Increasing proportion of herpes simplex virus type 1 among women and men diagnosed with first-episode anogenital herpes: a retrospective observational study over 14 years in Melbourne, Australia.

OBJECTIVES: Reports of rising herpes simplex virus type 1 (HSV-1) genital infections relative to HSV-2 have been published up to 2006 in Australia. These changes have been attributed to declining childhood immunity to HSV-1. We described the temporal trends of HSV-1 and HSV-2 up to 2017 in Melbourne, Australia, to determine if the earlier trend is continuing. METHODS: We conducted a retrospective review of the medical records of 4517 patients who were diagnosed with first episode of anogenital HSV infection at the Melbourne Sexual Health Centre, Australia, between January 2004 and December 2017. HSV-1 and HSV-2 were calculated as a proportion of all first episode of anogenital HSV infections. The change in the proportions of HSV-1 and HSV-2 over time was assessed by a χ2 trend test. Risk factors associated with HSV-1 were examined using a multivariable logistic regression model. RESULTS: The proportion of first episode of anogenital herpes due to HSV-1 increased significantly over time in women (from 45% to 61%; ptrend<0.001) and heterosexual men (from 38% to 41%; ptrend=0.01) but not in men who have sex with men (MSM) (ptrend=0.21). After adjusting for condom use, partner number and age, the annual increase remained significant only in women (OR 1.08, 95% CI 1.03 to 1.13, p<0.001). In MSM, HSV-1 caused up to two-thirds of anogenital herpes in most years and HSV-1 was more likely to be diagnosed at an anal site than genital site (OR 1.69, 95% CI 1.23 to 2.32, p<0.001). Younger age (<28 years) was an independent risk factor for HSV-1 in all groups. CONCLUSIONS: The proportion of first-episode anogenital herpes due to HSV-1 has been rising in women since 2004. HSV-1 has become the leading cause of anogenital herpes in younger populations, women and MSM.

Syphilis, human immunodeficiency virus, herpes genital and hepatitis B in a women's prison in Cochabamba, Bolivia: prevalence and risk factors.

OBJECTIVE: To determine the prevalence and factors associated with syphilis, human immunodeficiency virus (HIV), hepatitis B (HBV) and herpes type 2 (HSV2) among women in the prison of San Sebastian in Cochabamba (Bolivia). MATERIAL AND METHODS: We carried out a cross-sectional study including a standardized questionnaire to assess socio-demographics characteristics and risk factors (sexual practices and exposure to blood); and serological tests for syphilis, HSV2, VIH, and HBV. We performed bivariate and multivariate analyses to test the associations between variables of interest and infections. RESULTS: A total of 219 out of 220 prisoners (99.5%) participated in the study. For syphilis, 12.8% of participants had both reactive tests (RPR+/TPPA+). The prevalence of HSV2 and VIH was 62.6% and 1.4%, respectively. Anti-HBc, indicating a resolved or chronic HBV, was positive in 11.9% of participants and 0.5% had active HBV (HBsAg positive). A low level of education was associated with syphilis, HSV2 and HBV. Having occasional sexual partners was associated with syphilis and HSV2. Being over 36 years old and having more than 3 children were associated with HBV. The number of sexual partners, history of prostitution and rape, having sexual intercourses in prison and detention time were not associated with any of these infections. DISCUSSION: The prevalence of syphilis, HIV, HSV2 and HBV was higher in this vulnerable female population than in the general population in Bolivia. Control measures in detention are needed to limit the spread of these infections both in prisons and in the community.

[Knowledge about herpes simplex virus type 2 and human papillomavirus, and risk perception to acquire infections among college students]. / Conocimiento sobre el virus herpes simple tipo 2 y virus del papiloma humano, y percepción de riesgo a adquirir las infecciones entre estudiantes universitarios.

INTRODUCTION: herpes simplex virus type 2 (HSV-2) and human papillomavirus (HPV) are the most frequent sexually transmitted infections (STI) among college students 18-24 years old. Educational interventions for STI prevention can help to decrease viral STI prevalence among students. OBJECTIVE: to know the change in knowledge, perception of risk and sexual behavior among 182 students of the Autonomous University of the State of Morelos. MATERIAL AND METHOD: a community intervention trial (before-after) was carried out, using brochures for prevention of HSV-2 and HPV, including information about these STI, with emphasis on the risk factors identified in students of the same university. RESULTS: we found a change in the perception of STI risk during the intervention (56.5 before vs. 67.7% after intervention), possibly the brochures assisted students to learn more about their own risk behaviors. Likewise, there was an increase in knowledge in both HPV and HSV-2. CONCLUSIONS: it is necessary to increase the sample size in future interventions to assess further the change in knowledge, sexual behaviors and the prevalence of infections.

