Genital Herpes: A Hidden Epidemic

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Genital herpes may not be deadly, but it can be physically painful and emotionally debilitating. Those who have it may suffer from painful sores as well as feelings of shame, regret, isolation, and undesirability.

"We, as a society, don't do well with STDs," says Terri Warren, R.N., owner of the Westover Heights Clinic in Portland, Ore., specializing in the treatment of sexually transmitted diseases. "When people have a lifelong STD, they feel dirty, damaged, and unapproachable. Most people have a dramatic drop in self-esteem."

Barry was devastated when he first discovered he had genital herpes. "I was very interested in finding a new successful long-term monogamous relationship," says Barry, who had been divorced before he became infected. "I was having difficulty as it was. With herpes I thought it would be impossible. I thought I was unlovable, untouchable, undesirable."

Genital herpes is on the rise. Since the late 1970s, the number of Americans infected with the virus has increased 30 percent to about 45 million, according to the Centers for Disease Control and Prevention (CDC).

Genital herpes infects more than 1 of 5 adolescents and adults, the CDC says. It is more common in blacks than in whites, and more likely to infect women than men. Compared to 20 years ago, it's about five times more common in 12- to 19-year-old whites and twice as common in adults ages 20 to 29.

The scary part is that most people with genital herpes don't know they have it, and are unaware they may be spreading it to others, says Warren. Many have no symptoms or mistake their symptoms for something else, such as jock itch, insect bites, hemorrhoids, yeast infections, razor burn, or allergies to laundry detergent.

Of even greater concern is growing evidence that people with genital herpes are at greater risk of getting HIV (the virus that causes AIDS) if they have unprotected sex with someone infected with HIV. And HIV-infected people who are also infected with genital herpes may have more frequent and severe outbreaks and their episodes may be more difficult to treat.

In the past, genital herpes was diagnosed solely by visual inspection and laboratory culture of an active sore. Herpes may now be diagnosed with a blood test, even when no symptoms are apparent or after sores have healed. And while there is no cure for herpes, antiviral drugs have been approved by the Food and Drug Administration that greatly reduce the frequency of outbreaks and shorten their duration and severity.

What is Genital Herpes?
Genital herpes, a sexually transmitted disease (STD), is an infection caused by the herpes simplex virus (HSV). HSV is in the same family of viruses that causes chickenpox, shingles and mononucleosis. There are two types of HSV: HSV-1, which infects 80 percent of the U.S. population, usually appears on the lips in cold sores; HSV-2 is usually found in the genital area. However, if a person with HSV-1 oral herpes (cold sores) performs oral sex, it is possible for the partner to get HSV-1 genital herpes. And HSV-2 can infect the mouth through oral sex.

HSV can cause sores, or lesions, to appear in and around the vaginal area and within the cervix in women, and on the penis and scrotum in men. Both males and females may also get lesions in the urinary tract, around the anal opening, on the buttocks or thighs, and sometimes on other parts of the body.

The First Episode
Symptoms of genital herpes can vary in appearance and intensity. Some people have no symptoms or such mild symptoms that they don't suspect they have an infection. For others, the first episode of herpes (primary infection) can cause one or more very painful lesions to erupt on the skin.

For many people, this primary infection may be more severe and have more generalized symptoms than recurrent episodes. During a first episode, the lesions may be accompanied by flu-like symptoms such as fever, headache and muscle aches. Some people experience painful or difficult urination and swollen glands in the groin area. Women may also have a vaginal discharge.

Genital herpes lesions usually appear within two to 10 days after being exposed to the virus, and can last from two to four weeks. First to appear are small red bumps, which develop into blisters. Then the blisters become open sores, which later dry up, crust over, and heal without leaving a scar. Sometimes a second crop of lesions appears.

Recurrent Episodes
Once HSV infects a person, the virus travels through the nerves and settles at the base of the spine. During this inactive phase, the virus is dormant. But it may wake up later, travel along the nerve paths to the surface of the skin, and cause another outbreak of lesions. This recurrence of HSV usually causes lesions to appear around the same area of the first outbreak. (See "Harboring Herpesvirus," page 12.)

Some people have only one or two recurrences in a lifetime, while others have them frequently. "The recurrence rate is far lower in HSV-1 than HSV-2," says Rhoda Ashley, Ph.D., director of the University of Washington's diagnostic virology laboratory at the Children's Hospital and Regional Medical Center in Seattle.

Most people diagnosed with HSV-2 affecting the genital area typically have four or five symptomatic recurrences the first year. After the first year, most people have fewer and milder recurrences, lasting a week or less. Many people get warning signals of a recurrence, known as prodrome. With prodrome, there may be a tingling or itching in the genital area, or pain in the buttocks, down the legs, or in the lower back. Sometimes these symptoms go away and no lesions appear.

