Chronic infections resulting from oncogenic viruses typically do not produce viral particles and persist throughout the lifespan of the infected person. These mechanisms of viral persistence and/or latency align with the biological nature of the carcinogenic process as they prevent the common occurrence of cell death in acute lytic infections, while also concealing the infectious agent from the immune system [1]. HHV-8 is associated with Kaposi sarcoma, multicentric Castleman disease, and primary effusion lymphoma [2]. Approximately 12% of all cancers globally are brought on by oncogenic viruses [1]. HHV-8 is a virus of the Herpesviridae family, Gammaherpesvirinae subfamily, and Rhadinovirus genus [3, 4]. Human herpesvirus 8 (HHV-8), is the only human species present in the genus Rhadinovirus. Although infection alone is insufficient, the HHV-8 virus is present in all forms of Kaposi's sarcoma and is necessary for its emergence (classic, endemic, post-transplant and epidemic or associated with HIV) [5-7]. HHV-8 is most commonly transmitted through sexual contact and saliva [8]. It can also be transmitted through organ transplants. Although the virus remains largely latent, there is evidence that blood transfusion may be a route of transmission of this virus. HHV-8 infects B lymphocytes, epithelial cells, endothelial cells, and eventually monocytes. HHV-8 infection is higher in populations with high KS incidence and lower in populations with low KS incidence. HHV-8 then establishes itself as a persistent infection that can signal pro- angiogenesis and inflammation. This cycle can eventually lead to the development of tumors [9,10].

Abnormal expression of the c-myc gene, which normally plays a role in regulating cell transcription, differentiation and apoptosis, has been linked to angiogenesis [11-14]. Recent studies have helped to better define this role by demonstrating c-myc amplification in secondary angiosarcomas [15,16]. However, it is important to note that Kaposi's sarcoma-associated herpesvirus (KSHV) infection alone is not enough to cause Kaposi's sarcoma (KS) disease [17,18]. In vitro investigations have demonstrated that the c-Myc protein plays a crucial role as a regulatory molecule in the proliferation and migration of spindle cells in Kaposi's sarcoma (KS), which is a tumor characterized by abnormal blood vessel growth and is frequently linked to HIV infection [19]. P53 is often cited as the most frequently mutated gene in human cancer, with most alterations found in the DNA-binding domain of the protein [20]. Production of viral proteins with the ability to inhibit the tumor suppressor protein p53 has been associated with KSHV oncogenesis [21].

Overall seroprevalence in the adult population varies from less than 5% in most Western countries (United States, Nordic countries) and Southeast Asia, to more than 50% in East and Central Africa and approximately 10 to 20% in the Mediterranean region. Basin countries (Italy, Greece, etc.), South America, West Africa. Hundreds of millions of people worldwide are estimated to be infected with this virus, including at least 150 million in inland tropical Africa. Countries with low endemicity (<5%) and those with medium and high endemicity (>10%) do not seem to have the same modes of infection, or at least the relative share of them [22]. The research on HHV-8 transmission among blood donors in Australia revealed that none of the blood donors were discovered have active asymptomatic HHV-8 infection. 1, 5.83% of the donors tested positive for antibodies against the virus, indicating past exposure [23]. In adults in sub-Saharan Africa, the prevalence of HHV-8 can surpass 50% [24], and the prevalence among healthy blood donors is equally high. The potential of transmission of HHV-8 through blood transfusion has been proposed [25-27] and justified in a Ugandan study [28]. A study conducted in Mali showed that the seroprevalence of HHV-8 among Malian blood donors was 10.4% [29].

HHV-8 also known as Herpesvirus 8, is a double-stranded DNA virus enclosed in an envelope. It has the ability to stay dormant within host cells for extended periods before reactivating and causing a viral infection. Transmission of herpesviruses, including HHV-8 can occur from apparently healthy blood donors to individuals who are immunocompromised, putting them at risk of primary infection. It is important to emphasize that not all herpesviruses can be transmitted by blood donors; only beta and gamma herpesviruses are lymph trophic. A recent study reported an HHV-8 sero prevalence of 19% among People Living with HIV in Brazzaville, Congo [30]. HHV-8 seroprevalence is currently being assessed in several countries, and the potential of HHV-8 transmission associated with blood transfusions differs between regions where the disease is native and regions where it is not native. In this sense, we carried out this study with the aim of evaluating the hitherto unknown prevalence of HHV-8 in the midst of all categories of blood donors in Congo-Brazzaville.

