Genital HSV-2

• Other human herpes viruses can cause genital ulceration
  • herpes zoster virus [HZV]
  • Epstein-Barr virus [EBV])
• Initial episodes may be severe, and treatment should never be delayed while waiting for a test result
• Most HSV is asymptomatic or mild enough that diagnosis is never sought. 
• If symptoms do appear, it can be days or years after HSV was first acquired
• More than 50% of primary genital infections are caused by HSV 1 in young people.
• Recurrences are more common in the first year with HSV 2
• asymptomatic viral shedding, and the attendant risks for sexual transmission of HSV to occur during asymptomatic periods (asymptomatic viral shedding is most frequent during the first 12 months after acquiring HSV-2

TYPES OF INFECTION

— The clinical designations of genital herpes simplex virus (HSV) infection are: primary, nonprimary first episode, and recurrent:

Direct viral test result	Type-specific serologic status		Classification of genital HSV infection
	HSV-1 antibodies	HSV-2 antibodies
HSV-1 detected	–	–	Primary HSV-1 infection
	–	+	Nonprimary first episode HSV-1 infection
	+	– or +	Recurrent HSV-1 infection
HSV-2 detected	–	–	Primary HSV-2 infection
	+	–	Nonprimary first episode HSV-2 infection
	– or +	+	Recurrent HSV-2 infection

• Primary
  • Primary infection refers to infection in a patient without preexisting antibodies to either herpes simplex virus type 1 (HSV-1) or herpes simplex virus type 2 (HSV-2).
• Nonprimary 
  • Nonprimary first episode infection refers to the acquisition of genital HSV-1 in a patient with preexisting antibodies to HSV-2 or the acquisition of genital HSV-2 in a patient with preexisting antibodies to HSV-1 (eg, an individual with prior orolabial herpes and subsequent development of an HSV-1 antibody response develops genital herpes due to HSV-2 exposure).
• Recurrent
  • Recurrent infection refers to reactivation of genital HSV in which the HSV type recovered in the lesion is the same type as antibodies in the serum.

• Each of these types can be either symptomatic or asymptomatic (also called subclinical). 
• Asymptomatic infection will be detected only if the patient is tested by culture or polymerase chain reaction (PCR).
• Severe and frequent recurrences may be treated with continuous suppressive or episodic antivirals
• Avg incubation period after exposure: 4 days 2-12 days)
• pustular lesions which resolved after a mean of 19 days 
• Symptoms tended to be more severe in women than in men

Symptoms

Site/Specimen and Testing

• Swab of Base of Ulcer or Deroofed Vesicle:
  • Test: HSV NAAT (Nucleic Acid Amplification Test)
  • Consideration:
    • Positive result indicates HSV infection.
    • Negative result does not rule out HSV infection; see anogenital ulcers section for further assessment.
    • Self-collection of NAAT specimens at the first onset of recurrent symptoms may be useful for confirming diagnosis in patients who have not had confirmation during clinical visits.
• Serology:
  • Do not screen asymptomatic individuals with serological tests for HSV types 1 or 2.
  • Use serology only in specific situations where results provide meaningful clinical information (e.g., an asymptomatic pregnant partner of a newly diagnosed person) and consult an infectious diseases specialist.

Management

Principal Treatment Options

• Initial Episode:
  • Recommended:
    • Valaciclovir 500 mg PO, BD for 5-10 days.
  • Alternative:
    • Aciclovir 400 mg PO, TDS for 5-10 days.
• Recurrence: Episodic Therapy:
  • Should be self-initiated at the first hint of symptoms.
  • Valaciclovir 500 mg PO, BD for 3 days.
  • Famciclovir 1 g orally twice a day for 1 day.
  • Aciclovir 800 mg TDS for 2 days.
• Recurrence: Suppressive Therapy:
  • Valaciclovir 500 mg PO, daily for 6 months.
  • Famciclovir 250 mg PO, BD for 6 months.
  • Aciclovir 400 mg BD.
• Suppression in Pregnancy:
  • Valaciclovir 500 mg PO, BD from 36 weeks until birth.
  • Aciclovir 400 mg TDS from 36 weeks until birth.
  • Pharmaceutical Benefits Scheme (PBS) streamline authority scripts required.