Barry's outbreaks were so frequent that they made him irritable, he says. "I would get an outbreak, and as that outbreak was fading over a week or so, suddenly a new one would crop up. As a result, I was really only 'clear' for as little as one week a month."

Researchers don't know why recurrences happen, or why their frequency and severity vary. Some people report that recurrences are triggered by stress, illness, poor nutrition, menstruation, and friction in the genital area, such as that caused by vigorous sex. However, many of these supposed triggers have no scientific basis, says Ashley. "You can't say stress is a trigger. It's like the chicken and the egg. Which came first--the herpes or the stress?" Nevertheless, for many people, trying to avoid their triggers seems to work for them, says Ashley.

Stress is a "huge factor" in triggering outbreaks for Pat Adams of Washington, D.C. Adams has had genital herpes for about 20 years. "Anything I can do to calm myself down during a stressful period and take better care of myself can help," says Adams. She finds that a good diet and exercise help her to keep the virus in check.

Asymptomatic Shedding
In many instances, people with genital herpes know the virus is active because they have symptoms, such as lesions. But this isn't always the case.

The herpes virus can become active without causing symptoms. During these times, small amounts of the virus are present on the skin, often at the place of first infection. This reactivation without symptoms, known as "asymptomatic shedding," may also occur in rectal tissue or in fluids from the penis and vagina.

"Even if you're asymptomatic, you can transmit the virus," says Stanka Kukich, M.D., a medical team leader in the FDA's Center for Drug Evaluation and Research. In fact, studies have shown that most people get HSV from sexual contact during times of asymptomatic viral shedding.

Researchers have found that people with HSV-2 genital herpes tend to have more shedding than those with HSV-1. In addition, people with new infections are more likely to shed the virus than those with an infection more than a year old. Those with frequent recurrences may also shed the virus more often, but this is still an area being studied.

Transmission and Prevention
Genital herpes is spread only through direct skin-to-skin contact or mucous membrane contact. It can be transmitted through penile-vaginal intercourse, anal intercourse, oral-genital sex, and other sexual body-to-body contact.

To reduce the risk of transmitting genital herpes, people who have the virus should avoid sexual contact from the time they first feel any symptoms until their lesions are completely healed. During times when there are no symptoms, using latex male condoms for genital-to-genital contact reduces the risk of transmission, according to the American Social Health Association. But condoms are only effective if they cover or prevent contact with the area of the body that has a lesion or active virus.

In one study of more than 400 monogamous couples in which one partner had genital herpes and the other didn't, condoms were found to offer significant protection against HSV-2 infection in women, says study leader Anna Wald, M.D., medical director of the virology research clinic at the University of Washington in Seattle. Since women shed the virus from a wide genital area, condoms may be less protective for men than for women, says Wald, whose study was published in the June 27, 2001, issue of the Journal of the American Medical Association. However, more studies are needed to address how well condoms work for men, she says.

Lambskin or other natural membrane condoms should not be used for disease protection because the naturally occurring pores in the material are large enough to allow some viruses to pass through. The FDA recommends latex condoms or polyurethane condoms for those sensitive to latex.

Partners can be infected with different strains of herpes, but are highly unlikely to reinfect each other, says Ashley. Even if they did, each person's symptoms are unlikely to change. "You're not going to be suddenly having twice the attacks because you have [your partner's] strain too."

The virus is not transmitted through the air, nor are there any documented cases of a person getting genital herpes from an inanimate object such as a toilet seat or hot tub. "Herpes doesn't do well in chlorinated water," says Ashley. "The virus can be present in a hot tub, but it won't be active." The virus doesn't survive well in the environment, even on a wet towel, says Ashley. However, she advises to avoid sharing razors, especially with someone who has an active cold sore. The virus can be transmitted from the razor to the skin. Other viruses, such as hepatitis C, also can be transmitted by sharing razors.

Spreading herpes from one part of your body to another (autoinoculation) is possible, but unusual. To be safe, wash your hands with soap if you touch a herpes sore.

Treatment
Although there is no cure for genital herpes, there are medications that significantly reduce the frequency and duration of outbreaks and have few side effects in most people.

In 1985, the FDA approved Zovirax (acyclovir), the first genital herpes drug, which is now available in a generic form. More recently, the FDA approved two other drugs to treat genital herpes: Famvir (famciclovir) and Valtrex (valacyclovir).

