Genital Herpes Min Kim, MSN, APRN, ANP-BC

Overview Common STD caused by herpes simplex virus Chronic, life-long viral infection Two serotypes: HSV-1 & HSV-2 Majority cases caused by HSV-2 HSV-1 is usually associated with oral lesions, but can cause genital herpes

Epidemiology At least 50 million persons in the United States infected An estimated 81% of infected persons have not been diagnosed 1.6 million new cases each year More common in women than men, about 1 in 4 women vs 1 in 8 men

Epidemiology(cont.) Many persons have mild, asymptomatic, or unrecognized infections Asymptomatic persons can shed virus intermittently in genital organs Majority of HSV infections are transmitted by person unaware that they have infection

Transmission HSV-2 is transmitted sexually and perinatally HSV-1 is usually transmitted via a non-sexual route; however, sexual transmission appears to be increasing Risk of spreading the infection is much greater when a person has active signs or symptoms Transmission can occur even if there are no visible ulcers It is possible for a person to develop genital herpes after exposure to a cold sore on an infected person's lip during oral sex; in this case, genital herpes may be due to infection with HSV type 1

Transmission(cont.) Incubation period after acquisition is 2-12 days Washing with soap and water readily inactivates HSV There is no risk of becoming infected after exposure to environmental surfaces door knobs, toilet seats, utensils, bed sheets

Clinical manifestations types of infection Primary Non-primary (non-primary first infection) Recurrent

Primary infection The first infection ever with either HSV-1 or HSV-2 No serum antibody is present when symptoms appear More severe symptoms than in recurrent disease. Serum antibody may take several weeks to a few months to appear

Non-primary first infection Newly acquired infection with HSV-1 or HSV-2 in an individual previously seropositive to the other viral type Type-specific antibody to the prior infection is present initially Manifestations tend to be milder than those of primary infection

Recurrent infection Reactivation of genital HSV The HSV type recovered in lesion is the same type as antibodies in the serum Infection in which antibody is present when symptoms appear May not be aware of previous episodes Symptoms are mild and short in duration

Signs and symptoms of primary infection Numerous bilateral painful lesions Lesions last average of 11-12 days Typical lesion progression: papules, vesicles, pustules, ulcers, crusts, then healed The median duration of viral shedding is about 12 days Systemic symptoms peak within 3-4 days of onset of lesions and gradually recede over next 3-4 days (fever, headache, malaise, myalgia) Local symptoms include pain, itching, dysuria, vaginal or urethral discharge, and tender inguinal lymphadenopathy full recovery takes an average of 17-20 days

Genital Herpes Typical lesion progression: papules, vesicles, pustules, ulcers, crusts, then healed

Latent stage After initial outbreak, virus travels to a bundle of nerves at the base of the spine Remains dormant for a period of time There are no symptoms during this stage Triggers for recurrence — Illness, stress, sunlight, fatigue, and menstrual periods in women

Signs and symptoms of recurrent infection llness lasting 5-10 days Prodromal symptoms (localized tingling, irritation) are common and begin 12-24 hours before lesions develop Systemic symptoms usually absent Duration of genital lesions is approximately 4-6 days Average duration of viral shedding is 4 days Lesions tend to be unilateral, and much less extensive than with primary infection HSV-2 primary infection is more likely to recur than HSV-1 primary infection Recurrences are more frequent if the primary episode is prolonged (i.e., greater than 30 days)

Diagnosis Clinical diagnosis of genital herpes should be confirmed with laboratory testing Classical symptoms are often absent in many patients Need to distinguish genital herpes from other STIs that also produce genital ulcers, such as syphilis and chancroid

lab tests Virologic tests Type-specific serologic tests

Virologic Tests Viral culture is gold standard for HSV diagnosis Preferred if genital ulcers / lesions present Most cultures will be positive within 24-72 hours Antigen detection Better than culture for detecting HSV in healing lesions   The direct fluorescent antibody test distinguishes between HSV-1 and HSV-2 Cytology (Tzanck or Pap) identifies typical HSV-infected cells. It should not be relied upon for HSV diagnosis Polymerase Chain Reaction (PCR) assays PCR is the preferred test for detecting HSV DNA in cerebral spinal fluid Not FDA-cleared for testing of genital specimens Not widely available, and may lack standardization across laboratories

