Herpes - Everything you need to know

Of the more than 100 known herpesviruses at the moment, 8 of them routinely infect only humans, these are: herpes simplex virus types 1 and 2, varicella-zoster virus, cytomegalovirus, Epstein Barr virus, human herpesvirus 6 (variants A and B), human herpesvirus 7, and Kaposi’s sarcoma virus or human herpesvirus 8. [1]

In this article we will focus on 2 of the most common types of herpes, HSV-1 and HSV-2 which cause the sexually transmitted diseases of oral and genital herpes, but first, we should understand what genital and oral herpes are.


Herpes Types

What is Genital Herpes?

Genital herpes is a sexual transmitted disease caused commonly by the herpes simplex virus type 2 (HSV-2) and, increasingly, the herpes simplex virus type 1 (HSV-1). This disease, which is estimated to affect 20 million people in the U.S., can’t be recognized as easily, as it present symptoms in the body just in 1 of 4 cases. [2] When it does, it can manifest as primary or recurrent infection, showing symptoms such as (pain, itching, red bumps, white blisters, ulcers, scabs) in the genital area. It is also one of the most common sexually transmitted infections and due to associated physical and psychological effects, it constitutes a considerable and very often underestimated medical problem. [3]Besides normally being caused by HSV-2 virus, genital herpes, can be caused by the HSV-1 virus. In this case, the disease is frequently transmitted thought oral sex performed by a person infected with the oral herpes virus.

What is Oral Herpes?

Oral herpes, or “cold sores”/ ”fever blisters” as is commonly called, is a type of herpes commonly located around the lips, but which can locate as well on other parts of the face such as the upper lip, inside the nose, the chin or the cheek (oral-facial herpes). [4] It is caused by an infection with the Herpes Simplex Virus HSV-1 in (80%) of cases and HSV-2 in (20%) of cases. The period between the contact with the virus and the symptoms (incubation period) is short as it lasts on average 4 days but can range between 2-12 days. [5]

How is Herpes spread? How Do You Get Herpes?

  • Oral Herpes: It is important to note that transmission of HSV most often occurs without symptoms.[6] You can catch oral herpes usually by engaging in intimate or personal contact (e.g., kissing or oral sex) with someone who is infected, [7]  the virus is then typically transmitted through contact with cold sores or via contact with oral secretions during these activities. Additionally, the virus technically can be passed thought asymptomatic shedding, such as when utensils or food are shared, [8] but please take note there is no evidence of these being a common route of transmission. Additionally, although the virus can be found in tears (0.85%) and nasal mucosa (3%), this isn’t also a common route. In comparison, the virus does appear to be constantly present on oral surfaces (13%) such  as the lips, tongue, pharynx and palate on a daily basis, even when a person does not present symptoms [9] This is the reason why frequent oral fluids as saliva, may contain frequently HSV-1 virus and may increase the risk of transmission both to oral and genital mucosa of sexual partners. [10]  
  • Genital Herpes: Genital herpes is usually spread by an infected person who does not have visible lesions, (and usually does not know it has the infection either) thought sex activities (vaginal, oral, or anal). [11]. These infections are transmitted thought the contact with HSV in herpes lesions, mucosal surfaces, genital secretions, and oral secretions or fluids. Is important to highlight the effect of the last route of transmission (oral secretions), as the number of cases of genital herpes caused by HSV-1 have been increasing in the last years (50-78% of cases), especially in adolescent and college populations due to oral sex activities, for this reason is important to clarify that oral sex does carries a substantial risk of transmission from oral to genital herpes, [12] even when the person shows no symptoms at all. Finally, both HSV-1 and HSV-2 can be shed from normal-appearing oral or genital mucosa or skin. In the case of HSV-2, generally, a person can only get HSV-2 infection during genital contact with someone who has a genital HSV-2 infection.  [13] Finally, rather is not impossible to get genital herpes from non-sexual contact sources, it is at least, very rare, with the CDC stating that “you will not get it” from toilet seats, bedding, towels, soap, etc. [14]

Who Is at Risk?

As the herpes virus can be transmitted by both sexual intercourse and oral sex, any person who involves in sex activities possess a considerable risk of infection. For this reason, is important to note that although HSV transmission is most likely when the sores are present, a person with no symptoms has also a very considerable probability of spreading the disease to others, and which increases with every sexual act.

