Patients' perspectives on the burden of recurrent genital herpes

Vaccine value profile for herpes simplex virus

Herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) are chronic, highly prevalent viral infections that cause significant morbidity around the world. HSV-2 is sexually transmitted and is the leading cause of genital ulcer disease (GUD). It also increases the risk of HIV acquisition, fueling the HIV epidemic. HSV-1 is typically acquired in childhood through nonsexual contact and contributes to oral and ocular disease, but it can also be sexually transmitted to cause GUD. Both HSV-1 and HSV-2 cause neonatal herpes and neurologic disease. Given the ubiquitous nature of HSV-1 and HSV-2 infections and the limited existing prevention and control measures, vaccination would be the most efficient strategy to reduce the global burden of morbidity related to HSV infection. Vaccine strategies include prophylactic vaccination, which would prevent infection among susceptible persons and would likely be given to adolescents, and therapeutic vaccinations, which would be given to people with symptomatic genital HSV-2 infection. This document discusses the vaccine value profile of both types of vaccines. This 'Vaccine Value Profile' (VVP) for HSV is intended to provide a high-level, holistic assessment of the information and data that are currently available to inform the potential public health, economic and societal value of pipeline vaccines and vaccine-like products. This VVP was developed by subject matter experts from academia, non-profit organizations, government agencies and multi-lateral organizations. All contributors have extensive expertise on various elements of the HSV VVP and collectively aimed to identify current research and knowledge gaps. The VVP was developed using only existing and publicly available information.

Estimated economic burden of genital herpes and HIV attributable to herpes simplex virus type 2 infections in 90 low- and middle-income countries: A modeling study

BACKGROUND

Economic losses due to herpes simplex infections in low- and middle-income countries (LMICs) are unknown. We estimated economic and quality-of-life losses due to genital herpes in 2019, in 90 LMICs, and from 2020 to 2030 in 45 countries in the World Health Organization (WHO) Africa. We additionally estimated economic losses due to human immunodeficiency virus (HIV) attributable to herpes simplex virus type 2 (HSV-2) infections.

METHODS AND FINDINGS

We estimated genital herpes-related spending on treatment, wage losses due to absenteeism, and reductions in quality of life, for individuals aged 15 to 49 years, living with genital herpes. Had HSV-2 had contributed to the transmission of HIV, we estimated the share of antiretroviral treatment costs and HIV-related wage losses in 2019 that can be attributed to incident and prevalent HSV-2 infections in 2018. For the former, we used estimates of HSV-2 incidence and prevalence from the global burden of disease (GBD) study. For the latter, we calculated population attributable fractions (PAFs), using the classic (Levin's) epidemiological formula for polytomous exposures, with relative risks (RRs) reported in literature. To extend estimates from 2020 to 2030, we modeled the transmission of HSV-2 in 45 African countries using a deterministic compartmental mathematical model, structured by age, sex, and sexual activity, which was fitted to seroprevalence gathered from a systematic review and meta-regression analysis. In the 90 LMICs, genital herpes contributed to US$813.5 million in treatment and productivity losses in 2019 (range: US$674.4 to US$952.2 million). Given observed care-seeking and absenteeism, losses are in the range of US$29.0 billion (US$25.6 billion to US$34.5 billion). Quality-of-life losses in the amount of 61.7 million quality-adjusted life years (QALYs) are also possible (50.4 million to 74.2 million). The mean annual cost of treatment and wage losses per infection is US$183.00 (95% CI: US$153.60 to US$212.55); the mean annual cost of quality-of-life losses is US$343.27 (95% CI: 272.41 to 414.14). If HSV-2 has fueled the transmission of HIV, then seroprevalent HSV-2 cases in 2018 can account for 33.2% of the incident HIV infections in 2019, with an associated antiretroviral therapy (ART) cost of US$186.3 million (range: US$163.6 to US$209.5 million) and 28.6% of HIV-related wage losses (US$21.9 million; range: US$19.2 to US$27.4 million). In the WHO Africa region, the 3.9 million seroprevalent genital herpes cases from 2020 to 2030 contributed to US$700.2 million in treatment and productivity losses. Additionally, quality-of-life losses in the range of 88 million to 871 million QALYs are also possible. If HSV-2 has contributed to the transmission of HIV, then in 2020, the PAF of HIV due to prevalent HSV-2 will be 32.8% (95% CI: 26.7% to 29.9%) and due to incident infections will be 4.2% (95% CI: 2.6% to 3.4%). The PAF due to prevalent infections will decline to 31.0% by 2030 and incident infections to 3.6%. Though we have accounted for the uncertainty in the epidemiological and economic parameter values via the sensitivity analysis, our estimates still undervalue losses due to limiting to the 15- to 49-year-old population.

