Introduction - A Guide for People with Genital Herpes
The aim of this information is to improve understanding of what genital herpes is and what it means, so that it is easier to live with.

Genital herpes is surrounded by myths and misinformation that lead, all too often, to fear, anguish and self-persecution.

Included is information on medical aspects and treatment of the infection, as well as sexual relationships and pregnancy.

There are also some practical guidelines for developing a positive approach to living with genital herpes. As each person's response and attitude to genital herpes is different, these guidelines are general. You may wish to seek further advice and information to suit your own needs.

The Infection

What is genital herpes?
Genital herpes is a common virus infection caused by herpes simplex virus (HSV). There are two types of this virus: types 1 and 2. As well as the genitals, the virus can infect the anus, buttocks, top of the thighs, mouth, lips or face; infection on the lips or face results in facial herpes, which includes cold sores. These infections have an essentially identical appearance when on external surfaces.

What is a virus?
Understanding viruses and how they thrive is the key to understanding genital herpes. As an intracellular parasite, a virus cannot survive by itself and is entirely dependent on the cells it invades.

Viruses and bacteria are the microbial organisms that most commonly cause infection in humans, but bacteria are larger and comparatively independent. These factors make bacteria easier to isolate and eliminate.

Virus infections
The virus invades the human body, often through a crack in the skin or through the mucosa of the mouth and genital area.

Once inside the human cell, the virus uses the material in the host cell to reproduce (known as replication). In this process the cell is destroyed. The destruction of the host cell is responsible for the characteristic signs (blisters, etc) and symptoms (tingling, pain, etc) of a herpes episode.

Besides entering and taking over cells at the site of infection, particles of the virus enter sensory nerve fibres at the site of infection, and proceed to move upward to where the fibre begins. Sensory nerve fibres carry signals that allow us to sense pain, touch, cold, light etc. Sensory nerve fibres start from a small cluster of cells known as a sensory ganglion. In the case of facial herpes, the virus settles in a ganglion at the base of the skull, known as the trigeminal ganglion. In the case of genital herpes, the virus retreats to the sacral ganglia, situated near the tail of the spinal cord. Once the virus reaches the ganglion, it remains there for the rest of our lives. Periodically, HSV reactivates in the ganglion and virus particles travel down the nerve fibre to the skin or mucosa, to cause recurrent symptoms.

Herpes simplex isn't the only virus many of us live with. Anyone who has had chickenpox is host to the varicella zoster virus. This virus remains mostly dormant, however, it can reactivate but only very rarely. When this happens, virus particles leave the nerve ganglia, travel down the nerve fibres to the skin and cause shingles.

Once a virus enters our body, antibodies are produced to fight it. Antibodies are found in the blood stream and are important in the body's natural defence (immune response). They continue to be produced for several weeks after the initial episode.

With genital herpes, antibodies help ensure that recurrent symptoms are milder than the first episode. It's interesting to note that it is quite common to find antibodies in the blood of people who have never apparently experienced an episode of genital herpes. Either the episode was so mild that the person was unaware that it was taking place, or it was diagnosed as a different medical condition, or it was totally without symptoms and therefore unrecognized.

Genital herpes infection occurs through exposure of the genitals to the virus from a partner with active herpes (this can be the result of either genital or oral contact).

The first episode is called the initial or primary infection and it is at this stage that some virus retreats to the nerve ganglia. Subsequent episodes, known as recurrences, occur if and when the virus replicates in the ganglion, releasing virus particles that travel along the nerve back to the site of the initial infection.

Sites of infection
In women, the genital areas most commonly affected are the vulva and the entrance to the vagina. Sores can also sometimes develop on the cervix.

In men, sores are most common on the glans (end of the penis), the foreskin and shaft of the penis. Sometimes sores can develop on the testicles.

Less commonly, both men and woman can experience sores around the anus, on the buttocks and tops of the thighs.

The initial genital HSV infection
Symptoms of the initial infection are usually the most severe as the body may not have been exposed to the virus before and antibodies will not have been produced to trigger the immune response.

