Importance and Practicalities of Patient Counseling in the Prevention and Management of Genital Herpes

The laboratory test report is on your desk, and the patient is waiting in the exam room. The polymerase chain reaction (PCR) test you gathered a week ago from a small genital fissure has confirmed your suspicions: Your patient has herpes simplex virus type 2 (HSV-2) infection. We've all been there, wondering exactly what to say, how to disclose this difficult news, and what to advise about infectivity and sexual behavior; it never seems to get easier.

We know a lot more about genital herpes than we did 5 years ago, but there are still many misconceptions about genital herpes, what it means to be infected, and how it is spread. Because this knowledge can be used to help patients manage their infection and prevent its transmission to their sexual partners, it is now more important than ever to speak frankly, accurately, and effectively with patients about HSV-2 infection and transmission, and the management and prevention tools available to them.

We now have the ability to identify patients with HSV-2 infection with type-specific immunoglobulin (Ig)G blood testing, which has allowed us to get a handle on the large number of people who have this infection: In the United States, 1 in 4 adults (> 18 years old) is infected, although as many as 90% are unaware that they are infected.^[1,2] We have also learned that persons with asymptomatic genital herpes infection not only can transmit genital herpes, but are in fact the main source of transmitted HSV-2. Viral shedding -- that is, the giving off of HSV-2 with or without symptoms -- is now understood to be the crux of the problem of genital herpes transmission. And up to 70% of new infections result from viral shedding by persons who have no clinical signs or symptoms of genital herpes.^[3-5] Research studies with HSV-PCR in which people swabbed their genitals on a daily basis for weeks at a time have shown us that people shed virus quite often. On average, a person with genital HSV-2 infection sheds virus on 15% of days; a person with oral HSV-1 (ie, type 1) infection sheds virus on 18% of days.^[6] These studies have also shown that asymptomatic persons shed virus at the same rate as those who have up to 12 outbreaks per year.^[6,7] Clearly, what you see is not what you get when it comes to genital herpes.

Most patients with genital herpes do not have truly asymptomatic infection; they have symptoms but aren't tying them to genital herpes. Common misinterpretations in this regard include vaginal yeast infections, bug bites or poison oak on the buttocks or thighs, friction burns on the penis, and the infamous "recurrent shingles" (which almost never actually happens). In the majority of cases, however, once a person is told that they have HSV-2 infection, they are able to accurately identify symptoms of an outbreak. But even when people start to recognize subtle outbreaks, they cannot identify all periods of viral shedding. Approximately 50% of shedding occurs just before, during, or after an outbreak, and approximately 50% occur completely at random.^[6] For this reason, coupled with the fact that reactivation of genital HSV-2 infection and viral shedding occurs in virtually all infected persons, experts in the field of herpes management and prevention have moved away from focusing on outbreaks to focusing on the behavior of the virus itself. This shift is particularly important with respect to preventing the transmission of genital herpes. HSV-2 infection is no longer understood as a disease transmitted by persons with genital lesions, but as one transmitted by persons who are chronically infected with a virus that is shed from genital mucosa regardless of the presence of clinical symptoms.

The significance of this shift in focus begins with testing and diagnosis. I liken it to hypertension. If you never measured someone's blood pressure, you would never know that they had high blood pressure until, perhaps, they had a stroke. A similar principle applies to herpes. If you never do serologic testing, you may never know that someone has herpes until he or she infects someone else. Testing allows us to turn asymptomatic patients into patients who can start to identify recurrences and gain some control over their ability to transmit infection to their sexual partners.

The aforementioned shift in focus has very important implications with regard to the counseling messages that we give our patients. In the past, we told patients to simply avoid sex during outbreaks and they would not transmit. Now we know that that's not correct. There is no day that a person can tell his or her sexual partner "today I will not infect you." It's not that people are infectious every day; they can't know which days they will be infectious. Patients need to understand this thoroughly. In some ways, this may make patient counseling more difficult, but it is also much more honest and accurate.

What should patients tell their sexual partners? First of all, if 1 in 4 adults is infected, then regardless of whether someone thinks that he/she is infected or not, he or she should have a blood test. With respect to monogamous couples, if both partners are infected with HSV-2, then they need not worry about herpes in the relationship -- it's a done deal. However, if one person turns out to be susceptible, then reducing the risk of transmission becomes a desirable goal. Patient counseling in this regard should center on a discussion of both risk of transmission and the means available for reducing it, which include the use of condoms and chronic suppressive antiviral therapy. If there is no intercourse during outbreaks, no condoms regularly used, and no antiviral therapy taken daily, then the approximate transmission rates are as follows: If a man is infected and a woman is not, then transmission will occur in approximately 10% of couples each year. If a woman is infected and a man is not, then the transmission rate is around 4% per year.^[4,8] (Transmission rates in same-sex couples are not yet well defined.) Regular condom use can reduce these rates by around half.^[9,10] The use of daily valacyclovir therapy has also been demonstrated to reduce the risk of transmission by about half.^[8] It must be stressed, however, that even with the best compliance to these recommendations, there are no guarantees and no perfect solutions -- there will always be some degree of risk.