CONCLUSIONS

Economic losses due to genital herpes in LMICs can be large, especially when considering the lifelong nature of the disease. Quality-of-life losses outweigh spending on treatment and reductions in productivity. If HSV-2 has contributed to the spread of HIV in LMICs, then nearly one third of antiretroviral costs and HIV-related wage losses can be attributed to HSV-2. Given the magnitude of the combined losses, a vaccine against HSV-2 must be a global priority.

Impact of primary and recurrent genital herpes on the quality of life of young people and adults: a mixed methods systematic review

OBJECTIVE

This review sought to identify the experiences of persons living with genital herpes and what interventions improve the health-related quality of life of young people and adults with primary or recurrent genital herpes.

INTRODUCTION

Genital herpes is commonly associated with psychosocial challenges. However, a growing body of evidence suggests that its impact can be ameliorated through pharmacological and psychosocial interventions.

INCLUSION CRITERIA

This review considered English- and German-language studies of community-dwelling males and females, of any ethnicity and geographical location, aged 15 years and older, who had primary or recurrent genital herpes. The quantitative component of the review included studies that reported on the virus' impact on patients' health-related quality of life and/or the efficacy of interventions in improving their health-related quality of life. Studies compared antiviral suppression therapies and psychological interventions with usual care or placebo, or against one another. The qualitative component of the review included studies that investigated the perceptions and experiences of young people and adults with genital herpes.

METHODS

Eleven databases were searched from January 1980 to March 2020. The JBI approach to mixed methods systematic reviews was followed at each stage of the review, and a convergent segregated approach to synthesis and integration was adopted.

RESULTS

A total of 31 publications covering 30 studies were deemed suitable for inclusion. Studies encompassed quantitative (n = 27, across 28 publications), qualitative (n = 1), and mixed methods (n = 2) designs. Critical appraisal scores were variable, particularly among the randomized controlled trials and the analytical cross-sectional studies. All studies were included regardless of methodological quality. The quantitative components identified that depression, illness concern, stress, anxiety, isolation, stigma, and a lowering of self-esteem, self-concept, self-confidence, and health-related quality of life may be experienced by both those newly diagnosed with genital herpes and those with recurrences. It was also identified that genital herpes can have an adverse effect on work or school, sexual relationships, and relationships with friends and family. Depression was found to significantly decrease after self-hypnosis and certain psychosocial interventions. Anxiety significantly decreased following pharmacological treatment, psychosocial interventions, and hypnosis. Psychosocial interventions significantly improved mood, and a self-help module with counseling significantly improved participants' satisfaction with intimate relationships and their self-esteem. Pharmacological treatment significantly improved health-related quality of life; however, there were no significant differences between different active treatment regimens. The qualitative component of the review led to the identification of two synthesized findings: "Disclosure of a diagnosis of genital herpes poses a dilemma for people who have the virus" and "A diagnosis of genital herpes has a significant emotional impact for the individual."Integration of quantitative and qualitative evidence revealed a consensus that a diagnosis of genital herpes has a significant emotional impact for individuals and that disclosure is stressful, affects relationships, and affects health-related quality of life; however, there is a lack of consensus regarding efficacy of different interventions.