Participants

In this cross-sectional study, we conducted a thorough analysis of 127 blood samples obtained from male and female blood donors who were 18 years of age or older. The study was conducted in compliance with the national guidelines on blood donation and the samples were collected from the blood bank of the National Transfusion Center in Brazzaville. As part of the routine blood bank screening process, all donors were tested for HBsAg, HIV 1/2 antibodies, HCV and VDRL.

Genomic DNA extraction

HHV-8 DNA analysis was conducted solely on data obtained from blood donors who tested negative during regular screening. Following the routine blood bank screening process, DNA with a high molecular weight was isolated from cryopreserved peripheral blood leukocytes of the chosen samples using the RNA/DNA/Protein Purification Plus Kits (Norgen Biotek). Subsequently, the concentration of the extracted DNA was measured using NANODROP to evaluate he standard of excellence of the DNA extracts.

Internal control

An initial PCR was conducted using DNA extracts to qualitatively test the amplification of the human beta globin gene (268 bp) GH20: 5'GAA GAG CCA AGG ACA GGT AC 3' and PC04: 5' CAA CTT CAT CCA CGT TCA CC 3' After amplification on a thermal cycler, the samples were subjected to analysis on a 2% agarose gel to assess their quality. The results revealed that all samples tested positive for beta globin, indicating that they were indeed reliable and of high quality.

Positive and Negative Controls

As a positive control we used samples declared positive for HHV-8 during a study carried out with People Living with HIV in Brazzaville [30], and as a negative control we used Ultra-Pure Water for PCR.

Figure1: Agarose electrophoresis gel with 2% beta globin, DNA Ladder: Molecular weight marker; bp: Base pair.

Detection of HHV-8

HHV-8 infection was identified through nested PCR targeting the K1 gene (ORF-K1) (Table 1) 1. The experiment was conducted using 2 μl of DNA in a total volume of 25 μl. 12.5 μl of Green Taq Mix VAZYME, Add 6.5 µl of ultra-pure water, along with 2 µl of the sense primer and 2 µl of the antisense primer.

Table 1: HHV-8 primers.

The two reactions were conducted using the following cycle conditions:

• In the first nested PCR (1st Round), the process began with an initial denaturation at 94°C for 120 seconds. This was followed by denaturation for 35 cycles at 94°C for 30 seconds, hybridization at 50°C for 60 seconds, elongation at 72°C for 120 seconds, and finally, extension at 72°C for 5 minutes.
• In the second nested PCR (2nd Round), the conditions remained the same, except for the hybridization step, which occurred at 50°C for 45 seconds. After amplification using a thermal cycler, the results were observed on a 2% agarose gel.

Analysis of P53 and c-myc Messenger RNA (mRNA) Levels

The mRNA was also extracted using the RNA/DNA/Protein Purification Plus kit. mRNA concentrations were measured using a Nanodrop, according to the manufacturer's instructions. Each group yielded one microgram of total RNA post-extraction. The levels of P53 and c-myc mRNA were expressed identified using RT-qPCR, a method that integrates reverse transcription and quantitative PCR. GAPDH (human glyceraldehyde-3-phosphate dehydrogenase) was chosen as the internal parameter [31]. 1. The c-myc and P53 genes were magnified utilizing the RT-QPCR Easy?? (One Step) kit - Taqman Foregene. This kit enables reverse transcription and PCR to be carried out in a single tube, streamlining the process into one step. For a total volume of 20 µl in each tube, the reaction mixture contained 10 µl of 2x RT- qPCR Easy?? master mix, 2 µl of extracted RNA, 0.8 µl of each primer (10 µM), 1 µl of specific probes P53 and c-myc (4 µM) (Table II), 4.4 µl of RNase-free ddH2O, 1 µl of ROX 20x reference dye. The temperature conditions started with a reverse transcription (RT) step, where incubation was carried out at 42°C for 30 minutes in a single cycle. The subsequent step consisted of the PCR process, which commenced with an initial pre-denaturation phase at 95°C for 5 minutes, followed by 45 cycles consisting of denaturation at 95°C for 10 seconds and hybridization at 60°C and 62°C for c-myc and P53 for 20 seconds. Ultrapure PCR water (Bioline, UK) was included in each assay as a negative control.

Table 2: Primers and probes.

