Genital herpes is under-recognised and under-treated. Minor lesions are common; any recurring localised anogenital symptoms or lesions should be investigated as possible genital herpes.
Oral antiviral treatment of the first clinical episode (without waiting for results) should always be offered, regardless of the time of symptom onset. The ‘72 hour’ herpes zoster rule does NOT apply to first episode genital herpes infection.
Antiviral therapy of recurrent genital herpes may be suppressive or episodic.
Some patients prefer suppressive antiviral therapy. It is often considered for those with frequent and/or severe recurrences or associated psychosocial morbidity. Adherence to suppressive treatment reduces but does not eliminate transmission.
For those on episodic antiviral therapy, it is more effective when patients start therapy themselves at the first signs of a recurrence; this requires anticipatory prescribing (“pill-in-the-pocket” antibiotic prescription).
Neonatal HSV infection needs specialist advice on management for women with a history of genital herpes and active lesions at term and especially in the high-risk situation of a first episode up to 6 weeks prior to delivery.
Neonatal HSV infection is a rare, but potentially fatal, disease of babies, occurring within the first 4-6 weeks of life. Symptoms are non-specific and a high index of suspicion is required. Most neonatal HSV infections are acquired at birth, generally from mothers with an unrecognised first genital herpes infection acquired during pregnancy.
What’s New Since 2015
The special authority and Hospital Medicines List restriction were removed from 1 March 2016 (Pharmac). This is recommended first-line treatment.
Treatment of First Episode of Genital Herpes
Oral valaciclovir 500mg bd for 7/7 or longer if new lesions appear during treatment or healing is incomplete.
Immunocompromised patients consider valaciclovir 1g bd for 7 to 10 days.
Alternative: oral aciclovir 400mg 3 times daily (8 hourly) for 7 days.
Management of First Episode of Genital Herpes Algorithm
Treatment of Recurrent Genital Herpes Including Suppressive Therapy
Oral valaciclovir 500mg bd for 3/7.
Alternative: oral aciclovir 800mg 3 times daily for 2 days.
Prescribe enough tablets for patients to be able to self-initiate treatment at the onset of symptoms.
Only recommended for people with HSV confirmed on testing. Given daily to prevent recurrences and reduce asymptomatic shedding. Suggest prescribing for 12 months, followed by a break of 3 months to see if recurrences are still frequent and/or bothersome.
Oral valaciclovir 500mg daily (increase to 500mg bd on an individual basis of clinical presentation and/or having breakthrough recurrences on 500mg daily).
Alternative: oral aciclovir 400mg twice daily.
Management of Recurrent Episodes of Genital Herpes Algorithm
As many as one in five adults in New Zealand have genital herpes due to HSV-2, most will have the asymptomatic or unrecognised disease.
Genital herpes due to HSV-1 (through oral to genital transmission) has also become common; HSV-1 is a frequent cause of primary genital herpes.
The natural history of genital HSV-1 infection involves significantly fewer clinically apparent recurrences and less subclinical shedding than HSV-2.
Management of Women With Suspected Genital Herpes in Pregnancy (In Consultation With a Specialist)
Management of Women With History of Genital Herpes Prior to Pregnancy and Women With First Clinical Episode Greater Than 6 Weeks Prior to Delivery (In Consultation With a Specialist)
Key Information to Provide Patients on Diagnosis
Up to one in three people have genital herpes, but only 20% of them experience symptoms. (This includes genital herpes caused by both HSV-1 and HSV-2.)
Most people (80%) who become infected with genital herpes will not have any symptoms or have such mild symptoms that they will not be recognised or diagnosed as genital herpes. 75% of herpes is acquired from partners unaware they have it.
For most people who experience symptoms, genital herpes is a sometimes-recurring ‘cold sore’ on the genitals. It does not affect your overall health or longevity of life.
A small percentage of people who get genital herpes may experience problematic recurrences.
There is effective oral anti-viral treatment available.
People who experience the first episode of genital herpes will get better, lesions will heal and there will be no evidence of the initial lesions left.
Most people who experience the first episode of HSV-2 will have recurrences, but they are generally milder than the first episode. HSV-1 tends to cause fewer recurrences than HSV-2.
Getting genital herpes in a long-term relationship does not mean that the other partner has been unfaithful. However, a full sexual health screen may be reassuring.
Where both partners in a long-term relationship have the virus, use of condoms is not necessary as they cannot reinfect each other.
It is advisable to avoid sexual contact when lesions are present, as friction may delay healing.
Oral to genital transmission of HSV-1 is very common through oral sex. This can happen when ‘cold sores’ are not causing symptoms.
Genital herpes does not affect your fertility or stop you having children. Vaginal delivery is usual for most women with a history of genital herpes.
Genital herpes does not stop you having sex.
Anybody with genital herpes, whether they get symptoms or have never had symptoms, may shed the virus from time to time with no symptoms present.
There is no evidence that genital herpes causes cancer of the cervix.
Condoms reduce the risk of transmission. The use of condoms in a long-term relationship should be a matter of discussion between the individuals. It is advisable to avoid genital-to-genital contact, even with a condom, until any lesions are completely healed.
Even if the virus is passed on, the most likely outcome is that the person will never experience symptoms.
Ensure patients have access to the NZHF patient pamphlets and/or the HELPLINE TOLLFREE 0508 11 12 13 or visit www.herpes.org.nz
The Guidelines are a consensus opinion of the STIEF Professional Advisory Board (PAB). The PAB has representation from nationwide medical, nursing and allied disciplines involved in the management of STIs. The Guidelines are produced by considering available literature, both New Zealand wide and international, and by basing the medical recommendations on the evidence in the literature or reasonable supposition and opinions of medical experts.