Some others factors also increase your risk of infection:

1) Having Multiple Sex Partners (MSP)

2) Being a men and practicing sex with men (MSM) [15]

3) Having sex with an infected person (any person who has had previous sex activities and has not been tested negative is possible case)

4) Having prior sexually transmitted diseases

5) Having sex at an early age, and 6) Suffering from HIV infection or other health problems. [16]

Herpes Symptoms (Men & Women)

Talking about symptoms of herpes, is firstly important to recall asymptomatic cases (cases without symptoms) are more common than those who don’t, as it is the case with genital herpes, which has been evidenced to be asymptomatic in 75% of cases. 2 In those cases where symptoms do appear, the more common are:

  • Pain, tingling, burning (before blisters appear).

  • Grey blistering sores with a red base (in the mouth or on the genitals).

  • Pain during urination (genital herpes).

  • Itching.

  • Symptoms like flu (fever, tiredness, swollen lymph nodes headaches, tiredness, lack of appetite. [17]

  • Anal and perianal infections (MSM populations). [18]

     

How do I know if I have Herpes?

Besides your health care provider may diagnose your condition based on the location and appearance of the blisters when symptoms are present, a virus culture (PCR), blood test or biopsy are the only ways to confirm a diagnosis. 6 The type of test for HSV used to confirm diagnosis will then depend if symptoms show active sores or not. In the first case (when sores are present) a swab test could be performed to detect the virus. If this is not the case, and a confirmation of the diagnosis is needed, a blood test will indicate if the antibodies of HSV are present in the body. For that matter, the 2 most common are the swab and blood test:

  • Swab test: During an outbreak, a dermatologist often can diagnose herpes simplex by looking at the sores, but to confirm that a patient has herpes simplex, a dermatologist may take a swab from a sore and send this swab to a laboratory. The site to take the sample will depend on the location of the sores, being the possibilities on the swab to be oral, genital or anal. These type of tests can also be performed from home and are offered by health testing centers.  
  • Blood test: When sores are not present, culture is not feasible, or the clinical syndrome is unclear, other medical tests, such as blood tests, can find the herpes simplex virus. [19] As though there are different types of tests from blood samples (ELISA, immunoblot, POCkit), studies’ comparisons have evidenced very similar results for all tests, with 99-95% sensitivity and specificities of 98-93%. [20]   This test is also offered in home tests for herpes detection and is provided by different organizations in the U.S. as Letsgetchecked and Stdcheck for both oral and genital herpes.

     

How early can you detect Herpes?

After exposure to HSV, symptoms may appear within a short range of 2–12 days. Besides, please take note is very possible to have no symptoms at all after becoming infected with HSV, or in some cases, that the first outbreak occurs years after exposure. In the case the outbreak has passed, and no symptoms are visible, it is still possible to detect the presence of herpes HSV-1 or HSV-2 with a blood sample, as the antibodies will remain present in the body during all lifetime.

How do you collect a sample for Herpes testing?

The type of sample and location will depend on symptoms appearance and location:

  • If no symptoms are visible: If sores are not visible, then the collection of the sample will be made thought a little finger pick to collect a blood sample to take to the laboratory and test for antibodies presence. The test will look for antibodies to the virus that your immune system would have made if you were infected. The second type of herpes simplex virus, HSV-2, almost always infects the genitals, so if a test shows antibody to HSV-2 in your blood, you probably have genital herpes. A blood test that shows antibodies to the other type of herpes virus, HSV-1, means you could have genital or oral herpes. That’s because oral herpes, which is usually caused by HSV-1, can spread to the genitals during oral sex. [21]  
  • If symptoms are visible: In the other case, if symptoms are present and you or your physician want to confirm diagnosis or know the type of virus present, a sample will be taken. This will be normally performed using a swab on the area of the sores, being an oral, vaginal or anal sample. In case you want to visit a physician, go to your doctor and he will determine if you need to get tested. In the opposite case, please be aware there are already existent tests you can take from the privacy and comfort of your own home and will help you confirm if you have herpes or not.  

     

Where can I get tested?

Testing of samples for herpes HSV-1 and HSV-2 finally occurs in the lab. In the case of sample collection, you have the option to visit a physician or a lab first, or in the case you would like more privacy and convenience, to take a home-tests for both genital and oral herpes, as these are available nowadays. Both blood samples and swab samples can be collected from the comfort of your own home and following easy instructions which will be provided to you on the test package.

How Accurate Are Herpes Test Results?

As already mentioned, the type of test used to confirm the diagnosis of herpes will depend on the symptoms the person presents. In the case lesions are present, the best option will be taken using a swab test, in which case PCR offers a very high sensitivity and is a preferred option in comparison with viral culture.[22] In the case symptoms are not present, a serologic test, in this case, a blood sample is the best option available. Within the blood sample, a type-specific antibody to HSV will be detected, and this have been proven to be very accurate tests (80-98% sensitivity, 90% specificity).