The initial genital herpes episode can last for more than 20 days and it is not uncommon for someone to experience a range of generalized symptoms, such as fever, aches and pains, swollen lymph nodes, as well as specific genital symptoms. For others, the initial infection can be mild with minimal symptoms.

For most people, the first indication of infection starts between two to 12 days after exposure to the virus. The development of symptoms may take longer or be less severe in some people, especially those who have previously developed partial immunity to the virus from having facial herpes, e.g. cold sores.

Symptoms can start with tingling, itching, burning or pain followed by the appearance of painful red spots which, within a day or two, evolve through a phase of clear, fluid-filled blisters which rapidly turn whitish-yellow. The blisters burst, leaving painful ulcers that dry, scab over and heal in approximately 10 days. Sometimes the development of new blisters at the early ulcer stage can prolong the episode. On the other hand, the blister stage may be missed completely and ulcers may appear like small cuts or cracks in the skin.

Women particularly often experience pain on urinating, and when this happens, it's important to avoid problems of urinary retention by drinking plenty of fluids to dilute the urine and thereby reduce pain and stinging. Some women may also notice vaginal discharge.

Recurrences
Some people do not experience symptomatic recurrences but for those who do, recurrences are usually shorter and less severe than the initial episode. Over time, recurrences may decrease in both severity and frequency, although there is no definite evidence that this happens. Recurrences are usually preceded by warning symptoms (also known as prodromal symptoms) such as tingling, itching, burning or pain.

As with the initial episode, there is a large variation in people's experiences of recurrences. Approximately 80% of persons having a first episode caused by HSV-2 will have at least one recurrence, while only 50% of persons with HSV-1 will experience a recurrence. The most common scenario is occasional recurrences (about 4 attacks per year). However, a minority will more suffer frequent recurrences.

Genital herpes can be elusive
The severity of symptoms for genital herpes can vary greatly from one person to another. The initial episode can be so mild as to pass unnoticed and a first recurrence may take place many years after the first infection.

Up to 60% of people who have genital HSV infection show no signs of the disease and are unaware that they are infected. These people are, however, capable of transmitting the virus to others. In such cases, an occurrence of genital herpes can lead to confusion and bewilderment in people unable to understand the sudden appearance of infection and apparent transmission from someone else.

What triggers genital herpes?
The initial episode usually occurs two to 12 days after sexual contact with a person with active infection.

A recurrence takes place when the virus replicates in nerve ganglia and particles of virus travel along the nerve to the site of primary infection in the skin or mucous membranes (e.g. the inner, moist lining of the mouth, vagina etc). Although it is not known exactly why the virus reactivates at various times, causal factors can be separated into the physical and the psychological.

• Physical
  Physical factors differ from person to person. Being run-down, suffering from other genital infections (affecting the local skin area), menstruation, drinking a lot of alcohol, exposure of the area to strong sunlight, conditions that make a person immunocompromised (where the body's immune system is not functioning normally), prolonged periods of stress and, more unusually, ultraviolet light, are all factors that can trigger an episode. Friction or damage to the skin, caused by, for example, sexual intercourse, may also lead to a recurrence. In summary, anything that lowers your immune system or causes local injury can trigger recurrences
• Psychological
  Recent studies suggest that periods of prolonged stress can cause more frequent recurrences. It is also common to experience stress and anxiety as a result of having recurrences.

Transmitting the infection
Persons with herpes can be infectious both when symptoms of a herpes outbreak are present and also when there are no symptoms.

People who experience an episode of herpes, either facial or genital, should consider themselves infectious from the start of the episode to the healing of the last ulcer.

Facial herpes lesions (e.g. cold sores) are also a source of transmission through the practice of oral sex. Consequently, oral sex should be avoided if one partner has a facial herpes attack.

Infectious virus can still be present in people with no obvious lesions, during periods of asymptomatic virus shedding. Asymptomatic virus shedding cannot be predicted but is known to occur on at least 5% of days.

Occasionally, one partner in a long-term relationship may develop symptoms of herpes for the first time. Often this is due to one or both of the partners being carriers of HSV and not knowing it. The sudden appearance of herpes does not necessarily imply recent transmission from someone outside the relationship.

