Virally misunderstood

Genital herpes is common yet misunderstood. Despite infecting as many as one in five Australians, it can cause a great deal of anxiety. The herpes simplex virus (abbreviated to HSV) comes in two varieties. HSV-1 is mainly associated with cold sores of the mouth and lips while HSV-2 usually causes genital herpes, although HSV-1 related genital herpes is on the rise. This is partly due to the increase in oral sex but also relates to the fact that young people are not catching this common virus early in life as much as they used to. Somewhat unfairly, women are twice as likely as men to be infected with HSV-2.

The chance of acquiring genital herpes increases with age but many people are unaware they are infected. It is transmitted during sex via small splits on the skin’s surface and a ‘primary’ infection usually occurs within two to ten days of sex with an infected partner. Symptoms can range from mild to severe but sometimes there are no noticeable symptoms at all. If they do occur, symptoms are usually in the form of painful blisters lasting for five to ten days. Rarely, a primary infection can be so painful that even walking and sitting can be a trial. Getting in to see a doctor as soon as possible for anti-viral medication can be a relief!

Once infected with HSV-1 or 2, most people are immune to catching a new infection. In other words, a person infected with oral HSV-1 is very unlikely to contract genital HSV-1 in the future. However, once infected, recurrences are possible. The herpes virus infects the nerves of the genital area and travels to an area of the spinal cord called the nerve root ganglion. Until recently, it was believed that HSV stayed dormant, only to return to the skin’s surface during an outbreak, but it now seems more likely that the virus continuously travels to the skin’s surface where the body’s immune system usually stops it from turning into a frank recurrence. There is generally no predicting if and when recurrences will occur, but it is reassuring to know that they are almost always milder than the primary outbreak. Recurrences are usually heralded by a painful or tingling skin sensation followed by blisters lasting up to about five days. Since the virus can travel to the skin along a variety of nerve routes, it is not uncommon for blisters to reappear at an altogether unexpected place as the buttocks or lower back. Talking to a doctor about how best to manage recurrences is important. Some people choose to manage their outbreaks with medication while others prefer to manage their symptoms without the use of ant-viral drugs.

A new diagnosis of genital herpes can cause great anxiety. Anxiety about who it has been caught from can be coupled with anxiety about infecting others. It is not uncommon to see patients in long-term committed relationships with a ‘first’ outbreak of genital herpes feeling hurt and angry with their partner. The conversation may be along the lines of ‘my husband must have given it to me because I certainly haven’t slept with anyone else, so he must be the one having an affair’. While this scenario may be true, there are other possibilities. The newly diagnosed infection may not be a primary infection at all but rather a recurrence of an earlier unnoticed undiagnosed infection from a previous partner. Alternatively, the ‘accused’ partner could have been infected in a previous relationship but has never had a known outbreak or diagnosis. We believe about two-thirds of infections are transmitted by people who have never had symptoms and this is an important statistic when it comes to helping couples navigate their way through a new outbreak of genital herpes within their relationship.

Genital herpes is diagnosed by its appearance and confirmed by taking a swab from the skin lesion, either at the time of the primary infection or during a recurrence. Common non-infectious lumps and bumps on the genitals of both men and women can be mistaken for herpes. Visiting a GP or a sexual health or family planning clinic can be useful to allay the anxiety of an uncertain diagnosis. A blood test is, in most cases, unhelpful and can even muddy the waters. While a blood test can detect antibodies from a previous infection and distinguish between HSV-1 and HSV-2, it cannot tell us whether the infection is oral or genital or whether it is a new or old infection. That said, a blood test can sometimes be useful for a couple where one partner but not the other is known to have genital herpes. It will either be a relief to find out that your partner carries the same herpes virus as you or highlight the need to work out how best to proceed in a sexual relationship where one half of the couple has genital herpes and the other doesn’t.

Avoiding sex when there is an outbreak is important since transmission is most likely when herpes blisters are present on the skin. The virus can still be shed onto the skin between outbreaks but this is less likely as time increases  since the last outbreak. While not 100 per cent effective and and not 100 per cent popular, using condoms can also reduce transmission. A third strategy is for the infected partner to use anti-viral medication, although taking drugs for an uncertain outcome may not be everyone’s choice. By far the most important strategy when it comes to reducing transmission of genital herpes is communication. Being upfront about a previous diagnosis will not only allow discussion of how to manage sex in the relationship but will also reduce the anxiety associated with ‘not telling’. There are some great websites which help provide the words to talk about herpes to a new or not so new partner.

So for most people, genital herpes is a mild infection which is easily managed with no serious consequences. It would be a sad day indeed if Australia was to follow the UK in prosecuting a young man for giving his girlfriend genital herpes. That said, it is important to acknowledge that the global picture of genital herpes is not always so benign. For people at high risk of HIV/AIDs, a diagnosis of genital herpes substantially increases the chance of becoming infected with HIV. Neonatal herpes, infection of a newborn baby, can have devastating consequences but is extremely rare in Australia. It is important for women and their partners planning a pregnancy to know that neonatal herpes only occurs when the virus is caught for the first time in the very late stage of pregnancy and not in women experiencing recurrent outbreaks.

Knowing where to turn for correct information is essential when it comes to genital herpes. Information coupled with communication, both with a partner and your doctor, are the best strategies for overcoming anxiety about this common infection.

Dr Deborah Bateson is medical director of Family Planning NSW.

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The story Virally misunderstood first appeared on The Sydney Morning Herald.

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