Genital herpes beliefs: implications for sexual health.

STUDY OBJECTIVE: Genital herpes (HSV) is exceedingly common in the United States and women are disproportionally affected. This study aims to describe young women's beliefs about HSV and examine the correlates of those beliefs. DESIGN: A 40-item Herpes Representation measure (HSV-RoSTD) and a demographic questionnaire were administered to a convenience sample of young women. Data analysis included descriptive statistics, t-tests and Pearson's correlations. SETTING: Four women's health clinics and one large state university. PARTICIPANTS: 302 women aged 18-24 years. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Four dimensions of HSV representations (cause, identity, future perspective, and psychosocial consequences), age and STD testing history. RESULTS: Nearly all (98%) believed that HSV would result in genital sores and 68% believed they could tell if their sexual partner had HSV. Most (89%) understood the longevity of HSV; however, 30% believed that they could take a pill to get rid of the infection, and 15% indicated that it was likely they would die from HSV. Negative beliefs about the psychosocial impact of HSV were common as 95% indicated they would be depressed and 90% indicated concern about sex and partner notification. Those who were younger and those who had never been tested for STDs believed a genital herpes infection is highly symptomatic. Finally, negative beliefs about the psychosocial consequences of HSV were associated with beliefs about HSV being symptomatic, having a negative impact on future health, and being associated with sexual risk behaviors. CONCLUSIONS: Young women have misconceptions about HSV, particularly regarding the symptomatology and the role of HSV medication. Noteworthy concerns about the negative psychosocial consequences of an HSV diagnosis were also raised, all of which have implications for young women's sexual health.

Association of oral acyclovir and imiquimod for the treatment of hypertrophic genital herpes simplex in HIV positive patients: report of two cases.

Chronic herpes simplex can present as exuberant clinical lesions, especially in HIV patients. The most probable mechanism of formation of these lesions is the invasion of the epidermal CD4 T cells by the herpes simplex virus. Due to the therapeutic difficulties and the high rates of treatment failure amongst these patients, new drugs are currently being discussed on the literature. Studies based on the immunophatology of these lesions have suggested that imiquimod might work as an adjuvant therapy to the antiviral drugs. Here we present two cases of excellent response to treatment with topical imiquimod as an adjuvant drug to acyclovir.

Herpes hipertrófico perianal tratado eficazmente com imiquimod / Hypertrophic perianal herpes successfully treated with imiquimod

A infecção pelo vírus herpes simples tipo 2 (HSV-2) é frequente em pacientes infetados pelo vírus de imunodeficiência adquirida (VIH). Nestes casos, o herpes genital pode ter uma apresentação clínica atípica. As variantes hipertróficas e vegetantes são pouco habituais. Os autores relatam um caso de herpes hipertrófico perianal em paciente infetada pelo VIH, com resposta insatisfatória ao aciclovir e valaciclovir, tratado eficazmente com imiquimod tópico. O herpes genital hipertrófico é, frequentemente, refratário aos tratamentos antivirais. Na nossa experiência, o imiquimod é um tratamento eficaz, seguro e bem tolerado que deverá ser considerado na abordagem terapêutica destes pacientes.

Herpes simplex virus type 2 (HSV-2) infections are frequent in HIV (human immunodeficiency virus) infected patients. In those cases, genital herpes may have an atypical clinical presentation. Hypertrophic and vegetating variants are unusual. The authors describe a case of hypertrophic perianal herpes in an HIV patient with unsatisfactory response to acyclovir and valacyclovir, successfully treated with imiquimod. Hypertrophic genital herpes cases are frequently refractory to antiviral treatments. In our experience, imiquimod is an efficient, safe and well tolerated treatment that should be considered in therapeutic approach of these patients.