Gene Expression Fold Change Calculation

The Ct values of target genes P53 and c-myc were normalized with the Ct value of GAPDH for expression data. The calculation was performed using the ΔΔCt method. The fold change values for all donor samples were calculated in relation to the reference gene and the normal sample. The average Ct values of the genes and the average Ct values of the GAPDH gene were compared. If the relative quantification (Rq) was less than 1, the expression was considered low or under expressed. If the relative quantification was equal to or greater than 1, the expression was considered high or over expressed compared to normal samples. This indicates that the expression level was normal based on the organism's physiology.

Statistical Analysis

The correlation between HHV-8_PCR and independent variables such as gender, age group, type of honor and marital status were analyzed using Pearson's Chi-squared test or Fisher exact test with the software R Studio 2023.06.0+421 "Mountain Hydrangea" Release with R version 4.2.2. A level of significance was considered if the p-value was less than 0.05 (P<0.05).

Results

Prevalence of HHV-8 among Congolese Blood Donors

Of 127 screened donors, 13 donors were positive for detection of HHV-8 genomic DNA. The prevalence of HHV-8 was 10.3%.

Distribution of Variables According To the PCR Results

The prevalence of HHV-8 was greater among males compared to females, with rates of 8.7% and 1.6% respectively. Among the positive donors, 4.7% were regular donors, primarily falling within the age range of 18 to 30 years. Additionally, singles constituted the majority, accounting for 8.7% of the positive cases, and there was a significant positive correlation (p = 0.01) (Table 3).

Gene Expression of P53 and c-myc in Positive Cases

The analysis involved the assessment of the P53 gene and the c-myc gene expression in individuals who tested positive. To normalize the Ct value of each case, it was compared to the Ct value of the GAPDH gene. The obtained results were then compared to samples from healthy donors, allowing for the identification of variations in Ct compared to normal samples. A fold change greater than 1 indicates positive regulation, while a fold change less than 1 signifies negative regulation. It is worth noting that all samples exhibited normal gene expression.

Table 3: Socio demographic data for the 127 blood donors according to HHV-8 epidemiological status.

Congo does not have epidemiological data on HHV-8 in blood donors. Kaposi's sarcoma, multicentric Castleman's disease and primary effusion lymphoma are affected by HHV-8. Questions have been raised regarding the frequency and significance of blood transfusion transmission of herpesviruses from infected donors to previously uninfected or immunocompromised recipients, because acute infection with human herpesviruses can sometimes result in severe disease. A previous study has examined these questions in relation to HTLV-1; however, there have been no investigations conducted in Congo to determine the frequency and scope of herpesvirus infection. However, a study in the population of PLHIV (people living with HIV) shows a significant prevalence of this virus within this population, and shows the presence of HHV- 8 in Congo.

Evaluating the occurrence of HHV-8 among blood donors in Congo would enable us to determine the possible risk of HHV-8 transmission through transfusion. This is crucial as the methods of HHV-8 transmission are not well understood, and the transmission of HHV-8 by means of blood transfusion varies between regions with high and low prevalence of the virus. In addition, we have already observed that anti-HHV-8 antibodies were present in 19% of HIV-positive subjects in Congo [3], a prevalence higher than that manifested in other Western European countries [31].

This study found that HHV-8 was present in the DNA of 10.3% of the total population tested. This is slightly higher than other epidemiological studies [30], similar to [29] and higher than those found in HIV-infected patients, with or without KS, in Germany [32]. These differences may be linked to the origin of the populations tested. In our study, the most affected age group among blood donors was 18 to 30 years (6/13, 4.7% of the population), the difference being statistically insignificant. These results are similar to those found among blood donors in Mali [29]. Typically, within populations that have a high prevalence of the virus, like in Africa and South America, HHV-8 infection is predominantly observed in children. The primary modes of transmission in these cases are through siblings and from mother to child. On the other hand, transmission between adults seems to be less frequent [22, 33-36]. The reason behind why HHV-8 transmission is predominantly restricted to specific age groups within the general population remains unknown [37-39]. Transmission of HHV-8 is presently acknowledged to predominantly occur through infected saliva, irrespective of the population under investigation and the sociocultural practices employed [40]. In our study, the presence of HHV-8 tended to be higher in men than in women (8.7% versus 1.6%) without statistical significance (p=0.51). Regular donors and singles (with a statistically significant difference P = 0.01) seem to have a higher prevalence (6/13, 4.7%) and (11/14, 8.7%). These results are similar to those of [29].

