Prevention of transmission, counselling, and partner notification

• Condoms can reduce but not completely prevent transmission.
• Infected persons should be informed that male condoms, when used consistently and correctly, might reduce the risk of genital herpes transmission. The protective effect appears greater for women.
• Aciclovir, famciclovir and valaciclovir suppress symptomatic and asymptomatic viral shedding. These drugs in clinical trials have been shown to reduce (not eliminate) asymptomatic HSV shedding by about 80-90%.
• Suppressive antiviral therapy with valaciclovir 500mg once daily reduces the rate of acquisition of HSV-2 infection and clinical symptomatic genital herpes in serodiscordant couples. Other antivirals may be effective but efficacy has not been proven in clinical trials.

• Diagnosis often causes considerable distress.
• Most people with recurrent genital HSV infection adjust over time, but antiviral treatment can reduce anxiety, assist adjustment, and improve quality of life.
• Care must be taken in all consultations to ensure the appropriate language is used and that alarmist terms (incurable, chronic, attacks) are avoided.
• Counselling should be as practical as possible and address the individual’s particular personal situation; for instance, issues for someone in a long term relationship are likely to be different from those for someone seeking a partner.
• Disclosure is often a difficult issue for patients but is more likely to happen in the context of an ongoing relationship. The legal responsibility and requirements in serodiscordant relationships is currently unclear. However, it is important that the clinician raises the issue, and advises that disclosure is advised in all relationships since this is associated with lower transmission risks and may be protection against legal action. Discussions around disclosure should be documented.
• There is no evidence that failure by the patient to control everyday stresses affects recurrences.
• For most patients, one or two counselling sessions, with an invitation to return in case of difficulty, should be enough. Patients who have failed to adjust to the diagnosis within a year merit review for the consideration of more intensive counselling interventions. Consider referring to sexual health advisers for this detailed work.

Topics of counselling

Counselling should cover the following topics:

• The natural history.
• The use of antivirals for symptoms control.
• The risks of transmission.
• Uncertainties exists about the impact of suppressive therapy on infectivity, but suppressive therapy appears to reduce the rate of acquisition of symptomatic genital herpes in serodiscordant couples.
• Disclosure is advised in all relationships.
• Abstinence from sexual contact during lesion recurrences or prodromes.
• Transmission may occur as a result of asymptomatic shedding.
• The possible benefit of male condoms in reducing transmission, emphasising that their use cannot completely prevent transmission.
• Reassurance regarding transmission by fomites, e.g. towels, bedding, etc., and autoinoculation after the first infection is over.
• Evidence for reinfection of source patients at genital or distant sites is limited, although some work does suggest it is more likely than previously thought and maybe greatest for those who are immunocompromised or have HSV–I.
• Partners with infection should understand the importance of not transmitting a new infection to someone who is pregnant. Strategies aimed at reducing the risk of transmission should be explicitly stated:
• Conscientious use of condoms during pregnancy, especially in the last trimester as this can prevent transmission to a seronegative pregnant partner.
• Abstaining from sex at the time of lesion recurrence and in the last six weeks of pregnancy can also prevent transmission to a seronegative pregnant partner.
• If there is a history of oro-facial HSV, oro-genital transmission to pregnant women should be considered and strategies to avoid transmission discussed.

Although there is no evidence on which to base recommendations for partner notification at a population level, the clarification of whether a partner is co-infected or not may help to relieve anxiety about transmission and/or reinforce the need to reduce the risk of transmission between individuals. However, given the limitations of current type-specific serology and the non-specific clinical features of genital HSV infection, confirmation of the status of partners is often imprecise.

Although there is no definitive evidence that either antiviral treatment or patient education/counselling alters transmission rates of HSV at a population level, it seems logical to increase awareness of the diagnosis in partners when appropriate, with the aim of preventing onward transmission.