Tissues from 97 HIV-infected and 135 HIV-uninfected individuals were evaluated for inflammation. The median age was 30 years, and 64.2% (149/232) were married. Nearly one-third of participants (34.9%, 81/232) reported four or more sexual partners in the past 5 years (). One-third (32.8%, 76/232) were coinfected with HIVand HSV-2, 27.6% (64/232) were infected with HSV-2 alone, and a minority (9.1%, 21/232) with HIV alone. Overall, 53.5% of men (123/230) were HSV-2-seropositive at study enrollment. At 24-month follow-up, there were 15 incident HSV-2 infections among the 69 initially HSV-2-negative participants, increasing the overall proportion of HSV-2 infections among all men studied to 60.0% (140/232). In HIV-infected men, 76 of 97 (78.3%) were HSV-2 seropositive, compared with 47 of 133 (35.3%) of HIV-uninfected men (P=<0.001).
Participant characteristics, prevalence of inflammation and univariate prevalence rate ratios for epithelial and stromal inflammation
shows the prevalence and univariate PRR estimates for epithelial and stromal inflammation. The frequency of epithelial inflammation was 4.2% in men with neither HIV nor HSV-2 infection, 7.8% in men with HSV-2 alone (P=0.4), 19.0% in HIV-infected men without HSV-2 (PRR 4.5, 95% CI 1.1-18.6, P=0.04), and 31.6% in dually infected HIV/HSV-2 seropositive=men (PRR=7.5, 95% CI 2.3-23.8, P<0.001). In the stromal compartment, the prevalence of inflammation in HIV/HSV-2 seronegative men was 14.1%; in men with HSV-2 alone, the prevalence was 29.7% (PRR 2.1, 95% CI 1.1-4.2, P=0.03); and in men with HIV infection alone the prevalence was 33.3% (PRR=2.4, 95% CI 1.0-5.5, P=0.04). In dually infected men, the prevalence of stromal inflammation was 60.5% (PRR=4.3, 95% CI 2.3-7.9, P<0.001). Among 15 HSV-2 seroconverters, only one had epithelial foreskin inflammation (6.7%) and seven had stromal inflammation (46.7%), and this did not differ significantly from the prevalence of inflammation among all HSV-2 seroprevalent individuals. Epithelial inflammation was only observed when stromal inflammation was present.
There were 82 men with any inflammation (), and mononuclear lymphocytes were observed in 83.3% (30/36) of inflammatory sites in the epithelium and 100% (82/82) of inflammatory sites in the stroma. Neutrophils were seen in only six individuals with inflammation (7.3%, 6/82), and where seen, neutrophils were only present within the epithelium. Two of these latter individuals had a mixture of mononuclear cells and neutrophils. No other cell types were observed. Using IHC, preliminary qualitative phenotypic analysis of T-lymphocytes in inflammatory foci revealed a mixture of both CD4 and CD8 cell subsets ().
Fig. 1 Photomicrographs of (a) hematoxylin and eosin-stained foreskin from an herpes simplex virus type-2-only infected participant demonstrating focal inflammation of foreskin subepithelial stroma (selected area), final magnification, 40×; (b) higher (more ...)
Fig. 2 Immunophenotypic characterization of cell types expressing (a) CD4 and (b) CD8 receptors in the lymphocyte focus shown in . Positively staining cells appear red in sections counterstained with hematoxylin (blue), final magnification, 100×. (more ...)
shows the multivariate PRRs for epithelial and stromal inflammation. Dual infection with HIV and HSV-2 was strongly associated with epithelial inflammation (adjusted PRR 6.1, 95% CI 1.8-20.1, P=0.003) and stromal inflammation (adjusted PRR 3.6, 95% CI 2.0-6.9, P<0.001), relative to HIV/HSV-2 uninfected men. Among men with only HSV-2 or only HIV infection, the adjusted PRRs of inflammation were increased, but this was not statistically significant. Higher education was associated with a lower risk of stromal inflammation (adjusted PRR 0.4, 95% CI 0.2-0.9, P=0.03). Self-report of four or more sexual partners in the past 5 years was associated with more frequent inflammation, but this was not statistically significant. Epithelial, but not stromal, inflammation was associated with genital ulcer symptoms within the week prior to circumcision (adjusted PRR 2.4, 95% CI 1.1-5.3, P=0.03), although no genital ulceration was observed clinically at the preoperative examination. The presence of smegma on examination was associated with greater frequency of epithelial (adjusted PRR 5.9, 95% CI 1.4-24.4, P=0.01) and stromal inflammation (adjusted PRR 3.0, 95% CI 1.2-7.2, P=0.02). Age, primary occupation, marital status, transactional sex, condom use, and washing before or after sex were not associated with foreskin inflammation.
Multivariate prevalence rate ratios for epithelial and stromal inflammationa
As shown in , inflammation was more commonly observed in HIV-infected than in HIV-uninfected men, both in the epithelium (28.9 vs. 5.9%, respectively, P<0.001) and the stroma (54.6 vs. 21.5%, respectively, P<0.001). The inflammation was primarily focal (), and no HIV-uninfected men had diffuse inflammatory changes (), whereas among HIV-infected men, 13.4% had moderately diffuse inflammation confined to the stroma. Where present, moderate or prominent lymphocytic infiltrates were observed more frequently in the stroma of HIV-infected men (22.7%, 22/97), but were uncommon in the stromal compartment of HIV-negative men (2.2%, 3/135, P=<0.001). Overall, prominent intensity was infrequent and where seen, it was only found in HIV-infected men (3.1%, 3/97).
The prevalence, extent and intensity of inflammation in the foreskins of HIV-infected and HIV-uninfected men
Immediate precircumcision HIV viral loads were available for 70% (68/97) of HIV-infected individuals. Epithelial inflammation was present in 44.1% (15/34) of men with log viral loads above the median of 4.5 log10 cps/ml, and 14.7% (5/34) in those with viral loads below the median (Fisher exact test, P=0.02).