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Genital Herpes: Diagnosis and Counseling

Debra L. Hill-Busselle, MD

A diagnosis of genital herpes can be emotionally devastating. Many questions arise, including the issue of infidelity. Given the social and sexual components of this infection—which, furthermore, is incurable—counseling is an essential part of management.

Genital herpes simplex virus (HSV) is the most widespread—and most underdiagnosed—sexually transmitted disease in this country today. Although no cure yet exists for HSV, it is possible to greatly reduce the risk of further sexual and perinatal transmission, so that early and accurate diagnosis is paramount.

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PREVALENCE

Genital HSV is the most prevalent sexually transmitted disease (STD) in the United States. It is currently estimated that more than 60 million Americans are infected with genital HSV, 50 million with HSV-2 and 10 million with HSV-1. Seroprevalence also depends on the subpopulation: black Americans have a 50%+ seroprevalence rate for HSV-2; Hispanics, 25%+; whites, 18% to 20%; and Asians, less than 10%.1 Indeed, 19% of the adult US population is infected with HSV-2 (23.1% female, 11.2% male).1 However, between 80% and 90% of people who are infected with genital HSV have not been diagnosed.2

Lack of awareness by health care providers is a major contributing factor in the underdiagnosis of genital HSV. In a study that targeted middle- and upper-middle- class patients in the suburbs of 6 large US cities, 5400 patients aged 18 to 59 years underwent serologic testing: 25.5% tested positive for HSV-2, but only 12% of those infected had been previously diagnosed.3

Up to 50% of new cases of genital HSV are caused by HSV-1,4 which is characterized by fewer recurrences and less asymptomatic viral shedding than HSV-2. Genital HSV-1 infection does not prevent acquisition of HSV-2. Genital HSV-1 infection is usually transmitted by oral-genital sex, whereas genital HSV-2 is most commonly transmitted by genital-genital contact.4-6

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SYMPTOMS

Genital HSV infection causes a wide spectrum of disease. Classic HSV (painful genital vesicles or ulcers) presents in only 10% to 20% of cases.2,7 Most HSV episodes are more subtle, accompanied by vulvar erythema, vulvar/rectal itching and burning, dysuria, cervical/vaginal discharge, and excoriations or fissures. Herpetic lesions are not limited to the genitalia, and can occur anywhere in the “boxer shorts” area.7 Because of these wide variations, genital HSV is often misdiagnosed by both physicians and patients. Common misdiagnoses include vulvar yeast infection, vulvar contact dermatitis, hemorrhoids, urethritis/urethral syndrome, urinary tract infection (UTI), shingles, or vaginitis.8

First-episode infections, when symptomatic, are usually the most severe, causing multiple, painful lesions; inguinal adenopathy; systemic symptoms; and fever. Nonetheless, many initial infections are asymptomatic.9 Recurrent outbreaks are typically milder.

Up to 75% of initial infections are unrecognized by patients and physicians.10 A patient presenting with her first clinically recognized HSV outbreak does not necessarily indicate recent acquisition. Serologic studies show that up to 25% of first clinical episodes are in reality first recognized recurrences.10

One study showed that, after being educated on subtle HSV presentations, 87% of HSV-2–seropositive individuals who had denied symptoms could recognize genital HSV symptoms within 3 months of diagnosis.11 Most patients with genital HSV eventually develop symptomatic recurrences, but both patient and physician may attribute these symptoms to other etiologies—eg, yeast infection, allergic reaction, irritation from sex or exercise, UTI, hemorrhoids, or shingles.