Other Immediate Management

• Provide written information and support (e.g., www.herpes.org.nz).
• Regular analgesia.
• Topical lignocaine to reduce pain from erosions, fissures, and ulcers.
• Urinating in a bath or shower to relieve superficial dysuria.
• Urgent catheterisation and referral for neuropathic bladder.
• Avoid intimate contact with partners until symptoms resolve.
• Routine sexual health screening.
• Use of barriers, e.g., waterproof dressings.
• HSV is not a notifiable disease.
• Contact tracing is not recommended but patients may need support in disclosing to current or future sexual partners.

Treatment Advice

• Seek specialist advice for patients with HIV or immunosuppression.
• Do not delay treatment for moderate-to-severe episodes.
• Initial episodes may require a 10-day course if symptoms are slow to resolve.
• Consider patient adherence to dosing frequency when selecting treatment.
• Choice of suppressive therapy, episodic therapy, or no therapy depends on clinical features and psychosocial factors.
• Review the need for suppressive therapy every 6 months as recurrences usually become less frequent and severe over time.
• Higher doses may be required for frequent recurrences or immunosuppression (PBS authority required for increased medication).
• Ongoing symptoms despite antiviral treatment should prompt consideration of other causes.
• Address the psychosocial impact of diagnosis with facts about prevalence and mild clinical effects to reduce stigma.
• Refer to a psychologist for support if needed.
• Some sexual health services offer counselling.

Recurrence

• Recurrence Rate: 50% of individuals experience recurrence.
• Nature of Recurrences: Attacks gradually become milder and less frequent, lasting 5-7 days, and usually stop eventually.
• Triggers for Recurrence:
  • Menstruation
  • Sexual intercourse
  • Masturbation
  • Skin irritation
  • Emotional stress
• Need for Suppressive Therapy:
  • Review the need for suppressive therapy every 6 months as recurrences usually become less frequent and less severe over time.
  • Those with frequent recurrences (e.g., 2 or 3 times per month) or immunosuppression may require higher doses of antiviral medication.

Psychosocial Impact of Diagnosis

• Reducing Stigma:
  • Provide facts about high community prevalence: 70%-80% for HSV1 and 12%-15% for HSV2.
  • Emphasize the largely mild clinical effect of the infection.
• Addressing Relationship Concerns:
  • Explain that transmission can occur from someone unaware they have the infection.
  • Symptoms can manifest for the first time days or even years after acquisition.
• Reassurance and Support:
  • Reassure patients that multiple strategies exist to avoid transmission to future partners.
  • Refer to a psychologist for patients who:
    • Are unable to accept the diagnosis.
    • Are significantly distressed by the diagnosis.
    • Are anxious about having the infection despite testing negative.
  • Some sexual health services in Australia offer counseling services.

Special Treatment Situations

• Pregnancy:
  • Neonatal transmission may occur during pregnancy, delivery, or post-natally via skin-to-skin transmission.
  • Highest risk for the baby is when HSV is acquired in the third trimester or close to delivery.
  • Start HSV suppression from 36 weeks gestation for those with known infection.
  • Earlier suppression may be needed for those with recurrent lesions during pregnancy.
  • Consult a sexual health specialist for more information.
• Allergy to Treatment:
  • Seek specialist advice.

Follow-Up

• Review one week after starting treatment to:
  • Evaluate the response to treatment.
  • Complete sexual health testing if not done at initial presentation.
  • Educate on condom use, contraception, HIV PrEP/PEP, safe injecting practices, consent, CST, and vaccinations as indicated.
  • Provide further support and information as needed.
  • Obtain previous test results if tested elsewhere. Microbiological confirmation of diagnosis (NAAT) is desirable but should not delay treatment.