What is genital herpes?

Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex viruses type 1 (HSV-1) or type 2 (HSV-2).

How common is genital herpes?

Genital herpes infection is common in the United States. CDC estimates that, annually, 776,000 people in the United States get new herpes infections.22. Nationwide, 15.5 % of persons aged 14 to 49 years have HSV-2 infection. 21 The overall prevalence of genital herpes is likely higher than 15.5% because an increasing number of genital herpes infections are caused by HSV-1. 2 HSV-1 is typically acquired in childhood; as the prevalence of HSV-1 infection has declined in recent decades, people may have become more susceptible to genital herpes from HSV-1. 1

HSV-2 infection is more common among women than among men (20.3% versus 10.6% in 14 to 49 year olds).23 Infection is more easily transmitted from men to women than from women to men. HSV-2 infection is more common among non-Hispanic blacks (41.8%) than among non-Hispanic whites (11.3%). This disparity remains even among persons with similar numbers of lifetime sexual partners. For example, among persons with 2–4 lifetime sexual partners, HSV-2 is still more prevalent among non-Hispanic blacks (34.3%) than among non-Hispanic whites (9.1%) or Mexican Americans (13%).20 Most infected persons are unaware of their infection. In the United States, an estimated 87.4% of 14–49 year olds infected with HSV-2 have never received a clinical diagnosis. 21

The percentage of persons in the United States who are infected with HSV-2 decreased from 21.2% in 1988–1994 to 15.5% in 2007-2010. 21

How do people get genital herpes?

Infections are transmitted through contact with lesions, mucosal surfaces, genital secretions, or oral secretions. HSV-1 and HSV-2 can also be shed from skin that looks normal. Generally, a person can only get HSV-2 infection during sexual contact with someone who has a genital HSV-2 infection. Transmission most commonly occurs from an infected partner who does not have visible sores and who may not know that he or she is infected. 4 In persons with asymptomatic HSV-2 infections, genital HSV shedding occurs on 10% of days, and on most of those days the person has no signs or symptoms. 3

What are the symptoms of genital herpes?

Most individuals infected with HSV-1 or HSV-2 are asymptomatic or have very mild symptoms that go unnoticed or are mistaken for another skin condition. As a result, 87.4% of infected individuals remain unaware of their infection.23 When symptoms do occur, they typically appear as one or more vesicles on or around the genitals, rectum or mouth. The average incubation period after exposure is 4 days (range, 2 to 12). 5 The vesicles break and leave painful ulcers that may take two to four weeks to heal. Experiencing these symptoms is referred to as having an "outbreak" or episode.

Clinical manifestations of genital herpes differ between the first and recurrent outbreaks of HSV. The first outbreak of herpes is often associated with a longer duration of herpetic lesions, increased viral shedding (making HSV transmission more likely) and systemic symptoms including fever, body aches, swollen lymph nodes, or headache. 6 Recurrent outbreaks of genital herpes are common, in particular during the first year of infection. Approximately half of patients who recognize recurrences have prodromal symptoms, such as mild tingling or shooting pains in the legs, hips or buttocks, which occur hours to days before the eruption of herpetic lesions. Symptoms of recurrent outbreaks are typically shorter in duration and less severe than the first outbreak of genital herpes. Although the infection can stay in the body indefinitely, the number of outbreaks tends to decrease over time. Recurrences and subclinical shedding are much less frequent for genital HSV-1 infection than for genital HSV-2 infection. 7

What are the complications of genital herpes?

Genital herpes may cause painful genital ulcers that can be severe and persistent in persons with suppressed immune systems, such as HIV-infected persons. Both HSV-1 and HSV-2 can also cause rare but serious complications such as blindness, encephalitis (inflammation of the brain), and aseptic meningitis (inflammation of the linings of the brain). Development of extragenital lesions in the buttocks, groin, thigh, finger, or eye may occur during the course of infection. 6

Some persons who contract genital herpes have concerns about how it will impact their overall health, sex life, and relationships. There can be can be considerable embarrassment, shame, and stigma associated with a herpes diagnosis that can substantially interfere with a patient’s relationships. 5Clinicians can address these concerns by encouraging patients to recognize that while herpes is not curable, it is a manageable condition. Three important steps that providers can take for their newly-diagnosed patients are: giving information, providing support resources, and helping define options. 8 Since a diagnosis of genital herpes may affect perceptions about existing or future sexual relationships, it is important for patients to understand how to talk to sexual partners about STDs. One resource can be found here: www.gytnow.org/talking-to-your-partner

There are also potential complications for a pregnant woman and her unborn child. See “How does herpes infection affect a pregnant woman and her baby?” below for information about this.