But here's an interesting way to look at that risk. Let's say that Diane, who is truly uninfected (ie, HSV-2 seronegative), meets Bob who has HSV-2. Bob tells Diane about his infection. He offers to use condoms every time they have sex, take daily antiviral therapy, and agrees to try to be aware of any symptoms that may signal the beginning of an outbreak. Diane says that she just can't handle any risk, even though she really likes Bob. So she says goodbye and moves on. Then she meets Bill. She asks him right away whether he has herpes because now she's really worried about getting infected. He replies that he's "not that kind of guy" and is certain that he is not infected, only he really is (as approximately 1 in 4 adults are) but doesn't know it. Now we know that Bill is shedding virus at the same rate as Bob, but because he is unaware of his infection and doing nothing about it, he is more likely to infect Diane than Bob ever was. But Diane likes Bill's answer. She has sex with him with birth control pills instead of condoms, and within 2 months is infected with HSV-2. She's the one sitting in your exam room, waiting for the news. And the circle continues.

Knowledge of infection, condom use, and daily antiviral therapy could have broken this cycle and made a difference. Although we can't intervene for Diane at this point, we can for others.

In addition to addressing what can be done to prevent HSV-2 transmission, there are other extremely important counseling messages that we should deliver to our patients with genital herpes. Chief among these is that concerning the relationship between genital herpes and HIV infection. Persons with genital HSV-2 infections are at twice the risk of acquiring HIV infection, should they be exposed, than HSV-2 seronegative persons.^[11] There are at least 2 factors involved here. First, genital herpes infection can cause significant or microscopic breaks in the genital mucosa, facilitating the entry of HIV into the body. Second, the cells that come to defend against a herpes outbreak are CD4+ T cells, the main cell type that HIV infects. There they are, sitting on broken skin, vulnerable to HIV infection. In addition, the person who is dually infected with HSV-2 and HIV is more likely to transmit his or her HIV infection than the person who does not have HSV-2.^[12] So when we decide that genital herpes is simply an annoyance without any real health impact, consider HIV infection and tell your patients about it.

Psychological concerns are also common when genital herpes is diagnosed, and these too need to be addressed. Common questions include the following: "How long have I had this"; "where did I get it"; and "who will ever want me now?" These may or may not be answerable, but what we can answer is that life definitely goes on after genital herpes infection and that life can be full, rich, and sexual. It is tempting for patients to view genital herpes as life-defining, as a measure of one's worth, and clinicians should quickly move to squelch that idea. Although this may be obvious to a clinician, many patients need to be assured that genital herpes cannot affect the core of one's being, the worth and precious gifts that one brings to the world. It is a virus. It doesn't do a personality inventory before looking for a nice cell in which to live; it just looks for a cell. It happens to people who have 1 partner or 50 partners, who are rich or poor, who are in monogamous relationships, or who are in relationships in which more than 2 partners are involved.

Now one may offer this all-wonderful advice, but I have 6 minutes to see each patient in this managed care environment. So what can you do to deliver and help patients understand essential messages regarding genital herpes infection and transmission? Here are a few suggestions:

1. Use patient reading materials to the maximum (which can be downloaded and printed from the Web sites below);
2. Have someone in your office be the "herpes person" who can spend extra time with people who need it;
3. Set up a follow-up appointment just for talking about herpes, and bill appropriately for your time;
4. Refer patients to good and accurate Web sites; and
5. Know the phone numbers of herpes support groups in your area.

The most important thing that you can do, though, is this: Before your patient walks out the door, touch his or her hand, look him or her in the eyes, and tell that patient that he or she is in no way less of a person because they have herpes. It will go a long way toward helping ease the pain of this highly stigmatized disease.

Recommended Web Sites

www.herpesdiagnosis.com
http://my.webmd.com/medical_information/condition_centers/genital_herpes/default.htm
www.ashastd.org
www.healthcheckusa.com (for anonymous testing)
www.westoverheights.com (free Herpes Handbook available for download)

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