Herpes
From Encyclopedia of Sex and Sexuality
There is widespread confusion about genital herpes infections, due to a number of misconceptions that arose in the early 1980s, when the increased number of reported herpes cases began to attract publicity. To the public “herpes” meant the outbreak of painful lesions in the male or female genital region after sexual intercourse with an adult who knew he or she carried the virus. The public was judgmental about both victims and carriers: the former were believed to have acquired the disease through irresponsible sexual behavior; the latter, to have knowingly infected their sexual partners. (It was then widely believed that all carriers who had herpes symptoms knew that they had the virus when they spread it to a partner.) “Herpes is forever”—the virus can never be eliminated from the body—and infected males and females could infect future sexual partners. Carriers became social lepers, for when they revealed their medical history, relationships ended abruptly. For women there was the additional burden of knowing that the virus could be passed to the fetus during labor and delivery, resulting in an infection with potentially serious results to the newborn infant’s central nervous system.
Recent studies indicate that this is an extremely narrow and often inaccurate view of the range of herpes infections. Most adults infected with the herpes virus have never had clinical symptoms of the disease and can thus, unknowingly, spread the virus, infecting sexual partners or their babies.
There are two separate and distinct herpes viruses—herpes simplex 1 (HSV–1) and herpes simplex 2 (HSV–2) Different sites of infection show differences in the frequency of HSV–1 and HSV–2 infections. The two most common sites of infection are the mouth (cold sores) and the genital region (genital herpes). Approximately 85 percent of cold sores are caused by HSV–1 and the remainder by HSV–2, while more than 85 percent of genital herpes cases are caused by HSV–2 and the remainder by HSV–1. HSV-1 is not always sexually transmitted (though it may be spread by kissing or oral sex), but HSV-2 is usually transmitted sexually. The clinical manifestations of HSV–1 and HSV–2 infections are diverse. Most adults with an oral or genital tract infection with HSV–1 or HSV–2 do not know that they have the infection. For example, nearly 90 percent of adults with HSV–2 antibodies have no history or signs of genital herpes. They either had no symptoms or had symptoms so mild that they have not sought medical attention. In contrast, some patients have had recurrent herpes outbreaks, usually at the same sites in the mouth or the genital area. Adults with oral lesions—cold sores—often have outbreaks after excessive exposure to the sun. Victims of genital herpes outbreaks often find a relationship between the eruption of lesions and recurrent stress in their lives.
Many patients have preoutbreak symptoms that follow a pattern: a tingling or burning at the site of the infection, followed by the appearance of small lesions with clear fluid (vesicles), which rupture and heal, usually over five to eight days. The most severe illness due to the herpes virus occurs in immuno-compromised patients, particularly those with HIV infection: life-threatening infections of the central nervous system can be seen in such people. Once acquired, the herpes virus remains in the body and is held in check by the host’s immunological defense mechanisms. When the immune system is diminished or absent in a patient with the herpes virus, more serious forms of the disease erupt.
Because of the recent awareness of the diffuse nature of HSV–1 and HSV–2 infections in humans, there has been a change in the approach used to diagnose the disease. Formerly, diagnostic accuracy depended on a laboratory check of herpes cultures from patients with new or repeated genital tract lesions. Today, a positive culture is taken to be a definitive sign that symptoms and lesions are caused by herpes. However, the converse conclusion does not follow a negative culture. Recent studies indicate that many women with mild symptoms and small genital lesions do not produce a positive culture. Because of this, there has been increasing emphasis placed upon detecting the presence of HSV–2 antibodies in the blood.
Antibody screening could have widespread applications in the future. Many couples planning a long term relationship now contemplate HIV screening (for aids) before they become sexually intimate. A similar focus upon HSV–2 antibody screening would obviate the possibility of a future herpes infection acquired from a sexual partner with no symptoms but who is, nevertheless, infected and can spread the virus. If she is pregnant, an antibody-negative woman may be advised to either abstain from any sexual contact or require the use of a condom if the male is HSV–2 antibody positive.
Although the herpes virus cannot be eliminated from the body, treatment is available. Prevention is, of course, the primary strategy. Men and women with known oral or genital herpes should inform their partners, recognize their patterns of symptoms when they have outbreaks, and avoid intimate contact at that time. This is particularly true for pregnant women, since active genital lesions at the time of labor require a cesarean section to lower the risk of transmitting the herpes infection to the infant. For a pregnant woman, a first genital tract infection near or at the time of delivery is a far greater risk to the fetus than a recurrent infection.
In addition to these preventive measures, new antiviral agents are available for central nervous system herpes infection in the immuno-compromised. There are a number of instances in which the drug acyclovir can be an important treatment. For patients with genital tract herpes infection, the early use of oral acyclovir reduces the duration and degree of symptoms. For patients with frequent genital tract recurrences that prevent any chance of leading normal lives, acyclovir can be taken daily for six months to two years to markedly reduce the frequency of outbreaks. There will probably be a use for acyclovir in the prevention and treatment of newborns exposed to the herpes virus, but studies are not yet available to establish definite treatment guidelines (see also safer sex).
