Genital Herpes Update

True or False?

90% of the US population has HSV 1

30% of women in their 30’s in the US have HSV 2

Men are more often infected than women

Teens are getting HSV 2 more often than before

More people are infected with HPV than HSV 2

IgM tests can sort out new from old HSV infection

Early use of suppressive therapy can delay

seroconversion

Testing Scenario

25 year old woman presents for STI screening because she’s met a new partner. She’s had no sex

in 6 months, she has no symptoms at all. What HSV tests,

if any, do you include in her screening visit?

Exploring Prevalence of STIs

Hepatitis B

0.42Million

HIV

0.56Million

Chlamydia

2Million

HPV (warts)

20Million

HSV 2

~50MillionCDC estimate:

1.6 million new HSV 2 infections per year

Why do 90% of those infected with

HSV 2 not know it?

• Most HSV infections are subtle, not dramatic

• Outbreaks occur in entire “boxer shorts” area

• People attribute symptoms to other things

• Providers are misdiagnosing HSV as shingles

• Existing HSV 1 infection ameliorates HSV 2

• People aren’t being tested

How do you diagnose herpes?

Identifying infection in the symptomatic person:

Swab the affected area and look for virus

• PCR swab with typing •4 times more sensitive than culture•All major labs now have PCR

•Culture swab with typing•76% false negative rate compared to PCR

How do you diagnose herpes?

Identifying infection in the asymptomatic person:Draw blood and look for antibody

• Western Blot at University of WA (can be sent)• HerpeSelect (Quest)

•ELISA• Immunoblot•Express

• Biokit (in office test)• Captia (LabCorp)

Subtle Presentation—Excoriation

Photo courtesy of Jeffrey Gilbert, MD.

Buttocks Recurrent HSV

Photo courtesy of Jeffrey Gilbert, MD.

Anal Herpes

Thigh herpes

Urethral Herpes

Gilbert J.

Why do we need to know the virus type?• Source is often different

– Much HSV 1 is likely oral to genital transmission– Can happen in a completely monogamous couple

• Prognosis is different– HSV 1 recurs about 0.7 times per year– HSV 2 recurs on average 3-5 times per year

• Susceptibility to opposite type is different– HSV 2 largely protects against getting HSV 1– HSV 1 does not protect against getting HSV 2

• Treatment choice may be different– Early suppression for new HSV 2– may not be necessary for new HSV 1

Who are Blood Antibody Test Candidates?

• Current or previous partner has HSV

• Negative swab-test

• Trying to document first infection

• Has been diagnosed by exam, wants confirm /typing

• Requesting an STD screen

• Recurrent vague genital symptoms or dysuria/pyuria

• HIV positive patients

IgG Serology timing and IgM tests Time needed after infection to make antibody:

3 weeks 50% seroconvert 6 weeks 70% seroconvert 4 months most everyone seroconverts Importance of confirming 1.1 to 3.5 positives

Do not use ever use IgM

Cannot separate HSV 1 from HSV 2 Cannot separate the various herpes viruses IgM present in 35% of recurrences

What codes get HSV serology covered by insurance?

Genital itching 689.1

Pain with intercourse 625.0

Pain with urination 788.1

Female genital pain 625.0

Neuralgia 724.3

Burning, tingling,

numbness, prickling 782.0

Testing and Treatment scenario

• A couple, 42 year old male and 47 year old female, present to your practice requesting herpes testing as they begin a new sexual relationship because he has had a suspicious rash on his penis a couple times in the past. His HSV IgG test for HSV 1 comes back negative, his HSV 2 positive. Her HSV 1 is positive, her HSV 2 is negative. How do you counsel this couple?

What are usual HSV 2 transmission rates?

Conditions: The couple is aware that one has HSV

Abstaining from sex with outbreaks

Not using condoms regularly

Not taking antiviral therapy daily

Rates:About 10% male to female per year transmit

About 4% female to male per year transmit

Some studies show a little more, a little less

How do you reduce transmission?

• Antiviral therapy reduce transmission by 48%

• Condoms reduce transmission by about 30-50%

Antiviral Therapy - First Episode

First episode - treat for 7-10 days with any

• Acyclovir 400 mg orally three times a day for 7–10 days or

• Famciclovir 250 mg orally three times a day for 7–10 days or

• Valacyclovir 1 g orally twice a day for 7–10 days

Antiviral Therapy - Episodic

• Acyclovir 800 mg orally three times a day for 2 days or

• Famciclovir 1 gram orally twice daily for 1 day or

• Valacyclovir 2 g orally, then 12 hours later 2 grams again in one day

Antiviral Therapy - Suppression

• Acyclovir 400 mg orally twice a day or

• Famiciclovir 250 mg orally twice a day or

• Valacyclovir 500 mg orally once a day or

• Valacyclovir 1 g orally once a day

What is the frequency of viral shedding?

Giving off virus from the body - can happen with or without symptoms

• HSV 2 genital - about 20% of days

• HSV 1 oral infection - about 18% of days

• HSV 1 genital - about 5% of days

• HSV 2 oral - about 1% of days

Wald A J Clin Inv 1997.

HSV 2 triples the risk of HIV acquisition

Why?

1) HSV breaks in the skin allow HIV in

2) T-cells migrate to the site of broken skin to resolve the outbreak, those are the cells that HIV infects

Treatment

• 28 year old female presents to your practice complaining of frequently recurring HSV outbreaks. What information do you need from her and what interventions are appropriate?

Who benefits from suppression?

• Has an uninfected sexual partner• Has multiple sexual partners• Has new HSV 2 genitally (<6 months)

– Shedding up to 42% of days sampled (JID, Wald)• Women late in pregnancy with genital herpes

– Immunocompromised by pregnancy so shedding is increased

• High risk for HIV acquisition risk• Wants to have fewer outbreaks

Who may not need suppression?

• Has HSV but not sexually active and isn’t bothered by outbreaks

• The partner is infected with same type HSV (i.e. 1 or 2) and they aren’t bothered by outbreaks

• Couples who have made the conscious decision not to worry about sexual transmission

Patient Counseling Messages

• You are still the same person you were before this diagnosis

• You can still have a children/family• You can still have sex• You can transmit virus between outbreaks• There are effective treatments for herpes• Give yourself time to feel better• You can come back to talk to me