Herpes simplex virus (HSV) infection can cause painful, recurrent genital ulcer disease (GUD), which can have a substantial impact on sexual and reproductive health. HSV-related GUD is most often due to HSV type 2 (HSV-2) but may also be due to genital HSV-1, which has less frequent recurrent episodes than HSV-2. The global burden of GUD has never been quantified. Here we present first global and regional estimates of GUD due to HSV-1 and HSV-2 among 15-49 year old females and males.

We developed a natural history model reflecting the clinical course of GUD following HSV-2 and genital HSV-1 infection, informed by a literature search for data on model parameters. We considered both diagnosed and undiagnosed symptomatic infection. This model was then applied to existing infection estimates and population sizes for 2016. A sensitivity analysis was carried out varying the assumptions made.

We estimated that 187 million people aged 15-49 years had at least one episode of HSV-related GUD globally in 2016: 5.0% of the world’s population. Of these, 178 million (95% of those with HSV-related GUD) had HSV-2 compared to 9 million (5%) for HSV-1. GUD burden was highest in Africa, and approximately double in women compared to men. Altogether there were an estimated 8 billion
person-days spent with HSV-related GUD globally in 2016, with 99% of days due to HSV-2. Taking into account parameter uncertainty, the percentage with at least one episode of HSV-related GUD ranged from 3.2%-7.9% (120-296 million). However, the estimates were sensitive to the model assumptions.

Our study represents a first attempt to quantify the global burden of HSV-related GUD which is large. New interventions such as HSV vaccines, antivirals or microbicides, have the potential to improve the quality of life of millions of people worldwide.

Original languageEnglish
JournalBMJ Global Health
Publication statusAccepted/In press - 10 Nov 2019


  • Genital ulcer disease
  • herpes simplex virus type 2
  • herpes simplex virus type 1
  • disease burden
  • epidemiology
  • sexually-transmitted infection
  • world
  • humans

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