Spreading The Word About Herpes
First things first, we are going to debunk some common myths about genital herpes.
1. “Genital herpes only spreads during active outbreaks”
This is false.
2. “Genital herpes is different virus than the one that causes cold sores”
This is true, they are both caused by herpes simplex viruses.
3. “Genital herpes can be spread via surfaces”
This is false. The virus is dependent on direct skin-skin contact
4. “everyone knows when they have herpes”
This is false. 85% of people infected with a herpes virus don’t actually know it.
5. “My partner must have cheated on me if I’ve gotten herpes in the time we’ve been together”
This is false. The herpes virus can stay dormant in the body and can take a long time before symptoms present.
Genital herpes is a type of STI, much like many others, it is caused by a virus. There are two strains of the virus- Herpes simplex virus type 1, and herpes simplex virus type 2 (HSV1 & HSV2). HSV1 is the virus strain that causes cold sores and tends to be acquired during childhood. Interestingly, this strain of the virus can be spread to the genitals, causing genital herpes. HSV2 is the strain that causes genital herpes, and this strain is not usually spread genitally to orally.
Genital herpes infection is common, with 11.9% of all 19–45-year-olds having it. Roughly 1- in-5 of these individuals have HSV2 and rest is made up of people who have been infected by the HSV1 virus. These figures are difficult to determine because 87% of 14-49-year-olds with HSV2 have never received clinical diagnosis. This is most likely because HSV is not included in the routine STI panel screen test.
Genital herpes is more common in women than men because of how easily transmitted it is from man to woman during penile-vaginal sex. Other risk factors include being on hormonal contraceptives and having bacterial vaginosis, which are both female exclusive and adds to the higher incidence in women than men. HSV2 is also 3.4 times more common in non-Hispanic black people than non-Hispanic white people.
The virus is spread through direct contact with the herpes virus through herpetic lesions, mucosal surfaces, genital secretions or oral secretions. It can be shed from normal appearing oral or genital mucosa, as well as skin. As mentioned, HSV1 genital infection can arise from receiving oral sex from someone with oral HSV1. Genital herpes infection is often transmitted from an infected partner who doesn’t have visible herpetic lesions and doesn’t even know that they have it. Studies have shown that symptomatic HSV infections have a higher shedding rate (20%) than asymptomatic cases of HSV infection (10%). It is also common to have an increased viral shedding throughout the first year of infection.
Most HSV positive individuals are asymptomatic or only have mild symptoms which are easily mistaken for other conditions and go unnoticed. When symptoms do occur, genital herpes presents as one or more small vesicles around the genitals or mouth. The average incubation period for an initial herpes infection is 4 days, however this period ranges from 2-12 days following exposure. These vesicles then break, resulting in painful ulcers that usually take 2-4 weeks to completely heal. The first time this happens is usually the worst, with a longer duration of lesions, increased viral shedding and sometimes even systemic symptoms such as a fever, headache, body ache and swollen lymph nodes. This first recognizable outbreak may not even happen until a long time after the primary infection.
The virus can lie dormant in the nerve root of the spine and there is no way of knowing when you acquired the infection or whom you acquired it from. This is why myth number 5 is false, as the virus can lay dormant for such a long time period, it would be incorrect to say that your partner must have cheated in order for them to be having an outbreak.
Recurrent episodes are very common in HSV infection, with many patients learning to recognise their symptoms before an outbreak (known as prodromal symptoms) in order for them to manage their flare ups. Prodromal symptoms have been described by a range of sensations such as localised genital pain and tingling or shooting pain in the legs/hips/buttocks and can occur hours to days before the eruption of the herpetic lesions. With recurrent episodes, the symptoms tend to last less time (usually 6-12 days, as opposed to 2-4 weeks) and feel less severe than the first episode. Individuals with a HSV2 infection tend to have about 4-5 recurrences a year. Genital HSV1 infections tend to be milder than HSV2 infections, with recurrences only happening up to once a year.
When it comes to screening and testing for HSV. As mentioned, it is not part of the standard screening panel which means you need to specifically ask to be tested. There are a couple of different ways this test may be done.
1. If you are actively having an outbreak, they can take a swab of the lesion which will be sent for culture or PCR testing to see if HSV DNA is present in the sample.
2. If you are not having an outbreak, blood tests can be taken to look for antibodies present in the body –The potential issue with this is that if you are positive for HSV1, there is no way to know whether the infection is oral or genital without the presence of an outbreak. However, if the test comes back positive for HSV2, you know that reflects genital herpes.There is also a window of about 2 weeks to 6 months after the body’s exposure for the formation of detectable antibodies which means that they could potentially be missed if the test is done too early.
The CDC lists that there are a couple times when it is useful to screen patients for HSV.
· If a patient has recurrent genital symptoms or atypical symptoms and a negative culture or PCR
· Patient has clinical diagnosis but no laboratory confirmations
· Consider testing if a partner has genital herpes
· If a patient is being considered for STI evaluation and have has multiple sex partners
· If patient has HIV
· If patient is a man who has sex with men
There is currently no cure for herpes but there are ways to stay on top of and manage your symptoms. Antiviral medication can be used to prevent or shorten outbreaks. Daily suppressive therapy or episodic therapy can be used. Some choose to use daily suppressive therapy to reduce the likelihood of transmission or to try to reduce the number of recurring episodes they have. Others choose to use episodic treatment and take medication when an outbreak occurs, to decrease its duration. It is also common for people to not use any treatment at all. It is something very personal to you and should be discussed with your health provider to assess your best option.
Although herpes isn’t curable, it is manageable. One of the hardest things that accompanies a positive diagnosis is the embarrassment, shame and stigma that a patient may feel (which they absolutely shouldn’t!). This will be covered in a following blog post with an interview with an individual who shares their story following a positive diagnosis.
If you have HSV, there are ways to reduce your risk of transmission to others, but they don’t completely eliminate the risk. It is always important to provide full disclosure of your status to sexual partners, avoid sex during an outbreak if partner is negative, use suppressive anti-viral therapy and use condoms correctly and consistently – however the use of condoms doesn’t convey complete protection because virus shedding can still occur in areas not covered by the condom. Similar to other STIs, the risk of acquiring HIV is 2-4 fold higher due to the open sore making it easier for the transmission of the virus. This is why it is so important to stay as safe as you possibly can.
If you have HSV and are looking to get pregnant there are a few things that you should be aware of. Once pregnant, in your third trimester you will most likely be started on antiviral therapy in order to reduce the risk of transmission from mother to baby. Also, when you go into labour, it is important to know that, if you are having an outbreak, the delivery will potentially be switched to a C section to prevent the transmission from mother to baby during the skin-skin contact that occurs during natural labour.
Interestingly, if both you and your partner are positive for the same HSV strain, you will both already have the accompanied immunity. This means that you cannot be reinfected by the virus and neither of you will result in your partner having more outbreaks or changes to your existing symptoms, this is because flare ups are determined by your immune status and not by exposure to the same virus by an infected partner.