What is the link between genital herpes and HIV?

Genital ulcerative disease caused by herpes make it easier to transmit and acquire HIV infection sexually. There is an estimated 2- to 4-fold increased risk of acquiring HIV, if exposed to HIV when genital herpes is present. 9-11Ulcers or breaks in the skin or mucous membranes (lining of the mouth, vagina, and rectum) from a herpes infection may compromise the protection normally provided by the skin and mucous membranes against infections, including HIV. Herpetic genital ulcers can bleed easily, and when they come into contact with the mouth, vagina, or rectum during sex, they may increase the risk of HIV transmission.

How does genital herpes affect a pregnant woman and her baby?

Neonatal herpes is one of the most serious complications of genital herpes. Healthcare providers should ask all pregnant women if they have a history of genital herpes. Herpes infection can be passed from mother to child during pregnancy, childbirth, or in the newborn period, resulting in a potentially fatal neonatal herpes infection. During pregnancy there is a higher risk of perinatal transmission during the first outbreak than with a recurrent outbreak, thus it is important that women avoid contracting herpes during pregnancy. 12 Women should be counseled to abstain from intercourse during the third trimester with partners known to have or suspected of having genital herpes. 7

A woman with genital herpes may be offered antiviral medication from 36 weeks gestation through delivery to reduce the risk of a recurrent outbreak. 13Routine HSV screening of pregnant women is not recommended. However, at onset of labor, all women should undergo careful examination and questioning to evaluate for presence of prodromal symptoms or herpetic lesions. If herpes symptoms are present a cesarean delivery is recommended to prevent HSV transmission to the infant. 14, 7

How is genital herpes diagnosed?

The preferred HSV tests for patients with active genital ulcers include viral culture or detection of HSV DNA by polymerase chain reaction (PCR). HSV culture requires collection of a sample from the sore and, once viral growth is seen, specific cell staining to differentiate between HSV-1 and HSV-2. However, culture sensitivity is low, especially for recurrent lesions, and declines as lesions heal. PCR is more sensitive, allows for more rapid and accurate results, and is increasingly being used.15 Because viral shedding is intermittent, failure to detect HSV by culture or PCR does not indicate and absence of HSV infection. Tzanck preparations are insensitive and nonspecific and should not be used. 

Serologic tests are blood tests that detect antibodies to the herpes virus. Several ELISA-based serologic tests are FDA approved and available commercially. Older assays that do not accurately distinguish HSV-1 from HSV-2 antibody remain on the market, so providers should specifically request serologic type-specific assays when blood tests are performed for their patients. The sensitivities of type-specific serologic tests for HSV-2 vary from 80-98%; false-negative results might be more frequent at early stages of infection. Additionally, false positive results may occur at low index values and should be confirmed with another test such as Biokit or the Western Blot. Negative HSV-1 results should be interpreted with caution because some ELISA-based serologic tests are insensitive for detection of HSV-1 antibody.

For the symptomatic patient, testing with both virologic and serologic assays can determine whether it is a new infection or a newly-recognized old infection. A primary infection would be supported by a positive virologic test and a negative serologic test, while the diagnosis of recurrent disease would be supported by positive virologic and serologic test results. 16

CDC does not recommend screening for HSV-1 or HSV-2 in the general population. Several scenarios where type-specific serologic HSV tests may be useful include

  • Patients with recurrent genital symptoms or atypical symptoms and negative HSV PCR or culture;
  • Patients with a clinical diagnosis of genital herpes but no laboratory confirmation;
  • Patients who report having a partner with genital herpes;
  • Patients presenting for an STD evaluation (especially those with multiple sex partners);
  • Persons with HIV infection; and
  • MSM at increased risk for HIV acquisition. 7

Is there a cure or treatment for herpes?