During viral infection, many viruses use specific anti-apoptosis strategies to facilitate survival and viral replication [41]. c-myc and wild-type P53 are involved in cell survival, promoting cell cycle arrest and apoptosis upon exposure to agents that can induce cell proliferation. Throughout our investigation, we observed no irregular expression of P53 and c-myc. Similar to numerous other viruses, KSHV undergoes a lytic phase, characterized by a short duration, as well as a latent phase, where it remains dormant and predominantly active most of the time [42]. During its latent phase, KSHV does not cause obvious signs of pathology in its host [42]. After the virus enters the host cell, the latency phase begins and a very limited number of genes are expressed during this phase.

We encountered limitations when carrying out our study concerning the availability of tests, in particular the serological analysis which is recommended for the detection of HHV-8 (indirect immunofluorescence), this would have allowed us to expand the study by analyzing a large number of samples and do even more specific analyses, involving sequencing DNA from nested products. We suggest additional studies with an expanded number of samples. A larger prospective study will continue to follow patients who received HHV-8 positive bags in order to assess the risk of transmission.

In summary, we observed that the prevalence of HHV-8 among donors was relatively low, and that men and single people were more likely to carry HHV-8. Larger studies involving patients receiving multiple blood transfusions are needed to assess the risk of exposure and transmission of HHV-8 through blood transfusion. No abnormal gene expression was detected in this study.

Abbreviations

DNA                       : DeoxyriboNucleic Acid

mRNA                   : Messenger RiboNucleic

Acid Ct                  : Threshold Cycle

GAPDH                 : GlycerAldehyde-3-Phosphate DeHydrogenase

GH20                     : Glycoside Hydrolases family 20

HBsAg                   : Hepatitis B virus surface antigen

HHV-8                   : Human HerpesVirus type 8

IRSSA                    : National Institute for Research in Health     Sciences

KSVH                    : Kaposi sarcoma associated herpesvirus

LVO BEEN           : Laboratory of Virology, Oncology, Biosciences, Environment and New Energies

ORF-K1                 : Open reading frame-K1

Pb                           : Base pairs

PCR                        : Polymerase Chain Reaction

PLHIV                   : Person Living with

HIV RNase           : RiboNucleases

RT                          : Reverse Transcription

RT qPCR               : Quantitative Reverse Transcription

PCR SK                 : kaposi sarcoma

HIV                        : Human Immunodeficiency Virus

HCV                       : Hepatitis C virus

VDRL                    : Venereal Disease Research Laboratory

Thanks

We would like to thank the Ministry of Higher Education, the CNRST, the Laboratory of Virology, Oncology, Biosciences, Environment and New Energies (LVO BEEN) and the Faculty of Sciences and Technologies, Mohammedia, under the Hassan II University of Casablanca, Casablanca, Morocco for technical support. We express our gratitude to the Health and Human Biology (SBH) doctoral program at the Faculty of Health Sciences (FSSA) of Marien Ngouabi University (UMNG) for their assistance in gathering data.

Ethics declaration

This research was conducted in accordance with the ethical guidelines for health science studies (N0: 62/UMNG.FSSA.V-DOY) and with the approval of the Internal Committee of the CNTS.

Author contributions

JPIM      : Design, study planning, acquisition; analysis and interpretation of data. Writing the manuscript

ALMB   : Design, study planning, manuscript revision

FSP         : Data analysis

RBM      : Data acquisition

DM         : Design, study planning, manuscript revision

MME     : Design, study planning, manuscript revision, coordination. All authors read and approve the final manuscript.

Conflict of Interest: The authors declare no conflict of interest.

