Genital herpes: expanding the toolbox


For this highly infectious disease, a thoughtful and comprehensive approach to care and treatment are a necessity.

©Group of cheerful multi-ethnic teenagers:  Drobot

©Group of cheerful multi-ethnic teenagers: Drobot

In her IDWeek 2023 lecture, "Genital herpes: expanding the toolbox," Anna Wald, MD, MPH, FIDSA, professor at the University of Washington in Seattle, delineated the complexities surrounding herpes simplex virus (HSV). From stigma to the nuances of diagnosis and treatment, Wald emphasized the need for a mindful, comprehensive approach to HSV care.

Herpes, for reasons not entirely understood, is unique among sexually transmitted infections as a common target of ridicule and jokes. Personal accounts, such as one man’s story of betrayal and abandonment, or a women’s decades-long struggle with eroding self-worth, underscored the profound emotional impact than an HSV diagnosis can carry. These narratives highlight the necessity of empathy and judgement in medical practice for every case.

Accurate diagnosis remains paramount for effective HSV care. If any symptoms are present, Wald emphasized the importance of swabbing the area for PCR testing. A reliance on visual diagnosis alone is known to be misleading, with up to one out of five experienced STI clinicians falsely identifying a lesion as HSV. Furthermore, the distinction between HSV-1 and HSV-2 is important, given an increased recurrence rate for genital HSV-2 compared to HSV-1.

While commercially available EIA tests for HSV detection are accessible, they often necessitate confirmatory tests, with only a fraction of low-positive results being confirmed as true positives. The HSV Western blot stands out as the best method of HSV antibody detection, and Wald directed providers and patients to for more information.

The paradigm for HSV treatment has evolved over the past decades. Nucleoside analogues have proven effective in mitigating recurrence and transmission, and they are proven safe for long-term use. Looking forward, Wald discussed the potential of emerging drugs like helicase-primase inhibitors, which may herald a new era of potent treatments, albeit now accompanied by potential safety considerations.

The quest for an effective HSV-2 vaccine is ongoing. While therapeutic vaccines show potential in reducing viral shedding and recurrence, prophylactic vaccines face challenges, particularly given a low incidence of HSV-2 in the US and uncertainty in the global market.

One of the most promising frontiers in HSV research is gene editing. Given its latency in a limited number of neurons within a few ganglia, “HSV is an ideal candidate” for such interventions, Wald noted. Current methodologies focus on eradicating HSV DNA, holding the promise of a potential cure.

Wald also emphasized the importance of patient education by highlighting the ubiquity of fraudulent treatments available online. In 2 featured examples, a $1500 care package of natural, organic supplements guaranteed to result “in a negative blood test result,” while another book proports to be to cure herpes with an alkaline diet.

In concluding remarks, Wald re-emphasized that the care of those with HSV should be rooted in empathy and tailored to everyone’s unique situation. Practitioners should not aim to address every concern in a single visit and above all, Wald poignantly reminded attendees, "you will be remembered," underscoring the lasting impression health care professionals leave on a patient’s life.

Wald, A. Genital herpes: Expanding the toolbox. IDWeek 2023. October 14, 2023. Boston, Massachusetts.

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