Associação de aciclovir oral e imiquimode no tratamento de herpes simples genital hipertrófico em paciente com sida: relato de dois casos / Association of oral acyclovir and imiquimod for the treatment of hypertrophic genital herpes simplex in HIV positive patients: report of two cases

Herpes simples crônico é doença capaz de gerar apresentações exuberantes, principalmente em pacientes com sida. O provável mecanismo da formação dessas lesões hiperplásicas consiste na invasão viral dos linfócitos T CD4 situados na epiderme. Diante das dificuldades terapêuticas e da grande taxa de insucesso do tratamento nesses pacientes, novas terapias têm sido citadas na literatura atualmente. O conhecimento da imunopatologia ratificou o mecanismo pelo qual o imiquimode poderia ser eficaz como terapia adjuvante aos antivirais. Relatamos aqui dois casos de pacientes tratados com aciclovir associado ao imiquimode tópico que obtiveram resposta clínica excepcional.

Chronic herpes simplex can present as exuberant clinical lesions, especially in HIV patients. The most probable mechanism of formation of these lesions is the invasion of the epidermal CD4 T cells by the herpes simplex virus. Due to the therapeutic difficulties and the high rates of treatment failure amongst these patients, new drugs are currently being discussed on the literature. Studies based on the immunophatology of these lesions have suggested that imiquimod might work as an adjuvant therapy to the antiviral drugs. Here we present two cases of excellent response to treatment with topical imiquimod as an adjuvant drug to acyclovir.

Hypertrophic perianal herpes successfully treated with imiquimod.

Herpes simplex virus type 2 (HSV-2) infections are frequent in HIV (human immunodeficiency virus) infected patients. In those cases, genital herpes may have an atypical clinical presentation. Hypertrophic and vegetating variants are unusual. The authors describe a case of hypertrophic perianal herpes in an HIV patient with unsatisfactory response to acyclovir and valacyclovir, successfully treated with imiquimod. Hypertrophic genital herpes cases are frequently refractory to antiviral treatments. In our experience, imiquimod is an efficient, safe and well tolerated treatment that should be considered in therapeutic approach of these patients.

Associations between childhood adversity and depression, substance abuse and HIV and HSV2 incident infections in rural South African youth.

OBJECTIVES: To describe prevalence of childhood experiences of adversity in rural South African youth and their associations with health outcomes. METHODS: We analyzed questionnaires and blood specimens collected during a baseline survey for a cluster randomized controlled trial of a behavioral intervention, and also tested blood HIV and herpes simplex type 2 virus at 12- and 24-month follow up; 1,367 male and 1,415 female volunteers were recruited from 70 rural villages. RESULTS: Both women and men before 18 had experienced physical punishment (89.3% and 94.4%), physical hardship (65.8% and 46.8%), emotional abuse (54.7% and 56.4%), emotional neglect (41.6% and 39.6%), and sexual abuse (39.1% and 16.7%). Incident HIV infections were more common in women who experienced emotional abuse (IRR 1.96, 95% CI 1.25, 3.06, p=.003), sexual abuse (IRR 1.66 95% CI 1.04, 2.63, p=.03), and physical punishment (IRR 2.13 95% CI 1.04, 4.37, p=.04). Emotional neglect in women was associated with depression (aOR 1.82, 95% CI 1.15, 2.88, p=.01), suicidality (aOR 5.07, 95% CI 2.07, 12.45, p<.0001), alcohol abuse (aOR 2.17, 95% CI .99, 4.72, p=.05), and incident HSV2 infections (IRR 1.62, 95% CI 1.01, 2.59, p=.04). In men emotional neglect was associated with depression (aOR 3.41, 95% CI 1.87, 6.20, p<.0001) and drug use (aOR 1.98, 95% CI 1.37, 2.88, p<.0001). Sexual abuse was associated with alcohol abuse in men (aOR 3.68, 95% CI 2.00, 6.77, p<.0001) and depression (aOR 2.16, 95% CI 1.34, 3.48, p=.002) and alcohol abuse in women (aOR 3.94, 95% CI 1.90, 8.17, p<.0001). PRACTICE IMPLICATIONS: Childhood exposure to adversity is very common and influences the health of women and men. All forms of adversity, emotional, physical and sexual, enhance the risk of adverse health outcomes in men and women. Prevention of child abuse need to be included as part of the HIV prevention agenda in sub-Saharan Africa. Interventions are needed to prevent emotional, sexual, and physical abuse and responses from health and social systems in Africa to psychologically support exposed children must be strengthened.

