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GENITAL HERPES: A Hidden Epidemic

Genital herpes may not be deadly, but it can be physically painful and emotionally debilitating. Those who have it may suffer from painful sores as well as feelings of shame, regret, isolation, and undesirability.

"We, as a society, don't do well with STDs," says Terri Warren, R.N., owner of the Westover Heights Clinic in Portland, Ore., specializing in the treatment of sexually transmitted diseases. "When people have a lifelong STD, they feel dirty, damaged, and unapproachable. Most people have a dramatic drop in self-esteem."

Genital herpes is on the rise. Since the late 1970s, the number of Americans infected with the virus has increased 30 percent to about 45 million, according to the Centers for Disease Control and Prevention (CDC).

The virus infects more than 1 of 5 adolescents and adults, the CDC says. It is more common in blacks than in whites, and more likely to infect women than men. Compared to 20 years ago, it's about five times more common in 12- to 19-year-old whites and twice as common in adults ages 20 to 29.

The scary part is that most people with genital herpes don't know they have it, and are unaware they may be spreading it to others, says Warren. Many have no symptoms or mistake their symptoms for something else, such as jock itch, insect bites, hemorrhoids, yeast infections, razor burn, or allergies to laundry detergent.

Of even greater concern is growing evidence that people with genital herpes are at greater risk of getting HIV (the virus that causes AIDS) if they have unprotected sex with someone infected with HIV. And HIV-infected people who are also infected with genital herpes may have more frequent and severe outbreaks and their episodes may be more difficult to treat.

In the past, genital herpes was diagnosed solely by visual inspection and laboratory culture of an active sore. Herpes may now be diagnosed with a blood test, even when no symptoms are apparent or after sores have healed. And while there is no cure for herpes, antiviral drugs have been approved by the Food and Drug Administration that greatly reduce the frequency of outbreaks and shorten their duration and severity.

What is genital herpes?

Genital herpes, a sexually transmitted disease (STD), is an infection caused by the herpes simplex virus (HSV). HSV is in the same family of viruses that causes chickenpox, shingles and mononucleosis.

There are two types of HSV: HSV-1, which infects 80 percent of the U.S. population, usually appears on the lips in cold sores; HSV-2 is usually found in the genital area. However, if a person with HSV-1 oral herpes (cold sores) performs oral sex, it is possible for the partner to get HSV-1 genital herpes. And HSV-2 can infect the mouth through oral sex.

HSV can cause sores, or lesions, to appear in and around the vaginal area and within the cervix in women, and on the penis and scrotum in men. Both males and females may also get lesions in the urinary tract, around the anal opening, on the buttocks or thighs, and sometimes on other parts of the body.

The first episode

Symptoms of genital herpes can vary in appearance and intensity. Some people have no symptoms or such mild symptoms that they don't suspect they have an infection. For others, the first episode of herpes (primary infection) can cause one or more very painful lesions to erupt on the skin.

For many people, this primary infection may be more severe and have more generalized symptoms than recurrent episodes. During a first episode, the lesions may be accompanied by flu-like symptoms such as fever, headache and muscle aches. Some people experience painful or difficult urination and swollen glands in the groin area. Women may also have a vaginal discharge.

Genital herpes lesions usually appear within two to 10 days after being exposed to the virus, and can last from two to four weeks. First to appear are small red bumps, which develop into blisters. Then the blisters become open sores, which later dry up, crust over, and heal without leaving a scar. Sometimes a second crop of lesions appears.

Recurrent episodes

Once HSV infects a person, the virus travels through the nerves and settles at the base of the spine. During this inactive phase, the virus is dormant. But it may wake up later, travel along the nerve paths to the surface of the skin, and cause another outbreak of lesions. This recurrence of HSV usually causes lesions to appear around the same area of the first outbreak.

Some people have only one or two recurrences in a lifetime, while others have them frequently. "The recurrence rate is far lower in HSV-1 than HSV-2," says Rhoda Ashley, Ph.D., director of the University of Washington's diagnostic virology laboratory at the Children's Hospital and Regional Medical Center in Seattle.

