Preventing Sexual Transmission of Genital Herpes

Table 1.

	Per-contact Probability in the HIV-1-Susceptible Partner
HIV-1 Plasma RNA in Source Partner (copies/mL)	HSV-2 positive	HSV-2 negative
<1700	0.0001	0.00004
1700-12,499	0.0023	0.0005
12,500-38,499	0.0018	0.0002
≥ 38,500	0.0036	0.0007

Table 1. Per-contact Probability of HIV-1 Infection in HSV-2-Seropositive and HSV-2-Seronegative Partners of HIV-1-Seropositive (Source) Subjects, Stratified by Plasma HIV-1 RNA Level of the Source Partner*^[13]

*None of the source partners were treated with antiretroviral therapy.

Table 2.

	Women	Men	Total
Number of Patients Sampled*	132*	70	202
Number of days sampled	9098	4402	13,500
Median percent of days HSV detected (range)	16.6 (0-94.4)	12.1 (0-92)	15.0 (0-96.4)

Table 2. Frequency of HSV Reactivation as Measured by PCR Among Immunocompetent Men and Women^[15]

* Persons sampled for > 30 days.

Table 3.

	Valacyclovir (N = 743)	Placebo (N = 741)	Total	Hazard Ratio (95% CI)	P
	No. (%)
Acquisition of symptomatic HSV-2 infection	4 (0.5)	16 (2.2)	20	0.25 (0.08, 0.75)	.008
Overall acquisition of HSV-2 infection	14 (1.9 )	27 (3.6)	41	0.52 (0.27, 0.99)	.04
Acquisition of HSV-1 or HSV-2 infections	14 (1.9)	31 (4.2)	45	0.45 (0.24, 0.84)	.01

Table 3. Acquisition of HSV Infection Among Susceptible Partners, According to the Source Partner's Treatment Assignment*^[19]

*P values were calculated using the log-rank test. CI denotes confidence interval.

Table 4.

	Hazard Ratio (95% CI)
Risk	Univariate	Adjusted*
Risk for each additional sex act per week	1.16 (1.05, 1.28)	1.16 (1.03, 1.30)
Condom use > 25% vs ≤ 25%	0.38 (0.11, 1.30)	0.25 (0.07, 0.88)
Sex when lesions present vs no sex when lesions present	2.01 (0.78, 5.18)
Acyclovir use by partner vs no acyclovir use	0.64 (0.24, 1.73)

Table 4. Effect of > 25% Condom Use on HSV-2 Acquisition^[21]

*Adjusted estimates are from a model stratified by sex and adjusted for age, condom use, and sex acts per week.
CI, confidence interval; HR, hazard ratio; HSV-2, herpes simplex virus type 2

Table 5.

	Hazard Ratio (95% CI)	P	Adjusted Hazard Ratio* (95% CI)	P
Condom use during study, ≤ 65% vs > 65% of sex acts	0.56 (0.33, 0.97)	.039	0.57 (0.33, 0.96)	.035

Table 5. Effect of > 65% Condom Use on HSV-2 Acquisition^[22]

*Adjusted for age, race, and frequency of sexual activity.

Table 5.

	Hazard Ratio (95% CI)	P	Adjusted Hazard Ratio* (95% CI)	P
Condom use during study, ≤ 65% vs > 65% of sex acts	0.56 (0.33, 0.97)	.039	0.57 (0.33, 0.96)	.035

Table 5. Effect of > 65% Condom Use on HSV-2 Acquisition^[22]

*Adjusted for age, race, and frequency of sexual activity.

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Conclusions

The above-mentioned studies of condom use and valacyclovir indicate that there are clinically available "tools" that can be used to prevent transmission of genital herpes. In light of the extent and frequency of genital viral shedding among persons who are HSV-2 seropositive, the demonstration that a safe, once-daily antiviral drug can reduce transmission of disease between couples marks an important advancement with respect to clinical and population-level management and prevention strategies. As such, this author thinks there is sufficient reason to initiate extended programs to diagnose persons who are HSV-2 seropositive. There are ample studies to show that HSV-2 seropositivity is associated with subclinical transmission, and that persons who have undiagnosed genital herpes are more apt to transmit infection than those with known infections. Thus, high-risk populations should be screened by the commercially available glycoprotein G assays to identify HSV-2-seropositive persons. In this regard, HIV-infected persons and all persons attending STD clinics should be routinely screened for HSV-2, as the expected seroprevalence rates in these populations are 30% to 80% and 20% to 60%, respectively.^[25-27] Persons who are HSV-2 seropositive should be counseled about the issue of subclinical shedding and the risk of transmitting infection. Persons at risk of transmitting HSV-2 infection should be informed about and offered the tools available to prevent transmission, including condoms, daily antiviral therapy, or both. With proper case management, these tools provide an essential opportunity to extend a beneficial form of therapy to persons with this chronic genital infection, provide better quality care to HSV-2-infected patients, and allow patients to actively and effectively engage in the protection of their sexual partners against acquisition of HSV-2 infection.

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Clinical Tools for Preventing Sexual Transmission of Genital Herpes: Conclusions

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