There is no cure for herpes. Antiviral medications can, however, prevent or shorten outbreaks during the period of time the person takes the medication. In addition, daily suppressive therapy (i.e. daily use of antiviral medication) for herpes can reduce the likelihood of transmission to partners.

Several clinical trials have tested vaccines against genital herpes infection, but there is currently no commercially available vaccine that is protective against genital herpes infection. One vaccine trial showed efficacy among women whose partners were HSV-2 infected, but only among women who were not infected with HSV-1. No efficacy was observed among men whose partners were HSV-2 infected. A subsequent trial testing the same vaccine showed some protection from genital HSV-1 infection, but no protection from HSV-2 infection. 17

How can herpes be prevented?

Correct and consistent use of latex condoms can reduce the risk of genital herpes. 18, 19 However, outbreaks can occur in areas that are not covered by a condom.

The surest way to avoid transmission of sexually transmitted diseases, including genital herpes, is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Persons with herpes should abstain from sexual activity with partners when sores or other symptoms of herpes are present. It is important to know that even if a person does not have any symptoms, he or she can still infect sex partners. Sex partners of infected persons should be advised that they may become infected and they should use condoms to reduce the risk. Sex partners can seek testing to determine if they are infected with HSV.

Reference : http://www.cdc.gov/std/herpes/stdfact-herpes.htm


WHAT DOES A POSITIVE HERPES IgM TEST RESULT MEAN?

Question: Does a Positive Herpes IgM Test Mean I Was Recently Infected with Herpes? 

Answer: Not really.

Many doctors will tell patients with a positive herpes IgM test that their test result means they were recently infected with herpes (HSV). This is because HSV IgM antibodies are thought to peak shortly after an initial infection and then recede. In fact, that is the common wisdom for IgM antibodies in general.

Compared to IgM, herpes IgG antibodies develop more slowly. However, they are expected to remain high throughout the course of an infection.Therefore, a positive HSV IgG test is thought to mean that the detected infection is at least several months old. 

Interestingly, recent research suggests that the common wisdom about herpes blood test results may not be accurate. Individuals who were recently infected with herpes DO tend to have positive HSV IgM tests. However, so do many people with recurrent herpes infections. Between 30 and 70 percent of people with recurrent herpes are positive on HSV IgM tests, depending on the test and the study.

Herpes IgM tests are more likely to be positive in early herpes infections than herpes IgG tests. All this shows is that a positive herpes IgM test alone does not prove that an infection is recent. That's particularly true if it is accompanied by a positive herpes IgG test.

If you have a positive herpes IgM test and a negative herpes IgG test, then it is more likely that your results  signal a recent infection. However, it is possible to misinterpret false positive test results. Therefore, if you have no symptoms, you may want to go back for IgG testing at a later date.

If you do have symptoms, your doctor can test the lesions for herpes directly. There is no need to wait for an antibody response.

Detectable levels of herpes IgG take longer to develop than detectable levels of herpes IgM. However, even herpes IgM antibodies can take up to ten days to develop after primary infection with the virus. Therefore, if you believe you have been exposed but have no symptoms, don't run to the doctor. It's best to wait at least two weeks before getting tested - or even longer, depending on which tests are available in your area. You may also want to go for a repeat test after 6 months if you do not undergo regular screening.

 

WHAT DOES A POSITIVE HERPES IgG TEST RESULT MEAN?

What Does a Positive Herpes IgG Test Mean?

Herpes IgG tests are one type of blood test for the herpes simplex virus (HSV). Herpes blood tests look for the body's immune reaction to a herpes infection. They don't search directly for the virus. Because the immune reaction takes time to develop after the time of infection, it's not immediately detectable. In fact, depending on the type of test used, it can take up to four months to become positive on an HSV IgG test.

 

How Does an HSV IgG Test Work?

When a person becomes infected,the immune system tries to fight off the infection. That's true not just for herpes but for any pathogen, Part of that process involves the production of antibodies. These proteins are specific for each infection they are fighting.