Most people diagnosed with HSV-2 affecting the genital area typically have four or five symptomatic recurrences the first year. After the first year, most people have fewer and milder recurrences, lasting a week or less. Many people get warning signals of a recurrence, known as prodrome. With prodrome, there may be a tingling or itching in the genital area, or pain in the buttocks, down the legs, or in the lower back. Sometimes these symptoms go away and no lesions appear.

Researchers don't know why recurrences happen, or why their frequency and severity vary. Some people report that recurrences are triggered by stress, illness, poor nutrition, menstruation, and friction in the genital area, such as that caused by vigorous sex. However, many of these supposed triggers have no scientific basis, says Ashley. "You can't say stress is a trigger. It's like the chicken and the egg. Which came first -- the herpes or the stress?" Nevertheless, for many people, trying to avoid their triggers seems to work for them, says Ashley.

Asymptomatic shedding

In many instances, people with genital herpes know the virus is active because they have symptoms, such as lesions. But this isn't always the case.

The herpes virus can become active without causing symptoms. During these times, small amounts of the virus are present on the skin, often at the place of first infection. This reactivation without symptoms, known as "asymptomatic shedding," may also occur in rectal tissue or in fluids from the penis and vagina.

The herpes virus can become active without causing symptoms. During these times, small amounts of the virus are present on the skin, often at the place of first infection. This reactivation without symptoms, known as "asymptomatic shedding," may also occur in rectal tissue or in fluids from the penis and vagina.

"Even if you're asymptomatic, you can transmit the virus," says Stanka Kukich, M.D., a medical team leader in the FDA's Center for Drug Evaluation and Research. In fact, studies have shown that most people get HSV from sexual contact during times of asymptomatic viral shedding.

Researchers have found that people with HSV-2 genital herpes tend to have more shedding than those with HSV-1. In addition, people with new infections are more likely to shed the virus than those with an infection more than a year old. Those with frequent recurrences may also shed the virus more often, but this is still an area being studied.

Transmission and prevention

Genital herpes is spread only through direct skin-to-skin contact or mucous membrane contact. It can be transmitted through penile-vaginal intercourse, anal intercourse, oral-genital sex, and other sexual body-to-body contact.

To reduce the risk of transmitting genital herpes, people who have the virus should avoid sexual contact from the time they first feel any symptoms until their lesions are completely healed. During times when there are no symptoms, using latex male condoms for genital-to-genital contact reduces the risk of transmission, according to the American Social Health Association. But condoms are only effective if they cover or prevent contact with the area of the body that has a lesion or active virus.

In one study of more than 400 monogamous couples in which one partner had genital herpes and the other didn't, condoms were found to offer significant protection against HSV-2 infection in women, says study leader Anna Wald, M.D., medical director of the virology research clinic at the University of Washington in Seattle. Since women shed the virus from a wide genital area, condoms may be less protective for men than for women, says Wald, whose study was published in the June 27, 2001, issue of the Journal of the American Medical Association. However, more studies are needed to address how well condoms work for men, she says.

Lambskin or other natural membrane condoms should not be used for disease protection because the naturally occurring pores in the material are large enough to allow some viruses to pass through. The FDA recommends latex condoms or polyurethane condoms for those sensitive to latex.

Partners can be infected with different strains of herpes, but are highly unlikely to reinfect each other, says Ashley. Even if they did, each person's symptoms are unlikely to change. "You're not going to be suddenly having twice the attacks because you have strain too."

The virus is not transmitted through the air, nor are there any documented cases of a person getting genital herpes from an inanimate object such as a toilet seat or hot tub. "Herpes doesn't do well in chlorinated water," says Ashley. "The virus can be present in a hot tub, but it won't be active." The virus doesn't survive well in the environment, even on a wet towel, says Ashley. However, she advises to avoid sharing razors, especially with someone who has an active cold sore. The virus can be transmitted from the razor to the skin. Other viruses, such as hepatitis C, also can be transmitted by sharing razors.