CONCLUSIONS

Genital herpes can lead to extreme emotional, social, relational, and sexual distress, but there is insufficient knowledge concerning which interventions best improve health-related quality of life. More high-quality research is required.

Review of Whole Plant Extracts With Activity Against Herpes Simplex Viruses In Vitro and In Vivo

Herpes simplex viruses, HSV-1 and HSV-2, are highly contagious and cause lifelong, latent infections with recurrent outbreaks of oral and/or genital lesions. No cure exists for HSV-1 or HSV-2 infections, but antiviral medications are commonly used to prevent and treat outbreaks. Resistance to antivirals has begun to emerge, placing an importance on finding new and effective therapies for prophylaxis and treatment of HSV outbreaks. Botanicals may be effective HSV therapies as the constituents they contain act through a variety of mechanisms, potentially making the development of antiviral resistance more challenging. A wide variety of plants from different regions in the world have been studied for antiviral activity against HSV-1 and/or HSV-2 and showed efficacy of varying degrees. The purpose of this review is to summarize research conducted on whole plant extracts against HSV-1 and/or HSV-2 in vitro and in vivo. The majority of the research reviewed was conducted in vitro using animal cell lines, and some studies used an animal model design. Also summarized are a limited number of human trials conducted using botanical therapies on HSV lesions.

Contriving a chimeric polyvalent vaccine to prevent infections caused by herpes simplex virus (type-1 and type-2): an exploratory immunoinformatic approach

Herpes simplex virus type 1 (HSV-1) and 2 (HSV-2) cause a variety of infections including oral-facial infections, genital herpes, herpes keratitis, cutaneous infection and so on. To date, FDA-approved licensed HSV vaccine is not available yet. Hence, the study was conducted to identify and characterize an effective epitope based polyvalent vaccine against both types of Herpes Simplex Virus. The selected proteins were retrieved from ViralZone and assessed to design highly antigenic epitopes by binding analyses of the peptides with MHC class-I and class-II molecules, antigenicity screening, transmembrane topology screening, allergenicity and toxicity assessment, population coverage analysis and molecular docking approach. The final vaccine was constructed by the combination of top CTL, HTL and BCL epitopes from each protein along with suitable adjuvant and linkers. Physicochemical and secondary structure analysis, disulfide engineering, molecular dynamic simulation and codon adaptation were further employed to develop a unique multi-epitope peptide vaccine. Docking analysis of the refined vaccine structure with different MHC molecules and human immune TLR-2 receptor demonstrated higher interaction. Complexed structure of the modeled vaccine and TLR-2 showed minimal deformability at molecular level. Moreover, translational potency and microbial expression of the modeled vaccine was analyzed with pET28a(+) vector for E. coli strain K12 and the vaccine constructs had no similarity with entire human proteome. The study enabled design of a novel chimeric polyvalent vaccine to confer broad range immunity against both HSV serotypes. However, further wet lab based research using model animals are highly recommended to experimentally validate our findings.Communicated by Ramaswamy H. Sarma.

Health-related quality of life of young people and adults with primary or recurrent episodes of genital herpes: a mixed methods systematic review protocol

REVIEW QUESTION

The review questions are:The specific objectives are:This mixed methods review seeks to develop an aggregated synthesis of quantitative and qualitative data on the HRQOL implications of genital herpes for the individual in order to derive conclusions and recommendations for clinical practice and policy decision making.

Psychological adjustment among women living with genital herpes

This study investigated the psychosocial factors that influence psychological adjustment among women with genital herpes, while taking into account the physical factors. Women with herpes (N = 105, age 18-30) completed an on-line survey about factors related to their diagnosis and herpes-related quality of life. Perceived stigma, acceptance coping, denial coping, support from the Internet, and support from religious/spiritual figures accounted for 65.9 percent of the variance in quality of life scores. The findings reveal the importance of specific coping strategies and sources of support on psychological adjustment to herpes. Furthermore, a significant interaction between stigma and acceptance coping suggests a complex relationship between these two psychosocial factors that warrants future research.