Most women infected with HSV-2 do not know they have genital HSV because their recurrences are mild and infrequent.10,12 An HSV recurrence generally resolves within 6 to 8 days of symptom onset.5 Undiagnosed patients may self-treat with antifungal creams, anti-itch creams, and hemorrhoidal preparations. Because the symptoms abate, few patients seek the medical care that would yield the proper diagnosis. According to the US Centers for Disease Control and Prevention (CDC), the majority of HSV infections are transmitted by patients who are unaware that they have the infection or who are asymptomatic at the time.13

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TESTING

The CDC issued STD treatment guidelines in 2006, noting that the clinical diagnosis of genital HSV is both insensitive and nonspecific. Herpes infection should be documented by type-specific virologic or serologic testing.13 Viral culture is the preferred method for evaluation of mucocutaneous lesions, and can differentiate HSV-1 from HSV-2. A negative culture does not necessarily preclude infection, however, as false-negative findings are common. A primary infection in the vesicular or ulcerative stage has false-negative rates of 20% and 50%, respectively; the false-negative rate can be as high as 70% for recurrent lesions.4,8,13

Although polymerase chain reaction (PCR) testing is not FDA-approved for genital herpes lesions, it is used by many clinicians—and PCR testing is FDA-approved to detect HSV in spinal fluid. The false-positive and -negative rates for PCR are extremely low, and the sensitivity is 1.5 to 4 times greater than for viral culture. Lack of HSV detection (culture or PCR) does not mean lack of infection, as viral shedding is intermittent.8,13

Both type-specific and non-type–specific antibodies to HSV develop during the first several weeks postinfection, and persist indefinitely. Antibodies are present in 50% of patients 3 weeks post-infection, 70% at 6 weeks, and 95%+ at 12 to 16 weeks. It is important to order type-specific assays that are glycoprotein-based, which can accurately detect and differentiate between HSV-1 and HSV-2. Non-type–specific testing is available, but confers a 40% to 50% chance of cross reactivity between HSV-1 and HSV-2.14

Several glycoprotein G-based, type-specific assays have been approved by the FDA. The glycoprotein-based tests have a sensitivity of 80% to 98%, with a specificity of more than 96%. A negative finding means that either the patient is not infected, or that she has not yet developed antibodies, so that repeat testing may be indicated in 6 to 12 weeks.4,9 A positive serologic finding for HSV-2 implies an anogenital HSV-2 infection, because most HSV-2 infections are sexually acquired. If the HSV-1 antibody is present, this could indicate oral or genital infection. Asymptomatic oral HSV-1 is common, and is acquired in early childhood. However, genital HSV-1 infections are increasing, especially among teenagers and young adults.9,13,15

The CDC offers guidelines for patients who may benefit from type-specific serologic testing, including those with:

• Recurrent genital symptoms, or atypical symptoms with negative HSV cultures
• A clinical diagnosis of genital HSV without laboratory confirmation
• A partner who has genital HSV
• Multiple sex partners, HIV infection, or increased risk for HIV acquisition.

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COUNSELING

Counseling of infected persons and their sex partners is critical to the management of genital HSV. It helps the patient to cope with the infection, as well as preventing sexual and perinatal transmission. Counseling should include a discussion of the natural history of the disease—including recurrences, asymptomatic viral shedding, and the potential for transmission. Other essential topics include options for antiviral therapy (suppressive and episodic), avoidance of sexual contact during prodrome/outbreak, condom usage, partner notification, and partner type-specific serologic testing. Based on study findings, the CDC also recommends daily valacyclovir usage by the infected partner to reduce the risk of transmission to the uninfected partner.13

ACOG recommends that antiviral therapy be prescribed at the first clinical episode. Women should be offered antiviral treatment for recurrent episodes. Those with frequent recurrences should be offered suppressive therapy. In discordant couples, suppressive therapy should be recommended for the infected partner to reduce the rate of transmission of HSV-2. Condoms are also recommended to decrease transmission.9

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TREATMENT

All patients who present with first-episode HSV should be treated with antiviral therapy. Even if the symptoms initially seem mild, they can become severe and prolonged (Table 1).