Spreading herpes from one part of your body to another (autoinoculation) is possible, but unusual. To be safe, wash your hands with soap if you touch a herpes sore.

The emotional impact

For many people, the social and emotional distress of having herpes is far worse than the physical symptoms of the disease, especially upon first discovering they have been infected.

Here's one true-life scenario: After some marital difficulties and a separation, a wife and her husband reunited. But their tenuous relationship was further strained when he brought genital herpes back to the marriage. "It hurt our chances of getting back together," she says. The relationship ended in divorce.

The doctor who diagnosed this woman wasn't very understanding, she says. "I really felt betrayed on all counts." She found understanding and information from the herpes support group that she now helps facilitate. "It always hurts to see someone feel so worthless and angry at the world," she says. "We see people who say 'I haven't told anyone. I haven't dated in five years.' This virus has taken over their whole life. We let them see that we're OK. We all lead normal, happy lives."

She believes the hardest thing about having genital herpes is having to tell someone, but says it's important to tell a new partner about the disease before having sexual relations.

"People should have a right to make an informed decision," says STD clinic owner Warren. "The consequences of not telling are not only possibly infecting a person with a disease that they don't want, but the question of trust comes up. What else haven't you told them about yourself? Our experience indicates that far more people accept sexual partners with herpes than reject them."

After learning more about herpes and accepting their condition, people tend to be more at ease with telling. Talking openly with a partner can help people with herpes take control of their lives. "Once they understand it and recognize it, control is a lot easier," says Ashley. "Over time, it becomes a nuisance rather than a mind-altering and life-changing event."

Herpes and newborns

A mother with genital herpes can easily deliver a healthy baby. And most can have a normal vaginal delivery. Less than 0.1 percent of infants born in the United States each year get infected with genital herpes during birth, according to the American Social Health Association.

A mother who was infected with herpes prior to getting pregnant passes herpes antibodies on to her fetus, protecting it from becoming infected with the virus. After birth, as the baby develops its own immune system, it loses these antibodies.

The danger period is late in pregnancy. The greatest chance of delivering a baby infected with herpes occurs in women who first become infected with genital herpes in the last trimester, says Zane Brown, M.D., professor of obstetrics at the University of Washington in Seattle. "The mother doesn't have time to build up antibodies."

For newborns infected with herpes, the consequences are devastating. "More than 40 percent die or have severe brain damage," says Brown.

Brown recommends a cesarean section if the primary infection is in the latter half of the pregnancy, or if the mother with long-standing genital herpes has any symptoms of genital herpes at the time of labor. He also recommends that all expectant mothers get a type-specific blood test for herpes in the first trimester of pregnancy. If negative for both HSV-1 and HSV-2, her partner should be tested. If the partner has herpes, sexual contact that could put the mother at risk of acquiring genital herpes should be avoided in the last trimester of pregnancy.

For several months after birth, infants are at risk for getting herpes. People with oral herpes (cold sores) should avoid kissing the baby. Wearing a mask over the cold sore when around the baby is recommended.

If a baby is infected with herpes, early treatment is critical. The FDA has approved the drug acyclovir in injectable form to treat infants with herpes.

For more information:

National Herpes Resource Center, a service of the American Social Health Association:

Teen Web site for STDs:

National Herpes Hotline:

Centers for Disease Control and Prevention National STD and AIDS Hotlines:
1-800-227-8922 or 1-800-342-2437
En Español: 1-800-344-7432
TTY: 1-800-243-7889

University of Washington Virology Lab:

If you wish to be tested with the most accurate blood test for detecting herpes, the Western Blot, have your health care provider call 206-598-6066 to request the HSV type-specific serology information packet.

Patient Assistance Programs to help low-income people buy herpes drugs:

Novartis (maker of Famvir):

GlaxoSmithKline (maker of Valtrex and Zovirax):

Source: FDA ConsumerNews magazine (adapted from the American Social Health Association).

Posted: April 2002