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

2. 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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. Signs and symptoms of primary infection
Numerous bilateral painful lesions
Lesions last average of 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 days

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

14. 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

15. Signs and symptoms of recurrent infection
llness lasting 5-10 days
Prodromal symptoms (localized tingling, irritation) are common and begin 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)

16. 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

17. lab tests
Virologic tests
Type-specific serologic tests

18. Virologic Tests Viral culture is gold standard for HSV diagnosis
Preferred if genital ulcers / lesions present
Most cultures will be positive within 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

26. 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  

27. 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

28. References
Xu F, Sternberg MR, Kottiri BJ, et al. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. JAMA 2006; 296:964.
Corey L, Adams HG, Brown ZA, Holmes KK. Genital herpes simplex virus infections: clinical manifestations, course, and complications. Ann Intern Med 1983; 98:958.
3. Kimberlin DW, Rouse DJ. Clinical practice. Genital herpes. N Engl J Med 2004; 350:1970.
(Accessed on March 7, 2014)
Schillinger JA, McKinney CM, Garg R, et al. Seroprevalence of herpes simplex virus type 2 and characteristics associated with undiagnosed infection: New York City, Sex Transm Dis 2008; 35:599.
6. Berger JR, Houff S. Neurological complications of herpes simplex virus type 2 infection. Arch Neurol 2008; 65:596.
7. Gupta R, Warren T, Wald A. Genital herpes. Lancet 2007; 370:2127.