Type-Specific Serologic Tests Detect Antibodies to HSV HSV-2 antibody indicates anogenital infection as almost all HSV-2 infections are sexually acquired HSV-1 antibody does not distinguish anogenital from orolabial infection Type-specific serologic assays might be useful when Recurrent or atypical genital symptoms with negative cultures A clinical diagnosis of genital herpes w/o laboratory confirmation A sex partner with genital herpes As part of a comprehensive evaluation for STDs among persons with multiple sex partners, HIV infection, and among MSM at increased risk for HIV acquisition HSV antibody develops during the first several weeks to few months following infection and persist indefinitely

Treatment Antiviral drug therapy Partially controls symptoms Does not eradicate the virus Does not affect the risk, frequency, or severity of recurrences after the drug is discontinued Three oral meds: acyclovir, valacyclovir, and famciclovir Topical antiviral treatment is of minimal clinical benefit, and it is not recommended

Treatment for First Clinical Episode Patients with first clinical episode genital herpes should receive antiviral therapy Drastic effect on sxs, if sxs are of less than 7 day’s duration Acyclovir 400 mg orally 3 times a day for 7-10 days, OR Acyclovir 200 mg orally 5 times a day for 7-10 days, OR Famciclovir 250 mg orally 3 times a day for 7-10 days, OR Valacyclovir 1 g orally twice a day for 7-10 days Treatment may be extended if healing is incomplete after 10 days of therapy

Suppressive therapy Can be administered continuously Reduce the frequency of occurrences Acyclovir 400 mg orally twice a day, OR Famciclovir 250 mg orally twice a day, OR Valacyclovir 500 mg orally once a day, OR Valacyclovir 1 g orally once a day Rebound outbreaks when suppression tx is discontinued Suppression therapy does not eliminate latent infection

Episodic therapy for recurrent Genital Herpes Initiation of therapy within one day of lesion onset Provide pt w/ appropriate meds or Rx in hand Instruct pt to self-initiate tx immediately when sxs begin CDC recommendation Acyclovir 400 mg orally 3 times a day for 5 days, OR Acyclovir 800 mg orally twice a day for 5 days, OR Acyclovir 800 mg orally 3 times a day for 2 days; OR Famciclovir 125 mg orally twice a day for 5 days, OR Famciclovir 1000 mg orally twice a day for 1 day, OR Valacyclovir 500 mg orally twice a day for 3 days, OR Valacyclovir 1 g orally once a day for 5 days

Management of Severe Disease IV acyclovir Severe HSV disease Complications requiring hospitalization - disseminated infection, pneumonitis or hepatitis Complications of the central nervous system - meningitis or encephalitis Herpes in HIV Infected Persons May have prolonged or severe episodes Increased doses of antiviral drugs may be beneficial

Pt Counseling and Education Helping patients cope with infection Preventing sexual & perinatal transmission Natural history of disease Treatment options Transmission Prevention

Prevention Transmitted when lesions not present Transmitted mostly during asymptomatic periods Inform current SP about diagnosis with genital herpes Inform future partners before initiating relationship Abstain from sexual activity when lesions or prodromal sxs present Avoid oral sex if ulcers or blisters around the mouth Correct & consistent use of latex condoms reduce the risk Suppressive tx reduces transmission when used by persons with multiple partners including MSM  

Neonatal herpes prevention Risk of neonatal HSV infection should be explained to all patients, including men Advise to inform prenatal & neonatal care providers Advise pregnant women who are not infected with HSV-2 to avoid intercourse during the third trimester with men who have genital herpes

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