Herpes simplex virus infection in a university health population: clinical manifestations, epidemiology, and implications

OBJECTIVE

The authors described clinical presentations of oral and genital herpes simplex virus (HSV) infections in a university health population and implications of these findings.

PARTICIPANTS AND METHODS

Using a standardized data collection tool, 215 records of patients with symptomatic culture-positive HSV infections were reviewed.

RESULTS

HSV-1 accounted for 78% of female and 85% of male genital herpes (GH) infections, and oral herpes (OH) infections presented as an acute febrile illness (AFI) in 51% of those 18 to 24 years old. HSV-2 accounted for 68% of GH infections among adults 25 or older.

CONCLUSIONS

As seroprevalence for both HSV-1 and HSV-2 in the United States is decreasing, a growing college age cohort is at risk for primary HSV-1 infection. The proportion of GH caused by HSV-1 also continues to increase. This understanding has implications for clinical care, sexual health programming, and counseling strategies.

The development of the Herpes Symptom Checklist and the Herpes Outbreak Impact Questionnaire

OBJECTIVE

To develop measures of the day-to-day symptomatic and functional impact of recurrent genital herpes (RGH) outbreaks. The Herpes Outbreak Impact Questionnaire (HOIQ) and the Herpes Symptom Checklist (HSC) were designed to be acceptable to clinical professionals and to reflect patients' experience.

METHODS

Scale content was derived via literature review and interviews with RGH patients and physicians. Questionnaires were assessed for face/content validity in the UK and the language checked for acceptability in the United States. The US measures were assessed for face/content validity with patients. Scaling/psychometric properties were determined via web survey. Participants completed the questionnaires twice during an outbreak, with 24 to 72 hours between administrations.

RESULTS

Respondents found the questionnaires relevant and easy to understand and complete. Application of Rasch analysis resulted in the removal of two HOIQ items. Both scales were found to be unidimensional. Item stability testing for the HOIQ indicated that the measure is reproducible. Internal consistency was good (alpha: time 1 = 0.87, time 2 = 0.91). Discriminative validity was demonstrated by the measure's ability to distinguish between individuals who differed by self-reported severity of outbreak. The HOIQ and HSC were both responsive to change over time.

CONCLUSIONS

The HSC and the HOIQ can determine the impact of a herpes outbreak effectively. They are designed to be used daily during such outbreaks and to determine the effectiveness of RGH treatment.

Is suspicion of genital herpes infection associated with avoiding sex? A clinic-based study

OBJECTIVE

The present study tested the research hypothesis that sexually transmissible disease (STD) clinic patients suspecting genital herpes infection would be more likely than their 'non-suspecting' counterparts to abstain from sex to avoid transmission of a perceived STD.

METHODS

Recruitment (n = 351) occurred in a publicly-funded STD clinic located in a metropolitan area of the southern USA. Participants were tested for herpes simplex virus type 2 (HSV-2) using a rapid test manufactured by Biokit (Lexington, MA, USA) and they completed a self-administered questionnaire (using a 3-month recall period).

RESULTS

Well over one-third (38.7%) of those indicating suspicion also indicated avoiding sex with steady partners because of concerns about STDs as compared with 28.0% among those not indicating suspicion (prevalence ratio = 1.38; 95% CI = 1.02-1.87, P = 0.036). The relationship between suspicion and avoiding sex with non-steady partners was not significant (P = 0.720). The relationship with steady partners only applied to people who were female (P = 0.013), single (P = 0.017), reported symptoms of genital herpes (P = 0.003), perceived that genital herpes would have a strong negative influence on their sex life (P = 0.0001), and who subsequently tested positive for HSV-2 (P = 0.012).

CONCLUSIONS

Among STD clinic attendees, suspicion of genital herpes infection may translate into partner protective behaviour, but only for a minority of people and only with respect to sex with steady partners. Clinic-based and community-based education programs may benefit public health by teaching people (especially single women) how to effectively recognise symptoms of primary genital herpes infections. Reversing the often prevailing ethic of genital herpes as a 'community secret' will clearly be a challenge to these education programs.

