Impact of suppressive antiviral therapy on the health related quality of life of patients with recurrent genital herpes infection

Herpes Simplex Virus: A Practical Guide to Diagnosis, Management, and Patient Counseling for the Primary Care Clinician

Genital herpes is a chronic, lifelong sexually transmitted viral infection, which can cause recurrent, self-limited genital ulcers. It is caused by herpes simplex virus (HSV) type 1 and type 2 viruses. Genital HSV infection is a very prevalent STI, which causes self-limited, recurrent genital ulcers. Treatment decreases duration of symptoms and signs and can be provided as episodic or suppressive therapy. Genital herpes can have a substantial impact during pregnancy and on sexual health in general. Counseling on natural history, transmission, treatment, and management of sexual partners is an integral part of management of genital herpes.

Genital Herpes Infection: Progress and Problems

Genital herpes (GH) is a sexually transmitted infection causing recurrent, self-limited genital, buttock, and thigh ulcerations. Symptoms range from unrecognized or mild to severe with frequent recurrences. Herpes simplex viruses (HSV) type-1 or type-2 cause GH. HSV establishes latency in sacral ganglia and causes lifelong infection. Viral reactivation leads to genital ulceration or asymptomatic shedding which may lead to transmission. HSV infection during pregnancy can cause fulminant hepatitis and neonatal transmission. Severe and atypical manifestations are seen in immunocompromised people. Guanosine analogs treat symptoms and prevent recurrences, shedding, and transmission. Novel preventive and therapeutic strategies are in development.

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.

Health-related quality of life in individuals with genital herpes: a systematic review

Background

There is a significant global burden of herpes simplex virus (HSV) related genital ulcer disease yet little is known about its impact on quality of life. This systematic review aimed to identify studies that quantitatively evaluated the effect of genital herpes on various aspects of health-related quality of life.

Methods

Six databases were searched (MEDLINE, EMBASE, NHS Economic Evaluation Database, Health Technology Assessment, Database of Abstracts of Reviews of Effects, Web of Science Core Collection) for primary quality of life and economic evaluations of genital herpes from January 1, 2000 to January 7, 2021. Qualitative studies or those without primary data were excluded. Two authors independently extracted data from the publications. The study’s registration number with PROSPERO was CRD42021239410.

Findings

We identified 26 relevant publications: 19 presented primary quality of life data, and seven were economic evaluations. The primary studies presented a range of condition-specific tools for describing the quality of life in individuals with genital herpes, but only one study used a direct valuation that could be used to generate utility weights. All economic evaluations of HSV infection were from high-income country settings. Most (6 of 7) focused on neonatal HSV infection with utilities adopted from studies prior to 2000.

Interpretation

The extant literature on genital herpes-related quality of life is limited and requires updating. We recommend future studies be conducted in geographic- and population- diverse settings, and use preference-based condition-specific or generic-instruments to better inform economic modelling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01934-w.

Genital herpes - diagnosis, treatments, attitudes and response to disclosure amongst members of the UK Herpes Viruses Association

A diagnosis of genital herpes may result in psychological as well as physical morbidity. Many patients require on-going help and contact the Herpes Viruses Association (HVA), a UK patient support organisation. The HVA conducts occasional questionnaires relating to various issues surrounding herpes and this study reports on a survey conducted amongst members in 2015. The survey was done using SurveyMonkey and covered diagnosis/treatment, both allopathic and self-help, physical and psychological impact and disclosure to partners. Three hundred and fifty-eight women and 103 men completed the questionnaire. Male respondents were older than women (48.6 versus 42.9 years). The majority were first diagnosed in sexual health clinics. A high proportion had informed partners about the diagnosis and in 83% disclosure did not result in rejection. 57% were taking prophylaxis with more taking treatment episodically rather than continually; 11.3% sourced medications on-line. Alternative treatments were used commonly with Lomaherpan cream (Melissa officinalis), lidocaine ointment and a diet with reduced arginine and increased lysine the most frequent choices. Other alternative treatments included olive leaf extract, Eleuthercoccus senticosus and vitamin supplements. Women reported being troubled psychologically more than men. Neuropathic pain was reported by 80.4% of the women and 64.1% of the men. Although antiviral treatment is cheap and well-tolerated it is still being refused by some healthcare providers. There still appears to be a considerable degree of stigma experienced by patients which can be mitigated by support from patients' support groups such as the HVA.

Dynamics of HSV-2 infection with a therapeutic vaccine

Herpes-Simplex Virus type 2 (HSV-2) is a lifelong infection, which has infected over 400 million individuals aged 15-49 years, worldwide. While the disease can be treated with episodic and suppressive antiviral drugs to reduce the rate of recurrence (i.e., symptomatic disease) and viral shedding, none of the currently available therapies can clear the virus from the body of an infected person. A number of therapeutic vaccine platforms are currently in development in order to achieve similar effects to treatment. Due to the inadequate data from clinical trials of therapeutic vaccines, modeling efforts to quantify the impact of vaccination have been limited. In this study, we propose a compartmental deterministic model for the dynamics of HSV-2 to evaluate the effect of a potential vaccine candidate with the inclusion of a booster dose. Despite its simplicity that may not address the complexity of HSV-2 disease, the model shows that targeting symptomatic infection for vaccination is the most effective strategy in the long-term. This conclusion is based on the assumption of an optimal vaccine efficacy, conferring immunity levels that prevent viral shedding and recurrence transiently. Our model provides a framework for developing a computational system to include more heterogeneous characteristics of the disease and individuals, and investigate effectiveness and cost-effectiveness of vaccination scenarios when clinical data become available.

