (0.113 in the general population, because no data were available for 83 the study population), and e is the maximum acceptable error in the estimate (0.05).   The questionnaire data were entered into a database. Inferential statistics using 97 Pearson's χ 2 analyses were calculated, and all variables that were significant at the 98 univariate level (p < 0.05) were entered into unadjusted and adjusted logistic regression 99 models to predict the ORs and 95% CIs for associations with the dependent variable (anti-

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Characteristics of the study population 104 Analysis of the sociodemographic characteristics of the participating prisoners 105 (Table 1) indicated that a majority were male (84%), had fewer than 4 years of education 106 (66.7%), were married (60%), and were not users of injection drugs (84%). Most 107 participants (82%) worked before incarceration, and 65% of women and 94.6% of men 108 said they were not injectable drug users (IDUs). The average incarceration time was 17 109 months, and most participants were previously in jail. Analysis of the sexual histories of 110 the participants indicated that 94.1% were heterosexual, but 11.6% reported having a 111 previous homosexual relationship. In addition, 34.3% reported using condoms only 112 sometimes or never during intercourse.

Multivariable analysis 120
The multivariable model (  We further analyzed patients with active HSV-2 infections, based on anti-HSV-2 127 IgM positivity ( Table 3). The results of this multivariable analysis which adjusted for the 128 same factors in Table 2 indicated that non-married status (aOR=2.6, 95% CI = 1.03 to 129 6.5) and the presence of 26 or more prisoners in the same cell (aOR = 2.9, 95% CI = 1.2 130 to 7.2) were significantly associated with active HSV-2 infection. 131 Table 3: Multivariable analysis of factors associated with the presence of active HSV-2 infection* (n = 85) among those who were positive for anti-HSV-2 IgG (n = 184).

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The present study is the first epidemiological study of the seroprevalence of 133 HSV-2 in prisoners at penal establishments of Brazil.

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Our results have several important implications for public health. First, the 135 overall prevalence of HSV-2 infection was 43.1%, almost four-times higher than the 136 global prevalence (11.3%; [16,18], and also higher than the prevalence in the general 137 population of Brazil (about 30%; [19]. The prevalence of HSV-2 infection in this study 138 was also higher than reported in previous studies of prisoners elsewhere in the world. For 139 example, the seroprevalence was 20.5% at prisons in northern Italy, 21.3% at prisons in 140 southern Italy [20], 19.9% in a cross-sectional regional level study of prisons in Portugal 141 [21], and 14.5% at prisons in Nigeria [22].

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The higher prevalence of HSV-2 infection in Brazil may be due to the 143 ineffectiveness of its prison organization, in which incarceration can directly and 144 indirectly cause adverse health effects [3]. 145 We also found that the estimated prevalence of HSV-2 infection was greater in 146 female (68%) than male (37%) prisoners. Statistical analysis indicated the prevalence was 3.4-fold greater in women (95% CI = 2.3 to 5.0). A similar study in Australia [23] also 148 reported that women had a higher seroprevalence rate for HSV-2 than men. This may be 149 because the signs and symptoms in women occur in the vaginal mucosa, and therefore 150 tend to be less visible [24,25]; [26]. In addition, the sexual transmission of herpes from 151 men to women is much more efficient than the transmission from women to men [ are older simply have more years during which they could possibly be exposed.

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Our results indicated that prisoners who already had another STI had a nearly 5- STIs, including HIV [29]; this study also found that HIV seropositivity was associated 164 with a 5-fold increased risk for HSV-2 infection (95% CI = 3.1 to 9.8). A 2017 study by 165 our group found that the prevalence of HSV-2 in HIV-positive pregnant women was 3-166 fold greater than the prevalence of HIV-negative pregnant women [30].

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The presence of anti-HSV-2 IgM was detected in 46% of prisoners who were IgM positivity [36]. We also found that the presence of more prisoners in the same cell 186 (<26 vs. 26 to 50) is associated with an increased risk of active HSV-2 infection (aOR = 187 2.9, 95% CI = 1.2 to 7.2). This is likely because overcrowding increases contact among 188 prisoners, and is also associated with more intimate contact and worse hygiene.