Written by: Brandi Anne Berry (she/they), RN.
Edited by: Camille Zeitouni (she/her).
In high school, my sex education wasn’t abysmal, but STI prevention began and ended at condom usage. I spent a lot of time wondering what happened after someone acquired an STI. Surely STI’s happen, some are incurable, and I assumed people kept having sex and living life post-diagnosis.
I started nursing school when I was 18 – young and full of pep, ready to change the world. I wanted to figure out ways to encourage living well with recurrent STIs. It was around this point in my education I realized that, aside from nurses and students who had an interest in sexual health, my nursing curriculum fell short on holistically educating future nurses about sexual wellness.
There is a lot to say about herpes, and a lot of misinformation. This article will cover the differences in Herpes Simplex Virus (HSV) strains (type 1 and type 2), common misconceptions, and the benefit of using type specific IgG (immunoglobulin class G) tests to identify HSV strains when clinically necessary.
A Review of HSV:
Herpes Simplex Virus (HSV) is the virus responsible for herpes infections in both oral (cold sores) and genital regions. There is a common belief that the two strains of HSV cause location specific infections, with HSV-1 causing only cold sores, and HSV-2 causing genital outbreaks. In fact, more recent literature has shown that infections in either region can be caused by HSV-1 or HSV-2, with oral-genital transmission as a relevant mode of transmission of HSV-1 (1, 2). While the locations of infection may be more or less common depending on which strain acquired, it is by no means an indicator of viral type (1).
What do Healthcare Professionals Need to Know?
- HSV Strains:
- The belief held by healthcare practitioners that HSV strains are location-specific is troubling for two main reasons. The first being that HSV-1 infection occurring on a person’s genitals does not protect them from subsequent HSV-2 infection. Without proper counselling about the potential acquisition of both HSV-1 and HSV-2 on the oral or genital regions, patients may believe they are immune from infection when having sex with an HSV-seropositive partner or may believe they are unable to acquire herpes from oral sex (2). The second major concern is that HSV-1 and HSV-2 are managed by the same antivirals (valacyclovir, acyclovir) but are treated with different dosages and frequencies (3) – this creates the second problem of incomplete or ineffective treatment, particularly if a person has both infections on either region.
- Serological Testing:
- In Canada, HSV screening via serology is not part of a typical STI screening exam. Serological testing may not be offered unless asked for, and this is important to do since IgG specific testing to identify strain is necessary for the personalized management of patients (4). Unfortunately, serological testing may not be available for free in all practice settings. In part, this is because many people will have HSV-1, and the social stigma of being positive for herpes can outweigh the benefits of knowing. It is quoted that up to 89% of Canadians will be exposed to HSV-1 (5), but not all of them will have symptomatic infections or be diagnosed. From a harm-reduction or behaviour change perspective, asymptomatic HSV testing has not shown to alter a person’s sexual behaviours (ie using barrier method protection if positive) (6). However, without serological testing, many HSV infections go undiagnosed and are spread to others because they are asymptomatic or sub-clinically symptomatic (6).
- HSV Transmission:
- Another misconception about HSV infections is that they can only spread during active outbreaks with blisters. Although this is more likely, asymptomatic shedding occurs, transmitting the virus to a new susceptible host (2).The degree of asymptomatic viral shedding is different depending on viral type (7) adding to the need to serologically test to inform risk reduction strategies. Herpes can also spread even with the use of barriers (condoms, dental dams), as the transmission occurs from skin to skin contact rather than contact with only mucous membranes.
- Risk of HIV:
- Lastly, even in the absence of blisters, HSV infection in the genital region can alter the risk of acquiring HIV (1,6).
In conclusion, for these reasons, serological diagnosis of HSV should be done in partnership with patients, to provide appropriate counseling regarding asymptomatic shedding, facts about the prevalence of HSV, and methods to reduce HSV transfer to partners (barriers, antivirals). However, it is important to note that no serological test can determine the location of HSV infection in the absence of past clinical symptoms (6).
Take Away Message:
HSV is a common condition that can be well managed in partnership with patients. However, the type of HSV infection does matter, and can modify risk of disease and could impact quality of life. Type-specific treatment is necessary to promote better quality of life and reduce recurrence/transmission. HSV serology can even be used to diagnose type specific HSV infection in those who have been previously symptomatic, in tandem with viral swabs, or for those patients curious about their HSV status.
All interactions should include education and post-diagnosis counselling. Letting patients know about how common the virus is, walking patients through the process of treatment with antivirals, and informing them of prodromal symptoms (tingling, itching, swollen lymph nodes) are all key points to promote wellness. Simultaneously, counselling on safe sex practices (including the limitations of condoms and antivirals on transmission), asymptomatic shedding, and the risk of HIV are also important to protect health. If patients are overwhelmed by all this new information – offer follow-up services with the same practitioner when possible and revisit the key points.
References:
1) BC Centre for Disease Control. Herpes Simplex Virus [Internet]. [cited 2021 Feb 1]. Available from: http://www.bccdc.ca/health-info/diseases-conditions/herpes-simplex-virus
2) Wald, A. Genital HSV-1 Infections. Sexually Transmitted Infections. 2006 June; 82(3), 189-190. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564733/ doi: 10.1136/sti.2006.019935
3) Kimberlin D. W & Whitley, R. J. Antivural Therapy of HSV-1 and -2. In: Arvin A., Campadelli-Fiumme G., Mocarski E. et. al editors. Human Herpesviruses: Biology, therapy and Immunoprophylaxis. Chapter 64. Cambridge: Cambridge University Press; 2007.
4) Fraser Health [Internet]. Types of STI Tests. [cited 2021 Feb 1]. Available from https://www.fraserhealth.ca/health-topics-a-to-z/sexual-health/get-tested-for-stis/types-of-sti-tests#.YBo-uS2cbUo
5) BCCDC. Herpes: A Patient’s Guide [Internet]. [cited 2021 Feb 1]. Available from: https://smartsexresource.com/sites/default/files/handouts/Herpes_Patient_Guide_web.pdf
6) Singh, A., Preksaitis, J., Ferenczy, A. & Romanowski, B. The Laboratory Diagnosis of Herpes Simplex Virus Infections. Can J Infect Dis Med Microbiology. 2005 Mar-April; 16(2), 92-98. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095011/ doi: 10.1155/2005/318294
7) Wald A. Zeh, J, Selke, S. Ashley, R. L, Corey L. Virologic Characteristics of Subclinical and Symptomatic Genital Herpes Infections. New Eng J Med. 1995 Sep 21; 333(12), 770-5. Doi: 10.1056/NEJM199509213331205