The global and regional burden of genital ulcer disease due to herpes simplex virus: a natural history modelling study

Introduction

Herpes simplex virus (HSV) infection can cause painful, recurrent genital ulcer disease (GUD), which can have a substantial impact on sexual and reproductive health. HSV-related GUD is most often due to HSV type 2 (HSV-2), but may also be due to genital HSV type 1 (HSV-1), which has less frequent recurrent episodes than HSV-2. The global burden of GUD has never been quantified. Here we present the first global and regional estimates of GUD due to HSV-1 and HSV-2 among women and men aged 15-49 years old.

Methods

We developed a natural history model reflecting the clinical course of GUD following HSV-2 and genital HSV-1 infection, informed by a literature search for data on model parameters. We considered both diagnosed and undiagnosed symptomatic infection. This model was then applied to existing infection estimates and population sizes for 2016. A sensitivity analysis was carried out varying the assumptions made.

Results

We estimated that 187 million people aged 15-49 years had at least one episode of HSV-related GUD globally in 2016: 5.0% of the world's population. Of these, 178 million (95% of those with HSV-related GUD) had HSV-2 compared with 9 million (5%) with HSV-1. GUD burden was highest in Africa, and approximately double in women compared with men. Altogether there were an estimated 8 billion person-days spent with HSV-related GUD globally in 2016, with 99% of days due to HSV-2. Taking into account parameter uncertainty, the percentage with at least one episode of HSV-related GUD ranged from 3.2% to 7.9% (120-296 million). However, the estimates were sensitive to the model assumptions.

Conclusion

Our study represents a first attempt to quantify the global burden of HSV-related GUD, which is large. New interventions such as HSV vaccines, antivirals or microbicides have the potential to improve the quality of life of millions of people worldwide.

2017 European guidelines for the management of genital herpes

Genital herpes is one of the commonest sexually transmitted infections worldwide. Using the best available evidence, this guideline recommends strategies for diagnosis, management, and follow-up of the condition as well as for minimising transmission. Early recognition and initiation of therapy is key and may reduce the duration of illness or avoid hospitalisation with complications, including urinary retention, meningism, or severe systemic illness. The guideline covers a range of common clinical scenarios, such as recurrent genital herpes, infection during pregnancy, and co-infection with human immunodeficiency virus.

2014 UK national guideline for the management of anogenital herpes

These guidelines concern the management of anogenital herpes simplex virus infections in adults and give advice on diagnosis, management, and counselling of patients. This guideline replaces the 2007 BASHH herpes guidelines and includes new sections on herpes proctitis, key points to cover with patients regarding transmission and removal of advice on the management of HSV in pregnancy which now has a separate joint BASHH/RCOG guideline.

Oral antiviral therapy for prevention of genital herpes outbreaks in immunocompetent and nonpregnant patients

BACKGROUND

Genital herpes is caused by herpes simplex virus 1 (HSV-1) or 2 (HSV-2). Some infected people experience outbreaks of genital herpes, typically, characterized by vesicular and erosive localized painful genital lesions.

OBJECTIVES

To compare the effectiveness and safety of three oral antiviral drugs (acyclovir, famciclovir and valacyclovir) prescribed to suppress genital herpes outbreaks in non-pregnant patients.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the search portal of the World Health Organization International Clinical Trials Registry Platform and pharmaceutical company databases up to February 2014. We also searched US Food and Drug Administration databases and proceedings of seven congresses to a maximum of 10 years. We contacted trial authors and pharmaceutical companies.

SELECTION CRITERIA

We selected parallel-group and cross-over randomized controlled trials including patients with recurrent genital herpes caused by HSV, whatever the type (HSV-1, HSV-2, or undetermined), with at least four recurrences per year (trials concerning human immunodeficiency virus (HIV)-positive patients or pregnant women were not eligible) and comparing suppressive oral antiviral treatment with oral acyclovir, famciclovir, and valacyclovir versus placebo or another suppressive oral antiviral treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected eligible trials and extracted data. The Risk of bias tool was used to assess risk of bias. Treatment effect was measured by the risk ratio (RR) of having at least one genital herpes recurrence. Pooled RRs were derived by conventional pairwise meta-analyses. A network meta-analysis allowed for estimation of all possible two-by-two comparisons between antiviral drugs.