Socio-demographic and behavioral correlates of herpes simplex virus type 1 and 2 infections and co-infections among adults in the USA.

OBJECTIVES: Although herpes simplex virus (HSV)-1 and HSV-2 may co-exist and interact, some epidemiologic features including geographical distribution, secular trends, route of transmission, and established risk factors may distinguish these HSV sub-types. With recent data indicating a link between genital herpes and either strain, a re-evaluation of risk factors for HSV-1/HSV-2 infection and co-infection is needed. METHODS: We used the 1999-2004 National Health and Nutrition Examination Study (NHANES) data and logistic regression modeling to identify socio-demographic and behavioral risk factors that can independently predict HSV-1/HSV-2 infection and co-infection. RESULTS: Approximately 48% were positive for HSV-1 alone, 7% were positive for HSV-2 alone and 12% were co-infected with HSV-1 and HSV-2. History of genital herpes was found in individuals infected with either or both HSV sub-types. Whereas age, sex, race, and level of education independently predicted all three outcomes, lifetime sexual activity as well as use of tobacco products and recreational drugs mainly correlated with HSV-2 infection and HSV-1/HSV-2 co-infection. Lifetime use of alcohol was not consistently associated with HSV-1/HSV-2 infection and co-infection. CONCLUSIONS: Sexual activity played an important role for HSV-2 and was potentially important for HSV-1, with implications for healthcare practice and vaccine development.

Iron metabolism markers and haptoglobin phenotypes in susceptibility to HSV-1 or/and HSV-2 lesion relapses.

Different haptoglobin (Hp) phenotypes play a role in several pathologic processes including infectious diseases. In order to evaluate the role of iron storage and metabolism in susceptibility to herpetic manifestations, we studied the frequency of the Hp phenotypes and iron metabolism in patients affected by H. Simplex virus 1 or 2 (HSV-1 or HSV-2), compared with controls. Hp phenotype and iron metabolism were determined in 100 patients with recurrent HSV-1 or HSV-2 manifestations during the relapses, and in 110 healthy subjects. The frequencies of the three Hp phenotypes in the patient group compared to the control group were 18% versus 14.5% p = NS for Hp 1.1, 25% versus 40% p = 0.03 for Hp 2.2 and 57% versus 45.5% p = NS for Hp 2.1. All iron metabolism parameters tested showed significant differences between patients and controls; haemoglobin (Hb), ferritin, and serum iron were lower, while transferrin was higher in the patients than in controls. Reductions in iron availability may be a risk factor for relapsing lesions of HSV-1 or HSV-2. Hp 2.2 phenotype may offer some protection against the recurrence of Herpes labialis or genitalis manifestations.

Association between HSV-2 and HIV serostatus in pregnant women of known HIV serostatus attending Mulago hospital antenatal clinic, Kampala, Uganda.

BACKGROUND: Studies show that STIs such as HSV-2 increase the probability of HIV-1 acquisition and enhance transmission by increasing susceptibility and infectiousness respectively. The objective of this study was to compare the proportion of HSV-2 in HIV-positive and HIV-negative pregnant mothers attending the antenatal clinic in Mulago Teaching Hospital in Kampala, Uganda. METHODS: This case control study included 50 pregnant women who were HIV positive and 200 controls of pregnant women who were HIV negative and were aware of their serostatus. Data was collected in two parts: the first part involved a pretested interviewer-administered semi-structured questionnaire for socio-demographic characteristics, sexual and behavioral history. The second part consisted of a serological test using an ELISA assay specific for IgG against viral glycoprotein G, specific to HSV-2. RESULTS: The proportion of HSV-2 was 86% (43/50) among the HIV-positive cases and 62% (125/200) among the HIV-negative controls. The odds of being HSV-2 seropositive was 3.7 times higher (95% CI was 1.58 - 8.61) in HIV-positive cases than in the HIV negative controls. The odds of HSV-2 was significantly increased to 5.32 (95 CI was 1.92 - 14.73) among cases when adjustment was done for age, education, marital status, religion, age at first sexual experience, lifetime partners, type of earning, and whether the mother involved the partner in seeking treatment for sexually transmitted diseases. CONCLUSION: The proportion of HSV-2 was higher in HIV-positive cases than in the HIV negative controls.

