Understanding genital herpes
Dr. Peter A. Leone is an associate professor at the University of North Carolina School of Medicine and Public Health. He also directs the H.I.V./sexually transmitted disease prevention program for the state of North Carolina and serves on the National Coalition of STD Directors, a group of public health officials who promote awareness of sexually transmitted diseases.
Watch the full video “Doctor answers questions about herpes” when Dr. Leone came to our in-person herpes support group in Raleigh, NC.
Q: People are more worried about getting H.I.V./AIDS than genital herpes. Should we be paying more attention to herpes?
A: H.I.V./AIDS is viewed as a lethal disease, and herpes isn’t, so many have ignored it. The reason why we should focus on herpes now is that the relationship between herpes and H.I.V. is significant. Although people don’t die from herpes, there is a synergy between these two infections. If a person has genital herpes due to the herpes type 2 virus, their risk of acquiring H.I.V. is much higher than if they didn’t have herpes. And a person who has both H.I.V. and herpes 2 is more likely to transmit both infections.
These two epidemics are linked, and because herpes has been pushed to the side, we haven’t paid enough attention to it. There are 60 million adults in the United States alone who have herpes, and we have a million new cases a year. It’s a big epidemic.
Q:The herpes 2 virus is the main cause of genital herpes outbreaks, but many herpes infections are now being caused by herpes 1. How dangerous is a virus that typically causes harmless herpes sores around the mouth?
A: Herpes type 1 is not associated with H.I.V. acquisition. The reason is that these viruses adapt to each site, so herpes 1 is more likely to shed around the mouth and not as likely as to reactivate in the genital tract. Herpes type 2, on the other hand, is much more likely to shed and reactivate in the genital tract. As a result, there’s more of a risk of co-infection with H.I.V. from herpes 2.
But if a woman acquires genital herpes from either herpes 1 or 2 during pregnancy, the risk of having a severe outcome for the baby is high.
Q: How common is it for pregnant woman to have complications because of genital herpes?
A: It’s a pretty rare event, but women who acquire herpes during pregnancy can risk transmitting a fatal infection to the baby. There’s been a lot of debate of whether we screen all pregnant women and there’s been no consensus. It’s one of those things that’s often completely missed, but when it happens, it can be devastating.
Q: Is it possible to tell which type of herpes virus people are infected with?
A: The clinical presentation for herpes 1 and 2 are no different on the genital tract. You can’t distinguish them by how the lesions look or the severity of the first herpes outbreak. Herpes 2 is more likely to recur, but the symptoms of herpes are indistinguishable at first.
A misconception is that people think you can only transmit herpes from the mouth to the genitals when you have a cold sore, or an outbreak. That’s not true. You can have asymptomatic viral shedding from the mouth. We’re seeing a lot more oral transmission from the mouth to the genital track. About 30 to 50 percent of new genital herpes infections are from herpes 1. All cases should be confirmed by blood tests.
Q: Many doctors are not ready to endorse more widespread screening for genital herpes. What’s the hesitancy?
A: In pregnant women, there is concern that it would lead to unnecessary interventions and Caesarean sections to prevent transmission to the baby. And we’re still hung up about sex and herpes. People and doctors are uncomfortable talking about it and discussing testing with patients.
Some would say there’s not a whole lot to worry about because there’s not much you can do with herpes. It’s sort of this forgotten and neglected infection. But men who have sex with men are at an obviously high risk for H.I.V., and herpes is very prevalent. For certain groups, such as gay men, or men or women who visit a sexually transmitted disease clinic or who have another sexually transmitted disease, screening for herpes should be a routine part of their health care.
But it doesn’t take a lot of partners to acquire herpes: the average is three to four lifetime partners. If you’re an African-American woman, the prevalence rate is 50 percent. So, I think all sexually active adults should consider getting tested.
Q: One of the problems in detecting herpes is that many people don’t notice the symptoms of herpes. How can you tell if you have the disease, outside of getting a blood test?
A: The classic way to tell you had herpes was sores or ulcers on the genital area that were painful and lasted a few days, and then went away. But our understanding of herpes has increased as the technology has improved. What we’re finding now is that most cases do not fit this classic description.
The typical, common way herpes presents is mild irritation that may be mistaken for trauma to the genital area. Most people miss these signs, and most clinicians aren’t looking for it. But what we see is that most will have four to six of these outbreaks in the first year of infection, which decreases over time.
Q: How effective are condoms for protecting against genital herpes?
A: Condoms work best in preventing sexually transmitted diseases that are spread through ejaculate and vaginal fluid. But any skin-to-skin contact puts you at risk for herpes. Since most people are not covered in latex when having sex, condoms are not as protective as we see with H.I.V., chlamydia or gonorrhea.
Still, using a condom can reduce herpes transmission by 50 percent, and that’s true for men and women. It’s not a home run, but it does work. There’s been a tendency to say that it’s either all are none. Unless you wear condoms 100 percent of the time, there’s no benefit. That’s not true. Wearing condoms 25 percent of the time can reduce your risk by half. (Download the handouts on the herpes resources page.)
Q: How contagious is genital herpes from just skin-to-skin contact?
A: Any skin-to-skin contact from the genital area is sufficient. The area that is covered by, say, your boxer shorts is where the virus sheds. Even if you’re infected in one site, you can shed from multiple sites at different times.
About 50 percent of shedding is clustered around an outbreak, so you have a higher risk seven days before, or seven days after. The problem is you don’t know when you’re going to have an outbreak. And more sophisticated studies show that shedding happens all the time, in varying degrees.
There is still no way of predicting when herpes will spread, but we do know that recently infected people have a greater risk of shedding and transmitting herpes. So I think we need to redouble our efforts in identifying people who are newly infected.
Q: Three herpes medications can help relieve symptoms, but do we know how good they are at preventing the spread of genital herpes?
A: There has been only one study showing that a drug could reduce transmission. This involved heterosexual couples where one person had herpes and the other didn’t. They had been together, on average, for a couple of years. Daily suppressive therapy with Valtrex reduced the risk of transmission by 48 percent, on top of what our standard has been, which is using condoms, knowing your status and abstaining from sex around the time of an outbreak.
It’s the only study that we know has shown a benefit. But we certainly don’t think any of three drugs would make things worse. They should all reduce transmission because they all reduce viral shedding.
Q:. Still, is it just a matter of time before an uninfected partner gets herpes from a boyfriend or girlfriend who has the virus, especially the longer they date?
A: It’s not inevitable. The overall transmission rate is perhaps 6 to 10 percent a year. The average time for transmission in a new couple, where one has it and the other doesn’t, is about two months. So, if you’re going to transmit, it’s more likely to be early, not later.
This is important because there’s a tendency for folks to say, ”Well, let’s see how things work out, I don’t need to disclose this to my new partner because they won’t want to have sex with me, or they may tell others, so I’ll avoid it.” But you need to know your status and have open dialogue before you have sex, not after.
Publish date: 5/26/2010 | Original New York Times article
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