Ethical approval: Not applicable

Consent to Participate: Not applicable

Consent for Publication: Not applicable

Availability of data and Materials: Not applicable

Financing: Not applicable

1. Morales-Sanchez A, Fuentes-Panana EM. Human Viruses and Cancer. Viruses. 2014; 6: 4047?4079.
2. Borie R, Cadranel J, Galicier L, Couderc LJ. Pulmonary damage linked to the HHV-8 virus during HIV infection. J Resp Dis. 2012; 29: 1209?1223.
3. Dourmishev LA, Dourmishev AL, Palmeri D, Schwartz RA, Lukac DM. Molecular Genetics of Kaposi's Sarcoma-Associated Herpesvirus (Human Herpesvirus 8) Epidemiology and Pathogenesis. Microbiol Mol Biol Rev. 2003; 67: 175-212.
4. Ganem D. Kshv infection and the pathogenesis of kaposi's sarcoma. Annu Rev Pathol Mech Dis. 2006; 1: 273?296.
5. Rusu-Zota G, Manole OM, Gales C, Porumb-Andrese E, Obada O, Mocanu CV. Kaposi Sarcoma, a Trifecta of Pathogenic Mechanisms. Diagnostics. 2022; 12: 1242.
6. Kolios G, Kaloterakis A, Filiotou A, Nakos A, Hadziyannis S. Gastroscopic findings in Mediterranean Kaposi's sarcoma (non-AIDS). Gastrointestinal Endoscopy. 1995; 42: 336?339.
7. Ohe EMDN, Padilha MHV de Q, Enokihara MMSS, de Almeida FA, Porro AM. Fatal outcome in classic Kaposi's sarcoma. An Bras Dermatol. 2010; 85: 375?379.
8. Corey L, Brodie S, Huang M, Koelle DM, Wald A. HHV?8 infection: a model for reactivation and transmission. Reviews in Medical Virology. 2002; 12: 47?63.
9. Boccardo E, Villa LL. Viral Origins of Human Cancer. Current Medicinal Chemistry. 2007; 14: 2526?2539.
10. Brady G, MacArthur GJ, Farrell PJ. Epstein–Barr virus and Burkitt lymphoma. Postgraduate Medical Journal. 2008; 84: 372?377.
11. Levine AJ. p53, the Cellular Gatekeeper for Growth and Division. Cell. 1997; 88: 323-331.
12. Blancato J, Singh B, Liu A, Liao DJ, Dickson RB. Correlation of amplification and overexpression of the c-myc oncogene in high-grade breast cancer: FISH, in situ hybridization and immunohistochemical analyses. British J cancer. 2004; 90: 1612?1619.
13. Brandvold KA, Neiman P, Ruddell A. Angiogenesis is an early event in the generation of myc-induced lymphomas. Oncogene. 2000; 19: 2780?2785.
14. Ruddell A, Mezquita P, Brandvold KA, Farr A, Iritani BM. B lymphocyte-specific c-Myc expression stimulates early and functional expansion of the vasculature and lymphatics during lymphomagenesis. The American journal of pathology. 2003; 163: 2233?2245.
15. Manner J, Radlwimmer B, Hohenberger P, Mossinger K, Kuffer S, Sauer C, et al. MYC high level gene amplification is a distinctive feature of angiosarcomas after irradiation or chronic lymphedema. The American J pathology. 2010; 176: 34?39.
16. Mentzel T, Schildhaus HU, Palmedo G, Buttner R, Kutzner H. Postradiation cutaneous angiosarcoma after treatment of breast carcinoma is characterized by MYC amplification in contrast to atypical vascular lesions after radiotherapy and control cases: clinicopathological, immunohistochemical and molecular analysis of 66 cases. Modern Pathology. 2012; 25: 75-85.
17. Li N, Anderson WK, Bhawan J. Further confirmation of the association of human herpesvirus 8 with Kaposi's sarcoma. J Cutan Pathol. 1998; 25: 413?419.
18. Grossman Z, Iscovich J, Schwartz F, Azizi E, Klepfish A, Schattner A, et al. Absence of Kaposi sarcoma among Ethiopian immigrants to Israel despite high seroprevalence of human herpesvirus 8. Mayo Clinic Proceedings. Elsevier. 2002; 77: 905?909.
19. Feller JK. Correlation of amplification and expression of the c-myc oncogene in Kaposi's sarcoma. 2012.
20. Harris SL, Levine AJ. The p53 pathway: positive and negative feedback loops. Oncogene. 2005; 24: 2899?2908.
21. Petre CE, Sin SH, Dittmer DP. Functional p53 Signaling in Kaposi's Sarcoma-Associated Herpesvirus Lymphomas: Implications for Therapy. J Virology. 2007; 81: 1912?1922.
