Interview with Terri Warren, Nurse Practitioner
This month we are excited to bring to you an interview with Terri Warren, nurse practitioner. Terri is one of the leaders in Herpes research and treatment in the world. Her research papers abound in the medical literature in some of the most renowned and respected journals. Over the past 17 years, Terri has served as an investigator or sub-investigator on over 70 medical research studies, and speaks both nationally and internationally on the subject of genital herpes. A nurse practitioner, she is the owner of the Westover Heights Clinic in Portland, Oregon. Established in 1982, the clinic specializes in the diagnosis and treatment of sexually transmitted diseases. She has been a member of the executive committee of the American Sexually Transmitted Disease Association. She is the medical responder for the herpes website on WebMD. Terri is a member of the “Stop the Spread” committee of the American Social Health Association, devoted to herpes prevention. She also serves as the medical advisor for the local Portland HELP group.
In addition to Terri’s busy life as one of the foremost researchers and practitioners in the field, she is a single mother of three daughters, one of whom is also a nurse practitioner. We are so proud to have Terri as a member of our Medical Advisory Board, and we caught up with her at work on a busy day in Portland.
Dr. H. – Terri, thanks for taking a few minutes to answer some questions on the “cutting edge” of the state of herpes research as well as to offer advice to persons suffering with herpes infections.
One question that I get regularly is this: What percentage of relationships involving herpes infections are “discordant” according to the patient population that you see, where one member of the relationship has genital herpes and one does not?
Terri – I estimate that, of the patients in relationships that I see, approximately a third of those relationships are “discordant”, where one of the members of a couple has a type of genital herpes virus that the other does not. We always test both members of the couple, by the way, and we believe that all screens for sexually transmitted diseases should include HSV serology for both types of herpes simplex virus.
Dr. H. – You participated in some of the early research that indicated that when infected persons take antiviral medication such as Valtrex, the shedding of virus by the infected person is dramatically reduced, by as much as 80% or more. Recently, you’ve been actively involved in the multi-center study looking at the protective effect that the taking of Valtrex by the infected partner has for the uninfected partner in a discordant relationship. The results are to be announced soon. What can you tell us at this point?
Terri – While I can’t talk directly about the study until the results are announced, I can say that the statement of the Medical Advisory Board of Herpes.org appears to be correct, though the final data has not been analyzed. For years, I have been routinely telling the infected partner of a discordant relationship to take suppressive antiviral medication to help protect the uninfected partner, even though we do not have specific data about transmission but because it has demonstrated such a huge reduction in viral shedding for the infected partner. The results of the transmission study will be presented in September.
Dr. H. – So, you think that the results of the research will be happy ones for members of discordant couples?
Terri – I think that the results should be encouraging, yes.
Dr. H. – Well, we will certainly be looking forward to the results of the study to come out soon. On another note, I came across a study recently suggesting that taking antiviral medication for a prolonged period at the time of first diagnosis may be beneficial for the infected person, possibly reducing the severity of outbreaks later. Any thoughts on this?
Terri – No, there is no evidence that I am aware of that taking antiviral therapy for a prolonged period when first contracting herpes does anything to reduce the severity of herpes later on. I think you are referring to the Field mouse model study, and there is yet to be data to prove that it makes an impact in humans. However, I believe strongly in starting suppressive (daily) antiviral therapy at first episode for several other reasons. First, it reduces the number of outbreaks a person will have in the first year. Outbreaks are more common in that first year as the body mounts an immune response. Second, it reduces viral shedding, which is more common in that first year. And third, we believe it helps people have a “break” from outbreaks that allows them a chance to adjust psychologically. Currently, we are conducting a study to see if that last hypothesis is actually true or not.
Dr. H. – One thing that I had been concerned about in the past was in the setting of relationships where both members have genital herpes. Is it possible that one partner might infect the other partner in other locations of the body? What about if the partners have different types of herpes (one with genital type 1 and one with genital type 2)?
Terri – The current thought is that the whole sacral nerve ganglion plexus gets infected, though only certain skin areas may break out. So, if both partners have the same genital type, i.e. both have genital type 1 or both have genital type 2, we advise them that they do not need to use protection. All genital infections are “bilateral” almost from the beginning, or certainly become bilateral soon, with the infection going “up and across” to the other nerve ganglia, producing a “boxer shorts” distribution of the nerve ganglia that are actually infected. Steve Sacks, M.D. addresses this in his book, “The Truth about Herpes”.
