Genital herpes is a recurrent, lifelong viral disease. This is the one thing that patients and clinicians don’t like to say, but there’s no way around it, said at a conference on contraceptive technology sponsored by Contemporary Forums.
Other difficult truths about infection with herpes simplex virus (HSV) type 2? The overwhelming majority of people infected with the virus don’t know that they have it, and people with asymptomatic or unrecognized disease shed the virus intermittently in the genital tract, said by a certified family nurse practitioner who is assistant medical director of the STD Center for Excellence at Montefiore Medical Center in New York.
When we ask patients prior to screening for HSV-2 if they have a history of genital herpes . . . about 90% of those who ultimately test positive for HSV-2 antibodies reported having no history or symptoms of the infection. This under-recognition can be attributed to the fact that the leading cause of HSV-2 infection is asymptomatic shedding of the virus.
There is a misperception and some clinicians are still telling patients that the infection is spread only through [HSV-2] sores. This is absolutely not true. The virus can shed even when the skin looks normal, and that’s when the most infections occur.
Patient education about symptomatic disease is critical to an effective screening protocol. When patients come in and have no symptoms, it means nothing to us. Patients who come in for STD screening are told that, from this day forward, the fact that you or your partner have no symptoms means nothing; the fact that you and your partner look fine means nothing; and the fact that you or your partner had a negative screen 6 months ago, if you’ve had partner in the interim, means nothing.
Another factor contributing to the high rate of unrecognized disease is that many patients who have been screened for STDs believe they have been tested for genital herpes. A complete STD screen does not include testing for herpes. Clinicians don’t always tell this to patients, so many patients believe they are being tested for everything. If their STD screen is negative, they assume that means they don’t have herpes.
For this reason, clinicians who don’t routinely screen for herpes [as part of an STD screening protocol] must inform patients that they are not being tested and chart that in the patient record so there is no confusion.
If a patient asks to be screened for HSV-2, there are several points that should be addressed before testing.
• The absence of symptoms does not predict a negative screen.
• In patients with lesions, a herpes culture has low sensitivity, especially as lesions heal. As such, a negative culture does not rule out HSV-2.
• In the event of a positive HSV-2 test in an asymptomatic person, it is not possible to determine how long the virus has been present when or whether they will have outbreaks, or whether they will ever have a problem with herpes.
• In the event of a positive HSV-2 test, patients in some states have a legal obligation to inform current and future sexual partners in their infection status before genital to skin contact. It is a misdemeanor in New York State, for example, to knowingly pass on or put some else at risk for a sexually transmitted disease.
Counseling patients on these points before testing is imperative. If you wait until a positive screen, they can guarantee patients will no longer be listening. They need to know what to expect before they hear the work positive.
Among the tools used to screen for HSV-2, clinical examination and history are insensitive and nonspecific. Symptoms are easily confused with other conditions or may present atypically, for example, as redness rather than sores. Viral culture is the most valid test available, despite the high rate of false negatives.
Polymerase chain reaction assays are another diagnostic option. They have increased sensitivity but are not approved by the Food and Drug Administration, nor are they available in all laboratories. Cellular detection methods, including Tzanck test and Pap smear, are not recommended for HSV detection because of their low sensitivity.
Many type-specific serology tests, such as the older enzyme-lined immunoabsorbent assays tests, can result in false-positive results because of problems with cross reactivity. The newer type-specific JSV glycoprotein G1 (HSV-1), and G2 (HSV-2) tests are more reliable, but their sensitivities vary, noting that a positive test should be confirmed with a positive test to reduce the risk of false-positive diagnoses. The Western blot is the reference standard serology test, but it is not approved and is only available from one laboratory at the University of Washington, Seattle.
Do not underestimate the impact of this diagnosis on your patients. They will require extensive, thoughtful counseling (because) the physical impact of genital herpes is nothing compared to the psychological one.
Such counseling should include information about the natural history of disease, the ability to bear children, the transmission risk to sexual partners, and the variations in severity of primary vs. recurrent episodes. It also is important to dispel cancer myths, reiterate the fact that the virus can be transmitted in the absence of symptoms or lesions, remind patients of their obligation to inform current and future partners, and recommend counseling and testing for sexual partners.
Risk-reduction strategies also should be discussed, including avoiding sexual contact when symptoms or lesions are present and using latex barrier protection and suppressive therapy. There are three oral antiviral drugs — acyclovir, valacyclovir and famciclovir — approved for the treatment of genital herpes. Topical treatments, absolutely do not work and have no role in the treatment of genital herpes.