Can Herpes be cured?

Nowadays there are no cures for genital or oral herpes. Besides this, antiviral medications (oral or intravenous) and lifestyle measures can help relive or manage symptoms and reduce outbreaks. Taken daily, these medicines can lessen the severity and frequency of outbreaks. [23] They also can help prevent infected people from spreading the virus. Antiviral medicines approved for the treatment of both types of herpes simplex include: Acyclovir, famciclovir and valacyclovir 8  In some cases, as receiving a diagnosis may result in psychological distress, such as feelings of isolation, guilt, or anger, counseling can also be very helpful. In case of being positive of herpes, is important to educate yourself in order to reduce transmission to others as much as possible and to be honest about the disease with others. This will be very helpful to you and others. [24]

What happens if I don’t get treated?

If a person is not treated, specially when sores are available for the first time, complications such as bacterial superinfection, aseptic meningitis, as well as others could emerge,[25] for this reason, if you present similar symptoms and suspect of having oral or genital herpes, please visit a physician and test as soon as possible to receive proper treatment and prevent complications.

What Type of Long-Term Damage Can Herpes Cause?

  • Recurrent outbreaks: After an initial outbreak, the herpes virus goes into hiding in the nervous system. In women, it localizes in nerves near the vulva (the genital area outside the vagina). At some later point, the HSV virus becomes active again, causing another outbreak, or recurrence, this is the first long term consequence of genital herpes
  • Complications: In advanced HIV, HSV-2 can lead to complications such as meningoencephalitis, esophagitis, hepatitis, pneumonitis, retinal necrosis, or disseminated infection.
  • Neonatal herpes: Neonatal herpes occurs when an infant is exposed to HSV (HSV-2 or HSV-1) in the genital tract during delivery. It is estimated in 10 out of 100,000 births globally and the risk of this condition increases when the mother acquired the virus during pregnancy.  [26]

I’m pregnant. How could genital Herpes affect my baby?

If you are pregnant or looking to conceive a baby, genital herpes could be a major concern. This is because the virus that causes herpes can pass to the baby, which can be very dangerous. [27] Some research also suggests that genital herpes infection may lead to miscarriage, premature birth and low birth weight. [28] In both cases, testing for HSV is a great addition to your antenatal care routine tests.

Genital herpes is associated with a 2- to 3-fold increased risk for HIV infection.[29] Studies have also suggested that this may be caused as “HSV-2 lesions create an ideal scenario for the rapid spread of HIV infection,” with the virus being able to replicate 3 to 5 times faster in tissue which suffered from HSV lesions, even after being treated with i.e. acyclovir. [30]

Written by Tommy Gonzales on May 21, 2020

References

[1] Whitley, R. (1996, January 01). Herpesviruses. Retrieved May 20, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK8157/

[2] Guinan, M., Wolinsky, S., & Reichman, R. (1985). Epidemiology of genital herpes simplex virus infection. Retrieved May 20, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/2996917

[3] Sauerbrei, A. (2016, December). Herpes Genitalis: Diagnosis, Treatment and Prevention. Retrieved May 20, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5177552/

[4] Oral Herpes. (n.d.). Retrieved May 20, 2020, from http://www.ashasexualhealth.org/stdsstis/herpes/oral-herpes/

[5] DerSarkissian, C. (2018, November 23). Oral Herpes. Retrieved May 20, 2020, from https://www.webmd.com/a-to-z-guides/oral-herpes

[6] Globally, an estimated two-thirds of the population under 50 are infected with herpes simplex virus type 1. (n.d.). Retrieved May 20, 2020, from https://www.who.int/news-room/detail/28-10-2015-globally-an-estimated-two-thirds-of-the-population-under-50-are-infected-with-herpes-simplex-virus-type-1

[7] Oral Herpes. (n.d.). Retrieved May 20, 2020, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/herpes-hsv1-and-hsv2/oral-herpes

[8] Smith, Robinson, Kj, Looker, Vickerman, P., Gottlieb, . . . Jpt. (1970, January 01). Characterizing the transitioning epidemiology of herpes simplex virus type 1 in the USA: Model-based predictions. Retrieved May 20, 2020, from https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1285-x