A meta-analysis to assess the efficacy of oral antiviral treatment to prevent genital herpes outbreaks

BACKGROUND

Efficacy of oral antiviral therapies, ie, acyclovir, valacyclovir (VACV), and famciclovir, for suppression of recurrent genital herpes was studied at different doses and regimens.

OBJECTIVE

We sought to compare the clinical efficacies of the different oral antiviral drugs prescribed prophylactically to suppress recurrent genital herpes.

METHODS

MEDLINE and EMBASE databases were searched for articles on genital herpes and selected antiviral drugs. The selected trials were: parallel randomized clinical trials testing prophylactic oral antiviral treatment of genital herpes versus placebo in immunocompetent and nonpregnant patients.

RESULTS

Fourteen randomized clinical trials were selected, including a total of 6158 patients. The global relative risk of developing at least one recurrence during the study was reduced by 47% (95% confidence interval 45%-49%) in antiviral drug groups compared with the placebo. The best evaluated regimens, with comparable efficacies, were given twice daily, ie, acyclovir (400 mg twice daily), VACV (250 mg twice daily), and famciclovir (250 mg twice daily), or once daily (VACV 500 mg).

LIMITATIONS

The only end point available for all the studies was the number of patients presenting at least one recurrence of genital herpes during the observation period.

CONCLUSION

The results of this first meta-analysis confirmed the high clinical efficacy of oral acyclovir, VACV, or famciclovir for prophylaxis against recurrent genital herpes.

Superior efficacy of helicase-primase inhibitor BAY 57-1293 for herpes infection and latency in the guinea pig model of human genital herpes disease

The efficacy of BAY 57-1293, a novel non-nucleosidic inhibitor of herpes simplex virus 1 and 2 (HSV-1 and HSV-2), bovine herpesvirus and pseudorabies virus, was studied in the guinea pig model of genital herpes in comparison with the licensed drug valaciclovir (Valtrex). Early therapy with BAY 57-1293 almost completely suppressed the symptoms of acute HSV-2 infection, and reduced virus shedding and viral load in the sacral dorsal root ganglia by up to three orders of magnitude, resulting in decreased latency and a greatly diminished frequency of subsequent recurrent episodes. In contrast, valaciclovir showed only moderate effects in this set of experiments. When treatment was initiated late during the course of disease after symptoms were apparent, that is, a setting closer to most clinical situations, the efficacy of therapy with BAY 57-1293 was even more pronounced. Compared with valaciclovir, BAY 57-1293 halved the time necessary for complete healing. Moreover, the onset of action was fast, so that only very few animals developed new lesions after treatment commenced. Finally, in a study addressing the treatment of recurrent disease in animals whose primary infection had remained untreated BAY 57-1293 was efficient in suppressing the episodes. In summary, superior potency and efficacy of BAY 57-1293 over standard treatment with valaciclovir was demonstrated in relevant animal models of human genital herpes disease in terms of abrogating an HSV infection, reducing latency and the frequency of subsequent recurrences. Furthermore, BAY 57-1293 shortens the time to healing even if initiation of therapy is delayed.

Suppressive Valacyclovir Therapy: Impact on the Population Spread of HSV-2 Infection

OBJECTIVES

Recent trial results demonstrate that the transmission probability of HSV-2 in monogamous couples is nearly halved by the use of valacyclovir as suppressive therapy.

GOAL

The goal of this study is to understand the potential impact of suppressive valacyclovir therapy on the transmission of HSV-2 within a population.

STUDY DESIGN

A mathematical model of HSV-2 epidemiology was developed which included suppressive therapy with the efficacy observed in the clinical trial. The model represented HSV-2 spread in an age and sexual activity stratified population where rates of viral shedding declined based on time since infection. The model tested the impact of a range of suppression coverage levels.

RESULTS

Suppressive therapy reduces the population incidence of HSV-2. With coverage rates of 3.2%, the incidence of HSV-2 would be reduced by between 1.8% and 2.8%. Higher coverage rates were estimated to reduce the incidence of new cases up to 13%. Starting suppression closer to the time of infection also reduces the incidence of new cases.