MAIN RESULTS

A total of 26 trials (among which six had a cross-over design) were included. Among the 6950 randomly assigned participants, 54% (range 0 to 100%) were female, mean age was 35 years (range 26 to 45.1), and the mean number of recurrences per year was 11 (range 6.3 to 17.8). Duration of treatment was two to 12 months. Risk of bias was considered high for half of the studies and unclear for the other half. A total of 14 trials compared acyclovir versus placebo, four trials compared valacyclovir versus placebo and 2 trials compared valacyclovir versus no treatment. Three trials compared famciclovir versus placebo. Two trials compared valacyclovir versus famciclovir and one trial compared acyclovir versus valacyclovir versus placebo.We analyzed data from 22 trials for the outcome: risk of having at least one clinical recurrence. We could not obtain the outcome data for four trials. In placebo-controlled trials, there was a low quality evidence that the risk of having at least one clinical recurrence was reduced with acyclovir (nine parallel-group trials, n = 2049; pooled RR 0.48, 95% confidence interval (CI) 0.39 to 0.58), valacyclovir (four trials, n = 1788; pooled RR 0.41, 95% CI 0.24 to 0.69), or famciclovir (two trials, n = 732; pooled RR 0.57, 95% CI 0.50 to 0.64). The six cross-over trials showed larger treatment effects on average than the parallel-group trials. We found evidence of a small-study effect for acyclovir placebo-controlled trials (adjusted pooled RR 0.61, 95% CI 0.49 to 0.75). In analyzing parallel-group trials by daily dose, no clear evidence was found of a dose-response relationship for any drug. In head-to-head trials, the risk of having at least one recurrence was increased with valacyclovir rather than acyclovir (one trial, n = 1345; RR 1.16, 95% CI 1.01 to 1.34) and was not significantly different from that seen with famciclovir as compared with valacyclovir (one trial, n = 320; RR 1.18, 95% CI 0.86 to 1.63).We included 16 parallel-arm trials in a network meta-analysis and we were unable to determine which of the drugs was most effective in reducing the risk of at least one clinical recurrence (after adjustment for small-study effects, pooled RR 0.83, 95% CI 0.61 to 1.11 for valacyclovir vs acyclovir; pooled RR 1.04, 95% CI, 0.71 to 1.49 for famciclovir vs acyclovir; and pooled RR 1.26, 95% CI 0.89 to 1.75 for famciclovir vs valacyclovir). Safety data were sought but were reported as total numbers of adverse events.

AUTHORS' CONCLUSIONS

Owing to risk of bias and inconsistency, there is low quality evidence that suppressive antiviral therapy with acyclovir, valacyclovir or famciclovir in pacients experiencing at least four recurrences of genital herpes per year decreases the number of pacients with at least one recurrence as compared with placebo. Network meta-analysis of the few direct comparisons and the indirect comparisons did not show superiority of one drug over another.

Genital herpes beliefs: implications for sexual health

STUDY OBJECTIVE

Genital herpes (HSV) is exceedingly common in the United States and women are disproportionally affected. This study aims to describe young women's beliefs about HSV and examine the correlates of those beliefs.

DESIGN

A 40-item Herpes Representation measure (HSV-RoSTD) and a demographic questionnaire were administered to a convenience sample of young women. Data analysis included descriptive statistics, t-tests and Pearson's correlations.

SETTING

Four women's health clinics and one large state university.

PARTICIPANTS

302 women aged 18-24 years.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Four dimensions of HSV representations (cause, identity, future perspective, and psychosocial consequences), age and STD testing history.

RESULTS

Nearly all (98%) believed that HSV would result in genital sores and 68% believed they could tell if their sexual partner had HSV. Most (89%) understood the longevity of HSV; however, 30% believed that they could take a pill to get rid of the infection, and 15% indicated that it was likely they would die from HSV. Negative beliefs about the psychosocial impact of HSV were common as 95% indicated they would be depressed and 90% indicated concern about sex and partner notification. Those who were younger and those who had never been tested for STDs believed a genital herpes infection is highly symptomatic. Finally, negative beliefs about the psychosocial consequences of HSV were associated with beliefs about HSV being symptomatic, having a negative impact on future health, and being associated with sexual risk behaviors.

CONCLUSIONS

Young women have misconceptions about HSV, particularly regarding the symptomatology and the role of HSV medication. Noteworthy concerns about the negative psychosocial consequences of an HSV diagnosis were also raised, all of which have implications for young women's sexual health.

European guideline for the management of genital herpes, 2010

This is the guideline for genital herpes simplex virus (HSV) management for the IUSTI/WHO Europe, 2010. They describe the epidemiology, diagnosis, clinical features, treatment and prevention of genital HSV infection. They include details on the management of HSV in pregnancy, those who are immunocompromised and the clinical investigation and management of suspected HSV-resistant disease.

Genital herpes

INTRODUCTION

Genital herpes is an infection with herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2), and is among the most common sexually transmitted diseases.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent sexual transmission of herpes simplex virus? What are the effects of interventions to prevent transmission of herpes simplex virus from mother to neonate? What are the effects of antiviral treatment in people with a first episode of genital herpes? What are the effects of interventions to reduce the impact of recurrence? What are the effects of treatments in people with genital herpes and HIV? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 35 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antivirals, caesarean delivery, condoms, oral aciclovir, psychotherapy, recombinant glycoprotein vaccines, serological screening, and counselling.

Psychosocial well-being and quality of life among women newly diagnosed with genital herpes

OBJECTIVE

To assess the psychosocial well-being and quality of life among women with a new genital herpes simplex virus diagnosis.

DESIGN

Data were collected by a cross-sectional survey.

