Asymptomatic herpes simplex virus shedding from the genital tract whilst on suppressive doses of oral acyclovir

Current Issues in the Management of Genital Herpes

Genital infection by herpes simplex virus (HSV) produces a variety of clinical manifestations, patient presentations and management problems which differ in their severity and complexity. In the UK the currently available data for the incidence of genital HSV have been provided predominantly by the KC60 returns from diagnoses made in genitourinary (GU) medicine clinics. The increasing availability and recent publication of the first results, using HSV type-specific antibody tests within GU and non-GU patient populations, provide a tool to monitor trends in the epidemiology of HSV. It is, however, important to understand that the sexual behaviour which leads to this infection is variable and not necessarily general.

The clinical availability of type-specific HSV antibody tests also gives rise to the possibility of screening individuals and informing those who test positive of their, previously undiagnosed, condition. The practicalities and problems of this approach need to be fully assessed. The possibility of uncovering previously undiagnosed cases through general practitioners is being considered, first, in terms of surveys of the general practitioners' management of genital HSV and, secondly, because the funding of health care in the UK has put the cost-effectiveness in GU medicine clinics under the spotlight. This paper will explore the new developments in the management of genital HSV and suggests adherence to the clear principles of diagnosis and treatment that is in the patient's best interest. This has the clear aim of improving the patient's quality of life, a factor which must remain paramount as new technologies, healthcare strategies and therapies become available.

[An epidemiological model of genital herpes for assessment of potential impact of therapy and prophylaxis: application to France]

OBJECTIVES

This study was performed to quantify the development of the number of cases of genital herpes and to assess the impact of different treatment strategies in France.

METHOD

A model for the natural history of herpes simplex virus genital infection is presented and applied to the French population. The model encompasses infection by herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2), first episodes, recurrences, viral shedding and the effect of treatment on infected individuals.

RESULTS

In the Year 2000, 270,000 individuals would have suffered from genital herpes in France. A total annual cumulated number of 1.5 million episodes of recurrence and 23 million days of viral shedding were estimated. Seventy percent of viral shedding occurred in sub-clinical seropositive individuals. The expected number of attributable neonatal deaths remained very low. Systematic treatment of clinical episodes might reduce the number of days with lesions (- 27 p. 100), and is also effective on viral shedding (symptomatic: - 50 p. 100). Continuous treatment of the most severe patients (>or=6 recurrences per Year) might reduce viral shedding slightly more (- 85 p. 100). Antiviral treatment might have a major impact on the quality of life of these patients but would only slightly curb the number of new infections.

DISCUSSION

This model tries to integrate the various data currently available at international level on the epidemiology of genital herpes. However, many aspects are still not well documented and remain uncertain. It is therefore necessary to define various assumptions in order to simulate the natural history of the disease in a population. The lack of French data especially on the HSV-1 and HSV-2 seroprevalence profiles reinforces these uncertainties. Our results should hence be considered as exploratory. However, this modeling approach is the only possible way to integrate the multiple parameters describing the pathology and predicting of the public health impact of different interventions. This model is an open tool which may be modified when new data become available.

Virologic characteristics of subclinical and symptomatic genital herpes infections

BACKGROUND

The frequency, pattern, and anatomical sites of subclinical shedding of herpes simplex virus (HSV) in the genital tract, along with factors that predict such shedding, have not been well characterized.

METHODS

We studied prospectively the clinical and virologic course of genital herpes in 110 women. The women kept symptom diaries and provided daily samples from the vulva, cervix, and rectum for viral culture.

RESULTS

During a median follow-up of 105 days, subclinical shedding of virus was identified in 36 of 65 women (55 percent) with HSV type 2 (HSV-2), in 16 of 31 women (52 percent) with HSV type 1 (HSV-1) and HSV-2, and in 4 of 14 women (29 percent) with only HSV-1. Among women with genital HSV-2 infection, subclinical shedding occurred on a mean of 2 percent of the days. The mean duration of viral shedding during subclinical episodes was 1.5 days, as compared with 1.8 days during symptomatic episodes. HSV was isolated from several sites in the genital tract and rectum in 17 percent of subclinical episodes and 22 percent of symptomatic episodes. Half the episodes of subclinical shedding of HSV occurred within seven days of a symptomatic recurrence. The risk of subclinical shedding increased with the frequency of symptomatic recurrences. Subclinical shedding was more frequent among women with more than 12 recurrences per year than among those with no symptomatic recurrences (odds ratio, 3.3; 95 percent confidence interval, 1.4 to 7.9); it was also more frequent among women who had recently acquired genital herpes (odds ratio for women with HSV acquired in the past year as compared with those who had had the infection for a year or more, 1.85; 95 percent confidence interval, 1.1 to 3.1).

CONCLUSIONS

Among women with a history of genital herpes infection, subclinical shedding of HSV is common and accounts for nearly one third of the total days of reactivation of HSV infection in the genital tract. Women with frequent symptomatic recurrences also have frequent subclinical shedding and may be at high risk for transmitting HSV.

Applied relaxation training in the treatment of genital herpes

Four individuals with frequent recurrences of genital herpes simplex virus (HSV) were trained in Applied Relaxation (AR). Participants included in the research had been diagnosed with herpes at least 1 year prior to the study, experienced six or more outbreaks annually, and were not taking antiviral medications. The experiment employed a multiple baseline across subjects design. Participants maintained daily diaries of the frequency, duration and severity of herpes activity from baseline until a minimum of 3 months posttreatment. Treatment consisted of 10 individual AR sessions. Pretraining and posttraining frontalis electromyographic activity measures of subjects' ability to relax during rest and to apply the relaxation skill during stressful role plays were obtained. All subjects reported pretreatment to posttreatment reductions in herpes frequency. These changes were statistically significant across all subjects as a group and individually for three of the four subjects. These results suggest that AR is an effective technique for reducing recurrent HSV infection.

Herpes simplex virus infections during the decade since the licensure of acyclovir

The development and use of acyclovir accelerated in the area of the natural history, epidemiology, and biology of herpes simplex viruses. The development of serologic assays that differentiate HSV-1 from HSV-2 demonstrated the worldwide distribution of genital herpes, the role genital ulcers play in facilitating HIV transmission, and the high frequency in which pregnant women acquire HSV infection. The high reactivation rate of HSV-2 infections, the often silent nature of genital herpes, and its widespread anatomic distribution in the genitourinary tract lead to frequent subclinical transmission. Identification and counselling of the asymptomatic carrier is necessary if we are to decrease the transmission of genital herpes.