For a new type of infection, it takes time for the body to make strong antibodies. The body can make several kinds of antibodies to fight infections. The two types that herpes blood tests look for are IgG and IgM. Herpes IgM antibodies usually are detectable by herpes blood tests within 7-10 days after initial infection. IgM levels stay high for approximately two weeks. After that, they usually decline.

Therefore IgM testing is primarily considered to be useful for detecting acute infection. However antibody levels also sometimes go up during an outbreak.

In contrast, herpes IgG antibodies do not show up until slightly later after initial infection. A positive herpes IgG test, if the test result is accurate, means that your body has been infected with the herpes simplex virus.

Furthermore, type specific herpes IgG tests can  be used to distinguish between HSV-1 and HSV-2. Type-specific tests are far more accurate than non type-specific tests,However, they can not detect whether a particular infection is oral or genital. The only way to determine that is to watch for symptoms. 

HSV-1 usually infects the mouth, causing oral herpes, and HSV-2 usually infects the genitals. However, there are a growing number of people with genital HSV-1.  That's why herpes IgG and IgM tests can only tell you that you have been infected. They can't show where where.

 

HSV Blood Test Results & Timing of Infection

If you test positive for herpes IgG but not IgM, then your herpes infection is probably not recent. You've probably been infected for at least two months. Individuals with newer infections are more likely to test positive for both herpes IgG and IgM. They might also be positive for herpes IgM alone. The converse, however, isn't true. Positive herpes IgG and IgM results together do not necessarily mean you were infected recently. Between 30 and 70 percent of patients with recurrent herpes infections will test positive for herpes IgM.

Test Results and Timing of Infection
   Positive IgG Negative IgG
Positive IgM  Infection date indeterminate  Acute/Recent infection
Negative IgM  Established Infection  No infection detected

 

Test Accuracy

It is possible to have a false positive or false negative result. That's true for either a HSV IgG or HSV IgM test. Therefore, don't panic if your herpes blood test results do not agree with your known risk factors and sexual history. Instead, talk to your doctor about possible issues with testing. Diagnostic testing isn't perfect. You also may not be accurately assessing your risk. Many people do not understand that herpes can be transmitted even when their partner has no symptoms or does not know they are infected.

Sources:
Hashido M, Kawana T. Herpes simplex virus-specific IgM, IgA and IgG subclass antibody responses in primary and nonprimary genital herpes patients. Microbiol Immunol. 1997;41(5):415-20
Ho DW, Field PR, Sjögren-Jansson E, Jeansson S, Cunningham AL. Indirect ELISA for the detection of HSV-2 specific IgG and IgM antibodies with glycoprotein G (gG-2). J Virol Methods. 1992 Mar;36(3):249-64.Morrow R, Friedrich D. Performance of a novel test for IgM and IgG antibodies in subjects with culture-documented genital herpes simplex virus-1 or -2 infection. Clin Microbiol Infect. 2006 May;12(5):463-9.
Morrow RA, Friedrich D. Inaccuracy of certain commercial enzyme immunoassays in diagnosing genital infections with herpes simplex virus types 1 or 2. Am J Clin Pathol. 2003 Dec;120(6):839-44.
Page J, Taylor J, Tideman RL, Seifert C, Marks C, Cunningham A, Mindel A. Is HSV serology useful for the management of first episode genital herpes? Sex Transm Infect. 2003 Aug;79(4):276-9. Hashido M, Kawana T. "Herpes simplex virus-specific IgM, IgA and IgG subclass antibody responses in primary and nonprimary genital herpes patients." Microbiol Immunol. 1997;41(5):415-20.
Ho DW, Field PR, Sjögren-Jansson E, Jeansson S, Cunningham AL. "Indirect ELISA for the detection of HSV-2 specific IgG and IgM antibodies with glycoprotein G (gG-2)." J Virol Methods. 1992 Mar;36(3):249-64.
Morrow, R. and Friedrich, D. "Performance of a novel test for IgM and IgG antibodies in subjects with culture-documented genital herpes simplex virus-1 or -2 infection" Clin Microbiol Infect 2006; 12: 463–469
Page J, Taylor J, Tideman RL, Seifert C, Marks C, Cunningham A, Mindel A. "Is HSV serology useful for the management of first episode genital herpes?" Sex Transm Infect. 2003 Aug;79(4):276-9.

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