Prevention of New Genital Herpes Infections
by Curtis S. Phinney, Sc M
Gains New Importance in the Healthcare Provider Community
Medical studies over the last ten years have shown that genital herpes is characterized as a chronic infection that frequently demonstrates reactivation at the skin surface, i.e., “viral shedding.” In addition, significant increases in the prevalence of genital herpes have taken place. Current estimates indicate that 22% of U.S. adults have antibodies to HSV-II, and 1.6 million new infections occur each year (L. Corey, 2004.)
Although the high prevalence of genital herpes has been known to healthcare providers for years, population-based studies using new, sensitive analytical techniques have demonstrated the importance of addressing new infections in the management of genital herpes. People with herpes have said for years that the most important thing to them was often managing the possibility of transmitting HSV infection to an uninfected partner. Now the healthcare community recognizes the significance of transmission, often without symptoms, of genital herpes to uninfected partners as a major driving force behind the spread and persistence of genital herpes worldwide.
As a result of this new awareness, changes in the approach to the management of the condition are taking place. Dr. Corey states “This shift has finally placed the concerns of physicians and health officials in concert with those of patients with known genital herpes infections…” The result of this new awareness is several new approaches to the management of genital herpes infections. First, existing approaches to preventing transmission are being revisited. Foremost among these is the clinically proven use of an oral antiviral drug, i.e., valacyclovir (Valtrex®) to reduce the frequency of viral shedding at the skin surface. In addition, the use of condoms, although clearly less than 100% effective, has been shown to offer some degree of protection against new infections, particularly for women.
The second major change in the healthcare provider community is a new view of an old argument, i.e., whether to identify people who are seropositive for HSV-II but have not been diagnosed as having genital herpes. Until recently, the prevailing argument has been to “do no harm.” In other words, the negative implications of identifying and informing a person with antibodies to HSV-II, yet not having any clinical symptoms, was thought to outweigh any benefit that the disclosure might have. Now however, the advantages of identifying symptom-free individuals with HSV infection are seen as twofold. First, the individual would then be identified as a candidate for oral antiviral therapy. Second, informing the individual and providing resources will reduce the likelihood of inadvertent transmission to an uninfected partner by way of subclinical viral shedding.
Dr. Corey proposes that persons in “high-risk populations”, defined as “…HIV-infected persons and all persons attending STD clinics…” should be tested for HSV-II using commercial glycoprotein G assays. People who test positive should be educated with regard to the implications of their serostatus. This means that they need to know that they have been exposed to the genital herpes virus at some time in the past, that they can transmit the infection to others even without symptoms, that their lack of symptoms does not mean that they would only transmit mild infections to others, and that they can take advantage of existing tools to help prevent transmission to others.
Until recently, testing symptom-free individuals for HSV-II antibodies was seen as looking for trouble where none existed. In a similar vein, oral antiviral therapy, particularly daily suppressive therapy, was seen as treatment regimens that were to be reserved for the worst cases only. Now, identifying patients that have practically no symptoms, yet have been exposed to the herpes virus, is seen as a way to intervene with transmission prevention strategies before new infections have an opportunity to become established. Daily suppressive therapy, once reserved for patients who had proven that they suffered chronic clinical recurrences, is now seen as the front-line management and prevention tool for reducing the rate of new infections in the general population.
These new approaches to the use of existing tools for the detection, prevention, and treatment of genital herpes hold considerable promise for reducing the rate of new infections. In addition, the more widespread application of oral antiviral therapy will result in less physical, emotional, and social discomfort for persons who have been diagnosed with genital herpes. Perhaps the hard work by herpes patient advocates, who work almost entirely behind the scenes and without compensation, has helped bring about this very positive convergence of viewpoints between the patient population and the healthcare provider community.
*** Reference: Corey, L. Medscape Infectious Diseases 6 (1), 29Mar2004.
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