Epidemiology and therapy of chronic herpes virus infection with genital herpes manifestations.

Anaferon-supplemented complex therapy of chronic recurrent genital herpes reduced clinical symptoms of the disease and normalized the content of immunocompetent cells. Changes in the level of immunocompetent cells depended on the severity of genital herpes.

CXCR3 deficiency increases susceptibility to genital herpes simplex virus type 2 infection: Uncoupling of CD8+ T-cell effector function but not migration.

CXCR3 is a G-protein-coupled receptor preferentially expressed by activated T cells, NK cells, and dendritic cells. Signaling through gamma interferon-regulated chemokines CXCL9, CXCL10, CXCL11, and CXCR3 plays a critical role in the immune response of many viral pathogens. However, the relevance of CXCR3 for optimal T-cell activation and the induction of regulatory transcription factors (i.e., T-bet and eomesodermin) relative to host immune defense against genital herpes simplex virus type 2 (HSV-2) infection have been poorly defined. In this study, we evaluated the requirement of CXCR3 expression during genital HSV-2 infection using mice deficient in CXCR3 (CXCR3(-/-)) along with wild-type (WT) controls, assessing the resistance of mice to viral infection and focusing on the cytokine/chemokine response, phenotypic analysis of recruited leukocytes, and functional analysis of CD8(+) T cells. CXCR3(-/-) mice showed a heightened sensitivity to infection compared to WT animals in terms of the viral burden in infected tissues as well as elevated mortality. The poor response of CXCR3(-/-) mice to viral infection was associated with reduced cytotoxic T-lymphocyte activity through the impairment of T-bet, perforin, and granzyme B expression by CD8(+) T cells. Corresponding with the defective cytolytic activity, a reduction in recruitment of plasmacytoid dendritic cells and CD80 expression in CD11c(+) dendritic cells in the draining lymph nodes of CXCR3(-/-) mice were detected. Collectively, the results provide a new perspective to CXCR3 signaling for the appropriate activation of CD8(+) T cells required for host defense against genital HSV-2 infection.

A 3'-untranslated region polymorphism in the TBX21 gene encoding T-bet is a risk factor for genital herpes simplex virus type 2 infection in humans.

It was recently shown that the transcription factor T-bet is crucial for adequate innate and acquired immune responses to genital herpes simplex virus type 2 (HSV-2) infection in mice. To test the possible genetic influence of variations in the TBX21 gene encoding T-bet on susceptibility to infection, this study evaluated the frequencies of five different single-nucleotide polymorphisms (SNPs) in the human TBX21 gene in 159 HSV-2-infected individuals and compared them with those in 186 healthy HSV-2-seronegative controls. The data showed that one variation (rs17244587) in the 3'-untranslated region of TBX21 was strongly associated with the incidence of genital HSV-2 infection. The frequency of the A allele at this position was 0.19 in the group of HSV-2-infected individuals compared with 0.05 in the group of uninfected controls (P=9.3x10(-8)). Furthermore, a homozygous AA genotype was found only among HSV-2-infected individuals and not in seronegative controls. These results indicate that the host genetic background may affect susceptibility to HSV-2 infection in humans, with TBX21 as a strong candidate gene.

Viral sexually transmitted infections and bacterial vaginosis: 2001-2004 National Health and Nutrition Examination Survey data.

BACKGROUND: Bacterial vaginosis (BV) is a common condition believed to be associated with sexually transmitted infection (STI) susceptibility. Most studies of BV and STIs have come from treatment-seeking or high-risk populations. This study examines the association between 5 viral STIs, human papilloma virus (HPV), HIV, herpes simplex viruses types 1 and 2 (HSV-1 and HSV-2), and Hepatitis C (HCV), and BV among women in the general US population. METHODS: Data from the 2001 and 2003-2004 National Health and Nutrition Examination Surveys were combined. Crude and adjusted relative risks and 95% confidence intervals were estimated from logistic regression analyses for rare outcomes (<10%) and from Poisson regression with robust error variance for common outcomes. Complex survey design was taken into consideration using the survey functions in Stata. RESULTS: Crude analyses found an association between BV and the prevalence of all 5 STIs. After adjustment for important confounders, only HSV-1 and HSV-2 were significantly associated with the presence of BV. Moreover, crude analyses stratified by race/ethnicity suggested that associations between BV and viral STIs may not be consistent across race/ethnicity subgroups. CONCLUSION: This population-based study found that BV was significantly associated with the prevalence of HSV-1 and HSV-2 and potentially associated with HIV and HPV. Given the frequency of BV in US women, small increases in STI susceptibility may have important impacts on STI transmission.