[9]Medicine, F. (n.d.). Herpes Simplex Virus Type 1 Shedding in Tears and Nasal and … : Sexually Transmitted Diseases. Retrieved May 20, 2020, from https://journals.lww.com/stdjournal/fulltext/2016/12000/Herpes_Simplex_Virus_Type_1_Shedding_in_Tears_and.7.aspx

[10] Ramchandani, M., Kong, M., Tronstein, E., Selke, S., Mikhaylova, A., Magaret, A., . . . Wald, A. (2016, December 01). Herpes Simplex Virus Type 1 Shedding in Tears and Nasal and Oral Mucosa of Healthy Adults. Retrieved May 20, 2020, from https://insights.ovid.com/article/00007435-201612000-00007

[11] Genital herpes. (2019, January 30). Retrieved May 20, 2020, from https://www.womenshealth.gov/a-z-topics/genital-herpes

[12] Groves, M. (2006, April 01). Transmission of Herpes Simplex Virus via Oral Sex. Retrieved May 20, 2020, from https://www.aafp.org/afp/2006/0401/p1153.html

[13] STD Facts - Genital Herpes (Detailed version). (2017, January 31). Retrieved May 20, 2020, from https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm

[14] STD Facts - Genital Herpes. (2017, August 28). Retrieved May 20, 2020, from https://www.cdc.gov/std/herpes/stdfact-herpes.htm

[15] Smith, J., & Robinson, N. (2002, October 15). Age-specific prevalence of infection with herpes simplex virus types 2 and 1: A global review. Retrieved May 20, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/12353183/

[16] Risk Factors for Genital Herpes. (n.d.). Retrieved May 20, 2020, from https://www.winchesterhospital.org/health-library/article?id=103113

[17] Dock, E. (2019, March 21). Herpes Simplex. Retrieved May 20, 2020, from https://www.healthline.com/health/herpes-simplex

[18] Department of Health & Human Services. (2015, October 08). Herpes simplex infections. Retrieved May 20, 2020, from https://www2.health.vic.gov.au/public-health/infectious-diseases/disease-information-advice/herpes

[19] Herpes simplex: Diagnosis and treatment. (n.d.). Retrieved May 20, 2020, from https://www.aad.org/public/diseases/a-z/herpes-simplex-treatment

[20] Wald, & Rhoda. (2002, October 15). Serological Testing for Herpes Simplex Virus (HSV)–1 and HSV-2 Infection. Retrieved May 20, 2020, from https://academic.oup.com/cid/article/35/Supplement_2/S173/315739

[21] Johnson, T. (2019, September 26). What to Do If Your Partner Has Genital Herpes. Retrieved May 20, 2020, from https://www.webmd.com/genital-herpes/partner-faq

[22] Topic 8. Herpes Simplex Virus – Genital. (n.d.). Retrieved May 20, 2020, from https://www.std.uw.edu/go/pathogen-based/hsv/core-concept/all

[23] Sauerbrei, A. (2016, December). Herpes Genitalis: Diagnosis, Treatment and Prevention. Retrieved May 20, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5177552/

[24] Harvard Health Publishing. (n.d.). Genital herpes: Common but misunderstood. Retrieved May 20, 2020, from https://www.health.harvard.edu/mens-sexual-health/genital_herpes_common_but_misunderstood

[25] What are complications of herpes simplex virus (HSV) infection? (2020, March 22). Retrieved May 20, 2020, from https://www.medscape.com/answers/1132351-109391/what-are-complications-of-herpes-simplex-virus-hsv-infection

[26] Herpes simplex virus. (n.d.). Retrieved May 20, 2020, from https://www.who.int/news-room/fact-sheets/detail/herpes-simplex-virus

[27] Johnson, T. (2019, September 26). What to Do If Your Partner Has Genital Herpes. Retrieved May 20, 2020, from https://www.webmd.com/genital-herpes/partner-faq

[28] Screening for Genital Herpes Simplex: Brief Update for the U.S. Preventive Services Task Force. (n.d.). Retrieved May 20, 2020, from https://docplayer.net/23471515-Screening-for-genital-herpes-simplex-brief-update-for-the-u-s-preventive-services-task-force.html

[29] Looker, K., Elmes, J., Gottlieb, S., Schiffer, J., Vickerman, P., Turner, K., & Boily, M. (2017, December). Effect of HSV-2 infection on subsequent HIV acquisition: An updated systematic review and meta-analysis. Retrieved May 20, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5700807/

[30] Why Genital Herpes Boosts the Risk of HIV Infection. (2018, February 22). Retrieved May 20, 2020, from https://www.nih.gov/news-events/nih-research-matters/why-genital-herpes-boosts-risk-hiv-infection