CONCLUSION

The impact of suppressive therapy on the HSV-2 epidemic is modest at current coverage levels but could be substantially increased with higher rates of diagnosis and a focus on coverage soon after infection.

Genital ulcer disease in central Australia: predictors of testing and outcomes

OBJECTIVES

To identify factors associated with the uptake and outcome of testing for infectious causes of genital ulcer disease (GUD) in central Australia.

METHODS

Prospective investigation of GUD cases in central Australia from February 2002 to August 2003. Data were collected from primary health care clinics in remote indigenous communities of Central Australia.

RESULTS

During the study period, 134 cases of GUD were reported and investigated. Of these cases, 71 (53%) were in women (age range 14-75, median 28) and 63 (47%) in men (14-63, median 28). Testing for syphilis was undertaken for 111 (82.8%) cases, 75 (56%) were tested for herpes simplex virus infection, and 82 (61.2%) for donovanosis. Testing for at least one of the three sexually transmissible pathogens of interest was undertaken in 128 (95.5%) cases, while 99 (73.9%) were tested for two pathogens and 41 (30.6%) for all three agents. Of subjects tested, 19.8% had new syphilis infection, 51% had herpes simplex virus infection and 7% had donovanosis. In 19 of 41 (46.3%) subjects fully investigated no cause for genital ulceration was found.

CONCLUSION

This study provides the first quantitative description of GUD diagnosis in central Australia. Logistic constraints limited the systematic application of diagnostic tests. Current treatment protocols may need to be reassessed in light of the higher than expected detection of genital herpes as a cause of GUD.

[Quality of life with genital herpes]

Health related quality of life (HRQOL) indicators take into account the personal perception of health, and are proposed as an alternative for efficacy indicators in medical and therapeutic decision-making. They provide, after elaboration and validation of a questionnaire, a standardized assessment of the health status perception. The authors had for aim to review of a variety of HRQOL instruments developed for patients presenting with genital herpes infection. Generic instruments are designed to be applicable in general population and disease-targeted instrument are potentially more sensitive to the characteristics of a specific population. Among HRQOL instruments, we found 4 specific disease-targeted questionnaires developed for patients presenting with genital herpes infection: Genital herpes questionnaire, Herpes research center questionnaire, quality of life with herpes (QLH) scale, and recurrent genital herpes quality of life (RGHQoL).

Managing Patients with Genital Herpes and their Sexual Partners

There is increasing recognition of the growing size and significance of the genital herpes epidemic. Recent developments in the wide-scale availability of type-specific herpes simplex virus (HSV) sero-logic assays have meant that many previously undiagnosed mild,atypical, and subclinical infections may now be diagnosed with some degree of confidence without the use of Western blots. The value of such diagnostics is controversial. However, the importance of HSV with its facilitation of HIV transmission and acquisition, the availability of various preventative strategies for limiting vertical HSV transmission, and the growing evidence that condoms, some educational and counseling interventions, and antiviral therapies may limit sexual transmission, have challenged many of the arguments against wider testing of the population.

Immunotherapeutic activity of a recombinant combined gB-gD-gE vaccine against recurrent HSV-2 infections in a guinea pig model

The guinea pig model of recurrent genital herpes simplex virus type 2 (HSV-2) infection was used to test the immunotherapeutic activity of a glycoprotein subunit vaccine. Vaccine formulation consisted of three recombinant herpes simplex virus (HSV) glycoproteins, namely gB1s, gD2t and gE1t, plus aluminium hydroxide [Al(OH)3)] adjuvant. One month after viral challenge, infected animals were therapeutically immunised by seven subcutaneous injections of a low dose of antigens with a weekly interval for the first five and a fortnightly interval for the last two administrations. Results showed that the treatment was highly effective in ameliorating the recidivist pathology of animals, suggesting that this kind of vaccine formulation and administration may be helpful for therapeutic intervention in humans affected by recurrent herpes infections.