22. Plancoulaine S, Abel L, Tregouet D, Duprez R, van Beveren M, Tortevoye P, et al. Respective roles of serological status and blood specific antihuman herpesvirus 8 antibody levels in human herpesvirus 8 intrafamilial transmission in a highly endemic area. Cancer research. 2004; 64: 8782?8787.
23. Speicher DJ, Fryk JJ, Kashchuk V, Faddy HM, Johnson NW. Human Herpesvirus 8 in Australia: DNAemia and Cumulative Exposure in Blood Donors. Viruses. 2022; 14: 2185.
24. Henke-Gendo C, Schulz TF. Transmission and disease association of Kaposi's sarcoma-associated herpesvirus: recent developments. Current Opinion in Infectious Diseases. 2004; 17: 53?57.
25. Blackbourn DJ, Ambroziak J, Lennette E, Adams M, Ramachandran B, Levy JA. Infectious human herpesvirus 8 in a healthy North American blood donor. The Lancet. 1997; 349: 609?611.
26. Dollard SC, Nelson KE, Ness PM, Stambolis V, Kuehnert MJ, Pellett PE, et al. Possible transmission of human herpesvirus-8 by blood transfusion in a historical United States cohort. Transfusion. 2005; 45: 500?503.
27. Enbom M, Urassa W, Massambu C, Thorstensson R, Mhalu F, Linde A. Detection of human herpesvirus 8 DNA in serum from blood donors with HHV-8 antibodies indicates possible bloodborne virus transmission. Journal of medical virology. 2002; 680: 264-267.
28. Hladik W, Dollard SC, Mermin J, Fowlkes AL, Downing R, Amin MM, et al. Transmission of human herpesvirus 8 by blood transfusion. New England Journal of Medicine. 2006; 355: 1331?1338.
29. Malonga GA, Dienta S, Traore FT, Maiga Z, Ba A, Faye O, et al. Human Herpesvirus 8 seroprevalence among blood donors in Mali. J Med Virol. 2022; 94: 4554?4558.
30. Malonga GA, Jary A, Leducq V, Malanda DMM, Boumba ALM, Chicaud E, et al. Seroprevalence and molecular diversity of Human Herpesvirus 8 among people living with HIV in Brazzaville, Congo. SciRep. 2021; 11: 17442.
31. Saleh S, Lam A, Ho YH. Real-time PCR quantification of human telomerase reverse transcriptase (hTERT) in colorectal cancer. Pathology. 2008; 40: 25?30.
32. Albrecht D, Meyer T, Lorenzen T, Stoehr A, Arndt R, Plettenberg A. Epidemiology of HHV-8 infection in HIV-positive patients with and without Kaposi sarcoma: diagnostic relevance of serology and PCR. J clinical virology. 2004; 30: 145?149.
33. Dedicoat M, Newton R, Alkharsah KR, Sheldon J, Szabados I, Ndlovu B, et al. Mother-to-child transmission of human herpesvirus-8 in South Africa. The J infec dis. 2004; 190: 1068?1075.
34. Dow DE, Cunningham CK, Buchanan AM. A review of human herpesvirus 8, the Kaposi's sarcoma- associated herpesvirus, in the pediatric population. J Pediatric Infectious Diseases Society. 2014; 3: 66?76.
35. Mayama S, Cuevas LE, Sheldon J, Omar OH, Smith DH, Okong P, et al. Prevalence and transmission of Kaposi's sarcoma-associated herpesvirus (human herpesvirus 8) in Ugandan children and adolescents. Int J cancer. 1998; 77: 817-820.
36. Mbulaiteye SM, Pfeiffer RM, Whitby D, Brubaker GR, Shao J, Biggar RJ. Human herpesvirus 8 infection within families in rural Tanzania. J infectious diseases. 2003; 187: 1780?1785.
37. Butler LM, Dorsey G,Hladik W, Rosenthal PJ, Brander C, Neilands TB, et al. Kaposi sarcoma- associated herpesvirus (KSHV) seroprevalence in population-based samples of African children: evidence for at least 2 patterns of KSHV transmission. J Infectious Diseases. 2009; 200: 430?438.
38. Dedicoat M, Newton R. Review of the distribution of Kaposi's sarcoma-associated herpesvirus (KSHV) in Africa in relation to the incidence of Kaposi's sarcoma. British J cancer. 2003; 88: 1-3.
39. Sarmati L. HHV-8 infection in African children. Herpes: the journal of the IHMF. 2004; 11: 50?53.
40. Mbulaiteye SM, Pfeiffer RM, Engels EA, Marshall V, Bakaki PM, Owor AM, et al. Detection of Kaposi Sarcoma-Associated Herpesvirus DNA in Saliva and Buffy-Coat Samples from Children with Sickle Cell Disease in Uganda. J infectious diseases. 2004; 190: 1382?1386.
41. Teodoro JG, Branton PE. Regulation of apoptosis by viral gene products. J Virol. 1997; 71: 1739?1746.
42. Strings: Kaposi's Sarcoma-Associated Herpesvirus.