PARTICIPANTS

Eighty-three women diagnosed with genital herpes simplex virus by culture, visual exam and/or a description of symptoms within the last 3 months were recruited from primary health care clinics by their provider.

MEASURES

Participants completed the Hospital Anxiety and Depression Scale and the Recurrent Genital Herpes Quality of Life scale.

RESULTS

Thirty-four percent of the women qualified as "clinical cases" for depression, and 64% were designated as "anxiety cases" based on Hospital Anxiety and Depression Scale scoring methods. A majority of participants reported feeling ashamed about having herpes and worried about having an outbreak or giving herpes to someone else.

CONCLUSIONS

Despite substantial progress toward understanding genital herpes simplex virus epidemiology and transmission, a diagnosis of genital herpes continues to cause considerable psychosocial morbidity and to impact quality of life. There is a dearth of good evidence on how best to intervene to minimize the psychological impact of a diagnosis. Experts recommend addressing both the medical and psychological aspects of infection by providing antiviral therapy, written material, and resources.

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.

2-day versus 5-day famciclovir as treatment of recurrences of genital herpes: results of the FaST study

Background: The brief period of viral replication in recurrent genital herpes lesions suggests shorter therapeutic regimens may be as effective as standard 5-day courses. Objective: To demonstrate that a 2-day course of famciclovir 500 mg statim, then 250 mg twice daily was non-inferior to the standard 5-day course of 125 mg twice daily. Methods: Patients were randomly assigned either the 2-day or 5-day famciclovir course and initiated therapy within 12 h of onset of prodromal symptoms. They were instructed to complete daily questionnaires on herpes-related symptoms and functioning and to attend the clinic for assessment of healing 5.5 days after initiating therapy. Results: A total of 873 patients were randomised at least once and 1038 recurrences were treated. The proportion of evaluable recurrences with lesions present at 5.5 days was less in the 2-day arm (24%) than in the 5-day (28%) arm. The upper 97.5% confidence limit (CL) for this difference in favour of the 2-day arm was 2% in favour of the 5-day arm, well within the 10% predefined for non-inferiority. The upper 97.5% CL was similar in the intent-to-treat, evaluable and per-protocol recurrence populations and when adjusted for baseline differences (in gender, age, herpes history and HIV infection) or for clustering of recurrences within patients. Both treatments had similar side-effects; proportion of lesions aborted; time to next recurrence; patient-reported symptoms; and impact on daily functioning. Conclusions: The 2-day course was as safe and effective as the standard 5-day course and can only enhance patient convenience and compliance.

Genital herpes

Genital herpes is the main cause of genital ulcers worldwide; the prevalence of herpes simplex virus (HSV) type 2 infections in the general population ranges from 10% to 60%. Most genital herpes is caused by HSV-2, although HSV-1 accounts for about half of new cases in developed countries. The risk of HIV acquisition is three times higher in people with HSV-2. Neonatal herpes is an uncommon but serious complication of genital herpes. Most genital HSV-2 infections are unrecognised and undiagnosed; infected individuals, even with mild symptoms, shed HSV, and can infect sexual partners. Since clinical diagnosis is neither sensitive nor specific, virological and type-specific serological tests should be used routinely. Oral antiviral drugs for HSV infections are safe and effective and can be used both to treat episodes and to prevent recurrences. Antiviral treatment of the infected partners and condom use reduce the risk of sexual transmission of HSV-2.

Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management

Eight of the more than 80 known herpesviruses are human pathogens. Human herpes simplex virus (HSV) is a contagious infection with a large reservoir in the general population. It has a potential for significant complications in the immunocompromised host. In addition, psychological distress caused by the negative stigma associated with genital herpes and visible facial lesions in those experiencing frequent outbreaks renders it a challenging clinical dilemma. This article reviews the epidemiology, pathogenesis, and diagnostic features of HSV infections, providing the clinician with an up-to-date understanding of the available management strategies for mucocutaneous HSV-induced disease.

HSV-2 Serologic Testing in an HMO Population: Uptake and Psychosocial Sequelae

OBJECTIVES

To prospectively measure the uptake of Herpes simplex virus Type 2 (HSV-2) testing and psychosocial response to a new serologic diagnosis of HSV-2 in a health maintenance organization (HMO) population.

STUDY DESIGN

Randomly selected urban HMO enrollees were invited to be tested for HSV-2 antibody at a research clinic. Participants had blood drawn and completed demographic and psychosocial questionnaires.

RESULTS

Of 3111 eligible enrollees contacted, 344 (11%) were tested. Eighty-seven (26%) tested HSV-2 seropositive, and 44 (51%) of these did not report a prior genital herpes diagnosis. Distress, measured by the total mood disturbance, was 6.5 points higher on average following a new genital herpes diagnosis relative to baseline (actual range = 109 points, P = 0.003) but not statistically different from HSV-2 negative or previously diagnosed participants.

CONCLUSIONS

HMO enrollees unexpectedly testing HSV-2 positive showed short-term psychosocial distress that resolved during 6-month follow-up. Findings suggest that concerns about psychosocial burden should not deter voluntary serologic HSV-2 testing in primary care settings.

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.