All three of these oral antiviral drugs can be taken either episodically--when a person has an outbreak or feels one coming on, or suppressively--daily to help prevent the recurrence of outbreaks. Acyclovir and valacyclovir are also FDA-approved to treat an initial episode of genital herpes to help heal the lesions and to lessen the pain.

When taken episodically at the first sign of a tingling or itching sensation, an antiviral drug may prevent an outbreak altogether. "Once an outbreak occurs, if the treatment is started soon enough, the drugs can lessen the severity and shorten the healing time," says the FDA's Kukich. When taken suppressively, the drugs don't always prevent outbreaks, but help them to occur less frequently.

All three of the drugs work by interfering with DNA synthesis to prevent the virus from reproducing, says Kukich. Famciclovir and valacyclovir, which are better absorbed by the body, can be taken less often than acyclovir. (For more information on these antivirals, see "Genital Herpes Oral Antiviral Drugs," page 13.)

Diagnosing Genital Herpes
Herpes can be detected by a viral culture of a lesion, if one is present, or a blood test. Ashley recommends both methods.

With a viral culture, a doctor swabs a lesion to pick up cells, puts the swab in a special solution, and sends it to a lab for growing and analyzing.

Although a doctor may recognize a herpes lesion by examining it, a viral culture will confirm the presence and type of HSV, says Ashley. Once they know whether they have HSV-1 or HSV-2, people have a better idea of how often they will have recurrences.

But viral cultures do have their drawbacks. If the lesion has started to heal (usually 48 hours after its appearance), the swab may not pick up enough virus and the culture result will be a "false negative." (False positives in cultures are rare.)

A blood (serology) test can be used to confirm a negative culture. It can also be used to diagnose herpes in a person who has no symptoms, who has genital irritation but isn't sure it's herpes, or who has a sexual partner with herpes and wants to find out if he or she has already become infected.

"Diagnosing whether someone has herpes or not is quickly done by a serology test because once you've become infected, an immune-competent [healthy] individual will develop antibodies to the herpes that is infecting them," says Thomas Simms, a biologist in the FDA's Center for Devices and Radiological Health.

Herpes antibodies will usually show up in the blood several weeks after a person first becomes infected. Some blood tests can determine the type of herpes infection, but cannot indicate whether the herpes is oral or genital. So people without symptoms may not know for certain if their herpes is oral or genital.

In the past several years, the FDA has cleared three blood tests that accurately determine if a person is infected with HSV-1 or HSV-2. The HerpeSelect ELISA Kits and the HerpeSelect Immunoblot Kit made by Focus Technologies of Herndon, Va., detect both types. The POCkit Rapid Test made by Diagnology Inc. of Cary, N.C., detects HSV-2 only. (For more information, see "Herpes Blood Tests," page 14.)

Another blood test is the Western Blot. Although not 100 percent accurate, the Western Blot is considered the "gold standard" of blood tests and is used to determine the accuracy of other herpes blood tests that are developed. The University of Washington is the premier institution for performing and interpreting the test. (See "For More Information," page 16, to find out how you can have your blood tested with a Western Blot.)

Many older FDA-cleared blood tests for herpes are still on the market, and many labs use these tests because they are widely available and inexpensive. Although they may be labeled type-specific (can determine whether the infection is HSV-1 or HSV-2), they are not reliable, says Simms.

But it's difficult for people to make sure they are getting one of the newer, accurate tests, says Wald. Doctors and even lab workers may not know what test they're using. "The patient needs to ask, but it's a very tall order. It will take a significant amount of work on their part and phone calls to the lab themselves."

This is where a herpes support group can help, says Adams, who facilitates a group called HELP of Washington. "We keep a list of doctors who are up to speed, knowledgeable, and know what the right tests are."

The Emotional Impact
For many people, the social and emotional distress of having herpes is far worse than the physical symptoms of the disease, especially upon first discovering they have been infected.

Adams knows this well. After some marital difficulties and a separation, Adams and her husband reunited. But their tenuous relationship was further strained when he brought genital herpes back to the marriage. "It hurt our chances of getting back together," says Adams. The relationship ended in divorce.

The doctor who diagnosed Adams wasn't very understanding, she says. "I really felt betrayed on all counts." Adams found understanding and information from the herpes support group that she now helps facilitate. "It always hurts to see someone feel so worthless and angry at the world," she says. "We see people who say "I haven't told anyone. I haven't dated in five years." This virus has taken over their whole life. We let them see that we're OK. We all lead normal, happy lives."