Efficacy and Safety of Valacyclovir for the Suppression and Episodic Treatment of Herpes Simplex Virus in Patients with HIV

Three randomized controlled trials of valacyclovir for the management of recurrences of genital herpes in HIV-infected persons were conducted between 1991 and 2002. One study evaluated episodic therapy for the treatment of genital herpes, and 2 studies evaluated continuous suppressive therapy. Valacyclovir at 1000 mg twice daily for 5 days was comparable to acyclovir at 200 mg 5 times daily in accelerating healing of a single episode of genital herpes (hazard ratio, 1.0; 95% confidence interval [CI], 0.8-1.2; P=.89). Valacyclovir at 500 mg twice daily was effective in preventing or delaying recurrences of genital herpes compared with placebo (hazard ratio, 0.20; 95% CI, 0.13-0.30; P<.001) and with valacyclovir at 1000 mg once daily (hazard ratio, 0.56; 95% CI, 0.40-0.80; P=.001), in 6-month and 48-week studies, respectively. The safety profile of valacyclovir was similar to that of acyclovir. Valacyclovir is well tolerated, safe, and effective for the treatment and suppression of recurrent genital herpes in human immunodeficiency virus-infected persons.

Effectiveness of needs-based quality of life instruments

Several years experience has now been gained in the use of needs-based measures in clinical trials and such use is increasing rapidly. This paper shows how four needs-based quality of life (QoL) instruments have proved effective in determining the benefits of interventions from the patients' perspective in clinical studies and trials. The instruments discussed are; the Quality of Life in Depression Scale (QLDS), the Migraine Specific Quality of Life Scale (MSQoL), the Recurrent Genital Herpes Quality of Life (RGHQoL), and the Quality of life-Assessment in Growth Hormone Deficient Adults (QoL-AGHDA).

Dermatological applications of needs-based quality of life instruments

Needs-based instruments have been developed for a wide range of diseases. Recently, they have been applied widely in dermatology. This paper describes these applications and shows how they have proved of value.

Sexually transmissible infections other than HIV

Sexually transmitted infections (STIs) are notable for their fastidious requirements for transmission and growth in the laboratory and for their high physical and psychosocial morbidity. The combination of subtle or absent symptoms and stigma preventing the seeking of health care, leaves many infections undiagnosed. The development of nucleic-acid amplification tests heralded a new era in sensitive and robust diagnostic procedures for STIs. Unfortunately, many of these tests are not commercially available or are too expensive for the populations that need them most. Single-dose oral azithromycin has improved the treatment of several bacterial STIs, but quinolones are rapidly becoming ineffective for gonorrhoea. Self-treatment of genital warts with podophyllotoxin or imiquimod preparations is attractive to patients and might be cost effective for health services. The prospect of effective vaccines against genital papillomaviruses in the near future is real. Such vaccines could reduce the global incidence of some anogenital cancers. Episodic treatment of genital herpes is getting easier and cheaper, and suppressive treatment can reduce transmission to regular sexual partners. A vaccine against herpes simplex virus type 2 has shown some limited efficacy. Ultimately, better control of STIs, and reduction of their contribution to the spread of HIV, will require a broad health-sector response with adequate resourcing, and a change in social and political attitudes.