Suppressive Therapy With Valacyclovir in Early Genital Herpes: A Pilot Study of Clinical Efficacy and Herpes-Related Quality of Life

BACKGROUND

Suppressive therapy has not been studied during the first year after acquisition of genital herpes, the time of maximum frequency of reactivation, potential for transmission, and impact on quality of life.

OBJECTIVE

The objective of this study was to evaluate the effectiveness of suppressive therapy with valacyclovir initiated within 3 months of infection.

STUDY DESIGN

The authors conducted a double-blind, randomized, controlled trial of 1.0 g valacyclovir daily versus placebo for 6 months in 119 patients.

RESULTS

Herpes simplex virus (HSV) type 2 and HSV-1 were documented in 75 and 22 patients, respectively. In intention-to-treat analysis, annualized rates of symptomatic recurrences for valacyclovir and placebo, respectively, were 1.7 +/- 2.7 (mean +/- standard deviation) and 3.4 +/- 4.0 outbreaks per year (P = 0.012). Time to first recurrence was 80 +/- 47 days for valacyclovir and 54 +/- 49 days for placebo (P = 0.001). The differences in favor of valacyclovir were greatest in patients with confirmed HSV-2 infection. The Recurrent Genital Herpes Quality of Life score in HSV-2 infected patients rose 11.9 +/- 11.1 points for valacyclovir and 5.9 +/- 9.1 points for placebo (P = 0.040).

CONCLUSIONS

Early suppressive therapy with valacyclovir reduces symptomatic recurrent outbreaks, especially in patients with HSV-2 infection. Valacyclovir therapy was associated with improved herpes-related quality of life.

A Comparison of One Year of Episodic or Suppressive Treatment of Recurrent Genital Herpes With Valacyclovir

OBJECTIVES

We conducted this study to compare episodic and suppressive therapy for genital herpes about disease characteristics, disease burden, and psychologic impact.

STUDY DESIGN

The authors conducted a randomized, open-label, 1-year treatment trial.

RESULTS

Forty subjects were randomized to episodic therapy with valacyclovir (500 mg twice daily for 5 days) and 40 to suppressive therapy (500 mg daily). Subjects in the episodic arm experienced more outbreaks (7.87 +/- 4.65) than those in the suppressive arm (1.59 +/- 1.93) (P <0.001). Subjects in the episodic arm also had significantly more days with pain and lesions (6.5 +/- 7.3) than those in the suppressive arm (1.1 +/- 3.3) (P < 0.001), and other quantitative measures of disease burden also favored the suppressive arm. Both treatment groups had significant improvements in their recurrent genital herpes quality-of-life scores from baseline that persisted throughout the study; however, there was no significant difference between the treatment arms in these scores.

CONCLUSIONS

Suppressive therapy of recurrent genital herpes with valacyclovir has a greater impact on measures of disease frequency and burden than episodic therapy. However, both treatment strategies lead to significant improvements in recurrent genital herpes quality-of-life scores. Both treatment strategies benefit patients with recurrent genital herpes.

Genital herpes

INTRODUCTION

Genital herpes is an infection with herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2), and is among the most common sexually transmitted diseases.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent sexual transmission of herpes simplex virus? What are the effects of interventions to prevent transmission of herpes simplex virus from mother to neonate? What are the effects of antiviral treatment in people with a first episode of genital herpes? What are the effects of interventions to reduce the impact of recurrence? What are the effects of treatments in people with genital herpes and HIV? We searched: Medline, Embase, The Cochrane Library and other important databases up to August 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 35 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antivirals, caesarean delivery, condoms, oral acyclovir, psychotherapy, recombinant glycoprotein vaccines, serological screening, and counselling.

Validation of the genital herpes treatment satisfaction questionnaire (GHerpTSQ) in status and change versions

A new measure of treatment satisfaction (GHerpTSQ) for recurrent genital herpes simplex virus (HSV) was validated and used to evaluate two therapeutic strategies widely used for the management of HSV: episodic treatment, where individual herpes outbreaks are treated as they arise; suppressive therapy, where treatment is taken daily to prevent HSV outbreaks. Satisfaction with treatment is important since daily dosing with suppressive therapy is necessary in the absence of symptoms. A 12-item questionnaire was designed using a modified form of the Diabetes treatment satisfaction questionnaire (DTSQ). The psychometric properties of the GHerpTSQ were evaluated within a sample of 125 Canadians with a history of HSV (type 1, 2) infection participating in a 48 week randomised cross-over trial. Factor analysis suggested that the items can be analysed as two separate subscales corresponding to Control/effectiveness, and Convenience/lifestyle; the single item concerning side effects was retained for separate analysis. Forced one-factor analysis showed that the two subscales can be combined to obtain a total score relating to overall treatment satisfaction. The GHerpTSQ has good internal reliability, clear structure with little overlap of subscales and evidence of good sensitivity to changes in treatment.

Genital herpes: antiviral therapy for symptom relief and prevention of transmission

The episodic and daily suppressive treatment of genital herpes is safe and effective with the currently available antiviral agents: acyclovir, valacyclovir and famciclovir. Clinical strategies for the comprehensive management of genital herpes simplex virus infections are recommended. Data from recent clinical trials demonstrating the efficacy of shorter duration of therapy for recurrences and the use of antivirals for the prevention of transmission are reviewed in this article. The factors influencing the choice of therapy, such as cost, ease of dosing and acyclovir resistance are also discussed.