Adams, who used to have painful out-breaks every month, now has them rarely. She keeps an antiviral drug in her medicine chest just in case, but hardly ever has to use it. "I'm a firm believer that attitude is all-important. If you're upset about it and you think about it all the time, you're going to have outbreaks. Once you realize this isn't going to kill you, at that point you feel stronger and your whole immune system gets stronger."

"The hardest thing about having genital herpes is having to tell someone," says Adams. Like many people with herpes, Adams believes it's important to tell a new partner about the disease before having sexual relations.

"People should have a right to make an informed decision," says STD clinic owner Warren. "The consequences of not telling are not only possibly infecting a person with a disease that they don't want, but the question of trust comes up. What else haven't you told them about yourself? Our experience indicates that far more people accept sexual partners with herpes than reject them."

The first time Barry told someone, it didn't go well. He hadn't had the virus long and he was very distraught. "I transferred some of my anxiety about herpes to that person," he says. After learning more about herpes and accepting his condition, Barry was more at ease with telling. "I don't think the words or the setting are very important. I think the single most important thing was being well-educated and comfortable with my own condition."

When Barry told Keri, now his wife, he still faced several fears--"The fear of infecting someone else and also facing the possibility that someone I was interested in and wanted to be in a long-term monogamous relationship with would reject me."

But Keri was very accepting and willing to put things in perspective, says Barry. "She came with me to support group meetings. She told us [the group] that she had decided that I was the person she wanted to spend the rest of her life with and although she didn't want to get herpes ... it wasn't something that was an insurmountable block to establishing a relationship."

Barry was on suppressive antiviral therapy when he met Keri and he continues to stay on it. He has not had an outbreak in over a year. In the couple's six years together, there is no evidence that Keri has been infected. "We're operating on the presumption that by keeping my outbreaks in check, we're reducing the probability of my infecting her."

Barry's presumption is the subject of ongoing studies. Researchers have found that daily doses of antiviral herpes drugs reduce asymptomatic shedding, but whether this suppressive therapy can help prevent transmission is not yet known.

Another area of long-time study is a herpes vaccine. No vaccine has been shown to be effective in human studies, but researchers continue to work toward that end.

In the meantime, learning about the disease and talking openly with a partner can help people with herpes take control of their lives. "Once they understand it and recognize it, control is a lot easier," says Ashley. "Over time, it becomes a nuisance rather than a mind-altering and life-changing event."

Harboring Herpesvirus
The virus that causes genital herpes enters the body through the skin. It then travels along nerve pathways to settle in nerve roots near the base of the spine (sacral ganglia). (1) In this stage, the virus is inactive. But it periodically reactivates, reproduces, and travels along the nerves back to the surface of the skin or mucous membrane. (2) Symptoms of this reactivation vary widely. Sometimes there are no visible signs, but a person can still transmit the virus because it is present on the skin surface. Other times, there is an itching or tingling sensation, which may be followed by the appearance of one or more blisters or pimples. (3) The blisters may break into open sores, (4) crust over, (5) then gradually disappear.

Herpes and Newborns
A mother with genital herpes can easily deliver a healthy baby. And most can have a normal vaginal delivery. Less than 0.1 percent of infants born in the United States each year get infected with genital herpes during birth, according to the American Social Health Association.

A mother who was infected with herpes prior to getting pregnant passes herpes antibodies on to her fetus, protecting it from becoming infected with the virus. After birth, as the baby develops its own immune system, it loses these antibodies.

The danger period is late in pregnancy. The greatest chance of delivering a baby infected with herpes occurs in women who first become infected with genital herpes in the last trimester, says Zane Brown, M.D., professor of obstetrics at the University of Washington in Seattle. "The mother doesn't have time to build up antibodies."

For newborns infected with herpes, the consequences are devastating. "More than 40 percent die or have severe brain damage," says Brown.

Brown recommends a cesarean section if the primary infection is in the latter half of the pregnancy, or if the mother with long-standing genital herpes has any symptoms of genital herpes at the time of labor. He also recommends that all expectant mothers get a type-specific blood test for herpes in the first trimester of pregnancy. If negative for both HSV-1 and HSV-2, her partner should be tested. If the partner has herpes, sexual contact that could put the mother at risk of acquiring genital herpes should be avoided in the last trimester of pregnancy.

For several months after birth, infants are at risk for getting herpes. People with oral herpes (cold sores) should avoid kissing the baby. Wearing a mask over the cold sore when around the baby is recommended.

If a baby is infected with herpes, early treatment is critical. The FDA has approved the drug acyclovir in injectable form to treat infants with herpes.