By avoiding sex when the signs of herpes are present, and by using condoms with sexual partners between outbreaks, the chance of passing on herpes may be reduced.

Diagnosis
Because people's experience of genital herpes varies so greatly and because the treatment of any sexually transmitted infection is distinctive and specific, accurate diagnosis is essential.

Accurate diagnosis of genital herpes is made most easily and correctly at the time of an active herpes infection, preferably the initial symptomatic infection. Diagnosis involves the doctor taking a medical history, performing a physical examination and taking a swab to detect presence of the virus.

At this time, genital secretions and blisters containing fluid necessary for confirmation of infection are likely to be present, and a definitive diagnosis provides patient and doctor with the necessary information to optimise treatment.

Laboratory confirmation
In order to confirm a diagnosis of genital HSV infection, it is necessary to prove the presence of the herpes simplex virus. Detection of HSV antibodies in the bloodstream is not sufficient because this cannot define the site of HSV infection.

The usual procedure is for the doctor to perform a swab test, in which a sample of the fluid from a blister, from ulcers, or a sample of a genital secretion, is taken and sent away for analysis.

Laboratory analysis is usually made either by virus culture (where the virus is grown in material known as a culture medium) or by antigen detection where components of the virus are specifically identified.

Because it is possible for a person with genital herpes to have another sexually transmitted infection at the same time, a full genital check should be made. For women this may include a cervical smear test.

It is important to note that having genital herpes is not associated with the development of cervical cancer.

While a blood test may reveal infection with HSV at a time when no genital symptoms are present, confirmation of genital HSV infection is still essential. If the blood test is specific for detection of antibodies to HSV type 2, the likelihood of genital HSV infection is increased, but still not proven. The doctor may ask you to re-visit for a swab test when genital symptoms or discomfort appear.

What it Means to have Genital Herpes

Overall health
Primary genital HSV infection can be severe and involve generalized flu-like symptoms. This, combined with the pain and discomfort of the sores and, in some cases, secondary bacterial infection, can leave people feeling run-down. Fortunately, recovery is fast once blisters have healed.

Sexual relationships
People with recurrent genital herpes may reconsider some aspects of sexual intimacy. For example, using non-genital forms of sexual contact during an active episode. It also means considering if, how and when you are going to tell a sexual partner that you have genital herpes (see Herpes and Relationships: How to Tell ). Given the social stigma that seems to surround genital herpes, preparing your thoughts in advance before telling someone is preferable. Most people react supportively when told and appreciate and respect your courage and honesty. People who choose not to tell a sexual partner risk the burden of fear, guilt and secrecy.

In an on-going relationship, where both partners fully understand the chance of transmission, a decision to not use a condom may be agreed.

For people who experience very frequent herpes recurrences, and whose pattern of sexual relations is severely disrupted, antiviral therapy, which reduces the frequency of recurrences, can help restore a more acceptable sex life.

Fertility
Genital herpes is not hereditary. The virus has no effect on fertility and is not transmitted via men's sperm or women's ova (eggs).

Pregnancy
Women with genital herpes can experience a safe pregnancy and normal vaginal childbirth. This is especially so when a women has a diagnosis of genital herpes prior to becoming pregnant. In the situation where the mother already has a history of genital herpes, she will have antibodies circulating in her blood that will protect the baby during pregnancy and delivery.

There are only two situations in which the developing foetus may be at risk:

• a severe first episode during the first trimester (12 weeks) of pregnancy, which can lead to miscarriage. This is very uncommon and a hazard also present with a number of other virus infections, including the flu

• a first episode in the last trimester of pregnancy, as there is a large amount of virus present and insufficient time for the mother to produce antibodies to protect the unborn baby. Transmission of virus to the foetus causes neonatal herpes, a potentially fatal condition. However, neonatal herpes is extremely rare in developed countries. Careful monitoring, judicious use of antiviral therapy and/or Caesarean delivery can reduce the risk to the baby.