Recurrent genital herpes treatments and their impact on quality of life

Herpes genitalis is one of the most common viral sexually transmitted diseases in the world, with an estimated seroprevalence in the US of greater than 20%. Two viruses of the same family cause herpes genitalis: herpes simplex virus 1 and 2. After the resolution of primary infection, the virus persists in the nerve roots of the sacral plexus, often causing recurrent (though generally less severe) outbreaks. These outbreaks, as well as the infectious potential to the patient's sexual partners, results in significant psychological stress on the patient, and has a tremendous negative impact on QOL. Current treatment modalities may result in a reduction in the number of outbreaks and viral shedding, but no cure exists. Although studies have clearly demonstrated the negative impact of recurrent genital herpes on QOL, an assessment scale specific to herpes was not developed until recently. Earlier studies indicated that patients did not perceive a significant benefit from episodic treatment with antivirals, but studies using the Recurrent Genital Herpes Quality of Life Questionnaire (RGHQoL) have now demonstrated that suppressive antiviral therapy improves quality of life in patients with frequent recurrences of genital herpes. However, not all patients with recurrent genital herpes need suppressive therapy, and proposed factors to consider include frequency of recurrence, physical and psychological distress caused by recurrences, and the potential for transmission to the patient's sexual partner. Newer therapeutic modalities, including the topical immune response modifier resiquimod and herpes vaccines, may eventually be shown to further decrease the psychological morbidity of recurrent genital herpes.

Current treatments and perceptions of genital herpes: a European-wide view

A European panel of physicians reviewed the current treatments and perceptions of recurrent genital herpes (GH) across the continent. The panel consisted of specialists in dermatology and venereology from France, Finland, Germany, Italy, Norway, Spain, Sweden and the UK. A wide variety of factors that influence GH management were considered, including different health delivery systems, funding and cultural differences. The poor awareness of GH among both the general public and physicians was highlighted. The effectiveness of GH management was then examined from a patient's viewpoint, including the confirmation of the diagnosis, information and counselling about GH, as well as prescriptions for treatment. It was agreed that both physicians and patients often feel uncomfortable about discussing the disease, and that a European-wide effort is needed to re-educate patients and physicians about GH. The panel identified clear and unmet needs to manage a patient with clinical recurrences and to attempt to reduce the risk of GH transmission. Finally, resiquimod, an immune response modifier, was considered as a potential treatment option for GH.

Progress in meeting today's demands in genital herpes: an overview of current management

Treatment of genital herpes requires accurate diagnosis, patient support, and effective treatment. Diagnosis is usually straightforward for classic presentations characterized by vesicular lesions but can be challenging for atypical presentations, which are more common. Diagnosis of asymptomatic infection requires access to molecular technology or type-specific serologic assays. Misconceptions about herpes simplex infection are common and patient education is essential. Patient concerns extend beyond disease frequency and severity-the psychological impact should not be underestimated. Antiviral therapy is relevant at all stages of infection. Acyclovir, valacyclovir, and famciclovir are effective and well tolerated for genital herpes treatment. Continuous suppressive therapy controls all symptoms of recurrent disease and helps to relieve disease complications. The prodrugs valacyclovir and famciclovir offer easier, less-frequent dosing than required for acyclovir. Valacyclovir achieves effective suppression when taken once a day. Interventions to prevent genital herpes transmission and to control the global problem are urgently required.

Patient and physician partnerships in managing genital herpes

Genital herpes simplex virus infections are widespread throughout the world and are characterized by stigma, myth, and anxiety by patients and the public but are perceived as trivial by most physicians. Surveys in the United States, Europe, Australia, and South Africa have measured the unfavorable effect of genital herpes on infected patients, health care resources, and workplace productivity. These surveys identified limited satisfaction of patients with current care and support (41% satisfied), although satisfaction scores were greater for patients receiving suppressive antiviral therapy (56% satisfied). Bridging the gap between patients and physicians is vital for improving the management of genital herpes. Key to facilitating patient-physician partnerships is education and recognition by physicians that patients with genital herpes may have expert knowledge. In effective partnerships, physicians and patients can have informed constructive discussions such that patients share in the responsibility for managing their disease and in therapeutic decision making.

Psychosocial outcomes in individuals living with genital herpes

Genital infection, a common chronic sexually transmitted infection, is associated with physical and psychosocial concerns. While recognizing that some patients are able to take advantage of medication to chronically suppress the virus, researchers have examined the role that stress and other variables play in the frequency of outbreaks a patient might experience. In this article, several theories are reviewed from the stress literature that relate to patients' experience with herpes: the adjustment issues associated with having herpes, the role of social support, and the issue of disclosure. These theories and their clinical implications are discussed within the context of nursing interventions.