For More Information
National Herpes Resource Center

A service of the American Social
Health Association
www.ashastd.org/hrc/
Teen Web site for STDs:
www.iwannaknow.org
National Herpes Hotline:
919-361-8488

Centers for Disease Control
and Prevention

National STD and AIDS Hotlines
1-800-227-8922 or 1-800-342-2437
En Espanol 1-800-344-7432
TTY 1-800-243-7889

University of Washington
Virology Lab

http://depts.washington.edu/herpes/

If you wish to be tested with the
most accurate blood test for detecting
herpes, the Western Blot, have your
health care provider call 206-598-6066
to request the HSV type-specific
serology information packet.

Patient Assistance Programs

To help low-income people buy
herpes drugs:
Novartis (maker of Famvir):
1-800-277-2254
GlaxoSmithKline (maker of Valtrex
and Zovirax):
1-800-722-9294
Genital Herpes Oral Antiviral Drugs
Legend for Chart:

A - Prescription Drug
B - Manufacturer
C - Dosage for Initial Infection
D - Dosage for Episodic Therapy
E - Dosage for Suppressive Therapy

A B
C
D
E

Acyclovir GlaxoSmithKline
(Zovirax or generic) (Zovirax) and others
(generic)

200 milligrams (mg),
5 times a day for 10
days

200 mg, 5 times a
day for 5 days

400 mg, twice a day
(for up to 1 year; then
doctor should
reassess patient)

Famciclovir Novartis
(Famvir) East Hanover, N.J.

N/A
(not FDA-approved
to treat initial infection)

125 mg, 2 times a
day for 5 days

250 mg, twice a day
(for up to 1 year; then
doctor should
reassess patient)

Valacyclovir GlaxoSmithKline
(Valtrex) Research Triangle
Park, N.C.

1 gram (g), 2 times a
day for 10 days

500 mg, 2 times a
day for 3 days

1 g, once a day
Alternate dose for
those with a history of
9 or fewer recurrences
per year is 500 mg,
once a day
(for up to 1 year; then
doctor should
reassess patient)

These indications are for adults only. Dosage should be adjusted
for people with kidney disease or people infected with HIV.
Herpes Blood Tests
The standard testing procedure for herpes is to obtain a viral
culture of a sore within the first 48 hours after symptoms
appear. Beyond 48 hours, there is a risk of the culture
yielding a "false negative" result because the sore may
have begun healing and there may not be live virus present.
Blood tests can be used to confirm a negative viral culture
result or to help determine herpes infection in a person with
no visible symptoms.

The FDA has cleared three type-specific blood tests, as shown
below.

Legend for Chart:

B - POCkit Rapid Test
C - HerpeSelect ELISA Kits
D - HerpeSelect Immunoblot Kit

A B
C
D

Manufacturer Diagnology Inc.

Focus Technologies

Focus Technologies

Antibodies detected HSV-2 only

HSV-1 or HSV-2

HSV-1 and HSV-2

Sensitivity (no false 49-100% accurate[*]
negatives)

93-100% accurate[*]

91-100% accurate[*]

Specificity (no false 65-100% accurate[*]
positives)

89-100% accurate[*]

95-100% accurate[*]

Result time Less than 10 minutes

About 1 to 2 weeks

About 1 to 2 weeks

Can be used during No (has not been studied)
pregnancy

Yes

Yes

Cost of test About $80

About $100

About $170

Phone number 1-877-776-2548

1-800-445-4032 (to locate
a lab in a specific area)

1-800-445-4032 (to locate a
lab in a specific area)

Web site www.pockit.com

www.focusanswers.com

www.focusanswers.com

[*] Accuracy is in comparison to Western Blot testing

Adapted from the American Social Health Association
Harboring Herpesvirus

Barry and his wife, Keri, have learned to deal with the challenges posed by genital herpes. Barry is infected with the virus; Keri is not. Source: DAC Consultants, LLC

s (BLACK & WHITE): Genital herpes sores may vary in appearance and location. Small red bumps may appear (as on the penis, left). Then fluid-filled blisters may develop (as shown on the buttocks, center, and on the labia of the vagina, right). These blisters break, crust over, and eventually disappear. Many people with genital herpes have no symptoms or such mild ones that they don't realize they are infected.

Famvir (famciclovir) and Valtrex (valacyclovir) are the two drugs most recently approved by the FDA to help prevent recurring outbreaks of genital herpes. The first approved genital herpes drug, Zovirax (acyclovir), is now a generic.

~~~~~~~~

By Linda Bren

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Herpes is yet another STD that is spreading accross the world. We really need more information put in the hands of the people. Everyone needs to get tested as well there is no excuse. If you need free STD testing you can go to http://yourstdhelp.com they have a huge section of free testing. It's up to all of us to put a stop to this right away.