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Table 1. Therapy for New-Onset Genital Herpes

Episodic therapy is most effective if started during the prodrome or within 24 hours of the onset of lesions. Episodic therapy may help to reduce symptoms and speed healing by up to 48 hours. Episodic therapy does not reduce the number of outbreaks or decrease the viral shedding rate.4,7,9 Such therapy is most useful in patients with infrequent outbreaks and in whom transmission is not an issue (ie, concordant partners) (Table 2).

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Table 2. Episodic Therapy for Recurrent Genital Herpes

Suppressive therapy can reduce the number of outbreaks and days of viral shedding, symptomatic and asymptomatic, by 70% to 80%. This therapy can benefit patients with frequent outbreaks, and translates into a 48% reduction in transmission to the uninfected sex partner (Table 3).9,16

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Table 3. Suppressive Therapy for Genital Herpes

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CONCLUSION

Genital HSV is the most prevalent STD in the United States. An estimated 45 to 50 million Americans are infected with genital HSV-2, but only 10% to 20% of those infected have actually been diagnosed. Although clinicians are improving in HSV recognition and testing, many are reluctant to test for genital HSV; the fear of raising the question of infidelity is a real concern. A better understanding of the natural history of genital HSV, coupled with application of the CDC and ACOG guidelines, should help to ease the difficult diagnosis and management process.

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RESOURCES

• American Social Health Association
  www.ashastd.org
• International Herpes Management Forum
  www.ihmf.org

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CASE REPORT: Marital Counseling and Infidelity Implications

The patient is a 41-year-old woman who has been married for 19 years. She had 2 sexual partners prior to her marriage, but has been monogamous since then. She experiences 2 to 3 yeast infections per year, which she treats with a 7-day OTC antifungal cream. She presented after noticing a crack in her vulvar skin that itches and burns. The physician informed her that her symptoms could indicate genital HSV, and she reacted with shock and fear of infidelity by her husband.

Viral culture and serology are positive for HSV-2. From this, it is possible only to deduce that she is infected with genital HSV-2, but not when she became infected. She may have been infected years ago by one of her premarital partners; her “yeast” infections may have actually been unrecognized symptomatic genital HSV outbreaks. It is impossible to know whether her husband infected her, and he must undergo serologic testing.

The patient tells her husband about the HSV diagnosis, and he is angry and does not want to be tested. He wonders whether his wife has been unfaithful. He experiences “jock itch” about twice a year, which he attributes to sweating during exercise.

The husband agreed to testing to prove that he did not have HSV, but his results are positive for HSV-2. He was stunned because he claims to be asymptomatic, but his “jock itch” may have indicated HSV outbreaks. Men are more likely than women to have asymptomatic HSV-2 infections, but they still shed virus asymptomatically just as frequently as someone with recognized clinical outbreaks.11

There is no way to determine which partner infected the other, or how long the infection has been present. One could have infected the other, or both may have been infected by premarital partners. The diagnosis of genital HSV does not mean that anyone has been unfaithful.

Because both partners are infected, transmission of genital HSV to each other is not a concern. Episodic or suppressive therapy would be indicated to treat symptomatic disease in either partner.

If the patient’s viral culture had been positive for HSV-2 but her serology negative, it would indicate a new infection because antibodies did not have time to develop. However, it would not necessarily mean that her husband had been unfaithful, as he could have been infected premaritally and then infected her much later. If the patient’s viral culture and serology were positive for HSV-2, but her husband’s serology was negative, it would not mean that the patient had been unfaithful, either. She could have been infected premaritally, and has not transmitted HSV to her husband; HSV is less efficiently transmitted from female-to-male. The male-to-female transmission rate is 18% to 20% per year, whereas the female-to-male rate is only 4% to 5%.17 In that scenario, counseling should address ways to reduce the husband’s chances of infection.

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Debra L. Hill-Busselle, MD, is a board certified ObGyn, and Executive Director, WomenÕs Healthcare, Atlanta, GA.

References

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