Risk factors for incident herpes simplex type 2 virus infection among women attending a sexually transmitted disease clinic.

OBJECTIVES: To estimate the incidence of herpes simplex type 2 virus (HSV-2) infection, to identify risk factors for its acquisition, and to assess the protective effect of condoms. STUDY DESIGN: Prospective study of 293 HSV-2 seronegative women, aged 18 to 35 years, attending a sexually transmitted disease clinic in Alabama from 1992 to 1995. RESULTS: Incidence of HSV-2 infection was 20.5 per 100 woman-years [95% confidence interval (CI), 13.1-30.5]. Young women (18-20 years) had a significantly higher risk of incident HSV-2 infection [adjusted hazard ratio (HR), 2.8; 95% CI, 1.3-6.4] than older women. Women diagnosed with prevalent or incident bacterial vaginosis had a higher incidence of HSV-2 infection than those who were not so diagnosed (adjusted HR, 2.4; 95% CI, 1.1-5.6). No significant protective effect was observed for consistent (100%) condom use without breakage and slippage against HSV-2 acquisition (adjusted HR, 0.8; 95% CI, 0.2-2.3). CONCLUSION: Acquisition of HSV-2 infection among study participants was higher than previous estimates for adult female sexually transmitted disease clinic attendees, and no protective effect for condoms was demonstrated. The high incidence of HSV-2 infection with its potential for adverse health consequences emphasizes the need for better prevention strategies.

Geographic prevalence and multilevel determination of community-level factors associated with herpes simplex virus type 2 infection in Chennai, India.

Herpes simplex virus type 2 (HSV-2) is one of the most prevalent sexually transmitted infections, and it increases the risk of transmission of human immunodeficiency virus type 1 at least twofold. Individual-level factors are insufficient to explain geographic and population variation in HSV-2, suggesting the need to identify ecologic factors. The authors sought to determine the geographic prevalence and community-level factors associated with HSV-2 after controlling for individual-level factors among slums in Chennai, India. From March to June 2001, participants aged 18-40 years voluntarily completed a survey and were tested for HSV-2. Community characteristics were assessed through interviews with key informants and other secondary data sources. Multilevel nonlinear analysis was conducted. Eighty-five percent of eligible persons completed the survey; of these, 98% underwent HSV-2 testing, producing a final sample of 1,275. Participants were of Tamil ethnicity, were predominantly female and married, and were on average 30 years old. Fifteen percent were infected with HSV-2, and there was significant variation in HSV-2 prevalence among communities. After controlling for individual-level factors, the authors identified community-level factors, including socioeconomic status and the presence of injection drug users, that were independently associated with HSV-2 and explained 11% of the variance in prevalence. Future studies are needed to test mechanisms through which these community-level factors may be operating.

Knowledge about genital herpes amongst first time attenders at a department of genitourinary medicine.

BACKGROUND AND AIMS: Genital herpes is the most common cause of genital ulceration in the developed world, and its prevalence in the United Kingdom is rising. Public knowledge of the infection is often limited. We aimed to assess knowledge among patients attending an outpatient genitourinary clinic in Scotland. METHODS: A questionnaire was designed to collect information about educational qualifications and knowledge of genital herpes. In the knowledge section, each correct answer was given a score of 1; thus the maximum possible score was 12. Two hundred and ten individuals who attended as new patients at a walk-in genitourinary medicine clinic were invited to complete the questionnaire. RESULTS: Two hundred and seven patients completed the questionnaire. Overall 63% of responses were answered correctly. Knowledge of genital herpes was better in patients who worked in healthcare (8.3 v 6.9, p=0.019) and in patients with educational qualifications gained from college or university compared to those gained at school (7.6 v 6.5, p=0.009). Level of knowledge was not related to age or gender; receiving sex education at school did not appear to improve knowledge of genital herpes. CONCLUSION: Knowledge of genital herpes among patients attending an outpatient genitourinary clinic in Scotland is reasonable but needs to improve to combat the rising prevalence of the infection. The areas of misunderstanding identified in our study could be targeted for public education.