Care during pregnancy
It is important that a pregnant woman informs her doctor/obstetrician if either she or her partner has genital herpes. When the male partner has genital herpes and the woman has no evidence of infection, the following may help the woman to avoid acquisition of the virus during pregnancy:

• a blood test to establish if the woman has HSV antibodies
• the use of condoms after conception through to birth
• the woman's partner taking oral antiviral medication for the duration of the pregnancy to suppress genital herpes outbreaks
• if the woman's partner has a history of facial herpes or cold sores, avoiding oral sex for the duration of the pregnancy.

As the last stage of pregnancy approaches, regular checks should be made and the woman and her doctor can discuss the possibility of a Caesarean delivery or the use of antiviral drugs.

Other than this, the pregnant woman should simply observe the normal guidelines for healthy pregnancy as closely as possible. Good nutrition and rest are even more important at this time.

Recurrent genital herpes presents only a minimal risk in pregnancy, though it may interfere with the woman's enjoyment of pregnancy.

Being a parent
Genital herpes, in either parent, does not generally affect children and there is little risk of transmission so long as normal hygiene is practised.

Parents should be aware, however, that HSV can be transmitted from cold sores simply by kissing and can cause serious, widespread infection in the newborn. Fortunately, by the time a baby is around six months old, his or her immune system is better able to cope with exposure to the virus. Initial exposure to HSV in babies and young children, after being kissed by someone with a cold sore, can cause gingivostomatitis, an infection of the mouth and gums which goes largely unrecognized and untreated.

Managing Genital Herpes

Treatment
Genital herpes is manageable. Over the years, a number of treatments offering effective relief from symptoms of genital herpes have been developed.

Simple treatments for the relief of discomfort
The following non-specific treatments can alleviate the pain and discomfort of genital sores.

• SALT BATHS, used to wash the genital area, can clean, soothe and dry the sores. Use 1 teaspoon of salt in 600 ml of water or a handful in a shallow bath.
• PAIN RELIEVERS include simple analgesics (such as aspirin and paracetamol), ice (which can be soothing if applied directly to the sores) and creams with an anaesthetic component. Creams, however, can slow down drying and should therefore be used sparingly and only for pain relief. In addition, topical creams have limited value on moist mucosal surfaces, particularly in women.
• LOOSE UNDERCLOTHES, preferably cotton (not nylon), can help minimize discomfort and allow healing.

For anyone experiencing extreme pain when urinating, the process can be less painful when done in a cool bath. And it is important to remember to drink plenty of fluids as this dilutes the urine.

Antiviral Therapy
The standard, effective and specific treatment for genital herpes is antiviral therapy, which is usually in tablet form. Antiviral drugs stop HSV from replicating in the body. The treatment only works while you are taking the drug, and cannot prevent future outbreaks once you stop taking it.

Antiviral treatments can:

• shorten the duration of a genital herpes outbreak and help speed healing
• reduce the number of outbreaks suffered - or prevent them completely.

Antiviral medications can be used in two ways:

1. to treat outbreaks as they happen - this is known as 'episodic' treatment. With episodic treatment, the aim is to shorten the time each outbreak lasts and to relieve symptoms. If you are coping well and your outbreaks are not too frequent, you and your doctor may agree that episodic treatment is the most appropriate option.

2. to prevent or delay recurrent outbreaks - this is known as 'suppressive' therapy. If your recurrent outbreaks are frequent or severe - or if you find them particularly bothersome - your doctor may recommend that you take oral antiviral medication every day to help prevent outbreaks happening. Suppressive therapy is taken continuously, e.g. daily, for months or even years.

Oral antiviral medication is only available by prescription. If you are taking 'episodic' therapy then the earlier treatment starts after symptoms of an outbreak first appear, the more effective it will be. So see your doctor and ask him/her to prescribe treatment in advance that you can self-initiate immediately you detect the early symptoms of a herpes episode.

Specific Antiviral Therapies

Valaciclovir
When used as episodic treatment, valaciclovir helps the sores heal faster, and shortens the period of pain during the outbreak. Valaciclovir also cuts down the time during which the virus is detected on genital skin surfaces (virus shedding) - a time when the disease can be passed on to a sexual partner.

