Unrecognized versus asymptomatic HSV infection in HIV+ men

To evaluate the frequency of unrecognized and truly asymptomatic HSV infection among HIV positive men, we intensively followed 10 HSV-2 seropositive men (with daily home cultures of the genital, perirectal and oral area) for 60 consecutive days. Subjects kept a diary recording the presence of genital lesions and symptoms. In addition, they attended the clinic daily between Mon.-Fri. for repeat HSV cultures and daily examinations for oral, genital and rectal lesions. All 10 patients reported genital or rectal lesions during follow-up on 124 of 519 days. The most common reported sites were penis, perirectal and buttock. Physician observed lesions were noted on 247 of 519 days (p<01) (for patient versus physician observation). The frequency from which HSV was isolated was similar in patient versus physician observed lesions (46 vs 45%). HSV was isolated from 86/395 (22%) of days when the patient reported no lesions and 32/272 (12%) of days in which the physician reported no lesions (p<.01). The frequency of subclinical shedding based on patient observation was 5% of days from the genitals and 17.5% of days from the perirectal area, in contrast for physician reported lesions the frequency of subclinical shedding from the genitals was 2.2% and 8.5% from the rectum. Both unrecognized and true subclinical HSV shedding occur in HIV+ men. The frequency of symptomatic genital HSV is underreported by patients because of the difficulty in noting perirectal and buttock lesions. However, subclinical shedding of HSV from the genital and perirectal area is still frequent, even with intense phsysican observations. HSV is phenotypically a persistent infection in the HIV+/HSV-2+ male.