Valacyclovir for the treatment of genital herpes

Genital herpes is the most prevalent sexually transmitted infection in the USA. While sometimes mild in severity, it can be a distressing and painful chronic condition. Likewise, herpes labialis and herpes zoster can be both physically and psychologically painful. While there is no cure for these conditions, treatment to alleviate symptoms, suppress recurrences and reduce transmission has been drastically improved over the past 20 years with the use of guanine nucleoside antivirals, such as valacyclovir hydrochloride (Valtrex), GlaxoSmithKline) the highly bioavailable prodrug of acyclovir (Zovirax((R)), GlaxoSmithKline), and famciclovir (Famvir, Novartis), a highly bioavailable prodrug of penciclovir (Denavir, Novartis). Clinical trials involving approximately 10,000 patients (including patients from nongenital herpes studies, such as herpes zoster) have assessed the safety and efficacy of valacyclovir in the treatment of initial genital herpes outbreaks, episodic treatment of recurrent episodes and daily suppressive therapy. It was shown that valacyclovir has similar efficacy to acyclovir in the episodic and suppressive treatment of genital herpes. Valacyclovir is the only antiviral drug approved for a once-daily dose of suppressive therapy for genital herpes, as well as the only antiviral drug US FDA approved for a 3-day regimen of episodic treatment of recurrent genital herpes. In addition, valacyclovir is also indicated in the reduction of the sexual transmission of herpes simplex virus infection and for the treatment of herpes labialis. In herpes zoster, valacyclovir is more effective than acyclovir or placebo (and as equally effective as famciclovir) in shortening the length and severity of herpes zoster-associated pain and postherpetic neuralgia. Valacyclovir has an acceptable safety profile in patients with herpes simplex and herpes zoster. The less frequent dosing regimen makes it an attractive option in the treatment of genital herpes and other viral infections, and may contribute to increased patient adherence to therapy.

Sexual behaviour and condom use among individuals with a history of symptomatic genital herpes

OBJECTIVES

This study describes the differences in sexual behaviour in individuals with genital herpes (GH) during "symptomatic" and "asymptomatic" periods of the disease.

METHODS

A cross sectional questionnaire was undertaken by 1193 individuals attending clinics between 1998 and 2001. All participants in this analysis were in heterosexual, monogamous partnerships, self identified with a history of symptomatic GH and with confirmed HSV-2 infection.

RESULTS

Sexual activity reported during asymptomatic v symptomatic periods of GH was 98% v 40% (p<0.001), 76% v 29% (p<0.001), and 25% v 11% (p<0.001) for vaginal, oral, and anal intercourse, respectively, while "always" condom use during asymptomatic and symptomatic periods was 20% v 35% (p<0.001), 2% v 7% (p<0.001), and 10% v 15% (p = 0.131), respectively. The proportion of individuals who either abstained from vaginal intercourse or "always" used condoms was 21% v 74% (p<0.001), for asymptomatic v symptomatic periods. Multivariable analyses indicated that factors associated with engaging in intercourse during symptomatic periods of GH included current intrauterine device use (adjusted odds ratio (aOR) = 2.96, 95% confidence interval (CI) = 1.46 to 6.02); living in Latin America (aOR = 2.16, CI = 1.19 to 3.91) or Europe (aOR = 1.67, CI = 1.21 to 2.28), compared with North America; previous sexually transmitted disease (aOR = 1.42, CI = 1.08 to 1.89); a higher number of sexual acts per month (aOR = 1.09, CI = 1.06 to 1.11); and a higher number of GH recurrences per year (aOR = 1.08, CI = 1.03 to 1.12).

CONCLUSIONS

These data indicate that the majority of people with GH either abstained from intercourse or "always" used condoms during symptomatic periods of GH. However, condom use was relatively low during asymptomatic periods in comparison with symptomatic periods. These results highlight that further education on GH prevention is warranted, particularly for symptomatic periods.

The psychosocial impact of serological herpes simplex type 2 testing in an urban HIV clinic

BACKGROUND/OBJECTIVES

Herpes simplex virus type 2 (HSV-2) is a common infection among HIV infected people. HSV type specific serologies permit the diagnosis of previously unrecognised HSV-2 infection. While substantial psychosocial morbidity has been associated with a clinical diagnosis of genital herpes, the burden associated with a serological diagnosis of HSV-2 is unclear. This study prospectively measured the psychosocial response to a new serological HSV-2 diagnosis in patients receiving care at an urban HIV clinic.

METHODS

At entry, sera were tested for HSV-1 and HSV-2 antibodies by western blot. Participants completed a 90 item psychosocial and life quality questionnaire at enrollment, and at 2 weeks, 3 months, and 6 months after receiving test results.

RESULTS

Of 248 HIV infected participants, 172 (69.4%) were HSV-2 seropositive and 116 (67.4%) seropositive people did not have a previous history of genital herpes. After correction for multiple comparisons, no statistically significant differences were detected on the psychosocial and life quality scales between those who received a new HSV-2 serological diagnosis compared with those who were HSV-2 seropositive with a history of genital herpes, or those who tested HSV-2 seronegative. Additionally, no significant changes in scores were observed during follow up.