If you take valaciclovir as soon as you notice the first signs of an outbreak - such as tingling, itching or redness - you may be able to completely prevent the development of painful blisters. In clinical tests, valaciclovir prevented the development of painful blisters and ulcers in one third more patients who took the drug within 24 hours of noticing the first symptoms of the outbreak, compared to those who took a dummy (placebo).

Valaciclovir is taken twice a day when used as episodic treatment.

In many countries, valaciclovir can be used as 'suppressive' treatment. Clinical trials have proved it to prevent or delay up to 85% of herpes outbreaks. For suppressive treatment, you only need to take valaciclovir once a day, or possibly twice a day if outbreaks are very frequent.

Side effects with valaciclovir are usually mild and may include headache or nausea.

Aciclovir
When aciclovir is taken as episodic treatment, it can reduce the severity of outbreaks of genital herpes and shorten their duration, in a similar way to valaciclovir. Like valaciclovir, aciclovir also shortens the time during which the herpesvirus is detected on skin surfaces.

As episodic treatment, aciclovir should be taken five times a day. Aciclovir can also be used as suppressive treatment to help reduce the number of outbreaks. If you take aciclovir as suppressive treatment, you will need to take tablets two, three or four times a day.

The side effects of aciclovir are usually mild. They include nausea and diarrhoea.

Famciclovir
Famciclovir has been shown to reduce the time that outbreaks last when used as episodic treatment. The severity of pain with outbreaks is also decreased. Like valaciclovir and aciclovir, famciclovir also shortens the period during which virus is detected on genital surfaces.

Famciclovir is taken three times a day, when it is used as episodic treatment for the initial genital herpes episode, or two times a day to treat recurrent outbreaks.

Famciclovir is approved in some countries for daily use as suppressive therapy (your doctor will be able to advise you if this is the case in your country). When it is used in this way, it has been shown in clinical trials to increase the time between outbreaks. For suppressive therapy, famciclovir is taken two times every day.

The side-effects of famciclovir are generally mild with headache and nausea being reported.

You should consult your doctor for further information about antiviral treatment for your particular situation.

Counselling
A diagnosis of genital herpes often comes as a shock. Adequate information about genital herpes and the implications for the future are an important part of clinical management and treatment.

Counselling offers a way of dealing with your concerns.

Support groups
The experience and support of other people with herpes can be extremely valuable. Support groups for people with herpes exist in some countries and have the objective of providing support and education to people with herpes (see Support Groups section of the website).

For anyone who feels isolated by genital herpes, self-help groups can provide a much-needed arena for open discussion and the exchange of information and ideas.

Overcoming Genital Herpes

A practical approach
Methods of dealing with genital herpes may differ for each person but some practical guidelines are offered.

A positive attitude helps greatly, and it starts with a positive feeling towards oneself. On a practical level, it is important for individuals to have time and space so that they can learn about their strengths and develop them.

For anyone who finds stress a particular problem or has trouble relaxing, there are specific techniques, such as meditation and courses on stress management, that can help.

A person who experiences recurrent genital herpes should try to get to know the pattern of their outbreaks. This way, they may discover the particular circumstances that trigger an episode and learn to avoid them. To gain relief from frequent recurrences, antiviral treatment may help. It can prevent some recurrences and provide valuable 'breathing time' in which people can learn to strengthen their own resources.

Here are some practical guidelines that may be helpful for telling someone that you have genital herpes:
It's only natural to feel apprehensive about telling someone else about genital herpes, for the first time, but remember, a good long-term relationship is always based on honesty (see Herpes and Relationships: How to Tell and Genital Herpes: What it Means for Partners ).
Timing is important. Carefully choose the time and place for telling someone. Just as it is probably not necessary to tell someone right at the beginning of a relationship, it isn't fair to the other person, and certainly doesn't help the relationship, if the discussion is left until after a serious relationship is established.

Be prepared. Plan what is going to be said and have your facts about genital herpes clear. Printing out some information from this website for someone to read can be a good idea.

Finally, consider how you would feel if the roles were reversed and you were being told.

You can obtain more information on genital herpes by contacting your doctor or a sexual health clinic.