Understanding Genital Herpes
To Your Health -- CHRC Newsletter
Fall 2001
John Boggs, MD, PAMF Internal Medicine/Infectious Diseases
Over 45 million adolescents and adults in the United States have the viral sexually transmitted disease known as genital herpes. Despite a barrage of warnings aimed at preventing the spread of HIV and other sexually transmitted diseases, the incidence appears to be rising, especially in the group of white adolescents aged 12 to 19. The prevalence of genital herpes is higher among women than among men. It is higher among African Americans than among other racial or ethnic groups. Most people have no symptoms or only minimal discomfort, but many do have recurrent outbreaks, which can be painful and irritating. Although the majority of genital infections are caused by herpes simplex virus type 2 (HSV-2), up to 30% or more of new infections come from herpes simplex virus type 1 (HSV- 1), the usual cause of cold sores on the lip, also known as fever blisters. Most US adults (50-80%) have already had exposure to HSV- I during childhood, usually from kissing friends or relatives. As both types persist in a dormant or "latent" state inside spinal nerve cells, they are incurable. Owing to new developments in diagnostic techniques and well tolerated medications, however, this has become a very manageable situation for the vast majority.
HOW DOES SOMEONE GET HERPES?
Herpes is almost always spread by skin-to-skin contact during sexual activity. The skin around the mouth and genital areas is particularly susceptible. The virus is present in genital (and oral) sores and can be spread most easily from contact with these lesions, but transmission can also occur during the time between outbreaks, when a sore is not present or visible. As the herpes virus is fragile outside the body, it does not survive long on surfaces or in air. This makes it extremely unlikely that a person could acquire genital herpes from a toilet seat, bathtub, towel, or other inanimate object. Care should be taken to avoid touching active sores and to wash hands frequently, however, as the virus may be spread to other areas of the body, such as hands, eyes, or face.
SIGNS AND SYMPTOMS
Although one in four U.S. adults has genital herpes, most of these individuals (70% or more) have not been diagnosed and are unaware that they carry the virus. A first episode of genital herpes usually occurs four to eight days after exposure, and may be so mild as to go unnoticed. More often the symptoms are quite irritating: itching and burning at the site of viral entry, with painful or tingling blisters or sores on the genitals, buttocks, anal area, or mouth lasting up to two or more weeks. Fever, headache, lymph node swelling, burning urination, and other flu-like symptoms also often accompany the first ("primary") episode.
After the first outbreak, the virus travels to the nerve clusters ("ganglia") in the lower spinal cord. There, it becomes "latent", hidden inside the nerve cells in an inactive state, until it reactivates to produce another outbreak. Sixty to 90% of patients with symptomatic first episodes have recurrent outbreaks, on average 4 per year. Before visible sores actually develop with these recurrences, patients typically experience a "prodrome", consisting of localized tingling or itching in the area involved. Recurrences are fewer in individuals with genital HSV-1 than with HSV-2. In general, the virus is most active, detectable even at times without symptoms, during the first year of infection: recurrences tend to decrease in frequency and severity for most persons over a period of 5 to 10 years. Factors which trigger outbreaks are still poorly understood, and seem to vary from person to person, but may include sunlight exposure (especially for oral HSV-1), surgery, high fever, stress, onset of menstrual periods, and change in sexual partners.
HOW IS HERPES DIAGNOSED?
The most definitive way to diagnose herpes is by culture of the virus from a swab specimen taken from an active sore, or lesion. This can also determine whether HSV-1 or HSV-2 is the cause. Most individuals, however, do not see recurrent sores or do not have them and are unaware they are infected.
In the past, the only available blood tests measured antibodies made by the immune system in response to HSV, and could not distinguish between HSV-1 or HSV-2 as the cause. If a person tested negative for both, it was clear he or she was uninfected. If the test were positive, though, the result could not be reliably trusted to reflect HSV, but may have been positive due to the usual presence of HSV-1 from childhood exposure and not to genital herpes. A newer blood test is now available which can differentiate between antibodies made by the immune system against HSV- I or HSV-2. Although all tests are helpful if HSV is detected by a positive result, there is still a small possibility that a person may have HSV even if tests are negative.