CONCLUSIONS

HSV-2 was a common but often unrecognised infection in this urban HIV clinic and participants coped well with a positive HSV-2 result. Concerns about psychosocial burden should not deter serological testing for HSV-2. Given the epidemiological and clinical interaction between HSV-2 and HIV, these data support routine HSV-2 testing of HIV infected people.

[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).

Psychological symptoms associated with genital herpes virus infections: epidemiology and approaches to management

Genital herpes is a common, chronic, recurrent, viral sexually transmitted infection (STI) occurring worldwide. The first episode may be severe and prolonged, but most recurrences are usually short lived and minor. Although most individuals with this infection have no symptoms, STIs, including genital herpes, often cause psychological and psychosexual morbidity. Unfortunately, the existing data on the psychological symptoms associated with genital herpes have many limitations, including anecdotal reporting, evaluation of small and selected populations, use of varied and sometimes unevaluated questionnaires, and lack of controls. Some individuals with recurrent genital herpes display a range of emotional responses, including depression, anguish, distress, anger, diminution of self-esteem and hostility towards the person believed to be the source of infection. However, it is always important to consider the possibility of pre-existing psychopathology. Several retrospective studies have suggested that stress could lead to recurrences of genital herpes infection. However, prospective studies have been unable to demonstrate any relationship between pre-existing stress and recurrences. What these studies were able to demonstrate was that stress and recurrences occurred simultaneously, suggesting that perhaps it was the recurrences that were causing stress, rather than the reverse.

Health related quality of life in genital herpes: a pilot comparison of measures

BACKGROUND

Genital herpes (GH) is a common sexually transmitted infection. Novel tools for the control of GH (for example, tests and vaccines) are emerging, but optimal assessment of the cost effectiveness of such interventions requires scaled, preference based estimates of the impact of GH on health related quality of life.

METHODS

We provided self administered interviews to 39 individuals with recurrent GH recruited from an STD clinic and a GH support group in southern Ontario, Canada. Health preference estimates were generated using visual analogue scales (VAS), a time-tradeoff approach (TTO) and the Health Utilities Index Mark-II (HUI-II). Quality of life was also assessed with the Recurrent Genital Herpes Quality of Life scale (RGHQoL).

RESULTS

Average (SD) health values for asymptomatic and symptomatic genital herpes were 0.89 (0.21) and 0.89 (0.22) using TTO, and 0.76 (0.30) and 0.71 (0.30) using VAS. Health utility estimates generated with HUI-II for transient symptomatic and asymptomatic health states were 0.93 (0.08) and 0.80 (0.16). Log transformed health value estimates exhibited convergent validity when compared to RGHQoL, as did health utility estimates for symptomatic GH. Utility scores for symptomatic GH increased (improved) with increasing age; no other subject characteristic was predictive of preference weights.

CONCLUSIONS

Preference based measures of health related quality of life can be elicited with relative ease in the context of genital herpes, and preference weights are correlated with quality of life scores generated using the RGHQoL. Generation of preference weights will permit direct comparison of the economic attractiveness of herpes prevention interventions with that of other commonly available health interventions.

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.

Treatment of sexually transmitted diseases in women

Guidelines for the treatment of patients with sexually transmitted infection are developed by the Centers for Disease Control and Prevention after consultation with a group of professionals knowledgeable in the field. This article briefly introduces various infections, reviews new diagnostic information, and presents the latest guidelines for therapy. All recommended and alternative regimens are drawn from the most recent treatment guidelines. Although this article focuses primarily on therapy, it also emphasizes the importance of counseling and prevention. Clinicians have the opportunity and obligation to provide education and counseling to patients. Prevention messages should be tailored to the individual patient with consideration given to her specific risk behaviors.

Development of the PSORIQoL, a psoriasis-specific measure of quality of life designed for use in clinical practice and trials

BACKGROUND

Patients with psoriasis have significant impairment in their quality of life (QoL). Several patient-completed instruments are available to measure outcome in dermatological conditions but these primarily focus on severity of disease rather than on QoL.

OBJECTIVES

To develop a new instrument specifically designed to measure QoL in psoriasis-the Psoriasis Index of Quality of Life (PSORIQoL).

METHODS

The content of the instrument was derived from qualitative interviews with 62 psoriasis patients in the U.K., Italy and the Netherlands. Content analysis of the interview transcripts from the three countries identified potential items for the questionnaire. All further stages of the project were conducted in the U.K. only. Face and content validity were determined by means of a focus group held with seven psoriasis patients and face-to-face interviews with a further 21 patients. A new draft version of the PSORIQoL, together with the Dermatology Life Quality Index (DLQI) and the General Well-Being Index (GWBI), were completed by a new sample of psoriasis patients contacted by mail, in order to determine construct validity. A subsample of the respondents completed a similar package 2 weeks later, to assess reproducibility (reliability).