If one partner has genital type 2 and one partner has genital type 1, then the person with type 2 doesn’t need to worry about getting genital type 1 because the antibody to type 2 appears to be very protective against getting a new type. Indeed, the person with genital type 2 is almost non-susceptible to acquiring genital type 1. The person with genital type 1 should want to avoid acquiring genital type 2, however, because it can break out more frequently than the genital type 1 infection. So, precautions should be taken and it is very important that both partners in a sexual relationship know the type of their genital infection (1 vs. 2).
Certainly one should avoid transmitting any of the herpes infections to the face near the eyes, as it is possible to acquire the infection on the cornea. However, autoinoculation (infecting another part of the body from the main site of infection) occurs almost exclusively during first episode disease when an immune response has not yet been fully established.
Dr. H. – Terri, what’s the current status of vaccines for herpes infections?
Terri – A large-scale trial is going to begin this summer specifically on a vaccine that appears to offer some protective benefit for women who are not infected with either type of herpes simplex virus (type 1 or type 2). The project is sponsored by the National Institutes of Health and will enroll 7000 women for the study. Previous work indicated that this vaccine could prevent the acquisition of the virus in 45% of women who had no previous herpes simplex infection. It appeared to prevent the acquisition of disease in 75% of women, though.
Dr. H. – Does this mean that someone actually might become infected but, under the influence of the vaccine, might not develop disease symptoms?
Terri – Apparently, yes.
Dr. H. – You know, a high percentage of people who develop herpes simplex infections seem not to develop significant, if any symptoms. So, apparently the immune systems of many people are able to “control” the infection, for the sake of another term. Does this mean that this vaccine MAY be able to help induce the immune systems of uninfected women to be able to “control” the infection in most cases if they get infected, without developing symptoms?
Terri – Possibly. It’s still too early to know the actual mechanism of controlling infections through stimulating the immune system. It is also true that although many people don’t report having symptoms, they really do have symptoms but don’t recognize them until someone teaches them about all the possible ways that genital herpes can present itself. Once people are taught about that, about 50% of those unable to recognize symptoms previously can then do so.
Dr. H. – Speaking of stimulating the immune system, a good bit of research is being done now on a family of drugs called “immune modulators”. One is already on the market, called imiquimod, brand name “Aldara”, currently approved by the FDA for the treatment of genital warts. Another member of the family, resiquimod, is in testing now. The literature seems to suggest that the frequency of outbreaks is reduced, sometimes pretty dramatically, by the use of these topical chemicals. Any thoughts?
Terri – The preliminary results (presented by Dr. Steve Tyring in the Journal of Infectious Diseases) seem very positive as far as reducing frequency of outbreaks. However, even with the use of the chemical, recurrent outbreaks, when they occur, do not appear to be any shorter. And, the chemical can be quite irritating to the skin, sometimes producing skin ulcers in the area that it is used. So, it remains to be seen what the role of these immune system modifiers will be.
Dr. H. – I have read about a whole new class of antiviral chemicals called “helicase inhibitors” for herpes simplex infections. Any comments?
Terri – Drug companies appear to be reluctant to jump on this new drug family for treatment of herpes infections. They appear reluctant to develop them at this point, not being sure if they will be able to recoup their investment in the drugs. These drugs are not in human trials at this time, but perhaps in the future. We sure hope so!
Dr. H. – Last question: How can people get easily tested for herpes infections?
Terri – I recommend that people interested in getting tested go to www.healthcheckUSA.com . They can get their own serology for herpes by locating a facility in their area through the website that does the HerpesSelect IgG antibody blood tests. However, they also offer the IgM test for HSV 1 and 2, and that one should be avoided because it is not truly type specific and may not accurately define a true first episode infection. I refer lots of people there who request testing information at my WebMD herpes message board. There are still the old bad tests on the market, and sometimes people’s health care providers just don’t know which test their lab uses. At least this way, I know they are getting the new HerpeSelect test and that their results will be very accurate, assuming people wait 3 months from possible exposure to testing.
Dr. H. – Terri, thanks so much for taking the time for this dialogue, and thank you for everything you do for helping those dealing with these issues.
Terri – My pleasure! Take care!