TREATMENT
Although herpes is not curable, there are three medications currently available by prescription which can help keep the virus in check, and possibly prevent transmission to others. Acyclovir (Zovirax) has been used for over 10 years, and is now available in a generic form. Valacyclovir (Valtrex) also uses acyclovir as its active ingredient, but is formulated to be more efficiently absorbed by the body and can be taken less often. Likewise, famciclovir (FAMvir) is a similar medication, works in the same way against the virus, and may also be taken less often than acyclovir.
Clinical studies have not found any significant differences in effectiveness among the three medications. All are quite safe, very rarely producing any side effects at all. All work by disrupting the virus's reproductive ability. Acyclovir and famciclovir are also available in cream formulations for topical use on the skin, but are much less effective than oral medications and are not recommended.
Treatment may be given on an episodic basis, to accelerate healing once an outbreak occurs, or as suppressive therapy, taken on a regular daily basis to hold HSV in check and prevent outbreaks. As most outbreaks for most persons are mild, medication may be needed only rarely for episodes or even not at all. For individuals with severe or frequent outbreaks (more than 6 per year), however, suppressive therapy can greatly reduce the frequency of outbreaks, and in some cases prevent recurrences completely. It can also decrease asymptornatic "shedding" of virus, and possibly lower the risk of transmission (currently under study).
Although the amino acid lysine has been advocated by some, clinical studies have not supported its effectiveness in most patients. Warm compresses, tub baths, and analgesics (such as acetaminophen, aspirin, or ibuprofen) may be somewhat soothing.
HSV AND PREGNANCY
The spread of herpes to newborns is rare (less than 0. 1%), and most mothers with a history of recurrent genital HSV have normal vaginal deliveries. In this situation, the mother has antibodies from previous exposure which help by passing through the placenta to protect the baby while in the uterus. An infant who contracts herpes at birth can become very ill, however, so a cesarean section is usually performed if active herpes lesions are present at the time of delivery. In contrast, if the mother acquires HSV and has a first episode during pregnancy, protective antibodies are not present and the risk of transmitting HSV to the baby is greater. Thus, a woman with no history of herpes but with a partner who has HSV should take all possible preventive measures to avoid contracting HSV during the pregnancy. As with adults, medication can be helpful if given early to babies who do contract HSV.
SUPPORTIVE COUNSELING
When first diagnosed with genital herpes, many people experience depression, guilt, shame, or anger at previous partners, and often want to withdraw from relationships altogether. Though these feelings usually abate or decrease in intensity with time, they can cause considerable interim psychological suffering and disruption of social activity. Counseling may be particularly helpful during this time, obtained through primary care providers or by referral to specialists or local support groups. A reliable source of additional information is the Herpes Resource Center (American Social Health Association), (800) 230-6039, or at http://vww.ashastd.org.
PREVENTION-PROTECTING YOURSELF AND OTHERS
Because of its prevalence in one quarter of our adult population, preventing the spread of this highly contact-contagious condition is no easy matter. Short of abstinence, then, the surest way for an uninfected person to remain so is to maintain a monogamous relationship with an uninfected partner. While unprotected sexual contact with multiple partners certainly increases the risk, HSV is so prevalent that on average an individual acquires it more through bad luck than as a result of promiscuity.
For those who have genital herpes, condom use may help to prevent the spread, but will not help if sores are located outside the covered area. Sexual activity and contact with affected areas should be avoided during times of symptomatic outbreaks (including the "prodrome" period) or when sores are present, until these have completely healed. When sores are present, these should be kept clean and dry, touched only as necessary, with careful attention to hand washing after any contact with affected areas. Open communication between partners is essential to allow an informed choice regarding risk of transmission and to build trust in the relationship. Most people actually react well to this sharing of confidence; it is unusual for this disclosure to dissolve a relationship. Ideally, this mutual understanding and informed approach can put herpes into proper perspective -- as an annoying skin condition that is both treatable and manageable, nothing more and nothing less.