RESULTS

The first version of the PSORIQoL consisted of 61 items covering the needs identified in the interviews as having been affected by psoriasis or its treatment. These included fear of negative reactions from others, self-consciousness and poor self-confidence, problems with socialization, physical contact and intimacy, limitations on personal freedom and impaired relaxation, sleep and emotional stability. Following the focus group and field-test interviews, a new draft measure consisting of 45 items was completed by 148 patients, 88 of whom completed and returned a similar package 2 weeks later. Application of Rasch analysis identified a final 25-item version of the PSORIQoL. This version had a test-retest reliability coefficient of 0.89, indicating good reproducibility. The levels of association with the DLQI and PGWB indicated that the PSORIQoL measures a related but distinct construct.

CONCLUSIONS

The PSORIQoL appears to be a practical, reliable and valid instrument for measuring the impact of psoriasis on QoL. It remains necessary to establish the instrument's responsiveness to changes in QoL associated with treatment.

Patients' preference of valacyclovir once-daily suppressive therapy versus twice-daily episodic therapy for recurrent genital herpes: a randomized study

BACKGROUND

Valacyclovir is effective for suppressive and episodic treatment of recurrent genital herpes. Few data on patients' treatment strategy preferences are available.

GOAL

The goal was to assess patients' preference, satisfaction, and quality of life with suppressive versus episodic treatment of recurrent genital herpes.

STUDY DESIGN

This was a multicenter, open-label, randomized, two-arm, crossover 48-week study involving 225 patients with genital herpes.

RESULTS

Suppressive valacyclovir therapy was preferred to episodic valacyclovir treatment by 72% of patients (P < 0.001). Overall treatment satisfaction and quality of life were significantly greater during suppressive therapy (P < 0.001 and P = 0.002, respectively). The risk of recurrence during the first 24 weeks was reduced by 78% with suppressive therapy (P < 0.001). Significantly fewer patients experienced recurrences during suppressive treatment than with episodic treatment (P < 0.001). Valacyclovir was well tolerated.

CONCLUSIONS

Suppressive valacyclovir was preferred to episodic therapy by most patients. Suppressive therapy was associated with increased treatment satisfaction, and decreased risk and lower frequency of recurrences.

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.

Glycoprotein-D-adjuvant vaccine to prevent genital herpes

BACKGROUND

An effective prophylactic vaccine would help control the spread of genital herpes.

METHODS

We conducted two double-blind, randomized trials of a herpes simplex virus type 2 (HSV-2) glycoprotein-D-subunit vaccine with alum and 3-O-deacylated-monophosphoryl lipid A in subjects whose regular sexual partners had a history of genital herpes. In Study 1, subjects were seronegative for herpes simplex virus type 1 (HSV-1) and HSV-2; in Study 2, subjects were of any HSV serologic status. At months 0, 1, and 6, subjects received either vaccine or a control injection and were evaluated for 19 months. The primary end point was the occurrence of genital herpes disease in all subjects in Study 1 and in HSV-2-seronegative female subjects in Study 2.

RESULTS

A total of 847 subjects who were seronegative for both HSV-1 and HSV-2 (268 of them women, in Study 1) and 1867 subjects who were seronegative for HSV-2 (710 of them women, in Study 2) underwent randomization and received injections. Vaccination was well tolerated and elicited humoral and cellular responses. Overall, the efficacy of the vaccine was 38 percent in Study 1 (95 percent confidence interval, -18 to 68 percent; 15 cases occurred in the vaccine group and 24 in the control group), and efficacy in female subjects was 42 percent in Study 2 (95 percent confidence interval, -31 to 74 percent; 9 cases occurred in the vaccine group and 16 in the control group). In both studies, further analysis showed that the vaccine was efficacious in women who were seronegative for both HSV-1 and HSV-2: efficacy in Study 1 was 73 percent (95 percent confidence interval, 19 to 91 percent; P=0.01), and efficacy in Study 2 was 74 percent (95 percent confidence interval, 9 to 93 percent; P=0.02). It was not efficacious in women who were seropositive for HSV-1 and seronegative for HSV-2 at base line or in men.

CONCLUSIONS

These studies suggest that the glycoprotein D vaccine has efficacy against genital herpes in women who are seronegative for both HSV-1 and HSV-2 at base line but not in those who are seropositive for HSV-1 and seronegative for HSV-2. It had no efficacy in men, regardless of their HSV serologic status.

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.

Genital herpes simplex virus infection in the adolescent: special considerations for management

Genital herpes simplex virus (HSV) infections are increasingly common among adolescents. In developed countries, during the 1990s, adolescent HSV type 2 seroprevalence rates ranged from 4 to 30% depending on the population studied. The clinical diagnosis of genital herpes may be unreliable and laboratory testing is recommended. Aciclovir, valaciclovir, and famciclovir are three antiviral drugs that have proven efficacy in the treatment of genital herpes. These drugs can be used in the treatment of the first episode or for recurrent infections, or can be used long term to suppress recurrent infections. Once or twice daily administration regimens are preferable for adolescents for reasons of adherence, and because it avoids the need to take medication at school. Unproven remedies are used commonly and can be harmful. In addition to antiviral therapy, proper management of the adolescent with genital herpes should also include developmentally appropriate explanations of the diagnosis, treatment and potential complications, recommendations for symptomatic relief, screening for other sexually transmitted infections, and discussion of safer sexual practices. All adolescents should have follow-up visits to complete education and counseling and to assess compliance with antiviral therapy.

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.