genital%20herpes
GENITAL HERPES
Genital herpes is a recurrent lifelong disease with no cure, caused by herpes simplex virus (HSV).
HSV-2 is usually the cause but HSV-1 may occur in up to 1/3 of new cases.
HSV-1 tends to cause fewer recurrences & milder disease than HSV-2.
The incubation period is 2 days-2 weeks after exposure.

Counselling

Coping with Herpes Genitalis Infection

  • Reduce patient’s anxiety and help the patient to cope with the infection by educating them on the natural history of the disease and the risk of transmission, recurrent episodes, antiviral treatments, sexual relationships and partner notification, and perinatal transmission
  • Discuss treatment options: Episodic vs suppressive treatment

Prevention of Transmission

  • Abstaining from sexual contact during lesion recurrences or prodromes
  • Limiting the number of sexual partners
  • Informing sexual partner from preceding 60 days prior to diagnosis to also be evaluated and treated
  • Understanding that asymptomatic viral shedding may cause transmission
    • Asymptomatic viral shedding is more likely to occur with HSV-2 infection, in the 1st year following an infection, or if recurrences are symptomatic; however, shedding decreases with time
  • Using a condom may help protect against transmission
  • Taking daily suppressive antiviral therapy which decreases recurrent genital lesions, asymptomatic viral shedding, and transmission

Management Strategies for Recurrent Genital Herpes

Supportive Treatment Alone

  • Recurrent infections are generally self-limiting, less severe with a shorter duration of symptoms, and supportive treatment alone may be effective to control symptoms

Episodic Antiviral Treatment

  • Patient-initiated therapy that needs to be pre-prescribed
    • Start antiviral therapy as soon as possible within 1 day of lesion onset or during the prodrome that heralds some outbreak
  • Best for HSV-infected patients who have mild symptoms and infrequent recurrences
  • Reduces duration of symptoms by 1-2 days

Suppressive Antiviral Therapy

  • Recommended in patients with frequent recurrent genital herpes (≥6 episodes/year), severe or painful prodromes, pregnant patients with herpetic lesions in the last trimester, patients with psychological problems due to the infection, and in immunocompromised patients
  • Used to decrease frequency of recurrences, chance of transmission and provide relief of symptoms
  • Antivirals suppress symptomatic and asymptomatic viral shedding 
    • Reduces clinical outbreaks and viral shedding by 80% and 95% respectively
  • Full suppressive effect is usually obtained when in treatment for 5 days
  • Outbreaks during therapy should investigate for poor compliance, need for dose adjustments, resistance or incorrect diagnosis
  • Annual evaluation and cessation of therapy after 1 year is required to assess frequency of recurrences
    • Period of assessment should include 2 recurrences to view both severity and frequency
    • It is safe and advisable to restart suppressive treatment in patients who continue to have significant infection
  • Suppressive treatment may incur higher costs and inconvenience

Special Considerations

Immunocompromised and HIV Patients

  • Genital herpes is the most common sexually transmitted infection in HIV heterosexual patients
  • May have prolonged or severe episodes of HSV infection
  • Both symptomatic and asymptomatic HSV shedding are increased in HIV-positive patients
    • Non-HIV-infected patients with genital ulcers have 2-fold increased risk of being infected with HIV
    • HIV patients with genital lesions increase the risk of HIV transmission 2-6 times
  • Some specialists recommend HSV TSST to be done during their 1st evaluation and those positive for HSV-2 be managed with suppressive therapy
  • Clinical manifestations of HSV in HIV patients is reduced by suppressive or episodic therapy with oral antivirals
    • Antiretroviral therapy also reduces severity and frequency of genital herpes symptoms
  • Aciclovir, Famciclovir, and Valaciclovir can be used safely in immunocompromised patients
    • Duration of treatment is at least 10 days or until lesions have re-epithelialized 
    • If lesions continue or reappear, HSV resistance should be considered and sensitivity testing be obtained
    • All Aciclovir-resistant viruses are also resistant to Valaciclovir and Famciclovir
    • Systemic or topical Foscarnet and Cidofovir are effective in treating Aciclovir-resistant genital herpes
  • Episodic and suppressive therapy with standard doses of antivirals may be given to patients  
    • If disease is not adequately controlled, the standard dose may be doubled  
  • Pregnant patients who are HIV antibody positive and with a history of genital herpes infection should be offered daily suppressive doses of Aciclovir from 32 weeks of gestation to decrease the risk of HIV-1 infection transmission especially when vaginal delivery is anticipated

Pregnant Patients

  • Testing of asymptomatic pregnant women is indicated if partner has a history of genital herpes 
  • Risk for transmission from infected mother to the neonate is 30-50% among patients who obtained the genital lesions near delivery
    • <1% among patients who acquired the infection during the 1st half of pregnancy or among those with history of recurrent herpes
  • Risk for neonatal herpes includes 1st-episode genital herpes, HSV-1 infection, use of invasive monitors, delivery before 38 weeks of gestation, and mother <21 years of age
  • To prevent neonatal herpes, being infected during late pregnancy and exposure of neonate to genital lesion should be avoided
  • Acquisition during 1st and 2nd trimester
    • Treatment involves use of either oral or IV Aciclovir in standard doses
    • Vaginal delivery is expected as the risk for transmission at delivery is low
    • Daily suppressive Aciclovir from 36 weeks gestation may prevent HSV lesions at term and need for cesarean section
  • Acquisition during 3rd trimester
    • Cesarean section should be recommended for all women who presented with genital herpes symptoms during or within 6 weeks prior to delivery
    • Suppressive therapy in the last 4 weeks of pregnancy decreases the risk of clinical recurrence at term and delivery by CS; consider daily suppressive doses of Aciclovir to delivery 
    • If vaginal delivery is unavoidable, use of invasive procedures and prolonged rupture of membranes should be avoided; IV Aciclovir given intrapartum to the mother and the neonate is advised
  • Recurrent Genital Herpes
    • Vaginal delivery is appropriate if lesions are not present at delivery
    • For women who will choose a CS delivery if HSV lesions are present at onset of labor, daily suppressive Aciclovir from 36 weeks of gestation may prevent lesions at term and delivery by CS
    • If no HSV lesion is present during delivery, a CS is not needed to prevent neonatal herpes
    • Episodic or suppressive treatment during early pregnancy is not recommended
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